. - • i

Property of the

Lancaster City and County
Medical Society

No

I Received,

|Title,..^S^^r^.

! Binding ....j

I

i Residence,

I Cost,

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

EDITED BY

ISAAC HAYS, M.D.,

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE
AMERICAN MEDICAL ASSOCIATION J OF THE AMERICAN PHILOSOPHICAL SOCIETY J OF THE
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; ASSOCIATE FELLOW
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES,

&c. &c. &c.

NEW SERIES.
VOL. XXXV.

PHILADELPHIA:

BLANCHARD & LEA.

1858.

69461

Entered according to the Act of Congress, in the year 1858, by
BLANCHARD AND LEA,

in the Office of the Clerk of the District Court of the United States in and for the
Eastern District of the State of Pennsylvania.

PHILADELPHIA :
COLLINS, PRINTER.

TO READERS AND CORRESPONDENTS.

The communication of Dr. J. B. Porter is in type, and shall appear in our
next No., as shall also the papers of Drs. Casselberry and Halsey.

A number of communications are on hand which shall receive early attention.

In the review of the " Report of Sickness and Mortality in the U. S. Army."
which appeared in the number of this Journal for July last, an apparent dis-
crepancy in the statistics of cholera was noted {vide p. 138 of July No.). This,
we learn from an authentic source, is to be explained by the fact that all the
quarterly abstracts throughout that work are for quarters ending on the 31st
March, 30th June, 30th September, and 31st December ; the year being from
January to January. This course was adopted for the purpose of showing the
influence of the seasons in each year. In the consolidated abstract, which em-
braces the yearly record of all the diseases occurring in the army {vide pages
488 to 493 of Report), the official annual reports of the Surgeon-General were
followed, which are required, by law, to be made for the fiscal year, beginning
on July 1st, and ending on June 30th following.

The following works have been received: —

Medical and Statistical Returns of the Baltic and Black Sea Fleets during
the years 1854 and 1855. Ordered by the House of Commons, February, 1857.
(From the Admiralty.)

Disorders of the Blood. By Julius Vogel, M. D., Prof, of Clinical Medicine
in the University of Giessen. Translated and edited by Chunder Coomar Dey,
Graduate of the Medical College of Bengal. Calcutta, 1856. (From the
Translator.)

Ophthalmic Hospital Reports, and Journal of the Royal Ophthalmic Hospital.
Edited by J. F. Streatfeild. October, 1857. (From the Editor.)

The Medical Profession in Great Britain and Ireland, with an Account of
the Medical Organization of France, Italy, Germany, and America. By Edwin
Lee.M.D. Parts I. and II. London, 1857. (From the Author.)

Human Histology in its Relations to Descriptive Anatomy, Physiology, and
Pathology. With 434 illustrations on wood. By E. R. Peaslee, A. M., M. D.,
&c. &c. Philadelphia: Blanchard & Lea, 1857. (From the -Publishers.)

Lectures on the Diseases of Women. By Charles West, M. D., &c. Part I.
Diseases of the Uterus. Philadelphia: Blanchard & Lea, 1857. (From the
Publishers.)

Medical Lexicon. A Dictionary of Medical Science ; containing a Concise
Explanation of the Various Subjects and Terms of Anatomy, Physiology, Pa-
thology, Hygiene, &c. &c. &c, with French and other Synonymes. By Robley
Dunglison, M. D., &c. &c. &c. Revised and very greatly enlarged. Philadel-
phia: Blanchard & Lea, 1857. (From the Publishers.)

The Principles and Practice of Obstetrics ; Including the Treatment of Chronic
Inflammation of the Uterus, considered as a Frequent Cause of Abortion. By
Henry Miller, M. D., Prof, of Obstetric Medicine in Med. Depart. Univ. of
Louisville. With illustrations on wood. Philadelphia : Blanchard & Lea, 1858.
(From the Publishers.)

Materia Medica and Therapeutics ; with Ample Illustrations of Practice in
all the Departments of Medical Science, with very copious Notes of Toxicology,
&c. A new edition, revised and enlarged. By Thos. D. Mitchell, M. D.,
Professor of Materia Medica in Jefferson Medical College. Philadelphia: J. B.
Lippincott & Co., 1857. (From the Publishers.)

A Collection of Remarkable Cases in Surgery. By Paul F. Eve, M. D.,
Professor of Surgery in the University of Nashville. Philadelphia: J. B. Lip-
pincott & Co., 1857. (From the Publishers.)

4

TO READERS AND CORRESPONDENTS.

A Practical Treatise on the Diseases of Children. By J. Forsyth Meigs,
M. D., &o. Third edition, carefully revised. Philadelphia: Lindsay & Blakis-
ton, 1858. (From the Publishers.)

Report of an Operation for Removing a Foreign Body from Beneath the
Heart. By E. S. Cooper, M. D. Published by the San Francisco Medico-Chi-
rurgical Association. San Francisco, 1857.

Researches on Epilepsy : its Artificial Production in Animals, and its Etio-
logy, Nature, and Treatment in Man. By B. E. Brown-Sequard, M. D., &c.
Boston, 1857. (From the Author.)

Puerperal Fever: its Causes and Modes of Propagation. By Jos. M. Smith,
M. D., &c. Read before the New York Academy of Medicine, 4th April, 1857.
New York, 1857. (From the Author.)

Reports of Cases in the Surgical Practice of the Brooklyn City Hospital.
By Robt. 0. Butler, M. D. (From Dr. Jos. C. Hutchinson.)

Report on Infant Mortality in Lnrge Cities: the Sources of its Increase and
Means of its Diminution. By D. M. Reese, M. D.

Transactions of the American Medical Association. Instituted 1847. Vol.
X. Philadelphia, 1857.

The Transactions of the New Hampshire Medical Society (Sixty-seventh
Anniversary), held at Concord, June 2 and 3, 1857. Concord, 1857.

Transactions of the Medical Society of South Central New York, at the Tenth
and Eleventh Annual Meetings, held at Binghampton, June 3, 1856, and at
Owego, June 2, 1857. Binghampton, 1857. (From Dr. J. G. Orton.)

Transactions of the Second Session of the Medical Society of the State of
California, convened at Sacramento, Feb. 11, 1857. Sacramento, 1857.

Prize Essay. Rational Therapeutics ; or, the Comparative Value of Different
Curative Means, and the Principles of their Application. " Natura duce."
By Worthington Hooker, M. D. Boston, 1857. (From the Author.)

An Essay on the Preservation of Health. By Goodvvyn Nixon, M. D.,
Lowndes, Ala. Hayneville, Ala., 1857.

An Address on the Life and Character of Robert M. Porter, M. D., late Pro-
fessor of Anatomy in the University of Nashville. By J. Berrien Lindsley,
M. D., Chancellor of the University. Nashville, Tenn., 1856.

First Annual Report of the Superintendent of Health of the City of Provi-
dence; ending July 1, 1857. Providence, 1857.

Fourth Report to the General Assembly of Rhode Island, relating to the
Registry and Returns of Births, Marriages, and Deaths in the State, for the
year ending Dec. 31, 1856. Prepared under the direction of John R. Bartlett,
Secretary of State, Providence, 1857.

Experimental Researches Relative to the Nutritive Value and Physiological
Effects of Albumen, Starch, and Gum, when Singly and Exclusively Used as
Food. Being one of the Prize Essays of the American Medical Association
for 1857. By Wm. A. Hammond, M."D., Assistant Surgeon U. S. A. Philadel-
phia, 1857.

Urethro-Vaginal and Vesico- Vaginal Fistules." By N. Bozeman, M. D., of
Montgomery, Ala. Montgomery, 1857. (From the Author.)

Annual Report to the Legislature of South Carolina Relating to the Regis-
tration of Births, Deaths, and Marriages, for the year ending Dec. 31, 1856.
Columbia, S. C, 1857.

A Public Lecture on Medical Ethics, and the Mutual Relations of Patient
and Physician. Delivered by appointment of the Memphis Medical Society.
By A. P. Merrill, M. D. Memphis, 1857. (From the Author.)

Introductory Lecture delivered by D. Warren Brickell, M. D., Professor of
Obstetrics in New Orleans School of Medicine, Nov. 3, 1857. New Orleans,
1857.

Pneumonia; its Pathology and Treatment. By E. Read, M. D., of Terre
Haute, Ind. Nashville, 1857.

A Case of Fibrous Tumour of the Uterus, Accompanied with Excessive He-
morrhage, Successfully Treated by Excision. By B. F. Baker, M. D.

The Rights of Authors. By M. Paine, M. D.

TO READERS AND CORRESPONDENTS.

5

The following Journals have been received in exchange: —

Le Moniteur des Hopitaux Revue Medico-Chirurgicale de Paris. Redacteur
en Chef M. H. De-Castelneau. September, October, November, 1857.

Gazette Medicale de Paris. Nos. 34, 35, 36, 38, 39, 1857.

Revue de Therapeutique Medico-Chirurgicale. Par A. Martin Lauzer, M. D.
Sept., 1857.

Journal de Medecine de Bordeaux. Redacteur en Chef, M. Costes. March,
April, July, August, September, October, 1857.

Eco Cientifico de Venezuela, Nicholas Milanohigo, Editor. April, May,
June, July, August, September, October, 1857.

La Espagiia Medica. Official de la Academia Quirurgica Cesaraugustana.
Nos. 31, 36, 68, 69, 71.

The Medical Times and Gazette. October, November, December, 1857.

Edinburgh Medical Journal. September, October, December, 1857.

British Medical Journal. Edited by Andrew Winter, M. D. September,
October, November, 1857.

The Dublin Hospital Gazette. August, October, November, 1857.

The British and Foreign Medico-Chirurgical Review. October, 1857.

The Journal of Psychological Medicine and Mental Pathology. Edited by
Forbes Winslow, M. D., D. C. L. October, 1857.

Guy's Hospital Reports. Edited by Sam'l Wilks, M. D , and Alfred Poland.
Third Series, Vol. III.

The Glasgow Medical Journal. October, 1857.

The Sanitary Review and Journal of Public Health. Edited by Benjamin
W. Richardson, M. D. October, 1857.

Dublin Medical Press. Nov. 4, 1857. [This is the only No. of this valued
Journal we have received for several months.]

Archives of Medicine. Edited by Lionel S. Beale, M. B., F. R. S. No. 1.

The Medical Chronicle. Edited by Wm. Wright, M. D., and D. C. McCal-
lum, M. D. October, November, December, 1857.

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. October,
November, December, 1857.

Southern Medical and Surgical Journal. Edited by Henry F. Campbell,
M. D. and Robert Camfbell, M. D. October, November, December, 1857.

The American Journal of Insanity. Edited by the Medical Officers of the
New York State Lunatic Asylum. October, 1857.

The New Orleans Medical and Surgical Journal. Edited by Bennet Dow-
ler, M. D. November, 1857.

Charleston Medical Journal and Review. Edited by C. Happoldt, M. D.
November, 1857.

The North American Medico-Chirurgical Review. Edited by S. D. Gross,
M.D., and T. G. Richardson, M. D. November, 1857.

The New Orleans Medical News and Hospital Gazette. Edited by D. W.
Brickell, M. D., and E. D. Fenner, M. D. November, December, 1857.

The New York Journal of Medicine. Edited by Stephen Smith, M. D.
November, 1857.

Buffalo Medical Journal. Edited by Sandford B. Hunt, M.D., and Austin
Flint, Jr., M. D. November, December, 1857.

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling,
M. D., assisted by PaulF. Eve, M. D. September, November, December, 1857.

'The American Journal of Dental Science. Edited by Chapin A. Harris,
M. D., D. D. S., and A. Snowden Piggot, M. D. October, 1857.

The American Medical Gazette. Edited by D. Meredith Reese, M. D. Octo-
ber, December, 1857.

The Western Lancet. Edited by George C. Blackman, M. D. September,
October, November, 1857.

The Cincinnati Medical Observer. Edited by Drs. G. Mendenhall, J. A.
Murphy, and E. A; Stevens. October, November, December, 1857.

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. Octo-
ber, November, Dece'mber, 1857.

6

TO READERS AND CORRESPONDENTS.

The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard,
M. D. October, November, December, 1857.

The Southern Journal of the Medical and Physical Sciences. Edited by R.
0. Currey, M. D. September, October, November, 1857.

The Peninsular Journal of Medicine. Edited by Drs. Pitcher, Palmer,
Brodie, and Christian. October, November, December, 1857.

The St. Louis Medical and Surgical Journal. Edited by M. L. Linton,
M. D., and Wm. M. McPheeters, M. D. September, November, 1857.

The Medical Independent. Edited by M. Gunn, M. D., and L. G. Robinson,
M. D. October, November, 1857.

Atlanta Medical and Surgical Journal. Edited by Jos. P. Logan, M. D.; and
W. F. Westmorland, M. D. October, November, December, 1857.

The North Western Medical and Surgical Journal. Edited by N. S. Davis,
M. D. October, November, 1857.

American Journal of Pharmacy. Edited by Wm. Procter, Jr. November,
1857.

The American Journal of Science and the Arts. Edited by Professors B.
Silliman, B. Sillim an, Jr., and James D. Dana. November, 1857.

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D.
November, 1857.

The American Druggists' Circular and Chemical Gazette. October, Novem-
ber, December, 1857.

The American Medical Monthly. Edited by E. H. Parker, M. D., and J.
H. Douglas, M. D. December, 1857.

Memphis Medical Recorder. Edited by Daniel F. Wright, M. D. July,
September, November, 1857.

Communications intended for publication, and Books for Review, should be sent, free
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Me-
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar-
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us
safely and without delay. We particularly request the attention of our foreign corre-
spondents to the above, as we are often subjected to unnecessary expense for postage
and carriage.

Private communications to the Editor, may be addressed to his residence, 1525
Locust St.

All remittances of money, and letters on the business of the Journal, should be
addressed exclusively to the publishers, Messrs. Blanchard & Lea.

|g*gf The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

To secure insertion, all advertisements should be received by the 20th of the pre-
vious month.

CONTENTS

OF THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.
NO. LXIX. NEW SERIES.
JANUARY, 1858.

ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.

ART. PAGE

I. Observations on the Causes, Effects, and Treatment of Perforation of the
Membrana Tympani. By Edward II. Clarke, M. D., Professor of Ma-
teria Medica in Massachusetts Medical College. ----- 13

II. Clinical Report on Pulmonary Tuberculosis ; giving an abridged ac-
count of Twenty-four Cases of Arrested Tuberculosis, with Remarks on
the Management of the Disease. By Austin Flint, M. D., Professor of
Clinical Medicine and Medical Pathology in the University of Buffalo,

N.Y. o

III. The Vital Statistics of War, as shown by the Official Returns of the
British Army During the War with Russia, and by those of the United
States Army During the War with Mexico. By Assistant Surgeon
Richard II. Coolidge, U. S. Army. 8G

IV. Experiments with Bibron's Antidote to the Poison of the Rattlesnake.

By William A. Hammond, M. D., Assist. Surg. U. S. Army. - - 94

V. National Hotel Endemic. Autopsy ; Remarks. By Jas. J. Waring,
M. D., Professor of Physiology in the National Medical College, Wash-
ington, D. C. - - - - 97

VI. Adhesive Plaster the best Counter-extending Means in Fractures of
the Thigh. By D. Gilbert, M. D., Professor of Midwifery in the Medical
Department of Pennsylvania College. 105

VII. Case of Osteoid Growth connected with the Capsular Ligament of
the Right Hip-Joint. By A. F. Sawyer, M. D., one of the Surgeons of
the " Hospital of the Sisters of Mercy," San Francisco, Gal. (With three
wood-cuts.) 109

VIII. Cupping the Interior of the Uterus. By Horatio R. Storer, M. D.
(Read before the Boston Society for Med. Observation, Oct. 19, 1857.) 117

IX. Rupture of the Trachea, from a fall. Communicated by John L.
Atlee, Jr., M. D., of Lancaster, Pa. 120

X. Case of Fallopian Pregnancy resulting in Rupture of the Cyst and
terminating in Death. Reported by Robert P. Harris, M. D., Philadel-
phia. [Read before the Philadelphia Pathological Soc, Nov. 25, 1857.] 123

8

CONTENTS.

ART. PAGE

XI. A new Uterine Elevator. By J. Marion Sims, M. D., Surgeon to the
Woman's Hospital, New York. (With a wood-cut.) - 132

XII. Exsection of the Trunk of the Second Branch of the Fifth Pair of
Nerves, beyond the Ganglion of Meckel, for Severe Neuralgia of the
Face : with Three Cases. By J. M. Carnochan, Professor of Surgery in
the New York Medical College, Surgeon-in-chief to the State Hospital
(New York), &c. 134

XIII. A Singular Case of Catalepsy successfully treated with the Nitrate

of Silver. By Wm. K. King, M. D., of Louisburg, N. C. - - - 143

REVIEWS.

XIV. Elements of Pathological Anatomy. By Samuel D. Gross, M. D.,
Professor of Surgery in Jefferson Medical College, &c. Third edition,
modified and thoroughly revised. Illustrated by 342 engravings an wood.
Blanchard & Lea: Philad. 1857 8vo. pp. 771. 145

XV. Human Histology, in its Relations to Descriptive Anatomy, Phy-
siology, and Pathology. With 434 illustrations on wood. By E. R.
Peaslee, A. M., M. D., Professor of Physiology and Pathology in the New
York Medical College, of Anatomy in Dartmouth College, and of Surgery
in the Medical School of Maine, &c. &c. Philadelphia : Blanchard &
Lea, 1857. 8vo. pp. 618. ... - 173

XVI. The Principles and Practice of Obstetrics: Including the Treatment
of Chronic Inflammation of the Uterus, considered as a Frequent Cause
of Abortion. By Henry Miller, M. D., Professor of Obstetric Medicine
in the Medical Department of the University of Louisville. With illus-
trations on wood. 8vo. pp. 620. Philadelphia: Blanchard & Lea, 1858. 180

BIBLIOGRAPHICAL NOTICES.

XVII. Transactions of American State Medical Societies.

1. Transactions of the Indiana State Medical Society, at its Eighth An-

nual Session, held in the City of Indianapolis, May 19, 1857. 8vo.
pp. 74.

2. The Transactions of the New Hampshire Medical Society (Sixty-

seventh Anniversary), held at Concord, June 2d and 3d, 1857. 8vo.
pp. 104.

3. Transactions of the South Carolina Medical Association, at the Extra.

Meeting in Sumter, July 9, 1856, and at the Annual Meeting in
Charleston, February 4, 1857. 8vo. pp. 64.

4. Transactions of the Second Session of the Medical Society of Cali-

fornia, convened at Sacramento, February 11, 1857. 8vo. pp. 43. 199

XVIII. Reports of American Institutions for the Insane.

1. Of the Friends' Asylum, Philadelphia, for the fiscal years 1855-6

and 1856-7.

2. Of the U. S. Government Hospital, for the fiscal year 1855-6.

3. Of the Ohio Central State Asylum, for 1856.

4. Of the Ohio Northern State Asylum, for 1856.

5. Of the Ohio Southern State Asylum, for 1856. 213

XIX. American Surgical Tracts.

1. Remarks upon Fractures of the Scapula, with Cases presenting Strik-
ing Peculiarities. Read before the Medical Society of the State of
Georgia, at their Annual Meeting in Augusta, 1857. By L. A. Dugas,
M. D., Professor of Surgery in the Medical College of Georgia. 8vo.
pp.22.

CONTENTS.

9

ART. PAGE

2. Early History of the Operation of Ligature of the Primitive Carotid

Artery, with a Report of Forty-eight Unpublished Cases, and a Sum-
mary of Forty-four Cases, with Remarks by Valentine Mott, M. D.
By James R. Wood, M. D., Surgeon to Bellevue Hospital, President
of the New York Pathological Society, etc. etc. (Reprinted from the
N. Y. Journ. of Med. for July, 1857.) 8vo. pp. 59.

3. An Inaugural Thesis on Intra-Capsular Fractures of the Cervix Fe-

moris. By John G. Johnson, of the State of Massachusetts. (Re-
printed from the New York Journal of Medicine for May, 1857.)
8vo. pp. 32.

4. Surgical Cases, communicated to the Boston Society for Medical Im-

provement, October 27, 1856. By George H. Gay, M. D., one of the
Surgeons of the Massachusetts General Hospital. (Republished
From the Boston Med. and Surg. Journ., Nov. 1856.) 8vo. pp. 24.

5. Report of an Operation for Removing a Foreign Body from beneath

the Heart. By E. S. Cooper, A. M., M. D. (Published by the San
Francisco Medico-Chirurgical Association, as an additional paper to
its Transactions for the year 1857.) San Francisco, 1857. 8vo.
pp.8. - - - i", ^- - ' - - -'£22

XX. A Collection of Remarkable Cases in Surgery. By Paul F. Eve, M. D.,
Professor of Surgery in the Medical Department of the University of
Nashville. Including a copious index. Philadelphia: J. B. Lippincott

& Co., 1857. 8vo. pp. 858. - - - - - - - - - 230

XXI. Medical Lexicon — A Dictionary of Medical Science, containing a
Concise Explanation of the Various Subjects and Terms of Anatomy,
Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Phar-
macy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, etc.; No-
tices of Climate, and of Mineral Waters ; Formulas for Officinal, Empi-
rical, and Dietetic Preparations, etc., with French and other Synonymes.
By Robley Dunglison, M. D., LL. D., Professor of the Institutes of Medi-
cine, etc., in the Jefferson Medical College of Philadelphia. Revised
and very greatly enlarged. 8vo. pp. 992. Philadelphia, 1857: Blan-
chard & Lea. 232

XXII. On the Nature and Treatment of Club-foot and Analogous Distor-
tions, involving the Tibio-tarsal Articulation. By Bernard E. Brodhurst,
Assistant Surgeon to the Royal Orthopaedic Hospital, etc. etc; London:
Churchill, 1856. 8vo, pp. 134. 233

XXIII. Pathological and Surgical Observations: Including a short Course
of Lectures delivered at the Lock Hospital, and an Essay on the Surgical
Treatment of Hemorrhoidal Tumours. By Henry Lee, F. R. C. S., Sur-
geon to the Lock Hospital, Assistant Surgeon to King's College Hospital,
etc. London: Churchill, 1854. 8vo. pp. 232. 234

XXIV. The Practice of Surgery. By James Miller, F. R. S. E., F. R. C.
S. E., Professor of Surgery in the University of Edinburgh, etc. etc.
Revised by the American Editor. Fourth American from the last Edin-
burgh edition. Illustrated by 364 engravings on wood. Philadelphia:
Bianchard & Lea, 1857. 8vo. pp. 682. 236

10

CONTENTS.

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.

Anatomy and Physiology.

page

1. Researches on the Histology of
the Nervous System. By Prof.
Jacubowitsch. - 237

2. On the Structure of the Nervous
Centres. By Prof. Lenhossek. 239

PAGE

3. On the Nerves of the Intestinal
Walls. By G. Meissner. - -240

4. On the Function of the Thyroid
Body. By Dr. Peter Martyn. - 241

Organic Chemistry.

5. Method of Clinically Determin-
ing the Amount of Sugar in Dia-
betic Urine. By Dr. Garrod. - 242

6. Mode of Detecting Sugar in the
Urine, and on the Different Na-
ture of certain forms of Diabetes.

By Dr. A. Becquerel. - - 243

7. On the Presence of Sugar in the
Urine of Pregnant, Parturient,
and Puerperal "Women. By
Theodore Kirster. - - - 244

8. On the Elimination of Sulphur-
etted Hydrogen by the Lungs.

By M. CI. Bernard. - - - 245

9. Starch from the Animal King-
dom. By Dr. Pavy. - - 246

10. On the Immediate Principles
of Human Excrements in the
Healthy State. By Dr. W. Mar-
cet. 248

Materia Medica and Pharmacy.

11. Permanganate of Potash as a
Caustic, Deodorant, and Stimu-
lant. By Dr. D. F. Girwood. - 249

12. On the Oriental Bath. By Dr.
Haughton. - _ - - - 249

13. On the Preparation of Valeri-
anate of Ammonia of Definite
Composition. - 252

14. Formula for a Liquor Cin-
chonae to replace the Wine of
Bark. By M. Deschamps. - 253

15. Formulae for the Gelatiniza-
tion of Cod-liver Oil. - - 253

16. Caustic Glycerine in Lupus.

By Dr. Hebra. - - - - 253

17. On a Mode of Improving Cow's
Milk and rendering it more easy
of Digestion for Healthy and
Diseased Children. By Dr. Gum-
precht. 254

18. Mode of Preparing the Bran
Loaf for the Use of Diabetic Pa-
tients. By Mr. J. M. Camplin. 254

19. The Chemical Properties of
the Potato, and its uses as a
general article of commerce, if
properly manipulated. By Mr.

J. W. Rogers. - - - - 255

Medical Pathology and Therapeutics, and Practical Medicine.

20. Case of Marshall Hall, with 22. On some of the Prevalent Er-
the Post-mortem Appearances. 255 rors in relation to the Predispo-

21. Haemophilia. By Dr. Magnus eition to Hysteria. By M. Bri-
Huss. 259 quet. 261

CONTENTS.

11

23. Asphyxia of Submersion. By
Mr. A. T. H. Waters. - - 262

24. Asiatic Cholera and its Pre-
vention. By Henry McCormac,

M. D. 263

25. Nature, Causes, Statistics, and
Treatment of Erysipelas. By
Peter Hinckes Bird, F. R. C. S. 264

26. Action of Cod-liver Oil in Chest
Diseases. By Dr. E. Smith. - 264

PAGE

27. Injections of the Bronchi in
Pulmonary Diseases. By Dr. J.

H. Bennett. - - - - 265

28. Treatmentof Phthisical Vomit-
ing by Local Ansesthesia. By
Mr. Atcherley. - ; - - 266

29. Chloroform in Intermittent Fe-
ver. By M. Delioux. - - 266

30. Belladonna in Incontinence of
Urine. By Mr. Pollock. - - 267

Surgical Pathology and Therapeutics, and Operative Surgery.

31. Embolic Apoplexy from De-
tachment of Fibrinous Coagula
in an Aneurism of the Carotid.

By Dr. Fr. Esmarch. - - 267

32. Case of Arterio-Venous Aneu-
rism, which was treated by
Ligature of both the Artery and
the Vein. By Mr. Moore. - 268

33. Revision of the Doctrine of
Dislocation. By Prof. Roeser. 269

34. Luxation of the Os Coccygis.

By Dr. Roeser. - - - 270

35. On the Prevention of the Ill-
consequences of Operations. By
Prof. Deroubaix. - 271

36. Amputation of the Knee-joint,
leaving the Articular Surface
entire. By Mr. Lane. - - 272

37. Results of the Operation of
Tracheotomy performed for
Croup at the Children's Hospi-
tal, Paris, during the year 1856.

By M. Andre. - - - - 272

38. Treatment of Hemorrhoids.

By Dr. Van Holsbeek. - - 273

39. The present State of Surgical
Science in reference to Cancer
and its Treatment. ByxMr.Hird. 273

40. Escharotic Treatment of Can-
cer. By Prof. James Syme. - 274

41. Epithelial Cancer. By Mr.
Henry Thompson. - 276

42. Foreign Bodies introduced into

the Bladder. By M. Denuce. - 277

Ophthalmology.

43. Spasms of the Eye after Ex-
traction of Cataract. By Mr.
White Cooper. - 279

44. Diphtheritic Ophthalmia. By

M. Gilbert. - - - - 280

45. Two Cases of Strabismus and
very Imperfect Vision — Opera-
tion and Cure. By Mr.Critchett. 281

Midwifery.

46. Quadruplet Births. By Mr.
French. 282

47. A New Symptom of Rupture
of the Uterus. By Dr. McClin-
tock. 283

48. Two Cases of Hernia of the
Ovaries, in one of which there
was Periodical Enlargement of
one or other of these Organs.
By Henry Oldham. - - - 284

Medical J urisprudence and Toxicology.

49. Suicide and Intoxication by I of Laudanum ; Recovery. By
Chloroform. By M. Chereau. - 286 I Dr. G. C. Gibb. - - - 288

50. Death from Chloroform. By 1 52. Acute Poisoning by Phos-
Mr. C. Heath. - - - - 288 I phorus. By Dr. Th. Nitsche. - 288

51. Poisoning by Twelve Drachms

12

CONTENTS.

AMERICAN INTELLIGENCE.
Original Communications.

Encephaloid Tumour weighing ten
pounds, involving the Right Kid-
ney of a Boy four years old. By
M. Shepherd, M. D. - - - 291

Case of Compound Fracture of the
Skull, with Laceration and Loss
of a Portion of Brain, and Com-

pression ; Recovery. By D. J.

McRae, M. D. -
Confection of Cinchona as an Anti

periodic. By D. S. Gloninger

M.D. -
Case of Monstrosity. By John II

Hunter, M. D. -

PAGE

- 293

- 29^

:94

Domestic Summary.

Fracture of the Neck of the Fe-
mur ; Bony Union. By Dr. Gay.

Disarticulation and Removal of
nearly the Lateral Half of the
Lower Jaw. By Dr. C. E. Isaacs.

Simultaneous Dislocation of both
Shoulder-Joints. By Dr. Wm.
II. Van Buren. -

Anomalous Situation of the Left
Kidney. Dr. C. E. Isaacs.

294

295

295

Gun-shot "Wound of Bladder : Re-

295

covery. By Dr. R. II. Grinstead.
Chlorate of Potash in Stomatitis

Materna. By Dr. L. Faulkner. 296
Iodide of Potassium in Leucor-

rhoea. By Dr. Jos. B. Payne.
Application to Sore Nipples.
Statistical Table, exhibiting the
Mean Height of American Re-
295 I cruits. By Dr. Thos. Lawson.
I Ovariotomy. By Dr. Gay. -

296
296

296
296

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR JANUARY 1 8 58.

Art. I. — Observations on the Causes, Effects, and Treatment of Perforation
of the Membrana Tympani. By Edward H. Clarke, M. D., Professor
of Materia Medica in Massachusetts Medical College.

The following paper is founded on fifty-two carefully recorded observations
of disease of the ear, accompanied with perforation of the membrana tympani.
My object in bringing these observations together, and comparing them with
each other, is to investigate the causes, course, effects and treatment of per-
foration of the membrana tympani; or, to investigate diseases of the ear
from the point of view of perforation of the membrane.

It is my hope that the result of this investigation will not be altogether
devoid of interest for general practitioners. For, we shall find by an analysis
of the subjoined cases, that the diseases which are most likely to produce
perforation of the membrana tympani come almost altogether under their
observation ; and, moreover, that the most successful treatment of perforation,
viz., the prophylactic, can be conducted by such practitioners as well as by
specialists.

The following observations were made on private patients, and were re-
corded either immediately after the examination, or at the time of it. They
were made in a clear sunlight, and by the aid of Meniere's speculum auris,
or of the tubular speculum of Mr. Toynbee. The existence of perforation
was demonstrated, in a majority of the cases, by the patient's blowing air,
with a whistling rale, through the hole and out of the external meatus; or,
when this could not be accomplished, by the use of the Eustachian catheter,
or an examination of the perforation with a probe.
No. LXIX.— Jan. 1858. 2

14 Clarke, Perforation of the Membrana Tympani. [Jan.

M. E. Triquet, in a late memoir/ has well observed that " the affections of
the auditory apparatus are not so isolated as to be altogether unlike other
lesions of the organism." This remark is true of the particular lesion which
I propose to examine at the present time. For perforation is not so much a
disease in itself as the result of disease. And moreover, the diseases which
are the antecedents or causes of this lesion affect, for the most part, the whole
organism primarily; the auditory apparatus only secondarily.

Mr. Wilde, in his excellent work on Diseases of the Ear, closes an elaborate
discussion of affections of the membrana tympani with the following remark:
" M oreover, from the circumstance of the membrana tympani being the part
most easily examined, being that most frequently affected, and consequently
affording the safest means for diagnosis either for deafness arising from affec-
tions peculiar to itself, and confined to its own structure, or which it exhibits,
in common with other and deeper seated structures similarly diseased, it fre-
quently affords us not only the surest but the only faithful indication for
forming an accurate diagnosis."3 This statement is both an inducement and
a reason for general practitioners to study the affections of the membrana
tympani. Of these affections, and arising from various causes, perforation is
one of the most easily ascertained, one of frequent occurrence, and of disas-
trous consequences to the hearing.

Before examining the phenomena of perforation, it may be well to allude
to the appearance, position, structure, and importance of the membrana
tympani. It stretches across the inner extremity of the external meatus,
separating the latter from the cavity of the tympanum. It is a delicate,
translucent, opaline, or nearly colourless membrane. Occasionally it has a
grayish tint, but more generally it presents a clear and brilliant hue. Its
surface is irregularly curved and divided into two portions by the handle of
the malleus. It sometimes happens that a ray of sunlight, striking upon
some of these irregularities, gives the appearance of a perforation when none
exists. Hence some caution must be exercised in deciding upon the existence
of a perforation at first sight. What appears to be a hole may be only the
reflection of a ray of light.

In the healthy state no bloodvessels can be seen in the membrane. Anato-
mists, however, tell us that they are easily made visible by a fine injection.
They are often greatly enlarged by disease, and then give to the membrana
tympani a bright red appearance. When a perforation heals, a circle of red
vessels can often be seen around the circumference of the hole. I have fre-
quently verified the remark of Mr. Wilde that, " when the membrana tym-
pani has been perforated, a globule of air or a mucous bubble, entangled in

1 RechercL.es Pratiques pour servir a l'Histoire des Maladies de 1'Oreille, par M.
E. Triquet.

2 Wilde's Aural Surgery, p. 310, Lond. ed. [p. 298, American edition. PMla.,
1853.]

1858.] Clarke, Perforation of the Memhrana Tympani.

15

the aperture, pulsates synchronously with the heart and arteries."1 This
pulsation is produced by the beating of the tympanal vessels.

It is important for us to remember that the membrana tympani is not an
essential part of the auditory apparatus. A perforation through it interferes
with its function and impairs the hearing, but does not necessarily destroy
the latter. If the membrane is perforated, but not otherwise diseased, and
the other parts of the ear are uninjured, the hearing power may be only
slightly diminished. I have met with persons, carrying an aperture in
the membrana tympani of the size of half a pea, who could hear ordinary
conversation with ease. But this is not usually the case. A perforation is
generally the result of disease, which has seriously affected other tissues of
the ear besides the tympanal membrane, and by which the hearing is much
diminished. In some instances the diminished hearing amounts to complete
cophosis. In nearly all cases, the degree of deafness is such as to render
perforation a most unfortunate termination of disease of the ear. The mem-
brana tympani not only contributes to delicacy of hearing, but it serves to
protect the cavity of the tympanum. Whenever it is perforated, the cavity
below is exposed to changes of temperature, moisture, and other deleterious
influences, and hence is much more likely to become diseased. Otorrhoea is
often kept up simply by the existence of a perforation.

Let us now proceed to an examination of the cases themselves. The ac-
companying table, which is drawn up from my notes, presents an abstract of
all the cases of which I have an exact record. Some of them will be referred
to more in detail hereafter.

1 Wilde's Aural Surgery, London edition, p. 218 [p. 216, American edition. Phila.,
1853.]

16

Clarke, Perforation of the Membrana Tympani. [Jan.

Tabular View of Perforations

6

Sex. |

6
SD
<

1

M.

50

2

M.

3

3

M.

10

4

F.

6

5
6

P.
M.

32
9

7

M.

16

8

M.

10

9

F.

23

10

M.

11

F.

10

12

F.

45

13

M.

12

14

F.

18

15

M.

5

i'i

M.

17

F.

5

1 s

F.

12

19

M.

l2o

F.

21

M.

32

22

F.

14

23

F.

10

24

F.

25

F.

8

26

M.

24

® si

Good
Good

Good

Good
Good
Good

Good

Deli-
cate

Good

Ave-
rage

Ave-
rage

Good
Good

Good

Deli-
cate

Deli-
cate
Good

Good
Good

Deli-
cate

Good

Good

Good
Good

Good

(i(K)ll

Normal
Normal

Normal

Normal
Normal
Normal

Throat healthy ;

tonsils slightly

enlarged
Tonsils enlarg'd;

throat healthy

Ignorant

Tonsils natural;
fauces red and
granulated -

Tonsils enlarg'd;
throat red and
granulated

Normal

Tonsils enlarg'd;
throat congest-
ed

Normal

Throat congest-
ed; tonsils en-
larged

Throat healthy;
tonsils enlarg'd
Normal

Normal

Throat healthy;
tonsils enlarg'd

Throat red ; ton-
sils enlarged

Throat red ; ton-
sils ignorant

Throat red and
congested ; ton-
sils enlarged

Ignorant

Tonsils enlarg'd;

throat red and

congested
Tonsils enlarg'd;

throat red and

congested
Normal

Healthy

Enlarg-
ed

Ig-

Ig-

Ig-
Ig-

Normal

Enlarg-
ed

Ig.

Diseas-
ed; sup-
pura-
tion

Swollen

Healthy
Normal

Normal

Normal

Normal
Normal

Normal

Enlarg-
ed

Enlarg-
ed

Ig.

Normal

Enlarg-
ed

Normal

523

White, with de-
ficient wax

Secreting mode-
rately

White and hard
Healthy

White, hard, and
dry

White and no
wax

White, hard, and
dry

Right, white and
dry ; left, red
and swollen

Lined
crusts :

with
no wax

R., white, dry,
hard ; L. red
and secreting

Both white and
hard

White and dry

Red near mem.

tym. ; sufficient

wax ; white

elsewhere
Right, white and

ho wax ; left

healthy
White, smooth ;

no wax

White ; no wax

White ; deficient
wax

White; deficient
wax

White ; no wax

A little red ; no
wax

Reddened ; no
wax

Red and no wax

Red ; no wax
Red and swollen

Red and swollen

White, and suffi-
cient wax

Ignorant

Red and
congested

A suppu-
rating sur-
face

Red and
congested
Ignorant

Red

Red and
moist

Ignorant

Ignorant

R., of a pale
pink; L..
secreting

Red, swol-
len and se-
creting

Ignorant

Red and
congested

R., secret-
ing; L.,dry

Red ; con-
gested ; se-
creting

Red

Red and
congested

Pink and
clean

Red ; con-
gested

Pink and
smooth

Red and
congested

Congested

R., ig. ; L...

secreting
Red

Red; granu-
lated ; se-
ci-eting

Ignorant

None
None

Fungus

None
None
None

Polypus

None

Polypus
in left
meatus

Fungus

None

None
None

None

None

None
None

None
Fungus

None

None

Fungus

Polypus
None

None

None

l&sl

None

Copious, viscid, and
offensive ; muco-
purulent

Copious ; thick ; of-
fensive

Slight ; fetid ; waxy
None

Slight, and of a mu-
cous character

Moderate; muco-pu-
rulent ; curdy

Right ear none ; left
ear purulent;
bloody ; offensive

Right ear none; left
ear slight

Right ear none ; left
ear muco-purulent

Copious and offen-
sive, and thick

Copious ; offensive :
muco-purulent.

Moderate and offen-
sive in right ear ;
none in left

Copious ; thick ; of-
fensive

Slight ; thin ; mucous

Copious ; offensive ;
thick

Slight ; mucous

Copious; fetid; yel-
lowish

Moderate ; mucous
Moderate ; offensive

Copious ; purulent ;
thick; bloody

Copious ; offensive ;

cheesy
Moderate ; offensive ;

mucous

Moderate ; white ; of-
fensive

1858.] Clarke, Perforation of the Memhrana Ti/mpani.

of the Memhrana Tympani.

17

I Left
'Both

Both

Both.
Left
Both

Both

Both

Both
Both

Both

Eight
Both

Eight

Both
Both

Both
Both

Left

Both

Both

Left
Left

Left

Left

Size of a pea

Size of half a
pea

Memhrana de-
stroyed

Size of end of
probe
Size of pea

% of nienib.
tvm. destroy-
ed

Size of a pea

Eight, end of
probe ; left,
mem. tym.
half destroy' d

Both size of a
pea

Eight, size of a
pea ; left, ig.

E., mem. tym.
% destroyed ;
L., size of half
a pea

Size of end of
probe

Half of mem.
tvm. destroy-
ed

Eight, end of
probe ; left,
half a pea

Nearly whole
of mem. tym
destroyed.

Size of half a
pea

Eight, size of
a pin's-head ;
L., half pea

ignorant
Scarlatina

Scarlatina

Scarlatina

Ignorant

Scarlatina

Scarlatina

Ignorant 30 yrs.
Ignorant 5 mos

Whole of
m. tym.

Ignorant

Ignorant

Ignorant

Central

Ignorant
Otorrhcea

Pneumonia E., below
malleus;
L., cen-
tral
Central

Typhus fe- E, , up-
ver per; L.,

ignorant

E., size of pea,

L., half a pea
Nearly all of Scarlatina

mem. tym.

destroyed
Nearly all of Ignorant

mem. tym.

destroyed
E., size of half Scarlatina

pea ; L., pea

Scarlatina

Ignorant
Scarlatina

Scarlatina

Scarlatina

Ignorant
Scarlatina

Scarlatina

Both size of
a pea

Size of half pea
Size of half pea

Ignorant

Ignorant

Scarlatina

Scarlatina
Teething

Ignorant

Pneumonia

Central

Central
Inferior

Central
Central

Superior

Eight, in
centre ;
left, in-
ferior

Central

Central
Central

E., infe-
rior ; L.,
central

Central

Central
Central

Ignorant

Ignorant

5 yrs.

8 mos.

16 yrs.

6 yrs.

10 yrs.

7 yrs.

17 yrs.

18 yrs.

4 yrs.

6 yrs.
6 yrs.

12 yrs.

IS mos.

3 yrs.
2 yrs.

2 yrs.
3| yrs.

3 yrs.
15 yrs.

11 yrs.

5 yrs.
i yrs.

7| yrs.

3 yrs.

None

Not healed
Not healed

Syringe ; astrin-
gents ; counter-irri
tation

Otorrhcea Astringents ; iron Not healed
and iodine intern-
ally

Otorrhcea Syringe; astringents; [Not healed

counter-irritation
Otorrhcea with None

pain

Otorrhcea

Otorrhcea and
deafness

Otorrhcea and
afterwards
pain

Otorrhcea and
deafness

Deafness; after
many years
otorrhcea

Otorrhcea

Deafness

Otorrhcea and
deafness

Otorrhcea

None

Syringe and astrin-
gents

Astringents; syringe;
iron and iodine in-
ternally

Astringents, and ex-
traction of growth

Extraction of fungus;
asiringents

None

None

Syringe; astringents;
attention to general
health

Syringe

Otorrhcea Syringe and astrin
gents

Otorrhcea with ! Syringe ; attention to

otalgia
Otorrhcea

Otorrhcea
Otorrhcea

Otorrhcea

Otorrhcea

Otorrhcea

Otorrhcea
Otorrhcea

Otorrhcea

Otorrhcea
deafness

Not healed
Not healed

Not healed]

Ignorant

Not healed
Not healed

Not healed

Not healed
Not healed

Not healed

Not healed

general health
Syringe ; attention to Not healed
general health

syringe, p. r. n.

Syringe ; caustic ; as-
tringents, &c.

Syringe and astrin-
gents

Syringe, p. r. n. :
counter-irritation

Syringe; astringents:
constitutional

That of polypus

iSyringe; astringents:
I counter-irritafion ;

constitutional
Syringe; astringents;

counter-irritation

and: None

I

Not healed
Not healed

Not healed

Not healed

Not healed

Not healed
Not healed

Not healed

Not healed

18

Clarke, Perforation of the Membrana Tympani. [Jan.

Tabular View of Perforations of

M. 38
18

M
M
51] M.

Deli-
cate
Deli-
cate
Good

Good

Ignorant

Tonsils enlarg' d ;
throat congest' d
Healthy

Normal

Good

Good

Good

Good
Good

Good
Good

Good
Good

Good

Good

Good
Good
Good
Good
Good

Good

Good

Good

Good

Good

Good

Normal

Normal

Normal

Tonsils normal
throat red
Normal

Norm al
Normal

Normal
Normal

Normal
Normal

Tonsils healthy ;
throat congest'd
Ignorant

Fauces red ; ton-
sils normal
Normal

Ignorant

Ignorant

Normal

Throat red and
congested ; ton
sils normal

Normal

Throat congest
ed ; tonsils en
larged

Ignorant

Enlarg-
ed

Normal
Normal

Normal

Normal

Normal

Normal
Normal

Normal
Normal

Normal
Normal

Normal

Normal

Enlarg-
ed
Ig-

Ig-

Normal
Ig-

Ig-

Normal
Normal
Normal

w

Eeddened ; no
wax ; crusts

Eczematous
eruption

White and with
wax

Slightly red

Right, red ; left,
white

Slightly red ; no
wax

White ; no wax

White and hard ;

wax dry
Right, white and

hard ; left, red

White ; wax de-
ficient

Right, red and no
wax; left, white
and wax

Red and no wax

Reddened ; defi-
cient wax

Ignorant
Ignorant
Ignorant
Congested

Ignorant

White and
hard

Congested

White and
dry

R., congest-
ed ; L., do.

Ignorant

R, ig.; L.,
pale

Light red
Ignorant

White and little Congested
wax

Red ; no wax

Ignorant

White; deficient, Ignorant
wax

Swollen, tender, Inflamed
painful

Red and dry ; no Inflamed

wax

White and dry; Ignorant
no wax

Red near mem. Ignorant
tym. ; no wax

Red and tender ; Ignorant
no wax

Ignorant

None
None
None
None

None

None
Fungus

None

Polypus
in right
ear

None

None

None
None

R. none:
L. fun-
gus

None

None

None

None

Polypus

Fungus

Red

Red and no wax

Red and tender
no wax

Red and swol-
len ; no wax

Ignorant

Inflamed

Ignorant

Ignorant

None

None

None

Variable ; offensive ;
bloody

None at time of ex-
amination
None

Moderate ; offensive ;
thick

Slight ; mucous

None

Moderate ; offensive ;
mucous

None

Copious and offen-
sive in left ; mucus
in right

None

Right, muco-puru-
lent and slight ; left,
none

Moderate ; offensive
and thick

Slight ; muco-puru-
lent

Slight ; offensive ;
thick

Slight and bloody

Slight ; mucous
Moderate ; viscid
None

White ; purulent
offensive
Slight ; mucous

Moderate ; viscid

Moderate ; mucous

Ignorant

Moderate ; purulent

Copious ; offensive ;
purulent

Moderate ; muco-pu-
rulent

1858.] Clarke, Perforation of the Membrana Tympani. 19

the Membrana Tympani — Continued.

One or both
ears per-
forated.

Size and
shape of
perfora-
tion.

Following
what.

Position of
perfora-
tion.

How long
existed.

First symp-
toms.

Treatment.

Result.

Both

Ignorant

Ignorant

Central

16 yrs.

Otorrhoea

None

Not healed

Eight

Tgnorant

Eczema

Ignorant

2mos.

Eczema

Syringe ; local sooth-

Not healed

ing applications

Right

Size of half pea

Ignorant

Central

ISmos.

Pain and then

None

Not healed

otorrhoea

Both

~a of memb.

R , cold wa

Central

RHy.

R, pain and

Syringe; counter-ir-

Not healed

tvm. destroy-

ter inj ec-

L. 20 y.

otorrhoea; L.,

ritation; astringents

ed

tion ; L.,

otorrhoea

scarlatina

Both

Ignorant

R., a cold ;

Central

R., 3

R., pain, ten-

Syringe ; leeches ;

Not healed

L., ig.

w'ks ;

derness, and

counter-irritation

L., 45

otorrhoea; L.,

yrs.

ignorant

Left

Memb. tymp.

Ignorant

M. tym.

30 yrs-

Otorrhoea

None

Not healed

entirely de-

absent

stroyed

Left

Memb. tymp.

Scarlatina

Central

16 yrs.

Otorrhoea

Caustic to growth,

Not healed

nearly de-

and astringents

stroyed

Right

Mem. tym. %

Ignorant

Central

8 yrs.

Otorrhoea and

None

Not healed

destroyed

otalgia

Both

Both memb.

Violent sy-

Central

6 yrs.

Pain and then

Polypus extracted ;

Not healed

tymp. nearly

ringing,

otorrhoea

caustic

destroyed

probably

Left

Size of pin's-

Cold

Over

9 mos.

Pain

None

Not healed

head

malleus

Both

Right, oblong,

Measles

R., ante-

9 yrs.

Otorrhoea

None to left ear;

Not healed

1-16 in broad;

rior ; L.,

caustic to right, and

left, half pea

central

syringe

Right

Mem. tym. %

Measles

Central

6 yrs.

Otorrhoea

Astringents ; syringe

Not healed

destroyed

Left

Size of half pea

Ignorant

Inferior

2 yrs.

Otorrhoea

Counter-irritation

Not healed

and constitutional ;

syringe

Both

R., % memb.

Pertussis

Central

7 yrs.

Otorrhoea

Syringe ; caustic to

Not healed

tymp.; L,. %

tungus

memb. tymp.

gone.

Left

Size of end of

Puncture of

Ignorant

lldys.

Pain ; tender-

Syi'inge; astringents;

Healed

probe ; circu-

M. T. by

ness ; bloody

cathartic

lar

accident

discharge

Left

Oblong ; supe-

Ignorant

Superior

2 mos.

Otalgia ; otor-

Syringe

Healed

rior

rhoea

Right

Ig.; small

Cold

Superior

3wks.

Otalgia ; otor-

Leeches; blisters ;

Healed

rhoea

cathartics ; syringe

Left

Ig. ; small

Salt water

Anterior

1 wk.

Otalgia and

Counter-irritation ;

Healed

bathing

tinnitus

cathartics ; diet

Right-

Large

Ignorant

Ignorant

3 yrs.

Otalgia ; otor-

None

Healed

rhoea

Left

Small; an ob-

Ignorant

Ignorant

6 mos.

Otorrhoea and

Syringe ; caustic ;

Healed

lique slit : size

otalgia

constitutional

end of probe

Left

Small ; ig.

Cold

Ignorant

2wks.

Otalgia ; ten-

Blisters; syringe

Healed

derness; otor-
rhoea

Left

Size, end of

Ignorant

Inferior

2\ mos.

Otalgia ; ten-

Leeches ; blisters ;

Healed

probe

nerness; otor-

caustic

rhoea

Right

Ignorant

Scarlatina

Ignorant

8 to 10
yrs.

Otorrhoea

None

Healed

Right

Size of grain of

Cold

Inferior

3wks.

Pain ; tender-

Leeches ; syringe ;

Healed

wheat

ness ; otor-

counter-irritation;

rhoea

diet

Left

Size of end of

Cold and

Inferior

4 dys.

Otalgia; otor-

Syringe ; counter-ir-

Healed

probe

eczema

rhoea

ritation; cathartics

Left

Oblong

Syringing

Superior

6 dys.

Otalgia; swell-

Leeches; cathartics ;

Healed

ing ; tender-

blisters; diet

ness

20 Clarke, Perforation of the Memhr ana Tympani. [Jan.

Of these fifty-two cases, it appears that twenty-eight were males, and
twenty-four females. The preponderance of the former over the latter is not'
large enough to show that one sex is more liable than the other to perforation.
In a large majority of the cases, the general health was reported good : that
is, forty-six considered themselves to be, or their friends reported them to be
in good health. Six are recorded to have delicate health. This statement, of
course, refers to their condition at the time they applied for advice; not to
their condition at the commencement of the disease.

The state of the cervical glands, and of the throat and tonsils, was not so
satisfactory, in these cases, as that of the general health. Thus the cervical
glands are recorded as healthy or normal in 31 cases; as enlarged or other-
wise aifec ted in 9; and in 12 cases their condition was not noticed. Hence
we perceive that in more than one-sixth of the cases the glands of the neck
were diseased. The fauces appear to have been healthy in 30 cases, or more
than one-half; and to have been affected in 15, or nearly one-third. In 7
cases no record of the state of the throat was made. The tonsils were enlarged
in 13 cases, or exactly one-fourth; they were healthy in 31 cases, or more
than one-half. Their condition in the remaining 8 cases was not recorded.
If we neglect the unrecorded instances, we find the condition of the throat to
be stated in 45 cases ; of the tonsils in 44; and of the cervical glands in 40.
In 15 of the 45, the throat was affected, or exactly one-third. In 13 of
the 44, the tonsils were enlarged, or about four-elevenths. In 9 of the 40,
the cervical glands were affected, or about one-fourth. "We cannot infer from
this that enlargement of the cervical glands, or tonsils, or disease of the throat
especially predisposes to disease of the ear, inducing perforation ; but we can
infer that when disease of the ear appears in individuals of a scrofulous dia-
thesis there is greater danger of perforation than in those of a healthier organi-
zation.

Now if we compare diseases of the ear complicated with perforation of the
membrana tympani with all aural diseases, we shall obtain the following result,
at least so far as my own observations go. I have records of 298 cases of
disease of the ear. In 52 of these cases (which serve as a basis for the present
paper), one or both membrana tympani are perforated. There are a large
number of other cases which have come under my observation, and of which
there is no record. But as I have made no selection of cases to record, it is
not probable that the proportion of those with perforation to the total number
would be materially changed by adding the unrecorded ones. Comparatively,
as many of one kind were not recorded as of another. The above figures
(52 and 298) show that 0.17, or nearly \ of all diseases of the ear, produce
perforation of the external membrane.

Before examining the condition of the external meatus and the cavity of
the tympanum, let us ascertain the number of perforations in the above
mentioned 52 cases. It appears from the table, that the right membrana
tympani was perforated alone, 10 times; the left, alone, 19 times; and both

1858.] Clarke, Perforation of the Membrana Tympani.

21

membranes were perforated 23 times. Adding 23 to the right and left single
perforations, we find that the right membrane was perforated 33 times, and
the left, 42 times.' This makes an aggregate of 75 perforations (in the 52
cases). Hence, it would seem that the left ear is somewhat more likely to
suffer from perforation than the right. As the total number of single per-
forations is 29, and of double ones 23, it appears that in aural affections, in-
ducing perforation, there is great danger to both ears.

Let us next look at the condition of the external meatus. It appears from
the table, that the meatus presented a healthy appearance with an average
amount of wax only in 6 instances (out of the 75). In 6 cases, the walls of
the meatus were red and swollen. In 31 cases, they were more or less red,
without swelling. And in 32 cases, they where white and hard, without any
cerumen or with a deficiency of it. In this statement of the condition of the
walls of the meatus, no regard is paid to the presence or absence of otorrhoea.
Polypus or fungous growths existed in 12 instances. In the remaining 63
cases, there were no such growths. Otorrhoea was present in 60 out of the 75
perforations, or in exactly four-fifths of them. In 14, it did not exist; and
in one instance no record was made with regard to any discharge from the
ear.

It is an important remark that (in many instances) the above mentioned
abnormal condition of the meatus, the existence of otorrhoea, and probably
also of foreign growths, were consequences indirectly of perforation. For,
when the tissues of the membrana tympani have been eaten through by ulcera-
tion, the hole is apt to continue, after the cause which led to it has ceased to
operate. The destruction of even a small portion of the membrane exposes
the cavity within, of which it forms the natural protection, to the direct in-
fluence of atmospheric changes, such as cold, moisture, etc. The effect of such
exposure is to keep up a muco-purulent discharge from the mucous membrane
of the cavity. The walls of the meatus are bathed and irritated by the otorrhoea.
They become red, and swollen, and tender; or hard, cartilaginous, and in-
sensible. The secretion of wax is interfered with or destroyed. If the otor-
rhoea is copious and neglected, polypus or fungus is often engendered from the
sides of the meatus or the cavity of the tympanum. Unfortunately, these
consequences of perforation sometimes become additional causes of disease,
and the lesions which they lead to may assume the gravest character, and
implicate life itself. Under the best conditions, an individual with perforation
will have imperfect hearing. But these observations go to show that the
chance of escaping, after an aperture into the drum of the ear has been estab-
lished by disease, with imperfection of hearing and without other lesions, is
very slight. In only 6 cases out of the 15 was the external ear healthy — a
proportion of less than one-twelfth.

The condition of the cavity of the tympanum was not recorded in these
cases so carefully as that of the meatus. In 27 cases, the appearance of the
mucous membrane is not stated. In 2 it presented a rough and white sur-

22 Clarke, Perforation of the Membrana Tympani. [Jan.

face, not unlike a dense white membrane. In 14 it was pale red, and more
or less moist. In 32, it was inflamed, considerably congested, and of a bright
red colour. The state of the cavity leading to the white appearance just re-
ferred to, does not often exist. In this series of cases, it occurred only twice.
When it does occur, I am inclined to regard it as the most favourable termi-
nation of any aural affection complicated with perforation, except the closing
of the aperture, and the consequent restoration of the membrane to a normal
state. In these two cases, there was no otorrhoea. The walls of the meatus
were free from redness or tenderness, though there was a deficiency of ceru-
men. In one of these instances, the hearing was almost entirely destroyed;
in the other it was only moderately impaired. The patients, on the whole,
were in a much more comfortable condition than generally falls to the lot of
those suffering from perforation. Where neither this result is attained, nor
the aperture healed, the next best termination is that represented by the 14
cases, in which the mucous membrane of the cavity was of a pale red colour
and somewhat moist. In such eases, there is no congestion of the cavity.
There is usually no discharge ; and when there is any, it is of a mucous
character. The patient is occasionally troubled with otorrhoea, particularly
on taking cold, but the discharge is of short duration. Excepting a greater
or less degree of imperfection of hearing, he is not much annoyed by the con-
dition of his ears. The last group of 32 cases represents the state of the
cavity which is most apt to exist with perforation. The mucous membrane
in these cases was red and congested. Occasionally it was pushed through
the aperture like a fungus, and not unfrequently it poured out a copious and
disagreeable purulent secretion.

The size of the aperture is the next point of inquiry. In 12 cases, the
table contains no record of the size. In 4 cases, the hole was only an oblong
slit. In 38 cases its size varied from that of a pin's head to that of a pea.
In 21 cases, the membrana tympani was one-half destroyed, or wholly
destroyed. With a single exception all the apertures that healed were small,
being only about the size of the end of a probe. One large one only closed up.

The table contains no reference to the condition of the hearing in the cases
under consideration. By examining my notes, however, the following result
is obtained : Assuming the ticking of my watch as the measure of the hearing
distance, it appears that in 6 cases my watch was not heard at all. In 11
cases, it was heard only on the pavilion of the ear. In 23 cases, it was heard
from the pavilion to a distance of six inches. In 16 cases, the hearing dis-
tance varied from six inches to one foot; in 15 cases, from one to two feet;
and in 4 cases, from two to four feet. Where the membrane was perforated
on both sides, the hearing distance was of course measured for each ear
separately; when only the membrane of one side was perforated, means were
taken to prevent the healthy ear from hearing the watch during the examina-
tion. The above statement gives the hearing distance at the time when
patients applied for relief. In many instances, even when the aperture did

1858.] Clarke, Perforation of the Membrana Tyrrvpani. 23

not heal, the hearing improved after treatment, by which congestion or in-
flammation, or other morbid condition of the ear was relieved. The ticking
of my watch can generally be heard distinctly by the healthy ear, in the day-
time, a distance of about fourteen or sixteen feet. Comparing this distance
with the various hearing distances just given, we can form some notion of the
degree of deafness which generally attends perforation. In 56 of the 75
eases, the hearing distance was a foot or less ; and in 40 cases, it was six
inches or less. This statement confirms a remark previously made, that per-
foration is a most unfortunate termination of disease of the ear, but it also
shows that an aperture through the membrana tympani by no means destroys
the hearing.

Let us now return to an examination of the table. A comparison of the
column which gives the age of the patients at the time they applied for relief,
with the one which gives the duration of the disease, will enable us to ascer-
tain the age at which the disease commenced. By such a comparison, the
following result is obtained : The affection inducing perforation commenced
between the ages of six months and one year, in one case only ; between the
ages of 1 year and 10 years, in 28 cases; between the ages of 10 and 20
years, in 6 cases; and between the ages of 20 and 50 years, in 17 cases.
Hence, it appears that the period of life most obnoxious to this difficulty, is
that of early childhood, or that between the ages of 1 and 10 years. More
than half of all the cases, or 28 out of 52, commenced at this period. The
reason of this is to be found in the fact that the exanthemata and other dis-
eases of the general system which are apt to be followed by aural affections,
occur most frequently in childhood.

The length of time which elapsed before the patients applied for relief is
a curious illustration of the common notion that diseases of the ear may be
safely neglected. In only 7 cases out of the 52 had the disease continued
less than a month before medical advice was sought. In 4 cases, it had con-
tinued from 1 month to 6 months; in 3 cases, from 6 months to 1 year; in
25 cases, from 1 year to 10 years; in 9 cases, from 10 to 20 years; and in
4 cases, from 20 to 40 years. In some of these instances the patients had
applied to other physicians before calling upon myself, but in by far the
largest proportion they had not done so.

The causes of perforation are various. " It may exist congenitally," says
Mr. Wilde,1 and " it may happen by accident, such as a penetrating instru-
ment, a foreign body in the meatus, loud sudden noises, sneezing, coughing,
or blowing the nose, diving to any great depth, falls, and blows upon the
head. An ulcer may eat its way through, and leave from loss of substance
a permanent opening; but the most frequent cause of perforation is otitis, or
inflammation of the membrane in common with the lining of the cavitas

1 Aural Surgery, p. 298, Lond. ed. [American edition, p. 287.]

24 Clarke, Perforation of the Membrana Tympani. [Jan.

tympani." Our present series of cases confirms this remark,
tion of the table shows that perforation followed

An examina-

Scarlatina
Cold

Syringing the ear

Measles

Pneumonia

Typhus Fever

Pertussis

Eczema

Puncture

Salt-water bath

Teething

Unknown disease

18 cases,

6 "

3 "

2 "

2 "

1 case

1 "

1 "

1 "

1 "

1 "
15 cases

52

producing 33 perforations.
6

ft 4 <c '

3
3
2

" 2 "

" 1 perforation.

1

1

1

" 18 perforations.

. 75

It appears from this that in 15 cases, the disease which led to perforation,
or which preceded it, was unknown. In 20 cases the disease was measles or
scarlatina ; that is nearly two-fifths of the perforations were produced directly
or indirectly by the exanthemata ; or if we exclude the 15 unknown cases
from the calculation, we find that the exanthemata led to perforation in 20
cases out of 37, a proportion of 0.54, or more than one-half. Next to the
exanthemata, cold ranks as the most frequent antecedent of perforation.
Then comes improper syringing the ear, pneumonia, typhus fever, &c.

The importance of knowing the first symptoms of approaching perforation,
or of any disease which may lead to it, is obvious. By referring again to the
table, we learn that the earliest symptoms of the affections which finally pro-
duced perforation, were —

Otorrhcea alone in
Otorrhcea with otalgia in
Otorrhcea with otalgia and tenderness
Otorrhcea with deafness in
Otorrhcea with tinnitus in
Deafness alone in
Eczema alone in . .

Unknown in
Pain alone in

From this we learn that otorrhcea alone, or in connection with other symp-
toms, was the first evidence of disease — the first warning of what was destined
to cause perforation in 47 out of 52 cases. In only four of these cases, was
there sufficient deafness accompanying the commencement of the disease to
make it remembered as one of the first symptoms. In this statement we
find an urgent reason for a prompt and early attention to otorrhcea, and an
additional reason for condemning the let-alone practice, particularly after the

24

cases.

12

<«

6

u

4

it

1

case.

2

cases.

1

case.

1

<<

1

It

52

1858.] Clarke, Perforation of the Membrana Tympani.

exanthemata, which has been too often followed. It should not only be borne
in mind that the best time to treat an otorrhcea, and to stop it, is at its com-
mencement, but that it often is the only warning of an insidious and ulcerative
affection, which may speedily eat through the membrana tympani.

The position of the perforation in these cases varies considerably. The
aperture was central in 40 instances ; inferior, or through the lower half of
the membrane, in 9 instances ; superior, or through the upper half, in 7 j
anterior in 2; and unrecorded in 17 instances. Those cases in which the
membrane was nearly all destroyed, or two-thirds destroyed, are marked cen-
tral in the table. Of course, in such cases, the point at which the membrane
was first ruptured does not appear. It is my impression that the rupture
generally takes place in that part of the membrane which is opposite the
orifice of the Eustachian tube, whenever it is produced by the pressure of
matter within the cavity, as after scarlatina. The position does not appear
to exert much influence upon the process of healing. For, of the 12 aper-
tures which were healed, three were situated inferiorly; three superiorly;
one anteriorly ; and five were not recorded.

Let us now look at the condition of these cases after treatment. It appears,
that of the 75 apertures, 61, or 0.82 were not healed; 12, or 0.16 were
healed ; and in 2 cases, the result was not known. This statement refers
only to the perforations. In a large number of those which did not heal, the
condition of the cavity of the tympanum or meatus, or of both, was greatly
improved by treatment. The hearing, also, was frequently increased by the
measures which were taken to improve the condition of the ear. At the pre-
sent time, however, we are more concerned with the result as to the apertures,
than with the condition of the cavity of the tympanum or the neighbouring
parts, at the close of treatment. Of the 83 perforations which followed scar-*
latina, only one was healed. That one (No. 49 in the table) had existed for
eight or ten years. It closed by the efforts of nature alone. It received no
treatment at the time it healed, and consequently the process of healing was
not observed. Of the 6 perforations which followed exposure to cold, 4 were
healed. Three of these four apertures had not existed more than three weeks,
and the fourth one not more than four days before treatment was instituted.
Moreover, they were all of small size. Of the 4 perforations which followed
improper syringing, one was healed. This one was of small size, and sub-
jected to treatment in five days after the commencement of the attack. Of
the 3 perforations following measles, the 3 following pneumonia, the 2 fol-
lowing typhus fever, the 2 following pertussis, the 1 following teething, and
the 1 following eczema, none were healed. Of the 18 perforations following
unknown causes, 4 were healed. Of the remaining perforations which healed,
1 was caused by puncture, and 1 by salt-water bathing. The two latter
were placed under treatment in less than two weeks after they occurred. Of
the four, following unknown causes, one was of large size ; it had existed
for three years, and healed like one previously referred to, without any medi-

28

Clarke, Perforation of the Memhrana Tympani. [Jan.

cal treatment. One of the remaining three arose from some aural affection
which had existed for six months before medical assistance was called in ;
and the other two from some disease existing for two or three months.

The size of the aperture in ten of the twelve instances which terminated
in a closure of the hole, was quite small, not longer than the end of a probe;
in one, the aperture was large; and in one, the size was not observed. Of
the sixty-one apertures which did not heal, only six were as small as the end
of a probe. The remaining fifty-five were large, at least when they came
under my notice. They were of the size of half a pea, or larger.

From this statement it appears that the antecedents and the size of a per-
foration exert a marked influence upon its healing. Perforations which are
produced by, or which follow constitutional affections, seem to heal with great
difficulty; while those which are produced by a local affection of the ear,
alone, heal readily. Thus, out of forty-five perforations, following scarlatina,
measles, pneumonia, typhus, pertussis, teething, and eczema, only one closed
over. On the other hand, out of twelve perforations following exposure to
cold, improper syringing, puncture of the membrane, and salt-water bathing,
seven healed. The small size of the apertures which healed, contrasted with
the large size of those which did not heal, confirms what we should naturally
expect, that the smaller the size, other things being equal, the more readily
healing can be induced. It is possible that a proper treatment, instituted
sufficiently early, might have promoted the healing, or prevented the occur-
rence of many of the apertures, which are recorded in the previous table as
unclosed, but after making due allowance for judicious treatment, I have no
doubt the general result would show that perforations following constitutional
diseases heal with great difficulty ; those following local affections heal readily.

The following general conclusions seem to follow from the previous analysis.

1. Difference of sex does not exert any marked influence upon the occur-
rence of perforation.

2. Persons of delicate general health are not more in danger of perforation
than the robust. Disease will rupture the membrane as readily in the healthy
as in the feeble.

3. Disease of the ear, occurring in individuals of a strumous diathesis, is
more likely to terminate in perforation than in persons of a different consti-
tution.

4. Both membranes are more frequently perforated than either one singly.

5. The external meatus is rarely in a healthy condition, when an aperture
exists through the tympanal membrane. This diseased state is sometimes a
cause, but more commonly is a consequence of the perforation.

6. Foreign growths, like polypus and fungus, frequently co-exist with per-
foration, and often are an indirect consequence of it.

7. Otorrhcea is a very constant attendant upon perforation. This symptom,
for otorrhcea is a symptom and not a disease, is not only a frequent indication

1858.] Clarke, Perforation of the Membrana Tympani. 27

of perforation and often kept up by it, but, in a large majority of cases, is
the earliest warning of an insidious disease that will lead to it.

8. The mucous- membrane of the cavity of the tympanum is variously
affected by the existence of a perforation. It is sometimes of a pale red
colour, and without inflammation. More frequently it is congested. Occa-
sionally, it is congested so as to be pushed through the aperture. In rare
instances, it is covered and protected by a white, dry membrane upon its
surface.

9. Quite a large proportion of all affections of the ear are complicated
with or terminate in perforation. About one-fifth terminate thus.

10. An aperture (after it- has existed for some time) generally occupies
from a third, to a half, or two-thirds of the membrana tympani. The smaller
its size, the greater is the probability and the facility of cicatrization.

11. The power of hearing is diminished, but is not obliterated by a per-
foration. A simple aperture of moderate size, i. e. one uncomplicated
with disease of the cavitas tympani, or of the external meatus, produces only
a slight degree of deafness. A simple aperture of large size, or even a com-
plete'destruction of the membrane, does not destroy the hearing.

12. Perforation is most likely to occur in childhood. Its most frequent
cause is acute or subacute otitis. It is occasionally produced by accident or
puncture. The common causes of what might be called perforating otitis,
are the exanthemata, exposure to cold, eczema or erysipelas of the ear, and
improper syringing.

13. The position of the aperture is various. When large, it is central.

14. The condition of the ear, and the hearing, may be improved by treat-
ment, when the perforation- itself cannot be healed.

15. Perforations, following the exanthemata or constitutional diseases, are
the least disposed to heal. Those following exposure to cold or local causes,
inducing ordinary otitis, are more likely to heal. Those following puncture
or accident, heal readily.

Among the various subjects of inquiry suggested by the analysis of the
previous cases, there are two or three of especial importance. These are, first,
the course, symptoms, and treatment, prophylactic and otherwise, of perfora-
tion following the exanthemata, or of what might be appropriately called ex-
anthematous perforation; second, the symptoms and treatment of perforation,
when induced by other causes than the exanthemata, or of simple acute per-
foration ; and third, the general treatment of chronic incurable perforation.
The propriety of discussing exanthematous perforation separately from other
forms of rupture of the membrana tympani will be apparent as we proceed.
Let us examine these subjects briefly in the order they are mentioned above.

In the first place let me remark, that the importance of watching the
condition of the ear during and after scarlet fever and measles, can scarcely
be over-estimated. From the data upon which this paper is founded, it appears
that nearly one-half of all cases of perforation follow the exanthemata, a result

28 Clarke, Perforation of the Memhrana Ti/mpani. [Jan.

which only confirms the statements of other observers. "We have also seen
that the perforations which are produced by, or follow the exanthemata, are
the least disposed to heal of any. These facts are urgent reasons for watching
with extreme care the condition of the ear during and after scarlatina and
measles, and for employing all possible prophylactic means against the occur-
rence of so dangerous an accident as perforation. An additional and equally
urgent reason for this watchfulness and treatment is found in the fact that a
proper management of the ear, during the acute stage and convalescence of
the exanthemata, will go a great way towards preventing perforation. And
if perforation does occur, an appropriate treatment, instituted sufficiently early,
will, in a large number of instances, enable the aperture to close up. So
important is a proper attention to the ear during and after the diseases just
referred to, that a physician who treats such cases and neglects to give this
attention cannot be said to perform his duty to his patient. Indeed, I fear
the condition of the ear is too generally overlooked during the exanthemata.
The attention of the physician and the attendants is engrossed by the consti-
tutional disease. If there is a slight earache, or a little discharge from the
meatus, it is altogether neglected, or treated lightly. Perhaps the nurse is
directed to drop some kind of oil into the ear, or to syringe it ; more commonly,
the physician remarks that it is a matter of no consequence ; it will get well in
a short time, if it is only let alone, and possibly adds a needless caution about
meddling with runnings from the ear. Thus the fears of the patient and his
friends are quieted. He gets well, but his ear continues to discharge. In
the course of a few weeks or months, the continued discharge, or partial deaf-
ness, or both, compel him to seek medical advice. His ears are now care-
fully examined, and one or both membrana tympani are found to be perforated.
The evil is done. Only palliative treatment can now be instituted for the
relief of a lesion, which, I venture to say, might have been prevented in more
than half the cases of its occurrence. It is the duty of practitioners to examine
the state of the ear in all cases of scarlatina or measles. The attention of
the patient or his attendants should be called to the ear. They should be
told to watch it, in order to report the first symptoms of any derangement.
Instead of having their fears quieted, they should be told that the time to
prevent future evil consequences is at the beginning of the attack.

Fortunately perforating inflammation of the ear does not come on without
warning. We have already seen that in 47 out of 52 cases, otorrhcea, either
with or without other symptoms, marked the access of disease which resulted
in perforation. In 12 of these 47 cases, otalgia was associated with the
discharge from the meatus. In every case which followed the exanthemata,
otorrhcea, to which sometimes earache was added, gave warning of danger.
The practitioner, then, who has charge of scarlatina, measles, etc., should be
on the look out for the slightest otorrhcea, or otalgia. The nurse, or other
attendant, should be directed to watch the ears carefully, and to report to the
physician the first sign of moisture about the orifices of the meatus. In like

1858.] Clarke, Perforation of tlie Memhrana Tympani. 29

manner, any complaint of earache should be watched for and reported, and
the occurrence of one or both of these symptoms should be the signal for a
careful inspection of the ears. It is not difficult to examine them, nor to re-
cognize the existence of a morbid condition in them. The services of a
specialist are no more necessary to do this than they are to recognize the
existence of a pneumonia or of a congested os uteri. By means of a specu-
lum auris and a good light, the condition of the meatus and of the mem-
brana tympani can in most cases be satisfactorily ascertained. When a sun-
light cannot be obtained, or the patient is too sick to be placed in a position
which will enable the sun's rays (aided by a common mirror, used as a re-
flector), to enter the meatus, an artificial light can be advantageously substi-
tuted. A lamp, with a common reflector attached, which can be held so as
to throw a strong light upon the patient's ear, will answer the purpose just as
well as any of the expensive and complex lamps for the ear which have been
invented, and a great deal better than most of them.

It is not to be denied that there are many cases which do not admit of an
examination when the ear is first attacked. The patient may be too sick to
allow of its being done. The sides of the throat and face may be so swollen
as to nearly close the orifice of the meatus and prevent any exploration. Or
the meatus itself may be tumefied and tender, so as to forbid the necessary
manipulations. But after making due allowance for all such cases, there re-
main a large number, doubtless a majority, in which an examination could be
easily made, if the attending physician only felt the necessity of making it.
Moreover, it is not generally the case that such an examination is demanded
at the time when the constitutional disease is at its height. I have no statis-
tical data by which to decide this point, but my impression, so far as I can
recall the cases which have come under my observation, is, that in a large
proportion of the cases of perforation following the exanthemata, the local
affection does not begin till the acute stage of the constitutional disease has
passed; and more than this, the local affection frequently does not appear till
convalescence from the constitutional one is fully established. After the
general affection has subsided, an exploration of the ear can always be readily
made, and the extent of the local disease ascertained.

When the membrana tympani is perforated by ulceration, following the
exanthemata, the membrane itself is not usually, if ever, the part primarily
affected. The disease commences either in the cavity of the tympanum or
in the external meatus or in both. Most frequently it begins in the former.
When it commences in the meatus it is most apt to come on during the period
of desquamation after scarlatina, or, when the specific eruption has entirely
receded, after measles. If it commences in the cavity of the tympanum, it
generally shows itself at the time when the fauces are most seriously affected.
In some cases, the cavity of the tympanum and the external meatus are
simultaneously affected. The morbid appearances and the progress of the
No. LXIX.— Jan. 1858. 3

30

Clarke, Perforation of the Membrana Tympani. [Jan.

disease depend a good deal upon which of the two ways just indicated it
begins.

When the external meatus is the seat of the primary attack, its usual
course is the following. Soon after the specific eruption begins to subside,
perhaps a week or ten days later, or possibly while the eruption is at its
height, the patient complains of irritation about the meatus. If not old
enough to complain of this, he manifests it by working at the orifice, trying
to get his finger into the passage, and to scratch and pull the ear. Presently
a little moisture is seen about the orifice, which soon increases so as to become
decided otorrhcea. We have already seen that in forty-seven out of fifty-two
cases of perforation, a discharge from the ear gave the first warning of ap-
proaching danger. Frequently the commencement of the otorrhcea is accom-
panied with earache. Sometimes the latter is so slight as to be forgotten by
the patient, unless it is inquired for by the physician. The discharge is at
first slight and thin, resembling a serous secretion. It soon becomes copious
and thicker, and is often quite offensive. There is not usually much tender-
ness of the meatus, though in some cases, the orifice is sensitive to pressure.
More frequently, the passage is swollen, and sometimes it is rendered sore by
the acridity of the discharge. If only one ear is affected, there is no appa-
rent deafness, but in reality, on carefully testing the hearing, the latter is
found to be impaired. If both ears are affected, there is a notable diminu-
tion of hearing. The disease, which is now fully established, may stop
spontaneously. More often it continues indefinitely, and leads to the various
lesions which have been enumerated. When an ear which is thus attacked is
examined, the dermal tissue of the meatus at the commencement of the
attack is seen to be vascular, moderately swollen, and secreting a thin serous
fluid. No " gathering" or abscess has been formed and broken, but the
dermal tissue pours out a thin secretion, not unlike that which floods the eye
in conjunctivitis. The vascularity sooner or later extends to the external
lamina of the membrana tympani, and thus the external meatus is turned
into a secreting cul-de-sac. If the inflammation is not at once arrested, spon-
taneously or artificially, the delicate lamina of the membrana tympani are
eaten through, and perforation is accomplished.

The treatment before the membrane is perforated is both simple and
effectual. When the vascularity of the passage and the attendant discharge
is accompanied with tenderness and earache, and the strength and age of the
patient permit, one or two leeches should be applied to the orifice of the
meatus. The passage should be sedulously cleansed with warm water several
times a day. As soon as all tenderness has disappeared, or rather, as soon as
the acute stage has passed, astringent lotions of lead, zinc, alum or tannin,
should be instilled into the meatus four or five times a day, so as to fill the
canal, and should be kept in contact with the inflamed surface for at least five
minutes at a time. While astringents are used, it is desirable to keep up,
back of the ear, a moderate degree of counter-irritation by means of cantha-

1858.] Clarke, Perforation of the Membrana Tympani.

31

rides or croton oil. When the discharge is purulent and offensive, the ap-
plication of a solution of nitrat. argenti, by means of a bit of cotton and a
pair of slender bladed forceps, to the whole extent of the inflamed surface,
to the membrana tympani as well as to the meatus, if the former is involved,
is beneficial. The solution may vary in strength from ten to twenty grs. to
the ounce, and should be applied every (second or) third day. If the otor-
rhoea comes on without tenderness or pain, it is generally better to dispense
with leeching, and to employ astringents and counter-irritation immediately.
I have seen many cases get well, by simply cleansing the meatus with warm
water two or three times a day. It should be recollected that the inner ex-
tremity of the meatus is lower than the outer; its direction, going from
without inwardly, is on the whole downwards. Hence there is a mechanical
reason for the accumulation in the passage of the epithelial debris, which are
thrown off from the meatus as well as from other parts of the body after
the exanthemata. This accumulation is in itself a cause of irritation, and
the getting rid of it will often be sufficient to prevent further trouble.

When the cavity of the tympanum is the part primarily affected, the mem-
brane is perforated in consequence of an extension of the exanthematous
disease of the fauces, through the Eustachian tube into the cavitas tympani.
An inflammation is set up which Mr. Wilde very properly calls exanthematous
otitis, and which he admirably describes as follows : " In the otitis accom-
panying scarlatina, measles and smallpox, the disease either commences in the
mucous lining of the middle ear, or spreads into that cavity from the mouth
or fauces, through the Eustachian tube. Sooner or later, however, the mem-
brana tympani becomes engaged, and is ruptured, either by ulceration or from
the pressure of the contents of the tympanum, and otorrhoea, with its long
and varied train of consequences, ensues."1

The earliest symptoms of this extension into the ear are generally earache
and deafness. The otalgia is severe ; not unfrequently it is so intense that
the patient seems to be in agony with it, and is sometimes delirious. The deaf-
ness is also decided, though the hearing is not completely destroyed. After
the otalgia has continued for a few hours, sometimes for only two or three,
more often for twelve or twenty, the membrane is ruptured; a discharge of
pus pours through the aperture, and there is immediate relief. The relief is
so great that the patient feels all danger to have passed ; or, if too young to
think about it himself, his parents entertain this opinion, and look upon the
subsequent otorrhoea as a trivial matter. Perhaps the physician encourages
them in this notion, which a partial return of the hearing is apt to confirm.
Occasionally the attack is more insidious. The severity of the constitutional
disease may mark the local affection, or almost painless ulceration may eat its
way from the fauce3 through the Eustachian tube into the tympanal cavity.
The mucous membrane of the cavity then takes on the same unhealthy action.

1 Aural Surgery, p. 277, Lond. ed. [American edition, p. 268.]

32 Clarke, Perforation of the Membrana Tympani. [Jan.

Pus accumulates, distends the membrane, and presently burst through it. A
discharge from the meatus seems to be the first indication of the local diffi-
culty. But even when the ear is thus insidiously attacked, there are generally
symptoms enough to warn a physician who is aware of the danger and watch-
ing for it. The child is seen to roll his head around as if in distress; or he
complains of slight earache \ or he is deaf, without apparent reason ; or firm
pressure upon the meatus gives evidence of deep-seated tenderness; or deglu-
tition or mastication may cause pain in the ear. One or more of these symp-
toms are generally present as indications of the approaching enemy.

If the medical attendant, whose suspicions have been thus aroused, makes
an examination of the ear, he will find, if the membrane is affected, more or
less of the following appearances. The membrana tympani will have a colour
varying from a bright and diffused scarlet to a dark pink. If the cavity of
the tympanum is distended with pus or other fluid, and the membrane is not
ruptured, it may be seen evidently bulging out, like an abscess, pointing. If
the patient is old enough to inflate the cavity by a forced expiration, having
the mouth and nostrils closed, he should be told to do so. Let the physician
then apply his ear to that of the patient. When the cavity is inflated, he
will hear a distinct mucous bubbling if the air enters the middle ear, very like
the coarse crackling of a tuberculous cavity. Oftentimes the inflation will
produce a momentary and severe pain in the ear, caused by the unusual dis-
tension of the inflamed tissues. If the cavity is not inflated, the attempt
alone produces pain in the ear. The fauces exhibit the various appearances
which accompany the exanthemata. The unhealthy condition extends from
the soft palate, laterally and upwards, as far as the mucous membrane can be
seen. The morbid discharges, purulent, acrid and otherwise, themselves the
debris of destroyed tissues, find an exit through the nose as well as the
mouth, and often, as we have seen, through a rupture of the membrana tym-
pani, into the external meatus. Additional evidence of the diseased state of
the middle ear, can be obtained, if necessary, by pressing a finger, introduced
into the fauces just above and back of the tonsils, up towards the ear. This
sort of rough digital examination will cause pain in the ear as well as in the
throat, if the former is inflamed ; and if the membrana tympani is perforated,
it will often squeeze pus through the hole into the meatus. When perfora-
tion has taken place, a loud whistling rale is produced by inflation of the
cavity. This is so characteristic of perforation, that of itself it is sufficient
to determine its existence, even if the aperture cannot be seen through a
speculum.

When the external meatus, the Eustachian tube and cavity of the tym-
panum are simultaneously attacked, not an unusual occurrence, the morbid
condition of the external meatus, already described as preceding perforation
will be found to co-exist with the diseased state of the middle ear.

The extent to which this exanthematous affection of the middle ear is
amenable to treatment varies with the age of the patient, the severity of the

1858.] Clarke, Perforation of the Memhrana Tympani.

33

constitutional malady, and the decision and promptness of the physician. The
patient may be too young to admit of appropriate treatment. The constitu-
tional affection may be so grave as to preclude even an examination of the
ear, and still more any treatment of it. The physician may be timid or faith-
less, and let the opportunity for treatment pass by. Fortunately the first two
difficulties, the too tender age of the patient, and the severity of the general
disease, do not exist in the majority of cases. It is to be hoped that the lat-
ter difficulty is of still rarer occurrence.

The indications for treatment are, 1st, to avert perforation by subduing
local inflammation, altering the local morbid action, and keeping the Eustachian
tube, and especially its pharyngeal orifice, open, so that all unhealthy secre-
tions may find an easy egress out of the middle ear into the throat. 2d. If
perforation must take place, to make an artificial opening through the mem-
brana tympani, for the discharge of whatever may be pent up in the cavity of
the tympanum. 3d. After perforation has taken place, whether artificially
or spontaneously, to employ, immediately, all general and local means to
bring about a healthy action of the middle ear. 4th. To induce healing of
the perforation, when this can be done, and thereby restore the membrane to
its integrity.

The first indication requires a variety of measures- to meet its demands.
When there is acute inflammation, and the general strength of the patient is
sufficient, one or more leeches to the orifice of the ear will be found of great
service. In many cases, however, the strength of a patient, debilitated by a
previous constitutional malady, is not equal to the loss of blood produced by
a single leech. Blisters behind the ear are better borne, and should always
be applied, if there are signs of inflammation of the membrana tympani, or
if there is otalgia. Croton oil may be substituted for cantharides, if the
patient seems too weak to bear the latter well. The counter-irritation should
be kept up for a week or more after the appearances of inflammation have
disappeared. Local applications to the fauces and to the pharyngeal orifice
of the Eustachian tube are of great importance. The character of these ap-
plications should vary with the condition of the throat. In fact the local
treatment, which the morbid state of the mucous membrane of the throat
generally requires after the exanthemata, should be sedulously employed ; only
great care should be taken to make these applications reach the Eustachian
orifices. Solutions of muriatic acid, of the liquor sodse chlorinate and of
nitrate of silver, have proved in my hands the most serviceable. By means
of a sponge attached to a curved whalebone, it is quite easy to apply any
solution to the faucial extremity of the Eustachian tube. The sponge should
be quite small and soft. It can be easily passed back of the pillars of the
palate and up towards the ear, and thus made to sweep over the orifice referred to .
This accomplishes the double purpose of clearing out the opening of the pas-
sage, and often the passage itself, and of applying a caustic or alterative
solution to the membrane. Another application of equal importance is nasa

34 Clarke, Perforation of the Membrana Tympani. [Jan.

syringing. The floor of the nares enters the throat on a level with the open-
ing of the Eustachian tube. Hence a current of water, thrown into the
throat through the nostrils, will reach and cleanse the mouth of the Eustachian
tube. A gum elastic bag with an appropriate pipe or nozzle is the best in-
strument for this purpose, though an ordinary syringe will answer very well.
The water should be directed straight back to the posterior fauces, and not
in an upward direction towards the eye. The operation is so painless that
children, however young, rarely object to it seriously. The injected water,
or a large portion of it, generally passes directly into the stomach, without
producing much disturbance. This application should be repeated two or
three times a day in ordinary cases. "When the morbid secretions are copious
and the throat largely affected, it is well to repeat it every three or four hours,
during the day. As more or less of the injected liquid is swallowed, it is
not well to employ anything which would be injurious if swallowed. Medi-
cated liquids can be more safely applied by the sponge and whalebone, men-
tioned above. It is sometimes convenient to use, instead of the sponge, a
syringe with a long, delicate, curved pipe and a perforated extremity so as to
shower the parts which it is desirable to reach. If, by these measures, inflamma-
tion is allayed, and all morbid discharges removed from the external meatus and
the Eustachian tubes, and the mucous membrane of the throat brought into a
healthy condition, the practitioner will often have the satisfaction of seeing
the cavity of the tympanum preserved from any serious invasion ; and when
it is affected, its secretions will thus be enabled to find an outlet into the
throat instead of into the external meatus. Catheterization of the Eustachian
tube, and syringing through the catheter, cannot be safely employed in acute
cases. W7hen the acute stage has passed, however, there is less danger from
such an operation.

The second indication, viz., to make an artificial opening through the mem-
brana tympani, exists whenever it is apparent that a spontaneous rupture will
occur, if the membrane is not punctured. The symptoms which show this
indication to exist are the unhealthy condition of the fauces, referred to
above, occasional or persistent otalgia, deafness, and lastly and most import-
ant, a bulging out, or pointing of the membrana tympani itself. When this
convexity or pointing of the membrane occurs, it can be easily recognized.
The membrane can be seen through a speculum sticking out into the meatus,
not translucent but opaque and perhaps reddened, and clearly just ready to
break. The relief which follows a spontaneous rupture is well known. Equal
relief is obtained by an artificial one. The advantages of this proceeding
are, in the first place, that of making a clean cut through the membrane,
which is much more likely to heal than a hole eaten through by ulceration.
Secondly, the artificial opening can be and should be made large enough for
the contents of the cavity to empty themselves at once into the external
meatus. The spontaneous opening is usually a small one at first, not larger
than a pin's head, but it gradually becomes larger and larger, until, as the

1858.] Clarke, Perforation of the Memhr ana Tympani.

35

previously tabulated cases show, the whole or nearly the whole membrane is
destroyed. The artificial opening partakes more of the character of a slit.
Its edges fall together, when the cavity ceases to discharge, and readily reunite.
Thirdly, the operation is easily performed; it is almost painless, and with
moderate ease it can be done without any injury to the adjacent tissues. A
convenient instrument for the operation is a small exploring trocar, or a long,
slender delicate knife, double-edged at its extremitj^ or a cataract needle.
The place of selection for the puncture should be in the inferior and anterior
half of the membrane, just below the insertion of the handle of the malleus.
Let a tubular speculum, that of Mr. Wilde, of Dublin, or of Mr. Toynbee,
of London, be introduced into the orifice of the meatus. Then while the
patient's head is firmly held, and the surface of the membrane is illuminated
by the sun's rays or an artificial light, it is only necessary to cut through
the membrane at the point specified. The operator should of course bear in
mind the size of the cavity of the tympanum, and take care not to wound its
opposite wall. There is no danger of doing this if the instrument is pushed
slowly through the membrane, and withdrawn as soon as its delicate laminae
are felt to be divided.

I am not aware that aurists have generally advised puncture of the mem-
bran a tympani in cases such as are now under consideration. The proposition,
however, is not altogether unsupported by authority. Martell Frank, whose
admirable treatise1 on Diseases of the Ear has not yet been translated into
English, states that he is frequently in the habit of puncturing the membrane
for the purpose of applying remedies to the cavity, even when the latter is not
filled with any morbid secretion. Speaking of catarrhal inflammation of the
cavity, and of mucus pent up within it, he says : "We must here refer again
to the necessity of perforating the tympanum. It is impossible, especially in
chronic catarrh, to free the cavity from the mucus accumulated within it by
any of the proposed remedies or applications. In such cases we regard it as
necessary, in the first place, to perforate the membrana tympani." . . .
"After an artificial perforation of the membrane, we have often met with a
viscid, gelatinous, slimy mass, which was immediately forced into the external
ear by an injection of air or water, blown through a Eustachian catheter, in-
troduced into the Eustachian tube." ..." We have never had any
reason in a single instance to be dissatisfied with this proceeding, and can
emphatically recommend it, without hesitation, in most eases of chronic
catarrh."3 Dr. Martell Frank does not refer, in this passage, to the diseases
with which we are now concerned, nor does he elsewhere propose perforation
in accumulations within the cavity of the exanthemata. But his testimony is
exceedingly valuable to the simplicity and ease and safety of the operation.

1 Practische Anleitung zur Erkenntniss und Behandlung der Okrenkranklieiten,
von Dr. Martell Frank. Wiirzburg, 1845.

2 Op. cit. pp. 335-6.

36

Clarke, Perforation of the Membrana Tympani.

[Jan.

If it can be easily and safely done in one ease it can also in the other. For-
tunately, it is not necessary to call in the aid of a specialist for the perform-
ance of this operation. It is so easily performed, that any judicious
practitioner can do it as safely as he can open an ordinary abscess.

The third indication, viz., to promote as rapidly as possible a healthy action
of the tissues, after the membrane has been spontaneously ruptured or artifi-
cially punctured, is answered by a careful attention to the measures pointed
out under the first indication. It is needless to recapitulate them, or to urge
their importance. But whatever local applications are employed, the necessity
of frequently cleansing the external meatus by syringing with warm water,
and of cleansing also the pharyngeal orifice of the Eustachian tube by nasal
syringing should never be forgotten. This is a prerequisite to all other
local treatment.

I am afraid that practitioners are too apt to forget and neglect this
whole matter. At tbe risk of tiresome repetition, I must urge again and
again the importance of attention to it. When otorrbcea occurs after the
exanthemata, its cause should be carefully sought after, at the earliest possi-
ble moment. If upon examination it is ascertained that perforation has
taken place, the patient should not be given up as incurable, but the measures
already indicated should be at once put in force, in order to prevent further
injury. The sooner the local morbid condition is controlled, the less will be
the extent of permanent local damage, and the greater will be the chance of
a closure of the aperture. If perforation has not taken place, there is equal
reason for employing diligently the same measures in order to prevent it.

The means of fulfilling the fourth indication, viz., to induce healing of the
aperture and thereby restore the membrane to its integrity, have been partly
described already. They include all those applications which have been
mentioned as necessary to restore the external meatus, the cavity of the tym-
panum, the Eustachian tube, and the fauces to a healthy state. When this
has been done, the otorrhcea checked, and the inflammation allayed, and
when the perforation, which may still exist, is not too large, it is sometimes
possible to make the hole grow up. But the local treatment of the mem-
brana tympani and of the edges of the aperture, with this object in view,
can be more appropriately considered further on.

When the external meatus and the middle ear are simultaneously attacked,
the treatment should of course be addressed to all the diseased tissues. The
applications previously indicated for exanthematous inflammation of the
meatus should be added to those for exanthematous otitis; and all of them
should be modified so as to meet the exigencies of individual cases.

If these statements of the importance and favourable effects of treating
disease of the ear following the exanthemata are true, it may be asked, how
are we to account for the large number of perforations which the previous
table exhibits? The answer is, that most of the cases recorded in the table
were not treated for the local difficulty till months, and more frequently years>

1858.] Clarke, Perforation of the Membrana Tympani. 37

had elapsed after its commencement. During the exanthemata, when that
was the cause, little or no attention was paid to the ear; and when otorrhcea
or otalgia first occurred, no heed was given to the warnings they uttered.
The local disease was neglected when it should have been treated, and the
table exhibits the result of such neglect in the lesions it records. I do not
wish to make any sweeping assertions; and I do not say that these lesions,
perforation among them, can always be prevented, or the integrity of the ear,
when they cannot be prevented, always restored. But I do say that a great
deal can be accomplished in the way of prevention and relief, by appropriate
local treatment at the appropriate time. A great deal more can be accom-
plished than many will be willing to believe, until they make the trial for
themselves. It would be easy to detail a number of cases in support of these
views, but it would extend this paper, already largely prolonged, to too great
a length. I will only give a few as illustrations.

Case I. — M. C, a girl, set. 7, with light hair and eyes and large tonsils,
had measles in the summer of 1849. During the attack, she suffered several
times from otalgia, but as it soon disappeared, no attention was paid to it by
her friends or her attending physician. The measles went through their
ordinary stages, and the patient convalesced favourably. During convalescence,
a slight discharge appeared from the right meatus. It was unattended with
pain or odour. Hoping it would subside, the parents let it alone. At length,
when six months had elapsed, and the otorrhcea had not got well, my attend-
ance was suggested. I found the walls of the right meatus near the membrana
tympani, moderately red and secreting matter; the membrana tympani,
moist, slightly vascular, and not perforated. There were no other morbid
appearances. I directed the ear to be syringed twice a day with warm waiter,
and after syringing, a solution of acet. plumbi, gr. iij to 3j, to be poured
into the meatus, and kept in contact with the parts several minutes each time.
In eight days the otorrhcea stopped, and the walls of the meatus and the
membrana tympani were normal.

The only remarkable point in this case is, that an otorrhcea should have
existed so long with so slight a degree of local disease. It is possible that it
might have stopped spontaneously; but it is equally possible that it might
have increased, if it had not been artificially checked, till perforation had
taken place. This case is given merely as an illustration of the way in which
perforating ulceration of the membrana tympani following the exanthemata
often commences, when its origin is in the external meatus.

Case II. exhibits more clearly the early symptoms of exanthematous in-
flammation of the external ear passage. Gr. S., a healthy boy, £et. 4, had
measles in the spring of 1856. The eruption came out fully, and subsided
normally. In less than a week I was able to discontinue attendance. During
the attack, there were no symptoms of inflammation of the ear. I informed
his mother of the danger of aural disease, and directed her to watch his ears
carefully and let me know if there was any otalgia or the slightest otorrhcea.
Before many days had elapsed I was sent for, and told that during the night
previous to this call, Gr. S. was awakened by a severe earache. The pain
continued for about half an hour, and was apparently relieved by putting

38

Clarke, Perforation of the 31embrana Tympani.

[Jan.

some warm and moist application upon the ear. In the morning his ear
seemed to be well, and his mother said that she should not have sent for
me if I had not requested her to inform me of any occurrence like earache or
discharge. On examination, the walls of the meatus of one ear were found
to be somewhat vascular, and the surface of the mem bran a tympani of a diffused
red colour. The whole passage was moist, though not secreting largely.
Croton oil was applied back of the ear; the passage was gently syringed ; in
a day or two a mild solution of acet. plumbi was poured into the ear a few
times. In less than a week, the inflammation subsided. There was no more
otalgia or otorrhcea. The ear has since been well. This attack was mild,
and yet if it had been neglected, it would have been very likely to end in
perforation.

Case III. is an example of inflammation of the middle ear as well as of

the external meatus, and membrana tympani. M. , a healthy girl of

three or four years old, living in the neighbourhood of Boston, was attacked
with scarlet fever in July, 1854. The attending physician reported the child
to have been very sick. The characteristic eruption came out fully, and
disappeared in the usual way. The integuments and glands of the neck were
swollen, and the fauces ulcerated. When convalescence commenced, a copious
discharge poured from both ears, and an acrid running from the nostrils. I saw
the child in consultation, about 10 or 12 days from the beginning of the fever.
She was weak, irritable and restless. Her skin was desquamating freely.
Her fauces were red and swollen, with patches of a dirty white colour, at dif-
ferent points. This appearance extended as far up and back of the pillars of
the palate, as the mucous membrane was visible. A yellowish secretion
poured out of the nose and ears. Her hearing was impaired, though to what
extent could not be accurately determined. After syringing the ears, the
walls of each meatus were seen to be moist and red. Both membranse tym-
pani had a diffused red colour, and were perforated. The perforations were
small, being just large enough for matter to be seen oozing through from the
tympanal cavity into the meatus. I advised the application of diluted muriatic
acid to the fauces; syringing with water through both nostrils into the throat
several times a day; syringing of the ears often enough to keep the passages
free from purulent accumulation ; continued counter-irritation back of the
ears; and after the lapse of a day or two, the instillation of a solution of acet.
plumbi, three or four times a day into each meatus. The employment of
appropriate general measures, calculated to hasten convalescence were also
urged. I did not see the patient again, but was informed several months later
by her physician that her recovery was perfect. The otorrhoea soon subsided.
The apertures through the mem bran oe tympani healed, and her hearing was
normal. The proposed local treatment was faithfully followed.

Case IV. presents symptoms of a still graver character. My attendance
was requested on H. B., a boy, set. 3£, residing in Boston, and attacked with
scarlet fever in Jan. 1857. The eruption came out well and went off as usual.
While desquamation was taking place, the throat began to swell, and large
abscesses formed, first beneath one ear and then the other. They were lanced
and discharged copiously. The fauces were moderately but not largely ulcer-
ated. At one period, the renal secretion stopped entirely for 36 hours and
then came on again. Symptoms of dropsy of the head appeared, to such an
extent as to render recovery extremely doubtful. At length, after a conva-
lescence prolonged for three months, he got well. But what we are especially
concerned with now, is the affection of his ears. On the 5th day of the fever

I

1S58.] Clarke, Perforation of the Memhrana Tympani. 39

lie had severe otalgia of the right ear. The orifice and walls of the meatus
were swollen and tender, and the membrana tympani could not be seen.
Opiate fomentations- were applied, and the earache disappeared. Two days later
an acrid, watery discharge dripped from his nose, and at the same time an
otorrhoea appeared from both ears. He was too sick and feeble to admit of
any local treatment of his ears, beyond keeping them faithfully clean with the
syringe. By the third week of the fever, he seemed to be completely deaf.
He paid no attention to the loudest and sharpest sounds, even when close to
his ear. As soon as his general condition admitted of a careful examination
of his ears, I found both membranse tympani perforated. The perforations
were large enough to allow the passage through them readily of the end of a
common sized probe. The local treatment was the same as that of Case ill.,
except that liquor sodse chlorinat. was applied to the fauces instead of muriatic
acid; and, on account of the extreme weakness of the patient, nasal syringing
was not used. The meatus of each ear, however, was carefully syringed
several times a day after the appearance of the discharge. Counter-irritation
was employed as soon as the severity of the general disease abated. By the
time convalescence was fully established, that is, about three months from the
commencement of the fever, the aperture in the left membrana tympani was
closed, and the appearance of the meatus and the hearing were normal. The
perforation of the right membrana tympani still existed, though of such small
size as to render its closure probable.

Case V. is an illustration of the facility of puncturing the membrana tym-
pani and of the benefit derived from the operation. It is extracted from Mr.
Harvey's late work on aural diseases.

" Two children, sisters, were brought to the author for his advice ; they were
both suffering from otorrhoea and deafness, with perforated membrane on each
side, the result of a recent attack of scarlatina. A brother, nine years of age,
had been sent into the country to be out of the way of the contagion. The
author requested that he might have early tidings if this child were attacked,
which took place on his return home a week or two afterwards. The child was
delirious and suffering extreme agony in the ear. On examining the meatus,
the canal was much narrowed, and dilating it with the bivalve forceps showed
the membrane of the tympanum red and swollen. Placing the cases of the
other two children (who were suffering so much from the same cause) before
the parents, the author obtained permission to puncture the membrane, an
operation which he had long determined to perform on the first opportunity,
being anxious, if possible, to prevent the misery he had so often witnessed.
This was now performed on both ears with a broad-shouldered cataract needle.
Upon withdrawing the instrument it was seen to be besmeared with purulent
matter, and although there was not any immediate copious discharge, yet in a
few hours matter was seen to run freely from the meatus. The child expressed
himself as much relieved by the operation, and the result was highly satisfactory.
The discharge continued for two or three weeks, and then ceased. The aperture
closed on each side, and not the slightest imperfection in hearing is discover-
able, whereas both the sisters are slightly deaf to this day, and have not yet
got rid of the otorrhoea. The author has since repeatedly opened the tympanum
in cases of suspected accumulations of matter from other causes, and has seen
no reason to regret taking this step, as in every case the membrane has healed
so readily that a repetition of the operation has been sometimes needful."1

I have preferred to quote the above case rather than to present one from
my own experience, because it lends the authority of Mr. Harvey to the

5 The Ear in Health and Disease, by William Harvey, F. R. C. S. pp. 101-2. London.

40

Clarke, Perforation of the Memhrana Tympani. [Jan.

operation, as well as illustrates its beneficial results. We have already seen,
by a previous quotation, that Dr. Martell Frank is frequently in the habit of
performing it and with manifest advantage-
Let us now return to the second subject suggested by the table, viz., the
symptoms and treatment of perforation when induced by other causes than
the exanthemata, or of simple acute perforation. This form of perforation
seems to be essentially different from the exanthematous variety. Its cause
is rarely of a constitutional character. The affections which lead to it do
not generally implicate so extensively the tissues of the ear. Its progress is
milder, and it is much more amenable to treatment.

It may be produced, as we learn from the table, by exposure to cold, im-
proper syringing, eczema, pneumonia, typhoid fever, accidental puncture, etc.
Of these various causes, cold is the most frequent. When this leads to per-
foration, it does so by setting up an inflammation of the middle ear, a true
otitis, which, if not arrested, goes on to suppuration, involving in its action
the various tissues of the part, including the menjbrana tympani. The latter
is perforated, as in exanthematous perforation, by ulceration making a passage
for the confined pus. The other causes which have been mentioned, such as
salt water getting into the ear during a sea bath, or violent syringing, or
pharyngitis, or pneumonia sometimes induce otitis, and thus lead to perfora-
tion. It is perhaps needless to say that to accidental puncture of the mem-
brane, the above explanation of the production of perforation does not apply.

It is apparent from these remarks, that the symptoms which attend simple
acute perforation resolve themselves into those of otitis. We should always
bear in mind, when attending a case of inflammation of the middle ear, the
probability of perforation, and carefully watch from day to day the condition
of the membrana tympani. In this as in the exanthematous variety, the two
symptoms which are of most importance as warnings of the approach of
danger — as urgent reasons for an examination of the ear — are otalgia and
otorrhcea. The occurrence of one or both these symptoms mark the onset of
the attack. It is not necessary to give a detailed account of otitis, as an
antecedent of perforation. The severe pain, the tenderness, the painful
mastication and deglutition, the swelling and the deafness are too well known
to require recapitulation. The points to which I wish to draw attention now
are that these severe symptoms attend a disease which is apt to perforate the
membrane of the ear; that when perforation takes place, all the violent
symptoms are greatly alleviated ; and that hence both the practitioner and
patient are in danger of being lulled into a false security, and of neglecting
a treatment which is still important. The aperture will generally close, if
an appropriate local treatment is pursued. If this is neglected, it will often
remain open.

The circumstances which have been alluded to as causes of otitis, not un-
frequently lead to inflammation of the membrana tympani alone; that is, to
myringitis, without the mucous membrane or cellular tissue of the middle

1858.] Clarke, Perforation of the Memhrana Tympani.

41

ear being much if at all affected. This form of inflammation occasionally
results in perforation, though it more frequently terminates in thickening and
opacity of the membrane. When there is danger of perforation, the myrin-
gitis partakes of an ulcerative character. A simple inspection of the mem-
brane in a clear light is sufficient to determine whether the inflammation is
accompanied with a deposit of lymph or with ulceration. In the former case,
the membrana tympani presents a radiated red surface, tense, more or less
opaque, and without any secretion; in the latter case, there is a diffused red
surface, swollen and secreting a purulent or muco-purulent fluid. Sometimes
a distinct spot of ulceration can be discerned on the surface of the membrane;
but this cannot with propriety be called myringitis. Sometimes ulcerative
inflammation of the membrane of the tympanum comes on insidiously; that
is, without pain, but never without more or less otorrhcea. Hence the great
importance of examining the ear whenever there is any discharge from it,
not only after or during the exanthemata, but in all cases of otorrhcea.

The form of insidious and painless inflammation of the membrana tympani,
just alluded to, is too important as a cause of perforation to be passed over
with a bare allusion. It occurs most frequently in persons of a strumous
diathesis, or of an enfeebled constitution. A slight exposure to cold, or to a
high wind, or to anything which irritates the ear is a sufficient exciting cause.
Generally the cause is so slight as scarcely to be remembered at all. It is
followed by a sensation of moderate discomfort in the ear, but without posi-
tive pain. Little or no attention is paid to the state of the ear ; and pre-
sently, in a day or two, or it may be within twelve or twenty-four hours,
otorrhcea commences. This may be the first symptom which compels the
patient to notice his ear. If at this stage, an examination is made, the mem-
brane is found to be largely ulcerated and perhaps already perforated. The
following case illustrates this form of perforation better than any descrip-
tion.

Case VI. — Mrs. A. N., an American, about 27 years old, with light hair
and complexion, requested my attendance Jan. 25, 1857, on account of a
sudden discbarge from the right ear. Mrs. N. was by no means robust, and
yet enjoyed tolerable health. The glands of her neck were apt to enlarge
when she took cold; her tonsils were larger than usual and fauces congested.
Three or four days before the otorrhoea appeared, she was exposed to cold by
passing through a cold passage way without sufficient protection. She felt
the cold sensibly in her head at the time. An hour or two later she had
some pain in the right ear. But this was very slight and. soon passed away.
It way so slight that she did not think of it again, till a discharge commenced.
For a day or two she was conscious of a slight degree of irritation in the ear,
without actual pain or any other symptom. On the 24th of Jan. there was
a slight discharge of a thin watery fluid from the ear, which on the 25rh
became more copious and thicker. I found the meatus red, considerably
swollen, slightly tender, not painful, and nearly full of matter. The mem-
brana tympani could not be satisfactorily seen. A blister was applied back
of the ear; the meatus syringed three or four times a day, and a wTeak solution

42

Clarke, Perforation of the Memhrana Tympani.

[Jan.

of acet. plumbi. (gr. ij to Sjj) instilled into the ear twice a clay. Two clays
later, the swelling of the meatus had diminished so that the membrane could,
be seen. A perforation was found in the lower half of the membrane,
through which I saw bubbles of air and mucus blown by inflating the cavity.
The malleus was in situ. The remaining portion of the membrane was of a
diffused red colour. The discharge was of a mucous character and not offen-
sive. The cavity of the tympanum and the Eustachian tube did not appear
to be much implicated in the inflammation. The ticking of a watch could
be heard only when the watch was close to the ear. Decided counter-irrita-
tion was kept up back of the ear; the inflamed surfaces were touched every
other day with a solution of nit. argent, (gr. xx to warm syringing was
employed pro re na ta ; the instillation of a solution of lead was continued,
and the strength of the solution was gradually increased to grs. x to Jj ; at
the same time the iodide of iron was given internally, and a generous diet
with wine or porter advised. Under this treatment, the discharge gradually
diminished, and the meatus and membrana tympani assumed a healthy aspect.
Ey the first of March, five weeks from the commencement of the attack,
there was no otorrhcea, the orifice of the meatus was coated with wax, its
walls were healthy, the membrana tympani had a small perforation through
its inferior half, but was otherwise healthy; and the hearing on that side
was so much improved as not to inconvenience the patient, though it was far
from being equal to that of the left ear. A few months before this attack I
had occasion to examine the ears of Mrs. N., and found both of them in a
normal condition. I was, therefore, assured of the integrity of the membrane
previous to the attack just described.

The treatment of simple, acute perforation should vary somewhat according
to the character of the attack which precedes it. When it is preceded by
acute inflammation of the tympanal cavity, antiphlogistic measures should be
promptly employed. One or two or half a dozen leeches should be applied
back of the ear and around the orifice of the meatus ; a brisk cathartic should
be given and repeated till the force and rapidity of the pulse are brought down;
a rigid diet of gruel or simple farinaceous food only should be allowed ; opiates
will often be required to allay pain and produce sleep. The local treatment
should consist of measures calculated to allay irritation and promote the free
discharge of any accumulation. Steaming the ear with an infusion of poppies
or with laudanum and water, will often give great relief, particularly if ap-
plied to the throat and fauces as well as to the ear. If the membrana tym-
pani is seen pressed out from any accumulation in the cavity, it should be
punctured. Whenever there is any discharge into the meatus, the latter
should be gently washed out with warm water, often enough to prevent pus
from accumulating in it. As soon as the acute stage is passed, counter-irri-
tation back of the ear will be found of service. When the otitis is relieved
by a discharge from the meatus, the care of the physician should not be in-
termitted ; for the otorrhcea, which seems to relieve the pain, is generally an
indication of rupture of the tympanal membrane. If the meatus is not
swollen, the perforation can be readily seen through a speculum. If the
meatus is swollen so as to obscure the membrane, the existence of perforation

1858.]

Clarke, Perforation of the Metnbrana Tympani.

43

can be determined by asking the patient to inflate the cavities by a forced
expiration. If a perforation exists, the air will be heard, on auscultation of
the ear, to pass through the aperture with a whistling rale. In case rupture
of the membrane has taken place, the meatus should be well and frequently
syringed out with tepid water. The local and general antiphlogistic treat-
ment should be continued till the inflammation of the ear has subsided. In
most cases the aperture will close without any further treatment. As soon
as the inflammation is subdued, the edges of the hole grow together, and the
hearing is restored. There is often a slight degree of opacity perceptible for
several weeks after such an attack ; but this gradually disappears.

If the membrana tympani is inspected daily, while the process of the
closing of an aperture is going on, the redness of the membrane will be seen
to disappear gradually. The edges of the perforation, however, remain red
and congested for some time after the other portions of the membranous
surface have become clear. The perforation closes, as we should naturally
expect, by an inflammatory process. And so long as the inflammation is
confined to the edges of the hole and does not spread over the whole surface,
it is to be regarded as a healthy action and not to be interfered with. This
is an important matter. For on the one hand there is danger if active and
antiphlogistic treatment is not promptly employed, that all the tissues of the
ear will be sc seriously affected as to destroy the hearing ; on the other hand,
there is danger of carrying local depletion so far as to prevent the setting up
of inflammation enough to heal an existing perforation. When an aperture
exists, the amount and continuance of local depletion should be regulated by
the condition of the tympanal membrane. So long as its whole surface is
red, either local bloodletting or counter-irritation should be kept up. But
when the redness is confined to the edges of the aperture, depletion in any
form is more likely to do harm than good. If this local inflammatory pro-
cess is arrested before the aperture is closed, the perforation will in all
probability be permanent. Indeed, if the myringitis subsides suddenly,
leaving an opening through the membrane, with its edges clear and free from
redness, means should be taken to excite local inflammation for the purpose
of closing the aperture. In some instances this can be accomplished. Of
this I will speak presently. When the acute stage has passed, and the surface
of the membrane, notwithstanding the appropriate use of depletion, retains its
red and congested appearance, local astringents, such as the sugar of lead or
the acetate of zinc, or an alterative astringent like the nitrate of silver, should
be applied directly to the surface of the membrane. This can be easily done
by instilling them into the meatus. The strength of the solution should vary
with the circumstances of each case. It should be weak at first and increased
daily in strength, if the desired effect of constringing the bloodvessels of the
membrane is not produced. As soon as the redness has disappeared from all
parts of the membrane, except from the immediate neighbourhood of the

44

Clarke, Perforation of the Membrana Tympani.

[Jan.

aperture, the astringent should be discontinued. A longer use of it would
be likely to prevent the healing of the perforation.

When the inflammation of the tympanal cavity has subsided, and the aper-
ture refuses to close, it is of great importance to induce its healing, if this can
be done. I have already alluded to the possibility of doing this. Observation
teaches that a simple puncture of the membrane heals with great facility. We
also learn from observation that small apertures, spontaneously induced, heal
with almost equal facility if the diseased condition which caused them is promptly
subdued. We have seen that a certain degree of inflammation accompanies
the process of healing. Now when a membrane is ruptured in consequence
of disease of the cavity or of the membrane itself, the object of the local and
general depletive treatment, so far as the management of perforation alone is
concerned, is to get rid of inflammation and its attendants, whether suppura-
tion or otherwise, as rapidly as possible, and thereby bring the aperture, at
the earliest possible moment, to the condition of a simple puncture. But as
nature's way of closing an aperture is by means of inflammation, the inquiry
naturally arises whether, in cases wherein a perforation remains after the
disappearance of inflammation, it is not possible and safe to excite an artificial
inflammation in the membrane, and thus enable the hole to grow together.
With this object in view, I have been in the habit, for the last few years, of
touching the edges of perforations which appeared indisposed to heal with a
mild solution of nit. argenti or of iodine. The application has been followed
in a short time by a red blush around the edge of the hole, and in repeated
instances by a gradual approximation of its sides, till at length they united,
and the membrane was restored to its integrity. Mr. Wilde alludes to this
method of treating apertures in his late work,1 but does not give to it the
prominence which it seems to me to deserve. He employs for this purpose
the solid lunar caustic. In this form nitrate of silver is more apt to act as a
pure caustic on the membrane, destroying its tissues, than as a stimulant. I
have found more advantage from employing a solution of lunar caustic, of a
strength varying from a scruple to a half drachm to the ounce. Lugol's
solution of iodine may be employed for this purpose. My own experience,
however, leads me to prefer decidedly the action of nitrate of silver.

The easiest way of applying such a solution, is by means of a bit of cotton
wrapped around the end of a delicate pair of long and slender bladed forceps.
The cotton should be thoroughly saturated with the solution. In making the
application, the cotton should not be thrust through the hole roughly, but
gently touched upon the surface of the membrane close to the edge of the
aperture. Scon after the application, the edges of the hole will be seen to
redden, as if irritated. If this effect is not produced, the solution should be
again applied, and the application repeated a third or fourth time, if neces-
sary, so as to induce a slight degree of irritation. Sometimes an amount of

1 Op. cit, London ed., p. 303. [Am. ed., p. 292.]

1858.]

Clarke, Perforation of the Membrana Tympani.

45

inflammation is excited, which threatens to involve the whole membrane.
This, however, can be easily controlled by a blister behind the ear, or by
applying a leech to the orifice of the meatus. More generally, there is
greater difficulty in exciting a sufficient degree of inflammation than in pro-
ducing too much. The frequency of the application should be regulated by
its effect. If but little irritation is produced, it should be repeated every
day or every second day ; if the effect is more marked, every third or fourth
day will be enough. In favourable cases, two or three applications are all
that is requisite to enable the aperture to close up. While this treatment is
going on,r he membrane should be carefully watched ; and if, as sometimes
occurs, there is any disposition on the part of the aperture to enlarge instead
of contract, the local stimulating applications should be discontinued.

The cases of perforation in which this treatment can be advantageously
adopted, are those in which there is no suppuration or discharge from the
middle ear ; in which the aperture is not large ; and lastly, in which no great
amount of thickening or other organic changes have taken place in the mem-
brane or the adjoining tissues. While suppuration is going on it is obviously
impossible and probably would be undesirable to heal an aperture which affords
an exit for the discharge. If the hole occupies more than one-fourth of the
surface of the membrane, there is not much chance of making it close up ; if
it is of that size or smaller, and other circumstances are favourable, it can
sometimes be induced to heal. Organic changes, such as thickening of
the membrana tympani, unhealthy conditions of the mucous membrane of
the cavity, etc., interfere with the growing together of an aperture. When,
moreover, a perforation, of whatever size, has existed for several months, after
all inflammation, suppuration or discharge has ceased, it is very unwilling to
heal, probably owing to the existence of organic changes, which are out of
sight in the cavity of the tympanum. Hence the importance of commencing
this treatment as soon as the membrane is prepared for it. In some rare in-
stances, I have seen perforations heal which had existed for a year or more.
Cases No. 45 and 49 of the table are of this sort.

We have only space to present one or two cases in illustration of these re-
marks. The first one is interesting both on account of the length of time the
perforation had existed, of the facility with which it closed, and of the perfect
recovery of the hearing.

Case YII. (No. 48 of the table). Mr. J , a teacher in the University

at Cambridge, set. 23, with light hair and eyes, excellent general health, and
no enlargement of the tonsils or cervical glands, requested my advice in March,
1852. He stated that two and a half months previously he was attacked with
what, from his account, was probably otitis of the left ear. The pain at the
time was excessive. It was relieved, however, by a discharge from the meatus.
Soon after he called upon a physician who told him that the membrane of his
ear was perforated. The fact was made evident enough by his being able to
force air through the hole. He was ordered an acetate of lead wash for the
ear; blisters were put on back of the ear; and by the advice of a second
No. LXIX.— Jan. 1858. 4

46

Clarke, Perforation of ike Membrana Tympani. [Jan.

physician, an issue was opened on the arm. The discharge ceased, but he
was deaf on the left side, and his ear felt uncomfortable. When I saw him,
I discovered a perforation situated below the insertion of the malleus, and in
the anterior portion of the membrane. It was of the size of the head of a
large probe. The walls of the meatus were slightly red and also the remain-
ing surface of the tympanal membrane. There was a slight mucous discharge.
The perforation was not only evident to the sight, but bubbles of air and mucus
were seen to be blown through it by a forced expiration. The edges of the
hole were touched in the way already described with a solution of nitrate of
silver, gr. xx to £j ; and at the same time a leech was applied to the orifice of
the meatus. A mild solution of the subacetate of lead was instilled into the
meatus twice a day. Three days later, the edges of the hole were again
touched with caustic; and after another interval of three days, the application
was repeated for the third and last time. The diffused red hue of the mem-
brane disappeared after leeching. The astringent wash was used till this diffused
redness was no longer visible. In twelve days from the first application of
caustic, the aperture was completely closed. The inflation of the cavity was
distinctly heard, but no air could be forced through the membrane. There
was no whistling rale. The hearing was completely regained. More than a
year later I made a careful examination of the parts. There was no trace
of the previous disease visible, and no cicatrix to mark the situation of the
perforation. The meatus and membrane were in every way normal.

The following case illustrates the facility with which a tympanal aperture
closes, when it has existed for some time, if the affection which led to it is
relieved.

Case YIII. — U. F., an American lad, aet. 6, was brought to me for advice
on account of an otorrhoea, complicated with an eruption about the ears. Kis
general health was good. He had light hair and eyes, but no glandular
swellings about the neck, nor other indications of a scrofulous diathesis. Two
years previously I had treated him for a slight inflammation of the dermal
tissue of the meatus, accompanied with otorrhoea, from which he rapidly re-
covered. About four days before the last attack he took cold. His throat
was sore, and he had what his mother supposed to be influenza. In a day or
two he complained of earache. The otalgia was relieved by a discharge from
both ears. Simultaneously with the otorrhoea, an eruption appeared in and
around the orifice of each meatus. The otalgia did not return after the com-
mencement of the discharge, but he was quite deaf. I found a patch of
eczema on both ears, which extended on each side outwardly into the hollow
of the concha, and inwardly quite into the meatus. Each meatus was filled with
purulent and moderately offensive matter. There was some tenderness on
pressure. The fauces were congested, the tonsils slightly swollen, and a dis-
charge was running from the nose. After syringing, the walls of the meatus
were found to be red and swollen. Both membranse tympani, as far as they
could be seen, presented a radiated red appearance. The existence of perfora-
tion was not demonstrable.

Counter-irritation was employed back of both ears; syringing was ordered
pro re nata; a mild cathartic given, and an ointment of lard, glycerine and
lead applied to the eczema. Two days later, the swelling of the passages
had diminished so as to admit of a better view of the tympanal membranes.
A perforation of the size of the blunt end of a probe was discovered just
below the insertion of the malleus on the left side. Its existence was proved

1858.]

Clarke, Perforation of the Membrana Tympani.

47

by inspection, by the appearance of globules of air in the discharge, and by
seeing liquid matters pushed through the hole, when the patient blew his
nose. Decided counter-irritation was kept up behind each ear. In two or
three days a solution of acet. plumbi, gr. iv to ^j, was instilled into his
ears, several times a day. In seven days the eczema disappeared. The
otorrhoea ceased in a day or two later. In twelve days from the commence-
ment of the treatment, the aperture closed, and soon after, the hearing was
restored to its natural condition. In this case, the closure of the aperture
occurred so soon after the resolution of the inflammation and the cessation
of the discharge, that the application of caustic was not deemed advisable.
It should be added that the inflammatory affection of the fauces and nose
disappeared, paW passu, with the subsidence of the aural disease.

The next case is a remarkable instance of the spontaneous healing of a
large perforation. It shows what the restorative powers of nature are capa-
ble of, and is an encouragement to endeavour to imitate her processes, in
cases of perforation, where the prospect of a growing together of the hole is
by no means flattering.

Case IX. — (No. 45 in the table.) J. F., an American, set. 26, with ex-
cellent general health, was attacked with tenderness, pain and swelling of the
right ear, in July, 1850. He had suffered, for several years, from occasional
and offensive otorrhoea of the same side. The attack, just referred to, was
quite a severe one, and accompanied with cerebral symptoms. He was
leeched, blistered, freely purged, and kept upon a low diet. As soon as the
swelling of the meatus had subsided sufficiently to admit of an exploration
of the passage, I discovered a polypus adhering to the upper wall of the
meatus. This was easily removed. Its root was freely cauterized, and it
did not return. A large perforation was now apparent through which the
patient forced air and bubbles without difficulty. It is unnecessary to give
the details of treatment. At the end of three months, the inflammation and
swelling were gone. The perforation remained, but in other respects the ear
had recovered. I gave the patient some necessary directions with regard to
the care of his ear, with especial reference to the perforation, and dissuaded
him from further treatment. In Sept., 1851, a year later, he called upon
me for advice on account of slight vertigo with uncomfortable sensations in
the same ear. I was surprised to find, on examination, that no perforation
existed. The aperture was healed. The surface of the membrana tym-
pani was clearly visible, but the membrane itself was opaque and almost
white like paper. The process by which the aperture was filled up had
thickened the membrane. He was moderately deaf on that side ; but not-
withstanding this, his ear was in a much better condition than could have
been expected.

I do not mean to imply, by the preceding remarks, that either acute or
chronic perforations can always be healed. On the contrary, there are a
great many which will refuse to close up, under the most careful management.
I have repeatedly tried to stimulate the edges of old perforations, and excite
inflammation enough to induce this closure, and found my efforts unavailing.
But I have also had the satisfaction of seeing many grow together, after local
treatment, which several years ago, I should have regarded as incurable.
Chronic cases are the most unsatisfactory to treat. Acute cases are more

48 Clarke, Perforation of the Membrana Tymjpani. [Jan.

easily controlled. As I have already insisted, the local management of acute
perforation is all important. When an appropriate treatment is instituted
sufficiently early, it will be found that a majority, instead of a minority of
cases, will terminate in a complete restoration of the membrane. The cases,
which have been given in detail, are all of them favourable. They were
selected on that account. Unfavourable cases will readily suggest themselves
in abundance to any one, and need not be detailed. The object of giving
them is to show, not what can always be accomplished, but what can frequently
be accomplished.

These remarks naturally bring us to the third subject of inquiry, suggested
by the analysis, viz., the treatment of chronic and incurable perforation.
When disease of the ear results in perforation of its tympanal membrane,
and the aperture, either on account of its size or from other causes, refuses to
heal, it is not safe for the patient to neglect his ear, as if it were an organ of
no further use to him, or one with some incurable malady, which does best
when let alone or least cared for. Neither should any physician, when con-
sulted on account of deafness, which on examination he finds to be caused, in
part at least, by this lesion, advise the patient to do nothing. It is very true
that there may be no use in trying to induce healing of the perforation. It
might be dishonesty or quackery to hold out promises of restoration of hear-
ing. Yet the ear should have especial care, on account of its imperfection,
and the dangers to which its imperfection exposes it.

The membrana tympani, besides other offices which it fulfils, serves as a
protection to the delicate tissues and machinery of the middle and internal
ear. When the membrane is ruptured, and especially when, as in most in-
curable cases, the perforation is of large size, this protection is taken away.
Inflammation is much more likely to occur in the mucous membrane of the
cavity in consequence of external changes of temperature. Particles of dirt,
cold water, and foreign substances of various sorts, are more likely to get into
the cavity of the tympanum, and produce serious trouble there. Patients
themselves frequently persist in pouring into the meatus all sorts of oils,
essential as well as fixed oils, and sometimes even substances like brandy and
lye, and laudanum, and tobacco infusions, and even urine, for the purpose of
"curing deafness." These articles, generally some patent nostrum, or the
recipe of an old woman, or an Indian doctor, are of course poured through the
aperture into the middle ear. Some of the severest instances of agonizing pain
and of dangerous inflammation, with cerebral symptoms, which I have ever
witnessed, have been caused in this way. It is a physician's duty, in cases of
perforation, to guard his patient as far as possible, against these sources of
danger, as well as to teach him how to take care of his infirm organ.

The treatment of incurable perforation, then, is of two kinds: first, the
prophylactic treatment, or the care of a perforated membrana tympani ;
secondly, the prompt treatment of any affection which complicates perforation.
Let us examine these points briefly in inverse order.

1858.] Clarke, Perforation of the Membrana Ti/mpani.

49

Perforation is frequently complicated with inflammation of the dermal
tissue of the meatus; with polypus, or fungoid growths; with congestion, or
catarrhal inflammation of the mucous membrane of the tympanal cavity ; and
it may of course be complicated with other aural affections. The above are
the most frequent. They are generally attended with otorrhoea. Sometimes
there is a slight, inodorous, but constant mucous secretion, which pours
through a perforated membrane, and which seems to be kept up by the ex-
posure of the cavity to the external air. But from whatever cause the otor-
rhoea may proceed, the meatus should be kept as free from any morbid
secretion as possible. Gentle syringing with tepid water should be practised
often enough, whether it be done once a day or half a dozen times a day, to
keep the ear passage clean. No unhealthy discharges should be allowed to
remain in contact with the undestroyed portions of the membrana tympani,
or to burrow about in the tympanal cavity, or in the mastoid cells. The use
of the syringe should be continued as long as the discharge exists, whether
the latter continue for a week or two only, or for years. Patients should be
instructed upon this point. They should be told that a perforated membrane
is apt to keep up a discharge, and that they must not be weary of removing
it. If they omit cleansing the ear, under the notion that it does no good —
that the ear will do just as well without it, they expose themselves to
the danger of an extension of the disease, and possibly to the danger of
serious or fatal cerebral complications. Whatever other treatment besides
syringing may be necessary, will depend upon the condition of the ear.
Polypus, inflammation of the dermal tissues, catarrhal inflammation of the
cavity, &c, should be treated in the same way as if perforation did not exist.
It is not within the design of this paper to describe such affections or their
treatment. If there are no complications, no local treatment beyond occa-
sional syringing when there is a discharge, is needed. If there is no otorrhoea,
the syringe should not be used.

The prophylactic treatment, or the constant care of a perforated membrane,
is not less important than the management of any affection which may com-
plicate it. A perforated membrane is an imperfect protector of the middle
ear. The watchfulness of the patient should make up for the imperfection of
the organ. The constant wearing of wool or cotton in the orifice of the
meatus is more likely to be injurious than beneficial. It prevents a free and
healthy circulation of air in and out of the meatus, and confines in the passage
any discharge or unhealthy secretions which may accumulate there. But
whenever a person with an aperture through the membrane is exposed to high
winds or to unusual cold, or to draughts of air about the head, or to driving
mists at any season, whether on land or sea, he should use some means of
artificial protection for the affected ear. In such cases a plug of wool will
answer to keep off the temporary exposure. A pad of silk or cotton, adapted
to the hollow of the concha, which may be applied or removed at will, is
better still. Cold water should never be poured into the ear. Whenever a

50

Clarke; Perforation of the Membrana Tympani.

[Jan.

river or sea bath is taken, the meatus should be carefully closed with cotton
or other substance, so as to completely prevent the entrance of water. In
short, all irritating substances should be carefully excluded. And especially
should the patient be warned not to pour into the passage oils or washes, or
other liquids, with the vain hope of regaining his hearing. Nothing of that
sort should be used, except by the prescription of a physician.

Of late years, various attempts have been made to find a substitute for a
destroyed or perforated membrane. Mr. Yearsley of London published in
the Lancet in 1848, several articles upon the advantages resulting from
applying a pellet of moist wool over a perforation, or of substituting it for a
destroyed membrane. Since then Mr. Toynbee has endeavoured to make a
substitute for the membrane out of vulcanized India rubber. He has invented
several ingenious instruments for the application of his artificial membrane,
and has not only published a series of articles explaining his discovery,
but has published an account of it, with cases, in a separate pamphlet or
monograph. Mr. Nottingham, of Liverpool, in his recent work on Diseases
of the Ear, gives a number of cases illustrating the advantages resulting from
such an artificial substitute. I have made the same application myself in a
large number of instances, but my observation does not confirm the enthusi-
astic statements of Mr. Yearsley and Mr. Toynbee. I should speak of its
advantages in much soberer language.

It must be conceded, however, that in many cases of perforated membrane,
the stopping of the hole by any unirritating material, such as moist cotton,
or wool, or India rubber, or gutta percha, or even paper, improves the hearing.
By rendering the partition between the meatus and the cavity of the tym-
panum complete, by absolutely shutting off the latter from the former, the
hearing is generally improved. Whatever may be the physiological explana-
tion, the fact is indubitable. The improvement is sometimes moderate, and
sometimes decided. But a great hinderance to the use of an artificial sub-
stitute is the difficulty of applying it, and after it is applied, of making it
keep its position. Unless the patient can apply it himself, as a pair of spec-
tacles can be put off and on, it is of little practical value. No person could
go to a physician or aurist every day to have his hearing apparatus adjusted.
After it is applied, it is apt to slip out of place. These practical objections
to the employment of an artificial substitute for the membrane have not yet
been overcome. When they are overcome, a substitute for the lost membrane
will be of great value. A case occurs, now and then, of an individual who
easily acquires the power of adjusting the substitute himself, and who is
enabled to keep it in situ. For such persons I have found the simple pellet
of cotton or wool decidedly preferable to the India rubber membrane of Mr.
Toynbee.

The conditions which are most favourable to the use of moist cotton or other
substitute for the membrana tympani have not yet been clearly recognized.
So much of the auditory apparatus is hidden from view that it is impossible

1858.] Clarke, Perforation of the Memhrana Tymjpani.

51

to determine these conditions by inspection alone. The following appear to
be necessary. The perforation should be larger than a mere puncture through
the membrane ; it should occupy a quarter or a third of the membranous
surface. On the other hand, the membrane should not be entirely destroyed.
At least a bare rim, marking its insertion into the bony meatus, should be
present. The Eustachian tube should be open. There should be a moderate
amount of secretion from the cavity of the tympanum, enough to moisten it,
but not enough to clog the parts with the discharge. There should not be a
congested or granulated state of the mucous membrane of the cavity. Acute
inflammation, or fungus, or polypus, should not exist. In a few words, the
conditions, or at least some of the conditions, necessary to the use of any
artificial membrane, are a hole of moderate size, patency of the Eustachian
tube, moisture of the cavity, the absence of acute or chronic inflammation
and of foreign growths. Moreover, the cotton or wool should be accurately
adjusted to the perforation. A pellet not much larger than the hole should
be selected. It should be moistened in water, or in glycerine and water. In
some instances, olive oil answers a better purpose than anything else. Ex-
periment alone can determine which is best. The less the pellet is worked
over by the fingers in preparing it the better. A very convenient way of
applying it is to pass a linen thread through the centre of a bunch of
cotton or wool, and tie it so as to hold the bunch by the thread. The free
ends of the thread can then be passed through a small and hollow silver or steel
tube. A tube of the size of a large wire or of a probe is large enough. By
means of the thread it is easy to keep the pellet close on the end of the hollow
tube, and carry it down through the meatus to the perforation. When it is
accurately adjusted, the tube is withdrawn and the cotton left. The thread,
which lies in the meatus, is a convenient means of removing the pellet when
it is desirable to do so. The operator can generally learn, by the sensations
of the patient, when the cotton is properly adjusted. The patient feels that
it is in the right place, and exclaims that he hears better.

As I have already remarked, too much must not be expected from this
substitute for a membrana tympani. In many cases, it cannot be applied.
In many cases where it can be applied it is of no use. In other cases, where
appropriate conditions exist, it is of service. In a few cases, the advantage
is very great. If it ever acts as a source of irritation in the passage, it should
not be used. Whenever it is employed, it should be removed at night and
a fresh one applied the next morning.

It is now time to bring this long article to a close. It has attained a length
which the writer was far from anticipating when it was commenced. If it
should serve in any degree, however slight, to draw the attention of observant
physicans to the study of a lesion of the auditory apparatus, so important as
perforation, and especially to perforation as one of the complications of the
exanthemata most likely to occur, and often of possible prevention or relief,
it will accomplish all that he expected from it.

52

Flint, Pulmonary Tuberculosis.

[Jan.

Art. II. — Clinical Report on Pulmonary Tuberculosis; giving an abridged
account of Twenty-Four Cases of Arrested Tuberculosis, with Remarks on
the Management of the Disease. By Austin Flint, M. D., Professor of
Clinical Medicine and Medical Pathology in the University of Buffalo,
N. Y.

Few subjects in practical medicine are more important than the manage-
ment of pulmonary tuberculosis. It is sufficiently established that recovery
from this disease may take place even when the lungs have been damaged to
a considerable extent. This has been settled by autopsical researches, taken
in connection with the ante mortem history, in numerous instances coming
under the notice of competent, trustworthy observers. Since the means of
diagnosis have been rendered precise and even demonstrative by the modern
methods of physical exploration, clinical observations have shown that in a
certain proportion of cases the deposit of tubercle, after a longer or shorter
period, may cease, and the destructive processes incident to the progress of the
disease, either be suspended or fail to occur. In short, the affection may be
arrested ; and if the injury done to the pulmonary organs be not completely
repaired by the cicatrization of cavities, absorption of the exuded material, or
by other modes, the condition of the patient in consequence of the non-pro-
gression of the disease is compatible with comfortable health. Now, what
measures of management are most likely to effect or favour the arrest of pul-
monary tuberculosis? Does it lie within the resources of medical art, by
judicious measures of management to accomplish or promote this object? If
there are not any known efficient means for attaining directly to this end, is
it true that certain therapeutical agencies which have been, and still are em-
ployed, to a greater or less extent, in the management of this disease, exert
an unfavourable influence, and hence the object may be indirectly favoured by
avoiding them? I shall endeavour in this paper to contribute somewhat to
the knowledge on which must rest our ability to answer these questions. I
propose to select from my clinical records the cases of pulmonary tuberculosis
in which the histories afford proof of an arrest of the disease, or a progress
so slow as to be inappreciable. I shall present a brief account of each of these
cases, and, afterward, institute a comparison as regards the points pertaining
to management in which more or less of the cases agree. In these points of
agreement lie the means which, it may be supposed, have been concerned in
arresting the progress of the disease. Is it found that certain remedies en-
tered into the treatment of all, or the greater part of the cases, then it is a fair
presumption that to one or more of these remedies the favourable result is due
in a greater or less degree, with this important provision, viz., that they have
not entered into the treatment of these cases in common with those in which
the disease has advanced steadily to a fatal termination. The same remark is

1858.]

Flint, Pulmonary Tuberculosis.

53

alike applicable to measures of management relating to diet and regimen. The
great question, in short, is, in what particulars do these cases, as regards
management, agree among themselves and differ from other cases in which
the progress of the disease is unfavourable? Other questions will arise in
connection with the comparison, which 1 will not now anticipate.

The following inquiry may properly be premised: What constitutes ade-
quate evidence of arrest or non-progression of the disease? In the living
body we can judge concerning these points only by means of local and general
symptoms, and, in some measure, by physical signs. With our knowledge of
the laws of pulmonary tuberculosis, if a patient present for successive weeks
and months a marked improvement in the symptoms referable to the lungs;
viz., cough, expectoration, respiration, and also in the condition of the
body as denoted by increase of weight and strength, the disease is certainly
not progressing, and may be retracing its steps toward recovery. The latter
may be considered to have taken place when pulmonary symptoms have been
wanting for several months and a healthy condition of the body is restored.
A comparison of the results of physical exploration before and after the arrest
of the disease, will furnish evidence, first, of the correctness of the diagnosis,
and, second, of the improvement which has taken place in the state of the
pulmonary organs, as well as of the permanent effects of the disease upon
these organs.

There are various pathological questions relating to tuberculosis which are
not only interesting but important in their practical bearings. Such, for ex-
ample, are, the nature of the exudation process, whether inflammatory or other-
wise; the capability of the deposit re-entering the vessels by absorption; the
relations of the local affection to a constitutional cachexia and diathesis; the
retrogressive changes which the exudation undergoes, and the different modes
in which recovery is effected. It does not fall within my plan to discuss any
of these questions or others of a like character. I purpose, at present, to
study the management of the disease exclusively in a clinical point of view,
and to restrict myself to the cases which have come under my own observa-
tion. The cases which I am able to gather exemplifying arrest of the disease
are twenty-four in number. The collection is not large, but in view of the
well known intrinsic tendency of the disease (according to past experience) to
advance steadily onward to a fatal termination in the vast majority of cases,
the number is not insignificant. It is highly probable that my records would
have supplied a greater number, were it not that in a pretty large proportion
of the cases of the disease coming under my notice, the patients were from a
distance, and I have not taken pains to procure information respecting the
subsequent history. As it is, the collection is, perhaps, sufficiently large to
render tedious an account of the cases severally. I shall endeavour to obviate
this as far as possible by condensing the histories and omitting details which
are not important with reference to my present object. The value to be
attached to the account of these cases individually, and to the results of an

54

Flint, Pulmonary Tuberculosis,

[Jan.

analysis of them, will of course depend on the correctness of the diagnosis.
Until within late years, instances of supposed recovery from phthisis were un-
reliable in consequence of the want of certainty in the means of determining
the presence of the disease. This uncertainty has been removed by the dis-
covery and improvement of the physical exploration of the chest. Physical
signs in conjunction with symptoms, render the diagnosis of pulmonary tuber-
culosis positive in the vast majority of cases. I shall include in this collec-
tion only cases in which the diagnosis rests on the conjoined evidence of signs
and symptoms. With some exceptions, the results of exploration of the chest,
together with the previous history and existing condition of the patient, were
noted prior to the arrest of the disease. In a few instances, however, the
cases came under observation subsequently to the arrest, and the diagnosis
was made retrospectively; that is, the physical signs and the previous history
were deemed sufficient to render it positive that the patient had been affected
with tuberculosis.

Case I. — Abundant Tuberculous Deposit; Arrest and Recovery ; Exa-
mination Jive and a half yea.rs after the case came first under observation. — ■
Ellen Thornbury, unmarried, aged 19 years, came under observation first in
Dec, 1850. Not aware of any hereditary predisposition to phthisis in her
family. Was attacked about two years previous with haemoptysis, not pro-
fuse. Slightly bloody expectoration continued for three weeks. Was in her
habitual good health up to four or five months prior to the haemoptysis, and
did not consider herself ill at the time this event occurred. Prior to this
event was less active and buoyant than usual, but does not recollect that she
had cough. Had been somewhat hoarse and was conscious of a ticking sound
in respiration at night. Was always delicate and subject to heavy colds in
the spring season especially.

She was engaged in weaving when the haemoptysis occurred, and had worked
hard. At the moment when she began to spit blood, she was carrying a pail
of water. Had been engaged in school teaching previous to this attack. She
kept the bed for three weeks after the haemoptysis, and had for a week stitch
pains in the side. She does not recollect that she coughed until the following
spring, when she noticed a cough and a thick yellowish expectoration. Dur-
ing this spring (1849), she had a second attack of haemoptysis, and six weeks
afterward, a third. Raised a little blood on the other subsequent occasions,
and still another recurrence took place in the autumn of 1849.

She has lost flesh moderately, but does not appear emaciated. Her aspect is
not morbid. The cheeks present some colour. Has occasionally had chilly
sensations. The appetite has generally been good. Was subject to diarrhoea
during the last summer and autumn. For the last two weeks has perspired
at night.

She was attended by a botanic practitioner for the eight or nine months
following the first attack of haemoptysis. In June last she went to a water-
cure establishment and remained there five weeks. She continued the water
treatment — the wet sheet, hip-baths, etc. — for three months afterwards. Has
not worn flannel since leaving the water cure. The' menses have been absent
since June last. She was regular prior to the first haemoptysis, but irregular
since that event.

The pulse is 120, small, vibratory. Respiration 25, and not laboured.
She experiences want of breath on exercise.

1858.]

Flint, Pulmonary Tuberculosis.

55

She sits up all day; has lost strength but is not very weak.

The foregoing account was noted when she came under observation in Dec,
1850, together with the following physical signs : —

Dulness in left supra and infra-clavicular regions; equal resonance at the
base of the chest and laterally on the two sides. Marked dulness over left
scapula.

Respiration in front, left side, superior third, feeble, non-vesicular, distantly
bronchial; right side more evolved and vesicular. Behind, over the left
scapula, feeble and non-vesicular, expiration prolonged; slight crackling and
occasional sibilant rale. Less superior-costal movement on left side obvious
to the eye. The voice slightly bronchophonic at the summit of left side in
front and behind.

She left the hospital Jan. 11.

In Jan., 1852, this patient again came under my observation. She had
progressively improved in strength during the year that had elapsed, and had
gained in weight considerably. She presented a healthy aspect. The cough
and expectoration had steadily diminished, and at this time the matter expec-
torated was quite small.

I had prescribed a year previous the cod-liver oil, which she continued to
take most of time during the intervening period. She had taken in all, three
gallons of the oil.

She has been in the country during the past year, occupied in doing house-
work, and more or less out of doors. She has at no time been confined to
the bed.

The appetite and digestion were good. The menses had returned six weeks
before, and again the day previous to this examination. The pulse was 80
and the respirations 20 per minute.

The physical signs were as follows. Summit of left side of chest depressed,
and expansibility lessened. Respiratory murmur at left summit in front
feeble, the inspiration shortened, more acute than on the right side, and no
expiratory sound. Behind in left inter-scapular space and at lower angle of
scapular, a murmur with both acts of respiration, resembling a friction sound.
Marked dulness on percussion at the summit of the chest on left side, in front
and behind.

This case came next under observation in August, 1855. She applied to
me at that time for a certificate of sufficient health to warrant her being re-
ceived as a candidate for admission into the order of the Sisters of Charity.
She presented a healthy appearance, having considerable colour in the cheeks.
She had slight cough and expectoration in the morning, and had recently had
a very slight haemoptysis.

The physical signs noted at this time were as follows. Upper third of
chest on the left side, notably depressed. Resonance on percussion notably
less at the left than at the right summit. The inspiratory sound notably less
intense at the left summit than at the right, but no marked disparity in pitch
or quality. On the left side a prolonged sibilant rale in expiration, and
no expiratory sound appreciable on the right side. Yocal resonance notably
greater on the left than on the right side.

I saw the patient again in July, 1856. Her aspect denoted health, and
she reported well, being free from any symptoms of pulmonary disease.1

1 This case is referred to in my work on Physical Exploration and the Diagnosis of
Diseases Affecting Respiratory Organs, page 508.

56

Flint, Pulmonary Tuberculosis.

[Jan.

Remarks. — This is one of the most striking of the cases contained in this
collection. The patient presented evidence of an abundant tuberculous de-
posit, and at the first examination had well marked tuberculous fever, the
pulse being 120. Five and a half years afterwards, the pulmonary symptoms
had nearly disappeared, and she was much disappointed that I did not deem
her prospect of health sufficiently good for her to undertake the duties of a
Sister of Charity. A year afterwards, the pulmonary symptoms had entirely
disappeared, and she reported quite well, the physical signs showing that the
lungs bad received a certain amount of permanent damage, but not enough to
compromise health. Although pains were not taken to determine the exist-
ence of excavations, it can scarcely be doubted that they occurred. Dating
from the first haemoptysis, the duration of the disease was between seven and
eight years. The processes of recovery occupied a period of about six years.

The only medicinal remedy employed in this case was the cod liver oil. A
considerable change was made in the habits of life. Leaving the duties of a
school teacher and the subsequent occupation of weaving, she engaged actively
in housework, and was often in the open air. She persisted in the latter
duties, and in not considering herself an invalid. No antiphlogistic or debili-
tating measures were at any time employed.

This case possesses so much interest that I have given to it greater space
than I shall generally accord to the cases which will follow.

Case II. — Small Tuberculous Deposit; Arrest and Recovery. — Dr. M.
applied to me for an examination of the chest and advice in September, 1851.
The following account is from the record made at that time.

He is about 22 years of age. Has recently obtained his medical degree.
He has applied himself very closely to medical studies, and has also been
occupied as an operator in a telegraph office. His mother died at 40 years of
age with what was called quick consumption. He lost a sister 13 years of
age with some pulmonary affection. His father is living.

He had slight haemoptysis some time ago ; has looked pallid for some months
and lost weight. Has not now and has not had cough. Respirations not
accelerated.

On bathing day before yesterday had slight recurrence of haemoptysis. He
noticed that the action of the heart was much increased at the time.

At the examination the pulse was much accelerated, which may have been
due, in a great measure, to nervous excitement. Sounds of heart normal.
Distinct dulness on percussion over left clavicular and infra-clavicular regions,
and still more marked over the left scapula. No spinal curvature. On aus-
cultation, slight but distinct crackling in both infra-clavicular regions, during
the inspiratory act : a species of dry, slowly evolved crepitation.

I advised him to throw aside his books and go into the country for several
months, devoting himself to out-door sports.

Three months afterwards I repeated the examination of the chest. In the
mean time he had beeu in the country, hunting, fishing, etc. His health had
become excellent. He had gained obviously in weight. He was adequate to
perform as much active exertion as most young men of his age. For example,
he rowed a boat a short time before sixteen miles. He had, however, as he
thought, contracted a cold three weeks before, and he had some cough and

1858.]

Flint, Pulmonary Tuberculosis.

57

mucous expectoration. Dulness on percussion in the left infra-clavicular
region still existed, and over the left scapula. In the left infra-clavicular
region a crumpling sound as if produced by dry parchment existed both in
inspiration and expiration, heard during the whole of both acts. The same,
but less in degree, existed on the right side.

He had just begun to take cod-liver oil. I advised its continuance, and
also habits of active exercise.

The following winter he passed at the south, and very much in the open air.
He was then appointed assistant surgeon in the army, and has passed the last
four years on the frontier in Texas, performing oftentimes laborious out-door
duties. His health has been good. He has been entirely free from symptoms
of pulmonary disease. I received this statement from him a few days prior
to the time I am now writing, and his appearance denoted perfect health.

Remarhs. — The evidence afforded by the symptoms and physical signs of a
small tuberculous deposit in this case is positive. A speedy arrest followed
change of habits, exchanging sedentary pursuits for active exercise out of
doors. The recovery was complete, the patient having now remained well
for nearly six years.

Aside from the cod-liver oil, which was continued but for a short time, the
management consisted in change of habits of life as regards out-door exercise.

Case III. — Small Tuberculous Deposit; Arrest and Recovery; no
Management. — Dr. B., of Gowanda, Erie Co., N. Y., requested an examination
and advice in May, 1853. His age was 28. Mother died of phthisis. Been
engaged in medical practice three years.

In October, 1852, after exerting himself in throwing down some bay from
a scaffold, he had slight haemoptysis. Up to that moment he had supposed
himself to be in perfect health. No cough or other pulmonary symptoms
preceded or followed this attack of hemorrhage

In Jan., 1852, he had a recurrence of the haemoptysis. This occurred while
he was perfectly quiet, sitting in his office. The hemorrhage was more abund-
ant than before, amounting to two ounces. No cough or other symptom suc-
ceeded. More recently two slight attacks of haemoptysis had occurred. He
notices that he is a little hoarse. Has had slight soreness in the chest, first
on one side and next on the other. His weight has not diminished since the
first haemoptysis. The pulse is not and has not been accelerated. The same
is true of the respirations.

On examination of the chest, relative dulness exists over the right clavicle,
and not elsewhere. The respiratory murmur at the left summit is well evolved
and vesicular, no expiratory sound being appreciable. On the right side it
is relatively feeble, and a dry, weak crepitation accompanies both inspiration
and expiration, obscuring the characters belonging to the murmur. Slight
vocal resonauce at the summit on the right side, and none on the left.

I advised him to attend to hygiene, and, if symptoms of tubercle should
become more evident, to change his residence for a southern climate.

In September, 1854, Dr. B. called upon me and reported himself to be in
as good health as he had been for several years. He had increased in weight.
Had had recurrence of the haemoptysis four times, but very slight with one ex-
ception. Has no habitual cough or expectoration. Has continued to practise
in Gowanda up to the date of this record, 1st Sept., 1854. On an examination
of the chest, I found marked dulness over the right clavicle. The respiratory

58

Flint, Pulmonary Tuberculosis.

[Jan.

murmur at the right summit was feeble and deficient in vesicular quality,
higher in pitch than on the left side, and a feeble, prolonged expiration was
appreciable (broncho-vesicular respiration). At left summit the respiratory
murmur was vesicular, well evolved, and no appreciable expiratory sound.
No rales on either side.

Remarks. — The evidence of the physical signs, in conjunction with the
repeated attacks of haemoptysis, will probably be deemed sufficient to establish
the presence of a small tuberculous deposit near the apex of the right lung.
The indications of the tuberculous cachexia, exclusive of the physical signs
and the haemoptysis, were wanting. The arrest of the disease may be said to
have been spontaneous. The cachexy was exhausted, as it were, by a small
exudation, and the latter speedily passed through retrogressive changes, or
remained quiescent.

There was, in reality, no management in this case, the patient not only
refraining from remedies, but not altering materially his habits of life. His
duties as a practitioner in the country, of course, involved much exercise in
the open air with considerable exposure.

Case IV. — Pulmonary Tuberculosis of Twenty-seven Years' Standing ; the
Disease Non-progressive ; Recovery not taking place. — This case came under
my notice in March, 1855, at Louisville, Ky. The patient, Mr. 0., was 51
years of age. His first haemoptysis had occurred twenty-seven years before.
Prior to that hemorrhage, he had been affected with cough, and had for many
years been a dyspeptic. He raised at the first hemorrhage about a gill of
blood. Since then, haemoptysis has recurred about half a dozen times. The
last attack was during the winter of 1854-5. The hemorrhages have always
been slight. He had never been free from cough since the first attack of
haemoptysis. For many years the cough and expectoration had remained
about stationary. He thinks he expectorates about a gill in twenty-four
hours. His weight is about 108 pounds, and has varied very little during
the last twenty years. He weighed 125 pounds before the first hemorrhage.

He has kept about ever since the first hemorrhage, having been in business,
successively, as an apothecary, a seller of dry goods, and a wholesale grocer.
For many years he has only taken some slight palliative remedies, and has
not had medical advice.

Both parents were free from pulmonary disease.

His appetite and digestion have generally been good.

The chest is considerably distorted. The spine is curved laterally ; the
sternum at the upper part projects, and the projection extends on either side,
but most on the right. Percussion sound relatively dull on the right side ;
the signs obtained by auscultation are not noted.

Remarks. — Although I have failed to note the physical signs, with the
exception of dulness on percussion on one side, there can hardly be room for
doubt that this person was affected with tuberculosis twenty-seven years
before he came under my notice. It is probable that an arrest of the disease
had long since taken place, but the pulmonary lesions were of a nature to
preclude complete recovery.

This case had never received any medical management. The patient had

1858.]

Flint, Pulmonary Tuberculosis.

59

taken only some simple palliative remedies, without placing himself under
the care of a physician. Nor did he at any time materially alter his mode of
living. His habits were temperate and regular, and he persistingly devoted
himself to business as far as his strength would permit. At the time of my
record of the case, and when I last saw him, a year afterwards, he did not
consider himself an invalid. The arrest of the disease in this instance must
have been determined mainly by an intrinsic tendency to that result.

Case V. — Pulmonary Tuberculosis of Eighteen Years' Standing; the
Disease Non-progressive ; Recovery not taking place— -Between this case and
the preceding there is a striking coincidence, and it is a curious fact that the
persons are husband and wife. This case also came under notice in March,
1855.

Mrs. 0. was then 45 years of age, and had been married twenty-one years.
Had never had children. Mother died of apoplexy, and father met with a
violent death.

She was attacked with haemoptysis eighteen years before, when she was 27
years of age. This was three years after marriage, her husband having then
been tuberculous for several years. Prior to this hemorrhage she had had good
health, save that she was subject to paroxysms of sick headache. The
haemoptysis has recurred frequently ever since. She .has averaged eight or
ten attacks yearly. The quantity of blood lost has generally been small, but
sometimes copious. She has never been confined to the bed except for a few
days at a time, when the hemorrhage has been considerable, or when affected
with either pleurisy or pleuralgia, which for several years recurred every
winter, lasting for two or three days. For the last seven years she has been
exempt from the latter attacks.

Up to four years ago, the menses were regular, but since then they have
been more or less irregular.

She has had cough and expectoration ever since the first haemoptysis; none
before. These symptoms have remained about stationary ; if there is any
change within the last few years, there has been some improvement. The
quantity of expectoration daily is about half an ordinary teacupful. It occurs
mostly in the morning.

Her weight is within a few pounds of what it was prior to the first hemor-
rhage. She weighs about 130 pounds.

Generally the appetite and digestion have been good.

About twelve years ago she had night- sweats for several weeks. She
remained within doors all the winter of that year.

She states that if she is in the habit of going out of doors daily, she feels no
inconvenience from want of breath ; but after remaining in the house and
sewing for several days in succession, she lacks breath on taking exercise.

She has taken very little medicine, following the example of her husband
in this respect. She has never had medical attendance, except when attacked
with pleurisy or copious hemorrhage.

There is lateral curvature of spine in this case. The right side is relatively
dull on percussion at the summit, in front and behind. Right clavicle
is projecting; vocal resonance marked at the right summit, and absent at the
left. Respiratory murmur more evolved on the left side ; sounds and impulse
of heart normal.

This patient considered herself in tolerable health, taking charge of a family
with six boarders.

60

Flint, Pulmonary Tuberculosis.

[Jan.

Remarks. — The remarks appended to the preceding case are equally applica-
ble .here.

Case VI. — Small Tuberculous Deposit; Arrest and Recovery. — A. C.,
aged 19, consulted me, May, 1852, for a cough which had existed for three
weeks. The cough was at first dry, but had recently been accompanied by
expectoration of frothy mucus. He had not been as well as usual for some
time prior to the appearance of the cough, but there had been no definite ail-
ment. He was serving his time as a printer's apprentice, and for a couple of
years had worked steadily as a compositor. The pulse was accelerated. Had
not noticed any want of breath on exercise.

On examination of the chest, at the summit of the left side, the percussion-
sound was relatively dull ; the murmur of inspiration more acute, and the
vocal resonance greater than on the right side. No rales.

I advised him to quit work, and prescribed for the cough a solution of the
sulphate of morphia dissolved in the syrup of senega.

On the 16th of June following, he again consulted me. He had remained
away from his business for two weeks, and during that time improved rapidly.
His cough, which had ceased, again returned a few days previous, and he
complained of a sense of debility. Repeating the examination of the chest,
I found marked dulness on percussion in the left clavicular and infra-clavi-
cular regions; the respiration at the summit of the chest on the left side was
broncho-vesicular with an expiratory sound higher in pitch than the inspira-
tory. On the right side the respiratory murmur was feeble, vesicular, and no
sound of expiration. The pulse was 76. Respirations, 28.

I advised him to give up the occupation of a printer, and to be as much as
possible in the open air. In addition to the cough mixture mentioned al-
ready, I prescribed a solution of the citrate of iron and the sulphate of quinia.

This patient adopted my advice to relinquish the business of a printer, and
he obtained a situation as salesman in a paper warehouse, where he has since
remained. The pulmonary symptoms soon disappeared; he regained his
strength and healthy aspect, and is now in good health.

A brother of this patient died under my care with phthisis, eighteen
months prior to the date of the first consultation.

Remarks. — The history and physical signs sufficed for the diagnosis of a
small tuberculous deposit. An arrest of the disease followed speedily the
change from the confinement to the printer's form to an occupation involving
more exercise both in and out of doors, this change being preceded by a vaca-
tion devoted to recreation.

No medical treatment was pursued in this case except the remedy to allay
cough, and the solution of iron and quinia.

The recovery has been permanent as well as complete, more than five years
having elapsed since his restoration to health.

Case VII. — Small Tuberculous Deposit; Arrest and Recovery. — Mr. N.
came under my observation while I was engaged in making a series of exami-
nations of the healthy chest in the winter of 1854-5. He was then attend-
ing medical lectures at Louisville, and had been a practitioner of medicine for
four years. Father not living, but did not die with a pulmonary affection.
Mother still living. His age was 29.

He enjoyed good health up to about seven years prior to the date of my

1858.]

Flint, Pulmonary Tuberculosis.

Gl

record, Jan. 1855. He was at that time engaged in school-teaching. After
continuing this occupation for a year or so, his health suffered. He lost in
weight; his appetite was impaired, and his muscular strength diminished.
He had a slight haemoptysis six years prior to the date of my record, not pre-
ceded or accompanied by cough or any other pulmonary symptoms. Had
no medical treatment. Took more exercise, but continued school teaching.
He had a recurrence of the hemorrhage four or six months afterwards, more
abundant than the first. Still no cough nor other pulmonary symptoms save
a sense of constriction in the chest. In the mean time, his general health
had not improved. These attacks were in 1848. He attended medical lec-
tures at Lexington during the winter of 1849-50. • During this winter he
had a cough with small mucous expectoration and a sense of constriction felt
especially in the left side of the chest. After the close of the lectures he had
a third attack of hsemoptysis, which was quite profuse; he thinks he raised a
pint of blood- He continued to raise blood for several days after this attack.

Shortly after this he engaged in medical practice in the country. His
practice lay in a rough portion of the State of Kentucky, near Frankfort.
His habits became very active. He continued in active practice up to his
coining to Louisville to attend lectures in the autumn of 1854. His cough
ceased soon after he commenced practice. He became strong and vigorous,
gained in flesh, and had no symptoms of pulmonary disease afterwards.

He had no medical treatment at any time, except that he took a little ace-
tate of lead, opium and tannic acid during the last hemorrhage. His aspect
was perfectly healthy. His weight was about 155 lbs. His habits of living
were temperate.

On examination of the chest, the following signs were noted : Chest sym-
metrical; the superior costal movement on forced breathing somewhat greater
on the right side; slight but distinct relative dulness at the summit of the
left side in front, over the scapula behind and in the interscapular space. At
the base of the chest, behind, the percussion-sound equal on the two sides.
The respiratory murmur on the left side, at the summit in front, and over the
scapula, scarcely appreciable on forced breathing, even with Cammann's
stethoscope. On the right side, tolerably evolved and vesicular. Below the
scapula the murmurs were evolved and equal on the two sides. Vocal reson-
ance everywhere more marked on the right side.

Remarks. — The diagnosis in this instance was retrospective; but taking
the physical signs in connection with the history, the occurrence of a deposit
of tubercle six years prior to the examination can hardly be doubted. An
arrest .of the disease in this instance followed an exchange of the confinement
within doors, and sedentary habits of school teaching and attending medical
lectures, for the duties of a medical practitioner in a rough country, requir-
ing him to be in the open air on horseback much of the time, and involving
not a little exposure. This constituted the sole management. The recovery
was in this case complete and permanent.

Case VIII. — Small Tuberculous Deposit; Arrest and Recovery. — Mr. T.,
of Lewistown, N. Y., consulted me in June, 1848. He was 20 years of age,
and was pursuing the study of the law. His health had not been good since
an attack of bilious fever the preceding spring. A dry cough had existed
for some weeks. He had lost much in weight, and his countenance was pal-
lid. He was able to be about, although considerably debilitated. Appetite
No. LXIX.— Jan. 1858. 5

02

Flint, Pulmonary Tuberculosis.

[Jan.

variable. Complained of no embarrassment of respiration, but panted after
exercise, and tranquil respiration was hurried, with dilatation of the nostrils.
The pulse was accelerated, exceeding 100 per minute, and had a vibratory,
thrilling character.

On examining the chest, no obvious disparity between the two sides in the
percussion resonance was found; but in the left infra-clavicular region there
was a distinct, although slight crepitation at the end of the inspiratory act.

With the foregoing physical signs, although few, in view of the marked
symptoms in the case, the patient was regarded as tuberculous. He was ad-
vised to throw aside his books and live as much as possible in the open air.
Tonic remedies were prescribed.

The patient was referred to me by Dr. Eddy, of Lewistown, and nine
months after the date of the examination, Dr. E. informed me that he had
completely regained his health, had engaged in business, and gone to Cali-
fornia.

Remarks. — The physical sign noted in this case may not seem sufficient
to establish the correctness of the diagnosis. The evidence is certainly less
complete than in the great majority of the cases in this collection, but taking
the facts contained in the history into due consideration, I think that there is
not much room for doubt. I may remark that this case came under my ob-
servation more than nine years ago, when I had less confidence in my prac-
tice of percussion than now, and was not fully aware of the importance of
carefully percussing over the scapulae.

The management in this case consisted in changing the habits of a student
for out-door exercise, and the use of tonic remedies. This case occurred
before cod-liver oil came into vogue.1

Case IX. — Pulmonary Tuberculosis; Arrest of the Disease.— Judge C\,
aged 37, consulted me in July, 1857. His parents are both living. He
had seven brothers and two sisters, and has lost a sister and brother by con-
sumption.

In 1851, he had cough and expectoration for several months, with loss of
weight and night-sweats. All these symptoms disappeared on leaving his
office duties, which had been laborious and confining, and travelling for several
weeks in the winter season, although much exposed to inclement weather.
He took no remedies except some simple palliatives of the cough. Last
winter (1856-7) he had recurrence of cough, and he passed several months
in South Carolina, taking much out-door exercise. He returned to this city
much of the way on horseback. He gained in flesh during his southern
sojourn, exceeding his weight at any previous period of his life. Prior to
this winter he had for several years been constantly occupied by his judicial
duties.

At the time he consulted me, his aspect was healthy; he felt no deficiency
of breath on exercise; the appetite and digestion were good; the pulse and
respiration not abnormal, but he had slight cough and expectoration. He
had slight haemoptysis during the last winter, never before.

1 Since this article was written, the father of this patient has informed me that he
is living and well at this time, nine years from the time he came under my obser-
vation.

1858.]

Flint, Pulmonary Tuberculosis.

63

On examining the chest there was depression at the right summit, and
relatively less expansion on forced breathing. Distinct dulness on percussion
on the right side in .front and behind. No spinal curvature. Respiratory
murmur at summit of left side well evolved, vesicular, and no sound of expira-
tion appreciable. On the right side, in front, the inspiration notably more
acute and less vesicular than on the left, but no expiratory sound appreciable
(broncho-vesicular respiration). Yocal resonance about equal on the two
sides. Whispering souffle notably more intense at the left summit.1

Behind, over both scapulae, the respiratory murmur feeble, but more evolved
on the left side. An expiratory sound appreciable on both sides, and higher
in pitch than the sound of inspiration.

Remarks. — The evidence from the physical signs of a deposit of tubercle
at the summit of the right lung, is conclusive ; and, in view of the history,
it can hardly be doubted that the deposit existed in 1851. His condition of
late years, and at the present time, shows the disease to have been non-pro-
gressive.

In this case no medicinal remedies have ever been employed, excepting some
simple palliatives for the cough. He tried to take the cod-liver oil, but it
offended the stomach, and he very soon laid it aside. He pursued this course
under the advice of my friend and colleague, Prof. Hamilton. He has lived
generously, taking frequently a little wine or spirit. Although an arrest , of
the disease has evidently taken place, the recovery cannot be said to be com-
plete, inasmuch as he still has a little cough and expectoration. He is, more-
over, stouter, and presents a more healthy aspect than for several years before
the occurrence of the tuberculous deposit in 1851.

Case X. — Pulmonary Tuberculosis ; Ancient Pleurisy produced by an
Injury to Chest; Arrest of the Tuberculous Disease, and Recovery. — R. P.,
aged 31, ship carpenter, formerly seaman, came to me for an examination of
the chest and advice, September, 1856.

About four years before, he had received a severe injury at sea on the
lower part of the right side of the chest. He raised blood the day after re-
ceiving this injury. He felt pain and weakness in the side for some time,
but had no medical aid. From the examination of the chest it is probable
that pleuritis with liquid effusion followed that accident. After this he had
good health, but two or three times had haemoptysis without cough or any
other pulmonary symptoms.

He had never been troubled with cough till two months prior to my exa-
mination. During this period it had existed constantly, and had progressively
increased. At first the cough was dry, but he soon began to expectorate, and
the quantity of expectoration had steadily increased. The matter expecto-

1 The souffle produced by the act of whispering, or whispering bronchophony, is
often a valuable sign, to which I have called attention in my vrork on the Diagnosis of
Diseases Affecting the Respiratory Organs. Since the publication of that work, my
observations have satisfied, me that this souffle is normally more acute, i. e., higher
in pitch at the summit cf the left than of the right side, but generally more intense
on the latter. 1 avail myself of the present opportunity to make this statement, which
is of practical importance.

64

Flint, Pulmonary Tuberculosis.

[Jan.

rated was quite consistent. He thought it would amount to a gill in the
twenty-four hours.

For five or six weeks he had had diarrhoea daily, but as regards this symp-
tom he had improved. He had taken several patent medicines for the diar-
rhoea which had occupied his attention more than the pulmonary symptoms.
He had had lancinating pains at the summit of the chest, shooting through
beneath the scapula. These had occurred on both sides, but most on the
right. He had lost considerably in weight, as he thought about 20 lbs., within
two months. He had observed some want of breath on exercise.

He had not given up work except for a few days, and expected to return
to it the next day. He had sweat at night occasionally. The pulse was not
accelerated; the respirations 20 per minute, and not labored.

Physical Signs. — The right side somewhat contracted. The right inter-
scapular space diminished, but the nipple and shoulder not lowered. The
right infra-clavicular region depressed and mobility less than on the left side.
The left scapula more elevated than the right on forced breathing. Dulness
on percussion marked at the right summit, in front and behind. The whole
right side relatively dull, but the disparity much greater at the summit than
below. At the right summit in front and behind, the murmur of inspiration
almost inappreciable with Cammann's stethoscope, but a prolonged, acute expi-
ration heard both in front and behind. On the left side a vesicular inspira-
tion well evolved, with scarcely an appreciable sound of expiration. Yocal
resonance everywhere more marked on the right side, but the disparity much
greater at the summit, in front and behind, than below. The whispering
souffle notably more acute, intense, and nearer the ear on the right than on
the left side, both in front and behind.

In view of the signs and symptoms, the diagnosis was tuberculosis of the
lungs, and the patient was advised to try the cod-liver oil; to live generously,
taking a little spirit daily, and to continue in his occupation. The patient
was strictly a temperance man. For the diarrhoea a mixture of the syrup of
krameria, paregoric elixir, and the chalk mixture, was prescribed.

October 13th, 1856, this patient reported improvement as regards cough,
expectoration, and strength. The diarrhoea was promptly relieved. The
appetite was good. He had not begun to take the cod-liver oil, but promised
to commence it at once ; nor had he taken spirit as advised. Had kept
steadily at work since the date of the previous record.

December 23d, 1856, this patient had gained considerably in weight. He
presented a ruddy, healthy aspect. He had no habitual cough, and was com-
petent to do full work as a ship carpenter. His business involved exposure
as well as severe labour, requiring him to be in the open air, and much of the
time, as he stated, he worked with his coat off. Excepting some few cays
occasionally, he considered himself a rugged man. He took the cod-liver oil
for several weeks, and discontinued it because it appeared to act as a laxative.

This patient continued to work during the whole winter, remaining in good
health, and in spring last, emigrated to Kansas.

Remarks. — A deposit of tubercle in this case occurred during the summer
season, and the arrest took place in the following autumn, the patient pur-
suing, unremittingly, the business of a ship carpenter, working laboriously in
the open air, in all kinds of weather, and much of the time in his shirt
sleeves.

The only remedy prescribed was the cod-liver oil, which he began to take

1858.]

Flint, Pulmonary Tuberculosis.

G5

after an improvement bad commenced and continued for a few weeks only.
He took spirit for some time sparingly, to which he had previously been un-
accustomed.

Case XI. — Small Tuberculous Deposit; speedy Arrest and Recovery. —
Mr. D., aged 22, clerk in a clothing store, was examined by me, August,
1856. Two months prior to this date he had a cough for several days, which
ceased entirely, and he regarded himself well until a week before the exami-
nation, when he had an attack of haemoptysis. The hemorrhage recurred for
three successive nights, and then ceased, but he continued to expectorate for
several days bloody mucus. He had considerable cough in the morning with
small expectoration. His aspect was not morbid. He was not aware of
having lost in weight. The appetite was poor.

Both parents are dead. The father died many years ago, he did not know
with what disease. The mother died of cholera. The pulse was 80, some-
what vibratory, compressible. The respirations 20.

Physical Signs. — No spinal curvature. Very distinct dulness on percus-
sion at the summit of the right side in front and over the scapula. Equal
resonance below the scapula on the two sides. Respiratory murmur on the
right side, in front and behind, relatively feeble, the inspiratory sound deferred,
and no appreciable sound of expiration. A subcrepitant rale at the summit,
in front, on the right side. Vocal resonance greater on the right side. Less
superior costal movement, on forced breathing, on the right than on the left
side.

I advised this patient to exercise in the open air as much as possible, and
on the approach of cold weather to change his residence to a milder climate.
The latter advice he did not adopt. I prescribed no medicine.

October 28, 1856, this patient reported quite well. He was entirely free
from cough. His aspect was healthy, and he had gained in weight.

May 6, 1857, the patient reported the same. He was entirely free from
any symptoms of pulmonary disease and appeared quite well.

Remarhs. — A speedy arrest of the disease took place in this instance. He
took no remedies. The recovery, for the present, appears to be complete.

Case XII. — Small Tuberculous Deposit ; Coexisting Emphysema, ; the
Tuberculous Disease Non-progressive. — Mr. R. came to me to examine the
chest, August, 1856. I had made two previous examinations, the first time
five years previous, and the second time a year before. I failed to make
notes of these two former examinations. He stated that on the first exami-
nation I found no signs of disease, but on the second I told him that there
was a small tuberculous deposit at the summit of the left lung. He had had
haemoptysis shortly before the last examination. He is an intelligent man,
and his recollection of my statements of the results of these examinations is
doubtless reliable. After the last examination I prescribed a preparation of.
iron, but he did not take it, and had had no medical treatment in the mean
time. His age was about 25. His business, forwarding agent, required him
to be actively employed in the open air; he was accustomed to live freely and
recklessly, indulging occasionally in debaucheries.

Since the last examination he had had more or less cough and moderate
expectoration in the morning. At times, he was obliged to cough repeatedly
and with some violence before expectorating, but at other times the expecto-
ration was easy. He was short-winded on exercise.

G6

Flint, Pulmonary Tuberculous.

[Jan.

Physical Signs. — Clear percussion resonance on both sides in front, but on
the left side vesiculo-tympauitic in quality. Behind, relative dulness over
the right scapula. Resonance clear and equal below the scapulae. On the
left side the supra and infra-clavicular regions are fuller than on the right
side. The superior costal movement slight on both sides even on forced
breathing, but somewhat greater on the right side. No rales anywhere.
The respiratory murmur well evolved at the right summit in front, and rela-
tively quite feeble at the left summit. A feeble, prolonged acute expiratory
sound on the left side. Yocal resonance slightly greater on the left side.
The whispering souffle distinctly more intense and acute on the left side.

Over the scapula the respiratory sound almost dull on the left side; feeble
on the right side, with a prolonged, acute sound of expiration. Vocal reson-
ance and whisper almost null on the left side, and well marked on the right
side.

The condition of this patient since the last examination I have not learned.

Remarks. — The foregoing physical signs, taken in connection with the his-
tory, are considered as showing the presence of a tuberculous deposit, coexist-
ing with emphysema of the upper lobe of the left lung. It is assumed
that the physical evidence existed a year before; viz., at the second exa-
mination. The condition of the patient at the last examination showed the
tuberculous affection to be at least stationary. Excepting slight cough and
expectoration, the patient was in good health and actively engaged in busi-
ness.

The arrest of the disease in this instance took place without any influence
from management. The patient took no remedies and made no change in
his habits of life, continuing in active out-door business and given to dissi-
pation.

Case XIII. — Pulmonary Tuberculosis ; Arrest of the Disease, and Appa-
rent Recovery. — J. H. T., aged 24, printer, consulted me Nov. 15th, 1856.

In the spring of 1854 the lymphatic glands of the neck became swelled,
and slowly suppurated. The neck was covered with cicatrices presenting the
characters of scrofula, and occasionally there was still a little discharge. Prior
to 1854, always had good health; no scrofula in early life. Parents free
from tuberculous disease.

In the spring of 1855 he was suddenly attacked with haemoptysis, without
any obvious exciting cause. Prior to this event he had had no cough or
other evidence of the pulmonary disease. Cough and some expectoration
followed, and he had frequent repetitions of haemoptysis during the summer
of 1855. In the latter part of this summer he consulted S. S. Fitch, of
New York, who gave him medicines of a tonic nature ; advised him not to
wear flannel ; to go out as much as possible without an overcoat, and to be in
the open air a good portion of the time. He took the remedies during the
following autumn and winter, and followed these directions as regards dress
and regimen. He passed the winter on a farm in the country. He discon-
tinued for several months the use of tobacco by direction of Dr. Fitch. His
health constantly improved. He had no more haemoptysis. Cough and ex-
pectoration gradually ceased, and he regained his usual Weight. During the
previous summer he had fallen in weight from 160 lbs. to 130 lbs.

The summer of 1856 he passed in this city, and was occupied in business

1858.]

Flint, Pulmonary Tuberculosis.

67

out of doors, viz., obtaining subscribers, etc., for a daily paper. He resumed
the use of tobacco moderately. Was accustomed to drink beer daily, and
about once a month he drank to excess — going on a spree with companions
of the same kidney. His health was good during the summer and autumn.
Had no cough or any pulmonary symptoms prior to the day on which he
consulted me. On that day, while walking rapidly, he swallowed a little
tobacco juice, and immediately raised a single mouthful of blood. This cir-
cumstance led him to call upon me. Respiration was not laboured or accele-
rated. Pulse normal. Aspect healthy. Considerable embonpoint.

Physical Signs. — The chest on both sides apparently flattened ; the antero-
posterior diameter notably small contrasted with the width. The left side at
the summit, compared with the right, depressed; the clavicle more projecting.
Superior costal movement on forced breathing greater on the right than on
the left side.

Dulness on percussion marked in front, at summit, and above the spinous
ridge over the scapula on the left side. Clear and equal resonance on the
two sides below the scapula. Respiratory sound at the summit in front on
the left side less intense than on the right side; the inspiration less vesicular,
and higher in pitch, shorter and followed by a short, acute expiratory sound
(broncho-vesicular respiration). Over the left scapula the respiratory mur-
mur more feeble and less vesicular than on the right side. Vocal resonance
more marked on the right side in front and behind. The whispering souffle
more acute in front on the left side.

Remarks. — These physical signs, taken in connection with the history, are
attributable to a tuberculous deposit which took place during the summer of
1855. An arrest of the tuberculous disease followed giving up the occupa-
tion of a printer, living on a farm and much of the time in the open air,
together with the use of tonic medicines. Excepting the raising of a single
mouthful of blood during an act of retching, the recovery appeared to be
complete.

Case XIV. — Pulmonary Tuberculosis; Excavations; Fistula in Ano ;
Non-progress of the Disease. — H. F. L., aged 35, accountant, was examined,
August, 1855. Both parents died of consumption. Of eleven brothers and
sisters, all but four have died with the same disease.

When eleven years old he had some chronic affection of the knee, which
was called "white swelling," and was laid up for a year. After this, prior
to 15 years before the date of the examination, he had good health. At
that time he had haemoptysis at night after returning to bed. No cough fol-
lowed, and he kept about his business as usual.

Ten years previous to the date of the examination, after great fatigue and
anxiety incident to the illness and death of a child, he was attacked with a
fever, and was ill two months. He had no symptoms of pulmonary disease
at that time, nor between this event and the haemoptysis five years before.
During convalescence from this fever he contracted a cold, as he stated, and
had inflammation of the lungs. After recovering from the latter he went to
the south and remained eleven months.

Four years prior to the date of the examination he had haemoptysis several
times, unattended by cough or reduction in weight, and he kept about his
business as usual.

During the autumn and winter of 1855, he had cough which progressively

68

Flint, Pulmonary Tuberculosis.

[Jan.

increased. The cough was at first dry, but expectoration after a time occurred
and became considerable in amount. He had frequently lancinating pains
shooting under the right scapula. Feels want of breath on exercise, especially
on mounting stairs. He lost in weight in the autumn and early part of
winter, but afterward gained, and at the time of the examination was heavier
than four years before.

A fistula in ano had existed for five years, discharging daily more or less
and occasionally fecal matter.

Respirations 24, not laboured. Pulse 72.

Accustomed to take from 4 to 6 glasses of brandy daily for the past six
years.

Physical Signs. — Dulness on right side at summit in front and behind.
Respiratory sound broncho-cavernous on that side.1

August 25, 1855. This patient during the summer had good health;
was engaged actively in business, and took no remedies. He had gained in
weight, and his aspect was quite healthy. The fistula was his chief source of
trouble.

Nov. 14th, 1856. Patient reported as well as on the date of the last
record.

Remarks. — It is difficult to fix the commencement of the tuberculous dis-
ease in this case. The history shows its existence most unequivocally in the
autumn and winter of 1855. That a deposit had taken place years before is
probable. The disease advanced to the formation of excavations, and ceased
to be progressive at that stage.

There was in reality no management in this case. The patient took a few
doses of cod-liver oil, and then discontinued this remedy. He continued
steadily in business, and was much of the time out of doors. He indulged
moderately in drinking and lived freely.2

Case XV. — Pulmonary Tuberculosis remaining Non-progressive for many
Years; Coexistence of Heart Disease, the latter proving fatal. — C. A., aged
about 40, tobacconist, was examined by me in consultation with my friend
and colleague, Prof. White, Dec, 1848. Mr. A. had been in infirm health
for several years, but had kept steadily engaged in business. He had for
some years suffered from palpitations and dyspnoea on exercise. Had lost of
late, in weight, 20 lbs. He had had slight cough and expectoration for
ten years.

Physical Signs. — Marked depression at summit of the left side of the chest.
Dulness at that summit in front and behind, and the respiratory sound bron-
cho-vesicular. Sounds of heart pure but feeble. A diffused, feeble impulse
in the praecordia.

The diagnosis at that examination was, pulmonary tuberculosis, progressing
slowly j enlargement of the heart by dilatation, without the evidence of
valvular lesions.

1 The characters of respiratory sound are described in the record with minute
details, which are omitted here.

2 Since this was written, I have met this patient and find that during the present
summer his health has deteriorated. The pulmonary symptoms denote now pro-
gressive tuberculous disease, and he has tuberculous laryngitis.

1858.]

Flint, Pulmonary Tuberculosis.

09

This patient was under my care for a short time in Feb. 1853. He had
then considerable oedema of the lower extremities, with ascites, and he suffered
much from palpitation and dyspnoea. The area of dulness on percussion in
the praecordia was increased ; the impulse feeble and diffused, and the action
of the organ very irregular ; but no bellows murmur discoverable. The heart
affection was the most prominent. He had never been entirely free from
cough and expectoration, which still continued about as for many years past.
Since the former examination, he had kept steadily occupied in his business,
and during the preceding five years had accumulated a comfortable property.

He died in 1855, evidently of the affection of the heart.

Remarks. — In this case the existence of a tuberculous deposit was deter-
mined seven years before death, and undoubtedly had already existed many
years. The coexistence of disease of heart is an interesting feature of the
case. This disease steadily increased, while the tuberculous affection, as
judged by the symptoms, remained nearly or quite stationary. The manage-
ment had reference mainly to the cardiac trouble. The patient was a man
of great energy of character, and persisted in keeping about and attending to
his business nearly to the close of life. According to the views of Rokitansky,
disease of heart antagonizes a tendency to tuberculous deposit, and it may be
supposed that in this instance the tuberculous disease was retarded or rendered
stationary by the cardiac affection. Certainly diseases of the heart and pul-
monary tuberculosis are rarely found associated.

Case XVI. — Deposit of Tubercles; Expectoration of Calculi; Complete and
Permanent Recovery . — S., farmer, from Illinois, aged about 40, consulted me,
June, 1843. For some months prior to January of that year, he had a slight
hacking cough. During the month of January he had, as he thought, some
acute pulmonary affection, the symptoms of which are not noted. Subsequently
he began to expectorate calcareous concretions, and had continued to do so, after
successive intervals of a few weeks. He brought with him about twenty of
these calculi, of about the size of small peas, round and solid. They were
truly calculi, not concretions from the pharyngeal follicles which I have
known to be mistaken for pulmonary calculi. Those showed me were but a
small portion of the whole number which he had expectorated. He had
supplied different physicians with specimens, and not taken pains to procure
all that had been expectorated.

Before discharging these calculi, the cough was violent; and after their
discharge, the expectoration was tinged with blood. In the intervals, his
cough was slight with very small expectoration.

During the month of January and before, he lost in weight and strength.

After that month he had improved in these respects, and when I saw him
in June, he presented a healthy aspect.

On examination of the chest, no physical signs of disease were discovered.
At that time, however, my experience in exploring the chest had been small,
compared with that of a more recent date.

In July, 1856, this person called upon me to report the condition of his
health. He had for many years enjoyed perfect health. After consulting
me thirteen years before, he continued for some time to expectorate calculi
occasionally, until, at length, all pulmonary symptoms ceased. Shortly after
consulting me he had given up severe labour on a farm, purchased land in

70

Flint, Pulmonary Tuberculosis. [Jan.

Iowa, and had become quite wealthy. It appeared from his statement that I
had encouraged him with a favourable prognosis, and he called to tell me that
my prediction had been verified.

Remarks. — Regarding the calculi expectorated as produced by the crete-
faction of tubercles, this case is an instance of arrest of tuberculosis and re-
covery, the latter being complete and permanent. There was no medicinal
management in this case. The patient, prior to the development of pulmonary
disease, had worked very hard on his farm. He left home for several weeks,
and afterward relinquished severe labour, but engaged in business which
required exercise in the open air, buying and selling new lands.

Case XVII.-— Abundant Tuberculous Deposit; Formation of Large
Cavity; Arrest of the Disease, and Recovery nearly complete. — Mrs. V.,
German, aged 27, was admitted into hospital, Oct. 19th, 1848. She had
been ill twenty weeks. Stated that she took cold during her menstrual period
and was at once obliged to take to the bed. Prior to this she had good health.
During the attack just mentioned, she had considerable pain in the right side
and embarrassment of breathing. Some days after the attack she began to
cough and had free expectoration. She was confined to the bed for six weeks,
and afterwards had kept the bed a portion of the day, attempting to work the
remainder of the time.

At the time of her admission she had copious puruloid expectoration, the
sputa sometimes partially sanguinolent; respirations 44 per minute; pulse
104. There was moderate dulness at the summit of the right side of the
chest ; less superior costal movement on this side ; respiration bronchial.

The expectoration continued for some time abundant and occasionally tinged
with blood. After the lapse of a month, however, the quantity was greatly
diminished, and the condition of the patient in all respects was much improved.
In a little less than two months she thought herself sufficiently well to resume
her household duties, and left the hospital. The treatment consisted of pallia-
tives for the cough; an occasional laxative; the sulphate of quinia and iron,
and full diet.

The patient re-entered the hospital March 9th, 1849. The general aspect
was about the same as when she left the hospital 2 J months before. Cough
and expectoration continued. Pulse 100. Appetite good. The chest on
the right side at the summit was dull on percussion, and the respiration
bronchial. The day following, haemoptysis occurred and was pretty profuse.

May 14th, it is noted that the expectoration continued to be copious; some-
times bloody and generally fetid; the countenance not presenting marked
emaciation. The cheeks constantly red. The extremities of the fingers pre-
senting bulbous enlargement quite marked with incurvation of the nails.
Pulse 100. Profuse perspiration at night. Marked dulness on percussion
over upper part of right side of the chest. Well marked cavernous respira-
tion over a space about two inches in diameter. Slight depression over this
space, and pectoriloquy.

May 31. Copious haemoptysis occurred.

July 13. It is noted that the patient had daily improved in aspect and
strength; the cough and expectoration greatly diminished; she was able to
be up and about, and expected soon to be able to leave the hospital.

The treatment, as before, consisted of quinia and iron, palliatives and
generous diet.

1858.]

Flint, Pulmonary Tuberculosis.

71

Sept. 1851. Under this date I find the following note. This patient shortly
afterwards left the hospital. A year afterwards I examined the chest cursorily
and found the signs of an excavation still present, but less marked. She
had still some cough, but presented a healthy appearance, and considered herself
quite well; and she had during the year given birth to a living child.

A year or more after the date of the foregoing note I learned that this
woman had died ; under what circumstances I could not learn.

Remarks. — In this case there existed an abundant deposit of tubercle, and
the disease advanced to the formation of an excavation of large size. Never-
theless, an arrest of the progress of the disease took place, and considerable
advance was made towards recovery. The patient was nearly free from pul-
monary symptoms j regained her flesh and strength ; was able to discharge
laborious household duties; became pregnant and was delivered of a healthy
child. Whether she subsequently died from a return of the tuberculous disease
or some other affection, I could not learn.

The management in this case consisted in the employment of tonic remedies,
chiefly quinia and iron; generous diet; exercise in household duties as soon
as her strength permitted.

Case XVIII. — Pulmonary Tuberculosis; the Disease Stationary or Pro-
gressing imperceptibly without Management ; the Patient, a day labourer,
continuing at work. — B. D., labourer, aged about 30, was admitted into
hospital Dec. 6, 1856. He presented the following physical signs. Slight
lateral curvature of the spine, causing some depression of the right shoulder.
The left side at the summit is depressed; the clavicle more projecting than
on the right side. Superior costal movement notably greater on the right
than on the left side. Elevation of right scapula on forced breathing greater
than of the left. Percussion resonance at the summit on the left side in front
notably tympanitic; non-tympanitic at the base. Marked dulness over the
left scapula. Resonance in axillary region and behind below the scapula
equal on the two sides. At the left summit, in front, no respiratory murmur
appreciable except at the acromial extremity, where it was broncho-vesicular,
the expiratory sound prolonged, more intense than the sound of inspiration
and higher in pitch. Over the left scapula respiration well evolved below the
ridge and broncho-vesicular. On the right side, at the summit, respiratory
murmur well evolved and vesicular. Yocal resonance in front notably greater
on the right side ; almost null on the left side. No whispering souffle on left
side in front, but well marked on the right side. Over the scapula the vocal
resonance about equal, but the voice bronchophonic, i. e. near the ear, on the
left side. Sense of resistance on pressure greater on the left side at the sum-
mit. Below the scapulae the respiratory murmur well evolved and equal on the
two sides, or nearly so. Sounds and impulse of heart normal.

The patient stated that he had had cough for about two years. He began
to cough in Jan., 1855, and the cough persisted till the following May. He
had frequent lancinating pains at the summit of the left side. He had con-
siderable expectoration, and several times raised blood. At no time had he
been confined to the bed. Kept at work all that time, but frequently lost days.
Was not aware of losing in weight.

From May, 1855, to February, 1856, was free from cough. Had good

72

Flint, Pulmonary Tuberculosis.

[Jan.

health, and worked steadily. Cough began to be again troublesome in July,
1856. In March and April he was occasionally obliged to keep in bed.
Continued to labour during the following summer, but was often obliged to
quit for a few days. Kept at work till the week before he entered the hospital.

Had never had any medical attendance. G-ot a blister and applied it to the
chest in the spring of 1855, and in May, 1856, got bled. Drinks whiskey,
but not to excess.

His aspect was not morbid. He was not emaciated. He stated that he was
abundantly strong for work except that his health was somewhat deficient, and
he was liable to pain at the summit of the left side of the chest. The pro-
labia were of good colour, and the cheeks ruddy. Respiration 20, and pulse
84. Had some cough and expectoration chiefly in the morning.

He remained in hospital about a week, and during this time took cod-liver
oil and had full diet. The cough and expectoration were relieved, and he left
feeling able to return to work.

Remarks. — This case illustrates either the non-progression or extremely slow
progress of tuberculous disease in an Irish day labourer, without management,
the patient (excepting now and then, for a day or two at a time) keeping steadily
at work, living like other labourers of his class, exposed to the same hard-
ships, and drinking in moderation.

Case XIX. — Small Deposit of Tubercle; Arrest of the Disease. — Dr. C.
A. B., aged about 28, in the spring of 1855, had profuse haemoptysis. Prior
to this event, for some time his general health had not been good, and he had
had a dry cough. His weight had diminished, and his aspect was morbid.
He sailed for Liverpool, and after his arrival in England, at London, he had
another haemoptysis, also rather profuse, continuing for several days. He
remained in England two or three months, running about, not pursuing any
medical treatment, living freely, and returned in an emigrant vessel, having a
protracted voyage. He had recruited very much before sailing for America,
so that he performed the duties of surgeon to the ship. He continued to im-
prove on the voyage, and was quite well on his return. Very slight cough
and respiration, however, continued.

During the winter of 1855-6, and the summer of 1856, ho continued well,
doing very little in the way either of practice or study, and living rather
freely. During the winter of 1856-7, he was engaged in teaching anatomy,
and was most of his time in the dissecting-room. His general health evidently
failed in some measure; he lost in weight, and his aspect was pallid. In
April, 1857, he had an attack of pneumonia, affecting the lower lobe of the
left lung. He recovered from this attack rather slowly; but after recovering
from it, his general health improved; he gained in weight, his aspect became
healthy. He had still a little cough and expectoration. No want of breath
on exercise. Pulse not accelerated. Appetite and digestion excellent.

On examining the chest, July 23, 1857, the following signs were noted:
Well marked dulness at the left summit in front and behind. No spinal
curvature. Slight depression in front at the left summit. The respiratory
murmur at the left summit, compared with the right side, deficient, but no
disparity in pitch or quality apparent. Over the left scapula below the spin-
ous ridge, a well marked, prolonged, acute sound of expiration. Above the
ridge a click heard occasionally in inspiration. V ocal resonance everywhere
greater on the right side.

1858.]

Flint, Pulmonary Tuberculosis.

73

Remarks — There can hardly be a doubt that there has been a tuberculous
deposit near the apex of the left lung. The physical signs, in connection
with the history, warrant not only this conclusion, but that the deposit is not
recent. It occurred, probably, in 1855, and, in the mean time, the disease
has undergone arrest. Inasmuch, however, as there still remains slight
cough and expectoration, the recovery cannot be said to be complete.

This case cannot be said to have had any medicinal management. The
arrest followed the voyages across the Atlantic, and a sojourn of two or three
months in England, with free living.

Case XX. — Small Tuberculous Deposit; Armrest and permanent Recovery.
— Dr. W., aged about 35, in 1844 suffered for several consecutive months from
cough, with moderate expectoration. Haemoptysis occurred during this period
once. He gradually recovered without medicinal treatment, and with the
exception of a cough which lasted for two months in 1849, he has enjoyed
good health, being entirely free from any symptoms of pulmonary disease.

On examination of the chest, in 1852, there was distinct dulness on per-
cussion at the summit of the chest on the left side, and the respiration in
this situation broncho-vesicular ; the inspiration less vesicular, and higher in
pitch than on the right side. Vocal resonance about equal on the two sides.

Remarhs. — The retrospective diagnosis in this case seems remarkable in
view of the history and physical signs. The recovery is complete and per-
manent, thirteen years having elapsed since the deposit of tubercle occurred.
There was no medicinal management in this case; the arrest taking place as
a result of self-limitation. He continued without intermission the practice
of medicine, and in addition resorted to horseback exercise daily, in which he
persevered for several successive months.

This case is given in my essay on variations of pitch in percussion and
respiratory sounds, published in 1852.

Case XXI. — Pulmonary Tuberculosis ; Arrest of the Disease. — D. B.,
ostler, aged 26, admitted into hospital, Sept., L851. He stated that he had
had good health up to a few weeks before his admission. Thought he had
taken cold. Was attacked with cough, which at first was slight, but increased,
and was soon accompanied by expectoration. The latter has progressively
increased in quantity. Had lost about fifteen pounds in weight. The pulse
was 100; respirations, 20. Expectorates from two to four ounces in the
course of twenty-four hours. Perspires at night. Appetite tolerable.

On examination of the chest, the superior costal movement on the right
side was found to be less than on the left; the summit on the right side was
relatively dull on percussion, especially over the scapula; the respiratory sound
in that situation broncho-vesicular, aud a sibilant rale observed, limited to
the summit on the right side.

The patient was placed on full diet, and cod-liver oil was prescribed in dose
of half an ounce three times daily.

Nov. 6, 1851. The patient reported well, feeling abundantly able to leave
the hospital and resume his occupation. The cough and expectoration had
ceased. He had gained in weight. Slight depression existed at the summit
of the right side of the chest. Dulness on percussion remained and dimi-

74

Flint, Pulmonary Tuberculosis.

[Jan.

nished mobility. Dry crackling was observed, on auscultation, on the infra-
clavicular regions on this side.

The management consisted of nutritious diet and cod-liver oil.

Remarks. — An arrest of the disease in this case took place, but as nothing
was known of the patient after his leaving the hospital, it cannot be stated
that the recovery was permanent.

Case XXII. — Pulmonary Tuberculosis preceded and accompanied by
Dyspeptic Ailments, the latter persisting after Arrest of the Tuberculous Dis-
ease.— Rev. Mr. C, aged about 35, consulted me, December, 1851. He had
been in the ministry 14 years. During this period and longer he had been
a dyspeptic. Had always been a student with sedentary habits, taking very
little exercise, and not fond of out-door sports. He complained of a constant
sense of debility and of becoming very easily fatigued by any exercise. Had
suffered from chronic pharyngitis, which still continued. He was thin, but
not greatly emaciated. Had had more or less cough for years with small
expectoration. The latter symptoms had lately become more prominent. A
few days previous, slight haemoptysis had occurred. It had occurred once
previously, several years before. Pulse was 60 per minute; respiration 25.
Was easily put out of breath on exercise.

On examining the chest there were found dulness on percussion at the
summit on the right side without depression; crackling in inspiration and ex-
piration on both sides, but more marked on the right side in front and behind;
diminished mobility at the right summit, and the vocal resonance apparently
increased, the disparity between the two sides being more marked than usual.

The patient was advised to take the cod-liver oil ; to take a little brandy
daily; to relinquish his sedentary habits, exercising in the open air and living
generously.

July 2d, 1855, I made a brief note of a second examination of the chest.
The upper part of the right side was somewhat depressed. Dulness on per-
cussion continued. Respiratory murmur on the left side in front well evolved
and vesicular; on the right side less vesicular and extremely feeble— the con-
trast in intensity striking. Behind, no respiratory sound appreciable over
either scapula save a prolonged sound of expiration over the right.

During the period (4 i years) that had elapsed the patient had changed his
habits materially as regards exercise in the open air. lie had rode and walked,
and at one time was accustomed to saw wood daily for exercise. He had
passed a winter at the south, but returned with the conviction that he enjoyed
better health in a northern climate. At one time he adopted a milk and
farinaceous diet, and thought that this was favourable to his health.

Two years have elapsed since the date of the last record, and in reply to
a letter of inquiry addressed to him since I commenced writing this paper,
he states that he has now no fixed cough ; that he had a slight hemorrhage
a year ago, but has had none since; that his general health is about the same,
being troubled still with indigestion and debility. To quote his language, he
says : "I often feel as if I were a poor miserable wreck of a man, and gene-
rally endure life rather than enjoy it." Nevertheless, in the same letter he
states that he has preached regularly for the last ten months, going five miles
on the cars on Saturday evening and returning on Monday morning, without
having charge of the congregation during the week. As regards management
for the last two years, he writes as follows: " Since I saw you I have used up

1858.]

Flint, Pulmonary Tuberculosis.

75

hydropathy, homoeopathy, and shall I add, allopathy? That would cut me off
from the benefit of any suggestions which you may make in reply to this. I
will not say it then, but only say that since returning from the water cure a

year ago last spring, t have been under the care of Dr. ; have taken

some aloes, some iron, an occasional blue pill, lager beer to some extent, etc.,
but all does not avail to remove the old malady and give me strength. My
experiment of 4 J months at a water cure was more than a failure. If I had
remained there I believe I would have died. I left greatly prostrated."

It is evident that in this case an arrest of the tuberculous affection has
taken place, a fact the full force of which the patient cannot appreciate, espe-
cially so long as he finds his comfort and desire for useful activity compro-
mised by his dyspeptic ailments.

Case XXIII. — Pulmonary Tuberculosis, Arrest, Recovery, Return of the
Disease after Eighteen Years, ending fatally, and Autoptical Appearances.
— E. H., aged about forty, had an abscess in the perineum which ended in a
fistula in July, 1845. The gut was divided, and he was nearly but not quite
cured, a little discharge continuing. He was then, with this exception, ap-
parently in good health. In April, 1846, he was attacked with haemoptysis
which continued to recur for several days, and for which he was bled repeat-
edly and freely. The symptoms and physical signs of tuberculosis were now
distinctly declared. In addition to repeated venesections, he was treated with
digitalis and mercurials. The case ended fatally in the June following.

On examination of the chest, post mortem, the right lung was filled with
minute deposits of tubercle, and portions presented tubercular infiltration, a
few small puruloid collections existing near the apex. Disseminated through
the left lung were great numbers of miliary tubercles. These appearances
were manifestly due to a recent tuberculous affection. In addition to these
appearances, at the upper portions of each lung was a solid mass, of an oval
form, nearly as large as a hen's egg, somewhat larger on the right than on
the left side. Over these masses the pressure of the lung presented a marked
depression and a contracted, puckered appearance. On dividing these masses
they appeared to consist of condensed parenchyma; the colour was reddish;
they were rather friable, and contained an abundance of minute calcareous
particles. They were surrounded by a thick: firm cyst, isolating them from
the surrounding pulmonary structure.

The following facts relating to the previous history of the patient have an
important bearing on the explanation of the appearances first described. The
patient was engaged in the manufacture of burr mill-stones, and had many
years before worked at this business. While thus employed he became af-
fected with cough and other symptoms which were thought, at the time, to
denote pulmonary consumption. In consequence of these symptoms he ceased
to labour personally in the business, although he continued to carry it on,
and he devoted himself to the out-door duties connected with it. This was
18 years prior to his last illness. He speedily recovered his health, and for
the period just named was free from pulmonary symptoms, and enjoyed ex-
cellent health.

Remarks. — In view of the morbid appearances after death, and the ante-
mortem history, it is assumed that in this case there had been tuberculosis of
the lungs eighteen years before death, from which the patient had recovered,
having good health until the return of the disease which proved fatal.

76

Flint, Pulmonary Tuberculosis.

[Jan.

The arrest of the disease followed a change from confinement within doors
and the inhalation of stone dust for active out-door occupation.

Case XXIV. — Small Deposit of Tubercle; Arrest of the Disease and Reco-
very.— Mrs. R., aged about 22, during the summer of 1853 suffered from
cough and expectoration, and pains in the chest. She lost in weight; her
strength was considerably reduced, and she raised repeatedly bloody sputa.
I failed to make a record of this case, and the facts of the history are stated
from recollection. An examination of the chest revealed the physical signs
of a small tuberculous deposit, but I am unable now to describe the signs.

She passed the winter at the South, and on her journey thither she was
attacked with haemoptysis, raising from one to two ounces of blood. She
took quinia and iron, and also for a short time cod-liver oil. The latter remedy
was discontinued on account of the patient's antipathy to it. Her health
improved during the winter, and on returning in the spring she was free from
the symptoms of pulmonary disease. She became pregnant during the follow-
ing summer, and bore a healthy child, which is still living and well. The
winter of 1855-6 she passed at the South, and the next winter in this city.
Her health remained good j she has regained a rosy complexion, and at this
moment is perfectly well.1

. Remarks. — This is the only case in the collection in which the report is
not made from notes contained in my clinical records. Of the correctness of
the diagnosis I do not entertain any doubt. The management consisted in
change of climate, exercise out of doors, tonics, and the use for a short time
of cod-liver oil.

The foregoing series embraces the cases that have come under my observa-
tion, in which, judging from the history, symptoms, and physical signs, the
existence of pulmonary tuberculosis was unequivocal, and the arrest of the
disease equally clear. The collection might be enlarged by adopting a some-
what wider latitude in the admission of cases, including those in which a tem-
porary arrest took place, and those that have occurred too recently, or re-
mained under observation for a period too brief to determine as to the reality
of the apparent arrest. A still wider latitude would admit cases in which the
progress of the disease was remarkably slow. A comparison of the latter
cases, as regards the points of agreement in the management, would certainly
be a legitimate means of developing results in corroboration of the conclusions
drawn from the analysis of cases of recovery from tuberculosis. My records
for" the last few years would supply a pretty large number of cases falling
under these heads. In fact, I am sure that in a great proportion of the cases of
pulmonary tuberculosis which I have of late observed, the progress of the
affection has been retarded, taking as a standard of comparison the usual
course of the disease some years ago. The clinical observer for twenty years
need not be told that during this period there has been an entire revolution

1 A slight perineal fistula has occurred in this case, and been somewhat troublesome
at times for the past year.

1858.]

Mint, Pulmonary Tuberculosis.

77

in the management of the disease. As regards my own views and practice,
I am ready to admit that a better knowledge and appreciation of certain
points of management have led me to expect at least a marked improvement
in the symptoms of pulmonary tuberculosis, with much more confidence, in
the majority of instances, than I ventured to entertain until quite lately.
To these points I shall incidentally refer in the course of the few remarks
which are to follow.

The inquiry will naturally arise, what proportion do these instances of
arrest of the disease bear to the whole number of cases observed during the
years that these instances were noted. So large a proportion of the cases of
which I have notes, are incomplete as regards the progress of the disease and
the result, that I am unable to meet this inquiry. I wish it to be understood
that the cases in this collection are not reported in order to furnish data for
determining, statistically, the chances that the disease will be arrested ; still
less are they reported with a view to illustrate the success of any peculiar
plan of management. The object, as already stated, aside from the interest
which may belong to the cases individually, is to institute a comparison as
regards those circumstances common to more or less of the cases, which, it
may fairly be supposed, were concerned in bringing about an arrest of the
disease.

It will be noticed that in the caption prefixed to the cases, severally, some
are characterized by the terms "arrest and recovery," and others by simply
the first of these terms. An arrest of the disease, it is clear, may take place
without recovery ; in other words, the tuberculous affection may cease to be
progressive, the processes of restoration never being fully completed. The
patient who had been attacked twenty-eight years, or the wife eighteen years
before, for example, were not free from the symptoms of pulmonary disease,
yet the history and present condition showed that the disease, as regards
destructive changes, had for a long time remained stationary. The same is
equally true of other cases in which the date of the tuberculous deposit
was much less remote. A very marked degree of improvement in the
local symptoms, conjoined with the recovery of the normal weight and
strength, after the lapse of several months, suffices to show that the disease
is arrested; and this conclusion is not disproved by the renewal of the evi-
dences of the progress of the disease at a future epoch. Recovery from
the disease can be pronounced only when, in connection with restoration
of the general health, the local symptoms have entirely disappeared. This
recovery may be complete, albeit the patient subsequently falls a victim to
tuberculosis, as in Case No. XXIII., in which a fresh deposit of tubercle took
place eighteen years after a former exudation. There may be a recovery
which is not permanent, but not less a recovery on that account. To be per-
manent, the disease must not return, or, at all events, not for a considerable
space of time. Of the cases in this collection, in thirteen an arrest of the
disease was followed by complete recovery; in eleven, the facts show arrest
No. LXIX.— Jan. 1858. 6

78

Flint, Pulmonary Tuberculosis.

[Jan.

without furnishing evidence that the processes of restoration were fully com-
pleted. To what extent, if at all, are those who have recovered from tuber-
culosis rendered thereby more liable to the disease thereafter, is an interesting
question which cannot be answered without more data than are as yet availa-
ble. In Case No. XXIII. , as just stated, recurrence took place after a period
of eighteen years. In two of the cases, thirteen years have already elapsed
without any reproduction of the disease, the dates of the recovery in the
other instances, extending for variable periods between six years and a few
months.

In several of the cases the arrest of the disease was evidently due to an
intrinsic tendency to that result. In other words, the disease ceased to be
progressive, in consequence of its self-limitation. This is fairly to be inferred
in those instances in which no appreciable external influences, in the form
either of medication, diet, or regimen, were brought to bear on the course of
the disease. Eight of the cases may be embraced in this category, viz., Nos.
Ill, IV., V., XL, XII., XIV., XVIII., XX. In these cases the patients
took no remedies of importance j and continued, unchanged, the same habits
of living as before the development of the disease. Examining these cases,
severally, there are no apparent circumstances common to them and distin-
guishing them from the others, to which this inherent tendency to arrest may
be imputed. In conformity with the current pathological views, we have
only to say that in these instances the amount of the tuberculous dyscrasia
was limited, and was exhausted after a certain quantity of exudation had
taken place.

The fact of the existence of an intrinsic tendency to arrest in a certain pro-
portion of the cases of pulmonary tuberculosis, is highly important. It is a
fact hitherto not sufficiently appreciated j indeed it is but lately that such a
tendency, in any instance, has been recognized. Two questions suggest
themselves in this connection. One is, in how large a proportion of the cases
of pulmonary tuberculosis does this tendency exist? It will be long before
data sufficient for determining a definite answer to this question will have
been accumulated. The second question is, in a measure, involved in the
first. It is this : in a certain proportion of the instances in which an arrest
of the disease appears to be due to measures of management, is not the result
rather attributable to an intrinsic tendency ? This question it is of course
difficult to answer definitively in individual cases. Both these questions,
however, are equally applicable to other diseases than pulmonary tuberculosis,
and, with our present knowledge, are alike unanswerable. The truth is, our
acquaintance with the natural tendency of many diseases unaffected by ex-
trinsic influences, is extremely limited, and, for obvious reasons, this know-
ledge is slowly acquired. The importance of this knowledge, as the true
point of departure for the study of therapeutical agencies, is sufficiently
apparent. If it be probable, as must be admitted, that the arrest of the
tuberculous affection is due to its self- limitation in more or less of the cases

1858.]

Flint, Pulmonary Tuberculosis.

79

in which measures of management are resorted to, is it not also probable that
the intrinsic tendency to recovery is sometimes thwarted by injurious thera-
peutical or other means ? We cannot but indulge more than a suspicion that
this question demands an affirmative answer. Unpleasant as may be the
reflection, it must not be blinked that the natural tendency of the disease to
arrest, it is more than probable, was not unfrequently frustrated by the
measures formerly employed in cases of tuberculosis, consisting of general and
local depletion, mercurials, emetics, low diet, confinement within doors, &c.

Of the measures just referred to, in other words, all antiphlogistic and
debilitating measures, none entered into the treatment of any of the cases in
this collection.1 We are not, therefore, called on to inquire as to the influence
which any such measures may have exerted in contributing to the result. On
the other hand, we may ask if the fact of their non-employment was not an
important circumstance as regards the result ? The answer to this question
is anticipated in the closing sentence of the foregoing paragraph.

The occurrence of haemoptysis in a large majority of the cases is a point
worthy of note. It occurred in eighteen of the twenty-four cases. In ten of
these eighteen cases, it occurred more than once, and in some it occurred
several times.

This proportion exceeds that in which hemorrhage may be expected to
occur in cases of tuberculosis, according to the researches of Louis (57 of 87
cases), a fact which goes to show that this symptom is not unfavourable as
regards the possibility of arrest of the disease taking place. The fact accords
with the conclusion deduced by Prof. Walshe from his researches, viz., that
the occurrence of hemorrhage does not hasten the progress of the disease, but
appears to produce an opposite effect. The fact also accords with the infer-
ence from observations in individual cases in which hemorrhage seems to
take place in lieu of a fresh tuberculous exudation.

Comparing, now, the cases in which measures of management were em-
ployed [i. e., 16 of the 24 cases, excluding the 8 cases in which no measures
were employed), in nearly all a change was made in the habits of life. This
change, with a single exception, consisted in all instances in relinquishing,
partially or entirely, sedentary pursuits, and giving proportionately more time
to exercise in the open air. The pursuits relinquished were as follows :
Teaching school and weaving ; printing in two instances ; teaching school and
attending medical lectures; study of the law; office duties of a lawyer;
teaching anatomy ; theological studies and writing sermons y medical studies
and duties of telegraphist; making millstones; domestic seclusion. In the
excepted case, the patient relinquished severe labour as a farmer, for several
months of recreation and travel. In five cases, the change in habits consti-
tuted the sole measures of management. How much importance belongs to

1 The only exception to this statement is that in one of the cases the patient had
been bled once before coming under observation.

80

Flint, Pulmonary Tuberculosis.

[Jan.

the change in these cases ? in other words, in how far was the result due to
the change, irrespective of the intrinsic tendency of the disease? Here, again,
I must be content with raising a question without furnishing facts on which
to base a definite answer. Inasmuch as improvement followed the change,
and, moreover, in some instances occurred so speedily and in such a marked
degree that the relation of cause and effect seemed to be striking, a certain
amount of agency is fairly attributable to this change. It may be remarked
here that in none of the instances in which arrest of the disease occurred
without any measures of management, were the pursuits of the patients
sedentary ; in all the habits of life were more or less active, and generally
quite so. We are warranted, then, in concluding that out-door occupation is
conducive to the arrest of pulmonary tuberculosis.

The exercise in the open air was not generally of the kind which often goes
by that title, consisting in simply airings by gentle walks or drives ) but it
consisted in rough occupation, often involving considerable, and sometimes
great exposure to the vicissitudes of the weather. In three instances it con-
sisted in the labour of medical practice, which in two of the instances was in
the country, and in the remaining instance, in addition to visiting patients,
horseback exercise was taken daily, and persevered in for several months.
In two instances the patients (females) performed laborious housework. In
one instance, the in-door avocations of the lawyer, which had been extremely
arduous, were exchanged for several weeks of constant travel in midwinter,
during which the pulmonary symptoms ceased. In one case the patient left
sedentary pursuits which confined him constantly within doors, for hunting,
fishing, rowing, etc., to which for several weeks he devoted himself entirely.
A student at law gave up his profession, and, after recruiting by field sports,
engaged in business and went to California. One patient continued to labour
out of doors during the autumn and winter, as a ship carpenter. A professor
of anatomy left the duties of the dissecting room and of medical practice, and,
crossing the Atlantic, was on foot daily, running about London and its vicinity
for several months, a haemoptysis occurring during this time, to which he
gave no heed. A day labourer continued to work, occasionally losing a day
or two. A printer went to work on a farm, and afterwards engaged in the
out-door business connected with the circulation of a daily newspaper. A
clergyman took to riding and walking and sawing wood. These facts go to
confirm the correctness of the conclusions which practitioners have frequently
formed from their observations in individual cases, viz., that laborious, fatiguing
exercise in the open air is best suited to promote the arrest of pulmonary
tuberculosis. Such exercise is obtained, in some instances, by engaging in
field sports in which the mind becomes interested, or in travelling ; in other
instances by a change of occupation by which sedentary pursuits are relin-
quished for those requiring active, out-door employment, and in other instances
by a necessity which compels the patient to continue daily physical labour as

1858.]

Flint, Pulmonary Tuberculosis.

81

long as possible, as a means of support. This necessity, painful as it may
sometimes seem, may be far less a calamity than it appears.

Change of climate entered into the management of but few of the cases.
In two instances only was there a change of climate prior to the evidence of
an arrest having taken place. In one of these (No. XXIV.) the patient
passed the winter season in the southern part of our country; in the other
(No. XIX.) the patient crossed the Atlantic, and returned after sojourning in
England a few months. In these two cases there is room for the inquiry,
how far the climatic change contributed to the result — another inquiry which
is easier raised than answered. In three other cases, the patient passed a
winter at the South after the arrest had occurred (Nos. II., IX. and XXII.).
In two of these cases the health improved during the southern residence; in
the remaining case (No. XXII.) the patient thought the influence was un-
favourable. During the period that these cases of arrested tuberculosis have
been collected, not a few of my patients have resorted to change of climate,
and hence, in the great majority of these instances, the disease has not been
arrested. So far as my experience goes, then, it fails in furnishing even
much presumptive evidence in favour of a beneficial influence from change of
climate. . On this subject I have been led to conclusions to which others have
also arrived, viz : that climate, in itself, exerts no special agency in determin-
ing an arrest of tuberculosis; but that it may favour this result indirectly by
affording better opportunity for exercise in the open air, and furnishing objects
of interest to the mind which will secure that object. By the remark just
made, I do not, of course, mean to be understood as saying that tuberculosis
is as likely to be developed, other things being equal, in one climate as in
another. I refer to a remedial influence only. Entertaining the view just
expressed, it has seemed to me far less important to fix upon a situation sup-
posed to be the most favourable in its climatic aspects to the tuberculous
patient, than to select a residence where the inducements to active habits of
exercise are greatest. To place a patient in a group of invalids, in a particu-
lar spot where he is expected to derive some specific remedial influence from
the atmosphere, is rarely useful. The ennui incident to such a position, for
a man of active habits of mind and body is intolerable, and the moral effect
of his associations is injurious. Patients will do wisely in avoiding the fa-
vourite places of resort for those affected with the disease, and in choosing
points where the incitements to, and the resources for physical exertion
abound. Generally, the objects of change of climate are better secured by
frequent change of place than by remaining stationary. Travelling in foreign
countries, even when, so far as climate is concerned, the change is for the
worse rather than for the better, may be in a high degree useful, because the
exercise which it invites is not endured as a task, but accepted as a means of
mental gratification. .

As regards diet, it is already implied in what has been stated with reference
to antiphlogistic or debilitating measures, that it was not an object in the

82

Flinty Pulmonary Tuberculosis.

[Jan.

management of these cases to lower the powers of the system by reducing
the alimentary supplies either in quantity or quality. On the other hand,. it
was a prime object in the instances in which treatment was directed, to sus-
tain and develop these powers by a highly nutritious plan of dietetics. The
patients were encouraged to live generously, indulging and cultivating an
appetite for any and all the varied wholesome articles of food, with a full
proportion of meat.1

This statement expresses, in a few words, the dietetic management of cases
of pulmonary tuberculosis, which, as it seems to me, is alike consonant with
the teachings of experience, sound pathology, and common sense.

It is a significant fact, apparent on referring to the cases which I have re-
ported, that the appetite and digestion were, in general, not greatly impaired.
Dyspeptic ailments appear to have been prominent in but one instance (No.
XXII).2 It accords with the views just expressed to regard an unimpaired
appetite and digestion as highly favourable for an arrest of the disease. Ob-
servation undoubtedly shows us instances in which the tuberculosis is pro-
gressive notwithstanding the ingestion and apparent assimilation of nutritious
food; but it probably can show few examples of arrest of the disease when,
either from disinclination or injudicious management, the diet is insufficient
for the full support of the body, or fails to be appropriated for that end. In
the single instance in this collection of cases in which dyspeptic ailments were
prominent, abundant food was taken and digested notwithstanding the act of
digestion was accompanied by distressing symptoms.

No part of the management of pulmonary tuberculosis seems to me of
greater importance than that relating to diet. In fact, whatever efficiency
belongs to active habits of exercise, it is reasonable to suppose, is in a great
measure exerted by means of the increased activity of the processes of assi-
milation thereby induced. Without the latter it is sufficiently clear that the
powers of the system are lowered in proportion as the materials of the organ-
ism and the vital force are expended by the exercise of the voluntary organs.
There is much scope for remark under this head, but my limits will not per-
mit a more extended discussion of the subject.

1 Inasmuch as carbonaceous alimentary principles appear to be highly useful in the
management of tuberculosis, I have been led to think that saccharine substances,
when well borne, should constitute a good proportion of the diet. Acting on this
view, I have been accustomed to advise the free use of sugar by tuberculous patients.
If it be true that persons employed in sugar-houses are less prone than others to this
disease, it is a more rational supposition, as it seems to me, that the benefit is derived
from eating the sugar, than that which attributes it to inhaling an atmosphere loaded
with saccharine matter. The latter hypothesis has been advocated by Dr. Cartwright
of New Orleans.

2 Dyspeptic ailments preceded the development of tuberculosis in Case No. IV., and
continued to some extent afterward. The subsequent remark in reference to No.
XXII. is equally applicable to that case.

1858.]

Flint, Pulmonary Tuberculosis.

33

Diffusible stimulants — wine, beer or spirits — entered, more or less, into the
management of a considerable number of the cases. These were employed
mainly as subsidiary to alimentation, or, in other words, as contributing to
render the digestive processes more active and complete. They were given
for this end in moderate quantities. Within a period too recent to include
in this collection the cases of apparent arrest that have come under my ob-
servation, I have been led to take a larger view of the utility of alcoholic
stimulants in the management of tuberculosis. I have, of late, advised their
use much more freely than formerly, and I think I cannot be mistaken in
attributing to them much value. I have observed that patients affected with
tuberculosis are often able to take spirits in large quantity without experiencing
stimulant or intoxicating effects. The disease appears to be one of those in
which these effects are with difficulty produced. I am tempted here to cite
an instance which came under my notice not long since. I visited, in consulta-
tion with a professional friend, a patient in an advanced stage of tuberculosis :
he was scarcely able to sit up ; expectorated puruloid matter in great abund-
ance; had hectic paroxysms with profuse sweating, and was much emaciated.
My friend, who had just taken charge of the case, attached great importance
to the free use of stimulants in this disease, and I was not inclined to interpose
any restrictions. In a few weeks I learned that the condition of the patient
was greatly improved; the quantity of expectoration was much diminished;
the hectic paroxysms were less marked, and he had gained sufficient strength
to walk about the streets. He had taken daily three quarts of pretty sub-
stantial stock ale, with about half a pint of brandy! This was conjoined
with a highly nutritious diet. In this case, although the patient had not been
addicted to drinking, the very large quantity of stimulants taken daily pro-
duced no intoxicating effect. In my own practice I have not witnessed so
striking an illustration as this; but I have repeatedly known stimulants taken
in quantities which in health could hardly be borne without manifest excite-
ment and no stimulating effects produced on the circulation and nervous sys-
tem. The ordinary stimulant effects of fermented and spirituous liquors in
health I have been led to regard as furnishing a criterion by which to limit
their use in cases of tuberculosis. If these effects are produced the quantity
is too large, and any quantity within this limitation will be likely to be useful.1

1 With respect to the kind of stimulant best suited to cases of tuberculosis, whether
beer, wine, or spirit, I have nothing definite to offer as the result of my own observa-
tions. In some parts of our country it is supposed that the common whiskey of the
country is much to be preferred. My rule has been to consult the taste and experi-
ence of the patient. Generally, I think, the choice will be between spirits and beer.
Individual peculiarities must be taken into account. I had lately a patient who took
great pains to procure an excellent article of the Bourbon whiskey, but when obtained
the effect was inferior to the common corn whiskey, and he was obliged to return to
the latter. The superior virtue supposed to belong to the common whiskey has been
attributed to the larger quantity of fusel oil which it contains.

84

Flint, Pulmonary Tuberculosis.

[Jan.

A consideration of great importance is involved in this subject, viz., the lia-
bility that the patient will acquire habits of intemperance, which would cer-
tainly render questionable the advantage of an arrest of the disease. Assum-
ing that this liability is incurred, and, at the same time, that the free use of
stimulants increases the chances of arrest of the disease, can there be a ques-
tion as to the duty of the physician to give the patient the benefit of the
remedy even at a certain amount of risk of his becoming intemperate? If
this remote effect were not a contingency, but was shown to follow uniformly,
or even in a large proportion of cases, the question would be different. It
remains to be ascertained by a collection of facts how great is the liability to
this result. I have not space, were this a proper occasion, to discuss the
causation of intemperate habits,- but I will remark, I cannot but entertain
the hope, if not conviction, that drunkenness is rarely due to the use of
stimulants strictly as a remedy, divested of social associations, especially
when they are given under conditions of disease which antagonize the effects
for which they are taken in health, and when the production of these effects
is considered as contraindicating or limiting their use.

It remains to notice the measures more distinctly medicinal which were
employed in the reported cases. I shall omit ail reference to the various
palliatives which must play an important part in the treatment of cases of
tuberculosis as well as other diseases. These details were omitted in the con-
densed histories of the cases reported. The remarks under this head will
occupy small space, for it is a striking feature, which the cases present in
common, that very little medication was resorted to. In no instance were
any remedies given with reference to a special influence on the tuberculous
cachexy, unless the cod-liver oil be regarded as a remedy of that kind. To-
nics frequently entered into the management. These were given with a view
to their effect on the processes of digestion and assimilation, and their import-
ance is to be measured by this effect. In so far as they tend to increase the
activity of these processes, remarks on their value are already anticipated in
what has been said under the head of dietetic management. I cannot doubt
that in many cases they form an important part of the treatment.

The cod-liver oil does not hold a conspicuous place in the management of
these cases. Several of the eases occurred before this remedy came into
vogue. In other instances it was not taken, or taken for a short time only,
in consequence either of a strong repugnance to it on the part of the patient,
or its being found to disturb the digestive organs. In very few of the cases
was its use persisted in for a long time. It was continued longest in one of
the most interesting and striking cases in the collection (Case No. I.). The
inference which the reader might naturally draw from the histories of these
cases as regards the writer's opinion of the value of the cod-liver oil, would
do injustice to this opinion. Had a larger number of these cases occurred
within a more recent period, or were I to report the cases during the last few
years in which the progress of the tuberculous affection appeared to be greatly

1858.]

Flint, Pulmonary Tuberculosis.

85

retarded, although not arrested, this remedy would be found to enter more
generally and often largely into the treatment. That it is a valuable remedy
in the management of pulmonary tuberculosis I can scarcely entertain a doubt;
but it is to be considered that since it has become emphatically the remedy
employed in this disease, improved pathological views and the lessons of ex-
perience have wrought a radical change in the management as regards other
measures — a change consisting in the abandonment, to a great extent, of an-
tiphlogistic and debilitating measures, and a recognition, more and more, of
the importance of measures of an opposite character. Consequently, assuming
(what is undoubtedly true) that the disease is managed more successfully of
late than a few years ago, it is not easy to determine how much of this greater
success is to be attributed to the use of the cod-liver oil and how much to the
change just referred to. Practically, this is an important problem, but data
sufficient for its solution are not yet available. The facts which I have col-
lected certainly show that arrest of the disease takes place when it is not due
to this remedy.

A point pertaining to the mental constitution of persons affected with
tuberculosis seems to me worthy of notice. As regards the successful manage-
ment of the disease, much depends on the patient's energy and perseverance.
Tuberculous patients, as is well known, usually entertain sanguine expectations
of recovery; but in a large proportion of cases they expect recovery to take
place without any extraordinary agency on their part to secure that result.
The disease, while it engenders hopes which are so often fallacious, seems
frequently to impair that determination of purpose without which the means
requisite to effect an arrest will not be efficiently pursued. A passive expect-
ancy of recovery and a calm acquiescence in the prospect of a fatal termina-
tion, belong to the natural history of the disease. On referring to the cases
which I have reported, I find that, in general, the persons manifested greater
resolution than is usually associated with the tuberculous cachexy. This was
due in some instances to innate strength of character, and in other instances
to the force of circumstances. A feeling of inability from his situation to
give up to the disease may operate in behalf of the interests of the patient
much more powerfully than the apparent advantage of leisure and wealth.
I was impressed with the truth of this remark by a conversation since I began
to write this paper, with a person whose case is included in the foregoing
report. The person referred to is an esteemed medical friend who was affected
with tuberculosis thirteen years ago (Case No. XX.). At that time young in
the profession, and dependent upon it, it seemed to him out of the question
to relinquish, even temporarily, its duties; and, fully sensible of his danger,
he deliberately resolved to continue his labours as long as possible, and to die
in harness should the disease prove fatal. He attended to all his calls, night
and day, and, in addition, practised daily and systematically the curative mea-
sure pronounced infallible by the great Sydenham, viz., horseback exercise.
A person of a character less resolute, or so situated as not to feel the same

86

Coolidge, Vital Statistics of War.

[Jan.

incentives to exertion, would perhaps have succumbed to the same amount of
disease.

In conclusion, the general views which, with our present knowledge, are to
govern the management of pulmonary tuberculosis may be summed up in a
few words. The grand ends to be attained are, the removal of the cachexy
on which the progress of the disease depends; the consequent arrest of the
disease, and the promotion of the processes of restoration. There is no spe-
cial medication to be pursued for the attainment of these ends; they are to
be attained by measures which, in general terms, develop and strengthen the
powers of the system. This mode of expression, it is true, in a scientific
point of view must be considered rather vague; but in a practical sense it has
a meaning sufficiently definite. The measures are hygienic rather than medi-
cinal; but much importance often belongs to the latter. The hygienic mea-
sures which are most important are laborious exercise in the open air conjoined
with agreeable mental occupation, and, as conducive thereto, frequently change
of business, the selection of a more eligible climate, and travelling are desir-
able, if not necessary; generous diet, and in many if not most instances, the
free use of alcoholic stimulants. The medicinal remedies, in addition to those
which are simply palliative, are chiefly those of the tonic class, and in this
category may be included the analeptic remedy which has of late years had
so much celebrity — the oleum jecoris aselli.

September, 1857.

Art. III. — The Vital Statistics of" War, as shown by the Official Returns of
the British Army During the IVar with Russia, and by those of the United
States Army During the War with Mexico.11 By Assistant Surgeon
Richard H. Coolidge, U. S. Army.

Within the last ten years two memorable wars with their brilliant feats of
arms, their instances of consummate generalship and of individual heroism,
have attracted in a pre-eminent degree the attention of the civilized world.
Is it not the province of the medical profession to examine the official records
of those wars, to ascertain the amount of sickness and mortality with which

1 Dispatches and Papers relative to the Campaign in Turkey, Asia Minor, and the
Crimea, during the War with Russia in 1854-55-56, &c. &c. Compiled and arranged
by Captain Sayer, Deputy Assistant Adjutant General, Horse Guards. London, 1857.
(Statistics and returns prepared by authority.)

Statistical Report on the Sickness and Mortality in the Army of the United States.
Compiled from the records of the Surgeon General's office, and published by authority
of the Senate. Washington, 1856.

1858.]

Coolidge, Vital Statistics of War.

87

they have been attended, and to devise, if possible, some means by which the
terrible sacrifice of life consequent upon a state of war may be lessened ?

The war between France, England and Turkey on the one side, and
Eussia on the other, was distinguished by the greatness of the numerical
force engaged, and the vast amount of material employed, as well as by the
science, energy, and perseverance displayed on both sides ; while that of the
United States and Mexico, though carried on with a less imposing military
array, was nevertheless characterized by events no less brilliant, and by feats
of arms exhibiting no less of perseverance, and of military skill.

The records of military surgery attest that the advance made in military
science, and the improvement and multiplications of the means of attack and
of defence, have lessened rather than increased the loss of life arising from
actual conflicts of arms. It is to be feared, however, that although the pro-
gress made in medicine and surgery may, and probably has, lessened the
proportion of deaths to the number of sick and wounded, yet that the loss of
life from diseases incident to large armies, has not, in the aggregate, been
diminished. The application of known principles of hygiene to armies and
navies, has, under ordinary circumstances, been attended with the happiest
results. Thus, in the British navy, the deaths in " 1779 were 1 in 8 j in
1811, 1 in 32; and in 1836, 1 in 72." It is, probably, impossible to apply
those principles, or to enforce prophylactic measures, as generally and as
rigidly in large armies as in fleets, but surely the sanitary condition of troops
in the field exhibited in these statistics, not only admits of, but imperatively
demands correction.

It is believed that though the circumstances of the respective campaigns in
which the armies of England and of the United States were engaged, widely
differ, the statistics of both admit of comparison; and that the general results
afford material for the serious consideration of all concerned in the formation,
discipline, and economy of armies, as well as for those immediately connected
with their hospital service.

It is evident that in a comparative analysis of statistics not based upon
precise or uniform data, but relating to dissimilar numbers and covering un-
equal periods of time, much room is afforded for error, and for so stating the
results as to make them conform to the opinion of the individual, or, in
instances like the present, to render them subservient to national prejudice
or pride.

The writer has no other object in view than that of presenting the general
vital statistics of those wars as shown by the official returns j and of exhibit-
ing in a clear and concise form the magnitude of those evils of war which, in
his opinion, admit of palliation.

The material at command is not such as to admit of the consideration of
the diseases of those armies, or of the special causes which led to them j but
as the returns embrace the statistics of several kinds of troops engaged in

88

Coolidge, Vital Statistics of War.

[Jan.

dissimilar operations, the results will, it is believed, give a close approxima-
tion to the average loss of health and of life incident to a state of war ; and
will also show the ratio of such loss consequent upon actual conflicts with the
enemy, to that from diseases following the ordinary exposure and hardships
of an active campaign.

In order that these statistics may be understood, and receive their true
value and nothing more, it is considered advisable to precede them by a sum-
mary statement of the principal events of the war with Russia, and of that
with Mexico; to point out the leading circumstances affecting the two armies;
and to note those things which serve to compensate for the different character
of their campaigns, and for the disparity in their relative strength.

The principal events of the war with Russia as connected with the service
of the British Army, may be summarily stated as follows : The embarkation
of troops from England commenced on the 22d of February, 1854, and the
first divisions of the British Army arrived "in the East" in April following.
The Allied Armies landed in the Crimea, September 14, 1854, and on the
20th of that month fought the battle of the Alma. The first bombardment
of Sebastopol commenced on the 17th October, 1854, from which time until
the final assault and capture of that city, September 8, 1855 — a period of ten
months and twenty-two days — the allied armies were continually engaged in
the siege of that place. In addition to the exposure and frequent conflicts
with the enemy necessarily attendant upon siege operations, those armies
fought five battles. The battle of Balaklava, October 25, 1854; the battle
of Inkerman, November 5, 1854 ; the "first general assault" upon Sebasto-
pol, June 18, 1855 ; the battle of the Tchernaya, August 16, 1855; and the
final assault upon Sebastopol, September 8, 1855.

The declaration of peace was announced from the Foreign Office, London,
March 31, 1856.

A portion of the " old," or regular army of the United States, which had
been for some months encamped at Corpus Christi, Texas, advanced on the
8th of March, 1846, to tjie Rio Grande, opposite the Mexican town, Mata-
moras. On the 25th of April, a detachment from that army was attacked by
a large Mexican force. The principal events of the war which immediately
followed this act of hostility, may be thus enumerated : The battles of Palo
Alto, and of Resaca de la Palma, May 8th and 9th, 1846 ; siege of Fort
Brown, May 4th to 9th, 1846 ; battle of Monterey, September 21st, 2 2d,
and 23d, 1846 ; battle of Buena Yista, February 22d and 23d, 1847 ; siege
of Vera Cruz, March 9th to 28th, 1847; battle of Cerro Gordo, April 18th
and 19th, 1847; battles of Contreras and Churubusco, August 19th and 20th,
1847 ; battle of Molino del Rey, September 8th, 1847 ; battles of Chapulte-
pec and City of Mexico, September 12th, 13th, and 14th, 1847.

The President's proclamation declaring the termination of the war, was
announced in orders from the War Department July 6th, 1848.

1858.]

Coolidge, Vital Statistics of War.

It appears from the preceding statement of facts, that the actual duration
of the two wars was nearly the same ; and that in both, a period of about
eighteen months elapsed between the first movement of troops towards their
respective theatres of war, and the crowning events of those contests, the
taking of Sebastopol, and the capture of the City of Mexico.

At the ' commencement of hostilities, the United States Army present at
the seat of war numbered about 3000, being about one-fifth of the total
regular (old) force employed during the war.

At the landing in the Crimea, the number of British troops amounted to
26,800, being a little more than one-fourth of the aggregate strength of that
regular army during the war.

It is probable that with both armies the relative proportion between the
average numbers actually on duty at the seat of war, to the aggregate force
employed in each during the whole period of the war, was maintained with
some degree of uniformity ; but the data to determine this point are wanting.
In the tables which are herewith presented, the official figures are strictly
adhered to, the losses per cent, being calculated therefrom. As, however,
the results of such calculations do not truly represent the relative loss per
cent, to the actual average number of officers and men in the field, it has been
assumed in the last table of the series, that the average force constantly in the
field throughout the war, or for the whole period of service, was one-half 'of the
aggregate force mustered into service, or employed in the war. As respects
the British Army, the writer has no positive means for judging whether this
assumption is a fair one, whether it does or does not approximate the true
average ; but with regard to the regular (old) army of the United States, and
to the volunteer force, he believes that it does represent very nearly the true
average. The "additional force," known as the "ten new regiments/' called
into service during the war with Mexico, had probably an average of two-
thirds of their aggregate numbers actually in the field.

The official returns of the condition of the British troops, from which these
statistics have been compiled, cover a period of twenty-five months and six
days, commencing February 22d, 1854, and ending April 1st, 1856. As,
however, only " the G-uards" and three regiments of infantry had embarked
from England prior to the 1st of March, the six days in February have been
neglected in calculating the ratios of losses sustained, and the term of service
has been stated at twenty -five months.

The official statistical tables respecting the " old" or regular army of the
United States, which have been used in this paper, cover a period of twenty-
six months, from May 1st, 1846, to July 1st, 1848. The statistics of the
" additional force," or the "ten new regiments," and of the " volunteer force,"
are given separately, both for the reason that their terms of service were
much less than that of the regular army, and because it is desirable on many
accounts to compare the results of different organizations. It is to be par-

90

Coolidge, Vital Statistics of War.

[Jan.

ticularly observed, that the sole object of this paper being to show the effects
of war upon the health and lives of those engaged therein, the losses set down
in the official returns of the British Army under the headings " Prisoners of
"War," and " Desertions/' and in those of the United States Army under
"Resignations/' "Desertions," and "Discharges by Expiration of Service,"
are not included in the statistical tables which follow.

Under the "Invalided Home" of the British returns, and the "Discharges
for Disability and by Order," of the United States returns, are included all
those who from disease or wounds were rendered non-effective. The persons
thus discharged from the United States Army, were sent to their homes at
the public cost, and most of them were pensioned. It is known that the
mortality in this class was very great, but there are no data by which to ascer-
tain its actual amount.

The sufferings of the British Army from the severity of the winter in the
Crimea, and from cholera, find their counterpart in the exposure of the
United States Army to the intense heat and fevers of the Bio Grande and of
Yera Cruz, and in the general prevalence of "Mexican Diarrhoea" which
proved its severest and most fatal scourge.

With these preliminary and explanatory remarks the tables are submitted.

No. I.— Table showing the Aggregate Strength of each Army in Officers and
Men; the Deaths; and the Numbers rendered Non-effective from all causes.

Forces.

Total strength ;

officers and
men, including
reinforcements.

Deaths from
all causes at
the seat of
■war.

Invalided home
(British Army).
Discharges for dis-
ability and by order
(U. S. Army).

Total loss.

British Army.
Regulars

Laud Transport Corps
British German Legion .
British Swiss Legion

97,864
7,575
3,753
2,121

Total .

111,313

21,097

16,308

37,405

United States Army.
Regulars
Additional Force
Volunteers

Volunteer General Staff .

15,736
11,186
73,260
272

Total .

100,454

12,896

12,252

25,148

In the other tables of this series the statistics of the regular troops of the
British Army will alone be given, as the Land Transit Corps did not arrive at
the seat of war till the spring of 1855; and the German and Swiss Legions
not until the fall of 1855.

1858.]

Coolidge, Vital Statistics of War.

91

No. II. — Table showing the Loss sustained in consequence of Engagements

with the Enemy.

Forces.

Total
strength
officers
and

men.

Total
period

01

ser-
vice.

KILLED IN BATTLE.

DIED OF WOUNDS.

TOTAL KILLED AND
DIED OF WOUNDS.

Offi-
cers.

Men.

Total.

Offi-
cers.

Men.

Total.

Offi-
cers.

Men.

Total.

British Army.

Mos.

Regulars .

97,864

25

157

2598

2755

86

1933

2019

243

4531

4774

United States Army.

Regulars .

15,736

26

41

422

463

22

307

329

63

729

792

Additional Force

11,186

15

5

62

67

5

71

76

10

133

143

Volunteers

73,260

101

46

467

513

0

100

100

46.

567

613

Forces.

British Army.
Regulars .

United States Army.
Regulars .
Additional Force
Volunteers

LOSS PER CENT.

Whole
ser-
vice.

4.87

5.03
1.27
0.83

Month-
ly ave-
rage.

0.19+

0.19+

0.08

0.08

WOUNDED IN BATTLE.

Offi-
cers.

515

118

36
129

Men.

11,361

236
1,189

Total.

11,876

1,803
272
1,318

Proportion
of deaths
to the
number

■wounded.

1 in 5

1 in 5.48
1 in 3.58
linl3.18

Proportion
Total | of killed and
killed [wounded to

and the total
wound-! strength,
ed. officers and
men.

14,631 1 in 6.68

2,266j 1 in 6.94
339 1 in 33.00
1,831 1 in 40.01

Having appended a note to this table, explaining the comparatively small
loss in battle of the " additional" and volunteer troops, it is proper to direct
special attention to the comparatively greater losses from ordinary causes
sustained by those troops, as shown in the following table. It is believed that
the "additional force" had a greater number of men constantly in the field,
in proportion to their aggregate strength, than either the regulars or volun-
teers, and that the volunteers had the smallest number in proportion to their
aggregate force. The " ratios" in Table III. are therefore too high for the
" additional force," and too low for the volunteers.

1 The regiments of volunteers were mustered into service for unequal periods, from
three to twelve months. The average period of their service is given in this table as
officially reported by the Adjutant-General of the Army. As nothing is further from
the intention of the compiler than to lead to erroneous conclusions, the reader is de-
sired to bear in mind, while examining this table, that the proportion of volunteers
actually engaged in battle was relatively less than that of either the "additional" or
regular troops; that their period of service was very much less; and also the fact
that the "additional force," as well as the larger portion of the volunteers, were not
brought into service till after many of the battles had been fought. The relative loss
in battle of these troops was, from these circumstances, of necessity less than that of
the regular troops.

92

Coolidge, Vital Statistics of War.

[Jan.

No. III. — Table showing the Number of Deaths from Ordinary or Accidental
Causes, and the Numbers "Invalided Home," or Discharged for Disability.

Total

Period

ORDINARY AND ACCIDENTAL DEATHS.

Forces.

strength,
officers
and men.

of
ser-
vice.

Men.

Total.

Loss per cent.

0

leers.

Per month.

Total.

British Army.
Regulars

97,864

25

143

15,667 "

15,810

0.64+

16.15

United States Army.
Regulars

Additional Force .
Volunteers .

15,786
11,186
73,260

26
15
10

49
36
Not stated

2,713
2,085
6,448

2,762
2,121
6,448

0.67+

1 Oft 1

0.88

17.55
18.96
8.80

INVALIDED AND DISABLED.

Total
loss per

opr\t

Loss per
cent,
per

Loss per
cent,
per

Forces.

Total

Loss per cent.

Aggre-
gate loss

officers
and men.

Per month.

Total.

month.

annnm.

British Army.
Regulars

16,050

0.65

16.40

31,860

32.55

1.30

15.60

United States Army.
Regulars

Additional Force .
Volunteers .

2,155
881
9,169

0.53

0.52+

1.25

13.69
7.87
12.51

4,917
3,002
15,617

31.24
26.83
21.31

1.20
1.79
2.13

14.40
21.48
25.56

Assuming that in the British army, and in the regular and volunteer troops
of the United States, the average number of officers and men actually engaged
in the campaigns through the entire period of the war, or of their term of
service, was one-half of the aggregate number mustered or received into ser-
vice during the war; and that in the " additional force" this average was two-
thirds of its aggregate strength (believed to be a near approximation to the
true average), we have the following results : —

Forces.

Term

of
ser-
vice.

Mos.

KILLED in battle

AND DIED OF
WOUNDS.

deaths: ordi-
nary AND ACCI-
DENTAL.

INVALIDED

AND
DISABLED.

LOSS PER CENT.
FROM ALL THESE
CAUSES.

Loss per cent.

Loss per cent.

Loss per cent.

Loss per cent.

Total.

Annual.

Total.

Annual,

Total.

Annual.

Total.

Annual.

British Army

25

9.75

4.68

32.31

15.48

32.80

15.72

74.86

35.88

U. S. Army

26

10.06

4.56

35.10

16.20

27.38

12.60

72.54

33.36

Additional Force

15

1.9]

1.51

28.44

22.68

15.74

25.02

46.09

49.21

Volunteers

10

1.25

1.49

17.60

21.12

25.02

30.02

48.87

52.63

It is possible that the "loss per cent." on the basis assumed in the above
table may give a higher ratio than the true one. This is more likely to be
the case with regard to the British army than with that of the United States;

1858.]

Coolidge, Vital Statistics of War.

S3

for although the precise data are not at the command of the writer in either
case, he is familiar with the details of the official returns of the one army,
and knows little or nothing respecting the records of the other. That the
average assumed does approximate somewhat to the true one for the British
army, may, with some reason, be inferred from the fact, that the annual loss
per cent, in officers and men, calculated upon that basis, approximates the
loss sustained by that army in the Peninsular war. In a paper compiled by
Mr. Edmunds from returns in the Adjutant-G-enerars office — quoted by Sir
George Ballingall in his work on Military Surgery — it is stated that, "in
the Peninsular army, averaging a strength of 64,227, including officers and
men, the annual ratio of mortality, from the 25th December, 1810, to the
25th May, 1813, was ten per cent, of the officers and sixteen per cent, of the
men." On the basis assumed in this table, the annual mortality of officers
is 9.48 per cent., and that of the men 20.64 per cent.

In stating the average number of volunteers in the field at one-half their
aggregate strength, the error, if any, is in favour of the volunteers; for if, as
the writer believes, their average force was less than that assumed, the ratio
of mortality would be higher. The difference in the loss of life and of health
between regular and irregular troops, shown in these tables, is, in the most
favourable view, and with every allowance for error in the returns, sufficiently
great to render the fact one of national importance.

Since the above was written, the report of the Minister of War to the
Emperor of France, respecting the affairs of the Army of the East, has been
received. As that report gives the aggregate number of deaths occurring in
the army, without designating separately those who were killed in battle or
died of wounds, no attempt has been made to incorporate the French statis-
tics in these tables.

The report shows that France sent 309,268 soldiers to the seat of war.
Of this number 62,492 died previous to the declaration of peace, March 30,
1856, and 4,564, between that period and the final evacuation of the Crimea,
July 5, 1856; making 67,056 deaths. If to this be added the missing, and
those lost in "la Semillante," we have a total loss of 69,229 men. There
returned to France 65,069 men, " on leave or on sick leave." This class is
supposed to correspond with the " Invalided Home" of the British, and the
" Discharged for Disability," of the United States returns, and will be so
considered in the following table, which is intended to show the actual loss in
effective men sustained in these wars, by France, England, and the United
States.

No. LXIX.— Jan. 1858. 7

94 Hammond, Experiments with Bibron's Antidote. [Jan.

Armt.

Aggre-
gate
force.

M'ths
in
ser-
vice.

Total
died.

Loss p

. cent

Total
inva-
lided.

Loss p. cent.

Total
loss.

Loss t

. cent.

Total.

An-
nual.

Total

An-
nual.

Total.

An-
nual.

French .

309, 26S

25

62,492

20.20

9 72

65,069

21.04

10.08

127,561

41.24

19.80

British .

111,313

25

21,097

18.95

9.12

16,308

14.65

6.96

37^405

33^60

16.05

United States

Regulars .

15,736

26

3,554

22.58

10.44

2,155

1Mb

6.21

5,709

36.27

16.68

Additional Force

11,186

15

2,264

20.23

16.20

881

7.87

6.24

3,145

28.10

22.44

Volunteers and

Vol. Staff

73,532

10

7,078

9.62

11.54

9,216 12.53

I

15.03

16,294

22.15

26.57

Total, U. S. Army

100,454

12,896

12.83

12,252

12.19

25,148

25.02

Fort Riley, Kansas Territory, November, 1857.

Art. IV. — Experiments with Bibron's Antidote to the Poison of the Rattle-
snake. By William A. Hammond, M.D., Assist. Surg. U. S. Army.

Some four years since, Prince Paul, of Wurtemberg, the celebrated natural-
ist, communicated to my friend, Mr. De Vesey, the results of some experi-
ments performed before the French Academy of Sciences by Professor Bibron,
relative to an antidote to the poison of the rattlesnake. According to Prince
Paul, Professor Bibron allowed a rattlesnake to bite him in the lips, cheeks,
&c, and, by taking the antidote discovered by him, prevented all alarming
symptoms, and, in fact, suffered no inconvenience therefrom.

The antidote in question, as stated by Prince Paul, is prepared according
to the following recipe: R. — Potassii iodidi gr. iv; hydrarg. chloridi corros.
gr. ij j bromini $v. — M. Ten drops of this mixture diluted with a table-
spoonful or two of wine or brandy constitute a dose, to be repeated if necessary.
It must be kept in glass-stoppered vials well secured.

Prince Paul forwarded a small quantity of the above mixture to Mr. De
Vesey, who used it successfully in the cases of two men bitten by rattlesnakes
near his residence in Iowa.

During a recent expedition to the Bocky Mountains, I had several oppor-
tunities of testing its efficacy, and, since my return, have performed additional
experiments with it. The results have been, upon the whole, exceedingly
satisfactory, and I think that when taken in time it may be entirely depended
upon in the poisonous wounds of the rattlesnake, and, perhaps, also in those
of other venomous serpents.

1st Experiment. — Heinrich Brandt, Acting Hospital Steward, was bitten,
on the 2d of July, 1857, in the index finger of the right hand by a large rat-
tlesnake (crotalus confluentus), which he was in the act of putting into a jar
for preservation. The snake inflicted a very deep wound, and hung by his

1858.]

Hammond, Experiments with Bibron's Antidote.

95

fangs to the finger for a second or two before it could be detached. About
four miuutes after the bite, and before much pain or swelling had ensued, I
administered one dose of Bibron's antidote. The symptoms almost immedi-
ately disappeared. Forty minutes after giving the first dose the pain and
swelling returned attended with considerable throbbing. I repeated the
medicine, and in less than five minutes the finger had regained its natural
appearance, and all pain and pulsation had vanished. He remained perfectly
well and resumed his duties in an hour from the reception of the injury.

2d Experiment. — A very large rattlesnake was made to bite a young wolf
(Canis occidentalis), about three months old. The serpent wounded the ani-
mal severely in the left flank. Fifteen minutes after the bite the leg was
much swollen, and the wolf exhibited signs of great uneasiness, yawning,
stretching, and looking about in an anxious manner. These symptoms con-
tinued to increase in intensity till inability to stand, drowsiness, and slight
convulsive movements ensued. I now (thirty minutes from the infliction of
the wound) gave six drops of the antidote, with the almost instantaneous dis-
appearance of the observed symptoms. In a few minutes afterwards the ani-
mal ate a large piece of meat.

2>d Experiment. — On the following day the same snake was made to bite
the wolf three times in the space of five minutes, in the flank, neck, and chest.
In two minutes after the last bite the effects of the poison were evidenced by
the inability of the wolf to stand, gasping respiration, and a fixed expression
of countenance. Some delay occurred in getting the antidote ready, and
before I could administer it all signs of life had apparently ceased. Never-
theless, I placed six drops far down the throat where it seemingly remained,
as no effort of swallowing was perceived. However, in one minute respira-
tion again commenced, and the heart could be felt to pulsate. The wolf lived
for twenty-seven minutes, and then died comatose.

The rapidity of the action of the poison in this case, owing to the large
quantity introduced into the system, prevented a successful issue. The good
effects of the antidote were, however, sufficiently apparent to every observer,
and I have no doubt that, had it been given before the faculty of swallowing
was lost, the life of the animal would have been saved.

4:th Experiment. — After my return to Fort Riley, a large Crotalus conflnen-
tus, which I had brought with me from the Rocky Mountains, was made to
bite a dog five months old. The wound was made in the right shoulder. The
poisonous effects of the bite commenced in ten minutes, causing gasping respi-
ration, inability to stand, &c. I attempted to give a dose of the antidote but
the dog would not swallow, and I had no means at hand by which to intro-
duce it into the stomach. I again tried to administer the remedy but with-
out success. The third dose was inhaled into the lungs. By this time the
dog was perfectly senseless, and was dead in forty-five minutes after the in-
fliction of the bite. Very slight swelling occurred in the wounded part.

bth Experiment. — Forty-five minutes after the last experiment the same

96

Hammond, Experiments with Bibron's Antidote.

[Jan.

snake was made to bite another dog of the same litter as the preceding. The
wound was inflicted in the lower jaw very near the mouth. At the end of
three minutes, and before any violent symptoms ensued, a dose of the anti-
dote was given. The dog swallowed it readily. Five minutes afterwards the
animal seemed very uneasy. Respiration was accelerated, and he preferred
to lie down in the shade. At the end of about fifteen minutes he could stand
with difficulty ; and, as the sickness appeared to be on the increase, another
dose was administered. Nearly half of this was lost. Slight swelling was
now perceived in the face and neck. When roused the animal would walk a
few yards though with great difficulty, and evidently preferred rest and quiet.
About one hour after the bite he lapped a little milk and seemed to be better,
wagging his tail when spoken to, and walking with less effort. No increase
of the symptoms occurred, and, in fact, the dog was, to all appearance, per-
fectly well in two hours after the reception of the injury, except that slight
swelling of the under jaw still remained. I saw him no more till next morn-
ing, when this had disappeared, and he was as active and lively as ever.

I had no further opportunities of repeating the experiments with other ani-
mals. During my absence, however, the antidote was used by Dr. Coolidge, U.
S. Army (to whom I am also indebted for assistance in the latter experiments),
in the following case, of which he has favoured me with the subjoined ac-
count:—

"In July, 1857, a girl, aged fifteen years, was bitten at Fort Riley, by a
rattlesnake, on the dorsal aspect of the first phalanx of the ring finger of the
right hand. In a few moments the finger became swollen and bluish, and
when I first saw her, about ten minutes after the receipt of the wound, the
forearm had begun to swell, and pain extended to the elbow. She was de-
pressed and somewhat nauseated. An elder sister had sucked the wound
from the first instant. There being sufficient space above the wound, I ap-
plied a cord tightly around the finger, and then made a free incision down to
the bone. As soon as the articles could be procured from the hospital, I gave
10 drops of the bromine mixture diluted, and injected into the wounded
finger the preparation recommended by Dr. David Brainard, of Chicago, Illi-
nois. (See Annual Report, Smithsonian Institution, 1854.) Yiz: R. — Iodinii
gr. x; Potasii iodidi gr. xxx; Aquas destillatse fjj. Solve. The patient
expressed herself relieved after the first dose of the bromine; a second was
given in twenty minutes. The solution of iodine injected caused severe
smarting pain; the fluid and air from the syringe could be felt a little above
the wrist, and ultimately caused suppuration of the cellular tissue on the back
of the hand. Nothing more was done. The girl recovered."

In conjunction with the mixture referred to in this paper, it will be
observed that Dr. Coolidge laid open the wound and injected the cellular
tissue with tincture of iodine, as recommended by Dr. Brainard, of Chicago,
so that the favourable result in this instance cannot be attributed solely to
the use of Bibron's antidote.

1858.]

Waring, National Hotel Endemic.

97

Art. V. — National Hotel Endemic. Autopsy; with Remarks. By Jas. J.
Waring, M. D-, Washington, D. C.

It is well known that a singular disease broke out in one of the most
popular and frequented hotels in the city of Washington, at a time (in
the months of January and March of the Inauguration year) when that
hotel was most densely crowded with the distinguished and known from
every section of our common country. So universal and yet so local was
the disease that scarcely an individual escaped who remained for any length
of time within the walls of the hotel; whilst not a case is on record as oc-
curring out of its precincts, however near. This morbific agent, so powerful,
so all pervading, and yet boxed up within four narrow walls, what was it?
Much abstract and pointed discussion has arisen as to the nature of this
agent, some supposing it to be a mineral poison— arsenic or some of its pre-
parations; others to be a miasm created by the defective sewerage (notori-
ously bad) and accumulated by the defective ventilation (equally bad) of
that hotel. By accident I was present at and took an active part in the
only autopsy made, to my knowledge, upon any victim of this strange dis-
ease. Major G-eorge McNeir, aged 64, a citizen of Washington, dined at
the hotel about the period of its first outbreak. No period of incubation
intervened for him. The disease manifested itself before retiring to rest on
the very day of the fatal dinner, and never left him afterward. An autopsy
in such a case was of evident interest, not only to the scientific but
to the general public. Therefore, by the request of Drs. R. K. Stone and
J. E. Morgan, the committee appointed by the Board of Health to investi-
gate this matter, the following gentlemen attended to aid in conducting it,
viz: Dr. Wm. Jones, President of the Med. Society, D. C, and Attending
Physician; Thos. Miller, Prof, of Anatomy, National Medical College; Prof.
E. W. Hilgard, Analytical Chemist, Smithsonian Institution; Dr. C. F.
Force, Commissioner of Health; Dr. Jas. J. Waring, Prof, of Physiology,
Nat. Med. College.

Some few weeks afterward notes of the autopsy were sent to me by Dr.
B. K. Stone, with the request that I would make some report of them, stating
at the same time the following as his reasons for so doing : " 1st, that I had not
seen or treated a single case of the disease, and up to the time of the post
mortem had not been specially interested in anything referring to it; 2d, that
I was not a member of the Board of Health, who had already published its
opinion of the cause of the endemic; therefore that I would not be influ-
enced to make use of the material here so opportunely afforded to protect or
sustain a previously expressed opinion or foregone conclusion." Desirous of
carrying out the wishes of Dr. Stone, so expressed, my comments are made
solely and entirely in reference to the history, symptoms, and pathology of

98

Waring, National Hotel Endemic.

[Jan.

the present ease. The history and symptoms are given in the following let-
ter : though not communicated by one in the profession, they are described
graphically and with sufficient accuracy.

Washington, June 20, 1857.

Dr. Wm. Jones:

Sir: At your request we (my mother, brothers and sisters) herewith furnish
you with our recollections of the symptoms, &c. attending the illness of my
lamented father, which resulted in his death on the morning of the 12th inst.
It may not be out of place to preface our recollections with a statement of the
fact that up to the commencement of his late sickness he had enjoyed most
remarkable health, never having, within our recollection, been confined two
successive days to his bed.

On the 8th of January last (in company with a friend who was attending the
Convention of the Soldiers of the War of 1812) he dined at the National Hotel
in this city: returning home between 9 and 10 o'clock that night, he complained
to my wife of nausea, and great pain in the stomach (my mother being with
my sister, who was quite sick): after undressing he called for a basin and
chamber, which were furnished him, and my wife left his room: returning soon
after, she found him leaning against the bed and still complaining of suffering
much pain, so much so as to need her assistance in getting to bed: the cham-
ber indicated that he had had a copious evacuation. The next morning my
wife carried his breakfast to his room: he ate but little, and stated that he had
had frequent evacuations during the night, and still complained of the pain and
nausea. My wife suggested to him that he had probably indulged his appetite
too freely the previous day at the hotel. He stated to her that he ate very little
meat, but ate heartily of soup, and particularly of float. I myself heard him
say that before going to the table he went to the bar of the hotel and drank
either whiskey or brandy.

About 9 o'clock he went out, as usual, to attend to his business, but soon
returned, very much debilitated. He continued to complain of the pain and
sickness, and suffering from frequent discharges from the bowels; also com-
plained of great thirst, and burning in the mouth and throat, which created a
constant desire for ice water. The symptoms as above stated continued with-
out intermission (the frequency of the evacuation to some extent restrained by
the use of. laudanum) until Sunday, Feb. 8, on which evening he was much
prostrated by frequent and copious discharges — so much so that he fainted un-
der the operations, in which state you saw him and administered to him. This
attack confined him to his bed ei^ht or ten days, from the prostration of which
he never fully recovered ; but the disease appeared to gain upon him, rendering
his nights almost sleepless on account of the frequency of his stools, notwith-
standing he was, on an average, taking 75 drops of laudanum a day. About
this time, in addition to his other symptoms, he complained of a hardness or
enlargement of the abdomen or liver, also of great internal heat. Although at
this time very feeble, he attended partially to his business until about the 1st
of March, when he again was brought to his bed, and on the night of the 2d
of March was so ill as to require the family to be up with him all the night.
This attack confined him to his bed and room until about the 10th of March,
and left him with a fever, from which his feelings induced him to believe that
he was rarely if ever free. From this time he frequently complained of acute
pain in his extremities: about this time he was also taken with a cough, which
increased rapidly and was at times very troublesome, particularly in his last
illness. His face, which up to this time — say middle of March — was appa-
rently bloated, and his complexion muddy and unnatural, now became very
clear and transparent, remaining so for several days, when it again assumed
the former muddy and unnatural appearance, accompanied with great dulness
of the eyes and a heaviness of the brow.

At the beginning of his illness he had very little or no appetite, but during
the last several months it became so great that he could scarcely satisfy it,
although he indulged it to a very great extent. His great desire for ice water

1858.J

Waring, National Hotel Endemic.

99

was produced no less by thirst than by the great burning, which he frequently
described as eommencingat the roof of his mouth, and continuing in a straight
line to his stomach, which sensation continued to increase up to his death.

The interval, say from 1st April to his death, was mostly passed in bed, or
in his room, during all of which time he suffered greatly from an almost con-
stant pain in the stomach and bowels, as well as from the great burning in the
mouth and throat.

On the 4th of June the disorder of the bowels became greater than usual, and
on the night of the 5th for the first time he passed blood, which discharges
continued at intervals of about a half hour, until to within a few hours of dis-
solution, which occurred on the morning of Friday, the 12th inst.

I remain, &c. &c. &c. THOS. S. McNEIR.

The points of interest in the above recital may be summed in a very few
words. It is to be observed that whilst sickness, nausea and pain are spoken
of no mention is made of vomiting. Moreover a copious evacuation marked
the very first step in the disease, and its frequent recurrence is evidently
dwelt on as the symptom : nausea simply continued. Throughout the day
which succeeded the onset of disease the discharges were still frequent, and
now he complained of a symptom so common in profuse diarrhoea — great
thirst and burning in the mouth and throat. These symptoms, viz., thirst,
burning, and frequent evacuations (to some extent restrained by laudanum),
we are told continued without intermission for thirty days, when the great
symptom — the copious evacuations — became aggravated to such a degree as
to produce complete prostration, even fainting. This prostration, these eva-
cuations, continued occasionally checked and again aggravated, according to
the history, till his death. Fever appeared 62 days after the onset of the
disease, and continued sufficiently to be noted by the patient to the end. In
the onset of all disease, perturbation of the functions causes loss of appetite,
but when the system becomes accustomed to a drain inordinate appetite suc-
ceeds. Such was the fact in the case of McN. He was not compelled to
keep his bed until the 1st of April, three months after he took sick, and
during this time occasionally attended to his business. He commenced to
pass blood from his bowels only eight days before his death, and he died five
months after having eaten and drank and breathed within the walls of the
National Hotel.

Summary. — The earliest and throughout the most prominent symptom
was a simple but profuse diarrhoea, with its concomitants, insatiable thirst,
burning in the mouth and throat, inordinate appetite, and complete prostra-
tion. Death was the result of the exhaustion of that profuse diarrhoea and
of the steadily but slowly progressing disease of which that diarrhoea was
but a symptom. No fever appeared for 62 days after the attack, and then
it was obscure, not violent. Blood was passed 129 days after. Death oc-
curred in 131 days.

What mineral poison will produce such a series of symptoms? What
miasm is known to produce such a disease?

Autopsy, 16 hours after death. — Temperature 80°. On laying open the
abdominal parietes the peritoneum, both visceral and parietal, was found

100

Waring, National Hotel Endemic.

[Jan.

discoloured, red, but varying in intensity in different parts; it was by far the
most marked on the surface of the transverse colon ; here it deepened in
intensity almost to a purple hue. The great omentum was decidedly con-
gested, and darkened of a dark red hue. The appendieae epiploicae were
also congested and red. The colon, as before remarked, was externally of a
dark red, whilst the stomach and lesser omentum were perfectly normal in
colour. This colour existed on the surface of the ascending and descending
colon, but to a much less marked degree, except at the caecum and sigmoid
flexure, where the colour again deepened, though not to the same intensity.
There was no effusion in the abdominal cavity of either coagulable lymph
or fluid.

Stomach. — On opening the alimentary canal we found — -in the stomach, no
ingesta but a little mucus and discoloured fluid. The mucous membrane was
slightly thickened near the pyloric orifice, but was not softened. It was of a
dirty gray colour with stellated points of congestion near the cardiac orifice.
On the lesser curvature and posterior wall, and midway between the cardiac
and pyloric orifices a circular ulcer existed, deep, with sharp undermined edges
and with a fungous growth of exuberant granulations overhanging and pro-
jecting. The ulcer penetrated to the muscular coat, which formed for it a
smooth base.

Duodenum. — A bright saffron yellow fluid, homogeneous and abundant,
filled the duodenum. This viscus was perfectly healthy in appearance, and
stained with healthy bile.

Jejunum. — -The contents were mucoid, and of a duller yellow hue. In
the first few inches, the valvulse conniventes were reddened. The solitary
glands were enlarged and distinctly prominent, looking like large pins' heads.
Peyer's patches were remarkably distinct. These glands did not seem so
much to be diseased as to have been diseased. There was a deposit of pig-
ment in spots dotting over their whole surface, and they were slightly pro-
jecting. There was no ulceration or marked softening of the mucous mem-
brane, and the coats were not much thickened.

Ileum. — The whole course of this intestine was in a perfectly healthy
condition. The contents were thicker than in the upper portions of the
alimentary canal, containing fresh and healthy-coloured bilious matter. The
glandulag agminatae were universally and distinctly marked, looking pre-
cisely as they did in the jejunum, but much more abundant.

Caecum and Colon. — The ileo-caecal valve was in an ulcerated state, an
honey-comb like ulceration in myriad spots. These little ulcers were circu-
lar, and did not penetrate beyond the submucous cellular tissue. The coats
of the caecum and commencing colon were enormously hypertrophied, more
especially the muscular and cellular. There was a reddish and fungoid ele-
vation and thickening here and there of the mucous membrane. In the
colon, just beyond the caecum, for 5 inches in total length, and 9 or 10 in
number^ partly upon and partly between the rugae were seen transversely

1858.]

Waring, National Hotel Endemic.

101

linear projections of the mucous membrane. These were hard, prominent,
granulated, and ulcerated, so as to give an honey-combed appearance. Their
surface was of a dark-brownish red colour. These placqites were from g inch
to an inch in length, and from a £ to £ in. broad, and elevated about £ in.
above the mucous surface. The transverse and descending colon was simi-
larly diseased. The mucous coat was much thickened, and covered with
minute ulcerations, circular in character, and in no case penetrating beyond
the submucous cellular tissue. The ulcer mentioned as existing near the
cardiac orifice of the stomach alone evidenced a tendency to perforation. The
transverse colon was more decidedly congested and diseased than any other
part of this intestine except the caecum before described. Here too the
little ulcers were so abundant and so closely set that they became fused
together, so as almost to lose their circular character. It was matter of
astonishment to observe the extent of surface denuded of mucous membrane.
It remained intact only in patches, and yet the denuded cellular coat had no
where ulcerated beyond the muscular coat. The rectum presented the same
marks of disease as the caecum.

All the other important organs of the body, as heart, lungs, liver, &c,
were in a healthy state; no further lesions of any kind were found.

Such an autopsy could not but impress me with certain convictions.
These I have attempted, though imperfectly, to embody in the following
remarks.

In the stomach of McN. no evidences existed of previous or present gas-
tritis; no evidences of the application to its coats of any corrosive substances.
This too is in perfect accordance with the symptoms during life. The circular
ulcer found on the lesser curvature and posterior wall, and midway between
the cardiac and pyloric orifices was recent, and corresponds to the perforat-
ing ulcer of Budd and Rokitansky, and the chronic gastric ulcer of Cruveil-
hier. The following quotations will make this more than probable.

Diseases of the Stomach, by George Budd, M. D., F. R. S. American
edition. (Pages 91, 92.)

" In most cases, the stomach presents no marks of disease, except a single
ulcer on its inner surface. This ulcer is seldom larger than a shilling, but
sometimes, especially when it is situated on the posterior wall of the stomach,
grows to the size of a crown piece, or even larger than this. It is generally
circular or oval, and in all cases extends through the mucous membrane, the
edges of which are clean-cut as if a portion of the membrane had been punched
out; sometimes the mucous membrane only is destroyed, and the ulcer has
then an even base, formed of the submucous cellular tissue. * * * * The ulcer
is generally situated along the lesser curvature of the stomach, or near it ;
usually nearer the pyloric orifice than the cardiac ; and much more frequently
on the posterior wall of the stomach than on the anterior." * * * " In most
cases of simple ulcer of the stomach the ulcer is solitary."

See also Rokitansky, vol. ii. page 36, American edition, for precisely
similar quotations.

We stated, it will be remembered, that no evidences existed of inflamma-

102

"Waring, National Hotel Endemic.

[Jan.

tion in the stomach; the duodenum, jejunum, and ilium, in like manner,
presented no evidences of inflammation of any kind. One lesion of marked
interest presented itself, however ; this was the enlargement and development
of the solitary and agminated glands. Peyer's patches were scattered over
with black spots, as if from previous ulceration and eventual healing, with
a deposit of black pigment in the little cicatrices.

The seat of the true disease which produced the death of McN. was evi-
dently not above the ileo-caecal valve. The moment, however, this narrow
boundary is reached, extensive disease presents itself. Honey-comb like
ulcerations of the mucous membrane on the very edge of the valve, and
continuing with the same characters, though even more extensive, up and
around to the rectum; thickening of all the coats beyond this point, even
forming thick dark red ridges for some distance beyond the valve ; red con-
gestion of these coats through to the peritoneum ; congestion and irritation
if not inflammation of the peritoneum — these were some of the results of
this disease. The thickening of the coats referred to was most marked in
the caecum and rectum ; the coats were thicker however in the transverse
colon than in either the ascending or descending colon. The transverse
colou, cascum, and rectum, were plainly the chief seats of disease. The
coats through to the peritoneum in these parts were intensely red, especially
those of the transverse colon. The congestion of the peritoneum was plainly
due to a transmission of irritation or inflammation through the mucous,
cellular, and muscular coats. It should be noted that there was no fluid in
the peritoneal sac, and no secretion of plastic lymph or pus, the usual results
of inflammation, and yet the great omentum was reddened and darkened,
showing that this irritation was rapidly becoming of a very serious nature.

The disease plainly commenced in the mucous coat, affecting the other
coats only from contiguity of surface. A wider conclusion may still further
be drawn from this case. Death was the result of the extensive disease of
the mucous coat of the large intestine. The external agent, whatever it
was, seems to have confined its ravages entirely to this intestine, commencing
on the very edge of the ileo-caecal valve, and terminating only at the sphinc-
ter ani. Further we may conclude, by combining the symptoms with the
known pathology that the cause, whatever it was, attacked at the very out-
set the mucous membrane of the large intestine, and did not produce any
change in the stomach and small intestines, sufficient to affect or modify the
symptoms, which were the result solely of the lesions in the large intestine.

The perforating gastric ulcer was recent, and no doubt the result of the
depraved and weakened constitution of the patient. It is possible that the
changes in the glands of the small intestines were the result of some typhoid
condition of the blood, possibly of an irritation transmitted to them from
the colon.

The mucous membrane of the large intestine was so extensively ulcerated
in places as to be left only in little islets, whilst in other places these ulcera-

1858.]

Waring, National Hotel Endemic.

103

tions assumed the form of circlets, leaving the membrane otherwise intact,
and giving the honey-combed appearance, before referred to. In fact the
destruction of this membrane was so extensive that it became matter of
astonishment the individual could live at all with such a condition of things.
These myriad ulcers, whether small and well-defined, or large and more
irregular, yet invariably affected the circular form, did not penetrate beyond
the submucous cellular coat, and presented at their bases neither softening,
darkening exudation, nor other evidences of a tendency to penetrate further
or perforate.

Eokitansky, whose authority in pathology none will doubt, speaks of four
distinct forms of inflammation of the large intestine, viz : a, erythematous ;
h, exudative; c, typhous; d, dysenteric. Under which of these forms should
we classify the disease before us ? The following quotations, I think, will
determine : —

" Catarrhal (erythematous) inflammation — or, in a lower degree, mere catar-
rhal irritation, catarrh — presents itself as genuine entero-catarrhus, with a dis-
charge of a thin muco-serous secretion in catarrhal diarrhoeas, namely, as a
consequence of suppressed cutaneous exhalation. It may result from mechani-
cal or chemical, &c. &c." * * *; "or, lastly, it frequently shows a specific,
contagious property (exanthematic typhoid catarrhs) * * "Catarrh is either
acute or chronic, and it either attacks the mucous membrane uniformly, or is
developed mainly in the villi and follicles. * * * Chronic inflammation rarely
admits of a complete cure. It is generally followed by a blennorrhoeic condition ;
and we thus find, in well-marked cases, a permanent dilatation of the vessels
established, with the following alterations in the tissues :" * * *

"Increase of substance, or permanent tumefaction of the mucous membrane,
its follicles, or villi, with increased density and consistence (hypertrophy),
giving rise in higher degrees to elongation of the membrane and formation of
folds and polypi ; hypertrophy of the submucous cellular tissue and the mus-
cular coat, &c. &c." * * *

"The seat and extent of the catarrhal inflammation and of the blennorrhoea,
differ according to the cause." * * * " They are not common in the small in-
testine, their usual seat being certain portions of the large intestine, viz., the
caecum and rectum. A peculiar disease, which we must here advert to, is
ulcerative inflammation of the follicles of the colon, such as we find in lientery,
brought on by tedious diarrhoeas. An ulcer results, which is distinguished
from the catarrhal ulcer just described, by the shape which it derives from the
follicle, and still more by the total absence of reaction, which is brought on by
the excessive destruction of tissue, and which produces an atonic and relaxed
state of the tissues at the base. In this disease, which in the dead subject is
commonly not observed until it has committed extensive ravages, the follicles
are at first tumefied in various degrees, and consequently project as smaller or
larger round conical nodules on the internal surface of the intestine, being
surrounded by a dark red halo. Ulceration now ensues in the interior of the
follicle, the small abscess penetrates the mucous membrane within the vpscular
halo, and a fringed ulcerated opening of the size of a millet-seed appears, which
leads to a small follicular abscess with red spongy walls. The ulceration con-
tinues, and the follicle is eaten away." * * * The ulcer is of the size of a
pea or lentil, round or oval, the mucous membrane at the circumference is
pale, slate-coloured, livid, and much relaxed ; the cellular tissue at the base is
dull-white, anasmic, sanguineous or dark blue. At this period a secondary de-
struction of the intestinal mucous membrane commences, which proceeds with
great rapidity. The original follicular ulcer now enlarges." * * * "Several
ulcers coalesce." * * * "The most extensive destruction is found to occur in

104

Waring, National Hotel Endemic.

[Jan.

the sigmoid flexure and the rectum. It is always confined to the colon." * * *
" On account of the alvine discharges, which are invariably associated with
this ulcer, the affection may not inappropriately be termed ulcerative diar-
rhoea."1 * * * ' 1 L '

It must be evident to those who have read the above quotations, that the
disease of which Major George McNeir died was a superficial erythematous
or catarrhal inflammation of the mucous membrane of the large intestine.
The attack assumed the chronic form, and lasted 131 days. It evidently
also had its seat in the follicles of the large intestine, and plainly corresponds
to the disease called by Rokitansky " Follicular Erythema or Catarrh" of
the large intestine, or "Ulcerative Diarrhoea."

Could arsenic, in any of its forms, whether introduced into the stomach,
into the blood directly, or inhaled in the form of arseniated hydrogen, pro-
duce such a disease? Nothing can be more easily answered. Consult Tay-
lor, Christison, Budd, Rokitansky, &c.

Every candid mind must agree that it cannot. Can, then, foul emanations
from bad sewers, pent up and breathed only for four or five hours, produce
such a disease ? I confess myself incapable of producing a single authenti-
cated case where such a cause was followed by such a disease. Yet I leave
this subject with my mind convinced, even though this be a new observation
of the mysterious effects of miasm, that this and this alone was the cause of
the death of the unfortunate gentleman, the subject of the present comments.

We append the following letter from Dr. J. C. Hall, of Washington, D. C,
who was so fortunate as to attend a large number of those affected by this
disease during the whole period of its continuance. His observations led
him to a certain conclusion already published. He now kindly communi-
cates a fact which confirms him in his previously expressed opinion.

"Washington, Nov. 30, 1857.

Dear Doctor: The National Hotel was closed about the first of April, and
the furniture was sold in the rooms about the middle of June. I am informed
by the auctioneer that he and several of his assistants were attacked with a
diarrhoea similar to that which prevailed in the house during the winter. They
neither ate, nor drank in the house. This fact (of which I have no doubt), to
my mind, affords conclusive evidence of the atmospheric or miasmatic theory
of this very peculiar disease. Yours, truly,

Dr. Waring. J. C. HALL.

1 Rokitansky, vol. ii. pp. 59, 60, 61, American edition, 1855.
Washington, D. C, Nov., 1857.

1858.]

Gilbert, Adhesive Plaster in Fractures of Thigh.

105

Art. VI. — Adhesive Plaster the best Counter-extending Means in Fractures
of the Thigh. By D. Gilbert, M. D., Professor of Midwifery in the
Medical Department of Pennsylvania College.

Since the publication of my first case of severely complicated fracture of
the thigh (Am. Jonrn., Jan., 1851), in which adhesive plaster was so suc-
cessfully used in keeping up extension and counter-extension, I have had
numerous opportunities of testing its value and confirming the good opinion
then formed of it. In every case the necessary tension, however great the
muscular resistance to be overcome, was kept up without abrasion of the sur-
face, or pain as the result of pressure. In the cases of adults, or even younger
persons, who could appreciate the importance of quietude in the treatment,
these perineal bands seldom required renewal during the entire period of con-
finement. Adhesive plaster, when well applied to the surface, becomes united
with the skin, so as to form a composite body; consequently friction and pres-
sure are transferred to the areolar, adipose and other tissues beneath. These
are characterized by histological and physiological endowments which fit them,
in a peculiar manner, for the toleration of pressure and motion without pain
or anatomical disturbance or lesion. The skin is thus protected, and, conse-
quently, abrasion, excoriation, or ulceration, either or all of which are the
usual products of pressure and friction upon its surface, when the ordinary
perineal bandages are used, do not occur. The adhesive bands, moreover,
act upon a surface much more extensive than that of their mere attachment,
through the elasticity of the skin, and thus contribute still more to its pro-
tection in protracted extension and counter-extension. All who have treated
fractures of the lower extremities must admit that freedom from suffering at
the seat of counter-extension is a great desideratum; this being secured,
another, equally important, viz., continued quietude of the fracture after
reduction and the adjustment of the retentive apparatus, is also attained.

The following cases, which are extraordinary in their character, have been
selected for publication at this time, in order that the attention of the pro-
fession may be more fully directed to the subject, and to demonstrate the
great value of the plan in cases of extreme difficulty.

Case I. — C. Youngandrews, of N. 9th Street, aged eleven years, fell on
the street and fractured his thigh obliquely, above its central part, June 12th,
1852. D. M.' Fort, M.D., of Vine Street, became, at my request, associated
with me in the case, both having been sent for simultaneously. The splint
and apparatus described in my former communication, including adhesive ex-
tending and counter-extending bands, were applied. No pain, except at the
seat of fracture, was complained of. In four and a half weeks the splint was
permanently removed, complete union having taken place. During this period
the anterior or upper counter-extending adhesive strip only required renewal.
The cure in this case was not only accomplished in an unusually short period,

106

Gilbert, Adhesive Plaster in Fractures of Thigh.

[Jan.

which is mainly attributable, in my opinion, to the perfect quiescence secured
by this method, but it is the more remarkable since this boy was slightly non
compos, and, ordinarily, very difficult to control by his parents.

Case II. — Dr. Fort was so well pleased with the method by adhesive plaster,
that he used it in the following case, which he has kindly furnished to me: —

A twin daughter, aged eighteen months, of Mr. D. Steinmetz, of this city,
fell out of bed, May 29th, 1853, and fractured her right thigh near the
trochanter. The fracture was reduced, and retentive apparatus, precisely as
in the case of Youngandrews, was applied. In thirty days the cure was com-
plete. The anterior counter-extending strip required renewal once during the
treatment.

Case III. — The late Dr. N. C. Nancrede, of this city, requested me to
meet him in consultation, June 9th, 1858, at the residence of Mr. A. Sieber-
lich, in Spruce Street. The infant son of Mr. S., aged seven months and a
half, had fallen out of bed and fractured his thigh about its middle. The
fracture was evident from the deformity and shortening. The following re-
tentive apparatus was prepared. One light splint, about one and a half inch
wide, to be applied from the crista of the ilium to a little below the knee;
three short splints of the same width, for the anterior, posterior and inner
aspects of the thigh; and numerous adhesive strips, eighteen inches long and
one and a half inch wide. The splints were padded with wadding on the
one side, so as to adapt them to the contour of the thigh. Adhesive strips
were used, instead of the ordinary roller, in supporting the wadding upon the
splints. Reduction of the fracture having been effected, the long splint was
applied to the outer surface of the thigh, and fixed there by its covering of
adhesive plaster, and adhesive bands applied to the knee and distal extremity,
so as to maintain extension; whilst other bands were applied to the inside of
the thigh, perineum, groin and proximal extremity of the splint, to secure
counter-extension. The short splints were then applied and secured in place
by adhesive strips instead of the ordinary roller. Thus, all the splints were
held securely in their places by the adhesive plasters which composed their
covering, as well as by the strips which encircled them and the thigh, and
thus extension, counter-extension and coaptation were fully maintained. The
motion of the hip and knee-joints was free, and the child was comparatively
free from pain, immediately after this retentive apparatus was applied. The
patient was not only carried about the house but taken to the family summer
residence in the country and brought to town once a week for our inspection
and the readjustment of the dressings, which were more or less displaced by
the incessant movements peculiar to infancy. In four weeks from their first
application the retentive means were removed, union having taken place
without deformity or shortening.

Case IV. — I was summoned in great haste, May 2d, 1854. to Wm. Henry,
aged nearly five years, son of T. N. Triall, residing in Noble above 9th St.,
who had just been run over by several coal cars on the Willow Street rail-
road in the vicinity. The accounts of the manner in which the accident oc-
curred were very unsatisfactory, none but children having witnessed its occur-
rence. There was no evidence of the passage of car-wheels over any part of
the body or the extremities. I found, upon examination, that the left thigh,
above its middle, the tibise and fibulas of both legs and both bones of the right
forearm were fractured. There were numerous contusions on the body and

1858.] Gilbert, Adhesive Plaster in Fractures of Thigh,

107

extremities, and the fractured ends of the bones had lacerated the soft parts
in their vicinity extensively, although the fractures were all simple. The
usual splints, compresses, adhesive bands and rollers were applied. On in-
quiry I learned that H. Deitrich, M.D., of 10th St., was the family physician,
who, at my request, was sent for and became associated with me in the case.
The splints which were hastily provided for the first dressing, after a few
days, were removed, and Dr. Gibson's modification of Hagedorn's splint was
substituted; which, with the adhesive bands for extension and counter-exten-
sion, answered the indications in this case more fully than the ordinary splint,
especially in restraining more fully the movements of the lower extremities.
Our patient was totally unwilling to be confined, and made constant persever-
ing efforts to disengage himself, which gave us a great deal of trouble in
maintaining the proper adjustment of the retentive apparatus. Febrile re-
action supervened on the second day of an active character, accompanied by
delirium, which increased our already existing difficulties very greatly. By
appropriate constitutional treatment and perseverance in the plan adopted to
procure reunion of the fractured bones, this case, so unpromising in all its
aspects in the commencement, was conducted to a happy termination at the
close of two months, precisely, from the date of the accident, viz., July 2d.
The splints and bandages were removed on that day, and, to my utter sur-
prise, I saw our patient in the street with his playmates on the tenth of the
same month. There is neither shortening nor deformity.

Case^Y. — I was requested by B. Price, M.D., of N. 9th Street, to meet
him in consultation September 12th, 1855, at 20th and Spring Garden Streets,
in the case of a little girl, aged five years, the daughter of Mr. T. Kane.
We found the left thigh-bone badly fractured in its upper third by the passage
over it of a heavy earth-cart. The soft parts were seriously contused, and the
deformity and shortening were remarkable. We provided a splint, about 2j
inches wide reaching from above the crista of the ilium to several inches below
the sole of the foot. This was padded with cotton, so as to adapt it to the sur-
face upon which it was to be applied. Bands of adhesive plaster were used for
extension and counter-extension, as well as to all intervening parts except the
seat of fracture, instead of the ordinary roller. After the adjustment of these
retentive means, the child declared itself free from pain, except at the imme-
diate seat of injury, and was moved from room to room without seriously de-
ranging the dressings or interfering with the fracture. This child recovered,
without deformity, in six weeks, although placed in most unfavourable circum-
stances as regarded ordinary attention — the father being constantly under the
influence of liquor, and the mother having all the cares of the family resting
upon her, without any one to aid her.

The following cases show the value of adhesive plaster as a means of ex-
tension and counter-extension in fractures of the leg : —

Case YI. — Michael Gillis, drayman, set. 40 years, had compound fracture
of both bones of the right leg, caused by a kick of his horse on the loth of
December, 1852. Dr. Fort, of Vine Street, was called and requested my
attendance in consultation. We found the tibia comminuted. A fragment
measuring about one and a half inch in length, and comprising more than
half of the diameter of the bone (tibia), was detached and required removal.
The wound was large and ragged, owing to the fact that the horse had just
been rough-shod. Gillis being a robust man, of large muscular development,
very considerable extending and counter-extending force was necessary in

108 Gilbert, Adhesive Plaster in Fractures of Thiyh. [Jan.

effecting reduction. A modification of Hutchinson's splint, adapted to com-
pound fractures of the leg, which I had used successfully on a previous case,
was applied. For counter-extension four bands of adhesive plaster, about
eighteen inches long by two inches wide, were used. These were applied
spirally, so as to cross each other — the two anterior below the tubercle of the
tibia, the two posterior at a point opposite; and as each one of these, in its
spiral course, became lateral, in passing from below upwards, and from above
down, they cross each other again directly opposite the joint, internally and
externally, after which the balance, or the free proximal extremities, were
passed through the holes in the upper end of the splint and securely tied.

The bands used in extension were applied in the usual way, laterally
and extending below the foot in the form of a short loop. This received
the strap of the tourniquet, the framework of which rested upon a cross-
piece attached to the distal extremities of the splints, and thus, by means
of the tourniquet, as in fractures of the thigh, extension and counter-
extension were kept up. In this apparatus no support was provided for the
posterior surface of the leg except that afforded by the straw mattress upon
which he was laid, which was unsteady. To remedy this defect Dr. Fort
suggested the use of the common fracture-box, altered so as to admit of ex-
tension by the tourniquet's resting upon a cross-bar below the foot, and counter-
extension by passing the adhesive bands through the holes in the upper part
of the sides of the fracture-box. To accomplish this the sides of the fracture-
box were composed of three separate pieces each. The upper and lower on
each side were firmly screwed to the bottom board, whilst the middle pieces
only were attached by hinges. Thus, as extension and counter-extension were
being kept up, the central segment of either side of the apparatus could be
let fall away from the leg, and the wound exposed byopeniDg the many-tailed
bandage, whenever this became necessary.

The fracture box was removed at the end of the ninth week, without
shortening or deformity. There was no pain complained of at the seats of
extension and counter-extension during the entire treatment.

Case YIL — I was summoned in great haste to Mr. B. F. Dutton, on the
16th of March, 1853, who had fallen from the fifth story of Messrs. Hall &
Boardman's factory, in Arch Street below Third, through the hatchway to the
first floor, a distance of about fifty feet. Mr. D. is a large man, weighing
about 200 lbs. He very imprudently tried the strength of a board which
was laid across the opening in the floor of the fifth story by standing upon
it. The board broke, and he fell. The force of the fall was received by
his feet, they continuing to be the most dependent parts. The concussion
was very profound, so that at first it was supposed he was dead. When I
arrived reaction was gradually taking place. On a careful examination I
found fracture of both bones of both legs near the ankle-joints. The frac-
tures were oblique and irregular. In the right leg I had reason to believe
that the lower fragment of the tibia was split longitudinally into two pieces.
The malleoli were distorted in both legs, and, no doubt, the ligaments of the
ankle-joints were extensively lacerated. There were severe contusions over
the course of the spinal column, which were, doubtless, caused by striking
against the floor as the body passed through the hatches. After sufficient
reaction was established, he was conveyed on a settee, by his friends, to his
residence in N. Twelfth Street above Poplar.

Assisted by Dr. Royer, of Schuylkill County, who happened to be near the
place where the accident occurred, temporary bandaging, so as to support the

1858.]

Sawyer, Osteoid Growth at Right Hip joint.

109

parts after their reduction, was applied, and cold water dressing enjoined.
An anodyne was given. Finding, next day, when reaction became somewhat
excessive, that the muscular contractions could not be controlled in this way,
and that there was danger of serious displacement, adhesive plasters were
applied in the usual manner, except that those by which extension was made
had to be confined in their attachments to the feet alone. By means of these
and the many-tailed bandage the eoaptated fragments were kept in place until
it was deemed safe to use the immovable dressing, which, when applied seve-
ral days after, answered a very good purpose in conjunction with the plan
already adopted. On the forty-fourth day after the accident all retentive
means were permanently removed. Mr. Dutton now has full use of his
ankle-joints, not even using a cane in walking.

Art. VII. — Case of Osteoid Growth connected with the Capsular Ligament
of the Right Hip- Joint. By A. F. Sawyer, M. D., one of the Surgeons of
the " Hospital of the Sisters of Mercy," San Francisco, Cal. (With three
wood-cuts.)

The patient, a native of France, set. 47 years, entered the hospital for
treatment, March 16, 1857. He has a full adipose habit, with the general
appearance of sound health.

His own account of the case is as follows :—

About a year ago his attention was directed to the presence of a small
apparently movable tumour, on the anterior surface of the thigh in its upper
third. At first it did not seem to increase in size, and gave him very little
inconvenience. During the last six months, it has been rapidly enlarging,
especially towards the ilium, attended with sharp pricking pains, exaggerated
at night, more particularly after a hard day's labor. He has continued his
occupation as a miner, until within a few weeks, when, becoming apprehensive
as to the real nature of the disease, he for the first time solicited medical
advice. He could give no rational cause for the origin of the tumour. His
parents were healthy and long-lived ; and although his previous history has
been one of great exposure physically, he has never suffered much from gene-
ral sickness. The only circumstance narrated, which can have had even an
indirect bearing on his case, is in connection with an accident he met with
about two years previously to the development of the tumour, at which time
he received severe injuries in the back from a mass of earth falling upon him.
He was not, however, so severely disabled that he could not rescue himself
unaided, and afterwards walked some distance to his cabin. Something like
six weeks elapsed before he could resume his usual employment, suffering
more especially from severe pains in the lumbar region, attended with some
swelling of the soft parts, and general sympathetic fever. No pain was felt
about the pelvis. There was no lesion of its contained viscera, and he pre-
served an entire command over the motions of the lower extremities, without
any symptoms whatsoever involving the ilio-femoral articulation. Within the
last four months a lameness has gradually supervened, and latterly he has re-
quired a cane to assist him in locomotion.
No. LXIX.— Jan. 1858. 8

JIO Sawyer, Osteoid Growth at Rhjlit Hip-joint. [Jan.

On examination, there was found on the upper and anterior portion of the
right thigh a large tumour extending from near the anterior-superior spine of
the ilium downwards nine inches, in the direction of the long axis of the
femur. Above, the tumour was widely expanded, apparently placed against
the ilium, and covered in by the muscles of this region. Inferiorly, the
tumour became gradually tapering, and its well-marked bifurcated extremity
could be felt quite superficially beneath the skin. It had a hard cartilaginous
consistency, and appeared to be movable, as was certainly the case in the
lower and superficial portion of it. The integument was somewhat stretched
over the tumour, but not discoloured. There seemed to be but little tender-
ness, and even with rough manipulation no complaint of additional pain.
The pain, as described, was always of a pricking character, and confined to
the tumour itself.

The right lower extremity was shortened five-eighths of an inch, when his
body was in repose, yet the limb could be drawn down to correspond with its
fellow. On rotation of the thigh, and in flexing and extending it upon the
pelvis, a most extraordinary freedom of motion was found in the hip articula-
tion, attended with extensive grating and crepitus, which could be heard some
distance from the bedside. By forcible abduction and adduction of the limb,
the head of the femur traversed the acetabulum abruptly, and with loud
crepitus. There was certainly an unnatural laxity of the capsular ligament,
perhaps rupture of the round ligament, and the grating indicated that the
articulating surfaces of the joint were deprived of their natural cartilaginous
coverings. The patient voluntarily, and without pain, could move his thigh
in every direction ; flexing it, rotating it, etc., yet always with the same
grating sounds. These movements of the head of the femur, jumping about
as it were in the acetabulum, were, to say the least, very peculiar. The
patient does not at present, nor has he ever suffered the slightest pain in the
articulation, either in walking, or even when the head of the femur is driven
forcibly against the acetabulum. All the pain experienced, whether in a
reclining or upright posture, is referred directly to the tumour, and becomes
somewhat aggravated after over-exercise of the limb. He could bear the
weight of his body on the affected limb, and walk about with tolerable ease
without any support. The lameness in walking appeared to result rather
from the shortening of the limb than from any loss of direct power over its
movements.

He made no complaint of his general health, had a good appetite, and
appeared strong and vigorous. Some general febrile symptoms were com-
plained of, as thirst, dryness of skin, and constipation of the bowels. This
condition of the system he reported as paroxysmal, although not preceded by
chills, a remark of some importance, as the patient, during his residence in
the mines, had often suffered from light attacks of fever and ague. Pulse 78,
full and strong.

In our investigation of this case we could not make a decided diagnosis,
and we shall now briefly consider the points of certainty or uncertainty con-
nected with it.

The general appearance of the tumour, its position, solidity of texture, and
particularly its bifurcated end, which was obvious to the eye as well as to the
touch, where it protruded through the muscle beneath the integument, rea-
sonably led to the idea of an exostosis, which had its origin from the upper
part of the femur or some portion of the pelvis in the neighbourhood of the

1858.]

Sawyer, Osteoid Growth at Right Hip-joint.

Ill

acetabulum, an examination of the bulk of the tumour indicating deep-seated
attachments. These positive features of the case strongly demanding the
diagnosis of solid bony growth, having its origin in bone, were negatived by
the single fact of mobility, which, if not fully distmct in the mass of the
tumour, was unquestionably so in the superficial, and from the singularity of
its formation, in this connection, its most important part, since it could be
readily grasped by the hand, and exhibited motion quite distinct from flexi-
bility.

The consistency of the tumour was too great for simple sarcomatous, adi-
pose or cystic growths; and for the same reason it was necessary to reject the
probability of any purulent deposit, although the position might be an ap-
propriate one for abscess connected with caries of the spine, especially in a
case where, from the previous injuries which the back had received, we might
have suspected the results of inflammatory action kindled up in the bodies of
the lumbar vertebrae. The bifurcated end of the tumour forbids the idea of
aneurism. Apart from this circumstance, it bore many points of resemblance
in position and outline to a case of aneurism of a branch of the " profunda
femoris" that recently fell under our observation, which was entirely without
bruit or pulsation, and the true nature of which was only disclosed by an
explorative puncture into it. And lastly, could it be considered a case of
malignant disease of a fibroid nature in its primary stage of development, and
without presenting as yet the well-marked local and constitutional signs which
may make a diagnosis certain ? It is to be remembered that excessive pain
and tenderness are not always necessary concomitants of malignant disease.
One of the most extensive cases of osteo-sarcoma of the tibia that we have
ever seen was attended with only trifling uneasiness, never sufficient to pre-
vent rest. In this case there was no tenderness, but the nature of the pain
was suspicious, a constant pricking pain. Added to this was the general
character of the growth itself, and the inguinal glands were decidedly enlarged.

With an opinion inclining in this direction as to the real nature of the
tumour, the hip-joint now becomes an interesting study, as its extensive ana-
tomical lesions indicated a more or less intimate relationship with the tumour,
especially as the unnatural condition' of the articulation began to develop
itself at a period subsequent to the appearance of the tumour.

We have already mentioned its leading peculiarities as an unnatural mo-
bility of the joint, associated with a decidedly bony crepitus, and a very con
siderable shortening of the limb. A fair inference would be that the joint
had suffered at some time previously from direct violence applied to it, causing
perhaps fractures of the neck of the femur or of the acetabulum, complicated
with a tearing of the fibrous textures of the joint and with more or less dis-
placement of the bony fragments. Is it possible that from the activity of the
inflammatory processes thus kindled up a nidus could have been formed for
the development of the tumour? Such extensive lesions, had they occurred,
would probably have been within the knowledge of the patient. So far from

112 Sawyer, Osteoid Growth at Right Hip-joint. [Jan.

this being the case, the patient noted these changes only after the tumour had
excited his attention, and they became steadily progressive as the tumour en-
larged, and in his narration of the injuries really received there is nothing
that implicates the integrity of the hip-joint. Again, it was scarcely possible
that caries could have existed from constitutional or external causes; for there
had never been pain, swelling or tenderness about the joint, and he had always
preserved the most entire voluntary control over the limb; such pain as was
complained of being referred to the body of the tumour. The tumour could
not be regarded as an abscess connected with such caries, granting its exist-
ence, for the reasons detailed when speaking of lumbar abscess.

If his statements were to have any value in a review of his case, we were
rather disposed to regard this unnatural condition as resulting from the irrita-
tion occasioned by the attachment of the morbid mass to the joint itself, or
in its immediate neighborhood, and thus leading to a progressive absorption
of the bone and cartilage which enters into its formation. At all events, from
some cause or other, the acetabulum had suffered severely, and it is only by
granting these extensive changes that the extraordinary freedom of motion
and grating of bone in the joint could be accounted for.

The peculiarities of this case attracted considerable attention from the pro-
fession in this city, and we are not aware that any unlimited diagnosis was
ventured concerning it. It was generally considered to hold an anomalous
position in the class of affections the surgeon is called upon to treat.

Operation. — March 21. Having determined to extirpate the tumour, and
having previously stated to the patient the dangers to be apprehended from an
operation, which I conceived if the disease was of a malignant nature might end
in an exarticulation of the limb, and to the performance of which he gave his
entire consent, he was placed under the influence of sulphuric ether. The
thigh being placed in a position to relax the muscles, a longitudinal incision
was made downward through the integument from a little above the anterior
superior spine of the ilium, to the lower third of the thigh. Just above the
insertion of the tensor vaginae femoris a second incision was made intersecting
the former at right angles, and the flaps of skin then lifted up so as to expose
freely the inferior portion of the tumour. It was found to consist of a fibrous
and cartilaginous texture, with an extensive deposit of bone within it, which
appeared to be articulated with the more deeply seated portion. Superiorly,
the tumour presented in the interval between the tensor of the fascia and the
m. sartorius, its base being packed as it were against the crest of the ilium.
The bulk of the tumour was located in the m. rectus, and muscular fibres
radiated from all portions of it. After enucleating the tumour by dissection
in order to reach its attachment, it was necessary to divide partially the ten-
dons of all these muscles. The anterior portion of the capsular ligament was
found completely involved in the diseased mass, and a pedunculated bony con-
nection existed at the margin of the acetabulum, external to the short head
of the m. rectus, and which was separated with some difficulty. The cavity

1858.]

Sawyer, Osteoid Growth at Right Hip-joint.

113

of the joint presented a remarkable condition. The acetabulum was very
much enlarged, and rather flattened by the absorption of old and the deposit
of new bone. The round ligament had disappeared. The head of the femur
was rough and flattened, and not a trace remained of the articulating carti-
lages. On dividing the bony attachment above referred to there was an escape
of what appeared to be synovial fluid, perhaps Jss in amount, and of a healthy
appearance ; but not a trace of synovial fluid or pus existed in the cavity of
the joint. From its pathological condition we might justly have expected an
abundance of the latter; but the opposite character rather existed — a peculiar
dryness of the articulation which we are at a loss to account for.

There was not much hemorrhage during the dissection. Two large branches
of the profunda femoris directly supplying the tumour required ligature;
otherwise a few superficial vessels only.

Doubts still existing as to the malignancy of the tumour, and as the wound,
although severe, appeared clean, with no traces of the tumour remaining, and
as it was thought, notwithstanding the cavity of the joint had necessarily
been opened into, that its altered relations would protect it from the severe
results usually to be apprehended from wounds of healthy articulations, it
was deemed expedient, on consultation, to attempt to preserve the limb. The
edges of the wound were brought together with sutures, cold-water dressings
applied, and stimulants allowed according to the will of the patient.

Dissection of the Tum,our. — The
tumour was seven inches in length, of Flg-
a lobulated form, gradually tapering
towards a slender bifurcated extremity;
its surface was very irregular, and mark-
ed with the attachment of muscular fibre,
which soon became lost in the cartila-
ginous matrix of the tumour. There
were also radiating patches of condensed
fibrous substance stretching out into the
surrounding muscle. There was no
cyst-wall or a semblance of the partially
distinct en'velop formed of the hyper-
trophied areolar tissue often observed
partly or entirely surrounding fibro-
plastic tumours. It was composed of
distinct masses of bone connected with
each other and surrounded by con-
densed tissue like fibro-cartilage. They
appeared to result from special cen-
tres of ossification, which would have
eventually coalesced into a solid tumour.

114 Sawyer, Osteoid Grovjth at Right Hip-joint. [Jan.

As it was, the union being incomplete between the separate pieces permitted
a latitude of motion in them to such an extent as to convey the idea of a'
movable tumour in the examination previous to the dissection. The largest
of the fragments was five inches in length by two in breadth, somewhat re-
sembling a long bone in appearance, with an extremely dense exterior, and
with its central medullary cavity, although very irregularly developed. The
smaller pieces could be easily cut with a knife and had more the appearance
of the cancellated texture of bone. The fibrous matrix in which they were
formed was quite firm in texture, and distributed through it were numerous
cells varying from the size of a bean downward, containing a peculiar curdy
substance of a yellowish colour. These cells were also quite abundant in the
parts ossified, and had firm walls of a fibrous character. Bands of white lus-
trous fibre traversed the smaller ossified pieces without preserving any uniform
direction. The portion of the tumour covering in the hip-joint had a rough
villous surface; no trace of the synovial membrane could be found. The
tumour was very vascular, the more solid parts being highly injected with
bloodvessels resembling bone in an inflamed state.

The microscopical appearances of the tumour are worth noting. Its matrix
was composed for the most part of condensed filamentous tissue. The wavy
fibres of a pearly lustre were clearly brought out in any section of what ap-
peared to constitute the cartilaginous portion of the growth. The indurated
nodules cropping out from the surface of the growth and imbedded in the

surrounding muscle, evidently nuclei for
the additional deposit of bone as the tumour
increased in size, were purely made up of
this texture. Interspersed among the meshes
of the filaments was found an amorphous
granular matter, an abundance of oil glob-
ules, and cells containing nuclei and nucleoli
such as are represented in Fig. 2. The
ossified portions had the structure of true
bone. The corpuscles of Purkinje with
the radiating canaliculi were beautifully dis-
tinct. An abundance of nutritive canals
(corresponding to the canals of Haver) were
observed, although irregularly distributed and soon lost in the surrounding
fibrous tissue.

The cysts previously described, found in the bone and the less solid parts of
the tumour, contained an abundance of oil globules, granular matter, and the
cell growth as seen in the accompanying drawing.

As the result of our observations in this case we suspect that the areolar or
filamentous texture is really that which in its modifications from a healthy con-
dition, growing out of obscure, perhaps impenetrable causes, gives origin and
material of progress, more frequently than is ordinarily supposed, to a large class

Fig. 2.

1858.]

Sawyer, Osteoid Growth at Right Hip-joint.

115

of factitious growths which are engrafted on the human body. One of the most
rudimentary forms of abnormal ossific structure is found in the subserous fila-
mentous texture of arteries, where we have under the microscope simply an
amorphous granular deposit. There is still a tendency towards a structure
exhibited here, as the plates are arranged with a tolerably uniform thickness,
preserving the calibre of the vessel. The modelling process by which this is
accomplished belongs to the subserous tissue, and at all events shows an effort
at arrangement not apparent in the masses of granular calcareous particles,
loosely connected by fibrin, much resembling a precipitate from the blood,
as we have seen in one instance, nearly obliterating the cavity of the aorta,
the walls of which were almost completely transformed into a bony tube. In
this case the ossific plates were found very numerously distributed in the coats
of the larger veins.

That the filamentous tissue may possibly form the nidus for the extension
of morbid growths, when their nutrition becomes active, derives some support
from the wide-spread anatomical relations of this texture to the organic fabric.

The curious attachment of muscular fibre to the surface of these tumours
is thus easily accounted for. As the tumour grows, the sheaths of successive
fasciculi being gradually incorporated with it, making for them new and inde-
pendent attachments, we believe the muscular fibre to be gradually lost by
the absorption of its elements, and not transformed into the proper texture of
the tumour. Tn the case of osteo sarcoma of the tibia, already cited, the
principal mass of the disease posteriorly corresponded directly in outline with
the m. popliteus, a few shreds of this muscle only remaining superficially.

The various forms of abnormal structure of which the etiology is so little
understood, may well be regarded as the genuine parasites of the human body,
corresponding approximative^ to the fungi of the vegetable world. All pa-
thologists agree in considering them as textures of a low vital type, and were
it reasonable to draw conclusions from a single case, we should assert that the
more primitive structures in the animal body afforded the most natural habitat
for their development, as the lowest forms of vegetation, to pursue our analogy,
connect themselves with the least vitalized portion, as the bark of the higher
orders of plants.

These reflections are simply suggestive, to provoke inquiry, rather than to
intrude on the profession dogmatical statements.

In the evening after the operation, reaction was well established, and the
patient made no complaint. Pulse 100, full and soft. Opiates were allowed
to promote rest.

22d. The patient rested tolerably well during the night. The tongue con-
tinued moist, although there was some thirst. Pulse 110. Some pain in the
wound, not severe enough to occasion distress, with slight tumefaction.

Strongly nutritive drinks allowed ; anodynes continued, with moderate use
of stimulants.

23d. Eeported himself as more comfortable. Slept well during the last half
of the night. The bowels have not been moved since the operation. Pulse

116 Sawyer, Osteoid Growth at Right Hip-joint. [Jan.

116, rather sharp. The thigh is somewhat swollen; the margins of the
wound reddened, with a considerable discharge of sanies.

A full nutritive diet ordered. Castor oil to act on the bowels.

24/A. Irritative fever, with marked constitutional prostration. Two dejec-
tions from midday of yesterday. Sharp pains complained of through the lower
portion of the abdomen. Wound as previously described. Pulse 127, sharp.

Stimulants and opiates continued, with warm fomentations over the abdo-
men, and a light yeast poultice to envelop the thigh.

7 P. M. The patient was suffering the most agonizing pains, with a sense
of tightness and constriction through the lower portion of the abdomen. No
additional tumefaction or irritability about the wound. Discharge scanty, of
a sero-purulent character. A greenish discoloration over the m. glutei ob-
served stretching across the lumbar region of the back. The pulse can
scarcely be counted.

25th. Well-marked gangrene established in the parts mentioned in the
previous report. The patient finally sank after extreme exhaustion.

Autopsy 12 hours after death. — Slight cadaveric rigidity. The discolora-
tion of the integument was confined to the lower back and buttocks, without
any tendency to a line of demarcation, and not involving either the wound or
the thigh. The muscular textures were generally much softened, including
the muscles of the thigh, otherwise but little change had taken place in the
track of the wound. About 3 ij of sanious pus, without marked fetor, was
found in the cavity of the joint. No traces of excited action existed in the
joint itself, or textures immediately adjoining. No traces of inflammation of
either the veins or arteries could be discovered. Viscera of the chest and
abdomen perfectly healthy.

We have added a drawing of the pelvis and head of the femur, showing the
condition of the bone entering into the hip articulation (see Fig. 3). The gross

Fig. 3.

1858.]

Storer, Cupping the Interior of the Uterus.

117

appearances will immediately strike one as similar to the changes often observed
in coxalgia, and were accomplished by the progressive absorption of old bone
and the deposit of new ossific material. There were no evidences of caries or
necrosis. Absorption was more active than the reparative process, as the new
deposits seen about the margin of the acetabulum and the head of the femur
were of a light porous character, it being possible to compress many of the
little nodules between the thumb and forefinger. External to the acetabulum,
although the form of the pelvis had been preserved, the bone had become so
thinned and porous by absorption, as to admit rays of light to readily pass
through the minute intervals from one surface to the other. The neck of the
femur appears, at first sight, shortened. On comparison with its fellow this
was found not to be the case. The head of the femur was flattened and
fissured, its margins irregular and expanded by the deposition of new material.

The cause of gangrene in this case was a little obscure. It will be observed
that it did not display itself in the parts where we should have more naturally
expected, either in the wound itself or the thigh, but in the back and gluteal
region. It could not have resulted from loss of blood, for the hemorrhage
during the operation was trifling, the two large branches of the profunda
being ligated as soon as divided.

It is more probable that death resulted from the prostration of the nervous
centres connected with the operation, although this is diflicult to concede, for
the patient was remarkably comfortable, considering the severity of the case,
up to the day preceding his death.

Art. VIII. — Cupping the Interior of the Uterus. By Horatio R. Storer,
M. D. (Read before the Boston Society for Medical Observation, Oct. 19,
1857.)

Case I. — Catharine , of Roxbury, aged thirty, and unmarried, applied

for treatment at the Eustis Street Dispensary, February 2, 1857.

Catamenia reported as entirely absent for seventeen years ) having com-
menced at twelve, continued regular for one year, and then on her taking
cold, permanently ceased. A general leprous eruption, which immediately
followed this suppression, has been constantly present since, disfiguring the
patient and otherwise causing her much discomfort.

Somewhat dyspeptic and anaemic ; costiveness ; addicted to headache, flatu-
lence, nausea. Old ulceration of tonsils. Vaginal leucorrhcea.

She was at first mainly treated for the disease of the skin. The diet was
carefully regulated and the bowels kept moderately open. Iodide of sulphur
was used locally, Fowler's solution by mouth till specific effect; in vain.

The protoiodide of mercury was then given, though all syphilitic taint had
been denied. It was pushed till great irritability of the bowels was produced,
though it had been combined with an opiate ; patient not improved. The

118

Storer, Cupping the Interior of the Uterus.

[Jan.

mercurial was subsequently resumed and continued till April 1, when the
gums were sore. It was then stopped, and the arsenic again commenced. •

In the mean time, the catamenial disturbance had not been lost sight of.
There was never present any decided menstrual molimen; it was therefore
impossible, save empirically, to time the attempts at assisting nature. Ther<?
was, it is true, pain in the head and back, but irregular and uncertain, while
the leucorrhoea presented no monthly or periodic increase.

On March 14, alteratives and tonics having been given for six weeks, with
aloetic purgatives, hot hip-baths, &c. &c, from time to time, without benefit
either to skin or uterine system, a vaginal examination was made. The
abdomen had been previously ascertained to be free from enlargement or
tenderness. The uterus was found depressed and slightly retroverted ; its
cervix elongated, but of small diameter; os almost impervious. The sound
entered with difficulty about two inches.

Sinapisms to the breasts were now ordered, in addition to and with the
emmenagogues already employed.

March 19. No effect produced, other than that patient has so well tested
the mustard as to have blistered both breasts. These abrasions were treated
by collodion.

April 1. A succession of flexible metallic bougies, an eighth to a fourth of
an inch in diameter, were passed through the cervix uteri.

4th. A galvanic stem-pessary, an eighth of an inch in diameter, introduced
into the cavity of the uterus.

12th. Pessary still worn. Patient cupped at and below sacrum.

May 8. No effect having been produced, the intra-uterine air-pump here-
after to be described was applied, and by it £ss of blood drawn from the in-
terior of the uterus. This was early in the morning ; the discharge continued
throughout that day and night.

June 6. Patient reports herself as in all respects better. Air-pump again
applied, and flow again produced ; this time more readily than at first.

When last seen, early in July, the patient had still further improved in
general health and spirits, while her skin had begun to assume a more natural
hue and feel.

In this woman the cutaneous affection not merely accompanied, but was
apparently consequent upon the suppression of the catamenia. Such being
the case, its obstinacy, equal in intensity and duration to that of the original
disturbance, is explained.

In the treatment of the case, from the outset, I was aided by my friend
Dr. Hayward, of Eoxbury.

Case II. — Margaret , aged twenty-five, from Winchester, entered the

Lying-in Hospital, under my charge, October 10, 1856.

Patient unmarried. Catamenia never appeared till her twenty-first year ;
discharge always very scanty, ceasing and reappearing at intervals during one
or two days, and always attended with excessive local pain, which continued
throughout the period. Recurrence of menses irregular, frequently passing
five or six weeks, as is at present the case.

Dyspeptic, anaemic, hysterical; for which general treatment, hydrocyanic
acid, cannabis indica, &c. &c.

Upon examination, some tenderness of abdomen, which was retracted. To
the touch, the os seemed almost impervious; cervix somewhat elongated;

1858.]

Storer, Cupping the Interior of the Uterus.

119

uterus depressed. For this a ring pessary had formerly been introduced,
with some relief. Ordered aloes, hot hip-bath, sinapisms to breasts.

October 12. No appearance of menses. Uterine sound introduced two
inches, and followed by smallest sized galvanic stem-pessary.

The next morning the menstrual discharge was established, not very abund-
antly, but comparatively more so than ever before, and with very much less
pain. It continued for two days.

22d. To-day a series of four metallic bougies passed ; all, even the largest,
with ease.

November 15. Bougies repeated. Yesterday and the day previous, galvanic
pessary. To-day menstruates as before, and almost without pain.

The flow continued two days; and then, on November 17, patient discharged
from the hospital, much relieved.

In the spring of the present year, I was again consulted by this patient
The improvement above noted had continued for some time, and had then
yielded to a recurrence of all the former distress. I therefore applied the
air pump, the menses being overdue, and produced a free sanguineous dis-
charge. This was several times repeated, at the proper intervals, in July for
the last time, always with relief to the usual symptoms, and apparently with
permanent benefit to the general health.

The cases reported were instances of amenorrhoea — the one partial, the
other total ; and in both organic, for in both the uterus was found undersized
and undeveloped. In neither, however, was there any obstacle to the flow
had free excretion from the uterine tissue existed, for though the os in both
cases was extremely small, yet in neither did it offer any decided resistance
to the passage of bougie or uterine sound. In one the catamenia had appeared
very early, in the other very late. In one the suppression had been almost
immediate and total; in the other incomplete, but constant and accompanied
by intense dysmenorrhoea, apparently not obstructive as ordinarily defined,
but congestive in its character. They may each require an extension of the
treatment, but its immediate and decided effect for good, both on the uterine
system and general health, give hope that the improvement may prove per-
manent.

It will be noticed that the remedies most frequent or most powerful had
been faithfully but vainly tried. The fact that I avoided others that might
be mentioned, ergot, galvanism, vaginal leeching, and the like, was in part
owing to experience of their inefficacy, and in part to desire for testing the
mode of treatment now described.

The operation, bold as it is novel, of producing hemorrhage from the uterus
by actually cupping its internal walls, was conceived and apparently first
practised by Prof. Simpson, of Edinburgh, and I am not aware that it has
as yet, by himself or by another, been made public or described. It seems
philosophically based, and the only questions to be settled are those of its
safety and success. To these, answers in part at least are found in the cases
now reported, whose progress, communicated to them at the time, has already
afforded matter of interest to several members of the profession.

The instrument used, identical save in coupling, with one made for me at

120

Atlee, Rupture of the Trachea.

[Jan.

Edinburgh, in 1854, and now also exhibited, is from the hands of Messrs.
Codnian & Co., of Tremont Street.

Its construction is sufficiently simple. An air-pump, small but powerful,
and a perforated tube, itself of sufficient calibre to contain several drachms of
blood, yet not too large to enter the os and cervix uteri; its orifices of a size
to escape easy clogging with mucus or clots of blood, and yet too small for
extensive laceration or hernia of the mucous coat, and its axis curved to
correspond with those of the uterus and vagina. Its passing to a sufficient
depth within the uterine cavity is insured, its entering too far is prevented, by
a ring of gutta percha, bevelled above for more perfect closure of the os, and
adaptable to any case by remoulding. The exact position of this ring is to be
determined by previous careful use of the uterine sound. Like that of the
intra-uterine pessary, the point of the stem should almost, but not quite, reach
the fundus uteri. By this precaution danger is avoided, and a much more
thorough effect rendered probable.

To the manner of coupling l am inclined to attach some importance. In
the Edinburgh instrument, the pump is screwed to the upper portion of the
lower tube, while in the other I have joined them by caoutchouc pipe. The
liability of a screw-thread to become worn, and the less chance of violence in
case the piston should play stiffly, if the coupling, while perfectly tight and
fitting, were yet elastic and flexible, occasioned this modification.

I have used the cup in other cases than those reported, in every instance
with the effect of inducing the sanguineous discharge, and I have never seen
from it any permanently disagreeable result. Its power upon the nervous
system is, however, at times so decided that its use should be with care. In
one case, where the introduction of the instrument had been painless, the first
play of the piston occasioned instant and alarmingly profound syncope.

To the microscopist, this instrument might frequently prove of use, by
affording an easy means of procuring healthy or diseased secretions directly
from the cavity of the uterus.

Whether in practice the cup will be found to answer any other indication
than that for amenorrhoea already instanced, as for relieving ordinary con-
gestive and inflammatory attacks, either of the uterus itself, Fallopian tubes,
or ovaries, remains yet to be seen.

Art. IX. — Rupture of the Trachea, from a fall. Communicated by John
L. Atlee, Jr., M. D., of Lancaster, Pa.

On the 22d of July, 1856, a boy, four years of age, the son of J. W., a
resident of Lancaster, in running across the street, tripped at the curb-stone
and fell, striking his neck with force against the scraper at the side of the

1858.]

Atlee, Rupture of the Trachea.

121

door of his father's house. The blow caused for a few moments extreme
difficulty of breathing, and I was at once sent for.

I reached the house not more than five minutes after the injury had been
received, and the child was then seated upon his mother's lap, his head rest-
ing against her arm, and breathing naturally, or very nearly so ) there was
some blueness of the lip, but this soon passed on0 ; on his countenance there
was not much appearance of distress. Where the neck had come in violent
contact with the scraper, there was not the slightest mark upon the skin. I
was just about to congratulate the family upon the slightness of the injury,
when the child, struggling to free himself from his mother's arms, threw
himself violently backwards. He at once became enormously swollen, and
in a moment was dead. The cause of the swelling was evidently the entrance
of air into the cellular tissue, and it extended over the head, the neck, the
trunk, and the upper extremities to the ends of the fingers. At the sternum
the finger, before reaching the bone, penetrated fully an inch.

To my extreme regret, a post-mortem examination was refused. My
opinion of the case was this : That when the neck had struck the scraper, the
rings of the trachea had been separated from one another, but that they had
remained in place until dislocated by the act of throwing the head back-
wards ; when this occurred, the air contained in the lungs was forced vio-
lently into the cellular tissue of the body. The difficult breathing imme-
diately after the accident, must have been caused by spasm of the glottis,
produced by the direct blow, as we sometimes observe after severe blows of
the fist.

In wounds of the air- passages, all works on surgery warn us against im-
proper bandaging of the external wound, on account of the danger of emphy-
sema, but no notice is made of an injury similar to the one I have just
related, except in the work of Ryland.1 There is also a case reported in the
Lancet for the 6th of September, 1856, by Dr. Robertson, resident English
Physician of the Baths of Wisbaden, who styles it an " unique casualty/'
These cases have never been published in this country, and as they are very
extraordinary, and as, moreover, from the autopsies, they enable us to explain
the phenomena observed in the case I report, it may be well to give them.

Ryland, at page 250, says : —

■

Wounds of the larynx may prove fatal by causing emphysema of the
body to such an extent as to impede respiration, but this must always be
owing to a faulty or inattentive mode of dressing or bandaging the wound, or
to the injudicious use of sutures. If, however, the larynx be crushed or
ruptured without the skin giving way, emphysema is a certain result, and if
it be not actively treated, may destroy the life of the patient. The only
instance of this kind of injury that I have met with, is a case by Dr. O'Brien,
in the Edinburgh Medical and Surgical Journal, vol. xviii.

1 Treatise on the Diseases and Injuries of the Larynx and Trachea, by F. Ryland,
London, 1837.

122

Atlee, Rupture of the Trachea.

[Jan.

u A woman was brought into the Royal Infirmary of Edinburgh, on the
evening of the 23d of July, 1818. The face was tumid, lips livid, breathing
very laborious and stridulous. The skin was cold, and that of the thorax,
neck, face, and superior extremities, distinctly emphysematous; and the pulse
was scarcely perceptible. She pointed to the throat as the chief seat of pain,
and said she had been kicked under the jaw; on the lower anterior part of
the neck was a bluish mark. Scarification^ were made about the lower part
of the neck, and restoratives and opiates were administered internally. On
the following morning her breathing had become more difficult, and she ex-
pired about nine o'clock.

"Dissection. — The cellular substance of the neck was everywhere distended
with air. On the soft parts being removed, a rupture was found through the
whole depth of the thyroid and cricoid cartilages, on the left of their mesial
line, and then through the right side of the first ring of the trachea. The
ruptured edges of the cartilages were rather tumefied, and slightly inverted.
Most of the cellular substance surrounding the larynx, pharynx, and trachea
was emphysematous. The anterior mediastinum was also emphysematous.
On opening the heart, the blood was found not coagulable, and quite frothy
from the admixture of air, and that in the aorta and vena cava abdominalis
was in the same state."

In the case reported by Dr. Robertson, in the Lancet, and which is an ab-
stract of the report of Dr. Berger, the Surgeon-General, the injury, as will be
seen, did not affect the larynx at all.

" Cannonier B , of the Artillery of the Prussian Guard, was kicked by

a horse a little below the lower jaw, while engaged in washing his hind hoof.
A small unimportant skin wound exhibited itself at the edge of the jaw, and
some blood, but not much, flowed from the mouth. The neck, however,
rapidly swelled to an extent sufficient to materially impede respiration. The
patient complained only of a peculiar sensation of weight at the epigastrium,
and stated that he felt as if blood had collected in his windpipe, and pre-
vented his breathing freely. There was no fracture or injury to be discovered
in the larynx. The patient was at once bled ; generally from the arm, and
locally by leeches, without the slightest effect upon the orthopncea.' The
latter symptom continued to increase rapidly until so fearful an emphysema
had established itself that the chest, neck, and face of the man were swollen
to a frightful extent ; and in this state, suffering great agony, he died within
an hour and a half of the receipt of the injury.

" The post-mortem examination discovered a complete rupture of the trachea
from the larynx, the latter being uninjured. The separation commenced at
the left side of the cricoid cartilage, proceeding to the right as far as the mid-
dle of the posterior edge, so that a third part only of the union of the trachea
and larynx remained intact. Several of the cartilaginous rings and ligaments
of the trachea were ruptured, and it was found filled with coagulated blood.
The thyroid, cricoid, and arytenoid cartilages were quite uninjured. The
heart was in a normal condition ; the lungs were congested, and of an unu-
sually dark colour/'

In connection with the above mentioned cases of general emphysema from
external injury, it may be interesting to know that in the Gazette Medicate
for 1840, p. 698, a case is recorded in which it resulted from the perforation,
by ulceration, of the right ventricle of the larynx, a little below the vocal

1858.]

Harris, Case of Fallopian Pregnancy.

123

chord. The patient was a young girl, fifteen years of age, who had been
attacked with ulcerative pharyngitis and laryngitis.

In cases of this kind, when their true nature is at once ascertained, it would
certainly be advisable to resort immediately to tracheotomy. It is true that
the ultimate cure of the patient is very doubtful, but it would afford a rea-
sonable chance of at least prolonging life.

Art. X. — Case of Fallopian Pregnancy resulting in Rupture of the Cyst and
terminating in Death. Reported by Robert P. Harris, M. D., Phila-
delphia. [Read before the Philadelphia Pathological Society Nov. 25th,
1857.]

Mrs. S., the subject of the following report and observations, a lady of
medium height, somewhat full habit, 27 years of age, and the mother of an
infant a year old, ate her breakfast on the morning of the 24th of October,
1857, apparently in perfect health, and between nine and ten o'clock was
suddenly seized with excruciating pain in the lower part of the abdomen,
followed almost immediately by a feeling of faintness. Her pulse became
very rapid and feeble, extremities cold, and surface of the body very pale, as
though exhaustion was being produced by internal hemorrhage. Stimulants,
such as wine whey, brandy and water, milk punch, and carbonate of ammo-
nia were freely administered, and cataplasms of mustard and ginger, together
with frictions of Cayenne pepper and whiskey applied externally, but to no
purpose. The pain, which was at first very severe, snon diminished, and
finally ceased; she gradually became more and more feeble, no pulsation of
the arteries at the wrist was perceptible, and the whole surface of the body
became cold, so that in a few hours from the commencement of the attack
all hope of recovery was abandoned. She remained in a moribund condition,
with little apparent change, until, from a gradual loss of vital power, she
ceased to breathe about seven o'clock on the following morning, twenty-one
hours after the commencement of the attack.

The next great point of interest in the case was to find out the cause of
death, for although a correct diagnosis was not impossible, yet its uncertainty
demanded that, for the benefit of science, it should be verified by the only
sure test in such cases, i. e. a post-mortem examination of the body. By a
refusal to grant a certificate of death to the relatives of the deceased because
of incompetency to state positively the cause of death, permission, after some
hesitation, was obtained to make an autopsy, and twenty-nine hours after
death we entered upon the examination. Upon uncovering, the body, the
abdomen was found much distended and tympanitic over its whole extent,
and, incising the skin and soft parts down to the linea alba, a thickness of
adipose deposit, varying from an inch to an inch and a half, proved the full
state of health of the patient at the onset of her disease. Further dissection
showed that the intestines, both large and small, were very much inflated, and
that the omentum was wrinkled and drawn up to the right upper portion of
the umbilical region. Extending the vertical incision down to the pubis, we
were arrested in our examination by the escape of a small quantity of serous

124 Harris, Case of Fallopian Pregnancy. [Jan.

fluid, and upon drawing the intestines upward from the brim of the pelvis,
we found that the cavity of the pelvis, as well as the lower and back part of
the abdominal cavity, was filled with black blood in a partly fluid, partly
coagulated state. After this was removed by means of a sponge, to the amount
of perhaps half a gallon, a small abnormal growth in the course of the right
Fallopian tube arrested our attention, and caused us to dissect out and care-
fully remove the uterus with its appendages.

The uterus proved to be scarcely if at all enlarged beyond the size we
usually find it in healthy women who have borne children. Its cavity con-
tained a little mucus slightly tinged with blood, but no trace of a membrana
decidua; the ovaries were healthy, of normal size, but very pale in colour,
from their anaemic state, and the left Fallopian tube presented nothing unu-
sual; but in the right one, immediately above the ovary, was a tumour of an
oval form, slightly flattened antero-posteriorly, about an inch and a quarter
long, an inch in its vertical diameter, and of a reddish-blue colour. Upon
close examination, a small opening of a little more than a line in diameter
was detected at its upper surface, perforating the edge of the broad ligament.
This hole communicated with the peripheral portion of the body, but not
with its interior cavity. An incision made through the cortical portion so
as to divide the body to its centre, revealed a cavity containing a small dia-
phanous sac, within which was a human embryo of a pure white colour, and
half an inch in length, looking a good deal like a common maggot.

Here, then, was clearly revealed the cause of death, and the supposition
with regard to the nature of the disease proved to be correct. An ovum had
become arrested in the Fallopian tube in its progress from the ovary to the
uterus, had become partly developed in its abnormal situation, and when it
had attained the age of three or four weeks had bursted, thereby making a
direct communication between its bloodvessels and the cavity of the abdomen,
and the patient had died of internal hemorrhage. This Fallopian or tubal
cyst and the diameter of the perforation had in all probability been larger at
the time that rupture took place than they were found to be when the au-
topsy was made, as they would both naturally diminish somewhat after the
force of the discharging current of blood began to decrease. This would
account for the sudden prostration that took place at the commencement of
the hemorrhage, as well as for the length of time that the patient lived after
she appeared to be in a dying condition. The accident was no doubt in a
great measure determined at the time it did take place, by the condition of
the patient, who was menstruating. The increased flow of blood to the ute-
rine organs probably contributed to produce the rupture of the cyst, which
appeared to have given way very much after the manner of an aneurismal
sac. The chief peculiarity of the case was the very early age in the deve-
lopment of the ovum at which the rupture took place, a shorter time after
conception than any of the cases of similar accident that I have met with in
works upon extra-uterine pregnancy, or in the medical journals.

Remarks. — In view of the importance of this interesting case, it will be
perhaps profitable to examine more particularly into the nature of Fallopian
pregnancies, the most common to be met with of all the forms of extra-ute-
rine foetation. Embryologists whose researches have been most recently
brought before the eye of the profession divide the forms of extra-uterine
pregnancy into ten separate and distinct varieties, of which six are more or
less connected with the Fallopian tube. These have been denominated sim

1858.]

Harris, Case of Fallopian Pregnancy.

125

pie Fallopian or tubal; tubo-ovarian ; tubo-abdominal; utero-tubal; tubo-
uterine-interstitial, and utero-tubo-abdominal — names which in a very simple
manner convey to the mind a knowledge of the situations occupied by the
ovum.

Causes of Fallopian Pregnancy. — When we look into the nature of con-
ception, and the structure and uses of the Fallopian tube, we are not surprised
that cases of tubal pregnancy are met with, but are amazed that they do not
more frequently present themselves to our observation. M. Coste, of Paris,
who has for the last twenty-six years been investigating the nature of con-
ception and foetal development under the most favourable circumstances; M.
Velpeau, and other celebrated embryologists, have not yet been able positively
to determine the manner in which the ovule is carried from the ovary through
the oviduct to the uterus. The spermatic fluid of the male, it is now gene-
rally believed, passes along the Fallopian tube to the ovary and there fecun-
dates the matured Graafian vesicle, which, bursting through the parenchyma
of the ovarium, is grasped by the funnel-shaped extremity of the tube, to be
carried into the uterus for its future development; but how it is so propelled,
whether by a movement of the epithelial cilise of the mucous membrane lining
the oviduct, by a consecutive annular dilatation and contraction of the walls
of the tube, or by a combination of both species of movement, it is impos-
sible fully to determine, though from the fact of the existence of longitudinal
and circular muscular fibres in the walls of the tube it is most probable that
progressive motion is given by them to the ovule, somewhat after the manner
in which deglutition is effected in the oesophagus of a serpent. The canal is
much too small in its natural condition to admit of the passage of the ovule
without considerable dilatation, and, judging from the analogy which exists
between the structure of the Fallopian tube and other tubular organs of our
bodies whose propulsive power is much more readily and certainly determined,
we have great reason for supposing that it is by a species of vermicular or
peristaltic action that the Fallopian tube is enabled to perform one of its most
important functions. It may be very readily conceived that the physiological
action of the tube might by some disturbing cause of so slight a nature as not
to be appreciable, be so deranged that an arrest in the progress of the fecun-
dated ovule towards the cavity of the womb should take place, and the ovule
be developed at the point where it ceased to advance. In some of the cases
that have been reported by medical observers, injuries and severe mental dis-
turbances were assigned as causes for this cessation of the conducting action
of the tube; but in by far the greater number of those which have been pub-
lished no definite reason could be given why the ovule should not have con-
tinued in its onward movement until it reached the uterine cavity. In many
of the autopsies that have taken place in cases where death has resulted from
the bursting of a tubal fecundated cyst, the ovum had not advanced beyond
the enlarged extremity or infundibulum of the oviduct, constituting the tubo-
ovarian variety of extra-uterine pregnancy, in which situation the ovule is
No. LXIX.— Jan. 1858. 9

126

Harris, Case of Fallopian Pregnancy.

[Jan.

probably arrested, from its being too largely developed previous to its passage
into the funnel-shaped portion of the tube, to admit of its being carried
through the more contracted section beyond.

It is to be presumed that as there is no vascular sustenance afforded to the
ovule until adhesion takes place between it and some contiguous tissue, that
it does not increase in size in its passage from the ovarium to the uterus when
no impediment to its course exists; which will account in a great measure for
the infrequency of tubal pregnancies as compared with uterine. Simple tubal
pregnancy is more common than any of the other six varieties, from the fact
that as there is a long and narrow canal to be passed through, the ovule is
here most likely to meet with impediments to its progress, or to form adhe-
sions with the surrounding tissues; and cases are on record of the develop-
ment of ova at almost any point between the infundibular portion and the
uterine extremity of the tube, even in that portion of the canal which lies
between the external and internal surfaces of the womb itself, where the
passage is larger than the central section of the conduit.

Diagnosis. — The difficulty of determining the presence of abnormal growths
connected with the uterine appendages is well known to be very great; still
more does it approach to an impossibility to define their nature when the fact
of their existence is beyond dispute; and this is particularly the case in the
early stage of their development, whilst they are but yet small. Some of the
varieties of extra-uterine pregnancy can be distinguished with sufficient cer-
tainty in the latter months of gestation to warrant a resort to an operation
for the purpose of removing the foetus and thus favouring the cure of the
patient. This is particularly the case with that form denominated sub-peri-
toneo-pelvic, where the ovum is developed between the peritoneal laminae of
the broad ligament, and which, as it increases in size, presents one extremity
(generally that containing the head of the foetus) low down in the pelvis
alongside of the vagina, where it may be felt and recognized: but in most
tubal pregnancies the position of the sac not only renders it very difficult of
recognition by palpation, percussion, or an examination per vaginam or rec-
tum, but makes it almost impossible by such means to define positively to
which of the varieties the disease properly belongs. When the foetus is suf-
ficiently developed to afford recognizable cardiac sounds, the chances for mak-
ing a diagnosis as to the true nature of the disease are much increased ; but
we must not forget that here a mistake may be, as it has been made, for cases
are upon record where intra-uterine foetation was mistaken for preternatural,
and the sound of the arterial thrill in the aorta for that of the heart of a
foetus.

In those cases where a physician is called in to give his opinion as to the
nature of the complaint, gestation is almost always advanced beyond the pe-
riod when the patient this article refers to died, for in the first two or three
months, as a general rule, the attention of the female is not directed to her
condition by any symptoms sufficiently alarming to cause her to seek advice,

1858.] Harris, Case of Fallopian Pregnancy. 127

and she attributes her feelings to a natural condition consequent upon con-
ception. If menstruation continues, which it does not do in the generality
of cases, it will sometimes cause an earlier attention than otherwise; but not
always so, as in many cases of normal gestation it is well known that women
continue to be regular for a few months after conception has taken place.
Ovarian pregnancy is much more apt to attract early attention than Fallopian,
in consequence of the greater sensitiveness of the organ involved. Generally
the first symptoms of an alarming kind which are felt are certain anomalous
pains and spasms of the abdomen, accompanied by fainting turns and alarm-
ing prostration. In tubal and ovarian pregnancies these pains are seated low
down in the abdominal cavity, but in abdominal fcetation they are not much
confined to one situation, but extend more or less over the whole abdomen,
which is very tender to the pressure of the hand. These symptoms may be
the immediate precursor of rupture of the sac, or they may disappear and
return from time to time until either the foetus dies, the sac bursts, or some
other of the changes to be hereafter mentioned take place in the sac or its
contents.

If the pains experienced are those of actual labour and the period of ges-
tation be far advanced, there will be but little difficulty in telling whether the
foetus is within or without the uterus. The abdomen will in the latter event
be found of an irregular conformation and the foetus more to one side than
ordinary. If the bladder be emptied by a catheter it will not be very diffi-
cult to feel the fundus of the womb just above the symphysis pubis, as in
cases of normal parturition after the expulsion of the foetus, and when the
membrana decidua (if there be one) is expelled, to establish the non-existence
of a foetus in the uterine cavity by the introduction of the index finger.

The frequency of the existence of tubal pregnancy as compared with the
other forms of extra-uterine foetation, makes it probable, when we meet with
a case of preternatural gestation, that it belongs to the former class. The
collection of cases made by M. Daynac, of Paris, and published in 1825,
shows that in one hundred and fifty cases of extra-uterine pregnancy, about
ninety, or three-fifths, belong to one or other of the tubal varieties; thirty,
or one-fifth, to the ovarian, and the remainder to the abdominal, &c. Some
writers have stated the proportion of Fallopian pregnancies to be still greater,
as M. Czihak, who says that they are as three to one. In many cases of sim-
ple Fallopian pregnancy during the early months of gestation, the uterus is
little if at all augmented in size ) but in some, as the utero-tubal and utero-
tubo-abdominal varieties, where the womb makes a portion of the gestative
sac, it becomes considerably enlarged, thus deceiving the physician as to the
nature of the pregnancy when examined by the touch. In the latter months
of gestation the uterus is enlarged in all the varieties of extra-uterine preg-
nancy, though much more in those immediately connected with it than those
entirely separated from it. In order fully to comprehend the difficulties which
stand in the way of making an accurate and reliable diagnosis in extra-uterine

128

Harris, Case of Fallopian Pregnancy.

[Jan.

pregnancies it is only necessary to refer to the reports of cases to be met with
in medical books and periodicals and see the mistakes that have been made
by men of undoubted skill. When a small ovum has bursted there is often
less difficulty in determining the nature of the lesion than there is when the
sac is whole, and of much larger size than the cyst found in the case of Mrs.
S.; for although in the former case auscultation, palpation, and the touch are
capable of revealing nothing, yet the alarming symptoms present indicate
with some degree of probability the nature of the malady.

In determining the nature of the disease which had caused the death of
the patient whose case has been recorded in these lines, I reasoned, before
commencing the examination of the body, in this way : Here is a lady of full
habit whose health has for some months been excellent, and the age of whose
infant makes it highly probable that she may have conceived. The symp-
toms of her malady evidently denote that she died from the effects of internal
hemorrhage, and the manner of the commencement of the attack, that the
blood escaped into the cavity of the abdomen. Now where did this blood
come from? The patient, before her last accouchement and for some time
subsequently was troubled with diarrhoea : might she not have had perforation
of the intestines? The physical condition of the woman, and her excellent
health for some months past show almost to a certainty that no ulceration
sufficient to have produced such an event could have existed in the alimentary
canal. Was she pregnant? She thought not, because she was menstruating
when the attack came on : but this does not prove the non-existence of extra-
uterine pregnancy, as many cases which have been recorded show that the
menstrual function is frequently not affected by preternatural pregnancies.
The os uteri when examined by the touch soon after the commencement of
the attack, appeared to be very sensitive, which is often the case in disease of
the uterine appendages, but it is no positive indication of the existence of any
lesion, because menstruation of itself sometimes increases the nervous sensi-
bility of the uterus. The nature of the pain experienced, its seat at the lower
part of the abdomen, and the evidence of a sudden and continued discharge
of blood, commencing directly after the pain was first felt, so exactly corre-
sponded with the history of many recorded cases of rupture of extra-uterine
cysts that I was led to believe that a post-mortem examination would prove
that I was correct in pronouncing the cause of death to have been the "rup-
ture of an extra-uterine fecundated cyst." Having determined in my mind
the nature of the disease, it was of little practical moment where the cyst was
situated in a case of this character; from the frequency of Fallopian preg-
nancies over the other varieties of preternatural foetation, it would have been
natural to have supposed that the seat of the cyst would be found to be some
portion of the oviduct.

Prognosis. — From the nature of Fallopian pregnancies it will readily be
conceived that the prognosis is exceedingly unfavourable, an opinion which
will be fully confirmed by a reference to reports of published cases to be found

1858.]

Harris, Case of Fallopian Pregnancy.

129

in the collections of Dezeimeris, Petsch, Moreau, Daynac and others. Al-
though Fallopian gestation is not in all its varieties necessarily fatal, yet the
great majority of cases ultimately sooner or later perish, and most of these
from internal hemorrhage. The length of time that elapses between concep-
tion and a fatal termination varies very much in different subjects, being de-
termined in some cases by accidental causes, as blows, falls, &c, and in others
by distension and thinning of the walls of the sac; by mechanical pressure;
uterine gestation; hyperemia of the uterine vessels; conversion of the cyst
into a dropsical sac; suppuration, &c. Most of the cases of rupture terminate
before the fifth month, but some do not until the full period of gestation is
completed. The bursting of the tube is not in all cases followed immediately
by death, for in some the ovule escapes entire, falls into the abdominal cavity,
and there forms adhesions, becoming further developed as an abdominal preg-
nancy; in others the placenta remains attached within the tube, and the
membranous bag containing the foetus escapes to become thereafter developed
exterior to the tube in the abdominal cavity, constituting a tubo-abdominal
pregnancy. In the first case a cure may possibly take place by ulceration, so
as to discharge the foetus into the rectum or vagina, or be effected artificially
by the vaginal section ; in the latter, gastrotomy might possibly be performed
with benefit, but I am not aware of its ever having yet been attended with
other than fatal results so far as the effect upon the mother is concerned, owing
to the difficulty of removing the placenta without fatal consequences, the
impossibility of letting it remain and still saving the patient, and the danger
of peritonitis. A very interesting example of abdominal pregnancy in which
gastrotomy was performed may be found recorded in the Philadelphia Journal
of the Medical and Physical Sciences, vol. i., New Series, 1825, p. 129. The
patient died of peritonitis upon the fifth day after the operation.

Of the six varieties of extra-uterine foetation in which the Fallopian tube
forms the whole or contributes to form a part of the gestating sac, the utero-
tubal is the most favourable. In this form it is quite possible that the efforts
of nature alone, or if not, with the assistance of the hand of an accoucheur,
may suffice to deliver the woman through the natural outlet, for a proof of
which I refer you to the case reported by Bichter and reprinted in Moreau' s
work upon extra-uterine pregnancies,1 and to that reported by M. de Ritzen,
reprinted in the Medical Examiner (Philadelphia) of 1841, p. 638. The
favourable results of these two cases must not always or even generally be
expected in utero-tubal pregnancies, for it is this variety which by consecutive
action forms the utero-tubo-abdominal, perhaps of all the forms the most cer-
tain to result in the death of the patient. In the work of Moreau above
referred to (pp. 29 to 36), may be found three very interesting reports of
cases of this latter complicated preternatural pregnancy, which were observed
and described by Patuna, William Hey, and Hoffmeister, the last of whom

1 Des Grossesses Extra-Uterine, par M. Alexis Moreau, p. 27. Paris, 1853.

130

Harris, Case of Fallopian Pregnancy.

[Jan.

performed the operation of gastrotomy upon his patient immediately after her
death, in the hope of saving the life of the foetus, but without effect.

It is not necessary to the favourable termination of all cases of Fallopian
pregnancy that the contents of the gestating sac should be removed from the
body either by the efforts of nature or by a surgical operation, for there is
quite a number of cases on record whose recovery took place with the foetus
remaining in situ. Owing to some cause or other not to be readily accounted
for, the foetus sometimes ceases to grow, and loses its independent life without
being, properly speaking, dead, as it still remains an organized body, capable
of undergoing many of the changes to which such bodies are subject. From
published researches we learn that the following remarkable changes have
been observed to take place in the sac and its contents : Most commonly the
cyst has been found contracted, the liquor amnii in whole or a great measure
absorbed, and the foetus shrivelled, as though it had undergone a species of
mummification. In other cases the sac has been found changed to a cartila-
ginous substance, or converted partially or entirely into bone; and the foetus
into bone wholly or partially, or changed into a cretaceous substance, or into
a mass resembling adipocire. In Cloquet's Pathological Anatomy may be
seen a fine view and section of a cretaceous or petrified foetus. This trans-
formation is rare in tubal pregnancies, nevertheless it does occur; in proof of
which see the report of a case by Fritze, of Strasbourg, in 17 79, and referred
to in the works of Moreau and others. In abdominal pregnancies it is of
more frequent occurrence. After the transformations mentioned foetuses have
been carried in the abdomen with little or no inconvenience for a number of
years, reaching as high as fifty-four in one case on record. M. Majon disco-
vered an ossified foetus in a female who had died at the age of 78 years, and
MM. Varnier and Mangin found two in a woman of 74, one of which was
ossified and the other entirely decomposed, with the exception of the bones.

Treatment. — Fallopian pregnancy as well as the other forms of extra-uterine
foetation are to be regarded more in the light of curiosities than of diseases
which are amenable to treatment, though under certain circumstances much
may be done, either for the purpose of alleviating suffering or with a view of
restoring the patient to health. What is most to be desired in the early
months of gestation is the death of the foetus, and for the purpose of pro-
ducing this two plans have been proposed, one of which is to diminish the
supply of blood for the development of the embryo by frequent bleedings,
the quantity of fluid taken being proportioned to the physical condition of the
patient; and the other, to pass an electric current through the sac in which
the embryo is contained. These expedients appear to me to be of very doubt-
ful utility, particularly the first, for how often do we meet with pregnant wo-
men who by attacks of acute disease have been reduced very much in flesh
and strength, but in whom there is no apparent effect produced upon the foetus
other than to cause it to be below the standard in size and weight. In chro-
nic diseases, where the constitution is defective, it is quite common to meet

1858.] Harris, Case of Fallopian Pregnancy. 131

with miscarriages, and births of still-born emaciated infants; but this is due as
much to the state of the general system as to the want of circulating blood for
the nutrition of the foetus. Diminishing the amount of the circulating fluid
by venesection may possibly defer the time of the sac's rupture by preventing
too great a determination of blood to the point where the embryo is being
developed; but that it will produce the death of the foetus remains to be
proved by the future experiments of accoucheurs. With regard to the effects
to be derived from the use of electricity and galvanism, time will also tell
whether or no they are to prove of any practical use in the treatment of this
disease. The value of the electric fluid as a curative agent is as yet very
imperfectly understood, and every year, almost, introduces some new applica-
tion of it. As it has been found of use in the treatment of aneurism it is
not improbable that it may also prove useful in extra-uterine pregnancy, pro-
vided we can devise some way of applying it to the fecundated cyst so as to
send the current through its contents without the risk of producing peritonitis.

The spasmodic pains accompanying preternatural pregnancy are to be treat-
ed with opiates, and if any signs of inflammatory action are present, with
antiphlogistic remedies. If suppuration of the sac takes place (an event less
apt to occur in Fallopian than abdominal pregnancy), and there is any evi-
dence of a disposition in the abscess to open upon the surface of the abdomen,
emollient and anodyne poultices should be applied; and an incision made with
a bistoury, when the abdominal parietes have become sufficiently attenuated,
for the purpose of giving exit to the pus and the debris of the foetus. If the
foetus can be felt through the walls of the vagina, the vaginal section should
be resorted to, or if an abscess point there, the orifice should be enlarged and
the contents of the sac removed by manual assistance. The rectum may also
be made the means of communicating with the sac, and a number of cases
are on record where the foetus, either entire or piece by piece, has been eva-
cuated through this passage.

With regard to the operation of gastrotomy in extra-uterine pregnancies,
there is little to be said that is favourable, and much that is the contrary.
From the experience of the past, it is to be looked upon as almost as doubt-
ful an expedient as the ligation of the aorta, yet it has had, and still has many
advocates among French surgeons. Those who advise its performance, do not
recommend it in the early months of gestation, unless the patient is in imme-
diate danger from the prospect of a rupture of the cyst ; and most of its advo-
cates recommend that it should not be resorted to earlier than the seventh
month, in the hope of saving the foetus if the parent perishes. Moreau and
Cazeau, in their late works, strongly oppose the operation while there can be
any hope of a spontaneous cure, and recommend a resort to it only in cases
where the pains of parturition have already commenced, and have not yielded
to efforts made to subdue them. They evidently regard this operation as a
last faint hope, only to be justified by the speedy prospect of death, and only
to be performed when every other means is evidently useless.

132

Sims, A New Uterine Elevator.

[Jan.

Art. XL — A New Uterine Elevator. By J. Marion Sims, M. D., Surgeon
to the Woman's Hospital, New York.

Op all malpositions of the uterus, retroversion is the most common. Dr.
Meigs, who is certainly the highest authority amongst us in obstetric medicine,
says it comprises 75 per cent, of all cases that fall under his observation.
Whatever, then, facilitates its removal is of importance to the profession.
As a means of diagnosis Simpson's sound is perfect, and in many cases indis-
pensable; but as a remedial agent it is susceptible of improvement. When
passed downwards and backwards into a retroverted uterus, and then rotated
half round on its own axis, thus suddenly elevating the organ, it often lace-
rates the lining membrane, as shown by severe pain and hemorrhage. Besides,
if the surgeon has unfortunately given it too large a curve, the whole weight
of the uterus will be sustained upon the point of the instrument as it strikes
against the fundus, which, we are told, has produced perforation, with fatal
consequences. This accident, however, cannot happen if the curvature be
made short, and not more than 2| inches from the end of the instrument;
for then the weight of the uterus will be sustained principally at the point of
contact between the anterior lip and the sound at its curvature. But while
the short curvature obviates the danger of perforation, it does nothing for the
prevention of pain, and of violence to the uterine cavity.

I have long thought that Simpson's sound could be improved by making a
joint or hinge in it near enough the end to prevent its striking against the
fundus, and yet far enough to allow its fully entering the cavity, which,
making the os tincse the centre of motion, would enable us to roll the body
in a right line directly upwards, instead of throwing it round by a lateral
sweep, as when the instrument is rotated on its own axis. This idea is prac-
tically illustrated in the Uterine Elevator (see Fig. 2), which the artist has so
well represented that further description is almost useless. It is about 13
inches long, and consists of a handle (3 inches), a shaft (7 inches), and a
uterine stem (2i inches), inserted into a ball which revolves at the end of
the shaft, its axis being at right angles with that of the instrument. The
ball is of ivory, about fths of an inch in diameter, and has a belt of perfora-
tions ygths of an inch apart, extending around in a line with the stem. The
shaft is a hollow cylinder containing a rod which is retracted at will by the
slide g, Fig. 2, or pushed forwards by a spiral spring so that its point may
lodge in any one of the perforations in the ball, whereby the stem may be
held firmly at any desirable angle with the shaft.

Fig. 1 represents the upper part of the shaft with its rod a, the ball with
its perforations, and the uterine stem, all nearly of the exact size and propor-
tions. Fig. 2 represents the practical application of the instrument.

The sense of touch is sufficient to show the position of the uterus, and by

134 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan.

Simpson's sound we measure to the fraction of an inch its depth and degree
of flexure. Then, and not till then, are we ready for the Uterine Elevator,
taking care to adjust the stem best adapted to the case. The stem is set at
the required angle with the shaft, and thus passed into the retro verted uterus
b, with the ball close up to the os tincse; then, by pulling back the slide g,
the rod a is drawn out of the perforation in the ball, when it is free to revolve
in the direction opposite to that of the motor power. Thus by depressing
the handle and pushing the ball up towards the promontory of the sacrum,
the uterus becomes further retroverted, but by pushing it gently and firmly
downwards and backwards into the vaginal cul de sac d, the inevitable result
is to revolve the stem with the uterus b, directly upwards, as shown by the
dotted lines ee. The uterus may be arrested at any point of this evolution,
merely by letting go the slide that holds the rod; or, the movement may be
continued till it is completely anteverted, while the weight of the organ will
be sustained mainly by the cervix resting on the ball. There are three stems
which screw into the ball, one 2 inches, one 2|, and the other 3 inches long,
but the medium size is the one ordinarily used. Whenever the long or the
short one may be needed, the previous use of Simpson's sound will indicate it.
The instrument may be made of silver, of copper silvered, or of German sil-
ver. I prefer the first two, because the stem often requires a little flexure to
adapt it to acute uterine curvatures, particularly where there is much carti-
laginous degeneration of tissue. German silver is not soft enough for this
purpose.1

After the malposition is rectified, it will, of course, require some mechanical
contrivance to keep it so : whether Meigs' ring, or Hodge's instrument, or
some of its various modifications, or Simpson's intra-uterine stem, will depend
upon the peculiarities of the case, and the tact and judgment of the operator.

Art. XII. — Exsectwn of the Trunk of the Second Branch of the Fifth Pair of
Nerves, beyond the Ganglion of Meckel, for Severe Neuralgia of the Face:
with Three Oases. By J. M. Carnochan, Professor of Surgery in the
New York Medical College, Surgeon-in-chief to the State Hospital (New
York), &c.

The accounts heretofore given by authors of neuralgia, or tic douloureux
of the face, are of a very vague and indefinite character. Numerous essays
and monographs have been written on this subject, since the time of Fother-
gill, who published, in 1776, an elaborate description of the disease, which
attracted considerable attention. In all these efforts, the pathology of tic

1 The instrument is made by Otto & Koehler, Chatham Street, New York.

1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 135

douloureux is described with ambiguity. In practice the treatment has been
as empirical as it has proved to be unsuccessful. The seat of the disease has
been referred to distant irritations, especially in the splanchnic cavities — to a
foreign body acting upon the nerve — to the pressure of bone upon some por-
tion of the nervous trunks. By some authorities, it is referred to increased
vascularity and thickening of the nerves ; while Astley Cooper, on the con-
trary, states, that the nerves present their natural colour, and are rather di-
minished in size than enlarged. It can scarcely be supposed that beneficial
results should follow from treatment based upon theories so different in cha-
racter.

Tic douloureux of the face, proper, or of the second branch of the fifth pair
of nerves, is by far the most common form of facial neuralgia. This may be
explained by the more numerous branches, which are given off by this trunk,
and by the position which these branches occupy — in some places pent up in
osseous canals, and in others, subjected to exposure, to changes in tempera-
ture, as well as to the agency of morbific influences, from which the other two
trunks of the fifth pair are exempt.

The same laws which govern neuralgic disease of one of the branches of the
fifth pair, must be applicable to the disease in the other trunks. I believe
that the phenomena of neuralgia can be explained with as much precision as
in any other disease, when well understood. In cases similar to those de-
scribed below, whatever may have been the original exciting cause, I have
no doubt that the real seat of the disease is in the trunk of the nerve, in
front of the foramen rotundum — in some part of it, or in the whole of it.
The causes of the disturbed and changed condition of the trunks of the
nerve may be numerous — prolonged irritation upon the periphery — expo-
sure— injuries — tumours; diseases of the teeth — pressure resulting from
periosteal or osteal thickening of the osseous foramina or canals — sudden
suppression of any of the important secretions, as of the catamenial dis-
charge. From one or more of these causes, the trunk itself may be pri-
marily affected, or acting upon its ramifications, the irritation may be propa-
gated to it. Prolonged irritation induces inflammation, and this generally
remains passive or chronic. Some of the terminations of inflammation — such
as the effusion of lymph among the interstices of the neurilemma or the
nervous tissue itself — may become developed; leading to a vascular, engorged,
thickened and enlarged condition of the nerve, or to a softening of it, at one
or more points. In fact, vascular engorgement, or inflammation, with some
of its consequences, of the neurilemma alone, or of it and the nerve together,
by whatever cause produced, is the condition which constitutes the pathologi-
cal changes in the trunk.

The three cases related below afford proof of what has just been stated. In
each instance, the exsected nerve was found to be red, vascular, engorged and
considerably enlarged.

The diffused character of the pain can be easily understood, if we take into
consideration the numerous ramifications of the second branch of the fifth

136 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan.

pair, and the extensive surface over which their ultimate filaments are distri-
buted. The periphery of the nerve occupies not only the superficial parts of
the face, but extends deep amongst the bones of the upper jaw, to the nasal
fossae, to the septum nasi, to the hard and soft palate, to the pharynx, to
the inner ear, to the orbit, and to the temporal and malar regions.

It is well established, that if the trunk of a nerve be irritated along its
course, the painful sensation will be referred to its periphery. If the ulnar
nerve, for example, be struck where it passes behind the internal condyle, a
sensation of pain is excited, which is referred to the little finger and to the
ulnar border of the ring finger ; and if a prolonged irritation be kept up at
this point, the skin of these fingers becomes tender to the touch, the sensi-
bility being very much increased.

It is by this principle — which governs the action of the stimuli upon the
nerves of sensation — -in connection with the anatomical distribution of the
nervous ramifications, that the various phenomena of neuralgia can be ex-
plained. The disease being seated in the trunk of the nerve, we can readily
understand that the pain must be referred to the peripheric extremities of the
nerves, and will there be felt, as long as the branches are in communication
with the encephalon.

From these views, we can perceive how futile the operation of division of
the nerve at the foramen infra-orbitale must be. Where the trunk of the
nerve is extensively diseased, no operation can rationally lead to a successful
result, unless all the branches emanating from the trunk are cut off from com-
munication with the brain ,

I believe that, in such aggravated cases of neuralgia, the key of the opera-
tion is the removal of the ganglion of Meckel, or its insulation from the en-
cephalon.— Where even a large portion of the trunk of the second branch of
the fifth pair has been simply exsected from the infra-orbital canal, the gan-
glion of Meckel continues to provide to a great extent the nervous ramifica-
tions, which will still maintain and keep up the diversified neuralgic pains.
Besides, the ganglion of Meckel, being composed of gray matter, must play
an important part as a generator of nervous power, of which, like a galvanic
battery, it affords a continual supply ; while the branches of the ganglion, un-
der the influence of the diseased trunk, serve as conductors of the accumu-
lated morbid nervous sensibility.

Case I. — Henry Rousset, a French physician, residing in Greensborough,
Caroline County, Maryland, consulted me in the early part of October, 1856,
for severe neuralgia, which had for several years rendered him incapable of
following his profession. He was of nervous temperament, good constitution,
and sixty-nine years of age.

The disease first made its appearance in September, 1851, commencing
with severe and lancinating pains about the region of the left cheek and orbit.
These pains continued for five or six days, and then disappeared, leaving him
almost free from them for about four months. At the expiration of that
time, the neuralgic pains again returned with more violence, extending over

1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 137

the region of the left cheek, and continuing almost without intermission, for
more than a week. After this exacerbation, the patient again became com-
paratively free from pain for a short interval ; after which, the attacks re-
turned with increased severity, and were renewed with greater frequency,
more especially in the cold season, and in damp weather. As the disease
progressed, the pain was not confined alone to the eye and cheek, but would
also attack the lip and nose ; each paroxysm being of longer duration than
the preceding. With but slight variation, the disease went on in this way
to harass and distress the patient for four years. About the commencement
of March, 1856, the neuralgic exacerbation assumed a more violent form,
marked by excruciating and almost unremitting suffering. He was at this
time unable to eat, drink, converse, or laugh, without having a most violent
paroxysm, causing him to shriek in anguish. The paroxysms were more se-
vere during the night than day : sleep left him : his constitution began to
give way, and his mind became much enfeebled. The slightest touch upon
the surface of the face, a current of air or a mouthful of water acting on the
palate, would throw the patient into a violent paroxysm of agony. During
this long period of suffering, all the known remedies which have at times been
extolled for neuralgia of the face had been tried — narcotics, tonics, antispas-
modics, with counter-irritants, and galvanism, without producing any appre-
ciable result. In this distressed condition, the patient, wearied of existence
and unable any longer to endure a life so made up of excruciating torture,
presented himself to me for my advice, at the beginning of October, 1856.
He expressed himself willing to undergo any operation, however severe, which
held out the prospect of relief. Having no internal remedy to propose which
had not already been administered, and having no faith in the mere division
of the nerve upon the face, I proposed to him the exsection of the trunk of
the second branch of the fifth pair of nerves to a point beyond the ganglion
of Meckel. Being a physician himself, I explained at length my views (as
expressed above) in regard to this malady. He immediately consented to
have the operation performed, and desired that the earliest time should be
appointed. I consequently agreed to perform the operation the following day,
the 16th of October.

Operation. — The principal instruments necessary for this operation are a
trephine, the crown of which is three-quarters of an inch in diameter, an
elevator, chisels of different shapes and sizes, a leaden or iron mallet, the bone
forceps of Luer, small pieces of sponge tied to a stick or a piece of whalebone,
and a small fixed trephine of half an inch in diameter, which may be used to
perforate the posterior wall of the antrum. The assistants being properly
arranged, the patient was seated upon a solid chair, opposite a good light,
and was put under the influence of chloroform. The head was rested upon
the breast of an assistant, who maintained it in this position. An incision
was now made on the cheek, commencing near the internal angle of the eye,
on the inferior edge of the orbit, opposite the anterior lip of the lachrymal
groove. This incision was carried downwards and slightly outwards, for
about an inch, to a point opposite to the furrow on the lower portion of the ala
of the nose; another incision, which also terminated at this point, was made,
commencing about half an inch below the external angle of the eye, opposite
the edge of the orbit, thus forming a V incision, in the area of which is
situated the foramen infra-orbitale. The flap thus resulting was thrown up-
wards, and the branches of the second branch of the fifth sought for; some
of these being found, they served as a ready guide to the trunk of the nerve.
This was now isolated from the surrounding tissues up to the poiut of exit

138 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan.

upon the face from the foramen. The lip was now everted, and the mucous
membrane detached from the superior maxilla along the line of junction be-
, tween the cheek and the gum. A sharp-pointed bistoury was now inserted
at the apex of the V incision, into the mouth, and carried downwards, so as
to divide entirely the tissues of the cheek and upper lip, along a line passing
midway between the ala of the nose and the commissure of the lips. The
two flaps thus formed were now dissected from the osseous tissue beneath,
one being reflected outwards, towards the ear, the other internally, towards
the nose. The whole front wall of the antrum maxillare, with the nerve
passing through the foramen infra-orhitale, was thus exposed. The crown of
the trephine was now applied on the anterior wall of the antrum, immediately
below the foramen infra-orhitale, and an irregular disk of bone removed, so
as to expose freely the cavity of the antrum. The circumference of the fora-
men, the hardest portion of the canalis infra-orbitalis, was now destroyed by
Luer's forceps, and a small chisel. The trunk of the nerve was now traced
along the osseous canal in the floor of the orbit, which was broken down with
care, so as not to encroach upon the tissues in the cavity of the orbit. Ar-
riving at the back of the antrum, the posterior wall of this cavity was broken
down with a small chisel, and the portions of bone removed. The trunk of
the nerve was now still further isolated from the other tissues in the spheno-
maxillary fossa. The posterior dental nerves being divided, and the dis-
section being carried still further, the branches given off to form the ganglion
of Meckel, were reached. These were divided, and also the branch given off
to run up towards the orbit. Lastly, by the use of blunt-pointed scissors,
curved on the flat side, the trunk of the nerve was divided from below up-
wards, close up to the foramen rotundum. The hemorrhage was not very
profuse, the labial arteries being easily controlled by pressure of the fingers,
and the branches of the internal maxillary artery, in the spheno-maxillary
fossa, by dry lint, or what is better, the compressed sponge. The lips of the
wound were brought together and maintained in place by thirteen points of
twisted suture, the German or Carlsbad pins being used.

This severe and trying operation is perfectly justified by the fearful nature
of the disease for which it was projected. It is one of those operations which
could not be supported by the patient without the influence of chloroform.
The handling of so large a nervous trunk with the forceps, and the necessary
contact with the hard instruments, while separating it from its surrounding
connections, would, I suppose, be beyond human endurance, without the aid
of the anaesthetic influence of chloroform or ether. For the rest, the effects
of the cicatrices upon the countenance can scarcely be called disfiguring, and
the patient speedily recovers without suffering from much constitutional dis-
turbance.

In this operation, and in those connected with the two succeeding cases, I
was assisted by my colleague Prof. Cox, by Drs. Proudfoot, Abrahams, Sel-
den, Gi-uleke, and Casseday; and by my pupils, Messrs. Dougherty, Henry,
Scudder, and others.

Condition of the Nerve. — The trunk of the nerve in this case was much
larger than natural in nearly its whole extent. The neurilemma was very vas-
cular, and the nervous tissue proper was also engorged and red ; the trunk,
after its removal, was so red as to have somewhat the appearance of muscular
tissue. The length of the nerve removed was a little more than an inch and
three-quarters. The lining membrane of the antrum was sound, as well also
as the bones of the antrum and the osseous wall of the canalis infra-orbitalis.

Progress of Union and After-treatment. — Oct. 16/A. Six hours after the
operation, the patient was visited. His pulse was 100; there was a slight

1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 139

fever; lie complained of thirst, and lemonade was ordered. He spoke of a
desire he had to vomit, which he ascribed to the chloroform. He stated that
he felt slight twitchings on the nose, and at the corner of the lip.

11th (Friday). The patient was remarkably well under the circumstances;
sitting up; pulse 90; tongue lightly covered with a white fur; complained
of pain in the wound, also of shooting pains in the left eye; he remarked
that he could stick a pin into the upper lip and cheek without causing pain,
there being no sensation in that region. Ordered chicken broth, and wine
and water.

18th (Saturday). Patient improving; wound healing; pulse natural; no
fever; spoke of the numbed sensation in his faee.

19th (Sunday). Pulse full and natural; good appetite; partook of a beef-
steak; in the afternoon four suture pins were removed; slight pain in the
wound ; no return whatever of the neuralgia.

20th (Monday). Cure progressing ; healthy suppuration from wound; ap-
petite excellent ; general health much improved.

(Tuesday, Wednesday, Thursday). During these days the rest of the pins
were removed; patient felt no pain whatever either in the wound or cheek;
wound in the antrum syringed with tepid water.

25^ (Sunday). Patient attended church ; feels no pain whatever; incision
of the upper lip and cheek entirely healed.

2Sth. Patient entirely well.

30^. Returned home to Maryland in high spirits, and delighted at the
result of the operation.

December 7thy 1857. Fourteen months after the operation he writes to me
that he is enjoying excellent health, and has been entirely free from neuralgic
pain.

Case II. — Florence Cordello, a native of Italy, aged 54 years, of lymph-
atic temperament, chocolate maker by trade, was admitted to the State Hos-
pital on the 14th of September, 1857, suffering from severe tic-douloureux of
the left side of the face. The following is the account handed to me by the
Assistant Surgeon, Dr. G-uleke. In the year 1828, the patient contracted a
very severe cold from exposure, and about this time he was seized with the
pain for the first time. According to his own description, the pain started
from the foramen infra-orbitale, extending upwards to the forehead, and
downwards into the teeth; the paroxysm lasting about ten minutes. He
supposed it to be toothache, and had one or two teeth extracted. An inter-
val of eight years took place, when he was again attacked with neuralgic
paroxysms, lasting from five to ten minutes. Again, after the lapse of a
year, the paroxysms reappeared in a more severe form, and at shorter
intervals.

The patient, still believing his teeth to be the source of the disease, had
all of them extracted on the left side of the upper jaw, but without any be-
nefit. During these attacks he had been subjected to many kinds of treat-
ment, both internally and externally : he also repaired to some of the mineral
springs on the Rhine, but still to no purpose. He continued thus to suffer
more or less intensely from the neuralgic paroxysms, for a period of time
extending from 1837 to 1846, and with detriment to his general health.
In 1846, while passing through the city of Heidelberg, in Germany, he con-
sulted the celebrated Chelius with the hope of obtaining some beneficial
result from his advice. That professor divided the nerve as it emanated from
the infra-orbital foramen, by incisions from the mouth, and six weeks after,

140 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [J an.

again performed the same operation, without any favourable result. During
the next six years the patient continued to suffer from the neuralgic parox-
ysms of more or less intensity.

Oppressed by extreme suffering, he again sought relief from an operation,
and in 1852 the nerve was again divided from the mouth by forcing up the
lip ; the actual cautery being at the same time applied, by pushing the in-
strument from the mouth upwards into the wound as far as the foramen infra-
orbitale. This operation appeared to give some relief, and during the two
succeeding years, the patient's sufferings were somewhat alleviated. About
two years ago, the paroxysms returned in the most aggravated form, pro-
gressed, and continued without much abatement. He, on the 1st of Sep-
tember last, being in New York, again submitted to an operation for division
of the nerve. This time, the branches of the nerve were divided by cutting
through the integuments directly upon the infra-orbital foramen j this opera-
tion caused no other effect than insensibility to the touch in the soft tissues
near the infra-orbital foramen. Two weeks after this, he entered the State
Hospital. The condition of the patient was then as follows: Notwithstand-
ing the repeated division of the nerve, there was sensibility to the touch over
the whole region of the cheek ; the inner side of the lip alone appearing to
be insensible. The patient describes the pain as starting from the foramen
infra-orbitale and extending up as far as the lig amentum palpebrse internum,
and also to the external corner of the eye ; from the latter point, the pains
shot down in nearly a straight line to a point about one inch to the outside of
the left corner of the mouth, and a little below a line drawn horizontally on
a level with the commissure of the lips. The pains also extended backwards,
through the more deeply seated portions of the face, shooting from the inner
corner of the eye, along the base of the nose, and striking backwards towards
the spheno-maxillary fossa. The pain was of the true neuralgic character,
and so intense as to drive the patient into a condition verging .on delirium.
A slight touch on the cheek, the inside of the mouth, or on the hard or soft
palate, swallowing, or speaking, excited almost instantaneously the paroxysms
in their severest form.

The Operation. — The operation in this case was performed after the same
manner as the preceding, and was modified only by the greater depth of the
antrum and face. There was also more hemorrhage from the spheno-maxillary
fossa; this was controlled by compressed sponge pressed into the fossa. Sup-
posing that hemorrhage might return, the lips of the wound were brought
together by adhesive plaster, one suture only being used. The other'sutures
were inserted the following day. The nerve was cut from above downwards.
The ganglion of Meckel was drawn out, hanging to the trunk of the nerve.

Progress of Union and After-treatment. — Compressed sponge was applied
in the deeper portion of the wound ; the external surface was closed with
one suture ; an anodyne was ordered for the night.

Oct. 11 (Sunday). Patient slept well during the night; pulse 76; no
bleeding; five suture-pins applied; ordered an anodyne.

12th. Patient slept well; no pain whatever; pulse 84; complained of
thirst; but little appetite ; speaks and swallows without pain.

ISth. Slept badly; had an attack of dysentery; pulse 96; felt a slight
pulsating pain in the wound, which, however, was doing well; states that
there is no feeling over the surface of the left cheek from the inner angle of
the eye, descending along the nose to the lip, and upwards to the* outer angle
of the eye, including the lower lid; ordered opium and quinine. {Afternoon),
dysentery subdued; pulse 96; more cheerful.

1858.] Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. 141

14th. Patient improving; pulse 92; a portion of the pins removed.

15th. Kemaining pins removed; wound presents a healthy appearance ;
pulse natural; slight. pain felt in the course of the wound.

16th. Kemoved the piece of compressed sponge, which had been placed at
the back of the antrum during the operation, to restrain the bleeding from
the spheno-maxillary fossa.

18th. Patient doing well; eats well, and sleeps naturally.

2Qth. Still entirely free from neuralgic pain ; the whole expression of the
face changed from that of suffering and anxiety, to cheerfulness and serenity.

2Sth. Discharged from the hospital entirely cured, and in good health and
spirits.

Dec. 8. Visited the hospital; still free from pain and in good condition.

Condition of the Nerve. — The nerve in this case, as in the previous one,
exhibited a similar appearance. It was thickened, vascular, and engorged.
The neurilemma and proper tissue of the nerve were both affected. The length
of the trunk removed was two inches.

Case III. — Mrs. Mary Gr. Stevenson, a native of Portsmouth, England,
and who had borne children, 55 years of age, of full habit and sanguineous
temperament, consulted me in the month of September, 1857, for severe
neuralgia of the left side of the face. She had been a resident of the North-
ern States for thirty years, and had enjoyed, generally, remarkably good
health.

On the 12th of August, 1851, while eating a plum in her garden, she was
suddenly seized with a vivid shock of pain, commencing on her cheek, and
passing through her jaw, as if caused by a sharp-pointed instrument, suddenly
driven through her face ; shooting pains of this character, with intermissions
of entire abatement, Continued for several days. A dentist was consulted,
who, attributing the symptoms to the teeth, extracted several of them, but
without the slightest benefit to the patient. The paroxysms continued with
more or less severity for two months.

At the end of this time, they suddenly abated in their severity, and the
respite lasted for about six weeks. Upon hearing of the sudden death of a
friend to whom she was much attached, the paroxysms were again renewed ;
they became more frequent; the intervals were shorter, and the intensity of
pain was increased more and more with each succeeding attack. During the
year 1852, the pain and paroxysms still continued with unyielding severity.
The tic would now last for two and three months, with scarcely any of the in-
tervals which had heretofore occurred. Cold air, the drinking of fluids, the
slightest touch upon the cheek, or any sudden mental emotion, would inva-
riably excite the most fearful paroxysms. During the year 1854, her condi-
tion was not in any way ameliorated; the pain, if possible, was more severe,
and her general health suffered from the want of rest. During the year
1855, the disease progressed with the same severity. In the early part of
the year 1856, the paroxysms became still more aggravated; the patient, at
times, becoming almost delirious — starting up, running about her room, and
screaming like a maniac. In the latter part of September, she sought relief
from a surgeon in this city, who divided by subcutaneous incision the branches
of the infra-orbital nerve, as it issues from the infra- orbital foramen.

About this time, she also took large quantities of various narcotics, and of
the carbonate of iron. After the operation, she experienced some relief.
The amelioration continued from October, 1856, until May, 1857, when the
paroxysms were again renewed in their severest form.
No. LXIX.— Jan. 1858. 10

142 Carnochan, Exsection of Second Branch of Fifth Pair of Nerves. [Jan.

The pain now became almost continual, depriving her nearly entirely of
sleep ; she was unable to eat without torture, the act of swallowing invariably
bringing on a paroxysm. During these exacerbations, the pain was diffused
in different directions, extending from a point a little below the infra-orbital
foramen, or from the ridge of the gums, and striking through the superior
maxillary bone towards the deeper portions of the face, and towards the orbit,
and sometimes extending towards the region in front of the ear. She de-
scribed the pain as of a beating character at times; each shock succeeding
another in rapid succession, as if keeping time with the ticking of a clock.
During this long period of suffering, she had been under the alternate care of
several physicians; the various remedies most approved of in this kind of disease
had all been faithfully and sedulously tried; stramonium, aconite, belladonna,
hemlock, opium, morphia, chloroform, carbonate of iron, valerianate of ammonia,
and other medicaments had been administered internally; while externally,
in addition to the division of the nerve, blisters, sinapisms, hydrocyanic acid
liniment, tincture of aconite, and chloroform had been resorted to — also elec-
tricity and galvanism. At the time I was consulted, she was suffering night
and day from repeated and excruciating attacks, and, as she herself stated,
she had visited the city to have an operation performed at all hazards, how-
ever desperate it might be, if I could only hold out any prospect whatever of
its affording relief. Her general health was tolerably good, and she did not
complain of loss of appetite. I explained to her the nature of the operation
which I believed to be the only one suited to her case. She immediately
assented to submit to it as early as possible.

The operation was performed after the same procedure. The face was in
this instance, also, very deep. The hemorrhage from the spheno-maxillary
fossa was considerable, and was stopped by a piece of compressed sponge to
which a strong ligature was attached, by which it could be removed.

Progress of Union and After-treatment — Nov. 5 (Thursday evening). As
soon as the operation was completed, the patient retired to her bed. Vomit-
ing came on a few hours after, owing, probably, to the quantity of chloroform
which had been used.

6th. Had slept tolerably well during the night; felt very little pain; pulse
80; no fever; complained of some pain in the wound, but had no neuralgic
pain.

7th. Left side of the face slightly swollen; puffiness about the eyelids;
has no pain; has slept well without any anodyne; states that she feels better
than she has for months; pulse 80; skin natural; slight thirst; five of the
suture pins removed; line of incision looks as though union by first intention
was going on favourably. Still kept on fluids for nourishment — gruel, rice-
water, ice-water, toast-water, and chicken tea. Ordered a gentle aperient.

8th. Had slept well; tumefaction of face subsiding; complains of head-
ache; cloth wetted with cold water applied on forehead; same diet continued :
pulse natural ; removed the sponge which was used to stop the bleeding
from the spheno-maxillary fossa ; this came away without any difficulty by
slight traction, a little blood following. Complains of slight pain in the orbit.
Removed six suture pins, leaving one only — that uniting the free border of
the lip. Fluid diet as before.

9th. Patient slept well ; headache less; pulse 78; no neuralgic pain; a
weak solution of the tincture of arnica ordered, to bathe the cheek with ;
removed the last pin ; union by first intention, along the line of incision,
complete.

From the 9th until the 16th all has progressed favourably. No neuralgic

1858.]

King, Catalepsy treated with Nitrate of Silver.

143

pain whatever; sleeps well; swelling on cheek diminishing; pain has entirely
left the orbit ; secretion into the mouth from the wound in the antrum dimi-
nished. Ordered a gargle of the tincture of myrrh. Appetite has also re-
turned. Had been sitting up, and walking about her room without any
inconvenience. Has taken a little sulphate of magnesia ; has not required
any anodyne.

Dec. 3. The patient has been progressing favourably up to this time. The
wound has healed entirely, the line of cicatrix is becoming effaced; not the
slightest trace of tic douloureux remaining. There is no paralysis of the
muscles of the face upon the side operated on.

In the case of this patient, the nerve was enlarged, very vascular, thick-
ened and red. Two inches of the nerve were removed.

45 Lafayette Place, New Yokk, Dec, 1857.

Akt. XIII. — A Singular Case of Catalepsy successfully treated with the
Nitrate of Silver. By Wm. K. King, M. D., of Louisburg, N. G.

The patient was a girl aged 11, delicately formed, dark complexion, black
hair, with unusually brilliant black eyes, sprightly countenance, quick spoken,
and playful in manners. She had a slight attack of sickness during the
month of August, 1856, accompanied with fever and headache. However,
her symptoms were so mild that her parents considered it unnecessary to call
in a physician. She soon recovered, but during convalescence it was ob-
served that she occasionally became affected with spams, chiefly in her upper
extremities.

I was called to visit her in consultation with the family physician, and very
soon after approaching her bedside she had spasms in the upper and lower ex-
tremities, which I supposed was caused by mental agitation at the sight of a
stranger. The fingers and toes were in a semiflexed position, the feet being
extended in a line with the legs, which were in a rigid state of spasm, also the
arms throughout their length. The spasm was of the tonic order, the parts
remaining perfectly rigid, which required considerable force to overcome. The
limbs remained in every position in which they were placed, as in ordinary
cases of catalepsy. She was conscious of all things around her, and answered
questions promptly, though in a subdued tone. Her pulse was accelerated and
small, but became greatly reduced in frequency when she was free from spasm.
Her father remarked that she would remain in that condition an indefinite time,
unless the contraction of the muscles was overcome by force; whereupon he ex-
tended the fingers, which caused an immediate relaxation of the spasm of the
upper extremities, but the legs and toes remained fixed until the same pro-
cess of " unlocking" (to use his own language) was performed, when she im-
mediately assumed a happy and playful countenance as formerly. Pressure
on the nape of the neck, where I found considerable tenderness, also on the
crown of the head, over a space about the size of the palm, would immediately
produce the same state of things. Sweeping the floor, patting the foot, saw-
ing wood, and all harsh or grating sounds, from whatever cause proceeding,
had the same effect. If she was in a profound sleep the floor could not be
swept ever so softly without awaking her and causing spasm to some extent.

141 King, Catalepsy treated with Nitrate of ' Silver. [Jan.

The treatment consisted, first, in a mild purgative course with blue mass,
&c, followed by the valerianate of zinc, with counter-irritation over the
cervical vertebrae and subsequently the various chalybeate preparations were
tried, but without any improvement whatever in her condition. This plan
of treatment was pursued for several months at irregular intervals.

My second visit was made some time during the month of May last, when
I found the same symptoms existing, and in some respects in an aggravated
form, although on my arrival I found her at play. Pressure on the crown of
the head, as formerly, produced spasm commensurate with the amount of
force applied. At one time it became so violent as to cause considerable
distortion of the features by a spasmodic action of the muscles on the right
side of the face, as well as the right oblique muscles of the eyes, drawing the
globe considerably to the right and downwards. She became speechless,
but retained her consciousness. Whenever she was thus violently affected,
which her father informed me was not often, he could not unlock her in the
usual mode of extending the semiflexed fingers and toes, but would take her
in his arms and toss or swing her to and fro, when a sudden relaxation fol-
lowed.

The tenderness which was found to exist over the cervical vertebrae at my
first visit had now been transferred to the four lower dorsal and lumbar
vertebrae, over which there was considerable tenderness. Appetite and diges-
tion good.

The treatment was renewed with J gr. doses of the nitrate of silver three
times a day, gradually increased to J gr., with counter-irritation with strong
croton oil liniment over the tender vertebrae, under which she rapidly im-
proved and entirely recovered from all nervous disorders. Whenever, during
the treatment, she complained of headache or any other cerebral disturbance,
the nitrate was suspended for a while, and the bowels gently moved with
small doses of blue mass, followed by a saline cathartic or castor oil. The
patient will be kept upon some mild chalybeate until her general health
is thoroughly invigorated ; but she has been for many weeks entirely free
from all her former symptoms. There remains considerable tenderness of the
scalp and vertebrae, and pressure applied to either part causes much pain, but
without the slightest spasm of any of the muscles. Her general appearance
is now good, complexion beginning to assume a healthy hue j and her gait,
which formerly was cautious and somewhat tottering, is now nimble and
strong.

1858.]

145

REVIEWS.

Art. XIY. — Elements of Pathological Anatomy. By Samuel D. Gross,
M. D., Professor of Surgery in Jefferson Medical College, &c. Third edi-
tion, modified and thoroughly revised. Illustrated by 342 engravings on
wood. Blanchard & Lea: Philad, 1857. 8vo. pp. 771.

This book may be considered as a representative work. It marks the level
of the anatomical school, being just such a book on pathological anatomy as
an intelligent surgeon of large experience might be expected to write. This
understood, nobody, who begins with the title page and reads perseveringly,
need be disappointed. The reader, who confidingly accepts the guidance of
Dr. Gross, will be conscientiously led over the whole surface of the domain
justly belonging to pathology, and will find the way very pleasantly beguiled
by clear and simple descriptions. Measurements will be given with scrupu-
lous exactitude — and the hues of all objects that have colour will be noted
down to the most delicate shade. He will learn the feel and the smell of every-
thing wnich can come within reach of his digits and nose. He may gain a
complete acquaintance with the whole outside of pathological anatomy by
means of Dr. dross's introduction; but, after all, it is as incomplete and un-
satisfactory as to attempt to know a man by looking through the windows of
his dwelling.

How anatomy may be studied, and how anatomy should be taught, are
general questions of no little practical weight, and we propose- — since we have
so little reason to find fault with the facts contained in the book before us,
which are really inexhaustible in amount and stated with admirable clearness
and simplicity in most cases — to draw the reader's attention to the errors
of philosophic method which belong to this, in common with a large class
of treatises on pathological anatomy. It is of no avail to sneer at medi-
cal philosophy, or to assert that there is nothing to represent it but preten-
tious folly. Every medical man has a medical philosophy which is rooted in
the groundwork of his nature — close by his politics and his religion. And
every medical book represents in some sense, a phase of medical philosophy.

All the systems of anatomy, and all the individual students of anatomy,
divide themselves by a natural repulsion, into the two classes which represent
with more or less exactitude, the modes by which almost all the subjects of
human observation and speculation may be approached. There is an esoteric
and an exoteric phase for all matters of sight and subjects of faith. Philo-
sophers, theologians, poets, social reformers, mathematicians, painters, music-
makers, as well as anatomists, classify themselves on this basis. Thus we
find Serres, Oken, Owen, Paget, De Blainville, Bobin, and Bouchut standing
vis-a-vis to Kolliker, Lehmann, Quain, Carswell, and Gross; Locke stands
versus Schlegel and Comte; Malthus against Coleridge; Tennyson and Keats
against Scott and Campbell; Edwards against Fenelon; Louis Napoleon
against Prudhon ; Buskin against Joshua Beynolds ; Bellini against Wagner,
and Prof. Pierce against Merriam.

146

Reviews.

[Jan.

Had all these men studied medicine, it were easy to conceive from what
point of view each one would have looked at life, health, and disease. Look-
ing closely at these disputants we should see, on the one hand, the Anato-
mists, pur sang, who work from without inward ; from the particular towards
the general; from the material form towards the msaisissable ; from special
organs towards developmental principles — but without attaining so far, as a
matter of course. Most of them fall short in the pursuit and lose sight of
the end of biological investigation. " How hard it is to compass the means
by which one mounts to the fountain head ; and before he has got half way,
a poor devil must probably die !" said the wearied student who began at the
wrong end of the tangled thread. Anatomists may travel all over the pal-
pable and the sensible with great assiduity and keenness of vision, and with
"best luck catch only a fox." But they go with knowledge and safety as
far as they go— -taking care to affix one end of their telegraphic wire to a
rocky fact on shore, before starting off into the deep with the other. This
class is well represented in our Young America School, and is unquestionably
oa the right course ; we would only ask of it, to look a little deeper through
solidism and humoralism till it arrive at the apprehension of the dynamics as
well as the statics of life.

Among the Vitalists are men of broader view and deeper ken — men who
possess capacity for large generalization. But most of them overleap and
outrun the slow rolling ball made up by toilsome investigation, and playfully
knock about hypotheses like snow-flakes. For Stahl, Boerhaave, and the
school of Montpellier, the study of pathological anatomy could have but little
interest. They do not need pegs to hang their theories on, for most of them
are lighter than air, and keep quite out of sight. The men of this class are,
for the most part, unsafe practitioners of medicine, having an unequivocal
leaning towards mediseval therapeutics; yet they are clinging to a great truth,
while plodding near-sighted skeptics are scratching the earth's surface in
quest of the No^oj, and measuring cranial bumps to gauge the divinity that
has its throne inside. They have apprehended a great underlying fact, but
they forget that vital force is not an entity, but only a "special property" of
organic structures.

Out of the midst of these is developing the new school. Its basis is broad and
its aim is high. These thinkers have found out that there can no more be an
absolute solidism, than an absolute vitalism, and there can no more be either of
these than matter without spirit, or spirit without matter— the power without
the deed. Thus escaping the "coarse hypotheses of materialism, and the ab-
surd logic of immaterialists," they are promulgating the doctrines of modern
Organo- Vitalism." of which De Blainville, Bobin, Bouchut, and Littre are
the ablest exponents. They talk rather of general than of local disease— of
idiosyncrasies, inheritance, types, diatheses and morbid elements more than
of the numerical force of so many cases collected^ or of the colour, size, weight,
and consistence of hepatized structures.

These are not differences without consequence — they are of primal import-
ance. But we should not dwell upon them at this time if we did not, in the
book under consideration, see practical errors directly traceable to what we
believe to be faults of philosophy — and, not only in this book, but in all the
libraries and in all the lecture-rooms the lookers from within face the lookers
from without. What coincidence of opinion can there be when the first prin-
ciples fly apart to the two poles. Let us look at it in the common questions of
the time. To one mind, puerperal fever appears simply as the result of ute-

1858.]

Gross, Elements of Pathological Anatomy.

147

rine phlebitis, or peritonitis, or inflammation somewhere else about the •womb,
or its appendages. While to another, puerperal fever is plainly an example
of blood-poisoning, manifesting itself in the particular locality which it selects
through the accidental circumstances of the patient's child-bed condition.
For this observer it is as much a case of blood-poisoning as is scarlatina with
its local excitements and exudations, or hospital erysipelas.

Again, pneumonia appears to one to be simply an inflammation of the
lung — and, since inflammation is a unit — a uniform, well-defined, and inva-
riable condition appertaining to all organs and tissues — as a matter of course,
inflammation of the lung does not differ in essence or phenomena from inflam-
mation of the subcutaneous tissue produced by a foreign body. While on the
contrary, the same pneumonia is regarded by the deeper searching eye as a
general disease. It may have arisen from a local irritation — as from the ab-
sorption of some morbific material— (but if in this way local, the primitive
effects are not with any certainty to be found in the lungs); but, when fairly
germinated, it is an essentially general disease, manifesting itself by various
phenomena, among which are pulmonary softening, with an afflux of blood ;
exudation of serum and fibrin; new formations of cells and globules, and
the retention of chlorides which should have been eliminated with other
urinary elements. The heat of skin and purple flush of cheek are not results
necessarily of the impairment of respiratory function. Still further to illus-
trate this point, let us select an erysipelatous cynanche; to one, it appears as
nothing more than a sore throat, and is treated as such, notwithstanding the
preceding chill, headache, and pains throughout the limbs. Another, to
whose mind the succeeding blush over a square inch of mucous surface seems
an inadequate cause for a preceding malaise, looks upon the quinsy as the
counterpart of the rose spots of typhoid, the herpes of catarrh, and the semi-
lunar whorls of measles.

We think it of the first importance that teachers should impress upon their
pupils a sound, approximately sound, philosophy. There have been many
who have affected a disgust for all hypotheses and philosophies of medicine.
Thus raising the old question of the Dogmatists and the Empirics, who were
debating in the time of Celsus, and have not yet settled the dispute between
them, whether there can be a speculative medicine, and whether all the ac-
cepted facts and ideas of medical science were or were not based upon empiric-
ism. This oscillating point has not yet been fixed, nor has such a consum-
mation been possible till the late advances in general natural history, had
established certain bases, from which a science could be constructed from the
known towards the unknown. To-day, says an enthusiast, we may boast that
we have the knowledge of a speculative system of medicine, and it has been
every day of these last years developing itself before our eyes by means of
investigations which more and more demonstrate the relations of pathology to
biology. All the facts and recognized principles of pathological anatomy are
based upon general anatomy, just as those of pathology rest upon general phy-
siology. Thus medicine, the medicine of the future, is fast coming to that
state of promise when its foundations shall be as sure as those of the science
of life; and the reproach uttered by Cruveilhier acknowledged to be unde-
served, for it will no longer be true, that il n'y a d' autre calcul possible que le
calcul des probabilites. The most hopeful would undoubtedly confess, how-
ever, that many questions presented to the student of medicine must, from
their very nature, forever remain without positive solution.

As there are different ways of practising medicine, so are there various
modes of studying the science, which is the living spirit of the art. When

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we give advice, we say : at the beginning let every one seek out and take to
himself a stock of good definitions. Many a man goes the wrong way on
account of a bad definition working in his head, and quite as many go with-
out persistence or certainty, because they have no definitions and never had
any, and have never found out that they wanted any. A beloved preceptor,
ever to be remembered with reverence, was accustomed to say, when you
get a new book, read the Pre/ace and pick out all the plums of definitions,
for they give the flavour. When you have the definitions look for the
classification, and then you have hold of your man, and you know at once
whether you can get on together, and if it will be of any use to seek a more
familiar acquaintance. But avoid the mistake of Pinel, who, while he believed
justly in a good classification and thought that a correct nomenclature would
accomplish the perfecting of medicine, was not careful of his facts, but, as
Louis asserts, trusted to his young pupils for the collection of them. Whether
the proposition, la medecine est tout entiere dans V observation, be accepted
or not, the following one is indisputable : IS incertitude des connaissances
me die ales tient a la fois a une observation imparfaite des /aits particuliers,
et a la maniere non moins imparfaite dont ceux-ci sont etudies. — (Louis,
Mem. de la Soc. Med. d' Observation?)

We ask, then, at the start, for good definitions. Those who write books
on pathological anatomy must expect to be catechized on first principles.
The student comes up and he wants to know, he persists ; and so we inter-
rogate the teachers. We ask them, before we care to hear about the effects
of the dead man, what is life, and what is death, and what are health and
disease? It can be seen at first glance that this departed person has gone
off and left his cadaver with, perhaps, a tumour on it about the size of a
cocoa-nut, and of the consistence of white-oak cheese. But that does not
tell us the half; and is, in truth, a very useless piece of intelligence if we do
not associate with it an immense amount of other intelligence. The tumour
is not the disease, nor does it tell much about its antecedents, nor does it
more than hint at all the consequents of the disease. But this is such a pal-
pable truism that one need not utter it if it were not also just as true that
most books on pathological anatomy are deficient in that amount of other intel-
ligence which everybody sees is essential and needed, but which nobody, in
the ranks of the pure and simple pathological anatomists, seeks to supply. To
look at that man's cadaver and his cheesy tumour with persevering penetration
will not enable us to persuade the next man not to leave his cadaver in the
same way. We fear there has been a fearful waste of material in this cutting
up business. Cutting up must be done. There can be no getting at the truth
in a cytoblast without cutting up. But let it be done with the expectation of
finding only the coarse and altered illustration of a small part of the complex
processes which preceded death. Some teachers of pathological anatomy have
wofully misled their pupils by pictures of disease, which have only the outlines
of morbid specimens for their frames. There is a science of diseased anatomy
which is a part of the foundation-structure of medicine, but its investigations
are commenced upon the living body. Many acknowledge this in the abstract
who write as if they never thought of it. In fact, the scholastic style of the
lecture-room is not a whit better. So that the student, who does not have the
chance to change off at the clinique his second-hand stock of notions obtained
from the anatomical pathologists of the college, gets a wrong start in life. He
may gaze at highly-coloured plates, and bad smelling specimens in transparent
jars, and think he sees there the inheritance which falls to all flesh, disease
itself, body and spirit. So that he secure the pearl what matter how the

1858.]

Gross, Elements of Pathological Anatomy.

149

oyster sickened ! He starts up, and bunts out quantities of monstrous spe-
cimens and rarities, and does not find out that they may be worth to him
no more than so many coffins, till the granting of a license to practice medi-
cine lets him down to the clinical common places, which pathological anato-
mists, by profession, have either ignored or shown to him through a darkened
glass, darkly enough. He has groped "with greedy hand for treasures, and
exults at finding earth worms/' Instead of the animated nature, he has, like
Faust, " naught around him but beasts' skeletons and dead men's bones in
smoke and mould."

These anatomists are like some numismatologists. One man finds pleasure
in collecting, polishing, and arranging all the medals of all the ages. But
though he should find them all, and know them all by sight, and call them all
by name, put each one into its own place ; though he should measure, and
weigh, and value, and burnish all the coins of every die, they might be of no
more worth to him than so much brass. Let him read dates and inscriptions
with all pedantry, his cabinet would be only a junk-shop, if each little medal
did not teach him whole chapters of history, facts, and philosophy, poetry, and
the arts of war, designing, engraving, die-sinking, in a word, the genius of the
people whose signum it has been.

What a pity that dead men tell no tales. Hollow skulls are supposed to
have said something to St. Jerome, and to Oken and Owen, but, in some com-
pany, they are as silent as they are sightless. An anatomist has a skeleton
in the house, and a vitalist is overrun with spirits. Each of them has effected
%vgi$ xai %u>pio[xo$ tyvxys <*7t6 flea/tar1 oj, but neither has a man.

The basic-idea or philosophy of Dr. Gross's Elements of Pathological Ana-
tomy, is plainly enough indicated by the following passages which we pick out
from their contexts, and expose as independent propositions :—

I. u All organic diseases, whatever be their seat or extent, are the result of
inflammatory action.''

II. " Every inflammation, irritative or morbid action, is originally of a
local nature."

III. u It may be doubted whether under any circumstances there can, strictly
speaking, be a functional disease without some change in the anatomical ele-
ments of the part."

It is our purpose to present a detailed exposition of these axioms as they
have been applied by Dr. Gross to the different organic lesions and elements
of disease in their author's own words, and in accordance with his arrange-
ment, as far as is possible. The plan of his book consists in the consideration
of the general principles of pathological anatomy, including inflammation,
transformations, tubercle, cancer, &c, occupying the first two hundred pages;
followed by a very full and satisfactory application of these principles to all
the organs and tissues, beginning with the blood and proceeding from the
cellular tissue through the muscles, bones, &c, of the adult to the placenta
of the foetus..

The completeness of this work, as regards the subjects treated, is especially
admirable. But, en revanche, many subjects are necessarily slurred, and some
but dimly hinted at. It is, in short, as encyclopaedic as the lectures of a
practised, popular, and fluent professor of surgery are likely to be. It is like
reading a dictionary or gazetteer. The time has gone by when one man can
be competent, or live long enough to travel all over the medical cosmos and
describe its wonders in one volume, even though the book pretend only to
treat of elements. By elements should be understood first principles — and

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not a catalogue resume of the titles in brief of all the remarkable facts and
phenomena that ever were heard of. We might as well expect to enjoy the
scenery of a country by reading a conveyancer's abstracts of titles to its real
estate, as to find substantial profit in such compact enumerations of anatomical
splendors.

The book is opened with a short and general review of the facts of normal
anatomy. These opening paragraphs, brief as they are, we find to be charac-
teristic ; being shaded by a dark hue of materialistic, or rather mechauico-
organic morbid anatomy, which we enter protest against here in advance.

The human body (chap. i. p. 33) is composed of solids and fluids. Of the
fluids the blood is the most important, although Dr. Gross does "not feel dis-
posed to attach that great importance to it which the advocates of the old
humoral pathology did." The solids consist of tissues, which, combined in
various ways, constitute the organs, whether parenchymatous, pulpyQ.), glan-
dular, or erectile.

Connected together by vessels and nerves, as well as, m some instances, by
continuity of surface, there subsists between the various parts of the body,
the closest felloiv-feeling. After allusion to various examples of " sympathy,"
our author continues : "I have thus briefly adverted to the relationship sub-
sisting between the principal organs of the body, and endeavoured to account
for it upon anatomical principles." One might as well attempt to explain on
known anatomical principles the contractions of the uterus after nine months'
gestation, or the evolution from a Graafian vesicle once in four weeks. No hint
is here given of an incipient conception of the idea of an unseen pervading
power or property, which makes of a community of molecules, of myriads of
active agents, having a certain independence, a single larger being of a com-
pound and complex organization. But as the author doubts whether the dis-
cussion of this subject (sympathy) would result in good, we proceed, objecting
here only to the dictum which he throws in as a plea for evading the question.
He says: "What is most worth knowing is soonest learned and least subject
to dispute." Then have nurses and practitioners of the routine school the
advantage over those who practise experimental physiology, and study the
general laws of life. The statement would not be seriously noticed, if it were
not apparent throughout his book, that Dr. Gross attaches an exaggerated im-
portance to the outside and measurable characters of morbid specimens, and
undervalues to the same degree, or ignores the subtle impalpable psychological
influences which really give the character to a particular disease. Do not the
anatomical characteristics of a local manifestation of disease vary with its dia-
thetic character? Are ordinary pneumonia, an inflammation of the lung from
a fractured rib, and an inflammation of the lung preceding a manifestation of
gout in the limbs, to be described as identical? Taking a step backward, let
us inquire with Dr. G. " what constitutes disease, for everybody knows what
is meant by health" — excepting those, we may interpolate, who agree with
Vogel, that uil n'y a pas oV organisme humain qui off re V ideal de la sante dans
toute sa perfection" * * * * (Jourdan's Trans.) Disease may be defined to
be a departure from the sound state, whether this departure consists simply in
a derangement of function or structures." [That is brief and clear.] "So long
as the solid and fluid materials of the body act in concert, health must be the
result, but ivhen the blood and the tissues are arrayed as it were against each
other, there is disease." We have heard of disturbances of molecular attrac-
tion, and perversion of nutrition, but the latter part of this definition bears
more resemblance to the following, taken from a recent work on General

1858.]

Gross, Elements of Pathological Anatomy.

151

Pathology. "Disease is a common accident, appertaining to the organization,
which, like the words life and health, is altogether indefinable."

We are curious in .matters of definition, and enjoy a good one ; we shall
put this in our collection. From a recent work on Pathology we extract the
following definitions de la maladie, as illustrating the philosophies of medi-
cine that have had sway, and the oscillations of the sacred faith from the
vitalism of Sauvages, in whose eyes a malady was the "reaction of the interior
vital principle against deleterious agents," to Buffalini's materialism, which
held disease to be a " change in the material condition of the body."

Thus we have at hand an epitome of the history of medicine, from Van
Helmont, who saw in disease only the results of disturbances occasioned by
the grand Archceus (a puissant dignitary who held court-chambers, in the
neighbourhood of the cardiac orifice of the stomach) all the way down through
the ages to that dreadful field where the tissues find themselves pitted against
each other in bloody array. [Gross, p. 36.] But in our retreat to quieter
times, we learn that Hippocrates considered disease to be the sum of phe-
nomena, resulting from the reaction of the conservative principle of the organ-
ism against an impression of evil or injury.

Stahl was of the same opinion, for he defined disease to be an effort of the
anima to re-establish an equilibrium of the normal functions, and to expel
injurious agents.

Sylvius de Libae, professor at Leyden about 1650, told his pupils that dis-
ease was a simple lesion of the functions of the living body.

Sydenham believed disease to be an effort of nature, set up for the patient's
relief, and the destruction of morbific matters.

Frederic Hoffmann (Halle, 1660 to 1742) called maladies efforts or struggles
with death — conatus moriendi.

Brown, the man of "Excitability" (1736 to 1788), thought that disease
should be treated as a "painful, difficult, or irregular exercise of one or more
functions."

Reil, J. C, Professor at Berlin (1759 to 1813), regarded disease as a
" peculiar action of the organization which replaced ordinary operations when
disturbed by unusual circumstances, by an operation altogether new."

Broussais' famous dictum was to the effect that disease was nothing but the
effect of functional irregularities.

Cayol taught that disease was a function, destined to react against disturbing
causes and the destruction of the living body.

Dubois d' Amiens (Sec. Perpetuel de FAcademie de Medecine) proclaims
that maladies are lesions of innervation which produce secondary organic or
structural lesions.

We have thus founded a formidable opposition to the doctrines of the mate-
rial localization of diseases, whose advocates, however, make a fair show of
hands, stretching from the earliest times to this present day.

Asclepiades (about b. c. 70) heads the list, with the doctrine that disease is
an unnatural state produced by the irregular motion of the atoms.

Themison found in all maladies only tension or relaxation of the fibres of
the body.

Galen, with a sharp insight, but inconsistent rhetoric, endeavored to explain
how disease had its point of departure in a structural lesion, although no dis-
ease could really be said to exist except in a lesion of function.

For another, "disease is a peculiar state of the body resulting from a super-
abundance or from a deficiency in the quantity of fluids, or some change in
their relative proportions."

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Frederic Hoffman described disease as being a disproportion or irregularity
in the natural order of movements, whether general or partial.

Among the aphorisms of Boerhaave we find this : Disease is a structural
change which deranges the vital, natural and animal functions.

From Fernel we learn that disease is an alteration of the blood, humors, or
spirits, which occasions structural changes.

It may justly be said that these definitions render no account of the numer-
ous dynamic maladies which present no demonstrable alteration of structure
•or modification of fluids.

The following are representatives of the compromising organo-vitalistic
doctrines which include in their definitions both the dynamic elements and the
material elements of the organization.

G-aubius, of Heidelberg, 1768, taught that " disease was a condition of the
living body, which prevented the exercise of those functions which were
proper to a state of health."

Chomel covers broad ground when he says la maladie est une alteration nota-
ble survenue, soit dans les dispositions mater idles des solides ou des liquides, soit
dans l' exercise d'une ou plusieurs fonctions.

Andral describes disease as an alteration of the constituent parts of the
body and of the functions appropriate to them.

Bouchut defines with brevity, " diseases are transformed impressions." A
disease is then a disorder of the forces and of the parts of the body, and of
the functions local or general.

As a knowledge of disease implies a knowledge of health, so Pathology im-
plies a knowledge of Physiology and Pathological Anatomy, which treats of
all the disorders of which the organization is susceptible, from the immediate
principles to the organism considered in its indivisible totality, and involves an
acquaintance not only with (a) Anatomy, (b) Physiology, but also with (c) the
science of Media, or the external agents which surround the body, and in-
fluence its functions —

Wer sie niclit kennte

Die elemente

Ibre kraft

Unci Eigenschaft,

Ware kein meister

Ueber die Geister.

To gain the knowledge of the earth, one man walks all over its surface,
and another bores Artesian wells; but when they have done they must both
go to the dog-star to find out the secret of this little ganglion of the universal
solar plexus — they must study through the great and little world. Some one
has said, "For the phenomena of life, we want the whole concourse of nature."
The pathologist, who only interrogates death for what can be learned concern-
ing life, must be prepared to range over the whole circle of the sciences.
What is life? Says one, "Life is the sum of the functions by which death
is resisted." The metaphysician sees in life " the result of organization '."
For another mind, life is the principle of individuation.

The definition accepted by the school whose characteristic views we are
endeavouring to represent, is the one proposed by De Blainville, as follows :
" Life is the twofold internal movement of composition and decomposition, at
once general and continuous."

" This," says Comte, " is the only definition capable of fulfilling all the
multifarious conditions required. It presents the exact enunciation of the
sole phenomenon rigorously common to the ensemble of living beings con-
sidered in all their constituent parts, and in all their modes of vitality.

1858.]

Gross, Elements of Pathological Anatomy.

153

A man, sick or well — which qualities are only relative — is to be considered
with regard to his static and his dynamic condition; all his organs, all their
actions or properties, and all the media which surround and affect him, are to
be known.

The English school was at one time looking at this matter of " the sur-
roundings," as those who remember Connelly's lectures in London must be
aware. But the microscope has now made everybody near-sighted, and in
setting them at little things, has let them forget the greater. But that is not
the fault of the microscope, as it is not a fair charge against the speculum that
men endeavour through it to cure a general disorder by the topical application
of the solid stick.

What, in life, is disease ? It is not merely organo-pathic states, which can
be materially appreciated by the senses — but these and something more;
these are material effects, or rather a part of the chain whose beginning at-
taches to a primal disturbance of the forces which preside over the growth
and development of individual anatomical elements, and binds them into a
complex unit.

The assertion of Agassiz is undoubtedly true, that the most complicated
combinations of structure and adaptations can be rendered independent of the
physical conditions which surround them; but it is also true that in their
progress towards a state of toleration of their new circumstances, especially
if the change be sudden, they are likely to present temporary manifestations
of disease. It is curious to note here the illustration to the statement that
Pathology is following in the footsteps of Anatomy, but afar off — so far be-
hind, indeed, that the latter has forsaken a stand-point just as the former ar-
rives on the ground. Thus Agassiz (Contributions to Nat. Hist, of the U. S.,
vol. i.) announces that to assert the dependence of structural peculiarity upon
climatological conditions is an unsound dogma, just at the time when patholo-
gists are beginning to question the media with more rigorous severity as being
among the chief causative elements of disease.

Pathological Anatomy cannot be separated from Pathology, and Dr. Gross
has not succeeded in divorcing their union, though he seems to have tried
with intermittence. Pathological Anatomy, in the narrow and limited sense
in which it is taken by some writers, is rather a subject for iconographic re-
presentation than for verbal description.

Following our author, we come now to the consideration of the chief of all
the morbid, actions, inflammation. We call this the chief, as does Dr. G.,
but it seems to be implied, in some parts of the book, that inflammatory action
is the only morbific action; that inflammation is, in fact, the only disease.

This opinion differs so entirely from our own, that we would prefer to ex-
punge the word altogether from the medical glossary, or limit it within the
bounds to which fever and irritation have been reduced. If inflammation
means everything, it describes nothing ; and is of no more utility as a means
of defining a state or result, than is the word disease.

The difficulties of expressing a correct definition of inflammation are recog-
nized by all recent writers, and specially noted by those who use the word
with restrictions. But neither stasis nor hypersemia — words suggested as
synonymous with inflammation — express all the phenomena belonging to that
complex disturbance of functions, and alteration of structure, recognized as
inflammatory. As we have said, we do not like the word inflammation, and
would be glad to find good substitutes for it; but there 1 are very many ob-
jections to pulling out a word so firmly fixed as that has become. We do not
like it, because it is suggestive of a uniformity and identity of processes and

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[Jan.

results in connection with phenomena which have no common essentials.
Wherever it is possible, let there be used specific phrases which indicate with
more exactitude the particular constitutional or general element — as whether
(a) inherited or acquired; (b~) its dyscrasic character — scorbutic, syphilitic,
scarlatinal ; (c) the locality ; (d) the results — as exudations, softening ; (e) as-
sociated disturbances of function.

It is not proven, nor is it probable, that a phlegmasia process arising from
an internal cause, bears any resemblance to an inflammation produced arti-
ficially. A drop of cantharides and a tadpole's tail cannot, by any possible
conjunction, enlighten us on the subject of mumps, lung-fever, or boils.
Everybody agrees to that, even those who go on in the classical way, talking
about redness, heat, pain, and swelling. The reformation of nomenclature
will lead to more truthful and exact notions of the phenomena if expressed
in scientific terms of definition. For some maladies and classes of disease,
the change has been already effected. Thus, we do not lump together herpes,
pemphigus, psoriasis, and porrigo. The ignorance or carelessness of desig-
nating a squamous sypliilide with so little nicety as to call it an inflammation
of the skin, would be considered quite inexcusable; but no more nicety is
shown in the designation of the great majority of similar internal manifestations
of disease which are all called by the generic name inflammations. What es-
sential resemblance is there between gonorrhoea and bronchitis ? The inde-
tectible poison of the one and the butyrates of the other, are alike overlooked
by those who see in these diseases only examples of common inflammation of
mucous membrane. A gouty enlargement of a great toe, and a whitlow of a
finger phalanx might, without inconsistency, be regarded by some pathologi-
cal anatomists as effects of identical processes; but in real differential charac-
teristics they are as far apart as are the two extremities of the body. The
whole of rickets is not told in Virchow's masterly description of softening
bones ; dysentery is not merely an inflammation of the lower bowel ; cholera
infantum is more than an inflammation of glandules in the small intestines ;
and just as epidemic catarrh is more than an inflammation of the faucial and
bronchial mucous membranes, and typhoid fever more than inflammation of
Peyer's patches, so is intermittent fever more than inflammation of the spleen,
and the cerebral disturbances of scarlet fever more than intra-cranial inflam-
mation. Everybody says amen— but in everybody's books these simple
truisms do not appear with the emphatic distinctness which they might claim ;
and by such faults of omission and commission of the treatises which should
give sound principles, and ready method rules for the prompt and intelligent
treatment of the sick, but do not give them — by such faults, the student finds
his unsound principles as much in his way when he comes to sit down at a
bedside, as a long broadsword would be.

It is because we are ill satisfied with the imperfect teachings, and fear the
dangerous errors of classical morbid anatomy, that we do not share Dr. Gross's
regret that in the forty-five medical colleges of the United States, there are
but few chairs of Pathological Anatomy; and we certainly cannot regard this
destitution of our schools as attributable to a " strange and culpable over-
sight." Let us have all the Professors of the Theory and Practice of Medi-
cine which the number of students in each college may warrant — and as no
one man can have time, strength, capacity or cultivation to teach the whole
science well, let there be special teachers of special branches; and let each
one begin at the ultimates, and make a complete development from the radi-
cles of physics to the efflorescence of vitalistic speculations.

Some of the best expositions of Pathological Anatomy extant are contained

1858.]

Gross, Elements of Pathological Anatomy.

155

in clinical lectures on special subjects; and this is the way we desire to have
medicine taught, with its anatomy, pathology, and therapeutics of special dis-
eases simultaneously presented.

The lectures on special subjects in the hospitals of our large cities do more
good to advance Pathological Anatomy than chairs of Pathological Anatomy
or systematic treatises are likely to, for the reason that the former approach
the subject from the right direction.

Towards the removal of erroneous and imperfect notions of morbid pro-
cesses, much progress would be made by a reformation of nomenclature.
Very simple terms may be used. In these anti-classical times it is not worth
while to dig with Piorry too deeply for Greek roots. Let there be, as far as
possible, a plain statement of the organic changes and vitalistic disturbances.
For inflammation, substitute in most cases the word disease, and express,
after the various localities have been mentioned, the specific process, whether
simple or complex, as exudation of lymph or serum, &c. ; with the qualifica-
tion then of the peculiar dyscrasic condition, as scorbutic, diphtheritic, scro-
fulous, and their mutual relation to the derangements, as primary or second-
ary. We shall have, in most cases, not only a plain scientific designation of
the morbid processes, but also such a full description of the case contained in
the enumeration of the elements of the disease that very little more need be
added in reporting cases to render them fit to be tabulated. " We may learn
the essence from the name."

The following case may illustrate the design of these remarks.

A middle-aged lady, with a solid ovarian tumour of many years' growth,
had a chill when resting by an open window after a brisk walk. She con-
sidered herself in full health at the time, and was so in appearance. She had
the same day pain in the abdomen, followed by constipation, which lasted
eleven days; then a low form of fever for six weeks without disturbance of
the bowels, and without any marked symptoms except watchfulness; then
repeated chills, or chilliness with imperfect reaction for two weeks; a cough
for two days; dulness on percussion of right side and entire absence of respira-
tory sound for one day, at the end of which abundant sweating, failure of
pulse, and death.

Post mortem examination revealed superficial layer of fat, thick; bed-sores
partially healed; right side of the thorax full of water, clear, without fiocculi;
pleural surfaces clear, shining, smooth, without redness or adhesion; no ves-
tiges of false membrane anywhere; every other part of the body healthy in
appearance except pelvis and lower part of abdomen; here was a tumour
weighing ten pounds, twisted on its ligamental attachments, so that its veins
were compressed and its surface mottled with distended vessels. A knuckle
of intestine had been compressed by false bands, but had got loose. There
were no signs of secondary exudative processes about this tumour, excepting
for the space of one inch in a large vein on its surface, where there was a red
coagulum with thick creamy looking fluid. From the Fallopian tube of that
side a little muco-purulent fluid oozed out.

What was the disease, and how to express it? Ovarian tumour; arrested
transpiration of skin; disturbance of bowels; strangulation of intestine; hy-
peremia of tumour; suppurative disease of vein ; pyaemia; hydrothorax — this
enumeration is needed to give a name, but its titles, like those of some other
things, include all there is of it. It is interesting to notice that one of the
obvious and striking phenomena here for the anatomist, viz., dropsy of the
chest, did not occur till within the last two days, and was not accompanied at
the time of the examination by either redness, loss of polish, or fibrinous exu-

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elation of the serous surface. The classical signs were wanting, excepting hy-
drothorax, and this, according to Laennec and Forbes, if it were not an inflam-
matory production, was indeed a rarity. There are many cases in which, as
in this just described, there are several associated phenomena, primary or se-
condary, which pathological anatomy should make note of, if it can offer no
explanation of the alliance. For example, the spangemia, hysteria, and disease
of glandules of fauces associated with induration and ulceration of the os uteri.
If it cannot explain or does not try to explain the association of redness of the
eyelids with spermatorrhoea; the occurrence of itching of the nares from intem-
perate coitus, or the occasional dependence of intercostal submammary pain
upon tobacco poisoning, and scores of acknowledged but unseen bonds of union,
it must be warned not to promulgate such false principles concerning the uni-
form character of inflammation and the universality of its presence at the
bottom of all morbific actions, as to mislead in regard to the diagnosis of such
consociations and their consequent treatment. It must not by any represent-
ation concerning inflammation teach us to treat a rheumatic disease of the eye
as if it were catarrhal. Nobody means with deliberation, to face out blun-
dering of that sort, but such instructions are sometimes given unwittingly,
and rather by implication than by downright statements to the same effect.

;js Jfc jfc

But to proceed, under our author's guidance. In the general exposition of
inflammation, Dr. Gross makes a very clear and comprehensive statement of
most that is known to be "real and substantial" in regard to the progress,
intensity and mode of termination of this disease. Under the head of Eti-
ology, the modifications associated with temperament, age, sex, habit, climate
and season are considered as well as the specific characters in relation to the
textures affected, and the predisposing cause.

Under the head of Phenomena and Nature of Inflammation the signs
usually enumerated as marking inflammation — discoloration, heat, pain and
swelling are mentioned at some length, and Dr. G. remarks that " they are
not always present, nor are they the only circumstances which occur in inflam-
mation in this disease : [what disease ?] in every case there is a perversion of
the vital actions attended with an altered state of the nutritive and secretory
functions:" and our author continues, "if we regard these four phenomena
as essential to the process there can be but few inflammations." We must
therefore invoke other names, such as irritation and fever. But Dr. Gr. objects
to these words because "they do not describe the peculiar conditions of the
nervous and vascular systems. Yet men continue to talk about irritation as
if they had the most perfect knowledge of its seat," &c. If he had included
inflammation in this indictment it would have been no injury to the cause of
justice.

In speaking of temperature reference is made to certain experiments of
Huber, Dunglison, Everard Home and Hunter, tending to demonstrate that
the temperature of an inflamed structure is higher than that of the blood.
But no reference is made to Bernard's experiments or Brown-Sequard's state-
ments. When speaking of pain Dr. Gr. says: "The degree of suffering evinced
by the mucous membranesQ.) in a state of inflammation is subject to much va-
riety, which may be perhaps explained by the fact that while some portions
are supplied by the ganglionic system, other parts derive their nervous filaments
chiefly from the cerebro-spinal axis." Many examples are given of "perverted
vital action" and altered function, which are well enough put; but we should
like to ask if those who have followed our author do not find enough, in addi-
tion to the evidence which the preceding descriptions furnish, to convict this

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157

inflammation of false pretences and have him banished forever — for he is
indeed a bad fellow — a consumer of nutrient substances, and an incendiary.
But he pretends to light fires for household economic purposes — to cook, to
prepare nutritious materials, to heat glue for adhesion, and generally to repair
damages. He deserves no such credit : there is a great amount of repara-
tion going on without his assistance. The fact is, whatever he undertakes to
do he damages. But, on the other hand, he is not to be made a scapegoat of.
There is a deal of mischief done when he is not by.

In considering the seat of inflammations, the state of the capillaries, altered
absorption and nutrition, the relative agency of the vascular and nervous sys-
tems, good use is made of the published investigations of Virchow, Henle,
Bennett, and Wharton Jones. What is known from them is compactly and
circumstantially stated.

Dr. G. still hangs on to the terminations, but we are disposed to cut
them off altogether. Instead of saying there are seven terminations of
inflammation: 1, resolution; 2, effusion of serum; 3, deposition of lymph;
4, suppuration; 5, hemorrhage; 6, softening; 7, gangrene; let these pheno-
mena be described with all the minuteness possible, as so many manifestations
of disease. It does not assist us to their better acquaintance to call them in-
flammation— and destroys the chance of standing upon a common therapeutic
basis. How much better, said Bichat, " inflammation terminates by, 1, re-
solution; 2, repercussion; 3, suppuration, or by other diseases.

Following Dr. Gross's classification we come to —

Effusion of Serum. — Dr. G. doubts whether oedema or anasarca occur,
without inflammatory action, and reasons in this manner (pp. 61, 62) : "It is
frequently extremely difficult to ascertain the condition of the seat of the ef-
fusion by anatomical inspection. In ascites, how often does it happen, that
there is the most copious accumulation of water, caused obviously by inflam-
mation, and yet, on examination after death, there is scarcely a single trace
of the latter malady. The absence of redness does not prove that there was
no inflammation, for the discoloration with other signs often vanish, just be-
fore death. Effusion from mechanical obstruction cannot exist without pro-
ducing a state of parts analogous to" (what state is then analogous to, and yet
not inflammation?) "if not really identical with inflammation. But it may
be said, that the effusion may result from perverted action, from irritation
or distended function, all this may be true and yet not in the least invalidate
our position. Everybody knows that in inflammation there is perverted ac-
tion, or deranged function with irritation or altered sensibility." Poor rea-
soners — like good navigators — stick to the great circles. Once more he
says: "In the same manner, hydrothorax is sometimes induced by tubercles
of the lungs; hydrocele by carcinoma of the testicle; hydrocephalus by heter-
ologous growths of the brain. In all these instances, effusion of water is
the result unquestionably, of inflammation lighted up in the serous covering
of the respective organs by the morbid deposit acting as a foreign substance."
In whatever relations the morbid deposit and the inflammation may stand to
each other, we would rather regard the diathesis which has produced the
solid growth to be a good and sufficient cause, proximate and remote for the
dropsy. And again : " The dropsical accumulations which supervene upon
scarlet fever, measles, and other eruptive diseases, can be traced in most cases
directly to phlegmasial irritation of the serous membranes." We think this
bad pathology which would be likely to eventuate in worse therapeutics.
The convulsion, coma, sore throat, desquamative disease of kidney, albuminu-
ria, and dropsy of scarlet fever, are no more the signs of local inflammation,
No. LXIX.— Jan. 1858. 11

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or any such process, as the frozen ear of a rabbit illustrates, than is the scar-
latinal redness of the surface due to an inflammation of the skin. We would
not call a variolous pustule an inflammation of the skin, though Piorry says
it is nothing but an abscess. But the definition of inflammation which really
defines, is to be the work of the Coming Man.

" Lymphization." — A term not found in any other pathological treatise, as
Dr. Gross confesses, is the heading of another chapter, The effusion of fibrin
is invariably of inflammatory origin, and is often the only sign of inflamma-
tion existing after death. Lymph is defined by Dr. Gross as a vital organiz-
able substance separated from the blood by a process of secretion. It does
not always exhibit the same appearance. When first exuded it is semi-liquid,
but its consistence thickens, and it may become organized and transformed
into tissues. An excellent description of the microscopic appearances is
given (p. 64). Of the inflammatory globule of Gluge,«it is said that it is
not confined to inflammatory lymph. Mention is made of Rokitansky's divi-
sions into croupous and plastic, and Paget' s into fibrinous and corpuscular,
and the various intermediate varieties, but no allusion is made to Virchow's
admirable researches on the nature and properties of fibrin, contained in
various papers published since 1845. An omission somewhat remarkable in
this connection, inasmuch as this subject has been for some time regarded as
the specialty of the Wiirzburg professor.

" The chemical composition of lymph proves it to be similar to the buffy
coat of the blood. It is effused under a considerable variety of forms de-
pendent upon the shape of the part which supplies it." This is a variation of
form which is not of the slightest consequence. Concerning the rapidity
of the formation of the plastic exudation, Dr. G. says it may form within an
hour and to a considerable amount in four hours, and a case is given in illus-
tration. Lymph tends to become organized, and becomes supplied with ves-
sels either by the vessels of the natural tissues shooting into it; or sponta-
neously by powers residing within itself.

This process is traced up, to the development of fibrous tissue, with the aid
of figures of cells and fibres, after Bennett.

" Plastic lymph organized, forms the basis of all the analogous tissues and
the bond of union of divided parts. It may become the seat of inflammation
both acute and chronic, pour out serum, lymph, pus, and even blood; and
undergo the same transformations precisely as the natural textures. It is,
likewise, the source of what is termed induration, and probably, also, in a
modified form, of scirrhus and tubercle." These statements are like many
other wholesale statements. They contain a great deal of verbal outside
fact with a little inner falsity — just enough to spoil them and make them
dangerous.

" The analogous tissues, formed out of the plastic element of the blood, are
nearly as numerous as the natural tissues; thus, cellular, serous, mucous,
cutaneous, vascular, adipose, horny, epidemic, fibrous, fibrocartilaginous, car-
tilaginous, osseous.

" Coagulating lymph performs a conspicuous part in the reunion of divided
parts. Without its agency, ulcers would not heal, and fractured limbs would
dangle about " in wild uncertainty." By this is produced union by adhesive
inflammation. What should we do without it? It is to be hoped that we
are all in a comfortable state of inflammation. If so, we are as well as could
be expected.

It is our belief that the term adhesive inflammation does not express a fact.
Suppuration. — "This is the third mode by which inflammation relieves it-

1858.]

Gross, Elements of Pathological Anatomy.

159

self. Pus is never deposited where there is an entire absence of inflammation.
A cold abscess is the result of inflammatory action quite as much as a phleg-
monous boil is. Pus, may be formed without a solution of continuity. It is
found much more readily and abundantly in organs which contain the largest
amount of cellular substance."

This is all very well, but hardly serves as a fit introduction for an article
on suppuration, which is intended to be up flush with the times, and so placed
as to reflect the light which Yogel and Wedl have shed on this matter. What
follows is much better. The consideration of abscesses, and especially the
paragraphs which treat of the nature, varieties, and tests of pus, leave hardly
anything to be said. This chapter resembles some others in being extremely
unequal in style and scientific method.

Chap. Y. Hemorrhage. — There can be no doubt that this chapter is en-
tirely out of place in occupying a position between suppuration and softening,
but we defer the suggestions on classification which we wish to make to an-
other place. After noticing the uncertainty of our opinions on this subject,
Dr. Gross remarks that, formerly, the idea prevailed that all sanguineous effu-
sions depended upon rupture of bloodvessels; and adds, nor is this notion
yet eradicated from the minds of some. It is not to be denied that most of
the good books recently published give evidence that such an opinion is by
no means entirely eradicated from the minds of the best pathologists. Our
author has no faith in exhalants, and devotes to these mythical structures a
paragraph or two. But he believes that the capillaries, being in a state of
debility and relaxation, have their pores rendered unnaturally patulous, and
thus allow the blood to have a more ready egress. Relaxation and Pores. —
"It is precisely where meaning fails that a word comes in most opportunely."
This process takes place within the limits of health (it is gratifying to know
that there is something that can take place within the limits of health), as in
the uterus where it constitutes the menses. The other subjects treated of in
this chapter, are the liability of different structures to hemorrhage, the causes,
the effect of inheritance upon it, vicarious hemorrhage, and the classes into
which hemorrhage may be divided. Under the head of changes in the effused
blood, it is said that the blood may be rejected, absorbed, may remain and
become organized, or may act as a foreign substance and produce fatal inflam-
mation, and, finally, may undergo various changes in colour and consistence.
This is an interesting subject, and entitled to longer consideration. That
effused blood ever becomes organized may reasonably be doubted.

Softening. — "One of the most singular effects of inflammation. The
term is synonymous with that of mollescence(l), so much in vogue among the
French pathologists. All parts are not equally subject to it. The parti-
cular anatomical element in which the changes are most marked is the inter-
stitial cellular. Cadaveric softening may induce mistakes. Its differential
characteristics are not, however, given in this place. There is a species of
softening in the nervous centres dependent upon closure of the arteries. This
interruption of the circulation, however, interrupts nutrition ; but it is not
by any means clear that 'the changes which the organ experiences are not of
an inflammatory character/ The bloodvessels in many cases seem to have
entirely disappeared, whilst in others they are so weak as to be incapable of
withstanding the slightest pressure or receiving the finest injection. There
can be no such thing as dry softening."

Softening of the heart is well described. It may co-exist with phthisis,
pleurisy, typhoid fever, or take place as an independent affection. The micro-
scopic appearances are not given by Dr. G. The subject (softening) is one

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of very great interest, and deserves treatment at length, being, perhaps, the
most common and widely distributed of all organic lesions.

The experiments of Hamont and Levret upon the blood in malignant pus-
tules are spoken of. It may be mentioned, in this connection, that different
forms of carbuncle and furuncular diseases with ecthyma have prevailed to an
increased extent in some of the large cities of this country during the last two
years. And it has been pretty well established, that Dr. Locock's opinion
concerning their contagiousness is founded on fact.

Gangrene from ergotism is treated at some length. Of the modus ope-
randi of this agency we are ignorant. It probably affects first the blood, and
then "the capillaries, causing inflammation in them followed by gangrene —
the nervous system is, no doubt, also seriously involved; all that is contended
for, is, that these are the parts which receive the primary impression what-
ever that may be." The scepticism which calls this agency in question is very
reasonable.

Ulceration may be defined to be " the molecular death of a part." " Of
the intimate nature of this lesion nothing is known, with any certainty, be-
yond the fact that it is essentially connected with inflammation." "The cuta-
neous, mucous, and cellular tissues are much more frequently affected than
all the rest put together. This is well exemplified in the numerous blotches
which so often cover the body, and in the erosions which are so frequently
noticed in the bowels, mouth, throat, vagina, and larynx. The liability to
this affection varies very greatly even in parts of the same structure ; thus,
1 for one erosion of the stomach we find at least a thousand in the ileum/ "

" Ulceration always manifests a tendency to extend towards the nearest sur-
face." The great cause of ulceration is inflammation conjoined with pressure.
The caries of bones produced by the pressure of an aneurism "disproves the
idea formerly so current that ulceration can never happen without the forma-
tion of pus."

What is the nature of the concomitant inflammation? The assumption is,
that it is specific, that it is modified by circumstances, local or general, or both
combined, which the pathologists cannot appreciate.

The subject of ulcers, in the second part, is excellently treated. But we
think that Dr. G. seems to consider a collection of processes, or a compound
one, as a single and simple one.

Ulceration may be a salutary process, a means employed by nature to rid
the animal economy of extraneous materials, collections of purulent fluids,
bullets, and tubercles. " In old drunkards it seems to be designed to relieve
the system of hurtful fluids, by establishing extensive sores on the legs,
attended with a perpetual flow of irritating matter. Thus we see that
ulceration, although apparently a very unpleasant, is; in many instances, a
most fortunate event, and one for which the practitioner often anxiously looks."
This chapter, though containing many good things, is very imperfect.

Granulation. — "This process is one of the grand operations, employed by
nature for the cure of wounds and the filling up of ulcers. A granulation is a
vascular body, consisting at first essentially of coagulating lymph. In this an
arterial and a venous branch — a small nerve and an absorbent, probably — are
developed. It is thus an absorbing as well as secreting body, and performs
the triple office of pouring out lymph, secreting pus, and absorbing such sub-
stances as are brought in contact with it. The concomitant inflammation
appears to be of a mixed character, as it is attended with the' simultaneous effu-
sion of lymph and purulent matter.^ We are getting befogged. This Pro-
teus appears in more characters, on the same occasion, than the infant phe-

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Gross, Elements of Pathological Anatomy.

161

nomenon — one kind effuses lymph and another pus. We had hoped that
granulation would heal the old sore; we look hopefully at the next chapter.

Chap. X. Cicatrization " It is the finishing stroke, if the expression be

allowable, of granulation — the labour necessary to polish the surface of the
sore, to contract its diameter, and to bring it as nearly as possible to a level
with the surrounding structures" — and it is expected to be up to the scien-
tific level of the times.

"This process is not limited to the skin. The first step in the process of
healing is the subsidence of the inflammation. The granulations contract and
coalesce, the surface becomes smooth, the centre being depressed or elevated.
The first evidence of real cicatrization is a thin pedicle along the breach where
it unites with the old skin by an interchange of tissue, of vessels and nerves;
and after the new organized deposit becomes thicker, and extends towards the
centre by successive experipheral additions of new material."

Dr. Gross is convinced that ulcers and wounds never heal from the centre ;
that the process described is the only way by which healing can be accom-
plished, with the exception of large wounds, which have left little islets of
sound skin.

" Are the original textures in the formation of cicatrices always regene-
rated? Cartilages and muscles are said to be the only parts not susceptible of
reproduction. But even this is extremely doubtful. At all events, in most
instances the reproduction is imperfect. There are no sebaceous follicles, and
no hairs on new skin. Cicatrices are liable to inflammation, contraction, hy-
pertrophy, and malignant degeneration."

Induration. — Increase of consistence may arise from the deposition of a
new product, from a deficiency of the natural secretion, or the transformation
of the elemental tissues of the organ affected. This excludes all the hetero-
logous formations. " The causes are referable for the most part to inflam-
mation followed by an effusion of lymph. In the lungs there is frequently, in
addition to this, more or less blood poured out, which, combining with the
natural structures, gives them a red colour. It is thus that red hepatization
is established." " That induration is susceptible of being cured, daily ob-
servation abundantly testifies." No allusion is made to more than one kind
of red hepatization, nor to any other, of Virchow's remarkable discoveries, in
this direction. There is a pneumonia with granulations and a pneumonia
without granulations.

Chap. XII. Hypertrophy. — The title of this chapter is provokingly sug-
gestive of Mr. Paget' s elegant lectures; but the merits of the chapter lie
chiefly in the postscript — suggestive of quite another kind of literature.

Of the causes of hypertrophy some are general, others of a local character;
of the former, very little can be said to be known. The local causes are
chronic inflammation, mechanical obstruction, inordinate exercise.

Hypertrophy essentially consists in an augmentation of the nutritive func-
tion. The elementary particles are increased in number, or augmented in
size. In that variety which results from chronic irritation it is not unlikely
that there is often superadded to the alteration just mentioned a deposit of
new substance in the spaces of the connecting cellular tissue, leading thus to
a real change of structure.

This subject is very defectively treated, both under the head of General
Pathology and in the detailed application to special organs and systems; for
example, in speaking of hypertrophy of the uterus, all that we find are the
following sentences : " Hypertrophy of the uterus, as a result of healthy nu-
trition, is very rare. The affection is usually most conspicuous in association

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with fibrous tumours, in which it is sometimes truly enormous. Thus, in a
specimen in my possession the walls of the organ are nearly two inches in
thickness, and of a firm, dense consistence, grating under the knife. Its
cavity is of extraordinary size, and several small tumors are seen projecting
from its outer surface. The hypertrophy is sometimes confined to the lips of
the uterus, which, especially the anterior, become thick, dense, and stumpy."

We might reasonably expect, in this connection, a description of the coarse
as well as of the microscopic appearances of this organ in the pregnant state.

Chap. XIII. Atrophy. — This lesion depends upon the imperfect exercise
of the nutritive function. " General atrophy, commonly called marasmus,
emaciation, or consumption, frequently arises from organic disease of the
lungs, heart, and stomachy and from morbid enlargement of the mesenteric
ganglions."

All animals have a period of growth, maturation, and decay. In senile
atrophy the solids waste, and the fluids are changed in character. " The jelly
which exists in such great abundance in young persons totally disappears in
decrepitude, its place being usurped by albumen and fibrin."

The causes of local atrophy may be cessation of the function of the organ,
diminution of the nervous influence, deficient supply of blood, and inflamma-
tory irritation. Under the last head our author says : "The irritation ex-
cited by the presence of biliary concretions in the gall-bladder is sometimes
followed by the complete wasting of that organ. Hepatitis often gives rise
to atrophy of the parenchymatous structure of the liver; and orchitis, espe-
cially when supervening on mumps, is not unfrequently succeeded by impo-
tence. How the lesion is produced in these cases it is not easy to determine.
It is probable that the chief fault is in the arterial capillaries, which cease to
perform their accustomed functions, and thus allow the absorbents to carry off
more than the usual amount of organic matter."

Atrophy of the muscles, brain, uterus and mamma is well treated in each
of the chapters of the special pathology devoted to these organs.

We make no apology for recalling to the minds of our readers the following
extract from the writings of one of the most gifted men at present adorning
our literature. When speaking of general atrophy he says —

"It could not be without interest to watch the changes of the body as life
naturally ebbs — changes by which all is undone that the formative force in
development achieved ; by which all that was gathered from the inorganic
world, impressed with life and fashioned to organic form, is restored to the
masses of dead matter; to trace how life gives back to death the elements on
which it had subsisted ; the progress of that decay through which as by a com-
mon path, the brutes pass to their annihilation, and man to immortality. With-
out a knowledge of these things our science of life is very partial, very incom-
plete ; and the study of them would not lack that peculiar interest which
appertains to inquiries into final causes ; for all the changes of natural decay
or degeneration in living beings indicate this design, that, being gradual ap-
proximations to the inorganic state of matter, they lead to conditions in which
the elements of the body, instead of being on a sudden and with violence dis-
persed, may be collected into those lower combinations in which they may best
rejoin the inorganic world; they are such that each creature may be said to die
through that series of changes which may best fit it, after death, to discharge
its share in the economy of the world, either by supplying nutriment to other
organisms, or by taking its right part in the adjustment of the balance held
between the organic and the inorganic masses.

"Nor would the student of the design of these degenerations do well to omit
all thought of their adaptation, in our own case, to the highest purposes of our
existence. When, in the progress of "the calm decay" of age, the outward

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Gross, Elements of Pathological Anatomy.

163

senses, and all the faculties to which they minister, grow dim and faint, it may
be on purpose that the spirit may be invigorate and undisturbed in the contem-
plation of the brightening future; that, with daily renewed strength, it may
free itself from the' encumbrance of all sensuous things, or may retain only
those fragments of thought or intellectual knowledge which, though gathered
upon earth, yet bear the marks of truth, and being truth, may mingle with the
truth from heaven, and form part of those things in which spirits of infinite
purity and knowledge may be exercised."

Chapter XIY. treats of Fistules, and is very much out of place between
Atrophy and Transformations.

Chapter XY., Transformations. "The human body is incessantly under-
going changes by which the nutrition of its elementary constituents is modified
until they are at length converted into totally different structures." (!)

The number of transformations is very small, and may be stated as follows :
1, cellular; 2, mucous; 3; cutaneous; 4, fibrous; 5, cartilaginous; 6, osseous;
7, adipose. Passing over the first four we come to the cartilaginous variety :
it usually appears in the form of thin plates or nodules. The subserous cel-
lular seems to be the texture the most liable to it. It occurs in the fibrous
envelop of the spleen, in the placenta, the gall-bladder, cysts, adventitious
membranes, &c. The new substance cuts precisely like a piece of costal car-
tilage, and passes, by insensible gradations, into the circumjacent cellular tis-
sue, which is generally unnaturally thick and indurated. It is in reality
devoid of all the elements of cartilage.

The most common transformation by far is the osseous. The new sub-
stance, which often bears but a faint resemblance to natural bone, is seen
under three forms, the lamellated, tuberoid, and spicular; but in the majority
of cases this so called osseous transformation does not present the usual uni-
form characters of true bone; it is rather a calcareous degeneration or a
deposit of chalky particles, with an absence of the natural elements of bone.
Accidental ossification is frequently witnessed in old age — the arteries, costal
and laryngeal cartilages are thus affected. In other cases it is directly charge-
able to inflammation.

"But the most remarkable transformation is the adipose, in which the tis-
sues undergo a real fatty degeneration. In the majority of cases it-is a true
replacement of tissue by oil. By some the alteration is supposed to consist,
essentially in the superaddition of fatty matter to the existing tissues, whilst
others consider it as the result of a true transformation." But no one, it
is fair to suppose, who has read Quain and Robin, confounds these two essen-
tially different processes.

How is it brought about? "In the human subject it sometimes seems to
depend upon the want of exercise of the affected part. But are these effects
really attributable to repose. Would it not be more philosophical to conclude
that something was due to the want of nervous influence, and to the altered
state of the circulation thence arising. Be this as it may, I feel disposed to
think that the transformation in question is uniformly the result of a low and
imperceptible grade of inflammatory irritation." This last sentence is not the
only unsatisfactory part of this paragraph.

Under the head of " Pneumatoses, or Collections of Aeriform Fluids," is
included the general consideration of pneumo-thorax, tympanitis, physometra,
pneumo-pericardium, pneumatocele, emphysema, &c.

The causes are external injury, chemical decomposition, and true secretion.

The next chapter introduces us to the general subject of Tumours, a word
which does not occur in the index of Dr. Gross's work, and is really an ob-

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jectionable term; but its use may conveniently serve a purpose. Our author
does not approach the subject as do those who have what might be called ra-
dical notions on the subject of new formation. He does not build up his
classification on a foundation of the nature, nor yet on any other good basis.
It is both faulty and eccentric.

Chap. XVII. Polypes. — We object that this word cannot properly stand
for a class, as it relates merely to a matter of form, and may embrace every
variety of tissue, homologous and heterologous. Dr. G. confesses that it is
not very appropriate. After considering briefly the situation, number, size, and
form, the author speaks of their structure. "In this regard polypes may be
divided into four species, vesicular, fibrous, vascular, and granular. As to
situation, it may be said in general terms, that the first variety occurs most
frequently in the nose; the second in the uterus; the third in the rectum,
ear, and vagina; and the last in the larynx and urinary bladder. These may
all undergo the various transformations, The fibrous is most liable to become
carcinomatous." Is such a transformation possible under any circumstances ?
We do not believe it, if it is intended to convey the idea that fibrous tissue
ever becomes carcinomatous tissue.

In regard to their origin polypes cannot be viewed, strictly speaking, in the
light of new formations, but rather as the result of a species of hypertrophy
of the mucous membrane. The development of the granular from mucous
follicles is traced and compared to the formation of a cyst from the closure of
a sebaceous follicle. All these varieties are covered by a mucous investment
continuous with that of the canal, from which they have sprung. They
possess arteries and veins. No nerves or absorbents have been detected in
these excrescences, though they undoubtedly exist there.

Hydatids. — Dr. Gross divides them into 5 genera; 1, the cysticercus; 2,
the polycephalus; 3, the diceras; 4, the echinococcus; and 5, the acephalo-
cysts; they all consist of a thin pellucid vesicle, varying in size, which is
filled with a clear watery fluid, and surrounded by a dense fibrous capsule,
upon which they depend for their nourishment and support.

These are well described by words and figures. The origin of hydatids is
involved in doubt. Recent researches tend to show that they are the ova of
worms, probably of the taenia, which reach a certain stage of development,
and then become encysted. The embryos of taenia have been seen perforating
the intestinal walls, in order to reach the parenchymatous structures in which
they were destined to become imbedded. Whilst the formative process is
going on, the parasite takes care to isolate itself by means of a capsule. This
capsule formed out of plastic lymph, is furnished with vessels, nerves, and ab-
sorbents ; these are derived either from the surrounding textures, or are of
spontaneous formation.

How are hydatids nourished ? They are isolated by a capsule, which is
lined by a thin, pulpy, fragile lamella, which Dr. Hodgkin supposed to be an
excrementitious secretion from the hydatid, but which Dr. Gross believes may
be an important structure designed to nourish the parasite. Some hydatids
are short lived, and some last for years. They may die of inflammation
terminating in suppurative gangrene.

This chapter, although one of the most thorough and complete expositions
of the actual state of science to be found in the book, contains no notice of
Kobin's remarkable explorations among entozoa.

Serous cysts are often confounded with hydatids, but may be readily distin-
guished by the fact of their being all intimately connected with the parent
sac, by the circumstance of vessels passing from one to the other, and by their

1858.]

Gross, Elements of Pathological Anatomy.

165

not containing any parasitic formations. — \_Vide passim, Robin and Paget,
Simon, Johnson, and Budd.]

Chapter XX. Heterologous Formations. — This chapter, divided into six
sections, introduces' the subject of heterologous formations. This is by far the
best part of the work we have as yet passed in review. Much of it is admira-
ble in style, and it is well illustrated by wood-cuts, old and new. Most of
the latter made from drawings by Dr. Da Costa, whose valuable assistance has
received from Dr. Gross the credit to which it was believed to be entitled.

There are, however, in the following sections, many opinions and statements
which may fairly enough be questioned. But, in accordance with the plan
already pursued to this point, we prefer that our author should announce his
ideas and fortify them in his own way.

By the term heterologous are understood certain morbid products of a solid
or semi-concrete consistence which have no resemblance whatever, or, at most,
only a very remote one, to the natural, normal, or pre-existing tissues of the
body. The number of these products is, probably, not more than six, viz., tu-
bercular, scirrhous, encephaloid, colloid, melanotic, and epithelial. All the
heterologous formations have one common property, they are all malignant, and
tubercle is unquestionably the most malignant of all. Their origin is, probably,
of an inflammatory nature, attended with an altered condition of the blood and
an aberration of the nutritious function.

Was there ever greater need of an Ashburton to settle boundary lines?

Section I. Tubercle. — In this section we find many well-arranged and
useful facts. As in other parts of the work, the external qualities of the pro-
ducts of disease, including those ascertained by the microscope, are presented
with marked fidelity and minuteness.

Tubercle is limited by Dr. Gross in its application to denote "a small solid
tumour of an irregularly spherical figure, more or less opaque, of a pale-yel-
lowish colour, seldom exceeding the volume of a pea, and composed of a pecu-
liar substance, which, sooner or later, undergoes a process of decomposition."
Passing over what is said concerning the situation, period of life, its occurrence
in the inferior animals, chemical constitution, we stop at varieties of form.
Here we learn that tubercular matter presents itself under four distinct varie-
ties, the miliary, encysted, infiltrated, and lamellated, besides that which is
known as gray granulations, which Dr. G. regards as a variety of the ordinary
gray tubercle.

In regard to the formation, it is said that all tubercular matter, whatever be
its form, site, or extent, is, in the first instance, of a liquid nature, becoming
solid by the absorption of the serosity which is poured out with it. It grows
by the superaddition of one particle to another. The effusion is always effected
under the influence of inflammatory irritation, preceded by a peculiar dys-
crasia. The doctrine of the inflammatory origin is countenanced, if not actu-
ally established, by the following circumstances, says our author : —

1. By chemical analysis.

2. Tubercular matter bears a very great resemblance to spoiled, degraded,
or cacoplastic lymph, which is an acknowledged product of inflammation.

3. The deposit is often excited by cold, especially when conjoined with mois-
ture and by bad food ; by the former are produced internal congestions, by the
latter an impoverished blood.

4. In many cases the disease is attended or preceded by hyperemia or ac-
tive congestion.

5. Well characterized tubercles have been produced on the lower animals
experimentally, by mechanical irritation.

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6. There is no appreciable deposit or effusion in any of the shut sacs, cells,
or cavities of the body, which is not, strictly speaking, the result of inflamma-
tory action, though this may be too slight to attract attention or to be attended
by the ordinary phenomena of that process.

This crowns the climax and completes the circle at one jump. Thus life
and growth are inflammatory actions, and we ourselves are only compound
inflammatory globules of considerable size.

Are tubercles ever organized? In answering this question, it is apparent
that Dr. G. takes that to be tubercle which Kobin, Wedl, Lebert, and others
have shown not to be tuberculous. The little masses once described as tu-
bercles comprehend many morphological elements. Besides cells with distinct
nuclei, and nuclei mixed with molecules, and granular corpuscles, and the
protein bodies with flocculent edges, there may be various other heterologous
or homologous formations, as cancer, &c. ; so that a tuberculous mass may
be like any other mass of tissues — a cancerous tumour even — made up of
various elements. In tubercle as in other structures, there may be various
pathological changes going on — degeneration, suppuration, exudation. But
we think it is not to be inferred from this that tuberculous matter is organi-
zable. To say that it has an organized blastema for its base is a different
thing, and more in accordance with the results obtained by the most minute
investigations.

We refer the reader for Dr. Gross's able presentation of the other side of
this double-headed question to pp. 158, 159 of the Elements of Pathological
Anatomy. This section manifests throughout a conscientious use of most of
the well-established facts, and a praiseworthy fairness in confessing to uncer-
tainties in matters of doubtful knowledge.

The paragraphs devoted to microscopical characters are full and compact,
but we have not space for further extracts, and pass on.

Section II. 31elanosis. — This subject introduces the subject of colouring
matters, whose history is yet to be written. For this material has been fur-
nished by Yogel, Virchow, Robin, Verdeil, Bence Jones, and Addison.
From our own observations we are led to coincide with those who believe that
all the pigments are but slight modifications of the one colouring matter of
the blood, more or less oxygenized, and having slightly different molecular
arrangements, whence they reflect light differently. They all have many
common characteristics, the most remarkable of which is invulnerability;
they are hard subjects, and resist assaults. The mortality which is supposed
to depend upon melanosis we should no more refer to the deposit of melanine
in the tissues than we should refer the deaths from Addison's disease to the
bronzing of the skin.

But in turning to our author we find him describing melanotic tumours as
tuberoid, lamellated, dot-like, infiltrated, ramiform, and liquid; and we add,
as an appendix, that it may be found in any form into which blastema or
stroma may be arranged. The subject is treated by Dr. Gross at considerable
length, and the section appropriated to it is one of the most interesting in the
book.

Sections III., IV. and V. treat respectively'of scirrhus, encephaloidand colloid.
The imperfect definition which stands at the beginning of Section III. is an
index of the false point of view from which Dr. G. regards all the new
formations. It is from the external and anatomical side that the subject
is viewed. Thus it is said : " Scirrhus may be defined to be a hard, crisp,
opaque substance, of a light grayish colour, with dull, yellowish, fibrous in-

1858.]

Gross, Elements of Pathological Anatomy.

167

tersections organized, liable to lancinating pain, occurring for the most part
after the middle period of life, and passing sooner or later into ulceration."

Scirrhus may occur as a solitary tumour, in disseminated masses, as an
infiltration, or as a lamella. After the general consideration of these forms,
follows a good description of the appearances on section.

The characteristic cancer-juice, on which Lebert, Nelaton, and others in-
sist so much as one of the first-sight, reliable signs, is dropped with two lines
thus — " a creamy-looking fluid is occasionally incorporated with the hetero-
clite mass, and constitutes the most decided evidence of its carcinomatous
nature." The student who reads this fact for the first time in this book —
and we suppose that it is for that class of readers the book is chiefly designed- —
will be at a loss how to turn the information to any account as an aid to a
differential diagnosis.

Scirrhous tumours present considerable variations of structure, dependent
upon the quantity of adventitious matter, its vascularity, its mode of aggrega-
tion, and the pressure which is exerted upon surrounding parts; whence
names indicative of peculiar appearance have been assigned — such as mam-
mary, pancreatic, lardaceous, and reticular.

Under the head of organization, a very minute and complete description of
the microscopic appearances is given, which we have not space to transfer.

As a summary of several remarks our author says : " It may be concluded
first, that the deposit of scirrhus is preceded by inflammation; secondly, that
it has a great predilection for the glandular viscera; thirdly, that it rarely
occurs under the age of forty ; fourthly, that the matter of which it consists,
when first deposited, strongly resembles that of tubercle; and lastly, that this
matter is deposited always into the cellular tissue of our organs in such a man-
ner as to transform their proper parenchymatous structure."

The scirrhous matter is liable to softening ; this change may begin at any
part of the mass.

A scirrhous ulcer is exceedingly well described by Dr. Gross, p. 176.

Finally, scirrhus, after having attained a certain age and bulk, is occasion-
ally assailed by destructive inflammation, followed by sloughing of the whole
of the heterologous matter.

The section in which encephaloid is treated, bears marks of an intermittent
development. Scattered throughout it, and in the midst of a style every
way scientific and appropriate, occur occasionally paragraphs which, from the
absence of the new terms, the phraseology indicative of the late discoveries,
show an origin of a much earlier date than the context. Thus, " intimately
allied to scirrhus, in its mode of origin, yet differing from it widely in many
of its essential features, is encephaloid * * * * as the term indicates, this morbid
growth bears a great resemblance to the cerebral tissue, not only in appearance
but also in chemical composition. " That is what Dr. Gross calls a great resem-
blance, and illustrates like a steel cut, what we mean by the outside way of
looking at pathological anatomy. It is to be hoped that the students will not
confound resembling with analogous; if they should, they would have to
look long, before finding any structures that could fairly be called heterologous.

We think the space in which the forms, as tuberoid and stratiform, are
described, should have been given to something more important. The forms
are accidental, but, presented as we find them in this section, might be sup-
posed to be a good basis for classification.

It may be assumed that encephaloid, when first found out, is always fluid.
Its structure is not uniform, and its consistence is so various that it has given
rise to various designations. The well known microscopic appearances are

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clearly described. For them and what is said on the chemical constitution
and etiology of this form of cancer, the reader is referred to pages 180-184.

The ulcerated mass sometimes sloughs completely away, as if dissected out,
but is soon followed by a reproduction of the disease. It might be added
that such growths are not likely to be injured by explorations with a needle,
in the hands of a scientific man, nor yet radically cured by applications of
chloride of zinc and sanguinaria.

Section V. Colloid. — Known also as gelatiniform cancer, alveolar cancer,
and gum cancer. "By some," says Dr. G., "this heterologous formation is
regarded merely as a modification of the carcinomatous products already
described." The same might be said of tubercle, scirrhous and encephaloid.
It might have been added that some observers do not regard colloid as carci-
nomatous at all. We agree with our author, in thinking it possessed of
sufficiently distinctive features to entitle it to separate consideration.

The description given of the structure is excellent, but we can give only a
general idea of it.

Colloid is composed of two distinct elements, a containing and a contained
part — a stroma of fibrous tissue, forming cells of different sizes and shapes,
freely communicating with each other, whence a colloid tumour bears some
resemblance to a sponge. The other substance is a straw-coloured jelly, un-
organizable.

How this disease originates, or what its causes are, we are entirely ignorant.
Its progress is usually slow. It manifests no disposition to ulcerate, is never
the seat of hemorrhage, or of much pain ; the general health usually holds
out well, and the countenance rarely acquires that sallow, cadaverous hue; so
common in ordinary carcinoma.

Section VI. Epithelial Cancer. — This subject has received special atten-
tion from Dr. Da Costa, and plates representing a papilla and encysted cells
are taken from drawings by this microscopist. The section embraces a
general view of all that is known on the subject, although no special reference
is made to Lebert or Bennett.

This brings us to the close of the first part of Dr. Gross's work, that which
treats of general pathological anatomy. Its faults or errors of doctrine we
conceive to be those of its class. It is too much anatomical, and too little
pathological. We believe that Dr. Gross is as much convinced as we are,
that there cannot be an exposition of morbid anatomy of any value, without
pathology, but he always puts the anatomy first, and that disposition has
controlled his figures of speech and illustrations, but especially his classifica-
tion, and has compelled him, or permitted him, to leave the greatest things
unsaid, or but faintly indicated. The great facts of diathesis, dyscrasise,
and all that contributes to make idiosyncrasy, are overshadowed by protu-
berant tumours, from the size of a billiard ball to a dinner plate, and re-
sembling everything that ever has been served up on a dinner plate. We
have brought in, by three or four pages, one after the other, peas, Lima beans,
currant jelly, boiled egg, moist cheese, arrowroot, custard, potato, turnip,
orange, mustard, calf's liver, and an adult head. These are here enumerated
only for the purpose of illustrating our meaning. They are given by the
author, to describe qualities, which, we think, are not of much consequence,
and may be present or absent, without changing the character of the produc-
tion, being indifferently applicable to all sorts of growths, heterologous and
homologous. But it must be acknowledged that it is his aim to give his
pupils clear ideas of these external properties, such as first strike the eye, and
are noted by the quick diagnostician and prompt clinical lecturer, rather than

1858.] Gross, Elements of Pathological Anatomy. 169

the essential qualities, which the medical philosopher should look for. "We
have, therefore, no doubt that the students, whose privilege it is to listen to
Dr. G., receive from him well-defined principles for the diagnosis of external
disease, and the coarser specimens of internal disease. But there is much
more than this that comes within the domain of pathological anatomy.

In the second part, treating of the application of general principles to spe-
cial organs, we find nothing challenging criticism except the repetition of the
doctrines to which we have already called attention ; but we do find much that
indicates a vast erudition, and patient, conscientious labour. Its collection of
facts is so great that it must ever be an extremely convenient vacle mecum on
the office table — with other books, we should add parenthetically, for it re-
quires those that are complementary by its side.

Having now fairly presented Dr. Gross's doctrines according to his own
classification and in his own style and method, we beg our readers to look, for
the sake of contrast, at the ideas which have been generally adopted by the
members of what may be called the French biological school, and are given
here as an answer to the inquiry how anatomy should be studied and taught.

The idea of life, properly speaking, does not belong to the organs and tis-
sues as such, but to certain elements which by their reunion make tissues.
These elements may be considered (a) in relation to their form or size; (b) in
relation to dynamic attributes. They have, 1, physico-chemical properties, and
2, vital properties.

There are, I. Constituent Elements: II. Elements of Production.

I. Constituent elements are divisible into (a) amorphous elements, (j3)
globules, cells, nuclei vesicles, (y) fibres, (S) tubes, canals, (£) amorphous sub-
stances mixed with corpuscles, cells and cavities.

II. Elements of Production may be (a) Homceomorphic, (j3) Heteromor-
phic productions, as globules of exudation, globules of inflammation, of pus,
cancerous elements, corpuscles of tubercle.

All compound tissues consist of, 1st, a fundamental form or species of ana-
tomical element which makes up the mass of the tissue, and whose properties
give the specific character to the tissue, and, 2d, of one or more species of
elements which do not enter into the constitution of the tissue except as ac-
cessory, and whose properties only modify the tissue in a secondary manner :
ex. gr. striated fibres are the essential anatomical element of muscular tissue;
the accessory elements are areolar or laminated fibres, fat vesicles between the
fibres, capillaries and nervous tubes. This law is of great consequence and
should especially be borne in mind in the study of morbid products: thus —

Homoeomorphic tumours exhibit this peculiarity ; an accessory element
which nominally exists in small quantity becomes enormously increased rela-
tively and finally predominates over the fundamental tissue and really becomes
the fundamental tissue. • Most of the amorphous substances, the homogeneous
intercellular substances which in the normal condition are quite secondary or
accessory, may become greatly multiplied, as is seen in epithelial, tubercular,
and cancerous formations.

The Heteromorphous tumours present many examples' of the normal ele-
ments becoming accessory, the nature of the production being unchanged.
Globules of pus are often accessory elements of cancerous and epithelial
tumours. Pavement epithelium is also accessory and secondary in cancerous
tumours. The granular globules of exudation are secondary elements of a
large number of tumours.

By Homoeomorphic elements are understood morbid fluids or tissues con-

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stituted by anatomical elements of the same nature as those existing in nor-
mal tissues and fluids.

Heteromorphic elements are new productions, solid or fluid, differing in
nature from those normally existing in the body; their presence is, therefore,
a pathological sign. Examples: pus, granules of tubercle and cancer cells,
and, according to Robin, one or two others not yet well known.

These never have been observed to be the production of other existing nor-
mal elements, by metamorphosis or as a consequence of simple development;
they are always the results of processes of new 'production at the expense of a
blastema found under abnormal conditions : thus, Products of new generation
— neoplastic growths — are made up essentially of, 1st, an abnormal increase —
hypergenesis — of elements which belong to the economy, but are normally
secondary to some tissue : 2d, the production of elements which are essen-
tially dissimilar from those which exist in the normal state.

Blastema is a" generic word used to designate the basis of all anatomical
elements, normal or morbid. Pathologically considered, there are as many
different blastemata as there are causes of effusion. Whenever exudation of
lymph occurs its nature depends upon the cause; local or general, which ex-
cited it.

By the word tumour is meant a persistent collection of morbid productions,
characterized by a tumefaction which is limited, but having no other fixed
physical peculiarities. This definition embraces every variety of morbid tis-
sue and concretion, as well as all collections of fluid circumscribed by new
epigeneses, however these latter may have been produced, whether at the
expense of the normal structure and fluids, or by means of heteromorphic ele-
ments.

The first observation to be made in relation to these growths or tumours is,
that they are of a complex nature — of fundamental and accessory elements.
These are relative elements, which are always shifting ground — sometimes an
accessory element becoming, under other circumstances, fundamental. Amor-
phous elements, however, remain accessory. These last are of great import-
ance in relation to the differential characteristics of growths, for according as
these amorphous elements exist in greater or less abundance, do we find the
external appearances of the growth vary without essential change in the ele-
mentary structure.

Much embarrassment has been created in the course of earlier investigations
with the microscope, from the fact that the new growths were not considered
in their proper relation with normal elements, and especially from misconcep-
tion as to the modifications to which the epithelia are subject, as regards their
number, size, shape.

The whole subject of morbid growths — deposits or exudation — in respect
to their essential characters, their benignity or malignity, has been much sim-
plified by the new methods of investigation, which now include, besides a
measurement and description of each of the substances in the field of the
microscope, and their quantitative chemical analyses, the study of the nutri-
tion, growth, and reproduction.

Still another advance has been made by the discovery that behind the par-
ticular growth which is the subject of observation, there is an inexhaustible
fountain of materials assimilable to it, and a constant vis a tergo which keeps
the current towards it in active motion j "new fresh blood is constantly cir-
culating." Practically, then, tumours cannot be made to absorb. This rule
has but few exceptions. The same law which is an obstacle to their absorp-
tion is the cause of their reproduction after their removal. That means for

1858.]

Gross, Elements of Pathological Anatomy.

171

effecting a change of the dyscrasia, for a constantly increasing number of
morbid products are in hand; is a matter of fact. In that direction the sci-
ence of Therapeutics makes progress.

" It is a law binding only on devils and phantoms that they must go out
the same way they stole in." Once these sprouting tendrils get in, the death
struggle begins — one or the other must be cut off — there is no remedy but
ablation, and that to be early enough.

On the basis of the preceding facts and dogmas a classification of morbid
productions has been erected the most complete that can be found in medical
literature ; but before we proceed to quote it let us look, by way of compari-
son, at some others. One of the best in design, though at this time quite
limited and incomplete, is Bichat's arrangement. He begins with alterations
of the fluids; then follows a brief chapter on inflammation; then the mala-
dies of serous membranes in general and particular; then maladies of the
mucous membranes ; maladies of cellular tissue follow; and maladies of the
lungs. Maladies of the glands in order: Maladies of the cutaneous surface;
maladies of the muscles of organic life; maladies of the muscles of animal
life; maladies of the absorbent system; maladies of the fibrous system; mala-
dies of the synovial system; maladies of the cartilaginous system; maladies
of the medullary system ; maladies of the osseous system; maladies of the
pilous system; maladies of the epidermic system.

The arrangement followed by Mr. Paget in his Lectures on Surgical Pa-
thology is quite scientific, and one of the best and most convenient for use
that can be found. We therefore make no apology for asking our readers to
look it over again in this connection. This author very properly begins his
discourses on Pathology with an exposition of the processes of nutrition and
passes seriatim through growth, hypertrophy, atrophy, repair, inflammation,
and ends this first part with local or molecular mortification, limited death.

Having finished the consideration of Inflammation, the general malady or
basic disease, according to some pathologists, Mr. Paget begins anew with
specific diseases, and, passing to morbid materials in the blood and tissue,
comes to the second chapter, on Overgrowths or Tumours. These are either
benign or malignant.

The benign are divisible into cystic and solid. The cystic, simple, barren;
gaseous and serous cysts: proliferous, ovarian: proliferous, glandular, mam-
mary; epidermal, dentigerous: fatty, fibro-cellular, areolar: fibrous, painful
subcutaneous: fibrous polypi, fibro-calcareous; fibro-cystic: malignant fibrous,
recurring fibrous ; fibro-nucleated : enchondroma, cartilaginous, simple and
mixed: myeloid; fibro-plastic, osseous: mammary: erectile: — all these are
innocent or benign.

The malignant are : Scirrhus, medullary cancer, epithelial cancer, melanoid,
hsematoid, osteoid, villous, colloid, tubercles.

Dr. Gross's classification may be thus represented : Inflammation at the be-
ginning, fons et origo; then its terminations and conditions, as effusion of se-
rum, lymphization, suppuration, hemorrhage, softening, gangrene, ulceration,
granulation, cicatrization, induration, hypertrophy, atrophy, fistules, trans-
formations, pneumatoses, polypes, hydatids, serous cysts, heterologous forma-
tions, tubercle, melanosis, scirrhus, encephaloid, colloid, epithelial, and then
special pathological anatomy. This we believe, after thoughtful looking, could
not be made worse.

The completest of all we have yet seen, excepting that of Bouchut's These
de Concours, is this which follows : —

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ORDER I. — Solid Homceomorphic Tumours.

First Species. Tumours formed by Laminated Areolar Tissue.

1st variety. Proper fibrous tumours.

2d " Colloid.

3d " Fibro-cystic tumours.

4th " Fibrous — Pediculated — Uterine.

5th " Cheloides cicatricial.
Second Species. Fibro-Plastic Growths.
Third Species. Myeloplaxis — Osseous Medullary.

Fourth Species. Tumours of Cytoblastions — Chalazion Gumma — Yams —

Syphilitic Fungosities.
Fifth Species. Myelocysts — Cerebral Cellules.
Sixth Species. Dermic,
f 1st variety. Keloides.

2d " Keloid, or cicatricial vegetations.
■{ 3d " Condylomita — Cauliflower excrescences.

•^th " Nsevi — Hypertrophic.
[ 5th " Verruca Warts.
Seventh Species. Adipose Tumours — Cholesteatomata — Lipomata.
Eighth Species. Enchondromata.

1st variety. Periosteal tumours. "]
j 2d " Exostosis.
I Ninth Species.

L 3d variety. Osteoid, periarticular, senile, and rheumatismal. J
Tenth Species. Hypertrophic, Glandular, Exdermoptoses, and Sebaceous.
Eleventh Species. Condensed Glandular Tumours.
Twelfth Species. Colloid Glandular Tumours.

1st variety. Arterial fungous tumours, acquired — Aneurism.

2 " Nasvi materni — Congenital erectile tumours.
Thirteenth Species.

3d variety. Varicose venous erectile tumours — Epididymitic — Tes-
ticular— Thyroidal — Ovarian.

4th. " Aneurism by erosion — Extravasated blood — Dissecting
and osseous aneurism — Erectile tumours of liver.
Fourteenth Species. Parasitic — Heterotopic.

1st variety. Testicular.

2d " O.varian.

3d " Cutaneous.

r

OQ fH P

P m O

£ M P

a p

° 3 H

P «

1st variety.

2d
3d

4th "

5th "

6th "

7th "

Epitheleomata.
Horny tumours.
Pigmentary — Melanosis.
Exostoses dental.
Gouty concretions — Tophaceous.
Calcareous tumours — Inter- glandular — Cutaneous-
Salivary.

Tumours formed by products of conception — Moles.

p i m

P £ P

O O m

SO g

H n H

m § %

M g p

P P H

ORDER II.— Homceomorphic Tumours — Fluid.

First Species. True Aneurisms,
i Second Species. Haematic Tumours — Cephalhsematoniata — Hematocele

— Polypiform — Hsematomata.
I Third Species. Gaseous Tumours — Emphysema — Pneumatoses.

P o

J jFVrstf Species. Glandular Cysts of many varieties.

Second Species. Cysts formed in Excretory Ducts.
J Third Species. Cysts formed of Parenchymata, not Glandular.
] Fourth Species. Cysts, Synovial.
Fifth Species. Cysts of Accidental Synovial Bursas.
& Sixth Species. Cysts of Cellular Tissue — Congenital — Hydrocephalic.
3 I /

1858.]

Peaslee, Human Histology.

173

f ORDER I. — Solid Heteromorphic Growths.

First Species. Tubercle.
Second Species., Typhus Matter.
Third Species. Thnetoblastic, or Fatal Cancer.
Fourth Species. Heterodenic — Butyroidal Sacs.
^ Fifth Species. Tumours resulting from Anatomical Wounds.

ORDER II. — Liquid Heteromorphic Tumours.
First Species. Purulent — Abscess — Anthrax — Furuncle.

Second Species. Parasitic Tumours — Cysticercus Hydatids with Echinococci —
Hydatids without Echinococci.

In our summary we call disease any disorder of the forces or of the consti-
tuent parts of the body. But, absolutely, there is no health. There is always
disease, with more or less of actual and prospective manifestation. There is
always a disturbance from the too much or the too little, if not from empoi-
sonment or other harmful absorption. There is no more likelihood of abso-
lute health than of an absolute quietude of the winds, or an absolute electrical
equilibrium. So long as there is variableness of temperature, so long will
there be disturbances of the media, and so long disturbance of the functions
of organisms. As long as the sun shines will continents upheave, and blaste-
mata degenerate. When will the media be at rest? Not till then will the
forces and the elements within the body of man be at rest.

So long as the sun chimes in with the music of his brother spheres, and
the pomp of the earth revolves, and the " brightness of paradise alternates
with deep-fearful night" — and the "sea foams up in broad waves," and
storms roar — so long shall the body of man be sick, and his mind unstable ;
so long shall there be sins for repentance and sorrow for consolings. As long
as aggregate cytoblasts shall be prone to disturbances, so long shall masses of
men be liable to revolutions and conflicts. So long as there shall be social
sins and degradations, so long shall there be maladies of individual or-
ganisms.

Thus " all revolves into the whole, and through the All, ring harmoniously
all the heavenly influences." C F. H.

HP

HH I— I

J O

Art. XV. — Human Histology, in its Relations to Descriptive Anatomy,
Physiology, and Pathology. With 434 Illustrations on Wood. By E.
K. Peaslee, A. M., M. J)., Prof, of Physiology and Pathology in the
New York Medical College, of Anatomy in Dartmouth College, and of
Surgery in the Medical School of Maine, &c. &c. Philadelphia : Blanch-
ard & Lea, 1857. 8vo. pp. 618.

The plan of Prof. Peaslee' s book is to combine in a single volume a de-
scription of the ultimate chemical elements entering into the composition
of the human body, that of the proximate principles, of the anatomical or
structural elements, and of the tissues proper, together with some account
of their healthy functions, and the morbid alterations to which they are
subject in disease. The first part is accordingly devoted to the consideration
of the chemical elements and the proximate principles ; and the second part
to the more purely anatomical description of the minute forms and structures
demonstrable by the microscope.

No. LXIX.— Jan. 1858. 12

17-1

Reviews.

[Jan.

The consideration of the ultimate chemical elements of the animal frame,
naturally requires but a very limited space. It amounts, properly, to little,
more than an introduction to the main subjects of the work. For a know-
ledge of the ultimate elements into which the animal solids and fluids can
be decomposed by chemical operations, though essential as a basis to the
commencement of anatomical and physiological studies, really carries us on-
ward but a very short distance in their prosecution. The cases are quite rare,
in the present state of our scientific attainments, in which any important
anatomical or physiological question can be decided by investigations in that
direction.

We may indeed determine, as Boussingault has done, by comparing the
total quantity of nitrogen taken in with the food with that discharged in the
excretions, whether this substance be habitually absorbed or eliminated in
the process of respiration; and in some instances the presence or absence of
the same element becomes an important distinctive characteristic of various
animal substances. But the business of the anatomist and physiologist is,
after all, mostly with the proximate principles, and not with the ultimate
elements of which they are composed. The characters of the former are,
to a great extent, peculiar, and their transformations in the living body
readily subject to observation. The latter are not at all distinctive of or-
ganized bodies, and the changes which they undergo in the animal economy
are, for the most part, too obscure to be followed by the contrivances of the
experimenter.

In describing the proximate principles, the author has adopted the plan of
Robin and Yerdeil, first brought forward in their admirable work on Physio-
logical and Anatomical Chemistry, published at Paris in 1853, and which was
reviewed in our number for July last {see p. 158, et seg.) It is very grati-
fying to see that the views advanced in this work, so full of originality, and
at the same time so extremely useful in their application, have met with a
generally prompt and cordial reception on this side the Atlantic. The true
nature and relations of the proximate principles, and the manner in which
they should be studied, were indeed never fairly understood before the ap-
pearance of Robin and Verdeil's book. They treated the subject from an
entirely novel point of view, but one which seems only to have required a
fair and distinct announcement to be almost universally acknowledged as
correct. A proximate principle, according to this view of the matter, is a
substance which may be extracted from an animal solid or fluid by means
which do not destroy or alter its chemical nature and properties. Proximate
principles may, in fact, be said to exist in all homogeneous solids and fluids
of mixed composition, and may be extracted from them by the same means
as in the case of the animal tissues and secretions. Thus, in a watery solu-
tion of sugar, we have two proximate principles; 1st, the water, and 2d,
the sugar. The water may be separated by evaporation and condensation,
after which the sugar remains behind in a crystalline form. These two
substances have therefore been simply separated from each other. They
have not been decomposed, nor their chemical properties altered. On the
other hand, the oxygen and hydrogen of the water were not proximate prin-
ciples of the original solution ; for they did not exist in it under their own
forms, but only in a state of combination, and in the form of water — a fluid
whose physical and chemical properties are entirely different from theirs. If
we wish to ascertain, accordingly, the nature and properties of a saccharine
solution, it will afford us but little satisfaction to subject such a solution to
an elementary analysis ; for its nature and properties depend not so much

1858.]

Peaslee, Human Histology.

175

on the presence of the ultimate elements — oxygen, hydrogen, and carbon —
as on the particular forms of combination (water and sugar) under which
they exist.

These considerations, which are so plain in regard to a simple fluid like a
watery solution of sugar, become still more important when applied to mix-
tures of a complicated character, such as the- animal tissues and fluids. In
examining these substances, their ingredients must be, as above, simply
separated from each other, not decomposed. The analysis of an animal solid
or fluid is therefore properly an anatomical operation, and not a chemical
one, and must be conducted from an anatomical point of view, so as to pro-
duce results useful to the anatomist and physiologist. So fully was Robin
impressed with this idea, that he at first wished to adopt for his book the
title, Fundamental Anatomy and Physiology, instead of Anatomical and
Physiological Chemistry. Though the former would have been altogether the
more correct title, in a scientific point of view, he adopted the second, " in
order/' as he expressed it, " not to break away too suddenly from the esta-
blished association of ideas, and thereby run the risk of not being fully
understood."

Since the investigation of the proximate principles, therefore, is really to
be regarded as an anatomical and not as a chemical pursuit, it very properly
precedes the study of microscopic anatomy, which is to carry us one step
farther in the examination of the complicated structure of the animal frame.
Robin's Chimie Anatomique was, in fact, designed by him as the introduc-
tion to a work on Minute or General Anatomy, which has yet to make its
appearance.

Dr. Peaslee has united the two subjects, as we have mentioned above, in
a single volume, but has retained the order of precedence, treating first of
the proximate principles, and afterward of the minute anatomical forms of
which the tissues are composed.

The water, for example, which enters, as a proximate principle, into the
composition of different parts of the animal frame, is to be extracted and
examined as in the case of the simple saccharine solution above mentioned.
All the animal solids and fluids, without exception, are thus found to contain
a certain proportion of water, which may be separated by the process of eva-
poration. The water, furthermore, which is obtained in this way, from the
solids as well as from the fluids, is not simply entangled in the interstices of
the former, but actually united everywhere with their substance. The pecu-
liarity of the condition, therefore, under which the water exists in the tis-
sues, becomes evident; for in those which are firmest in consistency, such as
the bones and teeth, the water which they contain is actually in a solid form,
not crystallized, as in the case of ice, or of saline substance which contain
water of crystallization, but amorphous and solid, simply by the fact of its
intimate union with the animal and saline ingredients of the tissue. The
water is therefore, in these cases, solidified by the matter with which it is in
union, as, under other conditions, solid substances may themselves become
fluid when* dissolved in water.

Different proximate principles being always mingled together, in this way,
in the animal fluids, form their simplest or fundamental anatomical consti-
tuents, and hence the propriety of the title, Fundamental Anatomy, pro-
posed by Robin for the study of this subject. Every tissue, furthermore,
and even every anatomical form, no matter how minute, consists of a mix-
ture of at least two, and generally many more, proximate principles inti-
mately united with each other. Every muscular fibre, and even each fila-

176

Reviews,

[Jan.

ment of white fibrous tissue, not more than 2 oio otn °f an ^ncn m thickness,
if isolated and examined, would be found to contain, on the one hand, water,
and, on the other, a peculiar animal matter in union with it. Several sa-
line substances are also always present, in varying quantity. Each red glo-
bule of the blood, not more than g^^th of an inch in diameter, yields to a
properly conducted anatomical analysis : 1st, water ; 2d, two different animal
substances (globuline and hsematine) ; 3d, fats, in a free or saponified con-
dition ; and 4th, no less than eight different saline substances. It will readily
be seen, therefore, that in a strictly scientific arrangement, the study of the
proximate principles holds the first place, and that of the fluids, the micro-
scopic elements, and the tissues, the second and the third. Practically, of
course, it is different. Before analyzing any particular portion of the frame,
we must become familiar with its figure and dimensions, so as to isolate it
from the surrounding parts ; but once having done so, the subsequent arrange-
ment of our anatomical studies must be in the order which we have indicated
above.

In the first division of the part devoted to microscopic anatomy proper, the
author treats first of the simple histological elements, and afterward of the
tissues. The simple histological elements are divided into —

1st. Homogeneous substance.
2d. Simple membrane.
3d. Simple fibre.
4th. Cells.

The first of these, or homogeneous substance, is an important anatomical
element, owing to its wide distribution, and the large quantity of it which
exists in the body. There is hardly a tissue or an organ which does not
contain more or less of it. It is this which occupies the space between the
cells of cartilage and between the filaments forming the bundles of areolar
tissue. It unites the scattered cells and fibres which are imbedded in it into
a continuous and more or less resisting mass. It is a substance which can-
not be directly observed under the microscope, owing to its amorphous con-
dition, and the uniformity of its appearance. Its presence is only indicated
by observing that the cells and granules, or the fibres and fat globules seen
under the instruments, are not floating loosely about the field, but are re-
tained in their position by the intervening material. It is only in some in-
stances where it is more or less granular in texture, as in the case of some
kinds of cartilage, that it can be directly seen. Here, however, the above
name ceases to be entirely applicable, as it is no longer a strictly homogene-
ous substance.

Notwithstanding the importance of this material, as an anatomical ingre-
dient of the tissues, but very little can be said of it since it exhibits no
definite characteristics under the microscope ; its optical properties being,
in fact, altogether negative in character. Very widely different substances,
so far as regards their proximate constitution and their physiological proper-
ties, will present precisely the same appearance under the microscope, pro-
vided they be completely homogeneous. Even the plasma of the blood, when
examined by the microscope, differs from the hyaline substance of cartilage
only by its fluidity. The term homogeneous substance, therefore, is a gene-
ral, not a specific term. It does not belong to any particular anatomical
element, but only indicates a certain combination of optical properties which
may be shared by several indifferently.

Simple membrane is a special form under which the above-named homo-

1858.]

Peaslee, Human Histology.

177

geneous substance shows itself. It occurs, according to the author, in the
walls of cells, in the sarcolemma of muscle, and the tubular covering of
nerve fibres. In it are often imbedded nuclei, as, for example, in the case
of the capillary bloodvessels, &c. Very nearly the same remarks may be
made as to the varying characters of this membrane in different tissues and
organs, as we have already given above in regard to the homogeneous sub-
stance. It is, in fact, not identical in the different situations in which we
meet with it, but is really to be regarded as often composed of different sub-
stances, presenting themselves under the same apparent form.

Simple fibre is also spoken of as one of the elementary forms of the ani-
mal tissues. The term " simple fibre" would be generally understood to
include all fibres of homogeneous structure, such as those of white fibrous
tissue, or of elastic tissue, as distinguished from the compound fibres of
nerve, or of voluntary muscle. The author, however, restricts this term to
the interlacing fibres of the membrane of the egg-shell, and those of coagu-
lated fibrin, when it exhibits the peculiar condition known as " fibrillation."
Understood in this sense, the simple fibre is hardly to be regarded as an or-
ganized anatomical element, since it is simply the effect of coagulation tak-
ing place in the fluid fibrin, and does not form an integral part of any of
the permanent tissues. The fibrillation of fibrin, indeed, is regarded by
many, and, we think, justly, as not, in any degree, a form or process of or-
ganization, but one merely of solidification — the coagulated fibrin being inert
and useless for all purposes of nutrition or textural development; as much so
as coagulated albumen or coagulated casein would be, under similar circum-
stances. Whenever new formations of a permanent character, therefore,
show themselves subsequently to the deposit of a fibrinous exudation (such
as vascular and fibrous pleuritic or peritoneal adhesions), it is not the coagu-
lated fibrin which is supposed to be directly converted into these new tissues.
The fibrin is thought to be reabsorbed after its exudation, as extravasated
blood or serum would be, and as happens also, in some instances, with pus ;
while the new tissues are produced by a slow process of nutrition and growth,
the materials for which are exuded gradually in a liquid form by the neigh-
bouring parts, as the process of formation goes on. This is the view enter-
tained by Robin, and one which has many points of evidence in its favour.

In the chapter on Cells, the author passes in review the anatomical cha-
racter of the nucleus, nucleolus, and other parts of the cell structure. He
regards the ovum, also, as a cell; with the germinative vesicle as a nucleus,
and the germinative spot as a nucleolus. The adipose vesicle is, besides, in-
cluded in the same category. Both these forms are considered by some
microscopists as distinct from true animal cells, not only by their very much
larger size, but also by the details of their anatomical organization. The
peculiarities of pigment cells, in different parts of the body, are described
in the same chapter, and finally those of cancer cells, cancer nuclei, &c. In
regard to the latter the author adopts the views of Lebert, which have been
received with such general favour by microscopists in this^ country as well as
in France.

In the second division we have " Hydrology/' or the description of the
fluids of the human body, as follows : 1st, the blood ; 2d, serous secretions
and exudations ; 3d, mucous and glandular secretions ; and 4th, the cuta-
neous secretions. In treating of mucus the author describes certain micro-
scopic elements, the " mucous corpuscles," which he regards as a regular
product of development from the albuminoid ingredients of the fluid. These
corpuscles, which present very different appearances in different kinds of

178

Reviews.

[Jan.

mucus, are considered by some authors as characteristic of mucus, in the
same manner as pus-globules are characteristic of pus. Many directions
have accordingly been given, from time to time, for the purpose of enabling
the observer to distinguish microscopically mucus from pus ; but the charac-
ters relied on for this purpose were so indefinite that they have been found
of but little practical utility. Many of the bodies described as mucus-
corpuscles are undoubtedly pus-globules, accidentally present in the secre-
tion; for nearly all mucous membranes produce pus, in greater or les abund-
ance, on very slight irritation. Others are, as plainly, abnormal or imperfect
epithelium cells, separated accidentally from the free surface of the mem-
brane, and mingled with its fluid secretion. These facts have led some
microscopists, of very high authority, to express the opinion that there is no
such thing as a " mucous corpuscle," properly speaking; that is, that there
is no constant and peculiar microscopic element characteristic of mucus, as
the pus-globule and the blood-globule are of their respective fluids. Mucus,
as they understand the term, is simply a mixture of watery, saline, and
albuminoid ingredients, presenting no anatomical form to the eye on micro-
scopic examination, any more than the serum of the blood, the synovial
fluid or the pancreatic juice : but having a perfectly colourless and transpa-
rent appearance, and a more or less viscid consistency. "We confess that
this view seems to us altogether the most correct one ; since when mucus is
collected from situations where no foreign admixture has been possible, as
where it has been taken, for example, directly from the cavity of the follicles
of the cervix uteri, it is actually perfectly clear and transparent to the naked
eye, and does not show any anatomical forms on microscopic examination.
Mucous secretions become opaline and discoloured, just in proportion as they
are mingled with other fluids of a different consistency, or with puriform
and epithelial elements. Practically, however, we seldom observe them in
a condition of complete purity, unless we take the trouble, as above men-
tioned, to obtain them directly from the situations in which they are pro-
duced.

Beside the microscopic elements of the animal fluids, the author speaks
of their physical properties and their chemical constitution. A very
important fact concerning these fluids, and one which could not have been
anticipated beforehand, is the remarkable quantity in which some of them
are secreted. The experiments of Bidder and Schmidt on the gastric juice
in dogs, for example, led to the conclusion that the quantity of this fluid
secreted in twenty-four hours was not less than y^th the weight of the whole
body ; and though the same estimate applied to the human subject would
give 12 to 18 pounds of gastric juice per day, these numbers are probably
rather below than above the real quantity ; for all the fluids are, generally
speaking, more abundant in the human subject than in the lower animals.
The difficulty which is generally felt in accepting so high an estimate of the
daily quantity of these secretions as the true one, is, however, rather appa-
rent than real; and it is possible that even a much larger quantity may be
discharged daily by the glandular apparatus of the mucous membranes,
without producing any ill effect on the system at large.

The author, for example, rejects some of these high estimates for a reason
which we cannot but regard as altogether erroneous.

"Experiments," he says (p. 199), "lead to the conclusion that dogs secrete
in twenty-four hours an amount of gastric fluid equal to one-tenth their weight.
This would give a range between 12 and 18 pounds for a man. Lehmann
states, however, that ■ according to several direct observations on a woman, as

1858.]

Peaslee, Human Histology.

179

much as one-fourth of the weight of the body has been found to be secreted as
gastric fluid ;! ! ! Of course this is all secreted directly from the blood, and
the latter is estimated by Lehmann to constitute but one-eighth of the weight
of the body. ]STo further remark appears necessary upon his estimate of the
gastric fluid."

It is in reality, however, not at all impossible that a quantity of gastric
juice equal to 25 per cent, of the entire weight of the body should be secreted
from the blood, which equals only 12$ per cent, of" the same weight. For
the gastric juice is not separated at once from the circulating fluid, and dis-
charged from the body. It is secreted gradually ; and almost immediately
afterward begins to be reabsorbed, together with the elements of the food
which it has digested and dissolved. Its secretion and reabsorption after-
wards go on simultaneously; and the fluids which the blood loses by one
process are immediately restored to it by the other. Examinations of the
alimentary canal, while digestion is going on, show that there is comparatively
but little fluid present in its cavity at any particular moment during this
process; but, at the same time, the successive portions of gastric juice which
enter the alimentary canal by exhalation, and then leave it by reabsorption,
would amount, if taken together, to a quantity equal or superior to the entire
mass of the blood. It is unnecessary to say, moreover, that in the experi-
ments referred to by Lehmann, the entire quantity of gastric juice (7 pounds
in the dog, 31 pounds in the human subject) was never actually withdrawn
from the gastric fistula during any one day; but small quantities were taken
at different intervals, and even in some instances on different days, at various
periods after feeding; and the whole quantity estimated from these data.
This estimate, furthermore, is fully borne out by the result of calculations as
to the amount of food which a given quantity of gastric juice is capable of
digesting.

The third division comprises the description of the tissues. The classifica-
tion of the tissues which is adopted is into simple and compound ; the simple
comprising epithelium, yellow, and white fibrous tissues, and osseous tissue,
including that of the teeth; the compound comprising areolar and adipose
tissues, cartilages, muscle, nerve, membranes, vessels, alimentary canal, and
the various glandular, respiratory, and sexual apparatuses, together with the
organs of which they are composed. The simple tissues are defined to be
those in which there is but one kind of simple histological element, while
in the compound tissues there are two, three, or more of these elements
mingled together. It will be seen that the author ranges osseous tissue,
which would usually be regarded as compound, under . the head of the simple
tissues; considering it as constituted, not by lacunae and canaliculi, and the
soft substances which fill them, imbedded in a solid matrix — but by the solid
matrix alone, this consisting, in its turn, only of the ultimate granules or
minute angular corpuscles, welded together into laminge, which have been
described by Bowman and others.

^Ve doubt, however, whether this granular aspect of the bony substance
should not be regarded in the same light as that of" cartilage, or as the
granular texture of the substance of lymph and pus-globules, or of organic
muscular fibres. The ultimate granules themselves, as they exist in the
bony substance, are exceedingly minute. Their size is given (page 321) on
the authority of Kolliker, as of an inch. This is undoubtedly a mis-
print for solo oj which is really Kolliker' s measurement (.0002 of a line).
Todd and Bowman give the size of these granules as <joVo *° ttsoo of an
inch, and Tomes about tfooo to johov of an inch. The larger of these

180

Reviews.

[Jan.

measurements, however, are derived from the examination of bone which
has been burnt and crushed, or boiled in a Papin's digester j while those of
Kolliker are taken from the direct examination of the osseous substance in
its natural condition, and are, on that account, probably the most accurate.

In his description of the minute anatomy of the liver, the author has
introduced the recent and extremely important discoveries by Dr. Beale,
viz., the arrangement of the network of cell-containing tubes within the
substance of the acinus, and their connection with the interlobular hepatic
ducts ; as well as the dilatations or glandular sacculi, seated in the coats of
the biliary ducts in some of the lower animals.

The whole volume is plentifully illustrated with wood-cuts from the stand-
ard works of Lehmann, Bennett, Todd and Bowman, and the classical
Microscopic Anatomy of Kolliker, and, altogether, gives a very full and
complete account of the histology of the human body, so far as it is known
at the present time. J. G. D.

Art. XVI. — The Principles and Practice of Obstetrics: Including the Treat-
ment of Chronic Inflammation of the Uterus, considered as a Frequent
Cause of Abortion. By Henry Miller, M. D., Professor of Obstetric
Medicine in the Medical Department of the University of Louisville. With
Illustrations on Wood. 8vo. pp. 620. Philadelphia: Blanchard & Lea,
1858.

On the appearance of the original edition of Dr. Miller's obstetrical
treatise, we were among the first to introduce it to public notice, and the
highly favourable judgment of its merits then pronounced by us, has been fully
sustained by the suffrages of the profession generally. In the new edition
now before us, the entire work has been greatly enlarged and improved, so as
to give it a form and a value that cannot fail to place it permanently among
our standard systematic treatises on the theory and practice of obstetrics.

Without, perhaps, precisely the same elaborateness of detail and display
of erudition which distinguish some of these, the work of Dr. Miller, by the
clearness and distinctness with which each question embraced in it is dis-
cussed and elucidated, and the direct practical tendency of all its teachings,
is one especially adapted as well for the use of the student as for consultation
by the practitioner, on the spur of the moment, that he may confirm the cor-
rectness of his own conclusions, or detect their fallacy, by comparing them
with those that have been arrived at from the experience and investigations
of acknowledged experts.

The treatise commences with an account of the physical structure of the
pelvis — its forms, regions, diameters, planes, and axes — and of the anatomy
of the sexual organs of the female, and their physiological functions. To all
these subjects due prominence is given, as constituting some of the most im-
portant points of that preliminary knowledge, an intimate acquaintance with
which is essential to form the successful and safe obstetrician ; and without a
perfect familiarity with which no one should be permitted to undertake the
management of a case of labour.

Dr. Miller adopts the modern view as to the menstrual discharge — that it
is simply blood discharged by the vessels of the lining membrane of the

1858.]

Miller, Principles and Practice of Obstetrics.

181

uterus, but rendered uncoagulable by becoming mixed with the acid mucus
and epithelial cells of the vagina. This view is so fully established by the
investigations of Donne, "Whitehead, and others, that we are surprised the old
notion of the menses being a specific secretion should be insisted on by so in-
telligent a writer as Churchill in the latest edition of his Midwifery.

The description of the pelvis, and of the female organs of generation, with
their functions, is followed by a consideration of the clinical exploration of the
uterus and its annexes; not merely with a view to the settlement of the ques-
tion of the existence or non-existence of pregnancy, but also to determine
whether any deviation or other abnormal condition of the womb or its annexes
is present; extending thus the subject of the physical exploration of the
female generative organs beyond the province of obstetrics, strictly speaking,
into that of uterine pathology generally. How far this may be considered
advisable in a treatise professedly devoted to the science and practice of mid-
wifery may admit of question. As the author, however, has considered it
necessary in a subsequent chapter, to enter at length into a consideration of
the pathology and treatment of inflammation and displacement of the uterus,
it was perhaps necessary that he should lay down, in the chapter before us,
the physical means adapted to their detection and diagnosis.

The subject of pregnancy is next discussed. In the several sections of the
chapter devoted to this important department of female physiology, the reader
will meet with a clear, succinct account of the successive changes that occur
in the uterus itself, and in the ovum deposited in its cavity, from the period
of conception up to the full term of utero-gestation. The several questions
involved in the discussion of the important phases of uterine life are examined
with much ability by the author, and his conclusions in respect to each will
be found to be, in general, borne out by the results of recent observations.

Speaking of the gradual development of the uterine cavity as the ovum aug-
ments in size, and of the supposed antagonism existing between the muscles
of the body and those of the neck of the uterus, in consequence of which the
former, it is taught, tend constantly to expel the ovum, and the latter to resist
its expulsion, until the close of the term of pregnancy, when the power of
the body of the uterus preponderates, and the process of parturition com-
mences and progresses, and the child with the secundines is expelled; speak-
ing of this theory of the forced development of the uterine cavity until finally
the cervix uteri is made to take part in it, which is taught by many distin-
guished obstetrical authorities, Dr. Miller remarks : —

"It is manifest that the theory rests on the assumption that the uterus is
naturally disposed to resist, unguibus et rostro, all intrusions upon its premises,
an assumption so contrary to analogy that it ought not to be admitted without
the clearest proof. But let us examine its pretensions in its twofold applica-
tion, and first as affording an explanation of uterine development. Here it
seeks to expound a phenomenon which is itself gratuitously assumed, namely,
such a development of the cervix as enlarges the capacity of the cavity of the
gravid uterus.

"According to the observations of M. Cazeaux, the neck, especially in women
who have borne children, preserves the whole of its length until the last fifteen
days of pregnancy, or at least until the commencement of the ninth month.
He avers that he has repeatedly verified this fact, which had already been noted
by Professor Stolz, of Strasburg, and publicly taught by Professor Dubois
since 1839."

"In primiparae, the cervix uteri offers some peculiarities, which, as far as
our present subject is concerned, consist in its shortening somewhat, instead
of preserving its usual length, throughout the greater part of pregnancy, as in

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multiparge, and in its internal orifice becoming dilated before the external.
Professor Stolz explains this shortening in the following manner : At the sixth
month, the vaginal portion of the neck begins to shorten, while it widens at its
superior part. The external orifice, continuing closed, approaches the internal,
and consequently the cavity of the neck becomes larger in the middle, until the
two orifices are brought near each other: the internal orifice then opens first, which
happens during the last fifteen days of pregnancy ; the rest of the body disap-
pears much more rapidly than it had done before, and a projection can no
longer be felt; the external orifice remains closed."

" The observations of Professor Stolz are substantially confirmed by M.
Chailly; and the entire account, which he gives of the changes that the neck
undergoes during pregnancy, contradicts the hitherto received opinions of
writers on the subject.

" There is one well-known fact, to which we may allude, that goes far to
establish the accuracy of these reseaches of MM. Stolz, Dubois, Cazeaux, and
Chailly, if it be not of itself sufficient to refute the opinion formerly entertained.
It is this: When the neck of the uterus is so much developed as to allow the
finger to be passed to its upper orifice, which it is by the seventh month in
multiparae, the membranes can be felt, and are organically united to the uterus
around the margin of the orifice. When, again, the neck is entirely obliterated,
as it is at term, the membranes can be felt, and are still attached around the
os uteri. Now, as it is admitted that during the first five or six months, the
ovum is confined to the cavity of the body, and that the neck is not lined with
decidua, were the obliteration of the neck owing to the expansion of its upper
part, either the membranes would be too high to be reached by the finger; or,
if they were sufficiently extensible to be pushed down into the expanding neck
by the growing ovum, they would not be found adhering to its surface. The
latter declaration is authorized by the fact that, in the progress of gestation,
the membranes become less vascular, and their adhesion to the internal surface
of the uterus is gradually weakened. But in either case, at the seventh or
ninth month, the membranes are found to have vascular connection around
the uterine orifice, for when separated by the finger, or by uterine contractions,
as in the latter case they are, so soon as labour commences, there is a slight
effusion of blood. We conclude, therefore, that the neck contributes nothing
to the cavity of the gravid uterus, which is made up entirely of the dilated
cavity of the body." * * *

" The secondary application of the theory to explain the induction of labour
is best met by demanding the proof that the uterus displays, during gestation,
such intolerance of its burden as is attributed to it."

" There is absolutely no evidence of such contractile efforts of the uterus as
this theory assumes, except the occasional tension of the membranes, some-
times observed towards the completion of gestation, the os uteri being then
sufficiently open to admit the finger. Slight contractions of the fundus may
produce this tension, but these are not such as constitute labour, for they are
unaccompanied by pain, and take place without the consciousness of the indi-
vidual herself. Allowing, however, that they are labour-pains in disguise,
their presence at so advanced a period of pregnancy is no proof of their exist-
ence during the earlier periods ; and in the complete absence of such proof, we
are loath to admit the assumption that they do exist, because it makes the uterus
the strangest anomaly in the body, if not in nature. It is destined first to contain
and nourish the foetus, and then to expel it when its maturity is acquired. But,
according to this assumption, the first is an irksome task imposed upon it which
it continually endeavours to quit by expelling its contents. Such a constitu-
tion of the gestative organ could hardly exist, and abortion be not perpetually
threatened, without, as far as we can perceive, any compensating benefit ; for
we cannot imagine that its development could be promoted by it. There is, in
fact, no conceivable way in which contraction of the uterine fibres during preg-
nancy could favour their development, except that imagined by Baudelocque,
viz., one class of fibres stretching another by the superior force of their contrac-
tions by which he attempts to account for the development of the cervix uteri.
How, then, are the fibres of the body of the uterus developed during the first

1858.]

Miller, Principles and Practice of Obstetrics.

183

six or seven months of gestation, the neck being quiescent all the while? If
these need no such force to aid their development, neither do those of the neck ;
both are developed after their own peculiar fashion, without the interference of
one with the other.' The neck, as we have seen, is developed in women who
have borne children, in a manner inconsistent with the idea that any sort of
force is exerted upon it by the body, that is, from below upwards."

"From what has now been declared, it may be inferred that I reject the notion
of Levret, indorsed by Baudelocque, and more recently by Meigs, that the neck
is the antagonist of the body of the uterus, during pregnancy, simply for the
reason that there is not a tittle of evidence that there is anything to be antago-
nized. The body quietly suffers itself to be distended by the product of con-
ception, or rather its growth keeps pace with that of the ovum, whilst the neck
is not at all concerned either in making room for the foetus or barring its es-
cape. But though the neck be not called on to exert a retentive faculty, it
holds, nevertheless, the key, if I may so say, which unlocks the uterine cavity,
by virtue of the relation, of which mention has been made, established between
it and the body by pregnancy, in consequence of which impressions made upon
it, specially upon its internal surface, are reflected upon the body and excite
its muscular fibres to expulsive action. Hence the necessity of keeping the
neck closed to so late a period of pregnancy, while the body is growing and
expanding in every direction. That labour is naturally excited in this way, I
shall endeavour to prove hereafter. The neck is not the active but the passive
custodian of pregnancy ; it simply withholds the key, until the time to unlock
the uterus has arrived."

In respect to the placental connection between the mother and foetus, Dr.
Miller adopts the views of Weber, that a congeries of colossal capillaries inter-
vene, into which the utero-placental arteries open, and from which the utero-
placental veins arise. Against these capillaries, in which the circulation is
extremely sluggish, the villi of the chorion impinge, and dive, so to speak, as
they push their growth outwardly; while in such a process they necessarily
become invested with a covering of the inverted membrane, forming the walls
of the decidual capillaries.

As to the uses of the placenta in reference to the foetus, Dr. Miller re-
marks : —

"First : It is its organ of respiration. The umbilical vessels, already described
as terminating in capillaries upon the dendritic processes of the chorion, belong
exclusively to the vascular system of the foetus. They consist, as we have seen,
of three trunks, two arteries, and one large vein — a branch of the inferior vena
cava — and have no communication whatever by anastomosis with the blood-
vessels of the mother. The arteries convey no inconsiderable portion of the
blood of the foetus to the placenta, which, after circulating freely and minutely
through it, is returned to the foetus, not a drop passing into the vessels of the
mother. While circulating in the placenta, this blood is brought in contact
with the blood of the mother, flowing through the canals of the maternal por-
tion of the placenta, or at least nothing intervenes but the thin walls of these
canals, and the delicate coats of the foetal capillaries. The foetal blood is thus
enabled to abstract oxygen from, and impart its superfluous carbon to, the blood
of the mother ; and although it may be supposed that this vital operation is
not as freely performed as in animals that inhale atmospheric air, it is at least
as advantageous an arrangement as the branchial respiration of such as inhabit
the waters, to which it is, in fact, analogous — fishes getting their oxygen from
water, and the foetus from maternal blood." * * *

" We have abundant proof that the foetal blood is aerated in the placenta, in
the consequences that arise from compression of the cord to such a degree as
to arrest the circulation of the blood in its vessels. Such compression is liable
to happen, during labour, when the cord prolapses before the head of the child,
in vertex presentations, and also while the head is passing through the pelvis,
in nates presentations ; and whenever it does, death is the consequence, while

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both the celerity and manner of death show clearly that it is caused by suffo-
cation. The cord ceases to pulsate, and the foetus, after a short convulsive
struggle, evinces no further indications of life.

" Secondly: The placenta is the organ through which the foetus derives its nour-
ishment from the mother. Of this, it must be confessed, there is no positive
evidence ; but, at the same time, it may be safely affirmed that, in relation to
this point, negative evidence is altogether satisfactory. There is absolutely no
other medium through which the foetus can obtain its supplies of alimentary
matters. The only other possible source is the liquor amnii, the fluid which
surrounds the foetus ; and the doctrine that this is appropriated, either by ab-
sorption or deglutition, has long since been exploded, by facts and arguments
that cannot be answered, which need not be rehearsed in this place. How or
in what form nutriment is received through the placenta is not known ; most
probably there is a set of vessels, in connection with the umbilical capillaries,
which open into the maternal portion of the placenta, and, abstracting from
thence the needful supplies, convey them at once into these capillaries, to be
incorporated with the foetal blood. Whether these hypothetical vessels take
up blood, or only certain of its elements, we do not know ; nor, as far as I can
see, is it a matter of the least practical moment that we should know. Nature
here, as elsewhere, is chary of her revelations that might gratify the curiosity,
without adding to the resources of her votaries/'

In treating of the position of the foetus in utero, and the cause of the great
preponderance of vertex presentations, Dr. Miller enters into a somewhat ex-
tended exposition of the facts which disprove the generally received mechanical
explanation, that it is due to the weight of the head, compared with that of
the rest of the body, at all stages of foetal development. He adopts the views
of M. Dubois, that the cause of the greater frequency of head presentations
is in some manner dependent upon the vitality of the foetus, and that the
position is probably assumed and maintained by the voluntary or instinctive
movements of the latter. In which views Dr. Simpson also coincides, except-
ing that he contends the movements on the part of the foetus, in consequence
of which its head is made to be the most dependent part, in utero, are purely
of a reflex or excito-motory character.

All this, however, is but mere hypothesis. The most usual intra-uterine
attitude of the child, with its limbs flexed and folded upon its body and its
head dependent, shapes it, if we may be allowed the expression, into a form
exactly adapted to that of the uterine cavity, while it is the one most favour-
able to the mechanism of labour. We may, therefore, safely conclude that it
is the one impressed upon the foetus by the same vital laws which govern
everything that relates to intra-uterine gestation. The exact forces by which
it is effected are beyond our ken, as well as those which occasion the frequent
deviations from what may not improperly be assumed as the normal foetal
position and attitude.

The subject of abortion very naturally follows that of pregnancy. Dr. Mil-
ler denies the position of Dr. Meigs, that the hemorrhage which is the invaria-
ble concomitant of abortion proceeds from the placental surperficies of the
womb, and always implies a detachment of the placenta to a greater or less
extent. He maintains, and we think with great show of reason, that it is
derived chiefly from the decidual vessels, probably, from both layers of the
decidua, and that it may proceed from any point of the ovum or the inner sur-
face of the uterus. He believes that in abortion the hemorrhage is often
pathological rather than traumatic in its nature, the result of decidual hype-
remia— an exudation from the distended and overloaded bloodvessels of the
decidua, without rupture.

" This may be inferred," he remarks, " from the fact that a sense of fulness

1858.] Miller, Principles and Practice of Obstetrics.

185

and weight is not unfrequently complained of previous to the eruption of blood,
and also the further fact that the hemorrhage may precede the uterine contrac-
tions, and is always coeval with them, even in their incipiency, when they are
too few and feeble to disturb the relations of the ovum to the internal surface
of the uterus."

As to the causes of abortion, Dr. Miller, after enumerating the usual acci-
dental causes, febrile diseases, drastic purgatives, and diseases of the ovum re-
sulting in the death of the foetus, concludes that, whatever influence these
may have in bringing on abortion in the case of a perfectly healthy uterus,
the most prolific cause of the expulsion of the ovum in the early months of
pregnancy is a diseased condition of the uterus itself, particularly inflamma-
tion of the uterine mucous membrane, either of the cervix or body.

" Inflammation of the mucous membrane of the body of the uterus may, doubt-
less, directly excite contractions which shall expel the ovum, just as inflamma-
tion of the intestinal mucous membrane may directly excite increased peristaltic
movements which shall expel the feces ; but when the inflammation is limited
to the cervix uteri (and this is most frequently the case), it acts as an abortive
through the medium of the relation existing between the neck and body of the
organ, alluded to in a previous chapter, by virtue of which impressions made
upon the cervical nerves are reflected, through the spinal cord, upon the mus-
cular fibres of the body and fundus, exciting them to contraction."

But, according to Dr. Miller, it is endo-uteritis more than inflammation
of the cervix which exercises a morbid reaction on the ovum. When the
mucous lining of the body of the uterus is involved in disease.

" It may be either altogether incapacitated to undergo transformation into the
deciduous membrane or an imperfect metamorphosis of it may be the conse-
quence. In the first case, abortion, and that speedily, must ensue, for the ovum
cannot effect an attachment to the uterus, and may be degraded into a mole or
a mass of hydatids ; in the second, the disease may be communicated to the
placenta and through it to the foetus, deranging its nutrition and variously af-
fecting its growth, so as to produce, perhaps, even monstrosities."

The series of facts and arguments adduced by Dr. Miller strongly impress
his views as to the dependence of abortion, in a large number of cases at least,
on inflammation of the lining membrane of the uterus, upon our attention.
These views are consistent with a host of facts and observations that could
easily be adduced. That they do not explain all cases of abortion not directly
attributable to some accidental cause, or to diseased conditions of the system in
which the uterus is only indirectly implicated, is very certain. There are cases
of abortion which cannot be traceable to accidental shocks and injuries, to
violence, constitutional disease, or any appreciable lesion of the uterus, either
of its body or neck, and which would seem to depend upon some condition of
the womb by which it is rendered intolerant of the presence of the ovum when-
ever the latter has arrived at a certain degree of development. At the same
period, or very nearly so, of each succeeding pregnancy, we have known the
ovum to be expelled, in patients in whom not a trace of uterine disease could
be detected upon the most careful, thorough, and repeated examination, and
who had never suffered from the slightest symptom of leucorrhoea. Whether
we refer such intolerance of the uterus to abnormal irritability of the womb,
or some other occult condition of the organ, it is very evidently unconnected
with inflammation of the lining membrane of its body or cervix.

Dr. Miller presents a very good account of the resistive and palliative treat-
ment of abortion, and under the head of its prophylactic treatment enters at
length into the general subject of the treatment of uterine disease — of cervical
inflammation, or ulceration, endo-uteritis, and uterine displacements. The

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therapeutic directions for the treatment of cervical and uterine inflammation
and ulceration, in which are discussed the propriety of local depletion from
the affected part, cauterization of the os uteri, intra-vaginal injections, etc.,
with the circumstances under which each is to be employed, the proper me-
thod of employing it, and the precautions necessary to its successful manage-
ment, are all marked by good sense, but differ in no important particular from
those ordinarily pursued by skilful practitioners. They are deserving, how-
ever, of a careful perusal on the part of all who are called upon daily to pre-
scribe for the diseases peculiar to the female sex.

On the subject of displacements of the uterus, Dr. Miller takes the mid-
dle ground between those who consider them as invariably the result of inflam-
mation, and those, on the other hand, who refer them to other causes, but
consider them, when produced, to be productive of inflammation; he believes
that they are sometimes a sequence of inflammation and sometimes its cause.

In relation to Dr. Simpson's pessary for the rectifying of anteversion, re-
troversion and flexion of the uterus, Dr. Miller holds the following decided, but
in our estimation, very correct language.

" This kind of mechanical contrivance for holding the uterus in its proper
situation appears to me to be the most unphysiological of all others that have
been proposed. The uterus, in its natural state, possesses great mobility,
amounting almost to locomotion, by which it is enabled to accommodate itself
to the various disturbing influences by which it is surrounded. Pressed upon
by the contractions of the diaphragm and abdominal muscles, during great
muscular exertions, it descends towards the vulva ; pushed up during coitus,
its fundus is tilted forwards and its cervix backwards, whilst considerable dis-
tension of the urinary bladder necessarily retroverts it ; in a word, it readily
adapts itself to its circumstances, whatever they may be. Now, to rigidly fix
such an organ upon a metallic axis, and leave it no possibility of escape from
the thousand impulsions which it daily receives, is to place it in a more unna-
tural predicament than any malposition can possibly be. The intra-uterine
pessary is, however, not more unphysiological than unpathological. Rarely is
inflammation altogether absent in these displacements, and sometimes it is very
intense; to irritate the uterus, in such a state, by thrusting a foreign body into
it to compel it to keep its place is a species of surgery which would not be tole-
rated in the outward parts. That some of Prof. Simpson's patients should not
have been able to bear his pessary is not surprising ; the wonder is that any of
them could bear it, whilst it is a miracle that many of them got well."

" After all, the intra-uterine pessary fulfils its indication — albeit it performs
its duty somewhat too sternly — that is, it keeps the uterus in the place allotted
it by obstetric authority, with its metallic axis coincident with the axis of the
pelvic brim. And this is more than I am warranted to say in favour of any
other pessary that has been recommended for retroversio uteri, not even except-
ing Prof. Meigs' elastic annular pessary, so much lauded by him."

" If it should be inferred from the foregoing remarks that I have but a poor
opinion of pessaries, the inference would be logical and just, for though I have
tried all kinds of pessaries, not excepting Dr. Simpson's, I have derived but
little benefit from them, whilst they have been a fruitful source of vexation to
myself and of annoyance to my patients. As, however, I have admitted the
validity of the indication to restore the uterus to its natural position, it maybe
reasonably demanded, if pessaries are unavailing or mischievous, how is the
indication to be accomplished ? After I had discarded pessaries in the treat-
ment of endo-uteritis complicated with retroversion, I was led to conjoin re-
peated replacement of the uterus by the sound and cauterization of its cavity,
whilst the organ is in situ, and by this method of treatment, which I may ven-
ture to call my own, have obtained more satisfactory results than by all other
methods which I had previously tried."

The subject next treated of is the flooding of advanced pregnancy and in-

1858.]

Miller, Principles and Practice of Obstetrics.

187

cipient parturition. This accident forming, as it were, " a fit connecting link
between the study of pregnancy and parturition."

These floodings are invariably the result of a detachment, to a greater or
less extent, of the placenta from the inner surface of the uterus ; the pla-
centa in a large proportion of cases being abnormally situated at the mouth,
as it is commonly expressed, of the womb. This circumstance leads of course
to a consideration of the subject of placenta prsevia, it being one immedi-
ately connected with the pathology of the floodings that are liable to occur
during the latter months, or at the close of pregnancy. It is true that, ac-
cording to our experience, accidental hemorrhage, that is, hemorrhage resulting
from a partial or entire separation of the placenta, its position being normal,
is of much more frequent occurrence than that dependent upon placenta
praevia, nevertheless the consideration of the latter in the present connection
is, we consider, most appropriate.

To acquire a correct notion of the nature of placental presentations, it is
necessary to recollect that, " during the first six months of pregnancy, the cer-
vix uteri preserves its cylindrical figure and keeps both its orifices, but espe-
cially the superior, tightly closed ; it is plain, therefore, that the placenta is
implanted originally over the cervix, but attached, nevertheless, to the parietes
of the inferior part of the body of the uterus. It is with the body, and the
body only, that it forms an organic union by the reciprocal passage of blood-
vessels between them." It is not, and in the nature of the case, never can
be implanted upon the internal surface of the neck of the womb. This fact
Dr. Miller has rendered perfectly clear by a course of reasoning which ap-
pears to us to be irrefutable.

The mechanism of the hemorrhage which necessarily takes place in cases
of placenta praevia is explained by Dr. M. from the development of the ute-
rine parietes occurring more rapidly than the placenta can follow, causing,
therefore, a separation of the maternal from the foetal tissue, with rupture of
the connecting vessels.

From various considerations, but more especially from the analogy of ute-
rine hemorrhage often occurring under other circumstances of parturition,
particularly post partem, where the placenta is wholly separated and expelled,
Dr. Miller concludes that the great source of the hemorrhage, in cases of
placenta praevia, and in other cases of partial and entire detachment of the
placenta in the latter months of pregnancy, is the placental surface of the
uterus itself.

Besides the unavoidable cause of hemorrhage in cases of placenta praevia,
other causes that may operate to excite hemorrhage during advanced preg-
nancy are referred to by the author ; the most frequent of these is perhaps

" Mechanical violence of any kind, such as falls, blows, &c, sufficiently vio-
lent to produce detachment of the placenta from its normal connections. Pro-
bably, also, an excited state of the circulation, especially in plethoric habits,
may suffice, in some instances, to bring about the same disastrous result. Irri-
tation of the intestinal canal, whether induced by disease or the operation of
drastic purgatives, exciting tenesmus and violent straining efforts, may also
be reckoned among the causes of uterine hemorrhage."

We have given merely a bare outline of the leading views of Dr. Miller on
this important subject of flooding — accidental and unavoidable — occurring in
the pregnant female ; for a full exposition of those views, which certainly de-
mand a candid examination, and of the considerations upon which they are
based, we refer to the work itself. The chapter devoted to the consideration
of the subject of flooding, will amply repay the time devoted to its attentive
study.

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A very full and instructive account is given of the symptoms, diagnosis,
course, and termination of flooding. In respect to treatment : in cases of
accidental hemorrhage, Dr. Miller advocates the plan pursued by Puzos,
a description of which, as it would appear not to be generally understood, we
here present in the translation furnished us by our author.

" The means of remedying this slowness of natural delivery, is to borrow
something from forced delivery, which, I am satisfied from experience, is en-
tirely practicable — namely, to increase the dilatation of the os uteri with the
fingers, in the same gentle manner in which nature is wont to proceed. It is
seldom that the loss of blood, produced by the detachment of the placenta,
does not occasion more or less dilatation of the uterine orifice, the coagula
about it acting as so many wedges, that distend it and dispose it to yield. This
incipient dilatation has a tendency to bring on labour, and is sometimes accom-
panied by slight pains. But, inasmuch as the exhaustion and faintness arising
from the loss of blood are opposed to the continuance of the uterine contrac-
tions, we must renew these when wanting, and increase them when too feeble.
With this view, one or two fingers must be introduced within the os uteri,
which is to be gradually opened by the employment of force proportioned to its
resistance. These dilating efforts should be suspended from time to time, to
allow intervals of rest. By this means, the uterus is roused to action, labor
pains come on, and the membranes are rendered tense. The next object is to
rupture the membranes without delay, to give escape to the liquor amnii, and
bring about a diminution in the size of the uterus equal to the space the waters
had occupied. The condensation of the uterus, that succeeds the discharge of
the liquor amnii, presses the foetus upon the os uteri, when stronger pains
ensue, which, aided by the pressure of the fingers around the margins of the
orifice, succeed in advancing the child. Meanwhile, the blood that would other-
wise have escaped, is retained in the vessels by the contraction of the uterine
fibres, and the compression to which they are subjected. By this co-operation
of nature and art, the delivery is greatly expedited, and we may enjoy the
satisfaction of saving both mother and child, who must have been lost if left
to nature alone, and might have been destroyed by artificial delivery."

In cases of unavoidable flooding, from partial presentation of the placenta,
experience, Dr. Miller assures us, has equally declared in favour of the effi-
cacy of Puzos' plan of management. Where the placenta is implanted cen-
trally over the mouth of the womb, some modification of the plan is, however,
demanded. In these cases Dr. M. is opposed to the artificial separation of
the placenta from its attachments, as proposed by Simpson and strongly ad-
vocated by others. He enters into a long chain of reasoning to show that
whether considered in a scientific point of view, or tested by the results of the
practice, so far as these have been made known, it does not present such strong
claims as to warrant its being generally pursued. He is equally adverse in
vertex presentations, in view of the unfavourable results that are so frequently
observed in the cases in which it has been practised, to a resort to turning
and delivery by the feet. The plan he ventures to propose is a modification
of that of Puzos. This consists in " originating expulsive contraction of the
uterus by the tampon or plug, and then puncturing the membranes, relying
on the tampon to control the flooding until the liquor amnii is evacuated."

" This," he remarks, " is the only method of treatment of which I have any
experience, and I have employed it with uniform success, so far as the mother
is concerned. This is strong testimony, but it must be mollified by the con-
fession that my experience, in placenta praevia cases, has not been large; yet
I have encountered them sufficiently often to have acquired some acquaintance-
ship.

" To expound this method of treatment and at the same time vindicate it,
it must be observed that the tampon is preferable to manual dilatation, as an
oxytocic, in placental presentations, because forced dilation could not be prac-

1858.]

Miller, Principles and Practice of Obstetrics.

189

tised without necessarily still further detaching the placenta, giving rise to
additional hemorrhage, all the more profuse on account of the non-parturient
state of the uterus. Then, again, such manipulations would be objectionable
because of the greatly more vascular and sensitive condition of the portion of
the uterus contiguous to the os, which has been already mentioned as a reason
why delivery by turning ought to be refrained from.

" In arousing the uterus to expulsive contraction, the tampon acts, I sup-
pose, through the channel that has been more than once indicated in the pre-
vious pages of this work, viz : irritation of the incident nerves of the cervix,
leading to reflex action of the fibres of the fundus and body. Explain as we
will, however, the fact is generally admitted that the tampon is competent to
excite uterine contraction and bring on labour. Should it fail (and what may
not ?) it may be reinforced by the puncture of the placenta, as recommended
by M. Gendrin, which, considered merely as a means of bringing on labour,
is excellent and wholly unexceptionable, and it will be observed that I am not,
just now, speaking of the restrainment of hemorrhage, but of the excitement
of labour. No case can occur, I think, in which the tampon, aided, if neces-
sary, by puncture of the placenta, will fail to bring on labour, in a longer or
shorter time, and where the tampon alone is sufficient, and labour is regularly
established by its instrumentality, either the placenta must be punctured to
evacuate the liquor amnii, or the finger must be pushed up beyond its margin
to rupture the membranes during a uterine pain. I have myself usually prac-
tised the latter alternative, and always felt that my patient was safe when ad-
vanced thus far on the road to recovery.

" The supervention of labour — the evacuation of the liquor amnii — these, in
their order, are the great bulwarks of a flooding woman, no matter where the
placenta is implanted. It is a maxim in obstetrics that a contracted uterus
cannot bleed ; it might, I think, be amended and enlarged by adding that
neither can a contracting uterus bleed when it is emptied of its waters — or at
any rate, if it bleed, the hemorrhage is no longer dangerous.

"Notwithstanding that the tampon may be generally depended on to re-
strain hemorrhage, it is certainly possible that it might disappoint our expecta-
tions, and then the evacuation of the amniotic fluid by placental puncture may
be had recourse to, as an auxiliary, on the authority of M. Gendrin. Should
this fail, and the hemorrhage threaten to destroy the mother ere uterine con-
traction can be excited, there can be no doubt of the propriety of separating
and extracting the placenta, according to the letter of Dr. Simpson's proposal,
viz: solely with a view to the safety of the mother, losing sight of the child,
whose interests are altogether subordinate. Such a procedure excludes, of
course, delivery by turning, by which, as it has been shown, many maternal
lives have been sacrificed that might have been saved, had the expulsion of
the child been left to nature."

The subject of labour is next considered. We do not intend to follow the
author in his very excellent examination of the efficient and determinative
causes of labour, and the forces which co-operate in the expulsion of the con-
tents of the gravid uterus. The entire chapter devoted to this branch of
obstetrical physiology is replete with interesting views which demand a favour-
able consideration, and which, whether received throughout as established
truths, or as merely plausible hypotheses, cannot fail to point the road to a
more correct and intimate acquaintance with the subject.

Dr. Miller teaches that the real cause of the occurrence of labour at the
completion of uterine and foetal development, is that suggested by Dr. John
Powers, the irritation, namely, of the cervix, and especially of the os uteri,
arising from the contact, which then takes place, of the ovum with the latter.
This he supposes to be proved, 1st, by the peculiar manner in which the
uterine neck is unfolded during pregnancy, and 2dly, by the fact that the
rectum and bladder are both excited to expel their contents by irritation of
their orifices. The objections that have been made to this theory are candidly
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examined, and, with much apparent plausibility, refuted. To understand the
real value of the cause assigned by Dr. M. for the inception of labour, regard
must be constantly had to the true relationship of the condition of the neck
of the uterus to that of its body at the different stages of pregnancy.

The phenomena of labour are the subject of the following chapter. They
are clearly and fully detailed in the order of their occurrence.

In regard to the utility of the membranes, or pouch of waters, as it has
been termed, both before and after the protrusion of a portion of the pouch
at the uterine orifice, as a means of promoting the expansion of the os uteri
and facilitating the progress of labour, Dr. M. makes the following sensible
remarks. There is, it is true, nothing especially novel in them, corresponding
as they do with the experience of nearly all skilful and observant practition-
ers. It may not, however, be improper to call attention to them on the part
of the younger members of the obstetrical corps, inasmuch as their validity
has been denied, and there are even some who incorrectly suppose that the
premature rupture of the membranes and discharge of the waters will not
tend to retard labour, or render it more painful. Some have even pretended
that their early rupture will often facilitate and shorten it. That these latter
positions are incorrect, Dr. Miller believes is shown by the following consider-
ations : —

" First. The integrity of the membranes before the pouch is form*ed is valua-
ble, because the propelling force has then a more suitable medium wherewith
to act on the cervix than any part of the foetus would be. This medium is the
waters inclosed by the membranes, which, adapting themselves to the shape
and inequalities of the cervix, make more equable pressure on its fibres, and
consequently subdue their resistance more equally ; whereas any part of the
child that can present is not so well adapted to distend the cervix equally, and
hence, while some of its fibres may be benumbed by pressure, others are not
conquered, but provoked to inordinate resistance, thus retarding labour by the
irregular contraction which is excited.

" Secondly. The integrity of the membranes, after the pouch is formed, is
beneficial until the dilatation of the os uteri is considerably advanced, if not
completed ; because the pouch, though it does not cleave like a wedge, opens
the portals for the egress of the child in the gentlest manner. Should it rup-
ture before the orifice is prepared to allow the presenting part of the child to
take its place, the ruder contact that ensues not unfrequently irritates the cer-
vix to a renewal of its opposition, and labour is thus protracted and rendered
more painful.

" Thirdly. The pouch serves, by its presence in the uterine orifice, the most
sensitive portion of the neck, to sustain and enliven the propelling contrac-
tions, upon the principle of orificial irritation. By its agency, these contrac-
tions are, in proper time, rendered truly expulsive, and the auxiliary forces of
the diaphragm and abdominal muscles called into action. When the pouch
ruptures, the presenting part of the child takes its place, and keeps up the
requisite grade of irritation until the labour is completed. That this is no
fancy sketch, the phenomena of shoulder presentations will abundantly prove.
In these cases, the membranes frequently protrude in the form of a long, cylin-
drical purse, which inadequately stimulates the os uteri, and consequently the
pains are feeble for an unusual length of time; and when at length they rup-
ture, if the shoulder is not ready to occupy the orifice, as often happens, there
is an entire suspension of the pains for several hours."

In proceeding to a consideration of the mechanism of labour, the several
presentations and positions of the foetus in utero are first described. The
classification of these as adopted by Duges, is the one followed by Dr. Mil-
ler. The mechanism of labour in each of these is separately discussed. To
the subject all that extension is given which its importance demands. With-

1858.]

Miller, Principles and Practice of Obstetrics.

191

out a clear conception of the manner in which the foetus, in each case, is
transmitted through the pelvis, the course it takes, and the successive changes
which occur in the condition and direction of the presenting part, as it is
gradually propelled from the womb into the world, no one is competent to
conduct properly and safely the most simple and easy case of parturition,
much less to act promptly and efficiently in cases attended with delay or
difficulty, or in which manual or instrumental interference is required to in-
sure the safety of the mother or child, or both.

In the chapter devoted to this subject the views and explanations of the
most authoritative masters in midwifery are laid down, but not implicitly
followed. Dr. Miller has had the courage to examine and judge for himself,
and to express his own conclusions, however these may differ from those of
others. His explanatory and critical remarks appended to the account given
of the mechanism of labour in each presentation are marked by much good
sense. We have perused them with both pleasure and profit.

In the ensuing chapter on the diagnosis and prognosis of labour, a very
good account is given of the means of ascertaining whether labour has actually
commenced or not, and, when it is found that labour has actually set in, the
manner in which the presentation and position of the child are to be deter-
mined, with some very judicious remarks on the prognosis of labour gene-
rally, and in each of the several presentations and positions.

It is very certain that in respect to the prognosis of labour, considered as
to its probable duration, its favourable termination if left to the powers of
nature, and the necessity for instrumental interference, there can be but few
positive rules laid down that will admit of universal application. From close
observation, the experienced practitioner acquires a certain tact by which he
is able to form in each case of labour a very accurate judgment of its proba-
ble course, and to infer its favourable or unfavourable termination if left to
itself. But this tact can scarcely be taught by books or oral instruction : it must
be acquired from clinical experience, and from that only by such as have made
themselves intimately acquainted with the form, structure, planes, axes, and
normal dimensions of the pelvis, the anatomy and admeasurements of the
foetus in utero, and the physiology and mechanism of labour according to the
presentation and position of the child, as well as with all those causes that
may increase the pain of parturition, retard or arrest its' progress, and the
particular dangers incurred by mother or child, or both in cases of tedious,
difficult, and obstructed labour. It is true that there are many cases in
which the danger of trusting the accomplishment of delivery to the unaided
powers of the uterus, or the impossibility of the birth of the child without
manual or instrumental assistance, can be determined with almost positive
certainty. The general rules by which the diagnosis and prognosis of such
cases are governed are clear and explicit ; ignorance of them would be highly
culpable in any practitioner of midwifery.

The retarding and impeding causes of labour as they present themselves in
its different stages are treated of by Dr. M. in his chapter on the management
of labour. They are, in the first stage, obliquity of the uterus; the ineffi-
cient or impeded action of the organ; rigidity of the os uteri; and, in the
second stage, inefficient and impotent action of the uterus.

In cases of obliquity of the uterus, Dr. M. insists upon the importance of
restoring the os uteri to its natural position.

" This," he teaches, " may generally be effected by regulating the posture
of the patient, enjoining her to lie on the side opposite that, towards which the
fundus inclines." When anterior obliquity exists, in a great degree, a properly

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adjusted bandage around the abdomen will materially contribute towards re-
storing the uterus to its natural situation.

" Should strict attention to posture, continued for a reasonable time, fail to
correct the obliquity, and the labour in the meanwhile make but tardy pro-
gress, it is proper to hook the os uteri by inserting the extremity of the finger
within its orifice, and draw it towards the centre of the pelvis, in the intervals
of the pains. When a pain comes on, its tendency to relapse to its former
position is to be resisted, with as much force as can be safely employed. If
this tendency is too powerful to be resisted, the finger must yield to it ; but,
as soon as the pain ceases, bring back the os uteri to the centre, and again en-
deavour to maintain it there during the next pain. By cautiously and gently,
but perseveringly, acting thus, the os uteri will, after a succession of centri-
petal and centrifugal movements, be restored to its proper place, and, the par-
turient forces having been brought to bear upon it, its dilatation will be effected
as speedily as in ordinary cases.-"

"In deliberating upon the propriety of artificial aid, in cases of obliquity of
the uterus," Dr. M. believes that, " the ability of nature ultimately to overcome
the difficulties which they offer, should not be taken into consideration. The
primary question is, can obliquity seriously retard labour ? and this has been
answered in the affirmative, even by Dr. Hunter, in his commendation of pa-
tience, but less equivocally by Dr. Denman and others of the same sect. Obli-
quity ought, then, to be remedied in all cases, when it unduly protracts the
first stage of labour, if the principles of Dr. Hamilton should govern our con-
duct. Labours, rendered tedious from this cause, may undoubtedly hobble to
their end, even to the expulsion of the foetus in some way — nevertheless all the
mischiefs that grow out of delay, are justly chargeable to the obliquity, and
might have been averted, had it been remedied." * * *

Awkward and unskilful attempts at rectification of the obliquity may, Dr. M.
admits, produce inflammation of the uterus, but this, he remarks, is chargeable to
the operator, not to the operation, which need not cause pain, much less any such
serious consequences. "For my own part/' he adds, " I can safely declare that
no mischievous effects of any kind have ever resulted, in my practice, from such
tractions upon the os uteri as have been recommended, and the testimony of
Dr. Dewees is equally decisive in regard to their safety and efficacy. Nay, this
eminent practitioner deemed them of so much importance as to advise the in-
troduction of the entire hand, well lubricated, into the vagina, in order to get
hold of the os uteri with the finger, when it cannot be reached by a well-
directed search in the ordinary way ; and, under the circumstances that he
has specified, I should not hesitate to follow his advice, although I have not as
yet had occasion to do it."

In cases of inefficient action of the uterus the proper course, according to
Dr. M., is, if any morbid state of the system can be reasonably assigned as
its cause, to correct it ; if the pulse is full and strong, blood should be ab-
stracted ; if the bowels are confined, they ought to be relieved by an enema,
or a dose of castor oil. But if these means fail, or not being indicated, are
not resorted to, the proper remedy is, irritation of the uterine orifice oy means
of the finger, for the purpose of exciting more efficient contractions of the organ.

After describing the mode of effecting this irritation, he remarks : —

" Speaking from abundant experience, I can truly say that it is equally sur-
prising and gratifying to observe the prompt effects of this manipulation, in
many cases of the kind under consideration. Not unfrequently, a few move-
ments of the finger are sufficient to impart such energy and aim to the uterine
contractions, that the waters begin to gather, as the phrase is, and cause the
membranes to protrude."

Dr. M. states that he has been in the habit for many years of employing,
under the circumstances indicated, the manipulations he has described, and
in the great number of cases in which they have been practised no evil con-
sequences whatever have resulted, but labour has been greatly assisted, and

1858.]

Miller, Principles and Practice of Obstetrics.

193

many accidents, as he is firmly persuaded, have been averted, which would
otherwise have happened from its undue protraction.

The chief course of impeded action of the uterus during the first stage of
labour is, according to our author, premature rupture of the membranes. In
the treatment of tedious labour resulting from this accident, he recommends
if the os uteri be hot, tender to the touch, and rigid as well as tumid, the
free detraction of blood. He believes, however, that the judicious employ-
ment of the fingers in aid of the uterine contractions is much more frequently
indicated, and is often the only thing that can be done to assist the patient.

"The fingers are not to be used," he observes, "to excite uterine contrac-
tions (for they are already too strong), nor to stretch the os uteri, but to press
upon its margin, during the pains, in order that their counter pressure may
keep it in as firm contact with the head as the rest of the cervix, and the ori-
fice be thus brought within the pale of the dilating influence of the uterine
contractions. Both Hamilton and Gooch highly recommend this practice, but
their object is to push up the edge of the orifice over the head of the child ; to
liberate the band of the cervix, supposed to be incarcerated — a condition which,
if it really existed, could scarcely be reached by such a procedure."

In cases of rigidity of the os uteri, Dr. M. recommends copious bloodlet-
ting, opiate enemata, the administration of tartarized antimony, the local
application of extract of belladonna or of stramonium to the os uteri, tepid baths
and demi baths. Should all of these means fail, or but partially succeed in
overcoming the rigidity of the os uteri, and the cervix descend in advance of
the head of the child, it is necessary, he remarks, to raise and support the os
uteri.

" As this is a measure of considerable importance, I shall endeavour," says
Dr. M., "to explain how it is to be practised. The index finger is to be ap-
plied just underneath the anterior lip of the os uteri, and with its edge or
palmar surface pressure is to be made, in the intervals of the pains, so as to
push up the os uteri as high as possible, or the extremities of two or three of
the fingers may be used in the same way. When a pain comes on, the tendency
to descent is to be resisted, unless this be so strong as to require more force
than it would be prudent to employ ; in that case, the finger must gradually
relax its counter-pressure and allow the descent to take place. But as soon as
the pain goes off, the os uteri is to be pushed up again, and its descent is again
to be resisted during the next pain. In this manner, acting with gentleness
and caution, but, at the same time, with firmness and perseverance, the os
uteri must be supported until it is sufficiently dilated to allow the head to exe-
cute its rotatory movement, and emerge from under the symphysis pubis.

" The principle upon which this manoeuvre acts does not appear to have been
well understood, even by those who have practised it. The support given to the os
uteri prevents it from prolapsing, to be backed, if the expression will be allowed,
by the floor of the pelvis, and places it in a position that will permit a portion
of the head to become insinuated within it during a pain. The finger is not
used to stretch the os uteri, as many writers direct, but to hold it up that it
may be dilated by the head, which can then be pushed, by the uterine contrac-
tions, lower than the level at which the os uteri is held. The head dilates the
os uteri far better than the finger could, because it acts upon the whole extent
of the cervix, whereas the finger could act only on the circle of the os uteri."

In the second stage of labour, it is a fixed rule of practice with Dr. M. in
all cases, without exception, to rupture the membranes, when, the dilatation
of the os uteri being completed, the pains become expulsive, or even in the
absence of expulsive pains with a view to excite them. The rule we think a
good one.

It is in this stage that Dr. M. considers the production of anaesthesia by
the inhalation of chloroform to be a boon of inestimable value to the partu-

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rient female by annihilating the pangs of childbirth, and thus removing the
"certain fearful looking for" of its ordeal, by which the parturient female is
so liable to be tormented.

" I have been in the habit/' he says, "of employing etherization in my ob-
stetric practice, for nearly ten years, in natural as well as in difficult labours,
and during that period, must have given it in several hundreds of cases, and I
am not aware that mischievous effects have followed in a single instance. I
have occasionally known it to diminish the energy of the uterine contractions
and lengthen the intervals between them, to such a degree as to make it expe-
dient to suspend its use for a time, or altogether to discontinue it. But in
these exceptional cases, no harm resulted, and when the anassthesia passed off
— which it did in a short time — the labour resumed its course and progressed
as though it had suffered no interruption."

" The relief afforded by etherization is not confined," he adds, "to the par-
turient state ; it extends also to the puerperal state. I have often been struck
with the remark, spontaneously made by patients who had been previously de-
livered without the benefit of chloroform, that they felt very much better than
after their former confinements, having little or none of the muscular soreness
and stiffness, or the fatigue and exhaustion which before they were accustomed
to feel — and I think I may safely say that their convalescence is altogether
better."

Dr. Miller very properly presents in strong relief the dangerous conse-
quences that almost invariably happen to the child as well as to the mother
by the imprudent administration of ergot to overcome the inefficient action
of the uterus that may occur during the second stage of labour. There can
be no doubt that, provided the os uteri is dilated, the vagina and vulva re-
laxed and moist, the presentation natural or such as to offer no great impedi-
ment to the birth of the child, that it is the vertex, face, or nates that pre-
sents, and there is no disproportion between the presenting part and the
pelvis — ergot, judiciously administered, will seldom fail to excite powerful
uterine contractions by which the child will be promptly expelled. But if all
these conditions for a prompt termination of the labour are not present, it is
very certain that the powerful and continued contractions of the uterus pro-
duced by the ergot, may prove destructive to child or mother, or both.

As it is not always an easy matter to decide confidently that all the con-
ditions exist, which justify the exhibition of ergot, whenever there is a doubt
upon this point, ergot should be withheld, while, according to Dr. M., the
same manipulations that are recommended by him in cases of inefficient
action of the uterus in the first stage of labour, may be had recourse to, and
with marked effect.

In forming our opinion as to the necessity of artificial delivery in cases of
impotent action or inertia of the uterus, occurring from exhaustion, the result
of the long-continuance or severity of the parturient efforts, Dr. M. very cor-
rectly remarks that our attention should be directed to the evidences of ute-
rine impotency; in proportion as these thicken, the necessity of delivery
becomes more and more urgent.

" It is not wise to wait until the urgency is extreme ; and, in general, the
earlier the woman is relieved by delivery the better, provided this can be done
with facility and safety. Suppose, for example, the head of the child is pre-
senting and has ceased to advance, while the uterus has evidently become im-
potent ; suppose, moreover, this head is within easy reach of the forceps, and
can be delivered without risk or additional pain to the mother — what would be
the use of waiting until we are driven to the operation? But if delivery be
not so easily and safely practicable, prudence requires that it should be de-
ferred until the necessity of it is more pressing — so pressing that, in our judg-

1858.]

Miller, Principles and Practice of Obstetrics.

195

ment, it is better to incur whatever risk the operation may involve, than wait
longer."

The remaining chapters of the treatise are devoted chiefly to an account of
instrumental delivery. The teachings of the author on this most important
branch of practical obstetrics are, in the main, sound and judicious, while his
directions are clear, simple, and precise, and well calculated, so far as it is
possible by printed instructions, illustrated by well executed engravings, to
point out, in the several cases and conditions in which instrumental aid is
required to terminate labour, the manner in which that aid is to be applied —
in a word, the proper application and management of instruments for the
delivery of the child in each presentation and position.

Under the head of delivery by the crotchet, or craniotomy, Dr. Miller dis-
cusses the question as to the necessity of promptly relieving the uterus of its
contents upon the occurrence of puerperal convulsions. He admits that, in
these cases, bloodletting early performed is of great value, indeed indispensa-
ble, as a means of protecting important vital organs, particularly the brain,
against the dangerous congestions which are consequent upon the convulsions,
as evinced by the swollen veins and turgid features during the paroxysms,
but he insists,- and very properly, that it is futile as a means of arresting the
convulsions. He consequently condemns the lavish waste of blood by large
and repeated bleedings, which have been deemed, by many, essential, in cases
of puerperal convulsions, to the safety of the patient, as not only useless but
absolutely mischievous.

Having depleted to an extent sufficient to put the bloodvessels in the best
possible state to bear the stress laid upon them by the successive convulsive
paroxysms, which should be done as early as possible, Dr. M. believes that
the lancet has performed all that it can do, and we must look to other means
to insure the safety of the patient. The most important and imperative of
these means, according to Dr. M., is the prompt delivery of the child. So
important does he consider this measure to be, that he believes it is the posi-
tive duty of the obstetrician in cases in which the forceps cannot be applied,
from the early period after the setting in of labour at which the convulsions
occur, to deliver by craniotomy, whether we have complete assurance or not
of the death of the child.

"For this operation," he remarks, "it is not necessary that the os uteri
should be so largely dilated as for delivery by the forceps, or even by turning
the child, and hence it enables us to evacuate the uterus, and abrogate the
cause that sustains the convulsions many hours earlier than it would be possi-
ble to apply the forceps.

"It is not recommended," he adds, "to have recourse to craniotomy in
every case of parturient convulsions so soon as the operation is practicable.
Not so ; for it may be that there is no such urgent and instant necessity as to
justify the operation. But if it be otherwise, and there are just grounds for
our worst apprehensions, whilst, from the tedious manner in which the dilata-
tion of the os uteri is going on, it is wholly uncertain how long we must wait
before delivery can be accomplished by the forceps, then the perforator should
be used, even if the child be alive."

Now, we candidly confess that we are not so well convinced, that, in any
case of puerperal convulsions, the necessity for prompt delivery is ever so
imperative as to justify the sacrifice of the unborn child for its accomplish-
ment. It is very certain that by etherizing the patient, the convulsive parox-
ysms may be so completely controlled as to allow, in perfectly natural labours,
sufficient time for the birth of the child to be accomplished by the unaided
powers of the uterus alone \ sufficient time, certainly to permit at least, the

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os uteri to become so far dilated and relaxed as to allow of the application of
the forceps, and that without augmenting the danger of the mother.

In regard to turning, so as to deliver by the feet, Dr. M., in view of the
many dangers both immediate or remote, which the operation, however skil-
fully and cautiously it may be performed, entails upon the mother, more than
doubts its eligibility, under any other circumstances than that of shoulder-
presentation, and he is strongly impressed with the belief that it ought to be
strictly confined to such cases.

" The object of it then," he remarks, " would be to correct such an aberra-
tion of the axis of the child's body, as precludes delivery ; not to see-saw this
axis, according to our whims or crude notions, and bring one of its extremities
or the other to the os uteri, as best suits our fancy, as if to run our hand up to
the fundus of the uterus, and gyrate the child in its cavity, were to be reck-
oned among the pastimes of obstetricy."

Dr. Miller is not strictly justifiable, we think, in absolutely restricting the
operation of turning to cases of shoulder-presentation; we, nevertheless, ad-
mit that it is far too dangerous a procedure to warrant any one having re-
course to it in any instance in which delivery may be safely accomplished by
other less objectionable means.

Cephalic version, Dr. M. believes to be applicable to but a limited number
of cases of shoulder-presentation, when " the labour is in its first stage — the
os uteri being barely dilated, the membranes whole or recently ruptured, the
uterine contractions not very powerful or decidedly expulsive, and the shoul-
der has not become impacted in the pelvis." He gives credit to Dr. Wright,
of Ohio, for having given the best and most precise description of the opera-
tive manoeuvre for the accomplishment of cephalic version in cases where it
is possible to effect it. It justifies, he thinks, the claim of that gentleman,
if not to originality, at least to the credit of having more clearly apprehended
the object to be attained, and of more perspicuously pointing to the proper
method of attaining it.

The general conclusions of Dr. Miller in regard to the comparative merits
of the two plans of version — cephalic and podalic — are as follows : —

" 1. That in simple cases of shoulder presentation, either cephalic or podalic
version may be practised, the former being preferable (provided it can be ac-
complished) on account of the greater probability of saving the child.

" 2. That, whilst cephalic version is not absolutely impracticable, in com-
plex and even in complicated cases of shoulder-presentation, it is more difficult
of performance and fully as dangerous, both to the mother and child, as poda-
lic version, in one or another of its forms.

" But granting, for the argument's sake, that cephalic version is, in its ulti-
mate results, as eligible as podalic version, still I should contend that in com-
plex, much more in complicated cases, it ought never to be had recourse to,
because the sufferings of the patient are uselessly protracted by it. Even if
there be not exhaustion of the uterus, it is impossible to know beforehand, in
any such case, whether the child will be expelled by the natural powers or re-
quire to be delivered by instruments, thus subjecting the patient to the com-
bined hazard of manual and instrumental delivery.

" To me it seems that cephalic version, under the circumstances we are now
considering, is an unfinished operation. The patient is made to endure all the
pain and incur all the risk of manual delivery, for the sake of having the head
of the child placed where it may be expelled by a second course of labour as
severe and, perhaps, as prolonged as the first might have been, had the head
originally presented instead of the shoulder.

"When a woman has been long in labour, the uterus striving in vain to
expel the child under a shoulder presentation, the necessities of her condition

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Miller, Principles and Practice of Obstetrics.

197

■will not admit of any temporizing expedients or halfway measures ; she needs
to be delivered, and turning by the feet alone can give us that dominion over
the labour, which is salutary alike for the mother and the child."

In the second section of Chapter XVI. will be found some excellent direc-
tions for the management of asphyxia in new-born infants — as to the proper
procedure in cases of retention of the placenta from either atony of the ute-
rus, hour-glass contraction, or morbid adhesion; and, finally, as to the treat-
ment of flooding occurring subsequent to delivery. On this latter subject,
the author's views and directions are particularly sound, and cannot be too
strongly impressed on the mind of the young practitioner.

Two means usually resorted to for the control of post-partum flooding are
held in very slight esteem by Dr. M. : we allude to ergot and the tampon.
Of the first he remarks : —

"There is no harm in giving the article, provided we put no trust in it. I
mean to say that ergot might possibly do good ; but that its operation is too
precarious to justify any one in relying on it, to the neglect of the more certain
resources which have been pointed out."

We should be sorry to inculcate any positive reliance on any one means for
the control of the hemorrhage from the womb occurring subsequent to parturi-
tion, but we must insist upon the very important aid afforded by ergot in most
of those cases where, after delivery, an undue discharge of blood is threatened
or has actually commenced. We know of nothing which will so generally
excite, and with the same promptness, that complete and permanent contrac-
tion of the womb on which alone in these cases the safety of the patient
depends. We say nothing of the beneficial influence of the haemostatic powers
of the ergot, which are very far from being either problematical or incon-
siderable. It is its specific properties as an exciter of uterine contraction
mainly that recommends it as a remedy in post-partum flooding. So import-
ant a remedy do we consider it in this form of uterine hemorrhage, that we
believe it should be early administered in every case in which we apprehend
the occurrence of the accident.

In regard to the tampon, Dr. Miller remarks :—

" To attempt to control hemorrhage from an empty and flaccid uterus, by
plugging the vagina, is highly hazardous. We may, it is true, prevent the
issue of blood by this expedient, but we can have no assurance that it will not
continue to pour from the vessels and collect in the uterine cavity, until life is
exhausted. It is better to contend with an open than a lurking enemy ; for
though we are fully able to cope with him, we might be circumvented by his
wiles. Let the blood, then, have an unobstructed channel ; we can, the more
clearly, discern our patient's danger — which it is folly to hide from our eyes —
and shall be incited to more earnest efforts to save her from impending death."

There is much truth in the foregoing remarks. The tampon is certainly
useless in cases of flooding after labour. Until the cause of the hemorrhage —
the flaccid state of the uterus — is removed, all attempts to control the external
discharge of the blood are worse than absurd. Until the^full and permanent
contraction of the organ has taken place the female is in imminent danger,
and should not be left by the accoucheur.

In the preparation of the treatise before us, while Dr. Miller has borrowed
largely from the standard authorities on the theory and practice of obstetrics,
he has not implicitly followed any master, even though by common suffrage he
may be ranked among the most authoritative ; but, observing, reasoning, and
judging for himself, he has infused into the work so much of his own mind,
that it may lay very legitimate claims to a certain character of originality

198

Reviews.

[Jan.

which press it strongly upon the attention of the medical profession of the
United States. In our examination of its several chapters we have met with
much more to approve than to condemn — far more in relation to obstetrical
principles and practical precepts and procedure to which we can cordially
assent, than of which we have been obliged to doubt or absolutely deny the
correctness.

The arrangement adopted by Dr. M. in the present treatise is somewhat
different from that pursued in most of the standard works on the same sub-
ject. In some respects it has unquestionably its advantages, but we are not
so certain that it is the one best adapted for a systematic treatise on obstetrics
intended for the use of students.

The style of the work is throughout simple, clear, and sufficiently correct,
though occasionally marred by colloquial expressions which neither give force
to the author's meaning nor impressiveness to his practical directions.

Dr. Miller admits that he has not attempted to introduce into his pages
" every topic, both large and small, that belongs to obstetrics still, in a
work professedly aiming " to present, in as condensed a form as possible, an
exposition of the cardinal principles of obstetrics, considered as a science and
an art," we should certainly have expected to meet with an account of the
management of twin cases, and of rupture of the uterus, and some notice at
least of the important question as to the propriety of the induction of prema-
ture labour in those cases in which, from deformity of the pelvis, delivery at
the full term is rendered impossible without the destruction of the child.
Besides these omissions, we notice, also, the omission of any account of the
circumstances which will warrant or imperatively demand a resort to the use
of instruments in cases of labour. Some of these circumstances are, it is true,
incidentally alluded to in the course of the treatise, but nowhere are all of
them indicated with that fulness of detail which would seem to be demanded
by the importance of the subject, the different opinions on many points con-
nected with it entertained by distinguished obstetricians, and the serious mis-
takes that are every day made by practitioners, in consequence of the erroneous
views they have formed in respect to it.

Without some notice of the several topics just alluded to, no treatise can
be properly considered as embracing an exposition of " the cardinal princi-
ples'' of obstetrics as a science and an art. We admit that full accounts of
them all may be found in other works ; nevertheless, one having similar pre-
tensions to the character of a systematic treatise on " the principles and prac-
tice" of midwifery must be considered incomplete without them. There is
as much necessity for their introduction as for that of the anatomical descrip-
tion of the pelvis and female organs of generation, and their obstetrical rela-
tions, which the author admits he has borrowed from the work of M. Dubois,
and very properly, inasmuch as he there found so good a description that he
was in some measure compelled to follow it in his desire to give a correct
account of these subjects considered in an anatomical and obstetrical point of
view.

Whatever, however, may be the faults of omission or commission in the
work of Dr. Miller, it must, nevertheless, be pronounced a most able one, con-
ferring the utmost credit upon its author, and fully entitled to that favourable
reception we are well convinced it will, receive on the part of the American
medical profession. D. F. C.

1857.]

199

BIBLIOGRAPHICAL NOTICES.

Art. XVII. — Transactions of American State Medical Societies.

1. Transactions of the Indiana State Medical Society, at its Eighth Annual Ses-

sion, held in the City of Indianapolis, May 19, 1857. 8vo. pp. 74.

2. The Transactions of the New Hampshire Medical Society [Sixty- Seventh An-

niversary), held at Concord, June 2 and 3, 1857. 8vo. pp. 104.

3. Transactions of the South Carolina Medical Association, at the Extra Meet-

ing in Sumter, July 9, 1856, and at the Annual Meeting in Charleston, Feb-
ruary 4, 1857. 8vo. pp. 64.

4. Transactions of the Second Session of the Medical Society of California, con-

vened at Sacramento, February 11, 1857. 8vo. pp. 43.

1. The first report comprised in the Transactions of the State Medical So-
ciety of Indiana, at its session of 1857 is on " the Practice of Medicine," by
Dr. T. J. Cogley.

This report is published only in part; enough of it being given, according
to a note appended to it by the committee of publication, "to show its most
prominent characteristics." Now, if the entire report was of that excellent
character it is pronounced by the latter committee, they have surely acted
unjustly, as well to its author as to those for whose instruction it was pre-
pared, in omitting any portion of it. It should have been published entire, or
omitted altogether.

We are not however inclined, so far, at least, as we are able to judge of the
character of it from the fragment in the transactions before us, to accord to the
report of Dr. Cogley the high praise bestowed upon it by the committee of pub-
lication of the society. It contains, it is true, many judicious remarks and
correct sentiments, but the account it presents of the actual condition of the
practice of medicine, in reference to the few diseases of which it treats, is much
too loose, general, and indefinite to afford much useful information to those to
whom it is addressed. As an example of this, we may refer to the remarks of
the reporter on the treatment of pneumonitis.

Dr. Cogley concludes his report with some general remarks on " the curative
resources of Nature."

" One of the first surgeons of London, Mr. Skey, says," remarks the reporter,
" 1 1 am persuaded that, in proportion as we study disease, and make ourselves
familiar with the curative resources of Nature, the greater will be our faith
in her power of reparation, and in her desire to exercise it.' Men adopt dif-
ferent views of the power of the curative art. With some it holds the relation
of a vicegerent ; with others, of a handmaid. Our minds are not universally
impressed with the conviction that Nature cures diseases, and not we ; and that
the province of the surgeon or physician, beyond which he cannot step one
foot, consists in removing obstacles in her path. If this wholesome fact were
impressed more deeply on the professional mind, would it not instinctively
lead to a closer observation, and, of necessity, to a higher appreciation of her
powers?"

That, in the larger number of instances when any organ or tissue becomes
the seat of an acute lesion, its tendency is to return sooner or later to its nor-
mal condition and functions there can be no doubt. It is questionable, how-
ever, whether it is safe to trust entirely to this tendency. Between the plan of
taking into the physician's own hands the entire management of every disease,
and "turning nature out of doors," as uncertain and inefficient, if not mischiev-
ous in her curative efforts, and, on the other hand, trusting to her entirely for
the cure of disease, there is a medium course to be pursued — neither entirely

200

Bibliographical Notices.

[Jan.

disregarding the curative powers of Nature, nor relying on them alone — but
interfering just so far as is necessary properly to direct those powers to the
production of the desired result; to aid them in their efforts to accomplish it,
and to remove from them all obstacles to their prompt and successful action.
And the skill of the physician is mainly exhibited in determining and pursu-
ing this proper medium in the management of disease — neither interfering too
much nor too little by the administration of active remedial agents.

The next report is on the "diseases of the eye and ear," by Dr. T. Parvin.
After a sensible exposition of the importance of a careful study of these dis-
eases— their nature, causes, diagnosis and treatment, and the necessity of pro-
vision being made, for a more full course of instruction in reference to ophthal-
mic and aural medicine and surgery, in our medical colleges, the report gives
a concise but interesting sketch of the recent improvements in these especial
branches.

The succeeding report is on " fractures and false joints," by Dr. Daniel
Meeker. The subject of fractures, however, is alone embraced in the portion
of the report before us ; Dr. Meeker promising to complete the report at a fu-
ture period.

So far as it goes, the report is a very sensible and instructive one. In its
exposition of the improved methods of treating fractures it is perhaps somewhat
too concise ; it will nevertheless be read with interest and profit.

A report on the medicinal properties of "Veratrum Viride," by Dr. P. H.
Jameson, is the one next in order.

In pneumonia, Dr. J. pronounces the veratrum to be an agent of great power
and utility. He has often seen it quiet the heart and change the quality of the
circulation — reducing the local inflammation, increasing the expectoration, and
indirectly restoring the depurating functions of the liver, in a marked degree,
without loss of blood, nausea, or salivation. It may be given, in different
cases, he remarks, either after bloodletting, or along with quinine. For an
adult he recommends the following formula. One fluidounce of Norwood's
tinct. of veratrum viride, combined with one drachm nitrate of potassa and one
ounce of water. A teaspoonful to be given every four hours, alternated, if
deemed advisable, with small doses of mercury.

"This treatment alone," Dr. J. remarks, "continued for twelve or eighteen
hours, in pneumonia, I have seen produce the most satisfactory results — the
patient's condition being very similar to that observed, in such cases, after a
copious bloodletting. The pulse will be softened, and have come down from a
hundred, or a hundred and ten, to seventy or eighty, and this, in many cases,
without nausea. If the remedy fails, the dose may be increased gradually till
it is nearly doubled ; this is seldom necessary. It is wrong and hazardous, I
think, to force the pulse down at once by full doses, and needless to reduce it
below what, in a given case, may be considered a normal standard, as to fre-
quency. A greater reduction than this must in some degree interfere with the
due performance of the functions of the system generally; and to cause it, is
to tamper with a remedy whose power may not be fully understood. After
the first twenty-four or forty-eight hours, the dose may be diminished one-
third, one-half, or even more, unless the pulse should rise, and the symptoms
grow worse ; such being the case, the dose should be increased."

Dr. Jameson speaks of the veratrum as a good remedy also in many cases of
typhoid fever, especially where there is a dry, hot skin, parched, dark brown
tongue, and a quick, sharp pulse, with sleeplessness.

" Six drops, he says, may be given every four hours, combined with nit. pot.,
and if there is irritability of the stomach or bowels, a little morphia may be
added. If the pulse is not reduced in twenty-four hours, the dose may be in-
creased. When the pulse is as low as seventy, in the adult, I do not attempt
a further reduction. Under this treatment the skin becomes moist and
cool, the urinary secretion increased, and the tongue is less dry ; indeed, all
the symptoms of the disease are mitigated, and in some cases, I have no doubt,
the duration of the fever is shortened. It is but fair to add, that in both ty-
phoid fever and pneumonia I have sometimes, though rarely, administered
verat. vir. so as to produce nausea, without the least impression upon the cir-

1858.]

Transactions of State Medical Societies.

201

dilation, and consequently with no benefit to the patient. The remedy is
valuable, not only in such cases of typhoid fever as before referred to, but in
all cases where the pulse rises above one hundred, whether attended with rest-
lessness or stupor.-"

Dr. Jameson has employed the veratrum in two cases of puerperal fever, with
what he considered favourable results.

"A very rapid pulse," Dr. J. remarks, "is characteristic of puerperal fever;
it is generally small, because the great current of blood is diverted from its
natural channel, and thrown on to the weakened and congested capillaries of
the inflamed peritoneum. These vessels cannot unload themselves until the
heart's action is reduced. To accomplish this end, Dr. Gordon of the last cen-
tury, Dr. Robert Lee, the younger Baudelocque, Dr. Meigs, and many others,
advise us to bleed early and freely, and repeat as often as the pulse rises. How-
ever scientific this treatment may be, I believe it does not meet with the gene-
ral approval of Western physicians. Bleeding modifies the character of the
blood by lessening its vitality, which in this locality is not always desirable.
With the verat. vir. the pulse can be as much reduced in frequency and kept
down as long as the practitioner desires. With it puerperal fever may be, if
not arrested at its outset, modified in its course, and effusion, that most fatal
of its consequences, in many cases, prevented."

In regard to the safety of the veratrum as a remedial agent, considering the
powerful influence it exerts over the action of the heart, the question is briefly
considered by Dr. Jameson.

"Sometimes, though very rarely," he remarks, "verat. vir. produces nausea
and vomiting, with great depression; but I have seen worse effects, and harder
to correct, from antimony. There are sometimes sensations of choking or
smothering, and difficulty in breathing; or there maybe hiccough or dizziness,
all of which soon pass away when the use of the remedy is suspended. Like
mercury, antimony, opium, quinine, or chloroform, verat. vir. is not only power-
ful for good, but doubtless, in unskilful hands, sometimes potent for evil. That
which can do no harm seldom does any good."

To the report of Dr. Jameson succeeds the history of a most interesting case
of amputation at the shoulder-joint, by Dr. Calvin West.

The operation was performed on a lad eight years of age, who had recently
suffered an extensive and serious injury of the entire arm of the right side,
destruction of the deltoid and coroco-brachialis muscles, fracture of the humerus,
close to, and extending, under the attachments of the capsular ligaments, into
the shoulder-joint, and destruction of portions of the pectoralis muscles. On
the thirtieth day after the accident, cicatrization was complete, and the patient
discharged cured.

The two reports which follow, the one on bloodletting in pneumonia, and the
other on purgatives in dysentery, give each, on the question embraced by it,
simply the opinion of a single practitioner, which opinion is neither given with
all the necessary details, nor with a clearness and definitiveness to render it
of value as a guide for the practice of others.

The next report, " on medical education," by Dr. Chas. Fishback, contains
much in relation to this most important subject, that is at once pertinent, judi-
cious, and practical. We confess that we are not particularly pleased with his
scheme of a free college, and a course of lectures to be continued through three
consecutive years.

To the foregoing report succeeds a biographical sketch of Dr. Elizur Deming,
by Dr. J. S. Bobbs.

The Transactions of 1857 close with the address of the President of the So-
ciety, Dr. Daniel Meeker. We had marked as particularly deserving of notice
many paragraphs of this very sensible discourse, but must confine ourselves to
that portion of the address which embodies the remarks of Dr. M. on the sub-
ject of the legal protection of the medical profession by legislative enactments.
We present these remarks without comment.

" When," says Dr. M., " the popular mind is legitimately and well informed,
whatever may be the opinions or wishes of the profession, I doubt not but the
legislature will enact positive laws — protection not merely to the profession,
but to the people." " When the people understand that their own interests in

202

Bibliographical Notices.

[Jan.

such enactments far transcend all that can accrue to the profession, surely
their aversion to protective means should cease." " We have no doubt that
judicious legal enactments regulating the practice of medicine in this State
would result in general good to the people as well as to the profession — requiring
some fixed standard of qualification for all those who practise the healing art."
" Should the time arrive when efficient laws are enacted for the encouragement
of the science of medicine, it will be through preliminary culture of the public
mind by the agency of medical men. The people are more ignorant of the
principles of medical science than they are of those of the other learned sci-
ences." " The public ministrations of the clergyman are laid open for the ap-
preciation of all. The majority of his congregation are competent judges of
his pulpit efforts. Yet he is not allowed to act in this capacity until he has
been examined and licensed by a competent board of officers of the church,
appointed for that purpose. The lawyer is brought to a still severer test ; all
his legal papers must be drawn up with the most scrupulous technical accuracy,
or disgraceful defeat and pecuniary loss is the result. Here all the great errors
committed are open and apparent, involving the reputation and standing of the
practitioner. He is brought into conflict with his opponent, before a sagacious
court that fully understands all the principles discussed, and that instructs in
its decrees which party is correct. The knowledge and abilities of the physi-
cian are not tested in the same open and direct manner. The character of his
business is such as to more or less conceal it from public gaze. His dealings
are with the secret and hidden things of life. He does not come in contact
with any opponent, his labours are not watched and decided upon by the same
sagacious tribunal. The grave may too often conceal his blunders ; few around
are competent to decide whether the protracted sufferings, the lost vigour, and
the shattered constitutions of those who survive are the necessary consequences
of disease, which could not have been prevented, or the result of inefficient or
injurious treatment. Indeed, so erroneous is the judgment of those around
him, that he is often praised for his errors and censured for his highest skill.
He sees the bold and unscrupulous pretender, ignorant alike of the diseases he
treats and the remedies he employs, exalted in public opinion for recoveries of
which the least can be said is, that his bad management did not effectually
prevent."

2. The Transactions of the sixty-seventh anniversary of the New Hampshire
Medical Society open with the Address of the President, Dr. Francis P. Fitch.
The subject of the address is a most important one — the want, namely, of sani-
tary knowledge.

That the health of a community has " a large and direct influence not only
on the happiness, but also on the wealth of the people who compose it," is a
truth which no one, who has examined the subject with the slightest degree of
attention, will be prepared to controvert. That the health of a community
may be materially improved, and the value of life in its midst considerably
augmented, is likewise a truth, which has been fully established by the result
of the judicious sanitary measures that have been carried into effect, of late
years, in many of the cities and towns of Great Britain.

We may, without the slightest exaggeration, adopt the language of Lemuel
Shattuck, Esq., in the report of the sanitary commission of Massachusetts,
"that in every year in this commonwealth," and the remark may be extended
to every other commonwealth throughout the land, "thousands of lives are lost
which might have been saved ; that tens of thousands of cases of sickness occur
which might have been prevented ; that a vast amount of unnecessarily im-
paired health and physical debility exists among those not actually confined by
sickness; that these preventable evils require an enormous expenditure and
loss of money, and impose upon the people unnumbered and immeasurable
calamities, pecuniary, social, physical, mental, and moral, which might be
avoided, and that means exist within our reach for their mitigation or removal;
and that measures for the prevention will effect infinitely more than remedies
for the cure of disease." And these views of the immense unnecessary waste
of physical energy and of life from ignorance and carelessness, are fully con-
firmed by the highest authorities in England. In some valuable " conclusions

1858.]

Transactions of State Medical Societies.

203

and suggestions," appended to an elaborate report on " diseases and compara-
tive rates of mortality/' the British General Board of Health express most
emphatically a firm conviction " that half the attainable period of human life
is lost to all who are born."

But to avoid disease, to promote health and physical vigour, and prolong
life amid a community, we must know what are the causes in each which tend
to depress the physical vigour, impair the health, induce disease, and shorten
the lives of its people ; we must be put in possession of those facts upon which
alone useful practical sanitary knowledge can be based. These facts comprise
those derived from, 1st, a careful survey of the medical topography of every sec-
tion of the State ; 2dly, an intimate acquaintance with the personal and domestic
habits and condition of the inhabitants, their occupations, and ordinary food ;
the location, condition, construction, and domestic economy of their dwellings,
and the density of the population ; 3dly, suitable enactments for securing, by
adequate sanctions, the full and accurate registration of births, marriages, and
deaths throughout the commonwealth, and the preparation and stated publica-
tion, at proper intervals, of a well digested and classified abstract of such
registration.

We quote the concluding remarks of Dr. F. in the address before us, and
earnestly press them upon the attention of every physician throughout the
length and breadth of the land.

"The subject before us has increased in magnitude and consequence with
every hour devoted to its consideration, and you will pardon the earnestness of
my convictions if I may seem to have overstated its importance. Habits of
thought, forced upon us by daily duties and anxieties, and confirmed by the
prevailing tone of public sentiment, very naturally incline us to the conclusion
that the appropriate, if not the exclusive sphere of the physician, is the cure' of
disease. But is that a complete or satisfactory definition of the purposes of our
high vocation ? Placed by our studies and pursuits upon a vantage ground
from whence we discern dangers, imperilling health and life, which are un-
known to others, shall we not prove false to the obligations we have assumed
if we neglect to point out these dangers, and to show, as we may, how they can
be averted? Here is presented an open and inviting field for the exercise of
that active and enlarged spirit of benevolence and philanthropy which should
everywhere characterize and adorn the votaries of medicine ; and if we would
in our day accomplish anything great or noble, in what way can it be so surely
effected as in thus labouring for the improvement of our race?"

The first of the professional reports is that on Surgery, by Dr. George H.
Hubbard.

The first subject noticed by Dr. H. is that of injuries of the head.

"Formerly/7 says Dr. H., "when an injury w*as inflicted upon the head, the
first thing to be done was to bleed the patient, without stopping to inquire
whether there was concussion, compression, or neither; and there can be no
doubt that many lives have been sacrificed to a blind submission to this popular
demand for bloodletting. We have learned, however, that the cases are few
which demand bloodletting at all, and very few indeed which require it imme-
diately after the injury.

Five interesting cases of the successful treatment of ununited fractures are
related by Dr. H. The first of these occurred in a lad twenty-two years of
age, the fracture being of both bones of the leg. It was managed simply by
appropriate splints and perfect rest. Complete union occurred at the end of
four week&. The second was in a male, twenty-four years of age ; the fracture
being of the humerus. The operation of resection was performed, and the ends
of the bone were then fastened together with gold wire, and the limb inclosed
in a gutta percha splint, fitted to it previous to the operation, and encircling
three-fourths of the arm, so as to leave space to dress the wound without dis-
turbing it. At the end of three months, union was perfect. The third case
occurred in a female, thirty-five years of age. The fracture was of both bones
of the leg. It was managed by putting the limb in a gutta percha splint, and
directing the patient to walk about the house with a cane, bearing as much
weight as she could on the affected leg. In a week, she complained of pain

204

Bibliographical Notices.

[Jan.

and throbbing at the place of fracture. She was then directed to keep quiet
in bed. In four weeks there was no motion at the fracture, and in due time
the cure was perfected. The fourth case was in a male, age not given. The
fracture was of the femur. Five months subsequent to the accident, there was
evidently no ossific union, and the limb was shortened an inch and a half.
" An attempt was made to break up the ligamentous union and bring the limb
to its proper length, and then perform Brainard's operation, and thus effect a
cure. The limb was accordingly dressed as for recent fracture, and extension
attempted. As much power was applied as the patient could bear, and con-
tinued forty-eight hours. At this time there was no appreciable lengthening
of the limb, but great pain, throbbing, and soreness were the result of the ex-
tension. This plan was abandoned, and, to take advantage of the inflammation
thus excited, the starch bandage was applied and the patient kept quiet in bed
a few weeks, and then on crutches a few weeks, the limb in the mean time get-
ting more and more strength, so that at the end of three months she could walk
with a cane, and is now perfectly cured, except the shortening of the leg/'
The fifth case was in a female twenty-five years of age. The fracture was of
the humerus. Four months after the accident there was no union, but very
free motion. Dr. Brainard's operation was performed Nov. 21, 1856, and re-
peated at the end of twelve days. In four weeks union was complete.

"The method of reducing dislocations of the hip-joint by manipulation," Dr.
H. remarks, "long ago taught by Professor Nathan Smith, and lately brought
prominently to public notice by Dr. Reid, of Rochester, N. Y., is becoming
firmly fixed in the favour of the profession. Cases are continually being re-
ported of its successful application. Discussion has fully proved that numerous
surgeons, who were students of Dr. Smith, have been for many years in the
habit of reducing dislocations in this manner, as they were taught by that dis-
tinguished surgeon. And reflection upon the philosophy of this method is
having a great influence upon the reduction of dislocations of other joints. We
are learning that but a small amount of force is necessary to reduce luxations,
if conjoined with an intelligent manipulation properly directed to relax those
muscles which are put on the stretch by the displacement of the head of the
bone. New ideas and principles are daily developed, and we may safely say
that, on this point, surgery is making improvement.

The reporter adduces the following case to illustrate what Nature will accom-
plish in extensive injuries of a limb, when carefully watched and slightly
aided, as a lesson to the surgeon not to be over-hasty in sacrificing a limb
that, without danger to the life of the patient, may become more serviceable and
much better, in all respects, than any artificial substitute.

" Ellen Ryan, aged thirty years, jumped from a car, which was in motion, at
the depot. Falling on the platform, she rolled off, and one foot was run over by
the car wheel. The soft parts of the dorsum of the foot were entirely jammed off,
the metatarsal bone of the great toe crushed to small pieces, and the remaining
metatarsal bones separated from the tarsus, but otherwise uninjured. The soft
parts of the bottom of the foot were uninjured. The great toe and its fractured
metatarsal bone were removed, preserving as much as possible of the sole of the
foot. The leg and foot were placed in a carved splint, which kept the foot in
proper position, and the whole dressed with cold water. Profuse suppuration
followed, and in about a week it became necessary to remove the second toe.
By keeping the bones in contact, they became attached or consolidated together.
The surface healed kindly, the contraction of the large cicatrix drawing the
sole of the foot up around the edges giving the appearance of an Indian mocca-
sin. At the end of about nine months, the foot became sound, and she resumed
her place in the cotton-mill, and is now tending four looms and earning good
wages. She walks the streets without a cane, and with scarcely a perceptible
halt in her gait."

From the several interesting cases appended to this report we select the fol-
lowing, communicated by Dr. Wm, Laughton: —

"I was called to a child, seven months old, which had been screaming vio-
lently; it was then sobbing and restless. The mother stated that it had had
several such spells. I discovered no particular cause for the condition. I pre-

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Transactions of State Medical Societies.

205

scribed turpentine mixture to be followed by an opiate. A day or two after, I
was called again to the child in the same condition. At this time the mother
directed my attention to the umbilicus, fearing hernia. On examining the
abdomen, I discovered a dark speck about one inch above and to the left of the
navel. It proved to be the open end of a sinus. By using a probe, I felt a hard
substance about half an inch inside the opening. By a very little cutting upon
a director, I was enabled to reach the foreign body, which I extracted with a
pair of fine forceps, and it proved to be a darning-needle. The direction of
the needle was transverse, and apparently between the fascia and external mus-
cle. It was corroded and surrounded by pus, was easily extracted, and the child
at once relieved. How long this needle had been there, or how it got there,
no one knew. It was probably accidentally pushed in while handling the child,
and escaped the notice of the mother in dressing. A knowledge of such cases
should lead to careful examination of infants, especially in cases of convulsions
or violent screaming."

A very instructive report on the " nursing sore mouth, its nature, causes, and
treatment," is presented by Dr. T. T. W. Pray.

The main object of this able and instructive paper is to show the identity of
the disease known as the sore mouth of nursing women with aphthae. This
identity Dr. Pray believes to be established by the following facts : Both dis-
eases occurring epidemically without any discoverable connection with season
and temperature; their having the same laws in regard to location — some places
being entirely free from the occurrence of either ; the similarity of their phy-
sical lesions, and their both affecting persons of similar constitutions and con-
ditions of health — those of a lax fibre, thin in flesh, of anaemic appearance and
scrofulous diathesis.

After a very full detail of the symptoms and progress of the nursing sore
mouth, Dr. Pray asks, What is its nature, or what is the disease itself?

"We answer that, with our present information on this subject, we must
pronounce nursing sore mouth and aphthae alike. Upon their physical histories
we cannot affirm them to be different. Their resemblance, both in their rise
and progress, would tend to show, with no small degree of probability, their
identity. This identity, however, resting upon this theoretical aspect of the
case — which seems to us, nevertheless, the just interpretation of all facts known
relative to this disease — may be held provisionally, until it be tested by future
investigation as regards the physical lesions of the disease, by which such
distinctions can be established.

"We regard the disease as local in its nature, occurring as an epidemic and
sporadically, just as all epidemic diseases do. It is a frequent complication
of idiopathic fevers and disordered states of the digestive organs. But the
reason why vesicles and ulcers should be first seen in the mouth or elsewhere,
we are unable to explain. The observations of Dr. Hale on this point are not
inappropriate here. He says : * From the great liability of the stomach to be
disordered in this complaint, and especially from the fact that those remedies
only are of permanent benefit which act upon the stomach, it would seem that
it is chiefly through the intervention of that organ that the disease is produced.
We know of no direct sympathy between the parts in which this affection first
appears and the mammae ; while the stomach is very closely connected with
the mouth and fauces on the one hand, and with the uterus, and all the other
parts associated with the latter organ on the other.' "

In regard to the treatment of the nursing sore mouth, Dr. P. remarks, that
different constitutions require different remedial measures. Tonics may be
best adapted to one class of subjects, while in another an entirely opposite de-
scription of medicines are demanded. Scarcely two cases will be found alike,
hence we can fix upon no general plan of treatment adapted alike, in all its
details, to every patient.

" The first thing that should be attended to is the state of the stomach. If
there be acidity, small doses of magnesia, or bicarbonate of soda, once or twice
a day, or sometimes the vegetable or mineral acids will serve to correct this state.
If constipation predominates, some mild laxative, such as a moderate purge of
calomel and soda, Seidlitz powder, castor* oil, sulphur and cream of tartar, will
JSTo. LXIX.— Jan. 1858. 14

206

Bibliographical Notices.

[Jan.

avert this difficulty. A gentle evacuation of the bowels is desirable in the
earlier stages of this complaint, because it exerts a curative influence over the
sensitiveness of the ulcerated surface. A prominent point in the treatment is
to keep the bowels, especially in the commencement of the disease, in a soluble
condition. But active and irritating purgatives should never be administered,
on account of the liability of the mucous membrane of the intestinal tube to
ulceration, and severe diarrhoea.

" The bowels being cleared, measures should be directed to subdue the feverish
excitement existing in some patients. Generally there is no difficulty in effect-
ing this, unless there be some constitutional irritation, occasioned by the exist-
ence of another disease lurking in the system. There are not many cases where
venesection would be advantageous ; it might be, indeed, dangerous to practise
it." "It is far better, in uncomplicated cases, to use other medicines which
eminently possess the qualities of lowering the pulse and allaying inflammation.
Sometimes a gentle emetic, especially when the stomach is disordered, will be
serviceable. For this, ipecac, is far the best.

" After the feverish state of the system has subsided, or even when there is
slight exaltation of the pulse, we have given internally the following mixture,
This has been used successfully for the last nine years, both in aphthae and
nursing sore mouth, and with like results; its virtues, doubtless, lie in its tonic
qualities : Myrrh, gij ; carb. potass., gr. xxx ; aq. rosae, 3 iij ; sulph. ferri, ^iss ;
spts. lavend. comp., ^vss; sacch., ; mix and compound in the same manner
as the mist, ferri compos, of the U. S. Pharmacopoeia." " We have given a tea-
spoonful of this three times a day, and at the same time used a wash of sul-
phate of zinc, six to eight grains to an ounce of water, for the mouth. If the
physician is called early in the disease, there is no compound more serviceable."
"In the more feeble subjects, other tonics are of importance. There are in-
stances, after the acme of the inflammation is passed, where quinine seems to
stay the progress of the ulceration, and render the mother able to nurse the
child. Here we would remark that almost every tonic is beneficial. Quassia,
iron in some of its preparations, iodide of potassium, arsenic (?), manganese,
etc., have been used with success. When the mouth is largely involved, care
should be had that all medicines be as palatable as possible, free from all irri-
tating properties. It is desirable that they be prepared without the use of
alcohol.

" Local applications have not unfrequently but a feeble power over the ulcera-
tion. Sometimes they seem to exert palliative influence, and occasionally pro-
duce permanent good. They are usually conjoined with medicines directed to
the stomach. Those generally employed are nitrate of silver, sulphate of zinc,
tannin, decoction of logwood, etc."

For the diarrhoea, the food should be unirritating from the onset. "When
the evacuations are green, or of a sour smell, magnesia, or a mixture of this
with rhubarb, may be administered ; or pure castor oil, with some astringent,
may be substituted. Prepared chalk, fluid magnesia, some of the vegetable
astringents — such as kino, catechu, rhatany, or tannic acid — can be taken with
profit. We have seen the use of creasote, six to ten drops to four ounces of
water, check the discharges when everything else failed. Friction over the
abdomen, flannel rollers about the body, rubefacients, especially if there is
pain, anodyne enemata, and warm clothing, are highly important adjuvants."

" There are some cases of the disease which seemingly reject all treatment.
The physician is called too late to check the progress of ulceration and the
exhaustive diarrhoea, or else there is some other complication which thwarts
all the appliances used to arrest the disease. To continue nursing will keep
up a constant irritation in the system. Weaning the child will almost always
cure the mother if seasonably undertaken. But there are instances where re-
sort to this is inconvenient, to say the least. In such instances we must balance
the risk taken, and in a good constitution nursing may be long continued. But
where there are any indications of exhaustion, or an anaemic state of the sys-
tem, a regard to the health of the mother should be paramount, and she should
give up nursing at all hazards. Even then, it will be difficult sometimes to save
life. In a majority of cases, however, there is no such danger, and, although

1858.] Transactions of State Medical Societies. 207

weaning is admissible when circumstances admit it, it is not indispensable,
and women worry through after much exhaustion and suffering, and after all
is over their health does not seem to be permanently injured thereby. As a
general rule, nursing should never be persisted in, when remedies are ineffica-
cious to stop the course of the disease. The length of time which one must
wait to test the inefficiency of remedies must of course vary according to the
urgency of the symptoms."

" When the condition of the patient will permit, the diet should be mild,
generous, and of easy digestion ; such as a good supply of fresh, tender, animal
food, milk, milk-porridge, rice, eggs, and good vegetables. Ale and porter will
assist digestion, and their use cannot be well dispensed with. Sometimes
broths and soups do not disturb the healthy operations of the stomach. Food
of an undigestible nature should never be prescribed, as it will produce only
evil."

In regard to preventive measures, let the female, says Dr. P., " exercise fre-
quently in open air. Keep her bowels in a soluble condition. Let her food
be simple and nutritious. Employ her mind upon subjects that will interest,
rather than upon the annoyances of gestation, and, in fine, let there be a free
use of everything which can amuse and make the patient cheerful.

" To recapitulate : From the discussion of this subject, we arrive at the fol-
lowing conclusions: —

" 1st. Nursing sore mouth is not a nova pestis.

"2d. It is not indigenous to this country.

" 3d. It is often of an epidemic character, and therefore governed by the same
laws as govern other epidemical diseases.

44 4th. It is not anaemia, nor is it occasioned by the loss of a particular prin-
ciple of the blood ; nor can it be scorbutus, but most probably the disease in
question is aphthae of a severe and obstinate form."

The report cn practical medicine, by Dr. W. W. Brown, contains a brief
sketch of the principal epidemical diseases prevalent in the city of Manchester,
from the year 1853 to 1857 inclusive.

The diseases noticed are, cholera infantum, malignant cholera, dysentery,
typhoid fever, scarlatina, pleurisy, and pneumonia.

The report contains much that is interesting, but nothing that can be re-
garded as particularly novel. On the subject of venesection in pleurisy and
pneumonia, in regard to which some very heterodox opinions appear to be
prevalent among the practitioners in different parts of the United States, Dr.
Brown holds the following decided language : —

" During the past winter, pleurisy and pneumonia have prevailed to a greater
extent than is usual here, and we are sorry to be obliged to acknowledge the
fact, that many of our physicians are now, from some cause, too timid or too
cautious in the use of the lancet. One of our regular physicians was heard to
remark recently, that he had not bled a person for six years ! He was asked
how he cured pleurisy and pneumonia? With Dover's powder and tincture
of aconite, was his reply." " The argument is, that diseases have changed, and
require a milder treatment than formerly ; but the argument, cceteris paribus,
is without foundation. It is evident that a person of a robust constitution re-
quires depletion as much in these days, while labouring under acute inflamma-
tion, as he would have twenty years ago. And furthermore, we are constrained
to say that, in our belief, many persons die annually in the city of Manchester,
of acute inflammatory diseases, treated by various quacks, or in a feeble, in-
adequate mode by some of our regular physicians, that might be cured by pro-
per, energetic, and decided treatment. If the people choose to be led astray
by the multifarious varieties of empiricism of the present day, let it never be
said that we are forsaking the accumulated light of science, made brighter and
brighter by the addition of the labours and experience of all the illustrious
sages of our profession, from the days of Hippocrates to the present time. The
time will come, if not in our day, when the medical profession will have less of
charlatanism connected with it than at present, for ' truth is powerful and will
prevail/ "

The subject of an oration delivered before the New Hampshire Medical

208 Bibliographical Notices. [Jan.

Society on the first day of the session, the transactions of which are under con-
sideration, by Dr. Thomas H. Marshall, is " the contributions of quackery to
true medical science." We like the general tone of this oration. We freely
admit with its author, that, to the truly scientific physician, "all means are
his." " His is the search for truth, and he will not refuse the boon by what-
ever hand it may be offered. But in doing so, he takes nothing on trust.
' Prove all things, hold fast that which is good/ is his motto. His facts must
not be seeming, but fixed facts, and his conclusions will be based, not upon one,
or a few of those, but upon many, carefully collated and rigidly analyzed." We
are not disposed to deny that some few useful remedies, an occasional happy
formula have been introduced or made conspicuous even by empirical pre-
tenders ; and we have no objection to receiving these or any other really valua-
ble hints that may be offered us by outsiders. We agree with the late Dr.
Wistar, that " if an ignorant nurse should happen, in the course of long years
of practice, to stumble upon something that may be advantageously employed
for increasing the comfort or assuaging the suffering of a patient, it would be
folly in us to reject it, because of the humble source through which it reaches
us." But we should not feel disposed to dignify what means or hints we thus
derive as contributions made by ignorance or quackery to true medical science.
Dr. Marshall speaks of valuable "modes of practice" as having been introduced
or rendered conspicuous by empirical pretenders. Of these we must plead our
entire ignorance ; we are not aware of any valuable plan for the treatment of
disease, the parentage of which can be fairly traced to such a source.

While we freely admit that positive as well as negative good has accrued to
legitimate medicine from the very ignorance and recklessness of quackery, we
nevertheless insist that Dr. Marshall has conceded far more credit to certain of
the quackish practitioners of the day for the benefits they have indirectly con-
ferred on true medical science, than they justly deserve.

We are not prepared to credit quackery with the slightest contribution made
to legitimate medicine. If, perchance, from its blind ministrations some useful
hint may be derived, developed, and properly applied by the scientific physician,
good and well ; but as the boon thus conferred cannot be received as the legi-
timate fruit of quackery, let us not be over anxious to watch its empirical
practice as one of the sources through which sound therapeutics is to be bene-
fited and advanced.

In a report on the diseases of Strafford District, Dr. Levi G. Hill notices the
unusual number of cases of puerperal convulsions that occurred during the
year 1856, and the fact that, after parturition, recovery was not as favourable
as usual.

Of puerperal convulsions he relates the history of nine cases. Three of these
terminated fatally. The convulsions occurred at different periods before, during,
and subsequent to parturition, principally in young subjects. In all the cases
bleeding and purgatives were employed, and in most of them chloroform and
ether by inhalation.

" If we inquire," says Dr. Hill, " into the philosophy of these cases, we shall
see the importance of unloading, so to speak, the womb, bowels, and blood-
vessels, as soon after the convulsions occur, as prudence will permit, if indeed
we do not anticipate and prevent them by suitable evacuations."

An interesting article, containing miscellaneous observations in obstetrics
and diseases of women, is communicated by Dr. Wm. Henry Thayer.

In an inquiry into the effect upon the duration of labor produced by artificial
rupture of the foetal membranes, Dr. T. arrives at the conclusion that a rup-
turing of the membranes on the part of the practitioner is rarely called for,
either after or before complete dilatation of the os uteri. When the membranes
are so exceedingly tough as to delay the labor, as we may judge to be the case,
when with a large pelvis, a full dilatation of the os uteri, and regular and suffi-
ciently active pains, they remain unbroken, there can be no doubt as to the
propriety of their artificial rupture. Where, also, the labor is impeded by the
large amount of liquor amnii, or where there is a large quantity of fluid between
the amnion and chorion, the artificial rupture of the membranes will tend to
expedite delivery.

1858.]

Transactions of State Medical Societies.

209

To guard against flooding, Dr. T. recommends the administration of ergot
immediately after the termination of every case of labor, and we consider the
recommendation a safe and judicious one.

Dr. T. does not believe it to be necessary to wait until pulsation in the cord
has ceased before applying the ligature, and dividing it. From a careful con-
sideration of the subject, he concludes, that if respiration be fully established
in the newborn infant, the cord may be cut, whether pulsation has ceased or
not in the cord. We fully agree with him as to the correctness of this con-
clusion.

" There are cases," he properly remarks, " in which the establishment of
respiration appears to be actually prevented by too full a state of the vessels,
and the child would perhaps never breathe if the umbilical cord were not
divided."

Dr. T. relates a case of conglutination of the os uteri, the result apparently
of extensive and long continued ulceration of the cervix uteri, in which delivery
took place after the incision of the cervix.

3. In the minutes of the extra meeting of the South Carolina Medical Asso-
ciation we meet with some interesting remarks on the employment of chloro-
form. Dr. Mayes has seen prompt relief produced in colic, and similar affec-
tions from a few drops of a solution of camphor (one drachm) in chloroform
(one fluidrachm). As a local application in neuralgia, Dr. J. B. Witherspoon
highly recommends the following: R. — Camph., sulph. morphise, aa, 3j ; chlo-
roform ^j ; lard §ss. — M. Dr. A. N. Talley has given the chloroform by inha-
lation in lead colic with good effect, using at intervals, as a local application,
an ointment composed of chloroform ^ij ; oxyd. zinci gss : cerat. simpl. ^j. — M.

In the address, at the opening of the annual session by the president, Dr.
Horlbeck, it is very justly remarked, as one of the impediments to the success
of medical associations, that "we are too apt, in the inception of an under-
taking, to expect extraordinary results to arise at once from it, and when we
are disappointed at the non-fulfilment of overwrought anticipations, to sink to
a proportionate state of depression."

Unfortunately, too many of those who enter into our medical associations, in
full confidence that every desired reform in the condition of our profession is
to be promptly effected through their agency, overlook, or at least greatly un-
derrate the silent but not less beneficial influence these associations constantly
exercise, and not experiencing through their action, at once, results commen-
surate with their exaggerated anticipations, whether in reference to what they
esteem the chief good of the medical profession, or in the promotion of their
own individual interests, they permit their zealous co-operation as members
gradually to flag, and finally to become extinguished.

Well conducted and zealously supported medical associations, independently
of their agency in the accumulation, collation and arrangement of facts, adapted
to improve and extend the science and the practice of medicine, are promotive of
influences that are not less beneficial to the true interests of the members of
the profession, individually and collectively.

In the appendix to these Transactions, is contained a paper read at one of the
sessions of the society, by Dr. J. A. Mayes, presenting observations on the
medical properties of the gelsiminum semper vir ens, or yellow jessamine. The
following concluding paragraphs exhibit a summary of Dr. Mayes' opinion of
the remedial properties of the gelsiminum drawn from actual observation of
its effects.

" I regard it as a direct sedative; more safe and manageable than veratrum
viride, and more generally applicable in practice.

" I esteem it a most valuaole adjuvant to other treatment in all cases where
high arterial excitement exists, in which it is desirable to lessen the frequency
of the pulse and to calm excitement, and where, as in the case of injuries, it is
desirable to lessen the irritability of the nervous system ; also, in that trouble-
some hysterical exaltation of the nervous sensibilities, so often met with in
enervated females, its value cannot be too highly estimated.

" In short, it is a specific for no particular disease, but an admirable adju-
vant in the treatment of nearly all.

210

Bibliographical Notices.

[Jan.

"With its poisonous effects when given in overdoses, I have no acquaintance,
hut do not doubt the possibility of its doing harm in the hands of the care-
less."

In a paper by Dr. Ware, on the use of mercury in typhoid fever, we find a
very pointed protest against the employment of this, with many, universal fe-
brifuge, in that disease. The doctor founds his opposition upon the essential
difference there exists between the pathological character of typhoid fever and
those affections in which mercurials manifest their happiest effects, and upon
the efficacy of remedies of a totally different character, namely, stimulants and
anodynes.

It is unquestionably true that from mercurialization there is no disease in
which, as a general rule, less benefit is to be anticipated than in typhoid fever,
and yet in the early stage of this fever, and in certain of its complications
where a loaded condition of the bowels is manifest, mercury constitutes one of
our best and safest purgatives ; under certain circumstances, even when admi-
nistered so as to produce a gentle alterative impression, it will be found de-
cidedly beneficial.

The oration delivered by Dr. Smith at the annual session presents, in clear,
forcible, and manly language, a general sketch of the objects and efficiency of
medical organization, and an urgent appeal to the physicians of the state to
unite in their furtherance and support.

4. The physicians scattered abroad in California deserve credit for the early
efforts made by them to effect an organization, so as to " bring together, from
every section of the State, the regular members of the profession ; to harmonize
their views ; to elicit reports on the character and treatment of the various dis-
eases appertaining to the State; to encourage habits of careful observation and
patient research, and thus to elevate the moral and scientific grade of the pro-
fession individually and collectively/' The Transactions of the two annual
sessions that have been held of the California State Society evince a degree of
zeal and industry that was scarcely to have been expected when we take into
consideration the condition of the population amid which the physicians who
have gone there are located, and the adverse circumstances by which, in the
early period of their immigration, many of them were necessarily surrounded.
The results of organization, have, we are assured,1 been already realized among
the physicians of California, by the infusion into their ranks of a proper spirit
of emulation; by the establishment of the most useful and friendly relations
between the members of the profession throughout every portion of the State,
and the inauguration of a system of extended observation and research, which
cannot fail in due time to redound to the advancement of science.

The subject of the annual address by Dr. E. S. Cooper, of San Francisco, is
" deformities of the locomotive apparatus/' or, more properly, the description
of an apparatus by which patients labouring under chronic deformities of the
lower extremities are enabled to walk about during their treatment.

" I do not claim/' Dr. C. remarks, " that the series of apparatus which I have
invented will remove all difficulties and secure a complete exemption from fail-
ure in attempts to effect an entire cure of all cases ; but I do claim that they
simplify the treatment, and can be made to succeed in cases when failure must
be unavoidable by any other process heretofore brought into general use among
the profession, and I claim that they do so by possessing at least the following
superior merits: —

"1st. In distributing the pressure nearly equally over the entire surface of
the deformed limb, and thereby obviating the danger of sloughing, as well as
lessening, to a very great extent, the attendant pain produced by the use of all
ordinary apparatus.

"2d. By being so simple in their construction as to be readily applied by
any practitioner of ordinary ingenuity.

" 3d. Being nearly like the ordinary boots, which all experience proves to
be better adapted to walking than any other ; the ultimatum of our treatment

i Report of the Corresponding Secretary, Dr. T. M. Logan.

1858.] Transactions of State Medical Societies. 211

being to bring the foot as nearly as possible into proper condition to bear with
grace and ease the boot or shoe of everyday use.

" 4th. By rendering walking the great agent of cure ; being so arranged that
many steps the patient takes places the contracted tissue in a state of increased
tension, let the deformity be of what variety it may.

" 5th. In the great ease and comparative comfort with which they are worn,
and by which patients are rendered more persevering in their use. This is, of
itself, a desideratum, because in all very obstinate cases the orthopedic surgeon
has sufficient need of the greatest perseverance on the part of the patient.

" In fact, there are many cases susceptible of complete cure, and cause little
inconvenience by the use of apparatus, which keeps up slight but regular pres-
sure for two or three years, allowing the patient in the mean time to go about
as usual, in which any attempts to effect an immediate change in the parts,
either by knife or apparatus, would jeopardize the patient's life."

The apparatus of Dr. C. is thus described : —

" The spring boot is very like an ordinary boot, made on a last, two or three
sizes larger than the foot. The boot is open in front from the top to the toe,
but has buckles and straps by which it can be made to fit closely to the foot
and leg. The boot leg is studded with whalebone splints, which make it very
stiff. Two tin cups are fastened to the toe, one on either side. A tin splint
reaching from near the middle third of the thigh to the lower part of the calf
of the leg, being longer or shorter, owing to the degree of flexion, or in different
cases. A tin cup, on either side of this splint, is fixed on a line with those of
the boot toe. These cups contain spiral springs made of steel.

" The splint is fixed to the back part of the limb by broad leather straps
passing around the knee, which are kept in their proper position by loops
placed at short intervals over the surface of the splint. Wooden rods, of light
quality, rest upon the springs above and below, so that in the beginning of
every step the rods are made to compress the springs, which, reacting, com-
plete the step with very little effort on the part of the patient. When the ap-
paratus is properly adjusted, it is almost impossible for the patient to sprain
the limb by a misstep, even if it should be caused by a sudden descent of two
feet or more. In fact, the limb is so protected that, unless the patient fall
directly upon the front part of the knee, he is not liable to injury by moderate
walking, let the joint be as weak as it may."

In a paper on typhoid or enteric fever, Dr. Ira E. Oatman remarks that

"This disease prevails along the Pacific coast and around the Bay of San
Francisco to some extent, in the malarious valleys of the Sacramento, and ex-
tensively in the higher altitudes of the mining regions and the mountains. It
mostly affects the young and middle-aged, and is exceedingly variable in its
mode of attack, its prevailing symptoms, its progress, and termination ; its
fatal effects being often wrought before any positive indications are manifested
of their existence. Although it is stated in books that the disease is easily
controllable by treatment, I do not often find it so ; for even the cases which
recover seem to be little affected by the treatment employed. I have treated
this disease medically and hygienically through its whole course, and almost
wholly without medicine, with little apparent difference in the results. Yet I
am fully convinced that medicine is beneficial in most cases — if not at all times,
still it is highly useful to meet the various indications during its continuance.
With a single exception, the purely expectant treatment has given me the best
satisfaction.

" This exception is important, as it is not usually indicated by the direct
symptoms, but must be determined from a knowledge of the history of the case.
If the patient has resided in a malarious district within many months of the
attack, whether the fever is obviously remittent in its type or not, it is gene-
rally benefited, in a majority of the cases, by the liberal use of quinia sulphas.
Those who do not improve during its administration are, to say the least, not
injured by it. I usually combine with it the pulv. ipecac, et opii, in the pro-
portion of gr. v of the former to iv or v of the latter, for each dose, and, the
bowels being freely open, give this dose every four hours for about two days.
This treatment, in some cases apparently typhoid, will entirely eradicate the

212

BiLliograjphical Notices.

[Jan.

fever, and with it all its consecutive affections, proving that the fever was
purely malarious in its origin. But when the most favourable result does not
follow its use, still the heat of the skin abates, the aching pains in the head,
back, limbs, etc., subside, the tongue and mouth become more moist, and the
pulse reduced in fulness and in frequency, from 100 or 120 to 70 or 80 in a
minute.

" This state often lasts for two or three days, thereby removing, in a great
measure, for the time being, the danger of serious local disease. But if the
fever is not purely malarious in its origin, or if so, and follicular inflammation
is already fully established in the mucous membrane of the bowels, then the
avenues through which the nutrient properties of the ingesta reach the blood
being partially or wholly obstructed, the blood becomes impoverished, the
brain and nervous system become irritable, the heart and arteries act more
rapidly, and we have a fully developed case of enteric fever, but one more sim-
ple and less dangerous than it would have been without the action of the
quinia, &c, in removing the malarious influence.'"

An interesting case in which both the internal iliac artery and vein were in-
cluded in a ligature, is related by Dr. E. S. Cooper. No bad effects resulted,
the patient recovered completely and rapidly. Some remarks are appended
to the case in reference to the propriety of ligating "the satellite veins in con-
junction with the arteries which they accompany, in all cases in which a liga-
ture is demanded."

The report of the committee on obstetrics, by Dr. H. Gibbons, of San Fran-
cisco, presents a hasty sketch of the general causes which render so common
the prevalence of uterine disorders in California. These causes, according to
the reporter, are such as have a tendency to produce an undue excitement
of the female organs of reproduction. The potency of these causes

" Was soon observed in the frequency of conception among women who had
for years ceased to bear children. It was not uncommon for friends who had
relinquished the duties of the nursery for five, ten, or even fifteen years to find
themselves unexpectedly called to resume those duties. It was also exhibited
in the frequency of twin births, the greater tendency to miscarriage and to
uterine hemorrhage, the derangements of the menstrual function, and the count-
less host of neurotic maladies of uterine origin, so harassing to patients and so
perplexing to physicians.

" That infants at birth are above the average size in California is attested by
many accoucheurs. Ten pounds is a very common weight, and in my practice
of six years two children have been born weighing respectively 12j and 13
pounds, either of them larger than any child that I had delivered in nearly the
same range of obstetric practice in Wilmington and Philadelphia during
twenty-two years." " Twins, I believe, are indisputably more frequent than
in the old States, and triplets are by no means unheard of."

Dr. Gibbons presents a mournful picture of the practice which prevails
among pregnant females of procuring abortion to rid themselves of the pain,
cost, and annoyance of gestation, parturition, and lactation.

" The extent," he observes, " to which this practice prevails in California is
disgraceful. Married women often appear much more alarmed to find them-
selves pregnant than maidens. Every physician must have encountered the
most anxious and distressed inquiries on the subject. Not only does the prac-
tice pervade the circles of fashionable life, but it exists among women who
acknowledge in the general tenor of their conduct the restraints of morality
and religion."

" Miscarriages," Dr. G. informs us, " were more frequent six years ago than
now. In San Francisco they were attributed to the hilly and sandy walking.
Hard work at the wash tub and ironing table, and other drudgery, to which
delicate women have been subjected, aided in producing the result. But there
was evidently an inherent cause deeper than this — a strong tendency to ute-
rine hemorrhage has been observed in connection with miscarriages.

"Beyond all due proportion to the number of births is the number of still-
born children. This is partly owing to the frequency of untoward presenta-
tions, and of preternatural and complicated labours. But mismanagement

1858.]

American Insane Hospital Reports.

213

and neglect do much more mischief. This branch of practice is greatly in the
hands of ignorant women and inexperienced men, whose services are valued
because they are cheap. Human life in general being set at a low valuation
in California, such results might naturally be anticipated. Besides, there is a
want of the proper maternal instinct, or, at least, a low degree of it, in a
very large number of women. They are averse to the care and burden of off-
spring, and their indifference or dislike has its natural results, not only in the
large proportion of stillborn children, but in the great mortality after birth
and during infancy.

" Mammary tumours and abscesses are common, and, as a consequence,
many infants are deprived of the natural and most healthy fountain of nutri-
ment. This adds slightly to the infantile mortality."

" Apart from the direct influence of the uterine system on the brain and
nerves, which operates with undue force, the nervous organization is subjected
to greater excitement from other causes in this country than in older settle-
ments. From the exalted sensibility thus established, it might be inferred that
puerperal convulsions are not uncommon. Such appears to be the fact. I
may add, that chloroform and ether have relieved a number of unpromising
cases of this description. In one instance in my charge about two years ago,
I kept the patient for several hours under the moderate influence of ether.
The remedy was resorted to after the failure of other potent remedies, and to
it I attribute the saving of a valuable life. Conjoined with venesection, the
anaesthetic treatment is generally safe and efficacious, if not pushed too far.

" Fever is a common attendant on the puerperal state. In the large propor-
tion of cases it assumes an intermittent form, or a remittent bordering on an
intermittent, and yields readily to quinia. Peritonitis, if it exists at all, is not
often a prominent symptom in these cases."

A case of successful ligature of the common carotid is related by Dr. K.
Beverly Cole, of San Francisco. The ligature was applied for the arrest of
hemorrhage, in an extensive incised wound of the posterior and left side of the
neck, opening the pharynx and larynx, and in its course severing the internal
carotid or one of its larger branches. In five weeks subsequent to the opera-
tion, the patient was attending to business as usual. D. F. C.

Art. XVIII. — Reports of American Institutions for the Insane.

1. Of the Friends7 Asylum, Philadelphia, for the fiscal years 1855-6 and

1856-7.

2. Of the U. S. Government Hospital, for the fiscal year 1855-6.

3. Of the Ohio Central State Asylum, for 1856.

4. Of the Ohio Northern State Asylum, for 1856.

5. Of the Ohio Southern State Asylum, for 1856.

1. "The house," says Dr. Worthington, of the Friends' Asylum, Philadel-
phia, in his report for the fiscal year 1855-6, " has been as full, throughout the
year, as was consistent with the comfort and welfare of its inmates ; and, per-
haps, during no similar period have the designs of the contributors been more

fully carried out."

Men. Women. Total.

Patients at the commencement of the year . 59

Admitted in course of the year ... 24 11 35

Whole number 94

Discharged, including deaths .... 28

Remaining, March 1, 1856 .... 66

Of the patients discharged, there were cured . 14

Died 4

214

Bibliographical Notices.

[Jan.

The following truly remarkable statement is made respecting the patients
deceased : " One man and three women have died during the year. The first
was in his eightieth year, and died from the effects of old age ; one of the
women was seventy-nine years of age, and died of paralysis ; the second was
seventy-seven years old, and died of exhaustion from long-continued excite-
ment ; the third was in her ninetieth year, was deaf, dumb, and idiotic, and
died of an attack of diarrhoea."

It is to be hoped that the time is not far distant at which the superintend-
ents of all the hospitals for the insane may be enabled, like Dr. Worthington,
to write as follows: —

" It is gratifying to observe the improvement that has taken place within the
last few years, both in regard to placing the insane under medical treatment
at an early period of the disease, and also in allowing them to remain a suffi-
cient length of time to afford them a fair opportunity to derive all the benefit
the institution is capable of conferring. It is but seldom we have to lament
the premature removal of a patient, except when the pecuniary circumstances
of the individual forbid his longer continuance."

The results of this year " correspond with the experience of previous years,
in showing that about one half of those who recover are discharged within
three months from the time of admission ; that the term of six months nearly
represents the average duration of successful treatment, and that a considera-
ble number recover after having been under treatment for as long a time as
twelve months. It may be mentioned as an inducement for persevering in the
use of remedies, that the recoveries which take place gradually, and occupy
the longest time, are often the most satisfactory and permanent."

In regard to mechanical restraint, it is remarked that " 1 the sleeves/ (cami-
sole?) made of soft material, is the only form in which it is used among our
patients, and, during the last six months, no case has occurred in which it was
deemed necessary, or was resorted to."

In an asylum like that the report from which is before us, where all the reci-
pients of its benefits are " pay patients," it is much more difficult than in
State, County, or City institutions, extensively to introduce a system of manual
labour, or employment. Especially is this true in respect to the occupants of
the department for females. From the subjoined extract we infer that this
difficulty has been, measurably at least, overcome at the Friends' Asylum.

" A few of the female patients engage in assisting the attendants in their
household duties in the wings; but the greater number occupy themselves in
knitting, and the various kinds of needlework. The most of the clothing of
the female patients has been made up in the institution, and a large number of
garments for the poor, the materials for which were furnished by a friend in
the city, have also been made. The advantages of occupation have been par-
ticularly observable during the past year among the excited class of female
patients, some of whom, by persevering exertions on the part of the matron
and attendants, have been induced to engage in it."

It is universally acknowledged that of all the elements constituting what is
called the " moral treatment" of the insane, manual employment which contri-
butes to some useful or beneficent object or end, is the most beneficial. Hence
its extensive application is of paramount importance. We have found, by
experience, that much may be effected towards the object of inducing all the
patients of adequate physical ability to engage in it, by giving currency to,
and constantly sustaining, in the wards, the idea that such employment is
expected from every one ; that it is a part of the established routine; and that
he who refuses thus to occupy a portion of his time, disregards one of the
wholesome regulations of the establishment.

Among the additions to the means of entertainment of the patients at this
asylum, are two of Lloyd's Stereoscopic Cosmoramas. Within a few months
we have seen this convenient apparatus for the exhibition of photographic pic-
tures at several of the hospitals for the insane.

The report for 1856-7, like that of the preceding fiscal year, is ornamented
with two fine pictures; one, a front view of the asylum, the other a view of
the garden and library.

1858.]

American Insane Hospital Reports.

215

Men. Women. Total.

Patients in the asylum, March 1, 1856 . . 66

Admitted in course of the year ... 20 16 36

Whole number 102

Discharged, including deaths .... 44

Remaining March 1, 1857 .... 58

Of the patients discharged, there were cured . 21

Died 9

We hope that our friend, Dr. Worthington, will introduce into his reports,
hereafter, some method by which the whole numbers, of each sex, who have
been in the asylum in the course of the year, can be ascertained. Many im-
provements have been made in the organization, and the internal economy of
the institution during his administration : can he not now find time to revise
and reform his antiquated form of published statistics?

We quote, nearly entire, the doctor's remarks upon the " forms of insanity."

" In the nomenclature of the disease, I have preferred retaining the generic
names of Mania, Monomania, Melancholia, and Dementia, rather than adopt-
ing a more minute subdivision which, however it may appear more scientific
than the older method, scarcely answers as well all the purposes of classifica-
tion. If these terms do not express accurately the nature of the disease, they
are, as it were, consecrated by long established usage, and have at least the
merit of being intelligible. It is difficult sometimes, at first, to decide under
which of the above heads a given case shall be classed, from the fact of the
changing phases of the disease ; a case occasionally in its progress exhibiting
the character of two or more of the above forms. Thus a patient affected with
monomania, under some real or imaginary provocation, will break out into the
excitement and violent acts of mania; the depression of melancholia, though
essentially distinct, in some cases bears a close resemblance to the inertia of
dementia; some of the demented are subject to paroxysms of maniacal excite-
ment; and even the deep dejection of melancholia alternates, in some instances,
with the elevation of self-pleasing monomania. These changes show that the
above-named do not indicate so many distinct diseases, but rather varying
forms of one and the same disorder. Yet, in most of these cases, there are
predominant features which assign the patient to one of the above forms in
preference to the rest.

" One reason for the above classification of insanity, is the avoidance of the
term ' moral insanity,' which has been so greatly misunderstood and perverted
that it would, perhaps, have been better had it never been invented. As gene-
rally understood, this term conveys the idea of a condition in which patients,
without any impairment of their mental integrity, are so much under the con-
trol of some evil propensity as to be utterly powerless to resist it, and conse-
quently irresponsible for any act committed under its influence. There may
be cases of insanity in which a disposition to immoral conduct is conspicuous,
and in which mental disorder may not be very apparent; yet to say that the
indulgence of this disposition is of itself any evidence of the disease called
insanity, shows very confused ideas on the subject. The habitual indulgence
of bad passions may lead to insanity, but when this condition is reached, it is
manifested by other signs of mental impairment than mere inability to resist
them. Perverted sentiments and excited passions, though not alone constitut-
ing insanity, do often, however, enter largely into its manifestation. The
proneness of maniacs to irritation and anger, and their disposition to fancy
themselves the objects of actual or intended wrong, are among the forms under
which self-love manifests its predominance. The delusions of the monomaniac
often show the effects of inordinate self-esteem, and anxiety for promotion and
honour among men."

We cannot agree with Dr. Worthington in the desire to avoid the term " mo-
ral insanity." Unquestionably, there are cases in which perversion of the sen-
timents is as prominent and distinguishing a characteristic of the disease, as
are high excitement, vociferation, violent gesticulation, and turbulence, in acute
mania. We would, therefore, not only not avoid the term in question, but use

216

Bibliographical Notices.

[Jan.

it as frequently as convenience may require, if but for the purpose of establish-
ing in the minds of men the fact of the existence of such a disease. This fact
has been doubted, disputed, denied, ridiculed ; not among the laity alone, but
by members of the several professions, and even where it should be doubted
least, upon the judicial bench. Let, then, those persons whose professional
position best enables, and most requires them to do it, continue their exposi-
tions of the disease until it shall be generally recognized.

In the remarks upon " Occupation" in the report before us, it is stated that
" experience teaches that three or four hours each day is as much as can gene-
rally be required/' advantageously, of the patients.

" There are but few cases in which there is not discernible some derange-
ment of one or more of the organs or functions of the body, which must be
met by appropriate medical treatment. In most cases, tonic medicines and
those calculated to allay nervous irritation, are requisite ; while those of an
opposite character, as are all depressing remedies, must be carefully avoided.
The cases in which bloodletting would be beneficial, are extremely rare ; while
in a large majority it would be decidedly injurious.

"One of the large rooms on the first floor of the centre building has been
fitted up with seats and cases, and other necessary fixtures of a lecture-room,
for the use of the patients. The philosophical apparatus has been removed to
this room, thus affording increased facilities for demonstrating some of the
familiar principles of natural science."

2. The annual report from the Government Hospital for the Insane, near
Washington D. C, is signed by Dr. Benjamin S. Bohrer, President of the
Board of Visitors, and Dr. C. H. Nichols, the Superintendent.

Patients in the Hospital July 1, 1855
Admitted in course of the year

Whole number

Discharged, including deaths, .
Remaining July 1, 1856 .
Of those discharged, there were cured
Died

Men.

"Women.

Total.

26

34

60

36

11

47

62

45

107

8

6

14

54

39

93

3

2

5

4

4

. 8

We quote the following extract from the report, because it relates to a sub-
ject heretofore unmentioned, so far as we recollect, in any of the American
reports.

" Only five, or about 8 per cent, of the sixty-three persons admitted before
the commencement of the Hospital year to which this report relates, had been
insane for a less period than one year at the time of admission ; while of the
forty-seven admitted this year, nineteen, or about 40 per cent, had, as well as
could be ascertained, been insane less than one year, and were more or less
hopeful in respect to recovery.

" This very satisfactory improvement in the character of the patients re-
ceived the past year, is likely to continue for two or three years to come, when
the proportion of recent cases to the whole number admitted will reach its
maximum of about 64 per cent., as is made to appear in a late report of the
celebrated Friends' Retreat, near York, England, which now sums up a very
carefully recorded experience of sixty years.

" It might at first appear that when a particular institution has been in
operation long enough to receive all the protracted cases which had accumu-
lated in the absence of convenient provisions for their accommodation, the sub-
sequent admission from the vicinage would be mostly cases of short duration ;
but a little reflection will render it apparent that the experience of that ancient
establishment, just cited, is perfectly consistent with the probabilities every-
where.

" The thousand refined dissipations of modern civilization give rise to many
cases and forms of mental derangement whose existence is at first debatable,
and as it has often happened in the past, so it will probably continue often to

1858.]

American Insane Hospital Reports.

Ill

happen in the future, that the timidity, or affection, or pride, or cupidity, or
inability of friends, will defer a resort to hospital treatment till the disease
becomes as confirmed as it has long been apparent and troublesome."

Some of the peculiarities of the Government Hospital, and some of the ad-
vantages springing therefrom, are thus alluded to :- —

"That this establishment will afford a home for life for all its incurables ;
that they are separated from their friends, and are independent of them, and
dependent upon the institution ; that the soldier and the sailor are habituated
to obedience and order; are all circumstances which, taken together, are cal-
culated to give us a more complete and easy control of the time and habits of
our patients than has hitherto been practicable in any American Hospital for
the Insane. It is our aim as a permanent policy, to turn these favorable cir-
cumstances to account in effecting the gradual engagement of all our incurables
who have been accustomed to any form of manual labor, in some wholesome
and useful employment.

" Our efforts thus far have been encouraging beyond our most sanguine ex-
pectations. No accident has happened, though several patients have been
intrusted with tools who had previously been deemed dangerous. Refreshing
and sound sleep has taken the place of the most vicious indulgences ; pallor and
listlessness have given way to ruddiness and strength; and, above all, increased
interest in life and its objects and affairs, has added light to the eye and anima-
tion to the step. Indeed, we have often been astonished to observe how the
industry and good conduct of our patients have kept even pace with the encour-
agement and confidence they have received at our hands."

3. The Eighteenth Annual Report of the Trustees and Officers of the Central
Ohio Lunatic Asylum, at Columbus, is a pamphlet of seventy-six large duo-
decimo pages ; and yet it furnishes but little matter which comes within the
usual scope of our notices. The superintendent, Dr. R. Hills (superintendents
succeed each other at this institution almost as frequently as the annual reports),
occupies a large part of his report by an exposition of the " wants" of the
Asylum. We proceed to make some extracts.

"But little can be said of our farming. The principal portion of our farm
is but slightly removed from a state of nature, it being in the condition of what
is usually termed a woods pasture.

" An abundance of water in such an institution is indispensable. Our
arrangements therefor are very imperfect, troublesome, and expensive. Much
of the time during the past summer, it has been necessary to economize its
use carefully, and a portion of the time it has been necessary to carry it into all
parts of the house by hand.

" The barn ' is a wooden structure/ at this time in a state of complete dilapi-
dation, and it is with regret that we are compelled to use it for even another
winter.

" Workshops for a variety of mechanical operations are found in most other
institutions, got up for the benefit of patients. Ours has none I That at Utica
has a printing office. * * * * There are also cabinet shops, turning lathes, tailor
and shoemaking shops, &c. Other institutions are similarly provided ; but
what have we ? Absolutely nothing ! Not even a shoe-bench.

" As many as ten years since there were over six hundred volumes in the
library, and it was then the practice to make yearly appropriations to increase
the number. Now, the entire miscellaneous library comprises less than 275
volumes. Those in any manner touching the subject of insanity, number 31
volumes. Those on medical and scientific subjects, 37 volumes. They are
old, and most of them have little value.

" There is not a single sofa in the patients' halls ; there are three lounges of
domestic manufacture, hard and uncomfortable, and six split-bottomed rocking
chairs, with one wooden one in the eastern hall, for the comfort and convenience
of one hundred and twenty-five females ! There is scarcely a log-cabin in Ohio
that is not better provided in these respects."

These extracts are sufficient to convince the reader of the decadence of the
institution at Columbus, an institution which, during the first twelve years of

218 Bibliographica I Notices. [Jan .

its existence, sustained its position amongst the best of the kind in the United
States. This decadence is acknowledged by Dr. Hills, in the remark, " had the
asylum been originally intended for or purposely permitted to degenerate into
a mere receptacle for the incurable insane, where the simple physical wants
and ordinary necessities of life were to be provided for with even a generous
hand, then could I say that those for whose benefit it was created are as well
provided for as it is possible for them to be under any circumstances, or in any
institution of the country. But it is otherwise. It has a much higher aim.

" The question," he continues, " as to what, where, and when have been the
influences that have lost to us our former pre-eminence, it is not proper for me,
nor am I disposed, to discuss. I will only say, that without an intelligent,
active, and faithful superintendence; a wise, liberal, and harmonious directory ;
a generous and open-handed legislation ; and, with all, and over all, a Divine
sanction, we cannot expect success."

Unhappily this institution has been so wholly controlled by partisan politics
that, in the course of seven or eight years, it has had a succession of no less
than five superintendents, most of them elected in conformity with the modern
political dogma, " to the victors belong the spoils." Dr. Hills has given a long
detail of the "wants" of the Asylum, and says, "to specify all our wants would
be too tedious." Among those which are not specified are the first, the greatest,
the most important. These are separation from partisan politics, and a compara-
tively permanent superintendent. Supply these two primary and radical neces-
sities, and the number of other " wants" would very rapidly decrease.

Patients in the Asvlum, Nov. 15, 1855
Admitted to Nov. 1st, 1856

Whole number

Discharged, including deaths .
Remaining, Nov. 1st, 1856
Of those discharged, there were cured
Died

Causes of Death. — Phthisis puimonalis, 3 ; apoplexy, 3 ; typhomania, 3 ; epi-
lepsy, 3 ; hemorrhage from bowels, 2; dysentery, 1 ; organic disease of brain,
1 ; anasarca, 1 ; anaemia, 1.

Throughout the year the inmates enjoyed " an unusual exemption from epi-
demics, and even the ordinary diseases of the climate and season."

All statistics prior to the last fiscal year, are omitted from this report.

Men.

"Women.

Total.

109

107

216

68

86

154

177

193

370

75

72

147

102

121

223

30

34

64

9

9

18

4. On the 1st of December, 1854, Dr. L. Firestone commenced his duties
as superintendent of the Northern Ohio Lunatic Asylum, at Newburg. On the
5th of March, 1855, the first patient was received. On the 5th of August, 1856,
Dr. Firestone was subjected to the political guillotine, and his place filled by
Dr. R. C. Hopkins.

On the 14th of August, Dr. Jacob Laisey was appointed assistant physician,
and Mr. E. H. Doolittle steward.

Judging of the future by the past, the official existence of Dr. Hopkins will
be coextensive with the predominance of the party which has borne him into
office.

From the 5th of March, 1855, to the 31st of October, 1856—

The number of patients admitted was
Discharged, including deaths .
Remaining Nov. 10, 1856
Of those discharged, there were cured
Died

Men.

"Women.

Total.

]26

160

286

60

87

147

66

73

1391

47

57

104

4

11

15

1 The statistics in the Report, instead of being given in one place, by the super-
intendent, are partly included in the report of that officer, and partly in that of the
trustees. Dr. Hopkins states the number remaining on the 1st of Nov. to be 141.

1858.]

American Insane Hospital Reports.

219

" During the first two weeks of our occupancy of the house," remarks Dr.
Hopkins, " a few cases of dysentery, of a mild form, occurred. Fortunately no
deaths occurred from this cause."

" The year just past has shown a steady increase in the number of those
seeking relief in the asylum, so that at its close, we find it crowded to the full-
est possible capacity. * * * The number of applicants on file (25) which we
have been unable to accommodate, gives us no hope of a less average than for
the past three months.

From the state of things in Ohio, during the past few years, we infer that the
new hospitals were erected upon contracts, the giving of which was in the
hands of political partisans. Hence we are not surprised at the subjoined
language of the report: —

" The repairs upon the buildings and out-buildings have been expensive, and
still more expensive ones will be required in the year to come, or parts of the
buildings must go to speedy decay. This may appear almost incredible of
structures so nearly new. Yet the fact is plainly visible to the most casual
visitor. Among those which have been made, or are now in progress, the re-
building of the gas-well is most prominent. The gas-house can hardly be kept
from falling until spring, and it will be necessary to rebuild nearly or quite the
whole structure then, if not before."

" The removal of the barn and other out-buildings to a uniform and more
convenient locality, promises to add much to the comfort of our stock, and those
having them in charge."

" I am satisfied that prudence and economy would dictate the substitution
for the present rickety and badly-geared pump, a larger and more simple ma-
chine."

" A change of the kitchen and bake-room, from their present smoky, out-of-
the-way location, directly over the boilers, to a more central and convenient
one, is desirable — I might say absolutely indispensable. The fixtures of these
apartments will need to be nearly all replaced, somewhere in the approaching
spring."

All this is exceedingly encouraging information in regard to an establishment
which had been in operation but one year and eight months, and which was
constructed at a time when the knowledge of the best and most convenient
architectural arrangement of buildings and apartments for the insane had
arrived at a high degree of perfection.

5. Dr. Joshua Clements was the superintendent of the Southern Ohio Luna-
tic Asylum, at Dayton, from the time of its opening, September 1st, 1855, until
the 1st of May, 1856, the somewhat protracted period — protracted for Ohio — of
eight months. The star of his political opponents having now gained the
ascendant, he was "for such a worthy cause" removed, and his place supplied
by Dr. J. J. Mcllhenny.

Patients in the Asylum, Nov. 1, 1855
Admitted in course of the year
Whole number . . .
Discharged, including deaths .
Remaining, Nov. 1st, 1856

Men.

"Women.

Total.

23

23

46 1

87

88

175

110

111

221

40

44

84

69

64

1332

Causes of Death. — " Apoplexy, 1 ; exhaustion, 2 ; inanition, 1 ; hemorrhage
of bowels, 1 ; chronic dysentery, 1 ; apnosa, 1 ; chronic gastritis, 1 ; disease of
heart, 1 ; tabes mesenterica, 1.

The Italics of "apnasa" are ours. Some light is probably thrown upon this
case by the following statements, on a subsequent page of the report: " One of
our number committed suicide, by hanging himself to the window in his room,

1 According to the report of the preceding year, 48.

2 This line is given as in the report, although from the figures above it, it should be
70—67—137.

220

Bibliographical Notices.

[Jan.

with a strip torn from a sheet on his bed. He was early discovered, but too
late for resuscitation."

"In the months of May and June, erysipelas seized upon a number of our
patients, in quite a severe form, and at one time, threatened to seriously invade
the whole house ; but, by strict attention to cleanliness and regimen, it ceased
its violence, assumed a sporadic character throughout July and August, and
finally disappeared from the house, without producing any deaths, or any very
deleterious results."

Our business with the reports of the public institutions for the insane, relates
more to the matter which those reports contain, than to the manner in which
that matter is conveyed. Yet, when we meet with language like that of the
following extracts, we cannot help wishing that a little more care had been
taken.

" There have been three elopements the past year."

ii The relation of mind and body are so intimately and intricately blended
that neither can suffer injury without the other. The sympathetic relation
existing between the complex machinery of our systems is so mysterious in its
workings, that, to fully understand and comprehend the influences which, in
this way, may be exerted upon the mind, involves facts which have been, per-
haps, too little studied, even by medical men.

" The idea that it was rather disgraceful to send a near and dear relative to
an insane asylum has now, happily, but few advocates. But, on the con-
trary, at the very first onset of dethroned reason, many persons now are
not only willing, but solicitously anxious to have them cared for in a place of
this kind.

" Such a state of public sentiment needs not only encouragement, but a
care to instil it into the minds of the community."

Dayton, like Newburg, furnishes some of the beauties of buildings of which
politics is the foster-mother.

"It is impossible," say the trustees, " to wash the floors without endanger-
ing the plastering below. They were made, as the large cracks indicate, of
unseasoned or wet material."

"The cooking ranges were worthless. Their place has been supplied by a
cooking stove."

" Last winter it was found impossible to warm comfortably the four wards
then in use, though one hundred bushels of coal and five cords of wood were
daily consumed. We have been obliged to have the boilers reset, and new
castings provided for their fronts. * * * Attempts have been made to remedy
other important defects in the heating apparatus."

" The water-closets are defective ; health and comfort require their re-
modelling.

" The pumps and pipes now in use for elevating the water to the tanks in
the attic, are too small to furnish the necessary supply. New ones have been
ordered."

" The roof on many parts of the building leaked badly. After several in-
effectual attempts to remedy it without, we deemed it necessary to put an
entire covering of tin on the dome, and have contracted for the work."

" Owing to the leaking of the roof and floors, much of the plastering has
fallen, and must be replaced."

" There is a great defect in the system of ventilation for the whole house,
and particularly the wards. A small sum expended for the purpose might
effect a great improvement, though it is now impossible to render it as perfect
as it might, and ought to have been made in the construction of the building."

" From the basement to the cupola the locks were of a bad quality. The
most worthless have been removed, and better ones substituted."

We have now completed the task — a most disagreeable one, it is true — of
presenting to our readers some of the defects of the three State Institutions of
Ohio, as they are represented by their trustees and executive officers. Those
institutions stand as the monuments of a most deleterious policy — a policy
which blasts every philanthropic establishment into the management of which

1858.]

American Insane Hospital Reports.

221

it is introduced — a policy which we shall continue to denounce, wherever and
whenever, and by what political party soever it may be adopted. "We saw the
New York City Lunatic Asylum when it was under the political regime, and
we have seen it years after its emancipation therefrom. It presented, at the
two different times, a most remarkable contrast. The popular ideas of the two
opposite states in the future world are scarcely more dissimilar. The Xew
York Institution is regenerated ; and the institutions of Ohio are in the path
which, if long pursued, will reduce them to its former condition. Such a re-
salt is inevitable.

The superintendents of the institutions in Ohio will observe that we are
writing against a principle of action which, although it may have brought them
into office, does not necessarily in the least affect their qualifications for those
offices.1 They may be, for aught we know, better adapted to the peculiar posi-
tions which they occupy than any other persons in Ohio. Personally, we have
no acquaintance with either of them, yet we hope that, if they be properly
qualified for their places, they may retain those places until the institutions
under their care shall rank among the best in the country. Dr. Hopkins has
had considerable experience in the business as Assistant Physician at the
Central Ohio Asylum ; and the elaborate report of Dr. Hills very clearly de-
monstrates that he understands the necessities of an establishment for the
insane.

The buildings of the two new hospitals in Ohio are not the only ones of the
kind, in this country, which were shabbily constructed. All such edifices, if
built by contract, are very likely to be defective in the extreme. The building
of the Pennsylvania State Hospital for the Insane, although but six or seven
years of age, is already feeble, decrepid, rickety, superannuated, and will soon
be unable to sustain its own weight without additional assistance. A structure
of the kind ought to be intended for the wear and tear of centuries.

Unseasoned lumber has been used in many of the recently erected hospitals.
Hence, in many places where joints should" be perfectly tight, there is suffi-
cient space to admit the finger. There are base-boards with an opening of
from one-half to three-quarters of an inch between them and the floor, and
doors with the panels shrunk so far out of the frame that you may thrust your
hand between them. Much has been said and much has been written upon
the subject of ventilation. This is well ; and every properly constructed hos-
pital should be supplied with some means for changing the air, which for-
merly was not taken into consideration by the architects. But if the buildings
are to be like some to which we have alluded, all this extra labour and expense
is unnecessary. The greatest difficulty will be to prevent the air from being

1 Since the above was written, we have been informed that in the appointment of
Dr. Hopkins to the superintendency of the Asylum at Newburg/ political party con-
siderations were waived. He obtained his office simply for the reason that he was
qualified for the performance of its duties. How strangely soever it may appear to
the citizens of Ohio, that a man should succeed, by so novel a process, in getting into
a place of responsibility and profit, we trust that the result will be such as to induce
those who have the distribution of offices in the benevolent institutions, to persevere
in their commenced course of well-doing.

changed too rapidly.

P. E.

No. LXIX.— Jan. 1858.

15

222

Bibliographical Notices.

[Jan.

Art. XIX. — American Surgical Tracts.

1. Remarks upon Fractures of the Scapula, with Cases presenting Striking
Peculiarities. Read before the Medical Society of the State of Georgia, at
their Annual Meeting in Augusta, 1857. By L. A. Dugas, M. D., Professor
of Surgery in the Medical College of Georgia. 8vo. pp. 22.

2. Early History of the Operation of Ligature of the Primitive Carotid Ar-
tery, with a Report of Forty-eight Unpublished Cases, and a Summary of
Forty-four Cases, with Remarks by Valentine Mott, M. D. By James It.
Wood, M. D., Surgeon to Bellevue Hospital, President of the N. Y. Path.
Society, etc. etc. (Reprinted from the N. T. Journ. of Med. for July,
1857.) 8 vo. pp. 59.

3. An Inaugural Thesis on Intra- Capsular Fractures of the Cervix Femoris.
By John G. Johnson, of the State of Massachusetts. (Reprinted from
the New York lournal of Medicine for May, 1857.) 8vo. pp. 32.

4. Surgical Cases, communicated to the Boston Society for Medical Improve-
ment, Oct. 27, 1856. By George H. Gay, M. D., one of the Surgeons of
the Massachusetts General Hospital. (Republished from the Boston Med.
and Surg. Journal, November, 1856.) 8vo. pp. 24.

5. Report of an Operation for Removing a Foreign Body from beneath the
Heart. By E. S. Cooper, A. M., M. D. (Published by the San Francisco
Medico-Chirurgical Association as an additional paper to its Transactions
for the year 1857.) San Francisco, 1857. 8vo. pp. 8.

1. The object of the paper of Professor Dugas, as stated by the author, is " to
take a hasty view of the injuries to which the scapula may be subjected, to
direct special attention to fractures of the neck of this bone, and to relate two
cases presenting important peculiarities hitherto unnoticed by systematic
writers."

Fractures of the scapula are rare, and those implicating the neck of the bone
really demand the special attention of surgeons, for there are many obscure
points connected with them to be elucidated. The rarity of fractures of this
bone may be inferred from the statistics of Middlesex Hospital and of Hotel
Dieu, which are cited by Professor Dugas. In the latter, in 2,358 cases of
fracture, there were but 4 of the scapula; in the former, out of 1,901, there
were 18. The proportion of the Middlesex Hospital is slightly greater than
that we have found to exist in the Pennsylvania Hospital. In the Fracture
Book of this Institution, from December 6, 1852, to October 20, 1857, 1,578
cases of fracture are recorded, and of these 14 are of the scapula. In the Mid-
dlesex Hospital, 8 of the fractures implicated the body, 8 the acromion apo-
physis, and 2 the neck of the bone. In the Pennsylvania Hospital they are
thus marked: 4 of the acromion; 2 of the dorsum; 4, just below the spine;
1, of the spine about the middle ; 1, through the spine and the upper and lower
fossae ; 1, of the inner and upper angle ; and 1, of the neck. The fracture of
the neck was in a child two and a half years old, who fell from a table ; the
direction of the fracture is marked as uncertain. In all these cases, with the
exception of one in which the dorsum was pierced through, and the inferior
angle broken off by a load of shot that passed in the axilla, some under, some
over the scapula, the injury was the result of a violent fall upon the shoulder
or back, or the receipt of a violent blow upon those parts.

Professor Dugas studies these fractures separately as they occur in the body
of the bone, its spine, its processes, or its neck. For those of the body, the
spine, and the processes, we find the same directions as to diagnosis and treat-
ment as those usually given by authors. It appears certain that the details
given with so much precision in books of the various displacements, are de-
duced from theoretical views rather than from direct observation. According
as the fracture of the bone is higher or lower, the serratus magnus, the teres
major, and the latissimus dorsi would be supposed to influence more or less
the position of the fragments. This is not so, however. In the Fracture Book

1858.]

American Surgical Tracts.

223

spoken of, we find, as a general rule, that there was little or no displacement;
the only instance of marked displacement is in the case of fracture of the inner
and upper angle, which was caused by a fall of fifteen feet on the back ; and
where the fragment was pulled upwards and inwards by the levator anguli
scapulae. Of course under such circumstances, of all contentive apparatus, the
best will be that which causes the least annoyance ; and almost always a sim-
ple scarf, covering the elbow, the arm, and the forearm, is enough, a bandage
being applied in addition for the purpose of holding those parts against the
body.

All solutions of continuity of bones in the vicinity of joints, as has been
justly remarked by Dupuytren, give rise to numerous errors of diagnosis ; and
the observation applies with peculiar force to the injuries which occur in the
immediate neighbourhood of the scapulo-humeral articulation. Every expe-
rienced surgeon can recall to his recollection cases of injuries of the shoulder,
in which he felt the greatest difficulty in determining the exact nature of the
accident. The subject, therefore, of fracture of the neck of the scapula, the
lesion to which Professor Dugas wishes to direct special attention, and to which
he has devoted the greater part of his paper, is one of great interest.

Sir Astley Cooper, in his work on Fractures and Dislocations, in the chapter
(the xiith) "on fractures near the shoulder joint, liable to be mistaken for dis-
locations/' treats of fracture of the acromion, and fracture of the neck of the
scapula, by which he declares that he means fracture through the narrow parfe
of the bone, immediately opposite the notch of the superior costa. Of this latter
accident he gives three cases, and he states its diagnostic marks to be three :
first, the facility with which the parts are replaced ; secondly, the immediate
fall of the head of the bone in the axilla, when the extension is removed ; and
thirdly, the crepitus which is felt at the extremity of the coracoid process of
the scapula, when the arm is rotated. The best mode of discovering the cre-
pitus is stated to be, for the surgeon's hand to be placed over the top of the
shoulder, and the point of the forefinger to be rested on the coracoid process ;
the arm being then rotated, the crepitus is directly perceived, because the
coracoid process being attached to the glenoid cavity, and being broken off
with it, although itself uninjured, the crepitus is communicated through the
medium of that process. In the second of these cases, one in which he was
consulted by Mr. Alderman Partridge, it was the opinion of that surgeon that
the fall of the shoulder was owing to a considerable portion of the glenoid
cavity being broken off.

The doctrine professed by Sir Astley Cooper concerning the differential
diagnosis of fracture of the neck of the scapula is discussed by Malgaigne
(TraitS des Fractures et des Luxations) under the head of Fractures of the
Glenoid Cavity, in the section upon complex luxations of the scapulo-hu-
meral articulation, and it is doubtless from the fact that Malgaigne has
placed what he has to say of this accident in this position that Professor
Dugas has overlooked it, since he states it as "somewhat remarkable that
Malgaigne, in his elaborate work upon Fractures, makes no allusion whatever
to fractures of the neck of the scapula, either anatomical or surgical." Mal-
gaigne declares that it is very hard for him to believe that the glenoid cavity
can fall so easily into the axilla, the coracoid process being suspended to the
clavicle and to the acromion by ligaments of such great solidity; and if it did,
an infinitely more certain sign would be had in the movements of elevation and
depression alternatively communicated to the coracoid apophysis, without omit-
ting the projection in the axilla of the angular, sharp, or* at least irregular
inferior fragment, and which would be distinguished readily from the head of
the humerus. " As to the very insufficient signs of Sir A. Cooper," he con-
tinues, " they appear to me to correspond better with luxation downwards with
fracture of the glenoid cavity, than with any other lesion." The only case of
fracture of the neck of the scapula, which Malgaigne seems willing to accept
as such, is the one reported by Duverney, and cited in the first volume of his
treatise, at page 511. A young girl, twenty years of age, fell into a quarry,
where she was found dead; the autopsy showed a fracture which separated from
the rest of the bone, the neck of the bone and the coracoid process, which is

224

Bibliographical Notices.

[Jan.

fracture of the neck, as Cooper understands it. We regret that Professor Dugas
is not better acquainted with Malgaigne's work, both on account of the ques-
tion as to the exact situation of the fracture in these injuries, and also of the
important peculiarities presented by the two cases he has reported, which he
believes hitherto unnoticed by systematic authors.

After citing the opinions of a number of celebrated surgeons, Professor
Dugas says : —

"While it is very evident from these quotations that some practitioners not
only believe in the possibility of a fracture of the anatomical neck of the
scapula, but also think that they have seen cases of this accident, their lan-
guage is not such as to remove all doubt as to their true meaning in those
cases in which they refer to actual specimens examined after death. J. L.
Petit thinks he treated a case of fracture near the glenoid cavity — but he made
no post-mortem inspection, and may. therefore, have been mistaken. John
Bell's language is too ambiguous to authorize us to conclude positively that his
specimen was one of this kind. Samuel Cooper, Chelius, Yidal, and Furgusson,
have neither of them referred to any specimen, but simply believe that this
fracture has occurred. I do not recollect ever seeing a specimen of this kind,
and know of no author who unequivocally describes any. We may, therefore,
reasonably infer that if it does ever take place, it must be exceedingly rare."

The authorities cited by Prof. Dugas speak most positively as to the existence
of the fracture of the glenoid cavity, and we are at a loss to discover any am-
biguity in the language of Bell: " I have met with the accident in practice,
and have preparations of the fractured bone, so that there can be no doubt of
this accident sometimes occurring, yet it is very rare." Malgaigne describes
four cases, and, of course, unequivocally : one by J. Gregory Smith, taken from
the London Medical Gazette, 1834, vol. xiv. p. 280, where there was a fracture
of a small portion of the external edge of the glenoid cavity, discovered at the
post-mortem dissection ; another case which he saw himself in a man who died
four days after the reduction of an intra-coracoid luxation, in the wards of M.
Dononvilliers, where the internal edge had been broken off. A third case is
represented in his XlXth plate, fig. 3, where a fracture of the internal edge
accompanied an incomplete sub-coracoid luxation ; the patient died four days
after the accident, and the reduction of the dislocation. In all these cases the
limb remained in place after the reduction, on account of the small extent of
the fragment detached. In a fourth case, one of incomplete sub-coracoid luxa-
tion, represented in plate xxii, fig. 4, the fracture must be considered the
principal lesion, for it has detached the whole anterior third of the glenoid
cavity. In such a case as this a special apparatus would be required to main-
tain the reduced bone in its position, and we would have the three symptoms
given by Sir Astley Cooper, as diagnostic of fracture of the surgical neck.

The acromio-coracoid ligament goes from the summit of the acromion to the
posterior edge of the coracoid apophysis ; the trapezoid, or anterior coraco-
clavicular ligament, and the conoid or posterior coraco-clavicular ligament
fasten it to the clavicle ; we do not understand, therefore, how the arm would
fall considerably, from fracture of the surgical neck of the scapula, unless the
acromion process and the clavicle were fractured at the same time. In the
second case, reported by Prof. Dugas, he mentions distinctly that the coracoid
process evidently followed the upward and downward movement of the humerus,
and here the clavicle was broken two and a half inches from its acromial ex-
tremity, and the acromion process at its junction with the spine of the scapula.
We are fully satisfied that all cases, in which the clavicle and spine of the sca-
pula were both uninjured, reported as fracture of the neck of the scapula, from
the immediate return of the deformity of the shoulder, when the force which had
reduced it was dispensed with, should not be considered as fractures of the
surgical neck, but as fractures of the glenoid cavity; all cases, in which the
deformity from the displacement of the head of the humerus is at all con-
siderable.

Surgeons are seldom sufficiently precise in their statements of the symptoms
remarked in cases of fracture and of luxation. Even so correct and careful a
surgeon as Dr. Morris, in the history of a fracture of the neck of the scapula,

1858.]

American Surgical Tracts.

225

given in a report of the surgical cases treated in the Pennsylvania Hospital,
printed in the xxiiid vol. of this Journal (for 1838) does not mention the cora-
coid process at all. He says : " The clavicle and spine of the scapula were
uninjured ; the shoulder was thrown forward so much as to give at first sight
the appearance of a luxation forwards of the head of the humerus, but upon
taking hold of the arm the motions of the articulation were found to be perfect,
showing that the humerus had not left the glenoid cavity; the humerus too
could be traced in its whole extent, and was not fractured ; upon rotating the
arm or pushing backwards the shoulder, the trunk being firmly supported, cre-
pitus was very evident, and the deformity could be made to disappear, but
immediately that the force was dispensed with it returned. From the existence
of the above symptoms the injury was judged to be fracture of the neck of the
scapula." Now the data here given are not sufficient to make a precise diag-
nosis. As the clavicle and spine were uninjured we may conjecture, if we
are right in what we have said above, from the fact that the deformity was
considerable, that the fracture of the scapula did not extend inside of the
coracoid process, and that it was left attached to the body of the scapula, but
that is as far as we can go. It may be said that in all these cases the treatment
must be the same, and that so far as the good of the patient is concerned a
precise diagnosis is unimportant. The greater the experience and the more
enlightened the judgment, however, the less apt is this assertion to be made.
The words of the celebrated secretary of the Royal Academy of Surgery, Louis,
prefixed by Smith to his valuable memoir on the diagnosis and pathology of
fractures of the neck of the femur, cannot be held too much in remembrance ;
we thus translate : "Among all the parts of the art of surgery the science of
diagnosis holds the first rank, and it is the most useful, and the most difficult of
them all; without an exact and precise diagnosis, theory is almost always
faulty, and practice often incorrect."

The important peculiarities related by Prof. Dugas, as existing in the two
cases he records, and which he is not aware to have ever been mentioned by any
author in connection with this accident, are lesions of the axillary artery and
nerves, producing an absence of pulsation in the arteries of the limb, and
paralysis of its muscles. These lesions, it is true, are exceedingly rare, par-
ticularly that of the rupture of the axillary artery, but it is wrong to' suppose
that they have never been noticed. Nelaton [Path. Chirurg., torn. ii. p. 368)
records a case which occurred in his own practice, where in a luxation under
the glenoid cavity, the two internal tunics were torn to a very limited extent;
a false consecutive aneurism rapidly developed itself, and three months later
he was forced to have recourse to ligature of the subclavian, which he performed
above the clavicle ; the disease had already made such alarming progress, that
the aneurismal sac, in spite of the ligature, opened and destroyed the patient.
Malgaigne (torn. ii. p. 197) gives a case observed by Prof. A. Berard, of sub-
coracoid luxation, where there was no pulse after the accident; the vessels re-
mained obliterated, gangrene invaded several of the fingers, and the patient
died. At the post-mortem examination, the two internal tunics of the axillary
artery were found torn in their whole circumference, and the cellular tunic was
lengthened as a glass tube softened by heat and drawn out.

Sudden paralysis, after dislocation of the shoulder, is more frequent than the
absence of arterial pulsation ; indeed, it has been described so often that we
are surprised at Professor Dugas's assertion that it has never been noticed by
surgeons. It can be said to have always excited their attention. The muscle
usually paralyzed is the deltoid, which, as is well known; is supplied by the
circumflex nerve ; hence, this nerve was supposed to be lacerated by the acci-
dent forcing the head of the humerus from the scapula. But at times the
paralysis is much more extensive, and affects all the muscles of the arm, as in
the cases reported by Professor Dugas. We have seen a case ourselves, and
which we have reported elsewhere, in which the biceps, the brachialis anticus,
the coraco-brachialis, the supra-spinatus, the infra-spinatus, the serratus mag-
nus, and the supinator longus, were all paralyzed. In this patient, the paralysis
followed immediately a fall upon the shoulder, and there was no luxation of the
head of the humerus. Compression of the brachial plexus by the luxated head

226

Bibliographical Notices.

[Jan.

is usually assigned as the cause of this affection, but such compression has
never been determined in autopsies; and, so far as sub-coracoid and intra-cora-
coid luxations are concerned, it may be considered as impossible. Again, in
some cases, as in the one we just mentioned, the paralysis has followed a fall
upon the shoulder, without the head of the bone having left the glenoid cavity.
Could not the brachial plexus be contused by something else than the head of
the humerus ? It can very readily happen, as Nelaton first assured himself by
experiments upon the dead body, by a force pushing the clavicle against the
first rib, as in a fall upon the shoulder, by which the clavicle is carried
inwards and backwards. And, what it is important to notice, the axillary or
circumflex nerve is found at the points the most exposed to pressure. By
making a dissection of the parts, or even by glancing at a well executed plate,
any one can easily satisfy himself of this. This is a very interesting subject,
and one well worthy of study; we have, however, already exhausted all the
time at our disposal for the examination of Professor Dugas's paper.

2. According to the examination of the history of the operation of ligature
of the primitive carotid, made by Dr. "Wood, it appears, though it certainly was
performed before, that the first operation in which the date is fixed with exact-
ness, and the history of the case given with accuracy, is one in which it was
tied for hemorrhage, following an attempt at suicide, on board a British vessel
of war, the Tonnant, on the 9th of October, 1803, by Dr. Coley. Eighteen
days afterwards, it was tied by Dr. Cogswell, of Hartford, Ct., in the removal
of a tumour of the neck. These cases were not reported, however, for years
afterwards ; the first appeared for the first time in the Med.-Chir. Journal for
January, 1807, the other in the New England Journ. of Med. and Surg, for Octo-
ber, 1824. The celebrated operation of Cooper was performed on the first of
November, 1805 ; and it is very properly the first paper printed in the Medico-
CMrurgical Transactions. It may be judged, therefore, from the recentness of
these dates, that there are many points connected with this operation not yet
decided, and Dr. Wood has done well to place on record his experience in this
operation, and to add to it all the other unpublished cases of the city of New
York, in order that they may be examined by those interested in the matter.

The following is the summary prepared by Dr. Wood himself, which includes,
of course, only the reported cases: —

" The common carotid was ligatured for the following causes : —

Hemorrhage. — Whole number, nine ; of which six recovered, and three died.

Cause of Death. — Two became hemiplegic ; one, a few hours after the ope-
ration, dying comatose, no autopsy; the other, on the second day, also dying
comatose, and revealing, on post-mortem examination, softening of the brain
and inflammation of the pleura. One died on the eleventh day, and, on exami-
nation, was found to have had pericarditis, with collections of pus in apex of
lung, and liver.

Malignant Disease of Head or Face. — Whole number, seventeen ; of which
four resulted in the apparent cause of the original disease ; ten were decidedly
benefited, growth of the tumour being for a time arrested; two died; one not
noted.

Cause of Death. — In one, hemiplegia supervened twenty-four hours after
operation, and death occurred in sixty hours ; autopsy revealed extensive
softening of the brain ; in the second case, death occurred three or four days
after the operation, from exhaustion.

Aneurism by Anastomosis. — AVhole number, ten ; of which four were cured ;
one died ; five were benefited.

Cause of Death. — In the one fatal case, phlebitis was found to have existed,
pus found in cavity of deep jugular vein.

Aneurism of Branches of Carotid. — Whole number, four; all recovered.

Epilepsy. — Whole number, two ; both benefited but not cured.

Removal of Tumour. — Whole number, seven ; all recovered.

Secondary Hemorrhage occurred in five instances, slightly in two, and severely
in three ; all recovered, the hemorrhage being controlled by pressure.

Date of Separation of Ligature was noted in twenty-four cases; maximum

1858.]

American Surgical Tracts.

227

period, thirty-one days: minimum, nine days: average, fourteen days and
twenty-one twenty-fourths."

Of these forty-eight cases, as is seen, six were fatal ; and of these six, three,
or one-half of the whole number, were fatal from the direct action of the ligature
upon the nutrition of the brain. Out of nine cases operated upon for hemor-
rhage two died from this cause, and out of seventeen operated upon for malig-
nant disease of the face or head, one. According to the important statistics of
Dr. Norris, published in the XlVth vol. of this journal (1847), serious symptoms
of cerebral disorder showed themselves 12 times in 38 ligatures of the primitive
carotid practised for aneurism, or in about 32 per cent. ; in traumatic hemor-
rhage, 8 times in 30, or less than 27 per cent. ; and in erectile tumours 8 times
in 42, or 19 per cent. These proportions do not agree with those found to exist
in the cases given by Dr. Wood in different affections. This goes to support
what Broca says [Des AnSvrysmes, Paris, 1856, page 505), that neither the disease
for which the ligature is practised, nor the age, sex, or constitution of the
patient, in a word, none of the conditions which the surgeon can detect or
foresee, explain the occurrence of these cerebral symptoms, which seem to
depend chiefly upon the state of the anastomoses, peculiar to the individual.

Cooper's first operation was followed by paralysis of the leg and arm of the
opposite side, of which the patient had nearly recovered when she died of in-
flammation of the sac and the surrounding parts. The first fears excited by this
were soon dissipated, but from one excess surgeons went to another, and many
authors said that the ligature of one primitive carotid could never seriously com-
promise the cerebral functions. It is now, however, an unquestionable fact, that
it not only can, but does ; in Dr. Wood's cases, as was noticed, one-half of the
deaths had this for their cause. If the disease, therefore, be one of the exterior
arteries of the head, or one of parts supplied by them with blood, it seems to us
that the external instead of the primitive carotid should be tied. The operation
itself would be one of greater difficulty, but that should not be taken into the
account. There is reason to fear the influence of the neighbouring branches,
all of them large, given off by this artery, so soon after the bifurcation of the
carotid, and this is the only legitimate objection we can think of to the opera-
tion. Broca, in the work above cited, says, that he has seen the external carotid
tied with success in a case of traumatic aneurism of the parotid region. The
operator was Mr. Adolph Richard.

In the remarks communicated by Dr. Valentine Mott, the most remarkable
point is, that he has ligated the common carotid artery forty-four times.

3. The Thesis of Dr. Johnson was submitted to the public examination of the
Trustees and Faculty of Medicine of the College of Physicians and Surgeons
of the University of the State of New York, for the Degree of Doctor in Medi-
cine. The question, whether or no intra-capsular fractures of the neck of the
femur unite by bone is herein discussed, and the negative conclusion is arrived
at. The author thus sums up his argument : "1. It is. absolutely impossible
to form a certain and unmistakable diagnosis of all these fractures during the
life of the patient. 2. That the probabilities are all against union by bone,
from lack of nourishment to the fractured part of the head, from impossibility
of perfect rest, and from synovitis. 3. The argument from the analogy of frac-
tures of the patella, olecranon, etc., is an argument against, instead of for
osseous union. 4. Cases where every circumstance was favourable to union,
if any fractures of this kind could unite, yet which failed to unite. 5. The
cases given to prove this union not having proved it."

Many bitter controversies would never have occurred in the world, if it
had been rightly borne in mind that opinions may be discussed but not facts;
facts are determined. There are thousands of arguments of the most plausible
character in favour of the opinion that oxygen and hydrogen do not form water;
but this does not invalidate the fact in the least. The fact is determined, and
there is an end of the controversy. Supposing that the first four heads of the
above summing up were proven, which we are by no means willing to grant, it
would only result that the opinion was one to be discussed, that bony union
in these cases was improbable. As to the 5th heading, that the cases given to

228

Bibliographical Notices.

[Jan.

prove this union have not proved it; it gives evidence of far more credulity to
believe that all those who bear testimony to the fact of osseous consolidation
have been deceived, than to believe it true, were it a thousand times more im-
probable than it is.

The essential cause of a frequent failure in bony consolidation, in intra-
capsular fractures of the neck of the femur, is owing to a want of proper co-
aptation, due chiefly to the extreme mobility of the superior fragment. But
the most important of all causes preventing it must be imputed, we believe, less
to the fracture itself than to the apparatus employed. Sir Astley Cooper, con-
vinced that it was impossible in this variety of fracture, after a few days of rest,
permitted his patients to get up and walk with crutches ; is it surprising that
consolidation did not occur, and that the synovial membrane became inflamed ?

We have seen ourselves a case of bony union in an old patient who died of
cancer, and where no apparatus had been applied. The case is reported else-
where, but we will give it here.

An old woman died in the wards of M. Nelaton, in November, 1853, with ascites
from cancer of the liver. She had entered five months before, after a fall upon
the hip, with signs of a fracture of the neck of the femur, and a fracture within
the capsule. No apparatus whatever had been applied to the limb. At the
post-mortem examination, bony union was found to exist between the fragments.
There was a difference in length in the two thigh-bones of two-fifths of an inch ;
the fractured bone being shortened. The fracture was intra-eapsular, com-
pletely so in all its extent ; it followed the edge of the calotte articulaire. The
displacement was this : the body of the femur had undergone rotation, the
anterior and internal portion had been carried forwards ; posteriorly, the neck
was driven into the head of the bone, while anteriorly, the fragments were
separated. The specimen was afterwards divided by a saw, so. that a true bony
union between the fragments was made most evident. M. Nelaton will answer
for the truth of this. We see from this case that when the fragments are held
in contact by nature, they unite under very unfavorable circumstances ; and
we should, therefore, be encouraged to attempt by art to do the same.

The article by Professor Mussey, on Fractures of the Neck of the Thigli-hone,
published in the April number (1857), of this journal, contains testimony so
strong in favour of the osseous consolidation of such fractures, when intracap-
sular, that it is impossible to question it reasonably.

It seems to us that the question of the bony consolidation of intra-capsular
fractures of the femur is entirely settled by the facts brought forward ; it is one
of the veracity of the authors who have published examples of it. As Smith
says in his memoir on this subject, " If we believe these authors to have been
competent judges, that they have had opportunities of acquiring correct in-
formation, and that they have not been superficial observers, we must either
believe their statements, or expose ourselves to the charge of scepticism, and
render it obvious that our judgment has been so warped by theory and pre-
conceived ideas, that no amount of evidence would be sufficient to alter our
opinions." P. 56. There was a time in science when the weight of authority
sometimes prevented the acceptation of facts, now very often facts will not be
received, no matter upon what authority. It is remarkable at the present time,
how many young men there are in this country and abroad, who work at the
great storehouses of knowledge as if they were Augean stables to be cleaned,
and theirs was the Herculean arm to accomplish the labour.

4. The Surgical cases of Dr. Gay, in themselves very interesting, are related
in so able and so satisfactory a manner that it is really delightful to read them.
Three well executed plates, each containing two figures, accompany the text,
and assist in enabling the reader to thoroughly understand the state of the parts
affected in the first two cases, which are perhaps those of the greatest interest.

The cases are four in number. The first is one of large fatty tumour of the
left thigh, the weight of the tumour after removal being within a fraction of six
pounds. The diagnosis of the affection is particularly dwelt upon, as it is in
all the cases. The second is one of cystic tumour of the forearm, which was
operated upon as fibro-plastic, but found to be a cyst, with thick, tough walls,

1858.J

American Surgical Tracts.

229

adherent to the surrounding tissues, and containing in its cavity a free de-
tached scale-like piece of bone. The third is one of encephaloid disease of the
thigh, in which a correct diagnosis was almost, if not quite, impossible. The
fourth, one of venous erectile tumour of the forearm, in which the diagnosis,
here and abroad, had always been lipoma.

The reading of the histories of these four cases is a source of both pleasure
and of profit to one fond of surgery.

5. The extraordinary operation performed by Dr. Cooper, was reported to the
San Francisco County Medico-Chirurgical Association, and published, by the
authority of the association, by a committee appointed for that purpose. It is
extraordinary even for California, that land of enormities of every description.

A young man, 25 years of age, named B. T. Beal, by the premature bursting
of an old gun, was wounded by a slug of iron, which had been driven into
one end, as a temporary breech-pin. It entered the left side, fracturing the
sixth rib, and remained in the chest until it was extracted 74 days afterwards.
The patient at that time was in a state of extreme prostration ; purulent matter
was discharging through the opening made by the slug ; the left lung had lost
its function, and the symptoms of suffocation were most alarming. It was in
this condition that he was first seen by Dr. Cooper, and the operation was
performed without any delay.

A T-shaped incision was made in the situation of the original wound, the
soft parts were reflected so as to expose the ribs, and an effort was made, by
using a probe to find the breech-pin. Not succeeding, portions of the 5th, 6th,
and 7th ribs were removed, so as to make ample room to afford every facility
for the further prosecution of the search ; in doing this a discharge occurred of
about ten ounces of a fluid resembling venous blood, contained in a cyst con-
nected with a portion of the sixth rib, which was carious ; this was followed, soon
afterwards, on breaking up some attachments with the finger, by another dis-
charge of at least two quarts of purulent matter. The pleura was very much
thickened, and contained several large holes through which the pulsations of the
heart could be distinctly seen. During the whole of this time the patient appeared
to be rapidly sinking ; brandy was given freely, and after a time chloroform
was administered. The thoracic cavity was explored for at least three-quarters
of an hour with a sound, before anything like a metallic touch could be re-
cognized, which finally was accomplished by passing the instrument between
the descending aorta and the apex of the heart. The pulsations of the heart
against the instrument were so strong that it was very difficult to settle the
matter definitely, but it was at last evident that the locality of the iron was
found. The sound was held against it, until a pair of long lithotomy forceps
was thereby conducted to the spot and the breech-pin seized and extracted.
The forceps could not follow the sound and be expanded sufficiently to seize
the metal without lifting the apex of the heart considerably out of its natural
position.

The patient recovered rapidly after the operation, and at the expiration of a
few months seems to have been as well as before the accident, although the
left breast remained somewhat sunken.

In the remarks made by the operator upon the case, the recovery of the pa-
tient is attributed to "his great cheerfulness, good constitution, and to the
effects of our unparalleled climate, in which it appears nearly impossible for
a patient to die with almost any ordinary degree of injury, provided a rea-
sonable share of attention is afterwards given him." A serious objection to
the climate, however, is the frequent occurrence of these terrible injuries, and
we fear that it is an objection not likely soon to disappear. W. F. A.

230

Blhliograpliical Notices.

[Jan.

Art. XX. — A Collection of Remarkable Cases in Surgery. By Paul F. Eve,
M. D., Professor of Surgery in the Medical Department of the University of
Nashville. Philadelphia : J. B. Lippincott & Co., 1857. 8vo. pp. 858, in-
cluding a copious index.

This work is simply a "book of curiosities in surgery. As such, it will, in
spite of its scientific claims, almost inevitably drift into the company of the
numerous " Extraordinary" biographies, " Harrowing Adventures," and other
like sensation-stirring popularities.

In these days of exuberant journalizing, when some periodical is within the
reach of every respectable practitioner, and when all the rare and horrid cases
are printed and reprinted with dreary faithfulness and uniformity, we cannot
perceive the advantage of publishing, in an expensive octavo of over eight hun-
dred crowded pages, such an omnium gatherum of modern instances and thrice-
told tales, however curious in themselves or appropriately strung together.

With all due deference to the merits of the compilation, and of its supple-
mentary matter generally, we are inclined to regard the index, which occupies
some thirty-four pages, as the most useful portion of the book. This index
needs only the references to the original authorities, given with each case, to be
of more actual scientific value than all the rest of the work ; since it would then
point out to us, in a few alphabetical columns, the sources of a large number of
observations which are here to be traced only by searching through the many
wearisome pages of small type, upon which they are spread out according to
the fancy of the collector.

Dr. E. informs us, in his introduction, that he " has been studious to do injus-
tice to no one ;" and yet he "has taken the liberty, occasionally, to abbreviate
articles; in some instances to give them a more striking and appropriate title ;
and now and then to add a few brief comments." Whatever ideas the authors
of the various papers, which he has thus dished up after his own fashion, may
have of his mode of doing them "no injustice," we feel bound as a reader, and
still more as a reviewer, to protest decidedly against all pretensions to scientific
value in the reports of cases as he presents them. There are no distinctive
marks by which can be recognized either the alterations or the comments and
headings above alluded to ; and hence we have nothing to prevent us, in quot-
ing or reading Dr. Eve's versions, from misrepresenting or misunderstanding
the original reporters. None, therefore, but those who are content to study
the cases through the compiler's spectacles will be likely to resort to his pages
except to gratify curiosity, or to take comfort in the "one practical lesson,"
which, as he truly tells us, is suggested, " not to be easily discouraged in
desperate surgical cases."

According to the introduction, Dr. E/s object " has been merely to gather for
preservation the valuable material now existing mostly in a perishable form ;
to collect the important and instructive cases from our journals, &c, and ar-
range them for future reference." In prosecuting this peculiar enterprise, he
has grouped together an array of narratives and commentaries, good, bad and
indifferent, which is a marvel in itself; and, along with many that were long
since sufficiently embalmed, he has certainly rescued, and brought out to some
extent, many notable records which might otherwise have been generally over-
looked. The presence of these very cases, in the midst of others of vastly less
account, or out of place, in such a book, renders it especially provoking, not
only that they should be encumbered with such a mass of other matter, but
that we have no guarantee that any one of them is given in its strictly original
form.

No cases, we are told, " have been admitted into the collection but such as
are strictly authentic ; as it has been our aim to reject all of a doubtful cha-
racter." A very extended and careful examination inclines us to believe that
this claim of authenticity is generally well sustained. Some of the stories,
however, are too manifestly apocryphal to be accepted under any circum-

1858.] Eve, A Collection of Remarkable Cases in Surgery. 231

stances ; while others are given under authority which would scarcely be ad-
mitted as conclusive in a court of law. The first case of Sect. II., for example,
although quoted, with preliminary comments, from the Boston Med. and Surg.
Journal of 1847, has no authority for its accuracy but that of a country news-
paper. It is quoted as a remarkably striking demonstration of the "great
elasticity of the skull in a child," and is in the following words : " A few days
since," says the Amherst Express, " a son of Mr. Dudly, of Shutesbury, Mass.,
about five years old, accidentally fell from a cart containing about twelve hun-
dred pounds weight, which passed directly over his head. He received no
apparent injury except a slight bruise near the ear made by the wheel." This
instance of cranial "elasticity" is so well matched by another, at least as cre-
dible, that we venture to reproduce it here, as available for a second edition,
without any other voucher than the authority of the Calaveras (Cal.) Chronicle.
This paper states "that two 'colored gemmen' in that place, who had quar-
relled about ' a lady/ met in mortal combat. After an exchange of shots, the
sheriff arrested the parties and carried them to jail, when a pistol bullet was
found flattened out and lodged in the wool of one of the combatants, who was
quite unaware of having been touched." We are willing to allow something
for the " wool" in our case, but must nevertheless insist that it is quite as
much entitled to the honour of a place in Sect. II. as the adventure of Master
Dudly. It is strange that none of the parties concerned in circulating the Am-
herst story appears to have suspected the possibility of a mistake. The nature of
the accident would suggest itself at once to most hospital surgeons as a matter
of not unfrequent experience. We can recollect three different similarly mar-
vellous escapes, occurring under our observation within the last five years. In
the first case, a child of seven years was apparently run over in a paved street
by a mail wagon weighing at least a ton; although one of the massive hind
wheels was seen by several persons to pass directly across his right thigh, the
only perceptible injury resulting was a transverse fracture of the femur and
slight abrasion of the skin, without material contusion of the soft parts, from
which he recovered in the usual time. The pavement was a rough one of large
cobble stones, and the child, if really run over, was doubtless saved by the
bouncing of the wheel from one stone to another. The second case was that
of a youth of seventeen years, who, while dragging by the rope of a fire engine,
was overturned in a bed of snow ; the wheel of the heavy vehicle immediately
passed across his left thigh in such a manner as to produce a simple fracture
without other injury. The third case was that of a carter who fell into a mud
puddle in such a way that his cart, with a load of bricks weighing at least two
tons, passed with one of the wheels diagonally across his arm above the elbow-
joint. A compound fracture was the result ; but, in consequence of the yield-
ing of the bed of mud beneath it at the time, the limb was not so much injured
as to require amputation. The means of escape from more serious mischief
to the parts apparently exposed to certain destruction were obvious enough
in these latter two cases ; but the good fortune of the little fellow in the first
of the three, however evident, was surely not more explicable than that of the
child in Massachusetts.

With regard to the arrangement we may say, in a few words, that there are
ten chapters, each of which is divided into sections. Of these sections there
are some seventy-three in all. The cases, instead of being numbered in regu-
lar order of succession throughout the book, are numbered only in each sec-
tion ; so that it is impossible to ascertain the whole number without a needless
cost of time- and labour in the computation.

Each chapter is devoted to a particular anatomical region of the body, and
the sections to different portions of these regions ; the lengths of chapters and
sections being intended to indicate " the supposed importance of the respective
regions which they represent." Thus we have chapters on the Head, Spinal
Column, Face, Neck, Chest, Abdomen, Pelvis, Genito-Urinary Organs, and the
Extremities, each with its sections devoted to minor parts ; lastly, our compiler
is obliged to stow all unarrangeable matter, as usual, in a miscellaneous chap-
ter, which is the longest and most remarkable in the book.

Bulky and full as this surgical scrap-book is, we feel that it has occupied

232

Bibliographical Notices.

[Jan.

quite as much attention as can be afforded to it in a passing notice. With the
best disposition towards its sponsor, and respect for the zeal and talents which
have won him ample distinction in other more congenial fields, we trust that
his next experiment in authorship will yield him more undivided honours, and
that he may then wield the pen as freely as on this occasion he has used the
scissors.

It is due to the publisher, and particularly to the local editor, Dr. W. Go-
brecht, to say that the book is accurately printed and respectably got up ; and
that the index is especially meritorious as a characteristic and successful spe-
cimen of editorial labour. E. H.

Art. XXI. — Medical Lexicon — A Dictionary of Medical Science, containing a
Concise Explanation of the Various Subjects and Terms of Anatomy, Physiology,
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obste-
trics, Medical Jurisprudence, Dentistry, etc. ; Notices of Climate, and of Mineral
Waters ; Formulas for Officinal, Empirical, and Dietetic Preparations, etc.,
with French and other Synonymes. By Eobley Dunglison, M. D., LL. D.,
Professor of the Institutes of Medicine, etc., in the Jefferson Medical College
of Philadelphia. Revised and very greatly enlarged. 8vo. pp. 992. Phila-
delphia, 1857 : Blanchard & Lea.

A dictionary, if it but comprise a simple vocabulary of all the various terms
that occur in the different branches, direct and collateral, of medical science,
with a clear and concise definition of the sense in which they are employed — a
mere terminological lexicon — is a work which every medical man will find a
valuable appendage to his reading table. Some work of the kind is, in fact, in-
dispensable to student and practitioner, more especially now, when the progress
of discovery and of improvement in every department of medicine is such as
to require the constant adoption of new terms to express the many and varied
additions that are constantly being added to our stock of professional knowledge.
If such a lexicon is confessedly a valuable and frequent book of reference alike
to the physician and student, how much more so must be a dictionary, in which
they are presented with not simply a definition, but a concise explanation of all
the subjects and terms in every department of medicine, and in those sciences
that are directly or indirectly connected with it, with notices also of climate and
of mineral springs, formulse for officinal, empirical, and dietetic preparations,
etc., of everything, in short, upon which they may at any time demand prompt
general information, without the delay or trouble of consulting other works.
The explanations given being, at the same time, expressed in a clear and defi-
nite manner, and in strict accordance with the views and usages of the latest
and best authorities. It is precisely such a dictionary — full, copious, and accu-
rate— that is presented to the profession by Dr. Dunglison, in the fifteenth edi-
tion of his medical lexicon now before us.

Complete and comprehensive as the work appeared to be in the preceding
edition, the untiring industry and research of the author have enabled him to
add to the present, six thousand additional subjects and terms. Many of these,
he informs us, have been introduced into medical terminology in consequence
of the progress of the science, whilst others had escaped the author in the pre-
vious editions.

While we cheerfully concede all credit to Dr. Dunglison for the production
of a medical dictionary, better adapted for the wants of the profession than any
other with whieh we are acquainted, and of a character which places it far
above comparison and competition ; some praise we think is due, likewise, to
the publishers, who, by their liberality of expenditure in its passage through
the press, have enabled the author to arrange all his additions and improve-
ments in their appropriate places in the body of the work, instead of adding
them, as an appendix, to the preceding edition ; thus saving to those who have
occasion to consult the dictionary, the trouble and vexation of a double refer-

1858.]

Brodhurst, Nature and Treatment of Club-foot.

233

ence ; and this has been done, too, without materially increasing the bulk of
the volume, by the employment of a small but very clear type, cast expressly
for the work. D. F. C.

Art. XXII. — On tlie Nature and Treatment of Club foot and Analogous Distor-
tions, involving the Tibio-tarsal Articulation. By Bernard E. Brodhtjrst,
Assistant Surgeon to the Royal Orthopaedic Hospital, etc. etc. London :
Churchill, 1856. 8vo. pp. 134.

The introduction to the volume now before us is occupied with an historical
retrospect of orthopaedic surgery; and we are presented by Mr. Brodhurst
with an accurate account, for the first time in an English dress, of the earlier
operations practised for the relief of club-foot. That club-foot and its analo-
gous affections had been studied by the ancient physicians, is sufficiently proven
by a perusal of the chapters in which Hippocrates has discussed the subject;
in fact, the treatment by mechanical apparatus which he lays down, will answer
sufficiently well, even at this day, for the cure of the simpler forms of varus.
Subsequent to the time of Hippocrates, for a period of 2000 years, little im-
provement was made in the treatment of this deformity, although we find fre-
quent allusion to the complaint in the works of Pare, Severinus.- and Fabricius-
ab-Aquapendente. In 1784, tenotomy was successfully practised for the first
time by Thilenius, of Frankfort, for the cure of equino-varus. The next opera-
tion of which we have mention, was that performed by Sartorius, in 1806 ; the
result was not, however, favourable; indeed, we even wonder at the happy
result in the preceding instance, when we learn that the method of operating
adopted was by a large dissection with a free external wound. Subcutaneous
tenotomy had not as yet been practised ; it was reserved for Delpech. to make
this last and great improvement in the treatment of talipes. The rules which
he laid down some few years later are, as our author states, " absolutely those
which guide the surgeon at the present day." Stromeyer afterwards prac-
tised Delpech's operation extensively, although, undoubtedly, the merit of the
procedure is due to Delpech.

In Chapter II., Mr. Brodhurst passes to the consideration of congenital talipes,
and lays down the division of the various forms of the distortion. This portion
of the work is well illustrated, and the description of the tissues at fault is drawn
with exceeding clearness. The etiology of congenital talipes is next entered
upon. The different opinions as to the cause of the affection may be classed
as follows : —

1st. Malformations and displacements of the tarsal bones.

2dly. Affections of the muscular system.

3dly. Malposition in utero.

4thly. Disordered nervous influence.

The first three causes assigned cannot, in the opinion of our author, be sub-
stantiated by observation, for he adds, at p. 48, " It may be safely said that the
tarsal bones are never primarily affected, but, being acted upon by the mus-
cles, are twisted on their axes." * * * " The muscles are doubtless the
agents through which the tarsal bones become rotated, but being themselves
under the influence of the nervous system, other agency than that of the mus-
cles and ligaments is involved in the production of congenital distortions."
We are also told that the opinion of Cruveilhier, that malposition of the foetus
in utero is the exciting cause, is equally untenable. With regard to the fourth
and last cause mentioned above — viz., disordered nervous influence — Mr. Brod-
hurst informs us that club-foot, and all other distortions, are most frequently
met with in those foetuses in whom there is deficiency or marked change from
the normal state of the brain and spinal cord. In the anencephalic monster,
these deformities are most common.

The causes of non-congenital talipes, which are next considered, are arranged
by the author under the following heads — paralysis, spasm, inflammation,

234

Bibliographical Notices.

[Jan.

voluntary position, and debility. This chapter forms one of the most interest-
ing in the volume, and is fully illustrated by clinical cases. With some remarks
upon the structural pathology and degeneration of muscles, and the reunion of
tendons, Mr. Brodhurst then passes to the most important topic, practically,
connected with the deformity in question — viz., the treatment. To use his own
words, " The treatment of talipes resolves itself into, first, the removal of dis-
tortion and restoration to the normal position of the limb ; and, secondly, the
restoration of function. ;; The operation of tenotomy, we are informed at page
113, is only useful in the strictest sense to facilitate mechanical treatment; an
opinion in which we most heartily concur. In the adult, especially, tenotomy
alone does little or nothing towards the immediate reduction of the distortion.
At the same time Mr. Brodhurst says, and in this point we do not altogether
agree with him, that there are few cases in which extension alone is to be pre-
ferred to tenotomy. Upon this topic, we would refer our readers to the admi-
rable remarks of Dr. Little, which have recently appeared in the last numbers
of the London Lancet.

The period at which, in cases of congenital talipes, the author prefers ope-
rating, is from four to six weeks after birth, provided the infant be robust. The
after treatment consists in the application of proper extending apparatus, and
it is safest, according to the author, not to commence the extension of the heel
until the process of reunion shall have begun. If much elongation of the
achilles tendon be desired, it must be obtained during the second and third
week after the section.

We cannot bring our hasty notice of Mr. Brodhurst's monograph to a close,
without expressing our satisfaction with the volume. We have been forcibly
struck during its perusal with the pains-taking care of the author to establish
in each case a correct diagnosis of the deformity in question, and we entirely
agree with him in the following deprecation of unnecessary and hasty operative
interference: " Much obloquy has been cast on orthopaedy in consequence of
the abuse of tenotomy. The senseless division of tendons on every possible
occasion, and without reference to the cause of distortion, has occasioned infi-
nite injury to the cause of orthopaedy ; congenital and non-congenital affections
being similarly treated by those who, through ignorance of the pathological
condition of parts directly or indirectly involved, are unable to form an accu-
rate diagnosis, to distinguish between the various forms of non-congenital
distortions, and to decide between cases fitted and unfitted for the section of
tendons/' J. H. B.

Art. XXIII. — Pathological and Surgical Observations : Including a short Course
of Lectures delivered at the Lock Hospital, and an Essay on the Surgical Treat-
ment of Hemorrhoidal Tumours. By Henrv Lee, F. R. C. S.. Surgeon to the
Lock Hospital, Assistant Surgeon to King's College Hospital, etc. London :
Churchill, 1854. 8vo. pp. 232.

The volume before us comprises a series of surgical papers from the pen of
Mr. H. Lee, of London, Surgeon to the Lock Hospital and Assistant Surgeon
to King's College Hospital. Some of these papers have especial value from the
fact that they are founded upon direct observation, and also because the results
arrived at differ in many respects from opinions hitherto generally received.
A subject which seems to have engaged the attention of Mr. Lee more particu-
larly, and one which he has most patiently examined, is a study of the " Causes,
Consequences, and Treatment of Inflammation of the Veins." This article is
a continuation of a dissertation to which the Jacksonian prize was awarded in
1850.

The main conclusions arrived at in this last publication are, as stated by the
author: "1st. That inflammation, both of the veins and capillary vessels, usually
depends upon irritation, communicated to them through their contents. 2dly.
That pus is capable of producing such irritation, when detained in contact with

1858.] Lee, Pathological and Surgical Observations. 235

the lining membrane of the veins; but that it maybe conveyed along their
channels, without leaving any trace of its passage. 3dly. That pus, under
ordinary circumstances, cannot circulate in living vessels, in consequence of its
power of determining the coagulation of the first portions of the blood with
which it is brought in contact. 4thly. That when pus is carried along a vein
it is in consequence either of the disturbance of the coagulum which has first
detained it, or of the blood having, in some measure, lost its natural power of
coagulation."

Mr. Lee does not, in his present paper, recapitulate the evidence upon which
the foregoing propositions are based, but proceeds to a review of the labours
of other physiologists upon the same subject, and to a still further illustration
of his own conclusions. He advances a series of experiments, performed by him-
self and others, and also a collection of clinical cases, which have led him to
the belief that the injection of putrid substances into the blood does not, as is
generally supposed, prevent coagulation from taking place, but that, on the
contrary, such coagulation is induced and assisted. Of all foreign substances,
none possess this power in so marked and rapid a degree as pus. It is to this
fact the author attributes the formation of the large patches of congestion
found in internal organs when pus has accidentally entered into the circula-
tion; and to the more feeble influence of putrid fluids, or of mercury, the de-
velopment of patches of less size.

From the physiological analysis of these affections, Mr. Lee deduces two
principal indications : 1st. That in phlebitis there generally is a twofold dis-
ease— viz., a local inflammation and a constitutional infection — hence the treat-
ment to be pursued should be local depletion, whilst at the same time tonic con-
stitutional remedies should be made use of. 2dly. Direct experimentation has
taught him, that when a putrid element has been introduced into the blood,
the mucous membranes of the intestines and liver are the principal channels
by means of which the elimination of the morbid matter is attempted.

In an article at page 95 upon the deposition of fibrin from the lining mem-
brane of the veins, Mr. Lee seems disposed to reject the views generally held
by English pathologists, and which have lately been adopted by Hasse, relative
to the character of the serous tunic of the veins. He here questions the cor-
rectness of the analogy which has been drawn between this membrane and the
ordinary serous membranes of the body, in a pathological point of view. The*
deposits of lymph found in veins whose walls have become indurated, in true
cases of phlebitis, result, in the opinion of the author, from the previous coagu-
lation of the blood, and he believes that the visible appearances of inflammation
extend to the walls of the vein and not from them ; in other words, that they
are secondary to the formation of the clot, and that they do not precede it. A
repetition of the experiments of M. Gendrin, by the application of a double liga-
ture upon the jugular vein, and by observation of the internal processes taking
place, have led him to conclusions differing from those of the last-named ob-
server, and which go to substantiate his opinions as already expressed. Thus
he says (p. 99): "The principal conclusion to be drawn from the preceding
experiment and observations is, that the analogy which has been supposed to
exist between the lining membrane of bloodvessels and the closed serous
cavities of the body, cannot be maintained with regard to their morbid pro-
cesses ; and, consequently, that the mode of treating inflamed veins which has
been based upon the supposed resemblance, is not founded upon sound physio-
logical principles. Another point of secondary importance, but by no means
devoid of interest, is the power which the blood is shown to possess of separat-
ing directly from itself a fibro-albuminous element, without the intervention of
any membrane, and independent of any inflamed surface." * ' * * " That
the changes in the blood which immediately precede such an action may be
caused by the admixture of vitiated secretions — that the deposit, when formed,
is capable of undergoing various changes, which issue in the formation of a.
purulent-looking fluid, and is capable during these changes of communicating
irritation to surrounding parts."

The system of experimentation practised by Mr. Lee is interesting in the
extreme ; whether or not, however, its results will be borne out by future in-

236

Bibliographical Notices.

[Jan.

vestigation, it is impossible for us to say. In the mean time, we cordially re-
commend the perusal of these papers to all of those who may be interested in
the study of the diseases of the venous system. J. H. B.

Art. XXIV.— The Practice of Surgery. . By James Miller, F. R. S. E., F. R. C.
S. E., Professor of Surgery in the University of Edinburgh, etc. etc. Revised
by the American Editor. Fourth American from the last Edinburgh edition.
Illustrated by 364 engravings on wood. Philadelphia: Blanchard & Lea,
1857. 8vo. pp. 682.

"We have been so often called upon to express our approbation of Professor
Miller's admirable surgical writings, that we feel that comment at the present
moment is unnecessary. Indeed, the increasing demand which has necessitated
a fresh edition of his Practice of Surgery, affords in itself ample testimony to
the high position which his works occupy in the estimation of the surgeons of
this country.

The volume before us is the fourth American reprint from the third and last
Edinburgh edition. The supervision of the work, as it has passed through the
press in this city, has been confided to the care of one of our most able surgical
writers, who has, with characteristic good judgment, presented the volume to
the medical public almost entirely devoid of cisatlailtic annotations. In reality,
Professor Miller's Practice of Surgery makes its appearance before us this time
more nearly in the condition in which it left the author's table than it has ever
done before. W e are glad that such is the case.

Most of the notes which have been added by the present editor, refer almost
entirely to American surgery, and could not with propriety have been omitted
from a volume intended as a guide to American students and practitioners.
The admirable operations of Drs. Sims, of X. Y., and Bozeman, of Ala., for the
relief of vesico-vaginal fistula, are fully described at page 565. The success of
these operators in the treatment of this dreadful malady has been such as to
lead us no longer to look upon the result of all surgical interference as so " dis-
couraging" as Professor Miller is inclined to consider it.

The puncture of the bladder through the symphysis pubis, as suggested by
Dr. Brandes, of Jersey, and practised in this country by Dr. Leasure, of Pa.,1
is also alluded to ; a proceeding which, it appears to us, may be resorted to
with advantage in many instances of retention of urine, especially in those
cases where the bladder retains its normal position. We also observe, at page
630, a somewhat elaborate extract from the various papers of Dr. Reid, of Ro-
chester, N.Y., relative to the reduction of luxations of the femur by manipula-
tion alone without extension, a plan of treatment which is now generally and
deservedly coming into vogue, and which has been attended with much success.

Many additional illustrations have been introduced into this edition, and
although some of them strike us as familiar, having done duty already on more
than one occasion, yet certainly they enhance the value of Professor Miller's
useful treatise ; and we doubt not that the present edition will prove as de-
servedly successful as its predecessors. J. II. B.

1 See this Journal for April, 1854, p. 403.

1858.]

237

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

1. Researches on the Histology of the Nervous System. — Prof. Jacubowitsch,
a young Kussian physiologist, has been laboriously engaged, for the last four
years, in the microscopical study of the nervous centres. His discoveries an!d
drawings have recently excited great attention in Paris, and have been most
complimentarily noticed by M. Flourens at the Academy of Sciences.

The following is the resume of a communication made by him to the Academy,
drawn up by himself and M. Castelnau, the editor of the Moniteur des Hopitaux

1. The cerebro-spinal system is composed of three descriptions of cells, which,
while assuming the essential form of the animal cell in general, are distin-
guished by the following special characteristics : 2. Axis-cylinders arise from
the periphery of these cells, which by their number distinguish each species
of cell, (a) In the first species, or multipolar cells, the number of axis-
cylinders radiating from the periphery varies from three to eight, and is
habitually three or four. The form of this cell is irregular (6) in the second
species, or fusiform cells, the axis-cylinders are three in number, sometimes
four, but never more. They assume the spindle form, and are much smaller
than the multipolar cells, (c) In the third species, or bipolar cells, the axis-
cylinders are but two in number. These cells are of an oval form, and in size
are intermediate between the two other species. 3. (b) The multipolar cells
are met with in the medulla spinalis, in the cerebellum, and in the corpon
quadrigemina. It is remarkable that none are found in the medulla oblongata.
In the medulla spinalis they are situated in the anterior cornua and in the giay
substance. (6) The fusiform cells are found in the medidla spinalis and ob-
longata, in the cerebellum, in the corpora quadrigemina, and in all parts of the
cerebral hemispheres, which are almost entirely formed of them. In the me-
dulla spinalis these cells are placed in the posterior cornua. (c) The bipolar
cells are found in the medulla spinalis and oblongata, in the cerebellum, and in
the corpora quadrigemina; but the cerebrum does not contain any. In the
medulla spinalis they are principally found around the central canal. They
are very abundant in the medidla oblongata, constituting its 'greatest portion.
4. (a) The axis-cylinders proceeding from the multipolar cells form the nerves
of motion ; and it is for this reason that the author terms these cells, cells of
motion. (6) The axis-cylinders of the fusiform cells form the nerves of sen-
sation, and the cells are termed cells of sensation, (c) The axis-cylinders of
the bipolar cells are in relation with the grand sympathetic ; and the cells are
termed ganglionary cells. 5. The same and different species of cells com-
municate with each other as follows : [a) The cells of motion communicate
from one side to the other by the anterior commissure, or rather this commis-
sure is formed by the intercrossing in every direction of the axis-cylinders
No. LXIX.— Jan. 1858. IS

238

Progress of the Medical Sciences.

[Jan.

which proceed from these cells. Those of the same side also communicate by
the axis-cylinders, which proceed directly from one to the other. (6) The
cells of sensation communicate from one side to the other by the posterior com-
missure, or rather they constitute that commissure ; but they remain parallel
to each other, and do not intercross. Those of the same side communicate
directly. (c) The axis-cylinders of the ganglionary cells pass by either the
anterior or the posterior commissure ; and thus communicate from one side to
the other, like both the other species, Communications also take place between
those of the same side. (d) Communications, moreover, take place between
the different varieties of cells ; but the author has only met with them in the
cerebellum and in the corpora quadrigemina, in which the three varieties of
cells occur. 6. The different species of cells are not equally abundant in all
the regions of the medulla spinalis. Thus in the cervical and lumbar regions
the cells of motion predominate, while in the dorsal region those of sensation
are most numerous. 7. The medulla oblongata is purely and simply a pro-
longation of the medulla spinalis, a prolongation entirely formed of cells of
sensation, containing in their centre a nucleus of ganglionary cells. 8. The
cerebellum is formed of four elements, viz. (a) of three elements, constituting
the white substance, and which are prolongations by means of the peduncles
of the pyramidal bodies which furnish the elements of the cells of motion, of
the restiform bodies which furnish the elements of sensation, and of the gan-
glionary element which enters with each of the other two. (b) Besides these
three elements, the periphery, or cortical substance of the cerebellum, is formed
of characteristic pyriform cells peculiar to this organ. From these pyriform
cells prolongations are sent to the surface of the orgun, forming a layer termed
by the author the couche en baguettes. 9. The corpora quadrigemina, formed by
the prolongations or the peduncles of the cerebellum, by the restiform bodies,
and by the horseshoe shaped commissure, contain the three varieties of cells
which they derive from these various origins. But this is the last point
where these three varieties are found together. Above this, in the hemispheres,
as already stated, the cells of sensation, of which the corpus callosum forms the
commissure, are alone met with. 10. With the exception of the optic, the
olfactory, the auditory, the vagus, the glossopharyngeal, and the hypoglossal
nerves, which only consist of cells of sensation and ganglionary cells, all the
nerves are formed of the three varieties of cells, with this difference among
them, that the nerves of motion contain especially the cells of motion, and so
on. 11. Besides the elements now described, the cerebro-spinal system con-
tains a special connective tissue uniting the other elements, and which differs
from the connective tissue of other organs by not containing any cells. It is,
moreover, in infinitely small proportion as compared with the nervous tissue,
and seems to play no other part than that of a bond of union. 12. These three
categories of cells vary in different species of animals. They are smallest in
size in man, and in general they are small in a proportionate degree to the
intellectual development. The number of the nervous cells bears no propor-
tion to the size of the brain.

From this brief resume, M. de Castelnau observes, we are enabled to deduce
some of the principal consequences of the facts upon which M. Jacubowitsch's
researches are based.

1. The three entirely distinct functions of the nervous system, motility,
sensibility, and organic action, are not only exercised by three different orders
of nerves; but, moreover, these orders of nerves take their origin in different
central anatomical elements.

2. The medulla spinalis, whence arise the general nerves, contains equally
and naturally the three orders of elements ; but the brain, the organ of the
intellect, contains but the elements of sensibility, and the nerves of the special
senses are also made up of the same element, with which is united in small
proportion only the ganglionary element.

3. The element of sensibility is in different dimensions in man and animals,
being larger in the former and smaller in the latter ; so that for even an equal
cerebral mass the human brain is much richer in sensible elements than is
that of animals. To go beyond this, and to determine the relative richness of

1858.]

Anatomy and Physiology.

239

each man, arid especially of each human race, does not seem to be impossible.
Will it ever be accomplished? That is a question Ave must reserve for future
solution, but still with a doubt accompanied by much hope.

4. M. Jacubowitsch's researches scarcely promise less to the pathologist than
to the physiologist. They have already shown that in affections of the nervous
system, in which the most minute ordinai-y examination could detect no
material lesion, such lesion was nevertheless considerable, since one or more
of these orders of elements had become greatly altered in their form, or even
had undergone destruction. This single result sufficiently indicates the bril-
liant horizon that may be opening to the pathological anatomist. If it exhibits
to us clearly but a small part of that which we now seem to have a glimpse of,
M. Jacubowitsch will not have rendered less service to the practitioner than
to the physiologist and the true philosopher.— i/cwiYeMr des Hopitanx, Sept. 8,
1857.

2. On the Structure of the Nervous Centres. — Prof. Lenhossek has communi-
cated to the French Academy of Sciences an interesting memoir on this sub-
ject, of which the following is an abstract: —

" It results from my researches, 1st. That the central nervous system is
composed of gray substance, of white substance, and of an intermediate sub-
stance, termed the gelatinous substance of Rolando. 2. That the gray substance
is formed of a general hyaline mass, having three kinds of nerve-cells: (a)
Nerve-cells with all their attributes, generally diffused ; (b) Large nerve-cells
with all their attributes, united into groups. These are seen in the motor
columns, in the sensitive columns, and elsewhere, (c) Spherical-nerve cells
with all their attributes, filled with a deep brown pigment. These form only
the ferruginous substance, and the black substance of Soemmering. 3. That
the white substance is formed of primary fibres, which terminate in the form
of radiations in the different organs of the central nervous system. 4. That
the so-called gelatinous substance is formed by the gray substance, which
traverses, in the form of network, the fasciculi of the white substance. 5.
That the gray substance has the following relations : (a) In the spinal marrow
it constitutes four columns, two anterior motor and two posterior sensitive,
united together by the gray commissure: (b) In the medulla oblongata these four
columns change their relative position, the anterior columns becoming internal,
and the posterior external. They preserve this juxtaposition throughout the
extent of the rhomboidal sinus. Farther on, the motor columns are continued
alone to the bottom of the third ventricle, terminating in the infundibulum. The
sensitive columns, on the contrary, pass into the optic thalami and the corpora
striata, (c) At the point where the juxtaposition of the four columns takes
place, there the commissure disappears, and the median cldison of Vicq d'Azyr
commences, this being formed by a prolongation of the gray substance. This
cloison is continued through the entire length of the pons Varolii. 6. That in
the spinal marrow the white substance of the one side is completely separated
from that of the opposite side by the anterior and posterior longitudinal groove;
and in the medulla oblongata and pons Varolii an analogous separation is pro-
duced by the cloison of Vicq d'Azyr. 7. That at the point where the juxtapo-
sition of the four columns of the gray substance takes place, the white sub-
stance proceeds more and more forwards until the gray substance at last
remains exposed in the rhomboidal sinus. 8. That the primary fibres of the
roots of all the nerves arise in the gray substance, (a) In some cases these
fibres proceed from prolongations of the nerve-cells. (6) But, most commonly,
they arise in groups, without its being possible to determine their origin.
These fibrous groups traverse the white substance in different directions, in
order to form the roots of the nerves at the surface. They never contribute to
the development of the white substance, nor does the latter furnish any fibres
fur the roots of the spinal nerves. 9. That the motor roots of the spinal nerves,
and of the motor cerebral nerves, such as the hypoglossal, the external and in-
ternal motors of the eye, the facial, the small portion of the trigeminus, and the
common ocular motor, take their origin only in the motor columns. 10. That
the sensitive roots of the spinal nerves, and of the sensitive cerebral nerves —

240

Progress of the Medical Sciences.

[Jan.

as the auditory, the large portion of the trigeminus, the optic, and olfactory —
proceed only from the sensitive columns. 11. That the roots of the mixed cere-
bral nerves, as the two superior roots of the accessory nerves of Willis, and the'
pneumogastric, arise in both the motor and sensitive columns. 12. That there
are four kinds of crossings in the spinal marrow, medulla oblongata, and pons
Varolii, (a) In the spinal marrow, the primary fibres of the motor roots cros3
in front of the central canal, and the fibres of the sensitive roots cross behind
it. These intra-crossings are produced by a portion of the primary fibres of
the roots taking their origin in the opposite side, (b) In the medulla oblongata
and pons Varolii, the primary fibres of the roots of the cerebral motor nerves,
and only the motor portion of the mixed cerebral nerves, intercross at the mid-
dle of the motor columns, for the same reason as in the spinal marrow, (c)
In the cloison of Vicq d'Azyr there is an intercrossing from right to left of
some of the fibres of the white substance of the medulla oblongata, and of the
pons Varolii, (d) There is a crossing of the six walls of the fasciculi of the
white substance, and of the medidla oblongata, in front of the central -canal,
known under the name of the pyramidal decussation. 13. That the primary
fibres of the roots of the nervous plexuses of the pia mater, as also those of all
the roots of the accessory nerves of Willis (except the two superior roots), arise
from all the periphery of the gray substance. In the plexuses at the surface
of the pia mater are found : (a) Nerve-cells interposed between the primary
nervous fibres. (6) Nerve-cells in groups, suspended and floating at the ex-
ternal surface of the nerves of the pia mater. These latter are filled with
pigment. 14. That the two olivary bodies are composed of two substances, an
external, gray, having convolutions, and an internal, white. The white sub-
stance is formed by the irradiation of the primary fibres of the peduncles of
these bodies, which take their origin in the motor columns, and by the trans-
verse commissure which traverses the cloison of Vicq d'Azyr. 15. That the
central canal of the spinal marrow runs along its entire length, and opens into
the calamus scriptorius. The walls are formed internally by a covering of
cylindrical epithelial cells, and externally by a layer of the longitudinal fibres
of Clarke, which extend into the epithelial layer of the rhomboidal sinus. In
the lumbar region a granular mass is interposed between this fibrillary layer
and the epithelial cells. 16. That on each side of the central canal there is a
large vein, which successively bifurcates in the region of the medidla oblongata,
and in that of the medullary cone." — Moniteur des Hopitaux, Oct. 27, 1857.

3. On the Nerves of the Intestinal Walls. — G. Meissner looks upon the areolar
tissue between the muscular and the mucous coats of the intestines as one of
the parts most richly supplied by nerves in the entire body. These nerves, by
numerous anastomoses, form a network, the finest twigs of which appear to
penetrate the muscle. The primitive fibres for the most part, and perhaps
entirely, belong to the kind without any double contour, and are beset by
numerous nuclei. They form the finer and thicker branchlets, and are com-
prised in nucleus-holding sheaths, in numbers varying from five to twenty ;
whilst the finest branchlets only contain from two to three primitive fibres.
The small intestines appear to be the most rich in nerves, but in the walls of
the stomach the nerves are very sparing. In the walls of the intestine the
number of ganglia in the nervous plexuses is immense, corresponding for the
most part with the thickness of the nerve-branches in which they are found ;
and in the small intestines almost every nerve-branch leads to a ganglion. The
largest observed by the author consisted of from thirty to fifty cells ; but they
ordinarily contained from five to ten, having the ordinary appearance of gan-
glion cells. In man, pigment granules were often to be seen as contents of the
cells, but in the calf they were found to be quite clear and colourless. Many
of the cells were bi-polar, and this was evident whenever a single cell was seen
inserted in the course of a primitive fibre without a ganglion being formed.
Such cells were generally spindle-shaped, and projected themselves at opposite
poles into a fibre. Besides bi-polar cells, some were seen from which, either
at one side or both poles, two fibres passed close to each other. The ganglia
in the stomach are not relatively less than in the intestine. The ganglion cells

1858.]

Anatomy and Physiology.

241

in the stomach are larger than those of the intestinal walls. The author de-
scribes the best method of examining the nerves and ganglia of those parts,
and speaks of the fresh intestine being sufficient, by the aid of acetic acid, for
the examination ; but inasmuch as this method is tedious, moderately concen-
trated pyroligneous acid affords the greatest help, which, after some time,
makes the areolar tissue very transparent, leaving the nerves and ganglia un-
altered. After dilute pyroligneous acid has acted for some days, acetic acid
proves very serviceable. — Brit, and For. Med.-Chir. Review, Oct., 1857, from
Henle und Pfeuffer's Zeitschrift, Bd. viii. Heft 2.

4. On the Function of tlie Thyroid Body. — Dr. Peter Martyn communicated
to the Royal Society a paper on this subject. After referring to the form,
situation, connections, and internal structure of the thyroid body, its 'large
supply of blood, and its capability of sudden alterations of bulk, the author
briefly adverts to the unsatisfactory explanations which have been offered as to
its function, and then proceeds to state his own views, as follows : —

" The upper part of the trachea, the larynx, and the passage of the fauces
and mouth constitute the organ of voice ; the two former are the essential or
voicing part, as mechanicians call it, that which produces the tone. The
larynx and trachea — taking a share in other functions and being associated by
juxtaposition and attachment with contiguous organs — are always pervious
and open for respiration ; lengthen and shorten, fall and rise with the oeso-
phagus in deglutition, and bend and turn with the universal motions of the
head and neck.

" To admit of this great mobility and flexibility, a certain structure is neces-
sary. The larynx is a triangular box, inclosing the apparatus of the chords
vocales ; its two cartilaginous sides or alas, diverging from the front, are not
fixed, but free at the back, being completed by soft parts ; the trachea is com-
posed of a succession of incomplete cartilaginous hoops or rings lying apart,
the back and intervals being made up and the tube completed by soft mem-
brane.

" Now the structure of a wind instrument, such as that of the human voice,
requires the opposite properties. It must be rigid, tense, and inflexible. The
qualities of the tone will be in exact proportion to these properties. How,
then, is the soft, slack, and flexible vocal tube rendered thus rigid, tense, and
inflexible, and fit to produce pure tone ? The muscles of the larynx, the thyro-
hyoid and sterno-thyroid, merely raise or lower, or fix it in any position: not
lying on, or being parallel to, but diverging from the vocal tube, they cannot
affect the object referred to. It appears to me that the thyroid body is pro-
vided for this purpose. The act of uttering a tone or of speaking stops the
return of the blood from that organ, distends and renders it tense, and from
the nature of its attachment round the top of the trachea and on the free sides
of the alae of the larynx, renders them fixed, firm, and tense also. This effect
is aided by the aforesaid muscles, the thyroid body being interposed and giving
them more advantageous mechanical action. The tension may be in any de-
gree, and on energetic speaking or singing, the increased size of the part and
the fulness of the collateral veins may be seen. This is the reason of its large
supply and free distribution of blood. An instance of the want of this tension
in an instrument may be seen in the bagpipe, where the porte-vent is attached
to the chanter or voicing part by a flexible joint or by leather, and the tone is
in consequence squeaking and uncertain.

" Besides' thus giving rigidity, firmness, and tension to the organ of voice,
the thyroid body also acts in another capacity — as a loader. In most musical
instruments, loaders are used to render the vibrations slower and longer, and
the tone in consequence fuller, louder, and deeper. They compensate for want
of size and space, and give to a small instrument, or to a small vibrating or
voicing part of an instrument, the power and quality of a large one. The hu-
man organ of voice is 8 inches long, and has the same power as, and better
quality of tone than, the instrument that most nearly approaches it — the
French horn, which is 9 feet, or the 'vox humana' pipe of a moderate-sized
organ, which is from 4 to 8 feet long. This economy of size in the human

242

Progress of the Medical Sciences.

[Jan.

organ has always been wondered at, but never, that I know, explained. Be-
sides the thyroid body, another part, the structure of which I shall describe
on another occasion, aids in this admirable economy. The nearer mechanism
of human design approaches to perfection, the more it resembles similar struc-
tures in animal mechanics. The base of all stringed instruments and musical
boxes is loaded: in most wind instruments the voicing part is thus loaded and
strengthened, as in the organ-pipe, horn, flute, clarionet, &c. The bassoon,
which in its lower notes approaches the human voice, is uncertain and wheezy
in tone for want of this provision.

" When the thyroid body is small and thin, the voice will be found to be
small and shrill ; when large, the tone will be full and sonorous; when it is
morbidly enlarged, the voice will be deeper and more base; and when very
large, as in bronchocele, the voice will be smothered.

" The compass of the voice is in great part produced by the raising and
lowering of the larynx, the shortening and lengthening of the vocal tube. The
thyroid body partakes of this motion, at the same time firmly fixing and ren-
dering tense the parts in each position. By its change of shape, bulk, and
density — flattening and thinning when the larynx is raised, enlarging and
bulging when it is lowered — it aids in giving the particular tone or pitch, high
and acute in the first case, full and deep in the second ; and, in like manner,
by its varying shape, bulk, density, and pressure, it takes a great part in pro-
ducing the wonderful qualities of modulation and expression peculiar to the
human voice. In animated conversation, declamation, and singing, this may
be seen.

" Its function then appears to be threefold — rendering the slack, mobile, and
flexible vocal organ or tube rigid, tense, and inflexible, and fit to produce pure
tone ; by its bulk and density acting as a loader and strengthener, making the
tone more sonorous, full, and deep, and thus compensating for want of length
and size in the organ ; and finally, by its varying shape, bulk, density, and
pressure, furnishing an important aid in producing the inimitable qualities of
modulation and expression enjoyed by the human voice.

" That it is a part of the organ of voice and an important accessory in giv-
ing it perfection, may be inferred also from its situation on the larynx and
trachea, and its being supplied by the same nerves — its being largest in man,
where the voice and speech are perfect — its being proportionally larger in wo-
men and children than in men, their smaller and more mobile organs requir-
ing its peculiar aid. Among the lower animals, it is present (at least in a
fully developed condition) only in the Mammalia, but among them there is a
remarkable exception in the Cetacea — they have it not, and they have no voice.
In Birds, which have such great power and modulation of voice, the structure
of the vocal organ and tube is different from that in man, and sufficient in
itself to produce these qualities.

" The importance of the thyroid body must be admitted when it is shown to
be necessary for the perfection of the voice, and hence of speech—that great
and indispensable agent in the cultivating and advancing the highest faculties
of man." — Med. Times and Gaz., Oct. 24, 1857.

ORGANIC CHEMISTRY.

5. MeiJiod of Clinically Determining the Amount of Sugar in Diabetic Urine. —
Dr. Garrod brought before the Medical Society of London (Oct. 10, 1857) a
method recently discovered by him of clinically determining the amount of
sugar in diabetic urine, exhibiting at the same time a small instrument, named
a Glucometer.1 It is constructed upon the fact that glucose, or diabetic sugar,
when boiled with a solution of carbonate of potash, gives rise to an amber

1 The instrument is manufactured by J. Coxeter, Grafton Street East.

1858.]

Organic Cliemi&try.

243

colour, and that the tint is in proportion to the quantity of sugar. The appara-
tus consists of a standard, a graduated tube of the same calibre as the standard,
and an accurately divided minim measure, the standard being filled with a
solution of the exact tint produced by a known quantity (half a grain) of the
diabetic sugar to the fluid ounce. The following is the method of using the
glucometer : A small quantity of the urine, say half a fluidrachm, either
previously diluted or not, according to circumstances readily ascertained, is to
be accurately measured in the small minim tube, and mixed with the same bulk
of a solution of carbonate of potash of a given strength, and after the measure
has been washed out with a drachm or two of distilled water, the whole is to
be kept at the boiling point over a spirit-lamp for five minutes, either in a large
test-tube, or, still better, a very small flask. After cooling, the coloured liquor
should be transferred to the large tube, and distilled water added until the tint
exactly corresponds to that of the standard — a process which may be readily
effected by holding the tubes side by side, directing them to a moderately bright
light. All the required data for determining the amount of sugar are now ob-
tained. Suppose, for example, that the half drachm of urine employed in the
quantitative analysis requires to be diluted so as to occupy six and a half
drachms before the standard tint is obtained, such urine would contain six
grains and a half of sugar per ounce; for its bulk has been increased thirteen
times, and therefore thirteen half grains, or six grains and a half, of sugar
must be present. Again, suppose the urine had been diluted with three times
its bulk of water before being employed in the glucometer, which when the
urine is rich in sugar may be necessary, in order to prevent the graduated tube
being of inconvenient length, then it is only required to multiply the amount
of sugar by four to obtain the total quantity in the original urine. In the
above-named experiment it would therefore be twenty-six grains in each fluid-
ounce. Dr. Garrod alluded to various methods which had from time to time
been employed for the purpose of ascertaining the amount of sugar in the urine
in cases of diabetics; showed the difficulties which most or all of them pre-
sented, especially to the medical practitioner, which was practically proved by
their non-employment, and expressed a hope that by means of the glucometer
the clinical determination of sugar might become a matter of little difficulty,
and capable of being effected by any one engaged in the practice of medicine ;
and he also considered that such determination might prove of great value, not
only in ascertaining the amount of disease under which any diabetic subject
might be suffering, but also the value of various articles of diet and of different
remedies in the treatment of this most important disease. — Lancet, Oct. 17, 1857.

6. Mode of Detecting Sugar in the Urine, and on the Different Nature of certain
Forms of Diabetes. — Dr. A. Becquerel, Physician to the Hospital of La Pitie and
Professor Agre'ge' to the Faculty of Medicine of Paris, has recently submitted
a notice on this subject to the Medical Society of the hospitals there.

In this communication he says: "Five years ago, in my Treatise on Patholo-
gical Anatomy, and four years ago, at the hospital of Lariboisiere, in a series
of lectures reported in the Moniteur des Hopitaux, I pointed out the following
facts : First. That nearly all urines become discoloured, impart a green colour
to, and even precipitate the cupro-potass solution of Barreswil, or that of From-
merz, if heated with these reagents. Second. That a great number of these
same urines become brown, in like manner, on the addition of caustic potass,
however pure that may be.

"Nearly u year ago, in a new series of lectures delivered at the hospital of
La Pitie, I again strongly insisted on the erroneous conclusions to which the
reaction afforded by these tests might lead; an opinion which was merely that
prevailing among chemists who had paid attention to this subject at the time.
I shall content myself here by showing you that nothing is more easy than to
avoid this source of error, and that there is at our disposal a much more sure,
expeditious, and certain method of detecting the presence of sugar in the urine
than is usually employed.

"We take a certain determinate quantity of urine, say 60 grs.; this we treat
with a small quantity of solid and crystallized acetate of lead, say 4 grs. ; on

244

Progress of the Medical Sciences.

[Jan.

heating this mixture, there is immediately formed a copious precipitate of a
dirty white colour; the liquor is then to be filtered, and the solution treated by
sulphate of soda in excess. If, for example, we have added 4 grs. of acetate
of lead, we add 8 grs. of sulphate of soda. This being done, the mixture is
again heated, and sulphate of lead is deposited ; we then filter once more, and
there is afforded a clear transparent liquid, which contains the sugar, when
there is any, and some unimportant salts. The liquid thus obtained is neither
acted on by the cupro-potass reagents, nor browned by the caustic potass, unless
sugar is present. These two reagents are in this way perfectly reliable, very
accurate, and afford no results when no sugar is contained.

" Should the urine under examination contain albumen, it is immediately
coagulated by the acetate of lead at the same time as other organic matters,
and gives no further trouble.

" Thus, in all cases where it is desired to ascertain the existence of sugar in
the urine, whether along with albumen or not, we possess two excellent re-
agents in the cupro-potass solution, and in the caustic potass itself ; only we
require, in the first place, to treat the urine with the acetate of lead and the
sulphate of soda, by which means we get rid of all such matters as decompose
or discolour the cupro-potass or caustic potass tests.

" Since January, 1855, up to the present time, the urine of all the patients
under my care — and these have amounted to nearly 2000 — has been examined
according to the above method. But besides this, in all cases where the pre-
sence of sugar was determined, there was also an examination made by means
of the polarimeter, in order to discover the precise quantity of that principle
contained in every thousand grains of urine. These numerous cases have
afforded some curious results which I would desire to lay before the Society.

"Two species of diabetes appear to exist, viz., idiopathic diabetes, or diabetes
properly so called, and symptomatic diabetes. With reference to diabetes pro-
perly so called, I have here nothing to say ; it is a disease special in its causes,
and having an origin, a progress, and a termination altogether peculiar to itself.
That to which I at present allude is a disease of a somewhat different nature,
viz., symptomatic diabetes. By this name I would refer to a certain number
of cases in which the presence of sugar in the urine constitutes an accessory
or supervening symptom. This is a symptom which, like albuminuria, is com-
mon to very different diseases, and one which would never be suspected unless
the urine were submitted to examination.

"The characters of symptomatic diabetes are as follows: —

"1st. The quantity of sugar contained in the urine is never very great, al-
though I have frequently found as much as 25 or 26 grs. in 1000, which is a
pretty considerable proportion, but less than exists in idiopathic diabetes, where
it often reaches as high as 40, 50, 60, and even 80 grs. in 100.

"2d. The urine is very little or never increased in quantity.

" 3d. Although the density of the urine is no doubt increased, yet it is only
to a very slight extent.

" 4th. The sugar does not alter the other chemical elements contained in the
urine.

"5th. There are no phenomena present attributable to the fact of sugar being
contained in the urine; there is neither the increase of appetite, nor the immo-
derate thirst of idiopathic diabetes.

" Symptomatic diabetes shows itself occasionally in diseases of the brain and
spinal cord, of the liver, of the digestive apparatus ; in disease connected with
parturition and lactation ; and in other affections of various descriptions." —
Ed. Med. Joum., Nov. 1857, from U Union Medicate, Aug. 1857.

7. On the Presence of Sugar in the Urine of Pregnant, Parturient, and Puer-
peral Women. By Theodore Kirster, of Leipzig. — The researches of Blot on
the presence of sugar in the urine of pregnant, parturient, and puerperal wo-
men, suggested to Dr. Kirsten the expediency of independent inquiries with a
view to the verification of Blot's results. M. Blot arrived at the conclusion1

1 See Midwifery Report, British and Foreign Medico-CMrurgical Review, April,
1857.

1858.]

Organic Chemistry.

245

that the presence of sugar in the urine of women under these circumstances
was a physiological phenomenon ; and that its disappearance was the result of
an intercurrent pathological condition. Dr. Kirsten observes, that if this con-
clusion were true we should possess in the disappearance of the sugar a tolera-
bly sure measure of the condition of a puerperal woman, since this would
indicate a commencing pathological disturbance, whilst its return would indi-
cate reconvalescence. Dr. Kirsten examined the sugar relations in two women.
His observations do not altogether accord with those of M. Blot : they rather
point to the reverse condition — namely, that sugar is present in greatest quan-
tity in the urine of puerperal women when the milk-secretion — whether through
a pathological process, or the weaning of the child — is arrested. Thus he
observed in several puerperal women whose children had died, that on the
second, third, or fourth day after the death the sugar appeared in greatest
plenty. After this time, the quantity fell in the same degree as the milk
diminished ; but in four cases it could be demonstrated twelve days later. In
three cases in which the patients were seriously ill in the puerperal state, and
in whom the milk-secretion was almost null, the sugar was found in greatest
quantity. One of these last women had suffered from common oedema during
pregnancy. The examination of her urine revealed copious albumen, which
diminished with the oedema, without disappearing altogether. Towards the
end of pregnancy traces of sugar became apparent. She was delivered easily
of a badly-nourished child. Repeated attacks of peritonitis followed. The
milk-secretion was very scanty, and the milk very thin : sugar was present in
the urine in abundance. In the second patient, who suffered from peritonitis,
followed by pyaemia, Dr. Kirsten was able to detect sugar up to the day before
her death, this substance having been present in great quantity at the begin-
ning of her illness. The third case was quite similar. On the other hand, he
was rarely able to discover more than mere traces of sugar in the most healthy
women, who had well-nourished children and a superabundance of milk.

It hence appears that glycosuria belongs rather to pathology than to physio-
logy. The key, Dr. Kirsten thinks, is to be found in the most recent researches
of Bernard. This physiologist has shown that the formation of sugar in the
liver is especially apparent when the abdominal circulation is increased, and
the temperature rises. The biliary matter chiefly turns into sugar at a tem-
perature of 40° Cent. No time was more favourable for this transformation
than gestation, when the abdominal circulation and temperature are always
raised to the necessary point for sugar-formation : whence we ought always to
expect glycosuria in pregnant women. But as this is not the case, we are
obliged to conclude that the greater quantity of sugar produced at this period
is wanted for the nourishment of the child, so that it cannot be excreted. It
would be interesting, with a view to the verification of this hypothesis, to ex-
amine the urine of women whose children may die, as quickly as possible after
their death.

During the puerperal week the abdominal circulation is lessened, and the
afflux of blood takes place towards the periphery, as is evidenced by the milk-
secretion and sweats. This condition would not be favourable to the formation
of sugar. — Brit, and For. Med.-Chirurg. Review, October, 1857, from Monatsschr.
f. Geburtsk, June, 1857.

8. On the Elimination of Sulphuretted Hydrogen by the Lungs. — M. Cl. Ber-
nard desires to contribute to the solution of the question, why it is that sul-
phuretted hydrogen, which can be swallowed in large quantities with impunity,
will cause the death of a medium-sized dog, when breathing in the proportion
of g Jo, and of a horse, when in the proportion of Two hypotheses may

be raised. Either it is not absorbed in the alimentary canal, but digested, and
its peculiar effects neutralized; or, after becoming absorbed, it is modified, and
eliminated before it can reach the arterial system : the arterial blood being, in
fact, the immediate vehicle of all physiological and toxical action, inasmuch as
it is it which passes directly to the capillaries, where all organic changes take
place. In the event of this last hypothesis being the correct one, we have to
determine by what organ the elimination is accomplished. The pulmonary

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Progress of the Medical Sciences.

[Jan.

surface would seem best adapted for the exhalation of this gaseous poison ; so
that it would sometimes perform the part of an absorbent surface, as when the
sulphuretted hydrogen was contained in the air, or of an exhalant, when this
substance existed in the blood. This example, which is by no means an isolated
one in the economy, would seem to prove that the mucous surfaces, often indif-
ferent in themselves^ have no special action in relation to a substance, beyond
that which is determined by the conditions under which such substance is pre-
sented to them.

M. Bernard performed numerous experiments in order to show that the elimi-
nation really takes place by the lungs. It was found that after throwing in
the gaseous sulphuretted hydrogen, or a saturated solution of it, into the jugu-
lar, paper soaked in acetate of lead held at the nostrils became speedily black-
ened, and that almost immediately the substance entered the blood. This was
repeated at intervals several times, without the animal seeming to suffer incon-
venience. No ill effects result, because the substance is eliminated before it
can reach the arterial system; while, when it is inspired with the air, the ab-
sorbed sulphuret is carried by the pulmonary veins directly into that system.
In order to show that pulmonary elimination also takes place when the gas is
introduced into the digestive canal, sulphuretted hydrogen was also injected
into the stomach and into the rectum. When thrown into the stomach, the
paper was found blackened after some seconds; but with respect to the rectum,
this effect was not observed until sixty-five seconds after, the elimination not
being completed under five minutes.

Owing to the facility of its elimination, M. Bernard suggests that sulphuretted
hydrogen might possibly serve as a measure of the rapidity of certain physio-
logical actions, and especially of the phenomena of absorption and circulation.
Two experiments are related in illustration: three cubic centimetres of satu-
rated solution of sulphuretted hydrogen were thrown into the jugular vein, and
the first spot appeared on the paper at the end of three seconds. The same
quantity was thrown into the femoral vein of the same dog, and the earliest
manifestation took place only after six or seven seconds. When the quantity
injected did not exceed that mentioned above, two or three expirations, and
sometimes a single one, sufficed for the complete elimination of the sulphuretted
hydrogen.

The question arises whether, when we introduce sulphuretted hydrogen
either into the natural channels of absorption, or into the veins, the whole of
it becomes eliminated by the lungs. Doubtless, by accurate measurement, this
could be determined, but the probability is that it is not the case. Independ-
ently of other channels of elimination that may exist, it is probable that some
of the sulphuretted hydrogen remains in the blood in the state of sulphur.
Thus, when small quantities of the sulphuretted hydrogen are injected at a
point as distant as possible from the lungs, no pulmonary elimination takes
place, probably because there has been time for the whole to become modified
and changed into sulphur before reaching the lungs. It was found that inject-
ing small quantities into the carotid was followed by no elimination, until the
repetition of the operation gave rise to a certain amount of saturation. Another
proof that some of the sulphuretted hydrogen is retained in the blood, probably
as sulphur, is found in the fact that in blood drawn from the animal, and mani-
festing no odour of sulphuretted hydrogen, the addition of hydrochloric acid,
and the application of heat, lead to the disengagement of this gas.

The experiments made require to be repeated and multiplied, in order that
the action of sulphuretted hydrogen on the economy should be completely
studied. An important fact has, however, been thus far determined, viz., its
great tendency, when circulating in the blood, to become eliminated by the
lungs: and it may be asked whether such elimination is any way related to the
therapeutical effects attributed to sulphureous medicines in certain affections
of the chest. — Med. Times and Gaz., Sept. 5, 1857, from Archives Gtn., torn. ix.

9. Starch from the Animal Kingdom. — Dr. Pavy exhibited to the Medical
Society of London (Oct. 10, 1857) some of the newly discovered amylaceous
material which is obtainable from the healthy liver, and which forms the source

1858.]

Organic Chemistry.

247

of the animal sugar. In referring to the history of the saccharine secretive
function of the liver, Dr. Pavy stated that, upon the announcement of the dis-
covery by Bernard in 1848 that sugar was formed in the animal body, it was
referred to a transformative action of the liver on an albuminous constituent
of the portal blood. The celebrated experiment of puncturing the floor of the
fourth ventricle, and establishing diabetes, rather supported this view; for it
was thought that the irritation of the nervous centre stimulated the secretory
action of the liver, and led to the production of a superabundance of sugar,
which, accumulating in the circulatory system, was pumped off by the kidneys,
and thus appeared in the urine. The next step of information removed the
direct influence of the nervous system, and showed that the production of sugar
could not be regarded as analogous to the process of secretion. In September,
1855, in fact Bernard announced, at the Academie des Sciences, that the forma-
tion of sugar continued for as many as twenty-four hours after death in a liver
from which the blood had been entirely removed. If, for instance, the liver of
a healthy animal be removed immediately after death, and a current of water
be injected from the portal vein through its vessels, the whole of the blood is
washed out, and the organ is also quickly deprived of the saccharine material
it contained. Now, if such a liver be placed on one side and examined in a
few hours' time, it will be found to have become strongly impregnated with
sugar, the production of this material having continued in the exsanguine tissue
of the gland-. Upon this fact our knowledge had rested until within the last
few months. During the early part of the summer, Dr. Pavy had noticed, whilst
conducting his experiments on the destruction of sugar (which have led him to
new and unexpected results, which he will shortly communicate to the profes-
sion), that he could isolate a material from the liver which subsequently under-
went transformation into sugar ; and he had recorded in his laboratory book the
influence of chemical agents, such as acids, alkalies, and alcohol, on this ma-
terial. He had since learnt, however, on his recent visit to Paris, that Bernard
had most satisfactorily made out the nature and relations of this body, which,
from the analogy presented in its chemical bearings to starch, he had called an
animal amylaceous or starchy material. It had also been called glucogenic
material, and this was probably the best term to apply to it at present, because
it implied nothing more than we knew the substance in reality to be. The
specimen of this glucogenic material which Dr. Pavy exhibited had been pro-
cured from the liver of a dog in the following manner: The dog had for some
days been submitted to a strictly animal diet, so as to preclude the introduction
of any starchy material into its system from the vegetable kingdom. After
killing the animal, by the destruction of the medulla oblongata, the liver was
removed, and a tube firmly ligatured in the portal vein, for the purpose of pass-
ing a current of water through the vessels to wash out the blood, and at the
same time remove the sugar. In half an hour's time the water which had
passed through the vessels was colourless and destitute of sugar, as was also the
tissue of the liver itself. The organ was now cut up into small slices, placed
in an evaporating dish, boiled in the liquid which exuded from it, and subse-
quently strained and pressed to obtain all the liquid that was procurable. The
object, in fact, was to make a decoction of the liver, which holds in solution
the glucogenic material, and has, thereby, communicated to it an opalescent
or a milky appearance. This was then mixed with alcohol (in the proportion
of one part of the decoction to about five of the spirit), and immediately a pre-
cipitate was produced, which was collected on a filter and dried, and formed
the specimen then before the fellows of the Society. The substance before him
was of a grayish colour, which resulted from contamination with albuminous
matter. It might be made perfectly white by prolonged boiling in a solution
of potash, which did not at all affect its properties. It was insoluble in alcohol
and strong acetic acid. Its solution in water presented the same milky appear-
ance as the fresh decoction of liver. It gave no reaction with the sugar tests,
nor was it susceptible of undergoing fermentation. It was, however, readily
convertible into dextrine and sugar by the same agents which produced this
change in the starch of the vegetable kingdom. Indeed, boiling with acids and
contact with diastase, saliva, pancreatic juice, blood, or any animal matter in

'I

248 Progress of the Medical Sciences. [Jan.

a state of change, very readily effected its transformation into glucose, when it
gave all the characteristic reactions of this substance. Dr. Pavy further stated,
that by means of chemical agents and the microscope the natural seat of this
material could be shown to be in the interior of the hepatic cells. — Lancet, Oct.
17, 1857.

10. On the Immediate Principles of Human Excrements in the Healthy Stale. —
Dr. W. Marcet communicated the following paper to the Royal Society : —

In a previous paper, I had the honour of communicating to the Royal So-
ciety the results of a first series of investigations on the immediate principles
of the feces of man and animals ; since then I have continued my researches
on human excrements, being most ably seconded by my assistant, Mr. Fred-
erick Dupre, Ph.D.

The new results obtained were the following: —

1. Margarate of lime, phosphate of lime, and margarate of magnesia were dis-
covered to be immediate principles of human evacuations.

2. I found a new method for obtaining excretine, and its chemical formula
has been established.

3. The fact that vegetable food induces the presence of margaric acid in ex-
crements has been confirmed.

4. The existence of a comparatively large quantity of cholesterine in the
spleen, which I had mentioned before as probable, has been confirmed.

When human feces are exhausted with boiling alcohol, the fluid being
rapidly strained through a cloth, a clear extract is obtained, which, in cooling,
yields a deposit; this substance being collected on a filter, is partly soluble in
boiling alcohol, and there remains undissolved a residue insoluble in ether and
alcohol. The residue in question being boiled with a solution of potash, dis-
solves almost entirely, and the addition of hydrochloric acid induces the forma-
tion of a precipitate in the solution. On examining this precipitate, it was
found to consist of a crystallizable substance fusing at 60° Cent. : its structure
and other properties were precisely those of margaric acid.

The acid filtrate contained phosphoric acid and lime. From several quanti-
tative analyses, I concluded that there was more lime than is required to com-
bine with the phosphoric acid in the form of the neutral phosphate, the excess
of lime being exactly that which was necessary to convert the margaric acid
into a neutral margarate of lime, C34HS3+03CaO. Consequently it followed
that the three substances existed in the form of margarate of lime and phosphate
of lime as immediate principles of human feces.

The alcoholic filtrate from the deposit being allowed to stand for twenty-four
hours, deposited another substance, of a nearly white appearance, and which
proved to be margarate of magnesia.

The peculiar action of a vegetable diet on human feces was investigated by
means of experiments undertaken upon myself, when I observed that an en-
tirely vegetable diet was attended with the formation of a large quantity of
margaric acid in the excrements — most probably not in the form of a marga-
rate, but in the free state, inasmuch as it was obtained from the decomposition,
with hydrochloric acid, of the precipitate induced by adding milk of lime to
the cold and clear alcoholic extract of feces, after the separation of the above-
described deposits.

In the month of December, 1855, I had an opportunity of noticing that dur-
ing a cold night, when the temperature falls below the freezing point, excretine
crystallizes readily and in large quantity in the clear alcoholic extract of
feces ; this method I employed as often as possible, to prepare enough excre-
tine for its chemical analysis; but the cold weather not lasting long enough,
and this season having been remarkably mild, I was compelled to adopt a
modification of the process by milk of lime, described in my former com-
munication.

Having prepared a sufficient quantity of excretine partly by the action of
cold, and partly by means of milk of lime, the chemical composition of this
substance was now determined. A qualitative analysis showed it to consist of
carbon, hydrogen, sulphur, and oxygen (a) ; there was no water of crystalliza-

i

1858.] Materia Medica and Pharmacy. 249

tion present. Oxide of copper was employed at first for the combustions, but
they were subsequently undertaken with chromate of lead, on account of the
large proportion of carbon that excretine contains; no substance having been
found to combine with it, its atomic composition was calculated from the
assumption that one equivalent contained one equivalent of sulphur; and the
following formula was obtained : —

78 eq. Carbon . . ... .468

78 eq. Hydrogen 78

• 1 eq. Sulphur 16

2 eq. Oxygen 16

Atomic weight of Excretine 578

In my former communication I had stated that when the tissue of the spleen
is submitted to a process of analysis similar to that adopted for the extraction
of excretine, a substance closely allied to cholesterine is obtained. This sub-
ject being one of great importance in a physiological point of view, I have
resumed the investigation, and placed beyond doubt that this substance is
really cholesterine. Its presence in the spleen is evidently independent of that
which might exist in the blood retained by this organ after death. Is it that
the spleen secretes cholesterine ? This can only be determined by actual ex-
periment ; but it is very remarkable that a part of the blood which is supplied
to the liver should come directly from an organ containing large quantities of
a substance known to enter into the composition of the bile. — Med. Times and
Gaz., Oct. 24, 1857.

MATERIA MEDICA AND PHARMACY.

11. Permanganate of Potash as a Caustic, Deodorant, and Stimulant. — Dr. D.
F. Girwood extols [Lancet, Sept. 12, 1857) the permanganate of potash as a
caustic, deodorant, and stimulant, and if what he states in regard to it shall be
confirmed by the experience of others, it will be a most valuable medicinal agent.

"As a deodorant, as an escharotic, as a stimulant," he asserts, "it is a most
useful application, combining, as it does, all these three qualities."

In a case of cancer of the os uteri, Dr. G. employed it in the double capacity
of deodorant and escharotic, to destroy the fetid odour and to check the ex-
uberant granulations, and induce a healthy appearance of the ulcerated
surface. He injected twenty grains to the pint of water frequently during the
day, with much benefit.

In a case of cancer of the breast he applied it in powder sprinkled on the
sloughy mass, and as a lotion (ten grains to the ounce). From a gaping sore,
in most offensive condition, it occasioned the wound to assume in some parts a
disposition to granulate, and it entirely removed the offensive odour of the
apartment.

In various other cases of offensive ulcers he has used it with equal advantage.

When it is wished to destroy masses of cancerous growth Dr. G. uses it in a
solid form, either as a powder, or in a mass as the sulphate of copper or other
caustics. A piece of lint wet with the lotion, of the strength of two to twenty
grains, Dr. G; says, supersedes all the charcoal, yeast and carrot poultices.

A teaspoonful of the substance mixed with a tablespoonful of water in a
dinner plate, and placed under the bed or anywhere convenient destroys all
odour, and it has this great advantage over other deodorants, that it has no
odour of its own. Most deodorants are themselves a nuisance, for while
destroying one odour they create another; the permanganate is free from this.

12. On the Oriental Bath. — Dr. Haughton read before the Physiological
Section of the British Association at its recent meeting at Dublin, the following
interesting paper on this subject: —

250

Progress of the Medical Sciences.

[Jan.

" Some months ago, my attention being drawn to the oriental bath as a
sanitary institution, I was induced to undertake a journey to the East, for the
express purpose of determining what were its claims to consideration ; and
with this view I remained a month in Constantinople, collecting whatever in-
formation was to be had upon this subject, which is now commencing to attract
so much attention in this country.

" This bath is best known to the western nations by the name of ' The Turkish
Bath/ having been described under that title in most of the accounts which
have appeared before the British public ; but the truth is, that there is scarcely
a nation in the East which does not possess a somewhat similar institution.
There is a prevailing prejudice that the Eastern bath is only suited for tropical
climates, and could not be adopted in these latitudes without danger ; but we
find that not only the ancient Greeks, but also the Romans, were acquainted
with its virtues, and thought no expense too great to enable them to confer
upon every citizen the luxury of cleanliness, the foundation of all sanitation.

" It was the custom of the Romans to build baths in the different countries
which they conquered; and accordingly the historian Justin informs us that
they introduced them into Spain, after the second Punic war, where they con-
tinued in operation long after their suppression in other parts of Europe.
From thence, according to Baccius, they passed into Germany and France, and
even into the British Islands ; and there is reason to believe, that were anti-
quarian research directed to this point, remains would be found in these
countries, not upon the same scale as those of France and Germany, but suffi-
ciently perfect to show the principle upon which they were constructed. It is
of great importance that this principle should be well understood, and espe-
cially that we should observe the difference between it and the Russian vapour
bath, which it most resembles. It is simply that of an oven, large enough to
walk about in, and lighted from the top, that you may see what you are doing.
The medium by which the bather is surrounded is hot air, containing a little
moisture, that the tissues may not experience too great desiccation from its
contact, and that the softening of the loosened scales of epidermis, which is so
essential, may be the sooner effected. In this bath, water is not absorbed by
the skin, as in the Russian vapour bath, or the steam baths of this country ;
but it is, on the contrary, given out by both the pulmonary and cutaneous sur-
faces in great abundance.

"In the Russian bath, as described by Sir George Lefevre, the vapour is
raised by pouring water over a stove, whilst the American Indian uses for the
same purpose red-hot stones, covered by the inner bark of oak, and upon which
a small quantity of water is poured, to prevent too great desiccation ; thus
resembling the Oriental bath in being a sweating process, while it differs from
it in the subsequent immersion in cold water, which is not practised by the
Turks, although cold plunge baths, and even douches, may be found in Egypt,
in connection with the more essential processes presently to be described. In
the Western steam bath the vapour is obtained by boiling water externally,
and is conducted by pipes into the box or chamber which is employed ; but it
operates on the system rather by virtue of its derivative and sedative action,
than in consequence of any depurative or diaphoretic effect. All admit the
advantage of keeping the cutaneous surface in such a condition as may be most
favourable for elimination of the different substances which are got rid of by
means of this extensive system of drainage. But it is also worthy of remark,
that the pulmonary mucous membrane is capable of acting as an excreting
surface, especially when the body is exposed to the influence of hot air, as in
the Oriental bath. In this way a large quantity of alcohol and nicotine is
excreted in those accustomed to the use of spirits and tobacco — the powerful
odour communicated to the breath betraying the exit of the poison. In ex-
periments made on the lower animals with phosphorus, this substance has also
been exhaled with the expired air, the appearance presented in a darkened
chamber being that of waves of light issuing from the nostrils. Now, while
this pulmonary transpiration is very much increased in a hot, dry atmosphere,
it is almost completely checked when the air to be respired is heavily loaded
with vapour, as is also the case with the functions of the skin. This is what

1858.]

Materia Medica and Pharmacy.

251

constitutes the most striking difference between the bath of Eastern nations
and the vapour baths of the West; and it is by no means an unimportant
difference, inasmuch as the perspiration is intended by nature not merely as a
means of ejecting superfluous moisture and effete tissue, but also as a natural
safeguard to prevent the temperature of the body from being raised to an in-
jurious extent. This safety valve does not exist in the vapour bath ; and in
using it our very lives may be said to be dependent upon a thermometer ; for,
evaporation being checked, the temperature of the body may be very quickly
raised, and accidents are by no means rare from inexperience or carelessness
in the administration of the different forms of steam baths. People also imagine
that when in these baths they perspire very profusely, because on going out of
them they are covered with large drops ; but nine-tenths of these are simply
the superfluous vapour which has condensed upon the body, and whose pre-
sence greatly impedes the natural exudation. In the Oriental bath, the small
quantity of vapour which exists is only that which is produced by the water
which is spilled on the hot floor during washing, and produces an agreeable
soothing effect, instead of that suffocating sensation which one experiences in
the Russian bath, in which, after having been half boiled, you are scrubbed
with a hard brush, and flagellated with a bunch of twigs.

"The first chamber which is entered serves as a dressing-room, where the
clothes are deposited previous to entering the hot chambers, and where the
bather remains to cool himself on leaving them. For this reason it was called
the frigidarium by the Romans, although the temperature is about 25° centi-
grade, or something over the summer heat of our thermometers. The next
room is about 10° hotter, and is called the tepidarium, where the bather
reclines, and drinks some hot coffee, or smokes, until he is in a proper condition
for entering the third chamber, which is only about 5° hotter. I paid particular
attention to this point when in Constantinople, always bringing my thermo-
meter into the bath, and in no instance did I find the heat above 40° centigrade
(104° Fahrenheit). Were it considered necessary, however, an enormous heat
could be endured in the Oriental bath.' A French gentleman, who was nearly
suffocated by the vapour of the baths of Nero, near Pozzuoli, in a temperature
of 122° Fahrenheit, was able to bear a heat of 176° Fahrenheit, in dry air,
without inconvenience. The floor of the bath being the hottest part, the stratum
of air next it ascends continually, carrying with it the superfluous vapour,
which condenses upon the roof, and creates an imperceptible current, which
suffices to purify the atmosphere. In the third or hot chamber, corresponding
to thelaconicum of the Spartans, and the calidarium of the Romans, the bather
is shampooed — a kind of kneading of the muscles ; and the dead skin, with its
adherent impurities, is removed by means of the goat's-hair glove ; and the
amount of extraneous matter which is thus collected from the most cleanly
person, will excite some surprise in those only accustomed to the use of soap
and water.

" After the use of the glove the bather is next thoroughly washed with soap
and hot water, performing part of the washing himself, as he is never naked
during any part of the bath, the Turks especially being most scrupulous in
this respect. When he gets up he puts on a pair of wooden pattens, to keep
his feet off the hot floor, and returns to the second chamber, where he is lightly
wiped, and again clad with warm towels, the head being bound up to avoid
taking cold. The bath is now finished, but it would be imprudent to go out
without remaining some time in the frigidarium to become cool. Here it is
customary to lie down, well swathed in towels, and to drink some sherbet or
coffee, and smoke. Nor does the bather require much persuasion to induce
him to stop, as the sensations are so delicious, that it is only necessary to lie
still to enjoy a mental calm and exquisite consciousness of health that few of
us have ever experienced.

" Here we have a pleasure which is not a vice — a luxury which does not tend
to shorten life ; and which only awaits a sufficient demand to give encourage-
ment to capital, that it may become at once cheap and universally attainable.
There is no drug in the Materia Medica at all comparable with it as a purifier
of the blood ; for even poisons are thus eliminated from the system ; and it is

252

Progress of the Medical Sciences.

[Jan.

well known that alcohol is frequently taken by the Turks in large quantities
without producing inebriation. Besides which, they enjoy an immunity more
or less complete from various diseases which are here prevalent, and which
would be quite unaccountable were the influence of the bath to be denied.
Gout is scarcely known ; rheumatism is rare, and soon cured ; workers in lead
paints seldom are affected by colica pictonum ; chronic skin diseases are very
rare, and pulmonary consumption much less common than with us.

" The Turks are indeed seldom ill, and are, on the whole, longer lived than
the Western nations, if one may be allowed to judge from the number of old
men to be seen in the streets, for unfortunately the government keeps no
statistics. The physicians who have had the most experience in attending
them are, moreover, of opinion that these happy results are really owing to the
great attention which they bestow upon the functions of the skin ; and Dr.
Millinger (the Sultan's physician) informs me that the Turks themselves have
always considered the public baths of Constantinople as supplying the place
of a certain number of hospitals, which must otherwise be built. Of the former
there are 300 open to the public, and every gentleman who can afford it has a
private one in his own house ; while there are only two or three public civil
hospitals for a population of 900,000 souls, nor were these at all crowded when
I was in Constantinople.

" Facts like these may lead us to inquire whether the office which nature
has intended for the skin is not really much more important than we are in
the habit of considering it ; and whether cutaneous respiration be really re-
stricted to the lower animals.

" It is an important practical question to the British public to know whether
the Oriental bath is, in the first place, conducive to health, and, in the second,
whether it is suitable to this climate. The first of these questions has been
answered over and over again by travellers who have thus recruited their
wearied frames, and by the experience of one-fourth of the population of the
world, who look upon the bath as not merely the greatest of luxuries, but as
a necessity, without which life would be a burden to them.

"We may perhaps be told that the bath has been discontinued in the west
of Europe, because it was found unsuited for the climate and the genius of the
people ; but history furnishes other reasons to account for its disappearance —
luxury and depravity did indeed enter the sanctuary, and in the endeavour to
suppress them, the temple of cleanliness was destroyed. In the time of Con-
stantine, a regular crusade was waged against them by the clergy, and the
civil power being placed in their hands almost without restriction, they de-
stroyed at one fell swoop the two greatest bulwarks by which the physical
energy of the people had been preserved — bodily exercise capable of acting
upon the entire muscular system, and a habit of cleansing the entire body.
Thus fell the baths and gymnasia of Europe. The ancient bath is worthy of
restoration, both as a hygienic and remedial agent. A beginning has already
been made, and our native land has taken the initiative ; the only building of
this kind in the west of Europe being lately opened in the neighbourhood of
the city of Cork, where it is used as a medical agent, with, I understand, con-
siderable success. No doubt, further improvements will shortly be made,
which will render it more serviceable as a remedy, both by additions and
alterations in its manner of working. I myself have suggested the introduction
of a certain measured quantity of pure oxygen gas, which may readily be done
by means of small tubes, whenever that element may appear to require re-
newal ; and I am not without hopes that I may soon be enabled to bring before
the profession some further communication upon this interesting subject/' —
Dublin Hospital Gazette, Sept. 15, 1857.

13. On the Preparation of Valerianate of Ammonia of Definite Composition.
— This salt had hitherto not been obtained in a state of purity, and in the solid
form. In fact, even in the most recent treatises on chemistry, the valerianate
of ammonia is described as being liquid and amorphous ; and the manufac-
turers of chemical products have been unable to supply it in a solid and crys-
tallized state, pure, and of uniform composition. MM. Laboureur and Fontaine

1857.]

Materia Medica and Pharmacy.

253

have endeavoured to overcome this difficulty. Their process consists in pre-
paring pure valerianic acid and ammoniacal gas, and then uniting the two
bodies. In proportion as the combination takes place the salt crystallizes in
a confused form, but under the microscope, four-sided prisms, either terminated
in pyramids or bevelled at their extremities, are distinctly seen. The va-
lerianate thus obtained has been analyzed by a commission of the Academy of
Medicine, and its purity has been ascertained.

The following is the formula : Take monohydrated and pure valerianic acid ;
place it in thin layers in a flat capsule, covered with a perfectly fitting receiver ;
let anhydrous ammoniacal gas pass into the receiver, until the valerianic acid
is saturated ; preserve the valerianate of ammonia in small portions, in well-
stopped bottles. — Bull. G6n. de Therap., torn. 52.

14. Formula for a Liquor Cinchonas to replace the Wine of Bark. — M. Des-
champs proposes the following : Alcohol, s. g. 833, five ounces ; water, twenty-
seven ounces ; sulphuric acid, s. g. 1845, fifteen and a half grains ; yellow bark,
three ounces; orange peel, four scruples. Macerate the entire for ten days,
strain, and add to the strained liquor half its weight of sugar; dissolve the
sugar, and strain. One ounce represents the infusion of half a drachm of bark.

The advantages of the preparation are said to be, that while it is compara-
tively cheaper than wine of bark, the sugar it contains will modify its action
in the same manner as the organic matter contained in wine does ; secondly,
that its taste is more agreeable than that of wine of bark; thirdly, that the
preparation will always be uniform ; and fourthly, that children will not refuse
to take it. — Ibid.

T5. Formulas for the Gelatinization of Cod-liver Oil.

M. Stanislas Martin' s Jelly modified. — Take of cod-liver oil, two ounces ; fresh
spermaceti, two and a half drachms ; simple, or other suitable syrup, and
Jamaica rum, of each six drachms. Beat the ingredients together with the
aid of heat, and when the mixture has acquired some consistence, pour it into
a wide-mouthed bottle. Cod-liver Oil solidified with gelatine. — Take of pure
gelatine, half an ounce; water, simple syrup, of each four ounces ; cod-liver
oil, eight ounces ; aromatic essence, as much as may be sufficient. Dissolve
the gelatine in the boiling water, and add successively the syrup, the oil, and
the aromatic essence; place the vessel containing the entire in a bath of cold
water; whip the jelly for five minutes at most, and then pour it, while still
fluid, into a wide-mouthed glass bottle, furnished with a cork, or with a pewter
cap, or if a bottle be not at hand, into a porcelain or earthenware pot, which
should be carefully closed. Cod-liver oil gelatinized with Carrageen or Irish
Moss. — Take of fucus crispus, half an ounce ; water, eighteen ounces ; simple
syrup, four ounces ; cod-liver oil, eight ounces ; any aromatic, according to
taste. Boil the carrageen in the water for twenty minutes ; pass the decoctio n
through flannel; concentrate it until it is reduced to four ounces by weight ;
add the syrup, the oil, and the aromatic ; whip the mixture briskly, having
first placed it in a cold bath, and pour it, while still a little warm, into the
vessel intended to receive it. The syrup maybe replaced by an equal quantity
of Garus' elixir, mint, or vanilla cream, or rum, &c.

M. Sauvan proposes to combine cod-liver oil with Iceland moss. Lichen
and Cod-liver Oil. — Take of Iceland moss jelly, four ounces ; gelatine, four
scruples ; hydrocyanated cod-liver oil (to which two drops of essence of bitter
almonds have .been added), six drachms. Prepare the Iceland moss jelly in
the usual manner ; melt the gelatine and pass it into the vessel which is to
hold it ; then add the cod-liver oil ; stir the entire with a spatula, until the
mixture be homogeneous and the jelly begins to congeal. Dose — two or three
spoonfuls daily. — Ibid.

16. Caustic Glycerine in Lupus. — The following formula is employed by Dr.
Hebra, of Vienna : Iodine, iodide of potassium, of each one drachm ; glycerine,
two drachms. This is applied every second day by means of a brush ; it pro-
No. LXIX.— Jan. 1858. 17

254

Progress of the Medical Sciences.

[Jan.

duces pain which lasts for more than two hours ; but it possesses the great
advantage of curing lupus without giving rise to disfiguring cicatrices. — Ibid.

17. On a Mode of Improving Cow's Milk and rendering it more easy of Diges-
tion for Healthy and Diseased Children. — Dr. Gumprecht, of Hamburgh, re-
marks that milk often disagrees with children, producing indigestion, acidity,
flatulence, colic, diarrhoea, &c. &c. In consequence of this, it has been pro-
posed to improve it by the addition of water and sugar of milk, which experi-
ence has proved to have imperfectly attained the object in view. Reflecting
on the effect of salt in rendering the food for adults not only more palatable,
but also more digestible, increasing the activity of the glands of digestion, and
rendering the albuminous substances and fat soluble in the fluids of the sto-
mach, Dr. Gumprecht was led to the idea of adding salt to milk, both for
weaned and older children, with the result of not only preventing the derange-
ment of digestion, but moreover of removing them in cases where they pre-
viously existed. No author who has written on the nutriment of weaned
children has spoken of this most useful addition to milk ; but a Dutch physi-
cian mentioned to Dr. Gumprecht, in conversation, that in his practice in Hol-
land he had frequently added a little salt to milk for weaned children with
most satisfactory consequences.

In the rural districts in Holland, salt is frequently added to the fodder for
pigs and cattle, for the purpose of preventing diarrhoea, which so often exists
in consequence of imperfect digestion, and this suggested the adding salt to
milk, not merely for healthy children, but for strumous children and such as
are affected with worms. Dr. Gumprecht quotes a passage from L. Nussdorff's
Lehrbuch der Gesundheitspfege, 1856, on the importance of salt in the nutri-
ment of man and animals.

With regard to the quantity of salt which should be added to the milk, it
must depend on the age of the child. To render cows' milk like human milk,
it should be boiled and skimmed, and a little sugar of milk and salt added. —
Dublin Hospital Gazette, Oct. 1, 1857, from Journal fur Kinderkrankheiten.

18. Mode of Preparing the Bran Loaf for the Use of Diabetic Patients. — Mr.
John M. Camplin gives the following formula for preparing the bran loaf,
which Dr. Garrod considers the best substitute for bread, for diabetic patients,
with which he is acquainted: —

Take a sufficient quantity (say two or three quarts) of wheat bran, boil it in
two successive waters for ten minutes, each time straining it through a sieve ;
then wash it well with cold water (on the sieve) until the water runs off per-
fectly clear ; squeeze the bran in a cloth as dry as you can, then spread it
thinly on a dish, and place it in a slow oven — if put in at night let it remain
until the morning, when, if perfectly dry and crisp, it will be fit for grinding.
The bran thus prepared must be ground in a fine mill, and sifted through a
wire sieve of sufficient fineness to require the use of a brush to pass it through ;
that which does not pass through at first must be ground and sifted again,
until the whole is soft and fine.

Take of this bran-powder 3 ounces, Troy, 3 fresh eggs, 1J ounce of butter,
rather less than half a pint of milk; mix the eggs with part of the milk, and
warm the butter with the other portion; then stir the whole well together, add-
ing a little nutmeg and ginger, or any other agreeable spice. Immediately
before putting into the oven, stir in first 35 grains of sesquicarbonate of soda,
and then 3 drachms of dilute hydrochloric acid. The loaf thus prepared should
be baked in a basin (previously well buttered) for about an hour or rather
more.

Biscuits may be prepared as above, omitting the soda and hydrochloric acid,
and part of the milk, and making them of proper consistence for moulding into
shape.

If properly baked, the loaves or biscuits will keep several days, but should
always be kept in a dry place, and not be prepared in too large quantities at a
time. — Med. Times and Gaz., May 2, 1857.

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Medical Pathology and Therapeutics.

255

19. 27*e Chemical Properties of the Potato, and its Uses as a general article of
commerce, if properly manipulated. — Mr. J. AY. Rogers read before the section
of Chemical Science of the British Association, at its late meeting in Dublin, a
paper on this subject; the object of which was to show that the matter of the
potato was in reality equal in nutritive value to the dry matter of wheat, whilst
the quantum of food produced from a given quantity of land was nearly four
times that produced from wheat. Mr. Rogers exhibited some interesting
specimens of the potato in meal, flour, etc. ; and gave the following results of
analysis : —

Starch. Gluten. Oil.

Components of the potato per cwt, 84.0771b. 14.8181b. 1.1041b.

of wheat " 78.199 17.536 4.265

And he gave the following important fact as to the quantum of food from an
acre of land : —

Starch. Gluten. Oil.

Drv matter of potato .... 3,4271b. 6041b. 451b.

of wheat . . . • . 825 185 45

British Med. Journ., Oct. 3, 1857.

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

20. Case of Marshall Hall, with the Post-mortem Appearances. — To render the
case of this illustrious physiologist complete, it is necessary to go back some
years previous to the appearance of the last severe and fatal symptoms; for
some peculiar features connected with the earlier symptoms rendered the case
somewhat different to those generally met with in practice, and made the suf-
ferer himself, always patient, thoughtful, and suggestive, consider that it pre-
sented features worthy of notice; and also made him anxious that its investi-
gation should be completed by a post-mortem examination.

His own account of an early inconvenience or difficulty in swallowing best
explains the symptoms as they occurred : " Some fifteen years ago," he wrote
to a friend, " I undertook to deliver two long and distinct courses of Lectures on
the Practice of Physic, during the same winter." His custom was to lecture
from six to seven, and then from eight to nine, in the same evening. He felt
inconvenience during this winter from hoarseness and cough for the first time,
and began to perceive that minute portions of food were apt to remain in his
pharynx, and that after meals he occasionally raised some small portions. This
difficulty of swallowing very gradually appears to have increased ; and he was
induced, some years ago, to consult Sir Benjamin Brodie and Dr. Chambers
on account of the increasing symptoms of obstruction; but on Sir Benjamin
passing a bougie, no evidence of obstruction by contraction of the oesophageal
tube could be detected. Mr. Guthrie, whom Dr. Marshall Hall also consulted,
told him that he was only suffering from what was called " clergyman's throat."
But the dysphagia continued, and during deglutition much care was requisite
in the act of swallowing, and food could not be hastily taken, and while in the
act of swallowing much regurgitation could be heard by those sitting near
him.

He considered this condition to be due to a defective reflex action which pre-
vented the muscles of the pharynx from acting with sufficient power to propel
all the food lodged in it ; but the probability is, that there was some such dila-
tation of the pharynx at this early period as is sometimes met with, and which
in a measure acts upon the aperture of the oesophagus mechanically, and thus
interferes with the ready passage of food. Such were the symptoms which
continued slowly increasing, but which never prevented a sufficient amount of
food to be taken, both solid and fluid, to keep up proper nutrition, until about
the end of 1855, when Dr. Marshall Hall first perceived that in the expectora-

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Progress of the Medical Sciences.

[Jan.

tion which he usually had in the morning there was occasionally a slight tinge
of blood, and this especially after much speaking or exercise. The dysphagia
also commenced from this time to be troublesome and serious.

Previous to this date Dr. Marshall Hall had retired from active practice in
London, as he found his health was failing to a certain extent, and some spots
of purpura appearing on his legs. He wisely determined at once to give up
the anxieties of professional occupation, though it entailed the sacrifice of a
large professional income. He made a tour of the United States in 1854-55,
and spent the following winter and spring in Italy. He returned to England
much better in health, but not improved as far as the throat affection was con-
cerned. After a short stay in town, he went to Hastings, and came to town
again in October following. It was now that the symptoms of permanent
stricture of the oesophagus were fully established. He had some time ceased
to partake of solid food ; milk, cream, and coffee were the fluids he chiefly
preferred. With the evident obstruction there was constant copious expectora-
tion of purulent mucus, somewhat offensive in character, and occasionally dur-
ing each day tinged with blood. He was seen in consultation by Dr. Williams,
Mr. Caesar Hawkins, Mr. J. R. Martin, and Mr. Pollock, all of whom were
agreed as to the serious nature of the complaint. He was quite prepared for
the expression of their most unfavourable opinion, and was even cheerful whilst
under examination. In speaking to one of his medical friends, who was con-
stantly with him whilst in town, he said, " I don't ask you what your positive
opinion is as to my prospect of life, for no one can be certain of the result of
a hidden malady; but I look upon my disease as a fatal one, and have long
done so. I have no hope of recovery. I don't wish you to mention this to
Mrs. Hall. I have no fear of death, and cannot be alarmed by the truth. My
only wish to live is for the sake of others ; but I am resigned to the alternative,
if it be ordered that I should not live much longer." The calm, resigned, and
almost cheerful manner in which he spoke at once showed the preparation and
the courage of a man who knew his end was not far distant, though still, as
ever, unselfish, considerate, and affectionate, for those dear and near to him.

Whilst in London he had a wish to have the nitrate of silver applied in solu-
tion to the supposed ulcerated part of the pharynx ; but when advised not to
employ it, he readily acquiesced in the opinion of those he had consulted. He
had applied the solution to the throat when in the country, but had been ap-
parently much distressed by it ; and though he had expressed a wish for its
application a second time, he evidently had no great desire to persist in its use,
from the distress it had occasioned.

After a short stay in London he removed to Brighton. He now placed him-
self under the care of Mr. Wildbore, whose constant care and attention to him
he always spoke of with much gratitude, and to whose note-book we are in-
debted for the remaining particulars of his case.

After being settled in Brighton, he complained of, and suffered much from
cold. It always distressed his throat, and rendered more difficult the efforts of
swallowing. His room was obliged to be kept at a temperature of from 70°
to 75° ; his diet was entirely milk, cream and coffee. In January this year he
wrote to Mr. Pollock : " I have been for two months at Brighton, and the com-
plaint has made no progress, but in cold foggy weather my dysphagia is always
worse. I am intensely susceptible to cold. I have been many days lately
without blood in the expectoration ; but last night it came on after going to bed,
without any assignable cause. Everything I take is apt to leave particles in
my pharynx, even a light-boiled egg. Hence the cause of the irritation and
consequent ulceration there. If so slight a thing will irritate and produce ex-
udation of blood, there is surely ulceration there, and this, in fact, has all
along been my opinion." We shall hereafter see how true was the opinion he
had formed of his own case.

There was at all times, to a greater or less degree, " a stinging, bursting
pain" behind the larynx ; sometimes for a day or two it was absent. During
February the symptoms were variable, the dysphagia increasing as the tempera-
ture became colder. Once or twice there was slight regurgitation of the fluid
by the nose and mouth. Some considerable benefit was derived from sipping

1858.]

Medical Pathology and Therapeutics.

257

a solution of chlorate of potash in water several times a day, with marked
temporary benefit to the swallowing, but the effect was not permanent.

In March he had a severe attack of gout, when much uric acid passed in
the urine. This was relieved by small doses of potash sipped in water, and
also used in an enema. The dysphagia slowly but gradually increasing, four
pints of milk were now only taken in the course of the day, and it occupied
nearly half an hour to get down half a pint.

On the 10th of March he walked out, after four months' confinement to the
house. The sun was hot, but the wind very cold, and the following day he was
confined to bed, suffering from bronchitis, and all his ordinary symptoms aggra-
vated. During several hours no fluid could be swallowed, and on attempting
to pass a tube for himself, an obstruction was met with, opposite, as he said,
the first or second portion of the sternum. This attack left him very weak.
He complained much of thirst, and said his feelings of hunger were dreadful.
Still he was most patient, and even cheerful in conversation, under all his suf-
ferings.

In a few days the attack of bronchitis passed off, and he now derived much
comfort from supping iced milk and sucking small pieces of ice ; but the ex-
haustion and emaciation were becoming considerable, and the quantity of fluid
taken by the mouth was reduced to about two pints in the twenty-four hours.
Mr. Wildbore therefore recommended him to allow the administration of nutri-
tious enemata, of which the following was the mixture ; five ounces of strong
beef tea, one ounce of port wine, and three grains of quinine. This was given
three times daily, and the whole quantity always retained. The quinine was
added on account of his suffering from intermittent fever which came on every
night. The enemata were evidently absorbed, for the bowels only acted once
in three or four days under the influence of warm water enemata, with some
salt dissolved in it, and this would be followed by a healthy motion.

On the 10th of April, for twenty-four hours, there was complete interrup-
tion to the passage of fluid through the throat; but on the following day he
was again able to swallow milk and some wine-and-water. Towards the end
of the month the difficulty of swallowing was so great, that if more than three
teaspoonfuls were taken directly one after the other, the fourth would bring on
cough, and the greater portion would be returned by nose and mouth, mixed
with mucus, as if the fourth spoonful filled up the tube to the aperture of the
glottis, and thus excited cough.

During the month of May he suffered much from hunger; but taking the
enemata four and five times a day appeared to nourish him to the extent that
he was able to bear the erect posture, which he could not a fortnight previously,
owing to vertigo. The aguish attacks were also severe, and he took constantly
about twenty grains of quinine in the enemata, which had the effect of relieving
him, but produced deafness and singing in the ears.

In June the voice began to be affected; the expectoration, which had become
white and frothy, was again purulent and offensive. The efforts to swallow
were attended with much exhaustion, and the struggles to get fluid down were
very great. The loss of voice at the end of June was unchanged ; the "sting-
ing, burning pain" greater, and debility increasing; the expectoration very
copious. Notwithstanding his condition, about the middle of the month he
ate a fair dinner of lamb and asparagus for three or four days consecutively,
swallowing it all. Then came a cold wind and increased dysphagia.

In July, early in the month, he applied himself a four-grain solution of nitrate
of silver to the pharynx five times. This increased the u stinging, burning
pain " greatly for two hours after each application, but no beneficial result of
any kind was obtained. Chills and profuse sweats attacked him every evening,
and the aphonia continued. During July he gradually became weaker, and
the quantity of fluid taken by the mouth was about a pint to a pint and a half
of milk daily. It may be mentioned that nearly all the time he was at Brigh-
ton, up to the last few days of his life, he looked fresh and healthy, a circum-
stance somewhat remarkable.

By his own desire he went out, in the early part of August, in an open car-
riage, but all his symptoms were becoming worse : the breathing short and

258

Progress of the Medical Sciences.

[Jan.

asthmatic, and the air-passages clogged with mucus. The rectum also became
uncertain in its powers of retention, and the enematawere sometimes returned.
On August 11th, at twenty minutes past eight, he died, maintaining his con-
sciousness to within a few minutes of his death.

His friend, Mr. Wildbore, wrote of him, but a few days before his death,
" It is wonderful to me how he bears up against his disease. He is ever thought-
ful of, and kind and considerate to all around him, and most grateful for the
least kindness or attention shown him ; always interested in professional ques-
tions, and ever active in mind upon those subjects which have chiefly occupied
his attention. He is most patient, and perfectly resigned." All who knew
and watched him during the progress of his disease, and witnessed the high
courage and true resignation with which he submitted to his sufferings and to
the prospect of death, will feel that Mr. Wildbore's estimation and record of
him was only what was just to the character of the greatest of English physi-
ologists.

The post-mortem examination of the body was made by Dr. Ransom, of Not-
tingham, thirty-eight hours after death, in the presence of Dr. Hutchinson,
Dr. Robinson, Dr. T. Wright, Mr. Higginbottom, Mr. Addison, Mr. Wildbore,
and Mr. M. H. Higginbottom, and for the record of which we are indebted to
Mr. Ransom.

The body was emaciated. No external marks of decomposition.

Thorax. — The lungs did not collapse on the cavities being opened. The right
one was universally adherent by old adhesions ; the substance of the lungs
healthy; no pleuritic effusion.

The pericardium contained nearly two ounces of dirty red fluid. The heart
was flabby (perhaps from cadaveric changes) ; it contained frothy blood in the
right ventricle and auricle. The valves were competent. There were some
atheromatous deposits on the inner surface of the aorta, which was stained a
deep red.

The bronchial glands were larger than usual, soft and black.

On making examination of the parts higher up in the throat, it became evi-
dent that some undue thickening and adhesions existed behind the larynx.
The latter was therefore removed, with the pharynx, the oesophagus and trachea.
In doing this, the intimacy of the adhesions necessitated that the knife should
be carried close to the bodies of the corresponding vertebree ; with every care,
however, buttonholes were made in two or three places. On removal, it was
seen that the walls of the pharynx were extremely thin, and that its cavity
was dilated. Through the openings made by the knife there escaped a dirty-
brown flaky fluid, of a creamy consistence. The adhesions were to the bodies
of the sixth and seventh cervical and first and second dorsal vertebra3.

The parts removed, when examined, showed a stricture of the oesophagus,
about the level of the eighth ring of the trachea, and a dilatation, with ulcera-
tion and vasculation of the oesophagus and pharynx above the stricture, to the
extent of nearly three inches. The stricture was attended with but moderate
thickening of the tube, and the aperture was not very small; but the mem-
brane was folded in, so as to present a conical eminence upwards, the apex of
which was opposite the narrowest part of the stricture, which here was rather
larger than a goose-quill. In this way the passage was almost valved, and
food would have had the tendency to pass down by the sides of the eminence
into the pouches and sacculi of the ulcerated portion. Indeed, the finger
passed down from above, previous to opening the oesophagus, could not enter
the passage, though a similar difficulty did not exist if the finger was passed
from below the stricture. The upper border of the ulceration was, on each
side, about level with the bases of the arytenoid cartilages, but did not extend
so high in the middle. The dilatation was, throughout, irregularly ulcerated,
soft, pulpy, ragged, of a dirty-gray or slate-coloured, and with few loosely-ad-
hering flakes on its surface. Its base was not much thickened, though here
and there it was somewhat so, and felt firmer in such parts. The walls of the
pharynx and oesophagus were perforated in several places, leading to pouches
or sinuses amongst the muscles of the neck, having very thin delicate walls of
false membrane. Two of these pouches were very large, and ran upwards on

1858.]

Medical Pathology and Therapeutics.

259

the outer surface of the thyroid cartilage, one on each side, as high as its upper
border, the right pouch being the largest. A narrow slip of mucous membrane
remained at the back of the trachea, but this at the lower extremity was quite
undermined.

At the lower part of the dilatation the ulceration had nearly perforated the
trachea through the posterior membranous wall, and had set free the right
extremities of the fourth, fifth, and sixth cartilages. The pharyngeal mucous
membrane above the ulceration appeared nearly natural, except for two or
three little rounded elevations, as if there was a deposit in the mucous mem-
brane, each less than half a pea in size. There was a small pendulous polypus
attached to the thyro-epiglottidean fold. The oesophagus below the stricture
was healthy.

In the mucous membrane of the trachea directly corresponding to the deep
ulceration that threatened to perforate it, was a small deposit or growth — semi-
transparent, solid, and slightly elevated. There was a similar one higher up,
inside the cricoid cartilage, but it was more opaque and white.

The patch on the tracheal mucous membrane was cut across, and from a
section of it were obtained cells which possessed all the characters of cancer-
cells. They were delicate, large, irregularly angular, with elongated processes ;
some were, however, rounded, had peculiar large nuclei and nucleoli ; often
several of these in one cell, and sometimes a cell-wall around one or more of
the contained nuclei. Some few of the nuclei presented a delicate, regular
radial striation, which Dr. Ransom observes he had not before seen. These
cells were contained amongst the meshes of the elastic tissue. From the whiter
patch on the inside to the cricoid cartilage, similar cells were obtained, but
they were fattily degenerated, and therefore less characteristic. From the base
of the ulcerated surface Dr. Ransom found in parts examined no satisfactory
evidence of the nature of the pathological process which had preceded ; but
amongst a mass of granular and fattily degenerated elements, several bodies
were always seen resembling retrograde cancer-cells.

The fluids from the surface of the ulcer consisted mainly of molecular detri-
tus and fat, in drops and granules, with a great number of epithelium scales,
mostly of the scaly variety ; but a few were cylindrical and ciliated, probably
separated from the upper parts of the pharynx. In the little elevations on the
mucous membrane of the pharynx nothing was found but globular corpuscles
and cells filled with fat granules of various sizes ; and one beautiful hexagonal
crystal-like cystin was observed.

A portion of the pharynx and oesophagus, examined by Mr. Caasar Hawkins,
Mr. Pollok, and Mr. Holmes, curator of St. George's Hospital Museum, gave
the following results : —

1. A portion of the disease was surrounding the great vessels in the neck,
and apparently making pressure on the upper part of the pharynx. The in-
terior appeared of a cellular character. Sections showed fibrous tissue, with
numerous nuclear bodies, and much fat.

2. A small tubercle, beneath one of the rings of the trachea, contained an
immense number of nucleated cells, resembling those of healthy epithelium,
but of more curious form and size ; also a good deal of fat.

3. A mass containing dark masses (of black pigment), otherwise exactly
resembling the portion first mentioned.

21. Hanmopliilia. By Dr. Magnus Huss. — This term was first employed by
Grandidier-to designate that peculiar tendency to hemorrhage which charac-
terizes some individuals and families. The following case, which is reported
and commented upon at length by the well-known Professor Huss, of Stock-
holm, is almost unique of its kind.

Maria K., a servant, aged twenty-three, a country girl, the child of labouring
people who had always enjoyed sound health, and exhibited no hemorrhagic
tendency or other hereditary taint, was admitted into the Seraphim Hospital
of Stockholm, January 16th, 1851, of good complexion, healthy looking, and
well built. Catamenia appeared without abnormal features at the age of fif-
teen ; had never been ill, excepting convulsive fits in her infancy ; there had

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Progress of the Medical Sciences.

[Jan.

been do remarkable tendency to hemorrhage, but whenever she had met with
an injury the parts had cicatrized as in any other person. She went into
service when nineteen years old, and was maltreated on the 4th August, 1850.
She was severely buffeted, and struck about the head, in consequence of which
she was much excited and seized with convulsions, during which she screamed
and struck her head against the surrounding objects ; she was insensible for
about half an hour. On recovering herself she found that she had bled pro-
fusely from the head, without being able to find any lesion of continuity. She
continued in a torpid state during the succeeding three days; she merely re-
members that the hemorrhage persisted, and that blood also flowed from the
eyes, the left ear, and that she vomited blood. She continued very feeble after
this time, the hemorrhages recurring almost daily. They ceased after two
months, when she recovered her health for a fortnight ; without any cause, the
hemorrhage then returned one night from the cranium, and at the same time
she vomited coagulated blood. The hemorrhage from the cranium continued
for a week, then stopped, and the patient was well for two months. After
that, the hemorrhage recurred every eight or fourteen days from the cranium,
eyelids, and left ear. When examined after her admission, no traces of a pre-
sent or previous solution of continuity could be traced on the cranium ; there
was no trace of injury to the bones. The hemorrhagic attacks continued to
occur on the slightest emotion, but without special symptoms, except on one
occasion, when, at the commencement of copious hsematemesis, the patient was
seized with violent delirium, then lost consciousness, and remained for eight
days in a state of profound torpor. She then woke up, and the two left ex-
tremities were slightly paralyzed, and their sensibility somewhat blunted.
After the lapse of three weeks these symptoms had entirely disappeared.

In March, 1852, she is described as being anaemic, pale, somewhat emaciated,
and depressed, but the functions otherwise in normal condition ; the kidneys,
liver, sexual, and other organs apparently healthy ; emotion so directly influ-
enced the occurrence of the hemorrhage, that the patient by entering into a
dispute could generally produce it at will. When it took place, she felt so
fatigued as to be forced to lie down ; the hemorrhage occurred on each side of
the coronal suture, on a space three centimetres by ten. The blood was seen
to sweat out at the roots of the hairs, first forming a red point, which gradually
augmented to a drop which coalesced with others; if wiped off, the surface
would soon be again covered with blood ; its colour was that of arterial blood.
Examined by a lens, no lesion could be detected, but the blood could be seen
issuing from the hair follicle ; the root of the hair was not diseased. The
hemorrhage lasted from a few hours to two or three days ; the skin of the
bleeding part was not tumefied, but slightly tender, and its temperature ele-
vated. The attack was generally preceded for one, two, or three days, by a
sense of weight on the head and vertigo, with a feeling of heat and pulsation
at the spot immediately before the bleeding occurred. Hsematemesis and
bleeding at the left ear were only occasional concomitants of the attacks ; but
the former was always accompanied by stupor, alternating with delirium.

The treatment, which consisted in the administration of tonics and astrin-
gents of all kinds, with nutritious diet, only caused temporary arrests of the
hemorrhage. Strange to say, that in spite of the peculiar tendency to hemor-
rhage from certain parts, there was no predisposition to it from others, for
contusions and solutions of continuity were not followed by unusual hemor-
rhage. On the application of local astringents to the head, such violent
symptoms of cerebral congestion were manifested as to render venesection
necessary.

All treatment failing, the patient was sent home in the same state in which
she was admitted. The details of this interesting case are followed by an
analysis of the theories applicable to the hemorrhagic tendency, and Professor
Huss arrives at the conclusion that it is due to spasmodic contraction of the
veins passing from the capillary network of the parts, in which this form of
hemorrhage was manifested. — Brit, and For. Med.-Chirurg. Review, Oct., 1857,
from Archives Gen., August, 1857.

1858.] Medical Pathology and Therapeutics. 261

22. On some of the Prevalent Errors in relation to the Predisposition to Hys-
teria.— M. Briquet believes that most writers have been indebted more to their
imagination than to the observation of facts for the pictures they have drawn
of this disease. It has been attributed, by most of them, either to unsatisfied
sexual desires or to excessive excitement of the uterus and its appendages, and
a fanciful etiology to correspond has been invented. The object of this paper
is to show that these and other preconceived ideas have no solid foundation in
fact.

1. The hysterical constitution, about which so many positive assertions have
been made, has, in fact, no existence, the affection occurring in women having
the most opposite external appearances. The author examined 425 cases of
hysteria in this point of view ; of these, as regards height, 127 were tall, 168
medium size, and 106 short; as to strength, 99 were strong, 36 medium, and
26 weak ; as to flesh, 194 were stout, 106 medium, and 92 thin and spare; as
to colour, 220 were fair, and 164 dark, 27 having the hair light, 39 black, 177
light chestnut, and 188 deep chestnut. In 168 the face was pale or brownish,
and in 174 fresh coloured. Thus it will be seen these were the ordinary varie-
ties met with among women in general.

2. The temperament is also various enough. The following is the classifica-
tion M. Briquet made of 383 cases. In 143, it was lymphatico-sanguineous,
in 125 lymphatic, in 91 nervous or lymphatico-nervous, in 12 bilious, and in
11 sanguineous. These are evidently very much the proportions that are found
in females of from 15 to 30, part inhabitants of the country, and part of the
towns, as was the case with these. At all events, there is no temperament that
can properly be called hysterical.

3. Moral Disposition. — That which is not discoverable in the physical consti-
tution of hysterical females is, however, very evident in their moral disposition.
So much is this the case that, of 430 cases occurring to the author, not more
than 20, at the utmost, have not manifested it. The characteristic of this is
marked impressionability, foreshadowed in childhood by great timidity, exces-
sive susceptibility to blame, and a disposition to shed tears easily.

4. Mode of Life. — Another of the axioms that has been laid down as
undoubted, is that hysteria is the prerogative of the wealthy and luxurious,
and that poverty is a security against its occurrence. It is a complete error:
the common people being the subjects of hysteria in almost a double propor-
tion to the other classes. At a particular epoch, M. Briquet visited all the
female patients in the medical and surgical wards of La Charite, with the
exception of those suffering from epilepsy, apoplexy, insanity, or delirium.
The number amounted to 203, and of these 65 were hysterical (38 with convul-
sive paroxysms), 49 were impressionable, and 89 only were, neither hysterical
nor impressionable. Thus, among the common people, there was 1 woman in
5 who had hysterical paroxysms, and 3 out of every 8 were the subjects of hys-
teria. So far from being exaggerated, the statement is rather below the truth.
But where is the practitioner who meets with 3 cases of hysteria among 8 of
his private patients? According to the experience of many M. Briquet has
consulted upon the subject, there is about 1 in 8 or 10 in the easy classes of
society, not alluding to the very highest. The charms and simplicity of a
country life, too, have been sufficiently praised, and nervous diseases have been
said to be the almost exclusive affliction of civic life. M. Forget, in 1847, some-
what startled this belief by showing how frequently hysteria occurs among the
simple Alsatian peasantry. M. Briquet has obtained cognizance of the place
of abode, and' of early education, in 324 cases of hysteria, and of these, 168
were town-born and bred, and 156 from the country, the majority of these latter
having, in childhood, laboured in the fields. In the case of 42 of these country
girls, their mothers had been hysterical, 29 suffering from paroxysmal attacks.
Professor Lebert, of Zurich, also assures the author that hysteria is just as
often seen in the poverty-stricken cantons of Switzerland as in the most flourish-
ingones. A too tender and luxurious education has been assigned as a predis-
posing cause ; but of 81 cases of hysteria occurring before the age of puberty,
in 21 the harsh treatment they had been subjected to was the principal cause
of the disease. A third portion of the author's collection of cases had been

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Progress of the Medical Sciences.

[Jan.

submitted to ill-treatment or privation during childhood. In place of a tender
education being assigned as a predisposing cause, it would be more just to thus,
stigmatize a harsh one.

5. Continence has been stated by many authors as an unnatural condition,
predisposing to hysteria; but when it is remembered that the majority of cases
occur between 12 and 20, we naturally ask at what age it becomes unnatural,
as also for the explanation of the occurrence of the disease in 86 children under
11 years of age. Various authors since the time of Galen have deplored the
fate of widows, as the necessary victims of hysteria : but, in point of fact, their
solicitude has been little needed, inasmuch as among 375 cases collected by
Landovzy, only 12 of the subjects were widows, as were only 14 in the author's
own 430 cases, i. e., 26 in 800 cases, or 1 in 30. Of the author's 14 cases, too, in
6 the hysteria appeared on the day of the husband's death, and in 4 during the
first month after it, and should surely, with more probability, be referred to moral
emotion. Hysteria has been said to be, on the one hand, common among nuns,
and, on the other, rare among women who give free vent to their sexual desire.
But, in point of fact, it is rare in convents, and is chiefly found in those in
which there is great fasting and maceration. The reverse position so strongly
maintained by authors may also be disposed of. Thus, of 300 hysterical
females, above the age of 15, 139 were married or kept women, and among
them had 367 children, not counting miscarriages. Among the 161 remain-
ing, very few resigned themselves to continence. At the Lourcine, where
syphilitic work-women and servants repair, among 424 patients, 169 were hys-
terical. As to prostitutes, of 197 applying to St. Lazare, on account of syphilis,
106 were hysterical, 28 very impressionable, and 65 neither hysterical nor im-
pressionable. It results, from all this, that continent women are rarely hys-
terical; those who do not observe continence are frequently the subjects of
hysteria; while those who pursue the extreme of incontinence are the most
liable of all. The reason is obvious. Among these different classes of women,
the first lead peaceable lives, the second have much to go through, while the
last are a prey to frequent and violent emotions. Next, we may consider the
effects of marriage on hysterical women, which, to judge from the statements
made, have been truly remarkable. But, among M. Landovzy's and the author's
800 cases, in only 29 instances did decided advantage follow marriage, notwith-
standing the complex character of the modification ensuing upon this state.

6. Menstruation and Affections of the Uterus. — This class of influences has
been raised to the highest rank by those writers who are determined at placing
the seat of hysteria in the uterus. 1. This has been supported by the supposed
effects of normal or abnormal conditions of the menstruation. From the
author's observations, however, made on 411 hysterical women, in but 136 had
there been any derangement of the menses. Of 237 deliveries of hysterical
women, in but 12 were there any convulsive paroxysms, some of which, too,
might have been examples of eclampsia. 2. According to authors, it is com-
mon to observe hysteria in affections of the uterus. Now these diseases are
exceedingly common, and the connection ought to be easily demonstrable. But
this is not the case, for Landovzy, and other partisans of the opinion, are able
to collect but some 40 cases of affections of the genital organs giving rise to
hysteria: few enough as compared with the thousands of cases daily occurring.
Practitioners, moreover, having much to do with the various female diseases,
entirely deny such connection. — Med. Times and Gaz., Oct. 31, 1857, from Union
MSdicale, Nos. 36, 39, 40.

23. Asphyxia of Submersion. — Mr. A. T. H. Waters, from a series of experi-
ments instituted with the view of investigating the two following questions —
1st. How long the heart continues to beat in asphyxia produced by submersion ;
2d. What effect the hot bath produces on an animal asphyxiated by submersion
— arrives at the following conclusions: —

1. That in dogs and rabbits, when asphyxiated by submersion, the ventricles
of the heart do not, as a rule, cease to contract " in a few minutes after the ces-
sation of the functions of animal life;" but that in many instancestheir action
continues for a very considerable period, and that in all probability the same

1858.]

Medical Pathology and Therapeutics.

263

remark applies to man, and serves to explain how recovery has taken place
after lengthened submersion.

2. That the effects of the hot bath are, to produce great congestion of the
lungs, and a tendency to coagulate in the blood ; its use becomes thus directly
prejudicial; that it does not excite respiratory efforts, and prevents artificial
respiration being properly carried out; and it becomes thus indirectly pre-
judicial.

With reference to the treatment of asphyxia, from whatever cause, all our
efforts should be made to excite respiratory movements, and if these movements
can be produced before the heart has ceased to beat, there is great probability
of animation being restored ; and even should the action of the heart have
ceased, it is possible that by re-exciting respiration we may reproduce the cir-
culation.

In attempting to produce artificial respiration, the best method is that recom-
mended by Marshall Hall. Experiments on the dead body, and numerous
instances of recovery from asphyxia attest its value, and prove it to be the
most simple and efficacious means we know of. If artificial respiration be
attempted when the body is supine, the tongue should be drawn forwards and
kept so ; this has not been sufficiently attended to.

The rules for restoring suspended animation recommended by the Humane
Societies are defective. Their object is to restore circulation and warmth by
means of the hot bath and hot air, neglecting, or only imperfectly carrying out,
artificial respiration, on which alone safety depends. Moreover, the directions
involve very serious loss of time. Few, if any, instances are recorded by these
societies in which animation has been restored by the means recommended
after a submersion of more than five minutes — a fact not to be wondered at
when we consider what these means are. — Liverpool Medico- Chirurgical Journal,
July, 1857.

24. Asiatic Cholera and its Prevention. By Henry McCormac, M. D. — As
physician to the Belfast Cholera Hospital, I had unusual experience in the
treatment of Asiatic cholera. During the earlier outbreaks of this malady,
opium and calomel were among the remedies most confided in. During the
more recent outbursts, however, a new and additional remedy of great efficacy
was resorted to. This remedy consisted of the dilute acids, any of them. Use
and convenience gave the preference to dilute sulphuric acid, and to this dilute
acid, more or less combined with opiates, I habitually restricted myself. The
name of the person who introduced this remedy, like that of many another
benefactor of his species, is unknown. The elixir of vitriol, which is merely
sulphuric acid diluted with spirit, and the addition of a little aromatic is, in
respect of cholera, in very many cases, literally and truly the elixir of life.
Twenty drops, in a little water, may be taken every time the bowels are affect-
ed, also every two hours, for some hours after. But dilute sulphuric acid —
that is to say, sulphuric acid one part, water seven parts, has precisely the
same medicinal properties. Here, thirty drops in a little water, will be an
expedient dose. To children, two drops for each year of the child's life may
be given. Otherwise the mode of exhibition is the same.

I now come to another feature in respect to the efficacy of dilute sulphuric
acid. I find that it possesses preventive, as well as curative properties. On
the occasion of the outbreak of cholera in the Belfast District Lunatic Asylum,
and after many deaths had ensued, I put the whole establishment on a pro-
phylatic or preventive regimen. I added dilute sulphuric acid, in the pro-
portion of half an ounce of dilute sulphuric acid to twelve ounces of water.
Of this mixture I caused one tablespoonful, further diluted with a little water,
to be swallowed each morning by every inmate. Very soon after, the cholera
had completely disappeared. There is here the alternative of supposing that
the disease spontaneously vanished, or that the dilute sulphuric acid had acted
as a prophylactic. I myself prefer the latter conclusion. It is reasonable to
conclude that a substance which possesses the property of constipating the
bowels, should be adverse to the propagation of cholera. Now, dilute sul-
phuric acid possesses this property. It is also conformable to the efficacy of

264

Progress of the Medical Sciences.

[Jan.

prophylactic measures generally, though greatly exceeding the efficacy of most
in the prevention of disease. Sulphuric acid is as cheap as it is effective. A.
pound of strong sulphuric acid, costing one penny, will make seven pounds of
dilute sulphuric acid, which, further diluted, would furnish a prophylactic
draught to the whole of a regiment. And this brings me to the object and in-
tent of these remarks. They are intended to serve our suffering countrymen
in India, engaged with a murderous enemy, and assailed by cholera, equally
murderous. It is of great moment to cure disease, but it is yet more momen-
tous to prevent it. I, therefore, have recourse to the wings of the press in
order to disseminate a suggestion, which, if acted upon, I feel assured is cal-
culated to avert many a pang, and in the East, as well as elsewhere, rescue
lives of priceless value.

25. Nature, Causes, Statistics, and Treatment of Erysipelas. — The Midland
Quarterly Journal for May last, contains a highly interesting paper on this sub-
ject by Peter Hinckes Bird, F. R. C. S. The following are his conclusions: —

1. Erysipelas is merely an example on the skin of that diffuse inflammation
which, in other tissues, constitutes diffuse inflammation of the mucous mem-
brane, diffuse phlebitis, puerperal fever — all of which have a common origin, a
poison in the blood, are infectious and contagious, and may mutually produce
each other.

2. The term erysipelas should be confined to diffuse inflammation of the skin
and subcutaneous cellular tissue.

3. Erysipelas is best treated by stimulants and support, and when compli-
cated with inflammation of the subcutaneous cellular tissue, by early incisions
which should extend to the depth of the disease.

26. Action of Cod-liver Oil in Chest Diseases. — Dr. E. Smith read a paper
on this subject to the Medical Society of London (Oct. 31, 1857). The object
of the paper was to show that, whilst cod-liver oil is a valuable remedy, it acts
simply as a fat with certain physical qualities, and may be, and ought to be,
supplanted by the ordinary fats used as food.

He first considered the chemical constitution of the oil, and then the state of
system existing in phthisis, and particularly entered into an inquiry which he
had instituted upon 500 cases as to the appetite for the various fats in food, and
the appetite for, and effects of, the oil. He found that there was a diminished
appetite for fat in phthisis, but that in no case was the dislike absolute ; and
in all some kinds of fat could be taken when others were rejected. Thus, fat
meat was taken by more than half of the patients, and bacon fat by two-thirds ;
whilst suet in puddings, butter, and milk, were taken by more than nine-tenths
of the whole. Afterwards, he stated the result of the effect of cod-liver oil upon
150 in-patients, and proved that in nearly half of them the oil was rejected or
of no real service. Of 83 who reported themselves benefited, by far the larger
proportion referred the good effect to improved assimilation ; whilst of 67 who
were unable to continue its use, or who were not benefited, the ill effect was
referred to sickness and other circumstances connected with the first acts of
digestion. After thus showing the degree of good and harm resulting from the
oil, and the degree of appetite for, and dislike of, fat of various kinds in food,
he proved that in the large majority of cases there was an appetite for fats
when oil did good, and the contrary when it did harm, but this was not uni-
versal ; and he also proved that in the very cases in which the oil was rejected
there was always appetite for some kind of fat food, and in some cases even for
the fat of meat. Hence he proved that there was no ground for the assertion
that the oil was more easily digested and assimilated than some of the natural
fats in food. The inquiry and medical testimony now prove that cod-oil acts
beneficially as a nutrient ; and he affirmed, from special experience, that the
oil has no advantage over the fats in food, provided an increased quantity
be taken of such of the nutrient fats as the patient can eat. Hence he urged
the profession to distinguish properly between food and physic ; and, if the oil
is administered as a nutrient, to inform the patient that it is given as food, or,

1858.]

Medical Pathology and Therapeutics.

265

as he preferred, to direct them to increase the nutrient fats in proper quantities
and of a suitable kind, and to administer other articles as medicine.
The following were the author's conclusions : —
That neither cod oil nor fat of any kind removes phthisis.
That the cases of arrest of the disease are very few.

That commonly the disease progresses, and is as fatal now as it was before
the oil came into general use.

That in about half of the cases the rate of progress is retarded.

That the patient may be both stronger and stouter, and yet the disease
quietly progress.

That when the oil disagrees, it is chiefly from its influence upon the digest-
ive organs.

That when it agrees, it is generally by improving nutrition ; but that in
many cases it is believed by the patient to have a local influence.

That this local influence is most important in the pharynx and other parts
of the mucous tract.

That it acts almost entirely as a fat, and supplies a defect in the system.

That it has no advantage over fats used in food, and may, like some of them,
be taken and rejected.

That there is a large class in whom it is not beneficial, and it should be used
with discrimination.

That it is our duty and our interest to dissociate food and physic.

Lastly, that it leaves the essence of the disease untouched ; but that the
great good which it often does temporarily, proves the importance of fat in the
animal economy.

He showed how much more frequently there is appetite for fat in bronchitis
than in phthisis and mere debility, and particularly in liver diseases ; but he
deferred the discussion of the question, and of the use of fats in general, to an-
other occasion. He urged upon the profession the impropriety of poor-law
surgeons being compelled to supply the oil, when the guardians ought to give
fat in food ; and of the medical officers of hospitals and dispensaries taxing the
overburdened funds to supply so expensive a food.

Dr. Payne Cotton remarked that the opinions of the author respecting the
virtues of cod-liver oil were not those entertained by the other physicians of
the Hospital for Consumption. He himself was an advocate for its employment
in all cases. He did not pretend to explain why it did good, but that it was of
benefit was sufficiently evident by its effects. Under its use a great number of
patients improved, and though it failed in some instances, it did not do so so
frequently as Dr. Smith stated. He could only say he had undiminished con-
fidence in its effects. He had tried other oils with a view to determine whether
they could be substituted for it ; but they were all inferior to it. Amongst
those he had thus tested were train oil, neat's-foot, almond, olive, and cocoa-
nut oil. That which most nearly resembled the cod-liver oil was the neat's-
foot. When cod-liver oil was given in the earlier stages of phthisis, in many
cases it arrested and retarded the disease, and prolonged the life of the patient.

Dr. Cotton had employed glycerine, but it did not act beneficially.

Dr. Semple considered, from the experience he had had of the use of cod-
liver oil, that it was of signal benefit in cases of phthisis. In many cases
it prolonged life, and added to the comfort of the patient : in some instances,
when given in the early stages of the disease, it arrested the complaint and
prolonged life to its average duration. He had witnessed remarkable good
effects from its administration to children affected with various strumous dis-
eases.— Lancet, Nov. 7, 1857.

27. Injections of the Bronchi in Pulmonary Diseases. — Dr. J. H. Bennett,
Prof, of Clin. Med. in Univ. of Edinb., in a short paper in the Edinburgh Medi-
cal Journal (Nov. 1857) makes the following statement: —

" I have introduced the catheter publicly in the clinical wards of the Royal
Infirmary, in seven patients. Of these five were affected with phthisis in vari-
ous stages — one had chronic laryngitis with bronchitis, and one chronic bron-
chitis, with severe paroxysms of asthma. In several other cases in which I

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attempted to pass the tube, it was found to be impossible — in some because the
epiglottis could not be fairly exposed, and in others on account of the irrita-
bility of the fauces and too ready irritation of cough from pressure of the
spatula.

" My experience of this treatment is as yet too limited to permit my saying
anything of its permanent effects. In the case of bronchitis with asthma — a
female, aged 24 — I have now injected the lungs eleven times, at first throwing
in gij of a solution of nitrate of silver, of the strength of £ss of the distilled
salt to of crystallized water, and latterly I have thrown in ^ss of a solution
of the strength of to § j. She declares that no remedy has had such power-
ful effect in lessening the cough, diminishing the expectoration, or delaying the
asthmatic paroxysms. She breathes and blows through the tube, when inserted
four inches below the larynx, and I have been surprised at the circumstance of
the injections not being followed by the slightest irritation whatever, but rather
by a pleasant feeling of warmth in the chest (some have experienced a sensa-
tion of coolness), followed by ease to the cough, and a check for a time to all
expectoration."*

28. Treatment of Phthisical Vomiting by Local Anaesthesia. — Mr. Atcherley,
disappointed in the effect of the orthodox remedies — as hydrocyanic acid, opium,
bismuth, gallic acid, creasote, nitrate of silver, counter irritation, &c. &c. — for
this condition, states (Liverpool Medico- Chirurgical Journal, July, 1857) that he
was induced to try Dr. Arnott's method of producing local anaesthesia in two
cases with decided success. He directed " pounded ice and common salt to be
mixed together in the proportions used to produce anaesthesia. This poultice
was placed in a thin muslin bag and put upon the epigastrium, and retained
there until the skin became white and insensible; it was then removed, and
its place supplied by lint, dipped in cold water, to prevent too sudden a reac-
tion. As I had always witnessed great benefit from the internal administra-
tion of chloroform in previous cases of a similar nature, I directed ten minims
to be dissolved in two teaspoonfuls of brandy, with a sufficient quantity of iced
water to make a draught, to be taken whenever the feeling of nausea came on.
I gradually increase the quantity of chloroform if the smaller doses are insuffi-
cient ; but I have seldom had occasion to exceed sixteen or eighteen minims.
In this case it had not such an extended trial as its valuable sedative powers
entitle it to. I have generally found it to allay the sickness for a time, even
in the most urgent cases ; and when given in the remission of the paroxysms,
it relieves the feeling of exhaustion and overwhelming depression consequent
on the long-continued retching, more speedily than any other restorative. Still,
in this patient, no permanent suspension of the vomiting took place until after
the application of the ice poultice. No food of any kind was given till a clear
truce of four or five days had been established, the strength being maintained
by enemata of beef tea, jelly, and wine.

"The effect of this treatment was most remarkable : the stomach, which had
rejected everything in the shape of food for the space of ten days, accompanied
with violent retching, sometimes of two hours continuance, became suddenly
tranquillized. The vomiting ceased for a whole day and night immediately after
the first application of the ice poultice, although it returned to some extent on
the following morning, when the same means were employed with the same
beneficial results. The patient has since had no return of sickness, is now en-
joying a good animal diet, with beer or wine, as inclination dictates, and has
been able to resume the use of cod-liver oil."

29. Chloroform in Intermittent Fever. — M. Delioux, a professor in the French
Naval Medical School, has long been engaged in searching for succedanea for
quinine. Having observed that when he administered chloroform to phthisi-
cal patients, that it not only relieved the pain in the chest and cough, but also
moderated the fever and nocturnal sweats, he conceived it might possess febri-
fuge powers also ; and the result of numerous trials is the ample verification
of his supposition. He forms a syrup, by adding 5 parts of chloroform to 100
of simple syrup, of which he gives from £j to giij in a mixture, at the same

1858.]

Surgery.

267

intervals afc which quinine would be given. — Med. Times and Gaz., Nov. 21,
1857, from Union Med., No. 129.

30. Belladonna in Incontinence of Urine. — A number of cases have within the
last few years been reported, showing the beneficial effects of belladonna in in-
continence of urine ; but the following, reported in the British Med. Journ.
(Sept. 5, 1857), is the most remarkable we have met with.

Elizabeth S., aged 4 years 9 months, was admitted under the care of Mr.
Pollock in November, 1856, on account of incontinence of urine. It appeared
that she had never been able to retain water since the time of her birth. The
urine continually dribbled over her clothes, both by night and day, and she
was, besides, teased with constant desire to pass it. On examination, nothing
unnatural was discovered in the urine, except that it was extremely limpid.
It was slightly acid, and free from albumen or any other morbid product.

She was ordered purgative medicine (Pulv. scammon cum cal. gr. iv alt.
noct.), and saline medicine, with bicarbonate of potash. This treatment was
continued during the month of December without benefit. On December 30th
steel was tried (tinct. ferri sesquichlor. ttjvi ter die), with blister on the loins;
but after a full trial of this treatment for six weeks, it was given up, as no good
was effected. On February 10th, she was ordered extract of belladonna one-
twenty-fourth of a grain twice a day ; and this was increased on March 3d to
one-sixteenth of a grain three times a day. She now began to improve slightly,
so as to pass a few hours during the day without making water. On March
17th, the quantity of the belladonna was increased to one-twelfth of a grain
three times a day. She persevered in this treatment to May 26th, by which
time she had so far improved as to pass three or four nights consecutively
without passing water. The belladonna treatment was now combined with
steel, and she has ever since been steadily improving, and is now quite well,
with the precaution of waking her late at night to make water, and then giv-
ing her a dose of the medicine. Still, however, if she suspends the belladonna
the irritability of the bladder again shows itself.

SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

31. Embolic Apoplexy from Detachment of Fibrinous Coagula in an Aneurism
of the Carotid. By Dr. Fr. Esmargh. — Captain C.H., from Sweden, consulted
a medical friend of Professor Es march concerning an attack of angina tonsil-
laris, and at the same time drew his attention to a tumour of the left side of
his neck which had formed suddenly, three years previously, without appre-
ciable causes, and had now attained the size of a hen's egg. It occupied the
upper triangle of the neck, was slightly diminished by pressure, and communi-
cated a distinct thrill to the touch. It was at once diagnosed as an aneurism
of the common carotid. On repeating the examination a few days later, and
exerting pressure upon the tumour for the purpose of reducing it, the patient
suddenly fell back with symptoms of apoplexy. He was at once bled and con-
veyed to the hospital, where he was placed under the care of Dr. Esmarch, on
the 8th of May, 1855.

The patient was well built and robust ; in a state of coma, from which he
could only be roused momentarily ; the pulse was moderately full, heart nor-
mal. The whole right side of the face was paralyzed, the right cheek was dis-
tended in expiration ; there were spasmodic movements in the facial muscles
of the left 6ide. The pupils reacted to the stimulus of light. The tongue,
which was much furred, pointed to the left. Respiration was stertorous. The
thoracic muscles and diaphragm acted well, but only the left abdominal mus-
cles moved in respiration. Both right extremities were completely paralyzed.

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[Jan.

Deglutition, defecation, and micturition were normal. The tumour pulsated
isochronously with the carotids, but presented no murmurs.

Professor Esmarch diagnosed the detachment of fibrin from the aneurismal
sac, and a consequent obliteration of the left cerebral carotid. Ice was applied
to the head, sinapisms to the legs, and an enema with vinegar was administered.
Some improvement ensued ; the paralytic symptoms diminished, and the pa-
tient was able to converse with a countryman; a relapse, however, followed,
and on the 11th of May profound coma ensued ; the pulse was very quick, the
skin cool, the complexion livid, the right pupil was somewhat drawn out trans-
versely, but both pupils continued to react to the light ; both lips were dis-
tended by expiration ; urine was passed involuntarily. The liver increased,
the pulse became too quick to be counted, respiration slow, and accompanied
by screams in inspiration; and death ensued at midnight.

The cadaveric examination was made the day after by Professor "Weber.

The aneurism had a spindle-shaped form, and commenced about four centi-
metres above its issue from the aorta ; the external and internal carotids
quitted the upper end of the aneurism, preserving their normal size. The in-
ternal jugular vein was pushed outwards, the'vagus lay between the vein and
the aneurism and was unaltered, but the descending branch of the hypoglossus
was adherent to the tumour, and much altered in appearance. The whole in-
ternal surface of the carotid from its origin was in a state of atheromatous
degeneration, and contained enormous chalky formations ; both below and
above, a portion of the inner coat of the artery formed a projecting ridge in the
aneurismal sac. The sac was partly lined with a smooth red membrane, partly
with more or less firmly-attached, ragged, fibrinous coagula : much loose fibrin,
irregularly interwoven, was also in the sac ; a firm coagulum was drawn out
of the internal carotid, which tore off from its continuation within the carotid
foramen. There was no coagulum in the external carotid. Within the cra-
nium there was found considerable hyper£emia of the vessels of the pia mater,
a moderate effusion of serum under the arachnoid ; the whole middle portion
of the left hemisphere, including a part of the corpus callosum, was converted
into a pulp of a grayish-yellow colour. Beneath the aqugeductus Sylvii, in the
mesial line of the pons Varolii, was a perfectly recent extravasation of blood of
the size of a bean ; a smaller one, a centimetre in front of the former, and in
the vicinity several small capillary extravasations. Normal cerebral tissue
could not be discovered in the softened portion ; it consisted of granular mat-
ter and short fragments of broken-up fibres, with capillaries containing shri-
velled corpuscles. In the extravasations at the pons, the blood corpuscles
were unaltered. The cerebral carotid, the arteria fossa Sylvii, and the arteria
ophthalmica, were completely blocked up with coagula of a dark-brown colour,
inclosing numerous red and grayish-white plugs, which evidently were derived
from the aneurism. Their identity was proved by the microscope. The tho-
racic viscera presented no marked disorganization, except that the ascending
aorta exhibited extensive atheroma ; the same was the case with most of the
large arteries.

Professor Esmarch, in his concluding observations, dwells upon the danger
of much manipulation of aneurismal tumours, as being liable to give rise to
such consequences as those above described. He particularly discusses Mr.
Fergusson's mode of treating aneurism of the subclavia, recently brought be-
fore the Medico-Chirurgical Society, which consists in forcing the coagula con-
tained in the tumour into the axillary and brachial arteries. — Brit, and For.
Med.-Cliirurg. Review, October, 1857, from Archiv.fiir Pathol. Anat. und Phy-
siologie, Bd. xi.

32. Case of Arterio- Venous Aneurism, which was treated by Ligature of both
the Artery and the Vein. — Mr. Moore communicated the following case of this
to the Royal Medical and Chirurgical Society (Nov. 10, 1857).

A labourer, aged 60, was admitted into the Middlesex Hospital on Septem-
ber 30, 1857, pale and much depressed by loss of blood. Thirty-six years pre-
viously he had been bled in the left temporal artery, and he had ever since had
a pulsating swelling in the site of the lancet puncture. In the course of years

1858.]

Surgery.

269

it enlarged to the size of his fist ; the pulsation continued, and could he stop-
ped by pressure with his finger in the parotid space. He had no pain in the
tumour till August last, when it enlarged still more. One month ago it burst,
and he at once lost two quarts of blood. Hemorrhage recurred a fortnight
ago, which greatly reduced him, and large " lumps of flesh" were removed
from the aneurismal cavity. On his admission to the hospital, there was an
ulcer in the left temple as large as a crown-piece ; a clot of adherent blood
near its anterior part ; a large abscess above the ear, from which pus issued
in a stream through the ulcer ; and extensive oedema of the left half of the
scalp. Moreover, a cluster of enormous tortuous, soft, pulsating vessels could
be seen and felt above, below, beneath, and in front of the ulcer. There was
no purring tremor in the veins of the scalp ; but the left external jugular vein
was greatly enlarged, and had a visible arterial pulsation, together with a con-
tinuous vibratile thrill. No other vessels were enlarged. The enlarged ves-
sels being extremely thin, it was determined not to place a ligature upon them,
and the temporal artery was sought for at the highest point at which it was
presumed to be healthy. By means of a vertical incision over the parotid
space, a pulsating vessel was reached, and a ligature passed under it. Pulsa-
tion ceased in the temporal vessels when the finger was pressed into the loop
of the ligature, but continued after the knot was tied. Upon examination, the
pulsation was found to continue only on the distal side of the ligature, and the
tied vessel proved therefore to be the vein. The temporal artery, by com-
munication with which the vein received its pulsation, was then found in a
situation where it might have been compressed by the finger when introduced
into the wound. Upon tying the artery, the pulsations in the temple and in
the distal part of the vessel previously tied at once ceased. The pulsation and
thrill of the external jugular vein disappeared, the wound contracted," the tem-
ple shrank, the abscess closed, and the man left the hospital on the 19th of
October, convalescent, though still weak. The author briefly reviewed the
effects of the treatment by compression and by ligature, which had been
adopted in cases of permanently circumscribed arterio-venous aneurism-s.

1. A cure had been obtained by the complete closure of either the artery or
the vein at the site of the unnatural aperture.

2. The obliteration of one end only of either vessel had never proved suc-
cessful, the disease continuing or gangrene of the limb ensuing if only the
cardiac end of the artery were tied, whilst the closure of the distal orifice only
of the vein had but moderated the symptoms of the disease.

3. There was reason to think that the operation just related would prove
permanently successful, since all direct access and return of blood through the
main vessels were cut off by the ligatures; and the orifice of communication,
being beyond both ligatures, was reduced in importance to that of a passage
between vessels whose circulation was only collateral. — Med. Times and G<xz.,
Nov. 21, 1857.

33. Revision of the Doctrine of Dislocation. — Prof. Roeser lays down the fol-
lowing maxims respecting dislocation, as illustrated by dislocations of the
femur, derived from observations, inquiries, and experiments, continued over
many years.

1. The essential obstacle to the reduction of a dislocation almost always con-
sists, not in muscular contraction, but in the narrowness of the aperture in the
capsular ligament; 2. The difficulty of reduction generally arises only from
its not being at once possible to ascertain the direction and position of the
luxated head in relation to the rent in the capsule. When these are found,
the bone is either reduced of itself by muscular action, or a slight impulse,
rotatory movement, &c, causes the head to slide in ; 3. Much depends not
only upon the size but upon the position and direction of the rents in the
capsule ; 4. The head of a dislocated bone is not, as a general rule, found in
the primary position which was given to it by the force applied; but, under
the influence of the flexion, adduction, &c, of the dislocated limb, immediately
following, it assumes a secondary position; 5. The reduction-process must
No. LXIX.—Jan. 1858. 18

270

Progress of the Medical Sciences.

[Jan.

have for object, first, to restore the dislocated bone to its primary position, and
thence to effect its return ; 6. The classification of the dislocations of every
joint must be based upon the essential anatomico-mechanical points ; and the
symptomatic classification adopted by Malgaigne is as unscientific as it is im-
practicable ; 7. The most common dislocation of the head of the femur is
downwards, when it passes beneath the tendon of the obturator internus; 8.
This dislocation is produced by violent flexion of the hip-joint, during slight
rotation of the thigh inwards ; 9. The dislocation downwards becomes in gene-
ral converted during extension (with rotation inwards) into dislocation back-
wards, luxatio ischiadica ; 10. By abduction it may be converted into a luxatio
obiuratoria; 11. For the reduction of all these cases in which the hole in the
capsule exists below, strong flexion appears to be necessary, in order to bring
the head of the bone into its primary position, opposite the rupture of the cap-
sule ; 12. The dislocation on to the foramen ovale appears to be a mere variation
of the dislocation downwards ; 13. In the luxatio obiuratoria the head of the
bone is placed beneath and behind the obturator externus ; 14. Malgaigne's
41 perineal luxation" is only a slight modification of the luxatio obiuratoria ; 15.
The dislocation forwards, between the fossa ileo-pectinea and the psoas, is pro-
duced by excessive extension with rotation outwards. A secondary displace-
ment results from slight flexion. The reduction is brought about by extension
and rotation inwards ; 16. Luxation behind the pectineus is to be regarded as
a mere modification of the luxatio ileo-pectinea. It is not to be considered as a
luxatio obiuratoria ; 17. The extremely rare luxation on the outer side of the
anterior inferior spine must be regarded as a modification of the luxatio iliaca,
produced by violent rotation outwards ; 18. The luxatio iliaca is the rarest of
all the forms of dislocation, although it is commonly regarded as the most fre-
quent. The majority of those cases that have been so termed, and a consider-
able portion of those cases so denominated by Malgaigne, are, in fact, examples
of luxatio ischiadica; 19. The luxatio iliaca essentially arises from rotation
inwards, with adduction and flexion of the limb. Its reduction is based upon
rotation outwards. — Brit, and For. Med.-Chirurg. Rev., Oct. 1857, from Archiv
fur Physical. Heilk., 1857.

.34. Luxation of the Os Coccygis. — Dr. Roeser observes [Froriep's Notizen,
1857, Bd. II., No. 10) that in the few cases on record in which this bone has
bean dislocated, the luxation has been outwards or inwards, whereas in the
present case it was lateral. A large, corpulent women, thirty-six years of age,
while suddenly descending from a table on which she was standing, fell in a
riding position across the back of a low wooden chair. Severe pain in the
coccygeal region, which was much aggravated by attempting to sit, was the
consequence, but she managed to get about for some hours. At last it became
so severe that she was obliged to take to her bed, where she found she could
neither move nor turn. After she had passed the night in this way, the author
saw her, and found her with so changed a countenance, and such an immova-
bility and partial stiffness of the body, as to give very much the appearance
of approaching tetanus. Besides the severe pain in the coccygeal region, she
complained of a painful, tense, dragging sensation, extending from below
upwards towards the nape, stretching along the arms to the fingers, which
were numbed. The slightest voluntary movement of the body, or of the head,
to one side or the other, and still less sitting up in bed, could not be borne.
The head was confused, and the intellect somewhat clouded. There was no
unnatural sensation in the lower extremities, and the urine and feces were
passed naturally. Upon examination, a small swelling was felt on the left side
of the fissure of the buttocks, which proved to be the coccyx torn away from
the sacrum, and carried towards the descending ramus of the left ischium.
The end of the sacrum whence it had been displaced could be plainly felt.
When a finger was introduced into the rectum, the exact nature of the dis-
placement was still better ascertained; and when firm pressure was made
downwards and to the right against the displaced bone, it suddenly resumed
its normal position. The patient declared she immediately felt quite another
being, the confusion of the head and painful sensation along the spine and

1858.]

Surgery.

271

arms disappearing. At the end of the fifth day, no inconvenience beyond a
slight burning pain near the sacrum remained. — Brit, and For. Med.-Chirurg.
Rev., Oct. 1857.

35. On the Prevention of the Ill-consequences of Operations. — Prof. Deroubaix,
Surgeon to the St. Jean, Brussels, terminates a series of papers upon this sub-
ject with the following summary: —

1. If it is the duty of a surgeon to seek, by the improvement of his operative
procedures, to obviate the immediate accidents of operations, the endeavour to
discover the means of prevention of the secondary accidents, which are far
more dangerous, is still more imperiously demanded at his hands. 2. Could
the great surgical operations be rendered less dangerous in themselves, the
intervention of surgery would be much more clearly and more frequently indi-
cated in cases where the practitioner now often is obliged to remain a passive
spectator of disorders which infallibly prove fatal. 3. The danger of great
operations is not due to the size of the surfaces concerned, but to the number
and volume of the veins divided. 4. When the division of veins proves mis-
chievous, it does so by giving rise, through a mechanism the nature of which
it is not always easy to appreciate, to the production of purulent infection, one
of the most fearful consequences of traumatic lesions. The great danger and
extreme frequency of this complication justify the efforts made for its preven-
tion or removal. 5. There are two directions, both perhaps equally good, by
following which we may succeed in rendering pyaemia of much less frequent
occurrence. The first of these consists in improving and rendering less un-
certain the process of healing by the first intention ; and the second in so
modifying the divided surfaces as to convert them into a lesion of continuity of
far less dangerous character. 6. Metallic caustics, at least in the immense
majority of cases, do not give rise to purulent infection ; but they are not ap-
plicable to certain operations — as, e. g., amputations. 7. It is rational, then,
when seeking for substitutive or modificatory means for the prevention of
pyemia, to resort to such as most resemble caustics in their mode of action,
and yet are exempt from the disadvantages of these therapeutical agents. 8.
The tincture of iodine would seem to possess properties enabling it to fulfil
these indications, seeing the deep-seated modification it impresses on the tissues,
and the plastic effects it gives rise to. It does not act upon the ligatures, and
therefore does not give rise to the danger of secondary hemorrhage. When it
is applied to bleeding surfaces after an operation, it induces a general hypos-
thenic effect of short duration, and a local hyposthenic effect, which imparts
peculiar characteristics to the granulations and cicatrization. 9. The most
remarkable results of this hyposthenization are, the much less indolence of the
wound, the slight amount of suppuration, the notable diminution of the general
reaction, and the maintenance of a condition approaching that of health. These
phenomena offer no impediment to rapid cicatrization. 10. The discharge from
the surface of the wound is considerably diminished as a consequence of the
application of the tincture ; but this does not prevent arterial hemorrhage, or
the loss of blood from the large veins. 11. The putridity of the wound becomes
evidently diminished ; and when the tincture is applied to the divided extremi-
ties of the veins, these become corrugated and narrowed, and then agglutinated.
If phlebitis arises, it is obliterative and adhesive, not suppurating. 12. The
application of the tincture to the sawji surface of the bones does not lead to
necrosis. 13. The tincture imparts no preservative power against pyaemia
when an open -venous orifice, through which pus may be easily, so to say, me-
chanically introduced exists at any point of the surface. 14. In ordinary cases,
even the tincture is no certain preventive of purulent infection. When, after
it has been applied, we find the vicinity of the wound remaining very painful,
we should suspect a commencement of phlebitis, and the course of the pain
should be carefully inquired into. 15. It should be remarked that, as the
general hyposthenization which results from the application of the tincture
exhibits itself in symptoms, comparable to a certain point to those produced
by chloroform, prudence is required in the simultaneous or successive employ-
ment of the two substances. Perhaps this is the principal defect in the iodine.

272

Progress of the Medical Sciences.

[Jan.

16. The injection of the tincture into the veins is immediately fatal. It induces
an entirely peculiar coagulation of the blood, incapable of being confounded
•with any other pathological or spontaneous coagulation. 17. Nevertheless,
this medicinal substance cannot, when applied to a bleeding surface, be carried
in substance into the torrent of the circulation, unless, indeed, venous orifices
be maintained open by adhesions. It is absorbed in the state of an alkaline
iodide, and may be found in such a state of combination in the blood and urine.
The amount ordinarily absorbed exerts no ill effect upon the economy. — Brit,
and For. Med.-Chirurg. Rev., Oct. 1857, from Presse Med. Beige, 1857, Nos. 17-24.

36. Amputation at the Knee-joint, leaving the Articular Surface entire. — Mr.
Lane communicated to the "Western Medical and Surgical Society (Oct. 23,
1857) some remarks on this operation. He advocated its adoption in all cases
where the disease was confined to below the joint in preference to the more
common practice of removing the femur at its lower third. Mr. Lane stated
that he had, for the first time in England, performed this operation about five
weeks ago, and exhibited the subject to the members. It had been performed
in Glasgow in 1847 once, and in the Crimea seven times, in three of which the
patient recovered. It had been performed eighteen times in America, with
five deaths ; and twenty-eight times on the Continent, with twelve deaths ;
giving a percentage of 31 deaths, whilst that from amputation of the thigh
was about 43 J: hence the recommendation of the present plan. He described
the operation, recommending a large anterior flap to be made in front of the
joint down to the insertion of the ligamentum patella, which was to be turned
up and the knife carried through the joint, and a small posterior flap to be
then made, so that in healing it wroulddraw the anterior flap over the articular
surface, the cicatrix being then behind the joint. The advantages of this plan
were apparent in the decreased mortality, and in the after usefulness which
would arise from the stump being capable of bearing the pressure of the body
better than does the divided femur. Mr. Syme and Mr. Fergusson had recom-
mended a similar operation, but it differed in the removal of the articular sur-
face, and in the recommendation to make a large posterior flap, which was
objectionable on account of the tissues of the calf being unaccustomed to pres-
sure and unfit for the proposed work. — Lancet, Nov. 7, 1857.

37. Results of the Operation of Tracheotomy performed for Group at the Chil-
dren's Hospital, Paris, during the Tear 1856. — The Bulletin de Therapeutique
(May 30, 1857) contains an extremely instructive table respecting tracheotomy
in croup, taken from the thesis of M. Andre, late house-physician (interne) of
the Children's Hospital : —

Age.

No. OF
Patients.

Deaths.

Kecoveries.

Boys.

Girls.

Boys.

Girls.

From 15 months to 2 years .

G

2

4

" 2 years to 3 years

9

4

3

2

"3 " 4 " .

13

5

4

4

" 4 " 5 "

11

6

3

1

i

5 « Q U

6

3

1

1

i

" 6 " 6J "

o
o

1

1

l

2

1

l

" 8 "

2

1

1

" 9 «

1

1

" n- v<

1

i

From this table it appears that many successful cases of tracheotomy have
been observed, as nearly one-third of the patients recovered. The most notable
success has been obtained with children from nine to nine years and a half
old, and then with those children who were from five to six years old. The
least satisfactory results were observed from fifteen months to two years, for

1858.1

Surgery.

273

here we have six operations and six deaths. All the children under two years
are to be found in the column of deaths ; and all those who died, except two,
were just a little more than two years old. M. Andre thinks that these facts
may be explained by the greater amount of resistance with the older children,
both as regards the disease and the operation. He also conceives that debili-
tating means, as leeches, blisters, &c, should be sparingly used, so as to hus-
band the strength for tracheotomy.

38. Treatment of Hemorrhoids. — Dr. Van Holsbeek recommends the follow-
ing formula as of remarkable efficacy in the various forms of hemorrhoids, pro-
viding that these are uncomplicated: R. Sulphuri loti, sacchari canarini, of
each ; ext. strychn. nux vom., gr, vj. To be mixed with a sufficient quantity
of tragacanth so as to form twenty-four lozenges. Of these two are to be taken
the first day, the number being increased by one every day, until six are taken
daily. The patient is then to keep at that number during four days, when he
is to diminish it gradually until only two are again taken daily. If a radical
cure is not by this time effected, he must follow the same course again. The
amendment is, however, usually so rapid that the treatment at farthest lasts a
week. — Brit, and For. Med.-Chirurg. Rev., Oct. 1857, from Presse Med. Beige,
1857, No. 22.

39. The Present State of Surgical Science in reference to Cancer and its Treat-
ment.— Mr. Hird read before the Medical Society of London (Oct. 10th) a pa-
per on this subject. It was not his intention, the author observed, to enter
into a detailed report of individual cases treated by the escharotic applications
which of late have been revived by many members of the profession besides
himself, but to inquire whether recent experience has shown that we can con-
trol the progress of this destructive disease with more certainty, and on
sounder surgical principles, than our predecessors were enabled to do. The
questions whether carcinoma ever originates and continues as a local disease ;
whether it ever spontaneously disappears without the interference of art j
whether a tumour, originally innocent in its character, is susceptible of can-
cerous transformation ; whether it possesses anatomical, chemical, physiologi-
cal, and pathological characters, by which we can infallibly distinguish it
from other growths, which we are unable to do by the senses of sight and
touch ; whether, even supposing the constitution to be affected, the ablation of
the local disease may not arrest or retard its fatal course ; whether removal
ever accelerates it by bringing into activity a force which previously had lain
dormant in the system ; whether we possess remedial agents, by which we can
retard or resolve the disease, he considers, embrace subjects of vital conse-
quence, on the solution of which the life of the patient, the truths of science,
and the reputation of the surgeon depend. In his observations on the forms
of cancer, the author included the epithelial variety along with the encepha-
loid, scirrhus, and colloid, and objected to its removal from the cancerous
group, although it has less tendency to contaminate the lymphatic glands and
the system generally than the other three forms of cancer, and differs slightly
in its histological elements. After briefly reviewing the important subjects
embraced in the origin and development of cancer, in which the preceding
questions were answered so far as the present state of science would admit, he
proceeded to discuss the treatment. In this section the author dwelt on the
means of arresting cancerous growths by medicinal agents, and contrasted the
comparative advantages of removing the local disease by caustics and the
knife. In reference to medicines, the author believed that if any remedy pos-
sessed a power of retarding the progress of the disease, it was arsenic, which
he administered with cod-liver oil, and has not found the latter objectionable,
on the ground of animal oils tending to encourage the fatty matters in the
system, on which cancerous formations are supposed to feed. Arsenic as a
preventive of secondary formations after removal of the local disease, he (Mr.
Hird) had great confidence in, and in combination with iodine it was strongly
recommended by the late Dr. Anthony Todd Thompson ; Dr. Copland and the
late Mr. Hill witnessed great advantages from its use. The great question of

/

274 Progress of the Medical Sciences. [Jan.

removal by the knife or by caustics concluded the paper. Caustics the author
had found more tedious in their operation and more painful than the knife, and
occasionally failed to enucleate the tumour, and he has no faith in a supposed
physiological action on the constitution through the part treated, by which it
has been stated, without evidence to justify the statement, and, in opposition
to his own experience, the disposition to return after removal is less than when
the part has been extirpated by the knife. He has seen six cases in which the
disease returned after removal by caustics, and has read and heard of many
more. Nevertheless, there are cases in which caustics offer greater advantages
than the knife. In certain localities, and in particular conditions of the
tumour, and where loss of blood, or the dread of a cutting operation, would
greatly depress the patient. Early operation the author strongly advised, as
affording the only hope from surgery in scirrhus, colloid, and epithelioma. In
encephaloid he did not advise an operation.

40. Escliarotic Treatment of Cancer. By James Syme, Prof, of Clin. Surg, in
Univ. of Edinb. — The subject of cancer has been so mystified by the misrepre-
sentations of unscrupulous adventurers, that any attempt to re-establish its
treatment upon sound principles may seem a hopeless undertaking; but I ne-
vertheless beg to offer the following observations, in the hope that they will
still be of service where rapacity and credulity have not entirely superseded
honesty and common sense. It is not surprising that the dread of cutting, and
the bad success of operations, too frequently performed under unfavourable
circumstances, should have predisposed to the ready reception of any new pro-
posal for the remedy of a disease so formidable; and, accordingly, the employ-
ment of variously prepared caustics for this purpose has, during the last twenty
or thirty years, afforded a fruitful field for quackery without and also within
the profession. For, whatever may be the sentiments or laws of medical cor-
porations, I shall always hold that the worst form of quackery is, not practising
without a diploma, but using secret remedies, and pandering, by false pretences,
to the capricious folly of credulous patients. It could hardly, however, have
been anticipated that the medical officers of a metropolitan hospital would so
far forget the dictates of professional honour as not only to harbour in their
institution a secret cancer curer, but, by continuing to do so month after month,
sanction the delusion that he possessed some beneficial means of treatment
unknown to their brethren. Yet the surgeons of the Middlesex Hospital have
exposed themselves to this serious charge. They can hardly deny the former
part of it; and with regard to the latter, must either plead guilty or profess
belief that the juice of Sanguinaria Canadensis possesses more active powers
than the gilding of a pill. In their anxiety to escape from the horns of this
painful dilemma, they now admit that "the vegetable ingredient is practically
inert," that the caustic is an old one, and that there is nothing new in the prac-
tice of their protege except daily making incisions and stuffing the wounds with
escharotic paste — a proceeding utterly opposed to the established principles of
surgery, and eminently calculated to produce the most disastrous consequences,
but which, instead of indignantly condemning, they commend as deserving of
general adoption, and as entitling its author to public gratitude. The hollow
pretensions of secrecy having been thus indorsed and published with the au-
thority of a metropolitan hospital, it is requisite for the protection of sufferers
from cancer, that the principles of its proper treatment should, as far as possi-
ble, be no less extensively diffused.

It being admitted, by universal consent, that the various forms of disease
comprehended under the titles of cancer and carcinoma are not remediable
except through removal of the morbid part, the only room for question that
remains in regard to their treatment is limited to the choice of means for this
purpose. There can be no doubt that excision, if performed under chloroform,
affords not only the most speedy and effectual, but also the least painful mode
of extirpating the disease, so far as its extent can be recognized by seDsible
characters. On the other hand, it is alleged that through the use of caustic a
more lasting protection may be obtained against the danger of relapse; and if
such were really the case, there could be no hesitation in preferring the latter

1858.]

Surgery.

275

means. But, unfortunately, from being chiefly used empirically, they are sup-
ported by evidence of a very questionable character. For, in the first place,
patients who confide their treatment to irregular practitioners, are naturally
unwilling to admit that they have received no benefit or suffered damage from
venturing upon this course. They are, consequently, very ready to be per-
suaded that good has been done, and when the expectations thus excited prove
to be fallacious, no less slow to confess their disappointment. The wonderful
histories of cures, therefore, so frequently put in circulation on the ground of
such sanguine anticipations, are seldom counteracted by a knowledge of the
issue, however disastrous it may have been. Thus, an impudent quack — the
Middlesex surgeons call him a "gentleman" — industriously distributed penny
puffs, red, green, and yellow, of which the most prominent feature was an affi-
davit sworn before the Lord Provost of Glasgow, by a man who had been an
out patient at the hospital here, under my care, that he was cured by the said
quack, although he was not so, and died soon afterwards of the disease. Now,
this poor creature doubtless believed the assurance of that respectable person,
and probably signed his declaration from the amiable motive of leading fellow-
sufferers in a right direction; but having taken this unwary step, could not
retrace it, when taught by sad experience that he had been miserably deceived.

Then, again, there are so many diseased conditions apt to be regarded as
incurable, though not really so, that the most careful discrimination is required
to prevent their successful treatment from being erroneously assumed as ground
for belief in the curability of cancer. But the empirical practitioner is neither
able nor willing to make such distinctions, and so far from endeavouring to
dismiss the unfounded apprehensions of a patient, will always be anxious to
cherish and increase them, in order to enhance the value of his pretended ser-
vices. Thus, if a tumour of the breast, supposed to be carcinomatous, should
be a serous cyst, requiring merely evacuation and irritation of the surface, or
a fibrous growth removable without further disturbance of the gland, or a chro-
nic abscess, or even nothing more than that simple engorgement and painful
state so common in females whose health is out of order, the quack will not
vary his practice, or scruple to make the unfortunate patient pass through all
the horrors of a prolonged escharotic treatment. Indeed, I once saw a poor
woman who had both of her breasts destroyed by caustic, although there was
distinct evidence that neither of them had been at all diseased.

In regard to the comparative time, and danger of cutting and caustic, there
can be no doubt that, so far as the first of these points is concerned, the former
mode of relief is greatly preferable; while, as to the last one, there does not
seem to be much difference between the two. Unless, therefore, it can be shown
that the escharotic treatment is more complete and permanent in its effect than
excision, it will be difficult to discover any good reason for abandoning the
knife, or complicating it with the addition of caustic. The surgeons of the
Middlesex Hospital have published an account of the -cases treated under their
inspection, which, although evidently drawn up with the desire of presenting
a favourable view, may, of course, be regarded as an authentic statement, and
not as the mere trumpeting of quackery. They here relate, that the process
employed by their American coadjutor was to destroy the skin by nitric acid,
then to make numerous incisions, and introduce chloride of zinc paste into the
wounds, which were repeated daily for from two to seven weeks, until the ob-
ject appeared to be accomplished. They have not concealed the severe and
protracted suffering endured by the patients subjected to this painful and
tedious procedure, nor have they shrinked from confessing its dismal results.
Forty-two cases of cancer or scirrhous breast are recorded. Of these, five were
considered unfit for treatment and declined ; three left the hospital without any
apparent local disease ; and thirty-four still suffered from it, in the form of en-
larged glands, tubercles of the skin, or open sores. Anything more shocking
than this it is impossible to imagine ; and I sincerely hope that the conclusive
testimony thus published, in a form, externally at least, well suited if not in-
tended for the table of a drawing-room, may tend to counteract the present rage
for escharotic treatment.

It has long been a settled principle in surgical practice, that malignant tu-

276

Progress of the Medical Sciences.

[Jan.

raours or sores should be either allowed to remain free from disturbance or
completely removed, since tampering with them by irritating applications is
the most certain means of exciting disease in the lymphatic glands or other
textures. But the procedure advocated by the Middlesex surgeons was the most
extreme degree of deviation from this rule, since it kept the local disease, toge-
ther with the patient's system, in a perpetual fret for many weeks ; so that no
one need be surprised at the enacts, which, indeed, these gentlemen thus admit :
"Nothing could be more disastrous than this case; and there is no reasonable
doubt that the tumultuous increase of the disease was directly owing to the
local treatment." If caustic is ever used for destroying malignant textures, it
should, therefore, be of such power and so employed as to strike at once to the
root of the evil, and I am able to suggest efficient means for this purpose.

Mons. Velpeau, in speaking of the caustic made by mixing sulphuric acid
with saffron, expresses his persuasion that it would be the best of all eschar-
otics except for its expense and the difficulty of confining its action within cer-
tain limits. It occurred to me that sawdust would supply the place of saffron,
and my assistants at the hospital ingeniously devised the following effectual
means of restraining the extent of action : A solution of gutta percha in chlo-
roform is applied to the skin for some distance round the part to be attacked ;
then a thick piece of the same material, with an aperture cut in it of the requi-
site size, and softened by exposure to heat, is pressed firmly so as to adhere
everywhere to the surface thus prepared; a thin piece is next glued round the
edge of the opening, so that, when supported by a stuffing of lint, it may form
a wall inclosing the diseased part. Concentrated sulphuric acid, with about
an equal weight of sawdust stirred into it, until the mixture assumes a homo-
geneous consistence equal to that of thin porridge, is lastly applied, in quantity
proportioned to the extent of thickness concerned. In the first instance, as the
pain is acute, opiates or chloroform may be used ; but after a short while, so
little uneasiness is felt that the patient can easily allow the caustic to remain
for ten or twelve hours, when it will be found that the whole diseased mass,
though covered with skin and several inches in depth, has been reduced to a
cinder, presenting the appearance of strongly compressed tow. Under poul-
tices, the slough separates in the course of days or weeks, according to its depth,
and the sore then heals without any trouble. If, therefore, patients, from an
unconquerable dread of cutting, should prefer the escharotic treatment, or if
the circumstances, on any other account, should seem to render this method
eligible, the procedure just described may be found useful.

In conclusion, I beg to offer the following principles or practical rules for
the treatment of cancer.

1. The treatment of cancer may be divided into curative and palliative.

2. The curative treatment should not be undertaken when the local disease
is so seated or connected as to prevent its complete removal; when the lympha-
tic glands are affected ; and when the patient's general health is deranged.

3. Removal may be accomplished by means of the knife, escharotics, and
ligatures.

4. Of these means, in general the knife is best, and ligatures the worst.

5. Escharotics may be used with most advantage when the disease is super-
ficial.

6. Escharotics, employed with a curative view, should always destroy the
whole morbid part by one application.

7. The palliative treatment is generally best accomplished by means of sooth-
ing applications and attention to the general health.

8. When the local disease is very troublesome, it may sometimes be relieved
for a time by destruction of the morbid growth.

9. The best agent for this purpose, and also with a curative view, is concen-
trated sulphuric acid properly applied. — Edinburgh Med. Journ., Nov. 1857.

41. Epithelial Cancer. — Mr. Henry Thompson exhibited to the Medical So-
ciety of London (October 24th) a woman, aged 70, who was first seen by him
in July last, with an epithelial growth, the size of a large walnut, close to the
right eye. It was too close to remove entirely with the knife. He therefore

1858.]

Surgery.

277

employed a caustic, which, after six applications, had destroyed it completely.
On examining the woman, a healthy cicatrix alone remained, and no trace of
disease was seen. The escharotic employed was the strong sulphuric acid of
commerce, made into a paste with the exsiccated sulphate of zinc. Mr. Thomp-
son believed that the employment of escharotics for the removal of cancerous
growths could only be justified in exceptional cases, but that this was, from
the circumstances named, one in which it was decidedly preferable to the
knife.

Mr. Hancock had removed many cases of a similar kind with the knife, but
he never saw so perfect a cure by any means as the present case exhibited.
There was scarcely any scar. — Lancet, Oct. 31, 1857.

42. Foreign Bodies introduced into the Bladder. — M. Denuce relates ( Moniteur
des Hopitaux) the case of a woman who had introduced the handle of a stiletto
into her bladder. After several days of severe suffering she came to the hos-
pital, and as the urethra was found to be in a very dilated state, the extraction
of the foreign body was easily accomplished, by means of a polypus forceps
passed along the index finger.

M. Denuce has collected the particulars of 391 published cases, and the enu-
meration he gives of the bodies in question is both curious and useful. In 78
they were portions of catheters or lithotrity instruments, viz., 15 metallic ca-
theters, 9 gum-elastic catheters, 7 gutta percha catheters (a large proportion,
considering the short time these dangerous instruments have been in use), 28
catheters (their nature not being specified), 16 bougies, and 3 branches of brise-
jpierres. Then we have 82 needles, pins, or tags, 1 stiletto, 1 crochet-needle, 6
bone or ivory needles, 6 ear picks, 3 ivory whistles, 1 ivory spindle, 1 ivory sti-
letto handle, 15 leaden balls, 3 small keys, and 8 instances of metallic frag-
ments of various kinds. In 12 bones or splinters of bone, in 10 pebbles or
china, 6 pen-hoiders, 15 needle-cases, 10 pieces of tobacco pipe, 4 portions of
glass tubes. In 21 instances fragments of wood, as 3 pencils, 1 piece of a
match, 1 ramrod, 1 mustard-spoon handle, &c. In 34 there were fragments of
plants, as ears of corn, stalks, &c; in 26, fruits or kernels; in 4, tents of char-
pie, 1 strip of linen, 1 skein of cotton, 3 debris of cotton or wool, 2 pieces of
cord, 4 portions of wax candle, 3 pens, 1 piece of whalebone, 2 leather boot-
laces, 1 piece of tendon, 2 debris of fecal matter, 1 pessary, 1 shell, 14 instances
of various foetal debris, 6 locks of hair, 2 of larvae of insects, and in 1 pills.

If we abstract from this curious list the bodies which have obtained acci-
dental entrance into the bladder, whether from clumsy surgical manoeuvres, or
communications established through the walls of the bladder, either externally
(as in the case of balls and wounds), or with the rectum, vagina, or ovary, there
will still remain 258 cases in which no legitimate explanations can be given of
the presence of these bodies. Those assigned by the patient are usually as
singular as are the bodies themselves ; some being said to find their way there
while attempting self-catheterism, others from the patient having fallen on them,
while others again are stated to have been swallowed. The true and principal
cause of their introduction, when not accidental, is to be sought in the vagaries
of an abandoned depravity. Of these 256 cases, 119 are stated as having been
males, and 96 females ; while in 41 instances the sex is not indicated. In 14
instances they occurred in children from the age of a few weeks to fifteen
years.

After a foreign body introduced into the urethra has become propelled into
the bladder, in a few days it begins to be covered with incrustations. At the
end of some weeks these have attained a considerable thickness; while at the
end of some months, true calculi may be constituted. The form of the body,
however, exerts considerable influence upon the mode of deposit. In rounded
or short bodies the incrustation becomes general, while in those which are
elongated it takes place especially towards the middle. Thus, in most cases
in which calculi have. been formed on needles, the ends of these are found pro-
jecting beyond the deposit: and it is such calculi that especially give rise to
cystitis and other dangerous accidents.

Among the 391 cases collected by M. Denuce, in 21 death took place inde-

278

Progress of the Medical Sciences.

[Jan.

pendently of any operation. In 13 of these the affection was recognized at the
autopsy; but it is not stated with precision whether the vesical affection was
the cause of death ; in 2 death resulted from the debris of a foetus passing into
the bladder ; and in 6 it was the direct result of the introduction of the foreign
body. These last were examples in which the points of pins or needles became
imbedded in the walls of the bladder, giving rise to intense and fatal cystitis.
Cases in which art does not intervene do not, however, always terminate thus,
the efforts of nature in some sufficing to liberate the economy from their pre-
sence. Thus they may be carried out by the urine, especially when the bodies
are small and women are the subjects. In 31 instances in which the age is
specified, this occurred in 14 men and 17 women. Occasionally, certain bodies,
such as broken needles, escape by penetration of tissue, and this is stated to
have occurred in four cases.

As in the great majority of instances nature will not be able to secure the
discharge of these bodies, the surgeon, in order to prevent the occurrence of
dangerous accidents, must interfere, endeavouring first to secure their removal
by extraction, and if unsuccessful, resorting to lithotomy. In the cases here
collected, lithotomy has been had recourse to 125 times, viz., in males, perineal
lithotomy, 87 times; recto-vesical, 2; hypogastric, 2: and in females, urethro-
vaginal lithotomy in 22, and hypogastric in 12. Unfortunately, in only 61 of
these cases has the ultimate result been stated. In 39 occurring in males,
perineal lithotomy was performed in 36 (31 recoveries and 5 deaths), hypo-
gastric in 2 (both recoveries), and recto-vesical in 1 (fatal). In the 22 cases
occurring in females, there were 15 urethral or vaginal operations (13 reco-
veries and 2 deaths) and 7 hypogastric (5 deaths and 2 recoveries). In the
whole number, therefore, 48 recoveries and 13 deaths. The hypogastric ope-
ration has thus proved very fatal, 5 deaths taking place to 4 recoveries ; and
in the latter, in two instances the operation consisted simply in enlarging an
aperture already existing.

The performance of the operation may be rendered difficult by the nature of
the bodies to be removed. Thus, their softness may be such as to render their
recognition and removal difficult; the length of others may lead to their being
seized in the middle, and brought across the aperture; while, if they have
remained long in the bladder, the size and irregularity of the incrustations
present additional obstacles. The precision of measurement attainable by
lithotrity instruments, however, now comes to our aid. As to the particular
operation indicated, it may be stated in a general way that the perineal opera-
tion in men, and the urethral in women, suffice for small bodies, or for such
as are thin and elongated ; those which are of larger size require the bilateral
or vaginal operation ; while the hypogastric, seeing its unfavourable results,
should be reserved for quite exceptional cases. It must be remembered, how-
ever, that in women the urethral operation is almost always followed by incon-
tinence of urine, and the vaginal by vesico-vaginal fistula.

Extraction of the foreign bodies has been performed in 112 of these cases,
death following in 3. In reference to the influence which the introduction of
lithotrity has exerted upon the improvement of extracting instruments, M.
Denuce makes the following calculation : Of the whole 239 cases in which
interference has taken place, 127 occurred prior to, 122 subsequent to 1830,
when lithotrity may be considered to have generally established itself as an
operation. In the early series, lithotomy was practised 100 times, and extrac-
tion 27 times only; while in the latter series, it was resorted to but 21 times,
and extraction 101 times. Thus, formerly lithotomy, with its mortality of 15
per 100 was the rule ; while now, extraction, with 3 deaths in 112 cases, is the
rule, and lithotomy the exception. The progress that has been made is still
more apparent when we consider the case of the male urethra, with its long,
narrow, sinuous canal. Of 20 cases of extraction noted prior to 1830, 16 oc-
curred in women, and but 4 in men; while of 73 since that epoch, in which
the sex is indicated, 40 occurred in males, and 27 in females. — B. and F. Med.-
Chirurg. Rev., July, 1857.

1858.]

Ophthalmology.

279

OPHTHALMOLOGY.

43. Spasms of the Eye after Extraction of Cataract. — Mr. White Cooper, in a
clinical lecture {Lancet, June 6, 1857), makes some interesting observations on
this obstacle to success after extraction of cataract — an accident not sufficiently
dwelt on in the books, and one which is not of uncommon occurrence.

From the mode in which the muscles of the eye are arranged, any sudden
and strong contraction of them must compress the eye, and may force the iris
between the edges of the corneal section and interfere with the success of the
operation.

The symptoms of spasms of the muscles of the eye " are sudden, acute, grasp-
ing pain, with a sensation as if the eye were drawn back in the socket, generally
attended with coruscations of light and colours, the result of compression of
the retina. In the majority of cases it comes on within the first thirty-six hours
after operation, generally during the brief interval between sleeping and waking,
or just when the patient is dropping off to sleep, and is most marked in persons
who have suffered from disturbance of the nervous system, as indicated by
neuralgia, spasms, and cramps.

The immediate indication is to tranquillize the nervous system, and this
object is best attained by a soothing cordial draught, composed of thirty drops
of Hoffmann's anodyne, twenty drops of Squire's solution of bimeconate of
morphia, and a drachm of the compound tincture of lavender, in an ounce of
water. In some cases I have given six or eight drops of the tincture of Can-
nabis Indica on a lump of sugar with excellent effect. The most grateful
application to the eye itself is a fomentation of hot water, but in using this the
utmost gentleness is necessary, the irritability of the eye being so great that a
very slight touch will often bring on a return of the spasm. For the same
reason, it is preferable to darken the room, thoroughly excluding the light from
the patient, rather than to irritate the eye by compressing it with bandages.
And here let me give you a hint; never allow a looking-glass to remain in the
patient's room. I have several times known much annoyance caused by a
gleam of light falling on a mirror, and reflected to the patient's face ; for the
same reason have any chinks in the shutters stopped up; more mischief may
be done by a bright ray of light streaming through a crevice, than by a con-
siderable amount of general light, gradually admitted.

It must be borne in mind that, for the better illustration of my subject, I
have selected the most marked cases in my note-book. It by no means neces-
sarily follows that destruction of the eye should follow spasm of the muscles ;
the immediate effect will almost certainly be disturbance of the section, and
prolapse of the iris. The prolapse may, however, subside, or not be sufficiently
great to interfere materially with the success of the operation ; or again, if the
prolapse be so considerable as to cause obliteration of the pupil, vision may
still be restored by an artificial pupil.

Prolapse of the iris will be indicated by a slight oedematous swelling, com-
mencing at the inner canthus, and stealing along the margin of the upper lid;
the lid becomes exquisitely tender, so that the patient shrinks from the slightest
touch, and there is generally the sensation of a foreign body under it. There
is a copious discharge of scalding tears, the patient avoids light and the slightest
movement of the lid. If you do manage to raise the lid, you will find the cornea
thrown upwards, and there will be more or less redness of the conjunctiva and
sclerotic ; simultaneously with these local indications the patient will complain
of aching over the brow, extending down the side of the nose and cheek-bone,
which is tender to the touch ; the pain is aggravated at night.

The treatment which I believe to be best for prolapse of the iris is, first and
above all, absolute quiet of the eye ; the least handling or attempt to open the
lids almost certainly brings on a return of the spasm, and of course keeps up
the mischief. The object we should steadily keep in view is, to allow the iris
to recover its position, and the section to become firm. The utter inability to

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Progress of the Medical Sciences.

[Jan.

raise the lid points out that Nature requires it to remain closed, in order that
she may perform her work.

It is generally recommended that the prolapse should be touched with nitrate
of silver. In some cases I have seen this useful, in others hurtful; and on the
whole, I am of opinion that time and quiet will attain the great object better
and with less hazard than the use of the caustic. I remember a case in which
I assisted the late Mr. Dalrymple. Three weeks after extraction the eye re-
mained irritable, there being a small prolapse, but sight was returning favoura-
bly. Wishing to hasten matters, Mr. Dalrymple touched the prolapse with
caustic ; violent pain came on, subacute inflammation followed, and the eye
was lost. I believe that he used caustic no more in such cases.

Time and quiet, then, are the main agents in the cure of prolapse of the iris ;
when the cicatrix is forming, advantage may be derived from the use of bella-
donna ; and if there be congestion, the application of a leech or two from time
to time will be serviceable. There is one thing, however, which we are called
upon to ameliorate, and that is the frontal neuralgia. An ointment, composed
of one drachm of extract of opium to four drachms of strong mercurial oint-
ment, well rubbed in at night, is often efficacious : but I have found still greater
relief afforded by painting the painful surface freely with a lotion composed of
one grain of nitrate of silver dissolved in half an ounce of nitric ether. This
sometimes acts like a charm in removing the pain. Another useful application
is chloroform thus applied; a layer of cotton-wool is to be spread over the fore-
head, then sprinkled with chloroform, and covered with oiled silk. The vapour
is thus confined without coming in contact with the skin.

There is a point in the after-treatment of cataract cases to which I would
draw your attention — namely, the importance of avoiding any sudden startling
of the patient, especially from sleep ; as I look back upon the cases in my prac-
tice in which there has been prolapse of the iris, I may ascribe this mainly to
two causes — the eye being struck, or the patient being startled. It is not
necessary that there should be a real blow ; a mere touch will be sufficient to
cause a sharp action of the muscles of the lids and of the eye, and so the flap
may be displaced. When, therefore, the eye is being cleansed, the patient
should always be warned when the sponge or rag is going to be applied ; for
if not so prepared, a start will generally take place, and the eye may be struck.

44. Diphtheritic Ophthalmia. — This is an affection almost unknown in France;
nor is there any mention made of it, either in ancient or modern French trea-
tises, on diseases of the eye. In Germany, however, much has been published
regarding it ; and, from the nature of its progress — from its severity, and its
special characters, it is a malady deserving a place in our nosological tables.
M. Gibert of Geneva, whose service as interne in the hospital of St. Eugenie
afforded him an opportunity of observing the disease, gives a description of it,
and from his remarks we subjoin the following particulars: —

Diphtheritis of the mucous membrane of the eye is as general as that occur-
ring in the larynx. In 1846 and 1847 M. Chassaignac described a purulent
ophthalmia, which was accompanied by the formation of false membrane; this,
however, is quite a different affection, bearing the same relation to the diph-
theritis of the eye, which ulcero-membranous stomatitis does to true diphthe-
ritic stomatitis. In ocular diphtheritis, the mucous membrane is dry, of a pale
gray colour, and never during the whole period of the formation of false mem-
branes, exhibits the granulations characteristic of purulent conjunctivitis. In
the first case the circulation is almost completely interrupted, while in purulent
ophthalmia the mucous membrane is highly vascular and the circulation active.
According to Graefe, a characteristic sign of diphtheritis is, that on account of
a more marked condition of stasis, the mucous membrane contains less blood
serviceable for the purposes of circulation; moreover, in purulent ophthalmia,
at first a lemon coloured secretion takes place, which quickly becomes turbid
and purulent ; in diphtheritis, there is at the first no secretion, the eye being
completely dry ; at a later period, a liquid of a dirty gray colour oozes away,
composed, says Graefe, of tears, epithelial scales, and some colouring matter of
the blood.

1858.]

Ophthalmology.

281

The symptoms are, redness of the eyelids ; a degree of swelling, frequently
to an extent unusual in eye diseases; an amount of hardness of the eyelid,
which, upon being felt, imparts a sensation of some solid exudation ; a feeling
of heat often insufferable, and considerably greater than occurs in purulent
ophthalmia ; and pain, sometimes slight, at other times acute.

The false membrane, on being detached, may correspond in form to the eye-
lid, and sometimes even to the entire conjunctiva; it is extremely adherent, a
circumstance in which it differs from the false membranes described by M.
Chassaignac. Underneath it the mucous membrane is yellowish, smooth, and
glistening; the vessels are filled with coagulated blood, and are scarcely dis-
cernible.

Three stages in the complaint may be observed: in the first, the false mem-
brane is formed: in the second, it is detached: in the third, there is a contrac-
tion of the tissues, sometimes with incurvation of the conjunctiva — a state which
of itself is sufficient to distinguish this disease from purulent diphtheritic oph-
thalmia, where it never occurs.

The cornea becomes opaque, occasionally with remarkable rapidity; it may
become ulcerated, softened, or even perforated. These lesions are very serious,
and the more so accordingly as they are earlier in making their appearance.
This consideration is of much importance in our prognosis; indeed, Graefe lays
it down that if the first stage is in active progress when the cornea is attacked,
and no hope is left us of reaction commencing, the eye may be considered as
irrevocably lost. The prognosis must also depend upon two other circum-
stances, viz., the state of the general health, which in most cases determines
the local affection, and again, the characters of the disease in the eye, which
in its turn sometimes becomes so serious as in a few cases to lead to a fatal
result.

The severity of an epidemic must also influence the prognosis of the disease,
since, as in laryngeal diphtheritis, this disorder likewise assumes an epidemic
form. It has never been observed before the age of one year ; purulent oph-
thalmia, on the other hand, being common in newly born children. It fre-
quently supervenes during the course of another disease, such as measles,
hooping-cough, disordered dentition, etc.

With regard to treatment, Graefe disapproves of caustic applications, as only
adding to the severity of the disease, to the "stasis" already existing, by their
acting in a manner much like the malady itself; and states, that this method
of treatment leads to very different results in ocular diphtheritis, from those it
produces in other pseudo-membranous affections. He recommends, first, The
application of leeches to the root of the nose, "la ratine du nez," so as to pro-
cure a continual flow of blood ; and 2d, The application of ice, which allays
both the excessive heat and pain; but which must be suspended as soon as the
period of resolution begins to manifest itself. Along with these means mercu-
rial preparations, internally and externally, are employed. Besides, care must
be taken to keep the diseased eye clean, and to keep the healthy eye shut, as
a precautionary measure. Graefe has seen in adults a gangrenous form of
ophthalmia making its appearance, which he considers an additional proof of
the special nature of the malady just described. — Ed. Med. Journ., Nov. 1857,
from Archiv. Gin. de Med., Sept. 1857.

45. Two Cases of Strabismus and very Imperfect Vision — Operation and Cure.
— Two of the most remarkable cases in illustration of the advantage to vision
often obtained by the operation for strabismus that we have ever seen, have
just occurred in the clinique of Mr. Critchett. That patients who squint have
very defective sight, more especially in the affected eye, and that this impair-
ment is usually remedied by the operation is well known to all who have paid
attention to the subject. In the following cases, however, the defect was so
extreme, and yet the relief obtained so great, that we shall venture to record
them.

John F., a healthy-lookipg boy, aged 10, was brought to the hospital six
weeks ago, on account of his sight being very bad, and with the complaint that
he saw things double with the right eye. He had a most extreme convergent

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[Jan.

strabismus, the right eye being drawn quite into the palpebral angle. On
covering up the left eye he was made to walk across the room, when he stum-
bled against the chairs, etc., and even walked against a projecting corner of
the wall; a pen being held before him, he said that he saw three, and being
told to touch it put out his hand a foot to one side of it. With the right eye
he could not distinguish capital letters, though he could read small print with
the left. His progress at school had been very slow, owing, it was believed, to
his very defective sight. He could only see things clearly and without dupli-
cation when the right eye was covered. The eyes appeared perfectly normal
in every respect, the squint excepted, and he had no signs of brain disease.
The history given of the squint was that his eyes had been perfectly straight
until an attack of ophthalmia, which lasted from the age of two to that of four,
and during which intolerance of light was the chief symptom, and after the
subsidence of which the convergence was observed. He had never had fits.

The imperfection of vision being so unusually great, it was feared that either
retinal or cerebral disease must exist. A careful examination was made with
the ophthalmoscope, but no morbid conditions were observed other than that
the retina of the lowest part of the globe appeared as if a little raised. Of
cerebral disease there was not the slightest evidence.

The operation was performed at Mr. Critchett's request by Mr. Hutchinson ;
both internal recti being divided by subconjunctival section on the same day.
The rectification was perfect, and on testing the sight as soon as the boy re-
covered from chloroform, it was found that he could see nearly as well with
one as the other. A fortnight later the eyes were quite straight, without the
slightest undue prominence, and he could see to read small print with the
affected eye, and distinguished all objects perfectly. No doubt could be felt
but that the imperfection in vision had resulted solely from the squint.

A yet more remarkable case occurred a few weeks later. A very intelligent
boy, aged 11, of Scotch parentage, was brought on account of a severe squint
which affected the right eye. The squint had been first noticed after a pro-
longed attack of ophthalmia at the age of two, in which the eyes had been
closed for several weeks. He had never had fits or any severe illness. He
had learnt to read well, and could see perfectly with the left eye, but with the
right he could but just tell light from darkness. He spoke of it as his " blind
eye." When taken into the darkened ophthalmoscope room he could not see
the single gas flame, but on a strong light being thrown into the eye by the
reflector he exclaimed, "Now I see a light!" Thus there appeared no room
for doubt but his perceptive power with this eye was of the feeblest possible
description, and only extended to the recognition of brilliant lights. He was
taken immediately after this examination to the operating theatre, and Mr.
Hutchinson again performed the operation on both eyes. As soon as the effect
of the chloroform had sufficiently passed off, Mr. Critchett carefully tested the
boy's sight. With the sound eye covered he could distinguish all large ob-
jects, could tell the difference between coins, see watch-hands, &c, although
he could not see to read. A week later, vision had not much improved, al-
though the parallelism was perfect. He could, however, easily recognize all
large objects. There was a degree of double vision, and as the pupil was still
widely dilated and immovable from the effects of the belladonna used a week
before, there appeared every reason to hope for much further benefit.— Med.
Times and Gaz., Nov. 21, 1857.

MIDWIFERY.

46. Quadruplet Births. — These are so rare — as shown by the fact that in
170,901 labours in the Rotunda Hospital, Dublin, there was but one instance
of it — that the following case, which occurred in the practice of Mr. French,
of Ballygar, and communicated to the Dublin Obstetrical Society (March 25,
1857), will be considered of interest.

1858.]

Midwifery.

283

" Bridget Loghan, aged 38, a stout, healthy countrywoman, several months
advanced in this her sixth pregnancy, whose previous deliveries had been in
every respect perfectly natural, and who represents that, with the exception of
having recently become thin, pale, and suffering from oedema of the feet and
ankle-joints, her health has been as good as during former pregnancies ; her
unusually great size, which had attracted the attention of all her acquaint-
ances, and caused them to suspect that she was carrying twins, not even pre-
venting her from uninterruptedly discharging the laborious duties of her
household — was on Saturday, the 10th January last, attacked by slight uterine
pain, which continued until the following Monday evening, when, about 11
o'clock, she was, under the supervision of a midwife, delivered of a living
female child, which presented by the feet. Within the course of the ensuing
hour, a second female child, which presented similarly, was expelled without
assistance. All uterine action now disappeared ; and, after the lapse of twelve
hours, the uterus still continuing large, created a suspicion that there might
be still another child, and induced the attendant, who had moreover become
alarmed by the non-expulsion of the placenta, to at length summon Mr. French,
who arrived on Tuesday morning, at 12 o'clock. On placing the hand over
the umbilicus, Mr. French instantly detected the presence of the distended
uterus ; and on making a vaginal examination, found the head of a third foetus
floating above the brim. He at once administered a dose of ergot, followed in
half an hour by purgative medicine. After the lapse of two hours, finding the
patient still in the same state of uterine inertia, Mr. French at once proceeded
to deliver her by version. This child proved to be a male, and only breathed
for a few minutes. The abdominal tumour still being very large, the hand
was again introduced, when the membranes of a fourth child, also presenting
by the head, were detected. These being ruptured, delivery was effected, as in
the preceding instance, by version, the child, which was a male, being born
alive. The quantity of liquor amnii in both these cases was exceedingly great.
In consequence of the total absence of uterine contraction, it now became
necessary to remove the placentas by the hand. There were two in number.
The following is Mr. French's description of them : —

" ' To the centre of that first extracted there was attached a single " stalk-
like" funis, about one inch in length, which then divided into two branches,
the last child and its membranes being (according to Dr. French's views) in-
closed within a bag of membranes, common to it and to the third ; the other
placenta was of the ordinary " battledore" species. The children all died : the
first on the second day, the second on the third day, the third immediately
after birth, the fourth after the lapse of a few hours. The convalescence of the
mother was rapid and complete." '

Dr. Jennings concluded with the observation : " If Mr. French's description
of the first placenta be correct, the only way in which we can account for the
anomaly is, by supposing that two totally distinct embryos were developed in
a single blastodermic membrane, and thus became subsequently included
within a single amniotic membrane, a deviation from the customary law of
nature, directly contrary (so far as we are instructed) to all received doctrines
of ovology. Indeed, on more carefully reading his own history, we find that
he had to rupture a distinct set of membranes for each of the two last children,
thus proving that there must have been two separate amnions. It is probable
that had his examination of the placenta been more careful, he would have
found that there were originally two distinct ' battledore' placentee, the edges
of which, together with the placental extremities of the funes, had become in-
timately and similarly fused together by adhesion. Had both children been
in any way connected (as, for instance, the Siamese twins), we could readily
understand them to have been another specimen of ' monstrosity by inclusion,'
both being inclosed within a single amniotic sac, in consequence of two ovula
having been originally included within a single vesicle — a sport of nature, not
confined (as we are well aware from the writings of the immortal Harvey) to
the animal kingdom." — Dublin Quarterly Journ. of Med. Sci., Nov. 1857.

47. A New Symptom of Rupture of the Uterus. — Dr. M'Clintock related to
the Dublin Obstetrical Society (May 9, 1857) some cases of rupture of the

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Progress of the Medical Sciences.

[Jan.

uterus arid of the vagina, to illustrate the obscurity which may occasionally
surround the diagnosis of this accident when occurring during parturition.
He particularly drew attention to a symptom observed in one of the cases,
which he considered might hereafter be found of value as diagnostic of lace-
ration of the uterus or vagina. This symptom was an emphysematous state of
the integuments covering the hypogastrium. Its existence was detected by the
stethoscope while searching for the foetal heart. Examined for in this man-
ner, the crepitation was loud and distinct, but to the hand it was not so ob-
vious, except when firm pressure was made in the proper situation, then the
crepitus was evident, and was recognized by Dr. G. Montgomery, and by seve-
ral pupils who happened to be present at the case. The other symptoms pre-
sent were of so ambiguous a kind that the possibility of rupture having taken
place seemed doubtful. There was no prostration, no recession of the present-
ing part, and no cessation of the pains ; the woman was able to be up and to
walk about. Having ascertained that the emphysema had not extended down-
wards from the chest or neck, and that it was confined to the supra-pubic and
iliac regions, Dr. M'Clintock inferred that the air had obtained an entrance
through some rent in the genital passages. Acting upon this conclusion, the
woman was delivered by craniotomy (the foetal heart had not been heard for
two hours previously). She sank rapidly after delivery, and died in a few
hours. The left broad ligament was found emphysematous, and a tear existed
in the left side of the uterus at the junction of the body and cervix. At some
distance from this the peritoneum was found rent also, and a considerable
quantity of blood had been effused into the abdominal cavity. — Dublin Quar-
terly Journ. of Med. Sci., Nov. 1857.

48. Two Cases of Hernia of the Ovaries, in one of which there was a Periodical
Enlargement of one or other of these Organs. By Henry Oldham. — The two
cases which I beg to present to the Royal Society, are examples of a rare con-
formation of the female sexual organs, in which the two ovaria have descended
through the inguinal canals and have become permanently lodged in the upper
part of the external labia; and in both of them the most careful and repeated
physical examination has failed to detect either uterus or vagina. I should
hardly, however, have ventured to bring them before the Society simply as
examples of faulty conformation — because, although rare, yet they have been
observed1 — had not the first of the two cases presented the interesting physio-
logical peculiarity of a spontaneous periodical increase of one or other of the
ovaria, followed by its gradual reduction, thus supplying direct evidence of an
ovarian menstrual act.

The subject of the first case applied to me in September, 1851, for advice on
account of never having menstruated. She was nineteen years of age, of a
tall figure, symmetrical frame, well-expanded pelvis, and womanly aspect,
bearing all the marks of a full completion of the physical changes of puberty ;
and her general health, though not robust, was fairly good. She was one of a
family of five children, and her sisters had menstruated between fifteen and
.sixteen years of age. The principal point which was elicited from her history
in connection with her complaint was that, eighteen months before, a swelling
had somewhat suddenly appeared on the right side of the external organs,
which had caused her some pain for a few days and had then disappeared. In
four or five months a similar swelling again appeared, but was attended with
so much suffering that a medical man was consulted, who took it for an abscess
and ordered it to be poulticed. Again it passed away, again to recur at the
end of two months ; and so it had gone on at irregular intervals until the time
of her seeing me, when the pain of a renewed attack of unusual severity had
occasioned her some alarm. On examination, a swelling the size of a goose-
egg was found to extend between the external abdominal ring and the centre
of the labium on the right side, which was very tense and firm to the touch ;
and the cellular tissue, skin, and mucous membrane of the labium were oede-
ma to us and inflamed. It was painful, but by no means so painful as a labial

1 Vide Deneux, " Recherches sur la Hernie de TOvaire," 1813.

1858.]

Midwifery.

285

abscess, which in its general aspect it resembled; and there was but little
febrile disturbance. A more critical examination detected the presence of a
solid body of an oval shape within the tissue of the labium, which proved to be
the ovarium, whose enlargement had so compressed the surrounding tissues as
to swell and inflame them. On the opposite side there was another oval body,
the size of a walnut, which passed just beyond the outer ring, but readily
slipped into the canal. This was the left ovary in a quiescent state. The ex-
ternal sexual parts were normally formed; but the ostium vaginae was closed,
a slight indentation in the median line alone marking its position. Frequent
careful physical examinations failed to detect any tra^e of a vagina or uterus,
and the conclusion arrived at was that these central pelvic organs had not been
developed. The mammary glands were fully formed.

I have had repeated opportunities during the six years which have inter-
vened since first the case came before me, of examining the organs both during
the periods of ovarian excitement and during the intervals. For nearly two
years, however, I completely lost sight of her, when I learned to my amaze-
merit that in spite of my strong admonition both to her mother and herself that
she should lead a single life, she had married. For some time past I have
seen her more frequently, and have watched the recurrence of the ovarian
swellings.

For the first three years the right ovarium was exclusively enlarged, and the
intervals were not so regularly marked, varying between three and six weeks ;
excepting for the first year, when they were much longer, occasionally extend-
ing to three months. For the last two years the left ovarium has been far
more frequently affected, the right remaining quiescent ; occasionally both are
painful and tumid, but even then one more than the other. The intervals are
now pretty regularly three weeks. The acute inflammatory symptoms which
accompanied the onset of these swellings have long since ceased to recur,
which is obviously due to the loose state of the tissues from repeated stretching,
so that the swollen organ is no longer compressed.

The accession of a menstrual time is sometimes suddenly felt. She will go
to bed well, and in the morning the ovary will be swollen : more commonly,
however, it is very gradual, augmenting in volume for four days, then remain-
ing stationary for three days, and then gradually declining ; the whole process,
before the ovary is reduced, generally lasting ten or twelve days. On separat-
ing the ovary, when at its height of swelling, from the tissues surrounding it,
it appears scarcely, if at all, less than double its usual volume; its outline is
clearly defined, and it is plain that the whole, and not merely a part of the
organ is involved. There is no suffering worthy of notice during the time :
the swelling is tender if pressed ; and tender, too, in the act of sitting down or
rising up ; but she walks about as usual without distress, and there is but lit-
tle lumbar or hypogastric pain. Neither are there any manifest sympathies
excited, either of the mammary glands or other organs. Nor is there any
vicarious flux, either of blood or any secretion, with the exception of an excess
of saliva, but this not in any large flow. The ovary alone appeared to be en-
gaged in this periodical act, which it is not too much to suppose, in accordance
with modern physiological views, would have been attended with a flux of
blood, had not the organs which normally supply it been absent.

But while this may be said to represent the usual course of a period, yet the
volume of the ovary, and the length of time it remains swollen, is subject to
occasional variation ; sometimes being much less tumid, and dying away in a
shorter time. ■

The repeated attempts at sexual union have only had the effect of somewhat
loosening the tissues around the vulva, but the vagina remains imperforate as
before, and is beyond the reach of surgical remedy. It may be added, that the
subject of this history recognizes an increase of sexual feeling at and soon after
the periods of enlargement of the ovary.

The second case was that of a young woman who had attained the age of
twenty without having menstruated. She was a tall, strumous-looking person
in weak health. There had not been any well-marked efforts at menstruation,
but she had suffered slightly from lumbar pain. The mammae were well deve-
No. LX1X.— Jan. 1858. 19

288

Progress of the Medical Sciences.

[Jan.

loped. The pelvis was fairly formed. On examination I found the two ovaria
just appearing beyond the external abdominal rings, and readily returning by
pressure into their respective inguinal canals. They were of equal size and
similar shape, being ovoid bodies about the size of small chestnuts. They
were not tender when touched, although organically sensitive, and she had
never experienced pain in them. The external sexual organs were somewhat
less perfectly developed than usual ; the vaginal orifice was closed, and no
trace of a canal or uterus could be detected by exploration with a catheter in
the bladder and the finger in the rectum. These organs, as in the former case,
were absent. During the time I saw the patient, which was only for two
months, the ovaria did not enlarge, although her general health improved. —
Proceedings of the Royal Society.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

49. Suicide and Intoxication by Chloroform. — M. Chereau relates a very in-
teresting case in which suicide was produced by chloroform. It occurred in
the person of the head of a house of business, who had met with considerable
losses. A sufferer from hemicrania, he became also melancholy, endeavoured
to avoid the society of his friends, and exhibited eccentricities which alarmed
them. Except the neuralgia, he had not previously suffered from any illness.
He had long been in the habit of employing inhalations of sulphuric ether, to
a moderate extent, for the relief of the pain ; but he now made use of enormous
quantities, in the hopes of procuring death; his breath, skin, and elothes,
giving out a strong smell of this substance. One day he escaped from the
surveillance his family had placed over him, and, having procured 37^ drachms
of chloroform from a druggist, he repaired to an hotel, where his manners gave
rise to no suspicions. Not having shown himself for more than twenty-four
hours after, and a moaning being heard, his door was forced open, and M.
Chereau was sent for. He found him with a cadaverous countenance, the
presence of life being indicated by a slow, but regular heaving of the chest,
and some subsultus of the muscles. The pupils were widely dilated and in-
sensible, the mouth half open, and the tongue dry and parchment-like. The
jugular veins were distended, and the fingers were convulsively pressed against
the palms of the hand, leaving impressions of the nails. The whole surface of
the body, front and back, and the extremities, were covered with lividities,
exactly like those often observed on dead bodies, or in individuals asphyxiated
by carbonic acid gas. The heart still beat, but so feebly that it required sus-
tained attention to perceive its weak and rare contractions. The pulse was
felt with still greater difficulty. The respirations were sometimes irregular
and short, at others deeper, and separated by long intervals. The bladder was
distended, and the bedclothes were stained by urine that had escaped. A fire
was lighted in the grate in order to create a current of air, the room being
filled with suffocative emanations. The whole surface of the body was rubbed
with heated cloths, insufflation was performed from mouth to mouth, and
several cups of very strong coffee were administered. At the end of the first
hour the patient, by repeated calling to, could be got to answer in some sort;
and the appearance of hebetude and stupidity had not entirely passed away in
another hour. He looked around him, and the pulse furnished 50 feeble, de-
pressible pulsations. He continually twisted himself about in bed, suffered
from an unquenchable thirst, and complained of a terrible pain in the left
hypochondrium. No avowal of the deed could be extracted from him ; but the
smell sent forth by every column of air expelled from his chest, and the dis-
covery of the bottle, sufficed for an explanation. The hopes entertained of
continued amendment were not realized. The pulse did not rise, the counte-
nance did not improve, and the excessive pain in the hypochondrium resisted
all attempts for its relief. His friends, moreover, without the consent of his

%

1858.] Medical Jurisprudence and Toxicology. 287

attendant, removed him from the hotel to an hospital ; and although he retained
his consciousness on the road and conversed, he died when he reached the
doors. No autopsy was allowed.

In a subsequent number of the journal in which this case appeared, M.
de Meric, of London, related one of excessive use of chloroform that had
occurred to himself. A chemist, 30 years of age, originally of good constitu-
tion, having, a few years since, become habituated to the use of morphia, while
taking it for abdominal inflammation, found that it took no effect in relieving
sleeplessness, from which he frequently suffered. He therefore substituted
inhalations of chloroform, to which he became addicted, and the more so, be-
cause he sought by their means to render himself insensible to chagrin, which
was more imaginary than real. His excessive employment of chloroform was
discovered by his family some three years since, it then being found that he
passed portions of days, and especially the nights, under its influence, thus
producing a factitious sleep, and perhaps fantastic dreams. His countenance
had become altered, his manners were strange, and his moral disposition was
impaired. For a time, through the influence of a relative, the habit was
restrained ; but the use of the chloroform was resumed, and he is supposed to
have indulged in it for the space of five years. He remained in bed until
twelve or one o'clock in the day, repeating the inhalations whenever he awoke ;
and during the day he had the appearance of a man given to drink. He em-
ployed about a pound every five or six days ; and on arousing from the influence
of the chloroform he suffered not the slightest uneasiness from its employment,
escaping the headaches and other inconveniences suffered by those who con-
sume alcoholic fluids in excess. On the 8th August, returning home by the
railroad, after making a purchase of chloroform, and possibly while under the
influence of this substance, he fell from the carriage and broke both his legs.
Double amputation became necessary. The patient was exceedingly feeble ;
but, in spite of the habit he had acquired, there was no difficulty in rendering
him insensible by chloroform. To morphia, however, which was administered
to him after the operation, he was completely insensible, and it became im-
possible not to yield to his entreaties to be allowed to inhale chloroform. He
made, under the superintendence of a dresser, constant use of this at short
intervals, and in forty-two hours after the operation died completely exhausted.
No autopsy was allowed, and decomposition of the body ensued with frightful
rapidity.

M. Vigla, quoting the above eases, states that he had already related a case
in the Moniteur des Hopitaux, 1855, exemplifying the effects of the excessive
use of chloroform. His patient was an engraver, 33 years of age, of robust
constitution, and who had always enjoyed good health until his thirtieth year,
when he beeame the subject of spasmodic asthma. He had employed every
variety of means without avail, when in April, 1855, his medical attendant
advised the inhalation of chloroform. This was to some extent successful ; but
the tolerance of the remedy becoming established, the patient went on, of his
own accord, increasing the dose, until this had become enormous. Thus the
mean daily quantity he inhaled between the first and tenth of May amounted
to 352£. Jaundice coming on, on the 14th of May he diminished the quantity
during four days ; but, the paroxysms becoming insupportable, on the 18th he
inhaled the enormous quantity of gll2J. At the beginning of June a new
attack of jaundice occurred ; he again suspended the anaesthetic, and the
paroxysms increased. He returned to the inhalations, and from the 4th to the
25th of June-, the day he entered the author's maison de sante', he consumed
about ^40 per diem. In spite of these large doses, he was only slightly relieved,
slept but little, and was constantly in a state of hebetude, from which the
paroxysms scarcely aroused him. When he was admitted into the maison, his
countenance was peeuliar, his brilliant but moistened eyes, expanded features,
and smiling lips, giving him the appearance of one ravished with delight, or
under the influence of a commencing intoxication. For two or three days after
his admission small quantities of chloroform were still allowed ; but delirium
tremens then supervening it was entirely cut off. The delirium tremens con-
tinued from the 27th of June to the 4th of July — his delusion consisting a

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[Jan.

portion of the time in supposing that he was the subject of and in constant
danger of poisoning from chloroform. On the 4th he still exhaled some of the
odour of this substance, although he had not employed any of it since the 27th
June. His attacks of asthma had ceased, and he left the establishment 8th of
August. Seen since that time, however, it has been found that his asthma has
returned ; but his reason has continued free, and he declares he has not again
attempted the use of chloroform. — Med. Times & Gaz., Nov. 21, 1857, from
Union Med., Nos. 106 and 112, and Joum. de Pharm., Oct.

50. Death from Chloroform — Mr. C. Heath, House Surgeon to King's Col-
lege Hospital, gives the following report of this: —

" The patient was a female, aged 17, under Mr. Partridge's care, with
syphilitic warts and mucous tubercles. She was admitted July 8, and had
had chloroform administered twice, in order that the sores might be touched
with nitric acid, and on both occasions not the slightest ill effect was produced.
On Friday evening last chloroform was again administered for the same pur-
pose ; only a drachm was put in the inhaler (Snow's), and as soon as she
became unconscious the inhaler was removed, and the acid applied. I and
my assistant (who administered the chloroform) then went to see another
patient in the same ward, and then washed our hands, during which time the
patient was moving her legs about much as they do when recovering, and in
addition she made water over the bed. I gave directions to the nurse to apply
a poultice as usual, and left the ward, having been up to the bed first without
noticing anything unusual about the patient. In a few minutes the nurse
came down for some medicine for another patient, and mentioned that this one
was looking very pale ; I sent up Mr. Liddon to see her at once ; he found her
pale and senseless, dashed some water over her, and called me, and I went up
immediately. I found her pulseless and cold, and immediately commenced
artificial respiration (Marshall Hall), and sent for the galvanic battery; this
was brought and applied without effect, and the artificial respiration was con-
tinued for twenty-five minutes without the slightest effect being produced.

Post-mortem. — Great thickening of mitral valves, and organized lymph in
the pericardium, and attached to surface of heart. Other organs healthy." —
Med. Times and Gaz., Aug. 15, 1857.

51. Poisoning by Twelve Drachms of Laudanum ; Recovery. — Br. G. C. Gibb
records [Lancet, July 25, 1857) a remarkable case in which twelve drachms of
laudanum were swallowed, with a suicidal intent, by a gentleman seventy-two
years of age, healthy and temperate, and not in the habit of using opium.
No symptoms of poisoning occurred; the patient passed a restless, sleepless
night, and nine hours after the laudanum was taken spontaneous vomiting
occurred, and under careful treatment he entirely recovered.

52. Acute Poisoning by Phosphorus. By Dr. Th. Nitsche. — A soldier, set. 21,
previously healthy, was received into hospital on the 21st of May. On closely
interrogating the patient he admitted that on the 19th he had attempted self-
destruction: that he had first swallowed all the mercury in a barometer, but
that this passing away by his bowels, he determined on resorting to phosphorus.
On the evening of the 20th, he took the ends of six ordinary packets of phos-
phorus matches and in three hours afterwards was seized with vomiting, which
occurred frequently; and during his passage to the hospital, a large quantity
of the matches were expelled from the stomach. On being received into the
military hospital, his pulse was frequent, and tongue loaded; his head was hot,
and he complained chiefly of headache. Auscultation and percussion revealed
only a somewhat increased area of hepatic dulness. With the view of removing
from the stomach the phosphorated ends of the matches which remained, an
emetic of ipecacuanha and tartarized antimony was given ; cold applications
were directed to the head, and subsequently magnesia milk in considerable
quantity was administered. After the emetic, the stomach ejected a greenish
fluid which contained portions of undigested food, mucus, and some ends of the
phosphorus matches. The fluid did not emit any odour of phosphorus. On

1858.] Medical Jurisprudence and Toxicology.

289

the following morning (22d) the symptoms were little changed. The headache
was less severe ; pulse 92 ; face red ; the region of the stomach slightly sensi-
ble to pressure, and the patient complained of commencing pains in each hy-
pochondrium. The magnesia was continued. In the afternoon the turgescence
of the face had increased, as had also the hypochondriac pains, and there was
burning thirst, with dryness of the mouth. The headache had completely dis-
appeared. The urine was high-coloured and frothy ; its specific gravity in-
creased, and it was found to contain albumen and exudation-cells ; the colour-
ing matter was augmented, as were also the sulphates and phosphates, but the
chlorides were diminished in amount. This state of the urine continued dur-
ing the whole course of the disease. The estimate as to the quantitative ana-
lysis of the urine was only taken by the eye, so that it is not of much value.
On the 23d, three days after the poison had been taken, the thirst and dryness
of the mouth, with the hypochondriac pains, had increased, and there were,
moreover, darting pains in the chest. The turgor of the face was heightened ;
the sensibility of the epigastric region more marked, and the tympanitic per-
cussion-sound of the stomach audible over a greater extent. Giving credence
to the general impression that phosphorus induces inflammation of the stomach,
leeches were applied to the epigastrium, and iced applications employed. Ice
was also given with the view of assuaging the intense thirst. The magnesia
was continued. Up to the afternoon the symptoms had undergone no altera-
tion, except that the face had assumed a remarkable bluish-red colour, from
which, however, the middle of the face was perfectly free ; a colourless band
of about an inch in breadth, extended from the highest point of the forehead
to the chin, and was sharply defined, giving to the face a most peculiar ap-
pearance.

The bowels not having acted since the poison was taken, an enema was ad-
ministered, which produced an evacuation of a yellowish hue, but not possess-
ing any odour resembling that of phosphorus. Owing to the carelessness of
the attendants, the opportunity of chemical examination was lost. On the 24th
(the fourth day) the pains in the hypochondrium had to some extent abated,
but those of the breast had become intolerable, notwithstanding which, a phy-
sical examination of the chest did not show any remarkable change in the re-
spiratory organs. The bluish-red colour of the face had changed into a per-
fectly cyanotic hue, the median line continuing free from all colour. The
epigastric pain ceased; the patient sweated profusely, and the vapour arising
from the body gave out an intensely phosphoric odour, particularly perceptible
on raising the bedclothes. The breath was perfectly odourless.*

A peculiar symptom now showed itself, viz., the deprivation of sight. The
patient, who retained perfect consciousness, stated that in the horizontal pos-
ture he could perceive a feeble ray of light, but that when he sat up he could
not see at all. The pupils were so dilated that only a narrow ring of the iris
was visible, and they were uninfluenced by light. He now complained of dart-
ing pains in the eyeballs ; the pulse was 100, but moderately full and strong.
In the afternoon, the pulse rose to 140, and was small and weak ; the sense of
hearing was lost; the sweat was profuse, and the odour of phosphorus was
stronger than in the morning; the extremities were cool, and the second sound
of the heart and great vessels were no longer audible. The patient, who still
retained perfect consciousness complained of severe pains in the chest. At
seven o'clock in the evening, the case terminated in death, which was perfectly
tranquil. On the morning of the 26th an examination of the body was made.
The brain was pale, bloodless, and softer than natural ; the ventricles contained
a minimum quantity of serum ; the sinuses were distended with dark fluid
blood. The lungs were of a dark red colour ; in the right were many patches
of blood-extravasation ; the sub-pleural cellular tissue had numerous ecchy-
moses, and the cellular tissue of mediastinum presented the same appearances.
In the pleurag there was much bloody serum. The pericardium contained a
little reddish serum; the heart was soft, the left ventricle empty, the right ven-
tricle and the great veins contained much blood, partly in a state of loose coa-
gulation, and partly fluid. The liver was to some extent enlarged, fatty, and
perfectly bloodless. In the stomach there was some greenish fluid, with white

19*

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Progress of the Medical Sciences.

[Jan.

flakes ; and to the surface of the lining membrane much thick mucus adhered.
With the exception of the fundus of the stomach, which was somewhat hy-
persemic, the interior of this viscus did not exhibit any abnormal appearance.
The mucous membrane of the oesophagus and pharynx was normal; that of the
duodenum resembled the stomach. Along the course of the intestines, in many
situations, the subperitoneal cellular tissue presented patches of ecchymosis.
The small and large intestines did not contain anything unusual; in both there
was a moderate quantity of yellow feces. The spleen was bloodless ; the cor-
tical substance of the kidneys was granular. The Malpighian corpuscles pre-
sented a beautiful appearance, and resembled red points. On a microscopic
examination the rete-mirabile Malpighianum was found injected, and the urini-
ferous tubuli blocked up with exudation matter. The mucous membrane of the
pelvis of the kidney presented some spots of ecchymosis. In the urinary blad-
der, which was contracted, a little cloudy urine was found. The stomach and
a portion of intestines, with their contents, were conveyed to the laboratory of
the " Josephs-Academie," where a chemical examination was instituted, but
without succeeding in discovering the presence of phosphorus. There was no
smell of phosphorus from the body, and it may be observed that neither on the
body during life, nor after death, was there any appearance of phosphorescence.

The narrator of this most important case of poisoning by phosphorus, regrets
that, owing to the pressure of business, in a great hospital, it was found im-
possible to carry out as minute an examination as might have been desirable,
particularly in a chemical point of view; but he deems the publication of the
case valuable, as giving an accurate detail of the symptoms observed during
life, and also of the post-mortem appearances, as such erroneous views prevail
as to the effects of phosphorus on the system.

The most important results of the examination were, on the positive side, the
signs of general deterioration of the blood; and, on the negative side, the ab-
sence of lesion of the stomach.

This case proves that phosphorus does not always at least produce a local
action in its poisonous influence, as is almost generally believed ; for, during
life, in this example, there was no marked symptom of gastritis or gastro-
enteritis present; nor, after death, were there found signs of inflammation,
ulceration, or gangrene of the pharynx, oesophagus, stomach, or intestinal tube
— appearances recorded in most text-books, as found in cases of poisoning by
phosphorus. The poison in the case now recorded seems to have exercised a
general or constitutional influence, and the blood and the nervous system suf-
fered chiefly, as evidenced by the symptoms and morbid appearances — the pain
in the breast and hypochondria; the state of vision, and the evolution of phos-
phorus by the sweat, are worthy of remark. With respect to the existence of
albumen in the urine, and the signs of commencing Bright's disease, it is not
likely that this condition was present before the reception of the phosphorus;
for we find that the patient's health was excellent. It is much more probable
that the lesion of the kidney was produced directly by the poison, for the same
has been observed in instances of poisoning by other agents, and, moreover, it
should be remembered how much the kidneys are exposed to injurious influ-
ences in the separation of noxious materials from the system. As to the dura-
tion of the case (something over four days) it is to be observed, that this is
longer than that of previously reported cases ; but it must be remembered that
a great quantity of the phosphorus matches was rejected by vomiting, and that
the poison was in the solid form, and covered with an envelop of gum. The
fact of phosphorus not being detected after death, may be accounted for by the
duration of the case, by the phosphorus remaining in the stomach being partly
absorbed, and partly oxidized, and by the change which it underwent from
the moment of death to the period of the examination.

It only remains to be mentioned, that the symptoms which are stated in dif-
ferent works to have been observed as the effect of phosphorus, and evidencing
its stimulating or exciting property, such as erections, priapism, strangury,
&c. &c, were not observed in the case which forms the subject of the present
communication. — Dublin Hospital Gazette, Aug. 15, 1857, from Zeitschrift der
Jc. k. Gesellschaft der Aerzte zu Wien.

1858.]

291

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ORIGINAL COMMUNICATIONS.

Encephaloid Tumour weighing ten pounds involving the Right Kidney of
a Boy four years old. By M. Shepherd, M. D., of Payson, 111. — On the
night of the 19th of January, 1857, I was called to see Charley, a boy
four years old, the son of healthy, robust parents, each of whom will weigh
as much as two hundred pounds. The father is a farmer of middle age.
Charley is the youngest of five healthy children, and with the exception
of a protracted illness from cholera infantum when he was a year old, has
enjoyed good health and is well grown. During the month of October
last, he was noticed, occasionally, to spit or vomit up his food soon after eat-
ing. Their family physician was consulted, who stated that it was a slight
dyspeptic attack that would, doubtless, soon pass off without medication.
Early in the winter his parents observed a tumid state of the abdomen, and,
as is common in the country under such circumstances, administered some
domestic anthelmintic, believing the tumidity to be occasioned by worms.
There was no complaint on Charley's part up to this time, and he still in-
dulged freely at the table, but frequently rejected a portion of the amount
taken.

For several days before I visited him he had had high fever, with a coated
tongue, thirst, constipation, and complained of pain in the abdomen. The
marked fulness of that region soon directed my attention particularly to an
examination of its various organs. I found the right side was occupied by
an unnatural growth, which extended from the diaphragm to Poupart's liga-
ment, and laterally to the umbilicus. From the latter point to within a short
distance of the symphysis pubis the bounds of this growth were very distinct,
and the fingers could be pressed beneath its rounded edge. This resembled
so much the lobe of an enlarged liver that, in giving my opinion to the
parents, I located the disease in that organ, and added that if it should prove
to be so, in all probability, such an enlargement was without a precedent.
My prognosis, of course, was unfavourable. The treatment for the night
consisted in fomentation to the affected side, and 3 grs. cal. and 1 gr. of ipec.
once in three hours, until three doses were taken, and the whole to be moved
off with ol. ricini the next morning. The next day I found him with less
fever, but a good deal of tenderness in the region of the liver. Applied
epispast. over the entire diseased side, and ordered the same amount of calo-
mel and ipecac, for the following night. In a few days, Charley was up and
running about as usual, but without any abatement of the fulness of the
abdomen.

I did not see him after the 13th until the 30th of January. There was
no particular change during this time, the abdomen a little more prominent,
and in consequence less inclination to exercise ; lies in his cradle part of the
time ; appetite good j bowels regular ; tongue clean ; pulse 140 j respirations
hurried. Grave iodid. potass, in syrup.

Feb. 6th was called again j found him more feeble ; confined most of the
time ; still rejects a portion of his food. At my request, another physician

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American Intelligence.

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was invited to see the case with me. He was equally confident, with myself,
that we had an enlarged liver to treat, and proposed iodid. ferri and other tonics.
Within a few days the boy rejected all of the medicine administered to him.
Finding it impossible to gain anything by medication, our remedies were dis-
continued. The parents of the boy being in rather indigent circumstances, I
proposed to make regular, but gratuitous visits, in order that I might witness
the progress of the disease. In a short time, I invited another intelligent
physician of our village to see the boy. His view of the case coincided with
my own, together with the consulting physician before alluded to. In fact,
it appeared as if the liver was the only organ that could occupy and take
complete possession of the right hypochondriac and iliac regions, as they
were occupied in this case.

The boy lay most of the time on his back, slightly inclined to the right;
but for some weeks before his death he would ask to be shifted from one side
to the other every few minutes, and his cradle was kept in perpetual motion
day and night. The last two months of his life his appetite was good, almost
ravenous at times, while his stomach retained and perfectly digested all that
he took into it. His tongue was clean, and his bowels had spontaneous
evacuations daily. Within the above specified time he lost control, partially
at first, but finally completely, of his urinary organs, so that that fluid was
discharged guttatim. This was the first evidence we had of any derangement
of these organs, and it was accounted for, in part, by mechanical displacement
and pressure upon the organs concerned in its elimination. Notwithstanding
his good appetite and digestion, his freedom from any perceptible exhausting
influence, he steadily became more and more emaciated, until there was
scarcely a muscular fibre remaining, and nothing but attenuated skin to cover
his bones. He died April 30th.

Post-mortem 14 hours after death, conducted by Dr. Kendall, in presence
of other physicians. On opening the abdomen, contrary to our expectation,
a tumour, shaped very much like the stomach of the hog, somewhat longer,
and about the same colour, forced itself partly through the opening. It was
uniformly attached both to the right and posterior wall of the abdomen, from
the pubis to the diaphragm. Anteriorly, it involved within its investing
membrane almost the whole of the ascending colon. On the left side of the
tumour, along the entire length, the ilium was attached. Posteriorly, the
aorta and vena cava were involved together with the right kidney.

This tumour, notwithstanding the delicacy of its external covering, was
removed entire, and weighed fully ten pounds ! A heterologous monster of
this size in the abdomen of a boy four years old, of course would displace
every organ contained in it. The liver was compressed to its smallest dimen-
sions against the diaphragm on the right, while the stomach was forced into
the extreme left hypochondriac region. The spleen, pancreas, and small
intestines occupied the left also. We were restricted as to the extent of our
examination, and could not carry it further. The tumour was conveyed to
town, where we examined it at our leisure. It was opened in presence of
Drs. Bane, Reynolds, and Kay, and contained the right kidney almost en-
tirely transformed into purely white lobules of soft medullary matter which
surrounded it. There was no blood, and but few bloodvessels in this deposit.
The covering of this mass was so unlike any of the contiguous structures
where it had its origin that we feel it could not have been derived from them,
but was doubtless a new formation. From the hasty examination of other
organs within the abdomen, we feel satisfied that a similar deposit did not
exist in or about any of them.

Patson, III, Aug. 27, 1857.

1858.]

Original Communications.

293

Case of Compound Fracture of the Skull, with Laceration and Loss of a
Portion of Brain. Recovery. By D. J. McRae, M. D., of Sumpter Disk,
S. C. — Sharper, ask 13, slave, good constitution, on June 25th, 1857, at 9
A. M., about nine hours previous to our seeing him had received, by the fall
of a tree, a severe blow on the right side of the head, nearly parallel to the
coronel suture, producing a lacerated wound of about one inch in length,
through which blood and brain were oozing out. Enlarged the wound by in-
cisions; found a compound fracture of the skull, about three inches in length,
on the anterior portion of the right parietal bone, continuous with the coronal
suture, one inch from the sagittal. A portion of the bone was broken in causing
compression of the brain. Eemoved two pieces of bone, which were almost
separated from their membranes, leaving a cavity in cranium three inches in
length by one inch in the widest place, of an oblong triangular form. The
membranes of the brain were torn about two inches in length; the brain was
lacerated, and a considerable portion of it destroyed. The patient was en-
tirely insensible ; collapsed and showed symptoms of compression of the
brain. Slow, laboured pulse. There was complete hemiplegia of the left
side, convulsions, and contraction of the pupils.

His head was shaved, the wound closed by stitches and adhesive strips,
free vent being allowed for any matter to escape, and cold applied ; counter-
irritation to feet and legs. Could not see the patient before two days ; gave
orders to keep the head cool by large wet cloths constantly applied, and to
have the bowels freely opened with magnes. sulph.

July 28. Pulse 50, full; skin hot and dry; inclined to be comatose; in-
sensibility and paralysis increased. Bled him to ^xij, after which the pulse
increased in frequency. Wound healing kindly.

29th. All the symptoms a little improved, and notices when spoken to.
From this time he gradually improved. Cold wet cloths were continued to
the head and wound until it entirely healed; a very light diet and simple
cathartics to keep the bowels open freely were directed.

Aug. 20. He is entirely restored, with the exception of slight paralysis,
which is gradually diminishing.

Confection of Cinchona as an Antiperiodic. By D. S. Gloninger, M. D. —
I would recommend to the profession the "confection of cinchona" (made
of the Calisaya bark), as one of our most efficient antiperiodics, and greatly
superior to the many alkaloids now in use in the treatment of intermittent
fever. It sits well upon the stomach, does not produce the unpleasant cin-
chonism often complained of from sulph. quinia, &c, arid comprises all the
powers' of the cinchona, gratefully disguised, and in such a concentrated form
that the dose is too small even to be ungrateful to the most delicate stomach.
I speak from personal experience, having laboured under intermittent at least
during the space of a year, the disease relapsing every third week. The
alkaloids were all employed, but with no satisfactory results towards a perma-
nent eradication of the disease. I was induced by my. friend, F. L. John,
Pharmaceutist of this city, to use the confection, the formula of which has
been kindly furnished by him, and which is appended to this article; and so
beneficial did it prove that the writer has ever since used it as a substitute
for all other antiperiodics, and with great satisfaction to himself and patients.

Its tonic properties will apply excellently to the convalescence from fevers,
where heretofore we have used Huxham's tinck, wine of wild cherry, &c,
and with this in its favour, that there is so little danger from taking " too

294

American Intelligence.

[Jan.

much for the stomach's sake," so much to be deprecated in the indiscriminate
use of all alcoholic tinctures.

I feel justified in saying, that if the confection receives a trial by the medi-
cal profession, and their experience corresponds with my own, that it will
soon supersede all other antiperiodics now in use.

The following is the formula as furnished by F. L. John, Race St., viz: —
Confectio Cinchonas. — Cort. cinchon. calis. pulv. ; confect. sennae, aa ;
ammon. murias Jss; Syr. cort. aurant. Jij; m. f. confect. Dose, the size of
a shellbark, three times a day.

Case of Monstrosity. By Jno. H. Hunter, M. D., of Kanawha C. H., Ya. —
I send the following description of a " monster" which I assisted into the
world a few days since. The mother had been suffering for three days pre-
vious to the time I was called with false pains. I found her much exhausted,
and deeming it expedient to hasten the labour, immediately administered
ergot. In three hours the head and shoulders were delivered — to my sur-
prise the rest of the body was retained for an hour and a half longer ; but
upon seeing the infant, the cause of the detention was obvious.

Its head was small and cylindrical in shape ; face well formed, with the
exception of the nose, which was represented by a piece of integument of the
size of my little finger-nail; abdomen very large, and filled with serum,
amounting to at least two gallons, which exuded from it when the cord, which
was very weak, and peeled off from its attachment to the abdomen, was rup-
tured ; its legs were behind, on either side of the sacrum, and about half an
inch apart. But I think the strangest thing about this " freak of nature"
was the entire absence of any genital organs, unless two little prominences,
about the size of a pin's head, were rudimentary testicles. There was a very
small aperture, which I suppose was the anus; the cord was very frail, and
ruptured at both ends, which caused much difficulty in delivering the pla-
centa. The child had been dead about twenty-four hours ; mother was
about seventeen, and had been married two years. Primipara.

DOMESTIC SUMMARY.

Fracture of the Neck of the Femur; Bony Union. — Dr. Gay presented to the
Buffalo Medical Association (Sept. 1, 1857) a beautiful specimen of fracture of
the neck of the femur with complete bony union. Dr. G. stated that he was
indebted to Dr. Bissel, of this city, for the specimen. The person from whom
it was taken was a female, set. 62 years, residing in this county, the mother of
Dr. B . The fracture occurred from a fall on the hip ; Dr. G. was not posi-
tive, however, in regard to the nature of the fall. The limb was dressed, splints
being applied ; these were removed in a short time ; and in a few months she
regained the use of the limb. Previous to the accident, she had been labouring
under an attack of tuberculosis pulmonalis; during the time she was being
treated for the fracture, her health improved very much ; but she died about
four years after she had recovered the use of the limb, from consumption.

Prof. Hamilton remarked that the specimen was an interesting one ; the cap-
sule was present (although dry), which he had not often seen in the specimens
of this fracture which he had examined. Though this might be a fracture
within the capsule, as was supposed by Dr. Gay, yet it lacked the positive evi-
dence of such a fracture. Prof. H. had never seen a specimen of fracture within
the capsule, with bony union, which has entirely satisfied him. For several
reasons, he is led to think that this specimen is not one of fracture within the
capsule. First, a fall on the foot would have been much more likely to have

1858.]

Domestic Summary.

295

produced such a fracture than a fall — as in the present instance — on the hip.
Next, although the capsule was attached, yet he was unable to determine
that the line of fracture was within the capsule entirely ; he could not see the
line of fracture even. Furthermore, the neck of the femur was gone, except
about one-quarter of an inch above. He could not positively state where the
line of fracture was, possibly it might have been across the trochanter major;
the direction of the injury would tend to confirm this view. He further stated
that the bone was united completely by bone. The shaft was fairly within the
head of the bone. How did it get there? Not by direct injury. The shaft
was sent into the neck immediately ; absorption of the neck then took place,
leaving the shaft in the head. He could think of no other explanation. The
specimen was a very interesting one ; there was complete bony union. Yet it
lacked the positive evidences of fracture within the capsule. — Buffalo Med. Journ.,
Oct. 1857.

Disarticulation and Removal of nearly the Lateral Half of the Lower Jaw. —
Dr. C. E. Isaacs reports (New York Journ. of Med., May, 1857) a case in which
he performed this operation. The most interesting points in the history of this
case are : —

1. The extirpation of the jaw without ligature either of the common or ex-
ternal carotid.

2. The restoration of the function of the divided branches of the portio dura.

3. The removal of the masseter muscle, and the tracing of the cancerous
deposit from its internal, to its gradual disappearance near its outer surface,
thus showing the necessity of complete extirpation of all suspected parts.

4. The fact of the non-recurrence thus far of a disease which, as viewed both
by the naked eye and through the microscope, was undoubtedly of a cancerous
character.

Simultaneous Dislocation of both Shoulder- Joints. — An example of this rare
accident is recorded (New York Journ. Med., Nov., 1857) by Dr. War. II. Yan
Buren. It occurred in a well-built man, and was produced by a headlong fall
down a flight of steps. Death ensued in five hours from fracture through the
base of the skull with intercranial hemorrhage and laceration of cerebellum.

Anomalous Situation of the Left Kidney. — Dr. C. E. Isaacs, in making the
post-mortem of a negro who had died of phthisis, found the left kidney in the
cavity of the pelvis. Its superior extremity was in contact with the bifurcation
of the abdominal aorta. The inferior touched the posterior surface of the bladder.
The upper surface of the kidney was crossed by the sigmoid flexure of the colon.
The inferior surface reposed upon the left common iliac artery and vein, upon
the left internal, and the left external iliac artery, and the corresponding veins ;
also upon the fifth lumbar vertebra, and the first, second and third pieces of the
sacrum — cellular tissue and vessels intervening.

The right edge of the kidney was in contact with the rectum — the left with
the iliac portion of the brim of the pelvis.

There were three renal arteries, one of the size of a crow's quill, coming off
from the abdominal aorta, the others were branches of the right common iliac,
and were about the size of the radial arteries.

The renal vein entered the vena cava, at the point of its formation, by the
two common iliac veins. The kidney was of the ordinary size. The left supra-
renal capsule was twice as large as usual, and of the shape of a fig leaf. It
occupied its normal position in the lumbar region.

The right kidney was somewhat larger, and situated rather lower down than
usual. — New York Journ. of Med., Nov., 1847.

Gun-shot Wound of Bladder; Recovery. — Dr. Robert H. Grinstead records
[St. Louis Med. and Surg. Journ., Nov. 1857) an interesting case of this. The
subject of it was a delicate lad, 17 years of age, accidentally shot on the morn-
ing of the 4th July, 1857. The ball, which was discharged from a pistol, en-
tered in the hypogastric region a few lines to the left of the median line, and

298

American Intelligence.

[Jan. 1858.]

about half an inch above the symphysis pubis, passed through the bladder,
downward and outward through the great sacro-ischiatic notch ; and was
extracted from a point upon a line with the extremity of the coccyx, and about
two inches above the anus.

The bladder is known to have been in a state of distension at the time of the
accident. The boy was seated on the ground about five paces from the gentle-
man who had the pistol in his hand, and they were almost directly facing each
other.

When seen by Dr. G., seven hours after the accident, he was suffering intense
pain, and the urine was escaping profusely through the anterior wound. By
appropriate treatment, the wound closed in a little over two weeks, and by the
18th day he passed his urine by the urethra easily and naturally, and was dis-
charged as not requiring further treatment.

Chlorate of Potash in Stomatitis Materna. — Dr. L. Faulkner extols ( Virginia
Medical Journal, Dec. 1857) the chlorate of potash as a remedy in stomatitis
materna.

Iodide of Potassium in Leucorrhoea. — Dr. Jos. B. Payne, of Magnolia, Ark.,
recommends (New Orleans Med. and Surg. Journ., Nov. 1857) the iodide of
potassium in solution as an injection in leucorrhoea. He employs the solution
of the strength of one drachm and a half of the salt to a pint of water, three
or four times a day.

Application to Sore Nipples. — It is stated (Boston Med. and Surg. Journ., Oct.
1, 1857) that equal parts (by weight) of glycerine and tannin is an admirable
application to sore nipples, and also to chaps and excoriations of other parts.
The tannin readily dissolves in the glycerine.

Statistical Table exhibiting the Mean Height of American Recruits. — The follow-
ing, extracted from Surgeon General Thos. Lawson's report, exhibits the mean
height of 1800 men taken as they were entered upon the recruit list filed in
the Adjutant General's office. The results are given for 100 men from each
State. No recruit under 5 ft. 5 in. is received.

Mean

Six feet

Greatest

State.

height.
Feet.

and over.

height.
Ft. In.

Indiana . . .

5.7604

18

6.4*

Kentucky

5.7729

18

6.3f
6.3£

Ohio

5.7537

15

Tennessee

5.7779

18

6.3

Maine

5.7314

11

6.2

Vermont and New Hampshire

5.6951

6

6.1

Massachusetts and Connecticut .

5.6821

5

6.3

North Carolina ....

5.7814

24

6.3f

Georgia

5.8272

30

6.6*

South Carolina ....

5.7729

15

6.4£

Alabama

5.7647

17

6.4

Virginia

5.7488

15

6.2

New York

5.6505

4

6.1|

Pennsylvania ....

5.6756

5

6.1

New Jersey and Delaware .

5.6509

6

6.1

Maryland .....

5.7130

9

6.2

Illinois .....

5.7696

17

6.3

Missouri

5.7162

8

6.11

Ovariotomy. — Dr. Gat read before the Boston Society for Medical Improve-
ment (Boston Med. and Surg. Journ., March 19th, 1857), a case of ovarian
cyst, in a woman 54 years of age, in which he performed ovariotomy. The
patient died seventy-four hours after the operation.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR APRIL 1858.

CONTRIBUTORS TO THIS VOLUME.

JOHN L. ATLEE, Jr., M. D., of Lancaster, Pa.
W. F. ATLEE, M. D., of Philadelphia.
JOHN H. BRINTON, M. D., of Philadelphia.
BEDFORD BROWN, M. D., of Yanceyville, N. C.

EDWARD BROWN-SEQUARD, M. D., Professor of Physiology in the Cooper Institute,
N. Y.

J. M. CARNOCHAN, M. D., Professor of Surgery in the New York Medical College.
ISAAC CASSELBERRY, M. D., of Evansville, Ind.

EDWARD H. CLARKE, M. D., Prof of Mat. Med. in Massachusetts Medical College.
D. FRANCIS CONDIE, M. D., of Philadelphia.
RICHARD H. COOLIDGE, M. D., Surgeon U. S. A.
BENJAMIN CUTTER, M. D., of Woburn, 3Iass.

JOHN C. DALTON, Jk., M. D., Professor of Physiology and Microscopic Anatomy in

the College of Physicians and Surgeons, New York.
PLINY EARLE, M. D., of Massachusetts.

ANDREW FLEMING, M. D., late Resident Physician to the Pennsylvania Hospital.
AUSTIN FLINT, M. D., Professor of Clinical Medicine and Medical Pathology in the

University of Buffalo.
THOMAS J. GALLAHER, M. D., of Pittsburg, Pa.

DAVID GILBERT, M. D., Professor of Midwifery in the Medical Department of Penn-
sylvania College.

D. S. GLONINGER, M. D., of Philadelphia.

WM. S. HALSEY, M. D., Professor of Surgery in the Philadelphia College of Medicine.
WILLIAM A. HAMMOND, M. D., Assistant Surgeon U. S. A.
ROBERT P. HARRIS, M. D., of Philadelphia.

EDWARD HARTSHORNE, M. D., one of the Surgeons to Wills Hospital.

C. F. HEYWOOD, M. D., of New York.

JOHN H. HUNTER, M. D., of Kanawha C. H., Va.
WM. R. KING, M. D., of Louisburg, N. C.
ROBERT LANE, M. D., of Sutton, N. H.

J. MARION SIMS, M. D., Surgeon to the Women's Hospital, New York.

E. R. MAYER, M. D., of Wilkesbarre, Pa.

D. J. McREA, M. D., of Sumpter District, S. C.
JOHN B. PORTER, M. D., Surgeon U. S. A.

WM. READ, M. D., former Physician to the Boston Lying-in Hospital.

A. F. SAWYER, M. D., one of the Surgeons to the "Hospital of the Sisters of Mercy,"
San Francisco, Cal.

B. F. SCHNECK, M. D., of Lebanon, Pa.

JOHN D. S HELTON, M. D., of Jamaica, Queen's County, N. Y.
M. SHEPHERD, M. D., of Pay son, III.
HORATIO R. STORER, M. D., of Boston.
ROBERT M. STRIBLTNG, M. D., of Virginia.
MARCUS TAYLOR, M. D., of Mississippi.

LOUIS DE VESEY, Member of the Academy of Natural Sciences, Philadelphia.
A. G. WALTER, M. D., of Pittsburg, Pa.

JAMES J. WARING, M. D., Professor of Physiology in the National Medical College,
Washington, D. C,

J. J. WOODWARD, M. D., Assistant in the Surgical Clinic of the University of Penn-
sylvania.

TO READERS AND CORRESPONDENTS,

We take pleasure in acknowledging our indebtedness to Prof. L. M. Lawson,
of Cincinnati, for his kindness in calling our attention to an error, on p. 200
of our last No., in the formula for the administration of Norwood's Tincture of
Veratrum Viride in pneumonia. According to the formula there given, the
dose of the tincture is eight times as much as intended, which would not be
a safe dose. The correct formula, as given by Dr. Jameson, is: —

R — Tinct. verat. virid. (Norwood's) f^j;
Nit. potass, pur. ;
Aq. purse ^j. — M.
Of this the dose is a teaspoonful every four hours.

"We have on hand a number of communications, which shall receive early at-
tention.

The following works have been received: —

Medico-Chirurgical Transactions. Published by the Royal Medical and
Chirurgical Society of London. Volume the fortieth. London, 1857. (From
the Society.)

The Enlarged Prostate, its Pathology and Treatment ; with Observations on
the Relation of this Complaint to Stone in the Bladder. By Henry Thompson,
F. R. C. S., Assistant Surgeon to University College Hospital, &c. &c. London :
John Churchill, 1858. (From the Publisher.)

The Hygiene of the Turkish Army. By J. N. Radcliffe, M. R. C. S., Late
of the Staff of Omar Pasha. London: John Churchill, 1858. (From the Au-
thor.)

On Consumption: Its Nature, Symptoms, and Treatment. An Essay to
which was awarded the Fothergellian Gold Medal of the Medical Society of
London. By Richard Payne Cotton, M. D. Second edition. London: John
Churchill, 1858. (From the Author.)

The Physiology and Treatment of Placenta Prsevia ; being the Lettsomian
Lectures on Midwifery for 1857. By Robert Barnes, M. D., F. R. S., &c.
London: John Churchill, 1858. (From the Publisher.)

A Manual of Medical Diagnosis: being an Analysis of the Signs and Symp-
toms of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant Physician
to St. George's Hospital. Philadelphia: Blanchard & Lea, 1858. (From the
Publishers.)

Plates Illustrative of Wilson on Diseases of the Skin. Fourth edition. Phila-
delphia: Blanchard & Lea, 1857. (From the Publishers.)

The Dispensatory of the United States of America. By Geo. B. Wood, M. D.,
Prof, of Theory and Practice of Medicine in the University of Pennsylvania,
etc. etc., and Franklin Bache, M. D., Prof, of Chemistry in Jefferson Medical
College of Philadelphia. Eleventh edition, carefully revised. Philadelphia :
J. B. Lippincott & Co., 1858.

Introduction to Structural and Systematic Botany and Vegetable Physiology.
Being a fifth and revised edition of the Botanical Text-Book. Illustrated with
over 1300 wood cuts. By Asa Gray, M. D., Fisher Professor of Natural His-
tory in Harvard University. New York: Ivison & Phinney, 1858. (From the
Publishers.)

Biography of Elisha Kent Kane. By Dr. Wm. Elder. Philadelphia: Childs
& Peterson, 1857. (From the Author.)

Contributions to the American Medical Association. Essays on the Secre-
tory and the Excito-Secretory System of Nerves in their Relations to Physiology
and Pathology. By Henry Fraser Campbell, M. D., Prof, of Anatomy in the

300

TO READERS AND CORRESPONDENTS.

Medical College of Georgia. With Illustrations. Philadelphia: J. B. Lippin-
cott & Co., 1857. (From the Author.)

Robertson's Case of Jacksonville Fever. Charleston, 1857. (From the Au- '
thor.)

A "Brief Description of the Yellow Fever as it prevailed at Mount Pleasant, and
in Charleston Harbour, during the summer of 1857. By R. A. Kinlock, M. D.
Charleston, 1858. (From the Author.)

Medical Opinion in the Parish Will Case. By Pliny Earle, M. D. New
York, 1857. (From the Author.)

A History, Chronological and Circumstantial of the Visitations of Yellow
Fever at New York. By John II. Griscom, M. D., Physician to the New York
Hospital, Fellow of the New York Academy of Medicine. New York, 1858.
(From the Author.)

The Transactions of the Belmont Medical Society for 1856-7. Bridgeport,
Ohio, 1858.

An Address delivered before the Graduating Class of the Dartmouth Medical
College, at Hanover, N. H., Nov. 11th, 1857. By George H. Hubbard, M. D.
Manchester, 1857. (From the Author.)

New York Academy of Medicine. Discussion on Puerperal Fever. Remark
by Dr. Baker. New York, 1857. (From the Author.)

An Address on Scientific and Practical Medicine, delivered before the Medi-
cal Class, Nov., 1857. By A. H. Buchanan, M. D., Prof. Physiology and Sur-
gical Anatomy in University, Nashville. Nashville, 1857. (From the Author.)

Hahnemann and Paracelsus. On some Ancient Medical Delusions, and their
Connection with Errors still Existing. An Address delivered before the Nor-
folk District Medical Society, Nov. 11, 1857. By Henry A. Martin, M. D.,
(of Roxbury). Boston, 1857. (From the Author.)

An Essay on the Position and Duties of the Medical Profession in the Mid-
dle of the Nineteenth Century. By Charles E. Johnson, M. D., of Raleigh,
N. C. Raleigh, 1858. (From the Author.)

An Address read before the Esculapian Society of the Wabash Valley, held
at Paris, Illinois, on the 29th of October, 1857. By E. Read, M. D., of Terre
Haute, Indiana. Chicago, 1858. (From the Author.)

Nineteenth Annual Report of the Board of Trustees and Officers of the Cen-
tral Ohio Lunatic Asylum, to the Governor of Ohio, for the year 1857. Colum-
bus, 1858. (From Dr. R. Hills.)

Twenty-first Annual Report of the Trustees and Superintendent of the Ver-
mont Asylum for the Insane, August, 1857. Brattleboro, 1857.

Report of the Board of Managers of the Eastern Lunatic Asylum (at Lexing-
ton) for the years 1856-7. Frankfort, Kentucky, 1858.

First Semi-Annual Report of the Superintendent of the Lunatic Asylum of
the State of Texas. Rendered Nov. 27, 1857. Austin, 1858.

Report of the Trustees and Superintendent of the State Lunatic Asylum of
Pennsylvania, 1857. Harrisburg, 1858.

Report of the Pennsylvania Hospital for the Insane, for the year 1857. By
Thomas S. Kirkbride, M. D., Physician to the Institution. Published by order
of the Board of Managers. Philadelphia, 1858.

Constitution, By-Laws, and Code of Ethics of the North Mississippi Medical
Society. Adopted, May, 1856. Aberdeen, 1856.

An Introductory Lecture to the Course of Instruction in the Medical Depart-
ment of the University of Vermont. By R. Cresson Styles, M. D., Prof. Phy-
siology and Pathology, Feb. 1858. Burlington, 1858. (From the Author.)

Fifth Annual Report of the Surgeons of the New York Ophthalmic Hospital
at No. 6 Stuyvesant Place, near Ninth Street. With an Address. By Mark
Stephenson, M. D., to the Graduating Class of 1857. Subject — Law and Medi-
cine Contrasted. New York, 1858. (From the Surgeons.)

Report of the Board of Inspectors of the Western Penitentiary of Pennsyl-
vania, for 1857. Pittsburg, 1858. (From D. Pollock.)

A Report on Diseases of the Cervix Uteri; read before the Medical Society
of the State of Georgia, at the Annual Meeting in Augusta, April, 1857. With

TO READERS AND CORRESPONDENTS.

301

Additional Notes. By Joseph A. Eve, M. D., Prof. Obstetrics, &c, in Medical
College Georgia. Augusta, 1858. (From the Author.)

Ethnology of the Negro or Prognathous Race. A Lecture delivered Nov.
30th, 1857, before the New Orleans Academy of Science. By Samuel A. Cart-
wright, M. D. New Orleans, 1858. (From the Author.)

Silver Sutures in Surgery. The Anniversary Discourse before the New York
Academy of Medicine, delivered Nov. 18th, 1857. By J. Marion Sims, M.D.,
Surgeon to the Woman's Hospital. Published by the Academy. New York,
1858. (From the Author.)

The following Journals have been received in exchange: —

Annales Medico-Psychologiques. Journal destine a recueillir tous les docu-
ments relatifs a 1' Alienation Mentale, aux nevroses, et a la Medecine Legale
des Alienes. Par MM. les Docteurs Baillarger, Cerise et Moreau. October,
1857. January, 1858.

Le Moniteur des HSpitaux Revue Medico-Chirurgicale de Paris. Redacteur
en chef, M. H. De Castelnau. Dec. 1857. Jan., Feb., March, 1858.

L' Art Dentaire. Revue Mensuelle de la Chirurgie et de la Prothese Dentaires.
Par MM. Fowler et Preterre, Dentistes Am6ricains a Paris. Dec. 1857.

Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. Jan.,
1858.

Journal de la Physiologie de l'Homme et des Animaux. Publie sous la
direction de Docteur E. Brown-Sequard. Jan., 1858.

British Medical Journal. Edited by Andrew "Winter, M. D. Dec, 1857.
January, February, March, 1858.

British and Foreign Medico-Chirurgical Review. January, 1858.

The Liverpool Medico-Chirurgical Journal. January, 1858.

The Half Yearly Abstract of the Medical Sciences. Edited by W. H. Ran-
king, M. D., and C. B. Radcliffe, M. D. July, December, 1857.

Edinburgh Medical Journal. January, February, 1858.

The Journal of Psychological Medicine and Mental Pathology. Edited by
Forbes Winslow, M. D. January, 1858.

The Sanitary Review and Journal of Public Health. Edited by Benj. W.
Richardson, M. D. January, 1858.

The Retrospect of Medicine, being a half-yearly Journal. Edited by W.
Braithwaite. July, December, 1857.

The Midland Quarterly Journal of the Medical Sciences. January, 1858.

The Glasgow Medical Journal. January, 1858.

The Dublin Hospital Gazette. January, February, 1858.

The Dublin Quarterly Journal of Medical Science. February, 1858.

The Medical Chronicle and Montreal Monthly Journal of Medicine and Sur-
gery. Edited by Dr. W. Wright and D. C. MacCallum. January, February,
March, 1858.

Charleston Medical Journal and Review. Editor, J. Dickson Bruns, M. D.
January, March, 1858.

Boston Medical and Surgical Journal. Edited by W. W. Morland, M. D.,
and Francis Minot, M. D. January, February, March, 1858.

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D.
January, March, 1858.

Southern Medical and Surgical Journal. Edited by Henry F. Campbell,
M. D., and Robert Campbell, M. D. January, February, March, 1858.

The New Orleans Medical and Surgical Journal. Edited by Bennet Dowler,
M. D. January, March, 1858.

New Orleans Medical News and Hospital Gazette. Edited by Warren
Brickell, M. D., and E. D. Fenner, M. D. January, February, March, 1858.

The North American Medico-Chirurgical Review. Edited by S. D. Gross,
M. D., and T. G. Richardson, M. D. January, March, 1858.

The American Journal of Dental Science. Edited by Chapin Harris, M. D.,
D. D. S., and A. S. Peggot, M. D. January, 1858.

302

TO READERS AND CORRESPONDENTS.

Buffalo Medical Journal. Edited by Sanford B. Hunt, M. D., and Austin
Flint, Jr., M.D. January, February, March, 1858.

The New York Journal of Medicine. Edited by Stephen Smith, M. D.
January, March, 1858.

The Virginia Medical Journal. Edited by Drs. McCaw and Otis. January,
February, March, 1858.

The New Hampshire Journal of Medicine. Edited by Geo. H. Hubbard,
M. D. January, February, March, 1858.

Nashville Journal of Medicine and Surgery. Edited by Drs. Bowling, Fos-
ter, and Blackie. January, February, March, 1858.

The Peninsular Journal of Medicine. Edited by Drs. Pitcher, Palmer,
Brodie and Christian. January, February, 1858.

The American Journal of Science and the Arts. Edited by Professor B.
Silliman, B. Silliman, Jr., and J. D. Dana. January, March, 1858.

Atlanta Medical and Surgical Journal. Edited by Jos. P. Logan, M. D., and
W. F. Westmoreland, M. D. January, February, 1858.

The Medical and Surgical Reporter. Edited by S. W. Butler, M. D. Jan-
uary, February, March, 1858.

Cincinnati Lancet and Observer. Edited by Drs. G. Mendenhall, J. A.
Murphy and E. B. Stevens. January, March, 1858.

Iowa Medical Journal. Edited by J. C. Hughes, M. D., and W. R. Marsh,
M. D. January, February, March, 1858.

The American Journal of Insanitv. January, 1858.

The Chicago Medical Journal. Edited by N. S. Davis, M. D., and W. H.
Byford, M.D. January, February, 1858.

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D.,
and W. M. McPheeters, M. D. January, 1858.

The Pacific Medical and Surgical Journal. Edited by John B. Trask, M. D.,
and David Wooster, M. D. February, 1858.

The American Journal of Pharmacy. Published by Authority of the Phila-
delphia College of Pharmacy. Edited by William Procter, Jr., Professor of
Pharmacy in Philadelphia College of Pharmacy. March, 1858.

Communications intended for publication, and Books for Review, should be sent, free
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Me-
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar-
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us
safely and without delay. We particularly request the attention of our foreign corre-
spondents to the above, as we are often subjected to unnecessary expense for postage
and carriage.

Private communications to the Editor, may be addressed to his residence, 1525
Locust St.

All remittances of money, and letters on the business of the Journal, should be
addressed exclusively to the publishers, Messrs. Blanchard & Lea.

The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

To secure insertion, all advertisements should be received by the 20th of the pre-
vious month.

CONTENTS

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.
NO. LXX. NEW SERIES.
APRIL, 1858.

MEMOIRS AND CASES.

ART. PAGE

I. The Influence of the Placenta upon the Development of the Uterus dur-
ing Pregnancy. By William Read, M. D., formerly Physician to the
Boston Lying-in Hospital. (Read before the Boston Society for Medical
Improvement, Dec. 28, 1857.) 309

II. On the Alterations induced by Intermittent Fever in the Physical and
Chemical Qualities of the Urine, and on the Action of the Disulphate of
Quinine. By William A. Hammond, M. D., Assist. Surg. U. S. A.
(Read before the Biological Society of Philadelphia, February 15, 1858.) 322

III. On the Use of Iron. By Isaac Casselberry, M. D., Evansville, Ind. 327

IV. Glycerine as a Local Application in Pseudo-Membranous Croup. By

E. R. Mayer, M. D., of Wilkesbarre, Pa. - 338

V. On the Local Application of Belladonna with Mercurial Ointment in
the Treatment of Croup. By John D. Shelton, M. D., of Jamaica,
Queen's County, New York. 340

VI. Report of Cases treated at the Surgical Clinic of the University of
Pennsylvania. By J. J. Woodward, M. D., of Philadelphia, Assistant

to the Surgical Clinic. - 344

VII. Medical and Surgical Notes of Campaigns in the War with Mexico,
during the years 1845, 1846, 1847, and 1848. By John B. Porter, M. D.,
Surgeon U. S. Army - - - - 347

VIII. Case of Fracture of the Clavicle and Humerus of the same Side.

By B. F. Schneck, M. D., of Lebanon, Pennsylvania. - 352

IX. Resection of the Femur, and Removal of the Trochanter Major for the
formation of an Artificial Hip-Joint. By A. G. Walter, Surgeon, Pitts-
burg, Pa. 354

X. Resection of the Lower Jaw for Necrosis caused by Inhalation of the
Fumes of Phosphorus. By Wm. S. Halsey, M. D., Prof, of Surgery in

the Philadelphia College of Medicine. 356

XI. Case of Somnambulism. By Robert M. Stribling, M. D., of Virginia 360

XII. Exsection of the Entire Radius. By J. M. Carnochan, Professor of
Surgery in the New York Medical College, Surgeon-in-Chief to the State
Hospital (New York), etc. With a wood-cut. 363

XIII. Account of a Monster of the Genus Peracephalus. By Walter F.
Atlee, M. D. (Read before the Biological Society of Philadelphia, March

1, 1858.) - - - - - 370

304

CONTENTS.

ART. PAGE

XIV. Spontaneous Rupture of the Eye. By Andrew Fleming, M. D., late
Resident Physician to the Pennsylvania Hospital. 373

XV. Experiments with Bibron's Antidote to the Poison of the Rattlesnake.
By Louis de Vesey, Member of the Academy of Natural Sciences of Phi-
ladelphia. 376

TRANSACTIONS OF SOCIETIES.

XVI. Summary of the Transactions of the College of Physicians of Phila-
delphia. 377

1. Injurious Effect upon the Eye of the Light from the Fish-tail
Burner. By Dr. B. H. Rand. - - - - - - - 377

Fatal Enlargement of the Thymus Gland with Subjacent Tumour.
By Dr. Henry Hartshorne. 378

Congenital Malposition of the Liver. By Dr. J. C. Morris. - - 380

Foreign Body in the Lungs. By Dr. G. B. Wood. - - - - 380

Chronic Disease of the Urinary Organs characterized by Anomalous
Symptoms. By Dr. 0. J. Wister, 382

Fatal Disease of the Appendix Vermiformis. By Dr. Caspar Wister. 383

Foreign Body retained upwards of Twenty Years in the Nasal Pas-
sage. By Dr. I. Hays. 390

Epistaxis arrested by the Administration of Common Salt. By Dr.
Caspar Morris. 390

Melanotic Tumours of various Thoracic and Abdominal Viscera,
without External Evidence of Melanosis. By Dr. Griscom. - 392

Annual Report on Meteorology and Epidemics. By Dr. Wilson Jew-
ell. - 395

REVIEWS.

XVII. Clinique de l'Hopital du Midi — Lecons sur le Chancre, professees
par le Docteur Ricord, redigees et publiees par Alfred Fournier, Interne
de FHSpital du Midi, Paris, 1858. 1 vol. in 8vo.

Clinic of the Midi Hospital — Lectures on Chancre, delivered by Dr. Ricord,
collected and published by A. Fournier, House Physician of the Midi
Hospital, Paris, 1858. 1 vol. 8vo. 427

XVIII. On Stricture of the Urethra. By Henry Smith, F. R. C. S.,
Surgeon to the Westminster General Dispensary, formerly House Sur-
geon to King's College Hospital. London, 1857 : pp. 280 - 433

BIBLIOGRAPHICAL NOTICES.

XIX. Reports of American Institutions for the Insane.

1. Of the Central Ohio Lunatic Asylum for 1857.

2. Of the Southern Ohio Lunatic Asylum for 1857.

3. Of the New York City Lunatic Asylum, for the year 1856.

4. Of the Bloomingdale Asylum, for the year 1856.

5. Of the Vermont State Asylum, for the fiscal year 1856-7.

6. Of the Western Lunatic Asylum, of Virginia, for the two years end-

ing on the 30th September, 1857.

7. Of the Retreat, at Hartford, for the fiscal year 1856-7.

8. Of the New York State Lunatic Asylum, for the year 1856.

9. Of the Massachusetts State Lunatic Hospital, at Worcester, for the

year 1856.

10. Of the New Hampshire State Asylum, for the fiscal year 1856-7. - 449

XX. Proceedings of Westchester County Medical Society, at its Annual
Meeting, held in the Village of Sing Sing (N. Y.), June 3, 1856. 8vo.
pp.50. - - - - 462

CONTENTS. 305
ART. PAGE

XXI. San Francisco Medical Society ; Annual Address delivered before
the Society, pursuant to appointment, Jan. 27, 1857. By Henry Gib-
bons, M. D. 8vo. pp. 24. 465

XXII. Experimental Researches relative to the Nutritive Value and Phy-
siological Effects of Albumen, Starch, and Gum, when singly and exclu-
sively used as food. By W. A. Hammond, M. D., Assistant Surgeon

U. S. A. 468

XXIII. Essays on the Secretory and the Excito-Secretory System of
Nerves in their Relations to Physiology and Pathology. By Henry Fra-
zer Campbell, A. M., M. D., one of the Vice-Presidents of the American
Medical Association, and Professor of Special and Comparative Ana-
tomy, in the Medical College of Georgia (Augusta). With Illustrations.
8vo. pp. 135 : J. B. Lippincott and Co., Philadelphia, 1857. - - - 470

XXIV. The Enlarged Prostate ; its Pathology and Treatment ; with Ob-
servations on the Relation of this Complaint to Stone in the Bladder.
By Henry Thompson, F. R. C. S., &c. Octavo : pp. 329. London, 1858.

The Prostate Gland and its Enlargement in Old Age. By Decimus Hodg-
son, M. D., Demonstrator of Anatomy in the University of Glasgow,
London, 1856. 473

XXV. A Practical Treatise on the Diseases of Children. By J. Forsyth
Meigs, M. D., Fellow of the College of Physicians of Philadelphia, etc.
etc. Third edition. Carefully revised. 8vo. pp. 724. Philadelphia:
Lindsay and Blakiston, 1858. - 479

XXVI. Journal de la Physiologie de l'Homme et des Animaux* Publie
sous la Direction du DoCteur E. Brown-Sequard. Tome Premier, Jan-
vier, 1858. Paris, J. B. Bailliere et Fils. London and New York, H.
Bailliere. - - 479

XXVII. Comptes Rendus des Seances et Memoires de la Societe de Bio-
logie, pendant l'annee 1856. Octavo, pp. 748. Paris, 1857.

Minutes of the Meetings and Papers read before the Society of Biology in
the year 1856. 482

XXVIII. Archives of Medicine. A Record of Practical Observations and
Anatomical and Chemical Researches connected with the Investigation
and Treatment of Disease. Edited by Lionel S. Beale, M. B., F. R. S.,
&c. &c. London : John Churchill. 1857. No. 1. - - - 483

XXIX. A Theoretical and Practical Treatise on Midwifery, including the
Diseases of Pregnancy and Parturition, and the Attentions required by
the Child from Birth to the Period of Weaning. By P. Cazeaux, Mem-
ber of the Imperial Academy of Medicine, Adjunct Professor in the
Faculty of Medicine of Paris, etc. etc. Second American, translated
from the Fifth French edition. By Wm. R. Bulloch, M. D. With one
hundred and forty illustrations. 8vo. : pp. 992. Philadelphia, 1857.
Lindsay and Blakiston. 484

XXX. A Manual of Medical Diagnosis : being an Analysis of the Signs
and Symptoms of Disease. By A. W. Barclay, M. D., Cantab, et Edin.,
Fellow of the Royal College of Physicians ; Assistant Physician to St.
George's Hospital, etc. etc. Philadelphia: Blanchard and Lea, 1858.
8vo. pp. 423.- - 485

XXXI. On the Diseases, Injuries, and Malformations of the Rectum and
Anus, with Remarks on Habitual Constipation. By T. J. Ashton, Sur-
geon to the Blenheim Dispensary, &c. &c. Second edition, London,
John Churchill, 1857. 8vo. pp. 396. - - 487

XXXII. Plates Illustrative of Wilson on Diseases of the Skin. Fourth
edition. Philadelphia: Blanchard and Lea, 1857. - - - 490

306

CONTENTS.

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.
Anatomy and Physiology.

1. Choroid Plexus of the Human
Brain. By Prof. Luschka. - 491

2. Histology of the Supra-Renal
Capsules. By Dr. Harley. - 492

3. Function of the Supra-Renal
Capsules, and their supposed
Connection with Bronzed Skin.

By Dr. George Harley. - - 493

4. Variations of the Colour of Ve-

PAGE

nous Blood. By Prof. Claude
Bernard. 494

5. On the Properties and Uses of
the Red Blood, and of the Dark
Blood. By Dr. Brown-Sequard. 496

6. Membrana Meconii, and Rete
Vasculare, newly discovered
Structures existing in the Foe-
tus. By Dr. B. Ridge. - - 497

Organic Chemistry.

7. On the Physiological Relations

of Albumen. By Dr. Hayden. 497

8. On the Chemical Changes in

the Air during Respiration. By
Dr. Harley. - - - - 500

Materia Medica and Pharmacy.

9. Influence of Liquor Potassse and
other Alkalies on the Therapeu-
tic Properties of Henbane, Bel-
ladonna, and Stramonium. By
Dr. A. B. Garrod. - - - 501

10. Experiment on Colchicine, and
the Comparative Action of the
Dry Bulbs and the Seeds of
Colchicum. By Prof. Schroff. - 502

11. Emmenagogue Action of
Achillea Millefolium. By Dr.
Ronzier-Jolly. - 503

12. Defects of ordinary Escha-
rotics, with suggestions for their
Improvement. By Mr. Ellis. - 503

13. Sulphuric Acid and Sulphate
of Zinc as a Caustic Agent. By
Mr. Henry Thompson. - - 504

14. Administration of Cod-liver
Oil, and Substances soluble in
it, in Capsules. By Mr. T. Spen-
cer Wells. .... 504

15. Preparation of Iodide of Ca-
lomel. By M. Boutigny. - 505

16. Lotion for Strumous Glands. - 505

17. Cocoa-nut Oil Ointments. - 506

18. Proposed Substitute for Oils
and Fats in Ointments. By Mr.
Schacht. 506

Medical Pathology and Therapeutics, and Practical Medicine.

19. Treatment of Diabetes by Su-
gar. By Drs. Budd, Williams
and Corfe. -

20. Bronzed Skin — Disease of the
Supra-Renal Capsules. By Mr.
Hutchinson and Dr. Addison. -

21. Treatment of Inflammatory

506

509

Diseases of the Respiratory Or-
gans. By Dr. Semple - - 513

22. Treatment of Pleuro-Pneumo-
nia. By Dr. S. O. Habershon. 514

23. Hydropneumothorax treated
by Paracentesis Thoracis and In-
jections of Iodine. By Prof.
Trousseau. .... 515

CONTENTS.

307

PAGE

24. Specific Treatment of Con-
sumption by Salts of Phospho-
rus. By Dr. R. P. Cotton. - 516

25. Effect of Local Influences on
Spasmodic Asthma. By Dr.
Hyde Salter. - - - - 517

26. On (Edema Glottidis. By Pro-
fessor Pitha. - 518

27. Acute Rheumatism caused by
large doses of Hydriodate of Po-
tass. By Dr. Charles Campbell. 519

28. Principles of Treatment in
Chronic Rheumatism. By Dr.
Inman. 519

29. Perchloride of Iron in the
Treatment of Erysipelas. By

M. Aran. - - - - - 520

30. Guarana in Chronic Diarrhoea.

By Dr. Herve. - - - - 521

PAGE

31. Use of Kameela as an Anthel-
mintic. By Mr. Arthur Leared. 522

32. On the Employment of Tartar-
ized Antimony in the Treat-
ment of Chorea. By Dr. Adrien
Marcotti. 522

33. Lactate of Zinc in Epilepsy.

By Dr. Herpin - # - - - 522

34. Therapeutic Action of Chlorate
of Potash, with a New Mode of
Administering it. By Dr. De-
than. 523

35. Movable Kidneys. By Prof.
Oppolzer. ----- 523

36. Functional Paralysis. By Dr.
Handfield Jones. - - - 524

37. The Doctrine of Elimination,
as propounded by recent Au-
thors. By Dr. Thomas Inman. 524

Surgical Pathology and Therapeutics, and Operative Surgery.

38. After-Treatment of Surgical
Operations. By Dr. Broadbent. 525

39. Causes of the Pneumonia
which Supervenes upon Laryn-
gotomy. By Prof. Schuh. - 525

40. Process of Repair in Subcuta-
neous Diversion of the Tendo-
Achillis. By Mr. Holmes Coote. 527

41. Suppuration of Strumous
Glands. By Mr. James Paget. 528

42. Strumous Inguinal Glands. By
Mr. James Paget. - - - 529

43. Cancerous Lymphatic Glands.

By Mr. James Paget. - - 530

44. On Congelations. By M. Val-
lette. 530

45. A Mixture of Collodion and
Castor Oil as an Application to
Severe Cases of Burns and
Scalds. 532

46. Employment of Collodion in
Orchitis. By Dr. Losetti. - 532

47. Large Doses of Disulphate of
Quinine in Dysuria and Reten-
tion. By Dr. Serres. - - 532

48. Thoracic Aneurism success-
fully treated. By Mr. Tufnell. 532

49. Cure of Popliteal Aneurism
by Digital Compression of the
Vessel corresponding with the
Sac. By M. Vanzetti. - - 535

50. Excision of Enlarged Tonsils.

By Mr. James Paget. - - 535

51. Experience of the Surgeons of
the " Dreadnought" as to Piro-
goff's Operation at the Ankle-
joint. By Mr. I. Croft. - - 536

52. On some Points connected
with the Treatment of Obstinate
Stricture of the Urethra. By
Mr. Henry Smith. - - - 537

53. Diagnosis of Hydrocele. By
Prof. Nelaton - - - - 538

Ophthalmology.

54. On some Points in the Patho-
logy and Morbid Anatomy of
Glaucoma. By Mr. Hulke. - 539

55. Vascular Tumour of the Orbit
of many Years' Standing, and
latterly producing threatening
Symptoms, successfully treated

by the Injection of Tannic Acid.
By Mr. Haynes Walton. - - 542

56. Naevi on the Eyelids cured by
Perchloride of Iron. By Mr.

JHulke. 543

57. Dislocation of the Crystalline
Lens. By Mr. White Cooper. - 443

308

CONTENTS.

Midwifery.

PAGE

.58. Reciprocal Sympathies be-
tween the Uterus and Bladder in
Women. By Dr. W. T. Mont-
gomery. ----- 544

59. On Coagula formed in the
Veins during the Puerperal
State, and their occasional
Transportation into the Pulmo-
nary Artery. By Dr. Graily
Hewitt. 548

60. On the Membrana Decidua

which surrounds the Ovum in
Cases of Tubal Gestation. By
Dr. Robert Lee. - - - 549

61. Extra-Uterine Gestation. By
Dr. Diamantapuplos. - - 551

62. Ruptured Uterus. By Mr.
Dillon Kelly. - - - - 552

63. Intra-Uterine Fractures. By
Dr. Herbert Barker. - - - 552

64. Report on Cross-Presenta-
tions. By Professor Spaeth. - 553

AMERICAN INTELLIGENCE.
Original Communications.

Singular Result [Thrombus] of an ! Recovery. By Thos. J. Galla-
Injury in the last Stage of Preg- j her, M. D. - 559
nancy. By Bedford Brown,' I Case of Hernia. By Robert Lane,
M.D. - - - 557 M.D. - - - - -560

Tumour occurring thirty-six hours Dislocation of the First Phalanx
after Delivery. By J. Marcus of the Thumb upon the Dorsum

Taylor, M. D. - - - - 558 ' of the Metacarpal Bone. By

Case of Poisoning by Laudanum ; \ Benjamin Cutter, M. D. - -561

Domestic Summary.

Dislocation of both Thighs — one
into the Foramen Ovale, the
other on the Dorsum of the
Ilium, with Fracture of the Cer-
vix Femoris. By Dr. J. Mason
"Warren. 563

A Simple and Efficient Bandage
for Fracture of the Clavicle. By
Dr. Julian Chisholm. - - 564

Some Remarks on Cataract. By
Dr. C. S. Fenner. - - - 565

Thrombus of the Vagina. By Dr.
Boisliniere. ... - 566

Fatal Asphyxia from Imperfect
Combustion of Gas. - - - 567

Inverted Toe-Nail treated without
Operation. By Dr. Robert Camp-
bell. 568

Case of Impalement. By Dr. A.
C. Garratt, - - - - 568

Extraction of a Living Child, by
Turning, after the Death of the
Mother. By Dr. G. W. Thorn-
ton. - - - - _ - 569

Absence of Urea and Uric Acid in
Urinary Secretions in Yellow
Fever. By Dr. F. Peyre Porcher. 570

Creasote in Dysentery. By Dr.
G. E. Elmer. ^ - ^ - - - 570

Euphrasia Officinalis as a Cure for
Epilepsy. By Dr. J. G. Kyle. 570

Treatment of Prolapse of the Fu-
nis. By Dr. T. Gaillard Tho-
mas. 570

Inoculation with Gonorrhoeal Mat-
ter for the Cure of Granular
Lids and Corneitis. - 570

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR APRIL 1 8 58.

Art. I. — The Influence of the Placenta upon the Development of the Uterus
during Pregnancy. By William Read, M. D., formerly Physician to the
Boston Lying-in Hospital. [Read before the Boston Society for Medical
Improvement, Dec. 28, 1857.]

In the course of a somewhat extended consultation of obstetrical writers,
undertaken while investigating the subject of placenta praevia, nothing be-
came more evident than the insufficiency of any theory of the development of
the uterus as at present propounded, to account for all the phenomena which
manifest themselves in this unnatural form of pregnancy.

The theory of uterine development recognized by writers at the present
day, is, that the uterus begins to enlarge at the fundus; that the body of this
organ next takes part in the process, then the cervical portion, and finally the
cervix itself. That this process of enlargement goes on in the fundus and
body exclusively for 5, 6, or 7 months, or even longer, and that after this time
the increase of its cavity is gained at the expense of the neck, the rest of the
uterus remaining comparatively quiet. That in consequence of this process,
the uterus at the end of gestation acquires a fusiform shape, the smallest end
resting in the pelvic basin.

But while agreeing in the general plan of development, nothing can be
more vague and contradictory than the opinions expressed, as to the rate and
mode in which this development is carried on,

The absence, also, of any proof whether the cases on record, by which the
size and shape of the uterus at different periods of gestation have been deter-
mined, were all of them normal presentations, or whether a part of them were
not presentations other than those of the head, renders the results obtained
from them of doubtful value.

That the uterus enlarges as the foetal mass increases in size, is a fact that
No. LXX.— April 1858 21

810 Read, Influence of Placenta on Uterus during Pregnane!/. [April

admits of no dispute; but that it expands in one part before another, in
obedience to any organic law, as the consequence of the operation of a vital
cause, may be doubted.

If it should be proved that, irrespective of the position of the placenta upon
the uterine walls, the fundus always began to expand before any other por-
tion of the uterus, and that, as the development proceeded gradually down-
ward, the cervix was the last to lose its characteristic shape, until, at the close
of gestation, the outline of the whole organ was constant and symmetrical,
whatever may have been the presentation of the child, a strong and unan-
swerable argument might be made out in support of the present theory. But
in this conclusion we are not sustained by facts. In normal presentations, at
the period of its utmost development, the general outline of the uterus is pyri-
form, the base being above, and the apex resting in the cavity of the pelvis.
When the breech presents, it becomes almost globular; and in transverse pre-
sentations the long diameter is at right angles to the axis of the pelvis;
proving very conclusively that the shape of the uterus, at the termination of
gestation, is not the result of development, but depends upon the position of
the contained foetus.

Neither is the uterus symmetrical at the close of pregnancy. According
to Mr. Doherty,1 if a line be drawn round the body of this organ at the inser-
tion of the Fallopian tubes, which in the unimpregnated state are situated
nearly in the median line, it will be found that | of its circumference is
behind them, and § in front. Cazeau3 also makes the same remark. The
insertion of the tubes, also, from being nearly at the level of the fundus, is now
found to be one- third of the way towards the os, showing that a much greater
expansion has taken place in one direction than another. The gradual mount-
ing of the uterus in the cavity of the abdomen proves nothing, for, supposing
that the expansion should begin in any portion of its walls, the inability of
that expansion to extend beyond a certain degree in any other direction than
upward or downward, and the impossibility of its enlargement being accommo-
dated in the pelvic cavity, would of necessity force the mass in an upward
direction, and produce the same apparent effect as if the fundus alone was
enlarging. The mere fact, therefore, that the uterus rises out of the cavity
of the pelvis, as the gestation proceeds, is no proof that any particular portion
of this organ is being first developed.

Great reliance has been placed on the proofs derived from "the changes
which the neck undergoes during the latter portion of pregnancy : but except
in first pregnancies, even these are not to be depended on. In relation to
this point, M. Jacquemier3 remarks that "the period when the dilatation of
the neck commences has not as yet been fixed with any precision, and seems
to offer many individual differences. The dilatation and shortening of the

1 Braith. Ketros., July— Dec, 1840, art. 127.

2 Traite theorique et pratique de l'Art des Accouchement, 5th ed., p. 94, note.

3 Manuel des Accouch., vol. i. p. 177.

1858.] Head, Influence of Placenta on Uterus during Pregnancy. 311

neck are two phenomena intimately connected, which are observed simulta-
neously. But, although it has been very generally admitted that the dilata-
tion and the shortening of the neck begin at the fifth or sixth month, it
cannot be regarded as a term fixed by any exact observation." M. Cazeaux
states that the neck preserves its whole length until the last fortnight, and
that in that time only is it absorbed into the cavity of the uterus.1 The ab-
sence, moreover, of all data which would determine the position of the pla-
centa or the presentation of the child in each particular case recorded, renders
the results obtained from them almost valueless.

The greatest diversity of opinion also exists in regard to the period at which
the relative changes in the uterus begin. Mr. E. Murphy places the period
during which the cervix expands, from the 7th until the 9th month.2 Mr.
Burns3 states that the cervix begins to partake in the development of the
uterus at the 5th month, and continues till the 9th. Mr. F. H. Ramsbotham*
places it at the 6th; "when five months are perfected, or about that period."
Mr. J. T. Inglely5 says : "Before the fifth month, the development of the uterus
is confined to its fundus and body j but after the fifth month, the distending
power of the ovum is exerted upon the neck of that organ which it dilates cir-
cularly from above." Dr. John Ramsbothani6 remarks that for six or seven
months the uterus "has been more particularly developed in its fundus and
body • and that about that period the cervix uteri becomes shorter and thin-
ner." Br. Robert Collins7 places it in the last three months. Br. Robert Lee8
states that the shortening of the cervix takes place in the 7th month. Br.
Blundell9 says that, "during the two or three months in the end of pregnancy,
the cervix uteri gradually dilates itself, so as to form a part of the chamber
tenanted by the foetus." Br. Churchill10 remarks "that the increase in size of
the womb commences at the fundus, and as this is developed, the body en-
larges; last of all, and not before the fifth month, the cervix." Br. C. B.
Meigs11 puts it at the 7th month. Moreau13 states "that from the first to the
third month the development is principally effected at the expense of the
fundus ; from the third to the sixth, by the increase in the body ; in the last
three months it continues at the expense of the neck. This order cannot be
broken without a change in the duration of pregnancy."

According to Br. Bavis,13 it is during the last three months. Br. Conquest14
says it begins at the fifth month. Br. Maunsell15 at the 6th or 7th. Jac-
quemier16 places it at the 7th, but expresses no great confidence in these

I Sup. bit.,' p. 101. 2 Mid., Lond. 1852, p. 335.

3 Ed. by James, sect. 38.

4 Obstet. Med., Am. ed., p. 340, order 4th, sect. 1— a.

5 Prac. Treat, on Ut. Hem., p. 140. 6 Pract. Observ., 2d ed., p. 291.
7 Pract. Mid., Am. ed., p. 61. 8 Lect. on Mid., p. 363.

9 Lect., ed. by Castle, p. 444. 10 Theory and Pract. of Mid., § 157.

II Treatise on Obstetrics, p. 433. 12 Transl. by Betton, p. 40.

13 Obstetric Medicine, p. 1038. 11 Outlines of Med., 6th ed., p. 157.

15 Dublin Prac. of Med , p. 167. 16 Sup. cit., vol. i. p. 178.

312 Read, Influence of Placenta on Uterus during Pregnancy. [April

dates. Velpeau1 considers that the change has begun before the fifth month,
but qualifies his statement by remarking that " frequent observation, and
the most careful investigation, have singularly lessened the confidence I for-
merly had in them (referring to various assumed facts in regard to the changes
in the cervix uteri). The changes to which the neck is subjected during ges-
tation, vary almost as much as its anatomical characters in the unimpregnated
state. What I have said on the subject should therefore be understood only
in a general sense." M. Cazeaux3 believes that, "during the first six months
of gestation, the uterus is developed at the expense of the fibres in the supe-
rior part of the body, or fundus of the organ particularly ; while in the last
three months, the fibres appertaining to the lower third of the womb are de-
veloped in a rapid manner, and the cavity of the organ is enlarged in conse-
quence of the distension and growth of this lower part; a proof of which is,
that the body of the uterus, which was pyriform in the earlier months, is per-
fectly ovoidal in shape towards the close of pregnancy." Mr. Edward Rigby3
states that in the fifth month the change is distinctly perceptible. From all
this, we see how little reliance can be placed upon mere opinions, which allow
a latitude of three months for the commencement of a process, which, according
to all analogy, should, under equal circumstances, begin at a uniform period.

Nor are the proofs derived from the supposed rate of increase in the pla-
centa any more satisfactory in their nature. M. Cazeaux4 assumes that the
placenta gains its size almost entirely within the first six months, or during
the period while the fundus is enlarging, and hence derives an argument in
favour of their mutual adaptation. In this, in so far as he assumes that the
fundus is the proper location of the placenta, he is sustained by Jacquemier,5
who also considers that it is there situated in accordance with a vital law ;
" thus it fixes itself there in obedience to a pre-existing organic attraction, for
it is not to be supposed that all parts of its surface are alike fitted for the de-
velopment of the placenta." Velpeau6 states that " the placenta constantly
augments in the same proportion as the surface of the womb with which it
is in immediate contact." Mr. Carpenter7 gives as his opinion, that after the
third month the placenta " goes on increasing in accordance with the growth
of the ovum."

In answer to the proposition of Cazeaux, it may be said that, according to
the information already obtained, it seems to be proved that there is no par-
ticular location for the placenta in the uterus. Its diversity of situation is so
great that it may be assumed, as a general truth, that any portion of the in-
terior of the uterus which is out of the way of the changes which take place
at the end of gestation, when the os dilates, and which also is not liable to com-
pression from the child's head during labour, is proper and fit for the attach-

1 Transl. by Meigs, 4th ed., p. 139. 2 Sup. cit., p. 702.

3 System of Mid., part i. chap. 2. ' 4 Sup. cit., p. 702.

5 Sup. cit., vol. i. p. 273. 6 gup< c\tf p> 209.

7 Prin. of Human Physiol., 5th Am. ed., \ 983.

1858.] Kead, Influence of Placenta on Uterus during Pregnancy. 313

merit of the placenta. As to its seat on the fundus; long held to be the natural
position for its location, observation proves that it is situated there rarest of
all. Indeed, in 600 cases reported by Naegele,1 it was found more often over
the os uteri than the fundus, there being 11 instances of the former and only 7
of the latter. In 100 cases reported by Mr. Doherty,2 he found that it was
situated on the anterior wall in 25; on the posterior wall in 54; to the left
side in 10; to the right in 8; leaving only 3 cases for all the other positions
in which it could be. "Of 34 women," says Velpeau,3 "who died while preg-
nant, or soon after delivery, at the Hopital de Perfectionnement, I found, upon
examining the parts, that the centre of the placenta corresponded to the ori-
fice of the tube in twenty cases; it was in front of it in three cases; behind it
in two; below it in three; and in six cases only towards the fundus.'"

To compare the size of the placenta with that of the uterus, except in a
post-mortem examination, which must be done in order to substantiate the
theory of Yelpeau, is of course impossible, and the difficulties which must
always accompany attempts to measure these organs, are of such a nature and
so great that but little reliance can be placed upon the results ; and, moreover,
the size of the uterus is not always dependent on the size of the child, for
many small foetuses are surrounded by an immense quantity of water, and vice
versa; and why a larger placenta should be the result in one case and a smaller
one in the other, is difficult to perceive, and contrary to analogy.

In regard to Mr. Carpenter's statement, facts prove directly the contrary.
There is not the slightest agreement between the weight of the child and that
of the placenta, which ought to follow if there was a parallel growth. The
following weights, taken from the records of the Boston Lying-in Hospital,
prove this conclusively : —

Weight of child.

Placenta.

Child.

Placenta.

lb. 8£

lb. 1

7 oz.

7

lb. 1

8

1

6

1

4 oz.

8

1

8

6

i

Twins 11

2

7£

l

6

n

1

4

l

8

1

71

i

8

1

4

8

l

12

8*

2

9

2

71

1

7J

1

1

4

8|

1

12

1

8

7f

1

8

7

1

15

8£

2

4

9

1

4

I0i

1

4

•9

1

4

8*
8

r

4

7

1

l

8

9

8

1
1

x4

7

8

12

6£

1

10

l

4

9

1

4

10

l

9

1

4

IH

i

12

1 Braith. Retros., July— Dec. 1840, art. 127.
3 Sup. cit., p. 210.

2 Ibid.

314 Read, Influence of Placenta on Uterus during Pregnancy. [x\pril

But beyond the weakness of the evidence upon which the theory is founded,
it cannot account for all the phenomena which occur in placenta previa".
Based upon the assumption that the development of the uterus is from above
downwards, from the fundus to the cervix, and that the placenta acquires
most of its growth in the first six months, it follows of necessity that the
greater the surface of that organ attached to that portion of the uterus which
takes on its alteration of structure in the last part of pregnancy, the greater
will be the separation and consequent hemorrhage. M. Cazeaux, as before
quoted, assumes that the placenta acquires the most of its growth in the first
six months of pregnancy, or during the period when the fundus is under-
going the same process. "This double phenomenon," says he, "seems to
me quite sufficient to account for the production of hemorrhage; for when
the placenta is attached to the fundus, its growth is simultaneous with the
enlargement of that portion of the uterine walls on which it is implanted, and
there is evidently no loss of blood • but when the after-birth is inserted over
the cervix uteri, or on some adjacent point, the contrary must necessarily
occur, because the growth of the placenta is nearly completed, whilst a more
considerable extension of the lower third of the womb has yet to take place.
Of course, the placenta can no longer participate in this rapid development
by conforming to the increase of the uterus, and by following the widening
of the wall on which it is inserted; and hence it spreads out from the centre
towards its circumference, the fissures between its cotyledons become larger,
and its different lobes are thus widely separated; but the growth of the
inferior wall of the uterus is so rapid in the latter months that this mechanical
widening of the placenta, upon which M. Jacquemier has particularly insisted,
is no longer sufficient to prevent the tension of the utero-placental vessels, or
of the cellular tissue in which they ramify; and this tension being ultimately
carried to an extreme, all of these cellulo-vascular adhesions give way and
become ruptured, and thus give rise to the production of hemorrhage."1

M. Jacquemier proposes, instead of the single process of development,
another cause acting in concert with it, and which he terms mechanical dis-
tension, caused by the fetal mass, particularly when the head presents; and
in noticing the dilemma into which the supporters of the existing theor}*
must necessarily be placed when accounting for the discrepancy of the dates
of the first occurrence of hemorrhage, holds the following language : " If
the separation of the placenta when it is attached to the neck of the uterus
is the result of dilatation, how does it happen, upon the supposition that the
cervix begins to be changed gradually from top to bottom in the sixth month,
that flooding does not occur regularly at this period? If, on the contrary, as
appears to me in reality to be the case, the internal orifice remains entirely
closed until about the middle of the ninth month, why is it that the hemor-
rhage manifests itself often before that period? It is that its dilatation is not

1 Sup. cit. , p. 702.

1858.] Read, Influence of Placenta on Uterus during Pregnancy. 315

the only cause of the separation of the placenta. The rapidity of the develop-
ment of the inferior segment of the body of the uterus, and the mechanical
distension during the last months of pregnancy, which make it descend so
deeply, in a short space of time, into the pelvic cavity, particularly when the
head presents, constitute the ordinary cause of hemorrhage up to a period
very near the end of gestation/'1 The difference, however, between his
opinions and that of other authors is more apparent than real, for as to all
the other points, which are in reality more essential, viz., the place where the
development begins, the relative growth of the placenta with the fundus, and
the direction of the developing process, he holds the same belief with them.

Exceptions to the operation of all general rules are to be expected, and it
would be manifestly unfair to condemn the one already stated, on the single
objection that they occur; but exceptions should be merely exceptions. They
ought neither to be great in number, nor antagonistic in principle to the rule
itself, both of which qualities apply to that under consideration. We refer to
those cases in which, with complete presentation of the placenta, no hemor-
rhage takes place before the end of pregnancy. Of their existence Levret2 was
early aware. His language in relation to them is here quoted at length, both
for the reason that it gives the clearest exposition of the application of the
theory that can be found in any writer, and also from the fact that the theory
is essentially his own ; the principle upon which it is founded having been
first enunciated by him. "A question naturally presents itself here, which
it is interesting to clear up; it consists in knowing why some females who
have the placenta attached to the proper neck of the uterus, go their full pe-
riod, and why the majority of those who are in the like situation do not go
so long. This variety of effect, which proceeds from the same cause, must
necessarily be dependent upon the same particular circumstances which con-
stitute a determining cause. I will explain myself, and say that, according
as the placenta has been originally attached higher or lower in the true neck
of the womb, the hemorrhage will come on sooner or later ; moreover, when
this vascular mass shall have taken root very near the os tineas, the woman
will approach nearer the natural term of her confinement than if it had at-
tached itself at the top of the passage of the uterine neck, and in the same
proportion between their two extremes ; indeed, it is as well demonstrated by
the mechanism of pregnancy as by practical experience in the obstetric art,
that the neck of the womb does not begin to expand to aid in increasing
the size of the cavity of this viscus, until the last months^of pregnancy, and
that it is by small degrees that the portions of the uterine neck continue in
their turn to enlarge from top to bottom, from which it results that the neck
cannot aid in this expansion without causing the placenta, which is not
susceptible of the same extension, to become partially detached, whether
at a point of its circumference, if it is more advanced on one side than the

1 Sup. pit, vol. ii. p. 236.

9 L'Art cles Aceouch., p. 373.

316 Read, Influence of Placenta on Uterus during Pregnancy.

other, or at its centre, if that exactly corresponds to the middle of the top of
the neck of the womb ; it necessarily follows, then, that hemorrhage will en-
sue at a time more or less near, or more or less remote from the natural term
of the pregnancy, just as the placenta happens to be attached nearer or fur-
ther from the true neck of the womb." Now were the reason he adduces,
viz., "that the neck cannot aid in this obliteration without causing the pla-
centa, which is not susceptible of the same extension, to become partially
detached," the true one, exceptions to a general rule of hemorrhage in the
last months of pregnancy, ought to be of the rarest kind. The fact, however,
as he himself admits, is not so. The researches of Mr. Doherty1 upon this
point, show that there are many cases which go the entire term without he-
morrhage. He says : " I have been engaged in examining the records of cases
of this description, and although, in many, the distinction is not sufficiently
drawn between a partial and a full presentation, nor the period of the first
occurrence of hemorrhage defined, to make them available for our present
purpose, I have collected a sufficient number of which the details are accu-
rately given, to prove, that where there is merely a bit of the placenta over^
hanging the os, the woman scarcely ever goes beyond the seventh or eighth
month without an alarming discharge of blood; while, on the other hand,
although with a full implantation, hemorrhage, in the greater number of in-
stances, bursts forth at intervals during the latter months, it is not a very
unusual circumstance to find such patients proceed without any sanguineous
loss till their term is completed."

This he endeavours to explain by supposing that "when the placenta
springs from the cervix, or, as in one patient, although originally commenced
in one of the walls of the uterus, as indicated by the root of the cord, it enlarges
to such a magnitude as to cover completely the neck also, its growth has
been sufficiently concentrated or extensive to keep pace with the circular ex-
pansion then progressing in the inferior chamber of the womb; whereas,
when the substance, being at first elsewhere affixed, does not exceed its usual
proportions, but is merely developed so irregularly as to advance a portion of
its margin over that part, its growth is expended in other directions, and it
becomes unable to adjust itself to the daily increasing size of the region into
which it has, as it were, strayed."3 Mr. Edward Rigby also seems to have
been aware of this difference in favour of complete presentations of the pla-
centa, and in regard to it holds the following language :3 "Our own observa-
tions have rather led to the conclusion, that where the placenta is but partially
attached over the os uteri, the first attack of flooding is rarely delayed until
the full term of pregnancy, but makes its appearance some weeks earlier."
And in the report of a case in which the placenta was centrically placed, and
yet there was no gush of blood until the full term of pregnancy had expired,
asks:4 "Are not those hemorrhages from placenta prsevia which make their

1 Braith. Iletros , vol. xii. art. 175. 2 Ibid.

3 Sup. cit, part 5, chap. 12, Am. ed., p. 413. 4 Braith. Retros., vol. xii. art. 175.

1858.] Read, Influence of Placenta on Uterus during Pregnancy. 317

first appearance in the seventh and eighth months of pregnancy, generally
connected with a partial attachment of the placenta to the os uteri; and on
the other hand, when it is centrically detached, does not the patient usually
go to the full term of gestation before any hemorrhage takes place ?" His
explanation of this is, that " the os uteri being only in part covered with pla-
centa; that its other portion being free, is more capable of dilatation from
slight causes than it would be were the placenta centrically attached." To
the statements thus made by Levret, Mr. Doherty, and Mr. Edward Higby,
I am able to add the results of my own observations, extending over more
than 800 cases of placenta prasvia, in many of which the departure from the
rule is so marked as to attract the most casual observer.

In view of these exceptional cases, the theory of M. Cazeaux is faulty in
that it seems almost impossible to reconcile these cases with the general rule of
hemorrhage, which ought to prevail if his reasoning were correct, without sub-
stituting them for the rule itself. And, indeed, he seems himself to place
but little dependence on it, since in reference to these exceptional cases he
adopts the theory of Moreau, which he states to be as follows: " M. Moreau1
remarks that, in the cases cited, the infants were dead, and without doubt had
been so many days. But, says he, when the foetus dies in utero, there follow
in the circulation of this organ those changes rendered necessary by the ces-
sation of the foetal* circulation ; the blood arrested in the vessels coagulates
there; they become contracted, and oftentimes even obliterated; no more
blood comes to the womb than is necessary for its nutrition, the stimulus
which called there a great quantity no longer existing, and for this reason the
dilatation of the os can proceed without much hemorrhage, although the ves-
sels which unite its borders to the placenta may be ruptured. This appears
to me to be the more rational opinion." But by adopting this he does not
remedy the difficulty, for the children are not always dead, and therefore the
condition of things upon which Moreau has based his explanation does not
always exist, and the reasoning is good for nothing. The same objection ap-
plies to the proposition of M. Jacquemier. If we accept Levret's definition of
the theory as the true one, it is necessary to suppose in those cases in which
the flooding did not appear till just before the end of pregnancy, that the
placenta must have been situated so low down on the cervical portion as not
to have been reached by the changes which have been going on in the por-
tions above; for although the true neck does not begin to be obliterated till
the very last , period of gestation — the last fortnight according to some au-
thors— a portion of the lower part of the body has long ere this been deve-
loped to an extent sufficient to produce a separation. To suppose that all the
cases which have progressed without hemorrhage till the end of pregnancy are
of this description, would be to exceed the probabilities of the case, and, on the
other hand, if we can suppose the placenta to be thus placed, it ought to be so

1 Sup. cit, part 5, chap. 12, near the end.

318 Read, Influence of Placenta on Uterus during Pregnancy. [April

small in superficies that its circumference would not reach to the space where
those changes are going on — a supposition equally improbable.

Mr. Doherty1 assumes that in complete placental presentations the growth
of the placenta has been sufficiently concentrated or extensive to keep pace
with the circular expansion going on in the latter months, while, when only
a portion of it covers the os, its growth is expended in other directions, and
hence is unable to adjust itself to the daily increasing size of the lower part of
the uterus. That is to say, when the cervix is completely covered, the mag-
nitude of the placenta, the concentration and extent of its growth, give it a
property of keeping pace with the enlargement going on in the uterine walls,
which is not possessed by the same organ, although it may be just as large,
when situated elsewhere, and it may be in the immediate vicinity. His
theory of exceptional development is also objectionable, for, if we grant that in
a certain case the placenta has extended a portion of its circumference till, as
the elder Rigby describes it, it is " somewhat like the lines of a very irregular
island on the map, and one edge making almost a detached lobe/'3 the proba-
bilities that all the cases of partial presentation are of a like nature, or even a
majority of them, are very small indeed; and moreover there is still left un-
accounted for a large class of cases in which, while no portion of the placenta
is over the os uteri, it is nevertheless in such immediate neighbourhood as to
be exposed to all the changes to which it would have been subjected had it
been attached to the os itself, and yet no hemorrhage ensues. According to
Von Ritgen, the situation of the rent in the membranes with relation to the
edge of the placenta was —

At the edge in .

22 cases.

At the distance of one inch in

8 "

Between one and two inches .

12 "

Two inches .

7 "

Between two and three

16 "

Three inches . . .

5 "

Between three and four .

4 "

Four inches .

6 5 Ul-

Between four and five

8 "

Five inches .

3 "

Six inches .

6 "

Eight inches . . .

3 "

So that, in the 100 cases, the placenta was within two inches of the os uteri
in 49.

And again, the occurrence of hemorrhage before the fifth month, the period
which authors assign as the earliest at which the changes in the cervix begin,
ought to be of the rarest occurrence, if ever. This difficulty has no doubt in-
duced some to ignore these cases entirely. M. Jacquemier almost discredits
their existence ; his language is, that " hemorrhages3 which cannot be attri-
buted to causes independent of the place of the insertion of the placenta, which

1 Dublin Journ. Med. Sci., July, 1845, and Braithwaite's Ketros., vol. xii. art. 175.

2 Essay on Ut. Hem., p. 40. 3 Sup. cit., vol. i. p. 237.

1858.] Read, Influence of Placenta on Uterus during Pregnancy. 319

declare themselves towards the end of the fourth month, and during the fifth
and sixth, are in reality very rare." But while it may be true that many of
the reported cases of hemorrhage occurring in consequence of placenta prsevia
before the fifth month are of a doubtful nature, there is nevertheless a number
sufficient to establish the fact, which are guaranteed as to their authenticity
by the names of the observers. Prof. Simpson1 reports a case of hemorrhage
in the fifth month, in which, after severe flooding, the child and placenta were
expelled together. Mr. Everitt, of Ellesmere,2 one of three months, accom-
panied with profuse hemorrhage, in which the placenta was extracted. Rigby's
forty-fifth case3 is one of twenty weeks. In this the placenta was distinctly
felt to be attached to the os uteri, and there was flooding with every pain. His
seventy-fifth case is one in which hemorrhage commenced at the third month,
and returned at different intervals till delivery was effected at the middle of
the seventh. If, extending these limits, but still keeping within bounds, we
take those cases in which hemorrhage manifests itself in the fifth or sixth
month, the list, instead of being an exceptional one, will form a respectable
portion of any collection of cases.

Having thus shown that exceptions to a general rule of hemorrhage in the
last months of placenta prgevia not only do occur, but are so numerous and
so entirely at variance with the principle upon which that rule is founded as
to be altogether inexplicable, according to any legitimate interpretation of its
meaning, we come next to the question, what shall be substituted in its stead ?

The principle upon which the existing theory of development in the uterus,
as the consequence of pregnancy, is based, is, that this development proceeds
in a uniform direction, from a fixed point, irrespective of the position of any
of its contents, and at an equally independent rate. But we have shown not
only by the discrepancy which exists in the opinion of authors, but by the
facts themselves, that this assumption has no real foundation ; the data
upon which it was founded being capable of a general application only, with-
out any special bearing upon the point at issue. What seems to be required,
is, a theory which allows the development to commence at any portion of the
uterine walls, and to go on, not according to arbitrary laws, but in connection
with the increasing growth of the ovum, and in obedience to the ordinary phy-
siological laws, which are constantly at work in the living body. Not that it
is intended by this to ignore the vital part of the process — far from it; ac-
cepting as one of the essential elements of the problem, and as its very initial
term, the vital act of impregnation, it is intended to apply to what follows ;
that is to say, to the phenomena which appear in the course of the growth
and maturation of the ovum into the perfect child. As in the explosion of
a train of gunpowder, the application of a spark may be considered a special
act, while all that follows proceeds according to well known chemical laws

1 Collected works, Am. ed., vol. i. p. 606, Case 1.

2 Provincial Med. and Surg. Journ., Sept. 30, 1846, and Braith. Retros., vol. siv.
art. 175. 3 £ssay on Ut. Hem.

320 Read, Influence of Placenta on Uterus during Pregnancy. [April

which govern matter — just so in pregnancy, the act of impregnation is a vital
act, but the development and growth of the ovum are in obedience to the
same physiological laws which are ordinarily in operation in the organization
of living beings.

The substitute which is offered in place of the existing theory, may be stated
in the following terms : —

The attachment of the placenta to any portion of the uterus causes a de-
velopment at that place, ivhich proceeds pari passu, till, the limits of growth in
the placen ta having been reached, the enlargement is continued and kept up by
the pressure constantly exerted on the uterine walls by the growing contents, till
the time of parturition. That is to say, at whatever point the radicles of the
placenta first attach themselves after the issue of the ovum from the Fallopian
tubes, at that point the development of the uterus commences, and from that
point it spreads as from a common centre, and takes shape according to the
position of the contained foetus.

It is believed that the above statement is in entire accordance with the
inferences which may be legitimately drawn from known data, and also in
accordance with physiological laws. It is also believed that the exceptional
cases already alluded to, can be clearly explained, and by a very simple me-
chanism.

That the attachment of the placenta on the uterine walls should produce a
development at that spot, needs no elaborate proof. If we admit that the
same effects follow the same causes in pregnancy as in other processes going
on in the human organization, it would follow that the attachment of the pla-
cental radicles would, in the first place, produce a determination of blood to
that spot in a greater quantity than previously existed there, and following
this, and as a consequence of it, a development. That the supply of blood at
the place where the placenta is attached, is greater than at any other point,
has been established beyond a doubt, and granting this, the rest follows as a
matter of course. But in connection with the development which has been
going on in the region of the placenta, the other portions of the uterine walls have
become more or less distended, to accommodate the constantly growing foetus,
so that if we add together the effect of the two causes, we should expect, in
natural presentations, to find the uterus not very irregular, but approximating
to a globular shape, which, according to M. Jacquemier, it has, up to the time
of the development of the cervix.

The idea that the ovum can exert an influence sufficiently powerful to
gradually distend the uterine walls, is one which has been advocated by some
writers, and denied by others. Mr. Ingleby, quoted before, distinctly recog-
nizes it; so does M. Jacquemier;1 and it was a favourite notion of the ancients.
M. Cazeaux,2 in opposing it, remarks that " the expansive force of the ovum

1 Sup. cit, p. 237.

2 Sup. cit., p. 91.

1858.] Read, Influence of Placenta on Uterus during Pregnancy. 321

is powerless to overcome their resistance. * * * In a word, the growth of
the ovum is the physiological cause, but not the mechanical agent of the
development of the uterine walls." Velpeau1 states that the " dilating force,
altogether foreign to the product of conception, exists in the gestative organ
itself. A circumstance that beyond question proves this to be the case, is that,
in preternatural pregnancies, as remarked by Levret, Bertrand, Meckel, and
Chaussier, and as I have also myself remarked in five instances, the uterine
cavity, though empty, dilates as it does in ordinary gestation. " But in answer
to Velpeaux, and Cazeaux also, if the uterus expands in obedience to a phy-
siological cause, why do we not always find it developed to the size it ordi-
narily attains, at the period noticed, in any particular case when the ovum is
not within its cavity? — and even were this proved to be so, the fact that the
ovum, in growing, has the power to overcome the resistance of the walls of
the tube, in tubal pregnancies, shows that a distending force does exist in it —
and if so, why should it not act in the same way on the walls of the uterus
as on the walls of the tube ? And still further, facts derived from observing
the effects of intra-uterine tumours in enlarging its cavity, also prove that the
resistance of the uterine walls is either not so great as is assumed, or that the
force brought to bear on them during the process of growth in organized bodies
contained within its cavity is sufficient to overcome this resistance, whatever it
maybe; and if by one body, thus constituted, then also by all. We are
therefore justified in the conclusion that the uterine walls will expand under
the constant pressure exerted upon them by the growing ovum.

The exceptional cases to which we have alluded as being inexplicable by
any legitimate application of the present theory, owe their peculiar charac-
teristics to the attachment of the placenta in a greater or less degree upon the
cervix uteri. According to theory, the more complete the placental presenta-
tion, the earlier and more profuse ought to be the hemorrhage. According
to fact, it is in many instances directly the reverse. Now, if we suppose the
development to commence at the place where the placenta attaches itself, at
the lowest part of the cervical portion, for instance, and keep pace with the
growth of this organ, the difficulty disappears at once. For, by the time that
the placenta having passed the period of its most rapid growth, the foetal
mass has already begun to exert its effect upon the uterine walls to enlarge
them, the added strength which the thick, firm disk of the placenta gives to
the cervical portion to resist this distension, is enough to prevent its being
felt in that direction. And moreover, the general shape of the uterus being
finally determined by the position of the child irrespective of the placental
attachment, its form at the end of gestation would be the same, other things
being equal, and would be scarcely modified by this complication. It applies
also to partial presentations of the placenta of every degree, from that in which
the os is almost entirely covered, to that in which the edge only of the pla-

1 Sup. cit., p. 144.

322 Hammond^ Effects produced hy Intermittent Fever on Urine. [April

centa is at its margin. For, just in proportion to the amount of the neck
of the uterus covered by the placenta, is it protected from the distending pro-
cess to which it is exposed during the later periods of pregnancy, and in just
such proportion will the hemorrhage appear late or early, which is in accord-
ance with observed facts.

Those cases also where the placenta is on the cervix, in the immediate
vicinity of the os, but at the same time not overlapping it, which Yon Eitgen
proves to be of frequent occurrence, and which, according to every interpreta-
tion of the existing theory, ought to manifest a hemorrhagic tendency, but
do not, are perfectly accounted for by the same reasoning. For, if it be ob-
jected that the distendiDg process being exerted upon the cervical portions, it
would at the same time act upon the os uteri, to open it; it may be answered
that the same property which enables the os to keep closed during the
changes which take place in the cervical portion in normal gestation, would
preserve it entire in this. In short, it is believed that by adopting the theory
thus set forth, all the phenomena which appear in the course of pregnancy
when placenta praevia exists, and which depend for their cause upon the
changes going on in the uterine walls, at the point of the placental attach-
ment, may be clearly explained and accounted for by a much simpler me-
chanism than by the one already accepted and recognized. And while it does
not militate in principle with acknowledged physiological laws, it so applies
them as to leave fewer exceptional cases, and those cases not different in cha-
racter from what are constantly occurring in normal pregnancies.

Art. II. — On the Alterations induced hy Intermittent Fever in the Physical
and Chemical Qualities of the Urine, and on the Action of the DisvJphate
of Quinine. By William A. Hammond, M. D., Assist. Surg. U. S. A.
(Read before the Biological Society of Philadelphia, February 15, 1858.)

TVe know but little at present concerning the modifications produced by
diseases in the function of regressive metamorphosis of tissue, and yet it is
very obvious that here our observations, if properly directed, can hardly
fail to lead to results of very great importance. The exhalations from
the skin and lungs, the urine, and the feces, are so many points upon which
to concentrate our efforts ; and by carefully studying these several excretions,
a vast amount of knowledge may be obtained relative to the pathological
actions going on within the system. The facility and exactness with which
such inquiries can be prosecuted is only beginning to be perceived, and a rich
harvest is reserved for those who will devote themselves to this field of labor.

The condition of the urine in intermittent fever has been observed by Bee-

1858.] Hannnond; Effects produced by Intermittent Fever on Urine. 323

querel,1 and more recently by Stuart2 and others. Becquerel's investigations
are of the most limited character, being confined to the determination of the
specific gravity and general characteristics of the excretion. Stuart's re-
searches are also very unsatisfactory, and not of such a character as to lead
to any conclusions worthy of reliance — no means of analysis other than the
microscope having been employed.

The action of the disulphate of quinine upon the urine has, within a short
period, been investigated by Ranke,3 who found that the principal effect of its
administration was to diminish the amount of uric acid excreted.

During a recent attack of intermittent fever of the tertian type, I had the
opportunity of studying, in my own person, the effects produced by this dis-
ease on the physical and chemical qualities of the urine, and also of noticing
the results ensuing from the administration of the disulphate of quinine.

There are many obvious advantages to the physiologist, and also to the
science which he represents, in basing his conclusions, whenever practicable,
on investigations instituted upon himself. He is assured of their correctness,
and knows fully the conditions under which they are performed. On the
contrary, when others (such at least as are most likely to come under his ob-
servation) are the subjects of his researches, he can never be certain that his
directions have been complied with, or that he has not been otherwise deceived.

The investigations upon which this paper is based, being confined to one
individual, are necessarily not such as to lead to general conclusions, and are
only submitted as a slight contribution to our common stock of knowledge.
Aside from their correctness, therefore, I have but little to claim for them.

The quantity, specific gravity, and general appearance of the urine were
noted, and the amount of its urea, uric acid, free acid, chlorine, and phosphoric
and sulphuric acids separately ascertained. The methods used in these de-
terminations were the same as those employed in previous researches, and as
elsewhere indicated.

The attack commenced at about 3| o'clock P. M., on the 4th of January.
The cold stage lasted about 35 minutes; the hot until near 10 P. M.; when
profuse perspiration ensued, and I fell asleep and did not awake till morning.

I was eating a hearty dinner when the paroxysm commenced. At 6| P. M.
I ate a little bread and butter and drank a cup of tea. At breakfast the fol-
lowing morning I ate as usual. As far as possible, my food was the same
throughout the investigations, and my general mode of life was not materially
changed.

At the commencement of the cold stage, the bladder was evacuated of its
contents. At about 4 J P. M., it was again emptied. The quantity passed
at this time amounted to 93.4 cubic centimetres, and had a specific gravity of

1 Semeiotique des Urines, p. 286 ; and Traite de Ckimie Patkologique, p. 345.

2 Charleston Medical Journal and Review, May, 1857, p. 323.

3 Medical Times and Gazette, May 30, 1857, p. 537.

824 Hammond, Effects produced by Intermittent Fever on Urine. [April

1016.35. It was of a pale straw colour, and deposited no sediment on stand-
ing. The reaction was feebly acid. Before going to sleep, I passed 283.9
cubic centimetres of urine, having a specific gravity of 1022.19. This was
of high colour, strong acid reaction, and by morning had deposited a heavy
lateritious sediment. On examining this with the microscope, a few crystals
of uric acid were perceived.

In the morning, after rising, 495.3 cubic centimetres of urine were evacu-
ated, the specific gravity of which was 1020.43. It was of high colour and
strong acid reaction. A copious lateritious precipitate was thrown down after
a short time; it consisted of urates and a little free uric acid.

For the whole period of twenty-four hours ending at 3 J P. M. on the 5th,
the urine was as follows: —

Quantity 1221.7 c. cm.

Specific gravity .... 1020.06

Urea

Uric acid

Free acid

Chlorine

Phosphoric acid

Sulphuric acid

During the subsequent twenty-four hours of intermi
the ensuing character : —

Quantity 1650.4 c. cm.

Specific gravity .... 1022.17

Urea

Uric acid

Free acid

Chlorine

Phosphoric acid

Sulphuric acid

From these records it is perceived that during the intermission there was
an approach to the normal condition of the excretion under consideration.
The quantity of urine, its specific gravity, and the amount of urea, chlorine,
and sulphuric acid had increased, whilst at the same time the uric acid, free
acid, and phosphoric acid had very considerably diminished.

The second paroxysm came on at about 4 o'clock P. M. on the 6th, and
was of similar character to the first. At the termination of the chill, 104.5
cubic centimetres of urine were passed, the specific gravity of which was
1017.41. It was of a pale yellow colour, of feeble acid reaction, and remained
clear. During the hot stage I evacuated 325.01 cubic centimetres of urine,
of 1021.32 specific gravity, high colour, and strong acid reaction. After
standing long enough to reduce its temperature sufficiently, a heavy precipi-
tate of urates was thrown down, in which, with the microscope, a few crystals
of uric acid were perceived. The urine passed after rising in the morning

325.18 grains.
28.39
39.40
95.42
69.18
32,11

ssion, the urine was of

480.37 grains

16.84

34.73
114.58

52.95

38.14

1858.] Hammond, Effects produced by Intermittent Fever on Urine. 325

amounted to 518 cubic centimetres, was of 1022.04 specific gravity, and pos-
sessed the characteristics of that last described.

The following table shows the amount and character of the urine for the
whole period of twenty-four hours ending at 3 J P. M. on the 7th: —

Quantity . . . . 1387.2 c. cm.

Specific gravity . . . . 1019.45

Urea

Uric acid

Free acid

Chlorine

Phosphoric acid

Sulphuric acid

At 4 o'clock P. M. on this day, I took ten grains of the disulphate of quinia,
ten grains at 11 P. M., and the same quantity at 10 A. M. the following day.
The paroxysm which would have ensued at about 4 P. M. was thus prevented.

The urine passed during this period of twenty-four hours was of the ordi-
nary normal colour, and of tolerably strong acid reaction. No sediment was
deposited on standing.

The following table exhibits its characters more in detail : —

300.16 grains.
31.54 "
35.72 "

108.11 "
72.95 "
41.76 "

Quantity
Specific gravity

1750.3
1024.61

Urea

. 589.43

grains

Uric aeid . .

. 13.79

<<

Free acid ....

. 27.54

<<

Chlorine ....

. 129.83

(<

Phosphoric acid .

. 55.27

<<

Sulphuric acid . .

. 46.18

<(

The presence of quinia was demonstrated by means of Herapath's test and
viewing the crystals formed, with the microscope and by polarized light.

The effects resulting from the administration of the quinine are thus shown
to have been well marked. The quantity of urine, its specific gravity, and
the amount of urea, chlorine, and sulphuric acid were increased, whilst the
uric acid, free acid, and phosphoric acid were, on the contrary, diminished.

From 3 J P. M. on this day to the same hour on the following day, I col-
lected the urine evacuated, and submitted it to analysis. No quinine was
taken during this period, and no paroxysm of the fever occurred.

Quantity
Specific gravity

1806.3 c. cm.
1024.81

Urea

. . . 638.20

grains

Uric acid ....

. 12.71

li

Free acid ....

. 25.80

te

Chlorine

. 138.27

a

Phosphoric acid .

. 56.22

«

Sulphuric acid

. 40.10

It

No. LXX.— April 1858.

22

326 Hammond, Effects produced 1y Intermittent Fever on Urine. [x\pril

The above table exhibits pretty nearly the average condition of my urine
in its normal state. It is seen that, notwithstanding no quinine was taken,
the excretion maintained its general character of the previous day.

No more paroxysms ensued, and circumstances prevented me making at
that time any further analysis of the urine.

The accompanying table, in which the several results obtained are collected
together, will tend to facilitate reference : —

1st day.
Paroxysm.

2d day.
Intermission.

3d day.
Paroxysm.

4th day.
Administra-
tion of quinine.

Quantity of urine

1221.7 C.cm.

1650.4 c. cm.

1387.2 c. cm.

1750.3 c. cm,

Specific gravity

1020.06

1022.17

1019.45

1024.67

Urea

325.18 grs.

480.37 grs.

300.16 grs.

589.43 grs.

Uric acid

28.39 "

16.84 "

31.54 «

13.79 "

Free acid

39.40 "

34.73 "

35.72 "

27.54 "

Chlorine

95.42 "

114.58 "

108.11 "

129.83 "

Phosphoric acid

69.18 "

52.95 <<

72.95 »

55.27 "

Sulphuric acid

32.11 «

38.14 "

41.76 «

46.18 "

1806.3 c.cm
1024 81
638.20 ers.
12 71 »
25.80 "
138 27 "
56.22 «
40.10 "

From these data it is perceived that, during an attack of intermittent fever,
the uric acid and phosphoric acid are very much increased in amount, and the
urea and chlorine greatly diminished. During the intermission, there is a
close approach to the normal proportions of these constituents, but a subse-
quent paroxysm restores the former condition. The disulphate of quinia,
however, produces a permanent impression on the character of the urine, and,
with the return to the natural relations existing between the several substances
entering into the composition of this excretion, the disease disappears.

There are several facts indicated by the foregoing researches, to which
attention may be directed. Thus the increase in the amount of phosphoric
acid eliminated during a paroxysm points strongly to the nervous origin of
the disease. The excess in the amount of uric acid excreted, whilst at the
same time the quantity of urea was so strikingly diminished, are facts of the
highest importance, and, in connection with the circumstance that during the
intermission, and after the administration of the quinine, the urea was increased
and the uric acid diminished in quantity, show the close relation existing be-
tween these substances, and render more probable the theory that the former
body is a product of the continued metamorphosis of the latter.

From so limited an array of facts as the preceding, no hypothesis in regard
to the pathology of intermittent fever can be considered as tenable. If, how-
ever, the results of these investigations should be confirmed by subsequent
observers, a great step will have been made towards a satisfactory theory of
this disease, and a rational idea of the therapeutical action of the disulphate
of quinine may be formed. The subject is, therefore, left for the present,
with the hope that others will turn their attention to the furnishing of mate-
rial for its elucidation.

1858.]

Casselberry, Use of Iron.

327

Art. Ill— On the Use of Iron. By Isaac Casselberry, M. D.,
Evansville, Ind.

A brief notice of the anatomy and physiology of the blood will make its
morbid changes during fever more evident.

Anatomy. — The blood is a living fluid tissue, which is formed and matured
by the organizing force of the automatic nervous system out of the organizable
constituents of the maternal blood during embryotic life.

After birth, the organizable elements of the blood are derived from the
food, which is decomposed by the gastric juice. These elements are then
transformed and rearranged by the organizing force of the automatic nervous
branches of the stomach, and constitute chyme.

This is conveyed into the duodenum, in which additional organizable ele-
ments are received from the liver and pancreas. The whole mass is then
transmuted and reformed by the organizing force of the automatic nervous
branches of the duodenum into chyle.

This is absorbed by the lacteals, in which it undergoes a continued series
of molecular changes and combinations, until it is deposited in the subclavian
vein.

The blood consists of a vast number of cells, which are the agents the auto-
matic nervous system employs to perform its functions in the human organ-
ism. These differ in form, size, and functional endowments, according to the
varied duties they are designed to fulfil.

For practical purposes, they may be arranged into two classes ; one of
nutrition or reproduction, the other of secretion or removal. When the hu-
man organism is at maturity and in health, these processes should maintain
a relation of exact equivalence.

Physiology. — The cells of nutrition are endowed with an elective force, by
which they select and attract the nutritive elements of the blood, which they
transform and rearrange into molecular combinations. These combinations
undergo a continued series of molecular changes and recombinations, until
they attain maturity, when the elements they have elaborated are appropriated
and form constituent parts of the tissues, with which they possess identity of
elementary composition and arrangement.

The cells of secretion are, likewise, endowed with an elective force, by
which they select and attract the effete or worn-out elements which they
transform and arrange into molecular combinations. These combinations un-
dergo a continued series of mutations, till the elements they possess are com-
pletely elaborated in the capillaries of the depuratory glandular systems, in
which they are coalesced and removed from the blood as secretory products.
The form of force by which they are coalesced is a specific endowment of
each of these glandular systems, by which this important change is produced.

328

Casselberry, Use of Iron.

[April

One depuratory system cannot, therefore, compensate for deficient function
in another only so far as the elements conveyed to it are identical with those
of its own secretion.

The blood gives each tissue the means of repairing itself : first, by furnish-
ing it with material of new growth ) secondly, by removing from it those
elements of its composition which have become worn out and useless. Were
this the whole history of the blood, its investigation in disease would be com-
paratively easy. But it undergoes progressive changes analogous to the
growth of the solid tissues. The new materials it obtains from the food are
not blood at the time of their addition ; they are crude immature products
which subsequently mature.

The automatic nervous system endows the blood with a power to resist
changes, convert crude material into its own elements, and perpetuate its own
elementary composition and molecular arrangement. Physiology teaches that
the abundance of cell development measures the activity and constancy of
growth ; and that this developmental activity in the blood is infinitely
greater than in any other tissue. Cell-germs abound in the fluid of the
thoracic duct. But they attain their maturity and fulfil the purpose of their
creation only when received into the blood.

Not only does the blood grow, but its growth must precede that of every
other tissue in the organism. It grows, then the other tissues grow at its
expense.

Its functions in health will show sufficiently what peculiar difficulties
attend any investigation of its changes in disease. The extreme rapidity with
which all its changes transpire, and the minute quantities in which several
ingredients exist, oppose great obstacles to the research ; but these are greatly
enhanced by the physiological fact that all the elements of the blood corre-
spond to different periods of time, to different degrees of development, and to
different developmental cells.

Viewed as an object of scientific research, human life exhibits itself in a series
of manifestations, the connection and recurrence of which are determined by
the changes which the food and the oxygen absorbed from the atmosphere
undergo in the organism under the controlling influence of the automatic
nervous system ; for the first condition of life is the assimilation of nutritive
material, and the second is that of a continual absorption of oxygen from the
atmosphere. The intensity, the integrity, the quantity, and the quality of
the molecular combinations and rearrangements of the elements of the blood
depend on the mutual action of the oxygen of the atmosphere and the ele-
mentary constituents of the food.

The most convincing experiments have proved that the human organism
is absolutely incapable of producing an elementary constituent, such as
carbon or nitrogen, out of substances which do not contain it ; therefore it
follows that all kinds of food, to produce the tissues and maintain them in a
normal relation with each other, must possess the elements of which the tis-

1858.]

Casselberry, Use of Iron.

329

sues are composed. Fibrin and albumen, the chief ingredients of the blood,
contain seven chemical elements, among which are oxygen, carbon, hydrogen,
nitrogen, phosphorus, and sulphur. The serum retains in solution sea salt
and the salts of potassa and soda, in which the acids are carbonic, phosphoric,
and sulphuric.

The globules of the blood contain fibrin and albumen, with a red colouring
matter in which iron is a constant element. They are formed out of the ele-
ments contained in the serum ; because it is the atmosphere, and supplies the
material for cell development, which is constantly taking place within this
fluid. Hence it is the most important branch of haematology.

The chief constituents of the blood are compounds, in which the relative
proportions are invariable. These compounds are the nascent states of the
tissues, and maintain a relation of mutual dependence on each other. The
blood could not become organized, nor could it promote the growth of tissues
without the existence of albumen in the serum ; because the globules are de-
veloped in this fluid at the expense of its albumen, and they carry the oxygen
which they absorb from the atmosphere into every tissue of the organism,
where it determines the changes which may transpire.

Oxygen is necessary to the growth and maturity of the tissues ; it is neces-
sary for their conservation ; and it is necessary for their conversion into life-
less compounds ; but it can only be introduced by the agency of the globules.
These can only attain a condition favourable to the reception and conveyance
of the oxygen at the expense of the primary elements of the blood, which are
obtained from the elementary constituents of the food.

The absorption of oxygen and the secretion of carbonic acid gas constitute
the visible functions of respiration, and the vast absorbent and secretory
capacity of the lungs depends on the immense expanse of absorbent and
secretory cells brought in proximity to the oxygen of the atmosphere at each
inspiration, and on the quantity and quality of the molecular combinations of
the elements of the blood which are developed during that period.

The food must contain and supply the elements of which the blood is com-
posed; they must undergo normal transformation; they must grow and ma-
ture normally, before the necessary quantity of oxygen can be absorbed to
consume them by combination. For a more enlarged consideration of this
interesting subject the reader is invited to an essay in the American Journal
of the Medical Sciences, for July, 1855, on the Physiology of the Automatic
Nervous System, in which I maintain the unity and mutual convertibility of
all the different forms of external force and of all the different forms of the
automatic nervous force, and to another essay in the same Journal for April,
1856, in which I endeavour to show the causes of fever, and explain the
mode in which they produce diseased transformation of the tissues.

Pathology. — From, these physiological facts, it is evident that fever may
assume a vast multiplicity of forms, which are manifested by characteristic
symptoms. These have often been mistaken for the disease itself; and the

330

Casselberry, Use of Iron,

[April

error has been magnified and perpetuated by giving them names which have
been commemorated by learned authors. Symptoms are like sentinels on
duty ; they guard the organism, evince the existence of disease, indicate the
avenues of its approach, and the degree of resistance offered by the organism,
manifest its progress, portray its pathology, and proclaim its triumph or an-
nounce its extermination. Clothed in the attire of fancy, marshalled by the
mandates of theory, mantled by the nomenclature of authors, they are often
received and entertained in the mansion of affliction instead of the disease.

Fever is a diseased transformation of all the tissues; but the fluid tissues
suffer the most, because the solid tissues are formed in them and of them.
The blood contains not only the nutritive elements, but also the effete consti-
tuents of the transformed solid tissues. Both the nutritive and the effete
elements are formed, matured, and appropriated by cellular combinations.

These are the agents of the automatic nervous force acting on the organiza-
ble constituents of the food, and blood, or upon the organizable elements of
the transformed tissues.

The activity, the quantity, and the quality of the molecular combinations
depend on the intensity and integrity of this force, manifested as nutritive
attraction, molecular affinity, and effete repulsion. The nascent states of this
force in any of these forms are easily transmuted ; and both the developmental
cells and the molecular combinations, to the formation of which it contributes,
as the formative or organizing force, will partake of the abnormal mutation.
Hence the vast number of symptoms which arise during the incipiency and
course of fever. The cells of nutrition neither grow nor mature normally;
nor are their constituents appropriated to the nutrition of the tissues normally.
From the diminished quantity and feeble intensity of the organizing force
of the automatic nervous branches of the digestive and assimilative organs,
the organizable elements of the food are not decomposed, transformed, rear-
ranged, and absorbed in normal quantity and quality ; only a small amount
of nutritive material is received by the lacteals out of which blood may be
formed and developed; and the molecular combinations of the cells, contain-
ing this, are so imperfect, that they cannot undergo mutations with normal
force and celerity.

Imperfectly developed by molecular combination, the nutritive constituents
of the blood often aggregate in some of the capillaries, in which they then
constitute excessive and perverted nutrition, or inflammation. This is of
frequent occurrence during the progress of fever, and merits the anxious and
careful consideration of the physician.

During fever the secretory cells are neither formed, developed, nor matured
normally; nor are the elements which they should normally aggregate and
elaborate depurated from the blood; because the nutritive elements neither
absorb a normal quantity of oxygen from the atmosphere, nor does that
which is received undergo normal molecular combinations on account of their
imperfect molecular development.

1858.]

Casselberry, Use of Iron.

331

The imperfectly combined oxygen, when it is not consumed by molecular
combination with the protein elements of the blood, acts upon those elements
of the solid tissues, exciting the sensation of pain, when it consumes branches
of the sensitive nervous tissue, producing irregular and involuntary muscular
actions, when it consumes those of the excito-motory, and creating the sensa-
tion of thirst, oppression, and suffocation, when it consumes only those of the
automatic nervous system.

During the incipiency of fever, the effete elements of the blood, therefore,
undergo a series of abnormal transformations, and are chiefly retained in the
blood ; a lesion of nutrition and secretion exists, the organizing force of the
automatic nervous system, which, in a normal state, creates, maintains, and
governs the cellular formation and coalescence of the elementary constituents
of the blood is increased, decreased, or perverted; there is a lesion of capillary
circulation; the blood recedes from the external capillaries and accumulates
chiefly in the portal venous system ; a diseased transformation of all the
tissues is present; Fever exists; it is manifested by symptoms; these assume
a great multiplicity of appearances and forms, according to the pathological
condition of the tissues.

There is no longer a perfect equilibrium between the processes of waste
and repair; neither a normal quantity of food is desired, nor could it be as-
similated, were it ingested ; every tissue, therefore, suffers for appropriate
nourishment.

Those more immediately concerned in the processes of nutrition most early
evince the requirements of food, or the necessary elementary constituents for
the repair of their tissues.

As the automatic nervous system creates, governs, and maintains all the
tissues by its organizing force acting on the organizable elements of the food
and blood, it is the first tissue to manifest the want of nourishment by lesion
of the different forms of its force.

Quinine supplies nutritive elements to this tissue, and by this gives its
different forms of force increased intensity. Its physiological effects on the
organism are an increase of the developmental intensity and celerity of the
cells, and a promotion of their molecular combination and coalescence, by
which the transformation of the nutritive cells is increased, and those of
secretion augmented. When a diseased transformation exists, it should, there-
fore, be carefully administered, and its effects sedulously investigated.

In the June No. of the Cincinnati Medical Observer ^ for 1857, I have
given my views of the use of quinine in fever; and in the July' No. of the
American Journal of the Medical Sciences for 1857, 1 have discussed, at some
length, the use of water in fever.

In the latter essay I have maintained that the hydrogen of the water com-
bines with the imperfectly combined oxygen in the blood, forms water, and
is removed from the blood in the form of sweat or perspiration ; while the

332

Casselberry, Use of Iron.

[April

oxygen of the water combines with the carbon of the blood, evolves heat, and
is secreted in the form of carbonic acid gas.

The attention of the reader is invited to each of these essays.

After the employment of appropriate remedial agents, and the removal of
the more manifest symptoms of fever, there often remains an impoverished
condition of the blood, which is a fertile source of local dependent forms of
disease, especially when, during the progress of fever, a chill from time to
time occurs. This condition of the blood is sensitively evinced by lesion of
nutrition, loss of nervous energy, want of appetite, muscular debility, and
more or less perversion of secretion ; and it is caused by deficient develop-
mental intensify of the molecular combinations of the elements of the blood.

The large proportion of albumen generally found in this morbid condition
of the blood, is the result of defective cell-growth ; because there is more
nutritive material in the serum than could have remained there, if the normal
proportion of blood-cells had been developed out of it. The evidence is,
therefore, almost conclusive, that the albumen which exists in the blood does
not grow and mature normally, or it would be consumed by molecular combi-
nation.

The causes of fever, how slight soever they be, retard the developmental
intensity and activity of the blood cells ; and if they be long continued, fre-
quently repeated, or of great disturbing force, they impair the normal mole-
cular changes of the blood, and transmute them, with more or less celerity, into
the different forms of chemical force, when life may soon become extinguished.
If the abnormal mutations be arrested, a period of time must transpire before
the different forms of the organizing force of the automatic nervous system
can attain normal tranquillity and intensity; because the tissue of this system
has suffered for normal nutrition ; and its different forms of force have been
so disturbed and so transmuted, that time is required for them to regain
normal intensity and a controlling influence over the molecular combinations
of the blood.

When this is obtained, all the forms of the organizing force are united in
purpose, harmonious in action, and conspire to promote the conservation and
well-being of the organism. But they require organizable elements to elicit
their action ; and the lesion of nutrition opposes the attainment of this grand
object by not supplying all the constituents necessary to the developmental
intensity of the blood-cells.

Although so minute, these cells always act harmoniously ; they elaborate
the constituents of the blood in a continued series of succession ; each per-
forms a definite and distinct duty; but the blood must contain all the elements,
of which the tissues are composed, or these cells cannot be normally trans-
formed and rearranged; they cannot grow and mature normally, because the
absence of a single organizable element would disturb the unity of purpose and
the concert of action between the different forms of the organizing force, and
thereby impede the molecular growth and development of the whole. This

1858.]

Casselberry, Use of Iron.

333

is precisely what always transpires during the incipiency of fever; and it is
perpetuated throughout its course. The lesion of nutrition may be slight,
but it is sufficient to produce and maintain the continued absence or imma-
ture condition of one or more constituents of the tissues.

The development of the blood must, therefore, be imperfect ; and this im-
perfection will always be commensurate with the degree and duration of the
nutritive lesion.

The dependence of the capillary circulation upon the normal molecular
combinations of the elements of the blood always produces a lesion of this
circulation proportionate to the abnormal mutations, which transpire from im-
perfect development of the globules.

There is, therefore, always present more or less anaemia in fever ; because
the morbid changes of the molecular combinations of the constituents of the
blood prevent its introduction into the capillaries in normal quantity by
nutritive attraction; and although the arterial system may be bounding and
throbbing, these vessels convey an absolutely diminished quantity of blood
to the capillaries.

The mechanical force of the muscular action of the heart and arteries is
derived from the cellular changes of the elements of the blood at the ultimate
termination of their muscular fibres; so that it must be diminished in in-
tensity when these molecular mutations do not take place with normal force
and celerity from deficient development of the globules.

Enfeebled action of the heart and arteries is, therefore, always present in
fever. Their mechanical force is diminished ; they only propel a quantity
of blood to the external capillaries equal to their propulsive intensity ; and
as this is not equal to the whole quantity of the blood, a certain portion must
regurgitate from the heart, at each systole, into the portal venous system.

The morbid accumulation of blood in this venous system produces an
anaemic state of the external capillaries.

These abnormal states of the circulation perpetuate fever, because only a
small quantity of nutritive material can be elaborated and introduced into the
blood on account of the capillary lesions ; and the molecular mutations of the
blood in the depuratory glands are, consequently, so abnormal, that what
already exists is very imperfectly depurated.

Only a limited quantity of oxygen is absorbed; but that which is received
is not normally consumed by combination. Imperfectly consumed by com-
bination, it combines with the solid tissues, producing their death and decom-
position by conversion into lifeless compounds.

Fever, attended by the symptoms which arise from these states of the solid
and fluid tissues, is called typhus or typhoid. It is frequently observed in
the southwestern States in the autumn, when the days are hot and the nights
cool, especially if fever with intermittent symptoms prevailed during the pre-
ceding summer.

Throughout the southwestern States, fever, with chills at irregular periods,

334

Casselberry, Use of Iron.

[April

is often of protracted duration; and, during its course, the spleen is liable to
become hypertrophied, and the blood poor and attenuated. When the spleen
is greatly hypertrophied, and soft and yielding upon pressure, large granular
globules, two or three times the size of the natural colourless corpuscles, may
frequently be observed in great abundance in the blood; and usually the
ordinary colourless corpuscles are in great excess in this condition of the
spleen. Southwestern physicians, who have unfortunately employed bleeding
from a large orifice in the treatment of inflammation of the lungs, when the
spleen is in this pathological condition, can bear witness to the frequency of
these appearances of the blood.

When this pathological state of the blood exists, the hepatic functions are
always more or less disturbed by the morbid accumulation of blood altered in
quality in the hepatic capillaries. This disturbance, when it is of long dura-
tion, is usually manifested by a yellow appearance of the skin, clay-coloured
discharges from the bowels, and scant high-coloured urine, alternated with
green fetid evacuations from the bowels, and large quantities of yellow sedi-
mentary urine.

A serous diarrhoea sometimes supervenes upon these conditions, when the
sufferer is rapidly exhausted by the continuous drain of serum. Cruveilhier,
Becquerel and Rodier, Andral and G-avarret, have conclusively shown that
the attenuation of the blood by bleeding decreases the quantity of the cor-
puscles, while the other constituents undergo little change in their proportion
either to each other or to the entire mass.

The same law prevails in respect to hemorrhage and many exhaustive forms
of disease. The attention of the profession is particularly invited to menor-
rhagia, as it affects women who reside on our southwestern alluvion bottoms.
With them the hemorrhage often alternates with serous diarrhoea, when
general anaemia is soon produced and pervades every tissue of her organism.

The human female has a peculiar law of blood-development. During
about thirty years of her life she forms blood enough for herself and an infant.
If she be pregnant or suckling, this redundant blood formation fulfils its
purposes by nourishing her organism and that of her infant; but if she be
neither pregnant nor suckling, the large blood formation, which is normal to
her for these purposes, becomes excessive in their absence, and tends to effect
its own cure by means of recurrent hemorrhage from the mucous membrane
of the uterus, which attends the discharge of unfertilized ova from the
Graafian vesicles, and constitutes menstruation when it is normal, and monor-
rhagia when it is abnormal from the excessive quantity of blood discharged.
Lesions of this process most usually occur from general causes affecting the
development of the blood; and among these, in the southwestern States, the
most universal are those vicissitudes of the atmosphere which produce fever.
The morbid influences of the climate or locality impoverish the blood and
produce the pathological conditions which arise from the want of cell develop-
ment of the blood-corpuscles.

1858.]

Casselberry, Use of Iron.

335

The anaemia which so often takes place about the period of puberty in
young women in the western States, consists essentially in deficient growth
of blood-cells; and it is of much more frequent occurrence than is generally
apprehended. During the autumn, teething children often suffer of a serous
diarrhoea of protracted duration. This is perpetuated by the want of develop-
mental activity of the globules.

The physiological effects of iron conclusively evince, that it promotes the
development of the blood-cells and accelerates their maturity. This is in
accordance with a general law of the human organism, that the specific stimu-
lants of cell growth in every tissue are elements identical with the natural
contents of the cells, or convertible into them.

The globules of the blood contain increments of iron obtained from the food ;
and from the physiological fact that these are always present in normal blood,
it is self-evident that iron is absolutely necessary to animal life.

From the physiological fact that the globules do not contribute to the nu-
trition of the tissues until they have attained maturity; that they will not
mature normally without certain increments of iron; that when these are
normally present they greatly promote the developmental intensity and activity
of the blood-cells ; that they increase the capacity of these cells for the absorp-
tion of the oxygen of the atmosphere and for the secretion of carbonic acid
gas from the blood, by which the globules assume a bright-red colour ; that
the blood in this manner oxidized is conveyed and introduced into the capil-
laries, in which its elements are transformed, matured, and appropriated to
the nutrition of the tissues, evolves animal heat, and absorbs the effete con-
stituents of the transformed tissues; and that the pathological states which are
produced are those which are dependent on imperfect molecular development
of the globules, and the consequent deficient oxidation and depuration of the
blood; we can appreciate the causes of the perverted condition of the different
forms of the automatic nervous force, the abnormal forms this force assumes
in the molecular combination of the elements of the blood, when all develop-
ment is deficient, and the best means to effect its tranquillity and early restor-
ation.

Iron is the most efiicient agent to promote the normal restoration of these
lesions, because it supplies the element required to promote the growth and
maturity of the protein globules. The effects of few medicinal substances
are more immediate or more remarkable than that which results in disease
from deficient cell development from the exhibition of iron.

Every physician has observed how soon, under the influence of this remedy,
patients recover their natural complexion. A chemical analysis of the blood
explains this sufficiently. F. Simon relates a case in which, after a few weeks
of treatment, the proportion of blood globules rose from 32 to 95 in the thou-
sand; Herberger, one in which it rose from 38 to 98; Andral, one in which
it rose from 46 to 95.

Iron is seldom administered in a metallic state. It is usually oxidized, and

336

Casselberry, Use of Iron.

[April

combined with a vegetable or mineral acid. The compounds formed by com-
bination of iron with the vegetable acids are less powerful and efficient than
those by mineral acids. The citrate and tartrate of iron are mild in their
action, and they may, therefore, often be given before the stronger compounds.
We not unfrequently observe that the stronger compounds of iron, when first
administered, apparently increase all the anaemic symptoms, especially those
referable to the stomach and head. The potassio-tartrate of iron may be given
along with the bitartrate of potassa, when there is oedema of the ankles, or of
the cellular tissue generally. This is a valuable compound of iron in the
anemia of females, when there is local effusion in the cellular tissue.

Several of the compounds of iron are often given in larger doses than is
necessary when the design is to promote the absorption of the iron into the
blood. This observation applies especially to the carbonate, sulphate, and
muriated tincture. The regeneration of the globules, when much diminished
in quantity and altered in quality, must require considerable time.

That the efficacy of a ferruginous compound is not in proportion to the quan-
tity of iron it contains is shown by the fact that many mineral waters are very
powerful, though they contain less than a grain in the pint. This fact clearly
evinces the necessity of the greatest care in the selection of the compound we
are about to employ; because the efficacy of iron often depends on the com-
pound used and its mode of administration. Deficient cell-growth, which
occasions the necessity for the employment of iron, causes a vast multiplicity
of symptoms, which are produced by the functional disturbance of the visceral
glands. The compound of iron should, as nearly as possible, be adapted to
the particular state of the digestive organs, that it may be readily absorbed
and elaborated with the nutritive elements of the blood; for this is the only
mode by which iron can promote the growth and maturity of the blood. Sir
James Murray first recommended the administration of iron in the following
mode : Dissolve one drachm of the bicarbonate of soda in four ounces of water;
then add to this one drachm of the muriated tincture of iron. The draught
should be taken during effervescence. It should be repeated three or four
times a day. Although the quantity of iron is small, yet it is in a state of
subdivision so minute as to favour greatly the absorption of each increment.
The double decomposition which takes place forms, as one of its products,
muriate of soda. This saline is most congenial to the development of the
globules.

During the protracted continuance of fever, diarrhoea, dysentery, or any
other form of disease, during the autumn or winter in the Southwest, the use
of iron according to this suggestion of Sir James Murray, is often attended
with the greatest efficacy, especially when the fever, or other form of disease,
assumes what is usually termed a typhoid form. The iron should be adminis-
tered every three or four hours, alternated with other appropriate remedies.
The minute quantities of iron and muriate of soda thus presented to the
digestive and absorbent glands, which have been so long deranged and weak-

1858.]

Casselberry, Use of Iron.

337

ened, stimulate and promote the growth and maturity of their cells, and
thereby favour the digestion and accelerate the absorption of any nutritive or
medicinal substance. ' This will be clearly evinced by the increased secretion,
which will take place in a day or two from the beginning of the use of the
iron. The biliary, urinary, and cutaneous secretions will be greatly aug-
mented ; the tongue will become more moist, the thirst less urgent, and the
sleep more tranquil.

When inflammation exists, iron should be used cautiously and carefully.
When fever, dysentery, or diarrhoea assumes what is called a typhoid state,
iron is of the greatest efficacy, because it stimulates and promotes the growth
and maturity of the blood-cells. The matured blood-cells absorb and elabo-
rate more oxygen from the atmosphere; an increased transformation of the
elements of the blood ensue; the capillary circulation is accelerated and aug-
mented, and increased secretion from all the depuratory glandular systems
takes place.

When a typhoid state exists in any form of disease, western physicians have
often prescribed for several days without observing scarcely any effect from
the medicine they had directed. Let them employ iron, as here directed,
and, in a day or two, each medicinal article will begin to manifest its cha-
racteristic effects on the organism.

Muriated tincture of iron is a very efficacious compound in the treatment
of menorrhagia. Its use should be continued for a considerable time. It
may often be employed with the greatest advantage in fever with typhoid
symptoms.

Iodide of iron is a preparation which combines in some degree the properties
of iodine with those of iron, though the latter predominate. It seems to pro-
mote the secretions more than any other compound of iron. When it is not
too stimulating it is one of the best tonics in the anaemia of phthisis and scro-
fula ; and from my experience of its effects in these affections in this climate,
it is never too stimulating. It may be advantageously employed in all cases
of anaemia combined with enlargement of the lymphatic glands. It changes
the molecular condition of indurated glands and promotes their absorption.
It may be used advantageously in the chronic form of many diseases, in which
calomel slioidd have been employed during the acute state.

The citrated aromatic wine of iron possesses the most agreeable odor and
taste of any medicinal compound of iron. It is seldom rejected by the most
delicate stomach. I have directed it for children and young persons in various
forms of disease with debility, and I have never found it disliked or rejected,
and its repetition is most generally desired.

When excessive secretion from a relaxed state of the mucous membrane
in chronic bronchitis exists, combined with wine of ipecacuanha, it is of
peculiar efficacy. In all diseases which arise from deficient developmental
activity of the blood-cells, it is a remedy of great value. There are many

338

Mayer, Glycerine in Pseudo- Membranous Croup.

other compounds of iron of peculiar value and great efficacy; but I cannot
extend the limits of this paper by a definite notice of them.

When we contemplate the effects of the climate of the alluvion districts in
the southwestern States in the production of an impoverished condition of
the blood, the frequency with which this state of the blood is met with in
these localities, and its injurious consequences to the organism when allowed
to continue, the value of iron in the promotion of the growth and maturity
of the blood-cells, and the consequent removal of this condition of the bloocf,
ean scarcely be sufficiently appreciated.

Art. IV. — Glycerine as a Local Application in Pseudo- Membranous Croup.
By E. R. Mayer, M. D., of Wilkesbarre, Pa.

I have lately, on several occasions, made use of glycerine as a local appli-
cation in the treatment of membranous croup, with such apparent advantage
as to lead me to think its employment as an aid to the management of this
formidable disease, worthy of recommendation to the notice of the profession.

I was induced to make a trial of this liquid from having frequently
observed the great relief obtained by its being snuffed up or injected into the
nostrils in those frequently encountered forms of ozsenoid disease in which
the excretion hardens and dries, forming solid plugs or tubular casts of the
nasal fossae, analogous in compactness and tenacity, if unlike in composition
and mode of formation, to the false membrane of croup. In such cases, the
injection of warm water often fails to enable the patient to get rid of the
accumulation ; but the contact of a little glycerine is soon followed by the
expulsion of the offending substance in a softened state and by relief of the
irritation caused by its presence.

Glycerine is not only remarkable for its bland, solvent and undrying pro-
perties, and the completeness with which it sheathes surfaces exposed to its
action, but for its wonderful power of adhesion, extension and penetration,
particularly when applied to a mucous surface. These latter properties it has
in so great a degree, that it is only necessary to apply it to a portion of a
continuous secreting surface in order to secure its rapid contact with other
adjacent parts of the same which may not be within reach of its convenient
application. To effect its introduction into the larynx, for instance, it is not
absolutely necessary to use the modes of local laryngeal medication now so
much in vogue, however advantageous these may be ; for its mere apposition,
in any quantity, to the rima glottidis, or to the nearly adjoining surfaces, is
followed by its immediate entrance into the cavity, without provoking, to any
extent, the spasm and violent convulsive cough always caused by the forcible
introduction of a probang sponge into the orifice. An evidence of the facility

1858.] Mayer, Glycerine in Pseudo- Membranous Croup. 339

with which glycerine travels along a moist surface and extends its influence
from the fauces into the larynx, is derived from the fact that if the inferior
article of commerce— which has not been entirely deprived of the irritating
sulphur compounds generated during the process of separating the lead from
it — be forcibly snuffed up the nostrils or even applied to the pharynx or base
of the tongue, a sensation of something " going down the wrong way," and
a violent paroxysm of coughing are generally produced.

In pseudo-membranous croup, the larynx is lined with an excretion scarcely
more consistent or more adherent to the formative surface than that which is
sometimes found upon the pituitary membrane in the cases above referred to.
If the morbid product is capable of being softened down by the contact of
glycerine in the one case, even in a much less degree than in the other, and
if it be possible to keep the laryngeal surface bathed in the liquid for a time,
it seems manifest that a great obstacle to the expulsion of the former by
coughing or vomiting, and with it one of the greatest sources of danger to the
patient may be removed. My experience of the use of this remedy is too
limited to enable me to furnish any considerable number of cases advantage-
ously treated by it, but is still sufficient to lead me to believe that it meets
the above-mentioned requirements, and to suggest further trials of it.

I have several times during the last year applied glycerine with some
apparent benefit to the fauces and larynx in mild cases of membranous croup
and of other laryngeal difficulty • but as the local means were only used as a
palliative after the urgent symptoms had yielded to other active treatment,
I cannot rely upon the results as bearing upon this subject, and will confine
myself to a notice of two cases of very recent occurrence. These were exceed-
ingly severe and well marked cases, occurring within a few days of each other ;
the one, that of a boy, 18 months old; the other that of a girl 4 years old.
The disease was developed in both during the decline of the eruption of
measles, in each showed the characteristic fever, expression and movements,
cough and respiration, the excretion being visible in the fauces in the case of
the older child. Suffocation seemed imminent in both cases, when I saw
them some five or six hours after the parents first became alarmed. The
treatment consisted in prompt emesis by from two to four grains of sulphate
of copper, by which the severity of the symptoms was mitigated, and after-
wards in the rapid introduction of calomel into the system, in the use of from
one to three grains of sulphate of copper dissolved in water every two or
three hours, in the administration as often, but alternating with it, of tartar
emetic in nauseating doses, and of that still more efficient sedative, the vera-
trum viride, in doses of from two to four drops of the fluid extract, for the
purpose of lowering the circulation. Small blisters were also applied over
the upper part of the sternum, and the application of pure glycerine to the
rinia glottidis was commenced and repeated at intervals whenever its use was
called for by a return or increase of the brassy, ringing cough, or crowing
respiration. Its application was in each instance soon followed by a manifest

340 Shelton, Belladonna with Mercurial Ointment in Croup.

softeniag of the tone of breathing and cough, and by considerable reduction
of dyspnoea and general distress. After its use in the first instance, I was
forcibly reminded of the "dry pump sound," which the croupy respiration is
said to resemble, and was led to carry out the simile by the notion that the
lessening of harshness of sound was almost as great after the application to
the throat as it would be after oiling the dry valves and washer of the piston.

The improvement in the character of respiration continued after each em-
ployment of the glycerine usually for a few hours; but, notwithstanding the
short duration of the benefit thus obtained, I found it possible in each case,
by frequently repeating the appliance, to keep the disease in check and lessen
the local irritation, so as to let the patient enjoy a certain average of relief
throughout the illness, or until the system became sufficiently improved by
the constitutional treatment. The results were, in the case of the younger
child, the expectoration of softened false membrane in shreds and patches —
a genuine detritus, mixed with altered mucus and a little dark blood, twenty
hours after the applications were commenced, and in the other case relief in
the same way on the fifth day of the disease, the little patient's constitution
resisting powerfully the action of the depressing means. The croup symptoms
did not entirely disappear in either case until a day or two after the expulsion
of the false membranes, but the patients were soon convalescent. Expectora-
tion was promoted and recovery hastened by the administration of small doses
of quinia and of chlorate of potassa with syrup of senega.

I made use of Price's Candle Company's glycerine, an article much superior
to any that I have seen, and applied it by pressing down and drawing forward
the tongue with the finger, and squeezing out the contents of a long and thick
camel's-hair brush, dipped in the liquid, over the chink of the glottis, or as
near it as possible, concluding the operation by swabbing the whole throat.
I was prepared to employ a sponge attached to a piece of curved whalebone,
but was so well satisfied with my success with the brush, that I did not think
it necessary to use the former. The sponge or charpie, imbued with glycerine,
will doubtless be preferred in many cases, and may be required in some.

If I am not mistaken in my opinion of the advantages resulting from this
mode of treatment, it is evidently applicable to other diseased states of the
respiratory passages.

Art. V. — On the Local Application of Belladonna with Mercurial Ointment
in the Treatment of Croup. By John D. Shelton, M. D., of Jamaica,
Queen's County, New York.

Some three years ago, in a case of inflammatory croup which I was treat-
ing, the idea occurred to me that, in addition to the ordinary treatment which

1858.] Shelton, Belladonna with Mercurial Ointment in Croup. 841

I was pursuing with considerable activity, I might;, perhaps, derive much
benefit from the local application of a combination of belladonna and mercu-
rial ointment; supposing that, besides the powerful influence produced by
the local absorption of the mercury the relaxing effect of the narcotic, no less
than its peculiar influence on the mucous lining of the throat would be pro-
duced, and that the combined impression thus made on the disease would at
least materially aid the internal remedies.

I accordingly put the idea into immediate practical operation, and as I sup-
posed with at least some benefit. The preparation used was the following :
R.— -Ext. belladonna Jijj- Ung. hydrarg. mite 3vi- — M. This was rubbed
freely every two hours on the sound skin over the trachea.

I used this application in the same way afterwards in one or two other
cases, and finding the result justified my anticipation, at least measurably, I
reported the cases at a meeting of the Queen's County Medical Society, held
not long afterward — with the request that if any gentleman should see fit to
employ it, and should derive any benefit from it, he would report his expe-
rience.

My friend, Dr. William Stren, of Oysterbury, having been called not
long afterwards to a case of croup in consultation, recommended the use of
this application ; but, whether from misunderstanding my remarks or as an
improvement of his own I know not, advised the ointment to be applied to
a blistered surface. I subjoin the following report of this case, with which
Dr. S. has kindly favoured me, in his own words : —

" The case to which you refer occurred in the adjoining village of Cold
Spring, under the care of Dr. Fernan, in a healthy looking boy of four years,
who was suffering with the usual symptoms of cynanche trachealis.

" He had been treated with the usual remedies in such cases, including
calomel and ipecac, for some three or four days, when his symptoms became
so aggravated that I was called in consultation in regard to the operation of
tracheotomy.

" When I saw him, which was about 8 A. M., his breathing was very la-
borious, with sonorous inspiration, and from the anxious expression of his
countenance you would have supposed suffocation inevitable. He had been
freely vomited through the night and also that morning, and had just had
applied to the throat a blister of cantharides. There was a disposition on the
part of the friends to defer the operation as long as possible, if there was the
least possible chance in any other means.

" I recollected your remarks in regard to the effect to be expected from the
use of the ext. belladonna and mercurial ointment in such cases. I therefore
advised Ext. belladonna ^i; Ung. hydrarg. 3"j- — M., to be immediately ap-
plied to the blistered surface, and promised to see him again at 4 P. M.
Judge of my delight on my return to find every symptom of suffocation re-
lieved; his breathing easy; his surface soft and relaxed, and from his dispo-
sition to doze, and the dilatation of the pupils, his whole system evidently
under the specific effect of the belladonna. I therefore ordered the dressing
removed, and simple sperm ointment applied; with directions to resume the
belladonna ointment, if there should be any return of symptoms of suffo-
No. LXX.~ April 1858. 23

342 Shelton, Belladonna with Mercurial Ointment in Croup. [April

cation. I saw him again the following morning, and found he had rested
well through the most of the night. He now took a mixture of syrup of
ipecac and squill to relieve the dryness of his throat. I discontinued my
visits from this time, and the child convalesced rapidly."

In the early part of last winter (1856), I was called to an old lady whom
I had attended on two previous occasions in severe attacks of acute laryngitis,
and whom I then found suffering with a fresh attack of the same terrible dis-
ease. The symptoms were entire and persistent loss of voice — except in a
whisper — a hoarse, barking, croupy cough; fever, dyspnoea, and suffocation,
stridulous inspiration, and inflammation of the tonsils and epiglottis. On
both the previous occasions I had applied a strong solution nitr. silver to the
fauces and epiglottis, and blisters to the throat, besides the active and con-
tinued use of calomel, ipecac, and opium, with decoction of seneka and other
expectorants internally. But on both these occasions the disease had proved
obstinately stubborn, and the patient had barely escaped with life, having on
one occasion been unable to speak above a whisper for upwards of three
months. I attributed the recovery in these cases to the constitutional effect
of mercury, pushed to ptyalism. On this occasion, I think in the month of
January, 1856, as I took no notes of the case at the time, having now em-
ployed the local application of the belladonna and mercury in several cases
with good effects, and fortified by Dr. Stren's astonishing case, I determined
to commence my treatment with this application to a vesicated surface. The
symptoms were precisely similar to those on the two previous occasions, with
loss of voice, hoarse, barking cough, and suppurative dyspnoea. I applied a
blister of cantharides forthwith, and ordered it dressed with the following :
E. — Ext. belladonna 3j; UDg- hydrarg. mite ^\]) Lard ^j. — M. This ap-
plication was made in the forenoon. Early in the evening of the same day I
was hastily summoned ; when I found my patient delirious, walking around
the room, or rather staggering, catching at spectres, and with pupils largely
dilated. She was fully under the influence of the narcotic, although, I must
confess, it was not my intention to have produced this effect; at least, not to
T$uch an extent. Her friends were alarmed. I had her feet put in mustard
water; gave her a weak solution of antimony, and bathed the forehead and
temples with cold water. I should have added that her voice had returned,
although hoarse from the peculiar effect of the drug on the mucous lining of
the fauces and larynx.

The narcotic symptoms passed off during the night, and at my visit on
the following morning, her voice was natural, and her breathing easy and
natural. Recovery was prompt and uninterrupted.

On Sunday, Nov. 29, 1857, I was again called to a child of two years
with croupy symptoms. In the same family, an older child was also affected
with influenza and cough, and the old grandmother showed commencing
symptoms of a fresh attack. The children gave way readily to a solution
of antimony with Dover's powder at night and mustard foot-baths — but the
old lady proved stubborn. She again had hoarse cough, with difficulty of
respiration and of swallowing, and loss of voice. I examined her throat and
found the tonsils and fauces inflamed and swollen. I gave her calomel and
opium, an antimonial solution with strong decoction of seneka root. I also
ordered the following: R. — Ext. belladonna 5ij ; Ung. stramonium, Ung.
hydrarg. mite, aa 3ss. — M. to be thoroughly rubbed over the larynx and
trachea every two hours; having first held to the throat, for a few moments,

1858.] Shelton, Belladonna with Mercurial Ointment in Croup. 343

a sponge soaked with hot water. No benefit was, however, perceptible, and
the symptoms were rather increasing in severity, when I applied a blister over
the trachea (Wed., Dec. 2), and had it dressed with the following: R. — Ext.
belladonna 3ss; Ung. hyd. mite 3j; Lard 3vi. — M. At my evening visit of
the same day, I was delighted to find she had again recovered her voice and
was evidently much relieved in all respects, although no other narcotic effects
were perceptible from the belladonna than a feeling of confusion and giddi-
ness, with some blindness, but no delirium or other alarming symptoms.
I am most happy to add that the progress of this case to entire recovery
has been, as on the former occasion, almost immediate and uninterrupted, as
she continues at this date (Dec. 8) entirely well, having merely taken inter-
nally a decoction of seneka root and slippery elm bark.

I now feel it my duty to submit this treatment with these illustrative cases —
few in number, it is true, but certainly strongly marked and highly gratifying—
to the judgment of the profession, to be confirmed or condemned by a further
and more ample experience.

The district of country in which it has been my lot to practise physic is
a marshy and malarious one, about nine miles distant, north, from the sea.
Surrounded by a belt of swampy and undrained low grounds, the constant
exhalations from these, mingled with the sea air, produce a dampness in our
atmosphere peculiarly favourable to the production, no less of intermittents
than of throat affections. These latter are peculiarly rife. Although croup,
as compared with other prevalent diseases here, is somewhat rare, yet, as com-
pared with its occurrence in other places, it is, perhaps, somewhat frequent. In
my treatment of this disease, although my main reliance has been on antimony
and calomel combined with Dover's powder; and although a very large propor-
tion of cases have yielded readily to these far-reaching and powerful means, yet
I have had the distress and misfortune to be compelled to witness the death, by
lingering strangulation, of a very considerable number of lovely children, dur-
ing the last eighteen years, from this fearful disease, in which I had actively and
faithfully, though vainly employed, I believe, every variety of treatment — save
only tracheotomy — known to the profession. I have employed the turpeth
mineral successfully in some cases, but with no benefit in others. I have
succeeded in saving some cases by the topical application of nitrate of silver,
but have had a number die in my hands where this remedy had been used
freely. Of late, I had begun to turn my attention to tracheotomy as a last
desperate resort, where death might seem inevitable without it. Whether the
treatment which I now propose may be likely to prove a new and important
addition to the list of remedies in this awful disease, and especially as a sub-
stitute for tracheotomy, I fear to speak with confidence; yet I cannot but in-
dulge the hope that it may.

Why might not belladonna, from its peculiar effect on the throat, be ad-
vantageously administered internally in this disease, in conjunction with calo-
mel and ipecac, and the other ordinary remedies?

I have never, as yet; employed it in this way myself; but I am strongly

344 Woodward, Cases treated at the University of Pennsylvania. [April

inclined to believe in bad cases it would materially increase the efficacy of the
ordinary treatment. I have seen not the slightest allusion to its employ-
ment in this disease in any article or treatise I have as yet met with.

A valuable article on the employment of this narcotic in pertussis, was pub-
lished by Dr. Hiram Corson, of Montgomery County, Pa., in the No. for Oct.
1852, of this Journal. In that article he ascribes the credit of that peculiar
treatment in pertussis to Dr. Jackson, of Northumberland, and I can bear
my testimony to its value in that disease. But no allusion whatever is made
to its employment in croup. That it might control the paroxysms of laryn-
gismus, might be readily conceived; but I think no person of ordinary acu-
men would confound the distinction between that disease and cases of a
truly inflammatory affection, so well marked as those reported in this article.
December 9, 1857.

Art. VI. — Report of Cases treated at the Surgical Clinic of the University
of Pennsylvania. By J. J. Woodward, M. D., of Philadelphia, Assistant
to the Surgical Clinic.

Case I. — Reduction of an Anterior Luxation of the Humerus of nearly
four iveeks' duration by manipulation, with the aid of Anaesthetics. — The in-
terest excited in the minds of surgeons by the success which has attended
Reid's plan of reducing luxations of the head of the femur, renders import-
ant every attempt to carry out similar principles in the treatment of other
luxations, because such attempts are indicative of the progress of scientific
surgery, and the substitution of anatomical and physiological knowledge for
the purely mechanical force which has hitherto characterized the treatment
of these injuries.

The case which illustrates these points was presented to the medical class
at the Surgical Clinic of the University of Pennsylvania, Jan. 6, 1858.

The patient, J. D., was a blacksmith by trade, aet. 35, of powerful frame
and great muscular development, and the luxation, which was of more than
three weeks' standing, affected the right shoulder, the head of the humerus
resting beneath the clavicle and under the pectoral muscle.

Professor Henry H. Smith, in presenting the case to the class, stated that
he had for some time thought that the treatment of luxations by manipula-
tion alone, as recently described by Dr. Reid, of Rochester, in connection
with the femur, might with great propriety be extended to other articulations,
and he wished to test its applicability to the humerus in the present patient.
He should especially hope for the success of proper manipulations in luxa-
tions of the shoulder, because the shallow glenoid cavity presented certainly

1858.] Woodward, Cases treated at the University of Pennsylvania. 845

less mechanical difficulty than the brim of the acetabulum, and judicious ro-
tation would probably be sufficient to bring the head of the bone into its
proper articular position.

The following plan for effecting the reduction of anterior displacements
was therefore suggested. The patient being first fully etherized, the arm of
the injured side was to be carried off from the body as nearly to a right angle
as possible, and the forearm flexed at a right angle with the arm. Then
using the forearm as a lever, the head of the humerus was to be rotated down-
wards and backwards, by causing the palm of the hand to describe an arc
backwards and downwards, when, as was presumed, the head of the bone
would without difficulty slip into the axilla. The rotation of the humerus
being now carried a little further by continuing the motion of the forearm the
head of the bone could, it was thought, be brought upon the inferior edge of
the glenoid cavity, when a gentle reversion of the manipulation would cause
it to slip into its place by bringing it to the anterior edge of the glenoid
cavity at the point where the capsular ligament had been torn.

The patient being now etherized, Dr. D. H. Agnew, at the request of Dr.
Smith, proceeded to practise the manipulation as suggested; when the head
of the bone was readily thrown first into the axilla and afterwards into the
glenoid cavity. During the manipulation the inferior angle of the scapula
was steadied by the hand of an assistant.

The success of this mode of treatment is note worthy, not only on account
of the great muscular development of the patient, but also because of the
length of time which had elapsed since the occurrence of the injury, and the
case is certainly well calculated to recommend the manipulations suggested
by Prof. Smith to the favourable consideration of surgeons. Close attention
should be given during the manipulation to the proper rotation of the head
of the bone; its object being chiefly to modify the action of the supra and
infra-spinatus muscles which are much stretched in all anterior and axillary
luxations.

Case II. — Chronic Hydrocele of large size cured in two weeks by Excision
of the Tunica Vaginalis Testis. — B. C, A carpenter by trade, about forty
years of age, was presented at the Surgical Clinic, Wednesday, September
30, 1857, labouring under a hydrocele of great size, which had been pre-
viously tapped several times, and once injected with iodine in hopes of ob-
taining a radical cure. The effusion, however, had returned in spite of treat-
ment, and the tumour had now regained its original bulk containing over
twenty ounces of serum.

The patient being fully etherized, the operation consisted in slitting up the
tumour with a sharp-pointed bistoury to the extent of three inches and a half,
thus permitting its liquid contents to escape ; after which the tunica vaginalis
was rapidly dissected free from its attachments to the scrotum and excised
with scissors, except that portion of it which was immediately connected with

346 "Woodward, Cases treated at the University of Pennsylvania. [April

the testicle. The wound was then closed by sutures and adhesive plaster,
except at its lower angle, into which a mesh of lint was inserted. It rapidly
healed by the first intention, except this lower portion, which granulated, and
was not entirely healed until about two weeks after the operation. No
orchitis followed, and the patient was only confined to bed about four days.

Examination showed the excised portion of the tunica vaginalis to be
thickened to the extent of fth to Jth of an inch ; the thickness being due to
abundant new formation of white fibrous and yellow elastic tissue in various
stages of development.

It will be perceived that this operation closely resembles that of Boyer
(see Malgaigne's Operative Surgery, Philad. edit., p. 451), from which,
however, it differs in certain points. Boyer completely dissected out the
tunica vaginalis before it was incised, while it was still distended with fluid,
and afterwards incising the tumour to permit the fluid to escape, he excised
with scissors the part of the tunica vaginalis not connected with the testicle
and cord. This method, while giving, perhaps, some facility to the separation
of the scrotum from the tunica vaginalis, is objectionable, because it com-
pletely separates from the scrotum that part of the tunica vaginalis left in
connection with the testicle and cord, which was not done in the operation
practised in this case. Boyer' s operation, therefore, would be more liable to
be followed by orchitis, purulent infiltration of the scrotum, or sloughing,
than that here reported.

Case III. — Hydrocele cured by Excision of the Tunica Vaginalis. — C. R.,
a German labourer, about fifty years of age, was operated upon Saturday, Nov.
28, 1857, at the Surgical Clinic. The tumour in this case was of great size,
and had once been operated upon palliatively, but had since returned. The
plan pursued was the same as that employed in the last case, and was equally
successful, the patient not beiDg confined to bed more than four or five days,
and the wound being entirely healed in about two weeks from the date of the
operation. ,

It is not claimed that the plan of treating hydrocele here detailed is new
in principle, excision of a small part of the tunica vaginalis having been fre-
quently practised, and Boyer's operation, of which this is but a modification,
being well known to surgeons. The object in publishing these cases is, there-
fore, simply to call attention to the great Radical advantages of excision in
the treatment of hydrocele as it is believed to be at once more certain, safer
and more speedy than the iodine injections so commonly employed. The
patients being etherized, suffered but little from the operation.

Case IV. — Epithelioma of the Lip of seven years1 standing cured by the
application of Powdered Sulphate of Zinc. — Mrs. S., set. about 55 years,
was presented at the Surgical Clinic, Saturday, Dec. 5, 1857. She had a
well-marked epithelioma on the upper lip of a triangular form, extending from
the angle of the mouth to the ala of the nose, thus occupying the greater

1858.]

Porter, Surgical Notes of the Mexican War.

347

part of this side of the lip. The growth was nodulated and irregular, and
its surface ulcerated. The free margin of the lip was indurated, and the
case being of seven years' standing, certainly appeared an unfavourable one.

In accordance with a suggestion made some time since by Prof. Simpson,
Edinburgh, the ulcerated surface was dusted freely with the dry sulphate of
zinc reduced to a fine powder. Over this a piece of lint was placed, which
was secured in position by being saturated with collodion. This dressing was
retained for about a week, when it was loosened by the discharge of the ulcer
and came away. It was reapplied as before, and so on during nearly two
months, at the end of which time the growth had entirely disappeared and
the ulcer was healed, presenting a normal cicatrix. There was no serious
puckering or deformity of the lip, and the cure was apparently quite complete.
Little or no pain was produced at any time by the application.

Art. VII. — Medical and Surgical Notes of Campaigns in tlie War with
Mexico, during the years 1845, 1846, 1847, and 1848. By John B.
Porter, M. D., Surgeon U. S. Army.

(Concluded from Journal of October, 1853.)

A brief review of the diseases of our army at the close of the war in
1848, will conclude our remarks.

On the return of our army to the United States, in the year above men-
tioned, an encampment of regular regiments was formed at East Pascagoula,
Mississippi. This summer resort is situated on Pascagoula Bay, near the
mouth of Pascagoula River, about sixty miles from Mobile, and one hundred
and twenty from New Orleans. The village stands on a somewhat elevated
ground or bluff, which gradually slopes about two miles to Green Wood
Island, which is low and flat, so that high winds during storms sometimes
drive the waves over it, as in 1821 and 1853, in which years it was sub-
merged. On this island the General Hospital for the encampment was
established.

In the first part of July, the regiments began to arrive at Pascagoula,
direct from Mexico ; and, by the end of the month, the encampment, consist-
ing of five regiments of infantry, was fully formed, extending from the out-
skirts of the village to within one-quarter of a mile of Green Wood Island.
Seven companies of dragoons were encamped on the other side of the village,
two or three miles south of the hotel. Brevet Major-General Twiggs com-
manded the whole.

The troops arrived at Pascagoula in bad condition. The men were suffering
from chronic diarrhoea, chronic dysentery, and a scorbutic diathesis.

3-18

Porter, Surgical Notes of the Mexican War.

[April

Chronic diarrhoea and chronic dysentery were much the most common
diseases in the encampment. The following extract is taken from my reports
to the Surgeon-General: —

"From the arrival of the regiments, patients rapidly multiplied, and the
cases were of the worst description, being mostly chronic bowel affections.
For a large number of these cases medical treatment was useless, further than
to render the situation of the patient as comfortable as possible.

"Many of the men who were admitted into hospital, with chronic diarrhoea
and dysentery, date the commencement of their complaint three, four, six, ten,
and even thirteen months anterior to their arrival at this point ; numbers of
these men were emaciated to the last degree, being literally 'skin and bones/
and in some of the patients it seemed as if the loose integuments could be
easily made to form a second covering for the attenuated limbs. It must be
evident that a great amount of labour was required of the hospital attendants,
to render the patients comfortable and keep the hospital in decent police — the
clothing and bedding of the sick having to be frequently changed. One patient
required three complete changes in twenty-four hours — to the very bedstead —
for several days, and even then it was scarcely possible to keep him in a decent
condition. These chronic diseases originated at all points on General Scott's
line of operations.

" The treatment of confirmed diarrhoea and dysentery of long standing is
very unsatisfactory in its results. The changes have been rung on all the
remedies recommended for such diseases.

" Several autopsies were made during the season. In most, ulceration of the
large intestines was found, to a greater or less extent ; but, in some cases of long
standing, when the patient would seem to be almost or quite cured of the bowel
affection, emaciation would increase, and the patient sink from sheer exhaus-
tion apparently ; in these cases ulceration might not be found, but there was
almost always a morbid condition of the mesenteric glands; want of nutrition
seemed to be the cause of death, the patient at. last dying of inanition, the
system subsisting on itself until extreme emaciation and death were the
result."1

Yellow fever prevailed to some extent, and was malignant. To the con-
tagionist it may occur that the disease was imported from Yera Cruz, New
Orleans, or Mobile ; but this is not the fact. The first case, private John
Martin, Third Infantry, was admitted into hospital, September 3, from the
head-quarters of General Twiggs, which were between one-fourth and one-half
mile from the Pascagoula Hotel. Martin was General Twiggs's orderly. The
regiments marched directly through Yera Cruz, without stopping in that
town, and went on board ship to the port of destination. None of the
regiments went to New Orleans or Mobile, but the transport ships sailed
from Yera Cruz to Pascagoula direct. The Third Infantry arrived and
placed the sick in hospital on the 21st of July; Martin was taken sick on
the 1st of September, and was attended until the 3d by a regimental surgeon-
was in the second stage of the disease when he came to hospital. Recovered.

From the 21st of July to the 1st of September, there are forty-two days;

1 In some cases, the liver was enlarged, of a yellowish or clay colour, dry, friable,
anscmic, the gall-bladder nearly empty. Mucous membrane of the stomach eroded,
softened, and easily scraped from the subjacent coat : same membrane of the lower
portions of the small intestines injected. Kidney congested ; spleen enlarged and
congested.

1858.]

Porter, Surgical Notes of the Mexican War.

349

add eight days for an average passage from Vera Cruz, which is a good run
for a sailing vessel, and we have fifty days from Vera Cruz to the first case in
the camp at Pascagoula. The troops came from Vera Cruz in a perfect state
of health, so far as fever was concerned. The transport ships were clean and
in good condition • they could not get nearer to Pascagoula than three or four
miles, by reason of the shoal water; and the troops, baggage, stores, &c,
were transferred to light draught steamers. The fever was of local or domestic
origin, and there is no probability of its having been imported from any place
whatever.

The second case of yellow fever was admitted into hospital from the Fourth
Infantry, on the 10th of September, and on the 11th two cases were admitted
from the Second Infantry. From this time, scattering cases of this fever
occurred in all parts of camp, and the last one was taken sick on the 19th of
November.

Fever was somewhat prevalent during this season on the coast of the Gulf
of Mexico. There was yellow fever in New Orleans and Mobile, and in the
country around Pascagoula there were several remittent and congestive fevers.
In several instances, these fevers assumed the yellow fever type.

The whole number of yellow fever cases admitted into hospital among
soldiers, discharged men and teamsters, was 32. Add 5 cases among hospital
matrons, and we have 37 cases in all. It can scarcely be contended that a
disease is contagious when only thirty-seven cases occurred in more than two
and a. half months. From the first of September, the contagion should have
gradually and surely spread, so that in two months, or by the first of Novem-
ber, a large proportion of the troops and camp followers should have contracted
the disease, and no one connected with the hospital should have escaped. It
is the duty of hospital matrons in the army to do the hospital washing ; 5 of
them had yellow fever, 9 of them had no fever of any type. It is incredible,
that a contagious fever should appear in a camp filled with hundreds of persons
of all classes ; and that only thirty-seven cases of this malignant and con-
tagious fever should occur. W e would say, unhesitatingly, that such a disease
is not contagious.

A negro man died of yellow fever in October, on the main land, more than
two miles from the hospital, and at least four miles from Pascagoula. This
man often came to Green Wood Island, to supply the hospital with necessaries,
and hence it might be inferred that he contracted a contagious fever from the
patients ; but if this were the fact, the case is not altered. How could the
man's wife, children, and many other persons, both white and coloured, who
were in the house during his illness, escape the disease ?

The last case of yellow fever occurred on the 19th of November, as before
stated, in the person of private John Kauffold, Third Infantry. Orders came
from General Taylor to break up the hospital and transfer the sick to New
Orleans Barracks, and on the 23d — Kauffold being in a critical situation —
they were put on board a steamer. He was very sick — had hemorrhage and

350

Porter, Surgical Notes of the Mexican War.

[April

every symptom of the fever except black vomit, and was placed in the hospital
of New Orleans Barracks on the 26th, with other sick and invalids. Hemor-
rhage continued, and there was no visible improvement in the patient's con-
dition until two or three days after his arrival. He recovered. Not a single
case of yellow fever occurred afterwards on the steamer, nor was there a case at
New Orleans Barracks, in consequence of shipping this man and putting him
in hospital with others.

We came to the following conclusions : —

1. None of the transports were infected, nor was there a case of yellow
fever heard of afterwards in any of them.

2. The yellow fever was not imported from Vera Cruz, nor was it brought
from any other place.

3. The fever was of local or domestic origin.

4. The fever was not contagious.

We have been particular in giving the origin and history of this fever, for
it is commonly asserted that yellow fever never originates at the villages and
watering places "over the lake;" but that the disease has been, in all cases,
carried from New Orleans; and that, hence, it is contagious.

We (Assistant Surgeons Perm and Stone and myself) made several autop-
sies. Heart apparently healthy, containing coagulated blood. Lungs in general
healthy : in one case there were recent adhesions of the right lung to the
costal pleura, and hepatization. In every case we found an inflammatory
condition of the mucous membrane of the stomach — the inflammation being
in some cases pretty general and sometimes more intense at some points than
at others, softening, abrasions, &c. In some cases the membrane was so much
softened as to be easily rubbed off or separated. In almost every instance
the matter of black vomit was found, whether the patient had thrown it up
or not. The liver was anaemic, often dry and friable, and presented, on being
cut into, more the appearance of ginger-bread than anything it can be com-
pared with. Gall-bladder often nearly empty, sometimes partly filled with
dark bile. Spleen generally enlarged, congested, and sometimes softened.
Kidneys congested. The brain and spinal column were not examined, on
account of our numerous engagements and hard duty.

Consolidated Report of JSick, Mortality, &c.

Whole number of cases 757

deaths ....... .137

Mortality per cent. . . 18.10

No. of fever cases ........ 98

" deaths . . . . 22

Mortality per cent 22.44

No. of fever cases, exclusive of yellow fever . . .66
" deaths . . . . . . . . . . 8

Mortality per cent 12.12

No. cases of yellow fever 32

" of deaths .14

Mortality per cent. . 43.75

1858.]

Porter, Surgical Notes of the Mexican War.

351

No. cases of diarrhoea and dysentery .... 449

" of deaths 100

Mortality per cent 22.27

Add to the yellow fever table 5 hospital matrons, who had the disease, and
one death, and we have 37 cases and 15 deaths — a mortality of 40.54 per
cent. To be strictly correct, however, there were 6 cases of yellow fever and
1 death among the matrons, making 38 cases in all, 15 deaths, and a mortality
per cent, of 39.47 The matron who died had two distinct attacks of the fever,
with a considerable interval between them. This case was sufficiently alluded
to in a former paper.

The mortality from all diseases was aggravated by the scorbutic diathesis,
so prevalent among the troops. A person with this diathesis, and suffering
at the same time from chronic disease of the bowels, could stand but a poor
chance when attacked by yellow fever.

It appears, then, that the yellow fever was not imported into the camp at
Pascagoula from abroad; that the fever did not spread in the camp generally,
nor among the inhabitants of the vicinity; and that a case of malignant fever
(introduced from Pascagoula) did not affect the troops at New Orleans Bar-
racks, although the garrison consisted of two companies of unacclimated men,
who had never been exposed to the disease. I had charge of the General
Hospital, organized it, and remained with it until the sick were removed to
New Orleans Barracks; and it is my opinion, that the fever at Pascagoula
was of local or domestic origin.

Yellow fever occurred at New Orleans Barracks in the years 1847 and
1848, among invalids and others; and as it was contended by some that the
disease was imported to New Orleans by the troops from Mexico, and spread
by contagion, we will briefly examine into the circumstances attending the
origin and progress of this fever at the barracks. The facts which will be
presented, were obtained and committed to paper during the winter of 1848-9,
from the hospital records and Surgeon W. S. Sloan, U. S. A., who gave much
valuable information. The General Hospital at New Orleans Barracks was
in charge of Surgeons R. C. Wood and W. S. Sloan, U. S. A., in 1847 and
1848.

1847. Third quarter. — No. of cases . . . . .25

" deaths

Fourth quarter. — No. of cases . . . .13
deaths 8

Many of these cases supervened on other diseases, tlje patients having
been admitted into hospital a considerable time previous to the attack of
yellow fever. The first patient with yellow fever was a recruit belonging to
the post; admitted August 26; recovered. He had never been to Mexico.
The next case was admitted August 27, in a man who had been in Luzen-
burg's Hospital, N. 0. The third and fourth cases were recruits of the
Thirteenth Infantry, from Mobile; admitted September 8. They had not
been in Mexico.

352 Schneck, Fracture of Clavicle and Humerus of same Side. [April

1848. Third quarter — No. of cases . . . .8

" deaths 8

Fourth quarter. — No. of cases 3

" deaths 3

The first case was from a ship from a Mexican port; admitted July 9 ; died
July 10. The four next cases came to hospital July 22, from a ship in the
river, from Mexico. The next case was from a ship in the river, August 2.
All of these men were in a desperate or dying condition when received into
hospital. The next case was that of Assistant Surgeon Newton, U. S. A.;
taken sick August 4; died August 9. Assistant Surgeon Sloan informed me
that Dr. Newton probably contracted the^ disease by often walking to the city
proper — a distance of nearly five miles — in the hot sun ; nor was the fever
attended to sufficiently early and perseveringly. The next case was that of a
hospital attendant who had a severe frolic in the city; taken sick September
20; died September 26. These are all the cases in the third quarter.

The three cases in the fourth quarter of 1848, were Mexicans, belonging
to the Spy Company, from General Scott's line of operations. This company
was encamped near the barracks during the season. The men were idle,
dissipated, continually drinking in town, and it is surprising that more of
them were not seized with the fever. The three men, the subjects of these
cases, were no exception to the above character. They were taken from the
1st to the 3d of October; died from the 3d to the 6th.

Perhaps there were cases, in both quarters, which might have been termed
yellow fever, but they were not registered as such when the symptoms were
light and the patient was labouring under some form of chronic disease.
Every case of yellow fever on the hospital books is included.

Thus we have, in both 1847 and 1848, but 49 cases of yellow fever. In
both years the barracks were filled with all classes of persons, and if yellow
fever is contagious, why did not the disease spread universally ? In 1848 there
were only 11 cases, which were admitted into a hospital filled with patients,
nurses, &c. ; and it appears to me that a contagious disease ought, in such
circumstances, to become general. No person attached to the hospital, in any
capacity, had the disease in 1848, except the hospital attendant before men-
tioned, who had been on a drunken frolic in the city, unless we include
Assistant Surgeon Newton. Such a disease cannot be contagious.

Art. VIII. — Case of Fracture of the Clavicle and Humerus of the same Side.
By B. F. Schneck, M. D., of Lebanon, Pennsylvania.

A little daughter of Mr. Arnold, aged 5 years, was kicked, November 9,
1855, by a colt, upon the left arm in two places, as the marks indicated, upon
the outside of the elbow just below the joint, and upon the arm immediately

1858.] Sehneck, Fracture of Clavicle and Humerus of same Side. 353

below the shoulder. The latter being a direct blow, gave rise to a fracture
of the humerus above the deltoid insertion, close to the joint; the former,
being a counter blow, was communicated to the clavicle, and resulted in a
fracture of that bone at its middle.

Here was an unfortunate state of things, truly ! How I could treat the
fracture of the clavicle was a difficult question. The arm could not be used as
a lever, to lift and keep the shoulder up, and out, and back ; and in the
nature of the case it seemed impossible to devise a substitute that shall ac-
complish the same end. It seemed possible to heal only one of the fractures
well ; and the patient will suffer less inconvenience from a badly adapted
clavicle than humerus. Wishing time for reflection upon this unusual com-
plication, I applied a cold water dressing, and put the arm in a sling until
the next day.

In the interval I consulted, but in vain, all the accessible writers, in regard
to this novel case. The appliances of Desault, Fox, and others, were prepared
for no such patients ; and in that storehouse of broken bones of the indefati-
gable Hamilton, I found no sample to match this. Believing that I had met
with an almost unique case, I finally adopted Dr. Fox's apparatus, with such
additions as I conceived necessary. It will thus be seen that, notwithstanding
the fracture of the humerus, I nevertheless obtained the leverage required for
the coaptation of the fragments of the clavicle, by the contrivance now to be
detailed.

The arm, having been enveloped in a roller, was dressed as in an ordinary
fracture of this bone, with four binders' board splints ; and on the external
splint was secured, by a few turns of a roller, a slightly hollowed wooden
splint, of the whole length of the humerus. With this unyielding outer
splint it was intended to prevent that external angular displacement which
would otherwise be sure to follow the bringing down of the arm over the
axillary pad. But the splint, at this stage of the process, would not yet be
capable of preventing this salient angularity; but by the help of a broad belt
of webbing (a saddle-girth in this instance), it was most effectually prevented.
This girth, cut of the proper length, and fitted with a buckle, was made to
surround the thorax, passing under the axilla of the sound side, and directly
over and upon the seat of the fracture.

Thus, a not too thick axillary pad having been applied, the arm, secured
and fortified as above described, was gradually brought down alongside of the
body; while, by an assistant, the girth was tightened with every successive
degree of adduction of the arm, until finally, this lever, though broken, was
made to elevate successfully and bear the weight of the severed and drooping
shoulder. With a little adjustment, the fractured clavicle was coapted, and
remained so. An outward angular deviation of the arm being thus prevented
by the wooden splint, which kept the fragments in a line parallel with itself
(and which was really the lever, and not the arm), but mainly and entirely
by the belt, which made its counter-pressure immediately over the seat of

354 Walter, Formation of an Artificial Hip joint. [April

fracture, the indications were all fulfilled ; and the case was committed to the
care of Nature, who so well seconded the efforts of art as to have united the
clavicle in two, and the humerus in four weeks, without any perceptible
deformity or shortening of either bone.

Art. IX. — Resection of the Femur, and Removal of the Trochanter Major for
the formation of an Artificial Hip-joint. By A. Gr. Walter, Surgeon,
Pittsburg, Pa.

Sarah McC, of Beaver Town, Beaver County, Pa., aged 22 years, of
small stature, and delicate frame, with slender muscles, and highly nervous
temperament, called on me in April last, wishing to have the left femur re-
moved at the hip-joint, and gave the following history of her case : When
five years old she fell, dislocating the hip-joint on the dorsum ilii, and, though
unable to walk from the moment of the accident, yet her medical attendant
treated her for rheumatism, the true nature of her case being overlooked.
After six months' confinement to bed, suffering constant pain, which the anti-
rheumatic treatment failed to relieve, she was allowed to go about on crutches,
the limb being four inches shortened, the toes barely touching the ground.
Some time after she exchanged the crutches for a high-heeled boot, and was
thus enabled to walk with tolerable comfort. Two years ago she again fell
on the same hip, and suffered severe pain in the joint. After some weeks'
confinement to bed, the violence of the pain having subsided, she resumed
her crutches j but on account of the contracted state of the muscles at the
groin drawing the femur up to a right angle with the body, and the painfully
dragging sensation at the hip-joint, locomotion was sickening and tiresome.
A partial relief was obtained by supporting the limb with the left hand while
taking exercise. From the strained position thus produced, together with the
crouched posture assumed in bed to ease a tender joint, the chest, spinal co-
lumn, and ossa ilii have become twisted and misshapen. There was continued
pain in the whole limb even during rest • lying on the right side was alone
practicable. Tired of her helpless condition, and worn out with suffering,
exarticulation of the limb at the hip-joint appeared to her the only relief.
Determined to submit to this, she sought admission into my hospital. On
examination, I found a dislocation into the ischiatic notch, with anchylosis
vera, aud structural contraction of the adductor muscles, drawing the femur
up to a right angle. Pressure upon the trochanter and rotary motion pro-
duced great pain from contact of the head of the femur with the ischiatic
nerve. According to her statement, the configuration of the joint had be-
come changed after the second fall, the pain shifted further back, luxation on
the dorsum ilii having been converted to that into the ischiatic notch.

The distress and helplessness of the patient urged relief, but exarticulation
of the femur in a person with a constitution so feeble and delicate, and such
excitable nervous temperament, was not to be thought of ; it was therefore
proposed to establish an artificial joint at the trochanter by resection of the
femur, which would straighten the limb, relieve the tension and dragging at
the ischiatic notch, and enable her to walk on crutches with ease, the weight
of the limb supported by its own muscles. To this a decided refusal was

1858.]

Walter, Formation of an Artificial Hip-joint.

355

given. Nothing short of complete removal of the limb would satisfy our
patient. Such determination in a frail woman was unexpected. The dangers
incident to the operation, her enfeebled condition, and the certainty of afford-
ing relief by the formation of an artificial joint being fully explained, her
consent at last was reluctantly given, but only on condition that the limb
should be removed, if success did not follow the conservative operation. On
the 23d of April, 1857, the patient resting on her right side, and being fully
under the influence of chloroform, Doctors McGratb, Henderson, and Lusk
assisting, an incision six inches long was made over the trochanter major in
the longitudinal axis of the limb down to the bone, the femur was freed by
slight touches of the knife and a bent probe from the surrounding muscles
immediately below the trochanter, and sawn through by a chain-saw passed
underneath it, in a slightly oblique direction from below and inwards, up and
outwards. This section not facilitating the extension of the limb, the re-
sected lower portion being arrested by the prominence of the trochanter major,
this bone was next cut off by the chain- saw in an oblique direction outwards.
The limb was now readily extended, and after closing the wound by sutures,
the limb was encased in a hollow leather splint, reaching from the ankle to
above the crest of the ilium. The head of the femur was not interfered
with. After the operation an opiate was administered.

The resection of the trochanter was essential both for the free extension of
the limb and accommodation of the oblique surface of the shaft of the femur
upon a similar one of the trochanter, and for the induction of natural plasma
from the opened cells of the trochanter to form an artificial joint which would
be capable of bearing the weight of the body. A transverse section of the
femur could not have answered the purpose, as in extending the limb the tro-
chanter, neck, and head, being firmly fixed by anchylosis, the shaft of the
femur would have come in contact with the unbroken surface of the tro-
chanter major, which, covered with its periosteum, could not have assisted to
offer the materials for the formation of an artificial joint. Yery little blood
was lost during the operation; some febrile reaction followed; a part of the
wound closed by first intention; in the remainder, healthy suppuration was in
due time established. The condition of the patient would have been comfort-
able but for her inability to rest on the back, on account of lardosis of the
lower part of the spine, its lateral distortion, and the altered level of the ossa
ilii, that of the left side being much lower. Owing to this distorted condi-
tion of the trunk, the splint greatly incommoding the patient, resting on her
right side had to be removed; extension was maintained from the ankle;
opiates were required to allay the irritation which position and temper pro-
duced, as well as to support the system. During the first week the case pro-
gressed favourably, suppuration being moderate; but early on the morning
of the eighth day a violent chill, of nearly an hour's duration, set in, followed
by fever and profuse perspiration, with a painful swelling on the inside of the
femur below the groin, and sunken features; deep-seated suppuration and
pyemia were dreaded. The chills did not return, yet the condition of the
patient remained critical. The tongue became dry, red on tip and edges, the
throat dry and clammy, appetite failed, the pulse small and very quick, decu-
bitus on sacrum, and over trochanter of right limb; an abscess formed on the
inside of the femur near the groin, from whence matter was discharged by
pressure in large quantities through the wound. The pus, hitherto healthy,
became thin, greenish, and offensive; thirst very urgent; great irritability
and apprehension of death; bowels constipated. Chlorate of potass in 10
grain doses every three hours was administered to relieve the congested mu-

856 Halsey, Resection of the Lower Jaw for Necrosis. [April

cous membrane of the tongue and throat. Wine-whey and broths were freely
given. An improvement gradually took place under this treatment. About
three weeks after the operation the tongue had become moist again, and less
red; the pulse less frequent and fuller; appetite had returned, and pus of a
healthy character, and in less quantity, was discharged from the wound;
bandaging from below up to the groin had closed the abscess ; the wound was
rapidly healing, and the limb was kept extended, and as much as possible
everted. About a month after the operation, without any appreciable cause,
there appeared a pulsating tumour in the abdomen, under the short ribs of
the left side, near to the linea alba, simulating an aneurism of the abdominal
aorta. In seven weeks the wound was almost closed, the appetite very good,
bowels regular, tongue clean and moist, sleep natural, the pulsation in the
abdominal tumour remaining unaltered, though rather less strong. The limb
is movable at the artificial joint ; is extended, and can be everted. Some days
after, Miss McC. left for home with the prospect of the limb becoming useful.
Several months later I saw her walking comfortably on crutches, relieved of
a distressing deformity, and free from all pain and the dragging sensation at
the anchylosed joint. The limb, about two inches shorter than the other,
promises to become more useful in locomotion at a future day, when the
newly formed artificial joint will have acquired more firmness to bear the
weight of the body upon a high-heeled shoe without the aid of crutches.

The successful termination of this case is the more gratifying as it not only
relieved Miss McC. of a painful and distressing deformity, but saved from
mutilation, and probably from death, a feeble woman, who, worn out by suf-
ferings and tired of life, had urged with strong determination and rare forti-
tude the performance of an operation which prudent surgeons will not rashly
resort to. Nature, in her bounty, always ready to heal and repair injury,
was not wanting in her efforts in this case to offer the materials for the new
joint, and to perfect its formation, though, from the enfeebled condition of
the patient, a very different result might have been anticipated.

January, 1858.

, . . m

Art. X. — Resection of the Lower Jaw for Necrosis caused by Inhalation of
the Fumes of Phosphorus. By Wm. S. Halsey, M. D., Prof, of Surgery
in the Philadelphia College of Medicine.

James McK., set. about 40 years, is a match-manufacturer, and has fol-
lowed the occupation steadily for fifteen years. In the factory in which he
is engaged there are employed about thirty persons. McK/s part of the
business consisted in preparing and mixing the compound of phosphorus with
which the matches are tipped, and in dipping the ends of the small pine sticks
into this mixture.

In this process of preparing and dipping there is always emitted a large
amount of phosphuretted fumes. He says that he is the only one that he
has known to be affected with disease of the jaw in this establishment. His
habits have been always steady, and his health perfect up to the winter of
'57, when he began to suffer with a toothache in the right side of his lower
jaw. This lasted for some time, and was followed soon by a hard lump upon
the outside of the jaw. The pain continued to increase and the swelling to

1858.]

Halsey, Resection of the Lower Jaw for Necrosis.

357

enlarge until an abscess formed in the submaxillary region, and burst, and
discharged a large quantity of purulent matter. Being alarmed at the pro-
gress of the disease,, he applied in February, 1857, at the College clinique
for relief. The right side of his face was much swollen, and the right sub-
maxillary region especially was occupied by a large abscess which was dis-
charging pus very freely. Upon introducing a probe into the discharging
orifice, I found that it led directly to the jaw, which was deprived of its perios-
teum and in a necrosed condition. There was, however, no indication that
exfoliation had taken place from any part of the jaw, but, on the contrary, the
whole bone was firm and solid.

At this time the disease seemed to extend only from the right lower canine
tooth to the angle of the same side of the jaw.

He was put upon a tonic plan of treatment, and although he was exceedingly
anxious to have the diseased part removed, he was advised to wait for the
present, as it was hoped that exfoliation would take place, sooner or later, and
he be saved the necessity of undergoing a severe and dangerous operation.
He was advised also to leave off his occupation.

He made his appearance from time to time at the clinique, but with little
change, except that the swelling seemed to be slowly extending. He still
continued to pursue his dangerous avocation, on account of being unable to
procure any other, and because a large family was depending upon him for
support. For a few months nothing was seen of him. Again in September
he presented himself in a condition much worse than before. Up to this time
he had been obliged to continue his occupation, for the want of any other, but
now, from weakness and exhaustion, he has been forced to give it up. All
the teeth upon the right side of the jaw have loosened and fallen out. Be-
sides several openings upon the outside of the face, that were freely discharging
pus, there were two or three inside of the mouth, from which there issued a
large quantity also, and which led directly to the diseased bone. The disease
seemed now to involve the whole of the right side of the lower jaw, without
there being made the least attempt, seemingly, by the periosteum to replace
the dead bone with a new casing of osseous deposit such as usually forms in
ordinary cases of necrosis. This, however, is a peculiar characteristic of the
disease which is especially mentioned by Mr. Stanley in his excellent treatise
upon Diseases of the Bones, and by other writers also. Nor was there any
disposition to exfoliate or to form a sequestrum, but on the contrary the whole
jaw was as firm and solid as at the time when it was first examined. His
constitution had now become seriously affected — as he was much emaciated
and weakened by the great drain of pus that was constantly poured forth
from the diseased parts. Quinia, iron, and a good rich diet were ordered, so
as to put him in a condition as favourable as possible for the operation of
resection of the bone.

Oct. 14. His present condition is about the same as before. He is pale,
thin, and has an anxious look. He says his appetite is tolerably good, but he
cannot eat solid food. The right side of his face is very much swollen ; there
are several fistulous passages under the jaw. In the mouth can be felt and
easily seen the denuded jaw for an extent of two inches. His breath smells
very offensively. The disease now extends from the right temporo-maxillary
articulation to the left lower canine tooth.

The patient being placed upon the operating table, and etherized, in the pre-
sence of the class, and with the kind assistance of my colleague, Prof. Gobrecht,
and Drs. Hazzard, Bradley and Pittinos, I proceeded to remove the diseased
portion of the jaw. Commencing with an incision opposite the left lower canine
No. LXX.— April 1858. 24

358

Halsey, Resection of the Lower Jaw for Necrosis.

[April

tooth, and at the base of the jaw, I carried it parallel with the base around the
symphysis, to the angle of the right side, and met this with another incision
extending downwards from the zygoma, half an inch in front of the tragus.
The great tendency to free bleeding required the application of a large number
of ligatures, although on account of their ready application, but little blood,
comparatively, was lost. The incision was made down to the bone, which was
found to be entirely deprived of its periosteum. But little difficulty was
therefore encountered in raising the flaps, which required only a few touches
of the knife to free the bone from its attachments. A space being now cleared
at the junction of the left lower lateral incisor and canine tooth, a Hey's saw
was used to make a groove, and the division was completed with Liston's
straight bone forceps. On account of the extensive separation of the perios-
teum, it was found that the finger could be carried around the bone in its
whole circumference, and to nearly the whole extent of the diseased portion.
The attachments of the digastric, mylo-hyoid and genio muscles were all
found to be loosened from the jaw, as also were the buccinator and the mas-
seter muscles. The separated portion of the bone was now carried strongly
outward for the purpose of further facilitating the operation of disarticulation,
viz: the separation of the attachments of the pterygoid and the temporal
muscles — for, on account of the great amount of swelling that existed in the
ramus, and the pain that the patient suffered in this region, I felt convinced,
previous to the undertaking of the operation, that it would be necessary to
disarticulate ; or, in other words, the disease had extended so far as to involve
the whole of the side of the jaw; even the articulation itself was affected.
This was evident from the great immobility of the joint, and the great pain
that was caused by every attempt to produce motion in it.

Having then completed the division of the bone, I carried the divided end
out strongly for the purpose above mentioned, when it broke loose from its
attachments altogether — articular cartilage, ligaments, muscles and all — as
cleanly and perfectly as a hickory-nut is turned out from its pericarp or outer
shell. Thus, very unexpectedly, was completed the operation — the disarticu-
lation having been accomplished spontaneously so far as division of the liga-
ments and the attachments of the condyle to the surrounding parts is con-
cerned. The flaps were now brought together and retained by sutures and
adhesive straps, water dressing applied, and the patient soon removed to his
bed. At the end of four days the wound healed entirely by first intention,
except at one point in the middle, where there was a considerable discharge
of pus, which continued for five or six days longer, when it closed up completely.
In two weeks from the time of operation, McK. was able to go out of the house,
feeling perfectly well, except being weak, and with one of the best indications
of returning health, a keen appetite.

The appearance of the diseased bone is as follows : Its general form is not
altered; in size it is increased by a coating of osseous deposit, which is
irregular in thickness, varying from one to three lines, in some places being
much thicker than in others, with irregular eminences and depressions that
cause it to be very rough and uneven. This deposit, except upon the coronoid
process, the condyle, and the part near the line of division, has a dirty grayish
appearance, and a porosity that much resembles the character and appearance
of pumice-stone ; besides, it has a harsh and roughened feel like that of sand-
paper. Upon the coronoid process, condyle, and the front of the jaw at the
symphysis, the deposit is much thicker — it being two lines or more in thick-
ness, light in colour, smooth and more even, and has more the appearance of
healthy bone. The coronoid process, instead of being one-eighth of an inch

1858.] Halsey, Resection of the Lovjer Jaw for Necrosis.

359

in thickness, or thereabouts, at its base, and tapering off to a thin point as in
the healthy bone, is thickened in this specimen to the extent of nearly half an
inch at its base, while its apex is more than half an inch broad, and is nearly
as thick as at its base. The articulating surface of the condyle does not seem
to be much affected, but the neck and the part which constitutes the sulcus
between it and the coronoid process are increased to four times their usual
thickness. From the line of separation of the diseased portion from the
healthy, to the extent of three-fourths of an inch there is a similar deposit.
The interior of the bone, as seen from the divided end, has the appearance
of being perfectly healthy. In the middle of the body of the jaw where, it
will be remembered, the disease first appeared, this deposit has disappeared
for nearly the extent of an inch in breadth and depth and the jaw itself has
this pumice-stone appearance similar to that of the deposit. As the distance
from this part increases, the deposit thickens until we reach that upon both
extremities, which has more nearly the appearance of healthy bone. In other
words, this deposit is the thickest where the disease has existed the shortest
time, while the point where the disease first began is entirely denuded.

These facts, it seems to me, will give us an insight into the pathology of
this disease, which differs so entirely from the other forms of necrosis. In
the latter, whenever there is thrown out an osseous deposit, it is separate and
distinct from the dead bone, and is in no way connected with it, except to
act as a substitute for it when the necrosed portion shall have been removed j
while in this form, produced by the inhalation of the fumes of phosphorus,
the deposit is made directly upon, and is firmly adherent to the dead bone.
This results from the periosteum being first affected, and the bone dies only
after the deposit has been made upon it, while in the other forms the deposit
is secondary to the death of the bone.

The pathology I believe to be the following : "Water absorbs the phosphu-
retted fumes, which have been ascertained to be hypophosphoric acid and
phosphuretted hydrogen, and so does the saliva. A more convincing proof of
this is the fact mentioned by a French writer, that the operatives in match
factories sometimes belch up gases from their stomachs, which in the dark
are luminous, showing them to be phosphorescent. There certainly can be
no more rational way of accounting for this phenomenon, than that the gases
are absorbed by the saliva, and are taken into the stomach by being swal-
lowed with the saliva, which acts as a vehicle for them j here the higher
temperature of the stomach causes these gases to be evolved again, which mix
with the other gases, and with them are expelled the stomach by eructation.
Then, again, it is a well known fact that those persons are only affected with
necrosis who have carious teeth, and it is said that persons may work amid
phosphorus for years with impunity, so far as necrosis is concerned, if their
teeth be only kept in a sound condition. The saliva having absorbed a cer-
tain quantity of these gases, lodges into or comes in contact with the exposed
pulp of the tooth. Thus the pulp in consequence becomes irritated and in-
flamed. The inflammation is communicated to the periosteum of the alveolus.
Thence it spreads by continuity of texture to the periosteum of the body of
the jaw.

360

Stribling, Case of Somnambulism.

[April

The same effects are now produced that follow inflammation of the peri-
osteum ordinarily, viz., an osseous deposit is thrown out. This inflammation
proceeds on until the death of the periosteum takes place. Now the bone and
its deposit being deprived of their support, take on the process of decay.
Hence the formation of abscesses, exfoliation, etc., as shown so distinctly in
this specimen.

The death of the periosteum I infer from the fact that all writers agree
upon the statement that no bony casing is thrown out to act as a substitute
for the dead bone, which takes place in all other forms of necrosis ; and that
in this case, the part of the deposit where the disease had recently appeared
seems but just stripped of its periosteum, viz., the coronoid process, condyle,
and from that part near the symphysis; while the intervening portion is more
or less disintegrated, showing that nutrition had ceased, and that the part
was left to the process of decay.

This disease is an exceedingly rare one in this country, and although it is
much more common in England and on the Continent, yet but little attention
has been paid to its thorough investigation. On this account I have endea-
voured to describe this case as accurately as possible, that a better knowledge
of its nature and pathology may be obtained.

Art. XI. — Case of Somnambulism. By Robert M. Stribling, M. D.,

of Virginia.

A case of somnambulism (I so call it, in default of a better name) came
under my notice about a year since, which presented some interesting and
novel features; and with the hope that its publication may tend to throw light
upon the physiology of the brain, but more particularly upon that condition
of mental action known as mesmerism, I send it for insertion in the Ameri-
can Journal.

The subject of this affection was a man 32 years of age. He had spent
the greater part of his life as clerk in a mercantile house, and during the
spring of 1856, came to Markham Station, to live with a relative of his, who
had established a store there. Here it was that he came under my notice.
For many years he had been very dissipated, and had been treated several
times for delirium tremens he told me.

During the course of the following fall, one of the young men who lived
in the house with him, found that when suddenly awakened, he would com-
mence to talk about his goods, imagining that he was making sales to a pur-
chaser, and urging him to purchase some article. He found then, if he
pretended to be a purchaser, Mr. A. would go on recommending his goods,
would get out of bed, search for his yard stick, measure off any number of

1858.]

Stribling, Case of Somnambulism,

361

yards called for, whether it was of silk, cloth, or calico, from a newspaper.
That if he represented one of the young ladies who usually made purchases
at the store, Mr. A. would treat him with all the deference he usually bestowed
upon ladies, never for an instant seeming to doubt that he was dressed and wait-
ing upon the lady in the store, but would talk about, laugh at, and joke over his
goods, as he was known to do while selling goods to ladies. When in this
state, one after another the young men were brought up and introduced to
him, sometimes as ladies, and sometimes as gentlemen; always after he would
call them by the name by which they were introduced, and behave in all
respects towards them as if they were the real personages represented.
Sometimes one would represent a rowdy, and curse and swear; Mr. A. would
immediately seize him and attempt to put him out; often the scuffle was very
severe and long-continued, and during the scuffle some persons standing by
would pinch and slap him, to which he seemed very sensitive, but was not at
all aroused from the delusion by it.

Whilst in that state he knew no one, not even his employer, who was often
present; indeed, until introduced to any one, he would pass him as he would
a pillow or post, not seeming to be aware that he was a human being, but
when once introduced, he never after forgot the imaginary person, but would
recognize and talk to him whenever he met him. He would, when told to
go to the books and make off a long account, put on his overcoat and spurs,
though he was in night-clothes and had on neither socks nor shoes, and start
out of the room on a collecting expedition. When brought back and told
the gentleman he sought was in the room, he would, in his usual bland manner,
present the account and request payment, urging him after his custom to do
so. He was once captain of a militia company, and if at any time one of
the company struck up a march, he would hasten to put on his drill-coat,
sash, and sword, though his legs and feet were bare, and commence to
arrange those present in a line to go through a regular drill. In fine, tell
him he was at a ball, he would immediately think he was there, and would act
accordingly; so if you told him he was in Baltimore, Philadelphia, or New York.
He could not be made to lose sight of his own identity, but upon everything
else, his mind seemed to act upon any suggestion, no matter by whom made.

So long as he was acting under a delusion it was impossible to awaken him;
numerous attempts were made by myself and others, but we could by no
effort used succeed in the slightest degree, but if left alone for a few minutes
he would return to his bed and close his eyes in sound sleep; then if aroused
in a natural manner, he would awake perfectly rational, and without the
slightest consciousness of what had just passed. Usually in the morning
after he had been experimented upon, he would awake complaining a good
deal of soreness and lassitude, but had not the slightest idea of its cause. At
last his employer, at his urgent request, forbade any repetition of the experi-
ment; all saw, too, that his health was growing more precarious, and abandoned
it, for fear of doing him injury.

362

Stribling, Case of Somnambulism.

[April

A short time after, his employer told me, while standing conversing with
him on business, he suddenly commenced praising his goods and trying to"
sell to him, evidently falling into that state of somnambulism whilst awake,
and mistaking him for a customer. It required a considerable effort, he said,
to arouse him.

During the time we were experimenting upon him, he was drinking a good
deal, but I never saw him intoxicated, and he attended to his business with
great regularity. Soon after, however, he commenced to drink more, and his
stomach becoming irritable, an attack of delirium tremens supervened. Opium,
morphia, brandy, and the nervous stimulants were used, but to no avail ; he
sank daily, though the irritability of the stomach had been subdued, and he
could retain whatever medicine was administered. He would lay in bed all
day and night, imagining he was selling goods to some one, handing a dun to
some one, or engaged in his usual avocations, but when spoken to he would
answer any question rationally about his feelings or condition. He remained in
this state for a week or ten days, gradually sinking during the whole time,
until the night before Christmas, when I was sent for in haste to see him,
the messenger at the same time telling me that he was dying. I hastened to
him and found all pulse had left the wrist, his extremities cold, and his face
wearing the Hippocratic expression. The only signs of life were gasps at
short intervals, but they more resembled spasm of the diaphragm than any
combined effort of the muscles to effect respiration. He was pronounced
dying, and all sat awaiting the result, when from the much prolonged intervals
between his gasps, I supposed the next would certainly be his last, he suddenly
sprang into the middle of the floor, and it required the combined exertions
of three of us to replace him in bed ; then, upon feeling his wrist, pulse was
very perceptible in it and seemed to increase in force. Some brandy was given,
which he swallowed with but little difficulty, and that seemed to revive him
still more. Soon after, he sank into the same state again. Again, when
expecting death, he sprang up as before. He continued in this state for about
a week, when on the morning before new year's he suddenly expired.

No post-mortem was made, circumstances prevented, but so far as the
symptoms went they gave no evidence of any serious organic lesion of any
of the viscera. The prominent symptoms in the case were great prostration,
accompanied with delirium, but the delirium was never violent, and he
never became comatose ; on the contrary, up to Christmas eve, there was no
time when he would not answer rationally any question put to him. He
seemed to die from complete exhaustion of the nervous force, which for the
week preceding his death seemed to be flickering like a candle that had burnt
out.

Such was the history of the case, as far as I thought it important to note
it down. His somnambulistic exhibitions and illness were witnessed by
numbers of gentlemen and several physicians besides myself, attracted some
from interest in the patient, and some from curiosity.

1858.]

Carnochan, Exsection of the Entire Radius.

863

Art. XII. — Exsection of the Entire Radius. By J. M. Carnochan, Pro-
fessor of Surgery in the New York Medical College, Surgeon-in- Chief to
the State Hospital (New York), etc. (With a wood-cut.)

The following case of the exsection of the entire radius is without prece-
dent in the annals of surgery, and having already, in 1854, exsected, for the
first time, the entire ulna, I am justified in claiming priority for my exsections
of the long bones of the arm in their contiguities.

Surgical compilations have heretofore given credit to Butts, of Virginia,
for the operation of exsecting the entire radius, but it appears that the opera-
tion actually performed by that surgeon, was not on the radius, but on the
ulna; of which only the lower two-thirds were removed, (Philadelphia
Journal of the Medical and Physical Sciences, vol. x. p. 115, 1825.)

As regards the ulna, a case of the " entire removal" of that bone, and "all
but a portion of the end of the radius," is attributed by Prof. Blackman
{Mott and Blackmail's Yelpeau, vol. ii. p. 460, New York, 1856) to
Dr. Compton, of New Orleans. On looking, however, at the report as
transcribed, several valid and insurmountable objections present themselves
to the reception of the case as one of exsection. The operation is said to
have been performed by Dr. Compton, but is reported by a " Medical Stu-
dent/' in a very confused and contradictory style. As reported, the case was
one of compound comminuted fracture of the radius and ulna, wherein, " the
arm was in a sloughing state, and both radius and ulna were actually shat-
tered to pieces, and protruding several inches out of the mass of muscles."
The bones are described as having been disarticulated at the elbow, and yet
the arm is said to have remained at a right angle to the humerus, and still
further, "that it could be flexed and extended." (Id., p. 460.) The
utility of an exsection consists in the preservation of function, by avoiding
amputation, and it seems to be a physiological impossibility, that after the
removal of the shattered fragments of both bones of the forearm — with de-
stroyed vitality — the function of the muscles of the forearm should be pre-
served. Besides, although it might be conceded that in a case of chronic
necrosis of long standing, new bone might be thrown out, to take the place
of the original, yet such an occurrence cannot be admitted as possible in a
case of traumatic necrosis, resulting immediately from a severy injury.

Case. — Daniel Kane, aged twenty, a native of Ireland, a labourer, stru-
mous aspect, tall stature, free from syphilitic taint, received an injury by a
.severe blow upon the upper part of the forearm. This was followed be severe
inflammatory action of the whole of the forearm, as well as of the upper arm,
nearly as high as the axilla. The pain was excessive, deep-seated — depriving
the patient of sleep and appetite — and accompanied by high constitutional
fever. Anodyne applications, such as medicated fomentations and cata-
plasms, with suitable internal remedies, had been used under medical advice

364

Carnochan, Exsection of the Entire Radius,

[April

in the city. Punctures along the swelling had also been made. This treat-
ment had been continued for about three months, without much relief from
the pain or diminution of the extent or the hardness of the swelling along the
forearm, when he entered, as a patient, the surgical department of the State
Emigrants' Hospital, on the 15th of November, 1853.

At the time of his admission, his countenance bore the evidences of severe
and prolonged suffering. He was emaciated, feeble, and labouring under
irritative fever. The hand, forearm, and lower half of the upper arm, were
much tumefied and discoloured. The tissues of the forearm were hard, dense,
and unyielding. The arm was much increased in circumference.

The pain still continued with unabated severity. A cataplasm, medicated
with infusion of poppy-heads, was ordered over the swollen parts. Internally,
quinine, porter, good diet, and a quarter of a grain of muriat. morph. at bed-
time, were prescribed.

The elbow-joint now became immovable,* and towards the inner aspect of
the joint a slight fluctuation could be perceived.

A bistoury was passed into the abscess, down to the bone, and a small
quantity of pus was discharged. About two days after this, another abscess
formed upon the inner side of the forearm ; this was opened in the same
manner, and a considerable quantity of pus was discharged. About the 8th
of December, matter was perceived near the wrist, on the dorsal aspect of the
arm; this also was evacuated. From these different openings pus continued
to be discharged in considerable quantities ; the arm became somewhat less
tumefied; the pain ceased to be so severe; the febrile condition subsided;
and the general health showed signs of amelioration. Along with the pus
small pieces of diseased bone were discharged, and the probe could be passed
easily along the fistulous sinuses into the interior of the radius. These
sinuses were of considerable length, running through the tissues of the arm
to the extent of several inches, and opening at a distance from the cavities or
abscesses in the interior of the bone. From December, 1853, to March, 1854,
the fistulous openings continued to discharge considerable quantities of matter;
the patient, in the mean time, being kept under tonics and nourishing regi-
men. From March till the following October, the condition of the patient
remained much the same; at intervals, small pieces of dead bone continued
to be discharged along with the pus. The patient's health did not improve,
and the arm remained discoloured, swollen, indurated, and useless. It now
became evident that the disease was one which could not be cured or ame-
liorated by medical therapeutics. The disease was evidently, from the first,
an ostitis, followed by its most aggravated consequences — enlargement, caries,
abscess of the bone, &c.

From the general tumefaction of the forearm, it was difficult to decide
positively as to the extent of the ostitis ; whether both bones were involved,
or whether it was exclusively confined to one. The sinuses led to the radius
alone, and the inference from this fact was, that the disease was confined to

1858.]

Carnochan, Exsection of the Entire Radius.

365

that bone. Supposing this to be the case, the question arose as to the pro-
priety of amputating the arm above the elbow, or of exsecting the radius in
its contiguities. The success which had followed the exsection of the entire
ulna, as reported by me, induced me to select the latter alternative \ and,
accordingly, I performed the operation on the 31st of October, 1854.

Operation. — The patient was brought into the amphitheatre, and placed
supine upon the operating table. Assistants were arranged so as to main-
tain firmly the trunk and lower extremities; others were placed to be in rea-
diness to hand the instruments, and sponge the wound ; chloroform was cau-
tiously administered. The humero-cubital articulation, during the progress
of the disease, had become immovable, and the forearm remained flexed at
an obtuse angle with the humerus. One assistant held and supported the
upper arm of the diseased limb, compressing, at the same time, the humeral
artery. Another supported the hand and forearm, and maintained the latter
in such position as to expose conveniently the radial aspect. An incision
was now made with a strong scalpel, in the direction of the axis of the radius,
commencing at a point immediately below the external condyle of the hume-
rus, and extending downwards to a point opposite, and a little behind, the
styloid process of the radius j next, two other incisions were made at the ex-
tremities of the first one, extending transversely backwards, about three-
quarters of an inch. These incisions extended through the integuments, and
subcutaneous adipo-cellular tissue and fascia, which were thickened and indu-
rated. The middle third of the radius was now easily reached, and made
bare on its outer aspect, by dividing the intermuscular tissue, behind the ex-
tensor carpi radialis brevior.

The tissues were then separated, at this place, from the posterior aspect of
the bone; the edge of the knife being kept close upon the bone. The knife
was now carried along the corresponding anterior surface of the bone, using
at times the handle, and dividing the fibres of the supinator radii brevis,
so as to lay bare the anterior surface of the bone, as far as the attachment of
the interosseous ligament, along its cubital border. The outer surface of the
radius was further laid bare, by carrying the dissection upwards, between the
extensor carpi radialis brevior, and the extensor communis digitorum. The
muscular tissue, surrounding the radius at its upper part, was then detached
from the different aspects of the bone, as far as the insertion of the inter-
osseous ligament. Attention was now directed to the lower part of the radius;
and here the. necessity of preserving the different tendons, passing over the
posterior part of the radius to the hand, required the greatest caution. The
knife was carried behind the fleshy mass, composing the origins of the exten-
sor ossis metacarpi pollicis, and the extensores primi et secundi internodii
pollicis, detaching it from the radius, and the posterior part of the interos-
seous ligament. The tendons of these muscles were next insulated, and care-
fully dissected from their attachments, and from the groove beside the styloid
process of the radius, along which they pass. The tendons of the extensor

366

Carnochan, Exsection of the Entire Radius.

[April

carpi radialis longior and brevior were now insulated; and detached from the
groove along which they pass. The tendon of the extensor indicis was next
detached. The extensor communis digitorum, with its tendons, and the ex-
tensor minimi digiti were also liberated, and dissected from their respective
grooves on the lower part of the bone; and the knife was then made to
separate the supinator radii longus from its attachment.

At this stage of the dissection, it was deemed expedient to divide the bone
at its central part, in order to facilitate the detachment of its articular extre-
mities. An attempt was made to pass a large curved needle, for the purpose
of introducing the chain-saw through the interosseous space j but this was
found impossible, owing to the increased diameter of the radius, and its con-
sequent approximation to the ulna. The various soft parts were now held
apart from the bone, and protected by means of compresses; the bone was
then nicked, and divided by a metacarpal saw through three-fourths of its
diameter, the rest of the osseous section being completed by smart blows of
the hammer on a chisel. The dissection was now continued, so as to remove
the upper fragment, which was found to be immovable at the articulation
with the humerus. The upper fragment was held by the forefinger and thumb
of the left hand, and a blunt-pointed knife, curved flatwise, was slipped under
the bone, so as to separate the interosseous ligament from its attachment.
This ligament was next carefully detached upwards, as far as the insertion
of the tendon of the biceps muscle. The knife was then carried upon the
outer portion of the annular ligament, and this, with the external lateral
ligament, was divided. It was now perceived that bony union had taken
place between the inner half of the upper surface of the head of the radius,
and the lower part of the humerus; with a small chisel this union was easily
destroyed. It now remained to detach the insertion of the biceps muscle,
which was somewhat difficult, because the increased size of the bone made
it encroach upon the track of the artery.

Keeping the edge of the knife close upon the tubercle of the radius, the
detachment was effected. It next remained to detach the lower fragment. By
means of the blunt-curved knife, the interosseous ligament, and the pronator
radii quadratus were detached from the bone. The different tendons running
over the outer side of the radio-carpal articulation were now held aside by
blunt hooks, and the radial artery was felt for, and also held aside. The bis-
toury was then carefully passed along, and under the styloid process, so as
to divide the lateral ligament, and open the joint at the external part. The
other tendons crossing the posterior aspect of the joint were also pulled to
one side, so as to admit of the division of the posterior radio-carpal ligament.
The articulation of the lower part of the ulna with the radius, was now opened
upon its posterior aspect. The bone was next elevated and rotated, so as to
permit the entrance of the knife at the external part of the joint, and the
anterior radio-carpal ligament was divided. A few touches with the point of
the bistoury completed the exsection.

1858.]

Carnochan, Exsection of the Entire Radius.

367

The pressure on the artery was now removed, and the wound cleansed of
blood. The hemorrhage, which was chiefly venous, became trifling. It was
necessary to secure only the interosseous artery, and two small muscular
branches.

During the operation, the radial, ulnar, and brachial arteries, escaped
injury, as did also the median and radial nerves. The various tendons which
have already been mentioned, were also insulated, and separated from their
attachments, without in any case being divided.

Progress of Union. — After the oozing of blood had ceased, the different
tendons were placed, as nearly as possible, in sitfi, and the edges of the
wound were maintained together by points of interrupted suture : strips of
adhesive plaster, a layer of perforated lint spread with balsam Peru cerate,
scraped lint, compresses, with a retentive bandage, formed the dressing. The
forearm and the hand, in a state of pronation, were then laid upon a well-
padded splint, and secured in that position by means of a circular bandage.

At night, after the operation, an anodyne draught was given. Next day,
November 1st, slight constitutional fever; pulse rose to 105. Patient rest-
less, and suffering considerable pain; ordered an anodyne at bedtime.

Nov. 2. Had slept better, pain less severe, pulse 100. First dressings
removed in the afternoon. Union of the lower portion of the wound by first
intention for about two inches above the wrist. An anodyne at bedtime.

3d. Traumatic fever subsiding; wound dressed; suppuration profuse.
Some sutures were removed; ordered sulph. quinias, two grains every two
hours ; muriat. morphia at bedtime.

During the following three weeks, with but little modification of the treat-
ment, the patient continued to improve : the suppuration became less ; the
process of healing advanced favourably; and the lips of the wound were
nearly united in its whole length. There remained two sinuses leading into
the tissues of the arm; one opening near the elbow joint, another about the
middle of the forearm.

22d. Iodide of potassium and cod-liver oil were substituted for the quinine.

During the following four weeks, the patient's general condition went on
improving ; he gained flesh ; his countenance assumed the aspect of health ;
exercise in the hospital grounds allowed ; the arm being kept in a sling.

1855. January 2. The sinuses had entirely healed, and the whole line of
the wound cicatrized. The limb was still carefully and lightly bandaged,
and the splint used, in order to give support to the hand, while the tissues
along the radial aspect of the forearm were gaining solidity.

10th. Removed the splint, substituting the simple bandage. The patient
allowed to use his hand and arm ; general health restored.

Eleven weeks after the operation the patient was discharged cured.

Functions of the Arm, and its Appearance. — The patient returned after-
wards, and was again admitted into the hospital for an internal malady, from
which he soon recovered. He had regained, however, the use of his hand

368

Carnochan, Exsection of the Entire Radius.

[April

and arm so much, that he was enabled to perform the duties of orderly in
one of the surgical wards.

The radial aspect of the forearm presents the long cicatrix of the wound,
and a depression exists along the original site of the radius. From the
rigidity of the elbow joint, the forearm remains flexed at a convenient angle
with the upper arm. The deformity of the limb is not so great as might be
supposed would occur from the removal of the chief support to the hand.

The axis of the hand is not exactly in its normal direction, the hand being
drawn slightly towards the radial side of the arm ; and the styloid process of
the ulna, from this circumstance, seems to project more than is natural. The
functions of the hand are entirely preserved ; as a matter of course, the power
is not so great as it was, but, with this exception, prehension is unimpaired.
He can carry a bucket full of water without difficulty, and can also write
with ease.

The functions of the fingers are not diminished, and the sense of touch is as
good as it was before the operation. The rigidity at the elbow joint is the
result of the antecedent disease, and not of inflammatory action following the
exsection. The functions of the wrist-joint, where the most trouble was to
be anticipated, is but little interfered with. Flexion and extension are per-
formed without difficulty ; the hand can be turned prone or supine, and can
also be adducted and abducted. The large arteries and nerves of the forearm
were not injured during the exsection ; and the muscular tissue, with the
exception of those portions which had to be detached from the surface of the
radius itself, was left intact by the knife. The various muscles which passed
over the posterior and inferior part of the radius now, serve to effect extension
of the wrist and of the fingers ; such as the extensores carpi radialis, the ex-
tensor communis digitorum, the extensor minimi digiti, and the extensor
carpi ulnaris.

In the new position which the hand has assumed, the extensores carpi
radialis, with the extensor ossis metacarpi pollicis, and the extensor primi et
secundi internodii pollicis, with the extensor indicis, aid in effecting abduction.

Adduction is effected by the extensor carpi ulnaris and the flexor carpi
ulnaris ; while flexion is performed by the flexor carpi radialis, the palmaris
longus, the flexor carpi ulnaris, the flexor sublimis, the flexor profundus, and
the flexor longus pollicis.

Pathological Condition of the Bone. — The diseased radius is represented
by the accompanying wood-cut. Fig. 1 represents the posterior aspect of the
upper half. Fig. 2, the lower or carpal half — the posterior surface.

The entire bone presents the characteristic appearances which result from,
prolonged and severe inflammation of the osseous tissue; the bone is expanded
or enlarged in its whole extent; the measurement around, a little below the
middle, is 4| inches, and the weight is seven and a half ounces; the weight
of a healthy radius, recently removed, being only from two ounces and one
drachm to two ounces and two drachms.

1858.] Carnochan, Exsection of the Entire Radius. 369

Ylrr. l. Fig. 2.

lit

The upper third of the bone, when examined soon after its removal, pre-
sented on its anterior aspect the following appearances : the periosteum was
partially loosened from its attachments and thickened, resembling softened
cartilage rather than fibrous membrane. Numerous foramina were seen — en-
larged, well defined, and hemmed round by mammillated eminences. The
general surface of this portion, anteriorly, was rendered very irregular by the
addition of new osseous matter, thrown out by the periosteum, and forming
sulci, crests, and bridges of bone. The posterior aspect of the upper third
was not so much altered ) its surface, however, was rough and irregular.

The middle third was enlarged to a greater extent than any other part of
the bone ; being about five inches in circumference. It presented a surface
more uniformly irregular than the upper third. The periosteum was mainly

370

Atlee, Monster of the Genus Peracephalus.

[April

adherent, and but little thickened. Beneath it the bone was found every-
where honey-combed by large foramina; the osseous matter around each
foramen blending with that around the others in its neighbourhood, and
giving rise to minute fissures and irregularities, running in every direction.

At different points cloacse opened on the surface, and communicated with
a central cylindrical canal, containing an undetached and spongy sequestrum.
This canal was filled with pus, and formed an abscess in the interior of the
bone. The section of this part of the bone and the surface show that new
bone was being deposited from the periosteum and its processes, and that
absorption was going on internally.

The lower third presented fewer marks of disease. It was, however, con-
siderably enlarged; several enlarged foramina were seen on the anterior sur-
face; while, on the posterior surface, a cloaca, extending into a purulent
cavity, in the interior of the bone, and some irregularities on the surface,
constituted the changes to be noted.

45 La Fayette Place, New York, March 1858.

Art. XIII. — Account of a, Monster of the Genus Peracephalus. By Walter
F. Atlee, M. D. (Read before the Biological Society of Philadelphia,
March 1, 1858.)

This monster was the product of a double gestation, the mother being
delivered at seven months. The child born first lived fifty-five hours; it was a
female, and perfect with the exception of one club-foot ; this monster came
away about twenty minutes afterwards. One placenta was common to both.
The mother was a healthy woman who had previously borne three children, in
as many confinements. In the first two pregnancies the child was female,
and born at seven months ; in the third the child was male, and born at
eight months and a half. The woman had received, so far as is known, no
fall or fright in the course of her pregnancy.

The monster has no head or upper extremities. The trunk and lower ex-
tremities are of a size corresponding to those of a well-formed foetus of seven
months. A want of perfect symmetry, however, is very manifest, in the two
halves of the trunk, which is remarkable for a number of elevations, with
depressions between them. These elevations are due to the accumulation of
a great quantity of cellular tissue. This sort of lumpy condition exists like-
wise in the lower limbs, which present, in addition, several other imperfec-
tions. The feet are turned inwards, and they possess but four toes, two of
which, the smallest, on one foot, are not separated. The external organs of
generation are those of the female; the anus exists.

Upon the front of the trunk, between the umbilicus and its upper extremity,
is something having the appearance of a small empty bag or bladder, attached

1858.] Atlee, Monster of the Genus Peracephalus. 371

by a rather narrow pedicle. Both above and below this bag is a small tuft
of hair. Towards the sides of the thorax, in the places usually occupied by
the nipples, are small round orifices.

For the sake of preserving the original appearance of this monster, which
was deposited in the collection of the Biological Society of this city, the ex-
amination made of its internal structure was very limited; it was confined, in
fact, to an examination of the spinal column. The sacrum was found to have
its concavity looking backwards ; the lumbar vertebrae are five in number,
and the dorsal twelve; at the commencement of the cervical region the spine
is bent forwards and downwards, and it leads, by a chain of small rudiment-
ary bones, imperfectly formed but evident rudiments of vertebrae and a cranium,
to the empty bag, mentioned as existing on the front of the thorax. The exist-
ence of a few hairs in this place, rudiments of the hairy scalp, had already
foretold, what a slight dissertion has sufficed to prove, as to the termination
of the vertebral column.

According to the usually adopted classification of G-eoffroy St. Hilaire, in
his Traite de Teratologic, this monster is one of the genus peracephalus, the
Greek rtsga, beyond or further than, being prefixed to acephalus, to mark a
still greater deformity, the thoracic members being absent as well as the head.

St. Hilaire states that about fifty cases of this form of monstrosity have
been recorded, and that from their examination it appears that, generally —
they are not born of women in labor for the first time ; delivery takes place
from the sixth to the eighth month; the gestation is double; the placenta is
common to both the children; the other child is well-formed, the sex is the
same ; and the acephalic child is almost never born first. All these circum-
stances, said by St. Hilaire to generally occur, have been noticed in this
instance as already stated; the only exception being that the first child had
a club-foot, instead of being well-formed.

It is interesting to notice that, in animals, the only examples of this mon-
strosity have been in the sheep and the deer, ruminants both of them, and
like man, generally uni parous. In all these examples — they are four in
number — gestation was double.

As, for the sake of preserving the specimen, the dissection of this monster
was not carried far, the principal modifications of the internal organization,
found in these cases, will be given as they are stated by St. Hilaire. As in
every other point his statements correspond to what occurred and was found
in this case, there is no reason to doubt that they would also correspond to what
would be found were the dissection completed.

The diaphragm is wanting, or, at most, the separation of the thorax from
the abdomen is membranous. It will be recollected that a muscular separa-
tion of the thorax from the abdomen is only observed in mammiferous animals.

In the thorax the lungs are absent, or are in a completely rudimentary
condition. Even their presence as rudimentary is very doubtful.

The heart is most usually absent. It has been said to be constantly absent,

372

Atlee, Monster of the Genus Peracephalus.

[April

but it is possible to prove the existence of an imperfect heart in some cases
of acephalous children. This question of the existence of a heart is very
interesting, for, according to Aristotle, who has reigned over science almost
to the present day, it is the organ first formed.

What is true of the heart is true also of the liver, the spleen, and the pan-
creas. Their absence is the usual, their existence the exceptional case.

The alimentary canal constantly exists, but incomplete, and offering evi-
dent traces of imperfect development. The large intestine is always found ;
there is often, though not always, a considerable portion of small intestine;
a small stomach is sometimes found, and even, in one case, the inferior ex-
tremity of the oesophagus.

The urinary organs, after the intestinal canal, are the most constant parts.
The organs of generation are as constant as those of urination, but they are
very often imperfect, or even rudimentary.

The skeleton is always very incomplete, as are also the nervous, the mus-
cular, and the vascular systems.

It will be noticed that the order in which the different organs of acephali
disappear is almost exactly the order in which, in the series of normal
beings, the organization is seen to be simplified, and to be successively de-
graded. Thus, in animals, the heart and the lungs disappear before the sto-
mach, and this in its turn disappears before the genital organs, and above all,
before the intestine, which is the most constant of all organs. Should this
coincidence, between the degradation of the organism in the animal series,
and the disappearance of so many organs in the acephali, be considered as
only fortuitous, or does it depend upon necessary causes ? Almost all depar-
tures from the normal condition can be explained by arrests of development,
for they realize the normal conditions of the first ages of the life of the
embryo. Now the primitive conditions of the organization of the embryo,
are also the conditions of the organization of beings of the inferior degrees
of the animal scale. Hence the very natural explanation of this remarkable
similarity existing between the modifications of acephali and those in the
inferior classes of animals.

From the fact that the transitory or embryonic condition of a superior
animal resembles, in a more or less striking manner, the permanent condition
of another animal less elevated in the series, some authors have thought that
every superior animal, before reaching its definite form, passes through the
series of forms proper to the animals that are inferior to him, and that the
diversity of species results from a series of arrests, effected at different degrees
of the embryonic evolution. Serres (^Precis oVAnat. Transcendante Appli-
quee a la Pliysiologie, Paris, 1842) lays it down as a principle that "human
organogeny is a transitory comparative anatomy, as in its turn comparative
anatomy is the fixed and permanent condition of the organogeny of man."
This we do not believe to be true ; every animal bears in itself, from its
origin, the principle of its specific individuality, and the development of its

1858.] Fleming, Spontaneous Rupture of the Eye. 373

organism, conformably to the general tracing of the plan of structure proper
to its species, is always for it a condition of existence. The term arrest of
development, is not meant to express an embryonic condition, permanent for
some animals, transitory for others, but a form which has remained quite simi-
lar to that which the embryos of these animals, and of others derived from
the same fundamental type, possess at a certain period of their existence.

What Milne Edwards calls the "economy of means," by which the rich diver-
sity of products, to be found in the animal creation, has been brought about,
is most wonderful. One of the most powerful causes of this rich diversity,
is the inequality in the degree of perfection reached by animals. All animals
are equally perfect in their kind, as Cuvier says : they are perfectly fitted for
the part they are to play, but this part is far from having always the same
extent and importance.

It is only in the past few years that the true point of view under which
the physiological study of monstrosities should be embraced has been rightly
understood. All the facts and all the laws of teratology are only the conse-
quences of embryonic laws and facts ; and embryogeny, as the science is now
understood, was only begun some fifty years ago. Embryogeny has for its
fundamental basis, this principle, that the organs do not exist entirely formed,
from the beginning, but, on the contrary, are formed at epochs, that vary for
each of them. Necessarily very small and very simple when first formed,
these organs increase in size and undergo developments.

Universally, until the 17th century, all monsters were destroyed. It was
held to be a bold novelty when Biolan, one of the most distinguished men of
his time, declared that six-fingered children might be allowed to live. Bio-
Ian taught, moreover, that monsters, half man and half animals, should rather
be killed; as to monsters, made in the likeness of the devil, if allowed to
live, they must be constantly shut up and kept concealed.1 From the super-
stitions of that time, in the course of a century and a half, the science of
monstrosities has risen to the highest considerations of natural philosophy.

Art. XIV. — Spontaneous Rupture of the Eye. By Andrew Fleming, M.
D., late Besident Physician to the Pennsylvania Hospital.

Beuben Pond, aged 50, seaman, a native of New Jersey, was admitted
into the Pennsylvania Hospital Sept. 22,1856.

Two years ago he had some disease of his right eye, which lasted for a
month, when he lost the use of it entirely. Since that time it gave him no
trouble or uneasiness until two days before his accident, when he suffered
from a severe, acute and throbbing pain in it, but without increase of size.

1 Riolan was Dean of the Faculty of Medicine, in Paris ; he died in 1605.
No. LXX.— April 1858. 25

374

Fleming, Spontaneous Rupture of the Eye.

[April

He has been temperate, has, with the exception of the above, always been in
good health, and has received no injury which could have caused his present
condition. He had been engaged, during the day, in loading a sloop with
manure; which service required him to stoop a great deal, had quitted his
work, and while standing on the wharf conversing with a comrade, he sud-
denly felt a pain as of a knife cutting across his eye, when a gush of blood
started from the sightless globe.

On admission he was tossing about in great agony, perfectly sensible,
with a weak, rapid pulse and cold skin. On the outside of the lids was
a clot, about the size of the eye, resting upon the cheek. When this was
removed, a rent was found extending clear across the cornea and a copious
and steady stream of arterial blood welling up through it. After cleansing
the laceration carefully, no protrusion of the iris or crystalline lens could be
perceived, and a probe introduced gave no indication of the presence of the
latter. The eyeball was of the same size as the opposite one, and with the
conjunctiva and lids presented a healthy appearance. The examination caused
such exquisite pain, that a more minute inspection would have been injurious,
and the presence of the blood behind the torn cornea rendered it difficult to
recognize any alteration in the tissue. It is to be regretted, as in many cases
of interest, that the knowledge of the antecedents had to be obtained from
the patient alone.

A full anodyne was immediately given, and a piece of lint, dipped in tinct.
ferri ehlor., inserted in the eyeball through the opening, and retained by an
adhesive strip. He was then put to bed, sol. morph. s. given in sufficient
doses to quiet him, and, when reaction had been fully established, cold was
applied.

Sept. 23. No hemorrhage has taken place since the introduction of the lint;
there is some swelling of the face and oedema of the eyelids ; he has slept a
little and feels much better.

The case now progressed favourably ; suppuration took place, followed by
healthy granulation, the wound in the cornea healed, the eyeball was slightly
diminished in size, and he was discharged cured Oct. 31, 1856.

The cases are numerous and the circumstances very varied where spontane-
ous effusion of blood, without rupture of the cornea, takes place in the eyeball,
while those in which hemorrhage, with rupture of the cornea, does take place
or would be likely to do so, are confined to malignant disease of the orbit,
glaucoma (Mackenzie, Practical Treatise, and Desmarres, Mai. des Yeux), and
aneurism. There being no reason, from the healthy appearance of the eye,
and the absence of the lens, for supposing the existence of the first two, I
shall dismiss them.

Aneurism is here found, as in other parts of the body, of two kinds.

Traumatic aneurism of the ophthalmic artery is a very rare disease, and so
far as my inquiry goes, but three cases have been reported. Two of these
are reported in the Med. Chir. Transactions, vol. xxii., by Geo. Busk, Esq.,
one occurring in his and the other in the practice of Mr Scott, surgeon to

1858.] Yesey, Bibron's Antidote to the Poison of the Rattlesnake. 375

London Hospital. The third is that of Mr. T. B. Curling in (op. cit.') vol.
xxxvii. A very remarkable case of anastomotic aneurism of the orbit, result-
ing from injury, was treated by M. Velpeau, at la Charite (Mai. des Yeux de
Mackenzie, trad, avec notes par S. Laugier et Gr. Bichelot). In the above
cases the injuries received were of a violent kind, and followed by great en-
largement of the eye with protrusion, and all the characteristics of aneurism.
In each case the common carotid was ligated, and, with the exception of the
last in which the life was saved, were successful, not only regarding the con-
dition of the patient, but in restoring the use of the eye.

Of spontaneous aneurism, the number of cases is greater, and I shall enu-
merate but a portion collected. Mr. Guthrie [Lee. on Oper. Surgery) has given
a description of a true aneurism of this class, of both ophthalmic arteries as
verified by post-mortem examination. Others, whether of true or anastomotic
character, have been given by the following authors, viz., Mr. Travers (Med.
Chir. Trans., vol. ii.), Mr. Dalrymple (op. cit., vol. vi.), M. Jobert (Mem. de
V Acad. Roy. de Medecine, tome ix.), Mr. H. Haynes Walton [Lancet, 1852,
vol. i.), M. Petrequin (Oomp. Rend, de V Acad, des Sciences, tome xxi.), and
M. Bourguet (Archives Generates, 1856). Of these cases, in the first four
the common carotid was ligated, and a perfect cure (with sight restored)
effected ; in the fifth, the common carotid was tied, but the pulsation soon
returned, and one month after the galvano-puncturation was tried but without
success — the patient died in a short time, and the last was cured by injection
of perchloride of iron.

In all cases of aneurism of the orbit, whether of a traumatic or spontane-
ous character, there is considerable time required for the development of the
disease, and there is no case in which, besides the symptoms peculiar to aneu-
rism, there is not great enlargement and protrusion of the eye. From this,
it would appear that the case of which I have given the details was not one
of aneurism.

To explain the pathology of this lesion, it is necessary to suppose a varicose
condition of the vessels within the eye, increased by the occupation at the
time (Beer and Walton), with perhaps disease of their coats as described by
Ignaz Meyr (Canstatt's Jahreshericht, 1851), and at the same time a ramol-
lissement of the cornea (Mirault, Bosas and Stoeber) which offered no resist-
ance to the tendency of the vessels to rupture.

Art. XV. — Experiments with Bibron's Antidote to the Poison of the Rattle-
snake. By Louis de Vesey, Member of the Academy of Natural Sciences
of Philadelphia.

In the January number of the American Journal of the Medical Sciences,
Dr. William A. Hammond, U. S. Army, gives the details of several cases of

376 Vesey, Bibron's Antidote to the Poison of the Rattlesnake. [April

infection from rattlesnake poison in which Bibron's antidote was employed.
The nature of the antidote and its history are given, and need not therefore
be dwelt upon here.

The present paper, containing also the results of cases of poisoning from
rattlesnake bite, in which this remedy was used, is contributed with the hope
that a knowledge of its influence in obviating the ill effects which so generally
follow the wounds made by this venomous reptile may be more extensively
known throughout the country.

Whilst at Contra Costa, on my way to Fort Tejon, in California, a young
boy was bitten by a rattlesnake. In a short time the wounded limb (the leg)
was much swollen, and there was a good deal of pain in the part; his parents,
refusing my services, sent for a physician. His remedies, however, were
unavailing; the boy was completely prostrated, and the bitten limb and even
the body were much swollen. The next morning, all hopes of recovery having
been abandoned, I was requested to prescribe for him. I immediately gave
him ten drops of the bromine mixture, diluted with a little alcohol and water,
and four hours afterwards repeated the dose. Very soon after the first dose
amendment commenced, and progressed rapidly after the second dose. Towards
evening all swelling, pain, &c, had disappeared, and the next morning the
boy was as well as if nothing had happened.

In the vicinity of this fort rattlesnakes are found of very large size, and
desirous of further testing the powers of the antidote, I procured three dogs
and subjected them to a series of experiments with it after causing them to
be bitten by the snakes.

The first dog (a small but powerful animal) was bitten twice, in a very
short period, in the throat ; the characteristic symptoms which usually follow
infection of this kind soon supervened. I gave him ten drops of the mixture,
and he almost immediately began to improve. The next morning he was
well, but the swelling did not entirely disappear for two days.

The other two dogs yielded similar results, one dose of the antidote was
always sufficient, except with the crotalus lucifer, which inflicted wounds of
more than ordinary severity. Two or three doses, and even some alcohol,
were generally necessary in bites from this species.

In all, I performed seventeen experiments on the three dogs, with seven-
teen different serpents, and invariably with a successful result. In the course
of the investigations I found that dogs which had taken several doses of the
bromine mixture, were for some time afterwards incapable of being infected
by the poison of the rattlesnake.

I am sure experience will demonstrate the bromine mixture to be an effect-
ual antidote to wounds from the rattlesnake — the most poisonous member
of our fauna.

Fort Tejon, California.

1858.] Transactions of the College of Physicians of Philadelphia. 317

TRANSACTIONS OF SOCIETIES.

Art. XYI. — Summary of the Transactions of the College of Physicians of

Philadelphia.

1857, Aug. 5. Injurious Effect upon the Eye of the Light from the Fish-
tail Burner. — Dr. Rand desired to call the attention of the Fellows to the
injurious effect upon the eye of the unsteady light produced by a common
form of gas burner.

The burner alluded to is known as the "fish-tail, or union jet," and is
almost the only one now introduced by the gas-fitters. The gas issues at its
tip in two opposing currents, which impinging nearly at right angles, cause
the gas to spread in a sheet of flame, the plane of which is at right angles to
that joining the orifices of the jets. "When the pressure is increased beyond
a certain point, the flame rises in an irregular column, accompanied by a
hissing or humming noise; this is termed "blowing."

It must be manifest from an inspection of the structure of the burner,
that the least inequality in the amount of flow through the two tubes leading
to the jets will produce an unsteadiness of flame, and this unequal flow will
be most marked when the pressure is below the maximum for light, without
amounting to that sufficient to produce "blowing." To avoid this blowing,
the gas is generally kept turned down, below this maximum point, and it is
very rare to see a steady light from one of these burners.

The effect of this flickering is very annoying to one unused to it, causing
pain in the eyeball, confusion of vision, headache, and other symptoms of
fatigue of the optic nerve. In many cases the eye, after a time, becomes ac-
customed to it, but at its own cost; in others this tolerance does not occur,
and Dr. Rand was acquainted with several persons who could never employ
this light, but used candles or the Argand burner when reading or writing.

The almost .universal adoption of the "fish-tail" burner was due to its con-
venience and great relative economy, giving as it does about twenty per cent,
more light for the same consumption, when compared with the bats-wing
burner, but being equalled in this respect by the best forms of Argand. It
has also the advantage of giving warning by " blowing" when burning gas
wastefully, which the bats-wing does not.

Dr. Rand was not prepared to condemn entirely the use of a contrivance

378 Transactions of the College of Physicians of Philadelphia. [April

so convenient and economical; but merely suggested the propriety of substi-
tuting for it, for purposes of reading, writing, sewing, etc., the steady flame
produced by the bats- wing or the Argand burner. The former, from the shape
of its flame, is not well adapted for a shade; the only objections to the latter
are its requiring the use of a glass chimney and its liability under increased
pressure to smoke. He had, however, used an Argand burner for years, and
found it to give very little trouble, and was satisfied that no one who would
compare the effects of the two for a single hour would ever exhaust his eyes
by the flickering " fish-tail," when the steady sunlike blaze of the Argand
was within his reach.

Oct, 7. Fatal Enlargement of the Thymus Gland with Subjacent Tumour.
— Dr. Henry Hartshorne exhibited a specimen, obtained from a patient of
Dr. W. H. Hazzard, in which disease of the thymus gland appeared to be
the immediate cause of death.

The child was five months old when it died. It had always appeared to
be healthy and well developed; and presented no symptoms of disease to
attract attention, up to the moment of death. It was suckled by its mother
at 2 o'clock of the morning of its decease, when it went to sleep as usual.
At about 7 A. M., it was found dead, lying on its back, with blood about the
nostrils, and the jugular veins distended. Examination of the body displayed
no peculiarity except the morbid alteration of the gland, and the results of
its pressure upon other parts. The heart was forced down close upon the
diaphragm. The vena cava descendens contained an unusual quantity of
blood. The thymus itself was very much enlarged; and, below the proper
gland, but connected with it, and inclosed in a continuous enveloping mem-
brane, was a mass whose appearance and consistence resembled those of fatty
structure. At the time when first seen by Dr. Hartshorne, it had so shrunk
and altered under the influence of alcohol, that no minute or microscopic in-
spection of its characters was practicable. Its dimensions, however, even at
that period, were as follows : 3 inches in perpendicular length, 2 inches in
width transversely, and | of an inch in antero-posterior thickness ; being fully
twice the volume of the heart, and about half the size of the right lung.
The thymus at that age (five months) averages commonly about 1^ inch in
length by § of an inch transversely. In Sir Astley Cooper's monograph on
the thymus, it is described as weighing about half an ounce, according to
Meckel, at nine months, and increasing up to the end of the first year; after
which it decreases.

Very little information, however, is to be found in systematic treatises, or
elsewhere, in regard to the pathology of the thymus gland. A quite similar
case to the above was narrated, with a drawing, by Herbert Browne Beck, in
Guy's Hospital Reports, 1st series, vol. vi. p. 188. The principal difference,
in Beck's case, was, that the fatal result, occurring in the fourth month of

1858.] Transactions of the College of Physicians of Philadelphia. 379

the child's age, was preceded for a length of time by paroxysmal attacks of
dyspnoea, cough, &c. ; which were quite absent in the case of Dr. Hazzard's
patient.

Rokitansky simply expresses a doubt whether the " thymic asthma," de-
scribed by Drs. Kopp, Hirsch, Montgomery, and others, as occurring in deli-
cate children, is connected with enlargement of the thymus, It is asserted by
Handfield Jones and Sieveking, that it does not necessarily depend upon this,
as the asthmatic attacks have been shown to occur, in some instances, with
an unnaturally small thymus, and to be absent in other cases where the
gland was enlarged. Simon mentions a case in which suffocation was occa-
sioned by the pressure of a tumour apparently of a sarcomato-cystic character,
in the situation of the thymus; and Sir Astley Cooper met with a case of
encephaloid growth in this part.1 Dr. Gross states, in his Pathol. Anatomy,
that no well authenticated case of steatomatous degeneration of the thymus is
upon record. The case under consideration might be considered as one
rather of fatty deposit, or hypertrophy, than of degeneration. There is some
interest in remembering, in connection with it, the fact stated by Simon, in
his Essay on the Thymus, that this gland is annually converted, in the hyber-
natory rodentia (as the marmot), into a large fatty mass; and that in the
ophidia, especially those which are capable of hybernation, an accessory fat
body is associated with the gland.

There was nothing tuberculous in the organization of the child from
which the preparation exhibited was obtained. The main singularity of
this case — beyond the comparative rarity of recognized affections of the thy-
mus— was the absence of premonitory symptoms. Death seemed to be ac-
counted for by the pressure of the tumour on the descending vena cava and
right side of the heart, so as to obstruct the circulation to a fatal degree; but
why this pressure should not have occurred before, to such an extent as to
produce symptoms of congestion of the brain or lungs, is difficult to explain.

Dr. Condie had some doubts whether the symptoms were not due to an
undeveloped state of the lungs rather than to enlargement of the thymus.
Nearly all of the late writers, especially German, have concluded that Kopp's
asthma is not produced by enlargement of the thymus gland. There are three
or four cases in the German journals in which tumours below the thymus have
produced disturbance of the circulation and respiration, and finally death; but
these have nothing to do with the size of the thymus. In this case I cannot
believe that so soft a body could have pressed down the heart or interfered
with the circulation of the bloodvessels of the neck. Still the physiology
and pathology of this subject are unsettled.

Dr. H. Hartshorne called attention to the fact that in this case the com-
pressing agent was not only the thymus, but a tumour beneath the thymus.
Here the death was sudden; a child of four months, previously well, found

1 Jones and Sieveking, Path. Anat., p. 54X.

380 Transactions of the College of Physicians of Philadelphia. [April

dead — no other cause of death being apparent. The child was well developed ;
had had no asthmatic symptoms. The distension of veins seemed most pro*
bably to depend on pressure of this tumour.

Congenital Malposition of the Liver. — Dr. J. C. Morris drew the atten-
tion of the College to the following notes of an autopsy made by him : —

During the summer of 1853, I was for a time resident at the Episcopal
Hospital, and thus met with a case in which a mistaken diagnosis was made
in consequence of an unusual anatomical peculiarity. Mary Buchanan, aged
50 years, was admitted on the 23d of July, suffering with extreme oedema of
the legs and ascites. She was very feeble ; coughed incessantly day and
night, and retched frequently; the skin of her legs had ulcerated in many
places from the distension by fluid, which oozed away so fast as to form a pud-
dle under her feet while sitting till a bed could be prepared for her. I could
not detect any cardiac disease; the urine was highly albuminous, but not more
so than is often the case where the kidneys are not degenerated; the ascites was
not so great as to interfere with the recognition of hepatic dulness on percus-
sion, extending downward almost to the crest of the ilium, on a line with the
umbilicus. It was, therefore, supposed to indicate enlargement of the liver as
the cause of the dropsy. She was subjected to an ordinary routine treatment
of stimulants and tonics, calomel, squill, and digitalis, cream of tartar and juni-
per berries, until she finally sank on the 22d of August. On opening the
thoracico-abdominal cavities, the heart and lungs were found to be healthy;
the liver also appeared perfectly normal in structure, but instead of occupying
the concavity of the diaphragm, it was lying on the right side, so that the
left lobe occupied the ordinary position of the right lobe, while the latter was
forced downwards and forwards. This appeared to be congenital. Both
kidneys were far advanced in granular degeneration.

Nov. 5. Foreign Body in the Lungs. — Dr. Wood stated that he wished
to make a brief communication to the College on a somewhat interesting
event which had come under his notice. He would begin by quoting from the
Quarterly Summary of the Transactions of the College, Nov. 1, 1854, the
following statement by Dr. Pepper : —

" Within the last few weeks, I have examined the case of a little girl sup-
posed to have a piece of filbert shell lodged in the lungs ; the physical signs,
as well as the previous history, render it highly probable that such is really
the case ; and yet, although it is now about one year since the accident, the
general health is but little if at all impaired, the only inconvenience being a
slight occasional cough."

This patient, Dr. Wood went on to say, was a niece of his own, and was
about six years old at the time of the accident, which happened in May, 1853.
Ever since that time, up to a recent period, she had been subject to a cough,

1858.] Transactions of the College of Physicians of Philadelphia. 381

sometimes milder, sometimes more severe, with occasional violent paroxysms ;
and, upon slight exposure, or even without exposure, attacks of bronchial in-
flammation with more or less fever would supervene, sometimes confining her
to bed, and lasting several days or even weeks. There was frequently a
wheezing sound to be heard in her respiration at a little distance j and bron-
chial rales, sibilant, sonorous, and mucous, were observable upon auscultation
more or less at all times, and in almost all parts of the chest, but loudest over
the upper part of the right lung behind. There were never any physical signs
of pneumonia ; no blood or pus of any amount was known to have been ex-
pectorated ; no consolidation of the lung was in any portion or at any time
discoverable. What local disease existed appeared to be purely bronchial.

At one period there was so much paleness, emaciation, and debility, as to
suggest the idea that tuberculosis might be impending; but the symptoms
improved under the continued use of cod-liver oil and a nutritious diet.

Great care was at all times taken by the parents that the child should not
be exposed to the danger of taking cold, and that she should not be allowed
to over-exert or fatigue herself. When the symptoms of acute bronchial in-
flammation were apparent, moderate treatment of an antiphlogistic character
was adopted; as rest, low diet, and the use of gentle saline cathartics and
refrigerant diaphoretics. At other times an expectorant mixture was occasion-
ally used, with a little solution of morphia in it, to control the cough when
troublesome.

While absent from the city in August last, Dr. Wood received a letter from
the mother of the child, informing him that, in a suffocative paroxysm of
coughing, she had suddenly thrown up the offending cause, which proved, as
had been supposed, a piece of filbert shell, and that since that time the cough
had disappeared, and the child been restored to health. On his return he
examined the chest carefully, and could discover no abnormal sound ; and at
the present time the little girl is free from every sign of disease.

The fragment of shell was discharged on the 16th of August last; so that
it had remained within the chest for at least four years and two months. The
mother stated that when she first saw it, there appeared upon its surface a
covering of somewhat tenacious matter, having an offensive smell. Dr. Wood
presumed that the piece of shell had been lodged during this whole period in
the right bronchus, where it had probably become fixed immovably in conse-
quence of its size. It is of an irregularly oblong shape, with one rather
sharp and projecting angle, somewhat concavo-convex, four-tenths of an inch
long, by somewhat more than three-tenths in breadth, and about one-tenth
in thickness.

Dr. Wood exhibited the fragment to the College.

Dr. Gilbert said that he was acquainted with a boy who, in the fifteenth
or sixteenth year of his age, discharged from his air-passages a trunk nail,
five-eighths of an inch in length, which was supposed to have been swallowed

382 Transactions of the College of Physicians of Philadelphia. [April

several years before its expulsion. The health of the boy was subsequently
improved.

Chronic Disease of the Urinary Organs characterized by Anomalous Symp-
toms.— Dr. Euschenberger read for Dr. 0. J. Wister, of G-ermantown, the
following communication : —

The diagnosis of internal tumours is admitted to be sufficiently difficult and
uncertain; and the following case, in some degree illustrative of this, may not
be entirely without interest.

The patient, aged 64, of active and temperate habits, and free from heredi-
tary predisposition to any of the diseases which are ordinarily believed to be
transmissible, applied to me early last spring. He complained of loss of
appetite, and slight pain and nausea, which occurred about an hour after
taking food and continued in a greater or less degree for two or three hours.
There was no epigastric tenderness, the tongue was moist and slightly furred,
the bowels somewhat sluggish, and the general strength rather diminished ;
but beyond the inconvenience already mentioned, there was no complaint.
The case seemed to be one of laborious digestion, arising from debility of the
secreting apparatus of the stomach. I directed him to take five drops of
mtro-muriatic acid, with some comp. tinct. of gentian, before each meal, and
a pill of blue mass and comp. ext. colocynth at bedtime, should the bowels
remain torpid. Under this treatment he so far improved, that after three or
four visits he no longer came to me, and I lost sight of him till the early part
of October (about six weeks before his death), when I was sent for.

At this time he was extremely feeble and very much emaciated ; his com-
plexion had a pale ashy hue, the tongue was coated and rather dry, the pulse
frequent and compressible, and the whole appearance haggard and worn. He
said that for several weeks he had not been so well, but hoped to get on with-
out assistance ; and had, therefore, not applied for aid until the rapid increase
of his symptoms had alarmed him.

The discomforts of the spring had returned in an exasperated degree ; the
loss of appetite was total, and the nausea had increased to vomiting almost
every article of food as soon as it was swallowed. Still, he spoke of but little
pain, and the epigastric tenderness was so inconsiderable that firm pressure
was easily borne. After many questions, he finally informed me that when
he lay on his back the abdomen became hard ; and on putting him in that
position, I discovered a tumour which extended from the pubes to about an
inch above the umbilicus. The tumour was sufficiently prominent to be
obvious to the eye alone ; whilst on pressure it yielded to the hand a sensa-
tion at first somewhat elastic, but when more firmly pressed it seemed fleshy.
The examination gave the patient no pain, nor did the manipulations produce
any desire to pass water, as might have been anticipated had the disease
involved the bladder. The patient stated that for some years he had been

1858.] Transactions of the College of Physicians of Philadelphia. 383

accustomed to urinate more frequently than in earlier life, but did not think
that it required any particular effort.

Finding that some, enlargement of the prostate gland existed, I introduced
a catheter, from which trickled about a tablespoonful of natural-looking
urine, and then the discharge stopped.

During the period of my attendance, the tumour always presented the same
characteristics, and the urine continued to be passed regularly, and in suffi-
cient quantities. I concluded that he had chronic inflammation, or possibly
cancer, of the stomach; and the probability of the latter being the case was
much increased by the appearance of coffee grounds vomiting, which took
place repeatedly for some days preceding death. As to the nature of the
tumour I felt unable to decide, its obscurity baffling all certainty.

Autopsy, fifteen hours after death. — On opening the abdomen, the tumour
proved to be the bladder, dilated to the capacity of a quart, and filled, but not
distended, with urine. Old and firm adhesions connected the organ with the
walls of the abdominal cavity, as well as with some of the neighbouring viscera;
and I presume the small discharge of urine, which followed the introduction
of the catheter, was due perhaps to these adhesions, which prevented the
contractions of the bladder; while as the patient lay on his back, but a small
quantity would be enabled to escape by gravity alone. The muscular coat
was greatly thickened, but otherwise the organ presented a healthy appearance.

The lateral lobes of the prostate gland were enlarged about one-third, and
had the effect of reducing the orifice of the bladder to a very narrow longi-
tudinal slit, through which the urine must have been expelled with difficulty;
and hence the dilatation and muscular hypertrophy. The right ureter and
the pelvis of the corresponding kidney were much dilated, and the cortical
portion of the kidney itself was rather diminished — otherwise it was normal.

The stomach exhibited every evidence of widely spread and long existing
inflammation; the mucous membrane being generally thinned and softened,
and in many places entirely removed, but towards the pylorus it was thickened
and dark-coloured. The dimensions of the organ were greatly increased, but
its functional ability must have been almost entirely lost. The liver and other
viscera, save those already named, were quite healthy.

In reviewing the case, it seems strange that disease so situated and so ex-
tensive, could yet have given so little notice of its presence, that the comfort
and physical capacity of its victim were not seriously affected until within a
few weeks of dissolution.

Fatal Disease of the Appendix Vermiformis. — Dr. Caspar Wister read
the following paper : —

The appendix vermiformis exists only in man and two superior species of
the quadrumana, the orang and the ape. It is the type of the prolonged
caecum common to all other mammiferous animals. During foetal life it is

384 Transactions of the College of Physicians of Philadelphia. [April

continuous with the caecum, and of the same size, and is developed from the
cul-de-sac of the latter. Bischoff admits that the earliest recognition of its
origin was by Meckel, in a foetus seven lines in length.

The appendix is ordinarily three inches long, with a diameter of two lines,
but is subject to great variety of size as well as position. Occasionally it is
entirely absent, while Welga has seen it nine inches long, with many convo-
lutions, and Autenrieth four, and as large as the colon.

It is entirely enveloped by the peritoneum, which forms for it also a true
mesentery, holding it loosely in position. The muscular coat is not in bands,
as in the colon, but surrounds it as in the rectum. The lining membrane is
contiguous with that of the caecum, and forms a valve at the entrance, the
falciform edge of which looks towards the right and downwards. This valve,
in most instances present, prevents the introduction of foreign bodies, but per-
mits free exit to mucus, of which in adults there is a large supply, with rarely
any admixture of alimentary matter; in infants, on the contrary, it is filled
with meconium. The glands within are very numerous, and of the solitary
variety. The extremity of the appendix is found at times in the pelvis, more
commonly posterior to the colon; its position is entirely uncertain.

The function of this body is supposed to be similar to that of a gland ; it
furnishes an acid secretion which causes the chyme in the caecum suddenly
to acquire the property of reddening litmus paper.

The subject of the following notice was a boy of five years of age, fair skin,
light eyes and hair, and delicate physical development, the son of a father
lately dead with phthisis.

This child was visited professionally on the first of November; he was at
that time out of bed and in his ordinary dress. His expression was languid;
he had much fever, with a pulse of 130; his tongue was covered with a slight
white deposit, through which the papillae were projecting, the tip and edges
being unusually red. He complained of pain in the abdomen, describing it
vaguely as " stomach ache," without giving it any locality. This pain was
spasmodic, recurring at short intervals; sharp and griping, but followed by
complete relief. At this time there was no pain upon pressure, or soreness
over the abdomen. On the afternoon of the day but one preceding, an ordi-
nary walk had been followed by complaint of much weariness, and in the
course of the night by the first expression of pain, and this without any chill.
Throughout the following day there had been some fever and pain, but this
was not thought of sufficient gravity to require medical interposition. There
had been no motion of the bowels during the forty-eight hours immediately
preceding the first professional visit; and at that time the case had the aspect
of an ordinary slight attack of colic, with the sympathetic fever natural to a
child of sensitive organization, teeming with sympathies ready to respond to
slight disturbance of the economy. A mercurial purgative was directed, and
a febrifuge at intervals. There had been no unusual article of diet taken,

1858.] Transactions of the College of Physicians of Philadelphia. 385

except a moderate quantity of chestnuts. The night was much disturbed,
with an increase of both fever and pain ; the latter still in paroxysms.

The morning of the 2d, in consequence of the purgative not having ope-
rated, a copious enema was administered, which produced a large fecal dis-
charge, none of it of a dry or impacted description, but containing distinct
evidence of the operation of the mercurial. The child expressed a sense of
relief; and, after a dose of oil and a fomentation adjusted over the seat of
pain, he was confined to bed.

The following morning, Nov. 3d, there was a spontaneous motion of the
bowels, without any improvement; there was now tenderness over the abdo-
men although, during the paroxysmal pain, pressure with the hand was grate-
ful. This pain continued the chief subject of complaint, engrossing the
child's mind, and provoking constant expression of distress. He com-
menced frequent doses of small quantities of calomel, with full proportions of
ipecacuanha and opium, and employed gum in solution largely as a diet.

On the 4th, the symptoms were more grave, greater pain upon pressure,
some tympanitis, and soreness attending all motion of the person; the
spasmodic pain still, however, caused most complaint, and recurred at short
intervals. Leeches were now applied over the entire abdomen, all other treat-
ment being continued except the use of ipecacuanha; this was withdrawn in
consequence of slight vomiting. After leeching there was less complaint of
pain upon pressure, and soreness and nausea disappeared, while stimulation
was found necessary.

On the morning of Nov. 5th, he presented excessive tympanitis, constantly
recurring paroxysms of pain, great restlessness, sunken features, some tender-
ness upon pressure, and a pulse of 140. The child was, after consultation with
Dr. Wood, placed under the full effect of opium, with an increase of the mer-
curial, and a blister over the abdomen. The rectum was relieved of a laro-e
accumulation of gas by the introduction of a catheter, but all motion of the
bowels was in vain solicited. Under the full effect of the opiate there was less
exhibition of pain and restlessness, without any arrest of disease ; tympanitis
greatly increased, and compressing the stomach caused regurgitation of fluid,
and much depressed the vitality of the entire organism.

Nov. 6. Small quantities of oil of turpentine, with full doses of the offi-
cinal solution of morphia, were administered, accompanied by further stimu-
lation. Gradual sinking under the unchecked march of disease, aided by the
accumulation of gas, terminated in death on the 7th of the month, seven days
after the commencement of treatment; this being the result of a disease
deficient in symptoms sufficiently distinct for satisfactory diagnosis, and only
decided in the steadiness with which it resisted treatment.

After death the abdominal cavity was found dry, with indications of peri-
toneal inflammation, consisting most conclusively in a few patches of pasty
lymph upon the intestinal surfaces. There was an engorgement of the vessels

386 Transactions of the College of Physicians of Philadelphia. [April

of the intestines, but being in longitudinal bars from the diaphragm to the
pubis over the entire mass, there was some doubt as to the time of its occur-
rence, particularly as signs of incipient decomposition existed elsewhere. The
intestines, from the pyloric orifice of the stomach to the sigmoid flexure of the
rectum, were greatly distended with gas, and contained, beside, a large amount
of fluid fecal matter. The stomach was empty and much contracted, the accu-
mulation of gas having pressed it against the diaphragm, and in so doing caused
the latter to encroach upon the thoracic viscera, thus rendering the last hours
of life a most painful exhibition. The lining membrane of the intestinal canal
was healthy throughout, and the cause of death was not manifest until the
appendix vermiformis was examined. This was perforated at the lower ex-
tremity; the opening being large, with ragged edges, indicating ulceration, and
partially filled by a plug of concrete matter of the size and much the shape of
a date-stone, composed of small seeds, many of these, from figs, associated
with concrete matter deposited in layers, and arranged in concentric circles.

In this instance, the extremity of the appendix rested in the pelvis upon
the rectum, immediately over the fundus of the bladder; here an effusion of
the contents of the intestines had occurred, but in small quantity, owing to
the plug having filled the ulceration it had caused in the appendix.

The matter effused had given rise to excessive inflammation and the for-
mation of much lymph, an attempt having been made to form an abscess and
inclose the offending fluid. This deposit of lymph extended over a surface
of three inches in diameter, was dark in hue, passing into gangrene; and,
although adhering strongly to the intestinal surfaces, left them, when removed,
healthy in appearance. Those surfaces of the sigmoid flexure of the rectum
facing each other in the natural position were strongly adherent for a distance
of three inches, and consequently prevented peristaltic motion at this point.
This explained the retention of gas after the peritoneal symptoms became de-
cidedly marked, although there had been a free passage of fecal matter in an
earlier stage of the disease.

Again, the son of a very distinguished physician of this city, twenty-two
years of age, passed Sunday evening in the society of his family and a small
collection of his father's friends ; he was gay and apparently in good health.

A few days previously he had complained of vague pains in the abdomen,
not however of a degree to attract particular attention.

He retired on the evening above mentioned without any unusual sensations,
but awoke before daylight with intense colic. This increasing, his father
sent for a medical friend, after exhausting his own resources and failing to
procure relief. Throughout Monday the symptoms of colic continued with-
out abatement, and as the day wore on only presented indications of peri-
toneal complication. There was a large, though not excessive accumulation
of gas, the most prominent feature of the case being excruciating pain, from
which only partial relief was procured by complete narcotism. The bowels

1858.] Transactions of the College of Physicians of Philadelphia. 387

resisted every attempt to procure evacuation of their contents after the ear-
liest stage of the disease.

On Monday night and Tuesday morning the agony of the patient began
to abate, but only to be followed by collapse, with cold damp surface and
failing pulse j he gradually sank, and died in the course of the morning, after
an illness of thirty hours.

The abdomen was found after death much distended by gas, free from
effusion, and not affording any evidence of excessive peritoneal inflammation.
The effect of disease in this case could be traced with much confidence, as
the examination was made on Tuesday afternoon, a few hours after death,
and but a short time was allowed for decomposition to embarrass investi-
gation.

The appendix was much distended at its lower extremity by a concrete
mass composed largely of raisin seeds. Its walls had not been perforated,
and contained, with the foreign matter, an accumulation of pus, the whole
forming a mass the size of a walnut. The appendix partially embraced the
ilium, adhering to it strongly, and completely strangulated the small intes-
tines ; which were, for a distance of six feet above, of a dark mahogany colour
and passing into gangrene. At the point of strangulation there had been
much inflammation with large effusion of lymph; the walls of the tumour
were thin, bursting under pressure of the fingers ; but, having retained its
contents during life, there was no discharge of foreign matter into the peri-
toneal cavity giving rise to peritonitis and masking the earlier symptoms of
colic, as in the case just described.

Moreau cites a case identical with this, the ilium having been strangulated
by adhesion of the appendix to the mesentery; while Marteau has seen the
jejunum, and Scarpa the colon, embraced in the same manner and with a
like effect.

Klockhof reports a case in which the appendix adhered to the colon by its
extremity, thus forming a loop through which the small intestines had passed,
producing strangulation.

Merling, in examining a subject, found the appendix adherent to the colon
by its lower extremity, and forming a free communication between different
sections of the intestine, but was unable to learn anything of the previous
history of the individual, or under what train of symptoms this union oc-
curred, evidently followed by entire recovery.

Again, the appendix is at times metamorphosed into a hydropic capsule,
as reported by Eokitansky, from the presence of a concretion in the tube
closing the canal and preventing escape of the mucous secretion. This causes
the extremity to become dilated, and the mucus to pass into the condition of
a serous membrane secretins; an albuminous fluid.

Beside the foreign matter collecting in the appendix mechanically, tuber-
culous and typhoid deposits are laid down at times in its walls, giving rise

388 Transactions of the College of Physicians of Philadelphia. [April

to ulceration. When, in addition to these varieties of disease, we consider
the fact, that a long time may be required to establish the existence of serious
symptoms, since it is asserted that a concretion may exist and only give rise
to blennorrhoea, a correct diagnosis is only equalled in difficulty by its im-
portance. Ulceration of the appendix is not necessarily fatal, but forms
abscesses at times pointing in various directions, according to the variety of
directions assumed by the appendix; and it is of great moment that these
should be anticipated and discharged at the earliest period possible, and the
risk of an internal rupture of their walls diminished. In the cases cited
above, the earliest symptoms were of colic, excepting the obstinate constipa-
tion, the bowels having been freely evacuated without relief. In both, the
earlier symptoms were overlaid by peritonitis; while in one there was an
attempt to form an abscess, the constitution failing before it was accom-
plished.

Dr. Levick remarked that it would be a matter of interest to ascertain
if there were any peculiar symptoms which would enable us to localize dur-
ing life the seat of diseases of this kind. In neither of the interesting cases
reported by Dr. Wister was there anything which could have directed atten-
tion especially to the appendix vermiformis, the phenomena presented being
those of " colic without the ordinary constipation. ;;

Though not of very frequent occurrence, diseases of this structure exist
sufficiently often to render their observation of importance. Two autopsies
had come under Dr. L/s notice in which death had been produced by perfo-
ration of the appendix; while in a third case fatal strangulation of the intes-
tine had been occasioned by a diverticulum closely resembling in size and
appearance the vermiform appendage, but given off higher up the intestine.
A record of this case was printed in the Transactions of the College, vol. 1,
No. 10, N. S.; and, in the corresponding number of vol. 2d, a case of perfo-
ration of the appendix is reported by Dr. Gobrecht, and allusions are there
made by other Fellows of the College to similar cases seen by them.

In the earlier symptoms of the first case reported by Dr. W., and still
more so in that reported by Dr. Owen Wister, it would be remarked that
there existed very serious disease with little or no pain. This absence of pain
had been strikingly exemplified in some fatal cases which had come to the
knowledge of the speaker.

The first of these was that of a man who died a few years ago in the Penn-
sylvania Hospital apparently of another disease; who had never complained
of pain in either hypochondriac region. Upon examination, the liver was
found to contain numerous encephaloid tumours. Another very similar case
had recently occurred in the practice of a medical friend, in which there was
no pain or other symptom leading to a suspicion of disease of the liver, which
organ was found after death to contain quite a number of cancerous tumours.
The third case was that of a man admitted into the hospital last summer, who

1858.] Transactions of the College of Physicians of Philadelphia. 389

presented many of the symptoms of cancer of the liver ; this disease was
diagnosticated, and the patient especially interrogated as to the existence of
pain in the hepatic region, which he uniformly declared he was free from.
A post-mortem inspection showed the liver to be enlarged, and fairly studded
with medullary tumours. Here, then, were three cases of malignant disease
of an important organ, in which one of the most distressing symptoms was
absent. Other similar cases have been reported elsewhere.

Dr. Coates could not recall the case alluded to by Dr. Levick. He had
no doubt of the correctness of Dr. L/s description of it; but this, like many
other cases, had occurred at a time when taking notes was, from personal
causes, entirely out of the question. Dr. C. had seen several curious cases in
regard to the appendicula vermiformis.

Foreign bodies, such as may obstruct the passages, are more easily tolerated
in the csecum than in any other part of the alimentary canal; from the ana-
tomical and physiological character of the part, this cavity is adapted to quies-
cence, and to the gradual accumulation of feces; the motions for the removal
of which are unfrequent. The part is firmly fixed, well supported in the hol-
low of the os ilii, and but little supplied with nerves, or with irritability of
the mucous membrane. These characters were all exaggerated in the horse,
whose caecum was of enormous magnitude, and adapted to very bulky accu-
mulations from the character of the animal's necessary food.

Dr. C. then mentioned the very large calculus in his possession, the chemical
analysis of which had been published in the proceedings of the American
Philosophical Society by Dr. Boye.

This calculus appeared to be the largest on record. On reference to Berze-
lius, the latter authority was found to state that calculi of a similar description,
weighing 5 or 6 pounds, were not uncommon in the museums of Germany.
The one in question weighed 11 J pounds. It was originally in the anatomical
museum of the Pennsylvania hospital, and was presented to Dr. Coates by the
late Zaccheus Collins, Esq., in the name of the committee in charge, as a mark
of respect for the labour bestowed on the museum by the former. From the
record pasted on the stone, in the handwriting of the late Samuel Coates,
it appears that the horse exhibited no visible signs of disease till within a week
of his death. It occurred in a horse belonging to the late Mr. Peter Adams,
miller, of Montgomery County, Pennsylvania. It was in the collection of an
association called the School of Medicine, and was for several years in the
possession of Prof. Gibson. At a later period, the analysis of Dr. Boye was
made, and discovered it to be a mixture of the palese of cats, with a cement of
phosphate of magnesia, the latter not exactly corresponding, as appears from
the memoir of Dr. Boye, with the atomic proportions of any of the phosphates
of magnesia then on record; Dr. Boye giving his own formula in his paper.
After the process of Dr. Boye, performed on fragments, the mass was sawed
through the middle by Dr. Coates, who found it composed of concentric strata,
No. LXX.— April 1858. 26

390 Transactions of the College of Physicians of Philadelphia. [April

most of them similar in appearance to the external parts, but some of them of
a slate-blue colour, a greater degree of hardness and a finer grain, with less
exhibition of a chaffy structure; all surrounding one of those nails used to
secure the shoes of horses.

Foreign Body retained upwards of Twenty Tears in the Nasal Passage. —
Dr. Hays stated that the interesting case communicated to the College at its
previous meeting by the president, in which a foreign body had remained
four years in the lungs, recalled to his mind a case in which a foreign body
had remained in the nose for, probably, upwards of twenty years, and a brief
notice of which might interest the Fellows.

Some years since I was consulted by a lady of between twenty-five and
thirty years of age on account of ozaena, with which she had been troubled
ever since childhood. The disease resisted various means of treatment, and
I discontinued my visits and lost sight of the case.

About four years subsequently, a Fellow of the College, Dr. Wm. Darrach,
inquired of me if I recollected the case, and stated that the patient had after-
wards fallen under his care, and that finding it very intractable, he had deter-
mined to examine into the condition of the bones of the nose. With this
object he introduced a probe through the nose into the nasal fossae, and while
moving this instrument about there, he accidentally dislodged a mass which
dropped into the opening of the nostril, and by an effort on the part of the
patient was expelled. On examination, it proved to be an old-fashioned glass
button with a brass wire eye.

The mother of the lady stated she remembered distinctly that one of her
sons, when a child, had had a coat with similar buttons.

Dr. D. supposed that the lady, when a child, had been playing with one of
these buttons, had placed it in her mouth, whence it had slipped into her
throat and produced strangling, and that in the effort to expel the button it
had been forced up through the posterior nares and lodged in the nose. Here
as a foreign body it had become a source of irritation, and produced the dis-
ease for which we had been consulted.

Epistaxis arrested by the Administration of Common Salt. — Dr. Caspar
Morris reported a case of obstinate epistaxis, which had yielded promptly to
the use of common salt taken into the mouth in doses of a teaspoonful. The
idea of employing this remedy had suggested itself to Dr. M. while appre-
hending the probable necessity for resorting to mechanical means for the
relief of the hemorrhage. Dr. M. was not aware that it had been employed
in the treatment of this form of hemorrhage, and thought that, though appa-
rently a trifling matter, the hint might prove important in some cases of this
troublesome and sometimes fatal disease.

1858.] Transactions of the College of Physicians of Philadelphia. 391

Placenta Prasvia. — Dr. Rhoads read the following account of a case of
placenta praevia : Having had my attention arrested by an original explana-
tion of the spontaneous cessation of hemorrhage during labour, in certain cases
of cervical attachment of the placenta, offered by Dr. Barnes in a lecture pub-
lished in a late number of the London Lancet, I am induced to lay before
the College the following case as illustrating the views there set forth.

I was called, 9 mo. (Sept.) 9, 1857, to see J. B., who had suddenly been
seized with uterine hemorrhage. She was an apparently healthy woman, the
mother of three children, and believed herself near the fifth month of preg-
nancy with her fourth child. I learned from her that, subsequently to the
birth of her last child, she had suffered severely with inflammation of the
womb, but that she finally regained good health, except having occasionally
some leucorrhoeal discharge.

She had retired that evening in usual health, and was awakened by a sud-
den gush of blood from the vulva, which, however, had somewhat subsided
by the time of my arrival. Under the use of opiates and rest in bed for two
days all symptoms of abortion disappeared; but, on the 13th, the hemorrhage
again occurred more freely than before, with pain in the back and hips. Opiate
enemata, and afterwards pills of opium and acetate of lead, were resorted to;
and she was kept in bed for six days, only then being allowed to go into an-
other room and recline upon a sofa.

Notwithstanding great carefulness, regular labour pains came on during the
evening of the 23d, attended with such profuse hemorrhage that, when I saw
her at 11 P. M., she was already blanched and feeble. The pains, which were
weak and at long intervals, were accompanied and followed by an abundant
discharge of blood, which gradually subsided in the intervals. The os uteri
was sufficiently dilated to admit readily the introduction of the finger; but, as
it was high up and surrounded by clots, no presentation could be perceived.
The motions of the child were distinctly perceptible to the mother, and by the
hand placed upon the abdomen.

As an abortion seemed inevitable, ergot was administered with the hope of
bringing on more active pains. This result followed, the os uteri expanded
to the size of a quarter of a dollar, the peculiar spongy feel of the placenta was
recognized ; and, as the hemorrhage was yet free, a tampon was inserted and
stimulants given.

The tampon controlled the bleeding, and after remaining three hours it was
removed, when the hemorrhage was found to have ceased. The os uteri was
dilated, with the edge of the placenta protruding through it, the remaining por-
tion of the latter being still adherent to the left and posterior part of the cervix.
The finger was passed up beside the placenta to the membranes, which were
ruptured, and the presentation found to be a footling one. Traction upon the
oot was used, and the foetus readily delivered. The placenta still remained

392 Transactions of the College of Physicians of Philadelphia. [April

attached to the uterus, and required to be separated by the hand. Its tissue
appeared to be normal but unusually firm.

Now what is the rationale of this simple yet interesting case? The primary
cause of the abortion was, probably, the unhealthy state of the womb conse-
quent upon the acute inflammation it had undergone as shown by the leucor-
rhceal discharge. The uterine contractions parting successive portions of the
placenta, hemorrhage ensued from both the placental and uterine surfaces thus
exposed ; which hemorrhage was abundant during and just after the contrac-
tions, and subsided in the interval.

The pains were twice allayed by the opiates, but, finally continuing, the
portion of the placenta implanted over the os uteri was wholly detached from
and protruded through it. Now, since the longitudinal fibres of the uterus
contract less near the cervix than towards the fundus, no further disjunction
of the placenta took place; no new source of hemorrhage was supplied; while
the pressure, during the presence of the tampon, had stopped the previously
bleeding vessels by coagula. For the same reason the after-birth remained
adherent after delivery, and required to be peeled off by the hand, the facility
with which this was done proving the absence of any abnormal adhesions.

The remark of Dr. Simpson, that in these cases the child has usually been
long dead, and that hence the vascularity of the placenta and of the parts to
which it is adherent has greatly diminished, did not apply in this case, as the
foetus was certainly alive at the commencement of the labour.

1858, Jan. 6. Melanotic Tumours of various Thoracic and Abdominal
Viscera, without External Evidence of Melanosis. — Dr. Griscom gave the fol-
lowing verbal account of a case, the fatal termination of which he had recently
witnessed : —

On the 3d of 9th mo. (Sept.), 1857, I was asked to see M. M., set. about
58 years, who was then residing a short distance out of the city. I found her
in her bed, with some pain in her right side. She had moderate fever, a rather
harassing cough, with congestion of the lower lobe of the right lung; much
burning of the hands and feet; a tendency to sweat at nights; an exceedingly
irritable stomach, with water-brash and gastrodynia; her alvine evacuations
were light-coloured, and her conjunctivae were somewhat stained with a bilious
tinge. The water-brash was entirely relieved by bismuthi subnit.; her fever
subsided under the use of refrigerant diaphoretics, and she became in all
respects so much better as to ride out, and on the 22d of 10th mo. (Oct.)
came to the city.

She appeared a good deal exhausted by her ride, and continued to suffer
much prostration from slight exertion. She was, however, well enough to be
down in the parlour a part of the time, and acknowledged but little discomfort,
excepting a continual soreness in the right side over the upper surface of the
liver, and a repugnance to all food excepting buttermilk — of this she partook

1858.] Transactions of the College of Physicians of Philadelphia. 893

freely, and seldom rejected it, while every attempt to change her diet was
followed by speedy vomiting. Her pulse during this period was uniformly
about 80, her respiration natural, and very little cough, but her night-sweats
increased ; the burning of hands and feet became intense, and her skin was
rapidly growing pallid. The liver was somewhat enlarged, and pressure over
it gave pain; a hardened mass could be felt in the region of the pyloric
orifice of the stomach.

Towards the close of the year, the pain in her right side became at times
very severe; she was now obviously losing strength, and without any
marked change in her symptoms, she died on the evening of the 4th of 1st
mo., 1858.

Her previous history, as learned principally from a very intelligent acquaint-
ance, is, that at 25 she was a vigorous young woman, with a florid colour and
active temperament, but subject to hemorrhages from the mouth after severe
exertion; the discharge of blood was not accompanied by cough, but was
supposed to come from her stomach. She had been affected with water-brash
and gastrodynia at times for the last twenty years, with precarious appetite
and a very irritable stomach, accompanied by headache ; she had also at times
mild articular rheumatism, but was considered generally to enjoy good health.
About a year ago it was obvious to her friends that her vigour was diminish-
ing, although she did not acknowledge it.

The post-mortem examination was conducted by Dr. Levick, assisted by
Drs. Griscom, Stroud and "Whartenby.

Dr. Levick then exhibited a portion of the diseased structures, and gave
the following description of the appearances observed at the autopsy : —

The exterior was pale; no discoloration; a slight layer of fat in the line of
incision.

Thorax. — Upper portion of the pleura slightly adherent. An unusual
amount of dark pigment matter on the anterior surface of each lung. On
removing the lungs from the thorax, this dark deposit was found in great
abundance, both anteriorly and posteriorly. It appeared to be placed beneath
the pleura, near the surface of the lung itself, arranged in thin curved layers,
corresponding somewhat to the outline of the ribs. Besides being deposited
in this form, there existed also numerous round black tumours, in size varying
from a pin's head to a filbert. From the base of the right lung a melanotic
mass about three-fourths of an inch in length projected towards the diaphragm.

The bronchial glands were enlarged, and full of soft melanotic deposit.

The heart was of natural size, the muscular structure of the right side
having undergone to an unusual extent the fatty degeneration. The valves
were healthy. The aorta contained slight atheromatous degenerations with a
scarcely perceptible discoloration of its lining membrane.

The liver was of a pale violet hue, and imparted a doughy sensation to the
finger. More than thirty black tumours, varying in size from a pea to a

394 Transactions of the College of Physicians of Philadelphia. [April

horsechestnut, were found on the under, and numerous similar masses on the
upper surface of the gland. The interior structure was dotted throughout
with minute black points.

The gall-bladder contained a quantity of dark bile, and a calculus of the
size of a marble. Two masses of a greenish black colour projected from its
lining membrane, and hung loosely into its cavity. In colour, consistence
and general appearance, these closely resembled clots of blood undergoing
decomposition ; but were found, on close examination, to be of the same pig-
mentary formation.

The spleen was enlarged, and of a rich garnet colour.

The pancreas was hard, tumefied, and contained numerous melanotic
tumours.

The stomach was ulcerated near the pyloric orifice ; this latter was much
narrowed. The whole of the lining membrane was dotted with small black
patches. A similar discoloration existed throughout the whole tract of the
intestines.

The kidneys were of natural size, and contained on their outer surface several
small melanotic tumours. Three small black masses hung loosely in the
cavity of the left kidney, while the lining membrane of each pelvis was stud-
ded with minute black patches.

The uterus was in size, &c, natural, but on the anterior and posterior lips
were observed similar black patches encircling the os tincse.

There would appear to have been in this case a remarkable tendency to the
pigmentary or melanotic formation. Every internal tissue examined, with
the exception of the circulatory apparatus, exhibited this. The infiltration,
if we may use the word, extended to both normal and abnormal structure.
That such was the fact, was proved by careful microscopic examination.
Sections of the tumours taken from the liver were found by Dr. S. W.
Mitchell to contain, beside the pigment granules, numerous characteristic
cancer cells. In an examination of the melanotic matter taken from the
different organs by Drs. J. Darrach and Levick, the masses in the kidney and
pancreas were found to consist of cells and granules. The cells were filled
with large granules and had large nuclei, with two nucleoli. The colouring
matter from the lung was deposited in the sub-serous cellular tissue, and con-
sisted solely of granules. This was much darker than that deposited in the
kidney, liver and pancreas. Nitric acid added to the latter produced a yellow
colour; with the former no change was effected. The deposit on the tissue of
the pelvis of the kidney was of the same nature as that in the lung, nitric
acid having no effect upon it.

It will be noticed that though the supra-renal capsule was so much affected,
there was no discoloration of the exterior of the body.

1858.] Transactions of the College of Physicians of Philadelphia. 395

1858, Feb. 3. Annual Report on Meteorology and Epidemics. — Dr. Wil-
son Jewell presented and read the following report: —

The year 1857 has been one of almost unexampled health. With the
exception of scarlet fever, which prevailed to some considerable extent, dur-
ing the first quarter, no fearful epidemic has desolated our dwellings. The
usual endemics have been less aggravated and fatal in their character, while
the march of disease generally has been tardy in its progress, having failed
to return its accustomed complement of deaths.

This acknowledged preservation of the health of our city cannot be attri-
buted to the adoption of any special legislation for the removal of those in-
jurious agencies which owe their origin to large cities, and are ever active in
lowering the natural standard of mortality.

That there are existing causes for this unusual health will be readily ad-
mitted. But whether they are to be sought for in some concealed alteration
of the usual sanitary condition of our city, or have their origin in the me-
teorological and climatic elements surrounding us, which are beyond the
control of the hygienist, is a problem of great interest, but one that we are
not now called upon to decide, as its investigation is of sufficient importance
to entitle it to a separate consideration.

Notwithstanding, however, our apparent immunity from the visitation of
any violent epidemic, it is undeniable that there lurk in our midst numerous
patent, as well as latent disturbing causes, from which it is manifest the
annual harvest of death is made rich. This opinion is verified by the fact
that no less than 2,412 deaths have been recorded, during the year, from
causes which are recognized as removable, or amenable to the observance of
the laws of hygiene — morbid agencies, that would not have a place or a name
upon our professional escutcheon, had we approached even within sight of the
highest aim of the science of hygiene, " to the ultimate line of physiology —
to death without disease." (Blumenbach.)

Few cities in the United States are more favourably located or enjoy a
greater share of health than Philadelphia; and yet the force of circumstances,
as developed by our mortuary statistics, compels us to acknowledge this fact,
that there do exist disturbing influences — secondary causes, producing the
germs of disease, the removal of which are not only neglected by the autho-
rities, but, more than this, they are positively uncared for, it being neither
expedient nor politically profitable, as a municipal measure, to inquire into
their whereabouts and hasten their removal.

It is, or at least it should be, a subject of regret with every intelligent
physician and philanthropist, that "the slow, continuous, increasing inroads
of diseases, less rapid and alarming, but as certain and fatal as they are in-
sidious," should excite so little anxiety and attention in the community.
" The outburst of the epidemic will lead to a spasmodic effort at cleanliness,
but the spirit of vigilance, thus engendered, dies too often with the causes

396 Transactions of the College of Physicians of Philadelphia. [April

which called it forth." [Newman.') The weekly bill of mortality, if read at
all, is read with no apparent solicitude. It calls forth no inquiry. It is only
when the deaths are in excess from any one disease that the attention is
arrested, and even then only for a moment.

It can hardly seem possible, that for every day on an average, throughout
the year, upwards of thirty of the inhabitants of our city should pass away
to the grave, and yet "the mourners go about the streets" unheeded. Nor
does it but seldom, if ever, become a matter for serious inquiry, how many of
these could have been saved an untimely death, by the intervention of a sys-
tem of preventive measures faithfully administered.

It cannot be too frequently repeated that the abuse, neglect, or the viola-
tion of the laws of health, are at all times fruitful sources for a lengthened
catalogue of unnecessary and preventable diseases, as well as for a large share
of the mortality of our city. This annual waste of life, as a sequence of
neglecting the faithful observance of sanitary regulations, is alarming, while
it is not correctly appreciated. Its continuance is a blot upon the philan-
thropy of the people; it impugns their intelligence; it mars their comforts
and saddens their enjoyments of life, and as it should be the first duty of
every government to preserve the health and lives of its citizens, the atten-
tion of the authorities should be frequently directed to the subject, until it be-
comes with them the "great question of the day," and until, through their
investigations, the producing causes shall be corrected, and the evils we have
referred to be removed.

It is to be regretted, in the absence of a registration law, that there are no
data by which we can compare the deaths in our city population with those
in rural districts of the State. It is, however, an established truth, and has
attained an unenviable notoriety, that the proportion of deaths to population
is not only greater in cities, but that the average duration of life in cities is
much below that of a residence in the country.

According to the reports of the Registrar-General of England, and pre-
sented in a statement drawn up by Dr. Guy, the relative mortality to popu-
lation between town and country, is equal to 1 in 15 in favour of a country
life; that is, he shows the rate to be 1 in 52 in the country, and 1 in 37 in
towns. Taking this calculation as our guide, and fixing the death rate in our
city 1 in 45, the average for five years from 1850 to 1854 inclusive, we have
been hurrying to the grave annually 15 per cent, of the deaths recorded in
our mortuary tables from causes peculiar to cities, all of which may be classed
with deaths from preventable diseases. An English writer (Lee) on the com-
parative rates of mortality, has ventured the opinion, " that diseases of the
class termed preventable are not inherent in, essential or peculiar to places
of dense population," and his reasons are, that surplus water and organic filth,
unremoved by drainage, without reference to other considerations, will inevi-
tably increase the rate of mortality. We can readily understand, therefore,

1858.] Transactions of the College of Physicians of Philadelphia. 397

that in the midst of a crowded population, in confined and badly ventilated
neighbourhoods, the poison evolved exerts a fourfold influence over that of
an open and sparsely settled locality, and hence the increased amount and
high rate of mortality in cities.

But it will be impossible, in our limited report, to present this subject in
all its important bearings, as it involves questions appertaining to our physi-
cal, social, and moral interests, which cannot be too highly appreciated or too
ardently investigated. Suffice it to say, that "if the losses from evident ne-
glect in hygienic precautions in our cities could be accurately estimated, the
statements would be astounding."1 During the year under consideration
(1857), in our own city, the deaths known in the classification approved by
the American Medical Association as zymotic, embracing epidemic, endemic,
and contagious diseases, and which are ascribed to removable causes, amounted
to 2,412, or 23 per cent, of the mortality, and of this number, 2,018, equal to
83 per cent., were in children and youth. To calculate the amount of sick-
ness, on which these deaths depended, according to Dr. L. Playfair's theory,
of 28 cases for each death, will involve 47,536 instances of unnecessary sick-
ness. Add to this fearful picture its unnumbered calamities, the broken
down health, the ruinous expenditure, the loss of wealth, of business, of
friends, and the social, mental, and moral sufferings that follow in the train of
evils, and we present but a faint view of the privations experienced in every
community, from an ignorance of the laws of health and life.

To the politeness of our friend, Professor James A. Kirkpatrick, of the
Philadelphia High School, are we again indebted for the following abstract of
his meteorological observations for the year. These observations are made
with great accuracy for the Smithsonian Institution, and from the well known
character of Prof. K. for investigations of this nature; they are entirely re-
liable.

The mean temperature of the year was 53.48°, which is higher by 1.56°
than in 1856; but a very little less, say 0.19°, than for the last six years.
The coldest day of the year was the 18th of January, the mean temperature
being 1°; the minimum temperature, however, 5j° below zero, occurred on
the morning of the 24th of the same month, and was the lowest degree ob-
served for the last six years.

The warmest day was the 14th of August, when the mean temperature
was 87° ; the maximum, 94°, occurred on the same day.

The mean temperature of the month of March was nearly If ° lower than
that of February; the anomaly occurring in the latter month, it being more
than 7° warmer than the mean for six years, while March was but 1\° colder
than usual. The same departure from general laws manifested itself through
all the meteorological phenomena of February. The barometer was nearly

1 Rep. on Hygiene, Trans. Am. Med. Assoc., vol. ii. p. 534.

898 Transactions of the College of Physicians of Philadelphia. [April

half an inch higher. The dew point was 18° higher. The quantity of rain
was less than one inch, while the average amount for the same month for six
vears is 2.647 inches. Notwithstanding this deficiency of rain, the force of
vapor and the relative humidity of the atmosphere were greater than the
average; and the direction of the wind was 29° more southerly than usual
for that month. Indeed, the direction of the wind for the whole year has
been nearly as much S. of W. as it usually is N. of W., as will appear by an
inspection of the table.

The mean daily oscillation of the thermometer was 14.9°, the greatest
being 30° on the 6th of April, and the least 2° on the 20th of February.
The mean daily range of the thermometer, being the comparison of the tem-
perature of one day with that of the same hours of the preceding day, gives
for the year a variation of 5j°, the greatest being in February, and the least
in July.

The range of the barometer was 1.626 inch — from 29.012 on the 26th
of October, to 30.638 on the 12th of February.

The amount of rain that fell during the year was 48.448 inches, nearly 15
inches more than in 1856, and 5 inches more than the average for the last
six years. The greatest quantity of rain in any one month was 8.039 in
August; and the least 0.921 in February. The number of days on which
rain fell was 132; the greatest number in any one month was 18, in June,
and the least 7, in February. Snow fell to the depth of about two feet dur-
ing the year. The greatest snow storm was on the 18th and 19th of January,
when it fell on an average ten inches deep, but was drifted in some places to
the depth of 6 to 8 feet.

The Delaware River was closed with ice about the 22d of December, 1856,
and was not open again for navigation until the 8th of February, 1857.
The latest ice in the spring was formed on the 8th of April. The first in the
fall was on the 15th of November, though there was a pretty smart frost in
the neighbourhood of the city on the night of the 21st of October.

1858.]

Transactions of the College of Physicians of Philadelphia. 399

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400 Transactions of the College of Physicians of Philadelphia. [April

The whole number of deaths for the year (Table I.) in the consolidated
city, embracing the entire county, from all sections of which returns are made
to the health office, were 10,895. Compared with the deaths for 1856, as
shown in our last report to the College, amounting to 12,334, there is a differ-
ence of 1,439, equal to 6.19 per cent, in favour of 1857.

Estimating our population to be 575,000, an increase less than 4 per cent,
for the year, and which, by some statisticians, will be thought quite too low —
the rate of mortality has been as one to every 52 of the entire population,
and to every thousand, as one in 18 J. These rates exceed the natural stand-
ard of mortality assumed by statisticians for cities, that is, 2 per cent., or as
one death to every fifty of the inhabitants. It is well known, however, that
the ratio of mortality is much greater in large cities.

The above estimate for 1857 is one of unusual occurrence, and marks an
almost unexampled state of health during the year. For a series of years the
calculation will present a less favourable result.

In the five years, from 1850 to 1854 inclusive, the average ratio was as
one to every 45 of the population, or 22 in every thousand, which result will
be found a more favourable rate for a series of late years than in any other
city, with the exception of Charleston, S. C, where for eight years, up to 1849,
the average of deaths to population was as 1 in every 52.

The following table will show the comparative mortality of four of our large
Atlantic cities for 1857 : —

1857.

Per ct. of To the pop. To every 1000
Cities. Population. Deaths. deaths to pop. one in every of the pop.

Boston . . 170,000 3,958 2.32 42 23

New York . . 720,000 23,370 3.24 41 32

Philadelphia . 575,000 10,895 1.89 52 18

Baltimore . . 235,000 5,120 2.17 45 21

This statistical index to the comparative health of the cities named, con-
firms what we have already said of the uncommon health of our city for the
past year, and substantiates our assertions elsewhere, that in comparison with
other large cities we are decidedly the healthiest.

In every analytical shape it reveals the fact of our superiority in this par-
ticular relation. Contrasted with New York, the disparity is too obvious to
be misunderstood. The difference in the population of the two cities when
compared with the variation in the deaths forms a striking feature in the cal-
culation.

While the estimated population of New York city is greater by 145,000,
or 11 per cent., than that of Philadelphia, the deaths in the former were
more by 12,475, or 36 per cent., than those in our own city.

The death rate to population presents a like favourable comparison. While
in New York it stood 1 in 41, Boston 42, and Baltimore 45; in Philadelphia
it was 1 in 52, a gain of 1 in every 8 over the average proportion of the other
cities.

1858.] Transactions of the College of Physitians of Philadelphia. 401

The deaths for each quarter averaged 2,723; for each month 908; for every
week 209; for each day 29£, and for every hour throughout the year ljth.

A marked difference, however, exists in the rates of death for the four
quarters. In the third it amounted to 3,269, equal to 18 per cent, over those
for the fourth quarter, which stood 2,186. In the first quarter they were
3,042, exceeding those for the second by 11 per cent. The cause or causes
for these variations in the different seasons will be found in the fact, indepen-
dently of all general predisposing or exciting causes, either internal or external,
that the deaths in the first and third quarters were materially enhanced by the
prevalence of scarlet fever in the former, and cholera infantum in the latter.

The aggregate ages of those who died during the year reached to 221,327
years. This will make the average duration of life 20.31 years for each indivi-
dual. In Boston, the average for 1855 was 19.88, but for the entire State of
Massachusetts it was equivalent to 27.43 years. These calculations serve as
approximate evidence towards the truth of a favourite theory, that the dura-
tion of life is shorter in cities than in country districts. They also aid in
establishing the opinion advanced by statisticians that the duration of life in
cities, instead of increasing, is on the decline. In our own city, for instance,
from 1810 to 1820, the estimate fixed it at 26.25 years, and from 1840 to
1844 it was reduced to 22.01 years, and from that period to the present it has
been annually lessening. A similar result will be found to apply to New
York and Boston. In England, it is also affirmed that, in the application of
the principle to the population of large towns, there is a decline of their vital
energies, their powers of endurance being less, and as a consequence the aver-
age duration of life is diminished.

This early waste of life, as it applies to our own city and to other large
cities in this country, will be found to depend in a great measure upon the
alarming sacrifice of human life in infancy, a reprehensible immolation growing
out of the distribution of evils in every community that are not only preventa-
ble, but at the same time are culpably neglected.

In this city, for the last five years, the mortality in children under five years
of age will average 47 per cent, of all the deaths, In New York it is still
more frightful. For fifty years the average deaths under five years have been
equal to 50 per cent, of the mortality. And if for fifty years, how much more
deplorable within the last few years, when in a single year, according to their
own statement, "in 1853, the excess over one-half the entire number of inter-
ments of all ages in the city reached to thousands." From the City Inspectors'
report for 1854, '55, and 756, it appears that 58.83 per cent, of the mortality
was in infants under five years of age.

During the past year, in our own city, 48 per cent, of the deaths, or 1 in
every 2 and a fractional part that died, were under 5 years. Nor would it be
an exaggerated calculation, to so harrowing an extent have the causes for mor-
tality in early infancy increased, if we should estimate that more than a moiety
of those born in cities are hurried out of existence, perishing prematurely

402 Transactions of the College of Physicians of Philadelphia. [April

before their tenth birthday, the victims of a common neglect of the laws cf
health.

" An unripe liarvest for the scythe of death."

Of 10,000 living children born in England, only 8,461 are alive at the end
of the year; and of 1,000, there remained alive at the end of ten years 534.
Facts like these, a counterpart of which may be found to exist in the large
cities of the United States, where, as it is well known, the duration of life is
greater by 3 J per cent, than in those of Europe, make a forcible appeal to the
sympathies as well as to the intelligence of every physician and philanthropist,
and are arguments of the necessity for an improvement in the sanitary condi-
tion of our city. Blessed as we are with health, in comparison with some
other cities, an examination of our mortuary record still fastens the conviction,
of the unmistakable existence of pernicious causes for the early work of death,
that are removable, and may be reached through the enforcement of a sound
sanitary police. Having pointed to the inevitable necessity for such a reform,
we might inquire, and it is pertinent to the subject, why have not these salutary
measures been enforced? and where lies the fault? The intelligent and ob-
serving physician comes into daily contact with these evils; he analyzes them;
he traces them to their various sources; he points them out to those who have
the rule of the municipality; he teaches the doctrinal truth, that they are
susceptible of amelioration, and in some instances of entire removal, by proper
sanitary precautions that are within the control of human authority; but his
voice is hushed, in the demand for legislation far inferior to that of health
and life, exalted happiness and prosperity ; and he mourns over the indifference
with which his toilsome investigations and his wholesome and humane sug-
gestions are received, or at the ridicule and contempt thrown upon his state-
ments, and thus terminates too frequently his laudable efforts. These inju-
rious influences not being alleviated are annually increasing, because the civil
authorities, either from ignorance, or an unwillingness to consider sanitary
legislation essential to the political interests of the State, close their eyes upon
the adoption of those measures of sanitary reform, which would diffuse the
blessings of health throughout the entire community.

A more correct estimate of the health of our city may, perhaps, be obtained
by confining the calculations to deaths reported from actual disease. For
this purpose, it will be required to exclude those recorded under the following
heads: —

Casualties

. 118

Debility

. 378

Burns and scalds .

. 37

Fracture

. 20

Concussion of brain

7

Malformation

. 10

Exposure

5

Old age

. 195

Drowned

. 134

Stillborn

. 557

Poison ....

2

Unknown

. 291

Strangulation

1

Wounds

1

Suffocation .

9

Heat .

1

Suicide

. 26

Exhaustion .

6

Violence

8

From the country

. 75

Total .

1,881

1858.] Transactions of the College of Physicians of Philadelphia. 403

Deducting this number from the total mortality (10,895), and we shall
have left 9,014 deaths from certified diseases, showing that the mortality from
accidental and other causes, besides disease, amounted to 17 per cent.

Taking the above total as the true standard, we have only 1 death in every
63 of the population, or 16 in every thousand.

Table II. enumerates the deaths occasioned by those diseases peculiar
to the lungs and air-passages. They number 2,961, higher in proportion
than those for 1856 by 2.42 per cent., and are equivalent to 28.13 per cent,
of the mortality for the year, exclusive of stillborn.

The deaths from hooping-cough are appended to this table; they have been
few in number, only 51, a decline of 26 since 1856. The deaths from in-
flammation of the lungs have increased 14 per cent, and congestion of the
lungs 15 per cent, over those for the previous year, while inflammation of the
bronchi have lessened 16 per cent., and croup 2 per cent.

This variation does not necessarily indicate less disease, but is rather an
evidence that the spongy tissue of the lungs has been more liable to fatal
attacks of inflammation than the lining membrane of the tracheal or bron-
chial passages.

Thirty- three deaths, however, are assigned to catarrh and nine to influenza;
the former of these should have been with more propriety charged to bron-
chial inflammation. The latter may have been sporadic cases of influenza,
and are, perhaps, deserving of a distinct notice.

While the ordinary inflammations of the air-passages, as coryza, catarrh, or
bronchitis, have been unusually prevalent in a mild form during the last fall
and first winter months, we have not been advised of the appearance of in-
fluenza in an epidemic shape ; hence the deaths referred to may have been
only the usual catarrhal inflammations in an aggravated form.

The deaths from croup amount to 256, or 8 per cent, of the mortality from
affections of the respiratory organs, and represent a large proportion of the
deaths from diseases in children between the ages of one and ten years, equal
to 8.91 per cent.

Consumption of the lungs, inflammation, congestion and disease of the
lungs make up 75 per cent, of the deaths from diseases of the lungs and
respiratory passages.

In the table (III.) we have prepared in a separate form the annual mor-
tality from consumption of the lungs, designating the sexes and showing the
proportion of deaths for each decennial period.

The various points of interest in the character of this fatal scourge to the
medical historian ; its etiology, nature, pathology and treatment, but espe-
cially in all that refers to its mortality statistics from year to year in this
locality, render it in our judgment deserving of a more particular notice.

No one disease on record in modern times and under ordinary circumstances,

404 Transactions of the College of Physicians of Philadelphia. [April

sweeps off as many of the human family as pulmonary consumption. The
deaths in this city alone, for the last thirty years, have reached the enormous
sum of 24,734; and, according to the statistics of other large cities north of
us on the Atlantic slope, we are more highly favoured than either of them,
in point of locality, for consumptive patients; while, for nearly one-third of
the present century, every day on an average has chronicled 2,258 victims
for the grave from this fruitful source of death. And its insidious, though
certain work, is still progressing.

During the last year, 1857, the deaths were 1,544, showing an increase of
1.40 per cent, over those for 1856, and reaching a higher point than those of
any former year on record by 9.40 per cent.

More than half, or 52.14 per cent., of all the deaths from diseases of the
lungs and respiratory passages were from consumption.

Towards the annual mortality from all causes it contributed 14.17 per cent.,
an increase of nearly 2 per cent, over 1856.

The ratio of deaths to the population was as 1 in every 372.40, and 1 in
2.68 to each thousand.

From every period of life, even within the first year of infancy up to old
age, it claims its subjects. The highest mortality in any one decennial pe-
riod, between 20 and 30, reached 458; the next highest, between 30 and 40,
was 350. These rates correspond with the statistics of other cities, and with
the observations of writers generally, as to the influence of certain periods of
life upon the fatality of consumption.

The first five years of infantile life chronicles 108 deaths from this dis-
ease, and had we a more particular pathological system of certifying as to the
causes of death, this number would in all probability be increased, from the
numerous deaths in children that are now assigned to marasmus and debility.

December furnishes the highest number of deaths from consumption, viz.,
172, and April the next highest, 165. The lowest number, 103, is assigned
to November, and the next minority, 105, to May.

In our former annual statistics, the deaths in females exceeded those in
males by a sensible percentage. In these, however, they are nearly equal,
the males 768, the females 776, a difference of eight only in favour of the
females.

Herewith we append a table of the statistics of consumption for the last six
years, in continuation of Dr. Condie's table, calculated for a period of twenty-
six years, and published in the summary of the Transactions of the College
(N. S., vol. i. p. 261). We have constructed this table upon a similar basis;
that is, making the calculations upon the absolute deaths from disease instead
of the aggregate mortality.

The results of the computation by this method will not be found so favour-
able, during the past six years, for the decrease of consumption in our city,
as the tables of Dr. Condie show for an earlier series of years. Nor will
they present the same favourable estimates as if calculated upon the total of

1858.] Transactions of the College of Physicians of Philadelphia. 405

deaths; which plan we have adopted elsewhere, and is the one we believe
usually pursued by other statisticians in preparing their tables of mortality.
The former system, however, furnishes the fairest indication of the truth, and
as it is a subject of too much importance to be examined carelessly, and
glossed over, we should approach it with strict impartiality in order to secure
unbiased facts.

It will be seen that we have introduced several additional columns, one for
the population of each year, another for the percentage of deaths from con-
sumption to the annual aggregate mortality, as well as the proportionate
number to the total of deaths, that the difference annually may be more
readily compared.

Popula-
tion.

Years.

Total of
deaths.

Deaths from
1 external
j causes, old

age, still-
1 born.

Absolute
deaths
from dis-
ease.

Deaths from
consump-
tion.

Per cent,
of deaths
from do. to
absolute.

Proportion
of deaths
from do. to
absolute.

Per cent, of
deaths to
aggregate
mortality.

Proportion
to aggre-
gate mor-
tality.

409,000

3852

10,155

1532

8,623

1182

13.70

1 in 7.29

11.63

1 in 8.58

415,000

1853

9,711

1615

8,096

1246

15.39

1 in 6.41

12.82

lin 7.79

450,000

1854

11,815

1856

9,959

1378

13.85

1 in 7.22

11.66

1 in 8.50

525,000

1855

10,457

1895

8,562

1327

15.49

1 in 6.45

12.68

lin 7. 88

550,000

1856

12,384

2067

10,267

1501

14.61

1 in 6.83

12.16

1 in 8.21

575,000

1857

10,895

1881

9,014

1544

17.12

1 in 5.83

14.17

lin 7.05

Increase.
166,000
Per cent.
10.869
Average

Per cent.

10,892

1807

9,086
1.864

1363
increase
13.27

15.02

1 in 6.67

12.52

lin 8

By the act of consolidation, our population, as seen by the table, was greatly
increased in 1854. An extensive suburban territory, embracing the entire
county, with its several districts, was engrafted upon our city; from this increase
the mortuary returns were also gathered and computed. This addition of
population, amounting to more than 25,000, would very naturally enlarge the
mortality record. We find that during the period of six years, embraced in
the table, there was an increase of 166,000 inhabitants, equal to 10.869 per
cent. ; but the total of deaths from all causes was not materially increased
while the deaths from consumption increased 13.27 per cent.

In 1852, the deaths from consumption to population stood 1 in every
337.56, whereas in 1857 they were 1 in 372.40, making a gain of 1 in every
34.84 in favour of the decrease of consumption in its ratio to population not-
withstanding in 1857 they stood nearly two per cent, higher than in 1856
But we cannot say as much for their ratio to deaths from disease. The ave-
rage percentage of deaths from consumption to deaths from absolute disease
from 1852 to '57 inclusive, was 15.02 per cent., or 1 in every 6.67 • the
deaths averaging 9,086. Now, for the six years preceding this period or
from 1846 to 1851 inclusive, according to Dr. Condie's table, while the deaths
No. LXX.— April 1858. 27

406 Transactions of the College of Physicians of Philadelphia. [April

from absolute disease averaged 7,254, the percentage of deaths from consump-
tion was 12.60, or 1 in every 8.08 deaths.

Thus it will be perceived that the deaths from consumption have actually
increased, in the last six years, 2.42 per cent, over those for the six years
preceding. We cannot, therefore, congratulate ourselves that the deaths from
consumption are undergoing any favourable change; and, indeed, the results
of our comparative table would seem, in some measure, to verify the predic-
tion of the President of this College, at its meeting in January, 1851, in
reference to the falling off of the mortality from consumption in 1850. At
that period, cod-liver oil was extensively used, and he remarked that its ac-
knowledged effect might only postpone the fatal result, and " consequently
the diminution in the deaths from consumption the past year, 1850, be made
up in an increased mortality from this source, exhibited in the mortuary
tables of some later period."1

The deaths in 1857 have been 9.40 per cent, higher than in any former
year on record.

In the table (IV.) will be found the deaths from those diseases belonging
to the functions and organs of the nervous system. These number 1,792,
thus contributing 17.33 per cent, of the yearly mortality. A large proportion
of the deaths will be found in children ; convulsions and inflammation, con-
gestion and dropsy of the brain — diseases peculiar to infantile life — contribute
1,236, equivalent to 68.97 per cent, of the whole number. To convulsions
alone is charged a heavy percentage. This is one of those diseases prominently
destructive of life in infancy; the deaths amounted to 556, of which 522 were
in children. The first and third quarters of the year bear the heaviest pro-
portions, viz., 141 in the first and 188 in the third. Among the latter, were
many, in all probability, that owed their origin to cholera infantum, and,
with a correct system of registration, would have been found under that
name.

We are of opinion that the term convulsions, as found in our mortuary
tables, is by far too frequently made the scape-goat for the sins of other agents
in the destruction of infantile life. The term is quite too vague to be relied
upon as an idiopathic disease. Very many of the deaths in the record as-
signed to convulsions we believe to have been the result of dentition, cholera
infantum, indigestion, worms, or some pre-existing lesion, the eclampsia con-
stituting a symptom only of the effect of irritation, transmitted to the brain
or spinal marrow, instead of an isolated attack of either of those organs ;
charging to the effect, that which rightfully belonged to the cause.

The diseases of the organs of nutrition furnished 2,236 deaths to make up
the total mortality for the year, as will be found in table (V.). This gives
21.62 per cent, of the deaths, exclusive of stillborn.

1 Transac. College Phys , vol. i>, N. S., p. 258.

1858.] Transactions of the College of Physicians of Philadelphia.

407

The deaths from cholera infantum, marasmus, inflammation of the stomach
and bowels, dropsy, diarrhoea, and dysentery, amount to 1,895, or 84 per cent,
of the whole number.

Cholera infantum, a disease peculiar to large cities, and confined chiefly to
the three summer months, or more properly to the third quarter of the year,
contributed 534 deaths, less by 139, or 11.51 per cent., than the average
deaths from the same cause for the three preceding years. Last year they
stood 6 per cent, to the entire mortality; this year but 5 per cent. On the
other hand, marasmus, which in many instances, as registered, is the sequelae
of other diseases, has the credit of giving 506 deaths, which is 155, or 17.03
per cent, more than the average for the seven previous years.

The deaths in this table, from those diseases belonging to the zymotic class,
the causes for which are looked upon by the sanitarian as preventable, are
equal to 38.63 per cent.

We have again occasion to allude to the marked disproportion of the deaths
from dropsy to those in former years. They here rate 239, even higher than
the previous year (1856), and more than double those for 1854 and '5 com.
bined. The prevalence of scarlet fever during the first quarter of the year
may, to some extent, explain the cause, as a large proportion was in children,
and the heaviest mortality is represented in the first quarter.

The large mortality from this class of diseases during the third quarter of
the year, will not escape notice. They reached 1,198, or more by 160 than
the three remaining quarters united, exceeding 53 per cent, of the total.
This high rate of mortality will be found to have prevailed for a series of
years, must be attributed to the influence of the season upon health, is charged
principally to the several bowel complaints, fall heavily upon the younger
portion of the population, and is due to those diseases included in the class
" zymotic."

The deaths from diseases of the utero-genitai organs will be found in table
(VI.)- They amount to 126; falling below those of the previous year
12.19 per cent. Seventy-seven of these deaths, or 61 per cent., were occa-
sioned by disease of the uterus ; those from other causes were trifling.

Puerperal fever rates 49; less than in 1856 by nearly 17 per cent. The
highest proportion of this mortality, viz., 33, occurred in the first quarter, or
during the coldest period of the year. In the last quarter, when the season
was mild, there is but one death recorded.

The mortality from fevers claims a separate table (VII.), in which we have
registered the deaths for the year, amounting to 1,048, or 10.13 per cent, of
the entire mortality, exclusive of stillborn. This estimate is 2 per cent, less
than that for 1856, when the deaths to the entire mortality were 12 per
cent.

408 Transactions of the College of Physicians of Philadelphia. [April

These returns have been increased nearly two-thirds by the deaths from
scarlet fever, which amounted to 704, or 66.22 per cent.

The opening year was commemorated by the continued prevalence of this
fatal enemy to children, scarlet fever, which had raged so fearfully during
1856. It seemed unexhausted, and persisted in its depredations upon our
infant population until about the close of April, when, having gone through
all its phases, it gave evidence of abatement, and by the close of the second
quarter, J une, its epidemic influence had almost entirely disappeared. From
that period, however, until the close of the year, cases were still occurring,
many of which were fatal, and to such a degree, as to increase the rate of
mortality in children, as shown by the record.

During the last two years of its existence in the city, it has swept off 1,696
of our infant population, which was equivalent to 12.93 per cent, of all the
deaths under 15 years, exclusive of stillborn. This mortality, and the
lengthened period of the existence of the epidemic, justifies us in the conclu-
sion that it has never been exceeded in this city for violence, extent, or dura-
tion by any former epidemic of scarlet fever. Relying upon the estimate of
Dr. Tweedie, that 6 per cent, is the medium of deaths to cases, there could
not have been less than 28,226 cases of the disease within our city during
the two years of its prevalence.

The deaths from typhoid and typhus fevers have conjointly fallen off 13.23
per cent, since 1856. Nor have these fevers prevailed in as severe forms as
in previous years. Assuming a milder type, they have yielded more readily
to treatment. There are two deaths recorded from enteric fever, two from
continued and nine from nervous fever, all of which should have been classed
with typhoid fever according to the nomenclature of Dr. Wood.

Measles contributed 66 deaths for the year, as seen in table (VIII.); less
by one-half than the previous year. On a former occasion we alluded to the
alternate elevation and depression of the deaths from measles from year to
year since 1850. Upon further examination, we find a somewhat similar oscil-
lation in alternate years since 1840. In only two years of this period, em-
bracing 18 years, did they rise above 100. In 1841, they were 119, and in
1856, 141, the maximum mortality. The minimum was 1, in 1843.

The highest rate of mortality for 1857 was, in the first or winter quarter,
53, when it fell suddenly to 11 in the second quarter; and in the third quarter
it fell still lower, to 2. The fourth quarter registered none.

The winter and spring furnished the greatest amount of mortality, and this
rate agrees with all other statistics.

In the next group, table (IX.), will be found the mortality from those causes
which have proved most fatal during the year. Ninety being fixed as the
minimum number.

1858.] Transactions of the College of Physicians of Philadelphia. 409

The fluctuations in this table compared with the deaths in 1856, in the
second column, show a favourable result for the year. Of the thirty-three
causes named, 21 have fallen below those for 1856 in numbers, while the
remainder, 11, have increased.

Consumption of the lungs, the great destroyer of life, supplies the maximum
mortality in the list, and stands 37 per cent, above the next highest, scarlet
fever, which rates 704. Stillborn 557, and convulsions 556, occupy the third
position in the scale, followed closely by cholera infantum 534, while maras-
mus 506, and inflammation of the lungs 504, conclude the list of causes for
death above five hundred.

The deaths from " diseases of the heart," a very general term, embracing
both functional and organic derangement, present a considerable increase over
those of 1856, or any former year, equal in this case when compared with the
previous table to 10 per cent. The deaths from "drowned" also exhibit an
increase of 11 per cent.

Table X. furnishes a numerical analysis of the deaths for the year. Ex-
hibits the monthly mortality and the stillborn, with the sexes in both cases;
also the number of deaths at fifteen distinct periods of life with the per-
centages calculated for each to the total of deaths, exclusive of stillborn.

Of the entire mortality there were 5,873 males, and 5,022 females, bearing
the proportion of 53.91 per cent, of the former to 46.09 per cent, of the lat-
ter, an excess of 7.82 per cent, of the males. In the preceding year, 1856,
the excess was only 3.11 per cent.

The premature and stillborn deaths amounted to 557, or 5.11 per cent, of
the mortality, which is a more favourable estimate than the average for the
seven previous years, which gives 5.21 per cent. The highest mortality of
premature and stillborn children was, in September, 65. The lowest, 36, was
in May. The excess of stillborn children was in males, and was greater than
in any former year, amounting to 123 or 22.08 per cent.

From this table we also learn that the deaths under one year, exclusive of
stillborn, were 2,590, or 25.05 per cent., that up to five years they amounted
to 48.05 per cent. Between five and fifteen only 6.54 per cent.; from fifteen
to forty 22.13 per cent., from which decennial period there is a gradual dimi-
nution of the rates.

By this analysis it will be observed that the mortality was highest in child-
ren under one year of age, amounting to more than 50 per cent, of all the
deaths within the first half decade of life, or five years. * In adult life that
decade between 20 and 30 years shows the greatest percentage of deaths of
any other, amounting to 9.72 per cent.

The heaviest monthly mortality occurred in July, 1,162; of which 52.66
per cent, was under five years; the next highest was in August, 1,146, of
which, also, 58.17 per cent, was under five, a higher infant mortality by 5.51
per cent, than in July. January gave 1,140 deaths, and of these 49.64 per

410 Transactions of the College of Physicians of Philadelphia . [April

cent, were under five years, an unusually large percentage of infant mortality
occasioned by the deaths from scarlet fever, which amounted to 18.34 per
cent, of the monthly mortality. June contributed the lowest rate of deaths,
635, and November the next, 651.

Viewing the returns of mortality with special reference to the different sea-
sons of the year, they indicate that the two summer months, July and August,
and the second winter month, December, with the spring month, April, have
been most fatal to human life. The most favourable to life have been May,
June, October, and November.

It has been so frequently remarked that the value of vital statistics depends
upon their accuracy, that the opinion has ripened into a sanitary aphorism.
The radical defects of our present imperfect system, and the scanty resources
for procuring correct information, debar us the full advantage of this whole-
some truth.

In the absence of a registration act, which would apply to the entire State,
we never can have the vital statistics of Pennsylvania. Even the fragment-
ary statistics of births and deaths, which apply exclusively to our own city,
are so imperfectly furnished, that they are, at the best, only an approximation
to accuracy, not to mention the very meagre character of the tabular form re-
quired to be registered.

Every one interested in the collection and preservation of vital statistics, as
well as those who can appreciate their value, must regret that we are not living
under the guidance of a more complete and enlightened code of laws, both
registration and sanitary, applicable to the prevention of disease and the pro-
longation of life, or that those we already possess are not more zealously ad-
ministered.

As far as the general health law of 1818 applies to our city we have no
serious complaint to oifer. It contains ample provision for sanitary protec-
tion from both foreign and local sources of disease, if the conditions were
strictly carried out. But it is to the indefinite manner in which this law is
enforced that in common with others we make exception. This laxity is
either the result of ignorance, or an erroneous view of the responsible duties
imposed upon those to whom is confided the sanitary protection of the citizens,
as well as the improvement of the public health.

A change in this department of our city government is as necessary as a
registration act for the State. Both are imperiously demanded. The former
as the application of recent events has made singularly clear to the public mind,
needs revision. Like that of a neighbouring city, it has become so tarnished,
so perverted, that it is "a by-word and reproach among all classes of citizens. "
The alone cause for this degeneracy is the too frequent practice of mingling
science and humanity with politics, and of conferring responsible places
"merely as the rewards of party service to men no way qualified by habits of

1858.] Transactions of the College of Physicians of Philadelphia. 411

observation and study for the positions they occupy." (Newman's Report*
San. Police of Cities, p. 44.)

The importance of the latter, a general registration act, we have on former-
occasions commended, and shall continue to make it one of the cherished ob-
jects of our public offerings, until we secure for it the fostering care of the
State. In our estimation it possesses claims for the benefit of legislative favour
that far outweigh those numerous interests that are ever receiving the con-
sideration and patronage of government. Its value to the prosperity of the
State cannot be computed. As a source of happiness to the people it knows
no equal; and as a measure for the improvement of health and the prolonga-
tion of life, the experience of other countries guarantees its value.

The mission of the intelligent physician is not confined alone to the cure of
disease. The preservation of health, and the improvement of our race, lay
claim to a large share of his professional labours; hence we regard it as a prin-
ciple incontrovertible, that the true aim of the medical man, his highest,
noblest, most exalted, and truly philanthropic vocation, is to avert those evils,
both sanitary and moral, physical and mental, within reach of science, that are
destructive to health and dangerous to life; and in this extended field, where
the morbid seeds of sickness are sown broadcast, claim his victory over dis-
ease, and his triumph over death.

Entertaining these views, we would, in conclusion, most earnestly invite
the attention of the College to another trial of their faith, and in an associated
effort with the State Medical Society, endeavour to secure the enactment of a
well-defined and generally approved law, for a State registration of births,
marriages, and deaths.

412 Transactions of the College of Physicians of Philadelphia. [April
Table I. — Mortality for the year 1857, Collated from

DISEASES.

bowels

Abscess

" liver
Albuminuria
Anffiinia
Anasarca
Aneurism .

" of the aorta
Angina pectoris .
Apoplexy .
Asphyxia .
Asthma
Cachexia

Cancer and scirrhus

" of the stomach and
" " liver
" " uterus
Cancrum oris
Caries .

" of the spine
Carbuncle .
Catarrh
Casualties .

Burns and scalds
Drowned
Exposure
Fracture

" of leg
" pelvis
" skull
" spine
Neglect
Poisoning .
Strangulation
Suicide
Suffocation .
Violence
Cholera asphyxia
" infantum
" morbus .
Chorea
Chlorosis
Cirrhosis
Childbed .
Colic .
Coma .

Concussion of the brain
Congestion .

" of the brain

" " liver

" " lungs

" " stomach and bowels

Consumption of bowels

" lungs
Convulsions

" puerperal
Cramp
Croup
Coryza

Coup de soleil
Coxalgia
Cyanosis
Debility
Diabetes
Diarrhoea

Disease of the bladder
" brain
" chest
" ear
" heart
" . hip
" kidneys
" mouth

FIRST QUARTER,
Commencing January 3, 1857.

Jan.

59

Feb. March.

M. F. M

20

1 1

12 15

11

29

91

4
12 I

1

SECOXD
Commencing

April.

M. F

34

May.

M. F,

June.

M. F.

5 4
1 ..
1 ..

Ill 6

1858.] Transactions of the College of Physicians of Philadelphia. 413
Returns made to the Health Office. By Wilson Jewell, M. D.

QUARTER,
March 28, 1S57.

THIRD QUARTER,
Commencing June 27, 1S57.

July.

M. F.

Aug.

M. F

Sept.

M. F

FOURTH QUARTER,
Commencing October 3, 1857.

Oct.

M.

Dec.

M. F

25 1

i i ..

20

1 32
24 ! 19

2 7
15 2

2 .

10

79 136 119
2 3 2

51

10
1
1
1

50S 50S
3 6

302

14

60

56 61
32 25

14

22

13

16 10

'4 "2

19 20

'4 '2

6 S

14 14

326

38
3
45
1
1

66 392
98 106

12

414 Transactions of the College of Physicians of Philadelphia. [April

Table L — Mortality

FIRST QUARTER, SECOXD
Commencing January 3, 1857. Commencing

DIb.hAb.hb.

Jan.

Feb.

March.

a?
"3

■<

Minors.

3 1

s

tri 1

April.

May.

June.

M.

F

M

F

x .

M.

F

Disease ox the leg * . > • |

1

1

1

liver . . . •

1

••

'l

'i

1

2

3

2

1

2

1

lungs . . . .

1

5

2

0

4

10

8

18 !

6

2

2

2

2

" ovaries

H

1

1

2

2

" spine

I

4

3

3

■ "

stoniach and bovrels

*•

2

3

0
-

1

0

" throat . • • ■

1

1

uterus ....

2

2

2

ie

i -

10

1 >

10

. 8

q

35

4i

76

1 -

10

11

9

.5

10

" abdominal ....

• ■

• •

• ■

••

1

1

" of tlie brain ....

12

10

14

8

10

4

'i

57

5S

9

4

7

5

9

D

,; " cliest ....

5

2

2

4

1

9

24

6

5

3

4

" " heart . .

1

1

9

1

Q
O

2

3

3

1

3

3

g

7

io

3

1

3

5

4

0

M

Dyspepsia . ... .

1

Eczema .......

• •

Effusion on the brain ....

3

2

g

g

24

'i

0

2

2

" chest ....

lungs ....

1

1

1

2

2

2

2

1

• ■

Enlargement of the heart .

1

2

3

c

4

10

4

2

1

1

Emphysema . . .

1

Empyema ......

•*

• '

1

2

Q

2

0

X

4

7

's

lo

1

Eruptions

10

22

Erysipelas ... ...

5

3

6

a

13

oo !

g

9

4

2

2

5

2

1

3

4

0

Fever . ■ • . . r . - -

* "

''

•*

1

2

3

1

1

2

2 1

0

" brain ■ . . . • .

••

" congestive .....

■ ■

••

" continued

i

"i

1

1

" enteric • . . . .

" gastric . .

9

'*

9

j

" hectic or inflammatory

••

2

" intermittent ....

'2

2

1

3 !

2

..

'i

i

i

2

d !

'i

" puerperal

10

13

io

27

6

33

i

4

"7

" remittent . .

2

"2

1

*i

1

4

7

'i

3

1

ii3

96

59

67

58

32

7

418

425

39

43

iy

16

ii

22

9

6

14

3

3

7

25

17

42

6

9

8

9

3

1

3

1

1

3

3

5

s

1

1

1

1

1

Fungus hffimatodes ....

1

"i

2

Gangrene

1

1

1

i

2

2

2

1

1

2

1

1

1

2

2 j

" from the lungs

" stomach .

" " uterus

1

2

6

.2

2

9

4

2

2

4

*2

"

1

1

5

3

8 1

2

1

2

2

2

1

1

2

i

1

1

2

2 1

2

1

1

*i

1

1

1

1

1

Icterus . •

Infanticide

" of the abdomen

* " " brain .
n " bronchi
" " chest .
" " heart .

" " kidneys
" " larynx .
" " liver
" f* lungs .
M " peritoneum .

2
1

3

i

10

25

'i

1
2
1

36
1

2

4

2

3

'i

5

i

17
10
1

"
3

19

1 12

'2

5

*3

4
61
1
4

2
8
3
56
20

14
2
IS

*4

67
11
2

1
2
1

119
3

4

23

g

3
4

3

10
4

175

! 23

i
5
1
1

15
17
1
2

*2

34
1

4
2
1

1
1

8
13

"i
1
1

2
43
9

- 1

2
5

2

1

2

7

10
9

2

"2
1

34
5

4

k
:i

r?

2

a

12

1
1

i
1

2S
5

2

p

14
1

2

3

3

2
1

1

13
4

2
1

2

3

1

7
8
2

3
4

2
15
1

3
11
2

1
7
4

1858.] Transactions of the College of Physicians of Philadelphia. 415
for 1857 — Continued.

QUARTER,
March 28, 1S57.

THIRD QUARTER,
Commencing June 27, 1S57.

no

inoj

o

<

1=5

Eh

Julv.

I M. I F.

Sept.

M. I F. M. F.

FOURTH QUARTER,
Commencing October 3, 1S57.

Oct.

M. F.

Dec.

M. F.

6 1 2 1 li 2 1
11 ' 2 1 1 lj

1 6

2 41

7
2

S! 10 15
2.1 2

•• 1

21: 35

13

1 1

2 1

1 1
.-. ..
2

20.

1
1

IS 62
39 53

4

2

1 1
1 3

3 3

5 ; 11

S3 135
6 I 19

13

•2
22

i

16

1 1

2 i

3

105 1 1
20 I

1

1

1

\°.

65

10 II

12 11

ll

32

416 Transactions of the College of Physicians of Philadelphia. [April

Table I. — Mortality

DISEASES.

Inflammation of the pleura
spine

stomach and bowels
throat .
tonsils
trachea
uterus

Influenza
Intemperance
Intussusception .
Malformation

" of spine .
Mania ....
Mania a potu
Marasmus
Measles
Mortification

Obstruction of the bowels

Old age . . .

Ossification of heart

Ozena maligna

Palsy ....

Perforation of the bowels

Phlegmasia dolens

Purpura

Pyasmia

Rickets ....

Rheumatism.

Rupture of bloodvessels

" urethra
Scrofula

Scurvy ....
Smallpox

Softening of the brain .

" V heart .
Sore mouth .

" throat .
Stillborn

Suppression of urine .
Syphilis

Tabes mesenterica

Teething

Tetanus

Trismus

Tumour

" on neck .

" ovarian .
Ulceration

" of leg .
" scalp

stomach and bowels
throat
uterus

Unknown
Varioloid
Wounds
Worms .

Totals

From the almshouse
From the country
People of colour .

FIRST QUARTER,
Commencing January 3, 1 857.

Jan.

M. F

10

15

Feb.

M. F

.vie .<i.i!)

March,

Hi.") UC,

! i s;>

7

SECOND
Commencing

April.

32

May.

June.

313 315

1858.] Transactions of the College of Physicians of Philadelphia. 417
for 1857— Continued.

QUAKTER,
March 28, 1857.

40

26

THIRD QUARTER,
Commencing June 27, 1857.

July.
M. F.

Aug.

Sept.

43

FOURTH QUARTER,
Commencing October 3, 1857.

Oct.

M. F.

12

Nov.

Dec.
M. F.

14

1 4
14 2-1

37

42

23

30

78

36

71

13

3

i

132!)

1

2398

432

1

2

3269

380 308

346 305

47S 369

1073

1113

21S6

418 Transactions of the College of Physicians of Philadelphia. [April

Table I. — Mortality for 1857— Continued.

FIEST QUARTER,

SECOND QUARTER,

Commencing January 3, 1857.

Commencing March 28, 1857.

to

u

to

dul

o i a i

6
a

dul

dial

>-5

<

E-i

i-i

<

u

Eh

Under 1 year .

263

265

203

731

266

166

142

574

From 1 to 2 years

113

111

107

331

109

57

43

209

" 2 to 5 " .

231

142

128

501

125

84

72

281

" 5 to 10 " . x.

82

70

52

204

70

42

37

149

" 10 to 15 " . .

21

23

20

64

21

10

14

45

" 15 to 20 " .

26

31

25

82

23

22

26

71

" 20 to 30 " .

93

95

92

280

104

67

54.

225

" 30 to 40 " .

87

71

71

229

102

55

73

230

" 40 to 50 " . .

59

61

54

174

85

51

45

181

" 50 to 60 " .

55

48

53

156

53

48

47

148

" 60 to 70 " .

37

39

41

117

44

36

42

122

" 70 to 80 " .

43

25

40

108

45

30

22

97

" 80 to 90 " ...

25

11

16

52

22

18

16

56

90 to 1U0

3

3

6

12

7

1

8

" 100 to 110 "

1

1

1 'i

1

2

Total of monthly mortality

1139

995

90S

1070

693 635

Total males for the quarter

1595

1298

" females "

1447

1100

" adults "

1129

1069

" minors "

1913

1329

3042

2398

THIRD QUARTER,

FOURTH QUARTER

Commencing June 27, 1857.

: Commencing October 3,

L857.

tO

00

02

to

9

fab

O

a

Is

>
o

d

o
a

t-i

CO

<j

O
Eh

o

! O

ft

<

o
Eh

Under 1 year

449

479

365

1293

156

177

216

549

From 1 to 2 years

137

173

161

471

90

84

108

282

" 2 to 5 "

89

63

25

177

41

31

55

127

" 5 to 10 "

45

29

15

89

19

11

21

51

" 10 to 15 " .

20

12

16

48

6

9

12

27

" 15 to 20 " . .

36

26

29

91

24

24

29

77

" 20 to 30 " .

100

88

86

274

75

62

89

226

" 30 to 40 "

96

80

81

257

82

76

89

247

" 40 to 50 " .

61

57

64

182

66

56

SO

203

" 50 to 60 " .

49

39

49

137

50

44

54

147

" 60 to 70 " .

39

45

39

123

30

41

43

114

" 70 to 80 "

22

31

18

71

27

18

37

82

" 80 to 90 " . .

16

19

7

42

1 19

13

10

42

" 90 to 100 "

3

5

6

14

4

3

10

"100 to 110 '?

1 -3

1

1

2

Total of monthly mortality

1162

1146

961

1 688

651

847

Total males for the quarter

1776

1204

" females "

1493

982

" adults "

1100

1073

" minors "

2i69

!

1U3

3269

1 "

2186

1858.] Transactions of the College of Physicians of Philadelphia. 419

Table II. — Mortality from Diseases of the Lungs and Air-passages.

DISEASES.

Annual Aggregates.

Quarters of 1857.

1855.

1856

1857

1st

2d

3d

4th

Abscess, pulmonary ....

9

1

Angina pectoris .....

5

5

1

"i

Apncea ......

1

Asphyxia ......

28

28

15

9

3

3

Asthma ......

19

21

33

11

4

7

11

Catarrh . . . .

33

33

Collapse of lungs ....

1

Congestion of the lungs

82

97

132

29

29

29

45

Consumption, laryngeal

1

1

" of the lungs

1327

1501

1544

407

359

386

392

Croup ......

265

268

256

89

65

31

71

Disease of the chest .

10

6

7

4

2

1

" lungs ....

33

37

53

18

14

5

16

Dropsy of the chest ....

48

61

48

14

19

11

4

Effusion on the chest ....

3

7

3

1

2

" lungs

7

4

4

2

Emphysema .....

2

1

"i

1

Empyema . . . . . .

2

1

l

Gangrene of the lungs

"i

1

i

Hemorrhage from the lungs

21

28

18

8

7

2

1

Influenza ......

4

2

9

2

7

Inflammation of the bronchi

Zoo

OKA
ZOV

1 1 9

"TO

i z

53

20

34

" " chest .

10

7

16

3

5

6

2

" " larynx

13

34

14

10

3

1

" " lungs .

442

379

504

175

135

65

129

" " pleura

24

16

27

1

17

4

5

" " trachea

1

9

11

4

5

1

1

Ulceration of larynx ....

2

Totals . . . .

2586

2770

2910

858

727

578

747

Hooping-cough . . . .

90

77

51

14

10

13

14

Totals . . . . .
Total mortality, exclusive of stillborn
Per cent, from diseases of the lungs .
Per cent, from consumption of the lungs

2676

2847

2961

872

737

591

761

9869

11722

10338

26.20

22.77

28.13

13.45

12.80

420 Transactions of the College of Physicians of Philadelphia. [April

Table III. — Deaths from Consumption of the Lungs, during each Month in
the year 1857, at fifteen distinct periods of life, with the Sexes designated
for each month.

3ptember.

AGES.

pi
a

P

!arcli

"3

Pn

cS

0

ugus

ctobe

a

>
O

ecem

u

0

1-5

1-5

>-5

<

o

fi

Under 1 year

1

6

2

4

5

8

3

3

2

34

From 1 to 2 years .

2

6

3

5

2

3

5

8

"2

"i

4

42

" 2 to 5 " .

3

2

5

3

6

3

5

3

2

32

" 5 to 10 " .

1

3

1

2

*2

4

"2

15

" 10 to 15 " .

"i

3

"i

1

"i

1

2

5

"2

3

2

25

" 15 to 20 " .

ii

11

17

4

10

n

14

10

17

9

16

17

147

" 20 to 30 " .

43

42

40

52

29

27

47

37

33

40

23

45

458

" 30 to 40 " .

25

29

35

44

23

19

29

30

27

29

21

39

350

" 40 to 50 " .

19

15

17

25

13

10

16

12

14

12

17

33

203

" 50 to 60 " '.

14

7

12

16

7

14

8

11

13

9

11

15

137

" 60 to 70 " .

6

5

10

6

3

3

5

3

4

8

7

10

70

" 70 to 80 " .

1

2

3

4

3

1

2

2

1

3

1

3

26

" 80 to 90 " .

1

1

i

A

2

5

" 90 to 100 " .

" 100 to 110 " .

Male . .

59

63

76

89

50

40

72

56

70

65

46

82

768

Female ....

68

66

75

76

55

49

68

61

59

52

57

90

776

Monthly totals .

127

129

151

165

105

89

140

117

129

117

103

172

1544,

Quarterly totals .

407

359

386

392

1544

1858.] Transactions of the College of Physicians of Philadelphia. 421

Table IV. — Mortality from Diseases of the Nervous System.

Annual Aggregates.

Quarters of 1S57.

DISEASES.

1855.

i 1856.

1857.

1st.

1

2d.

3d.

1

4th.

. ....

Abscess of the brain ....

o

' ' '. K'
...

i

...

Apoplexy ......

110

123

115

32

33

26

24

Chorea ......

I

1

Catalepsy

1

Coma . ...

2

2

1

1

Compression of the brain .

8

8

Concussion of the brain

l

...

"4
7

A

4

3

Congestion of the brain

175

177

201

59

44

60

38

Convulsions . .

626

603

556

141

121

188

106

Coup de soleil . . .

2

6

6

Cramp ......

11

10

4

1

5

Disease of the brain . . .

97

107

100

33

15

37

15

Dropsy of the brain ....

254

242

173

58

40

66

9

Effusion of the brain .

72

94

92

30

13

39

10

Jjjpnepbj ......

25

24

!.8

15

2

1

Hysteria ......

o

o

Inflammation of the brain .

288

329

306

71

62

105

68

" " tympanum .

1

...

Tvtm to f i fin rif Vifnin mifl ^rnrml mfiwnw

1

Mania or insanity ....

17

1*2

7

3

"i

XlAciUKX U, L/ULL4.

25

43

62

8

19

17

18

Neuralgia . . . '. . .

1

1

Palsv

X cllOJ ......

106

104

92

21

26

29

16

Softening of the brain

90

40

i j.

Q
O

7

1

q
0

" " spinal marrow .

o

.

Teething . . . . .

1*6

29

17

7

3

*6

i

Tetanus ......

17

13

1

5

2

3

Trismus ......

8

2

X\

2

Totals ...

1866

1976

1791

493

399

588

311

Puerperal convulsions

15

2

1

1

" mania . .

2

Totals . . . . . .

1883

1978

1792

494

399

588

311

Total mortality, exclusive of stillborn

9869

11722

10338

Per cent, of total mortality

18.90

16.87

17.33

No. LXX.—April 1858. 28

422 Transactions of the College of Physicians of Philadelphia. [April

Table V. — Mortality from Diseases of some Organs of Nutrition.

Annual Aggregates.

Quarter

s of 1857.

DISEASES.

1855.

1856.

1857.

1st.

2d.

3d.

4th.

, .

Abscess ......

17

40

35

7

13

9

6

" abdominal

1

" of the liver ....

2

1

1

i

Cancer of the stomach and bowels

18

4

7

5

1

1

Cholera . .

33

16

3

...

2

1

" infantum ....

566

722

534

2

10

508

14

" morbus .....

29

35

10

1

9

Cirrhosis of the liver

7

6

3

1

1

1

Colic

8

17

7

3

2

1

1

Constipation .....

2

3

Consumption of the bowels

,4

3

5

4

1

Diarrhoea . .

177

149

119

12

18

66

23

Disease of the liver ....

25

27

41

7

6

9

19

" stomach and bowels

20

27

17

5

6

J

3

Dropsy .

110

213

239

76

57

45

61

" abdominal ....

31

8

6

2

4

Dysentery ......

266

301

198

15

18

144

21

Dyspepsia . . . . .

1

2

1

1

Gout .......

4

7

5

1

2

1

Icterus . . . .

27

21

11

4

5

2

Lleus .......

4

1

Inflammation of the liver . . .

38

39

25

"i

i'i

id

" " peritoneum .

54

68

56

23

19

10

"i

" " stomach and bowels

187

184

299

70

65

98

66

Intussusception .....

7

6

4

3

1

Marasmus ......

436

484

506

88

86

231

101

Obstruction of the bowels .

13

9

o

1

1

Scrofula ......

54

61

51

23

10

13

"5

Tabes mesenterica ....

28

36

44

7

4

24

9

Tuberculosis .....

6

Ulceration of the stomach and bowels

21

is

6

*3

"i

'*2

Totals

2196

2503

2236

361

343

1198

334

Total mortality, exclusive of stillborn

9869

11722

10338

Per cent, of total mortality

22.35

21.35

21.62

1858.] Transactions of the College of Physicians of Philadelphia. 423

Table VI. — Mortality from Diseases of the Utero- Genital Organs.

DISEASES.
-

Annual Aggregates.

Quarters of 1857.

1855.

1856.

1857.

1st.

2d.

3d.

4th.

Albuminuria .....

6

9

7

1

4

2

Amenorrhcea .....

2

...

Cancer of mammas ....

7

2

" uterus ....

18

5

'*4

"3

i

Childbed . . .

2

2

7

2

"3

2

Chlorosis . . .

1

2

1

1

Convulsions, puerperal

15

2

1

1

Diabetes ......

7

4

"i

"i

Disease of the bladder

i

"i

1

1

" kidneys . ,

3

16

8

3

2

2

i

" ovaries

3

1

2

0

" prostate gland

1

1

" uterus

3

5

*2

"2

Dropsy, ovarian ....

-i
i

-|

Fever, puerperal ....

41

69

49

33

12

*3

i

Xiciiiui i iici li um uici U3 • • •

13

7

5

2

2

1

Inflammation of the bladder

5

8

9

1

3

"5

" " kidneys

4

7

7

"3

g

1

" " prostate gland

1

" " uterus

8

15

"8

5

"2

"l

Mania, puerperal ....

2

Rupture of the bladder

1

" urethra

1

i

"i

" uterus

3

Stone in bladder ....

1

Suppression of urine

"3

"3

Syphilis

4

5

2

"i

"i

| Tumour, ovarian ....

2

1

1

1

Ulceration of the uterus

1

1

"i

Totals

148

161

126

66

30

16

14

424 Transactions of the College of Physicians of Philadelphia. [April

Table VII. — Mortality from Fevers.

DISEASES.

Annual Aggregates.

Quarters of 1857.

1855.

1856.

1857.

1st.

2d.

3d.

4th.

Fever ......

16

10

3

3

" bilious . . . . :.

36

24

25

2

3

7

13

i( cerebral . . . .

2

2

1

1

" congestive ....

7

3

5

I

3

" continued .

1

2

*2

" enteric .....

2

2

" gastric .....

"i

"i

4

2

1

'l

" hectic .....

4

2

2

2

" intermittent ....

7

14

5

3

2

" malignant ....

2

" nervous .

2

7

*9

"3

1

5

" pernicious ....

2

*f puerperal .....

41

69

49

33

12

"3

i

" remittent .....

48

22

23

7

5

4

7

" scarlet . . . . .

163

992

704

425

153

60

66

" typhoid .....

231

229

175

42

36

45

52

" typhus . . .

59

49

38

8

5

11

14

" " icterodes

5

" yellow

"3

Totals

Total mortality, exclusive of stillborn
Per cent, of total mortality

628

1428

1048

530

223

135

160

9869

11722

10338

6.30

12.18

10.13

Table VIII.— Mortality from Measles.

DISEASES.

Annual Aggregate's.

Quarters of 1857.

1855.

1858.

1857.

1st.

2d.

3d.

4th.

Measles . • ' y •

24

141

66

53

11

2

1858.] Transactions of the College of Physicians of Philadelphia. 425

Table IX. — Causes assigned for Death where the number is 90 and

upward.

DISEASES.

Annual Aggregates.

Quarters op 1857.

1855.

1856.

1857.

1st.

2d.

3d.

4th.

Apoplexy ......

110

123

115

32

83

26

24

C^.si <*n nl ti pq

vojcuainco ......

102

158

118

21

19

35

43

Cholera infantum . . . .

566

722

534

2

10

508

14

V^UiloUill U tlUIl UI lllv> ILllJ^o • • •

1327

1501

1544

407

359

386

392

P!nn orp<?ti nn nf flip hrnin

175

177

201

59

44

60

38

i 6 ( t Inn cr<2

i.UIJgb .

97

132

29

29

29

45

Convulsions .....

626

603

556

141

121

188

106

265

268

256

89

65

31

71

uauiiiiy ......

393

430

378

91

75

115

97

Diarrhoea ......

177

149

119

12

18

66

23

Disease of the brain ....

97

107

100

33

15

37

15

ft lion T>f

170

179

222

49

47

50

76

Dropsy

136

213

239

76

57

45

61

Ui Lilt/ UI <L1U • • • •

254

242

173

58

40

66

9

Ti-trcpntpTTr

1/ yoclliCl Y ......

266

301

198

15

18

144

21

Effusion on the brain ....

94

92

30

13

39

10

T^vtroi y~ip1 o a

IMjbiptUclQ .....

100

95

35

28

15

17

Fever, scarlet .....

163

992.

704

425

153

60

66

" typhoid .....

231

229

175

42

36

45

52

Hooping-cough .

90

Inanition . . .

104

li'i

Inflammation of the brain .

288

329

306

71

62

105

68

" " bronchi

233

250

179

72

53

20

34

" " lungs .

442

379

504

175

135

65

129

" " stomach and bowels

187

184

299

70

65

98

66

Marasmus ......

436

484

506

88

86

231

101

Measles . . .

141

Old age . . . . .
Palsy . . . .

172

172

195

45

40

61

49

106

104

92

21

26

29

16

Smallpox . . . .

281

390

Stillborn

588

612

557

129

125

167

136

Unknown ......

220

257

291

85

78

71

57

Drowned ......

106

105

134

3

44

70

17

426 Transactions of the College of Physicians of Philadelphia. [April

1

1140
995
907

1070
693
635

1162

1146
961
688
651
847

10895

1

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CM l — ! rH CM rH rH i — 1 rH r- 1 rH rH

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Stillborn.

■fejoi

Cqi^©OiCO©CO©iOrHOCD
^^TH-HHcOTHcOCOCOTflCOO

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rH CM rH rH t-H CM CM rH CM rH rH rH

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605
525
465
602
380
316
637
610
529
380
346
478

CO

1-

00

to

rH

OS
co'
to

Months.

January .

February

March .

April

May

June

July .
August . .
September
October .
November
December

Totals .

Percentages to totals

1858.]

427

REVIEWS.

Art. XVII. — Clinique de V Hopital du Midi — Lecons surle Chancre, pro-
fessees par lc Docteur Ricord, redigees et publiees par Alfred Fotjrnlek,
Interne de 1' Hopital du Midi, Paris, 1858. 1 vol. in 8vo.

Clinic of the Midi Hospital — Lectures on Chancre, delivered by Dr. RiCORD,
collected and published by A. Fournier, House Physician of the Midi
Hospital, Paris, 1858. 1 vol. 8vo.

This work contains many facts in proof of the doctrines formerly proposed
or maintained by M. Ricord, and the avowal of the adoption of some new
doctrines which the lecturer had opposed for many years. In the first lecture
M. Ricord states that he has changed his views on various points, and he
quotes the French verse, which declares, that he who never changes is ab-
surd. This is something new for the great syphilographer, who has hitherto
been very pertinacious in his opinions. Y\Te congratulate him upon his
change of views, and must add, that we think he has not changed enough, as
we propose showing hereafter.

M. Ricord maintains that a chancre is the sole origin of syphilis, except
when inherited. He insists upon the analogy of chancre and syphilis, on
one side, and the bite of a mad dog and hydrophobia on the other. He
still affirms that a chancre results always from a chancre, and cannot generate
anything but a chancre. The pus of blennorrhagia, of bubo, of a fiat pus-
tule, he still considers as incapable of generating a chancre and syphilis.
But he has given up the important doctrine which he had been so ardently
teaching for twenty-five years, that there is but one kind of chancre. He now
admits that there are two distinct species of this affection, and, with his usual
power of argumentation, he brings forward many reasons to support his new
view.

It is known that, before and since the time of Hunter, until the beginning
of this century, it was almost universally believed that the varieties in the
consequences of a chancre were dependent upon the differences of constitu-
tions, of sexes, ages, etc. In our century, Carmichael was the first who
disbelieved in the unity of the virulent principle, but he erroneously maintained
that there were four species of chancres. Two pupils of M. Ricord, during the
last eight or ten years, have tried to prove that there are two kinds of chancre.
One of these syphilographers, M. Bassereau, insists upon the existence of one
of these species among the Greeks and Romans j it is the simple contagious
ulcer of the genital organs, while the other, the indurated, the infecting chancre,
the only origin of syphilis, is a new affection.

The other pupil of M. Ricord, M. Clerc, does not believe that there are posi-
tively two species of chancres, but he admits two distinct varieties of the same
virus. One of them produces the indurated chancre, the other the simple or
non-infecting chancre. They both are usually transmitted as a distinct patho-

*

428 Reviews. [x\pril

logical species; but the simple chancre he thinks to be the result of the inocula-
tion of an infecting chancre in a person who has, or who has had constitutional
syphilis, and that it is the analogue of varioloid, so that he proposes to call it
chancroid.

M. Ricord points out the great differences of the species of chancre as re-
gards their symptoms, their relative frequency, the places where they are
found, their treatment, etc. As regards frequency, the non-infecting variety,
the simple chancre, is by far the most frequent. During three months at the
consultation of the Hopital du Midi, out of 341 cases of chancre there were
126 indurated or infecting, and 215 simple. M. Puche, from 1840 to 1852,
has seen only 1955 indurated chancres, and 8,045 simple chancres, out of
10,000 cases. This is a fortunate result if it be true that the simple chancre
never produces syphilis.

M. Ricord explains the great relative frequency of simple chancres : 1st.
By the fact that they secrete pus which is more active and preserves longer
the power of contagion than that of indurated chancres. 2d. They may exist
many times on the same person, whilst indurated chancres, generally, do not.
The learned teacher insists upon the impossibility of any one escaping the conta-
gion of a simple chancre, if well inoculated with the fresh pus of this ulcer
while it is at the period of virulence. In this, we think that he is mistaken,
and the inventor of syphilization, M. Auzias-Turenne, and many other able
and respectable physicians, such as Bceck and Sperino, have shown that men
and children saturated with syphilis, or si/philized, to use the new term, cannot
have any kind of chancre.

M. Ricord used to assert that chancre may be produced anywhere on the
surface of the human body; now that he admits two kinds of chancres, he
makes the important affirmation which is confirmed by his colleagues at
the Midi Hospital, which is, that the indurated chancre may appear any
where, but, strange to say, the simple chancre never occurs on the head (either
on the face or the cranium). He has shown it to his pupils on the genital
organs, on the thighs, on the legs, on the arms, on the abdomen, on the back,
on the thorax, etc.; but for twenty-five years he has never met one on the
face or on the cranium. On the contrary, he has seen the infecting or indu-
rated chancre on all the parts of the head, on the lips, on the tongue, on the
eyelids, on the forehead, on the nose, and even on the top of the head.

M. Ricord insists on the strange fact that the superficial lymphatic gangli-
ons are alone attacked, and in cases of simple or non-infecting chancres are
alone the seat of suppurative inflammation. It seems that the influence of the
absorbed matter is lost after it has acted on the first lymphatic glands that
it meets. This is the more strange, since the pus of a bubo can engender a
simple chancre, and, therefore, it seems to be similar to the pus which has
been conveyed to it by the lymphatics. How is it, then, that carried, as it
must be, to deeper lymphatic glands, it does not produce there a suppurative
bubo ?

The capital fact, however, concerning bubos is the radical difference between
those due to non-infecting chancres and those produced by infecting chancres.
In the first place, the simple chancre does not always give rise to the formation of
a bubo ; while it is not so in the case of an infecting chancre, which constantly
produces one or several bubos. The non-infecting sore produces an acute bubo,
i. e.f an inflammatory painful one, progressing rapidly towards suppuration,
capable of producing a real ganglionary chancre. Besides this, bubo exists gene-
rally, only in one of the glands of the region where it appears; it is an adenitis

1858.]

Ricord, Lectures on Chancre.

429

mono-ganglionary. M. Fournier states that out of 207 patients affected with
simple chancres, there were 65 only who had a bubo, and 142 without. The
pus of such a bubo can generate a simple chancre when inoculated. On
the contrary, the bubo due to an infecting sore, which very rarely gives
origin to pus, does not then furnish a purulent matter capable of producing
chancre when inoculated. This last bubo is indurated and is in this respect
analogous to the chancre from which it originates; it is multiple, painless, and
without inflammation. It appears precisely at the time that the induration
becomes evident around the chancre.

An infecting chancre is usually single, while the non-infecting sore is mul-
tiple either at first, or in consequence of the inoculation of neighbouring parts
by the pus of the first ulcer. This last is the kind of chancre which tends
to extend and to destroy tissues ; it is the most liable to acquire the phagedenic
character. The indurated chancre is quickly limited, and spontaneously pro-
ceeds to cicatrization; its pus promptly loses its virulent power, at least upon
the person on whom it exists.

M. Ricord adds to the above differences the following: The simple chancre
may, perhaps, be transmitted to inferior animals, while the infecting ulcer can
only be transmitted to man. The first can be reproduced indefinitely on the
same person, the second it seems cannot exist more than once. Besides
the first originates only from its own variety ; and the second, also, results
only from a similar one; but in a syphilitic patient, the infecting chancre ori-
ginates in an ulcer with a soft basis, which looks like a simple non-infecting
chancre. In this last case, however, we have proof that the infecting sore,
although it has not its characters, does not lose the power of generating, for
when by contagion the pus finds a virgin soil it produces an indurated chancre.

M. Ricord insists on the importance of these differences in relation to the
prognosis and the treatment. As regards prognosis it is quite evident that
it is of the utmost importance to be able to determine, as it is usually easy
from the absence or presence of induration to do, that a chancre will be a
simple local affection, or that it is the beginning of syphilis.

Although facts have been published which militate against the opinion of
M. Ricord, that a man who has had an infecting chancre cannot have another,
he resists the interpretation, and he has found a plausible way of getting over
most of these facts. The facts to which we have alluded are the following:
if an individual who has had syphilis be exposed to the contagion of an infect-
ing chancre, a simple sore is produced, but he transmits to others who have
not had syphilis an infecting chancre. Mr. R., therefore, admits the possi-
bility of a person who has, or has had, constitutional syphilis having a
simple sore, but he still affirms that such a person cannot have an indurated
chancre. He thinks that this apparently simple sore, however, is the source
of a kind of pus, which, when finding, what he calls, a virgin soil, will act as
the pus of the infecting ulcer would have done which had caused this simple
sore. In this respect M. Ricord will have to change again, as there are, at
least, some few facts proving that an indurated infecting chancre may exist
with all its characteristics in a person who has had syphilis.

Practitioners who are not willing to admit that a simple, soft chancre is
never the origin of syphilis, are not aware, according to M. Ricord, of many
circumstances which this able observer points out as the causes of their error.
In the first place, there are some anatomical regions where it is difficult to
ascertain the existence of induration, when we are not accustomed to detect
it. This is the case as regards the mucous membrane of the vagina, the car-

430

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[April

unculce myrtiformes, the anus, etc., where the induration may he extended in
surface hut is not deep, and resembles a piece of parchment ; sometimes it is so
thin that none but those much accustomed to it can detect its presence.
In the second place, indurations in the above named regions disappear very
quickly, and often before cicatrization. These are the causes of mistake which
have led some persons to say that infecting chancres had no induration in
women. M. Bicord insists upon the complete similarity of induration in
women and men in all the parts of the body common to the two sexes; and
he remarks that on the external parts (clitoris, etc.,) of the female genital
organs the induration is deep, well marked, and lasting. So it is also on the
uterus.

Cauterization of a soft sore may produce such an induration around it, that
it is almost impossible to distinguish it from an infecting chancre. The diag-
nosis in such a case may easily be established by the bubo.

An important fact concerning the differences between the two kinds of
chancres results from the comparative analyses of the blood. M. Grassi,
under the direction, and at a time when the eminent syphilographer had not
yet admitted the existence of the radical difference which he now acknowledges
between the two species of chancres, had found that the blood remained nor-
mal, or nearly so, in cases of simple sores, while the absolute quantity of
globules is notably diminished, and that of albumen increased, in cases of in-
durated chancres.

If simple chancres never give origin to syphilis, and if this kind of chancre
is much more common than the other, it may readily be understood how mis-
chievous it is to give mercury, at once, and indiscriminately to every patient
attacked with chancre whatever are its characters.

A soft, non-infecting chancre needs only local treatment, but it requires
very active and careful treatment on account of the dangers of phagedenism.
M. Bicord says that the whole secret of success in healing such a sore, is to
transform it from a specific, virulent ulcer, into a simple and non-virulent one.
To attain this end cauterization is the best means; but a deep, a thorough
cauterization, not a slight superficial one, is necessary. The caustic must be
spread not only over the whole surface of the chancre, but also a little further.
All the mild caustics are inefficient ; it is necessary to employ a destructive
caustic. M. Bicord has successively employed the Vienna paste, potash,
nitric acid, the red-hot iron, etc.; all of which have some inconvenience; and
he proposes a new agent, which he thinks to possess marvellous efficacy and
to be unobjectionable in any respect. This caustic is sulphuric acid, united
with powdered vegetable charcoal, in the proportions necessary to make a half
solid paste. Applied to chancres, this paste soon desiccates and forms a kind of
crust, which remains attached to the tissues and adheres for many days after its
application, not separating usually until the second week. When the caustic
becomes detached, the ulcer is nothing but a simple one without virulence,
and very quickly progressing towards cicatrization. Sometimes the work of
repair is almost completely achieved before the fall of the crust, and it is not
rare to find the cicatrix already formed.

This caustic unfortunately causes much pain, but the pain is much less than
that produced by nitric acid or the red-hot iron, and it persists for a shorter
period than that resulting from the application of the Vienna paste. M. Bicord
insists upon the immediate application of the caustic without the least delay ;
but, sometimes, patients are not willing to be cauterized. He then makes use
of lotions with aromatic wine, and dresses the ulcer with charpie saturated

1858.]

Ricord, Lectures on Chancre.

431

with this medicine. When there is a tendency to phagedenism, M. Ricord
employs tartrate of potash and iron; his prescription is the following: —

1st. Take every day three tablespoonsful of the following solution : Distilled
water, 200 grammes (6 ounces); tartrate of potash and iron, 30 grammes
(1 ounce).

2d. Dress the ulcer or ulcers twice a day with charpie saturated with the
above solution.

M. Ricord says that nothing can be more hurtful to soft sores than fatty
substances. The mercurial ointment is an irritant which is one of the most
frequent causes of phagedenism ; mercury is a very dangerous remedy against
this kind of chancre. When the soft ulcer exists in the urethra, M. Ricord
at first tries to diminish the inflammation, and he states that camphor, bella-
donna, digitalis, lupulin, etc., have no power in this respect, and that they do
not prevent erection. He orders the application of from 15 to 20 leeches on
the perineum or on the penis, baths, and abundant drinks. When the in-
flammation is diminished, he orders injections into the canal of a mixture of
aromatic wine and a decoction of poppies. If there is irritation caused by
this injection, he employs pure aromatic wine.

As a local affection the indurated chancre is to be treated almost as the
non-infecting ulcer, and even more simply. Regular dressings with aromatic
wine or calomel ointment may be quite sufficient, as the ulcer usually tends
to spontaneous cicatrization. But here, much more than for the soft chancre,
cauterization in the very beginning is of tj|e greatest importance. The general
infection not being an immediate result,^ it has so often been erroneously
said, the same thing must be done as after the bite of a mad dog, or of a venom-
ous snake, i. e. to destroy the infecting principle, as Hunter long ago taught.
M. Ricord proclaims that all the chancres which be has cauterized or which
have been cauterized in his presence from the first to the fourth day after
contagion, none have been followed by symptoms of constitutional syphilis.
It results from this that the syphilitic virus is not absorbed before the fourth
day after contagion.

It is important to add here to the assertions of M. Ricord, the testimony
of a distinguished physician of Vienna, Prof. Sigmund, whose practice is as
large as that of the Paris teacher of syphilography. The observation of more
than a thousand cases in a period of 11 years, has proved to Prof. Sigmund
that there are never secondary symptoms after the complete destruction of
chancres during the first four days. He says also that he knows of but two
cases, which even seem to be doubtful, in which the cauterization made on the
fifth day has not prevented the appearance of secondary symptoms. He cauter-
izes even after the fifth day, because he thinks that the chances of preserva-
tion are not entirely lost, and also with the view of preventing the communica-
tion of the disease to others. M. Ricord, on the contrary, neglects cauteriza-
tion so soon as induration has appeared, because he thinks that then the
virus has been absorbed. The treatment, after induration has appeared, ac-
cording to M-. Ricord, should always consist in the exhibition of mercury,
which is given either internally or by frictions on the skin, or pulmonary
inhalations. M. Ricord thinks that mercury should be given at once when
there is no doubt about the nature of the chancre, but if there is the very
least doubt, he insists upon the importance of waiting some time, so as to
be quite sure whether or not there is a real syphilis. He proposes to wait
a few weeks, if nothing appears, and if two, three, four months pass away
without any manifestation of syphilis, then we may be sure that the doubtful
ulcer was not an infecting one, and it is possible for the physician to give to

432

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the patient the positive affirmation that he has not had syphilis; while if
mercury had been employed it would have remained doubtful whether it had
prevented the disease manifesting itself, or done nothing if the disease was
not present. And now, as mercury may fail to prevent the future develop-
ments of this horrible affection, it is easy to understand what a social import-
ance there may be for the patient to have his mind relieved of all doubts in
regard to such a danger.

M. Eicord not only thinks that it is unnecessary to salivate a patient to
cure .him, but that the curative influence of mercury is generally suspended
when the morbid symptoms due to mercury show themselves. The great
Hunter had already asserted the same thing, but a great many physicians
ignore or forget, or wrongly deny the correctness of this assertion.

Concering the treatment of salivation, there is in the work we are reviewing
a paper on the use of the chlorate of potash, by M. Fournier, the house
physician, to whom we are indebted for the publication of these lectures of
M. Eicord. M. Herpin, of G-eneva, and, after him, M. Demarquay, have
pointed out the great benefit to be derived from the use of chlorate of potash
against mercurial stomatitis. But these practitioners at the same time that
they employed this medicine ceased the use of mercury. M. Eicord has per-
sisted in the exhibition of mercury while he gave chlorate of potash, and the
result has been that the salivation, the tumefaction of the gums, the ulcerations
of the buccal mucous membrane, the pain, etc., have disappeared in a few days.
It seems, therefore, that chlorate of potash is a real specific against mercurial
stomatitis. Besides, it seems from facts recorded by M. Fournier that chlorate
of potash may be regarded as a preservative of stomatitis ; and also that the
curative influence of mercury appears not to be diminished during the exhala-
tion of chlorate of potash. This substance is to be given internally, 6 grammes
(nearly 5 scruples), in a potion of 200 grammes (6 ounces).

It is well known that M. Eicord, as well as most physicians now, have
completely abandoned treating the tertiary symptoms of syphilis with mercury.
Iodide of potassium is the only medicine which M. Eicord employs against these
symptoms. He thinks it is a great mistake to give enormous doses of this
medicine, as some French physicians have done lately; but he uses larger
doses than Amerian practitioners are accustomed to employ. During the three
or four first days he prescribes 3 or 4 grammes (about 1 drachm) of iodide
of potassium a day, and afterwards he increases the dose to 5, 6, or 8 grammes
(4 to 6 or 7 scruples), or even more a day.

In the commencement of syphilis, M. Eicord's rule of treatment consists in
giving mercury for six months, and iodide of potassium for three months.

These are the most interesting facts and views to be found in the Lectures
on Chancre. We regret that M. Eicord leaves us in the dark concerning
two important points. The first of these consists in the doctrine long held
by this eminent syphilographer regarding the loss of contagiousness of infect-
ing chancres, when they are becoming mucous papulae. M. Eicord had
certainly well proved that the matter of these chancres, when inoculated on
the person upon whom they exist, does not produce a chancre, but he had
concluded that the same innocuity would exist on other persons. Many un-
fortunate consequences have been the results of the admission of this view as
a well founded one, particularly among French medical students. It is yet to
be determined at what time the muco-purulent matter of mucous papulae, re-
sulting from infecting chancres, can propagate syphilis ; and the energetically
maintained doctrine of M. Eicord, that a chancre alone can originate a chancre,

1858.]

Smith, Stricture of the Urethra.

433

must be considered as not absolutely correct, unless we term mucous papulse
of recent formation, still producing muco-pus, chancres.

There is another question which M. Ricord has not solved, and this is a
capital one ; it consists in the admission of the existence of one or two kinds
of chancrous virus. It would seem from so many statements made by the
learned teacher on the differences between the two kinds of chancres, that he
must admit that there are two kinds of virus. He declares, however, and rather
obscurely, that we must wait and not try now to solve this question. As
regards the existence of one or two syphilitic poisons, he is more decided and
he declares positively that there is but one kind of syphilis. It seems to us
that the solution of this question is also the solution of the other. If truly
there is one kind of chancre which never gives syphilis, as M. Ricord affirms,
and if there is another kind which always leads to syphilis, when not at first
properly treated, it is certain that there are two species of chancrous virus, a
syphilitic one, and another which is not syphilitic.

Except the portion of these lectures on chancre in which there is obscurity
and indecision relating to these doctrinal questions, this work is a model of
clearness in the exposition of almost all the views of the lecturer. It contains
many interesting cases as proofs of these views; and both teachers and prac-
titioners will find in it much which may prove useful to them. It furnishes
the reader besides the lectures, several additional documents of great interest,
and particularly various statistics collected by M. Fournier, the intelligent
pupil of M. Ricord, to whom we owe this work. E. B — S.

Art. XYIII. — On Stricture of the Urethra. By Henry Smith, F. R. C. S.,
Surgeon to the Westminster General Dispensary, formerly House Surgeon
to King's College Hospital. London, 1857 : pp. 280.

Mr. Smith intends his treatise, as he declares in the preface, to be strictly
practical, and to be restricted almost entirely to the exposition of his own
views on the various points connected with the disease of which it treats. He
trusts

"That the opportunities afforded to him as pupil, as house-surgeon, and as
visitor in the wards of King's College Hospital for ten years, by experience
among the numerous patients of two large public institutions to which he has
been successively attached for eight years, by attending many cases in his
own private practice, and by making use of the very valuable advantages
offered to him in the capacity of private assistant to Mr. Ferguoson for nearly
ten years, will entitle his opinion to a favourable consideration.'"

Two hundred and twenty pages of the work are devoted to the treatment
of strictures of the urethra. The author

" Not having considered it necessary, in a treatise which is intended to be
strictly practical, to dwell at any length upon the anatomy and physiology of
the sexual organs and "some points in connection with the pathology of the
disease have been but slightly noticed."

This work is a valuable one in many respects ; some modes of treating
stricture, particularly cauterization and external incision as recommended by

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[April

Syme, are very ably discussed ; but it is not what the author intended to
make it — a practical treatise. Or rather, the treatise would have been much
more practical, if the author had entered more fully into the anatomy, phy-
siology, and pathology of the urethra.

The author says himself, at the commencement of his description of the
anatomy of the urethra, that, " in no instance of surgical disease is it more
necessary to have a clear conception of the structure and relations of the parts,
than when the practitioner is dealing with stricture of the urethra j" and yet
he does not go beyond a description of the mucous membrane of the canal
and of the muscular layers surrounding it, with a mention of the artery of
the bulb, the dorsal vein, and a reference to the situation of the rectum.
Not a word is said even in regard to the diameter of the curve made by the
urethra in its course under the pubic arch ; and we doubt whether there be
any point of greater practical importance connected with the whole subject
of stricture of the urethra; and it is certainly one, in regard to which — judg-
ing from the curvatures often given to catheters — the most erroneous ideas
prevail. In connection with the organic muscular coating of the urethra, we
expected to see it stated that Kolliker had discovered it, as well as Mr.
Hancock, and we should have been glad to have seen an account of the
method to be pursued for finding it, as we have repeatedly heard anatomists
of no mean skill declare their want of success in its search.1 The physiology
of the urinary organs is not touched upon at all ; there is not even a word said
in regard to the condition of the walls of the urethra during life, or to its action
during micturition.

Chapter II., headed "Stricture; its Nature and Pathology," treats of the
pathological anatomy of stricture, its formation, its varieties, its most frequent
seats, and its pathological effects. As usual, strictures are divided into per-
manent and spasmodic; a better division than that which we believe is
adopted by Thompson,2 of permanent and transitory. We say it is better,
because it enables an author to find a place for inflammatory stricture, a kind
of stricture which, if he could, Mr. Smith would like to deny the existence of
(page 18) from the embarrassment he experiences on account of its being
neither permanent nor spasmodic. Inflammation may close the canal, from
congestion of the vessels and the outpouring of inflammatory products into
the tissues around ; audit may terminate by resolution, and leave the ure-
thra as pervious as before. It is well, therefore, to place strictures, due to
local vascular inflammation or congestion, causing temporary narrowing of
those parts of the urethra, and those due to unwonted muscular action alone
of the voluntary or involuntary fibres, under one class, as transitory.

1 As this is an important point in the anatomy of the urethra, we will give our-
selves the plan to be adopted ; it will be perhaps less out of place in a note than in
the text. A fresh urethra is slit up, and pinned upon a board so as to put the flaps
on a stretch. The mucous coat carefully removed, and then a firm substratum of
elastic cellular tissue, a grayish layer is reached ; this is the muscular coat. Tease
out a small piece, in water, with fine needles. Hunter, in his work on the Venereal
Disease, commences his chapter (VII.) treating of spasmodic stricture, by declaring
the tissue of the urethra to be muscular ; adding soon after, that the only proof we
have of the truth of this is that it is subject to diseases which are peculiar to muscles
in general. In the French edition of his works, a note of Ricord declares his pre-
visions to be partly realized, as anatomy has shown the membranous portion of the
urethra to be formed of muscular fibres ; at the present day, they are fully realized.

2 The Pathology and Treatment of Stricture of the Urethra, both in the Male and
Female. Being the treatise for which the Jacksonian Prize, for the year 1852, was
awarded by the College of Surgeons of England. By Henry Thompson, London, 1854.

1858.]

Smithy Stricture of the Urethra.

435

Permanent strictures being the most frequent, the most troublesome, and
those followed by the most serious consequences, this part of the subject is
commenced by their consideration. The pathological alterations of the urethra
which are found in the examination of these strictures are treated of in three
pages, two of which are occupied with stricture from deposit upon the mucous
membrane, as recently described by Mr. Hancock ; only one page is devoted
to the description of the changes which are found in and beneath the mucous
membrane. Now it is upon a correct knowledge of these changes that any-
thing connected with their treatment must be based ; no knowledge can be
more practical, and no treatise can be considered as practical in which they
are neglected. Of late years much attention has been paid in England to
this part of the subject of stricture, and our knowledge of it is become far
more satisfactory. The time is not so remote as most persons may be in-
clined to believe, when impediment to the flow of urine was supposed to come
from thickened humours fixed in the canal j from warts j from coagulated
blood ; from a stone. Thompson, for the preparation of the work we have
cited, declares that he examined closely more than three hundred preparations
for his pathological anatomy, and his chapter on the classification and patho-
logy of stricture is most valuable. So highly appreciated is this chapter of
Mr. Thompson, that we find a continental author offering it, translated of
course, to French surgeons.1 The only fault we have to find with Monsieur
Pro is, that he only says that he went to London to study " pieces anatomo-
pathologiques," and does not mention Mr. Thompson's book at all. His
abilities as a translator are of the first order ; so superior, that we will give
a specimen of them to the reader, assuring him, moreover, that from page 50
to page 73 of the memoir, the translation is of equal fidelity.

"What are the essential pathological
elements of organic stricture? And what
are the strictures in which the constriction
itself is seated? Their consideration may
be advantageously entered upon together.
The first effect of inflammation upon the
mucous membrane is a swelling or thicken-
ing of it, caused by engorgement of the
vessels. Then exudation of an albuminous
fluid takes place into its substance, and
into the tissues beneath, making them
cedematous, all which matter is readily
absorbed under favourable circumstances ;
and so far we have the condition which
exists in mere inflammatory stricture, one
of the transient forms of the affection, be-
cause resolution readily follows, &c." —
Thompson, page 58.

" Maintenant voyons quels sont les ele-
ments essentiellement pathologiques du
retrecissement organique, et dans quels
tissues se trouvent ces alterations; nous
croyons qu'il y-a avantage a traiter en meme
temps ces deux questions. Le premier
effet de l'inflammation sur la membrane
muqueuse consiste dans une tumefaction
ou epaisissement cause par l'engorgement
des vaisseaux ; puis on observe dans la
trame meme de la membrane, une exuda-
tion albumineuse qui s'etend aux tissues
environnants, qu'elle rend oedemateux.
Toute cette matiere se resorbe assez vite
dans des conditions favorables, c'est a dire
dans les retrecissement inflammatoires qui
se terminent par resolution, &c." — Pro,
page 50.

Mr. Hancock, who has done so much for the anatomy, both normal and
pathological, of the urinary organs, and who is so well known in this country
by the Lettsomian Lectures delivered by him, and published in the Lancet,
on that subject, discovered that permanent stricture from false membranes
within the canal, upon its free surface, is a common and frequent occurrence.
In his Lectures he relates cases which show that the fact was only to be de-
termined by the microscope ; " the membrane was so identified with the

1 Me*moire sur PAnatomie Pathologique des RetreVissements de l'Urethre. Par
Jose Pro. Paris, 1856.

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mucous membrane, it seemed rather thickening of the membrane itself that
caused the morbid appearances." In some cases a valve was formed by the
false membrane, and the greater the pressure from behind, the more the valve
was raised up, and the more the canal was closed. This condition of things
probably existed in many of the specimens examined by Mr. Thompson, but
the unaided eye being insufficient for its detection, it has been overlooked.
This is a very interesting discovery, and an important one in the treatment
of stricture.

As to the varieties of permanent strictures, Mr. Smith is not very de-
cided. Of course they are more or less hard, more or less hemorrhagic,
and more or less irritable ; but to be clear in classification it is necessary
to be clear in anatomy and pathology. We are much better pleased with
the remarks upon spasmodic stricture : " A pure spasmodic stricture," he
says, "is not to be denied, but in the majority of instances of so-called spas-
modic stricture, there exists at the same time an organic narrowing of the
canal, and the spasmodic contraction is an additional element, the result of
some accidental irritation, local or general." In the majority of cases the
spasmodic contraction is at the bulbous or membranous portion of the urethra,
where the accelerator urinas, the compressor urethrse, and the anterior fibres of
the levator ani exert their action. Why, however, as sometimes occurs, the
spasmodic action takes place in a portion of the canal where these muscles do
not extend, it was difficult to explain until the whole canal was shown to be
surrounded by organic muscular fibres.

In order to find the most frequent seat of stricture, Mr Smith examined 85
specimens in various museums of London : Bartholomew's, Cambridge, King's
College, and the Hunterian. In 50 the stricture was either in the bulb or
just in front of it; in 18, in the membranous portion, and in all but four of
these the bulb was involved as well; and in 17, in some part of the straight
or spongy portion, from the orifice to within an inch of the bulb. In on]}r
one case was there stricture of the prostatic portion, and that was in the shape
of a broad membranous expansion ! Thompson, in all the museums of Lon-
don, Edinburgh, and Paris, could not find a single case of stricture in this
region of the urethra.

It used to be considered by English authors, that strictures took place
chiefly at the membranous portion. Civiale says, that "this inexact indica-
tion is owing to the fact that the membranous portion has been confounded
by them with the point that separates it from the spongy portion."1 The
only way to fix upon the point affected is, not to trust to measurements from
the orifice only, but to identify the contraction with the anatomical region of
the urethra. The conclusions of Mr. Smith are undoubtedly correct; unfor-
tunately he persists in speaking of the bulb as a region of the urethra,
although he says himself, in giving the anatomy of the urethra, that it is well
to consider the bulb as a continuation of the spoiujy portion (page 2). Mr.
Thompson's examination of specimens was still more extended; he examined
320 strictures in 270 preparations, and dividing the urethra into three regions —
one, comprising the junction of the spongy and membranous portions, one
inch before an<J three-quarters of an inch behind, thus comprising the whole
of the membranous portion; another, extending from this first region to within
2£ inches of the meatus, about 2-| or 3 inches in length; and a third, extend-
ing from the second region to the external orifice, he found that the first

1 Mai. des Organ eg G6nito-Urin., vol. i. p. 147.

%

1858.]

Smith, Stricture of the Urethra.

437

region contained 215 strictures, or 67 p. c. of the whole number; the second,
51, or 16 p. c. ; and third, 54, or 17 p. c.

Stricture, then, is most common at the point where we should expect it to
be, namely, where the voluntary muscles cause spasmodic contractions of the
canal, which, frequently repeated, would lead to organic contractions, where
the urethra is in close relation with the anterior layer of the deep perineal
fascia, where its form is such that instruments in unskilful hands are most
likely to do harm; and again, and perhaps this is the chief reason, where
gonorrhceal inflammation lasts with the greatest obstinacy. Hancock has
thrown out a doctrine on this subject, which is somewhat curious. Strictures,
he says,

" occur most commonly at the junction of the bulb with the membranous por-
tion of the urethra ; for — setting aside the consideration, that this portion of
the urethra is the spot of all others most acted upon in the different conditions
of erection and relaxation of the corpus spongiosum, and that spot, consequently,
at which we should naturally expect stricture or mischief to occur — if we turn
to such affections in other parts of the body, we find that for the most part
they seem subject to a general law — that strictures, when single and organic,
taking place in canals possessed of varied dimensions, are commonly met with
at those points where the larger portion of the canal merges into a smaller
one, or vice versa. Of the oesophagus, almost always about the fifth cervical
vertebra, where the pharynx merges into the oesophagus. Again, we find per-
manant stricture where the oesophagus joins the stomach, at the cardiac ori-
fice; where the stomach joins the duodenum, or at the pylorus ; where the sig-
moid flexure of the colon joins the rectum ; and at the lower part of the rectum
where the dilated portion of the gut joins its more contracted termination.
Likewise in the lachrymal apparatus, we find that constrictions mostly obtain
where the lachrymal sac joins the ductus ad nasum. So, in the urethra, stric-
tures mostly occur at that spot where the narrower membranous portion passes
into the more dilated fossa of the bulb.,;i

The effects of stricture are well described at the termination of this chap-
ter, and what is rather remarkable, without exaggeration. It seems to be a
natural tendency of writers of monographs to exaggerate the frequency and
importance of the affection of which they write; and never more so than
when the affection regards the urinary organs. For instance, in his Practical
Observations on Diseases of the Prostate Gland, on account of its being often
affected in advanced life, Sir Everard Home says : —

" From its frequent occurrence, perhaps we may be justified in believing that
it is alluded to in the beautiful description of the natural decay of the body in
the Bible, in the Book of Ecclesiastes, 12th chap., 6th verse, where it is written
' or the pitcher be broken at the fountain, or the wheel broken at the cistern/
expressive of the two principal effects of the disease, the involuntary passing
of the urine, and the total stoppage/'

An exaggeration of this kind, however, is harmless, and we are pleased to
meet such a charming instance of the private interpretation of the sacred
writings. There is, however, an exaggeration of the horrible, by many
writers, in their descriptions of the effect of stricture, which may reasona-
bly lead us to question their motives. One celebrated writer declares that
" perhaps one-third of men pass more or less their life in the misery called
retention of urine," and then proceeds to describe their misery in a way to
rival the newspaper advertisements of charlatans. There is certainly in such

1 The Lettsorainn lecture, by Henry Hancock, in Lancet for April 3d, 1852.
No. LXX.— April 1858. 29

438

Reviews.

[April

cases the unworthy design of frightening patients into their hands, if they
cannot win the esteem of respectable surgeons. Their motto is,
"Flectere si nequeo Superos, Acheronta movebo."

Among these effects of stricture, we notice that dilatation of the canal,
behind the stricture, is declared to be " by no means of frequent occurrence,
and that in many instances of obstinate stricture there is no dilatation/'
This is contrary to the statement given by most authorities on this point.
The American surgeon, who has written most extensively on these subjects, states
it to be " one of the most frequent as well as most serious lesions consequent
upon stricture."1 We are inclined to think that Mr. Smith is wrong
on this point, when he differs from the great majority of surgical writers.
In another point, in which he agrees with all of them, the microscope shows
him to be wrong. In speaking of the effect of stricture upon the bladder,
all writers declare that its walls become thickened from hypertrophy of
its muscular coat, on account of the increased action required to overcome
the impediment. This thickening of the coats of the bladder, as well as the
columnar appearance of the inner surface, is due, however, not so much to
the muscular as to the cellular coat of the viscus; the microscope shows that
these projections are not muscular, but are composed of elastic cellular tissue.

Chapter lit. is upon the symptoms and causes of strictures. The symp-
toms of stricture are given with method and clearness, but if, in place of the
arrangement he has adopted, locating the effects in one chapter, and the
symptoms in another, Mr. Smith had made one chapter, entitled Pathological
Effects and Symptoms of Stricture, it would have been better. Such an ar-
rangement was particularly to be preferred in a work where it is desired to
treat of these subjects without occupying any great space, for it would have
avoided repetitions otherwise absolutely necessary. The main symptom or
sign of stricture, the one afforded by exploration of the urethra, is considered
in a subsequent chapter, the 5th, in which treatment by temporary dilatation
is treated of.

Of all the causes of stricture, he believes gonorrhoea to be the most fertile.
As to injections, he declares that it is much more reasonable to allege that
they prevent the formation of strictures; adding, however, that when used
in too great strength they may doubtless lead to stricture, and moreover,
his belief that " in one or two of his own patients,, a very strong injection of
nitrate of silver had led to the production of the disease; but in these cases
it acted very violently, producing severe pain and much hemorrhage." Next
to gonorrhceal inflammation, injury of the urethra is, in his opinion, the
most frequent cause of stricture. "Contusions of the perineum, caused
either by a kick, by a cricket-ball, or by a bump upon the pommel of a sad-
dle, or across a ship's yard-arm, are frequently attended with a laceration of
the urethra to a greater or less degree;" and "certain changes necessary for
the repair of this loss ensue, and the result is a cicatrix, and a contraction of
the canal." Even when there has been no actual solution of continuity, but
only a severe contusion of the canal, "a considerable amount of inflamma-
tion takes place, lymph becomes deposited around the urethra, and in this
way stricture may be formed." In those cases where contusions of the peri-
neum are ultimately productive of stricture, it not unfrequently happens that

1 A Practical Treatise on the Diseases, Injuries, and Malformations of the Urinary-
Bladder, the Prostate Gland, and the Urethra. By S. D. Gross, M.D., 2d ed. Phila.,
1855.

1858.]

Smith, Stricture of the Urethra.

439

the symptoms are not witnessed until some time has elapsed; "weeks, months,
or even years, may go by before the patient gets troubled with any difficulty
in passing his water." , Some very interesting cases are given as examples of
these points.

External injury is not usually given as the cause of a large proportion of
strictures, but we find Mr. Smith's opinion fully borne out by the table made
by Thompson, and recorded in the work we have already cited. In 220 cases,
the cause was

Gonorrheal inflammation in 164

Injury to the perineum in ... . .28

Congenital 6

True inflammatory stricture 8

Cicatrization of chancres 3

" following phagedena 1

Poisoning by nitrate of potash, lithotrity, masturbation,

of each one 3

True spasmodic stricture from irritation of rectum . 2
" " " no cause assignable . . 2
" " " under acidity and alkalinity of
the urine 3

220

In only three of these cases was the disease attributed by the patient to strong
injections.

The remaining chapters of Mr. Smith's treatise on stricture, occupying
nearly three-fourths of the whole work, are upon the treatment of this affec-
tion. They are replete with valuable information and judicious advice, and
what is quite remarkable, when the subject treated of is considered, they
are written in temperate language. We say when the subject treated of
is considered, for it must not be supposed that the operation of Mr. Syme
first called forth such abusive language, as the friends and opponents of
that operation have been recently using. In the beginning of the century,
though not so many books were written in England, yet their language
was about the same, in regard to cauterization.1 In France for many
years the same thing has been going on, Civiale, Leroy d'Etiolles, Heurte-
loup, Maisonneuve, &c, have been using language almost, if not altogether
as violent as any we have seen used in England. Some of the produc-
tions of M. le Baron Heurteloup are remarkable specimens of skill in abus-
ing rival surgeons.3 Of course all writers upon stricture have not been guilty
in this way; but we noticed with pleasure the tone in which Mr. Smith has
written, for he has been a party in several of the discussions that have recently
occurred in England, and particularly in one that took place at the Medico-
Chirurgical Society on the occasion of the reading of a paper by Mr. Syme,
in which his method was exposed.

Previous to describing the modes of treatment in cases of stricture, it would
have been well, we think, for Mr. Smith to have given some rules in regard
to those in which it is proper to institute any treatment, for, because the canal

1 See, for example : "A critical inquiry into the ancient and modern method of cur-
ing diseases in the urethra and bladder." By Jesse Foot, Surgeon.

i See, for example: " Retrecissements de l'urethre. L'Etat de la science de'voile a
l'occasion d'un nouveau procede feroce, avec un court mdmoire pour servir d'antidote.
Par M. Le Baron Heurteloup," or " De La guerison immediate des retrecissements de
l'ur6thre, &c, et sur les efifets dangereux des bougies," by the same author.

440

Reviews.

[April

has lost half a line or more of its diameter, or the jet of urine is more or less
irregular, it is not necessary for the surgeon to interfere. It is only where a
stricture continues gradually to become more narrow, or where it hinders and
compromises the direct functions of the urethra and those of the organs with
which it is connected, that it should be submitted to treatment.

Though it is very necessary to combine other measures with the employment
of instruments, in the treatment of stricture, yet the disease is chiefly a
mechanical one, so to speak, and one to be remedied by mechanical means.
The mechanical means invented for this purpose are innumerable, and the
modes of treatment are altogether so many and so various, that we must
judge either that an efficient mode is wanting, or that our present appliances
are not rationally and systematically applied to suitable cases. Another thing
to be noticed is, that stricture is one of the pasturages of quacks, as cancer,
phthisis, &c, and we may reasonably judge that it is because it is a disease
which regular practitioners often fail to benefit. A correct knowledge and
proper treatment of affections of the urinary organs by surgeons would greatly
diminish the number of quacks, for we believe that this want of success is
generally owing to their ignorance of, and inability to properly apply the means
at their disposal.

In the treatment of stricture two indications are to be fulfilled; the natural
calibre of the canal is to be restored, at least so far as is consistent with the
safety and comfort of the patient, and the canal is to be maintained in this
condition afterwards. This second part of the treatment is one of indefinite
duration, for, as in all the mucous outlets of the body, there is a disposition
to recontraction when once the canal has been narrowed. So that in by far
the greater proportion of cases of confirmed stricture, although by suitable
means the original calibre of the canal may be restored, there is always a
tendency for the stricture to return. For this reason, in his essay, Mr.
Smith declares that he will never mention the term cure in reference to stric-
ture.

The mechanical means invented for the treatment of stricture are, as we
have said above, innumerable ; they extend from the mild means of Bru-
ninghausen, who reports to have cured patients, by having them to distend
the urethra with urine, the meatus urinarius being closed while they en-
deavoured to expel it, to the means advised by Arnott, in which an empty
bag was to be introduced behind the stricture, and then inflated and drawn
forwards, a canula afterwards being pushed against the stricture in front, in
which a circular knife was contained cutting the stricture out at one push.1
All these means, however, can be classed under three heads — dilatation, de-
struction by chemical agents, and division by cutting instruments. Mr. Smith
says : —

" In the first place, then, we have dilatation, of which there are three modi-
fications— simple dilatation, permanent dilatation, rapid or forced dilatation.
Next, there is cauterization; and of this there are two methods, or rather, there
is the employment of two different substances, viz., nitrate of silver and potassa
fusa. Lastly, there is incision, under which somewhat comprehensive term we
place several varieties which are practised by the surgeons of the present day :
1st. Internal incision, performed either from before backwards, or from behind
forwards ; 2d. Incision of the stricture from the outside, or perineal section, of
which proceeding there are also two varieties. 1st. The section at the point of

1 In his "Treatise on Stricture of the Urethra, containing an account of improved
methods of Treatment, with an appendix, &c." By James Arnott, London, 1819.

1858.] Smith, Stricture of the Urethra. 441

an instrument which cannot be passed through the stricture ; and 2dly, the
section performed upon a grooved instrument previously passed along the urethra
into the bladder" (p. 62).

Of course, in addition to these mechanical methods general measures must
be adopted, to allay the irritability of the system, and to correct the state of
the urine ; a tolerable account of these measures is given, here and there, in
Mr. Smith's book. It is not so full as it should be, but more so than in very
many treatises on the subject. In the most important work on this affection
published in this country, one we have already referred to, in speaking of the
treatment of stricture, the condition of the urine is not attended to at all ; the
only directions we find are "demulcent drinks should also be used ; and there
are few cases which will not be benefited by the exhibition of bicarbonate of
soda, and balsam of copaiba." It is to be remarked also that those authors
who neglect general measures, are those who advise the use of the harshest
mechanical treatment. This is owing to the extreme to which Hunter went,
and to the influence of his authority ; he was not willing, in permanent
stricture, to make use of any means but local applications, as he declares
at the very outset.

Before describing the manner in which treatment by dilatation is to be
pursued, Mr. Smith gives an account of some of the various materials of
which bougies and catheters are constructed, and of the various forms given
to them. For reasons of safety and efficiency, he prefers the use of wax
bougies, until the urethra has been so far dilated as to admit a No. 4 or 5,
when he commences to use metallic instruments. A hollow instrument has
the great advantage of revealing, by the flow of urine, the situation of the'
instrument; the curve, Mr. Smith says, should be "moderate, neither too
small, too abrupt, nor too extended;" a conical point he objects to because
the instrument may more easily penetrate lacunas, and more readily tear the
urethra. Moreover, if there be more than one stricture, it will be difficult
or almost impossible to know whether the instrument be stopped by the second
obstruction or not; "for, in consequence of the diameter of the catheter in-
creasing from the point, it may be prevented advancing by the first stricture
only."

A surgeon, well acquainted with the management of instruments in the
urethra, will generally prefer an inflexible instrument to a flexible one;
indeed, we think he will only choose the latter when the obstacles opposing
the entrance are of such a kind that it must be allowed to worm its own way.
Of all inflexible instruments, the one producing the least abrasion of the
urethral mucous membrane is a perfectly well polished metallic sound. As
a general rule, they have too large a curve, from a mistaken idea of the
natural curve of the urethra, which Arnott, for instance, says has a diameter
of six inches; the "moderate curve" of Mr. Smith is not sufficiently precise.
The natural curve of the urethra commences at an inch and a half anterior to
the bulb, and from this to its termination in the bladder, forms an arc of a
circle three inches and a quarter in diameter, the chord of the arc being two
inches and three-quarters, or rather less than one-third of the circumference.
It is also a matter of importance to have the axis of the point of the instru-
ment at right angles with that of the shaft, for then the surgeon can best
judge where the point is going when hidden in the urethra. The gum-elastic
catheter is a valuable instrument, for it may be used as flexible or inflexible
by reason of the stiletto; it may be used as a straight instrument, or any
form whatever may be given to it; and, moreover, should it be requisite to

442 Reviews. [April

leave the instrument in the bladder, by withdrawing the stiletto the patient
is free to walk about.

A separate chapter is devoted to each form of dilatation ; that is, tem-
porary and permanent. As this is the method which undoubtedly should be
used as the rule in treating stricture, others being used only, if ever, when
the nature of the obstruction is such as to make it impracticable, or when the
urethra will not endure the repeated contact of instruments, it is impossible,
almost, to study it too carefully. The advice contained in these chapters is
excellent, and we doubt whether the surgeon need often have recourse to
other means if it be faithfully followed. We remark here again the attention
paid to constitutional treatment, for we believe that its neglect has often
caused the abandonment of dilatation and the adoption of other and danger-
ous measures. As Mr. Smith's preceptor, the celebrated surgeon to whom
his work is dedicated, teaches —

"In the great number of these troublesome cases (of excessive irritability),
it will be found that the general condition of the system is at fault, and it is
highly necessary that the surgeon should find this out, and, by the administra-
tion of proper remedies, endeavour to correct the morbid state."1

Yery many instruments have been invented for dilating stricture, but we
doubt whether there is much use in being acquainted with them, and Mr.
Smith has done well in his practical treatise in saying nothing about them.
Their inventors forget that the subsequent tendency to contract is strong in
proportion to the rapidity with which dilatation has been effected, so that, in
.■reality, the patient is no gainer thereby, and, moreover, that sudden dilatation
is apt to be followed by violent symptoms. With some of these instruments,
as, for instance, Arnott's tube of oiled silk, described in the work we have
before cited, page 96, they may be pronounced to be useless merely because
they can be used. If such an instrument can be introduced into a stricture,
we can do without it. Here, as in almost every surgical disorder, it is the
surgeon's judgment and manual dexterity that make the excellence of the
instrument, and not the strangeness of its mechanism.

At the commencement of Chapter VII., which is upon the treatment of
stricture by caustics, Mr. Smith says : —

"I have hitherto considered those methods of treating stricture which are
usually adopted in this country : and it has been shown that dilatation, either
temporary or permanent, is, for the most part, only suitable in those cases
where an instrument of some kind can be introduced through the stricture
without force ; and the majority of cases are those where the obstruction is not
impermeable to an instrument when cautiously and patiently used. Still, every
now and then, we shall meet with an instance where, either from the patient's
fear or neglect, the disease has been allowed to become so bad that the surgeon
cannot pass any dilator without exerting an unwarrantable amount of force.
In the mean time, the patient is suffering most severely from the effects of his
malady, and is urgent for relief. In such a case, it is necessary to employ
some other method by which the contraction may be overcome, and the mis-
chief which is going on be stayed in its progress. Then, again, it has been
seen that cases are met with in which, although a small instrument may be
passed, there is such a difficulty in carrying on dilatation, either from the den-
sity or irritability of the stricture, that the surgeon is compelled to resort to
some other remedial means which either prepare the way for dilatation or assist
this process when once it has been commenced. Fortunately, these means
exist in the form of caustics."

i Fergusson, Clinical Lecture in Med. Times and Gazette, 13th March, 1852.

1858.]

Smith, Stricture of the Urethra.

443

We cite the whole passage in order that it may be clearly understood with
what object Mr. Smith employs caustics. Hunter, who revived the use of
caustics in the treatment of stricture, employed it chiefly in cases where he
could not introduce a bougie at all, and laid it aside so soon as a small one
was admitted. Hunter, be it remarked, lays it down as an axiom that when
a bougie can readily pass, there is no necessity for the use of any other
method. Sir Everard Home extended the application of caustic to all stric-
tures, making its use the rule, and that of simple dilatation the exception.
The caustic used by Hunter and his pupil was the nitrate of silver. Mr.
Whately, in the commencement of the present century (1804), in a work
entitled An Improved Method of Treating Strictures of the Urethra, first
advocated the use of the potassa fusa. The plan of Mr. Whately was not
favourably received at the time, but of late years it has been much made use
of in England. Mr. Wade has, perhaps, been as instrumental as any other
surgeon in this revival. Some of the cases of cure reported by this surgeon
are certainly very remarkable; one is almost inclined to coincide with Mr.
Synie, who thus speaks of them at page 53 of his treatise: "On a whole, it
seems more reasonable to conclude that, in the cases of alleged cure by caus-
tic, there was no real stricture in existence, than to suppose that so improba-
ble or rather impossible an achievement had been accomplished." Mr. Smith,
as seen by the citation given from his book, makes use of caustic when no
instrument will pass, when the irritability is too great to allow of the frequent
passage of an instrument, and when, the density is so great that dilatation
must be assisted. The use of the nitrate of silver occupies one page and a
half ; the rest of the chapter, or thirty-five pages, is devoted to the use of
potassa fusa. Nitrate of silver he has not used to any great extent, but he
" has seen enough of it to know that it may produce very excellent effects in
allaying irritability." The potassa fusa is a far more powerful agent, and,
therefore, a far more dangerous one. Mr. Smith would have it used as an
agent, " producing actual destruction of the thickened tissue itself," though
he declares also that "its beneficial action on stricture must be mainly
attributable to its exerting an amount of irritation sufficient to produce
actual absorption of the thickened tissue." The application is made by
introducing into the extremity of a bougie a piece of the inside of a stick of
potassa fusa, about the size of a large pin's head, pressing the edges of the
cavity around it, so that it be but slightly prominent, and then passing the
bougie down to the stricture, against which it is lightly pressed for the space
of a few moments or more, according to the nature of the case. Of course,
the extremity of the instrument is previously dipped in oil, which, although
it unfortunately, as we think, does not always render the potash innocuous
by forming a soapy compound, yet must very much diminish its action. The
accidents which may result from this application are retention of urine, hemor-
rhage, false passages, and perineal abscess.

Mr. Smith relates a number of cases occurring in his own practice to show
that a stricture may be opened up or destroyed for a time at least by the use
of this caustic. Also one case to show that, "even after a -stricture has been
well opened up by it, there is just as great a chance of the stricture returning
again as after any other kind of treatment if the precaution is not taken to
pass a bougie every now and then."

He concludes the chapter on cauterization by saying that potassa fusa
should be considered chiefly in the light of an adjunct to dilatation, so that
the surgeon should not be led to trust to it alone, or to be led into using it

444

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[April

too frequently. " Above all things, it is necessary to bear in mind that
caustic, and especially potassa fusa, is not to be used without extreme caution,
either, indeed, as regards its actual application or the selection of the cases
for its employment "

We have a good deal of confidence in the prudence of Mr. Smith, as a
surgeon, but we believe that in the use of caustic he goes too far. A stric-
ture of the kind described by Mr. Hancock, where there is a false membrane
upon the free surface of the urethra, or a stricture accompanied by ulcera-
tions, or one depending upon vegetating fungosities, would get well sooner
by combining cauterization with dilatation, than by the latter proceeding
alone, if the caustic could be exactly applied upon the diseased surface, and
any extension of its action over the healthy tissues prevented. Again, it
would be necessary to diagnosticate these pathological conditions. But if
cauterization be employed, to destroy cicatrices, which other cicatrices, then
of greater extent must replace; if it be applied upon hard, callous strictures,
in which resolution is no longer possible, far from ameliorating the affection,
it is aggravated, and a cure, which other means more apppropriate might
have obtained, is prevented.1

Mr. Smith's experience with the potassa fusa has not been very great, and
we are inclined to think that his opinion as to its application in stricture may
undergo a change. In 1832, Mr. Benjamin Phillips published a Treatise
on the Urethra; its Diseases, especially Stricture, and their Cure, in which he
advocated strongly the use of the nitrate of silver. Eleven years afterwards,
in the Medical Gazette, for December, 1843, he states that a larger experience
has satisfied him that the conviction was not well founded. " I believe/' he
says, u we know no means of effecting a permanent cure of advanced cases
of stricture ; but I think the best means we possess is the prudent employ-
ment of dilatation. I apprehend the good derived from the use of caustics
is owing to the modification of the sensibility of the canal, which has allowed
of a more unreserved use of dilating bodies, than could have been had with-
out it." It is impossible, Thompson declares, to obtain information respect-
ing the subject upon which greater reliance could be placed

In this country, on the subject of cauterization, Dr. Gross writes that, in
his judgment, it should be restricted to cases u in which the stricture, without
being very tight or extensive, is of a firm, gristly, and resilient character, and
in which there is an undue amount of morbid sensibility of the mucous mem-
brane of the urethra. The nitrate of silver acts mainly as a sorbefacient,
rousing the absorbent vessels of the part, and inciting them to the removal of
the adventitious deposit." This is surely as far as it is proper to carry the
use of cauterization, but unfortunately, notwithstanding the advice of the
American writer, caustics are extensively used as destructive agents in this
country, and, as it requires but a limited experience to discover, with very
distressing consequences.

With Chapter VIII., Mr. Smith commences the consideration of the treat-
ment of stricture by division loith the knife. He makes no reference what-
ever to the punctures, filings, and scarifications, which have been, and still
are, recommended from time to time, and discusses only incisions, made either
from within outwards, when they can be made from before backwards, or
from behind forwards ; or from without inwards, when they can be made
either upon an instrument previously introduced into the canal, or without.

1 This is the opinion of Ricord, as given in the French edition of Hunter's Treatise
on Syphilis, Paris, 1845, page 320.

1858.]

Smith, Stricture of the Urethra.

445

The. incising of the urethra, from within outwards, is first studied by Mr.
Smith, under the title of treatment by internal section. The chapter he has
devoted to this is far from being a satisfactory one ; indeed, we are unable to
conclude from it what his opinions are. We believe, however, that he holds
it to be a dangerous operation, particularly when performed from before back-
wards ; sometimes to be one speedily fatal, and, moreover, one more speedily
followed by a return of the disease than dilatation. No description is at-
tempted of the host of instruments which have been invented, by Civiale,
Leroy, Ricord, Maisonneuve, etc. etc., for the purpose of making these inci-
sions. One of the men we have just mentioned, has alone described and
invented so many, that one of his enemies, in a work he has published, likens
him, with a grossness of language quite usual to him, to certain women "who
are always conceiving and never bringing forth, or, at least, bring forth before
their time, badly formed embryos." English surgeons do not seem, at least
so far as we can judge, to have ever been much in favor of the internal section^
as Mr. Smith calls it. Mr. Stafford's work, A Series of Observations on
Strictures of the Urethi'a; with a new Mode of Treatment, published in 1828,
by its strong advocacy of this means turned their attention to it, but it met
with no permanent favour.

It is remarkable how soon some modes of treatment, of wonderful safety
and success, and sometimes supported by high authority, have fallen. In
1852, the Imperial Academy of Medicine, in Paris, crowned the work of
Reybard, entitled Traite Pratique des Retrecissements de V Uretre, and be-
stowed upon him the great Argenteuil prize of 12,000 francs. The com-
mittee of the Imperial Academy was composed of MM. Ricord, Robert,
Roux, Gerdy, Bouvier, Huguier, Laugier, Larrey, and G-rissolle. Their
report says, " en resume, l'experience et le raisonnement sont d'accord pour
classer 1' operation de Reybard parmi les conquetes de la chirurgie moderne."

The operation of M. Reybard consisted in dividing, by means of an instru-
ment of his own invention, the whole thickness of the urethral walls, not
only at the stricture, but an inch before, and an inch behind : the wound
usually is about three inches in length. In order to prevent union by first
intention a full-sized bougie is to be passed twice a day for at least thirty or
forty consecutive days. " The production of granulations being thus insured,
a piece will be formed in the urethra to permanently enlarge it."

In May, 1855, this same operation of Reybard was discussed in the Societe
de Chirurgie; M. Ricord, one of the committee who gave the prize, as will
be noticed, said that it was not given for the affreux instruments of Reybard,
that he had voted for everything in his book, except for urethrotomy ; adding
" that when instruments can be introduced the patient can urinate himself,
and this should satisfy the surgeon, and be enough for the patient." M.
Debout had sought what the surgeons of Lyons, where Reybard resides,
thought of the practice, and, "to their knowledge, it had afforded deplorable
results in the hands of the inventor himself, and of those who had imitated
him. Long ago they had completely abandoned urethrotomy."1 Three years
were sufficient to show that an operation, proclaimed by a 'committee of as
competent men as the world can produce, to be "one of the conquests of
modern surgery" — shown to be so " both by reasoning and by experience" —
was frightful and followed by deplorable results.

On the 14th May, 1855, a memoir was read to the Academy of Sciences,

1 The discussion is published in the Gazette des Hopitaux, May, 1855.

446

Reviews.

[April

in Paris, by M. Maisonneuve, upon "a new method of catheterism and its
application to the radical and instantaneous cure of strictures of the urethra."
By this method, we are told, that " instead of an operation embarrassed with
complicated instruments, and above all, with long and painful preparatory
and consecutive treatment, we have now but a simple and rapid operation,
which can be practised completely in a few moments, and which, allowing of
the easy use of chloroform, causes no pain to the patient." This is the ope-
ration : a fine bougie is introduced into the urethra, to which a grooved ure-
throtome is screwed, and pushed in; the bougie conducting it, and remaining
coiled in the bladder. In the groove of the urethrotome cannele, a small
cutting blade is introduced and pushed from one end to the other, so as to
divide all the strictures at once. The urethrotome cannele is then withdrawn,
and the urethrotome cache is introduced without difficulty. When the ure-
throtome cache is in, the bascule is pressed upon so as to make the blade pro-
ject, and the instrument is withdrawn, so as to cut at once and deeply all the
strictures. Then, to be sure that the operation has effected its object, a full-
sized metallic bougie is introduced into the urethra, and at once withdrawn.
This done, the patient is left alone; he immediately urinates in a full stream
and almost without pain ; the slight smarting (!) which takes place at the
moment of the emission of urine, disappears at the end of a few days. M.
Maisonneuve, from motives of prudence, engages his patients to remain a
few days in bed, to take a bath and demulcent drinks, but sometimes they
have gone at once to their ordinary mode of living, without the slightest in-
convenience resulting. This pretty fiction of M. Maisonneuve perished far
more rapidly than that of Reybard. Ficta omnia celeriter, tanquam flosculi,
decidunt, nec simulatim potest quidquam esse diuturnum.

All operations, for the relief of stricture, by incisions, whether they be
performed from without inwards, or from within outwards, upon a conductor,
or without one, from behind forwards, or from before backwards, have the
same basis. They are all performed upon the supposition that by dividing a
stricture in which the deposit is very dense, or where there is great irritability,
and by not allowing the incision to unite by first intention, that the stricture
will be cured. The operation by internal incision has been performed in every
variety of ways, and by men of the greatest skill. So far as the cure of the
affection is concerned, the result has been unfavourable, for the stricture
gradually, and we believe invariably, returns. Moreover, experience shows
that it is attended with risk to the life of the patient. Under these circum-
stances, a prudent surgeon will not perform it.

Another method of treating stricture, that by external incision, remains to
be considered. The external division of the diseased canal has always, we
might say, been resorted to in certain severe and intractable cases, but within
the past few years the attention of surgeons has been particularly called to it.
Until within this time it was a proceeding limited entirely to cases of impass-
able stricture. It must not be supposed, however, that simple impermeability
to an instrument was supposed to justify what is now called by some the old
operation of perineal section. It was only performed when a considerable
extent of the urethra was so contracted that the urine only passed in drops,
and the irritation, local and general, was wearing away the patient. Or,
again, when the urethra had given way behind a close stricture, and infiltra-
tion of urine and suppuration had taken place, and the patient thereby
brought into such a state that his life is endangered. The chapter in which
Mr. Smith treats of this operation is quite a remarkable one, for it is rare to

1858.]

Smith, Stricture of the Urethra.

447

find so much good advice given with so much clearness, and so forcibly illus-
trated by examples.

Of late years, however, the operation of laying open the urethra in the
perineum has been urged in cases of permeable strictures. To Professor
Syme, of Edinburgh, belongs the credit of having brought it prominently
before the profession. It is an operation which has been extravagantly
praised and violently condemned. After studying carefully all that has been
written on both sides of the question, we think every one will reach the same
conclusion as that reached by Mr. Smith, and which has prevented him from
ever performing the operation.

" That it has appeared to him to be unnecessary to subject a patient to an
operation which may destroy life unless a very pressing emergency exists ; and
this, in his opinion, does not obtain, except under rare circumstances, so long
as an instrument can be passed through the stricture."

The July number of this Journal for 1853 contains a report of the paper
read by Professor Syme before the Medico-Chirurgical Society of London,
and in which is a full description of the operation. At that time he stated
that he had performed the operation upwards of seventy times without any
fatal or alarming consequences. The work of Mr. Thompson, to which we
have already referred, testifies strongly in its favour ; he gives a list of one
hundred and fourteen cases, of which only four were fatal; and he declares
that in these four cases death was not caused by any accident peculiar to the
operation, or necessarily connected with it, but by one which is known to
attend incisions and lacerations of any kind ; the cause of death, he says, was
undoubtedly pyohsemia.

On the other hand, Mr. Wade declares that, in London, the operation is
nearly as fatal as the operation of lithotomy; and, as to the ultimate effects,
the stricture returns with nearly its original severity. The editor of the
Lancet (3d September, 1853), writes thus : "In a word, we consider what is
called Mr. Syme's operation for the cure of stricture to be the greatest op-
probrium of surgery of the present day. Any surgeon who destroys the life
of a patient by the performance of that operation ought, in our opinion, to be
indicted for manslaughter." Words are insufficient to express Professor
Lizars' reprobation of the operation, and, in his work, plates are given to
show the "lamentable condition" of several patients after the perineal sec-
tion.1 In Great Britain, it seems to have been impossible to write coolly and
dispassionately on the subject of Professor Syme's operation. In the Archives
Generates, 4th Series, vol. xxix., is a paper upon it, with a review of English
works on the subject, by Dr. Follin. He has found, and he is a man of great
industry and accuracy, that the mortality of Syme's operation is one in five.
" Hence," he adds, " it must only be proposed in excessively rebellious cases,
and which threaten to become complicated with serious accidents."

There are many points connected with Mr. Syme's operation, which,
though of much interest, we pass by without mention. There is one thing,
however, we would wish to refer to, for it is connected with many other opera-
tions, as well as with that particular one of which we are writing. Pro-
fessor Syme first performed his operation because his patient " protested that
life was not desirable under the torment of his complaint," and demanded
relief, " no matter at what expense of pain or risk of danger." Now we

1 Practical Observations on the Treatment of Stricture of the Urethra and Fistula
in Perineo, 3d ed., by John Lizars, Edinburgh, 1853.

us

Reviews.

[April

hold that the responsibility of an operation always rests upon the surgeon.
It is he who is to judge as to the propriety of performing an operation, and
the protestation of a patient, or of a patient's friends, as is sometimes the
case, as to his weariness of life, should not influence the surgeon in his deci-
sion. The risk of danger can never be put aside, and it is this which is to
decide the surgeon, when his interference is sought; if the danger attending
his attempts to relieve be greater than that attending the disease, the sur-
geon should refuse to operate. When life is threatened, and death without
his assistance is sure and imminent, he cannot act too daringly; but no matter
how miserable and loathsome life may be, merely because it is so, the surgeon
has no right to stake it upon the success of a dangerous operation. There
are, of course, circumstances when life should freely be risked, for there are
things compared to which life must be held as nought ; but never can this
be done, because it is wearisome, never, because it is " not desirable."
There are cases where the surgeon must be resigned to palliate ; and the
patient to endure his suffering.

The 11th chapter, and the last, of Mr. Smith's work is upon the treatment
of spasmodic stricture and retention of urine. As it is, however, chiefly
with reference to the treatment of permanent stricture that we have under-
taken the examination of his work, we shall go no further. We will only
say that, like the other chapters of his book, it contains much useful advice.

W. F. A.

1858.]

449

BIBLIOGRAPHICAL NOTICES.

Art. XIX. — Reports of American Institutions for the Insane.

1. Of the Central Ohio Lunatic Asylum for 1857.

2. Of the Southern Ohio Lunatic Asylum for 1857.

3. Of the New York City Lunatic Asylum, for the year 185G.

4. Of the Bloomingdale Asylum, for the year 1856.

5. Of the Vermont State Asylum, for the fiscal year 1856-7.

6. Of the Western Lunatic Asylum, of Virginia, for the two years ending on

the 30th September, 1857.

7. Of the Retreat, at Hartford, for the fiscal year 1856-7.

8. Of the New York State Lunatic Asylum, for the year 1856.

9. Of the Massachusetts State Lunatic Hospital, at Worcester, for the year 1856.
10. Of the New Hampshire State Asylum, for the fiscal year 1856-7.

If there be any of our readers who have followed us, in our notices of the
reports of the institutions for the insane in the United States, during the last
fifteen years, they will probably recollect that, more than once, we have seized
an occasion to express our admiration of the beneficent and nobly liberal spirit
with which the State of Ohio first stretched forth her hand to shelter, to restore,
and to save those unfortunates among her children who suffer from mental
alienation. Of all the sister States of this Union, she was the first perfectly to
act the Good Samaritan, by literally taking her afflicted proteges to her own
house, and there gratuitously ministering to their wants. In plain and prac-
tical terms, she, first of all, paid from her own purse the bills of all the current
expenses of her Asylum for the Insane. Year after year that institution pur-
sued its progressive course, flourishing under her fostering policy, and under
the able administration of Dr. Awl, its comparatively permanent superintendent.

It is now some six or seven years since it became evident that the machinery
of the Asylum at Columbus was not working smoothly. Those evidences be-
came more and more manifest as time progressed, and, since the opening of
the two new asylums — at Newburg and Dayton — have been so conspicuous in
the three institutions, that " he that runs" could not fail to read them. Officers
have been compelled to resort to novel expedients for raising the funds neces-
sary for the current expenses of the establishment under their charge. Super-
intendents, like the leaves of most of their forest trees, have been deciduous,
falling, and giving place to others, in some instances oftener than the popular
change of almanacs. A law, at one time, has been enacted, by virtue of which,
"at one fell swoop," all the principal offices not only of the asylums for the
insane, but of the other State charitable and benevolent institutions as well,
became vacant. At length, in the reports for 1856, from the asylums at Co-
lumbus, Newburg, and Dayton, we had a picture, simultaneously drawn, of
the glaring deficiencies and defects of those three establishments ; a picture
which was in part transferred to our notices of those reports.

Effects so general cannot spring from a cause which, in its origin, is specific
to any one of the institutions. An influence so pervading throughout the rami-
fications of a philanthropic scheme, must be seated near the centre whence
issues the vitality of that scheme. Hence, when we have inquired — as we have
done more than once — for the origin of the difficulties at the Ohio institutions,
we have not been surprised by the answer — "Politics." We were prepared
to place confidence in this answer by previous observation in another State.
We had seen the principal offices in benevolent institutions filled and vacated
without the least reference to the special fitness or unfitness of the candidate

450

Bibliographical Notices.

[April

and the incumbent. We had seen many and mournful evidences of careless-
ness, inattention, and heedlessness of duty, upon the part of administrative
officials, and it has appeared to us that such are the inevitable results of a con-
nection of philanthropic institutions with the partial and unstable policy of
partisan politics, whereby the true interests of those establishments, and the
welfare of their inmates, are luwered to a position of secondary import-
ance. Under these circumstances, and with these views, we have believed it
right, when reviewing the reports of latter years from the Ohio asylums, freely
to express our opinions, perfectly willing that they should pass for just what
they are worth, and no more. If those opinions be erroneous, we are open to
conviction of our error. If we have been misinformed in regard to the source
of the various novelties, eccentricities, difficulties, and defects in the official
departments, the management, and the material of those asylums, we shall be
glad to be corrected.

Hitherto we have received reports for 1857 from but two of the Ohio asylums.
In the perusal of these, we have been induced to believe that a better day has
dawned upon those institutions. We here have unmistakable indications of a
strenuous effort, upon the part of all whose efforts are necessary to the result,
to elevate them to the rank which they ought to hold among their sister insti-
tutions in other States. We joyfully hail the auspicious omen, and look for-
ward, not indeed without anxiety, for the fulfilment of its promise.

1. From the report by Dr. Hills, of the Central Ohio Asylum, we extract the
following statistics : —

Patients at the commencement of the year
Admitted in course of the year .
Whole number " "
Discharged, including deaths
Remaining at the close of the year
Of those discharged, there were cured
Died

" The general health of the institution during the past year has been very
good. The exceptions to this fact are chiefly in the occurrence, during the
last winter and spring (1856-7), of a number of cases of erysipelas; and,
during the summer, a number of dysentery. The former prevailed to a con-
siderable extent during a few months, but the cases were very amenable to
treatment; that which invariably afforded prompt relief being iced water
applications, diligently applied. The attacks were mostly about the head and
face, though some were elsewhere, in the seat of wounds, or other localities."

The proportion of recoveries, from mental disease, is very large. Dr. Hills
attributes this in part to the greater number than usual under treatment, and
in part to other causes, of which "one of the most prolific is the greater amount
of occupation given to the mind and hands, in a variety of useful labours. * *
* * The number employed during the past season has been vastly increased,
oftentimes numbering thirty, forty, or fifty (men), in parties of from three or
four to ten or twelve. With recent or curable cases the convalescence has
oftentimes been immediate and rapid. The healthfulness in that class has also
been apparently increased, as not a death, or serious case of illness, with only
one exception, has occurred among those that habitually laboured in the open
air. While the above number of males have been occupied with suitable manly
employment, an equal or greater number of females have been engaged in
pursuits to which they are adapted. Thus has the asylum oftentimes presented
an appearance of bustle and activity, both without and within, that precluded
the possibility of many being considered as drones."

"All public days are properly observed. * * * * The fourth of July was
an eventful and ever-to-be-remembered day. The asylum was then literally
evacuated, there being 225 patients gathered at one time in the grove, for an
old-fashioned celebration. The ceremonies were similar to those of most other
assemblies convened upon our national holiday."

Men.

Women.

Total.

102

121

223

97

98

195

199

219

418

80

79

159

119

140

259

52

59

111

21

11

32

1858.]

American Insane Hospital Reports.

451

As our last notice of this asylum exhibited, in the language of its report,
some of its material defects, it is but fair that some of the material improve-
ments of the past year be here recorded. A new barn, forty by fifty feet, has
been constructed, and the old barn newly covered, inclosed, and "the interior
fitted up in the most commodious manner." A brick edifice, " eighty feet long,
thirty feet wide, two stories high, with a side wing one story high, and fifty feet
long by twenty feet in width," has been erected for a boiler-room, engine-room,
pump-room, wood-house, and carpenter shop. The apparatus for supplying
the buildings with steam, hot water, and cold water, has been extensively re-
paired and improved. The " old lodge building" is nearly completed, in its
conversion into a green-house — "the work being in a large share done by the
patients." " Much has been done toward getting the front grounds into better
order, with carriage drives, walks, arbours, &c. About one mile of carriage
drive has been laid out." A fountain has been placed upon the lawn in front
of the main building, and the hobby of the present day, an aquarium, com-
menced. "In the interior much has been done to increase the comfort and
gratification of the patients. Many more of the ladies' bed-rooms have been
carpeted; some of the halls have been repainted; a few pictures have been
placed upon the walls; and additional furniture has been supplied." A sofa
and rocking-chairs have been put into each of the front halls of the female
department, and a dozen substantial settees into the wing-halls. " For the first
time in many years the institution is free from debt."

Dr. Hills, when writing of his patients, says : " Even election-day brings
forth the ballot-box in the several 'wards/ Fearing that our 'returns' have
not been received, it may be proper to say that there was a small gain in each
ward." It is to be hoped that, as the doctor has got partisan politics fairly
into his wards, he will, in future, be enabled to keep it there, lest it again
intermeddle with the organization and the official staff of the institution. In
the Board of Trustees of one of the American asylums for the insane, there
was, a few years ago, a conscientious, but a very ready-witted member of the
Society of Friends. The Board were one day deliberating upon the proper
measures of moral treatment to be introduced among the patients. Among
other things, dancing parties were mentioned. Several of the members having
expressed their approbation of them, one of the gentlemen, turning to the

" Friend," said — "But perhaps Friend M will object to them." "0 not at

all, not at all," replied the "Friend," "a mad-house is exactly the place for
dancing."

2. The report for 1857, by Dr. Mcllhenry, of the Southern Ohio Lunatic
Asylum, shows that he is not only zealously studying the disease to the treat-
ment of which he has been called, but that, in this study, he has "got hold of
his pitcher by the right handle." His elaborate analysis and classification of
the cases treated, manifest a disposition to make a scientific use of the mate-
rials accruing to him, as a necessary consequence of his position.

Patients in the Asylum November 1, 1856
Admitted in course of the year .
Whole number " " .
Discharged, including deaths
Remaining, November 1, 1857
Of those discharged, there were cured
, ; .|?ied 1 . . .. . .

Causes of Death. — Mania 3, consumption 2, decay from old age 1, carcinoma
of brain 1, gangrene of lungs 1, hydrothorax 1, hypertrophy of heart 1, valvu-
lar disease of heart 1, apoplexy 1, t}Tphoid fever 1.

" During the entire season we have been exempt from not only the diseases
incident to our neighbourhood, but from any of those special maladies which
frequently find their way into hospitals and crowded institutions."

" The house has been full to repletion throughout the entire year. One hun-
dred and forty patients are as many as ever, at one time, should be crowded

Men.

Women.

Total.

69

64

133

74

78

152

143

142

285

66

58

124

77

84

161

44

33

77

7

* 6

13

452

Bibliographical Notices.

[April

into our halls. * * * * The average throughout the entire year has been about
one hundred and fifty."

From Dr. Mcllhenry's remarks upon various topics in relation to insanity,
we make the subjoined extracts: —

" Every day's experience among the insane more fully demonstrates to me
not only the necessity of providing them with abundance of good food, but of
allowing many of them a free indulgence in the use of such food. It is a dis-
ease that not only has a tendency to exhaust the system, but it has a strong
disposition to impoverish the blood, and vitiate, to some extent, all the secre-
tions. Nothing, therefore, can so well supply this deficiency, and correct those
morbid tendencies, as good substantial food, and a sufficiency of it.

"In a great measure, we have abolished from the discipline in this institution
the restraint system ; depending upon moral and intellectual action to control
our patients. It is true that we occasionally have to so confine the hands of
some that they cannot injure themselves or others ; but in nine-tenths of our
cases even this restraint lasts but a short time. By kindly care and culture,
they soon learn to conform to reasonable rules and regulations, without fear or
coercion.

"In the care and treatment of the insane, I am fully convinced that the
nearer we approach a family relation, the better. It is an easy matter to keep
them; but there is another consideration, much more important, devolving
upon those having them in charge. Socially, they have wants which suffer,
and will finally die out by confinement, if not properly and timely cared for.
The flagging energies of their minds must be supported by a proper cultivation
of kindly feelings; and their whole mental system must be kept alive by that
familiarity and frankness which, where properly applied, constitute the basis
of true health and happiness. It is not the best class of patients who demand
from us the most attention. They are better able to make known their wants,
and do much towards taking care of themselves. But it is those who, perhaps,
when admitted, or from long-continued insanity and neglect, have sunk into
almost hopeless dementia — their minds little else than a blank, their physical
energies often not sufficient, alone, to produce locomotion. By persevering
efforts and discipline, it is sometimes astonishing to witness the change which
takes place in such cases. From months of continued depression of mind, you
will have the satisfaction of witnessing such persons not only brightening up,
and being much improved, but occasionally they will return to an entire healthy
mental condition. W e have had two recoveries from this state of mind take
place in this institution : one who had been insane two years, and who scarcely
ever spoke ; the other, whose insanity existed nearly as long, and who never
uttered an audible word for nine months, and who never moved from her seat
without compulsion, and never ate a mouthful only as she was fed. Both are
now, after an absence from the institution of one year, remaining well, and
able to attend to their ordinary duties."

In amusements, "it is mostly through the eye and ear that melancholy and
demented patients can be reached. It is in such cases that music and dancing
perform an admirable part. The power of music on such minds must be seen
to be fully appreciated. The physical effect alone of dancing, upon persons
thus affected, by arousing the sluggish and, in many cases, almost dormant
capillary circulation, is of immense value ; besides the stimulating effect pro-
duced upon the mind by such exercise."

It is stated that, of the 152 patients admitted in the course of the year,- 36
had the suicidal propensity. Twenty-six attempted self-destruction ; the re-
maining ten merely threatened it. In our experience, we never found but one
patient in whom the propensity really existed that ever threatened to commit
suicide. Such threats have not unfrequently come from patients who would
be among the very last to put the threat into execution. Of the 26 above-
mentioned who attempted self-destruction, 30 attempts are recorded ; they
were 9 by cutting, 8 by submersion, 3 by suspension, 3 by leaps from windows,
2 by shooting, 2 by strangulation, 1 by burning, 1 by starvation, and 1 by
poison.

Of the 381 patients received since the opening of the asylum, it is asserted

1858.]

American Insane Hospital Reports.

453

Men.

Women.

Total.

238

335

573

149

217

366

387

552

939

135

207

342

252

345

597

174

32

34

66

that a hereditary predisposition to mental disorder existed in 111, or 29.13 per
cent. But from" a table showing the precise relationship, to 91 of these patients,
of their kindred who had been insane, it appears that in only 41 cases were the
direct ancestors so affected. In all other instances it was collateral relatives.
It need not be remarked that it is not fairly to be inferred that a man is heredi-
tarily predisposed to insanity, because he had a " cousin by his father's side,"
or a " grand-aunt," who was insane.

Twenty-one persons had insane brothers or sisters. In only one case had
both the parents of a patient been insane. In nineteen other cases, 7 males
and 12 females, the father was insane ; and in fifteen other cases, 2 males and
13 females, the mother. "Three patients, a father and two daughters, were in-
mates of the house at one time. There are also two sisters, members of whose
family have exhibited symptoms of insanity during four generations."

3. Our notices of former reports from the New York City Lunatic Asylum
have sufficiently indicated the vast ameliorations made at that institution since
it passed under the superintendence of Dr. Eanney. The march of improve-
ment has continued during the year 1856, and a very considerable interest in
the establishment appears to have been awakened among the citizens of New
York, manifested by contributions to its means of moral treatment.

Patients in the Asylum, January 1, 1856
Admitted in course of the year .
Whole number . . . .
Discharged, including deaths
Remaining, December 31, 1856 .
Of those discharged, there were cured
Died

The percentage of deaths is smaller than that of any preceding year.
" Although," remarks Dr. Ranney, "the general mortality has been so much
diminished, yet, in a few diseases, there has been a decided increase, especially
in that known as ' paralysie generale/ This fatal disease, which but a few
years ago was described as rare, has increased to such an extent in the city as
to have been the cause of nearly one-fourth (15 of 66) of all the deaths in the
Asylum the past year. It seems to result from a disorganization and softening
of the cortical portion of the brain, involving, if the disease be protracted,
the medullary substance. Almost universally certain in its results, its victim
seldom survives a longer period than two years after the first symptoms are
exhibited. Indeed, so fatal is it in its character, that in no case have I seen
recovery follow, where the symptoms were sufficiently well marked as not to
admit of doubt. High living, late hours, and strong mental excitement, com-
bined, have been considered the most frequent causes of the disease.

" The past year has been entirely free from the ravages of any epidemic ;
and no suicide, homicide, or unfortunate accident has occurred in our midst,
demanding an inquest."

The use of the mechanical means of restraining the body and limbs of
violent, destructive, and suicidal patients, is now almost wholly abolished at
this institution. The history of the past year, as recorded in the extract just
quoted, is one evidence, in addition to many others of antecedent date, that the
less those means are employed the fewer is the number of suicides. "The
experience of the last year," says the General Report of the Royal Hospital of
Bridewell and Bethlem, for 1843, " adds another confirmation to the now gene-
rally received opinion that mechanical restraint is an exciting cause for suicidal
propensities ; and though it may for the time restrain the attempt, it fortifies
and strengthens the desire it is intended to control. * '* * * From 1750
to 1770, when every patient was under restraint, the suicides were in the propor-
tion of 1 to 202; whereas during the last twenty years the proportion has been
only 1 in 963."

In the course of the last ten vears, there have been ten suicides at the New
No. LXX.— April 1858. 30

454

Bibliographical Notices.

[April

York City Lunatic Asylum. We are not informed of the years in which they
severally occurred. It would be interesting to trace them in connection with
the gradual diminution of coercive and restraining measures, and ascertain
the relation which the one bears to the other. That the suicidal impulse, other-
wise often transient or even momentary, may be, as expressed above, confirmed
by the adoption of restraining apparatus, we have no doubt. Feuchtersleben
relates the case of a man who, "being on the point of committing suicide,
wanted to quote the passage 'Quand on a tout perdu,' &c, and being in doubt
whether it was by Voltaire or Moliere, forgot his design." Now, had the
leather muff and waistband, or the strait-jacket come to the relief of this man,
instead of that to him fortunate quotation, there can be but little doubt that
his impulse would have been perpetuated to a fatal result.

The progress in the number of the inmates of the institution, the report of
which is before us, is shown by the subjoined table: —

December 31, 1826, patients in the Asylum . . . .89

" 1836, " " .... 143

" 1846, " " .... 383

" 1856, " " . , . . 597

A condensed statistical account of the medical history of the Asylum from
the first of January, 1847, to the 31st of December, 1856, is included in the
report. We extract some of its most important details: —

Number of patients, January 1, 1847
Admitted in ten years

Whole number

Cured . . ; .

Died

Single

Married

Widowed

From 20 to 30 years of age
From 30 to 40 . .

Causes of Death. — Consumption, 332 ; chronic diarrhoea, 173 ; cholera
(Asiatic), 169 ; paralysie generate, 78; congestion of brain, 60; paralysis, 48 ;
epilepsy, 44 ; dysentery, 34 ; dysenteric diarrhoea, 33 ; diarrhoea, 31 ; old age,
29 ; apoplexy, 27 ; typhomania, 24 ; typhus fever, 18 ; typhoid fever, 17 ; dropsy,
13 ; delirium tremens, 10 ; erysipelas, 8 ; suicide (by suspension 6, submersion
3, strangulation 1), 10 ; marasmus, 6 ; inflammation of brain, 6 ; hemiplegia, 4 ;
organic disease of heart, 4 ; pericarditis, 3 ; ascites, 3 ; inflammation of lungs,
3 ; albuminuria, 3 ; softening of the brain, 3 ; carcinoma, 2 ; scurvy, 2 ; dry
gangrene, 2 ; chronic peritonitis, 2 ; stomatitis, 2 ; hydrothorax, 2 ; chronic
pleurisy, 2 ; acute meningitis, 2 ; lumbar abscess, 2. Twenty-three other
diseases are mentioned as having been the cause each of one death; but they
are maladies and accidents which, with the exception of hydrocephalus, serous
apoplexy, and inflammation of the spinal marrow, are not seated in the great
nervous centre.

Of the whole number of patients (4,383) admitted, only 1,023 were natives
of the United States, while 3,360 were foreigners. The subjoined table includes
the names of those countries from each of which there were more than nine: —

Ireland 2,142 Switzerland .... 21

Germany 649 Canada 16

England 261 Wales 14

Scotland 72 New Brunswick ... 11

France 52 Italy 11

Prussia 22

The remainder were from twenty-seven different countries and colonial
islands, with the exception of two, who were natives of the " Atlantic Ocean."

Men.

Women.

Total.

171

212

383

2,090

2,293

4,383

2,261

2,505

4,766

2,105

593

646

1,239

1,108

1,058

2,166

875

966

1,841

107

269

376

677

857

1,534

677

675

1,352

1858.]

American Insane Hospital Reports.

455

The immigrants from Ireland furnished no less than 48.87 per cent, of the
whole number of patients.

4. Dr. Brown, of the Bloomingdale Asylum, in his report for 1856, has not
departed from his customary brevity in these annual publications.

Patients in the Asylum, January 1, 1856
Admitted in the course of the year

Whole number

Discharged, including deaths
Remaining, December 31, 1856 .
Of those discharged, there were cured
Died

Men.

"Women.

Total.

56

71

127

73

61

134

129

132

261

65

52

117

64

80

144

35

19

54

10

9

19

Causes of Death. — General paralysis, 1 ; phthisis, 3 ; chronic bronchitis, 1;
inanition, 2; apoplexy, 2; epilepsy, 1; acute inflammation of the brain, 2;
chronic disease of the brain, 3 ; dropsy of the chest, 1 ; exhaustion after dysen-
tery, 1 ; carbuncle, 1 ; suicide, 1.

"The health of the household, as a family, has been uniformly good ; and
the general condition of the patients as satisfactory as the peculiar construction
of the institution permitted."

Dr. Brown recommends the extension of the "lodge" for females, so as to
connect with the main building ; and the introduction of the system of heating
by steam.

In our notice of the Bloomingdale report for 1855, we made some remarks
upon the imperfect organization of that Institution, its need of an Assistant
Physician, and the defective method of heating the apartments of the principal
edifice. Since the publication of that notice, the office of Assistant Physician
has been created, and Dr. Corey elected as the first incumbent. The other two
objectionable matters remain in statu quo erant ; but as one important step in the
right direction has been made, we hail the fact as an auspicious omen for the
future.

Men. "Women. Total.

5. At the Vermont Asylum for the Insane, the
number of patients on the 1st of August,

1856, was 190 217 407

Admitted in course of the fiscal year 64 83 147

Whole number 254 300 554

Discharged, including deaths ... 62 79 141

Remaining, August 1, 1857 . . .192 221 413

Of those discharged, there were cured . 74

Died 37

In relation to the treatment of insanity, Dr. Rockwell says : " Whenever
any physical disease can be detected, it is treated as in other states of the
mind. The moral treatment consists chiefly in pleasant and useful employ-
ment, and especially that which requires sufficient physical exercise. We
always endeavour to employ both sexes according to their former habits and
tastes. After all, much depends upon the faithfulness of kind and intelligent
nurses, wholesome and nourishing diet, proper ventilation, the different kinds
of bathing, sufficient exercise in the open air — either by riding, walking, or
cultivating the garden and farm, and all such agreeable employment of the
mind and body as shall promote physical health and call into exercise those
faculties of mind that are unemployed. * * * * * If the minds of many
of the insane are allowed to remain inactive, they will soon become demented,
and manifest a brutish indifference. Sometimes, when confined without any
employment, they become fretful and irritable, destroying their clothes and
other property, and hasten to an incurable state. But let some useful and
agreeable employment be furnished them, and they will be pleasant and

456

Bibliographical Notices.

[April

cheerful through the day, and enjoy refreshing sleep at night. In this manner
the mind and body will become invigorated, and reason will be restored."

6. In the last biennial report of the officers of the Western Lunatic Asylum
of Virginia, the Trustees say: —

"During the latter part of the last year, our well-known Physician and
Superintendent, Dr. Francis T. Stribling, having conceived a wish to return to
the general practice of his profession, tendered a resignation of his office in the
Asylum, to take effect on the first of January last. The Board heard of this
determination with profound regret, both personal and official ; and to convey
to Dr. Stribling, in a lasting form, their sense of his ' long and faithful services
to the State, and invaluable benefactions to afflicted humanity/ they resolved
to present him with a piece of plate in token thereof. This resolution was
subsequently carried into effect, not, however, before urgent solicitations from
all quarters of the State — and many of them of a most affecting character,
from those who had themselves been objects of the doctor's care — had induced
him to abandon his intention of severing his connection with the Asylum; and
the board have thus the gratification of feeling that a tribute which at one time
they feared was to crown the period of the doctor's services to the State, now
serves but to mark a point in his career of public usefulness/'

Dr. Stribling remarks, in reference to the period over which his report ex-
tends, that " not only has the Institution been almost constantly crowded, but
we have again been compelled, to reject many, very many applicants for ad-
mission."

Patients in the Asylum, October 1, 1855

Admitted in course of two years

Whole number " " ...

Discharged, including deaths

Remaining, September 30, 1857 .

Of the patients discharged, there were cured

Died

Men.

Women.

Total.

226

162

388

81

55

136

307

217

524

79

56

135

228

161

389

29

33

62

32

14

46

The progress of this Institution is measurably indicated by the following
statistics of the number of its patients in the course of a fiscal year, at four
periods: in 1828, thirty-six ; in 1837, seventy-seven ; in 1847 two hundred and
fifty- six ; and in 1857, four hundred and fifty five.

In a letter to Governor Wise, published in this report, Dr. Stribling triumph-
antly vindicates the course which he has pursued in the admission of patients
under those trying circumstances in which the number of applications far
exceeds the ability of accommodation. In the course of this letter, the Dr.
bears testimony to the comparative disadvantages of large institutions. " I
can but think," says he, " a great error was committed in enlarging this Insti-
tution to its present dimensions, but take to myself a large share of the blame
resulting from such error."

Two conflagrations are recorded in this report. The first, of a detached
building for the worst class of females, on the 8th of November, 1855 ; and
the second, of a similar building, for a like class of males, on the 18th of October,
1856. The former occurred from a defective chimney ; the latter is attributed
to incendiarism by one of the patients. No patient was injured. " The roofs
of both buildings' were entirely destroyed before the flames could be subdued.
We then experienced the great value of counter-ceiling; and had we ever
doubted before its necessity, are now satisfied that it should never be dispensed
with. But for the fact that these buildings had thus been constructed, the fire
must have communicated with one or both of the stories below, and conse-
quently the damage have been far greater."

7. The most important of the statistical records of the Hartford Retreat, for
the fiscal year, ending with the 31st of March, 1857, are as follows: —

1858.]

American Insane Hospital Reports.

457

Men. Women. Total.

Patients at the beginning of the year . 98 99 197

Admitted in the course of the year . 73 88 161

Whole number . . . . . 171 187 358

Discharged, including deaths 72 80 152

Remaining at the end of the year . 99 107 206

Of those discharged, there were cured . 34 37 71

Died 5 9 14

Whole number, from 1824 to March 31,

1857 1,478 1,644 3,122

Discharged, recovered .... 1,534

Died 322

Causes of Death this Tear. — Exhaustion, 6 ; general debility, 2 ; general
paralysis, 2; pneumonia, 1; phthisis, 1; suicide, 1; paralysis, 1.

Dr. Butler, commenting upon the premature removal of some rapidly conva-
lescing patients, whereby injurious and in some cases incurable relapses were pro-
duced, says : "As the Institution possesses no power to retain a patient contrary
to the wishes of their legal or natural guardians, I can only lament that friends
should so often mistake temporary results for permanent restoration — the remis-
sion of the disease for its entire removal. It would be often quite as reasonable
to expect fair weather from every lull in the storm. Thus, every year, by the
unwise interference of friends, additions are made from among our convalescing
patients to our sad list of incurables. Some ten or twelve of those discharged
improved, ought to have been on the list of recovered. We can only look for
a remedy to a better appreciation of our curative means, and to a more correct
knowledge of the disease.

" There is one important improvement among practitioners at large which I
am gratified to notice. It is now a rare occurrence that I find maniacal patients
have been bled previous to admission. Of nearly two thousand patients who
have been under my charge, I have not found it necessary to resort to blood-
letting for insanity in a single case. My confidence in the lancet as a curative
means, has in no way diminished where the symptoms of the disorder indicate
its use. My experience tallies with that expressed in the excellent work upon
this subject from the pen of my estimable friend, Dr. Earle. I refer with con-
fidence to that volume.1 Cases of mania which have been bled previous to
admission, I have invariably found difficult of treatment, protracted in their
recovery, and sometimes sinking into hopeless dementia."

A description of the new "Lodge" for the violent class of female patients,
was mentioned in our notice of Dr. Butler's report for 1854-5. A new one for
the same class of men, has now been completed. " A valuable addition was
made to this by the construction of a second story. At a comparatively small
expense, ample accommodations for twenty additional patients have been ob-
tained. The centre and partition walls of the eight rooms upon the first story,
were carried up through the second, giving us eight rooms of the same dimen-
sions of those below, being eight by eleven feet. One of these is appropriated
for the attendant, and two others for the bath and clothes rooms, leaving five
single rooms for the patients. There then remained a large room (sixteen by
eighty-four feet), which was divided into three nearly equal parts by partitions,
in part of plank and part of lattice ; the centre room (sixteen by thirty) for a
parlor, the other two (sixteen by twenty-seven) for dormitories. The three,
being practically thrown into one at night, by the lattice doors, afford ample
space for fifteen beds."

In respect to the convenient and ornamental furnishing of the hospital wards,
Dr. Butler says: " I have aimed to inculcate the doctrine upon the friends of
patients and upon all visitors, that insanity should be treated like other diseases,
and so to arrange and decorate our wards, that they shall as nearly as possible
resemble the chambers of illness in our own homes, believing that whoever has
brought himself to consider a disease of the brain as differing only in degree

1 Earle, on Bloodletting in Insanity.

Men.

"Women.

Total.

230

225

455

141

101

242

371

326

697

140

96

236

231

230

461

59

41

100

22

8

30

458 Bibliographical Notices. [April

from a disease of the lungs, ' has robbed it of that mysterious horror which
forms its chief malignity.' " Donations in money to the amount of $716 00,
for the purpose of decoration above mentioned, are acknowledged, and the fol-
lowing remarks are made in reference to its appropriation : " I have thus been
enabled to purchase, in all, over two hundred prints and engravings, which
have been handsomely framed, and between twenty and thirty county, State,
and national maps. These have been distributed throughout our fifteen wards
(lodges included), excepting two halls in the north and two in the south wings,
where I have not thought best to introduce them. Over one hundred of these
have hung upon our walls upwards of two years ; most of the others were added
early in the winter. To this day, not one of these has been in the least in-
jured ! Our visitors can bear testimony to the lively and home-like character
which they have imparted ; but only those who are daily conversant with our
household, can fully appreciate their happy and grateful influence. v

8. We extract the subjoined items from the published record of the New York
State Lunatic Asylum : —

Patients in the Asylum Nov. 30, 1855
Admitted in the course of the year
Whole number ....
Discharged, including deaths
Remaining, Nov. 30, 1856 .
Of those discharged, there were cured
Died . . \

Causes of Death. — Exhaustion from mental disease, 7 ; general paralysis, 6 ;
phthisis pulmonalis, 5 ; epilepsy, 2 ; malaria cachexia, 2 ; suicide, 2 ; chronic
nephritis, 1 ; fibrinous concretion of heart, 1 ; ovarian dropsy, 1 ; remittent
fever, 1 ; gangrene of lung, 1 ; old age, 1.

" The only disease which prevailed to any extent, was a form of continued
fever, slightly remittent at the commencement of the attack, but which soon
assumed a marked typhoid type. The first case appeared in the latter part of
July, and was immediately followed by others. The peculiar features of the
disease, and the fact that these cases occurred in dormitories in the immediate
vicinity of the main sewers, led us to suspect the existence and operation of
some local cause. A close examination resulted in the discovery of numerous
rat holes opening directly beneath the windows of these dormitories, and com-
municating with the main sewers." * * * "No new cases occurred in these
localities after the removal of this source of atmospheric poison. Afterwards,
however, in the wards where the workmen were engaged in relaying partially
decayed floors, and removing the old wash and bath-rooms, the fever reappeared,
and though every precaution was taken, * * * * cases continued to occur
until the repairs in these wards were entirely completed. * * * Of the twenty-
six cases of fever, three died — one patient, and two of our most valuable em-
ployees."

Some of our readers may perhaps recollect that a system of forced ventila-
tion, by means of a revolving fan, has been introduced into the female depart-
ment of this Asylum, and that, in his report for 1855, Dr. Gray published a
table of the acute diseases which prevailed in the departments of the two sexes,
as illustrative of the hygienic advantages gained by the improved ventilation.
We extract a similar table from the report now under notice : —

Male Department. Female Department.

Continued fever . . . .17 Continued fever .... 6

Intermittent fever . . . 4 Intermittent fever

Erysipelas 4 Erysipelas

Dysentery 6 Simple fever .

Dysentery

" Through the summer and autumn, diarrhoea prevailed more or less among

1858.]

American Insane Hospital Reports.

459

the male patients, while, on the other side of the house, but seven cases
occurred throughout the entire year.

" Among the cases of fever, in some instances there was a subsidence in the
activity of the mental affection during the attack, while in others there was no
appreciable abatement. The larger number of cases occurred in persons who
had been but a short time residents of the Institution, and, as frequently ob-
served by those familiar with insanity, several recent cases of insanity began
to improve simultaneously with the invasion of bodily sickness. In one case
of melancholia, and three of acute mania, the improvement continued until
their final restoration.'7

The subjoined extract is made for two reasons : First, that the still-continued
barbarities towards the insane may widely be made known, in the hope of
hastening the day of their total extinction ; and second, to demonstrate the
superiority of hospital treatment.

A thing difficult of accomplishment by a person ignorant of the proper method
of performing it, is often easily done by one who knows how to do it. The sage
men gathered together with Columbus thought so, and said so, after he had
balanced the egg upon its smaller end.

" In one county where all the insane were, during the year, committed to
the care of the Superintendents (of the poor), all were placed in the poor-house
for medical treatment. Application was made to the Asylum for but one, and
in this instance, not until a continuous confinement in iron handcuffs and foot-
locks, and being chained to the floor for six months, had failed to subdue the pa-
tient. Then the officer wrote : ' We have a man so violent and dangerous that
we wish to place him in the Asylum/ He was brought to us in the irons above
mentioned, which were so firmly rusted that they could not be unlocked, but
had to be filed off. This man has worked steadily on the farm, and with the carpen-
ter at his trade, since the day after his arrival."

" Eighteen males and fifteen females (of the 242 admitted), manifested a strong
suicidal disposition, and one of the former and three of the latter, were, at the
time of admission, suffering from wounds more or less severe, inflicted for the
purpose of self-destruction. In one male, an irresistible impulse to homicide,
with perfect consciousness of the tendency, was the prominent symptom in his
case. In one male and two females, the same homicidal disposition was con-
joined with an equally strong suicidal impulse. The latter succeeded in de-
stroying the lives of four of her children at once, severely injured a fifth, and
inflicted a dangerous wound upon herself."

The New York State Asylum is not remote from the centre of a very exten-
sive agricultural district, and hence it might properly be supposed that, of its
patients, farmers would exceed in number those who have been engaged in any
other calling. Of the 242 admitted in the course of the year, 47 were farmers,
and 20 farm laborers. No other occupation was represented by a greater num-
ber than seven. Nevertheless, Dr. Gray expresses the opinion that " farmers,
farm laborers, artisans in wood and in the metals, enjoy an exemption from the
proportionate frequency (relative to the numbers engaged in each calling) of
attack, while persons engaged in literary pursuits, speculators, merchants, are
more frequently the victims of mental disease.''"

Patients admitted from Jan. 16, 1843, to Nov. 30, 1857 . . 4,830

Discharged recovered 2,017

Died 573

Six thousand five hundred and three articles of clothing and of bed and
table furniture, were made by the female patients and attendants in the course
of the year.

To show the value of a farm and a large kitchen garden in connection with
an institution which feeds many persons, and particularly one in which a large
portion of the labor of tillage may be performed by the inmates, beneficially to
themselves, we take a few from the large number of items of the products, for
the year, at this Asylum : —

460

Bibliographical Notices.

[April

Potatoes

Green peas .

String beans

Lima beans

Beets .

Onions

Carrots

Turnips

Tomatoes .

Cucumbers, pickled

1,000 bushels.

460 "
1,200 "

500 "

760 "

700 "
1,800 "
1,050 "

500 "
34 barrels.

Cucumbers, early
Cabbage
Celery .

Lettuce . .
Summer squashes
Winter squashes .
Pumpkins .
Strawberries
Sweet corn .

35 bush.
7,000 heads.
6,200 "
36,000 "
3,600 "
3,600 "
1,200 "
1,500 qts.
350 bush.

Men.

Women.

Total.

168

168

336

112

129

241

296

281

577

97

114

201i

376

46

51

97

18

17

35

5,197

2.381

590

9. Dr. George Chandler, who, in the language of the trustees, "for more than
ten years had most acceptably discharged the duties of superintendent of the
Massachusetts State Lunatic Hospital, at Worcester, retired from that office on
the 16th of July, 1856, and was succeeded by Dr. Merrick Bemis, the author
of the report now under notice.

Patients in the hospital, Nov. 30, 1855
Admitted in course of the year .

Whole number

Discharged, including deaths
Remaining, Nov. 30, 1856 ....
Of those discharged, there were cured
Died . . . ; . . .
Whole number admitted from opening of

hospital

Discharged, recovered ....
Died ......

Diseases proving Fatal in Course of the Year. — Epilepsy, 5 ; exhaustion from
maniacal excitement, 5 ; consumption, 4 ; palsy, 4; marasmus, 3 ; inanition, 3 ;
dysentery, 3; apoplexy, 2; pneumonia, 2; chronic dysentery, 1; diarrhoea, 1;
old age, 1 ; carbuncle, 1.

" Late in the summer there were several cases of dysentery, three of which
proved fatal; and in the autumn there were a few cases of fever. There have
been also several protracted cases of diarrhoea."

" The popular excitements of the day," says the report, "have not brought
to us so many patients as is generally believed by the community at large."

But a short time prior to entering upon the duties of his office, Dr. Bemis
returned from a visit to many of the institutions for the insane, in Europe.
Stimulated, probably, by what he had seen of the operation of the so-called
" non-restraint system" practised in some of the British hospitals, he soon
undertook to dispense, as far as he thought best, with the means of seclusion
and of restraint which had previously been employed in the hospital. He
writes as follows upon the subject: —

" Few of our patients are, or have been, in restraint during the year. Since
July last, no ' strong room' has been occupied. Patients often require some
seclusion, as one sick of acute disease requires a bed. But those whose malady
has made it necessary to resort to such means, have been kept in their own
room, the common dormitory of the house ; and only in few cases has the fur-
niture been removed, and fewer still have we suffered from much destruction of
clothing or furniture. We think that patients who have formerly been exceed-
ingly noisy, filthy, and disgusting during their periods of excitement in the
1 strong rooms/ have been, to say the least, more easily controlled, and less
troublesome, during similar excitements, when not removed from their ordi-
nary rooms."

The trustees, in their report, thus come in to the support of the doctor.

" Dr. Bemis, since he entered upon his duties, has not, in a single instance,

1 These figures are given as in the report. The sum of the two items is 211 in-
stead of 201.

1858.] American Insane Hospital Reports. 461

made any use of the strong rooms for the confinement of the patients, nor has
he as yet found it necessary to employ any extra attendants in the various
■wards. We are not fully prepared to draw any specific conclusions upon this
subject from the experience of the last four months. We are prepared, how-
ever, to state the fact, that during that period we have found the patients, as a
whole, at our monthly visits, more quiet than during any other four months
since our connection with this institution. Occasions have not been rare when,
out of some 370 patients, not a single one was subjected to any kind of re-
straint other than the care of the attendant within the ward. * * * In the last
annual report it was stated that of the thirty-six strong rooms, twenty-four had
been removed by order of the trustees, and that four large and airy parlours or
sitting-rooms had been substituted in their place. Of the twelve strong rooms
remaining, the six in the female department have not been used for more than
twelve months, and the six in the male department have not been used for the
last four months ; and the trustees have no doubt that these remaining twelve
strong rooms may be removed, and the space occupied by them be appropriated
to a much more useful purpose."

In relation to other improvements, Dr. Bemis writes as follows: " In order
to procure more intellectual amusement, and make it the means of instruction,
a plan is in operation to establish ,a system of daily, intellectual entertain-
ments— historical readings, with familiar explanations, courses of lectures, and
school exercises — thus beginning what we hope may prove a source of plea-
sure and profit, at least a part of the year.

"We have been trying of late to introduce a system of labor among our pa-
tients. So far as we have been able to succeed the result has been gratifying.
There seems to be no reason why strong, healthy men or women should not
perform some labour at an institution of this kind. It should not be compul-
sory. If it can be made pleasant and attractive, so that a considerable num-
ber will engage in it, I have no doubt that it will be found greatly useful as
a remedial measure."

Dr. Bemis does not mention the details of his system of labor, and hence we
know not the extent to which he proposes to introduce it. It is well known
that when this hospital was under the immediate guidance of Dr. Woodward,
the amount of labour performed by the patients was very large. If Dr. Bemis
sustains it at the same standard, he will do well.

10. The fiscal year of the New Hampshire Asylum for the Insane terminates
with the close of the month of May. In their last report, the trustees inform
us that, "in March last Dr. Tyler communicated to the trustees his resignation
of the office of superintendent of the asylum, and subsequently, at a meeting
of the board, his resignation was accepted, to take effect on the fifteenth day
of July next." On the seventh of May, Dr. Jesse P. Bancroft was elected as
successor to Dr. Tyler. After enumerating many improvements made in the
establishment in the course of the five years last past, the trustees say: "In
the execution of these, Dr. Tyler has ever taken a deep interest, and much of
their success is due to his sagacity in their device, and his assiduous superin-
tendence of their execution. His fidelity and skill in the management of the
patients committed to his care, is evinced by the success which has thus far
attended his efforts in their behalf."

Patients in the asylum, May 31, 1856 .
Admitted in course of the year

Whole number

Discharged, including deaths
Remaining, May 31, 1857
Of those discharged, there were cured
Died

Men.

"Women.

Total.

. 77

77

J54

. 48

49

97

. 125

126

251

. 41

40

81

. 84

86

170

. 24

23

47

. 6

6

12

Causes of Death.— li One of apoplexy, one of epilepsy, and the remaining ten
worn out by chronic insanity."

462

Bibliographical Notices.

[April

Whole number of admissions from opening of asylum . . 1476

Discharged, recovered 662

Died 140

An addition, called " the Rumford wing," was completed and opened to the
patients in the course of the year.

Dr. Tyler's report is brief, and chiefly devoted to matters of local interest.

P. E.

Art. XX. — Proceedings of Westchester County Medical Society, at its An-
nual Meeting, held in the Village of Sing Sing {N. Y.), June 3, 1856.
8vo. pp. 50.

The professional reports embraced in the Transactions of the Westchester
County Medical Society, though in themselves sufficiently interesting, present
but few prominent facts demanding especial notice.

In a report on the medical topography, epidemics and endemics of the
southern section of the county, drawn up by Dr. J. D. Trask, of White Plains,
the following statements appear in reference to the prevalence of intermittent
and remittent fevers, in that portion of country included in the report. They
show how little positive knowledge we possess as to the etiology of those
diseases : —

"The County of Westchester has, almost without exception, been regarded
as unusually healthful. Along the Sound, miasmatic diseases have always
prevailed to a certain extent, but within the past four or five years, intermit-
tents and remittents have appeared where they have not been known before
within the memory of the oldest inhabitants. This seems to have been due to
a wide-spread atmospheric influence, which has passed on northward to regions
rarely if ever before affected. Its northern limit, the committee have not, from
inquiry, been able to learn.

"An effort has been made to ascertain, as far as practicable, the probable
sources of malaria in those neighbourhoods where it always prevailed more or
less, before the spread of the general atmospheric influence to which allusion
has been made. It does not appear, however, that during the period of this
general diffusion of malaria, such diseases have been more prevalent and more
grave in places where they have always prevailed ; the poison has been diffused
through new localities, but not concentrated in old ones.

"Dr. Sands, of Portchester, writes : 'Previous to the last five years, I am
not aware of having met with a case of disease of decidedly malarious origin
in the neighbourhood. I was in practice here ten years before I saw a case of
intermittent; during the last five years, however, cases have abounded. The
disease has nearly disappeared, very few cases having occurred this summer.
Excavations and drainage have, in my opinion, increased its prevalence. I
have observed the disease in the neighbourhood of marshy grounds, particu-
larly on the east of such localities, when the residence is not much elevated
above the marsh ; this I have attributed to the prevalence of westerly winds/

" In relation to Mamaroneck, Dr. Stanley says : ' There appear to be certain
localities or houses, where intermittent fever has prevailed more than else-
where, but these seem to me to be so irregularly placed as to forbid the suppo-
sition that the ponds of fresh water or the salt marshes certainly produced the
increased severity of the disease. The large factory pond was drained in the
spring of 1854, and during the summer the channel through the centre of the
pond, which had been nearly obliterated, was opened, and the whole surface
became quite dry in June. The fever that year was about the same as the
year previous, certainly not less. In 1855, the fever in the vicinity of the
stream, and also of ponds a few miles off, very much diminished ; and no other
disease having the marks of an epidemic appeared in its place. The high
grounds three or four miles back are not exempt, but are less affected by inter-

1858.]

Proceedings of Westchester County Medical Society.

463

mittent disease than the first low ground back of the first ridge, which slopes
down to the tide water ; and there, I think, intermittens have been the most
prevalent/

" The occurrence of the disease five or six years ago, as an epidemic, so far
as special localities were concerned, was much as above stated ; but one great
source of its severity and continuance, was a disregard, in particular families,
of cleanliness, temperance, and good living, with proper rest of body and mind.
The disease increased, and badly, from 1848 to 1853 ; and that year and the
next it prevailed very extensively and severely, returning, in most cases, after
it was broken, on or very near the seventh, fourteenth, or twenty-first day.

"The factory pond above referred to, was indicted in the year 1853 as a
nuisance, from its presumed agency in developing malaria ; but it was proved
that malarious diseases at that time prevailed in regions previously unaffected.
Dr. Moulson says: 4 Intermittents are less prevalent in Mamaroneck since the
factory pond has been drawn off ; but this does not show a connection of cause
and effect, since the same has happened, pari passu, at New Rochelle, where
no pond has been drained/

" In reference to New Rochelle and its vicinity, Dr. Moulson says, after re-
ferring to swamps, or low grounds which become dry in summer: 'An island
in the Sound, nearly a mile from the shore, of about seventy acres, has upon
it a pond of fresh water, about fifteen rods in diameter when full, but of much
smaller dimensions in dry seasons. This pond is on the eastern side of the
island, where the ledges of rock project above the earth and breast the waves.
Large quantities of muck are taken from the bottom and sides of this pond,
when left naked in dry seasons, together with the flags and weeds which grow
luxuriantly on its borders, and spread upon the land as manure. Paludal
fevers prevail here as well as on the main land. I have never found such dis-
eases more prevalent, cceteris paribus, where salt and fresh water meet, than
where there was no salt water. Formerly, before intermittents became so
general, they were confined to the valleys, and to the neighbourhood of rivers
and swamps, and seldom occurred near salt marshes or meadows, unless fresh
water swamps were near; but I visited a family of seven persons in Pelham on
the third of September, 1853, four of whom were ill with intermitting fever, and
all had been seized within the preceding twenty-four hours. On the day fol-
lowing, two others had the same disease. No local cause or appreciable atmo-
spheric changes could be assigned as a probable cause. Intermittents prevail
in Pelham more than in New Rochelle, if I am rightly informed, and the
islands on its shore are not exempt from the disease, as they formerly were.
The isthmus called Rodman's is, like the islands, generally exempt from paludal
fevers/

" Intermittents and remittents were much more prevalent, and of a graver
character, three or four years ago, in New Rochelle and Pelham, than they are
at present, or within two years past, while they are increasing and becoming
more grave in East Chester within a year or two. I have seen nothing to in-
duce the belief that malaria is produced by excavations or drainage, nor have
I known it diminished by such means.

"In the town of Westchester, according to Dr. Ellis, ' intermittents do not
prevail to any considerable extent in my practice, and when occurring, are
confined almost exclusively to the labouring classes. I do not consider them
attributable to malaria or any local cause, but to improvident exposure, and
sudden changes of temperature/

" ' In the township of Yonkers/ says Dr. Gates, ' a mill-pond near the south-
east part, covering the most part of one hundred acres of flat, moist land,
appears to be the cause of intermittents, which have always prevailed in its
immediate vicinity. In the Saw-Mill Valley is a strip of moist land which has,
in some instances, produced intermittents. Aside from the above, we have been
exempt from the disease during the last thirty-two years, until the last five years,
during which they have prevailed a little more generally, commencing in a very
wet summer; still, we are comparatively exempt/

" Dr. David Palmer, formerly of White Plains, informs us that he commenced
practice in this place forty years ago. During the first few years of his prac-

464

Bibliographical Notices.

[April

tice, intermittent and remittent fevers were hardly heard of. ' Suddenly, how-
ever, these diseases made their appearance, and became very common all over
that part of the county. I recollect I used more quinine in one year than I
had previously done for some half-dozen years. According to the best of my
recollection, the season was both wet and warm, giving rise to the decompo-
sition of vegetable matters, to which, at the time, I attributed the prevalence
of the fever. Remittent fever was not uncommon at the time, but seldom of
such severity as occurred at New Rochelle, and here, again, although the gene-
rating cause, wet season, had passed by, still intermittent and remittent fevers
continued more or less common for several succeeding years, depending, I sup-
pose, on the original exposure, the poison remaining, for the time, latent/

" 'Nothing/ says Dr. Palmer, 'in the course of my practice of twenty-four
or five years, has led me to suppose that any peculiarities existed in that section
of country, to control or influence the character or type of the different diseases
as they appeared from time to time. I have always considered it a healthy
part of the county/

" White Plains, and its immediate vicinity, have been regarded as a singularly
healthy region, and for several years had enjoyed almost an exemption from
diseases that at times have prevailed along the North and East Rivers. It has
not unfrequently been remarked that epidemics, like showers in summer, pass
upward along the borders of those two great water-courses, leaving this locality
unvisited. For many years intermittents had not been enumerated among the
diseases, previous to the summer of 1853. A few cases had occurred occasion-
ally among those in the immediate vicinity of a mill-pond on the northeastern
limits of the town, and of another on the western borders. During the sum-
mer of 1853, there was much rain, and a luxuriant growth of vegetation covered
the earth's surface ; portions of this decomposed, giving rise to offensive odors
in the gardens. During the season, intermittent fever made its appearance in
this vicinity, and from seventy to eighty cases came under my immediate no-
tice. During the summer and autumn of 1854, it prevailed to a much less ex-
tent; while, in the summer of 1855, there occurred an epidemic of intermittent
and remittent fever of some extent/7

Similar facts to the foregoing have been noticed in Pennsylvania. From
many districts where, formerly, fevers of an intermittent or remittent type pre-
vailed annually very extensively, they have of late years almost entirely dis-
appeared ; while, in other districts, where formerly these diseases were unknown,
they have lately become, as it were, endemic, and this without any evident
change in the local conditions of the different localities. The circumstances
supposed to be favourable to the production of the fevers in question, have not
been removed in the one case, nor become more developed than before in the
other. There can be no doubt that, as a general rule, it is to those localities
in which the air is humid, and, at the same time, has not a sufficiently free cir-
culation, that intermittent and remittent fevers are endemic. That, however,
these diseases do not invariably prevail in, and are far from being exclusively
confined to such localities, facts innumerable incontestably prove. There would,
indeed, appear to prevail at irregular periods, and for a series of years, certain
conditions of atmosphere, extending over large districts of country, favourable
to the production of intermittent and remittent fever, irrespective of the pre-
sence of the supposed sources of miasmata. During the morbific conditions
of atmosphere alluded to, periodical fevers prevail extensively, and in situations
where, at other times, they are rarely or never observed ; while, in the absence
of such atmospheric conditions, they never or very seldom occur beyond what
are known as malarious districts, and in them often to a very limited extent.

A report is presented by Dr. G. J. Fisher, of Sing Sing, of cases illustrative
of the effects of needles accidentally penetrating different parts of the body.
The chief object of Dr. Fisher is to point out the ultimate danger that may and
often does result from needles or portions of needles accidentally driven into
the body being allowed to remain, and gradually work their way to the neigh-
bourhood of some important nerve, bloodvessel, or other organ, causing intense
suffering by the irritation they cause, or more serious and even fatal results, by
penetrating some vital part.

1858.] Gibbons, Address before the San Francisco Medical Society. 465

It is unquestionably the duty of the surgeon to endeavor, in every instance
where needles or parts of needles have entered any part of the body, to ascer-
tain their precise locality, and to attempt their removal, by an operation, if
necessary, whenever this can be performed "without involving any serious
risk of wounding some important nerve or other structure, or of exciting a
high degree of inflammation." But we cannot accede to the propriety of the
direction to spend hours in exploring with the scalpel in every direction, at the
part where the needle enters, particle by particle, until the needle is found.

The following cases of phlegmasia dolens — the one occurring after typhoid
fever, and the other, in both the upper and lower extremities, after parturition
— by Dr. James Fountain, of Jefferson Yalley, are not without interest : —

" The case of phlegmasia dolens I mentioned at our annual meeting, occurred
in a young, healthy girl, aged 14 years. A typhoid fever broke out in the
neighbourhood of her father, in the winter of 1847. The mother acted as nurse
in two fatal cases, and contracted the disease. Immediately on her conva-
lescence, her daughter had it. It ran through its regular stages, and subsided.
Some few days after its close, she was seized with pain in the calf of the left
leg, in the morning. The mother applied some warm flannels to the part
through the day, but, about ten o'clock in the evening, the pain had reached
the groin, and had become so extremely violent, that she screamed with it in-
cessantly. At twelve at night, her father called me up. I sent her three pow-
ders, each containing about three grains of opium, and two of camphor — one
to be taken every two hours, till relief be obtained. Next morning, I found
she had taken two of the powders, and had found relief. Her leg was tumefied
from the toes to the hip ; skin white, and extremely tender, but not painful,
unless the limb was moved ; the swelling was tense and elastic ; the joints were
not affected internally. In the afternoon, I gave her an emetic of tarfc. ant.
with tinct. sem. colchici. It operated freely, and the limb was immediately
less sensitive. On the next day it was far less so, and in a day or two it became
cedematous, and by means of bandaging and some mild diuretics, it disappeared.

" About thirty years or so ago, I was in the practice of waiting on a Mrs.
Horton in her confinements. For three successive labours, her pains seemed
not to remit in the least upon the expulsion of the child, but kept on with the
same expulsatory effort, after the placenta was expelled, until two or three
spoonfuls of tinct. opii had been taken. After the last labour, she had a regu-
lar attack of phlegmasia dolens, first in the right leg, then in the right arm,
then in the left leg. These were clear cases, and were not rheumatic, for no
more pain was produced by moving the joints than by moving the limbs gene-
rally. They yielded at once to full doses of opium and camphor, as they always
will, and emetics never fail to change the albuminous to a serious condition of
the affected limb/' D. F. C.

Art. XXI, — San Francisco Medical Society; Annual Address delivered before
the Society, pursuant to appointment, Jan7y 27, 1857. By Henry Gibbons.
M.D. 8vo. pp. 24.

From the annual address of Dr. Henry Gibbons, delivered before the San
Francisco County Medical Society, January 27, 1857, a production replete with
correct principles and liberal views, well and boldly expressed, we select the
following paragraphs, as presenting, in brief outline, a general view of the
climate and diseases of California: —

"The climate of the Pacific coast, in its etiological relations, opens an im-
mense field of observation and study. In the winter season, if winter it can be
called, from November to April inclusive, there is but little difference of tem-
perature on the seaboard, in a range of fifteen degrees, from the mouth of the
Columbia River on the north, to San Diego on the south. Nor is there much
difference inland, except that the more elevated regions are liable to colder

466

Bibliographical Notices.

[April

weather. Thus whilst snow and ice are rarely seen on the coast, the moun-
tains of the Sierra Nevada range are covered with snow nearly all the year.

"In the summer season, a similar uniformity of climate presents itself on
the seaboard ; but during this period, from May to October, a wave of cold air
flows daily from the ocean, often loaded with falling mist. So little differ-
ence is there in temperature between winter and summer in this wide range of
coast, that flannel garments are constantly worn, and no one thinks of changing
the dress from winter to summer. But beyond the mountain barrier, which
skirts the ocean, and walls out the sea breeze from the interior, the heat of
summer is often intense, the mercury rising frequently to 100 degrees or up-
wards. At the same time, the air is generally very dry. Almost invariably, how-
ever, the nights are pleasantly cool, so that sleeping is well done everywhere.

" A few years ago it was supposed that the climate of California was almost
proof against pulmonary disease. In 1850, if an individual happened to cough
in church, all eyes were turned on him with curiosity and amazement. The
native population, it was said, were entirely exempt from disorders of the lungs.
But time has dispelled the delusion. Pulmonary consumption and the kindred
affections have become the great enemy of human life, as in the Atlantic States.
Our entire climate everywhere is less injurious, it is true, to pectoral disorders
than the corresponding latitudes on the Atlantic. But, the cold and searching
winds of summer on the seaboard, while they often build up the strength by
their bracing and tonic power, are in general unfavorable to patients suffering
from the class of maladies under consideration; and the extreme heat of the
interior is equally noxious, from its debilitating influence. The relation of our
climate to this class of diseases may be summed up in a few words. Persons
afflicted with bronchial or pulmonary disorders, in the incipient stage, are
almost invariably benefited, and oft times cured by traversing a tropical climate,
and taking up their abode in California. On the other hand, such diseases are
developed ab initio in this country, about in the same degree as in the Atlantic
States. As the female population increases, the bills of mortality exhibit a
corresponding increase in the number of victims.

"Some years ago, it was a general practice to send pulmonary cases to the
Sandwich Islands. But experience has shown its futility. We stand in need of
some other sanitarium. In many cases, change of climate is the only remedy;
and a genial climate, not liable to sudden or material fluctuations, and exempt
from strong winds, are requisite conditions. In the summer season, the region
bordering on the Bay, at its northern and southern extremities, may serve the
purpose, holding, as it does, a medium place between the damp and chilly ocean
climate of San Francisco and the arid and scorching heat of the interior. In
the winter we must turn our attention to the south. Los Angelos and San
Diego, in the southern section of the State, are still too far north. The table
land of Mexico will probably supply the desideratum. But even in Mexico,
proximity to the ocean must be avoided. Twelve months ago, in a brief stay
at Manzanella, which is on the western coast, in latitude 19°, I observed among
the native population an extraordinary prevalence of pulmonary disease, caused,
in all probability, by their sleeping on the damp ground, exposed, more or less,
to the cool night wind. Sixty or seventy miles inland, in the vicinity of Cotima,
is a different climate, said to be much more salubrious. With all the know-
ledge I now possess on the subject, this spot appears preferable to any other,
and, accordingly, I have latterly recommended it to my patients, instead of the
Sandwich Islands. This subject, however, deserves much more consideration
than it has yet received."

"Epidemics are of rare occurrence in this State. At an early period, when
the comforts of life were greatly wanting, diarrhoea and dysentery were pre-
valent, and extremely fatal. In those days men dwelt in tents, and slept on
the earth ; they used a diet of animal food, almost exclusively, undiluted with
vegetables and fruit, and composed of beef run down before being killed, and
they employed that blessed prophylactic, brandy. With improved habits of life,
and wholesome diet, and a diminished antipathy to the internal use of cold
water, these diseases have greatly diminished, and death from dysentery or
diarrhoea is comparatively rare.

1858.] Gibbons, Address hf/ore the San Francisco Medical Society. 467

"In the winter of 1850-51, the malignant cholera was epidemic in various
localities, visiting our territory in its regular course of march on the western
coast of North America. In this city the mortality was light, but Sacramento
was nearly depopulated. Since that time, sporadic cases have occasionally
appeared, and patients laboring under the malady, and dying with it, have been
frequently landed from steamships from Nicaragua and Panama, and taken to the
county hospital, or otherwise disposed of. The disease has, in no well authen-
ticated instance, extended to others. Several cases were said to have appeared
in the neighbourhood where the clothing from an infected vessel was sent to
be cleansed, giving support to the theory which attributes the spread of malig-
nant cholera to exhalations from the feces of its victims. But as the state-
ments to that effect were connected with some pecuniary interests or specula-
tions, they are not entitled to credit.

"In June and July, 1851, bronchial affections first made their appearance in
San Francisco, in the form of an influenza. Since that date, catarrhal disorders
have prevailed nearly every summer, in a sufficient degree to be pronounced
epidemic."

"Croup is a disease from which the infantile population of our State suffer
very much. It is apt to be violent and intractable, terminating fatally in many
cases, perhaps as much for want of timely aid and proper nursing as from the
intrinsic violence of the malady. "

" Scarlatina first presented itself to the notice of the Amerian inhabitants in
the spring of 1851, on the heels of the cholera. There were few cases, how-
ever, and they were of a mild grade. Since that time it has occurred sporadi-
cally, and with the same tractable character. A form of disease bordering on
malignant scarlatina has committed sad havoc in certain localities in the past
two or three years. It commences with inflammation, and mostly ulceration,
of the fauces and tonsils, exhibiting no peculiar features, and exciting no alarm.
Sometimes a cough is present from the beginning. Suddenly the patient is
seized with croupy symptoms, and in a brief period, from six to fcwenty-four
hours, life is extinguished. The muscular strength and the faculties of the
mind are generally retained to a late period. The pulse is that of scarlatina,
but there is no eruption. Delirium and convulsions seldom occur. Children
are its ordinary victims, though adults are not always exempt.

"A striking feature of this malady is its fatality in certain families. It may
visit only a few houses in a village or neighbourhood, but in them it is apt to
carry off all the young children, in rapid succession. In San Francisco, it has
not prevailed so much as in Oakland, Sonoma, and some other towns. In the
only instances within my knowledge, in this city, where all, or nearly all the
children of the household were swept away, the victims were trophies of homoeo-
pathic practice. I have had no fatal, and no very malignant Cases, in my own
charge exclusively, but have visited a number in this city, and at a distance,
in consultation, where no opportunity was afforded for autopsic examination.
In these cases the fatal result appeared to arise from the rapid extension of the
inflammation to the air-passages and lungs, without a full development of the
proper symptoms.

"The treatment that has proved most salutary, under my observation, con-
sists mainly of the free internal use of quinia, and the application of nitrate
of silver, in solution, to the fauces, with a large blister to the chest in case of
pneumonia."

"Diseases of the urinary passages are frequent and troublesome, especially
chronic affections of the urethra, which often defy all treatment, yielding only
to time. In fact, it may safely be said, that an unusual tendency exists on this
coast to disorders of the mucous membranes in general.

"Insanity, as might be expected, is fearfully prevalent in California. It
grows directly out of the excited mental condition of our population, to which
the common use of alcoholic drinks is a powerful adjunct. Other cerebral dis-
orders do not abound, excepting meningitis in infants. It has been remarked
that, notwithstanding the constant exposure of a large portion of the male
population to the extreme heats of the interior, 4 sun-stroke' is scarcely ever
heard of."

468

Bibliographical Notices.

[April

" There has been observed in the diseases of this coast an extraordinary
tendency to the paroxysmal form, or to exacerbations, requiring the use of
quinia. This occurs in dysenteries, in pneumonia, in puerperal women — in
short, it is traced in almost every affection attended with febrile action. Fevers
to which the dubious term malarious is conveniently applied are scattered
everywhere, in city and country, and are often endemic in certain districts.
In the intermittent phase, they are often excessively annoying by their repeated
returns after apparent cure. Typhoid, or rather ataxic, fevers are frequently
met with.

" Acute inflammations, requiring the lancet, are not common. It is truly
singular to what extent venesection is discarded in California. I am appre-
hensive that we allow this potent remedy to be too much neglected."

D. F. C.

Art. XXII. — Experimental Researches relative to the Nutritive Value and Phy-
siological Effects of Albumen, Starch, and Gum, when singly and exclusively
used as food. By W. A. Hammond, Assistant Surgeon U. S. A.

The above is the title of an essay for which a prize was awarded by the
American Medical Association at its last session, and which treats of subjects
which should enlist the attention of every physician who wishes to practise
understandingly. Without a thorough knowledge of the effects of each article
of food upon the system, we prescribe at random particular articles of diet for
the sick, and are to some extent unable to understand some of the most fre-
quent causes of disease. And yet our actual knowledge on these points is very
limited. Magendie indeed showed that neither gelatin nor albumen would
suffice to sustain life ; and Boussingault proved that fat could not be assimilated
in sufficient quantities. Many other isolated facts might be quoted, which have
been recorded within the last twenty years ; but the want of an accurate
knowledge of tissue metamorphosis prevented most of these observers from
affording us the rationale of these facts. The experiments of Chossat on ani-
mals during inanition, and Lehmann on himself, under different diet, have
gone far to enlighten us. But Dr. Hammond has chosen a new field of inves-
tigation ; and with a diligence and sacrifice of personal comfort worthy of high
praise has given us the results of three series of experiments upon himself,
recording the daily amount of food and drink taken, and the daily loss of the
system by the different emunctories, with remarks upon the results obtained,
characterized by the careful consideration and general correctness.

The results of his experiments upon gum may be stated in a few words —
nearly the whole amount ingested during four days was discharged unaltered
by the bowels. This fact is important as showing that the chemistry of our
laboratories is after all identical with the chemistry which plays such an im-
portant part in all vital phenomena. It has long been known that gum was
not rendered endosmotic by any of the digestive fluids, out of the body; but
its long use as an article of diet in acute disease has induced among practi-
tioners the conviction that in some way it must be digested. Nothing but such
an experiment as Dr. Hammond's could finally settle this point: and henceforth
we hope to see gum discarded, or at least only used as a demulcent — it is no
more nutritive than rose water is astringent.

The other two series of experiments involve many points of the highest
physiological importance. It is not our purpose to discuss them fully. "We
shall content ourselves with indicating some of them, and advise our readers
to take up the essay itself and study it. These two series of researches occu-
pied ten days each; previous to the commencement of the first one, Dr. Ham-
mond determined, by observations of the ingesta and egesta for five days, the
ordinary amounts of excretion from the bowels and kidneys under usual diet.
Sufficient time was allowed to elapse between the albumen and the starch
series for the system to regain its tone. We are presented at the close of each

1858.] Hammond, Effects of Albumen, Starch, and Gum, as Food. 469

series with tabular statements of the ingesta and egesta (including the trans-
piration), temperature of body, variations in weight, height of barometer and
of thermometer for each day. Analyses of the blood on the 1st and 10th days
of each series are also given, together with tables showing the amount of
carbon absorbed in the' albumen series, and the relative proportions, in the
same series, of the nitrogen absorbed to that eliminated in the forms of urea
and uric acid. The conclusions from the albumen experiments may be thus
stated: —

1. The amount of albumen in the blood was materially increased, as was also
that of the fibrin and of extractive ; while the blood-corpuscles and salts were
diminished and fat almost disappeared.

2. The animal temperature underwent a very slight diminution.

3. The urea, uric acid, and residue of the urine were increased, while the
chlorine, sulphuric, and phosphoric acid diminished.

4. The feces diminished in quantity, relatively, until the 6th day ; upon the
8th diarrhoea ensued, thus augmenting the water ; the ether-extract diminished,
while the alcohol-extract and insoluble residue increased, especially the latter ;
thus indicating an increase of the bile-resins and the passage of a considerable
amount of albumen unaltered.

The albumen used was procured by boiling the serum of bullocks' blood ;
the quantity averaged 8343 grains daily. No derangement of health ensued
until after the 4th day, on which the amount consumed reached 12,725 grains;
headache and slight fever occurred. On the 6th day, albumen appeared in the
urine. On the 8th, a severe diarrhoea ensued, which continued some days after
the close of the investigations. By deducting the amount of insoluble residue
from the albumen ingested for each day, Dr. Hammond obtains, as he states,
the amount of albumen absorbed; and then proceeds to calculate the actual
amount of carbon introduced into the system, and to compare this with the
amount required for respiration. He thinks he has proved that the system can
absorb enough albumen to support respiration, as the temperature of the body
was nearly maintained ; and certainly, the daily variations correspond closely
with the amount of albumen taken. But is there not an error in assuming
that all the albumen which was not absorbed would appear in the course of
twenty-four hours in the feces? We think so; and to support it, Dr. H.'s
weight decreased continually except on two days, when he consumed about
3000 grains of albumen more than usual ; on these days his weight increased
a few hundred grains. This has an important bearing upon the other point
discussed by Dr. H., the proportion of nitrogen in the urea and uric acid to
that absorbed. We cannot help thinking that a part of the albumen remained
unacted upon in the bowels, and caused the diarrhoea of the 8th day; and that
if the stools had been watched for three or four days after the close of the ex-
periments, a large amount of the albumen would have been thus recovered. Of
100 grs. nitrogen absorbed, Dr. Hammond found but 30.08 grs. in the urea and
uric acid, instead of f , as stated by Lehmann ; Rigg and Barral found but 50
per cent, and 42 per cent, respectively ; so that we must either conclude that
these observers were mistaken, or that the nitrogen sought some other way of
exit, or remained permanently in the system. Of these, the second is the most
probable ; the residue of the urine would probably have yielded enough to
modify the above proportion considerably. The probability of some of the
albumen having escaped subsequently, must also be remembered. The dimi-
nution of the ether-extract of the feces indicates that the fat resorbed from the
system was consumed in respiration ; while the increase of fibrin in the blood
very likely was due to the inflamed state of the bowels.

Of the second series of experiments, we have not much to say. Debility
ensued on the third day ; and soon after palpitation of the heart followed, with
evident symptoms of deficient aeration of the blood. Sugar appeared in the
urine on the 5th day, and continued to be thus excreted for five days after the
experiments terminated. The weight of the body declined but slightly. The
urea and uric acid were reduced (we regret to find no mention made of the
presence or amount of hippuric acid): while the solid residue increased consi-
derably, probably from the presence of sugar. The ether-extract of the feces
No. LXX.— April 1858. 3i

470

Bibliographical Notices.

[April

was slightly lessened, the alcoholic and water-extract diminished considerably,
while the insoluble residue was very small, thus proving that nearly all the
starch (about 10,357 grs. per diem) ingested was disposed of. It should be
added, however, that Dr. Hammond continued to lose weight for some days
after the experiments ceased. From the analysis of the blood we learn that
the fibrin, fat, and extractive increased considerably, while the blood-corpuscles,
albumen, and salts diminished. The decrease of the latter is easily explained
when we remember that the system was living upon itself. The increase of
extractive (from 4.84 to 11.25 parts in 1000) corresponds closely with the
amount of sugar stated by Lehmann to exist in the blood before it appears in
the urine, though unfortunately no absolute determination of its amount was
made. The excess of fat is remarkable, and taken in connection with the fact
that the system did not lose weight as might have been expected, indicates
strongly the probability of some of the glucose absorbed having been converted
into fat. This is probably the most interesting physiological point in the
series ; while we may take an important lesson in therapeutics from the op-
pression of the circulatory system induced by the starch diet. We ought to be
careful how we administer amylaceous food to patients suffering under diseases
of the respiratory organs, for by so doing we put an additional amount of
labour upon the latter. A decided increase of temperature and elevation of
the pulse were noted by Dr. Hammond.

We hope that these are but the commencement of series of experiments by
Dr. Hammond, whose careful precision and sound mode of reasoning admira-
bly fit him for his undertaking.

Since the above was written, Dr. Hammond has kindly permitted us to test
his vital capacity, which we find equal to 225 cubic inches. As he is not accus-
tomed to the use of the spirometer, this probably falls below his actual capa-
city, which may therefore be considered normal. J. C. M.

Art. XXIIT. — Essays on the Secretory and the Excito- Secretory System of Nerves
in their Relations to Physiology and Pathology. By Henry Fraser Campbell,
A. M., M. D. One of the Vice-Presidents of the American Medical Associa-
tion, and Professor of Special and Comparative Anatomy, in the Medical
College of Georgia (Augusta). With illustrations. 8vo. pp. 135. J. B. Lip-
pincott and Co., Philadelphia, 1857.

We have experienced no little surprise at the apparent apathy with whi^h
the several communications of Dr. Campbell, in relation to the excito-secretory
system of nerves, have been received by the physicians of this country. We had
hoped that after the fact of the existence of an excito-secretory nervous action
had been fully recognized, and publicly announced by so imposing an author-
ity as the late Dr. Marshall Hall, of London, it would, at once, have attracted
the attention it deserved on the part of such as had the time and talents for its
further investigation — and of these we have, unquestionably, many in our midst
— in order that so important a truth should be confirmed and elucidated, and
its relations to physiology and pathology, already, in part, pointed out by Dr.
Campbell, more fully determined and developed.

The importance of the discovery of an excito-secretory function as a key to
the correct interpretation of many physiological phenomena, and to the eluci-
dation of numerous pathological conditions, in regard to which we have,
heretofore, been groping in the dark, must be evident to every one upon even
a superficial glance at the subject. To what extent it may lead to a modi-
fication and correction of our received opinions in respect to the correlation of
divers vital actions, during a state of health, and the true character and con-
nection of the diseased conditions of the several tissues and organs, is a ques-
tion that can only be determined by future observations and experiments.

That the sensory nerves of the cerebro-spinal system, are not only excitors

1858.] Campbell, Secretory and Excito- Secretory System of Nerves. 471

of the motory apparatus, but that, under certain circumstances, most of them
sustain, also, an analogous relation to the secretory nerves, exciting these, and
modifying their action, and thus diminishing, increasing, and altering the se-
cretions of the surfaces upon which they are distributed, according to the extent
and character of the excitation applied, is a proposition that we believe to be
incontrovertible. In our opinion, the expositions of Dr. Campbell, though con-
fessedly limited, and in many particulars defective, force upon us its adoption.
The subject, nevertheless, still opens up a wide field for investigation on the
part of both physiologist and pathologist, and it is one that will amply repay
those who shall enter upon its cultivation, with the right spirit, and in the
right direction.

Most of the essays comprised in the volume before us have been very fully
noticed in former numbers of this journal, and a very full abstract has been
already given, of the facts upon which are based the claim of Dr. Campbell to
priority in the discovery and naming of the excito-secretory system of nerves —
which all must admit are clear, positive, and conclusive.

In the essay to which was awarded the prize of the American Medical Asso-
ciation, at its tenth annual session (May, 1857), Dr. Campbell has endeavoured
to demonstrate the fact that many of the important acts of nutrition and secre-
tion are modified in both health and disease, through the agency of the excito-
secretory nerves, and that it is to aberrations in the functions of these nerves,
that many of the heretofore mysterious phenomena of diseased action are
mainly attributable.

After a general view of the secretory system of nerves, in which certain al-
lied facts pertaining to the functions of the two grand divisions of the nervous
system — the cerebro-spinal, and the secretory — are presented in a manner
which Dr. C. has deemed best calculated to sustain the deductions he advances,
subsequently, in reference to the excito-secretory function of the sensory nerves.

"We have seen," he remarks, "that to the ganglionic system, and to this
system alone, are confided all those important and mysterious processes which
pertain to nutrition and secretion; or, in the words of Bichat, 'those thousand
secret operations of a living body/ It presides over all our internal chemico-
vital actions, superintending and directing all blood-changing processes, and
instigating all metamorphoses occurring in the intimate structure of the animal
tissues. It is the system for the internal and individual wants of the organism,
and its possession enables the being to sustain an independent and individual
existence, carrying on, to a certain extent, all strictly organic actions, without
the aid of external influences."

In exposition of the excito-secretory function, Dr. C. adduces the phenomena
produced in the secretory surfaces within, by impressions made upon the external
surface of the body. The sudden exposure of the surface to a cold atmosphere,
or to a cold stream of water, it is well known, will increase the urinary secre-
tion. This fact has been variously explained. It has been supposed by many
that there exists an antagonism between the cutaneous surface, and the secre-
tory tubules of the kidney, whereby, when the exhalant function of the first is
arrested the secretory function of the latter is increased. This doctrine of an-
tagonism, Dr. C. regards as altogether unphilosophical, whether applied to the
kidneys, the mucous surface of the intestines, or to any other portion of the
animal organism.

"There is," he observes, "no such principle, in our humble opinion, as an-
tagonism to be recognized in any of the operations of nature in her conduct of
the vital processes, but a beautiful correlation and reciprocity are everywhere
manifest in her economy. Nor yet can we justly account for these sequences
upon the theory of revulsion, or a driving in of the blood upon the secretory
organ. The real explanation is far more simple, and far more in accordance
with the recognized principles of action in the nervous system. Under favour-
able circumstances, we irritate an excitor nerve, and we stimulate muscular
contractions, evidencing the existence of the excito-motory function. Now,
under the circumstances above related, the excitor or sensitive nerves, having
received an appropriate stimulus, excite, through the medium of the spinal
centres, the action of those ganglia and filaments dominating the secretory or-

\

472 Bibliographical Notices.

gans in question ; they control, as we have seen, their circulation ; they preside
over their secretions, and thus stimulated, they are excited to modify the circu-
lation and the secretion. So far this is a normal act, the result of that ordained
and wholesome correlation established between the two portions of the organ-
ism through these two systems of nerves, the sensory and the secretory ; but
should the excitation be unusually strong, amounting to what is popularly
termed a 'shock/ or too prolonged, we find the secretory system acting unduly,
and this action is then carried to an abnormal extent : the dynamic act so modi-
fies the circulation, that secretion becomes aberrated, or even arrested, and,
perhaps, a change in the condition of the tissue from altered nutrition may
result. Dr. Marshall Hall thus remarks, in his recent article upon this sub-
ject: ' A partial keen current of air, falling on any susceptible portion of the
skin, may induce inflammation in any susceptible internal organ. An exten-
sive burn, or scald, is apt to induce pneumonia/ "

Dr. Campbell next examines some of the phenomena occurring in the region
of the fifth pair of nerves, which send certain filaments to the sensitive parts
about the eye, others to the teeth, and also sensitive branches to the head and
face.

"Under certain circumstances," says Dr. C, "the sensitive conjunctival
surface of the occular globe is exposed to a sudden draft of air, or to some me-
chanical irritant. The first effect occurring from this exposure, is an imme-
diate increase in the secretion of the lachrymal gland. This may continue, or
it may be entirely arrested after continuing for a time. Secondly, the eye be-
comes perhaps dry, or it may become congested and secrete a puriform fluid,
which, drying, closes the lids, or it may become entirely bloodshotten or ecchy-
mosed, and in very favourable conditions, ulceration, and even opacity of the
cornea may result from this taking cold. This is a condition of the parts,
though arrived at much more gradually, which we find resulting from the ex-
periments so repeatedly referred to in this paper, and our explanation of them
is, that the sensitive fifth nerve becomes excitor through the spinal centre, to
the modifications in the circulation, secretion, and nutrition of the eyeball,
which acts are under the immediate reign of the ganglionic system. We can
observe the same character of phenomena in the secretory lining membrane of
the nostril, and also the same exposure to cold may, through the fifth nerve, or
other sensitive nerves, excite modified circulation in the fauces and pharynx
through the secretory or mixed branches, which, together with the pharyngeal
plexus, control the circulation of those mucous surfaces."

In a consideration of the relation of the teeth to the sensory or excito-secretory
branches of the trifacial nerve, and through them to the spinal marrow, and
thence to the entire system, is to be found, according to Dr. C, nearly all that
is necessary for the full portrayal of the excito-secretory system. For, he
remarks, in the phenomena which sometimes result from these relations, under
particular circumstances, are to be found illustrations of almost every charac-
ter and degree of modified secretion and nutrition.

In reference to those troublesome cutaneous eruptions so common in children
at the period of teething, Dr. C. remarks, no rational and satisfactory expla-
nation of their occurrence as concomitants of teething, had been presented be-
fore the enunciation of the doctrine of the excito-secretory function.

"A comprehension of that doctrine," he says, "affords to them a ready in-
terpretation by referring them to the modified action of the secretory system
controlling the capillary circulation of the cutaneous surface, which modifica-
tion is excited through the dental filaments of the fifth pair, the spinal marrow,
and that portion of the ganglionic system above referred to. In verification
of this view of the influence of these connections, and also of the effect of the
local irritation, we ask leave here to adduce an observation, which we are not
aware has been recorded elsewhere. It is generally admitted, that at the ter-
mination of the period of dentition, that is, when the child has acquired all its
teeth, the cutaneous eruption, of whatever nature it may have been, subsides,
and the skin resumes its natural condition, the patient not again being liable
to its return. This, according to our observation, is generally, but not inva-
riably the case. We have observed certain instances in which the eruption had

[April

1858.]

Thompson, Hodgson, The Enlarged Prostate.

473

subsided for several years, when on the advent of the second dentition, it came
out with almost its former violence and inveteracy, not subsiding until the
second period was entirely completed. So frequent has the return of the erup-
tion been a subject of remark with us, that we now seldom encourage parents
to expect permanent relief for their children, affected with these eruptions,
until after the completion of the second dentition. Again, we find that children
who have suffered severely during the period of dentition, are very liable to
become affected with dropsy ; this latter affection frequently presenting itself
at the termination of the above cases. Since the announcement of the excito-
secretory function of the nervous system, these cutaneous eruptions and drop-
sical affections which occur during dentition, in our opinion, need no extended
and elaborate explanation."

" We are aware that the above phenomena, indicating embarrassed or aber-
rated action of the secretory system of nerves, might receive an explanation in
the fact, that during this period several of the important emunctories of the
system, as the liver and kidney, suffer an arrest, or at least, a modification of
their eliminatory functions, but we will not contend here for the difference in
the value of these two opinions ; either one of them can only rationally ex-
plain the phenomena, by invoking the aid of the excito-secretory action origin-
ated by the irritation caused in the branches of the trifacial nerve, during the
evolution of the teeth."

From the foregoing, our readers will derive some idea of the manner in
which the excito-secretory function is applied by Dr. Campbell to the explana-
tion of various morbid conditions of the organism. Other of his expositions —
which are all ingenious and plausible, and bearing, apparently, the impress of
truth — might be adduced. To establish fully the agency of the newly disco-
vered function in the production of the foregoing, and various other abnormal
phenomena, will demand, however, a more extended and cautious series of
experiments and observations — the combined efforts of many labourers through
many years. Dr. C. is nevertheless deserving of the thanks of the profession,
for having directed attention to a subject, at once, so interesting and so im-
portant, as well as for the efforts he has already made in its elucidation and
development.

The volume of essays before us is deserving of an attentive study and care-
ful consideration on the part of every physician ; should we have succeeded in
directing to it the attention of such as may be inclined to investigate more
fully the truths it enunciates, we shall be fully satisfied.

D. F. C.

Art. XXIV. — The Enlarged Prostate ; its Pathology and Treatment; with Obser-
vations on the Relation of this Complaint to Stone in the Bladder. By Henry
Thompson, F. R. C. S., &c. Octavo: pp. 320. London, 1858.

The Prostate Gland and its Enlargement in Old Age. By Decimus Hodgson,
M. D., Demonstrator of Anatomy in the University of Glasgow. London,
1856.

Diseases of the urinary and reproductive organs have received at all times
great attention', and the works treating of them are numerous. The body
called the prostate gland, which occupies a very remarkable position, in re-
gard both to the organs of urination and those of reproduction, has attracted
much notice. Notwithstanding, however, the many works which treat of this
body and its diseases, it must be admitted that there is room for a new one.
Recent discoveries in general anatomy, the transactions of learned societies
of the past few years, particularly those of the Royal Medico-Chirurgical
Society and of the Pathological Society, of London, bear out the correctness of
this assertion. In this Journal, in the April and October numbers of the past
year, some account was given of several communications made by Mr. Thomp-

474

Bibliographical Notices.

[April

son to the Medico-Chirurgical Society; one, concerning the anatomy and pa-
thology of the prostate gland, the other, concerning the nature of certain con-
cretions found therein, and their relation to prostatic calculi. The character
of these communications, and the excellence of his work upon a somewhat
analogous subject, stricture of the urethra, would lead us to expect much that
is valuable in his treatise on the enlarged prostate.

The points to which Mr. Thompson desires especially to request the attention
of the scientific inquirer, are briefly stated, in the preface, to be as follows: —

" The assignment of the 'third' or 'middle' lobe, as a separate anatomical
portion of the prostate, to the abnormal history of the organ ; discussed in the
first chapter.

" The analogy between the enlargements and tumours of the prostate and
those of the uterus; discussed in the second chapter.

" An examination of the alleged causes of enlargement of the prostate, re-
sulting in new views of this subject; in the third chapter.

" The effects of enlarged prostate in relation to the functions of nutrition;
considered in the fifth chapter.

" The researches in relation to malignant and tubercular disease of the pros-
tate ; in the ninth and tenth chapters (tenth and eleventh).

" The consideration of 'the bar at the neck of the bladder;' in chapter the
twelfth."

The other chapters — there are fourteen altogether in Mr. Thompson's work —
treat of the symptoms of enlarged prostate; the diagnosis of prostatic and
other obstructions at the neck of the bladder ; the treatment of senile enlarge-
ment; the treatment of retention of urine from enlarged prostate; enlarge-
ment of the prostate from inflammation; prostatic concretions and calculi, and
the relation between enlarged prostate and stone in the bladder. It must not
be supposed, from having directed particularly the attention of the scientific
inquirer to certain portions of his work, that others have been neglected. The
subjects, the list of which we have given, as occupying the remaining chapters,
have been treated at length; more fully, probably, some of them, as the diag-
nosis and treatment of enlargement, than in any preceding treatise.

Although physiology is something more than " animated anatomy," and a
precise knowledge of structure does not always enable us to decide as to func-
tion, still there is a relation between structure and function which should not
be overlooked. Experiments skilfully conducted have thrown light upon a
few obscure phenomena of the animal organism, but by far the greater portion
of the recent progress in physiology has been effected by the advance of our
knowledge of anatomy. And when we speak of physiology, pathology also is
meant ; for all that we know with satisfaction, in pathology, has a physiologi-
cal basis.

Investigations in minute anatomy, made in late years with so much zeal,
have shown us that the body called the prostate gland has no claims to be
called "gland" at all; that is, in the usual sense of that term. It should be
considered as only an advanced portion of the circular muscular coat of the
bladder, having the power of acting independently of the vesical fibres, as is
shown in the propulsion of the seminal fluid. A number of small urethral
glands are contained in this muscular body, each of which has a separate duct
opening into the gutter at the side of the verumontanum. It is the liquid from
these glands that gives to the sperm its white colour ; it is white, creamy, not
at all tenacious, and is mixed with the other five liquids forming the sperm, at
the moment of ejaculation.

The views of Mr. Thompson in regard to the normal and pathological ana-
tomy of the prostate are contained in the paper we have already referred to,
as published in this Journal, for April, 1857. We have the strongest reasons
to believe in their correctness. In the preparation of that paper he made a
dissection of sixty specimens of the prostate, removed himself from the dead
body, and in its illustration fifty of these specimens, preserved in spirits, were
exhibited at the Medical and Chirurgical Society. The existence of a "third
lobe," as a fact in normal anatomy, has never been admitted by European ana-
tomists. Cruveilhier says : "In the normal condition, the prostate does not

1858.]

Thompson, Hodgson, The Enlarged Prostate.

475

project into the canal of the urethra; but it is not rare to see rising up from
the inferior part of the canal of the urethra, at the level of the base of the
prostate a more or less projecting tubercle, which forms an obturator more or
less complete at the entrance of the canal of the urethra ; this is the tubercle
designated by Lieutaud under the name of luette ve'sicale; by Everard Home,
under the name of development of the middle lobe of the prostate. But, on one
side, this tubercle belongs to a pathological condition ; and, on the other, there
is no middle lobe, unless it be desired to give this name to the slightly fur-
rowed and consequently less thick portion, that unites the two lateral halves of
the prostate." (TraitSd'Anat. Descrip., vol. iii. p. 631, Paris, 1852.) In Eng-
land and in this country, down to the latest treatises on the subject, a middle
lobe is recognized, and any one who would take the trouble to consult the ori-
ginal paper of Home, in the Philosophical Transactions, 1806, would be asto-
nished at the insufficiency of the grounds. A " third lobe" was proclaimed
after five examinations of the organ by dissection. In these five dissections,
the author says, " the appearance was not exactly the same in any two of them."
In one of them, " there was no apparent glandular substance" at all in the
spot indicated.

We are strongly inclined to agree likewise with Mr. Thompson in regard to
the incorrectness of the general opinion as to the frequency of enlargement of
the prostate in old age. His opinion is founded upon very numerous dissec-
tions, and moreover he finds the absence of anything abnormal which it is very
difficult and rare to find, and when found is generally to be believed true. Ig-
norant persons are those most apt to find the most pathological conditions, and
this is particularly true of enlargements.

Mr. Thompson examined the prostate in the bodies of fifty elderly people, as
they consecutively appeared in the dead-house of a large metropolitan institu-
tion, no kind of selection being made. Of the fifty prostates examined, four-
teen were affected with unnatural developments in one form or another. Of
these, six exhibited numerous isolated tumours in the substance of the lateral
lobes. The others show outgrowths, single, binary, or multiple, springing from
the posterior median portion. These isolated tumours, as those of the uterus,
called fibrous tumours, are formed of the same anatomical elements as the organ
in which they are situated ; organic muscular fibre. It is an interesting cir*
cumstance that the prostate — male homologue of the uterus — should exhibit
such striking analogies in pathology with the latter organ.

From the facts he has advanced, Mr. Thompson believes that it may be re-
garded as established, that enlargement of the prostate, "so far from being a
charge invariably, or even usually present in old age, is an exceptional con-
dition. And it may be further regarded as highly probable that a slight tend-
ency thereto, almost, if not quite unrecognizable during life, may occur in
about one out of three individuals after fifty years, and that a marked enlarge-
ment may be rarely met with in one out of eight — rarely, however, before sixty
years of age" — (p. 67.)

The three chapters of Mr. Thompson's work, the 4th, 5th, and 6th, treating
respectively of the symptoms of enlarged prostate, of the effects of its enlarge-
ment upon micturition, and of the diagnosis of prostatic and other obstructions
at the neck of the bladder, are most excellent. We notice with pleasure that
he refuses to use the word incontinence, in the sense in which it is generally
used, that is, as indicating a condition which, so far from being one in which
the bladder cannot retain, is one in which it retains too much. This misapplica-
tion of the term has been productive of fatal errors in practfce. In his work on
stricture, for this reason, the condition described was designated as " reten-
tion with incontinence ;" in this one he employs the word " overflow," a shorter
and preferable term.

In the great majority of cases in which habitual retention of urine with over-
flow of a surplus portion exists, he does not hesitate to affirm, that the cause is
a physical one ; in other words, " that there is an organic obstruction at some
part of the urethra, situated either at its commencement in the neck of the blad-
der, when it is usually constituted by enlarged prostate ; or in a portion of the
canal anterior thereto, when it usually takes the form of permanent or organic

476

Bibliographical Notices.

[April

stricture" — (p. 84.) He does not enter into any discussion of the subject, pre-
ferring to regard it as a question of fact, rather than as a theme for abstract
reasoning. " Experience alone has led him to reject the impalpable cause, and
to appreciate the material one, and to an extent sufficient to warrant him in
referring to the fact alone for corroboration of the assertion made above."

The only exceptional cases, he allows, are those in which there is a cerebral
or spinal lesion of some kind, which paralyzes more or less completely the
nerve functions of motion, voluntary and involuntary, of sensation, or of sen-
sation and motion combined, of the whole body below the situation of the in-
jury, and those cases in which, after voluntary retention of urine, there is over-
distension and atony of the bladder. In these latter cases, to which the term
of paralysis has been applied, there is no evidence whatever that the lesion
consists in any loss or impairment of the nervous force transmitted to the vis-
cus ; the muscular expelling apparatus of the bladder is overstretched, and
unable to perform contraction in a normal manner for a certain time. Para-
lysis of the bladder — that is, a condition of things in which its nervous supply
is either impaired or destroyed — Mr. Thompson does not believe to ever exist.
" There is no evidence of the existence of true paralysis — that is, a removal or
impairment of nervous influence limited to the bladder" — (p. 104.)

The paralysis of a muscle, after the section of a particular nerve, is easily
understood ; but it is very difficult to understand a partial paralysis from a
general cause. Nevertheless, such cases are witnessed; every one, for instance,
has seen paralysis of the radial nerve, from the effects of lead upon the sys-
tem; and also, in hysterical women, paralysis of the third pair. There is no
reason, therefore, for not admitting partial paralysis, limited to the bladder.
Mr. Thompson denies it because he has never seen it ; but other persons, well
worthy of credit, have reported cases of the kind.

The chapter (6th) on the treatment of senile enlargement of the prostate
occupies sixty pages. We think we may safely assert that no preceding author
has treated the subject so carefully and so satisfactorily. The subject is divided
into three distinct divisions, and they are considered separately, as follows : —

" 1. Treatment for the purpose of obviating the results of obstruction caused
by enlarged prostate.

"2. The general, or constitutional treatment and management of patients
with enlarged prostate.

" 3. Treatment directed against the enlargement itself."

This complaint is one generally admitted to be completely intractable, and
the surgeon almost invariably limits himself to palliating its most distressing
symptoms, and to retarding its progress. Mr. Thompson, however, does not
doubt that "the day will come when the complete control of this evil will be
in our power, adding another to the already numerous and splendid triumphs
of scientific medicine;" and urges with confidence and hope the employment
of treatment against it. Though strongly advocating treatment directed against
the enlargement itself there is also a most careful description of those means
which past experience and skill have placed in our power for prolonging the
life and insuring the comfort of the patient.

There exists a certain analogy, as has been already said, between prostatic
and uterine enlargement. The influence of iodine and of its congener bro-
mine over these affections of the uterus being testified to by many men of the
highest celebrity, it is only a legitimate inference to affirm that there may be
good grounds for believing that these remedies may be similarly effectual in
those of the prostate. Some years ago, Mr. Stafford, in an " Essay on the Treat-
ment of some Affections of the Prostate Gland" (London, 1840), called the at-
tention of the profession to the use of iodine and its preparations for the re-
moval of prostatic enlargement. His plan consisted in administering iodine
internally by suppositories in the rectum, occasionally by the mouth, and in
applying it to the prostatic portion of the urethra in the form of a weak oint-
ment. Mr. Stafford affirms to have been successful in a large number of cases,
in causing the disappearance of the enlargement. For some reason or other,
although very partial to the employment of iodine, and openly declaring his

1858.] Thompson, Hodgson, The Enlarged Prostate. 477

belief in the efficiency of treatment, Mr. Thompson speaks of Mr. Stafford and
of his plan of treatment with great harshness. After doubting his powers of
diagnosis and his accuracy in reporting, he adds: "All that can be said fur-
ther is, that the success was marvellous, and that other surgeons have been
less fortunate, notwithstanding that Mr. Stafford's experience certainly induced
numerous trials of his remedies by others/7

The plan recommended by Mr. Thompson himself is the use of the water
from the highly charged iodine and bromine springs of Kreuznach in Rhenish
Germany. Knowing that uterine enlargements were often much benefited by
it, he visited the springs for the purpose of inquiring as to its influence upon
chronic enlargement of the prostate, and, from the report of the physician,
was satisfied that valuable results were obtained from its employment. This
water, or ordinary water to which the bittern or mother-lye of the Kreuznach
springs has been added, he uses as a bath, and also as an enema. No results
are given of the effects of this plan of treatment. We doubt whether many
surgeons will make use of it in preference to the treatment recommended by
Mr. Stafford, and which is spoken of by Mr. Thompson with such disrespect.

Besides the medical part of the special treatment to be directed against the
enlargement, there is also the mechanical. The effect of compression in re-
tarding the progress of morbid growths and enlargements has long been recog-
nized, and is constantly employed with success. The attempt has, therefore,
been made to effect the reduction of the enlarged prostate by the same agency.
Physick, in this country, attempted to accomplish this object by distending with
fluid a small bag of gold-beater's skin, previously rolled up and introduced on
the end of a catheter, into the bladder; and by then attempting to withdraw
the dilated sac through or into the vesical orifice. Mr. Thompson says : " Pro-
vided that, without difficulty or danger to the patient, an efficient degree of
compression could be applied with ease and certainty to the prostate and neck
of the bladder, I think it reasonable to suppose that considerable benefit might
accrue from its application." The instrument he recommends is composed of a
catheter, an India-rubber tube fitting over the catheter, and a syringe. When
the tube is drawn over the catheter and fastened by a thread of silk close to the
handle, on applying the syringe previously filled with water, and making pres-
sure, the fluid passes through the eyes of the catheter, and the lower three
inches of the tube become very gradually distended, equally in every direction.
The manner of employing the instrument is so simple, that it scarcely requires
explanation.

Operations for the excision or the crushing of a protruding portion of the
prostate, Mr. Thompson mentions only for the purpose of expressing his dis-
approval of them. Division of the obstructing portion has been performed,
and it was advocated and practised by Mr. Guthrie ; this operation, however,
is not discussed here, but it is in the twelfth chapter, one devoted to the con-
sideration of " the bar at the neck of the bladder/'

The different operations for puncturing the bladder, which, though very
rarely, is, nevertheless, sometimes necessary, are judiciously examined. The
one, by which an opening is made through the symphysis pubis, a very interest-
ing case of which was reported in this journal for April, 1854, by Dr. Leasure,
of New Castle, is thus judged: "The experience of the operation of puncture
through the pubic symphysis is not extended enough at present to permit of a
comparison being made in regard to its results, with other modes; but that it
is sufficient, coupled with the apparent advantages derived from anatomical
considerations, to recommend the operation to the test of practice, in order that
its merits may be duly ascertained." When fluctuation can be felt with the
finger in the rectum, behind the prostate, this is the easiest and safest mode
of giving exit to the urine. The great objection to this operation by the rectum
is said by Dr. Gross [Practical Treatise on the Diseases, Injuries, and Malforma-
tions of the Urinary Bladder, &c, 2d edit., Philad. 1855, p. 389), to be the
formation of a vesioo-rectal fistula. We are inclined to think, however, that
this is incorrect; Mr. Cock, of Guy's Hospital, who has performed this opera-
tion twenty-four times, and seen it done at least twelve times more, never saw

478

Bibliographical Notices.

[April

a fistula left. In fact, there would appear to be difficulty in preventing the
opening from closing immediately.1

The three following chapters of this work are upon enlargement of the pros-
tate from inflammation ; on malignant disease of the prostate, and on tubercular
disease and cysts of the prostate. This part of Mr. Thompson's work is not
so satisfactory as the rest. Several things of importance have been left un-
mentioned ; for instance, there is nothing said of the necessity of introducing
a catheter after the inflammation has terminated in abscess, which has opened
into the urethra. Dr. Hodgson, in his work, insists upon the necessity cf in-
troducing the instrument, but he advises the use of a small instrument retained
in the bladder by the usual means, for " the urine then flows through the in-
strument without entering the cavity of the abscess, while the small size of the
catheter permits the matter to escape by its side." Whenever a catheter is
retained in the bladder, at the expiration of twelve hours, or thereabouts, the
urine flows away by the side of the instrument, which acts as a sort of con-
ducting tube. It is, therefore, better for the surgeon to introduce the instru-
ment and to draw off the water as often as may be required.

The twelfth chapter is devoted to " the bar at the neck of the bladder ;" an
affection so closely related to enlarged prostate, by identity of anatomical
situation, and of the symptoms resulting, that it is impossible to treat of one
without also considering the other. In the majority of cases in which there
exists an organic obstruction, having more or less the form of a ridge or bar-
rier, situated at the posterior border of the neck of the bladder, this unnatural
elevation is believed by Mr. Thompson to be constituted by an outgrowth
arising from the posterior median portion of the prostate. When an obstruc-
tion does exist, without the prostate being affected, he believes it to be most
commonly owing to an undue elevation of the uvula, associated with hyper-
trophy of the muscular elements of the bladder, originating in long-continued
irritability of the viscus, and generally occasioned by stricture of the urethra
or calculus of the bladder. He believes also that a fold of mucous membrane
and submucous tissue may form a barrier, though this very rarely happens.

The operations which have been performed and recommended by Guthrie,
Leroy d'Etiolles, and particularly by Mercier, for the purpose of practising
incisions in this barrier, are described and discussed. Before resorting to them
Mr. Thompson prefers to be fully assured that dilatation is unequal to afford-
ing relief; for it is a method which has yet to be fairly and effectively employed
in these cases.

His views upon prostatic concretions and calculi, the subject of the thirteenth
chapter, may be sufficiently judged from the account already given of them in
this journal for October, 1857.

In the fourteenth chapter is an excellent account of the relation between
enlarged prostate and stone in the bladder. It is a chapter, however, which
struck us as being rather out of place, in a work of this kind, and as belong-
ing to one on lithotrity.

Mr. Thompson's work, we feel assured, will be well received by surgeons.
The whole of it is valuable; and the first eight chapters are eminently so.

In Dr. Hodgson's treatise, the descriptive anatomy of the prostate, and its
general anatomical relations are given in minute detail. They are also cor-
rectly represented by plates attached to the volume, among which are a num-
ber displaying their pathological alterations. This book loses somewhat of its
value by a lack of method in the arrangement of the subjects; in which, we
would add, Mr. Thompson's excels. W. F. A.

1 See his paper in Medico-Chirurgical Transactions, vol. xxxv.

1858.]

Brown-Sequard, Journal de la Physiologie,

479

Art. XXV. — A Practical Treatise on the Diseases of Children. By J. Forsyth
Meigs, M. D., Fellow of the College of Physicians, of Philadelphia, etc. etc.
Third edition. Carefully revised. 8vo. pp. 724. Philadelphia: Lindsay &
Blakiston, 1858.

Of the first two editions of this treatise we expressed, at the time of their
appearance, a highly favourable estimate. In the edition before us the work has
undergone a very careful revision, while such additions have been made to it
as the author's more enlarged experience, and the contributions of contempo-
rary observers, both at home and abroad, have furnished. The treatise will, in
consequence, be found a very excellent and faithful guide to the pathology and
treatment of the more prominent of the diseases of childhood. Unfortunately,
the author has not yet found the opportunity to complete the work, by adding
an account of those diseases which were not included in the preceding editions.
To the practitioner this is a circumstance of minor importance; but to the
student, who consults the work as a complete treatise on the diseases of chil-
dren, it will be a source of some annoyance to find that he must refer to other
works for information in reference to affections peculiar to the period of child-
hood, on which Dr. Meigs has neglected to treat. So well has the author ac-
complished his task, in reference to the diseases embraced in this third edition
of the treatise, that we most fervently desire that the leisure necessary to pen
the chapters still wanting to complete the work in accordance with its title,
may be speedily furnished him. D. F. C.

Art. XXYI. — Journal de la Physiologie de V Homme et des Animaux. Publie
sous la Direction du Docteur E. Brown-Sequard. Tome Premier, Janvier,
1858. Paris, J. B. Bailliere et Fils. London and New York, H. Bailliere.

The appearance of a journal devoted especially to physiology, and under the
management of one so capable of successfully conducting it as Dr. Brown-
Sequard, is an event which all who feel the stimulus engendered by progress
in rational medicine, must regard with no ordinary feelings of interest. In
whatever light we view physiology, we cannot fail to perceive that on the facts
which constitute that science, reposes the whole structure of the healing art,
and that with the further development of the former, we have the most ample
assurances of continued advancement in the scientific appreciation and treat-
ment of disease. ■

The success of a journal restricted to the consideration of but one branch of
medical science, may be doubted by some, but when we reflect that though cul-
tivated assiduously for centuries, by learned men of all civilized nations, phy-
siology is nevertheless yet in its infancy, we see no reason to anticipate failure.
For to whatever point of the science we direct our attention, we find so vast a
field for investigation, that one not actuated by the high motive of labouring
for the good of his species, might well be dismayed at its contemplation, and
falteringly turn aside from a work which requires such unremitting sacrifices
for the establishment of the most simple fact.

The perseverance and ability of the editor of the Journal de la Physiologie,
are ample guaranties that the periodical he has undertaken to conduct, will
accomplish much for scientific medicine, and if future numbers reach the
standard of excellence attained by the number before us, it will, indeed, be a
valuable addition to medical periodical literature.

In order that our readers may form an idea of the subjects treated of, we
subjoin a list of the original memoirs: —

1. On the Laws which govern the Dynamical Phenomena of the Animal Eco-
nomy. By M. Brown-Sequard.

480

Bibliographical Notices.

[April

2. Memoir on the Temperature of the Palmiped Birds of the North of Eu-
rope. By M. Ch. Martins.

3. Note on the Low Temperature of certain Long-Winged Palmipides. By M.
Brown-Sequard.

4. Memoir on some Points in the Anatomy and Physiology of the Mucous
Membrane and Epithelium of the Uterus during Pregnancy. By M. Ch. Robin.

5. Researches in regard to the Effect produced on the Circulation by the pro-
longed application of Cold Water to the Surface of the Human Body. By Dr.
II. Bence Jones and M. W. H. Dickinson.

6. On certain Improvements in the means of establishing Artificial Gastric
Fistulas. By M. Blondlot.

7. Experimental Researches on the Physiological Properties and Actions of
the Red and Black Blood. By M. Brown-Sequard.

8. Experiments with the Stuffs used for Military Clothing, considered as Pro-
tective Agents against Heat and Cold. By Dr. Coulier.

9. New Researches on the Physiology of the Spinal Marrow. By M. Brown-
Sequard.

10. Experiments on Digestion. By Dr. F. G. Smith (reprint).

11. Experiments relative to the Transformation of Starch into Glucose in the
Stomach. By Drs. F. G. Smith and E. Brown-Sequard.

12. New Researches relative to the Importance of the Functions of the Su-
pra-renal Capsules. By M. Brown-Sequard.

13. On the Modifications effected in the Globules of the Blood of Mammals,
when injected into the Vessels of Birds, and in the Globules of the Blood of
Birds, when introduced into the Vessels of Mammals. By M. Brown-Sequard.

We are unable to notice in detail all the above memoirs, but this is of the
less consequence, as the results of several of them have been already published
through other channels. Even these, however, contain new facts, and are well
worthy of attentive perusal.

The memoir of M. Martins, and the note on the same subject by M. Brown-
Sequard, are particularly worthy of consideration, as containing some interest-
ing and accurate results relative to the temperature of the palmiped birds of
the North of Europe. From these researches it is seen that some of the long-
winged members of the order, especially the fulmar petrel [Procellaria Glacia-
lis), possess a temperature markedly lower than would be pre-supposed from a
knowledge of their habits.

The paper of M. Coulier, relative to the protecting power against heat and
cold possessed by the cloths used for the manufacture of military clothing,
though interesting, is not so complete and satisfactory as it should be for the
thorough elucidation of the subject.

M. Coulier seems to be unaware of how much has hitherto been done by
others in this matter, and that, consequently, he has been anticipated in the
more important of his conclusions. The subject of his memoir is of so great
interest in a hygienic point of view, that we hope our readers will pardon us,
if before stating his results, we recall to mind some of the facts in regard to it,
which may be considered as definitely established.

In 1792, Count Rumford instituted a series of experiments relative to the in-
fluence of colour over the amount of solar heat absorbed in a given time. He
found that, cceteris paribus, black was pre-eminent as absorbing more heat than
any other colour.

Franklin's researches followed, and were more complete and decisive than
Rumford's. This philosopher exposed cloths of different colours, laid on snow,
to the heat of the sun, and observed the different relative depths to which they
sank. From his experiments, he deduced the conclusion " that black clothes
are not so fit to wear in a hot sunny climate as white ones, because in such
clothes, the body is more heated by the sun when we walk abroad, and are at
the same time heated by the exercise, which double heat is apt to bring on
putrid dangerous fevers." He, therefore, thinks that soldiers and sailors in
tropical climates should wear white uniforms, and that white hats should be
generally worn in summer.

In 1799, Sir Humphrey Davy took up the subject; his experiments were per-

1858.] Brown- Sequard, Journal de la Physiologic 481

formed with pieces of copper of various colours, on the under surface of which
cerate was spread. His results accorded exactly with those of Franklin.

Stark, in a paper read before the Royal Society in 1853, and published in
the Philosophical Transactions for that year, contributes a good deal of valua-
ble information on the subject. The results which he obtained agree in a
striking manner with those of Franklin and Davy, as seen from the following
table, in which the several colours experimented with are arranged in the order
of their absorptive power: —

Stark.

Franklin.

Davy.

Coloured "Wool.

A

Coloured bulb of Therm.

Black

Black

Black

Black

Deep Blue

Blue

Dark Blue

Light Blue

Brown

Green

Green

Dark Green

Green

Pm-ple

Red

Red

Scarlet

Orange Red

Yellow

Yellow

Yellow

White

White

White

White.

In the Journal of the Franklin Institute for November, 1833, Prof. A. D.
Bache, of this city, gives the details of a series of experiments which he in-
stituted on the same point. Prof. Bache concludes that the colour of a sub-
stance only affects its absorptive power for luminous heat, and that if a person
keeps in the shade, it is immaterial what is the colour of his clothing.

In relation to the influence of colour over the absorbent power of a substance
for moisture, Stark, in the memoir above referred to, furnishes some important
results, to which we may briefly call attention.

On the 16th of January, 1833, he exposed during a foggy night 10 grains of
black wool, 10 of scarlet wool, and the same quantity of white wool, to the
action of the atmosphere. "When weighed in the morning, the black wool had
gained 32 grains, the scarlet wool 25 grains, and the white wool 20 grains, de-
posited as frost.

At a time when there was less moisture in the atmosphere, he repeated the
experiment. When the wool was weighed, the black had gained 10 grains;
dark green 9.5; scarlet 6 ; and the white 5 grains. It is thus seen, that a
direct relation exists between the capacity of a colour for heat and for moisture.

We come now to M. Coulier's conclusions, which are based upon a number
of experiments, evidently performed with great care, but which, with the ex-
ception of the second, are by no means original. His deductions are as fol-
lows : — ■

1. The colour of the clothing is without perceptible influence over the loss
of animal heat.

2. All cloths are capable of absorbing a certain amount of hygrometric water
[so called on account of its only being appreciated by the balance, or by the
lengthening of the textile fibres] ; this quantity is greatest for wool, next
greatest for hemp, and least for cotton.

3. This absorption is made without the immediate loss of caloric by the
human body.

4. The colour of a cloth exercises a great influence over the absorption of
solar heat, but whatever may be the character of the clothing, if its exterior
surface be suitably modified, all the advantages which white stuffs possess
when subjected to the heat of the sun are obtained.

The modification referred to in the fourth conclusion, consists in wearing a
white frock over the coloured uniform.

In this country, where our army has so much frontier service to perform, in
which the troops in summer are subjected all day on the plains to the heat of
an almost tropical sun, and in winter are exposed to snows, rains, and a tem-
perature frequently several degrees below the zero of Fahrenheit, the subject
of clothing for the soldier has not attracted that attention from the authorities
which it deserves. In winter or summer, in Texas or Maine, in Florida or on
the Pacific coast, the clothing of our soldiers is the same, the only difference

482

Bibliographical Notices.

[April

"being, that when occasion requires it, they are allowed to wear their overcoats.
The colours (dark blue for coats and light blue for trousers), though very good
for winter use, are almost the very worst which could be worn for summer
service.

Besides the original contributions, there is in this number of the Journal
de la Physiologie an excellent re'sumi of the recent progress of physiology, in
which abstracts of several important memoirs are given.

In conclusion, as we have said before, we see no reason why the attempt to
establish a physiological journal in France should fail. In Germany several
have been in successful existence for a number of years, and are among the
most valuable medical periodicals published. We are sure that, with the ac-
knowledged ability of the editor, and the aid of the numerous eminent physio-
logists, who have arisen in France, of late years, the Journal de la Physiologie
will assume a permanent and exalted position as an exponent of progressive
physiological science. W. A. H.

Art. XXVII. — Comptes Eendus des Seances et Me'moires de la SocietS de Bio-
logie, pendant Vannie 1856. Octavo, pp. 748. Paris, 1857.

Minutes of the Meetings and Papers read before the Society of Biology in the year
1856.

This, which is the eighth volume of the Transactions of the Biological So-
ciety of Paris, is not inferior in interest to those which have preceded it.

Founded in 1849 by the most talented and laborious young men of the French
capital, and having as perpetual president M. Rayer, a man who is celebrated
not only as a pathologist, but also for his acquirements in natural science, and
his generous aid to those who are zealous in its cultivation, this society has,
since that time, been yearly giving evidence of its valuable and well-directed
labours.

Instituted for the study of the science of organized beings in the normal
and the pathological condition, the subject of study embraced by this society
is vast. Living beings are not withdrawn from the action of the general forces
of nature, and all the phenomena, whether mechanical, physical, or chemical,
which occur in inorganized bodies, are observed in them. They are, moreover,
subjected to the influence of life, also, a force peculiar to them, and which gives
rise in addition to phenomena entirely special. This force — life — co-ordinates
the chemical and physical forces so as to produce phenomena seen only in
organized bodies, but it is not substituted for these forces, nor does it arrest
their results.

The society is composed of titular or active, honorary, associated, and cor-
responding members. The number of the first is fixed at forty, of the second
at fifteen, of the third at twenty, and of the last at eighty, all of the lists being
complete. In the whole number, there is not a name which is not well known
as that of a distinguished cultivator of science. Among the original members,
those by whom the society was founded, and who, to this day, have continued
its most active members, are Claude Bernard, Charles Robin, Brown-Sequard,
Follin, Lebert, Cazeau, Giraldes, Hirchfeld, Verdeil, and Verneuil.1

The comptes-rendus, or minutes, of the meetings of the society, published
every year, in one volume, together with the memoirs, form a mass of valu-
able and interesting information. Among these memoirs, or original papers,
are those of Bernard on the pancreatic juice and its part in the phenomena of
digestion, on the origin of sugar in the animal economy, on the different sali-

1 The members of the Biological Society hold their meetings in an ancient building,
which was formerly a portion of the Convent of the Cordeliers. This building, during
the great revolution, was used for the meetings of a society of the most violent of the
Jacobins ; so that the society of life has taken the place of the society of death.

%

1858.] Beale, Archives of Medicine. 483

vary fluids, and on the great sympathetic nerve, and especially upon the influ-
ence exercised by the section of this nerve upon animal heat; those of Lebert,
on the local and general nature of tumours, and upon inflammation ; those of
Robin, on the development of the substance and the tissue of bones, on erectile
tumours, on colloid and epithelial tumours, and upon hypertrophy of the ana-
tomical elements and those of the tissues; those of Sappey, upon the glands
of the eyelids and of the pituitary membrane, on the anatomy of the eye, and
on the structure of the tonsils and glands at the base of the tongue; the paper
of Brown-Sequard, containing his experiments upon the nervous system ; and
that of Davaine, upon hydatids and their development. These are some of
the papers which are of most interest to a medical man. The chemist, the
biologist, and the zoologist, will find others of greater interest, probably, in the
contributions of Rayer, of Montagne, of Mayer of Geneva, Huette, Gubler, and
Davaine.

That the zeal of the members of this society does not diminish is evidenced
by the fact that, while the first annual volume of their proceedings contains
362 pages, and the second 461, the present volume contains 748 pages. The
nature of their labours may be judged from the table of the original papers,
which is as follows : —

The physiological and therapeutical action of the chlorate of potash, by M.
Isambert.

Bronzed coloration of the skin, coinciding, in a phthisical patient, with fatty
degeneration of the two supra-renal capsules, by M. Second Fereol.

An affection characterized by palpitations of the heart and arteries, tume-
faction of the thyroid gland, and double ex-ophthalmia, by M. Charcot.

The mensuration of the facial angle, facial goniometers, and a new facial
goniometer invented by the author, by M. H. Jacquart.

Leucocythemia, by MM. Isambert and Robin.

Unilocular cyst of the ovary, by M. A. Laboulbene.

The existence of a co-ordinating principle of writing, and its relations with
the co-ordinating principle of speech, by M. Marce.

Spontaneous amputation of the neck and trunk, by the umbilical cord, in
the foetus, by M. Hillairet.

Physiological study of the venom of the toad, the triton, and the salaman-
der, by M. Vulpian.

Hemorrhages of the ovarian vesicles, by M. Robin.

Natural history of an insect of the order of coleopteri, which produces a
gall upon the draba verna, by M. A. Laboubene.
A gall of the tamarix brachystylis, by M. Amblard.

Proof that various tumours, called sarcoceles of the testicle, have their seat
in the epididymis, by M. Robin.

The characteristic cavities of bones, by M. Robin.

The anguillulus of smutty wheat, considered in regard to its natural history
and to agriculture, by M. Davaine.

The aortic narrowing at the place of junction of the ductus arteriosus, by
M. Dumontpallier.

The pathological anatomy of the elephantiasis of the Arabs, by M. Vulpian.
Studies upon monorchidia and cryptorchidia in man, by M. Godard.

W. F. A.

Art. XXVIII. — Archives of Medicine. A Record of Practical Observations and
Anatomical and. Chemical Researches connected with the Investigation and Treat-
ment of Disease. Edited by Lionel S. Beale, M. B., F. R. S., &c. &c. London :
John Churchill. 1857. No.l.

Dr. Beale, under whose auspices the Archives of Medicine makes its appear-
ance, is pre-eminently a practical man, and from his knowledge of physiology,
pathology, chemistry, and microscopy, every way fitted for the undertaking in

484

Bibliographical Notices.

[April

which he has engaged, and to which he seems so earnestly to have devoted
himself.

In the advertisement prefixed to the first number, Dr. Beale enumerates the-
following as the subjects upon which he expects to receive contributions : —

1. Practical clinical observations.

2. Original researches in physiology and pathology.

3. Results of the chemical and microscopical examination of the solid organs,
and secretions in a healthy and morbid state.

4. Descriptions of different processes employed for demonstrating various
structures, and for carrying out scientific inquiries bearing upon medicine.

5. Condensed reports of the researches of observers published elsewhere.
If the anticipations of Dr. Beale are realized, he cannot fail to present a

journal capable of conducing in a high degree to the advancement of scientific
medicine.

The papers contained in the present number are all of them of a highly
practical character, and, with the exception of two, contributed by Dr. Beale
himself. Among these is a very interesting one "On the Manner of preparing
Injected Preparations of the Liver," which we commend to those engaged in
micro-physiological investigations. The papers " On Microscopical Drawings
"On the Presence of Cholesterine in the Urine;" "On Chylous Urine," and
the two articles "On the Anatomy and Pathology of the Liver," are also worthy
of attentive perusal.

Dr. Moritz von Bose contributes a paper, to be continued in the ensuing
number, "On the Estimation of Urea, Chlorides, Sulphates, Phosphates, and
Sugar in Urine volumetrically." This, we believe, is the first attempt to place
before the profession in Great Britain a connected and detailed description of
those volumetric processes for the analysis of the urine which have for the last
few years been so successfully employed in Germany. For ease and certainty
in manipulation these methods are unsurpassed ; and we know of nothing better
calculated to insure accuracy in results, and, at the same time, by facilitating
physiological researches, to increase the number of labourers in the field, than
the wide-spread diffusion of such papers as the one now under notice.

An article follows, "On the Chemical and Microscopical Examination of
Morbid Specimens," in which several interesting cases are cited.

The number, besides several woodcuts, is illustrated with ten octavo pages
of lithographs, which, if not executed in the highest style of the art, are
amply sufficient for the purpose of correct representation, and add very much
to the value of the papers to which they refer.

In the enterprise which he has undertaken, Dr. Beale will, we hope, be sus-
tained by the enlightened members of the profession on both sides of the At-
lantic. W. A. H.

Art. XXIX. — A Theoretical and Practical Treatise on Midwifery, including the
Diseases of Pregnancy and Parturition, and the Attentions required by the
Child from Birth to the Period of Weaning. By P. Cazeaux, Member of the
Imperial Academy of Medicine, Adjunct Professor in the Faculty of Medi-
cine of Paris, etc. etc. Second American, translated from the Fifth French
edition. By Wm. R. Bulloch, M. D. With one hundred and forty illustra-
tions. 8vo. pp. 992. Philadelphia, 1857. Lindsay and Blakiston.

The Wise Man has said that, " of the making of many books there is no end."
Most truly is it, that of the publication of many treatises on the theory and
practice of midwifery there is no end. We have already so many admirable
works of this kind, from any one of which all the necessary knowledge, so far as
that knowledge can be communicated by books, may be acquired, that the
student and young practitioner can be at no possible loss in his selection of an
obstetrical guide. He will certainly not be disappointed, and can scarcely be
led astray in any important particular, whether in relation to doctrine or prac-

1858.]

Barclay, A Manual of Medical Diagnosis.

485

tical details, should he make choice of the admirable treatise of Meigs, or of
the equally excellent one of Ramsbotham, or of Rigby, Lee, Churchill, or Ca-
zeaux. The latter work, in the edition before us, is one of unquestionable ex-
cellence. Every portion of it has undergone a thorough revision, and no little
modification ; while copious and important additions have been made to nearly
every part of it. The author has selected from every authoritative source,
•whatever bears the impress of truth, and has been sanctioned by the concur-
rent experience of the masters of the obstetric art. Out of these materials he
has formed a body of doctrine and of sound practical precepts which he commu-
nicates, illustrates, and enforces with great directness and perspicuity. The
work is, in fact, precisely what it imports to be, a theoretical and practical
treatise on midwifery, based upon the labors of all antecedent writers in that
department of medicine, tested and confirmed by the author's own observations
and experience.

It is well and beautifully illustrated by numerous wood and lithographic en-
gravings, and in typographical execution, will bear a favourable comparison
with other works of the same class.

The translation appears to us, so far as we have compared it with the origi-
nal, to be faithfully and correctly executed.

D. F. C.

Art. XXX. — A Manual of Medical Diagnosis: being an Analysis of the
Signs and Symptoms of Disease. By A. W. Barclay, M. D., Cantab, et Edin.,
Fellow of the Royal College of Physicians ; Assistant Physician to St.
George's Hospital, etc. etc. Philadelphia : Blanchard & Lea, 1858. 8vo.
pp. 423.

The design of this work is to aid the student of medicine in the prosecution
of his clinical studies. If it be well adapted to this end, its usefulness will be
by no means restricted to the period of medical pupilage, for every practitioner,
great as may be his skill in diagnosis, based upon an experience ever so ex-
tended, must often feel doubt and difficulty, at the bedside, in the discrimina-
tion of diseases. The importance of diagnosis, as a province of medical science
and art, can hardly be over-estimated. It does not, it is true, constitute the
whole of medical science and art. The practice of medicine involves something
more. But it is the keystone of the arch. Without it, therapeutics are aim-
less, or as likely to be directed for evil as for good. All medical experience,
whether it be confined to the individual, or contributed to the public stock, is
either worthless or pernicious, unless based on a correct discrimination of dis-
eases. In view of the importance of the subject and the paucity of treatises
devoted to it specially, it was quite unnecessary for the author to apologize for
his undertaking.

After introductory remarks, the consideration of the method of diagnosis,
etc., the author treats of the objective and subjective phenomena referable to
the general condition of the patient ; febrile diseases ; rheumatism and gout ;
poisons and entozoa; diseases of uncertain or variable seat; chronic blood
ailments; depraved constitutional states, and quasi-nervous conditions. These
occupy about .one-third of the volume. The remainder is devoted to the diag-
nostic phenomena pertaining to particular anatomical systems and organs.
Fifty-eight pages are appropriated to the semeiology of diseases of the brain
and nerves ; diseases affecting the intra-thoracic viscera occupy over an hun-
dred pages; fifty pages are allotted to diseases of the organs of digestion;
nearly the same number to diseases affecting the genito-urinary system ; and
nineteen pages to diseases of the skin. The work is furnished with a copious
index in addition to a table of contents.

The author does not claim to have advanced any novel views. Without aim-
ing to enlarge our knowledge of medical diagnosis, his object is to present an
analysis of the symptoms and signs of disease, already sufficiently established.
No. LXX.— April 1858. 32

486

Bibliographical Notices.

[April

The originality of the work is in the arrangement of subjects and the manner
of making the reader acquainted with well-known facts. We think it would
have been better had the plan of the work been either more or less comprehen-
sive. As it is, he gives us as much, but not much more, relating to diagnosis,
than is embraced in most of the treatises on the practice of medicine. A
volume of a little over four hundred pages is insufficient to do justice to the
diagnostic points involved in the discrimination of nearly all the diseases in
the nosological calendar. In giving to the work so wide a range, and yet
restricting its size within moderate limits, a degree of condensation was neces-
sary, which renders it less readable and satisfactory than if the author had
accorded to himself greater space; and if a larger book was considered objec-
tionable, we cannot but think that the work would have been more attractive
and useful had its scope been less comprehensive.

In several instances the signa diacritica of diseases are treated of so briefly
as to be likely to leave in the mind of the inexperienced reader an erroneous
impression respecting the difficulty of the differential diagnosis. As an ex-
ample, we may specify croup. The diagnosis of this affection is considered in a
page and a half, and the distinctive features of true, as contrasted with those of
false croup, occupy twelve lines ! Again, pleurodynia, as distinguished from
pleurisy, is disposed of in a single paragraph ; and the diagnostic points which
characterize intercostal neuralgia, are not even alluded to. Under the head of
"alterations of sensibility," we were disappointed in finding no reference to
the hyperesthesia of the abdomen, which simulates some of the most promi-
ment of the symptoms of peritonitis, and not unfrequently misleads the young
practitioner ; nor is this condition mentioned under the head of peritonitis.
We cite these simply as illustrations to which others might be added.

We have not proposed to ourselves to write a critical review of the work.
Were we to do so, we should be compelled to notice several inaccuracies which
arrested our attention during its perusal. Some of these seem to arise from
want of care in the composition. We cannot, for example, suppose that, with
due reflection, a practitioner of Dr. Barclay's experience would make the fol-
lowing statement: "Irregularity of pulse invariably indicates disease of the
heart" (p. 190). As another instance of a careless mode of expression, we
quote the following: "The duration of the different affections of the chest varies
in a very remarkable degree; it is but a few days in acute inflammation; in
chronic bronchitis and phthisis, the more severe symptoms may be spoken of
as having existed for some weeks ; there have been probably months of con-
tinuous ailment in galloping consumption, etc." (p. 189). In the same cate-
gory belongs the following : "Erosion is found either as the result of ulceration
of the mucous membrane, or as the fatal termination of an aneurism when the
vessel has burst into the stomach. Both forms of hemorrhage are severe and
very often fatal" (p. 96).

The reviewer, however, might take exceptions to certain passages on other
grounds than carelessness of expression. For example, when the author states
that the blood in hsematemesis may be derived "by exudation from the surface
of healthy mucous membrane" (p. 96). Merely as evidence of the correctness
of the remark just made, we quote the following : " The name of remitting fever
is applied to a disease peculiar to warm climates. It is now very generally
believed to be only typhus as modified by atmospherical influences of the con-
dition of the nervous and sanguiferous systems of Europeans residing in tropi-
cal latitudes" (p. 57). This sentence includes all that is said respecting the
remitting fever of adults.

As a candid reviewer of the work, we should feel bound to criticize the au-
thor's style, which is deficient in the directness and clearness so desirable in
the composition of a scientific treatise. But with this defect and others to
which we have briefly alluded, the work may be studied with profit both by the
medical student and practitioner. We confess that it does not come up to our
idea of a work on Medical Diagnosis, such as we believe might be written and
such as it seems to us is much to be desired; but, in justice to the author, we
freely admit that its short-comings are in a great measure due to the incom-
patibility of its size and scope. A. F.

1858.]

Ash ton, Diseases, etc., of the Rectum and Anus.

487

Art. XXXI. — On the Diseases, Injuries, and Malformations of the Rectum and
Anus, with Remarks on Habitual Constipation. By T. J. Ashton, Surgeon to
the Blenheim Dispensary, &c. &c. Second edition, London, John Churchill,
1857. 8vo. pp. 396.

The success of this book of Mr. Ashton's and of the Clinical Lectures of Mr.
Quain, and also of the works of Syme and of Curling, would seem to show
that good treatises on diseases of the rectum are in extensive demand with Bri-
tish readers. A part of this demand, perhaps, may come from the victims of
rectal maladies themselves ; still, the great majority of purchasers must be re-
gular practitioners, who prove, by their eagerness in securing all information
on the subject, its urgent interest and importance.

Certain it is that there are few forms of human ailment more difficult to the
surgeon and distressing to the patient, or in which both parties are more likely
to look everywhere for assistance and relief. We cannot help feeling consider-
able surprise, therefore, that the excellent monograph of Mr. Bushe which was
published in this country some twenty years ago, and is still very nearly equal,
if not in some respects superior, to either of the British publications just alluded
to, should neither have gone to a second edition, nor had an original successor,
from the American press.

We regret this particularly, since the volume now before us, though con-
taining a large amount of useful matter and numerous cases and observations
which are entirely its own, nevertheless owes to the pages of Dr. Bushe
some of its best parts. To such an extent, indeed, have the appropriations
of whole successive pages, without allusion to their source, availed our author,
that, in this instance at all events, he might have followed the more hum-
ble example of his American confreres, and adopted, with propriety, if not
advantage, the much abused practice of reprinting with notes and additions,
which has excited the virtuous indignation of so many of the self-approving, and
the interested purists on both sides of the Atlantic.

Mr. A. gives ample evidence, however, in the original portions of his book,
of the ability to sustain himself without resorting to the labours of his pre-
decessors ; and he has made so many additions to his previous edition, sug-
gested by greater experience, extended reading and accumulated notes of
eases, that it is a great pity that he did not avail himself of the opportunity to
devote the additional time and labour needed to expurgate the new edition by
the substitution of his own language and arrangement, wherever necessary,
for that of Mr. Bushe, and by the distinct acknowledgment and reference to
the same authority for cases and other matter presented verbatim in the first
edition, but without quotation marks or any definite citation.

As this act of simple justice to his own production, as well as to one which
he justly acknowledges to have been his ablest monitor and the most complete
work of its day, does not appear to have been accomplished, we cannot regard
the essay of Mr. Ashton as entitled to rank as an original work with those of
Syme, Curling, or Quain, and still less with its model, that of Mr. Bushe.
Nevertheless its merits as a practical instructor, well arranged, abundantly
furnished with illustrative cases, and clearly and comprehensively, albeit too
diffusely written, are incontestable. They have been sufficiently indorsed by
the verdict of his countrymen in the rapid exhaustion of the first edition, and
they would certainly meet with a similar reward in the United States were the
volume placed within the reach of American practitioners.

After a short and sensible introduction, from which we shall quote a few
paragraphs, directly, he discusses the various affections of the rectum in twenty
chapters. Each of these chapters is concluded with a series of cases presenting
clinical examples of the disease with which it is occupied. These diseases are
severally discussed at greater or less length, according to their importance, in.
the following order: Irritation and Itching of the Anus; Inflammation and
Excoriation of the Anus; Excrescences of the Anal Region; Contraction of
the Anus ; Fissure of the Anus and Lower Part of the Rectum ; Neuralgia of

488

Bibliographical Notices.

[April

the Anus and Extremity of the Rectum ; Inflammation of the Rectum ; Ulcer-
ation of the Rectum ; Hemorrhoidal Affections ; Enlargement of Hemorrhoidal
Veins ; Prolapsus of the Rectum ; Abscess of the Rectum ; Fistula in Ano ;
Polypi of the Rectum ; Stricture of the Rectum ; Malignant Diseases of the
Rectum; Injuries of the Rectum ; Foreign Bodies in the Rectum ; Malforma-
tions of the Rectum and Anus ; Habitual Constipation.

The professional reader cannot fail to meet with a great amount of informa-
tion, upon numerous important questions suggested by the various captions of
the formidable list above enumerated, which is probably better and more fully
given in the chapters of Mr. Ashton than in those of any other author with
which we are acquainted. We are so well satisfied of this that, were it not for
the embarrassment inseparable from the palpably non-original character of
some portions of his volume, our brief notice might have been extended into an
elaborate review. The subject is so important, and so interesting to all medi-
cal inquirers, and comes home to more or less of the personal experience of so
large a majority of all classes of society, and yet receives so little formal atten-
tion in our journals as well as in the text-book and lecture-room, that no reason-
able opportunity ought to be neglected to arouse attention to its study.

In the absence of a methodical analysis and discussion of Mr. Ashton's work,
we cannot do better, in order to show his estimate of the subject, and his philo-
sophical and practical mode of treating it, than to conclude with the following
quotation from his introduction: —

" In the whole range of surgical pathology no class of diseases among civil-
ized communities is so prevalent, causes more suffering, or induces so many
varied and distressing sympathetic affections as those of the rectum ; happily
for the sufferers none succumb more readily to judicious, and, in the majority
of cases, to simple treatment, when it is put in force at an early period of the
malady ; but unfortunately, as it often happens, from a mistaken delicacy on
the part of the patients, or from some other cause, proper advice is not sought
till the constitution has become seriously deranged, or the local affection no
longer endurable ; or it may be that, under preconceived and erroneous notions
as to the nature of the affection, or from the prominence and severity of some
one of the sympathetic effects, the sufferers are induced to adopt a variety of
empirical remedies which fail to afford the desired relief and restoration of
health, and which are often productive of the most pernicious results.

" From the important functions of the rectum, from the constant or recurrent
pain attending diseases affecting it, induced each time the bowels evacuate
their contents, and the serious constitutional disturbance these diseases excite,
they require the careful attention and deep consideration of the surgeon. In
past ages and in the present time a popular idea has prevailed that a deeper
knowledge of, and a more intimate acquaintance with, the diseases of any
certain organ is obtained by an exclusive consideration of that particular part ;
but no greater fallacy can be conceived, it being only by a comprehensive
view, and after due consideration of all the symptoms produced, and the various
phases presented by disordered function and organic change in the various
parts of the animal economy, that a just conclusion as to the Jons et origo mali
can be arrived at. Perhaps few classes of disease exemplify the necessity of a
wide and mature consideration more than those implicating the rectum, either
primarily or secondarily ; for the same symptoms will often be found existing
under the opposite conditions of cause and effect. Thus, in the female, many
instances have occurred of stricture of the rectum being supposed to exist, and
a long and useless treatment had recourse to, when ultimately all the patient's
sufferings were found to depend on a displaced uterus, or on some morbid
enlargement or growth of that organ ; and the converse is not unfrequently the
case, of a patient being treated for leucorrhcea or uterine disease, whilst the
real source of the symptoms has been in some affection of the rectum. In the
male also, will be observed stricture of the urethra, diseases of the prostate
gland and bladder simulating those of the rectum : or, on the other hand,
diseases of this portion of the alimentary canal producing irritability and other
disturbance of the genito-urinary organs. Nor is it in contiguous parts alone

1858.] Ashton, Diseases, etc., of the Rectum and Anus.

489

that the reaction of one organ on the other is met with, it is necessary there-
fore to bear in mind the more remote sympathies induced in the cephalic,
thoracic, and abdominal viscera, as evinced by headache, vertigo, impaired
vision, palpitation of the heart, gastric distension, pain, and sickness ; and
deranged secretion from the kidneys, as exhibited by the various urinary
deposits.

" Formerly some of the affections of the rectum, which in reality are very
simple in themselves and easily relieved, rendered the subjects of them the
victims of the most painful and in many cases dangerous operations. But by
the advance of surgical science generally, and the study and observation of
these particular diseases, even the most painful of them may generally be
remedied by medical treatment ; and when an operation is necessary for the
removal of morbid structure or for the purpose of inducing a healthy reparative
process, it is simple in character, quickly performed, occasioning but a slight
amount of pain, and confining the patient for only a very limited period. Thus
fistula in ano, which, at a comparatively recent period, was considered among
the heaviest afflictions that flesh is heir to, from the barbarous treatment that
was then practised and considered necessary, as a consequence of the false
notions and erroneous pathological principles that prevailed, and which led to
the scooping out of the parts in the track of the fistula, or to the extensive
destruction of the surrounding tissues by corrosive unguents, is now remedied
by a slight incision, performed in a few seconds, and not occasioning the loss
of more than a few drops of blood. It was only a few years since it was deemed
essential for the cure of fissure of the anus to entirely divide the sphincter
muscle, but it is now proved that when an incision is required it is not neces-
sary to make it more than a few lines in length, and to extend it no deeper
than through the mucous and submucous tissues. In all operations about the
anus the general rule in surgery, that of not removing more of the integument
than is necessary, cannot be too forcibly insisted on ; for if this is not observed
the patient will be doomed to much inconvenience and misery by the contrac-
tion that ensues.

"The constitutional origin of these local affections and their reaction on the
general system, when their cause has been extrinsic, must always be borne in
mind, for if this be overlooked, our hopes of success in the treatment will often
not be realized.

"Besides prescribing proper remedies and giving strict injunctions with
regard to diet and exercise, it is advisable that the surgeon should apply the
dressings with his own hands, for though there is no difficulty in the matter,
and little skill required, yet it is essential to the comfort and recovery of the
patient that they should be accurately and properly adjusted; nurses and
attendants, from not thoroughly apprehending the object to be attained, are
too apt either to cram and distend the parts with the dressings, or not to ap-
proximate them with sufficient nicety ; the surgeon should also exhibit the
enemata, unless he has some intelligent and trustworthy person on whom he
can rely. These matters may appear comparatively trifling, but if they pass
unattended to we shall often be disappointed in the result of our treatment, let
it in other respects be ever so skilfully and well directed" — pp. 1-5.

We are satisfied, after a careful examination of the volume, and a comparison
of its contents with those of its leading predecessors and contemporaries, that
the best way for the reader to avail himself of the excellent advice given in the
concluding paragraph above, would be to provide himself with a copy of the
book from which it has been taken, and diligently to con its instructive pages.
They may secure to him many a triumph and fervent blessing, the value and
strength of which can be known only to those who have been scorched in the
furnace of affliction, the fires of which, it is their province to extinguish.

E. H.

490

Bibliographical Notices.

[x\pril

Art. XXXII. — Plates Illustrative of Wilson on Diseases of the Skin. Fourth
Edition. Philadelphia, Blanchard and Lea, 1857.

In the Number of this Journal for Oct. 1857, will be found a review of the
fourth edition of Wilson's Treatise on Diseases of the Skin, in which the highly
scientific and practical character of the work is pointed out, and its great
merits as a guide to a knowledge of the nature of those diseases, and of the
best means of treating them, are fully considered.

Although more than a year has elapsed since the publication, in this coun-
try, of the text of the work, the illustrative plates have only just now been
issued. While we think we have reason to complain of this delay, we are forced
to admit that it must have required some time to execute these plates, in the
style in which they are now presented to us. For beauty of drawing, accuracy
of illustration, and delicacy and finish of colouring, these illustrations are supe-
rior to anything of the kind hitherto published in this country.

The volume contains nineteen plates.

Plate I. represents, in eight figures, the structure of the scarf skin.
Plate II. exhibits the anatomy of the sensitive skin and nail, in six figures.
Plate III. contains eighteen figures, illustrating the anatomy of the sebipa-
rous glands.

Plate IV. exhibits the anatomy of the hair, in sixteen figures.

Plate V. represents two views of the acarus scabiei magnified 107 times, a
view of the fore feet magnified 456 times, and two ova of the animalcule.

Plate VI. contains ten figures, illustrative of the structure of warts and corns,
together with some diseases of the sebiparous glands.

Plate VII. represents congestive inflammation of the derma, in its several
forms — urticaria, roseola, and erythema.

Plate VIII. represents the asthenic group of effusive inflammation of the
derma — pemphigus, rupia, in their various stages and several varieties.

Plate IX. contains the delineation of the sthenic variety of effusive inflam-
mation of the derma — herpes and eczema, with their several species, and at dif-
ferent periods of their course.

Plate X. represents suppurative inflammation of the derma — impetigo and
ecthyma, their species and various appearances.

Plate XI. is devoted to the delineation of the depositive inflammation of the
derma — lichen, strophulus, prurigo, and their several species.

Plate XII. presents representations of the squamous inflammations of the
derma — lepra, psoriasis, and pityriasis, and their several species.

Plate XIII. represents lupus non exedens, taken from a characteristic case
which had persisted for thirty-three years.

Plates XIV. and XV. contain representations of the diseases of the hair-fol-
licles, and hairs — acne, sycosis, favus, trichosis.

Plate XVI. represents various exanthematous and papular syphilitic erup-
tions.

Plate XVII. represents tubercular syphilitic eruptions.

Plates XVIII. and XIX. contain representations of various syphilitic erup-
tions, and of diseases arising from syphilitic poison.

It cannot fail to strike the reader that this is a very complete atlas of Der-
matology, and we feel sure that, on examination, he will be satisfied with its
accuracy and artistic execution.

1858.]

491

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

1. Choroid Plexuses of the Human Brain. — Up to the present time anatomists
have not agreed on several points in the anatomy of the centres of the nervous
system, especially on the existence or not in adult age of a canal in the interior
of the cord, easily to be observed in foetal life ; or whether there be a commu-
nication of the subarachnoid space with the ventricles of the brain, and the
corresponding space in the cord, or not, etc. Professor Luschka, of Tubingen,
well known to anatomists by his treatise on the anatomy of the generative
organs, has taken up some of these doubtful points, and brought them, as it
seems, to a satisfactory conclusion, chiefly by his researches on the bodies of
three healthy criminals who were executed at Tubingen.

It follows from the researches of Professor Luschka, that the existence of a
canal in the interior of the cord in adult age is in some cases beyond doubt.
Often, however, this canal seems to be completely obstructed and filled by cel-
lular tissue, epithelium, and amyloid corpuscles.

The communication of the subarachnoid spaces with the ventricles of the
brain, and with the subarachnoid space of the cord, has recently been denied
by Professors Virchow and Kolliker at Wurzburg. Professor Luschka, how-
ever, proves the existence of this communication by anatomic preparations, by
experiments on dead bodies, and by appeal to well-established surgical facts,
so that we can no longer doubt that there is really a floating to and fro of the
cerebro-spinal fluid from the brain to the cord, and vice versa.

As the arachnoid membrane spans like a bridge over the convolutions and
furrows of the upper surface of the brain, the pia mater being in the depth of
these furrows, there must be spaces filled by fluid, and these are in open com-
munication with each other. Similar spaces or sinuses exist on the base of the
brain, out of which cerebro-spinal fluid flows in cases of fractures of the skull.
The largest subarachnoid sinus on the base of the brain communicates with
the fourth ventricle, and thereby with all the ventricles of the brain. From
this space may be drawn a very large quantity of cerebro-spinal fluid, as well
in the dead human body as in the living animal, the whole mass of which has
certainly not been contained in this single space, but has come from the other
spaces with which it is in open communication.

It has been proved by surgical observations and post-mortem examinations
made by Sir Charles Bell and Guthrie in this country, by Laugier and Chas-
saignac in France, and by DiefFenbach and Wtitzer in Germany, that in cases
of fracture of the sphenoid bone some cerebro-spinal fluid flows from the
nostrils ; this proceeds from a subarachnoid sinus lying between the crura
cerebri, the margin of the pons Varolii, and the commissure of the optic nerves,

492

Progress of the Medical Sciences.

[April

corresponding to the sphenoid bone. It has equally been proved that in cases
of fracture of the petrous bone, cerebro-spinal fluid flows from the ear ; then
the walls have been torn of the subarachnoid sinus on the anterior margin of
the pons Varolii, just at the conjunction between the petrous part of the tem-
poral bone and the margin of the body of the occipital bone.

The experiments made by Professor Luschka for proving the existence of a
communication of the different subarachnoid spaces with each other, and with
the ventricles of the brain, are interesting and conclusive. A fresh corpse was
suspended by the feet for four hours, so that the head hung quite free. Then
the skull-cap and the dura mater were taken off. The arachnoid membrane
was found very much enlarged by fluid collected under it, and in some places
was prominent like a bubble. It was then cut open, and one and a half ounce
of cerebro-spinal fluid flowed out. Another corpse having been suspended by
the head during five hours, the skull-cap was removed, and the dura mater
cut open. The subarachnoid spaces now appeared quite empty, and the arach-
noid membrane sunk into the furrows of the brain. The head of another body
was cut off at the fifth cervical vertebra, a tube introduced under the arachnoid
membrane, and some ink mixed with water driven in by very gentle pressure
of a syringe. Some time after, the head was held in an inverted position, in
order to bring the fluid into the subarachnoid spaces and ventricles of the
brain more by their specific weight than by the pressure of the syringe. The
skull-cap and the dura mater were then removed, and the spinal fluid was not
only seen on most of the parts of the hemispheres of the brain, and in the
sinuses at the base of the brain, but likewise in the fourth ventricle, from which
it had even come through the aquseductus Sylvii into the third ventricle.

For imitating artificially such fractures of the skull as are connected with
loss of cerebro-spinal fluid, Professor Luschka perforated, by means of a tre-
phine introduced into the nose, the body of the sphenoid bone, the dura mater
and the arachnoid membrane. Instantly a clear fluid flowed out, and a much
larger quantity could be drawn off by a syringe. Further, he introduced the
trephine into the external opening of the ear, and perforated the membrana
tympani and the labyrinth in the direction of the internal opening of the ear,
with the same result.

Finally, air was blown into the subarachnoid spaces of the cords of three
men who had just been decapitated, and in whom all the cerebro-spinal fluid
had come out through the widely opened subarachnoid space of the cord. The
air penetrated from this space into the subarachnoid spaces, as well as into all
the ventricles of the brain. This fact alone would leave no doubt about the
communication between all the subarachnoid spaces and with the ventricles. —
Med. Times and Gaz., Jan. 16, 1858.

2. Histology of the Supra-Renal Capsules. — Dr. Harley, in a paper on this
subject, read before the Royal Medical and Chirurgical Society (Dec. 8th, 1857),
began by pointing out that the supra-renal capsules could not properly be said
to diminish in proportionate size and activity of function with advancing years.
He placed upon the table several preparations of supra-renal capsules, taken
from individuals of different ages, to prove that their development proceeded
at a certain ratio after birth. He moreover stated, that as they did not become
proportionally more atrophied in old age than many of the other organs, it
might naturally be supposed that they had a certain function to perform in
adult as well as in foetal life. Dr. Harley then called attention to the great
variety of size and shape of the supra-renal capsules throughout the vertebrata,
and afterwards proceeded to point out the appearances presented to the naked
eye by healthy supra-renal capsules. He denied the existence of any large
cavity in the centre of the healthy human supra-renal capsule, and said that
when such was found it was the result either of accidental rupture of the me-
dullary substance, or as the effect of disease. He pointed out, however, the
existence of a number of small sinuses in the centre of the organ. Dr. Harley
said that the cortical and medullary portions of the supra-renal capsules, which
are so different in colour, have equally distinct microscopical characters. The
former, which constitutes the greater part of the organ, consists of a number

1858.]

Anatomy and Physiology.

493

of cells, arranged in irregularly-sized rows in a fibro-areolar matrix, the rows
of cells appearing like a number of dark-yellow columns placed perpendicu-
larly to the surface. The cells, when examined individually, are seen to be
composed of a homogeneous cell-wall, filled with granules, pigment, and some
fat-globules. Each cell possesses a well-marked nucleus, although it is not
always visible without the employment of reagents. The easiest way to demon-
strate the existence of a nucleus, the author said, was to colour the cells with
carmine.1 When floating free in the field of the microscope, the cells appear
irregularly round ; but when grouped together, they have a somewhat poly-
gonal form. The cells are arranged in a number of larger and smaller masses,
which are placed in regular rows, and thus give rise to the columnar appear-
ance. In some cases a column is composed of several cell-masses of different
lengths, placed end to end ; in others it consists almost entirely of one long
cell-mass. Each column, as well as each cell-mass, is separated from the others
by delicate fibrous tissue, in which is included the vessels and nerves. Some-
times the cell-masses present the appearance of long tubes, inclosing a single
straight row of quadrilateral cells. Each cell-mass is closed at the extremities,
and is surrounded by a delicate homogeneous membrane. The dark slate-co-
loured medullary substance of the supra-renal capsules has a very different
structure from that just described. It is composed of a network of fibres, in
the meshes of which are a number of large nucleated cells, which have been
described by various writers as ganglion corpuscles. Dr. Harley thinks, how-
ever, that these, like the cells in the cortical substance, are true secreting cells.
The supra-renal capsules are very freely supplied with bloodvessels. Their
course and distribution were minutely described. The author concluded his
communication by making a few remarks on the supposed functions of the
organ, in the course of which he observed that in the supra-renal capsules of
the frog he had found blood-corpuscles in various stages of development. Each
point of importance in the paper was fully illustrated by diagrams and micro-
scopical preparations. — Med. Times and Gaz., Dec. 19, 1857.

3. Function of the Supra-Renal Capsules and their supposed Connection with
Bronzed Skin. — The B. and F. Med.-Chir. Rev. for Jan. last contains a report
of some interesting experimental investigations relative to these questions by
Dr. George Harley. The following are his conclusions : —

1st. The supra-renal capsules are not solely foetal organs.

2d. The supra-renal capsules are not absolutely essential to life.

3d. The removal of the right is generally more fatal than removal of the left
capsule.

4th. That convulsions do not necessarily follow the removal of the capsules.2
5th. That the absence of their function (in rats) is attended neither by great

emaciation nor debility.

6th. That when death follows upon the extirpation of the supra-renal

bodies, it is in most cases in consequence of the injury done to the neighbour-

1 This is a new process lately discovered in Germany. It was very briefly described
by Dr. Harley. The principle of "imbibition," as it is called, is founded upon the
fact that various animal tissues absorb and retain pigments with different degrees of
avidity. Thus, for example, granular tissues possess a special attraction for colouring
matters. Homogeneous substances, on the other hand, display but a feeble affinity
for them. A cellular is consequently more readily tinged than a fibrous structure ;
and in the tissues composed of aggregated cells, various parts are coloured in different
degrees of intensity. Thus the homogeneous cell-wall retains its colourless appear-
ance long after its granular contents have become deeply tinged, and the nucleus,
which is usually the most granular part of the cell, has become of a prominent dark
hue.

2 In a letter dated Nov. 15th, Professor Virchow informs me that he also has extirpated
the supra-renal capsules, without having noticed the derangement of the central nerv-
ous system mentioned by Brown-Sequard. I should add, that I have seen two animals
suffer from convulsions after extirpation of the capsules. One, a cat, died soon after,
having slight tetanic symptoms.

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ing tissues; perhaps, most frequently the mutilation of the ganglionic system
of nerves.

7th. Absence of the function of the supra-renal bodies is not proved to have
any special effect in arresting the transformation of heematin, or in increasing
the formation of blood crystals.

8th. The suppression of the supra-renal capsular function is not attended by
an increased deposit of pigment in the skin or its appendages (in rats).

9th. The problem of the connection of bronzed skin and supra-renal capsular
disease is more likely to be solved in the dead-house than in the physiological
laboratory.

4. Variations of the Colour of Venous Blood. By Prof. Claude Bernard. —
From the period of the discovery of the circulation, two descriptions of blood
have been recognized ; the one red or arterial, the other black or venous ; and
so characteristic has this difference in colour of the arterial and venous blood
been considered, that it has served since the time of Bichat for the anatomical
division of the circulatory organs. The facts now about to be mentioned will
prove that henceforth we cannot regard as synonyms the terms venous and
black blood ; some venous blood being found, in the normal condition, as red
as arterial, and even sometimes red and sometimes black. But what will most
interest the physiologist is to learn that these variations in the colour of
venous blood correspond to different determinate functional conditions of the
organs.

As long since as 1845, M. Bernard, while experimenting upon dogs on the
eliminatory power of the kidney, was surprised at finding that the blood which
left that organ by the vein was as red as that which entered it by the artery.
Latterly, he has resumed the investigation of the subject at the College of
France. The same phenomenon that had formerly been observed in the dog
presented itself in the rabbit, and the red blood of the renal veins arriving
and visibly mingling with the black blood of the vena cava inferior. The
lumbar veins, on the other hand, discharged black blood very near the renal
veins, as did also a small muscular vein which opened into the left renal vein.
On multiplying the experiments, and varying the condition of the observation,
it was soon found that the usual red colour of the blood of the renal vein might
change in shade, and, under the influence of certain circumstances, become
completely black. Thus, contradiction would take place if we were contented
with the announcement of a single observation. This may unfortunately be
almost always the case in physiology, when we fail to distinguish amidst such
complex phenomena, the eminently variable conditions which every living
organism presents.

Having exhibited the two possible appearances of the blood of the renal
veins, the next point was to examine what relation they held to the perform-
ance of the function of the kidney. To this end there was placed in the ureter
a small silver tube, by which the urine was observed to flow drop by drop,
almost continuously, as it is known to do. It was then found that the blood
of the renal vein, as well as the tissue of the kidney, continued completely
red as long as the urine flowed abundantly by the tube ; but that this flow
ceased to take place under the influence of circumstances which, while they
rendered the blood of the renal vein black, gave at the same time a bluish tint
to the kidney itself. Hence it would seem that the red colour of the blood of
the renal vein was referable to the functional activity of the kidney, and its
black colour to the condition of repose or cessation of function. Moreover, it
was found that the nature of the reaction of the urine excited no influence on
the phenomenon ; the blood of the renal vein being alike red in the dog with
acid urine and in the rabbit whose urine is alkaline during digestion and acid
after twenty-four or thirty-six hours of abstinence.

Without enumerating the various influences that are capable of disturbing
the secretion of the urine, and leading to a change in the colour of the blood
of the renal vein, the author contents himself with adverting to the perturba-
tion that may ensue from the mode of operating. If it be desired to observe
the red colour of the venous blood, the abdomen must not be largely opened and

1858.]

Anatomy and Physiology.

495

the intestines displaced, for then suppression of urine will almost immediately
ensue, and the blood in the vein will often become as black as that of the vena
cava, A small opening should be made in the lumbar region, and especially
on the left side, the left renal vein being more easily exposed in consequence
of its greater length. Through the same wound the ureter may afterwards be
isolated, so as to introduce the silver tube, in order to make certain whether
during observation the function of the kidney continues to be carried on or
not.

From what has been said it clearly results that the blood of this vein, pre-
senting habitually a red colour in connection with the formation of urine,
which is almost continuous, does not correspond with the definition of venous
blood already given. The first question that presents itself to the mind is
whether this is an isolated fact, special to the kidney, or whether it may be
extended to the secretory organs, whose function is, in like manner, the sepa-
ration of a special organic fluid in their tissue. The submaxillary gland of the
dog offers great facilities by its superficial and isolated position for the inves-
tigation of this point; the numerous anatomical varieties which its vein exhibits
in nowise interfering with the observation of the physiological phenomena. In
the first experiment the blood it contained was found as completely black as
the darkest venous blood ; but this arose from the fact of the secretion by the
gland, which is intermittent, not then being active. When, however, some
drops of vinegar were instilled into the mouth of the animal, which by its
reflex action induced the secretory activity of the gland, the blood gradually
but rapidly exchanged the black for the red colour, the black colour being
again restored when the secretion had ceased. In order to render the inter-
pretation of the phenomenon yet more positive, a small silver tube was intro-
duced into the exposed excretory canal of the gland, and the nervous branch
of the lingual nerve going to the gland was isolated. It was then found that
as long as the organ remained in repose nothing passed by the tube, and black
blood passed through the vein ; while, whenever the nerve of the gland was
excited by galvanism, and secretion was produced, the colour of the blood
became red, regaining its black colour when the secretion was arrested after
the cessation of the stimulation. The trial was made several times, and with
similar results. There was always an interval of some seconds elapsed between
the production or the cessation of the stimulus and the changes of colour in
the blood, as if the gland required a short period for the discharge of the blood
it already contained. Moreover, it was observed that the blood flowed always
more abundantly when red, that is, during the state of functional activity of
the organ, than when black, the organs being then in a state of repose.

These two series of results obtained from the kidney and the submaxillary
gland certainly do not constitute isolated facts ; and the same observation
should doubtless be extended to other glands. The investigations as yet made
by the author on the parotid and on the glands of the alimentary canal have
furnished similar general results ; but the study of the subject will only be
complete when each particular gland shall have been experimented on.

" It results from the facts now stated, that if in the physiological condition
we may still designate arterial blood as the red blood, the appellation of black
blood cannot in this general manner be conferred on venous blood. We have
seen, in fact, that the venous blood may be found red or black in secretory
organs, accordingly as these are observed in a state of activity or repose. This
consideration of the activity and repose of the organ, which correspond in
some degree to its statical and dynamical conditions, appears to me to be an
important point for introduction into the chemical and physiological study of
the blood. In fact, it is not alone by its colour that the venous blood of an
organ at rest differs from the venous blood of an organ in activity ; but it pre-
sents also other important differential characters, which much depend upon a
profound difference of the chemical constitution. Thus the venous blood of
the kidney performing its function, which is red, is more diffluent, and some-
times even presents no coagulum; while the blood of the same vein, when the
kidney has ceased to act, becomes black, and presents a consistent coagulum.

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etc. Without doubt physiologists and chemists have already learned that
venous blood cannot, like arterial blood, be everywhere regarded as identical,
and that it is necessary to analyze the venous blood of each organ in particu-
lar; but what, I believe, has never yet been stated, and which, nevertheless,
seems to me indispensably necessary to be henceforth considered, if we desire
that chemical analyses should prove as useful as possible to physiology, is the
separate and comparative examination of the composition of the venous blood
of the same organ when in repose and in activity. From what has been stated
above, we may predict that there will be often found greater differences between
the two bloods of the same organ in the state of activity and of repose than
between the corresponding bloods of two different organs. This point of view
is not solely applicable to glands, but should be extended to all the organs of
the body, the venous blood of which will now have to be studied under these
two conditions. We may in some measure characterize each tissue by the very
different modifications its functional activity impresses on the blood that tra-
verses it. Thus, if the blood quits glands when active reddened, it leaves a
muscle that contracts with a very black colour and different physical charac-
ters. The mechanism of these different colorations of the blood will necessarily
receive its explanation through ulterior chemical analyses, of which we are
only at present desirous of indicating the physiological conditions. We will
conclude with the remark, that all these modifications which supervene in the
blood as a consequence of the functional activity of organs are always deter-
mined by the nervous system. It is consequently at this point of contact
between the organic tissues and the blood that we must acquire our ideas of
the special part played by the nervous system in the physico-chemical pheno-
mena of life. The development of the facts which relate to this point of general
physiology will form the subject of an early communication. " — Med. Times and
Gaz., Feb. 27, 1858, from Comptes Rendns, torn. xlvi. pp. 159 — 165.

5. On the Properties and Uses of the Red Blood and of the Bark Blood. — Dr.
Brown-Sequard communicates several observations which strengthen him in
the view that blood charged with oxygen, whether arterial or venous, has the
power of re-establishing the vital properties of the contractile and nervous
tissues, when applied within a certain space of time, after they have lost these
properties. After having repeated Sir Astley Cooper's experiments, that ani-
mals die from asphyxia, when circulation is stopped in their four encephalic
arteries, and that they recover almost immediately if the circulation is quickly
re-established — Brown-Sequard ascertained that if the circulation takes place
again a few minutes after the last respiratory movements had ceased, life does
not re-appear. But the red blood then still possesses the power of re-establish-
ing life, as insufflation of the lungs causes energetic movements of the limbs,
while the head remains at rest as long as the pressure on the arteries continues ;
but as soon as the latter is removed, the encephalon resumes its functions, and
the animal may be restored to full life, even fifteen minutes after the com-
mencement of the compression. The same author found also that in heads
separated from the trunk, injections of red blood — i. e., blood charged with
oxygen — may reproduce the actions of the encephalon (respiratory movements
of the face, movements of the eyes, &c). Further experiments have shown,
1. That the presence of fibrin in the blood is not necessary for this effect; 2.
That serum alone does not possess this power; 3. That the blood richest in
oxygen and globules does possess it in the highest degree — the globules acting
probably only as bearers of oxygen. Another series of experiments regarding
the properties of red and black blood, leads Brown-Sequard to the inference,
that the red blood increases the vital properties by nourishing the tissues, but
that it is incapable of making these properties appear by stimulating them ;
that the black blood is an energetic stimulant of the nervous centres, and also,
but in a less degree, of the nerves and contractile tissues, but that it does not
possess — or at least only in a small degree — the power of maintaining or re-
generating the vital properties. — B. and F. Med.-Chirurg. Rev., Jan. 1858, from
Compt. Rendus, Oct. 19, 1857.

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Organic Chemistry.

497

6. Membrana Meconii, and Rete Vasculare, newly-discovered Structures existing
in the Foetus. — Dr. B. Ridge asserts that in many instances he has proved the
meconium of newly-born infants to be inclosed in a special covering, which he
names the meconic membrane, and which is secreted by the reie vasculare — this
being, as its name implies, a vascular network lying between the foregoing
and the true mucous membrane of the intestines. The use of the meconium
during foetal life, he considers, is to keep the intestinal tube patent from end
to end as a " proper stuffing and that of the meconic membrane, to prevent,
by its interposition, the contact and consequent absorption of excrementitious
matter by the lacteals and absorbent vessels of the alimentary canal. At the
time when the new being is called into self-existence, the meconic membrane
and rete vasculare, which have served their turn, begin to become detached
from the infant ; as, by the same rule, the placenta, which has answered as
temporary lungs, is separated from the organisms of both parent and offspring.
On some occasions, Dr. Ridge states that he has found the meconic membrane
to come away with the conium itself at the time of birth ; but this is by no
means an uniform occurrence, as at other times, when retained together with
the rete vasculare, both are subjected to chylification by the action of the bile:
and the author attributes, in some degree, the healthy condition, or otherwise,
of infants for a certain period after birth, to the amount of rapidity with which
this process takes place. — Lancet, Nov. 28, 1857.

ORGANIC CHEMISTRY.

7. On the Physiological Relations of Albumen. By Dr. Hayden, Prof, of
Anat. and Phys. (Read before the British Association.) — The inquiry of which
this paper contains the first part, was undertaken with the view of determining
the relations which subsist between the albumen and other organic constitu-
ents of the blood. It was suggested by the apparently anomalous fact, that in
various conditions of the animal body — sometimes of confirmed disease, occa-
sionally of temporary derangement — one of the staminal principles of the blood
is eliminated in large quantity by the excreting organs ; and regarding these,
as I conceive we must, not only as depurants of the system, but likewise as
adjuvants of nutrition to the extent of removing from the body superfluous
alimentary matter, from whatever cause present, we are warranted in conclud-
ing that the state of the economy in which this occurs is one of repletion, or
over-supply as regards the principle eliminated and the actual requirements of
the body for that particular principle. It is well known that the " elements of
respiration" may be stored up in the body by a process of deposition in the
form of fat, to meet the urgent demand involving a large expenditure of these
elements, to which variations of external temperature and other circumstances
occasionally expose the animal. Not so, however, the plastic elements of nu-
trition : these are appropriated only as required for immediate use in the
renovation of the tissues, and if from any cause one happens to be in excess in
the blood, whether absolutely, as the immediate result of ingestion, or relatively
by loss of some of the allied constituents, then a process which may be conve-
niently designated elemental adjustment, is set up, by which the principle in
excess continues to be discharged from the system, till it attain the normal
proportion relatively to the other staminal elements.

Many facts may be adduced in proof of this self-adjusting property in the
blood. Kaupp asserts that the quantity of chloride of sodium excreted by the
kidneys is usually in proportion to that ingested ; but when, after prolonged
abstinence from this salt, a large quantity of it is taken, then the quantity ex-
creted in the urine is less than that ingested. Andral says that the first effect
of hemorrhage on the constitution of the blood is manifested in a decrease of
the corpuscles only, but if it be prolonged or repeated, the albumen and fibrin
are found to have undergone a corresponding diminution, whilst, according to

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Becquerel and Rodier, the equilibrium is not restored through the blood drawn,
in which the corpuscles and albumen observe a regular and equal ratio of de-
crease with each subsequent bleeding. Andral further states that some females
suffer during pregnancy a loss of corpuscles to the amount of twenty-seven
parts in a thousand of the blood, and become ansemic ; we know that it is in
such cases more especially albumen is found in the urine of pregnancy. An
absolute or relative decrease of the fibrin, as in scurvy and plethora, will give
rise to hemorrhage, by which, in the words of Andral, " the equilibrium is
spontaneously established between the fibrin and globules." Becquerel and
Rodier analyzed the blood in fifteen cases of Bright's disease, and found a
mean of 117.28 parts of corpuscles and 60.58 of albumen in a thousand ; the
decrease of albumen was greater in proportion to the length of time that had
elapsed from the commencement of the disease. This has an obvious relation
to the progressive diminution in the quantity of blood corpuscles, as evinced
by the increasing pallor of the patient. In thirteen cases of chronic Bright's
disease, in which the blood was analyzed by the same pathologists, it yielded
a mean of 108.8 parts of globules and 55.93 of albumen per thousand, whilst
the fibrin increased to a mean of 4.37. The blood occasionally found in the
urine in these advanced cases exhibits a marked alteration in the physical
character of its corpuscles, which are serrated or broken up into a detritus.

In order to determine the value to be attached to the views here enunciated,
I performed some experiments, the result of which I beg to offer to the Asso-
ciation. The experimental portion of the inquiry had a threefold object: 1st.
To determine the effect produced on the composition of the urine by inducing
a relative or absolute increase of albumen in the blood. 2d. The action of urea
on the blood-corpuscles as exhibited by the microscope ; and 3d. The propor-
tion of albumen contained in the serous effusion of renal and cardiac dropsy
respectively.

The first-mentioned object I thought would be best accomplished by abstract-
ing blood from living animals, the quantity to be such as to make a decided
impression on the system, and determined by the absolute weight of the ani-
mal's body. It is obvious that the effect of a first bleeding of this kind on the
constitution of the blood remaining in the body would be a decrease in the
proportion of corpuscles, and a relative increase of the albumen. An absolute
increase of albumen might be induced by bleeding an animal to a small
amount, and then injecting into the vein an equal quantity of a solution of
albumen, having the temperature and specific gravity of the serum of the blood.
The contrivance adopted for collecting the urine was a wire-crib, placed on a
concave zinc table, having an aperture conducting into a receiver fixed be-
neath ; in this the animal was imprisoned till a sufficient quantity of urine was
obtained for analysis, when it was liberated in order to take exercise till the
next experiment. A rabbit, weighing 3J lbs. was fed on cabbage, milk, and
water ; the urine passed next day was feebly alkaline, specific gravity 1.020,
and free of albumen. The animal was then bled to six drachms, and fed on
fresh grass and warm milk. The urine examined the following day presented
the same reaction and specific gravity as at first, but became distinctly opa-
lescent on the application of heat and nitric acid. A dog of 18 lbs. weight
was fed on milk and oatmeal stirabout ; urine neutral ; specific gravity 1.020 ;
contained no albumen. The animal was bled to eight ounces, on the 18th
August ; on 19th the urine collected during the previous night was examined
and found neutral, specific gravity 1.030, contained traces of albumen. Ex-
amined again on 20th, the urine was found alkaline — its specific gravity had
fallen to 1.020, but still a trace of albumen. August 21st, specific gravity
1.022 ; albumen as on yesterday. The quantity of blood taken in these two
experiments was determined by the estimate of Welker, according to which the
total quantity in the body of an animal is equal to one-thirteenth of its weight.

With reference to the detection of albumen in fluids containing only a mi-
nute trace of this principle, the aid afforded by the microscope deserves to be
noticed : if a drop of the suspected liquid, the opalescence of which is barely
discernible under the ordinary tests, be placed on a slip of glass under the
microscope, and a drop of nitric acid added, a cloud of minute vesicles will be

1858.]

Organic Chemistry,

499

observed to pass slowly over the field of view, and if the line of advance of this
cloud be accurately marked, the suddenness with which the constituent vesi-
cles start into view from an apparently structureless fluid, cannot fail to strike
the observer. These minute bodies present a highly refractive margin with a
light centre, and an average diameter of l-10000th part of an inch.

A young dog, weighing 12 lbs. 7 oz. was next subjected to experiment; the
urine collected before operating was free of albumen and alkaline ; specific
gravity 1.005 ; blood was now drawn from the jugular vein to the amount of 5
oz., and into the aperture in the vessel was injected half an ounce of fresh
dilute ov-albumen having the temperature and density of blood serum ; bread
and warm milk were given as food and ravenously eaten. The following day
it was found that no urine had been passed in the interim. August 27th, 4
oz. of urine were collected, neutral in reaction ; of specific gravity 1.030, and
highly albuminous, being almost gelatinized by heat and nitric acid. The
albumen was coagulated and collected by filtration, next dried, pulverized, and
deprived of impurities, by ether and boiling water, subsequently dried and
incinerated ; the total quantity of pure albumen thus obtained was nine grains.
In order to determine what proportion of this was due to the ov-albumen in-
jected, and what, if any, to the ser-albumen discharged in consequence of the
loss of blood sustained by the animal, I endeavoured to ascertain the amount
of pure dried albumen yielded by half an ounce of the white of egg, and found
it to be 72J grains. I had expected, and probably would have found, had the
operative part of the experiment been in all respects successful, a balance in
favour of the albumen excreted with the urine, as compared with the quantity
contained in half an ounce of the white of egg; but unfortunately at the mo-
ment when the last portion of albumen was injected, and before a ligature
could be applied to the open vessel, the dog struggled violently and caused a
fresh loss of blood, with probably a more than proportionate loss of the albu-
men injected, as the bleeding occurred chiefly by regurgitation from the heart.
Five ounces of urine were obtained from this dog on the 28th August ; specific
gravity 1.010; feebly acid, but no trace of albumen.

With reference to the next subject of inquiry indicated at the outset, namely,
the visible effect of a strong solution of urea on the blood corpuscles, the result
of my experiments was not as decisive as I had expected, yet it was sufficient
to show that when exposed for a few hours to the influence of this agent in a
concentrated form, the corpuscles undergo a considerable modification. They
are much diminished in number, and those which have not disappeared are
become tumid and spherical ; the action, however, is by no means energetic.

The proportion of albumen contained in the different dropsical effusions next
engaged my attention. I had reasoned thus, a 'priori. If albuminuria be the
result of an effort of the blood to restore the equilibrium between its corpuscles
and albumen, by ridding itself of a portion of the latter ; if anasarca be a con-
comitant symptom of the same disease, and produced by the same cause, then
we may not unreasonably expect to find an excess of albumen in the serum
effused. In order to determine this point, it became necessary to institute a
comparison between the fluids of cardiac and renal dropsy. I have been so
fortunate as to obtain a sufficient quantity for examination from two patients
affected with chronic Bright' s disease, but failed in the short time allowed me
to procure any from a case of cardiac dropsy.

This is the less to be regretted, since Andral's data are amply sufficient for
our own purpose with reference to the latter disease, although as regards the
former he has not supplied us with any information bearing on the point now
under discussion, Andral analyzed' the serous effusion in sixteen cases of car-
diac dropsy, and found a proportion of albumen ranging between four and
forty-eight parts in a thousand. The facts elicited by myself from the two
analyses I have made, do not, I am bound to say, support the hypothesis with
which I started, namely, that the percentage of albumen would be found higher
in the fluid of renal than in that of cardiac dropsy. In the first case examined,
the proportion was twelve, and in the second twenty-four parts in a thousand.

500

Progress of the Medical Sciences.

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It will be observed that the higher of these two numbers stands midway be-
tween the minimum and maximum of Andral.

I now venture to submit, in the form of propositions, the inferences which I
think may be drawn with at least the force of probability from the preceding
data. The inherent property of quantitative adjustment in the blood, probably
has reference mainly to nutrition, which would appear to require as an essen-
tial condition for its healthy exercise, certain fixed mutual proportions between
the constituent elements of the blood, but in part also to the maintenance of
the normal relative density between its serum and corpuscles. The appearance
of albumen in the urine is either transitory or persistent ; when transitory it
is produced either by an error of excess in the use of protein substances of
which the blood seeks to relieve itself through the kidneys, or by a state of
congestion of these organs in which the blood serum transudes through the
walls of the renal capillaries and is discharged with the urine. When per-
sistent it is probably always the result of loss or solution of the blood cor-
puscles, and produced by an inherent self-regulating property in the blood, by
which the normal proportion between its constituent elements is sought to be
re-established. In acute renal dropsy, the point de departin the blood changes
would appear to be loss of albumen ; but in the chronic form of the disease,
attended with uraemia, the starting point probably is solution of the corpuscles.
The loss of albumen experienced by the blood in Bright's disease, would ap-
pear to be inversely proportioned to the degree in which it appears in the
urine, and it may be in the dropsical effusion likewise. The quantity of fibrin
in the blood is regulated in great part by that of the corpuscles, not by adjust-
ment, but in virtue of the causal relation subsisting between the disintegration
of the one and the formation of the other. Diminution, therefore, of the quan-
tity of globules in the blood will not necessarily cause elimination of the fibrin,
because it involves diminished production of the latter ; but the converse of
the proposition will not hold, as diminished proportion of fibrin, by whatever
cause produced, may give rise to elimination of the blood corpuscles in the
form of hemorrhage. — Dublin Hosp. Gaz., Oct. 15, 1857.

8. On the Chemical Changes in the Air during Respiration. — Dr. IIarley has
published (Virchow's Archiv.), some experiments which he made under the
supervision of Bunsen, at Heidelberg, on the interchanges between the blood
and its various constituents and atmospheric air. He found that blood which
has been repeatedly shaken with successive portions of air, till it had appa-
rently given up all its carbonic acid, and become saturated with oxygen, when
left for twenty-four hours in an hermetically sealed vessel, with an equal vo-
lume of air, and frequently shaken, underwent a further change of the same
character. In one case, the air lost 10.54 per cent, of oxygen, and gained 5.05
of carbonic acid. In another, the loss of oxygen was 9.63 per cent., and the
gain of carbonic acid 5.96. In both experiments, the ratio of the oxygen lost
to the carbonic acid gained is greater than is accounted for by the usual law
of interchange during respiration, which inclines the author to the belief that
part of the oxygen is used for the formation of water. He confirms Scherer's
observation that fibrin has the power of absorbing oxygen, and giving off car-
bonic acid; and shows that albumen possesses the same property, but in a
minor degree. The interchange of gases was, of course, always much greater
when the coagulum was employed, than with serum only, a result which agrees
with some of Brown-Sequard's observations, presently to be noticed, on the
relative capabilities of blood and serum for absorbing oxygen. The power of
hsematin to absorb oxygen and give out carbonic acid is very great, a power
which Dr. Harvey thinks is common to all colouring materials, both in the ani-
mal and vegetable world. — Hornidge's Report on Anat. and Physiol., in Midland
Quarterly Journ. Med. Sci., Jan. 1858.

1858.]

Materia Medica and Pharmacy.

501

MATERIA MEDICA AND PHARMACY.

9. Influence of Liquor Potasses and other Alkalies on the Therapeutic Proper-
ties of Henbane, Belladonna, and Stramonium. — Dr. A. B. Garrod read an in-
teresting and important paper on this subject before the Royal Medical and
Chirurgical Society (Nov. 24, 1857). He first alluded to the frequent exhibi-
tion of henbane with liquor potasste, and brought forward many proofs that
such combinations were often administered. He also stated that the like
mixtures were recommended by both medical and surgical authors. Dr. Gar-
rod then proceeded to detail experiments, which demonstrated beyond doubt
that the active principle of henbane was destroyed by liquor potasste and
other caustic alkalies ; and that such a combination was inert, both when
topically applied (as evidenced by the absence of power in causing dilatation
of the pupil of the eye), and also when internally administered. Similar ob-
servations were next detailed upon the preparations of stramonium and bella-
donna, and the results were found to be the same. It was, however, shown
that the carbonates and bicarbonates of the alkalies were devoid of the property
of destroying the activity of the plants. In some of Dr. Garrod's experiments
as much as a drachm of the extract of henbane and an ounce and a half of the
tincture were administered in combination with potash without the production
of the slightest symptom.

The results arrived at in the communication may be thus summed up: —
1st. Caustic alkalies, such as exist in liquor potassae or liquor sodas, entirely
destroy the activity of henbane, preventing its action on the pupil when topi-
cally applied, and its influence upon the system when internally administered ;
and, combined with a proper amount of these alkalies, the largest doses of the
preparations of henbane may be given without the production of any symp-
toms.

2d. The same influence is exerted by the fixed caustic alkalies upon bella-
donna and stramonium.

3d. The carbonates and bicarbonates of potash and soda produce no injurious
effects upon the preparations of any of the three above named plants.

The deductions naturally to be drawn from these results are : —

a. That neither liquor potassag nor any caustic fixed alkali should be pre-
scribed with tincture or extract of henbane, as the virtues of the latter drug
are thereby completely neutralized.

b. That when it is desirable to administer an alkaline remedy with henbane,
either a carbonate or bicarbonate should be selected, which would probably be
equally efficacious upon the stomach, if such influence be required, and cer-
tainly as efficient in altering the condition of the urine, and the mucous mem-
brane of the urinary passages.

c. That the same precautions should be observed with regard to belladonna
and stramonium, if at any time prescribed in conjunction with alkalies.

To a question whether the caustic alkalies were an antidote to the poisons
under discussion, Dr. Garrod stated that he did not think caustic alkali could
"be introduced as an antidote, because it would require alkali of such a power-
ful character, or in such large quantities, that it would be injurious to the
coats of the stomach. He had no doubt that the destructive action of the
alkali commenced at the moment it was mixed, but in order to effect complete
neutralization a larger quantity would be required than it would be safe to
administer. He could, however, communicate to the society an antidote for
henbane, belladonna, or stramonium, which was perfectly efficacious. It had
been used on his own person a year and a half ago. It was animal charcoal.
If we took a solution of any of these poisons, and added but a small amount
of animal charcoal, the effect on the system was entirely destroyed. It
required only a few grains of animal charcoal to destroy complete^, or rather
neutralize and render of no avail, belladonna. The same applied in a greater
degree to stramonium and henbane, which were weaker than belladonna.
About a year and a half ago, he took by accident twelve grains of the dried
No. LXX.— April 1858. 33

502

Progress of the Medical Sciences.

[April

leaf of the belladonna, and a gentleman, a patient of his, took about a quarter
of an ounce of dried belladonna. To both of them animal charcoal was ad-
ministered, although almost too late. Both of them recovered; the gentleman
who took the quarter of an ounce, completely. He was perfectly certain that
if animal charcoal could be administered when these vegetable poisons had
been taken, it would prove completely efficacious. Of course, it was necessary
that the antidote should be administered before the poison was absorbed into
the system. If it had passed out of the stomach into the system, of course no
antidote would have any effect. He could detail an experiment which he had
tried more than once. He had given a dog a dose of aconite, and he had given
to a second dog thirty or forty times that dose, combined, however, with a
small amount of animal charcoal. The first dog died, but the dog to which
the animal charcoal was administered experienced no ill effects. He was per-
fectly convinced that animal charcoal was the most powerful antidote, better
than any of the alkalies, because, in the first place, the alkalies required time,
and, in the second place, they had to be given in large quantities, and, of
course, would be liable to injure the mucous membrane of the stomach and the
intestines. It was not necessary to have purified animal charcoal ; common
bone black would be sufficient. — Med. Times and Gaz., Dec. 5, 1857.

In a very recent journal {Lancet, Feb. 27th, 1858), Mr. John F. France re-
lates some experiments, the results of which are entirely at variance with those
of Dr. Garrod.

Mr. France mixed liquor potassge with belladonna, and also with hyoscy-
amus, in various proportions, and found their combination, when applied to
the eye, always produced dilatation of the pupil. If the peculiar influence of
belladonna and hyoscyamus on the iris, be adopted as the criterion of their the-
rapeutical activity, that activity — Mr. France says — remains unimpaired by
their admixture with liquor potassse.

The subject is well worthy of further investigation.

10. Experiment on Colchicine, and the Comparative Action of tlie Dry Bidbs
and the Seeds of Colchicum. By Professor Schroff, of Vienna. — The colchicine
employed was a light powder of crystalline appearance, of a clear yellow
colour, of a very bitter taste, afterwards grating to the throat. It was not
altogether pure, for then the substance is colourless and crystallizes in needles.
It is soluble in water, alcohol, and ether; the watery solution has a feeble
alkaline reaction. In order to study the taste of this substance, M. Heinrich
took ytjoth of a grain of colchicine, and soon after he experienced eructations
and great nausea, with augmentation of the saliva. The nausea lasted some
hours, even after supper, which was taken without appetite. The pulse fell
gradually eleven pulsations in the first two hours. Eight hours afterwards
the same observer took T§oths, enveloped in a wafer ; it was then half past
four o'clock in the afternoon. The pulse was not changed in the first two
hours. Until eight o'clock in the evening, nothing was evinced except eructa-
tions and slight ptyalism; supper was taken without appetite. After ten
o'clock there was broken sleep, from which M. Heinrich was awoke at half-past
one by painful dreams ; he had desire to go to stool, but he had scarcely left
his bed when the nausea increased, bringing on a fit of vomiting for two
minutes ; at the same time there was a very soft and copious stool, accom-
panied with violent griping. This painful scene was renewed three times at
short intervals. The first matters vomited consisted of the undigested dinner
and supper, then there was a greenish-yellow and bitter liquid. About three
o'clock he again went to bed, and slept till six o'clock, when fresh and abund-
ant vomiting and painful alvine evacuations of a mucilaginous greenish-yellow
liquid supervened. The vomiting ceased from that time, but eructations,
nausea, and total absence of appetite lasted for four days. Thus, the first day
after the experiment, M. Heinrich took nothing but cold water, and the three
other days, only a little soup. The abdomen was tympanitic, sensitive, and
gurgling. The second day there were two stools, on the third, one, and on the
fourth, three, accompanied with griping, and containing, particularly on the
second and third day, numerous rlocculi, similar to coagulated white of egg.

1858.]

Materia Medica and Pharmacy.

503

The weakness, already considerable on the first day in consequence of the
abundant evacuations, increased at the time of the appearance of febrile phe-
nomena ; M. Heinrich was obliged to keep his bed the first day, and could not
leave it without difficulty on the three following days. The fever commenced
towards the middle of the first day, with shivering, followed by great heat,
lasting for several hours, with thirst, very much accelerated pulse, cerebral dis-
tress, agitation, and want of sleep. The sensibility of the abdomen disappeared
only on the fourth day. The quantity of urine could not be determined, in
consequence of the frequency of the stools ; this liquid was thick, and had an
abundant white deposit.

Colchicine acts like acrid substances in general, and only after being ab-
sorbed. The stomach and intestinal canal are the parts on which it especially
acts ; the brain and the spinal cord remain altogether unaffected, or rather
experience only secondarily some vague functional disturbances which are not
constant. Death results probably from paralysis of the heart. The blood does
not coagulate; it thickens, becomes black and pitchy, such as is found in the
most violent cases of cholera ; it accumulates in great quantity in the right
cavities of the heart, very little in the left auricle. It is not possible to know
if the colchicine passes into the blood and urine unchanged, or whether it
undergoes modifications. — B. and F. Med.- Chirurg. Rev., Jan. 1858, from U Union
Med., June 9, 1857.

11. Emmenagogue Action of Achillea Millefolium. — Dr. Ronzier- Joly feels con-
vinced that the Achillea millefolium has a decided power in promoting the
uterine functions, and records two cases in support of this opinion. In the
first case, the patient, who was nineteen years of age, was attacked with a
slight sore throat, and in the course of the complaint the menses appeared, but
so scantily that only a few drops of blood were passed, and the period ceased
the same day. As the sore throat became worse in spite of treatment, it was
thought that the appearance of the menses might be attended with a radical
cure, and the millefolium was administered. The menses returned in abund-
ance, and lasted two days. In the other case, a woman was delivered of an
infant, and was going on well for two days, but on the third she was seized
with fever and delirium, and the lochia were suppressed. Sulphate of quinine
was administered in the intervals of the fever, and as the lochia did not reap-
pear, in spite of revulsions to the lower limbs, the millefolium was administered
as well as the quinine. The lochia reappeared the next morning, and nothing
unfavourable afterwards occurred. — B. and F. Med.- Chirurg. Rev., Jan., 1858,
from Bull. Gen., June 30, 1857.

12. Defects of Ordinary Escharotics with Suggestions for their Improvement. —
Mr. Ellis read before the Western Med. and Surg. Soc. of London, Dec. 4r
1817, some notes on this subject. After giving a definition and general history
of escharotics, the author made some observations upon the mode in which they
affected the tissues, either by destroying their continuity, organization, and life,
by combining with them, or by a mutual decomposition forming new compounds.
He then remarked upon the various chemical effects of acids, alkalies, and
metallic salts ; the first acting as oxidizing agents, the alkalies forming com-
pounds with albumen and fibrine, and the metallic salts uniting with albumen
to form metallic albuminates. Enumerating the acids in general use as escha-
rotics, nitric, hydrochloric, and sulphuric, he gave the preference to nitric acid,
but stated that he had found a difficulty in procuring it of sufficient strength,
and of a sp. gr. of 1.50 ; he thought its utility much impaired by its fuming
property and intense rapidity of action; also from the sore made by it being
very superficial and its effects not being permanent. Hydrochloric acid he
considered should have a sp. gr. of 1.21, but it was feebler than nitric acid.
Sulphuric acid he stated was weaker than nitric, but stronger than hydrochloric
acid; it had its advantages in not fuming; for obvious reasons it should be ap-
plied by means of asbestos. The author then gave his experience of the alka-
line escharotics, hydrate of potassa, and potassa c. calce, the former of which,
he said, although strong and quick in action, was defective from its deliques-

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[April

cence, its liability to spread, and its friability; the latter, although compara-
tively free from the above objection, was sometimes followed by hemorrhage.
As Mr. Ellis was chiefly alluding to the use of the above escharotics to the os
and cervix uteri, he had found in the friability of potassa c. calce a great defect,
also that great contraction of the canal of the cervix followed its application.
Of the metallic salts he observes that nitrate of silver was extremely valuable
as a mild escharotic, and that its effects were quite superficial. As usually
sold he had found it much adulterated, which greatly depreciated its value ; he
recommended the crystallized salt to be used instead, and melted into sticks
when required.

Another defect he had found in its brittleness, which rendered it dangerous
when applied to a part like the inner surface of the cervix uteri. To obviate
this evil he has been in the habit of melting the caustic in a small bullet-mould
having a core; this gives him a small globe, with a hole running through it,
which, by means of a pin, is easily fixed to the holder.

Chloride of zinc he showed to be an extremely powerful and valuable agent;
that it acted quickly and deeply. He uses it mixed with flour, and made into
a paste with water.

Deliquescence and giving great pain were its principal defects.

Having made a few observations upon the actual cautery, he concluded by
exhibiting the implements he used in applying the various escharotics he had
just mentioned, and the mechanical contrivances for melting the nitrate of silver,
and attaching it to the holder. — Med. Times and Gaz., Jan. 9, 1858.

13. Sidphuric Acid and Sulphate of Zinc as a Caustic Agent. — There is an
important chemical principle involved in the application of sulphuric acid for
the destruction of living tissues, which is that the acid mainly acts upon
•organized matters, by its powerful tendency to combine with the elements of
water contained in them, so that the carbon is left free, forming the black
charcoal-like mass with which we are familiar as the result of its action upon
^,11 such tissues. Now, the more concentrated is the acid, in its liquid form,
the greater is its power to decompose animal or vegetable tissues by abstracting
the elements of water. It is desirable, therefore, in adding material to the
acid for the purpose of giving it the form of paste, that the substance employed
-should not be an organized matter capable of furnishing water to the acid,
and so weakening its caustic power, but a substance which should add fresh
caustic power, so as to produce a combination possessing the greatest possible
degree of caustic force. The dried sulphate of zinc suggested itself to Mr.
Henry Thompson as such a material ; and upon trial it has fully answered his
expectations. He prepares it as follows : —

"The ordinary sulphate of zinc is to be dried in an oven or sand-bath, so
that the water of crystallization is driven off, and a whitish powder remains.
Enough of this is to be added to some strong sulphuric acid, in order to make
a semi-fluid mass of consistence sufficient to prevent its running beyond the
spot on which it is placed. The mixture should be kept in a stoppered bottle,
and be applied with a small glass spatula or rod. Before using it, the sur-
rounding parts should be protected by a thick layer of cerate or firm ointment,
so as to form an embankment limiting the surface to be destroyed, and a layer
of the caustic may be made upon this of about the eighth or tenth of an inch
in thickness. This is allowed to remain. As in the case of other caustics,. I
believe, the pain is less in the superficial than in the deeper diseased tissues. ,;

One advantage of this combination consists in the ease with which it is pre-
pared, and the facility with which its constituents may be obtained. — Lancet,
Jan. 9, 1858.

14. Administration of Cod-liver Oil, and Substances soluble in it, in Capsules.
— Many patients object to taking cod-liver oil in consequence of its unpleasant
flavour. It occurred to Mr. T. Spencer Wells that this objection might be ob-
viated by inclosing the oil in membrane capsules. This has been done by
Messrs. Evans and Lescher, and Mr. Wells is now in the habit of prescribing
these capsules containing cod-liver oil only, or holding in solution quinia, the

1858.]

Materia Medica and Pharmacy.

505

iodide of iron, and the biniodide of mercury. "Each capsule," Mr. Wells
states, " contains twenty minims of the oil, and the dose of the quinia, or
iodide, may be varied. Patients who object very much to the oil think nothing
of taking three, or even half a dozen, capsules three times a day.

"The combination of biniodide of mercury with cod-liver oil is particularly
useful in some of the chronic syphilitic superficial diseases of the skin and
mucous membranes. A tenth or twelfth of a grain with a drachm of the oil
in three capsules, three times a day, I have found to answer admirably in cases
of chronic pityriasis and psoriasis, with superficial ulceration of the fauces.
In some of the chronic joint affections of scrofulous subjects, the iodide of iron,
given in the same way, but in larger doses, is also very efficacious. When it
is desired to give iron in the oil without iodine, and to give larger quantities,
the wafer paper, so much used for taking the cubeb and copaiba paste, answers
extremely well. A paste may be made of the sesquioxide of iron— the so-called
carbonate — by mixing up with it a sufficient quantity of the oil. A teaspoon-
ful of this paste, enveloped in wetted wafer paper, is swallowed without the
least difficulty or unpleasantness by any one who can take a pill.

" In many cases of secondary syphilis in persons of broken down constitution,
it is desirable to combine the iodides of mercury and iron. In this combina-
tion, the iodide of mercury becomes soluble, and it may be given either in the
oil in capsules or in the form of a very elegant syrup, which Mr. Bastick pre-
pares. In prescribing this, however, the ordinary dose of the iodide of mer-
cury must be considerably lowered, as the action becomes much more powerful
when the salt is made soluble. The syrup is prepared of various strengths ;
but in the proportion of a quarter of a grain of the iodide of mercury to two
grains of the iodide of iron in a drachm of the syrup, it will be found extremely
useful, and not very disagreeable." — Med. Times and Gaz., Dec. 5, 1857.

15. Preparation of Iodide of Calomel. — The chemical compound called iodide
of calomel, discovered in 1847, by M. Boutigny, was prepared by mixing pro-
tochloride of mercury and iodine in the relation of one equivalent of iodine
and two equivalents of the protochloride, and it consists of a mixture of calomel
with biniodide and bichloride of mercury. It is consequently less active than
the two latter salts, but more active than the protiodide and the protochloride,
and is very much celebrated in the treatment of certain affections of the skin,
particularly in acne rosacea. M. Gobley endeavours to render the process of
M. Boutigny more practical and more easy of application. He takes iodine
reduced to powder in a mortar, and mixes it with calomel, and then introduces
the mixture into a small glass retort. This is then placed upon a sand-bath,
and some moments afterwards the mass is seen to assume at first a greenish
tint, and then enter into fusion. The retort is withdrawn, and the mass soon
solidifies ; it is at first greenish, then in the air it becomes gradually red, and
at last it remains so. The iodide of calomel is employed in pills and as a
pommade ; the former are prepared by mixing it together with gum arabic,
crumb of bread, and orange-flower water; the latter is made by mixing it in
powder with lard.

M. Bouchard at has lately announced that there are two iodides of calomel —
one which may be called a protiodide, and the other a biniodide ; and M. Per-
rens has proposed to prepare the two iodides, differing from one another not
only in their physico-chemical character, but also very probably in their thera-
peutical action. They are prepared in the same manner, except that one com-
pound is formed with half the quantity of calomel which is employed for the
other. — B. and F. Med.-Chirurg. Rev., Jan., 1858, from Bull. Gen. de Therap.,
Sept. 15, 1857.

16. Lotion for Strumous Glands. — The following application neither stains
the neck, nor annoys by its smell, while it acts with greater energy than the
ordinary iodine ointments: Dissolve of iod. pot. in aq. dest. and eau de
Cologne, aa gj, and spt. vini r. gvj. It is to be employed in frictions morning
and evening. — Med. Times and Gaz., Jan. 16, from Omodei's Annali Univ.,
vol. clxii.

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17. Cocoa-nut Oil Ointments. — The cocoa-nut oil is a more eligible body for
the formation of ointments than lard, keeping much better, not staining the
linen, and admitting of more complete absorption. To render the oil of com-
merce fit for pharmaceutical employment, it is in general sufficient to liquefy
it at a moderate temperature, and strain it through linen. But if it retains its
peculiar odour too strongly, and is of too yellow a colour, it may be purified
by digesting it for some hours in a water-bath, with some coarsely powdered
vegetable charcoal, and filtering it while warm through paper. The following
are some of the formulae that have been tried with success: R. — Iod. pot. ;
ol. cocos 3J. R. — Ext. bellad. 9j ; ol. coc. giij. R. — Veratrini gr. iij ; ol.
coc. giij. R. — Sulph. quin. 7)j ; ol. coc. ; ol. rosar. gtt. x (very useful
in pityriasis capitis). R. — Chlorof., ol. coc, aa §j (of great service in neural-
gic and rheumatic pains, rendering the chloroform more fixed, and its action
more durable). R.— 01. terebinth., ol. coc, aa R. — Hydr. ox. rub. gr.
iv.; ol. coc gij. — Ibid.

18. Proposed Substitute for Oils and Fats in Ointments. — The application of
cerates and ointments to diseased and tender surfaces is attended with certain
inconveniences, among which may be mentioned their insolubility in water,
and consequently the difficulty of removing them; their liability to become
rancid, and the insolubility of most of the remedies in fat.

Mr. Startin, some ten or twelve years ago, introduced a combination of gly-
cerine with amylaceous substances, as a basis of ointments.

Very recently (Jan. 6, 1858), G. F. Schacht, in a communication to the Phar-
maceutical Society (London), proposed as a substitute for these ointments, a
mixture of glycerine and starch. The proportions which have given him the
most favourable results are glycerine, f§j ; starch powder, 70 grs. The entire
process consists in mixing the ingredients cold, and heating the mixture gra-
dually to about 240° Fahr., constantly stirring.

This constitutes a basis, with which may be produced preparations corre-
sponding to most of the cerates and ointments of the Pharmacopoeia.

Mr. Schacht has adopted for this preparation the name of plasma; a better
name is glyceramyl, or, which has been proposed, glysamyl (from glycerine and
amyline).

We have employed this preparation in a few instances, and thus far with
very satisfactory results.

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

19. Treatment of Diabetes by Sugar. — Two years ago Andral reported a case
of saccharine diabetes, in which the general condition of the patient did not
improve, and the quantity of sugar increased during total exclusion from the
diet of all saccharine elements. The addition of these elements to her food
was followed by a diminution in the amount of sugar excreted. This altera-
tion, however, was temporary only; and at the end of three weeks from the
adoption of this plan, the urine contained 54 grammes to the pint, its acme
before having been only 49. Andral further states that this is not a solitary
case. Piorry more lately has noticed the inefficacy of an unmixed diet, and
lias recommended that the patient should be supplied with sugar candy in large
quantity.

Dr. Budd has tried the plan in the case of a diabetic man, who, "within a
few days after his admission, was put on a diet consisting entirely of meat,
eggs, carefully prepared diabetic bread, a small quantity of butter, and a few
ounces of wine. Under this regimen, contrary to what usually happens, the
diabetic symptoms began to grow worse almost from the first. " During the
first week after his admission, the quantity of urine varied from 9 to 12J pints

1858.]

Medical Pathology and Therapeutics.

507

its specific gravity from 1039 — 42. "The quantity of urine rose in the course
of a week from 9 to 17 pints, its specific gravity remaining much the same.
The patient's thirst increased, and he became daily thinner and weaker. At
the end of that time, an attack of diarrhoea occurred, which lasted, with more
or less severity, very nearly ten days. During that interval he took very little
food, and the precise amount of urine passed could not be estimated. When
the bowels had become settled, he was found to be voiding from 7 to 10 pints
of urine per diem, of specific gravity ranging from 1036 to 1044. On March
31st (twelve days after admission), the stomach rebelled so much against the
diabetic bread, that six ounces of common bread were allowed in place of it;
and these six were soon after raised to sixteen. His health now began to im-
prove somewhat, and he gained a little in flesh and strength. The diabetic
symptoms proper remained much as before.

" This improvement, however, was not of long continuance. In the begin-
ning of May, he had become so weak as to be obliged to keep his bed. His
tongue was very dry and brown, his pulse had become frequent, and he was
much harassed by cough and pain in the chest. " He seemed to be sinking.
On the 22d of May, Dr. Budd reversed his "plan of treatment, and ordered the
patient to be put on a varied and generous diet, with the addition of eight
ounces of sugar candy, and four ounces of treacle daily. This change had very
little effect at first, either on the quantity of urine passed, or on its specific
gravity. It is worthy of remark, however, that what little there was, was in
both respects on the side of diminution. The effect on the general health was
marked and immediate. * * * As he became stronger, the diabetic symp-
toms also gradually lessened — to such a point, indeed, that on the 22d of July,
exactly two months after the adoption of the new scheme, only three pints of
urine, of specific gravity 1032, were passed in the twenty-four hours ; and yet
at this very time the patient was taking, in addition to much vegetable food, as
much as eight ounces of sugar and six of honey daily — the honey having been sub-
stituted, at his own desire, for the treacle previously given. Since that time, the
quantity of urine passed has somewhat risen, its present daily average being
from four to five pints, of specific gravity varying from 1032 — 34. In other re-
spects, his state is very satisfactory. He is ruddy, looks in very good condition,
and declares himself to be strong and well. His tongue is moist; he no longer
suffers from thirst: and his skin, from being dry and harsh in the extreme, has
become soft and natural. He has increased in weight from 107 lbs., which was
what he weighed shortly before beginning the sugar treatment to 126J lbs."
"That a diabetic man should not only recover his health by eating sugar, but
that his diabetic symptoms should also very nearly vanish under the same
treatment, is a fact that stands in startling antagonism to all present views, as
well as to all prior experience on the subject."

Dr. Thomas Williams, Physician to the Swansea Infirmary, has made trial
of this plan of treatment in two cases.

Before the experiment, Dr. W. states {British Med. Journ., Dec. 19th, 1857)
that both patients had rigorously adhered to a non-saccharine dietary ; that in
Case A, the urine had scarcely ever, for six months previously, varied from 1040
in specific gravity, and three pints in quantity, in the twenty-four hours ; that
in Case B the conditions were very nearly the same, although not quite so un-
fluctuating.

In twenty-four hours after the change of diet in Case A, the urine increased
from three pints to four pints and a half, and from 1040 in specific gravity to
1042. In forty-eight hours, under the same diet, the quantity rose to five pints
and some ounces, and' the specific gravity to 1050. In another twenty-four
hours, being the third day from the commencement of the experiment, the vo-
lume rose to six pints, and the specific gravity to 1056.

Case B exhibited almost precisely the same change. The urine increased in
quantity and density, in the same time in an equally remarkable degree.

Neither of the patients could be prevailed upon to continue the experiments
any longer. Both grew rapidly worse in every respect, and became greatly
alarmed. The thirst grew more and more unquenchable. The skin became

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Progress of the Medical Sciences.

[April

drier and drier ; the bowels were every day more constipated ; the mind passed
from a calm state into a condition of rapidly increasing excitement, in one
bordering almost on mania. The symptoms in every sense exchanged the
passive for the active condition. Both patients regained their former tranquil
feelings by the use of opium for three or four nights ; and it was only slowly
that the urine returned to its former physical properties. These two gentlemen
emerged from this ordeal with the deeply-rooted convictions that the old sys-
tem was the best ; that practice is above and beyond theory; that the rule of
contrarieties is preferable to that resting its airy claims on fancied similitudes.

Dr. George Corfe, on the contrary, in a more recent communication {British
Med. Journ., Feb. 6th, 1858, relates a case in which he considers the sugar to
have been beneficial.

The subject of the case was a tradesman, 40 years of age, whose symptoms
had been creeping on him for five or six weeks. When seen by Dr. Corfe, Nov.
14th, 1857, his urine was loaded with sugar, and sp. gr. 1049.

He was immediately put upon the following treatment: R. — Creasoti IT^iv ;
mist. acac. gss ; aquae carui ^j. M. Fiat haustus ter in die sumendus.

In addition to the above, he was directed to take a tablespoonful of cod-liver
oil in milk after each meal. The usual diabetic diet, consisting of underdone
meat, greens, eggs, milk, and bran biscuits, was prescribed, with a total absti-
nence from saccharine, farinaceous, and amylaceous substances.

From this period to December 1st (two months) the patient became more or
less dispirited at the manifest downward course the disease was assuming.
The urine gradually increased in quantity, and the specific gravity ranged from
46 to 52, his vigour was fast waning, the disease assumed a most formidable
character, and threatened to cut short his life in a few weeks. By the aid of
polarized light, Professor Heisch ascertained that the urine at this period con-
tained 100.28 grains of sugar in 1000 parts, or less than two ounces in each
pint.

The weight of the patient at this stage was only 114 pounds, and as the symp-
toms were assuming every day a more dismal character, Dr. Corfe resolved on
changing the whole line of treatment as follows. The patient was now directed
to take zinci sulph. gr. ij ; cinchoninse sulph. gr. j ; extracti lupuli gr. ij, in form
of pill, with each meal, in lieu of the creasote mixture, and to continue the cod-
liver oil. He was desired to use the following articles of diet: fat mutton and beef,
and the same meats in form of soups ; fresh white fish boiled ; oysters, poultry,
game, tripe, and any one of the following vegetables, daily, parsnips, turnips,
carrots, spinach, greens, brocoli, endive, lettuce, celery, and to abstain from
bread and all farinaceous food, and potatoes. His drink was directed to con-
sist of a cup of coffee, with half an ounce of candy sugar, in the morning ; a
tablespoonful of rum in a glass of water, with the same quantity of sugar candy,
and five grains of carbonate of ammonia, at luncheon, and two glasses of claret
at dinner. In the evening, he was desired to take one ounce of honey on bread,
in lieu of butter, and to sup on boiled milk, with an egg, etc.

After having continued this line of treatment from Dec. 17th to the 30th, the
following results were obtained : the urine increased from four to eight pints in
twenty-four hours, the specific gravity was 1050; it gave proof of containing, by
polarized light, 112 grains in 1000 pints, or rather more than two ounces in
each pint, and yet he had not lost in weight more than one pound. It should
be here remarked, that he frankly acknowledged that he had not followed the
directions of treatment in so strict a manner as he could have wished; for, al-
though he felt stronger and more lively in mind, he had been to several festive
parties, and had eaten freely of potatoes and bread on several occasions, and
had drank beer, or bottled stout. But, after being reprimanded severely for
his indiscretion, he faithfully adhered to the prescribed form of dietary. The
pills were now increased one grain of each of the sulphates in strength, and
on the 17th January, the urine had a specific gravity of 1038, containing 83
grains in 1000 of sugar, that is, a diminution of more than a quarter of an
ounce in each pint of fluid, and for eight days prior to this report, the quan-
tity never exceeded four pints in twenty-four hours.

1858.]

Medical Pathology and Therapeutics.

509

Weight.

Urine.

Fluids taken.

lbs.

Pints.

Pints.

120

. 5

. 5

121

. 4|

124 .

. 3

. 3

\m .

. 3

132

at

. 3|

The patient gained flesh and strength. The following shows his progress :-

1858. Jan. 15
" 18
" 21

" 25
" 28

He can now attend to business comfortably ; he can walk four miles an hour
well. Perspired freely last night in bed, and exertion to-day induces a mois-
ture also.

The urine, Jan. 29th, was muddy, acid, sp. gr. 1032, and contained only 20
grs. per 1000 of sugar.

20. Bronzed Skin — Disease of the Supra-renal Capsules. — At a recent meet-
ing (Feb. 9th) of the Royal Medical and Chirurgical Society, a paper by Mr.
Hutchinson was read, entitled " Some Particulars of a Case of Marked Bronz-
ing of the Skin." The following brief abstract of this paper, and the report
of the discussion which followed, will be read with interest as exhibiting the
opinions of some of the prominent members of the profession in London, in
regard to this important, and, until lately, unnoticed disease.

The woman, whose malady formed the basis of Mr. Hutchinson's communi-
cation, was exhibited to the Fellows, and was declared by Dr. Addison to be a
good example of that peculiar condition, both of general health and discolora-
tion of skin, which he has found so frequently connected with disease of the
supra-renal capsules. Mr. Hutchinson's notes embraced the usual history of
these cases. He gave his reasons for arriving at the confident opinion that
this was a genuine example of diseased supra-renal capsules, as well as those
which induced him to conclude that both organs had probably been destroyed
as long as two years, and called attention to the two important points thus
illustrated — viz., the length of time during which life may be prolonged in the
human subject after destruction of those organs, and, consequently, the neces-
sity for caution in the attempt to deduce conclusions from experiments on the
lower animals.

Dr. Addison remarked, that in a matter somewhat novel, and so extremely
imperfect, it was natural that any one, although deeply interested in it, must
feel considerable reserve in speaking upon such slender testimony as at present
existed. If not irregular, he would refer briefly to a case of this kind, brought
before the Society a short time ago, as affording what he considered the most
perfect and unequivocal, and at the same time the most terrible illustration of
the disease to which the attention of the Society was directed. The case was
that of a young lady, only eighteen when she died, who was amiable, intelli-
gent, and accomplished, and till about two years before her death, during
which period she had been observed to lose health, and strength, and colour,
was apparently sound and healthy. When he went to Ashford to see her, he
was very much struck with her appearance; for a more terrible sight of disease
he never beheld. She was darkened, almost blackened, as if stricken by some
supernatural power; she was anaemiated, had a pulse like a thread, and so
feeble was the circulation that she could not sit upright without becoming
blind. He .could not, therefore, entertain a doubt about the case, and did not
hesitate to express his confidence respecting it. In no long time she died.
At the post-mortem examination there were present besides himself three
medical gentlemen, who had been struck during life by their inability to detect
a sign of disease in any organ. The body was not particularly emaciated ;
there was a fair supply of fat in the omentum and the region of the abdomen.
All the abdominal viscera were found perfectly healthy. The only vestige
of a disease was a small pediculated cyst, about the size' of the kernel of an
almond, attached to one of the broad ligaments, which he supposed could not
have much to do with the malady. A healthier chest he never saw ; there was
not the slightest adhesion even between the pleura ; the lungs collapsed, but

510

Progress of the Medical Sciences.

[April

were perfectly free from all deposit and trace of disease. The heart, as might
be expected, was feeble and flabby ; but there was no disease of the organ.
They then proceeded to examine the supra-renal capsules. Those capsules
were greatly enlarged, especially the left, and both of them were universally
converted into a bag of pus, which escaped in considerable quantity. Now,
suppose that the symptoms were not resulting from disease of the supra-renal
capsules, but from a diseased condition connected with some other lesion not
yet discovered, what were the chances of finding these organs diseased? The
chances were almost incalculable ; and they became much more strongly so
when it was remembered that there was no other organ in a diseased condition.
The conclusion, therefore, appeared to him inevitable, even if there were no
other cases on record, that the discoloration in this case did result from dis-
ease of those organs, and probably from disease of those organs alone. W e
knew, however, that these organs were situated in the direct vicinity, and in
contact with the solar plexus and the semilunar ganglia, and received from
them a large supply of nerves ; and who could tell what influence the contact
of these diseased organs might have on these great nervous centres, and what
share that secondary effect might have on the general health and in the pro-
duction of the symptoms presented? He did not know whether there had been
hitherto sufficient carefulness of examination to ascertain whether any positive
lesion existed in the tissue of the nervous structure ; certainly in the case to
which he had referred it had not been ascertained. There were, indeed, many
objections and difficulties raised upon the subject, and he had seen enough of
modified cases to justify many of them. Suppose, for instance, these organs
played an important part in the functions of the body, however slowly their
lesion might affect the general health or destroy it, it was not impossible to
suppose that they might be variously diseased, and in various degrees, and the
effects correspond with these various degrees of morbid condition. He could
very well understand that the organs might be even functionally diseased, and
there might be more or less of the discoloration, and the other symptoms that
had been described, without any organic lesion at all, as was the case with
other organs of the body. Some time ago a man called upon him with the
symptoms of the disease strongly marked ; but by good support, sending him
into the country, and giving him ammonia and other stimulants, he had shaken
off a great deal of the want of tone and energy he formerly manifested, and
considered himself, no doubt justly, very much better. He had also a woman
in Guy's Hospital, who had a psoas abscess in addition. That woman had
been very deeply discoloured, and her constitution appeared very powerfully
affected by one or the other, or by both ; but she had now more energy than
she had some time ago, and her colour was certainly less. From what he had
seen of the organic changes that take place he could understand why there
should be an arrest, very probably a complete and permanent arrest of the
disorder. We knew the depositions that took place into one or both of these
organs — more probably into both at the same time — and indicating a special
and peculiar tendency of the organs when affected ; some would call these
deposits scrofulous, some malignant ; we knew also the natural course these
depositions underwent, softening and being converted into a puriform mass,
they became quiescent, having been attended by inflammation during the pro-
cess ; and we could therefore very well imagine that while this limited deposit,
not such as to interfere with the whole of the functional part of the organ, was
undergoing a change, there would be a very considerable amount of inflamma-
tory action and disturbed function around, which would produce great general
distress and discoloration. But that on the softening process ceasing, and
the part becoming quiescent, the function of the kidneys would be restored,
and the health restored with it. This was, of course, reasoning from what we
knew of the disease of other organs. But there were other sources of dispu-
tation which were perhaps more avoidable, and perhaps less legitimate. He
had cases sent to him of discoloration of the skin, which did not approach
to anything like the discoloration attending this lesion. It had, again, been
more than once declared that these organs were diseased, and extensively so,
when there had been no disease at all. Several supra-renal capsules had been

1858.]

Medical Pathology and Therapeutics.

511

sent to him as samples of diseased organs, and they were in a state of perfect
health. Such a case had been published to the world as a remarkable instance
of universal disease of both organs, without any discoloration of the skin.
It appeared to him that the amount of discoloration had, in the instances he
had met with, been connected with the softening process or liquefaction of the
contents of the organs; so that where there had been great intensity of disco-
loration, there had also been great liquefaction.

Dr. Harlet said, the profession was greatly indebted to Dr. Addison for
having called attention to a peculiar, important, and hitherto unnoticed dis-
ease. He had listened with pleasure to the notes of the case, but could not
help feeling somewhat surprised at the conclusions of the author. He did not
think there was at present sufficient evidence to justify the dogmatic statement
that bronzing of the skin was pathognomonic of supra-renal capsular disease.
No doubt many cases had been reported in home and foreign journals, in which
a peculiar discoloration of the skin was found associated with disease in the
supra-renal capsules ; but that was not sufficient to establish the relation of
cause and effect. Indeed, during the last year a considerable amount of evi-
dence had been brought forward on the opposite side of the question — cases
having been reported in which extensive disease of the supra-renal capsules
was unconnected with any discoloration. He referred to the cases reported
by Ogle, Virchow, Davies, Fredrich, Brittan, Kolb, etc. On the other hand,
several cases of bronzed skin had been noticed, unassociated with any textural
change in the supra-renal bodies, as that brought before the Pathological
Society last summer by Mr. Hutchinson. He did not believe bronzed skin to
be the result of any particular disease attacking the glands; for Dr. Addison
had just shown that the discoloration accompanied tubercle, cancer, and
abscess of the capsules. It had been said that the bronzing of the skin was
the result of the suppression of the supra-renal capsular function; but how
could that be the case when the discoloration was found in cases where the
capsules were perfectly healthy, and was absent where the glands were too
extensively diseased to perform their function ? In discussing a subject like
the present, he considered it better to take a general view of the chromatogenous
function of the skin than confine attention to individual cases ; and he reviewed
in some detail the several causes regulating the deposition of pigment in the
skin of man and of the lower animals. Many physiological proofs were de-
duced to show that the chromatogenous function of the skin was entirely
independent of the supra-renal capsular function.

Mr. Hutchinsox remarked, respecting the greater part of Dr. Harley's ob-
servations, that they were admitted by every one. No one had ever doubted
the influence of the sun in browning the skin, and no one had ever dreamt of
asserting that disorders of the supra-renal capsules were the only causes of
increased deposit of pigment. There were, undoubtedly, many others. With
due discrimination, however, there could be but little difficulty on the part of
the trained observer in speaking confidently as to the particular form of bronz-
ing which did really result from diseased capsules. He would assert boldly
that there was as good evidence in support of the belief that such bronzing as
the patient before the Society exhibited was really dependent upon disease of
the capsules, as could be adduced in favour of the connection of any of our
best acknowledged symptoms with their respective lesions. The pathognomo-
nic indications of change in colour of the skin must be ascertained in each
instance by noticing its intensity, the parts on which it commenced, its slow-
ness of progress, and its concomitant symptoms. Above "all, the existence of
black stains on the mucous linings of the lips was of importance. To say
that bronzing was a symptom which, carelessly observed, was very liable to
lead to error, was to allege nothing whatever against its value when cautiously
appreciated, or to derogate one iota from the worth of Dr. Addison's discovery.
In adducing cases of the converse kind, those, namely, in which the supra-renal
capsules were found disorganized, whilst no bronzing of the surface existed,
Dr. Harley had also neglected to avoid a very palpable source of error. All
such cases were examples of recent disease of the organs. Now, as bronzing
required for its production a very prolonged interval, probably not much less

512

Progress of the Medical Sciences.

[April

than a year, it could not reasonably be expected in such cases. The patients
died before it had time to appear. No single instance had, as far as he was
aware, yet been recorded in which the disease of the capsules was such as to
make it probable that it had been long present, or in which the constitutional
symptoms had existed for more than a few months before death, where the
bronzing had not been noticed in greater or less degree.

Dr. Harley did not deny the importance of the functions the supra-renal
capsules had to perform ; in fact, no organ of the body could be considered
unnecessary. Still, it could not be said that they were indispensable to life,
for patients often lived for some time after the arrest of those functions. In
the case of Professor Walshe's patient, which he had recently brought before
the Pathological Society, the medullary substance of both organs was totally
replaced by tubercle, and even the cortical substance had almost entirely dis-
appeared, for only here and there could traces of the columnar cell masses be
detected. No doubt in that case the function of the capsules had been tem-
porarily performed by some other organ. The capsules could certainly be
removed from the lower animals without the destruction of life ; he had now
alive and well a rat from which he extirpated the supra-renal bodies and spleen
six months ago. Brown-Sequard, in a paper recently read to the French Aca-
demy, had stated that the reason why M. Philipeaux's and his (Dr. Harley's)
animals lived after the removal of the capsules was that they were albinoes ;
but this was not the case, for he had kept alive for several months animals
that were not albinoes. A piebald rat which he once had in his possession
became quite fat and healthy after the removal of both supra-renal capsules,
but died subsequently from the effects of the removal of the spleen. In
cases where death had followed the removal of the capsules, it might in
the majority of cases be traced to the injury done to the solar plexus. It
might be taken for granted, that the more intimate the connection between
the capsules and the ganglions, the more fatal were the operations ; and the
further removed the capsules were from the ganglions the more successful was
the result; for instance, the removal of the capsules from the guinea-pig was
more fatal than from the dog, from the dog than from the cat, and from the cat
than from the rat; and in the same species of animal the removal of the right
capsule was more fatal than the removal of the left, from the same cause ; the
right capsule being as a general rule very much nearer to the solar plexus
than the left. At present, however, there seemed to be no physiological evi-
dence to show that either of the supra-renal capsules was absolutely essential
to life, or had any direct connection with the chromatogenous function of the
skin.

Dr. Addison said he hoped Dr. Harley would not continue to entertain the
notion, that he attached extraordinary importance to the discoloration of the
skin. The term "bronzed skin" did not originate with him. All he ventured
to do was to describe the diseased condition that he met with; and the earliest
indication to the eye was this discoloration of the skin. He believed the
disease might occur, and had occurred, without any discoloration of the skin.
A case occurred at Guy's Hospital, where all the symptoms were those indica-
tive of the disease, and a physician there expressed his astonishment that he
should not have recognized it, notwithstanding the absence of the discoloration
of the skin ; and after death the lesion of the capsules was found. He should
like this simple fact explained to him by the gentleman who spoke last. He
saw a patient who presented this peculiar discoloration of the skin ; he offered
no explanation as to whence, or how, or why it came. He observed associated
with that discoloration a certain train and combination of general symptoms
— a pearly eye, a feeble pulse, a disposition of strongly-marked anaemia, and a
few other symptoms less constant and less urgent; and when he met with that
combination he said, '"There is a case in which you will find disorganization
of the supra-renal capsules." The body was examined ; no other organs were
found diseased, but these organs were found in a state of universal suppura-
tion. He did not profess to explain this ; he knew no more about it than other
people : but he believed, when the disease did occur in these organs, it led to
these consequences and to inevitable death. — Med. Times and Gaz., Feb. 20,
1858.

1858.]

Medical Pathology and Therapeutics.

513

21. Treatment of Inflammatory Diseases of the Respiratory Organs. — Dr.
Semple read before the Medical Society of London (Jan. 16th, 1858) a paper
on this subject. He commenced by observing that the treatment of pneumonia
was formerly supposed to consist almost solely and essentially in the abstrac-
tion of blood from the arm; but that in the present day, not only in this, but
in other inflammatory diseases, the use of the lancet was but seldom resorted
to, and by many practitioners it was abandoned altogether. It became a ques-
tion whether this great alteration in treatment was due to the varying fashion
of the day, or to the fact that disease had, in fact, altered its type, and therefore
required very different treatment from that formerly adopted. He (Dr. Semple)
was inclined to believe that disease had really altered its type, for he and others
had, at the commencement of their professional career, bled patients very con-
stantly, and certainly with good results, but at present the operation of vene-
section was not so much required. He had been for the last three years
connected with the Northern Dispensary, where all the usual forms of disease
presented themselves to his notice, and he had recommended bleeding only
once during the whole of that period in that institution. The fact appeared to
be, that the sthenic inflammatory diseases were dying out amongst us, and that
asthenic complaints were taking their place. The cholera which visited this
country in 1832, was certainly a disease of depression, and this was immediately
followed by the influenza, a disease of the same depressing class, and, like it,
requiring a tonic plan of treatment. Since the date referred to, neuralgia, also
a disease of depression, had become almost epidemic; carbuncles and carbun-
cular boils were at present decidedly so ; and Bright' s disease, the disease of
the supra-renal capsules giving rise to the bronzed skin, and the disorders
classed under the head of fatty degeneration, were all much more prevalent
than formerly, even if we do not admit them to be new diseases. In fact, it
now became a question whether bleeding should ever be practised at all, and
he (Dr. Semple) was as cautious in ordering a patient to be bled as a surgeon
would be in deciding upon the amputation of a limb. Nevertheless, although the
cases which were met with in practice required in general the adoption of tonic
and stimulating treatment, it was by no means proved that all forms of disease
were characterized by depression ; for cases of a sthenic type still presented
themselves, and demanded the application of antiphlogistic measures. The
remarks made upon the treatment of inflammatory diseases in general were
particularly applicable to those of the respiratory organs, which are essential
to life, and the inflammations of which require the most prompt and judicial
medication ; still it was impossible that any stereotyped rules could be laid
down for the treatment of these affections, which may present the most opposite
therapeutical indications.

The author then related the case of a lady in whom the treatment by bleed-
ing, calomel, and tartrate of antimony was adopted for an acute inflammation
of the larynx and trachea, extending to the bronchial tubes, substance of the
lungs, and pleurse. This treatment not having at first produced a well-marked
effect, the antiphlogistic plan was changed for a stimulating one, and carbonate
of ammonia and brandy were employed while the acute symptoms still con-
tinued. The result was, that the patient became decidedly worse, and appeared
to be on the point of death by suffocation; but on again changing the plan,
and resorting to bleeding, low diet, and tartrate of antimony, the disease
gradually subsided, and the patient, who is now alive and well, was restored
to perfect health, without any trace whatever of the previous illness.

Dr. Semple wished that it should be understood that'he had no dogmatic
views to offer upon the treatment of the inflammatory diseases of the respira-
tory organs. He could not advocate indiscriminately large bleedings, profuse
mercurialization, and repeated doses of tartar-emetic; nor, on the other hand,
could he approve of the universal adoption of the plan of stimulating such
cases by brandy and carbonate of ammonia; and it was difficult to determine
which would be the greater error of the two. He believed that many cases of
pure sthenic inflammation still presented themselves in practice, although they
were by no means so common as they formerly were ; and in such instances
the abstraction of blood, and the administration of mercury, of the alkalies

514

Progress of the Medical Sciences.

[April

and tartar-emetic, will effect a cure. But there are in the present day a great
number of epidemic, contagious, and diathetic forms of disease, which are, it
is true, accompanied by inflammation, but of a low or asthenic character, and
these require tonics, alteratives, and stimulants. Undue depletion ought to be
avoided in persons who are the subjects of the gouty, the venereal, or the scro-
fulous diatheses ; and whenever any of these affections co-exist with, or precede
inflammation, the disease ought not to be considered as of a sthenic character,
and the cure should be sought rather by correcting the prevailing morbid taint
in the system than in indiscriminate depletion ; and some of these constitu-
tional maladies, especially scrofula, required cod-liver oil, iodine, iron, meat,
wine, and beer.

The paper concluded with a sketch of the treatment of pneumonia as it pre-
sented itself in children, in vigorous adults, in the inhabitants of towns and
cities, in persons labouring under fever, in its typhoid form, and in its compli-
cation with tubercular phthisis, in each of which cases, although the name of
the disease was the same, yet the treatment required was very different, owing
to the peculiar features which the malady assumed.

In the discussion which ensued, Dr. Routh, Dr. Camps, Dr. "Webster, Dr.
Cotton, Dr. Chowne, and Dr. Stocker took part. The debate elicited nothing
very striking or novel; but it was remarkable that none of the speakers spoke
in favour of the stimulating plan of treatment in inflammatory diseases of the
chest.

Dr. Semple, in reply, feared that the nature of his remarks had been mis-
understood by some of the speakers. So far from advocating the indiscriminate
use of bloodletting, his paper had just the contrary tendency; and he believed
that a medical man was bound to dispossess himself of all dogmatic opinions,
and to treat his patients in such a manner as would most rapidly restore them
to health. This could only be done by studying the peculiarities of every case,
and paying strict attention to all modifying circumstances. However valuable
statistics might be, he thought that they did not throw much light upon prac-
tice ; and as to the number of cases which, it was said, recovered from pneu-
monia in the Vienna Hospital without any treatment at all, it was not stated
what the peculiar forms of the disease were, or what were their complications,
and the results might be quoted to support any doctrine whatever. He thought
that the subject of the modern treatment of the inflammatory diseases of the
respiratory organs, and of inflammatory diseases generally, was a very proper
one for debate in medical societies ; and as the arguments were not yet by any
means exhausted, he hoped that others would continue the discussion upon
some future occasion.

22. Treatment of Pleuro- Pneumonia. — Dr. S. 0. Habershon, Ass. Phys. to
Guy's Hospital, draws the following inferences from certain cases he has ob-
served and recorded.

1. That active mercurial, antimonial and opiate medicines are not necessary
in many cases of pneumonia, even without depression, and when seen at an
early stage.

2. That convalescence rapidly takes place in many instances under the saline
plan of treatment, as bicarbonate of potash, as shown by Dr. Hughes Bennett
and others.

3. That while some cases of pleuro-pneumonia, especially in young subjects,
as several of the cases related were, may recover, even without any medical
treatment, that salines appear to be of some value, perhaps by increasing the
action of the secreting organs, modifying the character of the blood, and has-
tening the absorption of the effused product.

4. That in other instances, mercury appears to be of considerable value, as
in cases where there is considerable pleuritic effusion.

5. That, in some, especially where there is much bronchitis, with great fe-
brile excitement, without prostration or struma, antimony also is of much ser-
vice ; but that the indiscriminate use of calomel and antimony in very many
cases retards convalescence, interferes with the return to healthy nutritive
action, and should be avoided.

1858.]

Medical Pathology and Therapeutics.

515

6. That opium alone, or as its alkaloid morphia, is also a valuable remedy in
pneumonia, either combined with ipecacuanha, as in Dover's powder, or with
antimony, when that is admissible ; that it acts possibly by diminishing the
frequency of the respiratory act, by its action on the nervous system, increas-
ing diaphoresis, when combined as just mentioned ; quieting the nervous sys-
tem, relieving pain, and diminishing the excitability of the nervous system, and
diminishing the excitability of the bronchial tubes.

7. That while, in some cases, general or local bleeding may be called for,
such are exceptional cases now ; and that many instances, on the contrary,
require the liberal administration of nourishing diet, and in some cases stimu-
lants.

8. That each case must be judged by its own peculiarities ; and whilst many,
from their age and other circumstances, will probably recover under most va-
ried treatment, other cases, of which I might adduce many instances, almost
invariably die, as those arising in very intemperate habits, or where it follows
in the course of pyaemia and allied conditions. We have thus sought by these
instances to show that, whilst calomel and antimony are sometimes of value,
much more frequently they may be dispensed with altogether in cases of
pleuro-pneumonia, rapidly advancing to consolidation of the lung, where a com-
paratively short time ago these remedies would have been prescribed. — Med.
Times and Gaz., Nov. 28, 1857.

23. Hydropneumothorax treated by Paracentesis Thoracis and Injections of
Iodine. — Three cases of this under the care of Prof. Trousseau are recorded in
L' Union MMicale (Oct. 31, and Nov. 10, 1857), one of which proved fatal, and
the other two resulted favourably. In the former, death did not ensue till six
weeks after the operation ; the disease for which it was performed having been
complicated with phthisis, which was not positively diagnosed during life, it
would not be just to impute the fatal result to the operation.

The most completely successful of the three cases was the second, of which
the following is an outline : A man was admitted into the hospital, November,
12, 1856, six weeks after having suffered serious injury by being squeezed
between two carts. He was still in great pain, the right side of the thorax
presented a considerable elevation; there was dulness posteriorly as far as the
spine of the scapula, and the respiratory murmur was inaudible at the base of
the chest ; in the infra-spinous fossa there was a blowing sound, egophony,
metallic tinkling, and hippocratic succussion caused a splashing which was
audible at a small distance from the thorax. In the subclavicular space the
percussion sound was abnormally clear. The abdominal organs were forced
downwards, the liver projecting considerably below the false ribs. There was
frequent cough, with expectoration, which was at times bloody and rusty, at
others frothy and colourless; respiration was quick and painful, the pulse small,
about 120. The patient's strength was good. M. Trousseau diagnosed hydro-
pneumothorax, and on introducing a trocar between the seventh and eighth in-
tercostal space, 5J litres (nearly twelve pints) of an odourless purulent fluid
were evacuated ; and having entirely emptied the pleura, 258 grammes of an
iodized solution were injected, which was partly removed after a few minutes,
and the wound shut up. No inconvenient symptom followed ; the wound
healed up in the course of eight weeks, during which it continued to discharge
a purulent serosity. The chest by this time had collapsed on the right side ;
the vesicular murmur was everywhere restored, but feeble, and mixed with
mucous rales- in some points posteriorly ; in front it was pure and audible,
even on the level of the puncture. The patient left towards the end of
January, and soon after was well enough to return to his employment as
carman.

The third case occurred in a man, aged thirty-five years, as the result of
pleurisy of the left side. The operation was performed as in the last case, fol-
lowed by iodized injections,1 repeated no less than twenty-four times at different

1 Fifty grammes of tincture of iodine, five grammes of iodide of potassium, with
one hundred to one hundred and twenty grammes of water.

516

Progress of the Medical Sciences.

[April

intervals. The patient did well ; the left side of the chest fell in, and the per-
cussion sound of the part affected was restored almost to the normal condition ;
but five months after the operation the orifice made by the trocar still continued
to discharge a small quantity of pus, and it was feared that there was tubercular
deposit in the lung, to combat which the hypophosphite of lime was prescribed
according to the formula of M. Churchill.

In the remarks that conclude the article, the propriety of performing the
operation is dwelt upon, and the iodized injections are spoken of as the only
remedy by which we may hope to obtain a cure of purulent effusions, and of
hydropneumothorax even, without serious danger. — B. and F. Med.-Chirurg.
Rev., Jan., 1858.

24. Specific Treatment of Consumption by Salts of Phosphorus. — Dr. J. F.
Churchill, in a memoir presented to the Imperial Academy of Medicine,
claims to have discovered that phosphorus, in certain combinations, is a specific
remedy for phthisis. A few months previously, Dr. C. had proposed its em-
ployment at the hospital for consumption at Brompton, but having declined to
make known its composition, the Medical Board very properly refused to make
trial of it. As the remedy has now been made known, and its efficacy so con-
fidently vaunted, Dr. R. P. Cotton, Physician to the Hospital, &c, at Brompton,
thought it his duty to give it a fair trial, and he has published (Med. Times and
Gaz., Feb. 13, 1858), the results.

Dr. Churchill is of opinion that the direct cause of tuberculosis is the de-
crease in the system of the normal proportion of phosphorus in an oxygeniza-
ble state, and that the natural remedy should be sought in some compound
of phosphorus, at the lowest possible degree of oxidation. The hypophos-
phites appeared to him to offer the nearest approach to such a quality; and
of these he selected the hypophosphites of soda and of lime, as being the
most soluble and "assimilable." " They produce," he observes (p. 15), "a
manifest increase of nervous power, sometimes even from the first day of
their administration, together with an unusual feeling of comfort and strength.
At the same time the nervous symptoms, if there have been any, disappear, as
well as the functional derangement, such as weight, etc., of the intestinal mu-
cous surface. The appetite increases, often in an extraordinary manner. The
evacuations become regular, and more abundant; the perspirations, if they
have existed, cease ; sleep becomes calm and profound." He administered it
to thirty-five consumptive patients, all of whom were either in the second or
third stage of phthisis. Of these, " nine were completely cured, eleven expe-
rienced great melioration, fourteen died," and one was still under treatment.

Dr. Cotton's experience with this remedy he states " is based upon carefully
made observations upon twenty of my own in-patients at the Hospital for Con-
sumption. Copious notes were taken by Dr. Walker and Mr. Ford, the resi-
dent clinical assistants; and are open to the inspection of those who may be
desirous of obtaining more information than I am able to offer in the present
communication. Dr. Churchill's rules for administering it were carefully at-
tended to; five grains dissolved in water, with the addition of a small quan-
tity of syrup, being given three times a day. The cases consisted of nine
males and eleven females, all of whom were adults. Three were in the first
stage of consumption, five in the second, and twelve in the third. All were
affected with the disease in its simple form, there being no other than the ordi-
nary complications. The remedy was administered for a fortnight, notes being
regularly taken ; if, at the expiration of this period, no improvement was ob-
servable, it was discontinued ; but, if the patients expressed themselves re-
lieved, other medicines were prescribed, with the view of testing whether such
relief was fairly attributable to ' specific' agency, or to other circumstances —
such as improved diet, rest, etc., which should always be taken into account in
estimating the effect of medicinal agents upon hospital patients.

" Of the three patients in the first stage of the disease, two were not percep-
tibly influenced by the hypophosphites, but afterwards improved considerably
under tonic treatment, and cod-liver oil ; the other considered himself much
stronger, but before admission to the hospital he had been almost starved, so

1858.]

Medical Pathology and Therapeutics.

517

that good diet, etc., may reasonably claim a fair share of the credit; and he
left before other medicines could be tried.

" Of the five patients in the second stage of the disease, two were not in any
way influenced by the hypophosphites, but subsequently expressed themselves
as feeling ' much better' under tonic treatment with cod-liver oil; two slightly
improved, but one of these afterwards advanced at a much more rapid rate
under steel and oil, and the other seemed to get on quite as well under steel
and quinine ; the remaining one became much worse, from a gradual advance
of the malady.

" Of the twelve patients in the last stage of the disease, one felt herself better
under the hypophosphite, than under any other remedy ; one improved greatly,
but not more than under the subsequent use of other tonics ; three improved
slightly, but afterwards progressed much more rapidly under steel and cod-
liver oil ; two were not at all benefited, but found themselves ' much better'
under a change of treatment ; in two cases no effect was observed, and in spite
of all treatment, the disease ran on : one of the patients became worse, but
subsequently gained strength under the oil and quinine ; the remaining two
died.

" Thug, in only two instances could this remedy be said to act with any marked
benefit, and in one of these its good effect was very equivocal, the patient, pre-
vious to admission, having been in an almost starving condition, and leaving
the hospital before the comparative trial could be made with other medicines.
In all the rest, it acted certainly in no way as a i specific ;' in most, it seemed
to be inert; and the few cases which slightly improved during its administra-
tion, were evidently instances of the post, and not the propter hoc, since some
advanced equally, and many of them more rapidly, under the subsequent use
of steel or quinine, with cod-liver oil.

" It is very possible that the compound of phosphorus, proposed by Dr.
Churchill, may, in some cases, have a tonic and beneficial influence ; but to any
' specific' action upon tuberculosis, it seems to have no claim.

"In a foot-note to the tabular statement made by the above-named clinical
assistants, I find the following remarks by Mr. Ford : ' As far as we can judge
from these cases, it is obvious that the hypophosphites are of no therapeutic
value, whatever, in the treatment of phthisis; indeed, they seem to be simply
inert, doing neither good nor harm, except indirectly in the latter sense, by
interfering with more positively beneficial modes of treatment/ This opinion
is fully indorsed by Dr. Walker.

" The employment of phosphorus in the treatment of phthisis is by no means
novel. For the last eight or nine years I have been in the habit of using a
mixture consisting of the dilute phosphoric acid, with phosphate of iron ; and
at my suggestion, it has been inserted in our hospital Pharmacopoeia. In many
cases much good has attended, and I think I may say been produced by, its
administration ; but I attributed to it no specific action. 1 believe it is a simple
tonic, adapted to certain depressed states of system.

" Phosphorus is a well known, and apparently necessary constituent, of all
healthy nerve structure ; and, in some conditions of low nervous vigour, its
medicinal employment may be of very great service. We find that it enters
largely into the composition of the most nutritive kinds of grain ; and we may
be quite sure that it is not placed there without a purpose.

" If phosphorus, then, be no specific for phthisis, but a simple tonic, acting
usefully in certain lowered states of nervous energy, are we to seek further for
specific remedies for this most intractable of all diseases? I believe the search
will ever be futile. Until we know what life really is ; until some new aid
can be brought to bear upon its demonstration ; until we find out in what con-
sists that diminished power of vitalizing new products, as exhibited in the for-
mation of tubercle, and other imperfectly organized substances from the blood,
we must be content with treating consumption, as at present, with tonics and
cod-liver oil."

25. Effect of Local Influences on Spasmodic Asthma. — Dr. Hyde Salter read
a paper on this subject before the Medical Society of London (Dec. 5th, 1857)
No. LXX.— April 1858. 34

518

Progress of the Medical Sciences.

[April

The purport of it was to show that, in a very large proportion of cases of
asthma in which it has been fairly tried, change of locality effects an instanta-
neous cure, which is permanent as long as the asthmatic continues his residence"
in the place that has cured him. The author remarked that, although the sub-
ject of his paper was a single method of cure of a single disease, yet that the
efficacy and completeness of the cure, and the painfulness and intractability of
the complaint, vindicated it from unimportance ; and, indeed, that in so dis-
tressing and unmanageable a disease, any remedy that offered even a small
percentage of cures might be considered the greatest possible boon. The paper
was illustrated by nearly thirty original cases, and the points that the author
considered to be established were as follows: —

a. That residence in one locality will radically and permanently cure asthma
resisting all treatment in another locality.

b. That the localities which are the most beneficial to the largest number of
cases are large, populous and smoky cities.

c. That this effect of locality depends, probably, on the air.

d. That the air that would be imagined to be the worst for the general health
is, as a rule, the best for asthma ; thus the worst parts of cities are the best,
and conversely.

e. That this is not always the case, the very reverse being sometimes so — a
city air not being tolerated, and an open, pure air effecting a cure.

/. That there is no end of the apparent caprice of asthma in this respect,
the most varying and opposite airs unaccountably curing.

g. That, consequently, it is impossible to predict what will be the effect of
any given air, but that probably the most opposite to that in which the asthma
seems worst will cure.

h. That some of these differences, determining the presence or cure of asthma,
appear to be of the slightest possible kind, arbitrary, and inscrutable.

i. That the mere conditions of locality appear to be adequate to the produc-
tion of asthma in a person whose disposition to it was never before suspected,
and who probably never would have had it, had he not gone to such a locality.

k. That, consequently, probably many healthy persons who never have had
asthma, and never may, would have been asthmatics if their lot had been cast
in other localities.

I. That possibly there is no case of asthma that might not be cured if the
right air could only be found.

m. That the disposition is not eradicated, but merely suspended, and imme-
diately shows itself on a recurrence to the original injurious air.

n. That change of air, as change, is prejudicial.

o. That, from the caprice of asthma, the constancy of the result in any given
case is often deranged.

The cases that were cited were very illustrative of these several positions,
and some of them were of great interest. In reference to the frequency with
which London air is beneficial to asthma, the author remarked that he was in
the habit of putting to country asthmatics the two questions: "Have you ever
been in London? have you ever had asthma there V and that, if an affirmative
answer was given to the first question, a negative one was pretty sure to be
given to the second. In his own experience he had found hardly any excep-
tion to this rule.

20. On (Edema Glottidis. By Professor Pitha. — In an interesting article of
considerable extent, on the whole subject of tumefaction of the glottis (which
applies rather to the epiglottis and the aryepiglottic folds than the true glottis),
we find the following instance of acute oedema, assumed to have been brought
on in a healthy person by an article of diet.

Madame Grabinger, a robust ruddy woman, aged thirty, on a hot summer's
day felt poorly and faint immediately after her dinner, which she had enjoyed
in perfect health. She lay down on the sofa and went to sleep quietly. After
about half an hour the children observed that their mother breathed laboriously
and noisily, so that they roused her. She awoke with difficulty ; her face was
distorted, pale, and swollen ; the voice hoarse ; the respiration became more

1858.]

Medical Pathology and Therapeutics.

519

laborious : the patient complained in broken words of constriction of the throat,
and a sense of suffocation. A few minutes later, Professor Pitha found the
patient wringing her hands in a state of most distressing dyspnoea. The fea-
tures pale and frightfully swelled, and the whole neck alarmingly swollen.
The voice had entirely disappeared, and the patient implored assistance in the
most painful manner, constantly pointing to the larynx. The Professor could
obtain no clue from the children, but on looking round the room he perceived
a plate with a few strawberries ; on pointing to them interrogatively, the pa-
tient nodded violently, evidently gratified by his suspicion. He at once pre-
scribed an emetic of tartrate of antimony, which put an end to the symptoms
as speedily as they had supervened. After the first spoonful copious vomiting
ensued, accompanied by a discharge of masses of mucus, upon which respira-
tion at once became easy, and voice and speech returned. The tumefaction of
the face and the other symptoms gradually disappeared, and on the following
morning the patient was quite recovered. Professor Pitha analyzes the symp-
toms, and while he admits that the presence of oedema was not absolutely
proved, he maintains that all rational signs of the affection showed it to .be
there. — Brit, and For. Med.-Chirurg. Review, Oct. 1857, from Prager Viertel-
jahrssclirift Jahrgang xiv., 1857.

27. Acute Rheumatism caused by large doses of Hydriodate of Potass. — Dr.
Charles Campbell extols [Dublin Hosp. Gaz., Feb. 1, 1858), the efficacy of the
hydriodate of potass in the treatment of acute rheumatism. He gives the
article in large doses — ten grains every four hours.

28. Principles of Treatment in Chronic Rheumatism. — Dr. In man read an in-
structive paper on this subject, before the Liverpool Medical Society. He
adverted to the frequency of the occurrence of chronic rheumatism, and the
multiplicity of the plans of treatment employed for it ; remarking that they
all, however, possessed something in common. Difficulty as to diagnosis, and
confusion as to treatment, he thought had arisen from the practice of classing
all sorts of aching pains under one head, as rheumatic. The uneasy sensation
experienced before the access of eruptive fevers, and during the course of ma-
lignant disease, or felt by those exposed to the action of mercury or lead, and
by those suffering from gout, gonorrhoea, or syphilis, and in cases where it was
evident that bile or urea was mixed with the blood, and by children affected
with struma — had all been set down as rheumatic, though due to most varied
causes. The term " chronic rheumatism," he believed strictly applicable to
cases in which there is dull pain, usually coming on during the night, referred
to the tendinous expansions of the muscles, the pulse not quickened, the skin
warm, excepting over the seat of pain, where the temperature is usually low ;
the pain remitting about 4 P. M., and not recurring till some time during the
night. There is usually no error of secretion, nothing visible at the seat of
pain. The duration may be from one or two days, to six weeks. Deposits in
the joints rarely take place; and that form which causes gradual contraction
of joints, and crippling of limbs, is rare. The rheumatic pain is usually sym-
metrical ; its chief seats those parts least protected by fat and integuments.
Loss of motor power accompanies the pain, which is increased by action, and
relieved by relaxation of the affected parts. Rheumatism is not occasioned by
dry and intense cold, but by the more moderate degrees of cold, especially if
the air be moist. The experience of Arctic navigators, and of the army before
Sebastopol, 'as well as the comparative rarity of rheumatism among carmen,
carters, and bricklayers, confirm this point. Firemen of ocean-going steamers
appear particularly liable to it. Persons of feeble constitution and languid
circulation are more obnoxious to it, than those with good circulation. It is
not common in women, except at advanced ages. The vigorous action of the
heart helps to remove the pain, as is evidenced by the improvement which
generally occurs after dinner. In a case where there was great pain and stiff-
ness in the arms, hands, and deltoid muscles, the immersion of the arms in
very warm water removed the pain for the time. Many rheumatic patients
feel quite well in a warm bath ; though often worse after it, from increased sus-

N

520 Progress of the Medical Sciences. [April

ceptibility. The influence of temperature on the local circulation has much
power over rheumatism. Patients take cold often through sitting near cold
walls, &c. The cause of the pain is probably, primarily, the contraction of the
pale muscular fibres of the skin, the stagnation of blood in their capillaries ;
the hot aching pain which succeeds, being due to reaction and dilatation of
the vessels : the one efficient cause of rheumatic pain in general, being deficient
flow of blood through the affected parts. With regard to treatment, the author
thought that no satisfactory results could be ascribed to colchicum, in large or
small doses. Warm baths are useful in some cases. Nitrate of potash had
proved useful in the hands of some, but he thought the iodide of potassium had a
stronger claim to efficiency. Guaiacum, aconite, opium, steel, and cod-liver oil,
all prove useful in some cases ; and the local application of heat by packing in
wet sheets, blisters, sinapisms, heated irons, red flannel, and red merino, also.
The indication appears to be, to restore the strength of the individual, and the
vigour of his circulation. In the most troublesome form, pain in the plantar
fascia, was removed by perfect rest and galvanism. — Liverpool Medico- Chirur-
gical Journal, July, 1857.

29. Perchloride of Iron in the Treatment of Erysipelas. — The use of perchlo-
ride of iron in the treatment of erysipelas has lately been brought again into
notice by the publication of a thesis by M. Louis Mathey, and by some observa-
tions made by M. Aran, physician of the Hopital St. Antoine in Paris. M.
Mathey relates ten cases of erysipelas treated with this medicine, and his con-
clusions are contained in the following remarks : —

The action of perchloride of iron on erysipelas is evident, and the course of
the disease is modified a short time after its administration. In fact, on the
second day, and sometimes even on the first, M. Mathey has seen the disease
become limited and circumscribed, and its further progress arrested. As to
.the duration of the disease, the effect of the perchloride is still very remarkable:
not only is the progress of the erysipelas sensibly modified from the first few
hours which follow the administration of the medicine, but it is completely
arrested; the radical cure of the disease is obtained in a very short time. It
was observed that in ten rather severe cases of erysipelas treated by the inter-
nal use of perchloride of iron, three were cured in two days, three were cured
in three days, two were cured in four days, one in five days, and one in seven
days. It cannot therefore be denied that erysipelas is advantageously modified
by the internal use of chloride of iron; that the cessation of the symptoms
proper to erysipelas is sometimes very rapid after the administration of this
medicine ; that in a series of ten obsei nations, made upon varied cases, this
treatment never failed ; that even where its efficacy may be doubted it has never
given rise to any bad symptom ; and that when administered in the dose of thirty
drops to a healthy subject, it has never given rise to any painful sensation, and
has never produced any notable functional disturbance.

M. Aran agrees with M. Mathey in never having observed any unfortunate
result from the administration of the perchloride of iron in larger doses than
those employed by M. Mathey — namely, thirty, fifty, sixty, and one hundred
drops a day, in certain exceptional cases. But a wider and more extensive
experience of the employment of the perchloride has shown him that there are
particular circumstances which favour the action of the medicine. M. Aran
believes that it would be vain to expect advantageous results from the admi-
nistration of perchloride of iron in all cases of erysipelas. He is convinced
that some cases of erysipelas will not yield to this remedy; as, for instance,
the cases which occur in young, strong, and robust subjects of a sanguine tem-
perament, and which are accompanied by a well-marked inflammatory action.
On the other hand, the cases of erysipelas which are developed in feeble, deli-
cate subjects, of a well-marked lymphatic or scrofulous temperament ; in indi-
viduals already weakened by previous diseases ; the cases especially which
exhibit, with well-marked tendency to spread, the oedematous form ; and in
which, even with a marked acceleration of the pulse, the arterial throbs are
weak and easily depressed, or when fever is completely wanting, as happens

1858.]

Medical Pathology and Therapeutics.

521

sometimes in old persons ; these cases are remarkably modified and often
arrested in twenty-four, thirty-six, or forty-eight hours, by the administration
of the perchloride. The erysipelas, "which is still more atonic, and which super-
venes in the course of serious diseases, around punctures, abrasions, or lacera-
tions of the skin, at other times even without appreciable causes, are amenable
to the perchloride of iron. Lastly, the cases which, even when they show
themselves in strong and robust subjects, after having been reduced by various
and appropriate treatment, still linger on and pass from one part to 'another,
throwing out unexpectedly its eruptions in places where the disease appeared
to have been long extinguished ; such cases are often terminated in twenty-four
hours by the perchloride of iron.

Another point connected with this subject is the propriety of administering
the perchloride as a prophylactic. " There are certain epochs and years," says
M. Mathey, "when cases of erysipelas of traumatic origin are multiplied to
infinity, and show themselves in such great number, that the disease is truly
epidemic. The application of a seton, a moxa, or a blister, is followed by
erysipelatous inflammation : and, a fortiori, the great wounds united by sutures
and bandages of diachylon are almost infallibly attacked with the disease. The
surgeon who operates under these circumstances is pretty sure to see erysipelas
among his patients. It would perhaps be proper to postpone the operation,
but sometimes the case is urgent, and the surgeon would think himself fortu-
nate and could act with more confidence if he could hope to put his patient
beyond the reach of a troublesome complication ; might we not, for the first
few days which follow a delicate operation, and during which inflammation is
to be feared, unite with soothing beverages some drops of perchloride of iron,
because it is fully established that its use in moderate doses is not followed by
any bad effect?" — B. and F. Med.-Chirurg. Rev., Jan. 1858, from Bull. G6n. de
Thtrap,, July 15, 1857.

30. Guarana in Chronic Diarrlioza. — Dr. Herve, of Lavour, calls the atten-
tion of the profession to the employment of a substance which is in common
use in South America, and particularly in Brazil, where cases of diarrhoea
and dysentery present themselves in a very severe form. Those who inhabit
that country know that every family has a little provision of guarana, and that
as soon as any one is seized with diarrhoea or dysentery, a little of the sub-
stance is scraped and infused in a cup of boiling water, which is swallowed at
once with or without sugar. Dr. Herve, following the advice of Dr. Mialhe,
has given it in infusion, in sugared milk, and it is then much more agreeable,
and does not lose its special characters. For the last five or six years he has
employed this medicine daily; it has never failed him in the most obstinate
cases of idiopathic diarrhoea, and almost always it has ameliorated the condi-
tion of the patient even in the most serious symptomatic cases. The guarana
or paullinia has been also employed in the treatment of headaches ; and it has
succeeded in some cases connected with gastric derangement, but it has failed
in others.

The guarana, as a medicine, was first described by Cadet de Gassicourt, in
1817, from a fragment which had been brought to him from Brazil by an officer
attached to the French embassy. On this specimen a ticket was fixed, import-
ing that this substance was much employed in Brazil for cases of diarrhoea
and dysentery. Towards the close of the year 1822, an inhabitant of the same
country, M, Gomes, sent to Merat a complete specimen ; itwas a mass present-
ing the form, colour, and volume of a sausage ; there was joined to it a very
rough bone, intended to act as a rasp, and which is always sold with the medi-
cine. The learned botanist, Martius, afterwards occupied himself in discover-
ing the plant which yielded the guarana, and he classed the climbing shrub
which furnishes the guarana seeds among the Sapindaceas, under the name of
Paullinia sorbilis, in consequence of its employment as a drink. It may be
used in the form of pastiles, syrup, pills, tincture, and pommade, as well as
in powder, and in combination with chocolate. — B. and F. Med.-Chirurg. Rev.,
Jan., 1858, from Bull. G6n. de Therap., May 15, 1857.

522

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[April

31. Use of Kameela as an Anthelmintic. — Mr. Arthur Leared relates [Med.
Times and Gaz., Dec. 19, 1857) a case of tape-worm in which most of the usual
remedies were tried without effect, and in which the kameela (the powder from
the capsules of the Rottlera tinctorial) was successfully used.

32. On the Employment of Tartarized Antimony in the Treatment of Chorea.
Dr. Adrien Marcotti, in a recent paper (Bull. Gen. de Therap., July 30, 1857),
gives an account of two cases of epilepsy successfully treated by M. Bouley,
at the HSpital Neckar. In the first case, that of a young girl, the chorea had
lasted a month, and was increasing in intensity. Large doses of the tartar
emetic were given on two successive days, and thirty hours after the first ad-
ministration of the medicine, all choreic movement disappeared. The patient
was at first thrown into a considerable state of depression, but some moments
of sleep sufficed to restore her, and the appetite was soon found to reappear.
The muscular disorder disappeared, but a bad state of the constitution remained,
and recourse was made to tonic medicines to improve her condition. The chorea
reappeared under the influence of a fit of passion, but on the administration
of the tartar emetic it again subsided. In the second case, the chorea was at
first general, and almost immediately became partial. It resisted for six months
and a half sulphurous baths, chalybeate tonics, and strychnine, and yielded in
twenty-eight hours to the employment of tartar emetic. — B. and F. Med.- Chirurg.
Rev., Jan., 1858.

33. Lactate of Zinc in Epilepsy. — Dr. Herpin's name is familiar to the medi-
cal profession on account of his urgent advocacy of the employment of oxide
of zinc in the treatment of epilepsy. He now abandons this preparation
entirely in favour of the lactate of zinc. The greater solubility and digesti-
bility of the latter would a priori engage our sympathies in its favour. The
following is one of the cases which have decided the author's preference, and
deserves to be recorded on account of the success obtained in spite of the un-
favourable prognosis which the case would have justified in the first instance.

Miss E., aged eleven and a half, consulted Dr. Herpin, February 1st, 1854.
She was well made, intelligent, and pleasing. Her paternal grandfather had
died epileptic at forty-nine years of age ; her maternal grandfather at seventy-
six, after being insane for six years, and in a state of melancholy for forty years.
No predisposing or exciting cause was traceable in the patient, excepting per-
haps the fright caused by a fire two months previous to the first attack. She
enjoyed excellent health till six years of age, when she had typhoid fever,
having on the right side a tendency to slight and evanescent deafness. Three
months before the first seizure she was attacked with frequent headache, gene-
rally commencing in the morning, and lasting till evening. The headache
ceased in December, 1853. The first fit occurred on August 15, 1853, the
second on September 5, the third on September 26 ; six then followed at vari-
able intervals, making altogether nine in less than five months ; they always
took place during the first hour of sleep, and the evening before the attack
she was observed to be somewhat excited. The symptoms, which are detailed,
leave no doubt as to the attacks having been those of genuine epilepsy. The
oxide of zinc had been prescribed for the patient from September to the fol-
lowing July, but she was unable to bear the doses which Dr. Herpin thinks
necessary in order to make a proper impression upon the patient. He was
once able to reach a dose of six grammes (ninety grains) per week, but he was
obliged to diminish it. Still the attacks ceased, from January the 8th to July
the 18th ; but a return on that day, brought on by a tepid bath, induced M,
Herpin to have recourse to the lactate of zinc, which he gave for above six
months, during which time the patient swallowed 306 grammes (4600 grains).
The tolerance of the remedy was complete, and when she left off taking it, she
was in perfect health. There was one recurrence of epilepsy two months after
commencing the lactate. Three years have since elapsed, and the lady's health
continues sound. — B. and F. Med.- Chirurg. Rev., Jan., 1858, from L' Union Med.,
No. 121, 1857.

1853.]

Medical Pathology and Therapeutics.

523

34. Therapeutic Action of Chlorate of Potash, with a New Mode of Administer-
ing it. — Dr. Dethan considers that chlorate of potash is a powerful sialagogue,
and that its elective action on the bucco-pharyngeal mucous membrane is well
marked. To this physiological action is added a very remarkable and valuable
success in pathology; its rapid and incontestable effects in mercurial salivation,
by checking the formidable mercurial affection, have permitted practitioners to
continue the mercury without fear, and thus to contend without remission
against the constitutional infection. As an especial and incontestable remedy
in ulcero-membranous stomatitis, this medicine need not, according to the
physicians of the Hopital Sainte-Eugenie, be swallowed; its topical application
is sufficient, and in a short time the mucous membrane recovers its normal
qualities and functions. Dr. Dethan concludes that the chlorate of potash,
administered under a special form, which would permit the local action to be
exercised slowly and certainly, although leaving the medicine to be carried
into the stomach in a state of solution with the mixed liquids of the salivary,
buccal, and pharyngeal glands, would be the mode of administration which
would combine all indications and all opinions. He therefore suggests the use
of the remedy in the form of pastiles, so that the patient may have at hand a
remedy against the injurious effects of a mercurial treatment which he may
be undergoing. The experiments of Dr. Ricord, and the publications of M. A.
Fournier, testify incontestably in favour of this successful simultaneous medi-
cation. In certain forms of angina attended with fibrinous exudations, it
prevents the intimate adherence of the false membranes to the mucous mem-
brane, and facilitates their expulsion, and assists the action of emetics. In
this affection the topical action of the chlorate, favoured by the bruising be-
tween the teeth, the natural solution in the liquids of the mouth, and its pene-
tration into all the points interested, will be certainly efficacious. In debili-
tating diseases, such as diphtheritis, and gangrene of the mouth, the child
will find an agreeable and reparative kind of food, together with the most
appropriate remedy hitherto discovered, against these diseases. — B. and P.
Med.-Chirurg. Rev., Jan. 1858, from L' Union Med., June 4, 1851.

35. Movable Kidneys. — "The knowledge," says Prof. Oppolzer [Wien Wo-
clienschrift, No. 43, 1856, and Med. Times and Gaz., No. 362), " of the possibility
of the existence of this affection is of importance to the practitioner, as, when
unaware of it, he may suppose the appearances observed to result from various
other causes, and submit the patient to an injurious course of treatment, or it
may give rise to unnecessary alarm upon his part. The abnormal movability
usually affects but one kidney, and especially the right one ; but the author has
met with cases in which it was observable in both, and that in a remarkable
degree. In all the cases he had the opportunity of examining, the patients
dying of some other disease, the kidneys were found healthy ; but in these
cases there has been observable a deficiency in the cushion of fat, or an exten-
sion of the renal vessels. In some cases, the practitioner's attention has been
drawn to the abnormality by the patient observing a tumour on one or both
sides of the abdomen, which only became perceptible while standing, or lying
on one or the other side, disappearing again during the horizontal posture.
Generally speaking, however, it is first discovered by careful exploration, when,
beneath the relaxed, painless, and not very thick abdominal parietes, a large-
ish, rounded tumour is perceived, deep under the liver or stomach. The inner
concave side can only be felt in very thin persons, and the upper end is only
accessible in some. The tumour can be easily pushed upwards, and then may
suddenly disappear ; but it cannot be pressed against the spinal column, or
downwards below the crista ilii, without great pain being produced. To very
firm pressure, made in any direction, the tumour is sensible ; and the patient
spontaneously complains of a sense of pressure and dragging, especially when
standing, performing active movements, during defecation, &c. In the cases
seen by the author, the condition has been normal."

The affection is usually congenital, as is shown by the lengthened condition
of the vessels. Rapid emaciation occurring in persons formerly fat, concus-
sion of the body, as in rough travelling, constipation, &c, may probably con-

524 Progress of the Medical Sciences. [April

tribute to its production. In fat persons the diagnosis may be impossible, but
it is not difficult in those who are thin, as the form of the swelling can be.
traced, while the tumour can be pushed into the lumbar region, and there felt.
The pain which it not unfrequently gives rise to, cannot be mistaken for neu-
ralgia, colic, or rheumatism, if the practitioner will only make an exact explo-
ration ; while the tumour, resulting from a collection of feces, assumes another
form, and does not appear in, or disappear from, the lumbar region, in conse-
quence of pressure. It may also be distinguished from a movable spleen, as
the latter lies in front of the intestines, under the parietes, and gives rise to
dulness on percussion. It can only be confounded with cancerous and tuber-
cular masses, when these are movable, and resemble the kidney in form. Treat-
ment of this affection by bandages and the like, is of no avail ; and the removal
of it, when present, must be chiefly sought from the horizontal posture. Con-
finement of the bowels, and the consequent straining, must be avoided. It is,
however, of great importance to tranquillize the mind of the patient as to the
nature of the affection, and to prevent injurious measures being adopted: and
hence the value of a correct diagnosis.

Mr. Adams was requested many years ago to examine the body of an old
lady who was said to have " slipped her kidney." The right organ could be
readily felt beneath the integuments in the lumbar region, and above the crest
of the ilium. The only peculiarity revealed by a post-mortem examination was
that the right kidney appeared to be bound down more loosely than usual. The
patient, from having been very corpulent, had been much reduced in size.
The condition of the kidney had nothing to do with the cause of death.

Dr. W. F. Wade states (Midland Quart. Journ. Med. Set., Jan. 1858), that he
has had under his care, during the past year, a female patient, whose right kid-
ney is the subject of this curious abnormality. The symptoms and history of
the case entirely confirm Professor Oppolzer's remarks.

36. Functional Paralysis. — Dr. Handfield Jones mentioned to the Harveian
Society, of London (Jan. 21, 1858), the particulars of two cases of what he
would be disposed to call " functional paralysis." The first was that of a girl,
aged 19, who, having been unwell for three weeks, was suddenly seized with
paralysis of the extremities, loss of consciousness, etc., which only lasted, how-
ever, a short time, and from which she recovered, and was convalescent in three
weeks. The second, that of a boy, aged 17, affected with slight sickness, im-
paired memory, and inability to hold objects in the hand for any time together.
In both cases, tonics were successfully administered ; in the first case, cod-liver
oil and strychnia, and in the second, a preparation of iron. Dr. Jones consi-
dered that in cases of this kind, the paralytic condition depended on an im-
paired or weakened state of the nervous centres, for which tonics were the
appropriate remedies. — Med. Times and Gaz., Feb. 13, 1858.

37. The Doctrine of Elimination, as propounded by recent Authors. — Dr. Tho-
mas Inman has published (Liverpool Medico- Chirurgical Journal, July, 1857), a

.very interesting paper on this subject, in which he inquires: 1st. What the
doctrine of elimination is. 2d. The arguments in its favour. 3d. The plan of
treatment it leads to. And he endeavours to show —

"1. That the processes by which poisons are expelled from the body are
passive, rather than active.

"2. That evacuations, emanations, or eliminations, are not to be considered
as ' salutary efforts of nature to cure/ but as symptoms of the normal nutrition
being modified by a new force.

"3. That it is dangerous in diseases of a humoral origin, to act upon an eli-
minant plan of treatment principally.

"4. That the mode of treating diseases, depending on the presence of poi-
son, is to enable the system in general, or any organ in particular, to resist its
action, or tolerate its presence.

"5. That anything which depresses the vital powers, makes an individual
more susceptible of foreign influences.

"It is not simply a pure condition of the blood that is necessary to health ;

1858.]

Surgery.

525

for a man may have the most healthy blood possible, and yet die of cold ; while
those whose blood is vitiated by tuberculosis, cancer, the paludal or gouty
poison, may appear to enjoy perfect health, for a lengthened period, if not for
the ordinary duration of life. No medicine, therefore, whose sole aim is to
purify the blood, and no plan of treatment simply eliminative, can be expected
to have more than temporary, or accidental success.

" There is, however, one plan for the elimination of all poisons, with which
we feel bound to concur. It is that which places the patient in the midst of
pure air and lovely scenery ; which takes him from the turmoil and wearing
activity of business, and gives him mental repose ; which supplies him with
nutritious diet, and abundance of the finest water ; which procures sound rest
at night, without any other opiate than healthful exercise ; and which does not
scour out the bowels by a daily purge.

" In this way, we believe, health may be regained, and poison be expelled ;
for there is in every living being a necessity for a constant renovation ; old
materials are daily being replaced by new ; and when the increments are all
healthy, and all old materials are being expelled, it is a necessary consequence
that the body should have as sound a constitution as it is possible to attain."

SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

38. Aft 'er- Treatment of Surgical Operations. — Dr. Broadbent, in a paper read be-
fore the Liverpool Medical Society, session 1855-56, referred to the object sought
— that of union by the first intention. He believed one most common obstacle to
this union to be the occurrence of hemorrhage, one or two hours after the ope-
ration ; not to such an extent as to require the removal of the dressings, but
sufficiently to form a coagulum of such a size as to seriously interfere with the
union of the wound — acting, in fact, as a foreign body. The cause of this ap-
peared to be, that in amputatictas, &c, when the surfaces were brought toge-
ther immediately after the completion of the operation, the vessels were tied
while the patient was still suffering from the shock of the operation, or it might
be, was somewhat depressed by the after-effect of chloroform, whilst the more
minute vessels were prevented from oozing, by their exposure to the air, and
that when reaction took place, the hemorrhage came on. The author thought
that those cases in which this occurred to such an extent as to necessitate the re-
opening of the wound, usually terminate more favourably than others. He there-
fore advocated the plan of postponing the dressing until all oozing had ceased,
and the cut surfaces had glazed over. The unnecessary removal of dressings,
he believed to be another frequent cause of non-union. He thought that the
sutures having been removed, the bandages, &c, should remain untouched till
the third or fourth day, and should then be carefully cut off. The inability of
the patient to maintain the required position, acted in the same way, and to
obviate this, it was suggested that the patient should, before the operation, be
habituated to the position in which he would have to lie after it. In the main-
tenance of the position of the parts, by means of pressure, the author believed
that small air-cushions might be advantageously used, instead of pads of lint.
— Liverpool Medico- Chirurgical Journal, July, 1857.

39. Causes of the Pneumonia whicli supervenes upon Laryngotomy. By Prof.
Schuh. — All surgeons of experience are aware that pneumonia is sometimes
observed after the performance of laryngotomy or tracheotomy ; but observers
are by no means agreed upon the causes of this. Most persons, however, seem
of opinion that the operation itself does not bear any direct causal relation to
this occurrence. Professor Schuh entirely differs from them, and the perform-
ance of a very large number of operations upon the air-passages, during his
twenty-three years' attendance at the Vienna Hospital, enables him to speak

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[April

with authority upon the subject. Although a great advocate for these opera-
tions under a variety of circumstances, he is convinced that the altered posi-
tion and amount of the column of air that is admitted into the lungs is not
unfrequently the sole cause of the supervening pneumonia. The following are
the grounds for this opinion: —

1. The air, after the operation, enters the lungs by a shorter passage, and by
one that is straight in place of being curved, as before ; and it does not pass
through an aperture which is alternately widened and contracted, as is the
case with the rima glottidis. The column of air, too, which passes through the
canula is larger than that which traverses the glottis, for if a smaller canula
were employed, it would be liable to dangerous obstruction. We have thus
two important changes in the mechanical conditions of respiration ; and the
lung becomes exposed to the pressure and impulse of a larger column of air,
arriving more rapidly by a shorter passage. This, so tender and vascular an
organ will not always support, and inflammation may be easily excited, just
as it may when, in the operation of paracentesis thoracis, the fluid is too rapidly
drawn off, and the lung is too suddenly exposed to the pressure of the air.
2. Experience confirms what d priori might have been expected. Any one
who has very frequently performed the operation, must have met with cases in
which the patient has complained of the admission of too large a quantity of
air, and has only felt at ease when the opening of the canula has been dimin-
ished a third or a half by sticking-plaster. If such an indication of an intel-
ligent and observant patient be neglected, pneumonia will follow. 3. The
author has lost several patients in whom, at the time of its performance, no
signs of pneumonia could be detected, and who seemed to be going on very
well to the tenth or even twenty-first day. Not only did no other cause for the
development of the pneumonia exist, but this was also always found on the
right side — this being on account of the greater width and shortness of the right
bronchus more exposed to the impulse of the air. The disease does not come
on actively, but is indicated by some acceleration of respiration and slight fever.
Physical examination, however, shows that very considerable infiltration has
taken place ; and the neglecting to institute this may be a cause that many
pneumonias have been overlooked. 4. Cases of cut-throat, in which the larynx
is wholly or partially divided, also strikingly exhibit the danger of an opening
into the air-passages, such patients not unfrequently perishing in a few days of
pneumonia, this always commencing on the right side, and in even fatal cases
being usually confined to that side. It may also spring up in smaller wounds
of this part, if these be not kept carefully closed either by sutures or suitable
dressings and bandages.

To the question, whether pneumonia after laryngotomy can be prevented,
the answer is, that it can in many cases, but not in all. For this purpose no
wider canula should be employed than is necessary to maintain uninterrupted
respiration ; and as soon as the patient can breathe freely enough through the
mouth, and can both breathe and speak when its orifice is closed, it should be
changed for a smaller one, or its opening should be partly closed by plaster.
When the breathing continues perfectly easy, the canula being stopped, before
this is entirely removed it should be allowed to remain in, completely stopped,
during twenty-four hours, care being taken that it should not project inwardly,
so as to narrow the normal passage for the air. The temperature of the room
should never be allowed to sink below 66° Fahr.

It is often exceedingly difficult to determine the time when the canula should
be finally removed. After such removal, the patient may continue to breathe
quite easy for from two to eight days, when the difficulty gradually returns,
until it becomes as bad as ever. If even a couple of days have passed, the re-
introduction of the canula can seldom be accomplished, and then only by first
passing through the canula a conical obturator, which can better overcome the
elasticity of the edges of the cartilage. The longer the canula has remained
prior to removal, the more readily may it be re-introduced. The recurrence of
dyspnoea is especially to be apprehended when we have reason to suspect ulcer
of or around the rima, open abscesses, and sinuses beneath the mucous mem-
brane. Tumefaction rapidly diminishes, and the normal permeability is soon

1858.]

Surgery.

527

re-established ; but on the admission of the stream of air to the diseased part
by the withdrawal of the canula, the former difficulties may soon be repro-
duced. Hence, when the diagnosis can be established, the canula in such cases
should be retained during several weeks, in order to give the surfaces time for
healing. According to Professor Schuh's experience, pneumonia never comes
on after the first twenty-one days are passed, and the canula may then be worn
for months or years without injury. On the other hand, the Professor has lost
cases by removing the canula too late, pneumonia unexpectedly appearing.
The sensibility of the lung to the unusual arrival of air, is especially great
when the difficulty of breathing that has given rise to the operation has been
of long duration, and the organ has become enfeebled by venous congestion
and a diminution of the contractile power of its cells. In a case in which Pro-
fessor Schuh performed laryngotomy in order to facilitate the removal of a large
pharyngeal polypus, the patient who had suffered for months from a difficulty
of breathing, was quite well on the day of the operation. The canula having,
however, been left in during twenty-four hours, pneumonia was detected by
auscultation within this period.

Thus, it results from what has been said, that pneumonia is sometimes a con-
sequence of breathing through an artificial opening ; and by due regulation of
the size of the volume of air, the temperature of the room, and the timely re-
moval of the canula, it may usually be prevented. This, however, is not always
the case, for the condition of the patient may require a long retention of the
canula, the lung may be excessively sensible to the changed mechanism, and
art has as yet furnished no apparatus as a substitute for the alternated dilata-
tion and contraction of the glottis. — B. and F. Med.-Chirurg. Rev., Jan., 1858,
from Wien Wochensch., 1857, No. 20.

40. Process of Repair in Subcutaneous Diversion of the Tendo-Acliillis. — Mr.
Holmes Coote states {Med. Times and Gaz., Jan. 9, 1858) that he has had an
opportunity of examining two specimens of subcutaneously divided tendo-
Achillis taken from the same subject, the one operated on three months, the
other rather less than two months before the death of the patient, which
resulted from pneumonia.

" The right tendo-Achillis was adherent to its sheath.

It presented the usual pearly white colour. The surrounding vessels, espe-
cially the veins, were full and tortuous. The external fibrous investment was
complete and of usual appearance ; but between the two extremities of the
tendon there was a compressed portion two inches in length, the transverse
measure of which, as compared to the obviously normal part, was as two-
eighths to three-eighths of an inch. A longitudinal incision through the
tendon showed an interval of just two inches between the divided ends of the
normal tendo-Achillis, which were united by a light gray semi-transparent
structure, through which were traced well-formed opaque pearly white fibres,
passing from one extremity to the other of the cut tendon. The new tissue
was clearly defined from the old, being of a totally different colour, the opaque
white hue of the normal structure standing out in strongly marked relief.
After drying for a short time the new tissue acquired a rosy tint, obviously
due to the blood contained in numerous capillaries.

The interval between the cut extremities of the left tendon did not exceed
one and a half inch. The transverse measurement was the same as in the pre-
ceding specimen ; but along the sheath there were numerous patches of extra-
vasated blood. The opaque white fibres of the original tendon were separated
in parts at their junction with the newly formed tissue, which appeared in the
interspaces, and were dove-tailed. Towards the lower end of the connecting
medium, near its junction with the calcaneal portion of the tendo-Achillis,
there was an oval cyst half an inch in length, containing dark fluid blood.

The examination of the newly formed tissue under the microscope exhibited
some points of interest. It contained a large proportion of oil globules inti-
mately mingled with the firmer and more fibrous material. The latter consisted
of granular matter and of newly formed fibres of ill-defined contour, yet ex-
hibiting, in many situations, the appearance of being formed of elongated

528

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[April

nuclei, for, at the broken edge of the specimen, numerous loose nuclei were
seen floating about free, or united in linear series of three or more. There
were some whiter and more opaque parts among the newly formed tissues ;
these closely resembled, but did not quite equal in clearness or in contour, the
normal white fibrous tissue of histologists.

The specimens here described are interesting as contrasted with others of
equal value presented by Mr. Tamplin to the museum of the Royal College of
Surgeons. These were the tendo-Achillis and the tendons of the tibialis pos-
ticus and anticus muscles of a child nine months old, in whom, at the age of
five months, these tendons had been divided for congenital varus. The child
had perfect use of its feet before death, and when it died, no trace of an opera-
tion could be detected even by microscopical examination.

The question here suggests itself — Does the absence of abnormal appearances
in the tendons of the infant arise from the gradual conversion of the connecting
medium into white fibrous tissue? or does the connecting tissue contract so as
ultimately to approximate the ends of the divided tendon and form a "linear
cicatrix?"

I must confess that in the specimens before me there is the very faintest
approximation of normal appearances in the connecting tissue. The divided
ends of the tendo-Achillis seem imbedded in a soft pulpy mass of quite differ-
ent consistence and colour. The absorption of the oily and soft material would
have reduced this structure to at least one-third its present bulk, and it would
have acquired the appearance of a narrow cord. I am not, therefore, prepared
to acknowledge that the newly formed tissue gradually acquires so much of the
properties and of the external characters of tendon as to be with difficulty dis-
tinguishable. On the contrary, it would rather seem that a slow process of
approximation is effected between the cut ends, and that this is combined with
an altered sphere of muscular action.

It may be urged in opposition to this view, that the interval between the cut
extremities of the first divided, and consequently more completely repaired
tendon, was longer than that of the opposite. It must be remembered, how-
ever, that no great length of time had elapsed since the operation — scarcely
three months — and that, in all probability, twelve months would be required
for the completion of all the processes of repair in an adult.

The cyst of blood at the lower extremity of the connecting tissue in the left
leg, due to some slight excess of the extending force, shows the necessity of
proceeding with care in the readjustment of the distorted parts. One of the
principal laws in the practice of orthopaedic surgery is to proceed slowly, that
tissues may yield and not tear. The specimens here quoted illustrate the im-
portance of the remark.

I should conclude that, when specimens are examined in which no trace of
the division of the tendon can be found, the divided ends have become approxi-
mated so as to constitute a close linear cicatrix. But that when the connecting
tissue has been elongated it always preserves some of its distinctive characters,
either as regards its bulk or its minute structure. ' I am of opinion/ observes
Mr. Tamplin, in his work on Deformities, ' that the new substance will and
does admit of sufficient extension to compensate for the greatest amount of
shortening met with in any deformity ; for I have repeatedly, in cases of
talipes equinus, found the new connecting medium full two inches in length
within three or four weeks following the operation, especially in those cases
where there is no resistance in the joint, and where the foot admits of being
rapidly brought into its normal position/ "

41. Suppuration of Strumous Glands. — Mr. James Paget states (Med. Times
and Gaz., Jan. 2d, 1358), that the greater number of strumous children, with
slowly suppurating cervical and other lymphatic glands, supply evidence enough
that the best plan in all such cases is to leave the suppuration to increase till
the skin over it is so thin, that one might think that in a day or two spontaneous
ulceration would ensue. The thinnest part of the skin should then be punc-
tured with a small knife, so as to make an opening not more than two lines
in length. Through this opening the pus should be allowed to flow out slowly :

1858.]

Surgery.

529

the abscess-walls should on no account be pressed. If the pus will flow in
mere drops, it is well ; if it stop altogether, no harm will follow. No more
should be done than to cover the abscess with a soft poultice or with warm
water-dressing, which should be removed twice or three times a day. The ab-
scess thus treated will slowly empty itself, as the inflamed and stretched skin
slowly recovers its elasticity and contractile power; or if the little wound
should heal before the emptying, it will in a day or two reopen ; or, at the
most, the puncture may need to be repeated. The advantage of the plan is,
that the punctured skin does not ulcerate or slough, the abscess-wall does not
inflame, and recovery ensues without disturbance of the general health, and
with a scarcely visible scar. In the great number of cases that I have thus
treated, I do not remember to have failed to obtain these advantages. Usually,
the healing of the abscess is completed within three weeks, in strong contrast,
as to both time and manner, with the tedious healing and ugly scarring that
often ensue when these abscesses are left to open spontaneously, or are opened
widely with the knife or caustic.

The internal treatment which I have always employed in these cases when
suppuration has taken place (and which, if any, will prevent its occurrence),
is the giving of tonics, or iron, and good food. The medicines for children
may be, according to the case, from two to five grains of the potassio-tartrate
of iron, or from five to ten grains of the liquor cinchonas, or a drachm of the
cod-liver oil, three times a day. The first I think best in ordinary cases, in
which the characters of struma are well marked, and not complicated ; the
second appears best when with struma there is marked debility, drooping,
deadly pallor, duskiness ; and I think it is a very good plan to give the bark
with lime-water ; the third seems fittest when great emaciation exists. In all
cases it appears useful to give occasional small doses of the hydrargyrum cum
creta, with rhubarb or the sesquioxide of iron. I doubt whether iodine does
good in any of these cases, unless in combination with iron.

42. St?,umous Inguinal Glands. — Among the affections often wrongly classed
with the syphilitic, is, according to Mr. James Paget, a form of suppuration
in the inguinal glands, which is apt to occur in those that are enfeebled and
of strumous constitution. The confusion of it with syphilis is probably due
to its often occurring after gonorrhoea ; but it is often seen with no such con-
nection, and when it does follow gonorrhoea, it is often so late after the ces-
sation of the discharge, that we can only ascribe its occurrence to the general
debility which gonorrhoea is apt to produce in weakly persons.

The disease may affect the glands both above and below the crural arch, or
either of these sets separately ; and the feature which most certainly distin-
guishes it from syphilitic glandular disease is, that the inflammation, which
leads slowly to suppuration, appears to involve separately each gland, with its
immediate investments. The glands are not collected, as in one inflamed
mass ; neither is there much external swelling, or much inflammation around
the proper substance of the glands; but they lie separately swollen, and com-
monly the skin over each, though scarcely, if at all, elevated, appears as a
separate small red patch. "When suppuration ensues, each gland suppurates
and opens separately, or with subcutaneous narrow tracks of communication
with the rest. Thus, late in the disease, we may see one or both groins, with
two, three, or more openings, leading to as many suppurating cavities or tracks
extending under comparatively healthy skin.

In all the characters just described, this disease of the inguinal glands bears
the admitted marks of usual, but not constant, distinction between syphilitic
and strumous inflammation ; of the former as leading to suppuration about the
glands, the latter to suppuration in them. And, in correspondence with this,
the usual characters of strumous inflammations are noticeable ; such as the
pale rosy redness of the inflamed integuments, the thinness of the pus, the
general tardiness of both the suppurating and healing process.

The best treatment appears to be, when suppuration has not yet ensued the
giving of iodide of iron, in doses of about a drachm of the syrup thrive daily,
with occasional aperients, good food, and the constant application of warmth.

530

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If the glands have suppurated, each, when the skin is thin or feels undermined,
should be punctured with a small knife ; and the pus may be allowed to flow
out slowly without pressure. The general treatment after puncture may be
the same as before ; and if the abscess-cavities appear very tardy in healing,
lotions of nitrate of silver should be dropped into them, or if there be sinuses
they should be injected with solution of iodine. Complete rest is not necessary;
the general advantage of moderate exercise in the open air is greater than the
injury done by moderate movements of the groins.

I know no disease in which the iodide of iron does so much good as in this;
and it appears better than any other preparation of either iodine or iron, and
better than bark in any form. — Med. Times and Gaz., Jan. 2, 1858.

43. Cancerous Lymphatic Glands. — Few diseases, says Mr. James Paget
[Med. Times and Gaz., Jan. 2, 1858), are so insidious in their early progress as
primary cancer in the cervical lymphatic glands. Beginning like an ordinary
hypertrophy or chronic inflammation of the glands, it may advance far without
exciting much, if any, suspicion of its terrible nature. Then, as the swelling
increases, and, if increasing rapidly, becomes softer at its most prominent part
and covered with florid skin, the imitation of suppuration may be so close as
to deceive the most practised touch. Puncture by mistake may now discover
what is going on; but in some cases, it may only prolong the oversight; for
suppuration may have taken place in the substance of a cancerous gland. I
have even seen repeated collections of pus in a cluster of cancerous glands,
emptied by repeated punctures, prolonging the belief that no cancerous disease
existed, though other signs of its presence seemed distinct.

I cannot tell how this error of diagnosis may be always avoided ; but the
following may be useful helps. In patients of middle or older age, all enlarge-
ments of cervical glands, that are not evidently inflammatory or sympathetic,
should excite some suspicion of cancer. The suspicion should be the greater
the older the patient is. It must be increased, if the glands affected are under
the upper part of the mastoid muscle, and still more if they are under the
middle of the muscle. It is a bad sign when they form a close compact cluster,
or when, after puncture, the swelling does not at all subside ; and equally bad
when the swelling, as it increases, becomes less movable. The harder the
glands are at first, the more they must be feared ; and the probability of cancer
is greatly increased if the patient loses weight and strength, or is a member of
a family in which cancer has occurred.

The difficulty of diagnosis which is here referred to occurs most commonly
in cases of primary cancer of the glands ; but it may occur also in those of
secondary cancer ; for the disease in the glands may so predominate over the
primary disease in the tongue, mouth, or jaws, that of this the patient may
know little and say nothing. All these parts therefore should, in every case,
be carefully looked to.

44. On Congelations. — M. Valette having had abundant opportunity during
the late war of studying this subject upon crowds of French soldiers in the
hospitals at Constantinople, suffering from congelation of the hands and feet,
has contributed an interesting paper respecting it to the valuable Journal of
Military Medicine published by the French Army Medical Department. The
following are his principal conclusions : —

1. A moderate degree of cold is sufficient to give rise to the more or less
serious effects of local congelation, when it is aided by numerous causes of
general debility. 2. These effects may be divided into five different degrees,
i. The sensibility and motility of the parts are chiefly affected ; but the effects
are usually dissipated within twenty days. n. The formation of phlyctgenge.
in. Ulceration of the superficial layers of the dermis, iv. Mortification of the
skin and subjacent cellular tissue, v. Sphacelus of a more or less considerable
portion of a limb. 3. This last form sometimes affects the whole of both feet
simultaneously, coming on insidiously with the symptoms of the first degree.
A brownish depression suddenly encircling the lower end of each leg, opposite
the base of the malleoli, is the sign of its invasion. 4. The fourth and fifth

1858.]

Surgery.

531

degrees have never been observed as the result of a too sudden return of the
circulation and warmth in the parts affected, the gangrene always supervening
upon the gradual extinction of vitality unattended by any local reaction. 5.
The progress of these congelations was rendered remarkable by the slowness
with which the functions of the parts became re-established in the two first
degrees ; and the great delay attending the process of cicatrization in the three
last. 6. The chief fatal internal complications were diarrhoea, tetanus, and
typhus. 7. Independently of complications, the congelations never gave rise
to the phenomena of general reaction; but in some patients, on the elimination
of an important part — e. g., both feet — the febrile action took on the form of
quotidian intermittent. 8. It was not in general possible to determine during
the first days with what degree of congelation the part was smitten. 9. In all
cases prognosis should be very reserved. Still, setting internal complications
aside, it may be said to be favourable in the first three degrees, and unfavour-
able in the last two. It is more favourable when the hands than when the feet
are affected, and it is highly unfavourable when diarrhoea of more than two
months' date, pseudo-membranous bronchitis, adynamic pneumonia, dropsy,
or tetanus is present. 10. The prophylaxis should consist in the frequenb
change of tents, the addition of preserved vegetables to the rations, the fre-
quent distribution of small quantities of alcoholic drinks, and in the anointing
the feet with some fatty body, as tallow, that may be spread into a thick layer.

11. General treatment exerts great influence on the progress of local congela-
tions, and should be directed in regard to the prevailing ansemia and debility.

12. The local treatment of the first degree should consist in the application of
lotions containing laudanum, conjoining with these, if oedema is present, fric-
tions, with tincture of digitalis and camphorated spirits. The parts should
afterwards be carefully wrapped in flannel or wadding. In the second degree,
the epidermis should be carefully preserved after evacuating the serosity. In
the third degree, the pain and itching of the ulcers should be allayed by fer-
mentation with infusion of elder containing laudanum and extract of lead,
while the process of cicatrization should be hastened by caustics. In the fourth
degree the danger did not consist in too active local reaction, as observed in
men in the full plenitude of vital power at the time of congelation, but in a
gradual, insensible extinction of life in the parts affected. Stimulant frictions
are at once indicated, and if eschars still form, they should be removed as
soon as possible, by carrying the knife along the limit separating the dead
from the living parts. In the fifth degree, elimination should be encouraged
by stimulating fomentations ; and when the ulcerative furrow has sufficiently
separated the dead from the living parts, any ligaments, tendons, or bones
which impede complete separation, should be divided level with the living parts
— an operation perfectly harmless, and much abridging the progress of the
case. [The harmlessness and propriety of this interference, we may observe,
is denied by M. Baudens and other Crimean observers.] 13. It results from
the observations made in Africa, and the experience gained in the Crimea,
that, as a general rule, amputations should be abstained from in cases of con-
gelation, leaving these to the reparative powers of nature, at the same time
aiding by general and local means the elimination of the dead parts. To this
general rule, however, the following cases are exceptions : I. When trismus
occurs in a subject too debilitated to admit of bloodletting, the patient will die
in twenty-four or thirty-six hours unless amputation is speedily performed.
ii. When a congelation of the fourth degree is complicated by diarrhoea, which
resists treatment, amputation must be performed, in order to render the
economy susceptible of the influence of therapeutical agents, ill. When
sphacelus of both feet is announced by the appearance of the brownish circle
at the lower extremity of each leg, amputation must be performed, or the
patient will sink under an exhausting diarrhoea. When internal complications
do not prevent it, the interval of a week may elapse between the two opera-
tions. 14. In the choice of the spot for the performance of the operation for
the sake of securing a more rapid cure, we should select this as far distant as
possible from the seat of congelation, short of endangering the patient's life
by a too near approach to the trunk. 15. When resection of one or more bones

532

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[April

is indicated, it is of great importance, in order to shield the patient from the
effects of purulent absorption, that we should confine our interference to the
limit between the dead and living parts, without implicating the latter. — B,
and F. Med.-Chirurg. Rev., Jan., 1858.

45. A Mixture of Collodion and Castor Oil as an Application to Severe Cases
of Burns and Scalds. — A mixture of two parts of collodion and one part of
castor oil has been extensively used at King's College Hospital, and is said to
possess many advantages over other applications. It is painted over the entire
surface of the burn, so as to afford a coating to the parts which entirely ex-
cludes the atmosphere without obscuring the surface of the sore from view.
It is said to have the effect of immediately lessening the pain ; and that in all
the cases in which it has been applied, the sloughs which have subsequently
formed have appeared to be much less deep than usual. These cases are re-
corded in the British Medical Journal (Dec. 26th, 1857), in which this applica-
tion was used with the most satisfactory results.

46. Employment of Collodion in Orchitis. — Having treated 64 cases of gonor-
rhceal orchitis in the Maggiore Hospital, Milan, solely by means of collodion,
Dr. Lossetti comes to the following conclusions : 1. Orchitis, epididymitis, or
inflammation of the spermatic cord, even when intense, arising from blennor-
rhagia, yields much more readily to the application of collodion than to the
ordinary antiphlogistic treatment, actively employed. 2. The most efficacious
means of obtaining certain and rapid recovery is the application of the collo-
dion (the author prefers to pure collodion a mixture of one part of castor oil
and twenty-four parts of collodion) twice a day until the cure is completed,
applying it oftener, however, in cases of extreme gravity. 3. Under the use
of the collodion, the indurations and enlargements which remain after the re-
lief of the inflammatory action will be dispersed without the aid of any other
means. 4. By means of its application, the erysipelas of the scrotum that
sometimes complicates the orchitis becomes resolved, and the cellular infiltra-
tion that almost always accompanies or succeeds it disappears. 5. The treat-
ment required besides only consists in the observance of a low diet, rest, and
cooling drinks. 6. This mode of treatment is more economical than the anti-
phlogistic mode, by reason of the shorter time it requires (according to the
author's cases, eight days as compared to fourteen by the ordinary treatment),
and the saving of expensive remedies, as leeches, etc. 7. The treatment is also
to be preferred, since the digestive organs are not disturbed by active purga-
tion, and the general powers are not enfeebled by this and the abstraction of
blood. 8. The sensation of burning produced by the application of the collo-
dion never amounts to the extent of acting as a contra-indication. It becomes
violent, and even insupportable, only when some minute lesions of continuity
of the skin of the scrotum are present; and these only require to be protected
by cerate or court plaster, to enable the patient to bear the application. — Med.
Times and Gaz., Jan. 16, 1858, from Omodei Annali Univ., vol. clix.

47. Large Doses of Disulphate of Quinine in Dysuria and Retention. — Dr.
Serres, of Dax (France), quotes eleven cases of his own practice where he
succeeded in removing the dysuria, or conquered the retention, by giving disul-
phate of quinine in doses varying from eight to ten grains every half hour. In
retention, urine began to flow after the second or third dose, and no instrument
was used in the cases mentioned. It would also appear that the quinine did
not produce any unpleasant symptoms. How does the alkaloid act in these
instances ? Probably by allaying spasm. One case is recorded where several
strictures had existed for a long time, and the quinine was, nevertheless, suc-
cessfully administered. — Lancet, Jan. 23, 1858.

48. Thoracic Aneurism successfully treated. — Mr. Tufnell related the fol-
lowing example of this to the Surgical Society of Ireland (Dec. 12, 1857).
Samuel Parkes, ost. 54, a die cutter and seal engraver, a delicate looking man
(and exhibiting considerable cardiac distress), was admitted into the City of

1858.]

Surgery.

533

Dublin Hospital on the 18th of September, 1854, with thoracic aneurism. He
stated that he had always been temperate and steady, but had worked very
hard at his trade, that of die cutting in steel. For some time back, he had
felt heaviness in his chest, but had not noticed anything particular until about
five weeks prior to admission, when one night, on taking a pill for constipation,
it passed into the trachea. He was seized with intense coughing, which lasted
for an hour, and was exhausted by its severity. Two days subsequently he
experienced severe pain in the right breast, and the next day a tumour ap-
peared elevated above the surrounding skin, which had gradually increased
up to admission.

At this time, the tumour was three inches in diameter, elevated in its centre
nearly two-thirds of an inch, with considerable pulsating action, the integu-
ment over it being apparently not thicker than three or four lines. The
integument itself was not discoloured. The tumour presented to the right
side of the sternum, in the situation of the third and fourth ribs, which,
together with a portion of the sternum, had been absorbed. There was a
double pulsation sound, but no murmur. The pulse was 88, full and regular,
and equal at either wrist. The patient's general health seemed good, and he
complained only of the pain in the tumour, which he said was excessive. He
had continued to work at his trade until obliged to relinquish it in consequence
of the severity of the pain.

The aneurism evidently sprung from the anterior aspect of the right side of
the ascending portion of the arch of the aorta, and was progressing rapidly to
the surface, absorbing all before it. It must have existed for some time unper-
ceived by the patient, and its appearance on the coughing fit shortly before
must have depended upon previous removal of the bony and cartilaginous
structures intervening between it and the integument.

Regarding the case as one suited for Dr. Bellingham's plan of treatment
upon restricted diet and rest, I spoke to the patient, and asked him if he would
aid in carrying it out, and confine himself rigidly to the diet and regimen pre-
scribed. I explained to him the critical condition in which he was placed, and
his almost certain progress to speedy death, unless the absorbent action then
going on could be arrested, and the sac so lined with fibrin from within as to
prevent further distension of it. He consented readily, and, I believe, strictly
kept his word, and took no food or drink whatever during the period of his
stay in hospital other than that which he was allowed.

I ordered him to have an excellent well made bed, with two hair mattresses,
and plenty of pillows for props, and once recumbent, not to rise for any pur-
pose whatever, a urinal receiving the vesical, and a bedpan the alvine dis-
charges. I desired him to speak as little as possible, and furnished him with
plenty of books. His diet was confined to two ounces of white bread and butter
for breakfast, with two ounces of good new milk; two ounces of white bread
and two ounces of broiled mutton for dinner, with two ounces of milk; and
two ounces of white bread and butter, with two ounces, of milk, for supper;
thus making the total of the solid food to amount to only eight ounces, and of
the fluid food to six ounces, in the twenty-four hours. Ice was applied in a
bladder at intervals over the tumour. This treatment was commenced upon
the 19th of September, and continued steadily until the middle of November.
Its effect was as follows : At first, he felt the loss of food, and used to look
anxiously at the other patients' meals, but being a sensible man, he restrained
his appetite. He suffered more from thirst than from hunger, and complained
a good deal of dryness of the throat and fauces at night, which, however, was
somewhat relieved by keeping a small pebble in his mouth.

He daily complained less and less of these annoyances, and by the 25th
September was progressing rapidly, the pulse being reduced to 70, and soft ;
the pulsation and pain of the tumour greatly diminished. An untoward cir-
cumstance now occurred which threw him back. A case of delirium tremens
was admitted into the ward, and the violence of this patient caused him agita-
tion and alarm. When visited on the morning of the 26th, the heart's action
was found to be tumultuous and impetuous, and the whole system much dis-
turbed. He was ordered a little port wine and opium, and by degrees confi-
No. LXX.— April 1858. 35

534

Progress of the Medical Sciences.

[April

dence and calmness of mind were restored. By the 28th, he had regained his
previous condition ; the pulse was full, but very compressible, and beat steadily,
at 70 in the minute. The tumour seemed flatter, and was described by the
patient " as feeling condensed into a smaller space." The ice had been dis-
continued for some days, and a thin piece of linen rag, moistened with water
only, kept as an evaporating medium to the surface. The double thump had
already disappeared in the tumour, and a single beat only could be felt, cor-
responding to the natural sound of the heart, but slightly louder. The patient
had ceased to complain of hunger or thirst.

Upon the 2d of October, the pulse had fallen to 62. He could now lie flat
upon his back for two hours at a time without experiencing any uneasiness;
after this, however, uneasiness was felt, and unless his position was shifted to
the side, cardiac agitation was experienced. I mention these particulars, for,
though apparently trifling in themselves, upon attention to them must depend
much of the likelihood of success in treatment, where all is dependent on
quietude of circulation and rest. The tumour now gradually became more and
more firm to the feel, and flattened and declined. Towards the middle of
November, his general health was excellent, and his weight had but very little
reduced.

His diet was slightly increased, and on the 13th of December he left the
hospital at his own desire, having been able for some time to walk about the
wards and up and down stairs without distress. For the latter part of his stay
in hospital, he was under the care of my colleague, Professor Hargrave, my
period of attendance having expired.

I saw nothing more of this man from that date until a short time since,
when he called upon me to request my advice for an irritable ulcer of the leg.
I partially recognized him, but not entirely, and on asking if I had not seen
him before, he replied, "Oh, yes, sir; you cured me of an aneurism; but it is
not about that that I am come, it never troubles me now." I looked at the
ulcer of the leg, but felt more anxiety to ascertain the condition of the contents
of the chest and the changes which had taken place. I should, however, pre-
mise by stating the nature of his occupation and proceedings during the inter-
vening three years. Upon being questioned, he said that on leaving the hos-
pital in December, 1854, he had returned home, "feeling able to do something
for his family's support ;" that in March following, he regularly resumed his
trade as a die and steel engraver, and had continued steady at work ever since.

Upon stripping him, the first point that attracted notice was the enlargement
and tortuous state of the abdominal and pectoral cutaneous veins, the epigas-
tric, circumflex, and mammary having assumed the condition of large venous
trunks. The tumour next arrested attention. It projected to the right side of
the sternum, nearly midway between the clavicle and nipple, but inclining to
the former, where it presented a bulging prominence the size of a small saucer,
occupying the situation of the cartilages of the second and third ribs, making
this side contrast strongly with the hollow intercostal spaces and marked ribs
upon the left. No pulsation was visible in the tumour, nor made apparent
when any testing object (such as a portion of white paper) was placed upon
it. To the hand it felt dense, and the cardiac impulse against the interior of
the sac was unheeded. The sound on percussion was dull over a very large
space around the tumour, whilst to the ear a double sound was given, inter-
mediate in time to the contractions of the heart. Upon deep inspiration of the
whole chest, this portion was not expanded. The heart's sounds were audible
over a very large portion of the chest, and the pulsation, aneurismal and car-
diac, was communicated to the hand or ear for a space of fourteen inches in
an oblique line from the right clavicle down to the left hypogastric region.

His general appearance indicated a barrier to the return of venous blood to
the right side of the heart. There was some congestion of the face, especially
increased upon stooping, with pufBness of the neck and face to a slight degree.
There was no interference by pressure upon the trachea, or, at least, to any
extent, none upon the oesophagus or the deep nerves of the chest; for stridu-
lous breathing, dysphagia, and aphonia were all wanting, his functions in this
respect being very good. He had some cough and expectoration, which caused

1858.]

Surgery.

535

him a good deal of annoyance, particularly at night. After coughing, he said
he occasionally feels pain dart into the tumour, but not at any other time.
There was no interference with either the carotid or radial pulses, and of the
latter, the circulation was equal on both sides. He stated that he lies at night
on the right side to sleep, and cannot rest upon the other, but changes over to
it occasionally prior to going to sleep. He said that he had during the past
year lost flesh, and is not as strong as he was, but still works regularly at his
trade, which is a fatiguing occupation. — Dublin Hospital Gazette, Jan. 1, 1858.

49. Cure of Popliteal Aneurism by Digital Compression of the Vessel correspond-
ing with the Sac. — M. Vanzetti submitted a short time ago to the Surgical So-
ciety of Paris two cases of popliteal aneurism, in which he obtained the
consolidation of the contents of the sac, in forty-eight hours in one case, and
five hours in the other, by the continuous compression of the femoral artery,
by means of the fingers alone. Relays of students were employed in these
cases. M. Michaux, a French surgeon, has also presented a similar case to the
Society, where a cure was obtained in twenty-four hours. The reporter on
these cases, M. Verneuil, took the trouble of collecting all the cases where this
treatment has been used, and he found that out of seventeen, only seven were
unsuccessful. From a review of these cases, the reporter thinks himself justi-
fied in submitting the following propositions to the Society: —

1. Indirect digital compression, either steadily continued or intermittent, and
kept up by skilful assistants, or by the patients themselves, has cured aneu-
risms without the assistance, before or during the treatment, of any other the-
rapeutical measure.

2. Digital compression, associated or alternating with the tourniquet, has
also led to rapid cures. Success, when likely to be obtained, is in general ra-
pidly attained.

3. It has cured aneurisms, when mechanical compression was impracticable,
or was forcibly given up. It is more easily supported than the latter, as the
fingers can exert compression, even when the skin is inflamed.

4. "Digital compression is more efficacious and less painful than any other
kind, as the action may be limited to the artery, and does not include the
neighbouring nerves and vessels. The skin also is less tried." — [Broca on
Aneurism, p. 807.)

5. Digital compression may fail to produce a cure ; but even then it advan-
tageously modifies the condition of the aneurism.

6. It may be surmised that, alone and unaided by other means, it would have
led to a cure, had it been applied more perseveringly and regularly than was
done in the cases above alluded to.

7. No accident whatever has to this day attended this mode of treatment.

8. Digital compression was first practised by Saviard, a French surgeon, after
an operation for aneurism by the old method ; this compression has not been
as generally and extensively applied in France as it could be wished. — Lancet,
Feb. 20, 1858.

50. Excision of Enlarged Tonsils. — For chronic enlargement of the tonsils,
whether through simple overgrowth or in consequence of chronic inflamma-
tion, the excision of the projecting portions, Mr. James Paget states [Med.
Times and Gaz., Feb. 6, 1858), seems by far the best treatment. So far as I
have seen, the cutting of tonsils is never followed by severe hemorrhage or
other serious inconvenience, provided they are not inflamed at the time of being
cut. And I believe that if other means of reducing the size of enlarged tonsils
be not quickly beneficial, the excision should be adopted both oftener and earlier
than it commonly is. One frequently sees cases in which delay in operating
has given time for the occurrence of the incurable " chicken-breast'-' deformity
of the chest, which Dr. Warren pointed out as a common result of the habitual
hard breathing of children with enlarged tonsils.

The double vulsellum and common probe-pointed bistoury are, I believe, the
most advisable instruments for this operation, because, among other reasons,
they are equally fit for all cases. There are certainly some cases for which

536

Progress of the Medical Sciences.

[April

even the most improved guillotines are insufficient instruments; those, namely,
in which the enlargement of the tonsil extends so far down by the side of the
pharynx, or up towards the soft palate, that a fair portion of the disease can-
not be taken within the ring or loop of the guillotine. For these broad-based
enlarged tonsils, the knife alone is applicable; and, to remove them effectually,
it is advisable to have a facility which will hardly be possessed if the knife be
used for them alone, but which the hands accustomed to the cutting of com-
mon enlarged tonsils will seldom lack. The general direction for the operation
must be to cut from below upwards, the blunted point of the knife being car-
ried well backwards, and its edge just internal to the posterior arch of the
palate.

51. Experience of the Surgeons of the " Dread7ioiightv as to Pirogoff's Operation
at the Ankle-joint. — The success attending the above operation at the "Dread-
nought" has induced Mr. J. Croft, the assistant surgeon, to call the attention
of the profession to the following facts : —

Six times the operation has been performed, and in four instances with most
perfect success ; but in the two remaining death removed the subjects of ope-
ration before cure was completed — in the first instance by granular disease of
the kidneys, and in the second instance by secondary deposits of pus in various
joints.

In two of the six cases in which cure was completed, the operation was per-
formed for the removal of scrofulous disease of the articulations between the
tarsal bones ; and in the two others the operation was for frost-bite of the an-
terior part of the feet.

Progress towards health was marked by suppuration along the tendons of the
tibialis anticus and posticus and the peroneal tendons in each of the cases, but
not by exfoliation of bone. The posterior part of the os calcis was united
firmly Math the tibia, generally in about three weeks ; but in one instance —
the last in which the operation was performed — union was good at the end of
twelve days.

I may here remark, that although the os calcis may be diseased at and about
its articulating surfaces in instances of scrofulous disease of the joints of the
tarsus, it is rarely that the posterior part is rendered too unhealthy to be made
use of in the formation of a stump.

The advantages of this operation over " Syme's" (the only operation with
which it can be compared) are, that it may be performed more rapidly as to
time, leaves a more vascular flap, forms a longer stump, and produces a firmer
pad for the subject to walk upon.

Less time is occupied in the operation for the somewhat troublesome dissec-
tion of the skin of the heel from the os calcis is avoided, and the os calcis sawn
through instead.

Greater vascularity of the flap is secured, for the plantar arteries are divided
in the hollow of the foot.

The length of the stump is a very important point; it is longer than that in
Syme's operation, by the portion of the os calcis left on the flap, which should
be quite one inch and a quarter. In the four instances mentioned, the differ-
ence in length between the foot operated upon and the sound foot, was never
more than three-eighths of an inch.

The mode of operation, as performed by Mr. Busk, Mr. Tudor, and myself,
is to grasp the projecting portion of foot with the left hand, then to enter the
point of the knife immediately behind the malleolus, and make a semicircular
incision, in front of the point, terminating at a corresponding point behind the
opposite malleolus; next, to carry the incision downwards and slightly for-
wards to the edge of the sole of the foot, straight across the sole, and terminate
it at the opposite malleolus, or the point at which the incision was commenced.

Having disarticulated the foot, the soft parts are to be separated from around
the os calcis in a line from the posterior margin of the upper articulating sur-
face to the under edge of the articulating surface of the cuboid, and the mass
in front of this line to be removed by the saw.

The ends of the tibia and fibula are sawn off in the way usual in Syme's

1858.]

Surgery.

537

operation. During the process of separating the soft, or rather tough parts,
about the os calcis, care should be taken to keep the edge of the knife close to
the bone, in order to avoid wounding the posterior tibial or plantar arteries.
The portion of the os calcis left on the flap should be placed in contact with
the end of the tibia, and if the saw has been entered well behind the calcaneo-
astragaloid articulation, and brought out at the under margin of the calcaneo-
cuboid articulation, the contact will be accurate. If the bones cannot be placed
in accurate contact, thin slices of bone from the upper and back part of the
portion of the os calcis should be removed by the saw until they can be adapted.
The saw we prefer is Bigg and Milliken's modification of Butcher's Dublin saw.
—Lancet, Feb. 6, 1858.

52. On some Points connected with the Treatment of Obstinate Stricture of the
Urethra. — Mr. Henry Smith read a paper on this subject before the Medical
Society of London (Jan. 30th, 1858). He commenced by defining the term
obstinate in reference to stricture, and referred to three forms of the disease
where this obstinacy obtained. The first was where the main source of distress
to the patient and difficulty for the surgeon, existed in the excessive irritability
of the urethra, which would not allow of treatment to be carried on satisfac-
torily by ordinary means. In the second class of cases, the stricture was marked
chiefly by its density, and by the peri-urethral condensation of the parts to the
perinseum and scrotum, accompanied occasionally with fistulous openings. In
addition, also, there might be the extreme irritability associated with the first
form of stricture: if so, the surgeon would have to deal with a most difficult
case. In the third form of the disease, the author referred to those cases of
stricture which were entirely caused by injury to the perinseum, which occurred
at the earliest periods of life, and which were especially marked by extreme
density of the parts, and rebelled generally against ordinary treatment.

For the treatment of these cases, which in the more severe forms so often
baffled the ordinary means employed, the author considered that much more
might be done than is at present. In the first kind of case, where the stricture
was accompanied by extreme irritability of the parts, great attention must be
paid to preparatory measures for some days before local treatment is com-
menced; entire rest, freedom from all stimuli, careful attention to the various
secretions ; and when these were improved, the liberal administration of opium
were the means administered. When the system had become less irritable
dilatation was to be commenced ; but when there were, as is often the case, two
or more strictures, and those excessively narrow, the treatment by the use of
metallic catheters and sounds has to be especially avoided, as much irritation,
is caused by them in severe cases ; whilst in others the patients will not allow
them to be used a second time. Wax bougies, however, when well made and
skilfully used, could be employed without producing irritation, and dilatation
could be carried on up to a certain point where no other instrument would effect
it. The objections urged against the wax bougie as an Unreliable instrument
were not founded upon good evidence. It was, however, only in the early stage
of treatment that Mr. Smith used the wax bougie ; for as soon as a fair-sized
bougie could be introduced, he went on with the treatment by using metal in-
struments. When from the excessive irritability of the urethra dilatation could
not be proceeded with, the author strongly advocated the use of potassa fusa,
as employed by Mr. Wade, applied very lightly, and detailed a case illustrat-
ing the benefits of that agent in a great degree.

In the second form of the disease, preparatory treatment was of great avail ;
but here the peri-urethral thickening should be reduced by applications of
leeches from time to time, by continual fomentations and poulticing. Then,
instead of forcing a small catheter through the tight obstruction, the author
recommended that a fair-sized solid sound or catheter should be passed down
to the face of obstruction, and held against it for some time. If these and other
measures failed, the potassa fusa was to be applied more freely than in the first
kind of cases referred to.

In the third form, where the stricture was traumatic, the surgeon would have
great trouble. Fortunately, however, there is little irritability in such cases,

538

Progress of the Medical Sciences.

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and therefore the surgeon might employ his measures somewhat more freely.
Retention of the catheter and the potassa fusa are the agents to be relied upon.

The author considered at some length the action and use of potassa fusa, and
spoke highly of it as an adjuvant to other treatment, but strongly deprecated
its frequent or free employment. He detailed some cases in support of his
views, and concluded his paper by some observations on the treatment of ob-
stinate forms of stricture by incisions. He considered cutting as a remedy for
stricture as bad in principle, and believed that a cure could not be effected by
it more than by any other measures. Cases related by surgeons and in hos-
pital reports hitherto could not be relied on, as the history of the patients was
generally only brought down to a few weeks from the operation. Years were
necessary before a proper appreciation of cutting could be made. Mr. Smith
detailed the particulars of two or three cases, where cutting had been performed
years previously, and where the results, at first satisfactory, were ultimately
quite the contrary.

53. Diagnosis of Hydrocele. — Prof. Nelaton recently addressed the following
observations to his clinical class : In some cases the diagnosis of tumours of
the testis presents almost insurmountable difficulties. The slightest circum-
stances then acquire the highest importance, and it becomes of importance
that we should not attribute to any sign a degree of confidence that it does not
deserve.

The Transparency of the Hydrocele. — In order that this should be effectually
exhibited, we should take care that the patient is not exposed in broad day-
light. Another point just as indispensable is often neglected. When the
surgeon commences his explorations, the sudden impression of cold causes a
contraction of the dartos, and however slightly the size of the tumour may
allow of its rising towards the ring, to that extent the scrotum becomes relaxed,
wrinkled, and increased in thickness. This is one of the impediments to trans-
parency, but there is another of much more importance. This ascending move-
ment, by bringing the tumour nearer the axis of the body, prevents the light
from falling perpendicularly on its surface ; and the rays which fall under too
oblique an incidence do not penetrate the tumour, and consequently cannot
exhibit its transparency. It becomes necessary, therefore, to isolate the tumour
as much as possible, to, so to speak, enucleate it, by taking hold of it near the
ring and pressing it forward, separate it as much as possible from the other
parts of the body. In this way, the wrinkles of the scrotum also disappear,
and the stretched skin diminishes in thickness. Transparency may now be
easily shown, by placing the light very close (two or three centimetres), and
on a transverse axis, passing through the middle of the tumour, so that the
rays may traverse it unreflected. This precaution, of no account in simple
cases in which error is well nigh impossible, is indispensable in those in which
the surgeon remains undecided as to the nature of the disease, precisely because
he cannot establish the transparency. M. Nelaton has met with many cases
in which the surgeon, from want of being aware of these facts, has mistaken
hydrocele for far more important affections of the testis.

Specific Gravity. — Most surgeons attach very great importance to this sign,
but it will be easy to show that it does not deserve the confidence placed in it.
The hand, raising the tumour, has to estimate the weight of the entire mass ;
and these tumours, when even of the same nature, possess very different amounts
of movability, accordingly as they are attached by pedicles, letting the hand
pass on all sides, or are bound down by the contraction of the cremaster, dartos,
and scrotum. Moreover, we have not to appreciate the absolute weight of the
tumour, but its relative specific weight, as compared with that of another mass
of a different size — a mass not now at hand capable of being compared, but
estimated at some former period, under similar unfavourable conditions, its spe-
cific gravity being retained in the memory.

Let a piece of gold of a certain volume be placed in the hand of an individual,
and a week afterwards give him a piece of copper of the same volume, desiring
him to appreciate the relative specific weight of the two metals. Certainly he
will not do this readily, and the task will become far more difficult if we pre-

1858.]

Ophthalmology.

539

sent to him pieces of different size. And yet is the specific weight of gold
more than double that of copper. What must happen, then, when we have to
compare with each other, under the above-mentioned unfavourable conditions,
masses of a specific weight so slightly differing as hydrocele and the other
diseases of the testis? For, in fact, the difference of the specific weight of the
liquid of hydrocele, and of that of the matters constituting other diseases of
the testis, is almost insignificant. Of this we may be easily convinced by
examining the figures M. Nelaton has obtained by comparing the weight of
various tumours with the weight of the same volume of water.

A hydatid cyst of the testis, weighing 466 grammes in the air, displaced 450
of water, giving a difference of less than An encephaloid tumour gave a
difference of and a cancerous sarcocele gave a difference of about T'^. Now
it is evident that a difference even of is quite inappreciable in the conditions
under which the surgeon operates, while the density of the serosity of hydro-
cele is somewhat greater than that of water, and in the experiments the weight
of the tumours are compared with that of water, without taking into account
the addition of tissues which exist in the living subject. But these tisssues,
viz., the testis and its coverings, are nearly of the same density as encephaloid
matter. It may be then said that the sign drawn from the specific gravity of
tumour of the testis is positively of no value. It is one of those signs invented
in the study, and has continued to be handed down to us because no one has
thought of examining into its exactitude. — B. and F. Med.-Chirurg. Rev., Jan.,
1858, from Gaz. des Hopitaux, No. 124, 1857.

OPHTHALMOLOGY.

54. On some Points in the Pathology and Morbid Anatomy of Glaucoma. — Mr.
Hulke read before the Royal Med. and Chirurg. Soc. (Jan. 12th, 1858) a paper
on this subject.

The ophthalmoscopic examination of many cases of glaucoma, and the dis-
sections of several eyes affected with this disease, have furnished the facts de-
tailed in this paper. Two chief forms of glaucoma have been long recognized:
they are the acute and chronic, but a large number of cases occupy an inter-
mediate position. The symptoms of acute glaucoma have been often and well
described, but the ophthalmoscopic signs are less widely known. They are: a
dilated state of the retinal veins, often tortuous and turgid with blood; small
ecchymoses scattered over the surface of the retina; occasionally small blood-
clots in the vitreous humour; pulsation in the arteria centralis retinae; and an
excavated state of the optic papilla. These last two signs were, the author be-
lieves, first noticed by Graefe, who insists upon their being pathognomonic of
this disease. Although in acute glaucoma the urgent symptoms often set in
very suddenly, yet in a large number of cases the outbreak has been fore-
shadowed by a train of premonitory symptoms. These are: occasional dimness
of sight, often towards evening, shooting pains in the eyeball, muscse, and a
gradual diminution of the field of vision. Graefe has drawn particular atten-
tion to this last point. The outbreak may be followed by a remission, only a
temporary improvement, for fresh paroxysms will occur, and blindness inevit-
ably result. In the advanced stages sclerotic staphylomata are apt to occur,
mostly behind the insertions of the recti tendons. Chronic glaucoma differs
from the acute chiefly by the insidiousness of its course, which is unmarked by
those violent symptoms which characterize the outbreak of the acute form. It
is quite as intractable as the acute form. The retinal veins are turgid, and the
retina is sprinkled with hemorrhagic spots, just as in the acute form. Some-
times in the same person one eye is attacked by acute, the other by chronic
glaucoma. The facts favour the supposition that acute and chronic glaucoma
are only different forms of the same disease. Graefe has called attention to a
peculiar form of amaurosis, in which the optic papilla is excavated. This affec-

540

Progress of the Medical Sciences.

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tion must be carefully distinguished from glaucoma, which may be done by
observing that the globe is not tense, and the other signs of hypersemia are.
also absent.

Morbid Anatomy of Glaucoma. — The small blood spots which are sprinkled
over the inner surface of the retina are small spots of capillary hemorrhage.
This condition was first recognized in glaucoma, by actual dissection, by Mr.
Bowman. The bleeding proceeds from the capillaries in the inner layers of
the retina, and the blood either spreads literally amongst the elementary struc-
tures of the retina, or bursting through the hyaloid membrane, it forms small
clots in the vitreous humour. The retinal capillaries are irregularly dilated
and studded with small fusiform and globular enlargements — little aneurismal
pouches. These dilatations do not occur on the large vessels. The pouches
and the vessels communicating with them are usually crammed full with blood
corpuscles. In the hemorrhagic spots the retinal tissues are infiltrated with
blood disks, which have escaped by the bursting of some of these little aneuris-
mal pouches. Excepting the changes described above, the retinal capillaries
have a healthy appearance, and do not present traces of fatty or atheromatous
degeneration. The coats of the arteries are hypertrophied. The vitreous hu-
mour sometimes has a yellow tinge, which is derived from the colouring matter
of the effused blood. It often contains blood disks and delicate fibrinous webs ;
and sometimes also small blood clots, which can be clearly seen with the un-
aided eye. The vitreous humour has a very remarkable degree of consistence,
and does not quickly flow off when the eyeball is cut across. Viewed by trans-
mitted light, the glaucomatous lens has a yellow tint like the vitreous humour,
and which is probably acquired from the same source — viz., the colouring mat-
ter of the effused blood. The relations of the lens and the vitreous humour
favour this supposition. In none of the dissections were any morbid changes
found in the choroid, unless when staphylomata were present. Corresponding
with the staphylomata, the choroid, retina, and sclerotica preserve their natu-
ral relations to one another, and are not separated by any effusions. The
choroidal pigment is irregularly distributed; the tissues seem opened out. The
subsequent changes in the retina and choroid, in the advanced stages of the
disease, have an atrophic character. The dilated retinal capillaries and their
contents have been found, dark and granular, in a state of fatty degeneration,
and the contiguous parts of the retina participate in these changes. The
symptoms, the ophthalmoscopic signs, and the structural changes which take
place early in the disease, all point to a state of great vascular excitement in
the retina, and a greatly increased internal pressure upon the walls of the
globe. It is this pressure which causes the blindness in the early stage of the
disease, and the fixed dilated pupil, for when the pressure is relieved by ope-
ration, sight and mobility of the pupil return.

Mr. Bowman thought that Mr. Hulke's paper afforded a remarkable instance
of the very great advances which had been made within a few years in our
knowledge of eye diseases, especially those which were deep-seated, and which,
within a comparatively recent period, were extremely obscure, and for the most
part very unsatisfactory in regard to treatment. With regard to the morbid
anatomy of those affections they were indebted to the great advances made in
microscopic anatomy; but these would have been comparatively ineffectual in
elucidating the nature of morbid changes in the deeper structures of the eye,
had it not been for the opportunities of inspection immediately after the tissues
had perished, which were afforded by the plan of treatment followed out by
Mr. Critchett and himself within the last three years, of excising globes affected
with chronic and excessive pain, more or less jeopardizing the other eye, and
at any rate rendering the patient's existence very uncomfortable. The opera-
tion of excising an eye which was destroyed already and of no use in the
economy, was now known to be an extremely simple proceeding, and one that
could be adopted with perfect safety ; it was done under chloroform, without
pain ; it was immediately followed by relief of the symptoms, and an artificial
eye could be worn in a few days. He alluded to the operation as having given
the means of examining the nature of the morbid changes in the deeper parts
of the eye within an hour after removal, and enabling the microscopist to ex-

1858.]

Ophthalmology.

541

plore with great accuracy all the minute structures which were concerned, and
to detail the several changes which they presented. Another circumstance of
still greater importance was the invention of the ophthalmoscope, an instru-
ment which was second to none in the exploration of the physical condition of
disease in parts not open to ordinary sight. It had laid open all the parts of
the eye, so long as they remained transparent, which were situated behind the
pupil, and which before were absolutely closed to inspection. Formerly one
might conjecture the condition of the eye behind the pupil, and sometimes by
dilating the pupil with belladonna, get a dim insight into certain parts of the
interior ; but nothing was known of the structure of the retina during life from
actual examination. With the ophthalmoscope everything near the axis of
vision could be explored if the media were clear, and if they were not clear
their opacity was thus disclosed. The Germans, by whom the instrument had
been invented, were in advance of the English and French in its application;
and no one had done more in the exploration, by its means, of the changes in
the deeper parts of the eye than Professor Graefe of Berlin, to whose work on
glaucoma the author had alluded. He had made out all the changes occurring
in that remarkable disease. He had shown that there was a gradually increas-
ing pressure within the eye contingent upon an increased afflux of blood into
the vessels of the interior, and that with this there were several secondary
changes. There was an enlargement of the veins on the surface of the e}Te in
the same way as the veins of the abdomen were enlarged when the circulation
through the liver was impeded. There was also an excavated state of what he
should not call the "optic papilla," but the entrance of the optic nerve.
Another remarkable condition alluded to by the author was the pulsation of
the artery of the retina. Naturally that artery had no visible pulsation; but if
the eye was pressed, even in a healthy person, for a certain time the pulsation
might be rendered visible, the circulation being so impeded that the afflux of
blood was shown at every jet. When this condition did not exist in glaucoma
the slightest pressure would produce it, and Graefe regarded it as a pathogno-
monic sign of the disease. All these conditions characterized the disease in an
unmistakable manner, and pointed to the mode of treatment which Graefe had
recommended. The practice at Moorfields had fully borne out the results which
Graefe had announced at the recent Brussels Congress — namely, that by ex-
cising a portion of the iris in a particular way, in acute or chronic glaucoma
(particularly the former) there was almost from the first a diminution of pres-
sure, followed by an abatement of the symptoms, and an improvement of the
vision, even when under great pressure it had been abolished for a time.
Graefe had shown that the loss of vision in the condition of early glaucoma was
not the result of any change primarily occurring in the retina, but of a pressure
of the vessels, and that if such pressure was removed the retina regained its
power, just as by compression within the head the brain might lose its func-
tions for a time, and regain them when the pressure was removed. A rather
interesting analogy was then shown by the ophthalmoscopic exploration of the
eye in glaucoma — an analogy between the condition of the eye under such cir-
cumstances and the condition of the head in cases of internal pressure. The
sclerotica, when tense, was just as effectual a source of counter-pressure upon
the bloodvessels as the cranial walls could be ; and he thought it probable that
if the cranium had its contents suddenly increased by an additional afflux of
blood the arteries would, if they could be seen, be found to be like those of the
retina, in a state of pulsation.

Mr. Critchett said that the chief point of value in the paper was that the
ophthalmoscope and microscope were seen to be beautifully illustrative and
confirmatory of each other; and in that respect he thought Englishmen were
in advance of the continent, however they might be behind the Germans in
some other matters. He had no doubt that M. Graefe and others who had
noticed certain points in reference to the appearances with the ophthalmoscope,
would be interested in knowing that those points were illustrated and con-
firmed by microscopic observations. Where the globe had been the seat of
serious disease, and was destroyed as an organ, remaining only as a source of
irritation, and threatening by its sympathy with the other eye to implicate

542

Progress of the Medical Sciences.

[April

that organ also, the best practice was to remove the globe ; and the introduc-
tion and carrying out of that principle had enabled the author to make a step,
in advance of the continent. All who had used the ophthalmoscope must have
constantly felt the difficulty of interpreting the phenomena observed, which
had been accordingly differently interpreted by different observers; but the
mode of practice to which he had referred had led to a more accurate examina-
tion, and thus a most important advance had been made in reference to the
scientific investigation of ophthalmic disease. The author had been one of the
first to lead the way in that special form of investigation, and he looked forward
with confident anticipations to the result.

Mr. Hatnes Walton said that he and his colleagues had long recognized,
and were among the first to point out the sympathetic irritation of the eyeball,
and the advantages to be derived from the removal of a globe thus in danger
of affecting the other. Extirpation, he believed, was the plan usually adopted
at Moorfields, but the same result might often be obtained by removing a por-
tion of the eyeball, so that a stump of the eye remained, which was better than
nothing, and more adapted for an artificial eye. It was said that the patient
did not recover so quickly as after extirpation, and that he fully admitted. It
was also alleged that troublesome bleeding might ensue; but if the operation
was performed quickly, and the parts were covered with lint or cotton wool,
and a slight compress applied, the hemorrhage would almost always be checked
and the recovery facilitated. He would, however, extirpate the eyeball when
it was very much disorganized, where there had been a great deal of suffering
in staphyloma, and where the sclerotica was much enlarged. The author's
paper, he believed, rendered obsolete nearly everything previously written on
glaucoma. He wished to bear testimony to the value of the ophthalmoscope,
the application of which he found more and more useful and easy. A man ap-
plied to him a few days ago stating that he had become suddenly blind while
at work. By the use of the ophthalmoscope he (Mr. Walton) at once discovered
the effusion (between the choroid and the retina), which fully accounted for all
the symptoms. Formerly the case would have proved very perplexing, and
been probably attributed to cerebral derangement.

Mr. Bowman said that the system of extirpation was not always adopted at
Moorfields. When the disease was confined to the front, the posterior part
being comparatively healthy and not gorged with blood, a portion of the globe
might be abscised ; but if the disease was chiefly behind, and there was an en-
larged condition of the vessels of the deeper tunics, excision he believed was
best for the patient, and afforded the most rapid means of cure. — Med. Times
and Gaz., Jan. 23, 1858.

55. Vascular Tumour of the Orbit of many Years7 Standing, and latterly Pro-
ducing Threatening Symptoms, successfully treated by the Injection of Tannic
Acid. — Mr. Hatnes Walton read before the Royal Medical and Chirurgical
Society the following case of this character. A lady, 20 years of age, was
sent to Mr. Walton by Mr. Square, of Plymouth, in 1856, on account of a
vascular growth in the left orbit. The eyeball was prominent, and turned
slightly upwards and outwards, restricted in motion, and incapable of being
directed inwards. The lower eyelid bulged, and was slightly discoloured, espe-
cially towards the nose. By turning down the tarsal margin, there was exposed
a growth, having the appearance of a congeries of veins attached to the eye-
ball, and which was evidently only a part of a larger mass. Pressure emptied
it, the act producing pain, and redistension took place very slowly. The chief
subjective symptoms were, pain on the slightest exertion, and in extremes of
temperature and during the catamenia; inability to lie down, in consequence
of unpleasant sensations in the orbit and head ; vision nearly extinct. The
affection was congenital. Very soon after birth, slight swelling of the lower
eyelid was discovered. At the age of thirteen it attracted attention generally,
and besides being larger, there was a bluish tint of the integument. Reading
or writing for some hours always caused temporary enlargement, and heightened
the colour. Mr. Walton diagnosed the tumour to consist chiefly of dilated and

1858.] Ophthalmology. 543

tortuous veins, and came to the conclusion that it was limited to the anterior
and inner part of the orbit, and did not pass posteriorly. He resolved to treat
it by the method of injection, and sought for an agent which might be safely
used. Some experiments with the perchloride of iron caused him to reject it
as unsuitable, from the tendency of the free acid which it contains to produce
sloughing, or at least severe local action — a result to be avoided in such a
situation. Ultimately, he determined to employ tannic acid, as an agent not
possessing caustic properties, and one readily producing coagulation of the blood.
A strong solution of this substance was thrown in with a syringe. There was
rapid cessation of the hemorrhage which followed the preliminary puncture, and
the solidity of the tumour showed the extent of the coagulating action. Con-
siderable swelling of the eyelid and chemosis of the conjunctiva ensued, accom-
panied with local pain and slight constitutional disturbance, but this was of
short duration. A slight incision deemed necessary in the tumour was in a
day or two followed by a dark brown discharge. Later an abscess formed
under the lower eyelid, and was evacuated by an external incision. The eye-
lid was long paralyzed, but ultimately the movement completely returned. The
discharge from the tumour continued for many weeks, varying in quantity, and
several times pain and local irritation preceded the escape of fibrinous clots ;
and twice a small cretaceous mass was discharged. "When the patient left
town, just three months after the commencement of the treatment, there was
no longer any secretion from the seat of the disease or the abscess, and all trace
of the tumour had long disappeared. The eyeball had fallen back nearly to
the natural plane, although all its movements were not perfect. It could be
directed downwards and outwards naturally, but not turned fully inwards, nor
could it be raised to more than half its proper extent.— Med. Times and Gaz.,
Feb. 6, 1858.

56. Ncevi on the Eyelids cured by Perchloride of Iron. — Mr. Hulke has, during
the last year, seen four cases of venous nsevi on the eyelids, three of which
were treated with perchloride of iron, not in the way of an injection, but by
dipping a piece of silk in the solution, and passing it through as a seton. A
little suppuration was excited in the track of the thread, but on the second or
third day the whole growth became solid, and no unpleasant effects were pro-
duced.— Ibid.

57. Dislocation of the Crystalline Lens. — Mr. White Cooper relates (Med.
Times and Gaz., Jan. 2 and 9, 1858) some very interesting cases of this acci-
dent, and lays down the following rules for the treatment of these cases.

"When an opaque lens lies in the anterior chamber, it can only be regarded
in the light of a foreign body, and the safest course will be to extract it. In-
stances have been mentioned where little irritation has been caused, but these
are exceptional, and it must be borne in mind that inflammation maybe lighted
up at any moment — the vibration of a railway, the shaking of horse exercise,
or a multitude of other circumstances, may give rise to it. According to my
experience the operation of extraction in such cases is attended with little risk,
and by its performance the eye is relieved from a great and constantly impend-
ing peril. Undoubtedly the consent of the patient may be withheld, and then we
can only adopt palliative measures if inflammation exists, or precautionary
measures if the patient has the good fortune to escape it. If the patient be
very young— and Mr. Walton mentions a case of dislocated lens in an infant
of three months old — absorption may take place without the necessity for an
operation.

"In proceeding to extract opaque lenses, I give the preference to the lower
section ; this enables the lens to escape at once if free, or if adherent to the
iris, the connection can be separated with facility. We should remember,
when dealing with a spontaneously displaced lens (especially if the lens be
osseous), that the vitreous humour is almost certainly fluid, and that, there-
fore, the gentlest handling will be necessary. If the hard lens is behind the
iris and attached to it, the pupil will probably be so rigid as to make it exceed-
ingly difficult for the lens to pass through ; under these circumstances it is far

544

Progress of the Medical Sciences.

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better to slit the margin of the pupil with a pair of scissors, and so to enlarge
it, than to endeavour to force the lens out; for the vitreous humour will escape,
though the lens will not, and so the globe may be emptied to a serious extent.

"Though not an advocate for the use of chloroform in ordinary extractions,
I consider it of the greatest value when dislocated and osseous lenses have to
be removed. Adhesions may exist; the operation is then necessarily prolonged,
and requires extreme care and delicacy in the performance. Without chloro-
form the eye becomes restless and irritable, retreating from every touch, while
the lids spasmodically close. The anaesthetic, then, is a great boon to the
operator, and a still greater to the patient, sparing much suffering while under
the surgeon's hands, warding off secondary neuralgic pain and irritation, and
thereby hastening convalescence."

MIDWIFERY.

58. Reciprocal Sympathies between the Uterus and Bladder in Women. — Dr. W.
T. Montgomery read before the Medical Association of the College of Physi-
cians, a very interesting paper on this subject. The reciprocal sympathy
between the uterus and bladder is familiar to every practitioner. This is con-
stantly exemplified, Dr. Montgomery observes, in the increased urinary irri-
tation so often accompanying ordinary healthy menstruation, and still more
remarkably, when the latter function happens to be painfully performed. Again,
in early pregnancy, the same thing is observed ; and the remark is trite, that
morbid actions in the uterus, whether benign or otherwise, often have the ear-
liest announcement of their invasion, in symptoms of disturbance first noticed
in the functions of the bladder.

Thus, congestion or slight ulceration of the cervix uteri, and still more
strikingly, malignant affections of that part, frequently excite, in the first in-
stance, in the patient's mind, only apprehensions of gravel, or some vesical
disease, for which alone she is induced to seek advice ; but woe betide us, in
this and many other circumstances, if we let ourselves be beguiled into the
belief that because a particular organ or locality is affected with certain ano-
malous symptoms, it is therefore the seat of some disease, of which these
symptoms are to be taken as indications; and so prescribe. Could we, for in-
stance, expect to cure the itching of the nose and angle of the eye which ac-
companies the presence of intestinal worms, by applications to the Schneide-
rian, or conjunctival membrane ?

Mrs. C. had, for a long time, intense, intolerable, distracting itching of the
perineum and anus, which really rendered her life miserable, and for which
she had consulted many, and used a multiplicity of remedies; many of them,
no doubt, very appropriate for pruritus, but not for her. When she came
under my care, I also, at first, adopted the wrong course; I prescribed for the
symptom, and not for its cause. But fortunately, after seeing her a few times,
something led me to suspect the existence of intestinal worms. I gave her a
dose of the Kousso, which caused the expulsion of some very large lumbrici,
and all her troubles were forthwith at an end.

Mrs. M. consulted me for pruritus of the pudendum, from which she suffered
to such a degree, and it was accompanied with other symptoms of so distress-
ing a kind, that she declared she loathed herself, and felt her life an intolerable
burthen to her. She had used gallons of lotions, and all sorts of ointments,
without the slightest relief. Examination showed an intense congestion of the
cervix uteri; this was made the object of treatment, and on its removal, the
pruritus and all its miserable concomitants totally ceased.

I have already called the consent between the uterus and bladder, a recipro-
cal sympathy, because it equally acts in the reverse direction, irritations of the
bladder being frequently found to influence and disturb the functions of the
uterus — a fact which should not be forgotten in practice, and especially in the

1858.]

Midwifery.

545

treatment of the diseases of pregnancy, when the administration of the more
irritating diuretics should be avoided, lest they should excite contraction of the
fibres of the uterus, and so induce premature expulsion of its contents. That
they are capable of so doing is, unfortunately, popularly known, and advantage
is taken of such knowledge for base and wicked purposes.

And again, we must remember that vesical disturbances may produce a group
of symptoms so closely resembling those arising from disease of the uterus, as
to be mistaken for them.

Several years ago, there occurred in this city, a case forcibly illustrative of
this, and which excited no small sensation. The wife of a general officer, at
that time holding the highest military command in this country, began to com-
plain of distressing symptoms, having all the characters of those produced by
uterine disease. Such was her own conviction, and on her consulting an ac-
coucheur, then in large and high practice, her worst fears were confirmed; he
pronounced the affection to be cancer uteri, and could only promise palliation.
But she had many anxious friends, whose happy privilege it is always to hope
for the best, and some of them urged upon her the necessity of having another
opinion ; to this, she at last consented, and the gentleman called in, pronounced
the case to be one of stone in the bladder; the stone was extracted, and the
lady passed at once from a state of pain and misery to one of comfort and hap-
piness.

A few years since, a patient came to consult me, stating that, to gratify her
friends, she had come to town for my advice, although quite aware that she
could not be cured. She also handed me a written statement of her case, which
set forth that she had had seven labours of terrible severity, owing to con-
tracted pelvis, always requiring instrumental delivery; that for some months
she had exhibited unequivocal symptoms of the existence of cancer uteri; and
I confess that, from this account, and the woman's own description of her
symptoms, I thought there was little room for doubt as to the nature of her
malady. However, I of course gave no opinion, and suspended my judgment
until I should have instituted a careful examination; on doing so, I could dis-
cover no disease of the uterus, but the neck of the bladder was distended, and
felt very hard. I passed a sound into it, which at once struck against a stone
of considerable size. Mr. Fleming now saw the case with me; the stone was
removed, and the woman soon returned home well, and continued so.

There are, Dr. M. states, four forms of disturbance of the bladder which are
not unfrequently produced by parturition, even when that process is easy and
natural: —

1st. Irritability, causing an inconveniently frequent desire to discharge its
contents; and this with a certain amount of pain.

2d. Loss of expulsive power; the natural sensibility being unaffected.

3d. Total loss of the natural sensibility, or irritability, which prompts to the
evacuation of the contents of the organ.

4th. A peculiar form of hysterical retention.

The first two of these states require little more than to be glanced at; the
third and fourth demand a somewhat more particular consideration.

1st. The irritability of the bladder which succeeds labour, almost always
yields readily to soothing measures, such as warm anodyne fomentations, a
linseed meal poultice, opiate and camphorated embrocations, an opiate supposi-
tory in the rectum, or the administration of the mist, camphorae c. magnesia,
with tincture of hyoscyamus and syrup of poppy. Should there be reason for
suspecting inflammation, it may be necessary to apply a few leeches, and use
other appropriate remedies; but this is rarely the case.

2d. When the expulsive power is in abeyance, but the natural sensitive irri-
tability remains unimpaired, the desire to evacuate the contents of the organ
becomes distressingly urgent, in proportion to the amount of accumulation
within it.

This condition is sometimes produced by pressure from the uterus happen-
ing to be larger or lower than usual, perhaps displaced, or from the presence
of an uterine tumour, in which case, raising up the obstacle may remove all
difficulty. Sometimes, merely permitting the patient to assume the sitting

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position may suffice. Should these plans not succeed, the introduction of the
catheter gives the desired relief.

3d. Again, there is the third and most important variety, in which there is
no irritability, not even the natural desire to evacuate the urine, nor sensation,
nor consciousness of requiring to do so, although a large accumulation is taking
place, which will soon produce symptoms, not alone very distressing in them-
selves, but what is worse, conditions which may lead us greatly astray, and
excite groundless apprehensions of great impending danger; and it will not
lighten our discomfort, should it turn out, as has often happened, that the
patient owes all her annoyance to our inadvertence, or to the carelessness of
the nursetender; for if we are careful in making the requisite inquiries, and
give the proper directions to the nurse, and she attend to them, the accident,
of which I am about to speak, could not happen.

The first time I remember to have had my attention drawn to this condition
was in the year 1832, and in the case of an esteemed medical friend's wife;
who was delivered of her first child after a natural labour of fifteen hours, pre-
senting nothing unusual, if we except the most tremendous rigor I ever wit-
nessed, which occurred shortly after delivery, and was so violent that I really
thought it must have ended in convulsions; but simple means removed it, and
she went on well. Before leaving her, I cautioned the nurse to encourage the
lady to pass water in the course of the evening, as she had not done so for
several hours ; this, however, was neglected, as the lady neither expressed, nor
felt any want; and at my next visit I found my patient very feverish, with
headache; a pulse above 120; the belly tumid and tender to the touch. Be-
fore proceeding to introduce the catheter, of which she had a great horror, I
advised her trying to pass water, which she did, to the amount of at least two
quarts, with instant relief to all the symptoms. Her convalescence was unin-
terrupted.

At a time when there were occurring several cases of puerperal fever through
town, a medical friend called on me to request that I would accompany him to
visit a patient of his, who had been confined two days previously, after a severe
and protracted labour. She was not going on well, and he thought he had to
deal with a case of the above-mentioned formidable disease, as his patient was
very feverish, had most distressing headache, a rapid pulse, with abdominal
pain, swelling and tenderness. On seeing her, I thought the presence of a large
quantity of fluid was beyond doubt; a catheter was introduced, and an enorm-
ous accumulation of urine withdrawn, with immediate and decided relief to all
the symptoms. It was then ascertained, that she had not passed water since
her confinement, nor for many hours before it ; she recovered perfectly.

The next case occurred to me under circumstances which invested it with a
very unusual interest, and caused it to make a great impression on me. I hap-
pened to be staying for a few days in a very fashionable watering-place in
England, where there resided a family of great wealth and consideration in
society; the eldest son of which, had married a lady of large fortune and high
connection. This lady had recently been confined of her first child; and, as
may be readily supposed, the attendance upon her had been a matter of warm
ambition among the local practitioners; and the gentleman who carried off the
prize was, I fancy, more envied than congratulated by his confreres.

I met this gentleman accidentally in society, and the following morning he
called on me in a state of painful agitation and distress; "I am," he said, "in
a terrible dilemma, and fear I am a ruined man/' He then proceeded to tell

me that he had attended Mrs. three days before ; that she had rather a

severe labour, and that at the end of thirty hours, finding the labour not likely
to terminate by the natural efforts, the head having remained stationary for
several hours, low down in the pelvis, and pressed strongly against its floor, he
had delivered her with the forceps, without, as he assured me, any difficulty
whatever. All then seemed well, but next day the lady was uncomfortable,
restless, feverish, and rather larger than she ought to be, and this state went
on increasing until the third or fourth day, when to his horror, the urine began
to trickle away incessantly, and a slough about the size of a sixpence was dis-
charged from the vagina. He at once, naturally enough, concluded that a

1858.]

Midwifery.

vesical fistula was established; and I, taking his account as my guide, thought
there was but little doubt that his worst apprehensions would be realized.

At his urgent request I accompanied him to visit the lady, whom I found
with a hot skin, much headache, a very quick pulse, a very distended abdomen,
which was moreover so tender that she could hardly bear it to be touched; but
I distinctly ascertained the presence of fluid. On examining per vaginam, I
could not detect by the finger any breach of surface along the anterior wall, or

back of the bladder, and I suggested to Mr. that it would be well to pass

a catheter into the bladder; which, at his request I did; and gave exit to a
quantity of urine, sufficient nearly to fill an ordinary wash-hand basin. Sub-
sidence of the abdominal swelling immediately took place, the lady felt inex-
pressible relief, and from this day went on well.

The truth was, that the bladder had been forgotten by all the parties con-
cerned; and the patient had never passed water since her confinement, nor felt
a desire to do so; until at last the bladder became so distended that the resist-
ance at its neck was overcome, and the urine leaked out at the front, as fast
as it was pumped in from the ureters at the back; and it so happened that just
as this began, a small slough had separated from the mucous membrane of the
posterior wall of the vagina, which had been strongly pressed on by the head
for several hours.

4th. Another state, not exactly ranging under any of the former kinds, seems
to be of a purely nervous or hysterical character, and mixed up with a certain
amount of mauvaise honte. The patient has a decided desire to pass water, and
suffers distress from its retention; but has at the same time, the greatest re-
luctance to make the necessary effort, and positively refuses to try, if any one,
even the nursetender, is present, declaring that it would be impossible for her to
succeed.

Under those circumstances, suitable arrangements should be made by the
nurse, and the patient then left by herself for a time, during which she may
succeed in accomplishing the desired object; if she does not, some anti-nervous
medicine should be given, with strong assurances of its potency in removing
such difficulties; let her try again during our absence, and if she has not suc-
ceeded when we come to pay our next visit, we must declare that longer delay
would be unsafe, that we will wait a little while in the drawing-room, and if
she does not then succeed, that we must draw off the water before we leave the
house ; this generally insures success.

In many of these cases they do not succeed, because they do not make the
proper effort; and this, I believe, is oftentimes simply because they cannot, and
not always because they do not choose; this state of nervous inability ought to
meet with much tender consideration. I may observe here, that I have never
met with this peculiar form of affection, except in the higher grades of society,
and almost always in women of a highly sensitive nervous temperament, some
of them having experienced a similar difficulty before marriage, and also under
ordinary circumstances distinct from pregnancy.

Now, is this state which I have just been attempting to describe, analogous
to, or identical with another, which I have a few times met with in practice,
and which may be thus described: A lady in perfect health retires to her bed-
room for the night, and before lying down to rest attempts to make water, and
finds she cannot — she is much surprised — goes to bed, and perhaps falls asleep;
in the morning she is in great distress, but still unable to empty the bladder,
and now her pain is so great, she is compelled to seek for assistance — the cathe-
ter is introduced and all her trouble is at an end; or, perhaps, for several days
its use continues to be required, and then all goes on as well as ever; but in
either case, no circumstance of general ill-health, or local derangement or dis-
placement can be discovered. The woman, in fact, is otherwise quite well.

The year before last a married lady of a highly nervous temperament, so
affected, drove six miles into town to my house, in great torture: I drew off the
water, and she required no further assistance.

Last year I was urgently summoned to see an equally nervous maiden lady
similarly situated; on laying my hand on the abdomen I felt a tumour, as large
as a melon, and as hard as a cricket ball; and per vaginam, it really, at first,

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Progress of the Medical Sciences.

[April

suggested the idea of a fibrous tumour of the uterus, this organ being quite dis-
placed. I introduced the catheter, drew off a large accumulation of urine, and
the abdominal tumour — which was nothing more than the distended bladder —
at once disappeared. The feature in this case which particularly arrested my
attention, was the extraordinary hardness and the distinct outline of the ab-
dominal tumour, which would readily have caused it to be mistaken for a solid
morbid growth.

I may here observe, that in the well-known case of the virgin mock pro-
phetess, Joanna Southcott, there was felt, by competent judges, a circumscribed
tumour in the abdomen, which was supposed to be the gravid uterus. Dr.
Reece, in his published history of the case says: ."In that part occupied by the
womb, there was a firm circumscribed tumour as large as a man's head, bearing
the shape of the womb ; I have no doubt of its being an enlargement of that
organ." But when she died no tumour existed, and that which was felt during
life was attributed to the prophetess having learned to retain the urine until
the bladder became considerably distended ; which seems highly probable.

In my case last related, it was necessary to relieve the lady every day for a
week; when she perfectly regained the power of micturition. I may just men-
tion, that the remedy which seemed to remove her inability was the ergot of
rye; did it do so by stimulating the fibres of the uterus in the first instance,
and then by consent, those of the bladder ? Perhaps so ; but as the same agent
has produced a similar effect in men, a direct influence may be equally ad-
mitted.— Dublin Hospital Gazette, Dec. 1, 1857.

59. On Coagula formed in the Veins during the Puerperal State, and their
occasional Transportation into the Pulmonary Artery. — Dr. Graily Hewitt read
before the Harveian Society (Dec. 3d, 1857) an interesting paper on this sub-
ject. " The painfully sudden death of a lady, a member of the late royal family
of France, which, according to the accounts given in the public prints, was
caused by the passage of a clot of blood into the pulmonary artery, had been,
the author remarked, the subject of much interest. He proposed to call the
attention of the Society to some observations suggested by the contemplation
of the case in question.

" The various morbid appearances presented by the veins and their contents
in cases described as 'phlebitis' have been always objects of much interest,
and up to within a very recent period were taken as evidence of the existence
of inflammatory action in those vessels. The author considered that the re-
searches of Yirchow conclusively proved that the appearances in question were
due to the formation of coagula in the veins, and the subsequent transforma-
tions through which these coagula had passed. According to the views of
Virchow, the study of the changes spoken of as phlebitis was in reality the
study of the 'thrombus,' as the coagulum is termed, and of its metamorphoses.

"In applying these views to the consideration of those cases of diseases of
the veins which are apt to occur after childbirth, and taking with Virchow the
starting point to be the formation of the coagulum, it was necessary to inquire
what are the circumstances which may lead to, or favour the formation of
coagula in the veins during the puerperal state ? Amongst these were enume-
rated : —

" 1. The large amount of fibrin in the blood, both positively and relatively,
during pregnancy, a condition predisposing to coagulation ; and possibly also
certain other morbid conditions of this fluid, as uraemia, &c.

" 2. The mechanical effects of the presence of the uterine tumour, which,
leading to congestion of certain parts — the vagina, rectum, lower extremities,
etc. — might favour coagulation; also, the impediment to the descent of the
diaphragm leading to distension of the right heart, and other parts of the
venous system.

"3. Pressure, unusual in amount or duration, on the large venous trunks in
the abdomen, produced by the head of the foetus in its passage into the pelvis ;
the head being too large, or the passage contracted.

" 4. Deficient contraction of the uterus, and of the large venous plexuses
situated near it (Virchow), after delivery.

1853.]

Midwifery.

549

"5. The most important, perhaps — the presence of the ' physiological coagula,'
as they may be termed, which close up the uterine veins at the point of attach-
ment of the placenta, and which must extend a variable distance, and have a
variable size, according to the degree of uterine contraction.

" 6. The morbid conditions of the blood liable to be produced after delivery,
owing to the occurrence of hemorrhages and other causes*.

"A description was then given of the morbid appearances usually observed
in the veins after childbirth. Affections of the veins generally occurred in
cases where some of the causes just alluded to as leading to coagulation had
been present. In most of these cases the veins first affected were those leading
from the uterus and ovaries ; the coagulation begins in the veins of these parts,
and travels onwards towards the heart. The coagulum always terminates,
according to Virchow (whose description is in conformity with those of Dr.
Robert Lee and others on this point), in a rounded extremity, which projects
a little beyond the next entering vessel, and by further deposition of fibrin,
the clot extends. The coagulum also travels backwards, occluding after a time
the veins which enter an already blocked-up trunk. The iliac, femoral, and
other veins of one or both sides may thus become occluded, by a coagulum
extending from the uterine veins of the same side, producing at this stage the
disease called ' phlegmasia alba dolens.' The ' physiological' coagula may thus
give rise to coagula of a pathological character, other circumstances favouring
the production of the latter being present; or, certain states of the uterine sur-
face following delivery may occasion a like issue of the case. The clot, once
formed, undergoes two kinds of change. It shrinks, becomes decolorigiae, ad-
herent, and with the vein is reduced to a cord-like substance (adhesive phlebitis) ;
or it softens, breaks down, and the result is the formation of a fluid in many re-
spects resembling pus (suppurative phlebitis). The outer non-softened portions
of the clot in the latter case remain as false membranes adhesive to the normal
walls. The attractions of the veins to the puerperal state are only peculiar in re-
spect of their causes ; the coagula once formed, are liable to the same kinds of
transformation as in other cases. The observations of Virchow respecting the
constant presence of the ' continued coagulum' are of especial interest in relation
to the occasional passage of portions of altered coagula into the pulmonary-
artery. This continued portion projecting into the still patent vessel, under-
goes, but more rapidly under certain circumstances than the other parts, the
' thrombus metamorphosis.7 It becomes adherent to one side of the vessel, and
the projecting part may, at a certain stage of its metamorphosis, be broken off
and carried away by the blood-current into the pulmonary artery. Death more
or less sudden, and attended, according to Virchow, with symptoms of a peculiar
asphyxia, followed the passage of these altered coagula into this vessel or its
branches. Dr. Simpson has collected nine cases in which death, more or less
suddenly, occurred a few days after delivery, apparently brought about by the
obstruction of the pulmonary artery, by transformed coagula introduced from
the veins. Probably death more often occurs from this cause than is generally
imagined, the cause being overlooked. Lastly, the author was of opinion that
the pulmonary artery might be occluded by clots, liable to be formed in puer-
peral women reduced by hemorrhage, etc., these coagula not having existed as
such for a sufficient time to have undergone the transformation previously
alluded to, and not having been formed quite in the same way. These clots,
at first perhaps small, would increase rapidly by further accretion of fibrin
around them, and forcibly obstruct the pulmonary arteries to such a degree as
to produce death." — Med. Times and Gaz., Dec. 12, 1857.

60. On the Membrana Decidua which surrounds the Ovum in Cases of Tubal
Gestation. — Dr. Robert Lee read a paper on the subject before the Royal
Medical and Chirurgical Society, January 26, 1858. He commenced by citing
the various authorities to prove that the common opinion from the days of
William Hunter to the present time was that the decidua, or outer surface of
the secundines, belong to the uterus, and not to the ovary, or that part of the
conception that is brought down from the ovary ; and that in cases of extra-
uterine pregnancy, a deciduous membrane was still to be found in the cavity
No. LXX.— April 1858. 36

550

Progress of the Medical Sciences.

[April

of the uterus. But a case is recorded in the seventh volume of the Medico-
Chirurgical Transactions, in which the uterus is stated to have been "consider-
ably larger than we observe that organ to be in the unimpregnated state, even
in women who have borne several children. On laying it open, the uterine
vessels were observed to be very large but empty, and there was a great
quantity of gelatinous matter in the cavity and neck of the uterus. When this
was washed off, the internal surface of the viscus looked very vascular, having
been highly injected ; but there was not the least appearance of a decidua."
A second case is recorded in the seventeenth volume of the Medico- Chirurgical
Transactions, in which the author himself was surprised at finding that " no
organized deciduous membrane lined the cavity of the uterus, but the whole of
it was coated with a thin layer of albumen/' This case occurred in 1829, and
the preparation was placed on the table of the Society in 1832 ; but until 1836,
when another example of tubal gestation came under his observation, it does
not appear that he made any attempt to determine whether the ovum in the
Fallopian tube was surrounded by decidua. The two preparations were then
examined together, and a description of the appearances observed was pub-
lished in the Medical Gazette for 1839-40. These cases, with four others which
have subsequently come under his observation, are the subject of the present
communication. In Case 1, on opening the tube, and examining the different
parts of the ovum, he found a deciduous membrane everywhere surrounding
the chorion, and closely adhering to the inner surface of the tube, as the de-
cidua usually does to the lining membrane of the uterus. Within the decidua,
the chorion, amnion, and embryo were distinctly seen. The uterus was larger
than natural, and there was no appearance of decidua lining its internal mem-
brane. In Case 2, on carefully examining the ovum contained in the right
Fallopian tube, it was evident that a deciduous membrane everywhere sur-
rounded the chorion, and adhered to the inner surface of the tube., The
placenta, which was situated at the extremity of the ovum nearest the uterus,
•was seen covered with the decidua, and coagula of the fibrine of the blood were
traced from the interstices of the placenta through the decidua into veins in
the thickened muscular coat of the tube. The uterus was considerably en-
larged, and its inner surface was coated with a very thick layer of yellowish-
white soft substance. There was no trace of any arterial or venous canal in
this cavity. In the third case, the foetus had reached the age of six months,
and was contained in a cyst which adhered to the omentum and intestines and
to the surface of the uterus, and contained a great quantity of thin, fluid-like
pus. The walls of the uterus were healthy, and the cavity empty. There was
no decidua or substance of any kind coating its inner surface, but a decidua
was attached to the placenta in the usual manner. In Case 4, the greater part
of the ovum had been removed, but still the decidua reflexa could be very dis-
tinctly seen covering a considerable portion of the villi of the chorion. In the
uterus was found a coating of considerable thickness, and of a yellowish-white
colour, in which neither arteries nor veins could be traced. Case 5 is also one
in which only a portion of the decidua was found in the tube. In Case 6, the
substance lining the cavity of the uterus resembled the fibrine of the blood,
and was of a red colour at its upper part; where it had been detached from
the surface of the uterus, the lining membrane presented a perfectly natural
appearance. The embryo was inclosed in the amnion, with the vesicula um-
bilicalis remarkably large. The cells of the placenta and the villi of the chorion
were distended with coagulated blood, and surrounded by deciduous membrane.
By a careful dissection subsequently made, the decidua was found to consist
of placental decidua, decidua vera and reflexa, with a decidual cavity. An
enumeration of the preparations in St. Bartholomew's and Guy's Hospital
museums is appended, illustrating the pathology of Fallopian tube conception.
In the former there are five examples, and in one of these the museum catalogue
states that " the outermost membrane inclosing the foetus has all the character
of decidua. Besides this membrane, the amnion and chorion are distinct; the
foetus and umbilical cord are also perfect." In the opinion of the author, there
can be no doubt that a decidua surrounds the ovum ; and though none of the
other preparations have been dissected with the view of ascertaining the point,

1858.]

Midwifery.

551

yet in all the separation of the ovum from the inner surface of the tube has
been carried to an extent sufficient to enable us to demonstrate the fact. There
are thirteen preparations in Guy's Hospital museum. The author was per-
mitted by Dr. Wilks, the conservator of the museum, to make a minute exami-
nation of the ovum in one of these, which had escaped entire through a rent
in the Fallopian tube. He had the satisfaction not only to discover the vesicula
umbilicalis, but to see the chorion completely surrounded by decidua, as in the
case described at the early part of this communication. There can be no doubt
that if the ova in these preparations were submitted to a similar examination,
a decidua would be found in all, surrounding the ovum in the Fallopian tube.
He did not wish to express an opinion on the nature of the membrane or sub-
stance found coating the inner surface of the uterus in the greater number of
these preparations, which has been almost universally considered to be decidua
since the days of Dr. William Hunter, although no bloodvessels in it have been
discovered. His great object was to demonstrate the existence of a decidua
around the ovum in cases of tubal gestation.

Dr. John Clarke called the attention of the Society to one of the preparations
of Fallopian tube gestation laid upon the table. The uterus, he said, was laid
open, exhibiting, as he thought, a true deciduous membrane; not the membrane
that was thought formerly to be formed by lymph poured out, but (as under-
stood of late years) the inner membrane lining the uterus, and presenting a
peculiar tubular appearance. In the neck of the uterus there was the usual
secretion in the glands. It was quite clear that in the Fallopian tube there
was no appearance of a strictly speaking deciduous membrane ; there was
nothing but the foetus, the amnion and chorion lying against the inner coat of
the tube. He did not venture to state, however, that in no case was a decidu-
ous membrane formed round the ovum in Fallopian tube gestation; but he
regarded the cases in which there was such a membrane as indicating an effort
of nature to accommodate the part to a new function, which it was not origin-
ally intended to perform. The ovum had escaped from the ovarium, and
lodged in the tube. Nature did not set up the inflammation, as in cases where
foreign bodies existed ; for this was not, strictly speaking, a foreign body, but
a living body, intended by nature to be matured and brought into the world,
and she accommodated, as far as possible, the tube to the purposes of the
uterus ; and accordingly there was a certain membrane thrown out somewhat
resembling a deciduous membrane, but, as appeared upon close microscopical
observation, totally differing from the decidua in the uterus, having, however,
certainly the function for a short time of sustaining the life of the ovum. The
preparations exhibited did not appear to him (Dr. Clarke) to support the views
of the author, since in almost all of them there was a deciduous membrane in
the uterus, whether called lymph or shreds; and in those cases where it was
not found the uterus was large, and there was some statement of uterine action,
followed by the discharge of a membrane or fluid ; and it was but reasonable
to suppose that in those cases the deciduous membrane might have escaped. —
Med. Times and Gaz., Feb. 6, 1858.

61. Extra-Uterine Gestation. — A case of this nature, dating thirty-three
months from its commencement, and terminating in abdominal fistulse, and the
extraction of the remains of the foetus, is reported by Dr. Diamantapuplos.
She was seventeen years of age : commenced to menstruate at twelve years
and nine months; was married at thirteen years; and aborted with her first
conception in May, 1853. She menstruated regularly afterwards until Decem-
ber 15th. About the presumed epoch of the present conception, she received
a blow on the lower belly.

During the first three months, she had nausea and vomiting: a little later
she perceived the motion of the child, which, with the secretion of colostrum,
continued until the normal term expired. At the sixth month, she had violent
pains at the lower part of the abdomen, which were completely removed by a
copious bleeding.

At nine months after fainting, labour pains commenced and continued for

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Progress of the Medical Sciences.

[April

four days. She had milk fever ; and the secretion of milk continued, alternat-
ing for three months, with an offensive whitish uterine discharge.

She continued under treatment with diuretics and bandaging, her general
health being pretty good, save a slight attack of mild typhoid fever, at about
the eighteenth month.

She was examined in May, 1855 ; and, in addition to evident fluctuation, a
tumour was found, which gave the sensation of the head of a foetus. Ballotte-
ment was manifest ; the uterus appeared retroverted.

About August, 1855, after a violent abdominal erysipelas, two fistulae were
established at the umbilicus, discharging a sanious liquid: at six months from
this date, hair came away with the discharge.

In February, 1856, she suffered from diarrhoea, indigestion, intestinal hemor-
rhage, extreme emaciation, hectic fever, &c. &c. The cavity of the tumour was
now explored most carefully, and the situation of the bones of the head, their
size, and the limits of the adhesions of the wells of the cyst to the abdominal
parietes, carefully made out.

On the 25th of September, 1856, the patient was operated on under the influ-
ence of chloroform, in the following manner : A crucial incision was made
from the centre of the fistulous opening ; and first one parietal, then the other,
was extracted ; afterwards, the two frontal, the occipital, the left temporal, and
lastly, the maxillaries ; then many bones of the trunk, putrefied: the cyst was
then well washed out with water. After some short time she completely reco-
vered, the menses reappearing towards December, 1856. — Midland Quarterly
Journ. Med. Sci., Jan. 1858-, from Gaz. Medicale d' Orient, June, 1857.

62. Ruptured Uterus. — Mr. Dillon" Kelly records (Dublin Hosp. Gaz., Jan.
15, 1858), a case of this, the chief point of interest in which was the enormous
size of the rent in the uterus, through which the free margin of the liver and
a mass of small intestine found entrance into the cavity of this organ.

63. Intra-TJterine Fractures. — An excellent paper on this subject, written with
a true philosophic spirit, was read by Dr. Herbert Barker, before the South
Midland Branch of the British Medical Association. In the case which formed
the basis of his communication, no peculiarity of constitution, hereditary or
acquired, could be traced to either parents. The mother had borne three
healthy children previously, and has since given birth to a fifth, also healthy.
During her pregnancy with the subject of the present case, she had a fall down
stairs : but, from reflections on the case, Dr. Barker does not connect this event
with the fractures as standing in the relation of cause and effect. The child,
when born, lived about ten minutes. On examination, no suture lines could-
be traced, and no bones could be felt through the scalp. The humerus of both
sides, and the radius and ulna of both arms were broken, as were both thigh
bones, and both tibiae and fibulae. On dissection, all the viscera were found to
be in a normal and healthy condition ; and the peculiarities of the foetus were
confined to its osseous system. The frontal, both parietal, the squamous por-
tion of the ethmoid, and the expanded portion of the occipital bone, were en-
tirely , absent. "The shaft of the left humerus bulged out in the middle into a
round ossified protuberance, of the size and appearance of a small bullet ; above
and below, the shaft was suddenly contracted to the diameter of a crow's quill.
There was ossification at these points, but the bone was so fragile that it would
not bear the slightest manipulation. Just above the protuberance in this con-
stricted portion, there was a distinct fracture, slightly oblique, but complete.
The fractured ends were jagged, and could be refitted into each other." The
right humerus was similar in appearance to the left, save being fractured in
two places ; the radius and ulna were fractured in two places ; the ulna of the
left side had also been fractured, and again united by cartilage. The left
femur had a tuberosity in the middle of the shaft: like the humerus, it was
obliquely fractured in two places above the tuberosity, and in one place below
it ; and when the ends of the bone were fitted together, it had a twisted ap-
pearance. The right femur was similarly fractured, but without distortion.
The shafts of the tibiae and fibulae were fractured in several places. One great

1858.]

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553

fact with regard to the structure of the bones generally, was their extreme fra-
gility, and the well-marked deficiency of inorganic matter. After carefully
burning out all the organic matter, Dr. Barker found the relative proportions
to be —

Organic matter 66.66

Inorganic matter ..... 33.34

100.00

Dr. Barker considers the cause of fractures in this case quite compatible
with the unusual amount of organic matter, from the fact that the earthy matter
was irregularly deposited.

The Doctor then proceeds to consider some analogous cases, as reported by
Dr. Moffat, Chaussier, Baudelocque, Arnaud, Carus, Billard, and Dr. Montgo-
mery.

With respect to the cause of these fractures, Dr. Barker thinks, arguing
from this case in particular, that the inequality in the deposition of earthy
matters, and the disproportion in construction between the organic and the
inorganic parts, was the main predisposing cause. In the modulated parts
there was an increase of earthy deposit ; in the constricted parts the bone was
formed, but was too feeble to bear the pressure to which it was subjected.

In the normal state there is more organic and less earthy matter in the foetal
bones: they are, consequently, less liable to fracture than at any subsequent
period of life ; and especially whilst protected by the mobility of the foetus in
the amniotic liquor. Hence, blows or falls are fortunately comparatively harm-
less in ordinary circumstances.

Dr. Barker draws two practical deductions from his case. Firstly, with re-
gard to labour; and, secondly, in a medico-legal point of view, cautioning the
practitioner nev^r to give evidence with respect to fractures in still, or newly-
born children, without having examined all the bones of the body with refer-
ence to their physical strength; their osseous development; the presence
or absence of certain bones ; the presence of previous fracture and reunion ;
the presence of external injury, and the contour of the bones and limbs gene-
rally.

A second case is reported by Mr. Davies, of Pershore, in which the thigh
had suffered a compound fracture, the bones overlapping nearly an inch. This
was the sole fracture in this case ; and the child has since grown to be a man,
with arrest of development in the limb, it being now only about a foot long.

A third case, in which a syphilitic taint was present in the mother, who mis-
carried at seven months, is reported by Mr. Murray. The child lived a few
days with the left humerus and left femur fractured : the whole of this side of
the body was soft, consisting of loose, unhealthy fat; whereas, the opposite
side was in a state of rigidity and atrophy. The state and composition of the
bones in this case were not observed. — Midland Quarterly Journ. Med. Sci., Jan.
1858, from British Med. Journ., Oct. 1857.

64. Report on Cross-Presentations. By Prof. Spaeth. — Among the 12.523
births which came under Professor Spaeth's observation while he held the post
of assistant accoucheur at the General Hospital, Vienna, 93 cross-births oc-
curred. Cross-presentations were also, besides these, very frequently diagnosed
in pregnant women with exactitude, which, on the commencement of labour,
were converted spontaneously into presentations of the long 'axis of the body.
In primary cross-presentations — i. e., before the rupture of the membranes, the
lateral portion of the child's body usually presented — although, in some in-
stances, the back or the abdomen was found turned towards the os uteri. In
the latter cases, the extremities were generally found presenting, and in one
instance, both the lower extremities and one of the upper were felt within the
os, while the axis of the child's trunk lay completely parallel to the transverse
diameter of the uterus. In secondary cross-presentations — i. e. the waters being
discharged — the foetus, when normally developed, always presented with its
shoulder ; of 56 exactly indicated cases, in which the lateral part of the body
or the shoulder presented, in 39 the back of the child was placed forward (24

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times with its pelvic end towards the left side, and 15 times towards the right
side), and in 17 it was placed backwards (11 times with its pelvic end to the
left, and 6 times to the right side).

The following may be enumerated as causes of cross-presentations : —
1. Twin births. Among the 157 instances of those that occurred, the second
child was found in the cross position 13 times — therefore 1 in 12. The first
child was always found in the long presentation. 2. Maceration of the child.
Among 176 macerated children, 7 — i.e. 1 in 25 — presented crosswise. 3. Pre-
mature birth. Of 655 children born between the fifth and ninth month, and
not in a macerated condition, 16 presented crosswise — 1 in 40. 4. Placenta
prcevia. In 13 cases of this, cross-presentation occurred 3 times. In these 3
cases, the placenta was always so placed as to entirely cover the os uteri, while
this was only found to be the case in 1 out of the other 10 cases. 5. Relaxation
of the walls of the uterus. Scanzoni correctly considers unusual relaxation of
the parietes of the uterus as one of the most essential circumstances in the
production of cross-positions ; and it is on this ground that the more frequent
occurrence of the position in women who have borne several children, is to be
explained. Thus of the 93 cases in question, only 20 (or, of 52 cases not in-
cluded in the above categories only 10), were primiparse. Moreover, in the
bulk of the great number of cross positions ascertained to exist during preg-
nancy, but which were spontaneously converted at the onset of labour into
long presentations, presented this condition of relaxation, the rectification tak-
ing place apparently because the contractions of commencing labour obliged
the hitherto relaxed organ to assume its natural form, thereby removing one
cause of the faulty position. 6. Abundant liq. amnii. This was also often
observed in pregnant women exhibiting cross-position. With the great mobility
of the foetus which exists in such cases, it is quite a matter of chance whether
the foetus, during labour, is not found in the cross-position. Among the 93
cases, such excess of fluid was observed in 10, and certainly occurred yet oftener,
in certain of the cases brought to the hospital only after the membranes were
broken. 7. The cor di form shape of the uterus — i. e. a slight degree of the ute-
rus bicornis. This was observed in one case only, but this was an example of
the recurrence of the position in three pregnancies. Braun relates a similar
case ; and there is hardly any doubt that this deformity of the uterus, which is
as perceptible after the birth of the child as before its expulsion, is a cause of
habitual cross-position. 8. Eventration of the abdominal viscera was observed
in 2 cases by the author — once at the hospital, and once in private practice,
the child being at about the seventh month in each case.
The course and treatment of the 93 cases were as follow: —

A. Spontaneous Turning. — This occurred in one case, that of a woman, aged
24, pregnant for the second time. At 8 A. M. (11th June), the waters were
unexpectedly discharged. The os uteri was found relaxed, and the ribs of the
child could be plainly felt through it. On external examination, the back of
the child was found to be turned forwards, its pelvic extremity lying nearer to
the entrance of the pelvis than its head, which Jay towards the right side. The
uterus was soft, and slight contractions only occurred at long intervals. The
patient was kept lying in bed on her left side, and strong pains only came on
in the afternoon of the 13th. Under their influence, the pelvic end of the foetus
passed spontaneously through the os, the uterus assuming its normal, longish-
round form. At 5 P. M., the living child was born with ease.

B. Spontaneous Delivery in Shoulder Presentation. — This occurred in five in-
stances, and these consisted in a foetus of five months, one of six, two of seven
months, and one at full time. The six months' foetus, and one of those at seven
months, were in a macerated condition, and the others died during labour.^ The
first of these cases, on account of the smallness of the child, was left to itself,
while the others only came under observation after repeated unsuccessful efforts
at turning had been made. The mechanism was the same in all these cases.
The shoulder, under the influence of strong pains, was gradually pressed deeper
into the pelvis, while the head advanced more and more forwards from the side
of the mother towards which it was turned, until at last it lay exactly over the
symphysis pubis. At the same time, the trunk moved towards the sacro iliac

1858.]

Midwifery.

555

symphysis on its side, and was, through the pressure excited upon the buttocks
by the fundus uteri, forced down the sacral hollow behind the head, so that first
the presenting shoulder, then the under part of the thorax, the buttocks, and
the feet passed out, and then finally the head was expelled. The complete ex-
trusion of the shoulder, while the head remained at the entrance of the pelvis,
was, however, only rendered possible by means of excessive extension of the
neck. Two of the mothers suffered from slight peritonitis, but all recovered.
C. Turning. — This was effected in 85 cases.

a. Cephalic turning. — Besides the very numerous cases of oblique cranial
position in which the head deviating to one side or the other, was directed by
manipulation into the pelvic entry, this procedure was put into force in six in-
stances of cross-presentation, the manipulation being external in 2, and internal
in 4 of the cases. In the two former, the membranes were as yet unruptured,
the uterine walls were relaxed, and the pains unfrequent, while the child was
sufficiently movable, without the liq. amnii being in excessive quantity. The
woman having been laid on her back, one hand was placed above the child's
head, and the other beneath its pelvis, and by simultaneous pressure the one
was directed towards the aperture of the pelvis, and the other towards the fun-
dus uteri. As soon as the head had somewhat approached the aperture, its
further progress was much favoured by laying the woman upon the side corre-
sponding to that towards which it had lain. The children in both these cases
were born alive. In the four cases treated by internal manipulation, the mem-
branes were still entire, and the hand corresponding to the side on which the
head lay, was, during an interval of the pains, passed sufficiently high between
the uterine wall and the head to enable it to seize the head, and draw it towards
the pelvic aperture. This manoeuvre was assisted by the other hand, placed
externally, either pushing the buttocks up towards the fundus, or aiding in
thrusting the head downwards. All the children were born living.

b. Turning by the buttocks was executed by external manipulation in one
instance, the child being born living.

c. Turning by one or both feet. — This was performed 78 times under the fol-
lowing different circumstances : —

1. Prior to the rupture of the membranes in 39, 10 being examples of twin-
births. The author places the woman on her back, with the pelvis somewhat
raised, and introduces the hand corresponding to the side to which the child's
feet are directed, when this can be ascertained. But before the waters are
discharged, it is indifferent to an experienced practitioner which hand he em-
ploys. With the exception of two cases, in which hemorrhage from placenta
praevia occurred, full dilatation of the os uteri was always waited for ; and the
membranes were preserved entire, when possible, until the hand had reached
the spot where the feet were expected to be found. They were then broken,
and where rapid delivery was required, as in placenta praevia, both feet were
brought down, otherwise only one. In the latter case, the labour was then left,
for self-completion, unless the state of the pulsation of the funis or other dan-
gerous circumstances called for haste. In all cases, however, the delivery of
the head had to be assisted, viz: in 37 by manual interference (a modification
of Smellie's method), and in 2 by the forceps. In the 37 cases, there were born
28 living (3 being stillborn but soon restored), 4 dead and 5 macerated children.
Of the 4 dead children, in 2 the birth had been preceded and accompanied by
severe hemorrhage, in one there was eventration, and one had to be extracted
from want of pains. Of the two children delivered by the forceps, one was
born alive, and the other in a macerated condition. As unfavourable compli-
cations, there were two instances of narrow pelvis, and three of placenta
praevia.

2. After the discharge of the liquor amnii. — These cases were also thirty-
nine in number. The operation was rendered much easier by choosing the
hand which corresponds to the side of the mother to which the feet are directed,
and which, when the waters are discharged, could always be ascertained. In
part of the cases it was introducted in the German method, by passing its volar
surface over the abdomen of the child to the feet. In others, the French method
was adapted, by which the presenting lateral parts are pushed farther away,
and the hands carried over the buttocks to the feet. From the former, none of

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the ill effects said to result from compression of the funis or abdomen were
found to arise. In difficult cases, great are the effects of a proper position of
the woman and choice of the hand, together with carefulness and steadiness
in its introduction. By observation of these points, the experienced accoucheur
will often succeed after many failures on the part of others. Still, there are
cases in which the observation of every precaution is not followed by success,
as when the uterus becomes so closely bound round the child by continuous,
tetanic contraction, as to forbid the passage even of a quill between them.
There are cases, too, in which vain attempts at turning have so excited the
uterus as to have aroused the most vehement pains, which follow one after the
other in rapid succession. Who, in attempting, under such circumstances, to
turn the fast-locked foetus, would not have the terror of rupture of the uterus
before his eyes ! It is in such cases that chloroform, or a mixture of chloroform
and ether, is of unqualified utility, rectification often becoming possible during
ansesthesia, when decapitation would be otherwise unavoidable.

Among these 39 cases of secondary cross-positions there were 10 cases in
which turning took place immediately after the rupture of the membranes. Of
these (L). There were 8 accompanied by unfavourable complications, viz : 2 with
hemorrhage — one child living, the other dying; 3 with prolapse of the funis —
2 living and 1 dying ; 1 with the induction of premature labour at the end of
the 8th month, the child dying ; 1 with very rigid genitals in a primipara, the
child living; and 1 with a large headed child, which lived. (2). The other
8 cases were uncomplicated, and all the children were born living. Altogether,
in the 16 cases, 10 of the children were born living, 4 came stillborn (one of
these dying), and 2 were born dead. (b). Cases in which turning was per-
formed within the first half hour after the rupture of the membranes. These
were six in number, in one of which only the child died. (c). Cases in which
it took place at a later period, either because the patient came late under ob-
servation, or that the waters were discharged prior to the commencement of
labour. Of these 7 cases, turning was executed in 4 in one hour, in 1 two
hours, in 1 five hours, and in 1 twelve hours afterwards. Two of the children
died. (d). In 7 cases the membranes were ruptured before the commencement of
the pains. In these cases, turning was accomplished after 9, 10, 23, 29, 37, and
64 hours, and in one case the exact time was not known, the child being dead
when the patient was admitted. Among all these cases, turning was not at-
tended with any difficulty, except in the first one. The cases under (c) and (d)
sufficiently prove that nature usually leaves space enough after the discbarge
of the waters to admit of turning with success, and without much difficulty,
providing always that unsuccessful attempts have not excited the impetuous
action of the uterus, which leads either to the death of. the foetus, or renders
turning exceedingly difficult or impossible, (e). Cases in which turning was
accomplished after prior unsuccessful efforts. Of these there were three, and
the author relates two others which occurred in his private practice. Chloro-
form was employed in three of these, and turning would probably have been
impossible without its aid. All the children were dead.

Summing up the results of the 85 cross-presentations treated by turning, we
find that 66 children were born living (of these 9 were stillborn, 8 recovering,
and 1 dying), 13 dead, and 6 in a macerated state. Separating the macerated
children, as already dead before the commencement of labour, the proportion
of dead to the living children was 1 in 5. Of the mothers, 69 were in good
health, 6 recovered after short illnesses, 1 was transferred to the hospital on
account of metastasis, and 9 died. It is to be remarked, however, that the
confinement of some of the fatal cases took place at a time when a bad form of
puerperal disease prevailed. Of the entire number of 12,523 confinements which
furnished these 85 cases, 546 women died of puerperal disease, and 73 were
removed to the hospital on account of metastasis, eclampsia, &c. Hence the
proportion of mortality in the whole was at least 1 in 22.

D. Decapitation. — This was performed in two instances, which are related,
the children being dead, and the shoulder being so much forced down, and the
child so closely compressed by the uterus, as to render attempts at turning dan-
gerous. Braun's modification of Smellie's hook was employed. — Med. Times
and Gaz., Jan. 9, 1858, from Wien Wochenschrift, 1857, Nos. 8, 9, 10.

1858.]

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AMERICAN INTELLIGENCE.

ORIGINAL COMMUNICATIONS.

Singular Result [Thrombus] of an Injury in the last Stage of Pregnancy,
By Bedford Brown, M. D., Yanceyville, Caswell Co., N. C.

I "WAS called early on the morning of July 18th, 1857, to visit Mrs. P., in
consultation with Dr. Roan, of this place. Dr. Roan informed me that he had
attended Mrs. P. the previous evening in a premature confinement, which, for
a primary labour, terminated readily, and with but little difficulty. After leav-
ing his patient comfortable, and with a good prospect of an early recovery, he
returned home, but not many hours after was summoned again in great haste
to Mrs. P.'s bedside. He found her suffering most excruciating pains in the
left iliac and inguinal regions, radiating over the back, hip, and thigh, in ad-
dition to which, a most intolerable strangury existed. The Dr. remained with
her during the night without being able to mitigate her sufferings, which were
so great as to produce extreme constitutional depression. On making a vaginal
examination, early the following morning, he found a considerable elastic
tumour occupying the left side of the pelvic cavity, between the walls of the
vagina, the pubis and the ischium, and beneath the deep pelvic fascia.

On my arrival, the dimensions, location, sensibility, &c, of this tumour,
were accurately examined by both of us. Dr. Roan thought it had evidently
increased in size since his previous examination. The increase during the
two succeeding hours was very perceptible. The patient was rapidly sinking,
with an exceedingly quick and feeble pulse, blanched complexion, cold per-
spiration, and her sufferings were on the increase. In fact, the case presented
all the indications of utter hopelessness.

In consultation, the first subjects for inquiry were the cause and nature of
this novel and most extraordinary formation, which had appeared since deli-
very. Mrs. P.'s mother informed us, that the day before her daughter's con-
finement, in attempting to get over a fence, she slipped and fell to the ground
alighting on both feet; the shock being very considerable. Immediately after
the accident, she felt a sudden pain in the left iliac region, attended with a
peculiar sensation, as if the parts beneath were torn apart. Many and vari-
ous ideas suggested themselves to our minds, as the probable cause of this
tumour. First, was it a retroverted womb? The uterine globe being still
above the pubis, satisfied us on this point. Could it be a large hernia ? The
tumour being smaller in the beginning, but having gradually and progressively
increased, the torture and pain increasing in intensity with it; the great elas-
ticity of the swelling, as if due to fluid contents ; the perfect freedom of the
intestinal canal from obstruction or disturbance ; all united to discourage that
opinion. In fact, the sudden appearance of the tumour after labour ; its pro-
gressive increase ; the characteristic pain in the pelvis, as if the tissues were
being torn and riven asunder ; the great tension and elasticity ; the peculiar
pain at the time of the accident, led us to believe that one of the deep-seated
vessels beneath the pelvic fascia had been ruptured by the jar which Mrs. P.
sustained, that a slight effusion of blood followed, a coagulum formed and
sealed up the orifice temporarily. But labour being hastened by the accident,

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[April

opened the bleeding orifice afresh, and gave vent to a large quantity of fluid
blood, which, continuously escaping, made its way under the deep fasciae of
the pelvis, and between the walls of the vagina, rectum, and the left ischium
and pubis, and part of the sacrum. In fact, the growth filled the whole
pelvic cavity as far as the brim, pushing the uterus and bladder entirely above
the upper strait. Concurring in this opinion, it became necessary to devise
some means by which to arrest the alarming internal hemorrhage, and thereby
put a stop to the growth of this tumour.

Mechanical means being of no avail here, we selected the gallic acid, as
probably being one of the most effective internal hemostatics, in scruple doses
every hour. In the mean time, the patient was put under the influence of
powerful anodynes, to relieve pain and constitutional suffering. This treat-
ment was energetically persevered in until evening, when the hemorrhage
appeared to have been arrested, as the tumour ceased to increase. The ano-
dynes had greatly relieved her sufferings, and though the abdomen was
exquisitely tender on pressure, she was tolerably comfortable, but greatly
prostrated ; evidently more from loss of blood in the pelvis, than the attend-
ing pain.

For the next fortnight, Mrs. P. suffered from occasional severe paroxysms
of pain and a low form of remittent fever, which quinine and tonics ultimately
relieved. After this I saw nothing more of the patient until some six weeks
had elapsed, when her husband requested me to visit and examine her, as the
pelvic tumour had given her more pain than usual of late, and she thought
probably something was escaping from it. On examination, I discovered a
fistulous opening, caused by ulceration, leading through the walls of the vagina
into the most dependent part of the tumour ) through which, by means of
pressure, I forced out a large quantity of grumous blood. Thus in the end
verifying our original diagnosis. After this, the patient under a tonic treat-
ment recovered her usual health.

Tumour occurring thirty-six hours after Delivery. By J. Marcus Taylor,
M. D., of Mississippi. — I received a message on the 27th November, 1857,
to visit Mrs. N., an extremely feeble and delicate lady, in labour with her
seventh child; but did not see her until about three hours after delivery.
The labour was natural, and the child was received and separated by a female
friend, who happened to be present. The placenta was expelled soon after
the child, and removed by the same lady. When I arrived I was apprised
of the above facts, and finding the lady suffering very severe after-pains, and
otherwise apparently doing well, I prescribed 3j tinct. opii cam ph., to be re-
peated as needed, gave the usual directions for the lying-in, and left. On
the night of the 28th I was called to see my patient in haste on account of
a tumour presenting itself at the vulva. On making an examination, I could
detect nothing at all corresponding to the description given me by the lady
and her friends. Mrs. N. informed me that while pressing on the tumour
with her hand it disappeared, and she supposed it to be the womb which she
had replaced in situ naturale. She was yet suffering considerable after-pains,
but being able to discover nothing abnormal, I reassured her, gave a dose of
morphia and Hoffman's anodyne, and retired for the balance of the night.
Very early in the morning, I was invited into the sick room to witness the same
difficulty for which I had been called in the night. On examination this
time, I found a tumour protruding at the vulva as large as a man's fist, very
smooth, round, and of a pear shape ; the large extremity or base presenting.

I at first suspected inversion of the uterus. The size and shape of the

1858.]

Original Communications.

559

tumour ; the general debility and want of tone in the muscular system of my
patient, and the unusually severe after-pains, all conspired to lend force to
that view ; but the smooth, serous surface of the tumour, and the absence of
any cul-de-sac around its neck, satisfied me at once that such was not the
case. And on making slight pressure with the ends of my fingers, the tumour
presented a boggy feeling, from which I inferred that it was a sac filled with
some semi-solid matter.

With very slight traction efforts, I removed the whole mass, which proved
to be a portion of the foetal membranes, about eight by twelve inches, when
spread out. Its internal surface being concave, served as a receptacle for the
blood in its exit from the uterus, and when removed it was filled with firm
coagula.

The pressure exerted upon the tumour by the hand of my patient before
my arrival, caused the blood contained in it at that time to escape around the
loose margin of the membrane, after which the sac collapsed, and lying close
upon the walls of the vagina, was not detected in my first examination; and
the membranes remaining in statu quo, refilled, and thus reproduced the
tumour.

Rienzi, Miss., January 7, 1858.

Case of Poisoning by Laudanum ; Recovery. By Thos. J. GrALLAHER,
M. D., Pittsburg, Pa.

On the evening of the 15th of January of the present year, T was called
to a female who was said to be extremely ill from having taken two ounces
of tincture of opium for the purpose of committing suicide. The patient was
a woman of loose character, about 28 years old, short of stature, very lusty
and obese, and much addicted to the use of intoxicating beverages. As she
was not seen until the poison had been drank one hour and a half, of course
it had full time to exert powerfully its toxical effects upon her.

She was lying upon her back on a sofa in a state of perfect coma j the in-
sensibility being so complete that ice water dashed violently into the face
produced not the least evidence of sensibility, nor contraction of any of the
voluntary muscles. The lips were livid; surface of the body cold and bluish;
limbs relaxed; pupils contracted to the size of a pin's head, and immovable
to the impressions of light; eyes everted, fixed, and strongly congested;
eyelids closed; carotid arteries beating violently; respiration slow, laborious,
stertorous, and very irregular, sometimes more than a minute would inter-
vene between the respirations, when inspiration would suddenly occur accom-
panied with a loud and disagreeable snore; and the pulse was slow, irregular
and feeble. From these symptoms and the history of the case I was convinced
that she had taken laudanum, and was then suffering from the poisonous
effects of that powerful narcotic. A dose of tartar emetic had been given
her by one of the inmates of the house in which she lay; but as the stupor
came on her before it had time to operate, emesis was not produced.

The treatment adopted was prompt. By the aid of a- stomach-pump the
stomach was soon relieved of its contents, and well washed out four or five
times, with tepid water. The material raised from the stomach gave by its
colour and odour unmistakable evidence of the presence of a considerable
quantity of laudanum and whisky. The head was then directed to be some-
what elevated, and two mustard cataplasms — one to the epigastrium and the
other to the space between the shoulders — were ordered to be applied, and
permitted to remain till redness of the skin was produced. In a short time,
symptoms of improvement became apparent ; the pulse became fuller and

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more regular; the respiration more regular, and the extremities slightly
warmer. In two hours she was again visited, but as there was no further
improvement, bloodletting was determined on. Failing to procure the re-
quisite quantity of blood from either arm, on account of the exceeding obesity
of the patient, the temporal artery was punctured, and several ounces of dark
blood, much resembling that usually found in the veins, obtained. Some
time afterwards a severe convulsion occurred, but this was of short duration.
During the night an occasional sinapism was applied to different parts of the
body, fresh air freely admitted, and heat applied to the extremities. Before
morning a messenger came to inform me that she had revived from her
stupor and become sensible, and was then very thirsty. Cold water in
small quantities was permitted.

In the morning I visited her, and was pleased to find her quite free from
coma. She complained, however, of headache, thirst, and vomiting, and an
intolerable itching of the skin. Remedies were directed for these disagreeable
symptoms, when, in a few days, I had the satisfaction of seeing my patient
quite restored to her usual health.

Case of Hernia. By Robert Lane, M. D., Sutton, New Hampshire.

Mrs. B., a matron of 50, large and muscular, has had femoral hernia three
or four years; thinks the tumour has been constant for the last two years; has
suffered but little inconvenience from it till the evening of the 10th Nov. 1857,
when she was attacked with symptoms of strangulation. Hot applications
were made to the tumour, a physician called at 12 o'clock, who endeavoured
by manipulation to reduce the hernia, but not succeeding, applied ice to the
tumour, and gave morphia freely. I first saw her at 12 M. on the 11th;
the pain and vomiting had subsided; there was an elastic tumour of the size
of a butternut, with a thickening and hardening of the cellular substance
around it an inch and a half broad from the elastic part of the tumour. No
increase of pain that afternoon; enema given in the evening produced free
evacuation.

Nov. 12, 10 A.M. Has rested well through the night; the tumour has an
odd doughy feel, different from the elasticity of yesterday; free from pain
when still, but complains of soreness on motion.

18^A. Called again; patient restless with pain in the abdomen; erythema
three or four inches broad, extending nine or ten inches up and down over
the tumour; vesication of the tumour; gave opium and enema with a mild
laxative.

20th. The laxative operated freely; less inflammation on the surface of the
abdomen. The true skin on the tumour so dead that I removed an elliptical
portion with the forceps and fingers, about one and a half inch long, by three-
fourths of an inch wide; under this I found a portion of gangrenous intestine;
raising this with forceps, one end separated, which was brought out of the
ulcer and clipped off with scissors, so as to take out one and a half inch of
intestine containing a portion of green vegetable. The part of the intestine
cut off was open so as to pass the finger in it into the abdomen, the ulcer ex-
tremely fetid. Gave bark and opium; enema and laxative.

22c/. A small quantity of fecal matter discharged from the ulcer, with free
discharges per anum. Pain and tenderness with other symptoms of peritoneal
inflammation; in two days these symptoms have subsided. Grave opium and
bark.

2bth. Removed about an inch and a half more of the intestine; less fecal
discharge from the ulcer; fetor abated.

1858.]

Original Communications.

561

28^. Natural discharges from the bowels, kept free by mild laxatives and
enema. Gave bark and opium ; ulcer filling up with healthy granulation;
still a little fecal discharge from it every day.

Dec. 2. Patient improving; continue the same treatment. From this time
no unpleasant symptoms, except from confinement. A small quantity of fecal
matter discharged from the ulcer till the first week in February.

1858, Feb. 14. The ulcer healed; the patient up about the house.

Dislocation of the First Phalanx of the Thumb upon the Dorsum of the
Metacarpal Bone. By Benjamin Cutter, M. D., of Woburn, Mass.1

This dislocation is generally caused by a severe blow received on the end of
the thumb, when the arm is extended to save one's self while falling. The pha-
lanx is forced backward upon the metacarpal bone, and firmly retained there
by the lateral ligaments. But should the phalanx be forced beneath the meta-

carpus, it is easily replaced. On looking through authors on dislocations, both
ancient and modern, mention will be found of great difficulty in treating this
dislocation, and no easy method of reduction suggested. Many powerful in-
struments for traction have been devised, and cases of tearing off the member
have been reported. In order to get a secure hold upon so small a limb, it has
been usual to protect the thumb with a covering of soft leather, over which a
strong tape is secured with a clove hitch so tightly drawn as to prevent slip-
ping, and to which manual or mechanical power may be attached — such as the
pulley, Jarvis's adjuster, &c. Many other ingenious contrivances, to secure
certain hold of the member and make extension, have been made and recom-
mended— such as Charriere's modification of Luer's pronged forceps ; Levis's
apparatus (see American Journal of the Medical Sciences for January, 1857) ;
the " Indian puzzle," recommended by Dr. Hamilton, of Buffalo ; VidaPs me-
thod with a common door key, advocated by Roux and many French surgeons,
&c. &c.

Dr. William Hey, of Leeds, a fine old English surgeon of the last century,
and an eminently practical one, acknowledges from experience that " the re-
duction is in some cases extremely difficult, if not impracticable ;" and it is
noticeable that he mentions no cases where he was successful. (See Hey's Sur-
gery, p. 206.) Many cases, after vain attempts, have been left unreduced, and
the patients have been obliged to submit to the inconvenience for the rest of
life, unless the division of one of the lateral ligaments, or the resection of the
end of one of the projecting bones be made, both of which operations are re-
ported.

The aforesaid devices and advices are all wrong, because unnecessary. There is
a better way. For several years past, Professor Dixi Crosby, of Hanover, N. H.,
has been accustomed to describe the accident and its treatment in his medical
lectures, so that the medical profession in New England are generally familiar
with his method. Drs. Doe and Morgan have published articles relating to it ;
Dr. Crosby has not. From one of his pupils, I learn that, some years ago,

1 An account of this method of reducing dislocation of the first phalanx of the
thumb, upon the dorsum of the metacarpal bone, has already been published in our
esteemed contemporary, the Boston Med. and Surg. Journ. (No. for Oct. 1, 1857), but
we are induced to insert it here, as it has been communicated to us by Dr. Cutter, with
corrections, and an important addition.

562

American Intelligence.

[April

Prof. Mussey had a case in which all the usual appliances were employed with-
out success, and resort was about to be had to the knife for the division of one
of the lateral ligaments, when Prof. C. was permitted to try a method which
had suggested itself as feasible in such accidents, and it succeeded admirably.
Prof. C. remarks in his lectures, " that he has never failed in the many cases
which have occurred in his practice, although in several instances all other
methods usually adopted had been tried without effect." And "in his opin-
ion, this method is equally applicable to similar dislocations of all the pha-
langes." I have verified this last opinion in one instance, the only one I have
met with.

Case first occurred about six years since ; the subject an Irish lad, about 8
years old, with his left hand thumb dislocated. After some ineffectual attempts

to reduce it by his parents and neighbours,
I was called. Having a general idea of Dr.
Crosby's method, I proceeded to put it in
practice. I placed the patient in a common
chair, and took a seat in another at his side,
both of us facing the same way. An assist-
ant sat behind us, to hold the boy's elbow
fixed. I then took hold of the metacarpal
bone with my right hand, my forefinger
passing between his thumb and forefinger,
and my thumb resting on the top of the me-
tacarpal bone, with its end touching the dis-
located end of the phalanx. With my left
hand I tipped the phalanx back, until it
stood perpendicularly on the metacarpal
bone ; then pressing the phalanx forward by
the end of my right thumb, it was readily
yr) carried by flexion into place, and the joint
/ / restored to its natural condition. The ma-
| nipulation was performed in a twentieth
! part of the time taken to describe it. A
bandage was applied for a few days to pre-
vent displacement, and some evaporating lotion to subdue inflammation.

About the same time another similar accident occurred in an adult, an officer
in the Customs, which, in my absence, was treated according to the same prin-
ciple by my friend Dr. Rickard, and with equal success.

The next case, and which is the occasion of this paper, occurred in S .

The subject, a young girl about thirteen years of age, had the first phalanx of
the right thumb dislocated on the back of the metacarpal bone. Dr. G., an
irregular practitioner, was called, and failed in his attempt to reduce it. She
was then taken to my friend, Dr. S., who sent her to me about the middle of
one of the most rainy nights last month. As she had suffered considerably in
the attempts to reduce the dislocation, she and her friends insisted on using
some anaesthetic, and, although I considered it unnecessary, she was gratified.
As it was the right thumb that was injured, I seized it with my left hand, the
forefinger underneath, and my thumb on the back of the metacarpal bone.
With my right hand I tilted up the phalanx, until the end of the joint rested
upon the metacarpus ; then pressing it forward with the end of my left thumb,
I flexed the phalanx into line and place with ease.

I have recently received, at second hand, from Prof. Crosby, a letter in
which he briefly states his claim, as the inventor of this process of reduction

1858.]

Domestic Summary.

563

by manipulation; and as it is well to fix the paternity of it on the proper
person, I append it.

Hanover, N. H., Feb. 4, 1858.
Dr. R., Dear Sir: Yours of the 30th is received, and I have to thank you
for the interest taken in the matter of dislocation. Dr. C, has stated the thing
so, that I doubt the propriety of adding anything to his article at present. I
would suggest that you may emphasize the fact that I discovered this method as
early as 1826. My first patient was a little boy, the son of Mr. Francis Ayers,
of Gilmanton, N. H. I had assistants for several hours, while I was trying
extension by the " clove hitch." At last I resorted to the method which I now
use and recommend in my lectures, with complete success. I came to Hano-
ver, Sept. 15, 1838, and, in a few days after, one Sunday afternoon, at the
Dartmouth Hotel, I accomplished the reduction on a patient of Prof. Reuben
D. Mussey, by the name of Williams. I refer to Dr. Mussey, now of Cincin-
nati, to corroborate. The first published case was by Dr. Arnold Morgan, of
Canaan, N. EL, who was my pupil, and derived the information from me in a
course of private instruction, and who was afterwards my assistant in business.
In a great number of these cases that have occurred to me, I have never failed
to effect the reduction in a single instance. I can, moreover, bring forward at
this time several parties, on whom I have practised this operation, since I hit
upon it, in 1826. It is a very simple matter, but of incalculable benefit to any
unfortunate who happens to have this luxation.

With regard, I remain yours, &c,

DIXI CROSBY.

DOMESTIC SUMMARY.

Dislocation of both Thighs — one into the Foramen Ovale, the other on the Dor-
sum of the Ilium, with Fracture of the Cervix Femoris. — Dr. J. Mason Warren
communicated to the Boston Society for Medical Improvement the following
interesting case: The patient was brought into the Massachusetts General
Hospital, having been crushed by the giving way of a wooden house, which he
was engaged in moving, being struck upon the back as he was making the at-
tempt to escape. The right leg first attracted attention. The thigh was fixed,
slightly flexed on the body, standing off from it, the foot presenting nearly for-
ward, the limb apparently elongated. A deep hollow was felt in the region of
the trochanter, which had itself disappeared. The man being etherized, and
the pulleys adjusted, a gradually increased force was applied to extend the
limb. A sheet was now placed under the upper part of it, and an assistant,
standing on the table, directed to lift the limb. A slight rotation was now
made to disengage the head of the bone, and it went into its place without any
perceptible noise or action of the muscles.

The right limb being replaced, it was now perceived that the left limb was
distorted, and presented all the signs of a dislocation upon the dorsum ilii. It
was firmly fixed, shortened, the toes everted and resting upon the upper part
of the other foot. The trochanter was prominent, and drawn up from its place
to within about three inches of the crest of the ilium. On making an effort to
move the limb, an indistinct, but very decided crepitus was perceived.

The pulleys being adjusted, and a fresh dose of ether administered, the limb
was slowly and with much difficulty drawn down, a slight rotatory motion
being given to it when the head was on a level with the socket. It went into
its place with a loud crack, which was heard by all the assistants. The limb
now appeared, at first, to have regained its natural condition. As the effect of
the ether upon the muscular system subsided, the limb gradually contracted,
and the foot became slightly everted. An examination now being made, by
rotating the limb, and placing the finger on the trochanter, it was perfectly
evident to all present, that there was a comminuted fracture of the thigh-bone,

564

American Intelligence.

[April

passing through the trochanter. The two limbs were therefore confined — the
right one by a weight attached to it, and a cradle placed over it. To the left.
Desault's splint, as used at the Hospital, was applied. In addition to the above
injuries, there was a fracture of two or three ribs on the left side.

The best explanation of the appearances offered by the left limb is this.
The violent crushing force dislocated the femur, at the same time breaking the
neck of the bone. The separation of the parts was not, however, sufficient to
prevent them from being replaced, but the fracture was made complete, on the
bone being returned to its socket.

The subsequent history of this case is not without interest. The patient,
from the time of his admission, had complained of his chest, where, it may be
remembered, one or two ribs were broken. Suddenly, one night, great difficulty
of breathing came on, and, upon examining the chest, it was discovered that a
congestion of the posterior part of both lungs had taken place, such as has be-
fore been observed at the Hospital, in patients who for a long period of time
have been confined on the back, without movement, after serious injuries to
the lower limbs. From this affection he very gradually recovered.

At the end of two months, he left the Hospital well. The motion of the right
limb was natural. The left leg was a little shortened. The motions of the
hip-joint were limited ; on examination, the trochanter was found irregular at
the point of fracture. As it had been thought possible that the head of the
femur might have been left on the dorsum of the ilium when the complete frac-
ture of the limb took place, search was made for it, but it could not be found
there.

In this connection, Dr. Warren mentioned the following case of dislocation,
and which was interesting in a practical point of view. A man was brought
into the Hospital with a dislocation on the dorsum ilii, which was caused by a
wagon passing over him, the limb being at a right angle with the body. Ether
was given, the pulleys applied, and the dislocation reduced. On raising the
limb slightly, to examine it, it at once slipped out of place, and was reduced
again with some difficulty. This experiment was once or twice repeated, with
the same result. Dr. Townsend, who saw the man, verified the fact. Slight,
though not very marked crepitus attended the movements of the joint. From
fear of displacement, and with the idea of a fracture of the edge of the upper
and back part of the cotyloid cavity, the limb of the patient was kept rigidly
confined in Desault's apparatus, and his desire to return home resisted. The
precautions taken in this case were afterward shown to be not without reason.
About three weeks after the accident, Dr. W. being out of town, the patient got
out of bed, and while resting on the injured limb, attempted to turn around,
thus giving a slight twist to the hip-joint. The bone immediately slipped from
its socket. This accident afterward, in the course of the next week, recurred
a number of times from simple motions made by the patient while in bed. It
was then determined to put on a permanent splint, and allow it to remain on
for several months. This had the desired effect, and the patient was seen by
Dr. TV. some months after leaving the Hospital; the joint was then slowly re-
gaining its mobility. — Boston Med. and Surg. Journ., Jan. 14, 1658.

A Simple and Efficient Bandage for Fracture of the Clavicle. — Dr. Julian
Chisolm describes [Charleston Medical Journal, March, 1S5S) a simple, and
what seems to be, at the same time, a very efficient bandage for fracture of the
clavicle.

The bandage is formed of a strip of cloth from three to five feet long, and
from eight to eighteen inches wide (according to the size of the patient) which
is slit from both ends in such a way as to leave a bridge from one to two inches
wide in the centre, connecting the two lateral half strips. A soft pad having
been placed in the axiila. to act as a fulcrum upon the riding fragment, the
affected arm is carried over the chest, the palm of the affected hand resting
upon the side of the thorax, under the border of the opposite armpit. This
position of the arm removes all deformity, and brings the fragments in apposi-
tion. The centre of the bridge of cloth is now placed under the elbow, the
superior strip, which covers half the height of the affected arm, is made to en-

1858.]

Domestic Summary.

565

circle the chest; one end is carried forward, the other backward, to meet the
opposite armpit, where, after enveloping the hand, and being firmly drawn upon
the affected arm, they are secured with needle and thread, pins, or an ordinary
knot. The inferior strap, which is placed under the affected arm as a sling, is
made to traverse the chest in the same way, the ends meeting over the oppo-
site shoulder, where they are secured by the same means. If at the several
points where the strips cross each other, a stitch or a pin is placed, the result
will be a firm casing, which, even in the most restless child, cannot be dis-
arranged. The needle and thread is by far the preferable mode of completing
and sustaining the adjustment, as the stitches are not apt to be interfered with
by the patient or friends ; pins, on the contrary, are often tampered with, par-
ticularly if there should be any restraint from the bandage. As the material
is quite soft, no binding nor excoriations are produced. The bandage supports
the entire limb in an easy position, and clasps the arm sufficiently to prevent
injurious motion, without being irksome to the patient. It requires no constant
renewal, as one single application, if carefully made and properly secured, can
be worn until the cure is perfected.

Dr. C. says he has used this simple contrivance for several years with satis-
faction.

Some Remarks on Cataract. — Dr. C. S. Fenner, of Memphis, Tenn., in a re-
cent paper, under this caption (North American Medico- Chirurg. Review, Jan.
1858), makes the following remark in regard to the operation of couching,
which, we think, for the credit of American ophthalmic surgeons, ought not
to be allowed to pass without notice.

Dr. F. states: "When the cataract is hard, couching is the operation gene-
rally preferred by American surgeons, although by most English and German
authors, it is placed in the lowest scale."

We feel quite sure that Dr. F. is mistaken in supposing that American Oph-
thalmic Surgeons differ from their brethren in England and Germany, in their
estimate of the operation of couching ; indeed, the very few in this country
who practise or advocate that operation, constitute the exception, not the rule".

Mr. Dixon regards depression " as an unscientific and destructive operation,"
and the same opinion of it is expressed in the last American edition of Law-
rence's Treatise on Diseases of the Eye (see p. 723). Mr. Walton and Dr. Mac-
kenzie both hold similar views in regard to it (see Ibid., p. 723 and 724).

Dr. Fenner, candidly admits, that his " own experience in displacement has
not been so favourable as that reported by some American Operators."

And he goes on to state: "In my operations for cataract by displacement, I
have often had to combat a subacute chronic internal inflammation, sometimes
coming on several weeks after the operation, and seemingly induced by atmo-
spheric influences. The presence of a hard lens in the vitreous humour in some
instances causes irritation, followed by slight redness of the conjunctiva, in-
ability to bear light, increased secretion of tears, a sensation of fulness in the
eye, soreness to the touch, and pain at times extending to the terminal branches
of the fifth pair of nerves. Iritis may supervene with effusion of lymph in the
pupil, but generally the pupil remains clear, the vision gradually fails, until
the eye becomes almost amaurotic. I have had this result to occur most fre-
quently in delicate, aged females. Mr. Lawrence remarks that "internal in-
flammation commencing in the iris, and proceeding slowly, is a common occur-
rence after depression and Mr. Mackenzie, that " chronic inflammation oi
the internal textures of the eye is a frequent consequence of depression or re-
clination. It is not attended by much pain, but prevents the eye from ever
attaining a degree of healthiness sufficient to render it useful. The patient:
perhaps, retains a considerable degree of recovered sight for some weeks after
the operation ; but epiphora, varicose dilatation of the external bloodvessels of
the eye, and in general a contracted, but sometimes a dilated pupil superven-
ing, the sight becomes weak, and in a few months is extinguished.''' I have
repeatedly had cataract patients return to their homes able to see to read line
print with ease, yet in a few months scarcely able to walk about, and I have
witnessed the same final termination in those who have been operated on by
No. LXX.— April 1858. 37

566

American Intelligence.

[April

experienced surgeons of the North and East; they returned home with good
vision, but this gradually failed them, until they became amaurotic. Such
being the occasional result, no case of cataract should be reported as cured,
unless the state of vision is known six or twelve months after an operation ;
and if operators would keep their patients in view for that length of time, the
final result of their operations, I am inclined to think, would not be so favor-
able as they sometimes report.

Every ophthalmic surgeon who has carefully watched the results of the ope-
ration of couching, has observed the same unfortunate consequences as those
described by Dr. F., and this so very frequently, that couching has now few, if
any advocates, anywhere among prudent and conscientious ophthalmic sur-
geons. Dr. F. is perfectly correct in his opinion, that no cataract should be
reported as cured until the state of vision is known twelve months after the
operation.

It is to the practice pursued by some surgeons, of hastily reporting their
cases, before the ultimate result can be determined, that so much false glare
has been thrown around operative surgery, and such erroneous estimates been
made of the value of certain operative procedures, and which has in the present
case, as we believe, misled Dr. Fenner.

Thrombus of the Vagina. — Dr. Boisliniere lately reported to the St. Louis
Medical Society the following interesting case of this rare accident: —

The patient, a primipara of leucophlegmatic habits, with a normal pelvis,
after an ordinary labour, ending with rather severe expulsive pains in the birth
of a living child, was left comfortable, when, an hour and a half after, he was
called to see her in haste. He found her in the greatest suffering, crying loudly
and assuring those around her that this was ten times more severe than her
labour pains. She complained then of a burning sensation in the vulva, and a
severe bearing down on the rectum, which gave her a pressing inclination to
go to stool. She suggested that it was piles. This pain was so agonizing that
she had no words to express it. In fact, she could hardly utter two words in
succession. This appeared to him the more strange from the great fortitude
she had shown during her labour. Dr. Boisliniere confessed that he fell here
into the same error committed by Dr. McBride in a similar case, and that he
took this at first to be one of those violent tenesmic pains that are experienced
sometimes after labour, when the child's head has quickly and violently swept
over the vagino-rectal septum — a sort of severe spasm — and he ordered opium
suppositories, and hot fomentations to the parts ; the latter, as proved on trial,
only aggravated the evil ; the pain continuing to increase instead of abating.
He made then a vaginal examination, which revealed to him the true nature
of the complaint — it was a very large thrombus, beginning on the left side,
ascending along the side of the pelvis as high up as the finder could reach, filling
the whole of the vagina, so that the finger could with difficulty only be intro-
duced, and descending as low down as the left labium, where it was charac-
terized by great hardness and elasticity. This tumour was rapidly enlarging
— he could ascertain this by keeping the end of his finger on its surface — the
patient was in the greatest agony, her pulse was getting quick, her countenance
anxious and distressed. There was only one course to follow — Dr. Boisliniere,
under these circumstances, availing himself of the great experience of Dr. M.
M. Fallen in matters of this sort, sent for him, and it was decided to open the
tumour largely at once. Dr. Pallen then incised the tumour which was pro-
jecting and bluish — his incision extended to three inches in length and reached
the eavity of this thrombus, after which he emptied it of the coagula it contained,
except the most adherent at the bottom for fear of inducing hemorrhage, and
a sponge was introduced in the vagina to act as tampon. The patient was
immediately relieved and recovered well. The amount of clotted blood ex-
tracted must have been several ounces.

Dr. Fallen said, that the case related by Dr. Boisliniere was a very inter-
esting one ; interesting on account of its rareness, and on account of the
fatality often attending them. He believed that the first published case in
British midwifery, was that of Dr. McBride, which occurred in 1776. It had

1858.]

Domestic Summary.

567

however been observed before. Since then, it has been noticed and described
by various writers. Dr. Denman saw three cases, and all recovering, he was
induced to think that the disease was devoid of danger; subsequent experience
has, however, shown that he was mistaken — death has frequently occurred.

This disease, which consists of an effusion of blood into the areolar tissue,
may be in one or both labia, may extend into the pelvis, and into the perineum.

It doubtless, sometimes, occurs in the unimpregnated female ; but it is usually
an accompaniment of labour, appearing either during its progress, or soon after.
The swelling of the labia, and the feeling of weight, are succeeded by great
pain. If the distension be very great, the pain is agonizing; fever of an active
kind ensues, and even delirium. The patient can only lie on her back, with
her thighs widely separated. The tumour is of a livid colour, almost black,
and is extremely tender.

Dr. Pallen added, that there could be no doubt that the effusion arose from
rupture of some vessel. In a state of pregnancy, the vessels are in a varicose
condition, and their rupture easily produces a large discharge of blood. What
particular bloodvessel is ruptured, is not determined, probably the pudic vein.

"If the tumour," said Dr. P., "occurs before delivery, and increases slowly,
and does not interfere with delivery, it might be trusted to nature. If it in-
crease rapidly and interfere with labour, it ought to be laid open, and the
coagula turned out. The same rules apply to the treatment, if it occur after
delivery. If it be of slow formation, and not large, the application of cold
cloths is all that is necessary; but if it form rapidly, and the pain is great,
then we ought to cut it open, turn out the coagula, leaving those which are
entangled in the areolar tissue, as they will tend to prevent further bleeding.
This being done, the tampon should be used, to produce pressure on the blood-
vessels.— St. Louis Med. and Surg. Journal, Sept., 1857.

Fatal Asphyxia from Imperfect Combustion of Gas. — The case of a gentleman
found dead in his bath-room, and whose death was attributed to inhaling air
rendered impure by a gas stove used to warm the room, was a short time since
communicated to the Boston Society for Medical Improvement. The Society
appointed a committee to investigate the circumstances, and in a recent report
[Boston Med. and Surg. Journal, March 18, 1858) made to the Society, the
committee express the opinion that an adequate and sufficient cause of the
fatal result in this case is found in the deleterious products resulting from the
imperfect combustion of coal gas.

The following account of an experiment upon a cat, placed in a room with
one of the gas stoves, was read to the Society by Dr. Ellis: —

"The cat was placed in an iron grated cage, elevated two and a half feet
from the floor, the room being eight feet square and ten feet high. The ther-
mometer indicated 90° when taken out. The first thing noticed was a snapping
of the eyes, then a crying (as is frequently heard in the night from cats), this
becoming, in fifteen or twenty minutes, pretty loud. In a short time this crying
stopped. The mouth moved, but without any noise. She sneezed fifteen or
twenty times, and rubbed the nose and face with her paw ; afterward tried to
bite the iron grating of the cage. There was a flow of watery fluid from the
mouth, but without any frothing. The mouth was open most of the time.
While lying down she would try to get up on her back legs, and would fall
over immediately. In thirty minutes there was a tremulousness and throwing
back of the head. The respiration became long and stertorous. Convulsive
movements came on about the epigastrium, which increased over the body
generally, and in forty-eight minutes the animal was dead."

We trust that this very conclusive experiment will tend to awaken the pro-
fession and the public to the incalculable importance of free ventilation, and
the employment of proper means for warming our houses ; and that gas stoves,
air-tight stoves, and many like economical means of warming — economical of
the purse, at the expense of comfort, health, and duration of life — will be
banished from our dwellings. Every means of warming which is not combined
with ventilation — in which there is not a full supply of pure, atmospheric air,
at not too high a temperature, combined with its entire and constant renewal —

568

American Intelligence.

[April

is deleterious to living beings ; it is productive of discomfort — sickness, and
tends to shorten life.

The claims of the stomach for food are universally admitted, but those of the
lungs for fresh air are almost as generally ignored, though the functions of
the latter are no less essential to life and health than those of the former.
Every human being requires eleven cubic feet of fresh air per hour for respira-
tion, and, if this be not supplied, the blood becomes deteriorated, which is fol-
lowed by an impairment of all the vital functions, and ultimately their cessation.

Inverted Toe Nail treated without Operation. — Dr. Robert Campbell states
{Southern Med. and Surg. Journ., Feb., 1857) that, dissatisfied with the operation
for evulsion of the nail, which he has long deemed, and very justly, we think,
an unwarrantable measure of torture, he was lead to devise some expedient
which might answer the indication of keeping the nail apart from the irritated
flesh. Whilst treating a severe case of inverted toe nail, in 1851, he tried an
apparatus which gave him so much satisfaction, that he has adopted it in all
cases since.

"This apparatus is formed of a bandage somewhat broader than the length
of the nail — say fths of an inch and 1J yard long, having a roll at one end
about Jth of an inch thick, to be used as a compress, to which the last turn of
the bandage is tacked, to prevent the disposition, otherwise, to unroll on trac-
tion. This compress is applied in the groove, between the flesh (which is gene-
rally much enlarged) and the nail. The margin of the compress, at which the
last turn of the bandage is sewed, must present always upward and opposite to
the direction in which the pressure is to be exerted — i.e., if the outer border of
the great toe on the right side is affected, the seam should be directed upwards
and towards the left side of the patient. Thus applied, the bandage will be-
come somewhat wound around the outer side of the compress, which is to be
pressed, at first, very gradually and tenderly, but somewhat forcibly, down-
wards and outwards, until secured in that position by several turns of the
bandage around the great toe, carrying it first down, between that member and
the second toe, and around several times. The great toe is then to be depressed
and forced outwardly, under the second, which is placed upon the compress,
and lightly bound in that position by a few turns of the bandage.

" The bandage should be re-applied, at least as often as once a week. If the
prominence of flesh, against which the compress is to rest, is very irritable, a
layer of lint, anointed with simple cerate, should intervene. At the first im-
pression of the compress to the sore flesh, the patient experiences some degree
of pain or soreness ; but the very prompt abatement of suffering following the
relief of the inflamed tissues from the irritation of the sharp nail, and also the
diminished turgescence of the part, induced by the uniform pressure of the
compress and bandage, will prove an ample recompense. The comfort of the
patient and celerity of recovery are much enhanced by keeping the limb in an
elevated position. It is a matter of surprise, bordering upon astonishment, to
see the great diminution of sensitiveness in the part, at each succeeding appli-
cation of the apparatus. Six or eight weeks is time sufficient for relief, gene-
rally, or for such an improvement as to render it safe to intrust the case to the
care of the patient."

A much simpler plan, and one we have pursued for twenty years, and which
perfectly fulfils the indication of keeping the nail apart from the irritated flesh,
is to introduce by gentle pressure with the edge of a pen knife, a portion of lint
between the nail and the flesh. By a little manipulation, this may be effected
with little if any pain, and the process is to be daily repeated. It will be found
that with each repetition of the process, the space between the nail and flesh
increases, that a larger portion of lint may be introduced, and that its intro-
duction becomes easier. We have employed this mode of treatment so often,
and with such satisfaction, that we confidently urge it on the attention of the
profession.

Case of Impalement. — Dr. A. C. Garratt, communicated to the Suffolk Dis-
trict Medical Society, the following remarkable case. The subject of it was

1858.]

Domestic Summary.

569

a sailor, whose magnificent chest attracted the narrator's attention particularly
on account of a very large depressed semilunar cicatrix, situated directly over
the region of the heart.

" His name was John Taylor. On the 6th of May, 1831, when about twenty
years old, he shipped on board the Danish brig Ann, of Scarborough, then lying
at the London docks, getting ready for sea; on that very day, while endeavour-
ing to direct and enter what is called the step-bolt, or iron pivot, of the trysail
mast into its socket in the rail, the tackling gave way, precipitating him back-
ward upon the deck. The mast, with the iron bar fixed in its lower end, drop-
ped almost perpendicularly upon his chest, driving the rough iron through him
into the plank beneath, while the square end of the spar fell upon his thorax,
compressing it in a most frightful manner. He remained thus transfixed to
the deck, with the mast upon him, until new tackling could be rigged to hoist
the spar. He was taken to the London Hospital, apparently in a dying condi-
tion, but, rallying under prompt surgical treatment, he gradually recovered.
At the end of twelve months, he left the hospital, soon after shipped again as a
sailor, and has continued in that employment up to the present time, about
twenty-six years. He said that he had not been in London for eighteen years,
but that his case must be known to the surgeons there, and that the bar of iron
was taken from the mast and placed in the Museum of the Royal College,
together with a sketch showing the position, size and shape of his cicatrices.

" So extraordinary a history seemed to warrant investigation, and I prevailed
on Mr. Taylor to accompany me to London, where Drs. Ferguson and Partridge
recognized him and corroborated his statement. In the Museum I found the
sketch and the bolt, and also a record of the case, from which I gained some
additional facts. The scalp was extensively laid open ; the inferior maxillary
bone was fractured, and a portion of it, with several teeth, removed, and there
was considerable exfoliation from the different wounds, during his convales-
cence. At the time of the accident, the anterior extremities of the fifth and
sixth ribs of the left side, together with their cartilages, were removed from the
wound in front, while portions of the necks of the seventh and ninth ribs of
the same side, with a mass of muscle and integument, were removed from near
the spine where the bolt made its exit. These are preserved as a wet prepara-
tion in the Museum of the London Hospital. The mast weighed 600 pounds,
and was thirty-nine feet in length. The bolt was six inches in length. He
left the hospital in good condition, and since the accident has had uniform good
health, suffering from no general or local weakness, no sensation of stricture
about the thorax, no pain, no cough. He lives well, but temperately. On aus-
cultation and percussion, the organs of the chest and abdomen seemed per-
fectly normal ; in short, he presented, in all respects, the appearance of a per-
fectly healthy and robust man.

" On reviewing this case, we are naturally led to inquire what circumstances
could have saved the man from instant death. Was it simply from the fact that
the bolt of iron was blunt on its end, and, therefore, after penetrating the ante-
rior parietes of the thorax, it pushed aside, without piercing the heart, blood-
vessels, and other important organs, and came out through the back without
having caused a necessarily fatal wound? It is instructive, because it is re-
corded that the man had prompt and thorough surgical treatment, as if he were
expected to recover. It also reminds the profession of what the ' vis medica-
trix naturae' can, and sometimes will do, if aided by skilful hands." — Boston
Med. and Surg. Joarn., Jan. 14, 1858.

Extraction of a Living Child, by Turning, after the Death of the Mother. — Dr.
G. W. Thornton records [Cincinnati Lancet and Observer, Feb. 1858), an inter-
esting case of this. The mother died suddenly whilst in labour, from some
unascertained cause. Forty minutes elapsed after the last expiration of the
mother before Dr. T. arrived, and was able to attend to the undelivered child.
He found that the membranes had been ruptured, that the head was in the
cavity of the pelvis, the vertex presenting at the inferior strait. Dr. T. raised
the foetal head, passed a hand into the flaccid womb, turned the child and ex-
tracted it as far as the head without delay ; at this point it momentarily hung

570

American Intelligence.

[April, 1858.]

until assisted by the fingers in its mouth. Thus, forty-five minutes elapsed
from the last expiration of the mother to the complete extraction of the child.

The child did not breathe, and was of a bluish colour; but a slight ticking
sensation could be heard on the ear being placed over the heart. The fauces
were cleared, Marshall Hall's ready method then diligently practised for half
an hour, when a convulsive inspiration took place. This method was persevered
in, assisted by aspersions and frictions, and at length respiration was established.
The child, a boy of the average size, sucked vigorously at the bottle, and lived
for three weeks and two days; its death, probably, resulting from want of
sufficient care.

Absence of Urea and Uric Acid in Urinary Secretions in Yellow Fever. — Dr. F.
Peyre Porcher states ( Charleston Medical Journal and Review, Jan. 1858), that
after careful microscopic and other examinations of the secretions from the
kidneys, during the whole course of an epidemic of yellow fever, occurring in
Charleston, in 1856, he has been able to trace the constant absence of uric acid
and urea. This failure of the urinary organs to eliminate this substance Dr. P.
regards as of great importance, and he attributes to it some of the most danger-
ous symptoms in the progress of the disease, as the coma and other indications
of torpor of the brain in the latter stages.

Creasote in Dysentery. — Dr. G. E. Elmer states (New Orleans Med. Kews and
Hospital Gaz., Jan. 1858), that in an epidemic dysentery of a very malignant
and fatal type, which prevailed twelve years since in a malarious section of the
Parish Avoyalles, and which resisted ordinary treatment, creasote in doses of
two drops in gum Arabic mucilage, given every two hours, arrested the disease.

Euphrasia Officinalis as a Cure for Epilepsy. — Dr. J. G. Kyle recommends
( Western Lancet, Dec. 1857) the Euphrasia Officinalis as a remedy for epilepsy.
His attention was directed to it, from its being used as a domestic remedy fur
the cure of the disease, and he has employed it himself with success. He gave
four ounces of the infusion every morning fasting.

Treatment of Prolapse of the Funis. — Dr. T. Gaillard Thomas, in a paper
recently read before the New York Academy of Medicine {New York Journ.
Med., March, 1858), recommends that in cases of prolapsus of the funis, the
woman should be placed on her knees, with her face and chest resting upon
the bed. His rules for the treatment of prolapsus are: —

1st. If the cord is detected before the waters have broken, let no manual as-
sistance be offered, but place the woman at once in position, and trust to this
for its return to the uterus.

2d. Should the waters have flowed away, and left the cord below the head,
place the woman in position, and push it up with the hand if practicable, or
with a porte cordon, consisting of a gum elastic catheter, with a tape passed
through it, if not so —

3d. Let no manipulations be commenced until the woman be placed in posi-
tion.

Inoculation with Gonorrhoeal Matter for the Cure of Granular Lids and Cor-
neitis. — A case is recorded in a recent No. of the Cincinnati Lancet and Ob-
server (Jan. 1858), of granulations of the lids with corneitis, treated by the
application of gonorrhoeal matter to the conjunctiva. We regret to find that
such a practice has been introduced in this country, for though sanctioned
by Piringer and Jaeger, we believe that it is wholly unnecessary, exceedingly
unsafe, and, in fact, calculated rather to aggravate the mischief than afford
relief. We had hoped that such eccentricities and extravagancies in ophthalmic
practice would find no imitators among ophthalmic surgeons in this country.

INDEX.

A.

Achillea millefolium, emmenagogue action
of, 503

Acute rheumatism cured by large doses of

iodide of potassium, 519
Addison, disease of supra-renal capsules, 509
Adhesive plaster as a counter-extending

means in fractures of thigh, 105
Air, chemical changes in, during respiration,

500

Albumen, physiological relations of, 497
Alkalies, influence of, on belladonna, hyos-

ciamus, and stramonium, 501, 502
American insane hospital reports, notices

of, 213, 449
Amputation at knee-joint, 272
Anaesthesia in phthisical vomiting, 266
Andre, tracheotomy in croup, 272
Aneurism, popliteal, cured by compression,

535

Ankle-joint, PerogofPs operation at, 536

Anthelmintic, kameela as an, 522

Antidote to poison of rattlesnake, 94, 375

Apoplexy, embolic, 267

Appendix vermiformis, fatal disease of, 383

Aran, perchloride of iron in erysipelas, 520

Arterio-venous aneurism, 268

Ashton on Diseases, &c, of the Rectum, no-
tice of, 487

Asphyxia of submersion, 262

from imperfect combustion of gas

in a gas stove, 567

Asthma, effect of local influences on, 517

Atcherley, anaesthesia in phthisical vomit-
ing, 266

Atlee, peracephalus, 370

rupture of trachea, 120

B.

Barclay, Manual of Diagnosis, notice of, 485
Barker, intra-uterine fractures, 552
Beale's Archives of Medicine, notice of, 483
Becquerel, method of determining sugar in

diabetic urine, 243
Belladonna and mercurial ointment in croup,

340

in incontinence of urine, 267

influence of alkalies on thera-
peutic properties of, 501, 502

Bennett, injections of bronchi in pulmonary
diseases, 265

Bernard, elimination of sulphuretted hydro-
gen by the lungs, 245

Bernard, variation in colour of venous blood,
494

Bibron's antidote to poison of rattlesnake,
94, 375

Biological Society of Paris, notice of Me-
moirs, <Scc, of, 482
Bird on erysipelas, 264

Bladder, and uterus, reciprocal sympathies
of, 544

foreign bodies introduced in, 277

gun-shot wound of, recovery, 295

Blood, uses and properties of dark and red
496

Bloomingdale Asylum report, notice of, 455
Boisliniere, thrombus of vagina, 566
Bran loaf for diabetic patients, mode of pre-
paring, 254
Briquet on hysteria, 261
Broadbent, after-treatment of surgical ope-
rations, 525
Brodhurst, on club-foot, &c, notice of, 233
Bronchi, injections of, in pulmonary dis-
eases, 265

Bronzed skin and disease of supra-renal cap-
sules, 509

Brown, singular result of injury in last stage

of pregnancy, 555
Brown-Sequard, Journal of Physiology, no

tice of, 479

uses and properties of red

and dark blood, 496
Budd, treatment of diabetes with sugar, 506
Burns, collodion and castor oil in, 532

C.

California, notice of Transactions of Medical

Society of, 210
Campbell, large doses of iodide of potassium

in acute rheumatism. 519
Secretory and Excito-Secretory

System of Nerves, notice of, 470

treatment of inverted toe-nail, 568

Camplin, mode of preparing bran loaf for

diabetic patients, 254
Cancer, epithelial, 276

escharotic treatment of, 274

present state of surgical science in

reference to, 273
Cancerous lymphatic glands, 530
Carnochan, excision of entire radius, 363
exsection of trunk of second

branch of fifth pair of nerves for neural-
gia, 134
Carotid artery, ligature of, 226

572

INDEX.

Casselberry, use of iron, 327

Catalepsy cured by nitrate of silver, 143

Cataract, spasms of the eye after extraction

of, 279

Fenner on, 565

Caustic glycerine in lupus, 253
Cazeaux's Midwifery, notice of, 484
Cervix femoris, intra-capsular fractures of,

227

Cliereau, suicide and intoxication by chloro-
form, 286
Chest diseases, cod-liver oil in, 264
Chisholm, bandage for fracture of clavicle,

564

Chlorate of potash in stomatitis mat em a, 296
Chloride of potash, therapeutic action of,

and new mode of administering, 523
Chloroform, death from, 288

in intermittent fever, 266

suicide and intoxication by, 286

Cholera, Asiatic, 263
Chorea, tartarized antimony in, 522
Choroid plexuses of the human brain, 491
Chronic rheumatism, principles of treatment

in. 519

Clarke on perforation of membrana tym-

pani, 13

Clavicle and humerus of same side, fracture
of, 352

bandage for fracture of, 564

Clinique of the Midi Hospital, review of, 427
Coagula in veins during puerperal state, 548
Cocoa-nut oil ointments, 506
Cod-liver oil, administration in capsules, 504

gelatinization of, 253

in chest diseases, 264

with Iceland moss, 253

Colchicine, experiments on, 502
Colchicum, comparative action of dry bulbs

and the seeds of, 502
College of Physicians of Philadelphia, Trans-
actions of, 377
Collodion and castor oil in burns, 532

in orchitis, 532

Confection of cinchona as an antiperiodic, 293
Congelations, 530

Consumption, specific treatment of, by phos-
phorus, 516
Coolidge, vital statistics of war, 86
Cooper, removal of foreign body from beneath

the heart, 229
spasms of the eye after extraction of

cataract, 279

dislocation of crystalline lens, 543

Coote, process of repair in division of tendo-

achillis, 527
Corfe, treatment of diabetes with sugar, 508
Cotton, specific treatment of consumption by

phosphorus. 516
Cow's milk, mode of improving, 254
Creasote in dysentery, 570
Croft, experience as to Perogofi"'s operation

at ankle-joint, 536
Cross-presentations, 553
Croup, belladonna and mercurial ointment

in, 340

glycerine in, 338

tracheotomy in, 272

Cutter, dislocation of first phalanx of thumb,

561

D.

Delioux, chloroform in intermittent fever, '

266

Denuce, foreign bodies introduced into blad-
der, 277

Derrubaix, prevention of ill consequences of

operation, 271
Deschamps, formula for liquor cinchona, 253
Dethan, therapeutic action of chloride of

potash, and new mode of administering it,

523

De Vesey, Bibron's antidote to the poison of

rattlesnake, 375
Diabetes, different nature of certain forms

of, 243

treatment of, with sugar, 506

Diabetic urine, method of determining sugar

in, 242, 243
Diagnosis, notice of Barclay's Manual of,

485

Diamantapuplos, extra-uterine gestation, 551
Diarrhoea, guarana in, 521
Diphtheritic ophthalmia, 280
Dislocation of crystalline lens, 543
of humerus reduced by manipu-
lation, 344

of os coccygis, 270

revision of doctrine of, 268

Dugas on Fractures of Scapula, notice of, 222
j Dunglison's Medical Lexicon, notice of, 232
Dysentery, creasote in, 570
Dysuria, large doses of quinine in, 532

E.

Elimination, doctrine of, 524

Ellis, defects of escharotics, and suggestions

for their improvement, 503
Elmer, creasote in dysentery, 570
Encephaloid tumours weighing ten pounds,

291

Epilepsy, lactate of zinc in, 522

Epistaxis arrested by administration of com-
mon salt, 390

Epithelioma of lip cured by sulphate of zinc,
346

Erysipelas, nature, treatment, &c., 264

perchloride of iron in, 520

Escharotics, defects of, and suggestions for

their improvement, 503
Esmarch, embolic apoplexy, 267
Euphrasia officinalis in epilepsy, 570
Eve;s Remarkable Cases in Surgery, notice

of, 230

Excision of enlarged tonsils, 535
Excrement, human, immediate principles of,
248

Extra-uterine gestation, 551

Eye, injurious effects on, of the light from

the fish-tail burner, 377
spontaneous rupture of, 373

F.

Fallopian pregnancy, 123
Faulkner, chlorate of potash in stomatitis
materna, 296

INDEX.

573

Femur, fracture of neck of, bony union, 294

resection of, 354

Fenner on cataract, 565
Fleming, spontaneous rupture of eye, 373
Flint, on pulmonary tuberculosis, 52
Formula for caustic glycerine, 253

for confectio cinchonae, 294

for gelatinization of cod-liver oil,

253

for liquor cinchonae, 253

for valerianate of ammonia, 253

Fournier, Clinic of tbe Midi Hospital, re-
view of, 427
Fracture of clavicle and humerus, same side,
352

Fractures, intra-uterine, 552

France on supposed influence of alkalies on

belladonna, stramonium, &c, 502
Frencb, quadruple births, 282
Friends' Asylum, notice of report of, 213
Functional paralysis, 524
Funis, treatment of prolapse of, 570

G.

G-allaher, poisoning by laudanum, 559

Garratt, impalement, 568

G-arrod, influence of alkalies on therapeutic
properties of hyoscyamus, belladonna, and
stramonium, 501

method of determining sugar in dia-
betic urine, 243

G-av, fracture of neck of femur, bony union,
294

ovariotomy, 296

Surgical Cases, notice of, 228

G-ibb, poisoning by laudanum, 288
Gilbert, adhesive plaster as a counter-extend-
ing means in fractures of thigh, 105
Girwood, permanganate of potash as a caus-
tic, deodorant, &c, 249
Glaucoma, pathology of, 539
Gloninger, confection of cinchona as an anti-
periodic, 293
Glyceramyl, a proposed substitute for fats in

ointments, 506
Glycerine in pseudo-membranous croup, 338
Glysamyl, a proposed substitute for fats in

ointments, 506
Gobley, preparation of iodide of calomel, 505
Grinstead, gun-shot wound of bladder, re-
covery, 295
Griscom, melanotic tumours of thoracic and

abdominal viscera, 392
Gross's Pathological Anatomy, review of, 145
Guarana in chronic diarrhoea, 521
Gumprecht, mode of improving cow's milk,
254

H.

Habershon, treatment of pleuro-pneumonia,
514

Haemophilia, 259

Halsey, resection of lower-jaw for necrosis,
356

Hammond, alterations induced by intermit-
tent fever in the urine, and on action of
disulphate of quinine, 322

Hammond, Bibron's antidote to poison of
rattlesnake, 94

Harley, chemical changes in air during re-
spiration, 500

histology of supra-renal capsules,

492

function of supra-renal capsules, 493

Harris. Fallopian pregnancy, 123
Hartford Retreat for Insane, notice of report
of, 456

Hartshorne, fatal enlargement of the thymus

with subjacent tumour, 378
Haughton, the oriental bath, 249
Hayden, physiological relations of albumen,

497

Hays, foreign body retained in nasal fossae

twenty years, 390
Heath, death from chloroform, 288
Hebra, caustic glycerine in lupus, 253
Hemorrhoids, treatment of, 273
Hernia, case of, 560
Hernia of ovaries, 284
Herpin, lactate of zinc in epilepsy, 522
Herve, guarana in chronic diarrhoea, 521
Hewitt, coagula in veins during puerperal

state, 548

Hip-joint, osteoid tumour connected with
capsular ligament of, 109

Hird, present state of surgical science in re-
ference to cancer, 273

Hodgson, Prostate Gland, notice of, 478

Hulke, pathology of glaucoma, 539

naevi of eyelids, 543

Humerus, luxation of, reduced by manipula-
tion, 344

Hunter, monstrosity, 294

Huss, case of haemophilia, 259

Hutchinson, disease of supra-renal capsules,
509

Hydrocele cured by excision of tunica vagi-
nalis testis, 345, 346

diagnosis of, 538

Hydropneumothorax treated by paracentesis
thoracis and injections of iodine, 515

Hyoscyamus, supposed influence of alkalies
on therapeutic properties of, 501, 502

Hysteria, Briquet on, 261

I.

Impalement, 568

Incontinence of urine, belladonna in, 267
Indiana, notice of Transactions of Medical

Society of, 199
Inman, doctrine of elimination, 524
principles of treatment in chronic

rheumatism, 519
Inoculation with gonorrhoeal matter for cure

of granulur lids, 570*
Insane hospital reports, notices of, 213, 449
Intermittent fever, chloroform in, 266
Intestinal walls, nerves of, 240
Inverted toe-nail, treatment of, 568
Iodide of calomel, preparation of, 505
Iron, use of, 327

Isaacs, disarticulation and removal of nearly

half of lower jaw, 295
anomalous situation of left kidney,

295

574

INDEX.

J.

Jacubowitsch, histology of nervous system,
237

Jewell, annual report on meteorology and
epidemics, 395

Johnson on Intra-Capsular Fractures of Cer-
vix Femoris, notice of, 227

Jones, functional paralysis, 524

K.

Kameela as an anthelmintic, 522
Kelly, ruptured uterus, 552
Kidney, anomalous situation of left, 295
King, catalepsy cured by nitrate of silver,
143

Kirster, presence of sugar in urine of preg-
nant, parturient, and puerperal women,
244

Kyle, euphrasia officinalis in epilepsy, 570

L.

Lactate of zinc in epilepsy, 522
Lane, amputation at knee-joint, 272

, case of hernia, 560

Laudanum, poisoning by twelve drachms of,
288

, poisoning by, 559

Leared, kameela as an anthelmintic, 522
Lee, membrana decidua in tubal pregnancy,
549

Pathological and Surgical Observations,

notice of, 234
Lenhossek, structure of nervous centres, 239
Leucorrhoea, iodide of potassium in, 296
Levick, melanotic tumours, 393
Liquor cinchona?, formula for, 253
Liver, congenital malformation of, 380
Lotion for strumous glands, 505
Lower jaw, removal of half of, 295

resection of, for necrosis, 356

Lungs, elimination of sulphuretted hydrogen

by, 245

foreign body retained four years in,

380

Lupus, caustic glycerine in, 253
Luschka, choroid plexuses of the human
brain, 491

M.

Marcet, immediate principles of human ex-
crement, 248

Marcotti, tartarized antimony in chorea, 522

Marshall Hall, case of, 255
520

Martyn, function of thyroid body, 241
Massachusetts State Hospital, notice of re-
port of, 460
Mathey, perchloride of iron in erysipelas,
Mayer, glycerine in pseudo-membranous

croup, 338
McCormac on cholera, 263
M'Clintock, new symptom of rupture of ute-
rus, 283

M'Rae, compound fracture of skull, and loss

of portion of brain, 293
Meigs, Diseases of Children, notice of, 479
Meissner, nerves of intestinal walls, 240
Melanotic tumours of the viscera, without

external symptoms, 392
Membrana decidua in tubal pregnancy, 549

tympani, perforation of, 13

Meteorology and epidemics, report on, 395
Miller's Obstetrics, review of, 180

Practice of Surgery, notice of, 236

Monster of the genus peracephalus, 370
Monstrosity, 294

Montgomery, reciprocal sympathies of uterus

and bladder, 544
Moore, arterio-venous aneurism, 268
Morris, congenital malformation of liver,

380

epistaxis arrested by administration

of common salt, 390
Movable kidneys, 523

N.

Nsevi of eyelids, 543

Nasal fossa?, foreign body retained in twenty

years, 390
National hotel epidemic, 97
Necrosis from fumes of phosphorus, 356
Nelaton, diagnosis of hydrocele, 538
Nerves of intestinal walls, 240
Nervous centres, structure of, 239

system, histology of, 237

Neuralgia, exsection of nerVe for, 134

New Hampshire, notice of Transactions of

Medical Society of, 202
State Asylum Report, notice

of, 461

New York City Lunatic Asylum Report, no-
tice of, 453

State Lunatic Asylum, notice of

report, 458
Nitrate of silver in catalepsy, 143
Nitsche, acute poisoning by phosphorus, 288

0.

CEdema glottidis, 518

Ohio Central State Asylum, notice of report
of, 213, 450

Northern State Asylum, notice of re-
port of, 218

Southern State Asylum, notice of re-
port of, 219, 451

Oldham, hernia of both ovaries, 284

Operations, prevention of ill consequences
of, 271

Oppolzer, movable kidneys, 523
Orchitis, collodion in, 532
Oriental bath, 249
Os coccygis, dislocation of, 270
Osteoid growth connected with capsular liga-
ment of hip-joint, 109
Ovaries, hernia of, 284
Ovariotomy, 296

INDEX.

575

p.

Paget, cancerous lymphatic glands, 530

enlarged tonsils, 535

strumous inguinal glands, 529

suppuration of strumous glands, 528

Paralysis, functional, 524
Pavy, starch from the animal kingdom, 246
Payne, iodide of potassium in leucorrhoea,
296

Peaslee's Human Histology, review of, 173

Perchloride of iron in erysipelas, 520

Permanganate of potash as a caustic deo-
dorant, &c, 249

Phosphorus, poisoning by, 288

specific treatment of consump-
tion by, 516

Physiology, notice of Brown-Sequard's Jour-
nal of, 479

Pitha, oedema glottidis, 518

Placenta, influence of upon the development
of the uterus during pregnancy, 309

praevia, 391

Plasma, a substitute for fats in ointments, 506
Pleuro-pneumonia, treatment of, 514
Pneumonia after laryngotomy, causes of, 525
Poisoning by laudanum, 288

phosphorus, 288

Popliteal aneurism cured by compression,
535

Porcher, absence of urea and uric acid in

urine in yellow fever, 570
Porter, notes of campaigns in the war with

Mexico, 347
Potato, chemical properties of, 255
Prostate, enlarged, 473

Pseudo-membranous croup, glycerine in, 338
Pulmonary tuberculosis, report on, 52

Q.

Quadruple births, 282

Quinine, large doses of in dysuria and re-
tention, 532

R.

Radius, excision of, 363

Rand, injurious effects on the eye of the

light from a fish-tail burner, 377
Rattlesnake, Bibron's antidote to poison of,

94, 375

Read, influence of placenta on development
of uterus during pregnancy, 309

Rectum, notice of Ashton on Diseases, &c.
of, 487

Red blood and dark blood, properties and

uses of, 496.
Report of Friends' Asylum, Philadelphia,

notice of, 213
— U. S. Government Hospital, notice

of, 216

Ohio Central State Asylum, notice

of, 217, 450
Ohio Northern State Asylum, notice

of, 218

Ohio Southern State Asylum, notice

of, 219, 451

Report New City Lunatic Asylum, 453

Bloomingdale Asylum, 455

Vermont State Asylum, 455

"Western Lunatic Asylum of Virginia,

456

Retreat at Hartford, 456

New State Lunatic Asylum, 458

Massachusetts State Lunatic Asylum,

460

■ New Hampshire State Asylum, 461

Respiratory organs, treatment of inflamma-
tory diseases of, 513
Retention of urine, large doses of disulphate

of quinine in, 532
Rheumatism, acute, treatment of, 519

chronic, treatment of, 519

Rhoads, placenta prasvia, 391
Ricord's Lectures on Chancre, review of, 427
Roeser, revision of doctrine of dislocation,
269

Rogers, chemical properties of potato, 255
Ronzier-Joly, emmenagogue action of achil-

lea millefolium, 503
Rottlera tinctoria as an anthelmintic, 522
Ruptured uterus, 552
Rupture of uterus, new symptom of, 283

S.

Salter, effect of local influences on spas-
modic asthma, 517

Sawyer, osteoid growth connected with cap-
sular ligament of hip-joint, 109

Scalds, collodion and castor oil in, 532

Scapula, fractures of, 222

Schacht, proposed substitute for fats in oint
ments, 506

Schneck, fracture of clavicle and humerus

of same side, 352
Schroff, experiments on colchicine, and on

the dry bulbs and seeds of colchicum, 502
Schub, causes of pneumonia supervening

after laryngotomy, 525
Semple, treatment of inflammatory diseases

of respiratory organs, 513
Serres, large doses of disulphate of quinine

in dysuria and retention, 532
Shelton, belladonna and mercurial ointment

in croup, 340
Shepherd, encephaloid tumours involving

kidney, 291
Shoulder-joints, simultaneous dislocation of

both, 295
Sims, new uterine elevator, 132
Skull, compound fracture of with loss of por-
tion of brain, 293
Smith, cod-liver oil in chest diseases, 264
Strictures of the Urethra, review of,

433

treatment of obstinate stricture of

urethra, 537
Somnambulism, 361
Sore nipples, application to, 296
South Carolina, notice of Transactions of

Medical Association of, 209
Spaeth, on cross presentations, 553
Spasmodic asthma, effect of local influences

on, 517

Starch from the animal kingdom, 246

576

\

INDEX.

Statistical table of mean height of recruits,

296

Stomatitis materna, chlorate of potash in,
296

Storer, cupping interior of uterus, 117
Strabismus, with imperfect vision, 281
Stramonium, influence of alkalies on thera-
peutic properties of, 501, 502
Stribling, somnambulism, 361
Stricture of urethra, 537
Strictures of urethra, review of Smith on,
433

Strumous glands, lotion for, 505

■ — suppuration of, 528

inguinal glands, 529

Sugar in diabetic urine, method of deter-
mining, 242, 243
presence of in urine of pregnant, par-
turient and puerperal women, 244

treatment of diabetes with, 506

Suicide by chloroform, 286
Sulphate of zinc as a caustic, 504
Sulphuretted hydrogen, elimination of by

the lungs, 245
Sulphuric acid as a caustic, 504
Supra-renal capsules, histology of, 492

function of, 493

disease of, 509

Suppuration of strumous glands, 528
Surgical operations, after-treatment of, 525
Syme, escharotic treatment of cancer, 274

T.

Tartarizecl antimony in chorea, 522
Taylor, tumour occurring after delivery,
558

Tendo-Achillis, process of repair after divi-
sion of, 527

Thighs, dislocation of both, 563

Thomas, treatment of prolapse of funis, 570

Thompson, epithelial cancer, 276

Enlarged Prostate, notice of, 473

sulphuric acid and sulphate of

zinc as a caustic agent, 504

Thoracic aneurism successfully treated, 532

Thornton, extraction of a living child from
a dead mother, 569

Thrombus of vagina, 566

Thumb, dislocation of, 561

Thymus gland enlarged with subjacent tu-
mours causing death, 378

Thyroid body, function of, 241

Tonsils, excision of enlarged, 535

Trachea, rupture of, 120

Tracheotomy in croup, 272

Transactions of Indiana State Medical So-
ciety, notice of, 199

of New Hampshire Medical

Society, notice of, 202

of South Carolina Medical As-
sociation, notice of, 209

■ of Medical Society of Califor-
nia, notice of, 210

Trousseau, hydropneumothorax, 515

Tufnell, thoracic aneurism successfully
treated, 532

Tumour occurring after delivery, 558

U.

Urethra, Strictures of, review of, 433
Urinary organs, chronic disease of with

anomalous symptoms, 382
Urine, belladonna in incontinence of, 267

new symptom of rupture of, 283

alterations produced in by intermit-
tent fever, and by disulphate of quinine,
322

U. S. Government Hospital, notice of re-
port of, 216

Uterine elevator, 132

Uterus, cupping interior of, 117

and bladder, reciprocal sympathies

of, 544

V.

Valerianate of ammonia, preparation of, 252

Valette, congelations, 530

Van Beuren, simultaneous dislocation of

both shoulder-joints, 295
Vagina, thrombus of, 566
Van Halsbeck, treatment of hemorrhoids,

273

Vanzinetti, popliteal aneurism cured by com-
pression, 535
Venous blood, variation in colour of, 494
Vermont State Asylum Report, notice of,
455

Virginia, report of Western Lunatic Asylum

of, notice of, 456
Vital statistics of war, 86
Vomiting, phthisical, anaesthesia in, 266

W.

Walter, resection of femur, 354

Walton, vascular tumour of orbit, 542

Waring, national hotel epidemic, 97

War, vital statistics of, 86

Warren, dislocation of both thighs, 563

Waters, asphyxia of submersion, 262

Wells, administration of cod-liver oil in

capsules, 504
Williams, treatment of diabetes with sugar,

507

Wilson on diseases of the skin, notice of

plates illustrative of, 490
Wister, chronic disease of urinary organs

with anomalous symptoms, 382
— fatal disease of appendix vermifor-

mis, 383

Wood, foreign body retained two years in
lungs, 380

on ligature of primitive carotid, no-
tice of, 226

Woodward, dislocation of humerus reduced
by manipulation, 344

hydrocele cured by excision of

tunica vaginalis testis, 345, 346

epithelioma of lip cured by sul-
phate of zinc, 346

Y.

Yellow fever, absence of urea and uric acid
in urine in, 570

American Journal of Med. Sciences.

577

GRADUATES OF JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA,

March, 1858.

At a Public Commencement, held on the 9th of March, 1858, the degree of Doctor
of Medicine was conferred on the following gentlemen by the Hox. Edward King,
LL. D., President of the Institution ; after which a Charge to the Graduates was
delivered \>j Professor Charles D. Meigs.

Acklev, Henry
Alexander, W. C. S.
Allison, James
Allison, J. A.
Applewhite, Louis J.

Bacon, S. L.

Barksdale, "William Leigh

Barrett, E. Calhoun

Bass, John N.

Bear, Benjamin, Jr.

Bell, George W.

Bell, James Eugene

Bell, J. H.

Bell, William

Berry, A. J.

Bertolette, J. C.

Bibb, Henry C.

Bill, J. H., Jr.

Black, John
Blount, T. M., Jr.
Bogle, R. L.
Bond, Francis E.
Bowyer, Edmund F.
Bradford, F. Standish
Branch, John H.
Branham, P. A.
Branin, Henry E.
Bright, George H.
Briscoe, Thomas W.

Brooke, John B.

Brown, N. M.
Brunson, Randolph
Bryant, William M.
Buehler, H. B.
Burks, Charles R. P.
Butcher, George E.

Cade, E. W.
Caldwell, Samuel H.
Campbell, J. M.
Capers, Le Grand G., Jr.
Carson, Samuel M. (M. D.)
Cessna, B. F. (M. D.)
Christie, James (M. D.)
Clark, Isaac J.
Clinkscales, F.

Combe, C. B.

Cook, Joseph L.

Coudrick, Charles R.

Crawford, John C.

STATE OR COUNTRY.

New Jersey.
Virginia.
Kentucky.
North Carolina.
Georgia.

New Jersey.

Virginia.

Virginia.

Kentucky.

Pennsylvania.

Pennsylvania.

Georgia.

South Carolina.

Virginia.

South Carolina.

Pennsylvania.

Alabama.

Pennsylvania, -j

North Carolina.

Dis. of Columbia.

Georgia.

Montevideo.

Virginia.

Rhode Island.

North Carolina.

Georgia.

New Jersey.

South Carolina.

Virginia.

Pennsylvania, -j

Ohio.

Tennessee.
Alabama.
Pennsylvania.
Virginia.
New Jersey.

SUBJECT OF THESIS.

Chlorosis.

Puerperal Peritonitis.
Typhoid Fever.
Typhoid Fever.
Medical Science.

Epidemic Rubeola.
Dysentery.

Entero-mesenteric Fever.
Signs of Pregnancy.
Strangulated Femoral Hernia.
Treatment of Typhoid Fever.
Puerperal Fever.
The Practice of Medicine.
Opium and its Preparations.
Intermittent Fever.
The Vegetable World.
Inflammation.

Specific Solvent Power of Simple

Syrup.
Congestive Fever.
A Case of Necrosis.
Southern Typhoid Fever.
Epidemic Yellow Fever.
Typhoid Fever.

Pathology of Diabetes Mellitus.

Esthetics of Medicine.

Erysipelas.

Congestive Fever.

Bright's Disease.

Rubeola.

Tartarized Antimony as a Remedial

Agent in Cardiac Dropsy.
Cholera Infantum.
Carcinoma.

Post-mortem Examinations.
Valerianate of Ammonia.
Cholera Infantum.
Dysentery.

Texas.

Tennessee.

North Carolina.

Texas.

Tennessee.

Ohio.

New Brunswick,
New Jersey.
South Carolina.

Kentucky.

Pennsylvania.

New Jersey.

South Carolina.

The Tongue as an Index of Disease.
Variola.

Oleum Terebinthinae.
Physiology of Digestion.
Ice.

Nature and Treatment of Phthisis.
Ferrum.

Cynanche Tonsillaris.

Enteric or Typhoid Fever,
f Etiology, Pathology, &c, of Yellow
( Fever.

Typhoid Fever.
( Arsenious Acid as a Poison and a
( Therapeutic Agent.

Inguinal Hernia.

578

American Journal of Med. Sciences.

NAME.

Crawford, William
Crockett, R. A. (M. D.)
Crump, Lawrence S.
Culler, J. P. H.
Cummins, J. M.
Cummins, Lewis C.

Daniels, Henry A.

Davis, Jesse Hudson
De Yampert, T. J. L.
Draper, Joseph
Drewiy, Henry Martyn
Du Pont, Charles E.

Eades, Upson R.
Epes, Algernon S.
Epes, J. W.

Evans, Edwin C. (M. D.)
Ewing, George C.

Figgat, William F.
Franklin, J. W.
Freyman, A. A.

Gait, William J.
Gartrell, Homer L.
Gilkeson, James B. (M. D.)
Gilliam, James S. (M. D.)
Gilmore, J. T.
Good, D. R.
Goodgion, W. H.
Gootee, Benjamin S.
Graham, John A.
Green, William
Guerrant, T. D. F.

Hale, Peter J.
Haley, Argyle
Harrell, Richard A.

Harris, William H.

Harvey, Granville
Hauser, R. A.
Hayslett, A. J.
Heath, William H.
Henderson, F. B.
Herndon, Charles L. C.
Hoffman, J. M.
Hoffman, J. R.
Holman, John N.

Hoover, George W.

Hopkins, James Alfred
Hornor, S. H.

Ingersoll, Charles J., Jr.

Jackson, La F.

Kent, Joseph W.
Kerr, WTilliam
Kimbrough, Andrew H.
Kindlebereer, David
King, A. M.
King, E. C.

STATE OR COUNTRY.

Ohio.

Tennessee.
Virginia.
Georgia.
Pennsylvania.

Pennsylvania. Menstruation.

SUBJECT OF THESIS.

Variola.

Nature of Tuberculosis.
Delirium Tremens.
Heterologous Formations.
Cold as a Therapeutic Agent.

England.

Pennsylvania.
Alabama.
Massachusetts.
Virginia.
South Carolina. Menstruation.

( Functions of the Great Sympathetic
( Nerve.
Typhoid Fever.
Chorea.
Bony Union.
Narcotics.

Georgia.

Virginia.

Alabama.

Missouri.

Pennsylvania.

Virginia.
Virginia.
Pennsylvania.

Pennsylvania.

Georgia.

Virginia.

Virginia.

Mississippi.

Pennsylvania.

South Carolina.

Maryland.

Virginia.

Virginia.

Virginia.

Virginia.
Virginia.
Virginia.

Georgia.

Missouri.

North Carolina.

Virginia.

South Carolina.

Alabama.

Kentucky.

Pennsylvania.

Tennessee.

Mississippi.

Pennsylvania.

Delaware.
New Jersey.

Mississippi.

Virginia.

Virginia.
Alabama.
Illinois.
Ohio.

Mississippi.
Texas.

Acute Dysentery.

Opium, its Preparations and Effects.
Entero-mesenteric Fever.
Occlusion of the Bowels.
Tabacum.

Puerperal Convulsions.
Femoral Hernia.
Acute Dysentery.

Menstruation.
Variola.
Cinchona.
Pneumonia.

Stricture of the Urethra.
Health.

Remittent Fever.
Erysipelas.
Inguinal Hernia.
Entero-mesenteric Fever.
Indigestion as a Cause of Disease.

Dysentery.

The Human Hand.

Intermittent Fever,
f Water, its Physiological and The-
( rapeutical Uses.

Typhoid Fever.

Dysentery.

Scarlatina.

Gonorrhoea.

Pneumonia.

Acne.

Ovariotomy.

Thesis Writing.

Entero-mesenteric Fever.
( Eclampsia Gravidarum et Partu-
( rientium.

Intermittent Fever.

Treatment of Diabetes.

Heterologous Formations.

Apoplexy.

Inflammation.
Acute Gastritis.
Inflammation.
Sleep.

Typhoid Fever.
Malaria.

American Journal of Med. Sciences.

579

NAME.

King, James T.

King, T. Starke

King, W. Norvell
King, William M.
Kirksey, E. Jehu

Lee, Paul C.
Legge, Josiah H.
Lewis, Charles I.
Lewis, Isaiah M,
Leyburn, John
Lockwood, N. S.

Madison, Charles P.
Marbonrg, H. W.
Marshall, N. S.
McCann, Robert C.
McCants, W. J.

MeCluney, J. F.

McConaughy, D. W.
McCormick, Charles (M. D.)
McFarland, R. W.
McNemar, M. R.
McQueen, S. F.
Meredith, Joseph S.
Merriman, W. H.
Miller, John F.
Mitchell, John F.
Mitchell, R, V.
Montgomery, John
Moody, J. Monroe
Moomau, James P.
Moore, E. D.
Moore, J. A.
Morrison, A. J.

Nelson, John A.
Nordmann, L. E.

STATE OR COUNTRY. SUBJECT OF THESIS.

North Carolina. Opium and its Effects.

...... ( Typhoid or Entero-mesenteric Fe-

Mississippi. < J r

Oliver, James W.
Paine, A. B.

Palmer, Valentine Jackson

Parberry, William

Paslay, E. C.
Patton, George E.

Payne, Philander W.

Pelot, J. Crews
Peyton, Lawrence R.
Phillips, P. Sandford
Pomerene, Joel
Pope, Sampson

Randall, William
Rankin, A. H.
Reiber, William F.
Reeve, Stephen S.
Rice, Thomas C.
Ricks, Fabius S.

Ohio.

Pennsylvania.
Alabama.

Alabama.

Maryland.

Virginia.

Pennsylvania.

Virginia.

New York.

Illinois.
Pennsylvania.
Pennsylvania.
Mississippi.
South Carolina.

South Carolina.

Pennsylvania.

Virginia.

Kentucky.

Virginia.

Alabama.

Virginia.

New York.

North Carolina.

Virginia.

Alabama.

Pennsylvania.

Tennessee.

Virginia.

Mississippi.

Alabama.

Kentucky.

Virginia.
Pennsylvania.

Virginia.

North Carolina.
North Carolina.

Missouri.

South Carolina.
Tennessee.

Indiana.

Florida.
Kentucky.
Alabama.
Ohio.

South Carolina.

Indiana.

Pennsylvania.

Pennsylvania.

Georgia.

Virginia.

Virginia.

Apoplexy.

Surgical Affections of the Joints.
Prolapsus Uteri.

Epilepsy.

Entero-mesenteric Fever.
Peritonitis.

Traumatic Hemorrhage.
The Obstetrician's Life.
Sulphate of Morphia.

Entero-mesenteric Fever.

Chorea.

Diagnosis.

Rubeola.

Tubercular Phthisis.
Y Functions and Phenomena of the
( Uterine System.

Acute Meningitis.

Chloroform.

Typhoid Fever.

Puerperal Convulsions.

Pneumonia.

Acute Laryngitis.

Vaccination.

Dysentery.

Relapsing Fever.

Duties of a Young Physician.

Functions of the Liver.

Cholera Epidemica.

Acute Dysentery.

Pelvic Presentation.

Pneumonia.

Erysipelas.

Dysentery.
Pernio.

f The Cerebrum in health and dis-
( ease.

Dysentery.

Typhoid Fever,
f Malaria and its Modus Operandi in
< the Production of Intermittent
( Fever.

Florida.

( Symptoms and Diagnosis of Dysen-
( tery.

j The Conservative Element in the
( Animal Economy.
Malaria.

Causes of Erysipelas.
Typhoid Pneumonia.
Typhoid Fever contagious.
Entero-mesenteric Fever.

Pathology of Congestion.

Variola.

Scarlatina.

Dyspepsia.

Syphilis.

Intermittent Fever.

580

American Journal of Med. Sciences.

NAME.

Robinett, John R.
Rogers, James A.

Scarburgh, George T.
Scearce, J. B.
Scott, W. J.
Sears, John H.
Sencindiver, Lewis M.
Seymour, Edward W.
Sheets, Abraham (M. D.)
Shotwell, C. H.

Shurlock, William Charles Pennsylvania.

Sims, William B.
Smith, D. M.
Smith, T. Albert
Smither, Charles G.
Snodgrass, William
Snow, J. B.
Snowden, Harold
Stacy, R. Q.
Stephenson, J. Thomas
Stewart, A. E.
Stewart, John R.
Stover, John M.

Thatcher, John P.
Thomas, Jerome B.
Towle, Samuel Knapp
Townsend, Gr. F.
Tribou, N. M. Jr.
Trippe, Henry W.
Trotman, Elisha
Turner, J. D.
Turner, J. H. Jr.

Vance, Thomas J.
Vastine, J. H.

Walker, Delavan N.
Walker, T. F.

Ward, Daniel O'Connell

Warnock, James T.
Warren, Orin
Watkins, Joseph F.
Webb, Joseph B.
Webb, S. V.
Weever, John B.
West, Hilborne

Wharton, John S.

White, Demosthenes

Willets, J. Howard
Williams, Urbane V.
Willis, T. Hay ward
Wilson, John W.
Wright, Astley Cooper

Young, George Kemper

STATE OR COUNTRY. SUBJECT OF THESIS.

Mississippi. The Medical Profession.

North Carolina. Inflammation.

Virginia. Scarlatina.

Kentucky. Differential Diagnosis.

Alabama. Menstruation and its Diseases.

Virginia. Wounds.

Virginia. The Practice of Medicine.

Connecticut. Insanity.

Ohio. Scarlatina.

Missouri. Conservative Influence of Pain.

Anatomico-physiological Peculiari-
ties of the Genital Organs of Wo-
[_ man.

Virginia. Acute Laryngitis.

North Carolina. Inflammation.

Georgia. Intermittent Fever.

Mississippi. Veratrum Viride.

Virginia. Inflammation.

Indiana. Varicocele.

Virginia. Bilious Remittent Fever.

Georgia. Absorption.

Kentucky. Theory of Inflammation.

Illinois. Pneumonia.

North Carolina. Glossitis.

Indiana. Veratrum Viride.

Missouri. Infantile Convulsions.

Illinois. Intermittent Fever.

Massachusetts. The Physician.

Maine. Acute Gastritis.

Massachusetts. Typhoid Fever.

Georgia. Mineral Acids as Irritant Poisons.

Tennessee. Entero-mesenteric Fever.

Virginia. Phthisis.

Mississippi. Chloroform.

Louisiana. Dysentery.
Pennsylvania. Puerperal Convulsions.

New York. Enteritis.

Georgia. Conservative Influence of Pain.

New Jersev I Duties of the Physician in the Ly-

•/* ( ing-in Room.
Alabama. Signs of Pregnancy.

Maine. Croup.
Virginia. Cathartics.
Virginia. Death.
Alabama. Concussion of the Brain.

Indiana. The Actual Cautery.

Pennsylvania. Traumatic Tetanus.

{Anatomical Changes of the Female
Reproductive Organs during
Pregnancy.

Missouri i De DiSestione Apparatuque Diges-

ts tionis.
New Jersey. Erysipelas.
Kentucky. Apoplexy.
Florida. Intermittent Fever.

Virginia. Conservative Influence of Pain.

Kentucky. Amenorrheea.

Virginia. Venesection.

Total, 209.

Date Due

Km er\ can Journal
Ned. Sciences

vol 3Vti^