. - • 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