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Full text of "The American journal of the medical sciences"

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• FRANKLIN afJ^LARSHALL* 


•©OLILEOE- 


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Property of the 

Lancaster City and County 
Medical Society 



No. 



\\1o 



I J- 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM, &C. &C. 



NEW SERIES. 

VOL. VL 



PHILADELPHIA: 

LEA & BLANCHARD, 

LONDON: 

WILEY & PUTNAM, & JOHN MILLER. 

1843. 



69433 



Entered according to Act of Congress, in the year 1843, by 

LEA & BLANCHARD, 

In the office of the Clerk of the District Court for the Eastern District of 

Pennsylvania. 



gVfrllHSGiy/, 




• T. K. & P. G. COLLINS, PRINTERS. 



G\0,5 
Med, 



TO READERS AND CORRESPONDENTS. 



The following works have been received:— 

Traite Pratique sur les Maladies des Organes Genito-Urinaires par le Docteur 
Civiale, Premiere Partre: Maladies de l'uretre; avec trois planches. 2d edit. 
Paris, 1843. (From the Author.) 

Mental Hygiene, or an explanation of the Intellect and Passions, designed to 
illustrate their influence on health and the duration of life. By William Sweet- 
ser, M. D., late Prof. Theory and Pract. Physic, and Fellow Am. Acad. Arts 
and Sciences. New York: J. & H. G. Langley, 1843. (From the Author.) 

A Practical Treatise on the Management and Diseases of Children. By 
Richard T. Evanson, M. D., Prof, of Med. in the Royal College of Surgeons, 
Ireland, and Henry B. Maunsell, M. D., &c. Second American edition, with 
notes. By D. Francis Condie, M. D., Fellow of the College of Phys., Philadel- 
phia, and M. A. P. S., &c. Philada: Edward Barrington & Geo. D. Haswell, 
1843. (From the Publishers.) 

The Kidneys and Urine. By J. Berzelius. Translated from the German, 
by M. H. Boye and F. Learning, M. D. Philadelphia: Lea & Blanchard, 1843. 
(From the Publishers.) 

A Demonstration of the Curability of Pulmonary Consumption, in all its 
stages, comprising an inquiry into the nature, causes, symptoms, treatment, and 
prevention of tuberculous diseases in general. By Wm. A. M'Dowell, M. D. 
Louisville, Ky., 1843. (From the Author.) 

Dissertation on the Diseases of the Maxillary Sinus. Read before the Ame- 
rican Society of Dental Surgeons at their third annual meeting, held in Boston, 
July 20, 1842. By Chapin A. Harris, M. D., Prof, of Practical Dentistry in 
Baltimore College of Dental Surgery, &c. Philadelphia: Lea and Blanchard, 
1843. (From the Author.) 

A Lecture on the Magnetism of the Human Body. Delivered before the Ap- 
prentices' Library Society of Charleston, S. C. By Robert W. Gibbes, M. D., 
of Columbia, S. C. Published by request of the Society. Columbia, 1843. 
(From the Author.) 

Operations for Fissure of the Soft and Hard Palate, (Palatoplastie.) By J. 
Mason Warren, M. D. Boston, 1843. (From the Author.) 

Tenth Annual Report of the Managers of the Pennsylvania Institution for the 
Instruction of the Blind. Philadelphia, 1843. (From the Institution.) 

A Conspectus of the Pharmacopoeias of the London, Edinburgh and Dublin 
Colleges of Physicians and of the United States Pharmacopoeia, being a practi- 
cal compendium of Materia Medica and Pharmacy. By Anthony Todd Thom- 
son, M. D., F. R. S., &c. &c. The Second American edition, much enlarged 
and improved. Edited by Charles A. Lee, M. D., from the 13th English edi- 
tion. New York, J. & H. G. Langley. (From the Editor.) 

Meteorology: comprising a description of the Atmosphere and its phenome- 
non, the laws of Climate in general, and especially the climatic features peculiar 
to the region of the United States; with some remarks upon the climates of the 
ancient world, as based on fossil geology. By Samuel Forry, M. D., with 13 
illustrations. New York, 1843. (From the Author.) 

The Annual Report of the Court of Directors of the Western Lunatic Asylum 
to the Legislature of Virginia, with the Report of the Superintendent and Phy- 
sician, for 1842. Staunton, 1843. (From Dr. Stribling.) 



IV TO READERS AND CORRESPONDENTS. 

Announcement of the Private Lectures of Heber Chase, M. D., with a Cata- 
logue of their classes, from their commencement in 1838. Philadelphia, 1843. 
(From the Author.) 

Dr. Bartlett's Valedictory Address to the Graduating Class of Transylvania 
University, 1843. (From the Author.) 

Address delivered before the Stark County Medical Society, May 2, 1843. 
By William Bowen, M. D. Also an Abstract of the Proceedings of the Meeting, 
with the Constitution and Code of Ethics adopted by the Society. Published 
by order of the Society. Massillon, 1843. (From the Society.) 

Homoeopathy Illustrated. An address, first delivered before the Rensselaer 
County Medical Society, at the annual meeting in the city of Troy, June 14, 

1842. And by request repeated before a popular audience, June 18, 1842. By 
Thomas W. Blatchford, M. D., President of the Society. Second edition, re- 
vised and enlarged. Albany, 1843. (From the Author.) 

Twenty-sixth Annual Report of the state of the Asylum for the relief of per- 
sons deprived of the use of their Reason. Philadelphia, 1843. (From Dr. C. 
Evans.) 

The Physical Diagnosis of Diseases of the Lungs. By Walter Hayle Walshe, 
M. D., Prof. Pathol. Anat. in University College, London; Physician to the 
Hospital for Consumption and Diseases of the Chest, Member of the Medical 
Society of Observation of Paris, &c. Philadelphia: Lea & Blanchard, 1843. 
(From the Publishers.) 

Acta Nova Regia Societatis Medicae Havniensis. Vol. 1,2 & 3. (From 
Professor Otto.) 

Guy's Hospital Reports. Second series, No. 1. April, 1843. (In exchange.) 

Fourth Annual Report of the Registrar General of Births, Deaths ?.nd Mar- 
riages, in England. London, 1842. (From the Registrar General.) 

Fifty-sixth Annual Report of the Regents of the University of New York, 
made to the Legislature March 1, 1843. Albany, 1843. (From the Regents.) 

Quarterly Summary of the Transactions of the College of Physicians of Phi- 
ladelphia. February, March, and April, 1843. (From the College.) 

Lithotripsy; or the Breaking of Stone in the Bladder. By Alban Goldsmith, 
M. D., late Prof, of Surgery, &c. New York, 1843. (From the Author.) 

The Horse, by Wm. Youatt. A new edition, with numerous illustrations. 
Together with a general history of the horse; a dissertation on the American 
Trotting Horse, how trained and jockeyed, an account of his remarkable per- 
formances; and an essay on the Ass and the Mule, by J. S. Skinner, assistant 
postmaster and editor of the Turf Register. Philadelphia: Lea & Blanchard, 

1843. (From the Publishers.) 

Catalogue and Circular of the Albany Medical College. Albany, 1843. 
(From the Faculty.) 

Catalogue of the Officers and Students of Kemper College for the Academical 
Year 1842-3. St. Louis, 1843. (From the Faculty.) 

Report of a Committee on the subject of Medical Legislation, to the Monroe 
County Medical Society, Rochester, Nov. 9, 1842. Rochester, 1843. (From 
the Society.) 

An Introductory Lecture delivered in the Castleton Medical College on the 
10th April, 1843. By James M'Clintock, M. D., Prof. Anatomy and Surgery. 
Albany, 1843. (From the Author.) 

Third Annual Announcement of the Baltimore College of Dental Surgery. 
Baltimore, 1843. (From the Faculty.) 

Facts and Arguments on the Transmission of the Intellectual and Moral 
Qualities from Parents to Offspring. New York: Wiley & Putnam, 1843. 
(From the Publishers.) 



TO READERS AND CORRESPONDENTS. V 

Edinburgh Medical and Surgical Journal. April, 1843. (In Exchange.) 
The Medico-Chirurgical Review and Journal of Practical Medicine. April, 

1843. (In exchange.) 
The London Medical Gazette. March, April and May, 1843. (In exchange.) 
The British and Foreign Medical Review and Quarterly Journal of Practical 

Medicine and Surgery. April, 1843. (In Exchange.) 

The London and Edinburgh Monthly Journal of Medical Science. March, 

April, May and June, 1843. (In exchange.) 

The Dublin Medical Press. March, April and May, 1843. (In exchange.) 
Provincial Medical Journal and Retrospect of the Medical Sciences. March, 

April and May, 1843. (In exchange.) 

The British Quarterly Journal of Dental Surgery. Edited by J. Robinson, 

Esq. Vol. i. No. 1. March, 1843. (In exchange.) 

Zeitschrift fur die Medicin, &c. Herausgogeben von F. W. Oppenheim. 

Dec. 1842. Jan. Feb. 1843. (In exchange.) 

Norse Magazin for Laegevidenskaben. Sept. Oct. Nov. Dec. 1842. (In ex- 
change.) 

Bibliothek for Laeger. Redigpret af dens Medlem, C. Otto, M. D. Aug. 
Sept. Oct. Nov. Dec. 1842, and No. 1, 1843. (In exchange.) 

Revue Medicale Francaise et Etrangere. Oct. Nov. Dec. 1842. Jan. Feb. 
1843. (In exchange.) 

Journal de Medecineetde Chirurgie Pratiques. Nov. Dec. 1842. Jan. Feb. 
March, 1843. (In Exchange.) 

Journal des Connaissances Medico-Chirurgicales. Nov. Dec. 1842. Jan. 
Feb. March, 1843. (In exchange.) 

L'Experience, Journal de Medecine et de Chirurgie. Nov. Dec. 1842. Jan. 
Feb. March, 1843. (In exchange.) 

Gazette Medicale de Paris. Nov. Dec. 1842. Jan. Feb. March, 1843. (In 
exchange.) 

Journal de Pharmacie et de Chemie. Nov. Dec. 1842. Jan. Feb. 1843. (In 
exchange.) 

Journal des Connaissances Medicale Pratiques et de Pharmacologic. Nov. 
Dec. 1842. Jan. Feb. March, 1843. (In exchange.) 

Annales de Therapeutique Medicale et Chirurgicale et de Toxicologie. April, 
1843. (In exchange.) 

The Boston Medical and Surgical Journal, April, May and June, 1843. (In 
exchange.) 

The Western Journal of Medicine and Surgery. March, April, May and 
June, 1843. (In exchange.) 

The Bulletin of Medical Science. March, April, May, 1843. (In exchange.) 

The New England Quarterly Journal of Medicine and Surgery. April, 1843. 
(In exchange.) 

The Maryland Medical and Surgical Journal. March and June, 1843. (In 
exchange.) 

The American Journal of Science and Arts. April, 1843. (In exchange.) 

The Western and Southern Medical Recorder. Feb. March, 1843. (In ex- 
change.) 

The Select Medical Library. April, 1843. (Tn exchange.) 

The St. Louis Medical and Surgical Journal. April, 1843. (In exchange.) 

The Medical News and Library, January, February, March, April, May and 
June, 1843. (From the Publishers, Lea & Blanchard.) 



VI TO READERS AND CORRESPONDENTS. 

Communications intended for publication, and Rooks for Review, should be 
sent, free of expense, directed to Isaac Hays, M. D., Editor of the Araer. Journ. 
of Med. Sci., care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed 
as above, and sent (carriage paid) under cover, to John Miller, Henrietta Street, 
Covent Garden, London, or to Wiley & Putnam, New York, or W. D. Ticknor, 
Boston, will reach us safely. We particularly request the attention of our 
foreign correspondents to the above, as we are often subjected to unnecessary 
expense for postage and carriage. 

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

(ty* The advertisement sheet belongs to the business department of .the 
Journal, and all communications for it should be made to the publishers, 
under whose exclusive control it is. 



CONTENTS 

i 
OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

No. XI, NEW SERIES. 

JULY, 1843. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE. 

I. Cases of Phlebitis, with some preliminary remarks on its Pathology and 
Treatment. By N. Chapman, M. D., Professor of the Theory and Prac- 
tice of Medicine in the University of Pennsylvania. - - - - 13 

II. Congestive Fever. Its Character, Symptoms and Treatment, as met 
with in Central Indiana. By Charles Parry, M. D., of Indianapolis, In- 
diana. - - - - - - - - 28 

III. Practical Observations on Continued Fever, as it prevailed in Middle 
Southern Virginia during the thirteen years from 1816 to 1829, inclusive. 

By John P. Mettauer, M. D., of Virginia. 33 

IV. Fungus Hasmatodes of the Knee — Amputation — Cure. By Henry S. 
Levert, M. D., of Mobile, Ala. - - 56 

V. On the Treatment of Puerperal Convulsions before the full term of 
Utero-Gestation. By S. Harris, M. D., of Clarkesville, Va. - - 58 

VI. On Staphyloraphy. By Joseph Pancoast, M. D., Professor of Anatomy • 
in Jefferson Medical College, Lecturer on Clinical Surgery at the Phila- 
delphia Hospital, etc. ----------66 

VII. Spiders discharged from the Eye. Hysteric Monomania. By A. 
Lopez, M. D., Mobile, Ala. - --74 

VIII. Carcinomatous Tumour connected with the Stomach simulating 
Aneurism — Disease of the Aortic Valves, &c. — Death, Autopsy, with 
Remarks. By George Spackman, M. D. 81 

IX. Gun-shot Wound. Extensive laceration of the Brain, without loss of 
consciousness, or impairment of mind. By J. H. Thompson, M.D., of 
Salem, N. J. 85 

X. Sphacelation of the integuments of the Male Organs of Generation, suc- 
cessfully treated. By W. L. Wharton, M. D., Surgeon U. S. Army. - 88 

XI. Poisoning with Lead. By A. B. Shipman, M. D., of Cortlandville,' 

N. Y. 89 



BIOGRAPHY. 

XII. Biography of Thomas C. James, M. D. By Hugh L. Hodge, M. D., 
Professor of Obstetrics, etc. in the University of Pennsylvania. Read 
before the College of Physicians of Philadelphia. - - - - 91 



Vlll CONTENTS. 



REVIEWS. 



ART. PAGE> 

XIII. Traite Pratique de la pneumonie aux differens ages et dans ses rap- 
ports avec les autres maladies aigues et chroniques. Par A. Grisolle, 
D. M. P. Medecin du Bureau Central des Hopitaux et Hospices civils de 
Paris, &c. &c. &c. 

A Practical Treatise on Pneumonia, as it occurs at different ages, and 
considered in its connections with some other acute and chronic diseases. 
By A. Grisolle, D. M. P. &c. Paris, 1841, 8vo. 747 pages. - - 107 

XIV. Traite du Ramollissement du Cerveau. Par Max. Durand-Fardel. 
Ouvrage couronne par PAcadernie Royale de Medecine. 8vo. pp. 526: 
Paris, 1843. 

A Treatise upon Softening of the Brain. By Dr. Max. Durand-Fardel. 
Paris, 1843. 128 



BIBLIOGRAPHICAL NOTICES. 

XV. An experimental and critical inquiry into the Nature and Treatment 
of Wounds of the Intestines. By Samuel D. Gross, M. D., Professor of 
Surgery in the Louisville Medical Institute. — (West. Journ. Med. Surg., 
Jan., Feb., March, 1843.) - 140 

XVI. 1. The Annual Report of the Court of Directors of the Western Lu- 
natic Asylum, to the Legislature of Virginia, for 1842, pp. 62. 

2 The Annual Report of the Physician and Superintendent of the Eastern 
Asylum, in the city of Williamsburg, Virginia, for 1842, pp. 38. 

3. Twenty -sixth Annual Report of the slate of the Asylum for the relief 
of Persons deprived of the use of their Reason,- pp. 28. 

4. State of the New York Hospital and Bloomingdale Asylum, for the 
year 1842, pp. 32. 

5. Sixth Annual Report of the Trustees of the Vermont Asylum for the 
Insane, pp. 16. 

C. Tenth Annual Report of the Trustees of the State Lunatic Asylum at 
Worcester, December, 1842, pp. 116. - - - - - - 144 

XVII. On Gravel, Calculi and Gout: chiefly an application of Professor 
Liebig's physiology to the prevention and cure of these diseases. By H. 
Bence Jones, M. A., Cantab., Licentiate of the College of Physicians, 
Fellow of the Chemical Society. London: Taylor & Walton, 1843, pp. 
142. - - - - 154 

XVIII. The Kidneys and Urine. By J. J. Berzelius. Translated from the 
German by M. H. Boye and F. Learning, M. D. Philadelphia: Lea & 
Blanchard, 1843, pp. 179. 164 

XIX. Lithotripsy; or, the Breaking of Stone in the Bladder. By Alban 
Goldsmith, M. D., late Professor of Surgery in the Medical College of 
Ohio, and the College of Physicians and Surgeons, New York. New 
Y'ork, 1843, pp. 24, 8vo. - - - - 167 

XX. Physical Diagnosis and Diseases of the Lungs. By Walter Hayle 
Walshe, M. D., Professor of Pathological Anatomy in University Col- 
lege, London; Physician to the Hospital for Consumption and Diseases 
of the Chest; Member of the Medical Society of Observation of Paris, etc. 
Philadelphia: Lea & Blanchard, 1843. 168 

XXI. A Practical and Theoretical Treatise on the Diagnosis, Pathology, 
and Treatment of Diseases of the Skin, arranged according to a Natural 
System of Classification, &c. By Erasmus Wilson, Lecturer on Anatomy 
and Physiology in the Middlesex Hospital School of Medicine, &c. Phila- 
delphia; Lea and Blanchard, 1843, 8vo. pp. 370. 170 



CONTENTS. IX 



XXII. Mental Hygiene; or, an Examination of the Intellect and Passions, 
designed to illustrate their Influence on Health and the Duration of Life. 
by William Sweetser, M. D., late Professor of the Theory and Practice 

of Physic, &c. New York: J. & H. G. Langley, 1843, pp. 270, 12mo. 172 

XXIII. Meteorology; comprising a description of the atmosphere and its 
phenomena, the laws of climate in general, and especially the climatic 
features peculiar to the region of the United States; with some remarks 
upon the climates of the ancient world, as based on Fossil Geology. By 
Samuel Forry, M. D. Extra New World, New York: J. Winchester, 
1843. 172 

XXIV. A Conspectus of the Pharmacopoeias of the London, Edinburgh, 
and Dublin Colleges of Physicians, and of the United States Pharmaco- 
poeia, being a Practical Compendium of Materia Medica and Pharmacy. 
By Anthony Todd Thompson, M. D., F. L. S. &c. The second American 
edition, much enlarged and improved. Edited by Charles A. Lee, M. D. 
From the thirteenth English edition, 12mo. New York, 1843: J. & H. 

G. Langley. 173 

XXV. Transactions of the Medical Society of the State of New York. Vol. 

V. Part III., 8vo. Albany, 1843. 174 

XXVI. Fifty-sixth Annual Report of the Regents of the University of the 
State of New York, made to the Legislature March 1, 1843. Albany, 
1843. pp. 316, 8vo. 174 

XX VII. Quarterly Summary of the Transactions of the College of Physi- 
cians of Philadelphia, February, March, April, 1843. - -174 

XXVUI. A Practical Treatise on the Management and Diseases of Chil- 
dren. By Richard T. Evanson, M. D., Professor of Medicine in the Royal 
College of Surgeons, Ireland; and Henry Maunsell, M. D., Professor of 
Political Medicine in the Royal College of Surgeons, Ireland. Second 
American edition, from the fourth Dublin edition, with Notes by D. Fran- 
cis Condie, M. D., F. C. P. P., Memb. A. P. S., &c. Philadelphia: Ed. 
Barrington & Geo. D. Haswell. -------- J74 

XXIX. Dissertation on the Diseases of the Maxillary Sinus. By Chapin 
A Harris, M. D., D.D. S., Professor of Practical Dentistry in the Balti- 
more College of Dental Surgery; Member of the Medical and Chirurgical 
Faculty of Maryland; Corresponding Member of the Western Academy 
of Natural Sciences, &c. &c. Philadelphia: Lea & Blanchard, 1843, pp. 
165, 8vo. -----._ 175 

XXX. A System of Clinical Medicine. By Robert James Graves, M.D., 
M. R.J. A., one of the Physicians to the Meath Hospital and County of 
Dublin Infirmary, &c. &c. Dublin: 1843, pp. 937, 8vo. - - - 175 

XXXI. The Horse. By William Youatt. A new edition, with numerous 
Illustrations, together with a General History of the Horse, &c, and an 
Essay on the Ass and the Mule. By J S. Skinner, Editor of the Turf 
Register, &c. Philadelphia: Lea & Blanchard, 1843 9 pp. 448, 8vo. - 176 



X CONTENTS. 

SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 

FOREIGN INTELLIGENCE. 

Anatomy and Physiology. 



1. On Fissiparous Generation. By 
Dr. Martin Barry. - 

2. Blood Corpuscles. By T. W. 
Jones, Esq. 

3. Structure and Composition of 
Nerves. By Dr. James Stark. 

4. On the special Function of the 
Skin. By Dr. Robert Willis. - 

5. On the import and office of the 
Lymphatic Vessels. By Dr. 
Robert Willis. - 

6. Mechanism of Digestion. 

7. Worms in the Blood of a Dog. 



177 

178 
178 
179 



180 
181 



By MM. Gruby and Delafond. 

8. Structure of the Teeth. By Mr. 
A. Nasmyth. - 

9. Structure of the Uterus. By 
M. Jobert. - 

10. Respiratory Capacity of the 
Lungs. By M. Bourgery. 

11. On Menstruation. By M. Ra- 
ciborski. - 

12. Chemical Theory of Nutrition. 
By MM. Dumas and Cahours. 

13. Urea in healthy Blood. By 
M. Franz Simon. 



181 

182 
183 
183 

184 
185 



- 18: 



Materia Medica and Phakmacy. 



14. Ferruo-'inated Pill of Mercury. 

By Dr. G. F. Collier. - - 187 

15. Cannabis Indica. By W. Ley, 

Esq. - - - - - 188 

16. Medicinal Properties of Indian 



Hemp. By Dr. John Clendin- 
ning. 190 

17. Remarks on the Pathogenic 
Action of the Ioduret of Potas- 
sium. By M. Ricord. - - 191 

18. New Caustic. By M. Payan. 196 



Medical Pathology and Therapeutics and Practical Medicine. 



19. Calculus in Appendix Vermi 
formis. - 

20. Emphysema of the Lung as a 
cause of Sudden Death. By M. 
Prus. ... 

21. Case of Paralysis without loss 
of Sensation, from disease of the 
Cervical Medulla. By Dr. John 
Webster. 

22. Leucorrhoea cured by Iodine 
By M. Ch. Van Steenkiste 

23. Stammering. By Dr. Aber 
crombie. ----'■ 

24. Decrement of Weight in Phthi- 
sis. By Dr. Robert Williams. 

25. Strumous Peritonitis. - 

26. Delirium Tremens cured by 
Ammonia. By Dr. Scharn. - 208 

27. Urea discovered in the Blood 
of individuals labouring under 
Inflammation of the Lungs. By 
Dr. F. Simon. - - - 208 



- 196 



- 198 



- 203 

'- 203 

204 

205 

206 



28. Spontaneous Rupture of. the 
.Spleen. By Dr. Alle. - - 208 

29. Supposed AntivariolousProper- 
ties of Tartar Emetic Pustules. 

By M. Lichtenstein. - - 208 

30. Death from enlarged Bronchial 
Glands. By Dr. Golding Bird. 209 

31. On the Epidemic Smallpox at 
Loreze in 1836, and the protec- 
tive power of Vaccination. By 
M. Millon. .... 

32. Confluent Smallpox in a new- 
born Child. By M. Gerardin. 

33. Universal Suppuration of the 
Cerebro-spinal Membranes with- 
out any corresponding symp- 
toms. By Professor Wagner. 

34. Typhus Abdominalis. By Pro- 
fessor Rokilansky. - 

35. Engorgement of the Uterus. 

By Dr. Clement Ollivier. - 213 



209 



210 



210 



- 211 



CONTENTS, 



XI 



Surgical Pathology and Therapeutics and Operative Surgery. 



36. Researches on the Decomposi- 
tion and Disintegration of Phos- 
phatic Vesical Calculi; and on 
the introduction of Chemical 
Decomponents into the living 

. Bladder. By S. Elliott Hoskins. 214 

37. Nitric Acid in Hemorrhoids. 

By Dr. Houston. - - -214 

38. Rupture of the Internal Jugu- 
lar Vein into an Abscess. By 
Alexander King, Esq. - - 216 

39. Pathology of Fracture of Neck 
of the Femur. By Professor 
Hargrave. - 218 

40. Glossitis in an Infant. By 
Surgeon Koettl. - 218 

41. Hunter's Operation for Aneu- 
rism. - - - - 219 

42. Aneurism. By Dr. J. Adair 
Lawrie. 219 

43. Osteo-sarcoma of Thigh-bone. 
Amputation. By R. A. Frogly, 
Esq. - - - - ^ - 222 



44. Treatment of Aneurism by the 
method of Brasdor. By M. Di- 
day. - 

45. Structure of Neuromatous Tu- 
mours in Stumps. By Dr. Ben- 
nett. 

46. The Starch Apparatus for 
Fractures. By M. Seutin. 

47. Rare Cases of Strangulated 
Hernia. By M. Gerdy. - 

48. Vesico-Vaginal Fistula. 

49. Cancer of the Mamma: statis- 
tics of the disease: treatment by 
compresses of hydriodate of po- 
tass, &c. By M.Tanchou. 

50. Imperfect Luxation of the Ra- 
dius. By Goyrand. 

51. Staphyloraphy. - 

52. Staphyloraphy in cases of 
Cleft Palate. By M. Roux. - 

53. Syphilitic Rhagades of the 
Soles and Toes. By Dr. Hersch- 
man. 233 



- 222 



223 

- 224 

225 
225 



- 227 

228 
228 

229 



Ophthalmology. 



54. Structure and mode of action 
of the Iris. Bv C. R. Hall, 
Esq. - - " - - - 233 



55. Lachrymal Calculi. By M. 
Desmarres. - 234 

56. Turpentine in Hemeralopia. 

By Charles Kidd, Esq. - - 234 



Midwifery. 



57. Abdominal Puerperal Neural- 
gia. By Dr. Golding Bird. - 234 

587 Rupture of the Uterus. By 
Dr. Mitchell. - - - - 236 

59. Prolapsus of the Uterus re- 
duced after sixteen years con- 
tinuance. By M. Durant. - 237 



60. Abscess in the Walls of the 
Uterus. By Dr. Frederic Bird. 238 

61. Statistics of Deliveries. By 
Mr. Wilde. - -;•...- - 239 

62. Statistics of Monstrosities. By 
Mr. Wilde. - - - - 240 

63. Statistics of Still-born Births. 

By Mr. Wilde. - - - 241 



Medical Jurisprudence and Toxicology. 



64. Kakodyle. (Cacodyle.) 

65. Insurance on Lives. 

66. Chloride of Gold as a test 
of certain Vegetable Alkalies. 
(Morphine, Brucine, Strych- 
nine.) By MM. Larocque and 
Thibierge. - 

67. Detection of Opium. By MM 
Larocque and Thibierge. 



241 

242 



- 244 



- 244 



68. Action of Alkaline Chlorides 
on Mercury and Mercurial Com- 
pounds. By M. Mialhe. 

69. Death by Suffocation. - 

70. Probable Case of Superfosta- 
tion in the Bilocular Uterus. By 
M. Billengren. - 

71. Deaf and Dumb Witness. 



244 
245 



246 
246 



XII 



CONTENTS,. 



Miscellaneous. 



72. M. Gibert's Letter en the late 
Epidemic in Paris. - 247 

73. Results of the Re-Vaccination 



PAGE. 

made in the Prussian Army 
during; the Year 1841. - - 248 



AMERICAN INTELLIGENCE. 



Remarks on Typhus Fever, as it 
prevailed in Delaware County, 
Penn. By William E. Haines, 
M. D., of Springfield, Del. Co. 249 

The Mulatto a Hybrid — probable 
Extermination of the two Races 
if the Whites and Blacks are 
allowed to intermarry. By J. 
C. Nott, M. D., of Mobile. - 252 

Case of Artificial Anus. By R. G. 
Wharton, M. D., of Grand Gulf, 
Mississippi. - 256 

Operations for Fissure of the Soft 



and Hard Palate. By Dr. J. 

Mason Warren. - 257 

Treatment of Vascular Noevus. By 

Prof. N. R. Smith. - - - 260 
Contagiousness of Puerperal Fever. 

By Dr. Oliver W. Holmes. - 260 
Caesarian Section on a Dwarf. By 

Dr. Cyrus Falconer. - - 264 

Influenza. ----- 264 
Necrology. - 265 

University of Pennsylvania. -266 

New Works. - 268 

Pennsylvania Hospital. * - - 268 



ERRATA TO VOL. V. 

Page 314, line 20 from top, for left read right. 
" 318, " 3 « left read right. 



THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES 



JULY, 1843. 



Article I. — Cases of Phlebitis, with some preliminary remarks on Us 
Pathology and Treatment. By N. Chapman, M. D., Professor of the 
Theory and Practice of Medicine in the University of Pennsylvania. 

It is only of late, that the pathology of the veins has been cultivated with 
any sort of success. Nothing indeed, was known of it, of any value, prior 
to 1784, when the celebrated Mr. Hunter read a paper on inflammation of 
these vessels, before the Society for the Improvement of Medical and Chirur- 
gical Knowledge, which was printed nine years afterwards, in the transac- 
tions of that body. But it seems not immediately to have attracted general 
notice. Even Bichat, determining from his immortal work, Anatomie Gene- 
rale, published in 1801, so recondite and comprehensive, was unacquainted 
with the preceding researches. Thirty-two years ago only, when I had oc- 
casion, from the occurrence of a very bad case of phlebitis in my own practice, 
presently to be related, to consult the authorities on the disease, I could 
find scarcely any thing regarding it. Commenced however, by Hunter, the 
investigation has since engaged the attention of several very able men, par- 
ticularly within the last few years, who have made great advances in it. 

As phlebitis shows itself, in an external or superficial vessel, there is pain, 
vastly increased on pressure, with swelling, stiffness, and a streak of redness 
along its course — the affection proceeding nearly always I believe upwards, 
in the direction of the current of blood to the heart. No instance have I 
seen to the contrary, and the fact is confirmed by general observation. The 
only exception, so far as I know, is related by Mr. Abernethy. Not here, 
passing up at all beyond the wound, the phlogosis descended down to the 
wrist. Constitutional disturbance is soon betrayed by febrile and other 
manifestations. The local affection rapidly advances, the pain is more poig- 
No. XL— July, 1843. 2 



14 Chapman's Cases of Phlebitis. [July 

nant, and the tumefaction sometimes enormous. Located in a limb, this 
may be of more than double its natural size, the skin tight, smooth, even 
glossy, and rather white than red, or purplish. The fever, at this period, 
may become decidedly typhoid, marked by extreme prostration, a feeble, 
rapid pulse, sometimes intermittent or otherwise very irregular, nausea and 
vomitings, precordial uneasiness, hurried respiration, deep sighing and de- 
jection of spirits, foul coated tongue, meteoiism, sallow skin, much cerebral 
and nervous disorder, low muttering delirium, and subsultus tendinum, with 
a haggard, wild, distracted countenance. Chills or rigors, and rheumatic 
like aches, in the joints, or wandering about the cavities of the body, also 
exist. 

It is not pretended, that such is the tenor of the affection. The case de- 
lineated, is one of violence, which has run through its course probably to 
suppuration of the vein, neither arrested nor abated. Frequently it is milder, 
or we are more successful in the management, and it passes away without 
any severity. Yet I have seen a case, even more terrible in several of its 
features, than has been described. Delirium or rather phrensy, with occa- 
sional spasms, and convulsions, soon came on, so fierce, so vehement, so 
continued, that several men were required to be always in attendance, to 
prevent the individual from doing injury to himself or to others. 

I have hitherto, had reference to phlebitis of the upper extremities, and 
more especially, as induced by venesection. But it occurs also, in the 
vessels of the inferior limbs, and as alleged, is productive of very wide-spread 
mischief. No doubt they have the same susceptibility, and being exposed 
to similar causes, would be equally affected. From venesection, however, 
I have seen only one case. My allusion is more directly to the extraordinary 
disease termed phlegmasia alba dplens, which is, at present, so confidently 
imputed to inflammation of the iliac and femoral vessels, as to be entitled 
crural phlebitis. Dissenting entirely from this hypothesis, as well as the 
extension of it to puerperal fever, as has recently been done, I shall reserve 
the discussion of this point to a subsequent occasion. Now, I deem it suf- 
ficient to remark, that among many other objections to it, both of the affec- 
tions have again and again occurred when no lesion of the vein, could be 
detected. 

Deep-seated veins have not an immunity from such attacks. The vena 
cava, hepatic, splenitic, spermatic, renal, vesical, vena porta, the pulmonary, 
the cerebral sinuses, <fcc. have all been found in this state. But as to the 
symptoms by which each or any one of them is designated, or even of the 
general condition exhibited, we have no precise or satisfactory information. 
An exception, perhaps, should be made in relation to the umbilical, which 
is unquestionably subject to inflammation and its effects after birth, is now 
maintained to be generally connected with the fatal erysipelas of new-born 
infants. Whether it be so, I cannot determine. 

But of this I am entirely satisfied, that neither in the exanthematous, 



1843.] Chapman's Cases of Phlebitis. 15 

nor the common typhous fevers, are the veins so deeply implicated as to 
warrant in any degree the conjecture, lately advanced, of the intimate de- 
pendence of these diseases on this pathological condition. Further, which- 
ever of the veins may be affected, when suppuration takes place, the pus 
thus secreted, we are told, may be eliminated from the circulation, and de- 
posited in any part of the body, though in the lungs and liver most uniformly, 
productive of abscesses, and of a series of secondary affections. Conceding 
that such purulent collections may ensue, of which indeed I have seen several, 
it has appeared to me that, not formed in this way, they were abscesses 
similar to those which are so often to be observed as coincident with other 
low and malignant diseases. They undoubtedly arise in the liver from a 
mere sympathetic irritation derived from an injured brain, or according to 
Morgagni, in any of the abdominal viscera, and so probably do they in the 
present instance. But the notion I am combating, seems to me completely 
refuted by the fact of their constantly occurring in the total absence of 
phlebitis. Both Velpeau and Tessier declare that they are extremely com- 
mon, — the latter ascribing their production under these circumstances to a 
general purulent diathesis! 

It very rarely happens that phlebitis originates spontaneously. Never 
have I seen a case of it, or met with any on record, which I would admit as 
indisputable. Cruveilhier, I am aware, it is said, has related one of the vena 
porta, which is often quoted. But so far from this being true, he expressly 
says, that the suppuration was of the cellular sheath, — the vein itself being 
perfectly sound. Generally it proceeds from some mechanical injury done 
to the vein by venesection, or other surgical operations, amputation, the ex- 
tirpation of tumours, and such like deep, and extensive incisions, involving 
large vessels. The tying of varicose veins, as was formerly practised so 
commonly, as a cure, proved a very prolific source of it, and we are not 
without examples of its happening in the same way, to the hemorrhoidal 
veins, of which, I once saw an instance, under the care of the late Professor 
Physick. Compression from adjacent tumours, does also induce it, and 
much is imputed to the introduction of a virus into the circulation by inocu- 
lation, or otherwise. Breschet goes so far as to affirm, that it may be 
occasioned by bleeding with a lancet previously used in vaccination, not 
thoroughly cleaned, and he cites several cases, where it proceeded from 
the cuts of a scalpel, charged with the matter of putrid bodies. Even the 
washing their excoriated hands, in water, employed in the protracted mace- 
ration of flesh, he saw do it in some of the attendants on a dissecting-room. 
Dance mentions an instance of a surgeon, who died of an attack of it, brought 
on by puncturing a small phlegmon with a carefully wiped bistoury, with 
which he had, a month before, laid open an anthrax. Numberless facts to 
the same purport, might be adduced. 

As a common cause, is also held to be the absorption of pus or acrid fluids 
from foul ulcers, or the secretions of various surfaces, as of the uterus and other 



16 Chapman's Cases of Phlebitis. [J u ty 

organs, and parts, to which so much, we have seen, has been referred in the 
production of phlegmasia dolens, &c. But in respect to the latter, I have 
always been exceedingly distrustful, and cannot help believing, that under 
these circumstances, the inflamed veins, which may be detected, have become 
so by a derivation fiom the structure through which they pass being previously 
in that state. For example, in hepatitis, or pulmonitis, &c, discovering these 
vessels phlogosed, it is to be taken as the effect, and not the cause, the se- 
condary, and not the primary lesion. This proneness of the veins to be thus 
affected, was remarked by Hunter, especially in those who had died of am- 
putation, compound fractures or gangrene, and the observation does not want 
confirmation. My impression on the whole, is, that phlebitis is owing almost 
exclusively to a wound of the' vessel, and that it is perhaps, never directly 
occasioned by a virus. Certainly, it may be excited independently of any. 
There are times and individuals, at all times, when the slightest incision or 
puncture, or even a scratch will lead to the most disastrous results of this 
nature, from the cleanest instruments. Every practitioner is aware, that at 
particular seasons, phlebitis is very apt to follow venesection, and I have 
known a lady for thirty years, who has never been bled during that period, 
however carefully the operation may have been performed, without suffering 
in some degree from it; — and on three occasions so severely, as to place her 
life in imminent danger. Even the pricking of a finger from a needJe, brought 
on immense tumefaction of the arm, up to the shoulder, with the other phe- 
nomena of well marked phlebitis; — and the late Professor Physick, who saw 
the case with me, mentioned that he had met with two others precisely like 
it. The instances of tumefaction from the insertion of a virus, I presume to 
be affections of the lymphatics. Notwithstanding all which has been urged 
of late to the .contrary, I cannot believe that veins in any mode are absorb- 
ents; — and it is truly said by an eminent authority, " that whatever may be 
found in those vessels, whether pus, or other unusual matters, is generated 
within, and not introduced from without." 

Except in traumatic phlebitis, and particularly from venesection, it is not 
uniformly easy to distinguish the disease, and when seated in the veins of 
the interior, never, perhaps, with any precision or certainty. The obscu- 
rity arises, under the most favourable circumstances, from the resemblance 
it bears to the inflammation of the lymphatics, and still more to that of the 
cellular tissue. Between these three affections, at their height the difference 
is the less appreciable, since the cellular membrane mostly becomes involved, 
in which event, the peculiarities of the others are merged and concealed. 
Diffusive inflammation of this tissue, fills up all interstices and inequalities, 
forming a perfect rotundity of surface, dense, smooth, and polished. But in 
the early or last stage, prior to excessive tumefaction, or on its subsidence, the 
phlogosed vein may be felt in a tortuous course, hard and knotty, and some- 
times, also, the lymphatics enlarged and indurated. 

That this is a dangerous disease sufficiently appears from the preceding 



1843.] Chapman's Cases of Phlebitis . 17 

history of it. Timely attended to, it is for the most part, easily arrested. 
But permitted to proceed till the vein is intensely inflamed, and especially 
suppuration has freely taken place, with the establishment of the multiplied 
sympathetic affections incident to this stage of the case, our efforts are mostly 
impotent, and death is to be anticipated. Yet, in a state apparently so 
desperate, the natural resources are sometimes applied successfully. 

By Hunter it was declared, that the veins in phlebitis reveal on dissection, 
inflammation, suppuration, and even ulceration. Experience has since fully 
confirmed the accuracy of his report, and to which, in relation to the ap- 
pearance of the vein itself, little has been added. Beginning usually in the 
internal or lining tissue, the phlogosis, when intense and persistent, may 
pervade the whole of the vascular parietes. Extravasations of lymph are 
common, and distributed in a similar manner. Deposits of it are on either 
surface or both, and inter-tissual, or in other words between the membranes. 
The same may be said of pus, and of ulceration, existing in one or the 
entire coats. But of these several anatomical characters, something more 
must be said. The inflammation is faint, or of a rose, or of a deep scarlet, 
or brownish hue, in specks, or striated or arborescent, local or extending 
along to the heart, continuously or in detached patches, between which the 
intervening spaces are healthy. Collections of pus and of lymph, are de- 
tected sometimes in the calibre of the vessel to an amount very seriously to 
embarrass, or even to obstruct the circulation, and coagula of blood have 
been seen, though seldom, separately or united to the other matters, having 
the same effect. There are instances too, where, from adhesions of the 
sides of the vessel a total obliteration is produced, and should recovery take 
place, it becomes ultimately a dense, impervious cord. The ulcers are few 
or many, superficial or deep. I once saw several that had gone entirely 
through the walls of the vessel. Lymph having been deposited on the ex- 
terior surface, it occasionally agglutinates the vein to the surrounding cellular 
surface and abscesses are formed. Generally the texture of the vessel is 
softened, sometimes to pultaciousness, and in one instance, from the colour, 
the odour, and other circumstances, I had reason to suppose the existence of 
gangrene, as well of it as the adjacent cellular membrane. 

These are the principal lesions, which may be restricted to a single vessel 
or extend to others more or less diffusively — or indeed, according to some 
writers, involve any one, or every organ of the body at different times in in- 
flammation and its consequences. Excepting, however, the purulent depo- 
sitions previously noticed, I am not sensible of any thing in the consequent 
derangements meriting further attention. Disseminated through the structure 
of the organ, they are detected from the size of a pea to a walnut, or some- 
times double or treble, or quadruple the size, the number always larger as 
they are diminutive. They are infiltrations of pus collected at a point or 
points, and not properly abscesses, as they have seldom or never any regular 
cyst. The organ is usually found mostly inflamed immediately around the 



18 Chapman's Cases of Phlebitis, [July 

deposit. It is the fashion of the day to elevate in importance and frequency 
the diseases of the veins, and the accounts we receive respecting them are 
exaggerated, and must be received with qualifications. Even more than the 
heart and the arteries are they susceptible to imbibition', — and mere redness, 
which 1 suspect has been too readily admitted as evidence of phlogosis, 
proves here equally delusive. Coloration, with heavy injection of the 
vessels of the surface warrant a suspicion of the existence of this state, 
though not conclusive. Demonstration of it is only afforded by the presence 
of lymph or pus, or thickening or softening of tissues or other changes of 
structure. 

Contemplating the pathology of this affection, we are, at once, struck 
with some circumstances in it exceedingly anomalous and heteroclite. The 
mode sometimes of its origin, — and that a trivial lesion of a vein, so 
often extensively injured with impunity, should lead to such wide consti- 
tutional disturbance, and this nearly always showing a tendency to typhoid 
debility and vitiation, are certainly very extraordinary. I have already 
alluded to the singular predisposition in these cases, without however 
assigning the nature of it, which I am unable to do. It occurs, perhaps, 
most frequently in various cachectic states, while on other occasions it is 
met with apparently in the soundest and most healthy conditions. Could it 
be demonstrated, that the local inflammation was rapidly and widely diffused 
through the veins, so as to embrace any large portion of them, then an ex- 
planation would be afforded of the enormous mischief produced. Granting 
it sometimes happens, it cannot be averred that it generally does. The 
contrary indeed is nearer true, or that in a large number of instances of 
traumatic phlebitis, especially from venesection, the inflammation is restricted 
to a few inches from the wound, and though it may run up to the heart, it 
seldom involves other veins. The phenomenon is only explicable on the 
supposition of the sympathies of the rest of the veins with the affected one. 
Considering that these vessels form a natural and homogeneous system, 
engaged in the same operations, it is presumable independently of other 
proof, that they have a very intimate consent of parts, by which there is a 
reciprocity of sufferings, oftener however of functional irritation than positive 
disease; — or in other words, that what was primarily a local phlegmasia, is 
rendered a constitutional affection, without an extension of actual inflam- 
mation. Different, however, is it in a more advanced stage of the case, 
where the adynamic degeneration has supervened. Great reason is there 
to suppose that suppuration here exists, and that the immense change thus 
suddenly wrought in the character and physiognomy of the disease proceeds 
from the mingling of pus with the blood. Endo-carditis alone, to which it 
has been imputed, will not account for it. The phenomena of the two 
cases are dissimilar, and those of the veins precisely such as are induced by 
injecting certain fluids, and above all, putrid fluids, into the circulation. 
Nor is the amount of matter secreted inadequate to the effect. In three 



1843.] Chapman's Cases of Phlebitis, 19 

extremely grave instances of phlebitis from bleeding, attended by me, at 
each visit I pressed out of the orifice of the vein, half an ounce or more of 
an ill-conditioned or illandable pus. 

Not conversant with any other form of the disease than that of which I have 
just spoken, and entertaining the conviction it is the only one capable of re- 
cognition with any certainty, at all events in time to do any thing efficient, I 
shall confine my practical remarks to it. These, however, should a case of 
spontaneous origin be detected in season, will be equally applicable to it, so 
far, at least, as concerns the general treatment. 

We are, in the first place, to support the limb, so as to secure an absolute 
state of rest, and which can only be attained by putting it into a nicely ad- 
justed case. It is very much the custom here, to have one carved, that it 
may be more exactly accommodated to the contours of the part, by which 
the main object is better secured, and the pain of motion prevented. The 
suspensory sling, made of a handkerchief, tied round the neck, commonly 
used elsewhere for the arm, is a miserable contrivance, having unquestiona- 
bly often led to the most disastrous consequences. The antiphlogistic plan 
is now to be adopted, and, as part of it, venesection would seem to claim 
priority of attention. Experience however teaches, that the benefit resulting 
from it is never proportioned to what might be reasonably anticipated, — that 
it is sometimes utterly unavailing, — and that a very serious objection to it, 
is, that it is very apt to be followed by a fresh attack of phlebitis, evidence 
of which has come under my own observation. It may, therefore, be best, 
not to resort to it unless excitement is high and general, — leeches, on the 
whole, being decidedly preferable. These are to be liberally applied along 
the course of the vein, and again and again repeated. Emollient cataplasms or 
fomentations may also be useful, and especially where the swelling is exten- 
sive. The case proving obstinate, menacing a serious career, of all remedies 
the one deserving of the greatest confidence is a blister. Numerous are the 
instances in which I have witnessed its superior efficacy, and I believe there 
is little division of sentiment, as to its extraordinary value, among the pro- 
fession in this part of the country. From what I have seen and heard lean- 
not entertain a doubt that it will at once arrest a large majority of cases. But 
though coming from the late Professor Physick — published by him some forty 
years ago, and since frequently alluded to with the highest commendation in 
the writings of this country, it seems to have attracted scarcely any attention 
in Europe, or, at least, I do not find it noticed in the treatises on the subject I 
have consulted, with a solitary exception. Cooper, in his Surgical Dic- 
tionary, appropriates a paragraph to it, without praise or censure. The 
manner of application is, to place a narrow strip of epispastic plaster along 
the course of the vein, as far as it appears to be inflamed, cutting an opening 
in it at the orifice, over which a soft poultice is to be placed, and the blister 
having drawn, is to be so dressed as to be kept freely discharging. Little 
further of any peculiarity appertains to the management of this state of the 



20 Chapman's Cases of Phlebitis. [July 

affection. Evacuations of the bowels, and the ordinary antifebrile mixtures 
are usually directed. But enormous doses of tartarised antimony are recently 
praised, and so is the profuse use of mercury. It is difficult to discern the 
motive for such practice, — there is no evidence of its success, and much in 
it to condemn. Chiefly do I rely, at this juncture, on a combination of calo- 
mel, ipecacuanha and opium, in moderate portions, and where pain and rest- 
lessness are prominent, increase considerably the latter article, or give at 
once the Dover's powder largely. The promotion of perspiration, I very 
strongly suspect, has not here been duly appreciated. 

As the case advances, the indication arises to prevent the pus, the secretion 
of which may now be apprehended, from being transmitted to the heart, and 
with this view divers expedients have been suggested to interrupt the com- 
munication. Compression above the orifice was practised by Hunter, so as 
to obliterate the canal by adhesion of the sides of the vessel. But this 
having failed, after a fair trial, was abandoned, and a division of the vein 
substituted with probably no greater success. Discouraged from the further 
prosecution of it, a ligature was next advised, and which, though promising 
more fairly, I do not know has ever been attempted. The project, therefore, 
of arresting the pus, would seem to be deemed hopeless. 

That the first two operations should not have answered is sufficiently in- 
telligible. Compression adequate to the end could not be made, it is pre- 
sumable, without at the same time interrupting the arterial circulation, and 
independently of the pain induced by it, I doubt exceedingly its feasibility 
at all, in a limb so swollen as happens at the period when the experiment 
becomes justifiable. Cutting the vein in two, does not intercept the progress 
of the blood effectually, while every objection to the ligature applies to this 
operation in an equal force. Determining, therefore, on any of these expe- 
dients, the ligature should be preferred. Yet it must be confessed, that it 
would be a very serious affair to lay open and tie a vein in the state of parts 
so irritated as they are when the operation is most demanded, and whether 
it would be for good or for evil, is uncertain. 

Caused as it may be, whether by the introduction of pus, as I think it is, 
or in any other mode, when the typhoid malignant stage sets in, whatever is 
calculated to uphold or renovate the vital forces, is resorted to, with however 
seldom any advantage. 

Designing to annex some cases, in which the treatment of this affection is 
more detailed, I have now, to avoid the prolixity of repetitions, presented 
Only an outline of it. The first of these cases is probably the second on 
record of suppurative phlebitis, it having been preceded only by the one re- 
ported by Mr. Hunter, to which I have before alluded. 

It is given as it was originally published more than thirty years ago, in 
the Eclectic Repertory, one of our Journals, which will account for some 
circumstances in the narrative, not otherwise very intelligible. 



1843.] Chapman's Cases of Phlebitis. 21 

Case I. — In the month of March 1810, I was requested by the late Mr. 
Thomas W. Francis, of this city, to visit his coachman. On inquiring into 
the case, I learned that three days before, while on a journey, he had been 
attacked in the evening with slight symptoms of pleurisy, which very readily 
yielded to a moderate bleeding. 

The next morning he felt for the first time some degree of pain and 
tension in the right arm, in which he had been bled. But the uneasiness 
was so trifling, and in other respects he was so well, that he continued on 
the journey. The exertion of driving, as might have been expected, aggra- 
vated exceedingly these affections. Yet such was his anxiety to reach 
home, that he studiously disguised his real situation, lest he might be left 
behind — and obstinately persevered against every remonstrance, to perform 
his duties as coachman. But on the last day of the journey, overcome by 
the severity of his sufferings, he reluctantly consented to be placed in the 
carriage, and was in this way conveyed to the city. 

My attendance on him commenced in the night, an hour or two after his 
arrival. Even at this early stage, the case presented a very serious aspect. 
The arm was swelled to perhaps twice its natural size, and the pain and in- 
flammation were excessive. By pressure, a copious stream of purulent 
matter issued from the orifice, and I could distinctly trace the enlargement of 
the vein for several inches, imparting the sensation of a hard, inelastic tube 
enclosed under the integuments. 

Nor were these the only untoward circumstances of the case. There 
was also considerable pain in the left side, with a universal soreness per- 
vading his body. Little or no fever was indicated by the pulse, which was 
weak, irregular, and quick; — of a contracted volume, and rather corded. It 
was more a disturbed than a febrile pulse — certainly evincing nothing of 
an inflammatory diathesis. But though apparently not much if at all 
feverish, he was greatly harassed by restlessness and inquietude. The 
temperature of his body was unequal and fluctuating. When his attention 
was fixed by conversation addressed directly to him, his mind seemed per- 
fectly rational: butctherwise he quickly became flighty; — talked incoherently, 
and endeavoured to get out of bed. Whatever were my doubts as to the 
ultimate event, I entertained none respecting the nature of the complaint, or 
the cause which had produced it. I was at once satisfied that the whole 
of the existing mischief was attributable to inflammation of the vein, extend- 
ing probably to the heart, and to the introduction of pus into the blood. To 
the latter cause I the more promptly imputed the train of nervous affections, 
as I had seen in a series of experiments, phenomena of the same kind in- 
duced by the injection of pus, of milk, of oil, of mucilage and other bland 
fluids into the veins of different animals. 

Nor could I hesitate long as to the practice to be pursued. To subdue 
the inflammation of the vein, and arrest the pus in its passage to the circu- 
lation, were obvious indications. 



22 Chapman's Cases of Phlebitis. [July 

Notwithstanding the feebleness of arterial action, I bled him to the 
amount of twelve ounces. I suspected a state of depression, and thought it 
not unlikely that the pulse might rise by depletion. Where so large a vessel 
was inflamed, and seemingly too, the heart itself, it certainly was not unrea- 
sonable to conjecture that the want of diffused excitement was owing to this 
condition of the system.* But my anticipations were not realized. The 
bleeding was indeed followed by no sensible effect, and the blood was with- 
out any very peculiar appearances. It did not, it is true, separate as it ordi- 
narily does. The se urn and crassamentum were commixed, as if slightly 
stirred together. I could detect no pus in the blood. 

I next enveloped completely the arm with a blister from the elbow to the 
shoulder, excepting at the puncture, which was covered with a small 
emollient poultice to facilitate the evacuation of the matter. During the 
night I ordered, moreover, that he should take at stated intervals a solution of 
salts till it purged him actively. 

In the morning he appeared in some respects to be better. The blister 
had drawn well, and the pain and swelling were in consequence considerably 
reduced. Neither was he so restless nor irritable, and his mind had ceased 
to wander. 

When at night I again called, he was much as he had been at my pre- 
ceding visit. The swelling of the arm was perhaps somewhat further 
abated. But in a few hours afterwards the pain in the side, which at no 
period had entirely subsided, reverted with violence. It did not, however, 
raise his pulse. 

Convinced by a variety of considerations, that the pain proceeded from 
inflammation of the heart, I placed a large blister over the region of that 
organ. Though relieved by this application of the pain, I had the mortifi- 
cation of seeing him the succeeding morning in a situation of increased 
danger. With a pulse weak, quick, and tremulous, he was wild and dis- 
tracted. I directed that he should lose six or eight ounces of blood by cups, 
from the neck and temples, and to have a blister put on behind each ear. 

It now appeared to me to be literally of vital importance, to intercept the 
pus in its course to the circulation. I, therefore, resolved without delay to 
make use of compression, though it seemed still to be forbidden by the 
tumefaction of the limb. A bandage and compress were accordingly applied 
a short distance above the puncture. But nothing material was gained by 
these applications. The swelling of the arm however declined, and no in- 
convenience was experienced from the compression. The pus continued to 
flow profusely from the orifice: this was late in the evening. 

* We are indebted to Sydenham for the important fact, that in many instances there 
is a depressed, in contradistinction to an exhausted system, and which is to be aroused, 
not by stimulation but by depletion. Brown, who had his direct and indirect debility, 
differs from him in maintaining that each of these states is to be relieved by stimulants 
properly graduated. 



1843.] Chapman's Cases of Phlebitis, 23 

My visit the next morning found him worse. To all the bad symptoms 
which previously prevailed, were now added some still more inauspicious. 
The morbid sensibility of his body had become so exquisite, that he could 
not bear the slightest touch, or scarcely the weight of the bedclothes without 
complaining. So sensibly alive was he to every sudden impression, that by 
opening or shutting the door, or walking across the room, or by a question 
put to him in a sharp tone of voice, or by a strong glare of light, he was 
startled and sometimes exceedingly agitated. 

At this critical juncture I resorted to the advice of Dr. James, who very 
obligingly met me in consultation. We agreed to give the camphorated 
emulsion in large doses, and to have stimulating injections repeatedly admi- 
nistered. But this treatment was equally unavailing, and my patient pro- 
gressively sunk. Low delirium, cold extremities, tremors of the nerves, and 
convulsive cough, soon supervened. His pulse became hardly perceptible. 
The pupils of the eyes were widely dilated, and his countenance assumed 
an expression uncommonly haggard, phrensied and distressed. Desperate 
as I deemed the case, I did not permit my exertions to be relaxed. By the 
constant use of the most powerful stimulants, such as camphor and opium, 
the volatile alkali, the spirits of turpentine, ether, wine, and brandy, I pro- 
tracted his existence for three days longer, without having, however, during 
this interval, a single gleam of hope afforded me by any change of his 
recovery. 

The morning after my patient expired, I made an examination, with a 
view of ascertaining the exact state of things. I exposed the vein from the 
wrist to the axilla. The external surface of the vessel was in many places 
inflamed, and especially above the puncture. Between this and the shoulder, 
matter had escaped from the vein by four distinct sinuses into the neighbouring 
cellular membrane, forming small abscesses. Two of these sinuses were 
high up the arm. 

I dissected very carefully the parts adjacent to the wound. Directly 
around it there was an abscess containing, I presume, a large spoonful of 
pus, mixed with a dark fetid sanies. Sphacelus had already destroyed a por- 
tion of the cellular texture. 

I next laid open the vein. There was inflammation more or less, from a 
little below the elbow to the final point of my dissection, without being any- 
where very great. By the appearance of the coat of the vein there was, 
however, the amplest proof of its having existed in the highest grade, and 
which is abundantly shown by the formation of the sinuses, &c. Below 
and above the orifice for several inches, gangrene had taken place, bounded 
by an extensive erysipelatous blush, and the inner surface of the vessel within 
this space, had begun to slough. 

The quantity of pus in the cavity of the vein was small. It ought, indeed, 
to have been stated, that for two or three days prior to his death, the dis- 
charge from the orifice had gradually diminished. No disposition whatever 



24 Chapman's Cases of Phlebitis. [July 

was evinced anywhere along the canal of the vein, to an adhesion of its sides. 
My wish to extend the dissection was frustrated. Enough however has 
been brought to light by this partial exposition, to confirm my original notions 
as to the nature and causes of this series of extraordinary affections. 

In reflecting on the management of the case, I have only to regret having 
confided too much in compression as a means of promoting adhesion. But 
surely I shall escape censure, for having adopted a measure which had been 
approved by the very high and concurrent authority of Hunter, Cooper, 
Abernethy, &c. &c. I had never before an opportunity of trying compres- 
sion under such circumstances, or of seeing it employed. My conviction 
now is that it will rarely succeed. It is confessedly at all times difficult to 
produce a union in tubular or fistulous ulcers, even where pressure can be 
used. It is yet more so, to effect a coalescence between the opposite sur- 
faces of blood-vessels, because among other obstacles, the coagulable lymph 
which is the medium of attachment, must in a great measure be swept away 
by the circulation as fast as it is deposited. It is besides almost impractica- 
ble to make adequate compression on any of the veins of the arm, without 
interrupting the return of the blood. I confess, however, that these specula- 
tive objections to the practice, have less weight with me than the melancholy 
instance of its failure which I witnessed. In the case of my patient the ex- 
periment was fairly made, — for five days and nights successively, I continued 
the compression, and with the utmost vigilance to the due regulation of it. 
Distrusting, therefore, the efficacy of this expedient, if ever I should meet 
with a similar case I would apply a ligature to the vein. The operation, 
however, will not often be necessary. It can only be required where sup- 
puration has taken place, and there are grounds for the apprehension that the 
matter is traveling into circulation. Cases of this sort are extremely rare. 
Few, at least, have been recorded. I have met in my researches with only 
one at all analogous.* They have hitherto been' contemplated by writers 
rather as a possible than an actual occurrence.! 

* This case is related by Mr. John Hunter. In dissecting the arm of a man, he traced 
a series of adhesions along- the course of the vein. But near the axilla, the vein, says he, 
"had taken on suppuration, beyond which adhesions had not formed, and this had given 
a free passage for the matter into the circulation, of which the patient most probably died." 

t Mr. Abernethy, in his essay on this subject, tells us that he had never seen a case of 
the vein suppurating from venesection. But he can conceive one, in which it might be 
proper to divide the vessel to prevent the pus from entering the circulation. With the 
greatest deference to the authority of this distinguished surgeon, I cannot help giving a 
preference to the ligature in those cases. It has all the advantages of tlie operation which 
he proposes, and is exempt from the hemorrhage and other inconveniences which might 
attend it. Nor does Mr. Charles Bell, another surgeon of great eminence and experience, 
appear to have met with such a case. Treating, in his System of Operative Surgery, of 
suppurating veins, he says, "the danger here is conceived to arise from the matter formed 
Within the veins being carried into the circulation," &c. In fine, all the writers whom I 
have consulted, hold the same sort of language upon this subject. 



1843.] Chapman's Cases of Phlebitis. 25 

Injuries to the veins from bleeding, are for the most part attended by only 
circumscribed inflammation. The suppurative process seldom ensues. 
Even when it happens, it is generally limited to the vicinity of the wound, 
through which the pus is either freely evacuated or is lodged in the surround- 
ing cellular texture, and the -abscess thus formed may be made by an opening 
to discharge externally, if, contrary to the ordinary course, it does not do it 
spontaneously. 

Case II. — It was in 1816, I think, for owing to a casualty, the date 
cannot be ascertained exactly, that I was requested by Dr. M. Phillips, a 
young physician of this city, to visit with him an elderly man, a native of 
Germany, whom he considered very strangely and alarmingly affected. 
Five days previously he had been bled for sciatica, and according to the 
popular prejudice of his country, in the foot of the same side in which the 
pain was seated. Being relieved of the rheumatism by the loss of blood, he 
the next day resumed his occupation of driving a cart, and of course was 
much on his feet. Early in the evening he came home with severe pain 
shooting up the leg, ascribed to a return of rheumatism. This increasing 
during the night with considerable swelling of the limb, Dr. Prtillips was 
sent for, who adopting a similar view of the nature of the case, treated it in 
the usual manner by general and local bleeding, purging, the mild diapho- 
retics, and divers local applications, fomentations, liniments, &c. Great as 
the pain and swelling were, his pulse had never been full or active, — the 
temperature even of the part high, or indeed any very unequivocal evidence 
of fever; — and though the orifice of the vein had not united, there was 
nothing very peculiar about it. The man becoming, however, restless and 
delirious, with chills, rigors, and other alarming symptoms, I was consulted. 
The preceding account I derived from the attending physician, and which 
was confirmed by the wife of the patient. 

In entering the chamber, I was struck with the wild and phrensied ex- 
pression of countenance, and soon perceived that he was greatly agitated and 
distressed. Not content scarcely for a moment in any one position, he was 
alternately up and down, or tossing himself from side to side of the bed, 
and had evidently a sort of spasmodic jerkings of the limbs. Examining 
the case, I found his intelligence very imperfect, the pulse feeble and 
tremulous; — the skin cool, covered with a dewy sweat, especially about the 
forehead and neck, and there were nervous tremors and difficulty both of 
articulation and of deglutition. The whole of the leg, and part of the thigh 
were prodigiously swollen, tense and pale, and around the orifice, which was 
closed by some thick glutinous matter, was an abscess of nearly an inch in 
diameter that had not before been observed. By gently pressing it, a sanious 
fluid flowed out freely, and from stroking the vein above it, amounted alto- 
gether to an ounce and a half. The whole of the affected portion of the 
extremity was covered with a blister except at the orifice, over which a 



26 Chapman's Cases of Phlebitis* [July 

poullice was placed — -and opium, the carbonate of ammonia, and brandy- 
toddy liberally given. In the evening he appeared decidedly worse, having 
had several tetanoid spasms, and become so furiously deranged, that several 
men were required to restrain him from acts of violence. He died in the 
night in a convulsion, of which he had several previously. Every effort was 
resisted to get an autopsic inspection even of the vein. 

Case III. — Not long after the preceding, I saw with Professor Physick a 
third case of this affection. It was in a middle-aged lady, corpulent, 
plethoric, and of sedentary or even sluggish habits. Frightened by a re- 
currence of an apoplectic admonition, which she had experienced several 
times before, she determined at once to resort to venesection. No longer, 
owing to extreme obesity, could blood be obtained from the arm, and on 
this occasion a vein in the hand was opened. Eleven days after this, and 
when the incision had completely healed, which indeed it did very promptly, 
she for the first time complained of sharp darting pains along the course of 
the vein up the limb. As Dr. Physick, her family physician, was confined 
at the period by sickness, the bleeder who had performed the operation was 
sent for, by whom she was told that a nerve or a tendon had been pricked, 
and that nothing was to be apprehended, as it was an injury temporary in its 
nature, and readily cured. Directing her to wear the hand in a sling, and 
to bathe it with an emollient liniment, he retired. But henceforward the 
pain and swelling of the forearm rapidly increased, and the same person was 
again consulted, who now advised the loss of blood by leeches, which were 
several limes repeated, followed by poultices. No advantage, however, was 
gained by these applications, and she becoming a good deal weakened and 
slightly wandering in her slumbers, Dr. Physick was urgently requested to 
see her. Discerning her perilous situation, and from the infirmities of his 
own health, being incapable of paying her the attentions he thought she re- 
quired, he waited in the house till I came to his assistance. The preceding 
history of the case was then related by him to me. This was late in the 
afternoon. Her general condition reminded us much of that of the incipi- 
ency of low typhoid fever. The eyes were injected, the pupils slightly 
dilated, with a swimming fatuous expression, and she felt some uneasiness 
of the head. Deep sighing was frequent, and though she had vomited once 
or twice she still complained of epigastric oppression and of nausea. There 
was some distension of the abdomen, probably owing to the loaded state of 
the bowels, as she was constipated; — the temperature of the surface unequal 
— the extremities cool and pallid, while the head was preternaturally warm, 
and the face rather florid. Her pulse was quick, irritated, and corded, of 
very small volume, and so irregular as to be somewhat intermittent. De- 
pression of spirits was very conspicuous, and she frequently declared that 
her sensations were such, that she was sure her death was inevitable. 

To the elbow, the arm was much swollen and exquisitively tender, with 



1843.] Chapman's Cases of Phlebitis. 27 

little pain in it, either lancinating or pulsatory, and pretty nearly of the 
natural hue, except here and there some livid spots appeared. The orifice 
was inflamed, and its lips pouting, and slighted retorted. Discovering some 
sanguinolent matter on the poultice, the vein was delicately pressed, when 
there oozed out nearly a couple of drachms of purer pus. 

We recommended that a stimulating enema should be immediately given to 
empty the bowels, and if not succeeding, an infusion of senna and salts, 
administered in repeated doses, till the effect was attained. The arm was 
also to be covered with a blister, except at the orifice, over which a poultice 
was to be placed, and then secured in a case. These instructions were faith- 
fully executed, and on my return in a few hours, I learnt that she had been 
amply purged by the medicine. Yet her condition had deteriorated, by an 
aggravation of cerebral and nervous disorder, and of jactitation and wretch- 
edness. An opiate was now ordered. The report of the morning was, that 
she had slept altogether some hours, with however, much muttering delirium. 
No improvement could we discern in any respect; — on the contrary, as related 
to the general condition, manifestly worse. The blister not having drawn, it 
was replaced by a fresh one very carefully prepared, and bound on the limb, 
by strips of adhesive plaster. Dover's powder and wine whey were given 
during the day. Towards evening we saw her again, and thought her better. 
For several hours, she had been comparatively tranquil, and took eagerly 
some nourishment, sago, with wine, and nutmeg. The nervous system was 
more steady, the intelligence perfect, the swelling of the arm considerably 
reduced, of the purulent discharge, scarcely any, and the aspect of the wound 
greatly improved. Having drawn well, the blister was removed, and dressed 
by a mixture of the basilicon and mercurial ointments. Her recovery hence- 
forward advanced so rapidly, that I ceased to take notes of the case. 

This is one of the many instances, certainly however, not of equal severity, 
which I could recite of the extraordinary control of vesication over phlebitis. 
Except it, nothing here was resorted to, of any decided curative power, and 
the whole of the beneficial effects may be justly ascribed to it. With entire 
rest of the limb, I have much reason to suppose, that it will arrest a very 
large proportion of these cases, antecedently to the suppurative stage, and 
even then where the attack is mild. Endocarditis, however, taking place, or 
such a quantity of pus having entered the circulation as to induce a state of 
poisoning, with all those complications of typhoid affections consequent on 
it, then, I believe, that it, in common with everything else hitherto devised, 
will prove nugatory. Fortunately, however, the most violent forms of the 
disease are not common. The inflammation in traumatic phlebitis is usually 
local, and when more extensive and suppurative, the quantity of pus secreted 
is small, or if copious, its introduction into the circulation is very often pre- 
vented by some of those provisions wisely instituted by nature, to which I 
have previously alluded. 



28 Parry on Congestive Fever. [July 



Art. II. — Congestive Fever. Its Character, Symptoms and Treatment, 
as met with in Central Indiana. By Charles Parry, M. D., of India- 
nopolis, Indiana. 

This disease prevails at the close of summer and through autumn, with 
other autumnal diseases; and, in the same situations, though generally while 
the usual fevers occupy the table-lands, the congestive cases are found along 
the low grounds skirting the rivers. 

Liability. This disease is confined chiefly to adults of both sexes; chil- 
dren are rarely affected. I never saw a case in an individual under twenty 
years of age. Old settlers are as liable as those recently arrived; this is not 
the case as to the bilious fevers. 

Once having had an attack, does not exclude the possibility of having 
another the same season, although a second attack is rare. I had one patient 
who had two attacks the same season; and I had one patient who had an 
attack in three successive summers. 

The general duration of this disease, is from six to nine days in recover- 
ing, so as to walk about; in fatal cases, from two to three days; death usually 
occurring in the second or third paroxysm, hardly ever in the first. The 
plethoric, young and robust, are most apt to die; the age, in a majority of 
fatal cases, is from twenty-five to thirty-five. 

The cause of death, appears to be a cessation of the circulation; in the 
more malignant cases the patients are sometimes pulseless, for from four to six 
hours before death takes place, and yet be able to sit up, or walk about in 
this condition. 

Proportional mortality. Without treatment, or with the usual treatment 
for bilious fevers, (which is little better than none in this disease), probably, 
three-fourths of the cases terminate fatally. But with a special treatment not 
more than one in eight. 

The attack may come on at any period of the twenty-four hours; fre- 
quently it is during the night. 

Symptoms. In the majority of cases, the symptoms of the first parox- 
ysm are such as occur in an ordinary intermittent attack. One main pecu- 
liarity is, a physiognomical expression of intense apprehension, or terror, 
without experiencing it. Perhaps the face is paler, or more livid than in 
common cases. There is also a general coldness of the surface of the body 
and extremities, felt by the physician, but not by the patient, as there is a 
lessened endermic sensibility. 

The several stages are very imperfectly marked in the first paroxysm of 
this disease; the fever is usually light, though the cold stage may have lasted 
an hour. There is not usually a distinct sweating stage in the first paroxysm, 



1843.] Parry on Congestive Fever. 29 

and the patient in the subsequent interval complains of malaise only, or 
some debility; being in other respects pretty well. 

The first paroxysm attracts so little attention, that after it is over, the 
patient meeting a physician or friend, says, that he feels as if he were about 
to be sick; not that he has been sick. 

There is seldom much, if any, gastric disturbance in the first paroxysm; 
and except as to its indistinctness, its slightness, and the malaise left behind, 
the paroxysm is like that of a very light intermittent. 

The interval between the paroxysm, is twenty-four or forty-eight hours; 
I do not remember which is the most common interval, or, if either prevails 
more in any particular year. 

The second paroxysm. This is always severe, not so much in the vio- 
lence of the rigors, as in the extreme coldness, and in the approaching 
death-like hue of the face and extremities: this condition is very prolonged, 
even until death takes place; or, after three or four hours, if there is a fa- 
vourable termination, until reaction occurs. 

In the chill. The gastro-intestinal irritation is very violent, the vomiting 
and purging almost incessant; the discharges are often mixed with blood, 
but not with bile; — as the hepatic secretions are seldom altered either 
in quantity or quality. The discharges do not resemble those of cholera 
(rice water), they have more the appearance of water in which a large 
portion of recently killed beef has been washed. Sometimes, however, the 
proportion of blood is much greater, at times amounting almost to clear 
blood, and from three to five, or even twelve ounces at a discharge, and 
frequently as often as ten, twenty, or forty minutes apart; the discharges 
have no particular or very little odour; there are little or no griping pains, 
though frequent efforts even without any discharge. The vomiting and purg- 
ing are so frequent, that I consider thirty minutes quite a long interval. 

Abdominal pain and tenderness on pressure, slight; the patient complains 
of a sense of weight and burning heat in the stomach. No abdominal intu- 
mescence or tympanitis, except that, in a favourable termination, there are 
in a few cases large evacuations of gas, as if it had been secreted after the 
cessation of the liquid discharge. 

The thirst is most intense. The constant cry is for cold drinks, cold 
ice water, and a very common exclamation is, " Oh that I could lay in the 
river," " If I could only have a stream of cold water running through me;" 
these symptoms too in the cold stage. 

The Respiration is often very peculiar. It consists of a deep drawn 
double inspiration (or double sigh) with one expiration; this double 
breathing is seen in perhaps more than two-thirds of the cases; it is a 
fatal symptom. It is seen very early in the second paroxysm, gene- 
rally at the beginning, and continues to its close, either in the agony of 
death, or to the febrile reaction; the respiration is seldom hurried; the interval 
No. XL— July, 1843. 3 



30 Parry on Congestive Fever. [July 

(the time between the end of the expiration and the beginning of the inspi- 
ration) is long, especially in fatal cases. 

No cough, no mucous rale, or sonorous respiration, except at the end of 
the scene, when we sometimes have the " death rattle." 

Circulation. The pulse, even from the beginning of the second paroxysm, 
is very small, thready, very frequent, 120 to 150 in a minute, hard, or 
wiry, sometimes irregular, intermitting, even to the omission of two or three 
beats. 

The capillary circulation appears stagnated, as indicated by the lividness 
and coldness of the surface of the body, the paleness remaining after pres- 
sure, a cold, clammy, sticky sweat, sometimes extending from head to foot, 
but frequently, only over the face and neck; the skin on the hands is shri- 
velled, wilted, and they look as if they had been soaked in ley, like a washer- 
woman's hands, and yet the patient actually complains of the "burning heat," 
begs for cold drinks, and often wants to be fanned. 

Restlessness is very great, the patient constantly tossing about from one 
side of the bed to the other; throwing his arms and legs around; incessantly en- 
deavouring to get out of bed, and he is able to do so, even to walk across the 
room if permitted, until within an hour or so of dissolution. I have positively 
seen persons get out of bed, walk across the room and stand in the doorway, 
hours after it was impossible to detect any pulse at the wrist, though the 
carotids could be felt plainly. Such is the intense desire of patients to get 
cold air, that they frequently express themselves determined to have it, at all 
hazards; and, indeed, it frequently happens, even with nearly all the sjrmp- 
toms above described being present, the patient does not think there is much 
the matter with him, and wonders why the attendants will keep him in bed, 
(and it takes two or three to do it,) why they will not let him go out. This 
ignorance of their dangerous situation continues up to the occurrence of the 
stupor, or soporose condition, which usually comes on an hour or more be- 
fore death. 

There are frequently muscular cramps in the calves of the legs and feet, 
though seldom abdominal spasms. 

State of mind and senses. No tinnitus, blindness, or perverted vision; 
the mind is usually undisturbed until the " agony. V In some cases, how- 
ever, there is severe headache, and delirium; and in others somnolency, or 
extreme coma, even from the access of the second paroxysm. In such 
cases, the determination of blood is mainly to the head, or it is a disturbance 
of innervation. 

Urine. Its condition not observed, the frequent purging in every case 
rendering it difficult to observe the state of this excretion. 

The usual length of the fatal paroxysm, is from three to six hours, though 
it is longer in some cases. The moribund symptoms increasing, the pulse be- 
coming more and more frequent, lessened in force, and growing more irregu- 



1843.] Parry on Congestive Fever. 31 

lar, sometimes scarcely felt, or conveying a fluttering sensation beneath the 
finger so fine as scarce to be perceptible. Prolonged inspiration, and 
extended intervals. Increased coldness, clamminess and wilting of the skin 
on the hands and arms; a sticky unctuous sweat from head to foot, collecting 
in large drops of the size of a half dime, if not wiped away. Hypocratic 
sharpness, and anxiety of look, without corresponding sensation, (for even 
here the patients may speak as if there was but little the matter with them;) 
seldom, if any subsultus, or hiccup, or convulsions; and death takes place 
easily, as if without cause. 

Treatment. The great principle of curation, is to conduct the paroxysm 
to a close, and then to prevent a recurrence of it. 

As the physician is called to the sick, in nearly every case, during the cold 
stage, the indications for him to follow are, 

1st, To arrest the discharges of the first passages. 

2nd, To determine to the surface; produce reaction. 

3rd, To relieve local congestion. 

For the first and second, I use extensive sinapisms of the strongest kind, 
over the whole abdomen and lower extremities, also hot bricks to the feet; 
cotemporaneous with this, to allay the vomiting, and check the discharges 
from the bowels, I give every half hour a pill composed of J gr. sulph. 
morph.; 1 gr. camph.; 2 grs. of mass, hydrarg.; with sometimes £ gr. cap- 
sicum; or if the evacuation is of a very sanguineous character, I give alter- 
nately with the above, a powder composed of 3 grs. acet. plumbi; \ gr. of 
sulph. morph., and 2 grs. calomel. My object in giving mercurials is, not 
so much for the immediate effect during the existing paroxysm, as for its 
auxiliary action in restoring the various secretions, after a favourable termi- 
nation of the paroxysm; for I really believe the patient would invariably die, 
if we were to rely for a cure on any specific action of mercury on the 
system; we cannot wait for this, no matter how energetically exhibited. 
We must secure our patient from danger by other means, as I shall 
enumerate. 

To assist in carrying out the 2d indication, I also use the most stimulating 
frictions to the hands, arms, and legs, such as cayenne pepper stewed in 
brandy, or if there is much of the clammy sweat, I prefer dry capsicum and 
very coarse flannel. 

3rd Indication. To relieve the local congestion. This is best done by 
cupping. If the determination has been to the head, apply cups around the 
forehead, temples, nape of the neck; also apply cloths wet with the coldest 
water, or a bladder of pounded ice to the top of the head. 

If the determination has been to the lungs, of course the cups will be 
applied over the chest, and to be of service, they should be very extensively 
applied. But if the congestion appears to be in the abdomen, I prefer the 
mustard plaster to the cups, as I think it produces a better revulsive action. 

Internal stimulants, either do harm or no good; the patients usually 



32 Parry on Congestive Fever. [Juty 

object to them, as they increase the sense of heat and distress. In the few 
cases in which ihey were used, the end was fatal; I do not attribute that to 
their exhibition, for those were desperate cases; but I saw no benefit from their 
use; but instead of stimulants, the patient almost screams for ice, or ice water, 
such is the intense desire for cold drink, and the patient appears to be greatly 
refreshed by the indulgence. 

If we are so fortunate by the foregoing means, as to establish general 
reaction, the patient has a fair chance for his life. In fact, I consider with 
the proper remedies the recovery certain. 

After watching the patient with much anxiety, for two or three hours, 
with the symptoms above described, with more or less violence, the pulse 
is found to gradually increase in strength and fulness; beat after beat 
under the finger; the warmth or heat of surface gradually extending, inch 
by inch from the body along the limbs, until it reaches the extremities; the 
vomiting and purging ceases, the skin becomes dry, a general heat is diffused 
over the whole body; or, in fact, fever established; but in nowise corresponding 
in violence to the malignant character of the cold stage; and in fact, it is sel- 
dom necessary to direct any particular treatment for the mere fever itself; 
nor do I let the fever interfere with my commencing immediately with the 
anti-paroxysmal remedies if it is necessary to economize time. Consequently, 
I consider this paroxysm as through, so far as its treatment is concerned. 

The next great object is, to prevent its recurrence, and whatever will 
prevent the concentration of the blood to the particular internal organ, arrests 
the disease; and this must now be done at all hazards, or the patient will 
die. Although I like all the collateral assistance I can receive from other 
articles, yet the " Sulphate of Quinine" is the remedy! It is the master 
article of the Materia Medica. With it, and reaction once established, I be- 
lieve nearly every case can be cured; but without it, scarcely any recover. 

To lessen the susceptibility to purging, opium should be used with it. To 
abate nausea, if any is present, camphor ought to be added. And to restore 
the mucous secretions, which are arrested, a mercurial must be also given, 
of which, the best is blue mass. 

Therefore, give modified as above, a pill composed of 3 grs. of sulph. 
quin.; H gr. of blue mass.; | gr. sulph. morph.; 1 gr. pulv. camph., repeated 
according to the expected length of the interval, to the next paroxysm; if the 
disease is of a quotidian character, the above pill must be given every hour, 
or hour and half apart; but if of the tertian order, it may be given from 
two to three hours apart; the object being, to give during the interval from 
30 to 60 grains of quinine, according to the force of the patient's general 
system previously. The paroxysm being prevented, continue for a time, in 
lessened doses, the above prescription, and treat other symptoms, (secun- 
dum artem). It not unfrequehtly happens, that in the beginning of winter or 
of spring, a person who has had in the summer or fall a congestive fever, is 
attacked with common ague. This is easily cured, never becomes congestive. 



1843.] Mettauer's Observations on Continued Fever, 33 

I saw but one case of repetition; after going about three or four weeks, this 
person recovered. 

I remember twelve very severe cases, of which only three recovered; all 
dying in the paroxysm to which I Was first called. I do not recollect one 
case in which the patient died, where I had a chance of treating the interval. 
No example of a paroxysm of a dangerous character, and but few of any 
character, after reaching complete reaction, and the already described treat- 
ment being used. 

Peculiar Cases. Mrs. W. had two attacks in one season, in the first 
attack, she was for forty hours in a cold, clammy sweat, skin not shrivelled; 
her pulse never became thready; no bloody discharges; excessive vomiting. 

In the second, copious intestinal hemorrhage; yielded to treatment; re- 
covered. 

Mr. Walker, setat. 23. First paroxysm very slight; out on his farm next 
day; in forty-eight hours the second paroxysm; in this there was the cold skin, 
violent delirium, pulse not depressed; in forty-eight hours again, another 
paroxysm, cold surface, watery diarrhoea, excessive vomiting, sunken pulse, 
great tympanitis; and finally, enormous discharges of flatus; ended favourably 
by reaction, and a recurrence was prevented by quinine. 



Art. III. — Practical Observations on Continued Fever, as it prevailed in 
Middle Southern Virginia daring the thirteen years from 1816 to 1829, 
•inclusive. By John P. Mettauer, M. D., of Virginia. 

Continued Fever is the occasional product of nearly every climate, but 
more frequently occurs in cold and temperate regions; it is unquestionably 
of malarial origin, and appears both as endemic, and endemico-epidemic. 

Three varieties of this fever have prevailed at different times, in the region 
of country, from which the facts and observations embodied in this paper 
are derived; that is, the Synocha, the Typhoid, and the Typhus. 

Synocha, which was only the more open and well developed form of the 
disease, prevailed during dry and warm, and warm and damp seasons, and 
always as an endemico-epidemic of considerable extent. From 1816 to 
1821, both years included, and especially during the warm months of those 
years, this was the predominant form under which continued fever appeared; 
and it was uniformly distinguished by the open characters of a well-marked 
inflammatory fever in a large majority of cases, throughout its more acute 
stage. During these years, too, all classes and conditions of society were 
equally affected by the disease, and, with few exceptions, it did not part with 
its peculiar open characters until the setting in of cold weather. Many cases 



34 Mettauer's Observations on Continued Fever. [J u ^y 

of ordinary continued fever, or as it is often termed typhoid fever, and typhus, 
also occutred during this period, though their number was small until after 
winter set in. From 1822 to 1829, the typhoid and typhus varieties were 
the predominant fevers, but there were also many cases of the synocha type 
to be met with, both during the warm and cold seasons of this period; and 
these fevers were almost exclusively confined to certain districts and neigh- 
bourhoods, favourable to the generation of a peculiar miasm, such as is 
believed to be formed during the slow decomposition of ligneous substances. 

Typhus did not generally make its appearance until many cases of the 
typhoid affection had previously occurred in a family; but when it did take 
place it was invariably distinguished by early cerebral disturbance, especially 
depression of the nervous energies. 

The face of the country and climate of the region in which this fever pre- 
vailed, presented nothing calculated to lead to the belief that it was necessarily 
obnoxious to the disease. The lands are more or less broken and undu- 
lating; they abound in numerous small water-courses, and creek-flats which 
readily overflow; and many of the small streams dry up during protracted 
droughts. 

The climate is not more variable than is usual in middle Virginia. With 
the exception of two of the years embraced in this history, there was nothing 
very remarkable or peculiar in the seasons favouring the production of con- 
tinued fever. 1816 was distinguished by an unusually dry and cool summer. 
From May until October there was not rain enough to wet the earth an inch, 
consequently nearly all of the water-courses large and small dried up. There 
were many instances of wells and springs failing entirely during this year, 
which had never been known to be materially affected by droughts before. 
And the summer of this extraordinary season was so cool as to be attended 
with frost every month. 

This was a year of fever, and the disease assumed the synocha form, dis- 
tinguished by well developed and highly inflammatory characters; and it 
prevailed most extensively, especially during the warm months. Towards 
the close of September the cases of typhoid fever, which until then had not 
been numerous, multiplied rapidly, and soon became decidedly the predomi- 
nant form, and maintained the ascendency during the succeeding winter. In 
1827 another exceedingly dry summer occurred: this year was also distin- 
guished by the almost universal prevalence of the synocha form of continued 
fever, though, there were occasional cases of the typhoid and typhus varie- 
ties, likewise to be met with. The summer of this year was very nearly as 
dry as that of 1816, but it was exceedingly warm. As autumn approached 
typhoid cases increased in number, and soon became the predominant fevers. 
But after winter set in, which was damp and remarkably mild, genuine 
typhus rapidly increased, and continued to do so the remainder of the season, 
and throughout the next year. 

The years not particularized in the foregoing sketch, were not dislin- 



1843.] Mettauer's Observations on Continued Fever. 35 

guished by any thing remarkable in a meteorological view, but they were 
years of fever; and the disease appeared chiefly under the typhoid and typhus 
forms, nearly in an equal proportion, though cases of synocha were often 
met with likewise. 1816 and 1827 were decidedly the sickly years of the 
period embraced in this paper; and, as already remarked, the synocha was 
the predominant form under which the disease appeared. In many instances 
the fevers of these years could be satisfactorily traced to malarial sources, 
especially at the commencement of the sickly season. But a vast number 
afterwards were as clearly referable to idiomiasma, or something like conta- 
gion, particularly as cases of fever multiplied in families, and as cold weather 
approached, or as the rigors of winter increased. Numerous cases occurred 
after the cold weather of the winter season set in, with individuals residing 
in uninfected neighbourhoods, who had assisted in nursing sick relatives; 
and such persons often communicated the disease to their families and neigh- 
bours who had assisted in nursing them. The propagation of every form 
of this fever by something like contagion was established by indubitable evi- 
dence in many instances; but it was not very communicable until it had con- 
tinued in a family some time, more especially, the synocha and typhoid 
varieties. The difference in the communicability of these forms and typhus 
was, that many cases of the former, or one of long continuance became 
necessary to their propagation by the contagious agency; while a solitary 
example of the latter in many instances was sufficient to communicate it. In 
a few instances we were induced to believe that fomites propagated these 
fevers, as washerwomen residing in neighbourhoods remote from the seats 
of the disease, who had received and washed the clothes of the sick, and 
who were exposed in no other manner, had regular attacks of them. 

Night exposure in sick rooms was the most favourable for the propagation 
of continued fever from the sick to the well. Comparatively few persons 
contracted either form, who only rentained a short time during the day in 
sick rooms. 

High and elevated situations in the vicinity of low grounds and water- 
courses, were the earliest seats of these fevers, unless when they occurred in 
or near log cabins in a state of decay; while table and flat lands immediately 
bordering on water-courses enjoyed nearly entire exemption from them, until 
the disease was conveyed to such situations by infected persons who had 
contracted it elsewhere. 

Most of the cases seen and treated by us could be very satisfactorily 
traced to miasmatic causes; and during the period embraced in this brief 
history, the disease prevailed as an epidemic more or less extensive in its 
range. 

The miasmatic sources from which these fevers originated were somewhat 
diversified. During the dry summers of 1816 and 1827, there was very 
little reason to doubt that the action of the sun's rays upon the beds of the 
water-courses, or their muddy margins, which had been exposed by the dry- 



36 Mettauer's Observations on Continued Fever. [July 

ing up of the waters, originated most of the fevers of those years. There 
were other sources of miasmata during those years, which doubtless con- 
tributed in some degree, likewise, to the production of fevers, especially such 
as were created by cutting down and clearing up wet flat lands; as well as 
by draining marsh-like bottoms. The excessive and alarmingly dr^summer 
of 1816, induced the farmers of this section of Virginia, to rely almost exclu- 
sively on their flat lands, especially for the culture of Indian-corn (maize), 
and tobacco (nicotiana), after that memorable year. After this year a 
general effort was made by our agriculturists to bring their low lands under 
tillage, which they accomplished by cutting down their timber, and by every 
species of ditching and draining. This system very soon exposed numerous 
moist surfaces to the action of the atmosphere and the solar heat, which had 
been for a long series of years accumulating vegetable deposits, but too moist 
to allow those chemical changes to take place in them necessary for the for- 
mation of miasmata until now. Many small water-courses, too, were 
straightened by ditching them, which left numerous stagnant ponds of water 
along the old beds of the streams, as well as exposed the muddy bottoms to 
the action of the sun. Many of the ditches formed during this period, ex- 
posed woody substances to the action of the sun and air, that must have been 
buried under ground for a vast number of years. During this period, too, 
extensive tracts of land were cut down, and the timber suffered to remain on 
them, until the leaves and small branches were nearly or completely rotten. 
The summers during this period, doubtless, contributed by their warmth, 
and the dry weather so apt to occur at such seasons, to augment the tenden- 
cies and activity of these several miasmatic causes, in rendering fevers more 
prevalent. From 1816 to 1829 inclusive, there was abundant reason for 
believing that the agricultural changes which have been hinted at, tended 
greatly if not chiefly to the production of fever, with the exception of 1816 
and 1827. 1829, the last year embraced in our history, presented fewer cases 
than either of the preceding: indeed the epidemic of this year terminated in 
August, and abruptly; and very probably a period was put to it by the fre- 
quent and excessive rains from this time till frost. Since 1829 there has 
been no year of the general prevalence of fever in this region, and we think, 
chiefly, because nearly all the principal and most prolific sources of mias- 
mata have been broken up, by the modes of cultivating flat lands generally 
adopted subsequent to that time. It is true, cases of fever have occurred 
since 1829 and down to the present period; but they were confined to par- 
ticular families, or filthy small villages, and proceeded from malarial causes 
entirely local and limited in their operation. In some instances the disease 
was evidently communicated from such situations by contagion to other 
neighbourhoods from which, in turn, it was again propagated to others. 
After many years careful investigation of the origin of our continued fevers, 
we are fully convinced that they were, in a large majority of cases, produced 
by miasmata, especially in the commencement, when they appeared as an 



1843.] Mettauer's Observations on Continued Fever. 37 

epidemic. But we are equally well satisfied that they were in many in- 
stances induced by idio-malaria or contagion— and it is in this manner that 
these fevers extend through families during the cold seasons. 

No age was exempted from continued fever; infants at the breast, and 
individuals upwards of sixty years old, with every intermediate age, being 
affected. Being between the ages of eighteen and thirty years was that 
most obnoxious to this fever. The black population were most subject to 
typhus, and the depressing forms of the typhoid variety. 

The disease was frequently superinduced by catarrhal affections, espe- 
cially during variable seasons. Measles; hooping-cough; chicken-pox; 
worms; conception; parturition; excesses in eating and drinking; surgical 
accidents and operations; terror; passion; grief; despondency; intense study; 
long fasting; colic; fatigue; and some others, at different times, also, seemed 
to excite the disease, but as accidental or occasional causes. 

The anatomical characters which were displayed during our post-mortem 
examinations* were lesions of the glands of Peyer; of the mesentery; spleen; 
mucous membrane of the small and large intestines; of the peritoneal coat of 
the small intestines and stomach; of the meninges of the brain, and especially 
of the arachnoid; effusion of serum, or blood and serum into the ventricles of 
the brain; congestion or softening of the lungs, and gangrene of the bladder. 
A dissolved state of the blood was also occasionally met with as a post obit 
appearance, especially in fatal cases of typhus: in such cases the lungs were 
more or less disorganized; and in every instance the membranes of the brain 
were greatly congested. 

We were early enabled to distinguish three stages in the progress of this 
fever, when opportunities were afforded us of observing it from its com- 
mencement; that is, 1st. The forming stage, before the febrile category was 
established. This stage was distinguished by languor; lassitude; a general 
feeling of weakness; irregular, unsteady and variable pulse; sensations of 
coolness, chilliness, or of transitory increase of warmth termed "flashings 
of heat" in popular language; loss of appetite, or morbid increase of it; 
vertigo; often uneasiness of the head and eyes, or even pain; sluggishness of 
the mind as well as body; often drowsiness, somnolency, or absolute sleep- 
lessness; reluctance for every kind of exertion; occasionally extreme depres- 
sion, or vivacity; distuibance of most of the secretory exercises, and some 
others. 

2d. The active or febrile stage. This stage was characterized by a regular 
series of morbid associations, progressively and gradually formed generally, 
though occasionally occurring abruptly as in synocha. It was attended 
with, or ushered in by a chill or chilliness at a particular period of the day, 
succeeded by a hot stage more or less perfectly formed, and steady in its 

* We treated more than four hundred cases from 1816 to 1829, and lost only twenty 
patients. Many of the cases were of the most unpromising description, perhaps a fifth. 



38 Mettauer's Observations on Continued Fever. [July 

duration for a limited time. The hot stage, which varied in different cases 
in the degrees of its intensity, was uniformly distinguished by an accelerated, 
and a more or less full and strong pulse; a hot and dry skin; the tongue 
coated, and white or yellow, and dry or moist: there was also more or 
less thirst, headache, pain of the neck, back, and extremities, the face was 
flushed; the temples throbbed; and the bowels were constipated, or preter- 
naturally loose: there was loss of appetite; diminution of the urinary secre- 
tion, and now and then increased desire to evacuate it: the senses of sight 
and hearing were occasionally exceedingly sensitive: not unfrequently there 
was delirium, restlessness, or quietude bordering on a state of the most per- 
fect resignation: occasionally almost universal soreness was experienced 
throughout the skin, though this sensation was more generally an attendant 
upon the preceding stage: nausea or vomiting; a peculiar cough; accelerated 
breathing, and some others, also generally occurred during* this stage as 
attendant phenomena. 

3rd. The subacute stage. This stage was distinguished by most of the 
phenomena of the acute stage, but their general character was more or less 
subacute, with a decided tendency to depression of the energies, and vital 
operations of the economy: it presented a very great variety of phenomena 
connected with structural or organic change, as we supposed in greater or 
less degrees. 

The forming stage continued from a few hours to several, nay, in some 
instances many days, and the phenomena by which it was distinguished, 
evidently indicated a versatile and unfixed irritation with which it was at- 
tended, implicating chiefly the functional operations. There was nothing 
like a febrile state manifested during this stage; nor could we distinguish 
any thing of a "paroxysmal aggravation of the attendant phenomena at par- 
ticular periods of the day, until it verged closely on the febrile stage. 

The febrile stage was generally ushered in with a chill, or chilliness, or 
coldness, which. was soon succeeded by the hot or reacting state, and the 
usual phenomena so constantly attendant upon this stage, constituting the 
febrile reaction. In many cases the febrile commotion of this stage acquired 
great intensity, and was attended with a highly excited state of the cir- 
culation; the pulse frequently ranging from 140 to 150, or even to 160 
beats in a minute, and full, strong, and in many instances bounding. This 
state was invariably followed by an abatement of the more acute symptoms 
after a few hours; and something like a remission came on which occa- 
sionally was attended with sweating, and these phenomena, after the first 
paroxysm, occurred twice in the 24 hours, and continued to recur daily, 
until the febrile course was arrested by crisis. This stage seemed to be con- 
nected with a fixed or pathological irritation from its commencement, though 
in the early period of it, the irritation was somewhat unsteady, seeming to 
partake of fluxionary or congestive characters: but irritation soon became 
steady, and displayed the disease in its most perfectly formed condition. 



1843.] Mettauer's Observations on Continued Fever, 39 

After some days continuance, especially if it lasted more than a week, it 
gradually parted with its more open characters, and imperceptibly glided 
into, of was merged with the subacute stage, which, as already-stated, was 
to be distinguished by the signs of exhaustion and depression of the consti- 
tutional energies in greater or less degrees. 

In the acute as well as the subacute stage, the exacerbations commenced 
from 7 to 9 in the morning, were at their acme from 11 A. M. to 2 P. M.; 
and were in remission from 4 to 7 P. M.: this we termed the diurnal 
paroxysm. The nocturnal exacerbation commenced at or a little after 7 
P, M., was at-its acme from 12 to 3 P. M., and was in remission from 6 to 
7 or 8 A. M. The nocturnal paroxysm was generally the most violent 
throughout the disease, though frequently much the shortest; and if dilirium 
occurred at all it usually made its first appearance during this paroxysm: 
this symptom, too, was always more violent at this period when both 
paroxysms were attended with it. We regarded continued fever a neuro- 
inflammatory affection, differing from ordinary inflammatory fevers, by 
reason of its quotidian reduplications, the less intense, and depressing nature 
of the febrile phlogosis, and the fluxionary and paroxysmal character of it, as 
well as all other miasmatic diseases. Although inflammation often occurred 
in this fever, we have never regarded it to be a necessary constituent of the 
disease, but rather an accidental associate; hence it always comes on more 
or less remotely from the commencement of the attack. In the early stages 
of this fever, as it has appeared here, and been particularly observed by us, 
its pathology evidently indicated chiefly neuro-functional disturbances; and 
these characters of the irritation were rarely ever lost entirely even after 
phlogosis had set in. Always the product of malaria, and acting, in all 
probability, primarily upon the nerves connected with the secretory opera- 
tions of the natural surfaces — more especially the mucous; and consisting of 
an unsteady and revulsive irritation, located chiefly in vital structures insus- 
ceptible of the highest degrees of inflammation, unless induced by irritants of 
a very different character, and in organs highly important to the well-being 
of the economy, it was to have been inferred that the febrile phlogosis would 
not acquire a very exalted intensity. In this view of the inflammatory cha- 
racter of the phlogosis of continued fever we are not singular, as several very 
distinguished pathologists have entertained and expressed opinions not very 
unlike it. Without pretending to explain the rationale of it, we will only 
now state the fact, that the fevers treated by us never exhibited the true 
sthenic, or hypersemal inflammation, not even in the most acute cases. 

Of the treatment: and first of the Forming Stage.— Before entering 
upon the treatment, we will briefly recapitulate the symptoms of this stage: 
they are languor, lassitude; a general feeling of weakness; irregular, un- 
steady and variable pulse, occasionally accelerated, or preternaturally slow; 
sensations of coolness or coldness, often succeeded by flashes of heat, and 
felt more particularly along the spine and scapula?; loss of appetite, or 



40 Mettauer's Observations on Continued Fever. U^y 

morbid increase of it; vertigo; often uneasiness of the head and eyes, or 
pain; sluggishness of the body as well as of the mind; often difficulty in 
computings or in measuring time; drowsiness, somnolency, or absolute 
sleeplessness; reluctance for every kind of motion or exertion; occasionally 
extreme depression, or hilarity; costiveness; disturbance of most of the se- 
cretory exercises, and some others. In numerous instances we succeeded in 
arresting the course of the disease at this early period by the decisive em- 
ployment and energetic use of emetics. We commenced with them as 
early as possible, and repeated them once in twelve hours until there was a 
complete subsidence, or an abatement of the symptoms; or until they were 
contraindicated by the signs indicative of the near approach of the febrile 
stage. When practicable we invariably commenced with them early in the 
morning, or late of an evening. In some instances the emetic was repeated 
morning and evening four or five times, and with the effect of breaking up 
the disease entirely. Sweating generally followed emesis when it arrested 
the disease; and our constant aim was to co-operate with that tendency by 
the employment of suitable auxiliary measures. Full and free vomiting was 
required to produce the relaxation necessary for diaphoresis, and to enable us 
to effect it large dilution of the stomach with bland tepid fluids was inva- 
riably directed. A coated tongue and complete anorexia indicated in many 
instances the necessity for the use of emetics. Occasionally the tongue 
was clean, while there was loss of appetite at the same time, with more or 
less impairment of the secretions generally. In such cases we did not 
hesitate to employ emetics, but were careful not to useantimonials, lest they 
might superinduce too much irritation in the gastro-intestinal mucous mem- 
brane, and thus hasten a condition to which this important structure is so 
prone in this fever. Ipecacuanha was uniformly employed in such examples 
of the disease; while we used either that article or the tartar emetic in the 
cases attended with a coated tongue. During the operation of the emetic, 
and for some hours after, measures which promote sweating were carefully 
used. When the skin was cool, and its capillaries torpid and bloodless, we 
invariably employed some form of rubefaction during the action of the 
emetic or very soon after, with the design of co-operating with the revulsive 
effects of the emetic. Artificial heat, friction, sinapisms and such like means 
were generally directed to be used to the surface for that purpose. After the 
vomitive commotion was over we always allowed patients to indulge in 
repose, to which there is generally so strong an inclination after the free 
operation of an emetic. 

When the bowels were constipated, or when the coating of the tongue was 
heavy, we generally united a few grains of calomel with the emetic, or, it 
was administered after the vomitive commotion had subsided. If the emetic 
was given in the morning without the mercurial, and that agent seemed 
necessary, we directed it to be taken at bedtime, in combination with one 
grain of ipecacuanha, made into a pill. Frequently, however, mercurials 



1843.] Mettauer's Observations on Continued Fever. 41 

were not employed with, or after the emetic; and in such cases, we «either 
used a pill containing one grain of ipecacuanha, three of aloes, and six of 
rhubarb; or, a mild purgative enema was administered. 

In very many of the cases of fever treated by us, an early disposition to 
gastro-enteritis was manifested; and in all such cases, calomel could not be 
so safely employed. This fact was derived from the treatment of several 
very intractable cases which early came under our care, rendered so by the 
officious and too free use of calomel. In two of the cases, the mucous lining 
of the stomach and intestines was completely denuded of its epithelium, and 
the surface thus exposed, as well as the gums and nose bled till death closed 
the scene. 

Diaphoretics of mild qualities were often employed in this stage likewise, 
and with distinguished benefit. In many instances we found the spirit, 
minder, and dulcified spirit of nitre united, and taken at bedtime, to be re- 
peated once an hour, for two or three times during the night, a most valuable 
diaphoretic. Wine whey, and a few drops of aq. ammon. we also fre- 
quently used with advantage. The Dover's powder was likewise occasion- 
ally employed beneficially, and when patients could not sleep, it was espe- 
cially useful. The teas of hops, sage, and even of corncobs were found 
eminently serviceable as diaphoretics in mild cases. Taken after bathing 
the feet in warm water, at bedtime, they rarely ever failed to induce sweating. 

Bleeding in a few cases was required in this stage, both as a preparatory 
measure to the administration of emetics, and to give efficiency to the diapho- 
retic measures. When plethora obtained, or strongly marked cephalic apti- 
tudes existed, and the patient was young and athletic, we invariably bled 
before giving an emetic. Rest, quietude, demulcent mild drinks; and a 
simple non-stimulating diet, consisting chiefly of liquids, were generally 
directed by us throughout this stage. We uniformly required patients to 
remain in bed as long as the disposition to sweat continued, which occasion- 
ally was the case for several days after every symptom of the disease had 
disappeared. 

The convalescence required from one to two weeks, and during this 
period, we deemed it all important to keep the bowels soluble by the use of 
proper remedies. 

The plan which has been premised, did not always arrest the course of the 
disease in this stage, though in many instances, it seemed at once to put a 
stop to it, and to produce speedy and complete recoveries. When emetics 
failed to arrest the disease in its forming stage, they rarely ever seemed to 
aggravate the fever in its succeeding stages, but on the contrary, if judi- 
ciously employed impressed upon it milder characters, and rendered the after 
treatment more easy, and the result correspondingly fortunate. 

The Acute or Febrile Stage. As in the forming stage, we will briefly 
recapitulate the symptoms of the acute, before considering its treatment: — 
they are an initiatory chill, or chilliness at a particular period of the day, sue- 



42 Mettauer's Observations on Continued Fever, [July 

ceedetf by a hot stage, more or less perfectly formed, and steady in its dura- 
tion for a limited time. The hot stage, which, as already stated, varied in 
different cases in the degrees of its intensity, was uniformly distinguished by 
an accelerated, and more or less full and strong pulse; a hot and dry skin; 
headache, frequently pain of the nape of the neck, back and limbs; thirst; 
tongue coated, yellow or white, and dry or moist; flushed face; temples 
throbbing: occasionally, sick stomach, and vomiting; constipation, or loose- 
ness of the bowels; loss of appetite; not unfrequently delirium; the senses 
of sight and hearing occasionally exceedingly sensitive; diminution of the 
urinary secretion, and now and then increased desire to void it; restlessness; 
a peculiar cough; accelerated breathing; sighing: drowsiness, or watchful- 
ness, and some others; and these constituted the symptomatology of the 
early or more acute period of the febrile stage. 

In treating this stage, every paroxysm afforded us an opportunity of com- 
bating the initiatory cold or cool state; and the ordinary means of restoring 
and equalizing the temperature, such as the application of artificial heat to 
the surface of the body, sinapisms to the extremities, friction, and mild in- 
ternal stimuli were the measures generally resorted to. The cool state, 
however, was not always well marked, and generally it soon terminated in 
the reacting or febrile state of the paroxysm. The acute stage in its early 
beginning required in a large majority of cases blood-letting, more or less 
freely used. In the synocha variety of the disease especially, it was impos- 
sible to control and reduce the pulse by any other means. Even in the 
typhoid form we found in nearly every case that bleeding was required to 
reduce the febrile excitement. With young and vigorous subjects, we always 
used this remedy decisively, more especially in synocha, as it was of the 
first importance to subdue the pulse at once. In some cases we bled two and 
three times during the earliest paroxysms, and largely at each time, before 
the pulse yielded. The blood was generally drawn from a free orifice, and 
when practicable the operation was always performed while the patient was 
sitting erect in a chair, or in bed, which enabled us to produce in many in- 
stances a very decided impression upon the pulse, with the loss of compa- 
ratively a small quantity of blood. When cephalic congestion was feared, 
we felt emboldened in the use of the lancet, and occasionally opened one or 
both of the external jugulars, or the temporal artery after free bleeding from 
the arm. With constitutions naturally feeble, or with persons advanced in 
years, one decisive bleeding well timed during the rapid increase of the 
paroxysm, often controlled the pulse. We never ventured to bleed such 
persons repeatedly, and freely at each time, even if the lancet was indicated, 
as collapse of dangerous character had resulted in several similar cases, from 
the officious and indiscreet bleedings of nurses. In all such cases the lancet 
was used with caution, taking care to moderate the pulse rather than reduce 
its force decidedly by the bleeding. We were much surprised to find with 
such constitutions, occasionally, that though the febrile action was of very 



1843.] Mettauer's Observations on Continued Fever. 43 

intense character, one free bleeding would produce decided swooning; but 
after a few moments the reaction would become as active and violent as before 
the bleeding. Our later observations have led us to regard the febrile com- 
motion in such cases, as the result of congestive irritation, or congestions 
with very little inflammation; and we suppose the sudden detraction of blood 
disperses the congestions so abruptly as to suspend for a few moments, or 
during the continuance of the swoon, the febrile irritation of the congested 
organs, without correcting or removing the febrile susceptibility. During 
the epidemic synocha of 1827, a large proportion of the cases demanded very 
free and repeated bleedings; but the remedy was frequently improperly used, 
producing in some instances sudden transformations of the fever into adyna- 
mic, and occasionally into the ataxic types. Of the latter description we 
met with a most perplexing variety, distinguished by an exceedingly active 
and rapid pulse, and possessing at the same time an expansiveness and volume 
assimilating it to a synocha pulse, or perhaps more properly to the hemor- 
rhagic pulse. This state was evidently produced by the improper use of 
bleeding, especially in the abstraction of blood beyond what was required to 
subdue the febrile phlogosis. In every case the further use of the lancet 
seemed indicated by the tumult and activity of the circulation, but bleeding 
only served to continue the morbid state. We witnessed many cases of the 
kind in consultation, but no case occurred in our own practice. Marshall 
Hall has well described this affection. We treated such cases with a com- 
bination of ipecacuanha, acet. plumb., aloes and gum camphor. A pill con- 
taining one grain of ipecacuanha, one of acet. plumb., half a grain of gum. 
camph. and half a grain of aloes, administered once in three or four hours, 
generally quieted the circulation, and often produced crisis by diaphoresis. 

Our object in bleeding in this stage was not so much to cut short, or to 
cure the fever, as to guard the organs implicated, or about to become so, 
against inflammation and its consequences; and to place the system as speedily 
as possible in a condition favourable for resuming the secretory exercises, 
influenced by proper internal remedial measures; and it was never found safe 
to dispense with it, or to regard the febrile action as decidedly impressed 
and corrected by it, until the pulse was bled down and softened. Our rule 
was the pulse, and we have never regretted that it was early adopted as our 
"regula regularis" in treating this fever. 

Refrigerants were generally employed in connection, or in alternation with 
the lancet, especially when the exacerbation was attended with a hot skin 
and tormenting thirst. We used cold drinks and pounded ice as internal 
refrigerants; and sponging the surface of the body more or less extensively 
with cold or iced water, or vinegar and water; and these measures were con- 
tinued throughout the exacerbation, or until the morbid heat abated, taking 
care not to urge their depressing influence so far as to endanger the system 
from collapse. In some instances the pounded ice relieved the internal heat 
and sick stomach almost as soon as swallowed; and it never failed to afford 



44 Mettauer's Observations on Continued Fever. [Juty 

great comfort to patients suffering from a burning fever and tormenting thirst. 
Occasionally, too, we have seen complete crisis by perspiration follow its 
use on the fifth and seventh days of the disease. 

Purgatives were indispensable remedies in this stage, likewise, and we in- 
variably employed them as soon as one or two decisive bleedings had been 
premised. If torpor of the bowels had existed for some days, we generally 
directed a purgative enema, especially if the case was seen after morning. 
When, however, they had only reposed for a short time, and no localizing 
tendency of the disease manifested itself, we preferred to employ internal 
cathartics. Even after free alvine evacuations from the use of enemata during 
the day, we generally employed internal purgatives; and our mode of using 
them was to give from two to seven grains of calomel, with one of ipecacu- 
anha at ordinary bedtime, to be succeeded the following morning by some 
brisk cathartic. In a large majority of cases we decidedly preferred the oil 
as a carthartic, and generally found it to succeed very well. Occasionally, 
however, it proved highly irritating and offensive to the stomach and bowels, 
by reason of an acrimony acquired by it in those organs. Sometimes it 
became so very acrid after remaining in the stomach only a short time, as to 
provoke vomiting, attended with intense gastric heat, and scalding of the 
fauces, which uniformly aggravated the febrile symptoms. The bowels, 
too, suffered from tormina, and in several instances a state came on resem- 
bling cholera morbus. These unpleasant effects from the oil occurred exclu- 
sively in the cases distinguished by great heat. In such examples, after many 
trials, we finally employed calomel followed by some of the compound saline 
purgatives, especially sulph. magnes. in combination with magnes. ust., or 
rhubarb. When a diarrhceal condition of the bowels existed — a state by no 
means unusual — we employed the rhubarb alone in doses varying from 12 
to 80 grains, more particularly if the oil was offensive, or objected to. In 
every case, with the design of quickening the action of purgatives, we advised 
patients to lie partly on the right side for one or two hours after the adminis- 
tration of the remedy, so as to favour its passage into the duodenum. This 
simple expedient has greatly assisted us in inducing prompt purgation, espe- 
cially when the stomach was irritable, and the reason will at once appear 
obvious to even the most careless professional observer. 

Purging in this stage, was chiefly designed to unload the bowels of in- 
gesta, and thus to remove irritation from their presence in the alimentary 
tube. It also had the effect in some degree, to emulge the secerning organs 
opening into, and existing along the intestinal cavity, especially the liver, 
and the muciparous glands. Not expecting to accomplish any positive 
curative ends by purging in this stage, we only resorted to it when the 
bowels became constipated, and when that state seemed likely to irritate the 
fever. In many cases we relied on purgative enemata of mild qualities, 
administered during the paroxysm, merely to produce a very partial effect 
upon the bowels, and with evident febrifuge results. This mode of eliciting 



1843.] Mettauer's Observations on Continued Fever. 45 

the action of the bowels in continued fever, cannot be too strongly insisted 
upon; after one decided purging in some cases, we have been enabled to 
make it supersede the use of internal purgatives, which sometimes are 
hazardous, by their tendency to produce or to hasten gastro-enteritis, and 
are always more or less offensive to patients. Even when there are decided 
cephalic tendencies, enemata may be safely and beneficially trusted as 
cathartic means in this stage: and as long as they elicited free dejections, we 
regarded them as effective in arousing the peristaltic movements of the 
bowels, and in emulging the liver and muciparous secernents. In some 
instances they seemed to act more decidedly as means of revulsion in the 
cephalic affections of this stage than internal cathartics. 

When purging was to be effected by internal remedies in a decided man- 
ner, we uniformly administered the cathartic early of a morning. At this 
time the bowels respond more readily and perfectly to the action of ca- 
thartics; and patients are more apt to sleep the night after, as sufficient 
time is allowed for the commotion from the operation of the medicine to 
subside before the hour for sleep arrives. It may not be out of place to state 
here, that we often succeeded in inducing sleep in this stage, by having a 
mild enema administered towards early bedtime. 

Anti-emetics were occasionally required to compose the stomach, and to 
relieve nausea, or vomiting, which not unfrequently occurred in this stage. 
Generally we found the pounded ice to succeed in relieving the sick stomach, 
especially when it was attended with internal sensations of heat. In some 
cases, however, it failed, and with such we employed at different times 
effervescing draughts, especially the soda water, dulcified spirit of nitre, 
diluted acids, fresh fruits, and absorbents. As an absorbent in such cases, 
we often used a teaspoonful of levigated carbon recently prepared, mixed in 
a wineglass of fresh water, taken once an hour, and with the happiest effects. 

The drinks employed by us, were generally cold and freely allowed, if 
desired by the sick, especially during the exacerbations of fever; and nothing 
generally, seemed to answer better than simple cold water, or cold slippery 
elm tea. Lemonade, peach, apple, and tamarind water, currant jelly dif- 
fused in water, and such like articles, were at different times employed as 
drinks by us in this stage. 

The diet was required uniformly, to consist of light, liquid preparations. 
Farinaceous substances were generally preferred. Rice-gruel, panada water, 
buttermilk, coagulated milk, occasionally new milk and water, baked apples, 
and such other articles as possessed mild unirritating qualities, with very few 
exceptions, constituted the diet of this stage. Even, these light articles were 
only allowed in small quantities, and after long intervals. We generally 
inhibited the use of food during the exacerbations of this stage. A cool, well 
ventilated, clean, and quiet apartment was invariably, if practicable, provided 
for the sick, and with as few nurses as could perform the necessary duties. 

The plan which has been briefly presented, furnishes a fair outline of our 
No. XL— July, 1843. 4 



46 Mettauer's Observations on Continued Fever, \Ju\y 

mode of treating the acute stage of the synocha, and typhoid varieties of con- 
tinued fever; and it may be regarded, too, somewhat as the plan adopted by 
us in treating the febrile stage of typhus, when distinguished by very acute 
symptoms, as was often the case. Many variations, however, were re- 
quired, especially in the employment of the lancet, and purgatives. With 
some patients a single moderate bleeding was sufficient to reduce and control 
the pulse permanently. With many others it became necessary to bleed freely 
in every paroxysm until, and in some instances, beyond the ninth and tenth 
days; while with others again, after the first or second exacerbation, the 
lancet was only required occasionally during the nocturnal paroxysms. 

Purgatives, too, required to be varied much. In some cases they were 
needed daily during this stage, as well as throughout the entire course of 
the disease. Others only demanded them once or twice in the commence- 
ment of the disease. While others again, only required them on the critical 
days. 

Regarding continued fever as periodic, after the establishment of the morbid 
category, and believing that it would pursue its course to a regular termi- 
nation by crisis, under any plan of treatment, our chief aim in treating it in 
this stage was, to conduct it safely for the economy, and favourably for a 
salutary crisis, to the subacute stage in which that important change always 
takes place, the treatment of which shall next claim our attention. 

The Subacute Stage. In this stage, the common symptoms differed from 
those of the acute chiefly in their intensity, which in some instances was 
very striking. New symptoms, too, generally occurred, to distinguish it 
from the preceding stage, and they were always regarded as peculiar to it, 
among which may be enumerated a peculiar rose-coloured eruption, confined 
chiefly to the abdomen and chest, composed of a kw red, papular elevations, 
or pimples, which disappear upon pressure, but immediady reappeared after 
the pressure was removed, and it recurred after the sixth day of the disease. 
Sudamina, also, frequently made their appearance in this stage, but at a 
more remote period: they recurred after the twelfth day on the trunk, neck, 
axillae, clavicles, epigastrium, limbs, and groins; and consisted of numerous 
minute vesicles filled with a colourless fluid. Epislaxis; hemorrhage from 
the bowels, bladder, gums, and uterus; and a peculiar suffused appearance of 
the eyes; tinnitus, or buzzing of the ears; great impairment of the memory, and 
of the faculty of attention; somnolency after being roused; slow and hesitating 
utterance; extreme unwillingness, and inability to exert the body or mind; 
deafness, and delirium, were pretty uniform attendants upon this stage also. 

As the disease advanced the tongue became decidedly drier and darker, 
and not unfrequently it was swollen, glossy, parched, cracked and bleeding; 
raw and bleeding — or, incrusted deeply with a flaky sordes — rouglf and dry, 
its motions tremulous — was protruded with difficulty, and withdrawn slowly. 
The teeth and lips were generally invested with sordes; the abdomen was 
more or less tumid and tympanitic; often the spleen was perceptibly enlarged; 



1843.] Mettauer's Observations on Continued Fever, 47 

there was cough, with sonorous rale; the countenance was more suffused, 
red, or purplish, sometimes swollen; the expression was sunken and vacant, 
or wild; the pulse greatly accelerated and more or less tense; skin pungently 
hot during the exacerbations of fever; respiration hurried, or preternaturally 
slow; there was subsultus tendinum, and spasms of the lips — of the muscles 
of the jaws — of the eyelids; rigidity of the muscles of the neck, limbs, and 
abdomen; the attitude was supine; there was a tendency to slide downwards 
in bed; there was sloughing of the skin and soft parts about the sacrum, 
trochanters, and of blisters; and in a few cases there was inflammation and 
suppuration of the parotids, and axillary and inguinal glands; and one in- 
stance of necrosis of the superior maxillary bone. Hiccough; involuntary 
discharges of fasces and urine; fetid breath; discharges of pus, or pus-like 
matter from the bowels and bladder; suppression of urine; paralysis of the 
bladder and retention of urine; paralysis of the limbs; and an exceedingly 
rapid, small and feeble pulse, were very often met with, also, in the more 
advanced stages of the disease. So much for the symptomatology. 

The treatment of this stage in many cases did not differ very widely from 
that pursued in some examples of the acute. In numerous instances blood- 
letting was demanded. We often bled in the nocturnal paroxysms, which 
were uniformly the most violent; and in many cases, bleeding was required 
in the diurnal exacerbations likewise. In the synocha form, especially, we 
found bleeding necessary; and in some instances as late as the 18th and 20th, 
and even the 25th days of the fever. Our aim was to maintain as moderate 
and equable state of the febrile reaction during this stage as possible, not 
only as the best means of preventing any serious injury to the organs gene- 
rally involved in the local affection, but as the most favourable condition for 
restoring the secretory exercises, from which the healthful operations were 
to follow. We bled during the exacerbation whenever the pulse was too 
active and strong, even until crisis occurred; but our bleedings were mode- 
rate, as they were only intended to enfeeble the organs of circulation for the 
time being: very often only one or two ounces of blood were required to 
impress the pulse. In many instances topical bleeding by leeching, or wet- 
cupping was found of very great benefit, especially when employed to the 
regions of the local affections. The abdominal walls often demanded leech- 
ing in this stage, to combat the enteritic irritation so constantly present. It 
was rarely practicable to cup the abdomen in such cases, in consequence of 
the. extreme tenderness of the soft walls, especially. The pectoral walls 
were also often depleted by leeching and humid cupping, in thoracic affec- 
tions of this fever, as well as the temples in the cephalic. 

Refrigerants were generally found highly beneficial in this stage. In some 
cases they succeeded much better in moderating, and in controlling the febrile 
reaction than the lancet. We employed pounded ice, or iced, or simple cold 
water as internal means of refrigeration; and had the surface freely sponged 
with cold or iced water, or vinegar and water, especially the temples, neck, 



48 Mettauer's Observations on Continued Fever. [Juty 

forehead, extremities, and abdomen, repeatedly, and after short intervals, as 
the external; and they were continued until the morbid heat of the surface 
and pulse were reduced for the present paroxysm. In many instances we 
directed patients to sponge, and drink freely of iced or simple cold water 
immediately after v. s., and with the effect of producing diaphoresis. In the 
cephalic affections, and especially when delirium was present, the internal 
use of ice or cold water, was always freely allowed. We employed them 
'also to the scalp, either by investing the head with a bladder partially filled 
with pounded ice, or, by pouring the iced water upon it until a decided im- 
pression was made. This plan enabled us in many instances of violent 
delirium to quiet our patients in a few moments. In milder examples we 
only employed cloths to the head saturated with the cold liquid. 

At every period of this stage refrigerants were employed and with great 
benefit, and we always advised them when the skin was hot and dry during 
the exacerbations. Great care, however, was required in their employment, 
in so graduating their effects as not to depress the enfeebled powers of the 
economy too decidedly, or to endanger them from overpowering collapse. 
Moderate reaction was always allowed to follow the use- of refrigerants; and 
to secure this result the spongings were used after longer intervals, and with 
decreasing force, as the paroxysm declined. We were very careful to cau- 
tion nurses not to sponge while the skin was cool, or only moderately warm, 
and when perspiring. Purgatives, too, were demanded in the subacute 
stage, but never to a very bold extent. In a large majority of the cases, we 
employed oil as an internal purgative. We likewise resorted very often to 
the use of mild purgative enemata. In this stage, it was of the first import- 
ance, to unite remedies with cathartics, which tended by their peculiar thera- 
peutic powers to extend the range of purgative influence throughout the 
economy. For this purpose we often associated with, or premised the ex- 
hibition of our cathartics with minute portions of ipecacuanha, or tartar 
emetic. One grain of ipecacuanha united with three or four of calomel made 
into pill with a [exv drops of water, and given at ordinary bedtime, to be 
followed next morning by an active purgative dose of oil, or any other 
cathartic applicable to the case, or even an enema, constituted the course 
generally pursued by us in this stage. There was much advantage in the 
administration of the ipecacuanha and calomel tlve night before the active 
purgative was given. Thus united they often operated as a diaphoretic com- 
pound, and never failed to render the action of the purgative dose which suc- 
ceeded next day much more effective. In many instances we found the 
tongue moist and secreting the day after the exhibition of that compound, 
when it had been previously, and immediately down to the time of giving it, 
dry. It was not always safe, however, to employ calomel in this stage, as 
it occasionally proved exceedingly irritating to the bowels, even when given 
in minute doses. A polished, or raw condition of the tongue, attended with 
irritable and loose bowels, generally contra-indicated the use of calomel. In 



184&.] Mettauer's Observations on Continued Fever. 49 

such examples we employed the blue mercurial powder, when a mercurial 
was deemed necessary, or the blue mass. Occasionally when we were un- 
willing to use any form of mercurial, two or three grains of aloes, or of aloes 
and rhubarb, united with one grain of ipecacuanha, were employed, and 
generally answered a good purpose. Aloes thus combined is not only a safe, 
but efficacious remedy in such modifications of continued fever, and its great 
efficiency and safety in these cases, after numerous and satisfactory trials 
many years since, induced us to make trial of it in dysentery, and the result 
* was most satisfactory. It was never safe to employ saline cathartics in this 
stage. Their tendency to elicit very thin or watery evacuations, and to 
prostrate the energies of the secretory organs, without ameliorating their con- 
dition, as reducing the febrile phlogosis, rendered them objectionable in our 
practice, in this stage of fever, almost from the commencement of our pro- 
fessional career. In a few cases, only, were we willing to employ the cal- 
cined magnesia, and chiefly, because it frequently produced liquid or watery 
stools. Oil, the rhubarb in powder or syrup, calomel, the blue powder or 
mass, aloes, and enemata were the purgatives employed by us almost exclu- 
sively in this stage. 

Diaphoretics were allowable and necessary in this stage very nearly from 
its commencement, and we employed many of the established agents of this 
class as internal remedies. In the commencement of this stage diaphoretic 
measures were only employed as auxiliaries to purging, though, as they oc- 
casionally produced their peculiar sweating effects, we now and then ventured 
upon their use as diaphoretics, especially, when early abatement of the febrile 
symptoms took place. Our chief reliance was on minute doses of ipecacu- 
anha, or tartar emetic when internal medication was designed; and these 
articles were only administered on the nights of crisis. In a very large pro- 
portion of the cases treated by us, the ipecacuanha in the form of a pill was 
the diaphoretic used; and we never administered more than one grain at a 
time, and the doses rarely ever exceeded three, and after intervals of three 
hours; more frequently only two were given during the night. In the early 
periods of this stage, as already intimated, we often united calomel with the 
diaphoretic; and even at a later period we occasionally employed such a com- 
pound. Generally, our design was to make an impression nearly simulta- 
neously on the gastro-enteritic mucous membrane and the liver, as well as 
on the skin; and the compound ipecacuanha pill already described, rarely 
failed when judiciously timed, to accomplish those ends. When tartar emetic 
was used as a diaphoretic in this stage, its watery solution, or the antimonial 
wine were the forms for exhibition invariably preferred by us, and -the doses 
never exceeded the fourth of a grain. From one-seventh to one-fourth of a 
grain constituted the extreme doses with adults. This article was only ap- 
plicable to, and safe in cases of pure synocha, or when the tongue was heavily 
coated: we occasionally employed it, too, in the thoracic and cephalic varie- 
ties, but never when the tongue was polished, or denuded and raw. Like 



50 Mettauer's Observations on Continued Fever, [July 

the ipecacuanha, it was only employed on the nights of crisis, and never more 
than three doses administered during the night. 

In certain cases we derived benefit from the use of the dulcified spirit of 
nitre in doses of from 25 to 30 drops once an hour, administered in some 
mucilaginous or diuretic vehicle. This remedy was particularly serviceable 
when the tongue Was dry and the thirst urgent; it afforded great comfort as 
a refreshing beverage, and was often followed by a marked improvement in 
the condition of the tongue after only a few doses. We often employed the 
nitre as a mouth-wash in such cases, and no remedy as yet tried b} T us has 
so uniformly tended to restore moisture, and to improve the condition of the 
tongue: a teaspoonful of the nitre mixed in an ounce of water is the form in 
which we employ it as a gargle. The aerated waters were likewise often 
used as diaphoretics, and generally with advantage; they were objectionable, 
however, in some cases, especially when a tendency to gastro-enteritic irri- 
tation was present. In several instances in which we used these drinks, 
violent and sudden pain in tire stomach instantly followed their entrance into 
that organ, produced no doubt by the instantaneous expansion of the tender 
and inflamed walls by the carbonic acid gas. These drinks are generally 
very grateful to patients; and they were allowed whenever desired by them, 
if possible, but caution was always used in the first trials of them. 

Alkaline solutions, especially of the carbonates of soda and potass, were 
often decidedly beneficial as diaphoretics. These articles first improve the 
secretions of the gastro-intestinal mucous membrane, and very early after 
diaphoresis takes place; they also exert salutary influences as exciters of 
secretion through the urinary organs; occasionally they irritated the bowels, 
and they were laid aside and very gentle purging resorted to. 

Revellents and rubefacients were often required in this stage, especially in 
its decline, to prevent collapse upon the approach of the remissions. In some 
cases it became necessary to employ them throughout this stage, by reason 
of the inordinate coolness of the extremities, as well as of the general surface 
upon the approach of every returning remission. Such depressions and 
fluctuations of the temperature in this stage of fever, when the organs were 
enfeebled from irritation, and the long disturbance of their functional opera- 
tions are fraught with much danger. In several instances death suddenly 
followed them, when the means of counteracting their evil tendencies were 
neglected, by the sudden occurrence of hemorrhage from the bowels, or, 
an overpowering collapse. 

We employed some form of revulsion or rubefaction upon the approach of 
every remission, if there was a tendency to sudden depression, or variation 
of the temperature of the surface. When the departure was inconsiderable, 
friction, or the application of artificial heat would generally answer in 
arousing, and maintaining the actions. But when the depression was con- 
siderable, and disposed to become more intense, we resorted to revellents of 
more active powers, and generally sinapisms, or vesicatories were preferred. 



1843.] Mettauer's Observations on Continued Fever, 51 

In a majority of instances, sinapisms applied in succession, to the inferior 
and upper extremities in the direction of the trunk, merely to redden the 
skin, were found fully sufficient to restore, and maintain for the time being, 
the actions of the surface. Occasionally, more energetic and permanent 
means of revulsion were required to recall to the surface, and fix in it a 
proper degree of action, as either the common vesicating plaster, or sina- 
pisms suffered to remain on long enough to blister. " These measures, occa 
sionally, when employed on the nights of crisis, co-operated decidedly 
with the natural tendencies to crisis; and very often, too, they enhanced 
the sudorific effects of remedies given to promote sweating. Blisters were 
generally employed to the inferior extremities, and when allowable to defer 
them, they were always ordered so as to be in full operation during the 
morning remission — a remission much disposed to be attended with col- 
lapse. These remedies were likewise often required as revulsives, to coun- 
teract internal inflammation, either of the abdominal, thoracic or encephalic 
contents, and with great benefit. They were generally most beneficial 
when employed to a comparatively cool and bloodless skin, and after the 
pulse had been decidedly enfeebled. They were always employed to an 
extensive surface, when used to counteract internal inflammation. We often 
blistered the abdominal walls, thorax, and head, in this stage with decided 
benefit. 

The treatment which has been premised, was our plan in the early periods 
of this stage; and we now propose to consider it as required in the remote 
periods, or, as it might very properly be termed, the Adynamic state. 

It was in this stage of the febrile course that most of the lesions of struc- 
ture occurred, and it appeared in many instances that the change of character 
or the accession of the symptoms indicative of adynamia resulted from those 
lesions of structure. Notwithstanding such was the predominant character, 
we often employed blood-letting in this stage during the exacerbations of 
fever. Whenever the pulse became decidedly strong, resisting and much 
accelerated, we bled, taking the pulse as our guide as to quantity. Generally 
very moderate bleedings answered, say from two to four ounces. Frequently 
the cautious employment of refrigerants, as already intimated, would reduce 
the force of the pulse, as well as the morbid heat of the skin, and render the 
lancet unnecessary. When we bled to any extent in this state, a commanding 
dose of aqua ammonias properly diluted was always directed at the close of 
the operation. This remedy by its prompt and transitory action prevented 
collapse from the loss of blood, without irritating the febrile operations. 
Great care to guard against inequality of excitement was required in this 
state. It was of the first importance to maintain the temperature of the sur- 
face, and the capillaries of the skin well filled, in guarding against those 
sudden introversions upon the internal organs. Throughout this state we 
found it necessary, in a majority of our cases, to employ counter-irritants at 
the close of every paroxysm to prevent collapse, and to protect the en- 



52 Mettauer's Observations on Continued Fever, [July 

feebled internal organs; and we sometimes used sinapisms, and occasionally 
vesicatories as the one or the other seemed required. Blisters were gene- 
rally demanded in the more intense forms of this state, either to the extremi- 
ties or trunk. The nape of the neck we often blistered, especially when 
delirium attended, and sometimes the head also. The vitiated condition of 
the secretions invariably in this state required unremitting attention to them, 
and to ameliorate them, we occasionally used combinations of calomel or 
blue powder, or blue mass, with minute portions of aloes and ipecacuanha 
administered at night; and if these failed to act upon the bowels by morning 
we either directed a moderate dose of oil or an enema at that time. It was 
very important not to employ the mercurial compound oftener than was 
absolutely required to stimulate the secretions. When internal aperients 
were not proper, and the bowels still tardy, we invariably relied on ene- 
mata; and gruel, mucilaginous fluids, milk and water, and occasionally soup 
rendered active by the addition of common salt, or molasses, or oil, were 
the preparations used as such. Diaphoretics were required throughout thie 
stage every critical night. We frequently at this period united two or three 
grains of carb. potass, or soda to the ipecac, pill; and rarely administered 
more than two doses during the night, and more frequently only one. The 
dulcified spirit of nitre was also often used as a diaphoretic, and with great 
benefit. When patients could not sleep, and especially if the bowels were 
loose or inclined to be so, small doses of Dover's powder, with a few grains 
of blue powder as a diaphoretic anodyne, were beneficial. In certain cases 
when the circulation was not sufficiently steady and energetic to favour 
diaphoresis, the addition of one or two grains of gum camphor to the ipecac, 
pill greatly enhances its sudorific effects; this form was particularly adapted 
to the periods of this state distinguished by increasing depression. 

Another modification of the ipecacuanha pill employed by us, was the 
combination of two or three grains of the inspissated bile* of the swine, with 
one grain of ipecac, and two of the carbonate of potass: this compound was 
most valuable in this stage; and it seemed to act with decided effect, as a sup- 
porting and secerning remedy, upon the mucous membrane of the stomach 
and intestines, and as a diaphoretic at the same time. It was especially 



* This article we have used since 1828, and we think its employment as a therapeutic 
agent is original with us. We were induced to resort to it first in the low depressing 
states of continued fever, with the design of acting especially on the gastro-intestinal 
mucous membrane, which we believed became disorganized in such cases in a great 
measure from the want of the biliary influences; and in these cases it always acted with 
decided benefit: it served to substitute the action of the bile. Simply heating the bile 
over a sand-bath until it becomes dry and pulverizable was our mode of preparing it. It 
is a valuable agent in dyspepsia, and in many chronic affections attended with defective 
biliary secretion. In chlorosis, amenorrhcea, some forms of dysmenorrhoea, and consti- 
pation, we have also often employed it with decided advantage. 



1843.] Mettauer's Observations on Continued Fever. 53 

valuable in those cases attended with a denuded and raw tongue; this organ 
always becoming more healthy after its administration. 

The highly vitiated condition of the gastro-enteritic contents during this 
state, in many instances required remedies especially directed to them. The 
fetor occasionally was intense, and seemed to exert a modifying and de- 
pressing influence with the vital movements. To correct the fetor we 
administered prepared carbon, in teaspoonful doses, mixed in water, once in 
two hours. During the remissions, the pulse frequently required the sup- 
port of stimulants to prevent collapse, or dangerous depression; and the neces- 
sity for such remedies generally increased with the duration of the disease. 
For the purposes of stimulation, mint julap or brandy toddy were generally 
used, and merely to maintain the action of the pulse steadily and equally 
during those periods. 

In most instances rubefacients, or even blisters were demanded in con- 
nection with internal stimulants, to prevent depression during the remissions, 
especially in the advanced stages; and occasionally it was necessary, too, 
to associate ammonia with the spirituous stimulants, to quicken their action, 
when sudden depression threatened. The ammoniated and camphorated 
mixtures and julaps were often employed in this state with or without the 
alcoholic stimulants, but were more especially adapted to and required in the 
advanced periods, when the disease assumed more decided characters of 
depression. At this particular stage, we found the internal use of the spirit 
of turpentine most valuable. Its peculiar tendency to arouse and maintain 
the actions, and to superinduce secretion without the least danger of pro- 
ducing over-action, eminently fitted it as a remedy at this period. The 
turpentine rarely, if ever, induces excessive action, either in the general 
circulation, or in parts to which it is directly applied, by reason we suppose 
of its strong secerning tendencies; and hence, perhaps, results its remarkable 
efficacy in burns, and non-secreting ulcers as a suppurant: we often em- 
ployed it as a diuretic of great certainty, combined with dulcified spirit of 
nitre. To blisters, which were generally so important at this period, when 
disposed to dry up, we often applied the turpentine with the happiest 
effects. This agent never failed to re-excite the blistered surfaces into a 
suppurating condition, and with comparatively little pain. With the same 
intention, and also with a view of communicating a decided shock to the 
general system at the same time, we occasionally applied the aq. ammon. to 
blisters about to dry up, and with distinguished benefit. The ammonia is a 
painful application, though transitory in its action as such, and should never 
be resorted to unless under peculiar circumstances. We are confident that 
several cases were rendered convalescent by its use to blisters, which sud- 
denly dried up, and which without it would have been lost. While on the 
subject of blisters we will remark, as already intimated, that these remedies 
were indispensable in the low states of this period of the disease; and it was 
important to continue their irritation after it was once excited. In several 



54 Mettauer's Observations on Continued Fever. U U ^Y 

instances fatal results followed the sudden drying up of blisters. Occa- 
sionally we employed mild cataplasms, if the blistered surfaces inflamed 
excessively, as was sometimes the case. The oiled silk we now employ in 
all cases after the second or third dressing. When strangury followed 
blistering, the free use of demulcent drinks was always directed, and oc- 
casionally bland enemata, and gentle rubefaction with sinapisms to the soles 
and tops of the feet, legs, and thighs in succession, until relief was procured. 

Tonics were often used in this stage, though not until great depression 
came on; or it was found difficult to sustain the pulse with stimulants only. 
The bark in substance, in the states of infusion, tincture, and extract was 
often employed by us, and with advantage. The quinine, we also occa- 
sionally used, but not very beneficially: it seemed generally to irritate the 
stomach, and in some cases produced most obstinate singultus. Columbo 
we now and then employed, as well as the infusion of quassia, but not with 
much advantage. Huxham's tincture properly diluted, the infusion of ser- 
pentaria, and good porter seemed to succeed best as tonics. Good white 
wine, also, especially Madeira, was often employed as a tonic stimulant, and 
very beneficially. In collapse with hemorrhage from the bowels, we used 
the bark in substance mixed either with Huxham's tincture, or wine; and in 
some cases gave a heaping teaspoonful every half hour until the hemorrhage 
was arrested. In hemorrhage from the nose and gums, we employed the 
bark by enema and in large portions, in combination with capsicum or gin- 
ger, and either ten grains of tartar emetic, or thirty-five of ipecacuanha to 
each injection, to be repeated once in three or four hours, or oftener in urgent 
cases, and generally with great benefit. Blisters to the nape of the neck 
were also resorted to, as well as local astringents. Singultus was occasion- 
ally troublesome; but was generally allayed by the use of acid syrups, car- 
bon, and the solution of the inspissated hog's-gall in doses of four grains, in 
a vehicle of sugared alkaline water; or, by the gall in combination with 
musk and gum camphor in common doses; and these last named remedies 
were repeated once in three hours until relief was obtained. 

Subsultus tendinum frequently occurred at this period, with or without a 
tympanitic state of the abdomen,, and when violent, fomentations to the 
tumid abdomen invariably greatly moderated it. Occasionally, too, the bile 
in combination with gum camphor, ipecac, and aloes, exhibited once in three 
hours, relieved it. 

Sloughing of the soft parts about the sacrum and trochanters was some- 
times troublesome. To prevent this the usual remedies were resorted to. 
When sloughs formed we generally cut them away as early as possible, and 
dressed the wounds with spirit of turpentine until suppuration was estab- 
lished; suppuration of these wounds generally exerted a salutary influence, 
and frequently seemed to induce favourable crisis by perspiration. 

To induce sleep in this stage we often had recourse to anodyne enemata; 
and three ounces of common soup, or starch gruel, with 20, 30, or 50 drops 



1843.] Mettauer's Observations on Continued Fever. 55 

of laudanum, constituted the injections used by us, administered at bedtime, 
to be repeated once in six or eight hours if necessary. 

Throughout this stage tonics and stimulants were most beneficial during 
the remissions, though they often became necessary at other periods like- 
wise; and great care was required not to omit or misapply them. The ob- 
jects in view in resorting to these agents, being to arouse the sinking or 
enfeebled energies, and to maintain them equably, littte difficulty was expe- 
rienced in adopting them, if the pulse was properly regarded. 

In several very unpromising cases in the low states of this fever, we em- 
ployed conjointly with tonics and stimulants, external heat, applied to the 
entire surface, save the face, and in intense degrees, with the happiest effects. 
In these cases the system was comparatively insusceptible to the action of 
tonics and stimulants until the capillaries of the skin had regained in a great 
degree their plenitude. The heat was applied nearly in a dry stale, and was 
continued the first trials until the skin became soft and supple. After a few 
hours it was repeated and urged to a very moderate sweating degree. The 
operations were then renewed from time to time as the condition of the skin 
indicated, until crisis* took place, which generally occurred in one or two 
days. For the purpose of applying heat in these cases, we employed the ad- 
mirable contrivance of Prof. Jennings, of Baltimore, — a contrivance which 
has never been properly appreciated by the profession, and which is worthy 
of all praise. 

The maintenance of a warm bloodful state of the skin in this stage, was 
not much more important as a means of cure, than a tranquil equable condi- 
tion of the mental exercises. Several fatal cases occurred evidently as the 
consequence of improper mental exertion. 

Cleanliness was of much importance, not only in promoting the comfort, 
but the recovery of patients. The mouth was always carefully washed be- 
fore drinks or food were taken. The body clothing and bedding were 
changed daily; and bed-pans or folded sheets, to receive the evacuations, 
were always employed to prevent the necessity for rising from bed to evacu- 
ate the bowels, and the consequent dangerous fatigue. As far as practicable 
the sick chamber was kept quiet and free from company. 

The diet and drinks were the same as we used, in the early stage. 

Convalescence was generally slow, and often required enemata, or internal 
aperients to correct costiveness. It was never safe to allow solid food during 
convalescence until patients were able to sit up. Many relapses followed 
from the too early use of animal food. Liquid or semifluid substances an- 
swered best as nourishment; and these were only allowed at stated regular 
periods, and in moderate quantities. Premature exposure to the sun's rays, 
or to inclement weather, or fatigue, were injurious. Many relapses were 
produced by an imprudent walk, or ride, and some of them proved fatal. 

The treatment which has been presented is identical with that adopted in 



56 Levert's Case of Fungus Hsematodes. [July 

typhus, with the exception of bleeding in the subacute stage. We never 
dared to use the lancet in the subacute stage of typhus. 

The critical days were generally the periods of crisis in this fever, and 
the 14th and 21st both days included, were the days on which most of our 
cases terminated. One case continued six months and resulted fortunately, 
though many of the inguinal and axillary glands sloughed away. Many 
recoveries followed hemorrhage from the bowels, bladder, nose and gums; 
but, generally, such conditions were unfavourable. Recoveries also took 
place in several cases, in which singultus, and involuntary discharges from 
the bowels occurred, and even in many instances after patients had been 
speechless, and powerless for an entire week. Only three cases terminated 
in suppuration of the parotids, and one of them recovered. One case result- 
ed in necrosis of the superior maxillary bone, and after losing one-fourth of 
the bone complete recovery followed: in this case no mercury was used. 
Rheumatism followed in numerous cases. In one case disorganizing ophthal- 
mia followed, completely destroying the eye. 

Prince Edward C. H., Va., March 30, 1843. 



Art. IV. — Fungus Hsematodes of the Knee —Amputation — Cure. 
By Henry S. Levert, M.D., of Mobile, Ala. 

Mrs. Strain, aged 28 years, of sanguine nervous temperament, and the 
mother of seven children, was attacked with ordinary cold, accompanied 
with slight fever, &c. in the month of October, 1841, which confined her to 
bed about one week. 

When she was recovering from this attack, she felt, for the first time, a 
slight uneasiness in the left knee, about the insertion of the ligamentum 
patellae, which she supposed was produced by some slight injury of the 
part, although she was not aware of ever having hurt it. It was particularly 
painful when ascending or descending the stairs, or in kneeling, which she 
was often compelled to do in washing her house. 

About six weeks from the first sensation of pain, she perceived a swelling 
on the inner side of the ligamentum patellae, in circumference about the size 
of an egg, slightly elevated and very hard to the touch. 

It remained in this condition, giving her more or less uneasiness, until 
about the 1st of February, 1842, when it commenced growing rapidly, as 
she supposed in consequence of the irritation of several blisters which had 
been applied in succession, followed by the tart. emet. oint. 

The remedies were prescribed by a physician, under the impression that 
the patient suffered from rheumatism. 



1843.] Levert's Case of Fungus Hsematodes. 57 

On the 10th of March I was requested to visit her: the appearances pre- 
sented were as follows: — viz. 

The'leg was flexed on the thigh at an angle of about 45°, and firmly 
fixed in that position. A large elastic tumour, somewhat irregular on its 
surface, measuring six inches in its longest and five inches in its shortest 
diameter, occupied and surrounded the knee-joint. The skin was not dis- 
coloured, but rather paler than natural, the superficial veins very numerous 
and greatly enlarged. 

She complained of constant dull heavy pain; no particular constitutional 
disturbance existed, although she was a good deal emaciated. 

This case presented to me a well-marked fungus hoematodes, and I at 
once recommended amputation as the only means of affording her even a 
chance of recovery. To this, after the lapse of several weeks, she consented, 
and the operation was accordingly performed on the 4th of April; the limb 
being removed by the double-flap operation of Lisfranc, at the upper third 
of the thigh. 

The muscles and cellular membrane presented a very unhealthy ap- 
pearance, the former were flaccid and soft, and the latter was filled with a- 
thin, yellowish, serous effusion. 

Six hours were allowed to intervene between the removal of the limb, 
and the dressing of the stump, which was done after the manner of Liston, 
by drawing the edge of the cut surfaces accurately together, with strips of 
oiled silk, which had been previously coated with isinglass. The stump 
was covered with lint, and kept constantly wet with cold water. 

No unpleasant symptoms followed; the wound united in a short time 
throughout its whole extent, with the exception of the point from which the 
ligatures hung. 

This happy result I did not anticipate, but very much feared extensive 
sloughing from the unhealthy appearances which the parts exhibited. 

At the time of this operation, Mrs. S. was pregnant with her eighth child, 
and had advanced to the fourth month, she having felt the motion of the 
foetus on the 2d of April, two days previous to the operation. 

Notwithstanding the apparent cure in this case, I entertained serious ap- 
prehensions (as did several of my medical friends who saw it), that the 
disease would attack some other part, most probably some of the internal 
organs shortly after parturition, and we looked forward with much anxiety 
to this period: such, however, was not the case; she was delivered at the 
expiration of nine months of a full grown male child, which only survived a 
few days; she soon recovered from her confinement, and has since that 
period enjoyed the most perfect health. 

I may remark here, that an examination of the amputated limb, fully con- 
firmed our diagnosis; it exhibited all the appearances of a well-marked 
fungus hsematodes; the heads of the tibia and fibula, and the condyles of 
the femur, together with the semilunar cartilages being destroyed, and could 



58 Harris on Puerperal Convulsions. [July 

not be distinguished from the muscles and other parts concerned in the 
disease. 

The ligature with which the femoral artery was secured still remains on 
the vessel, although more than twelve months have elapsed since the ope- 
ration; it however produces neither irritation nor discharge of pus. 

Mobile, Ala., April 20, 1843. 



Art. V. — On the Treatment of Puerperal Convulsions before the fill term 
of Utero-Gestation. By S. Harris, M. D., of Clarkesville, Va. 

Of the many accidents incident to pregnancy, that of puerperal convul- 
sions is among the most alarming, the most sudden, and the most unman- 
ageable. Intimately connected with and dependent on the gravid uterus, 
there is no period of pregnancy exempt from its attacks. It is admitted by 
all, that cerebral congestion is the most common cause of these convulsions; 
but it is contended by some, that they occur under an opposite state of the 
brain, and it cannot be denied but that there are some facts to sustain this 
opinion. Be this however as it may, they are generally preceded by un- 
doubted evidences of a fulness of the vessels of the head, such as a flushed 
face, headache, giddiness, drowsiness, tinnitus aurium, &c. They are most 
common in the latter stages of pregnancy, and in labour during the violence 
of the parturient pains; and it is said, that they sometimes come on after 
labour has terminated. It is no part of my present purpose to describe this 
disease, as the symptoms are familiar to almost every practitioner. My 
design is simply to call the attention of the profession to a material point in 
its treatment, when the usual remedies fail, and we are compelled to resort 
to delivery, but the os uteri is found undilafed, and undilatable by gentle 
means. We are advised, and on this point I believe all agree, to bleed the 
patient as long as the pulse will bear it, to give cathartics, and apply cold 
applications to the head. But in the event of these remedies failing, we 
must endeavour to evacuate the uterus with as little delay as possible. 
Different means of effecting this object are accurately and minutely pointed 
out, to be used according to the circumstances of the case. We are told to 
deliver with the forceps, if the head of the child be engaged in the pelvis and 
the os uteri dilated; or if not engaged in the pelvis, but above the brim, and 
the membranes have not been ruptured, the hand must be introduced, and 
the child turned and delivered by the feet; or if this be impossible, the per- 
forator must be used. Now all these operations are made to depend upon 
the condition of the os tincse. If not dilated or dilatable by gentle means, 
we are advised not to attempt any thing. • All the authorities that I have con- 
sulted, disapprove of a forcible entry into the uterus under any circumstances. 



1843.] Harris on Puerperal Convulsions. . 59 

Now I am not disposed to question the correctness of this established prin- 
ciple, as a general rule of practice; but in the disease which we are now 
considering, it frequently happens, that delivery or death are the only alter- 
natives presented. And must we then quietly seat ourselves, and witness 
the certain triumph of this terrible disorder? Do not the tears and entreaties 
of husband and friends justify, and even demand, a last and desperate effort 
to ward off the fatal result? 

We will suppose that a woman enjoying apparent good health, is taken 
suddenly with these convulsions in the fifth or sixth month of pregnancy; 
she is bled as far as her pulse or strength will allow, cold is applied to the 
head, cathartics administered either by the mouth or per anum, without 
any, or but slight abatement of the fits. On examination per vaginam, the 
6s uteri is found nearly closed, hard and callous, and no manifestations of 
uterine contractions. The patient, during the intervals of the fits, lies in a 
profound stupor, unconscious and helpless, with a stertorous breathing, the 
eyes fixed, with dilated or contracted pupils; the heart, though still true to its 
office, propels the blood with a weak and vacillating action; a cold clammi- 
ness spreads over the upper portion of the body, with other equally distinc- 
tive signs of approaching dissolution. What, I ask, is to be done under 
such trying circumstances? Must the case be given up to nature, or are we 
not justifiable in making a forcible entry into the uterus, and extracting its 
contents? I am decidedly in favour of this last painful resource. And 
hopeless as such an undertaking may seem to be, it is nevertheless prac- 
ticable in most cases, unless, perhaps, in the very early stages of pregnancy. 
But it may be asked, will this forced delivery, even if it can be accomplished 
without a laceration of the os and cervix uteri, save the life of the woman? 
I answer, that to judge from the few cases of the kind which I have seen, it 
probably will, unless pretty extensive effusion has taken place in the brain. 
In support of this opinion, I will relate a case that fell under my observation 
in the spring of 1838. 

I was called in consultation to Mrs. -, a strong, healthy, plethoric 

woman, about sixteen years of age, pregnant with her first child. She was 
in the fifth month, and up to the time of the attack of puerperal convulsions 
under which she was then labouring, had enjoyed robust health, with, per- 
haps, occasional transient pain and giddiness of the head, flushed nice, and 
ringing in the ears. The convulsions came on suddenly, and recurred at 
intervals of twenty or thirty minutes. Up to the time I first saw heY, which 
was probably ten hours from the commencement of the attack, she had had 
twenty-two or three distinct fits. A neighbouring physician, of some dis- 
tinction, reached her in the morning, soon after the onset of the disease, and 
bled her freely, indeed I may say largely, and repeated the operation several 
times during the day. The bowels were likewise emptied, and irritants 
applied to the extremities. I found her, on my arrival, totally insensible to 
surrounding objects. The most glaring light produced, no change whatever 



60 Karris on Puerperal Convulsions. [Juty 

in the pupils of the eyes, which were fixed and distorted. The loudest 
noise excited no manifestations of consciousness. Deglutition if performed 
at all, was involuntary, and the power of articulation was completely sus- 
pended. Her breathing was laboured and stertorous, and the pulse weak 
and fluttering, and sometimes not even perceptible at the wrist. There was 
no evidence of uterine action, and on examination the os tincse was found 
almost entirely closed, hard and unyielding. Viewing the case as nearly 
desperate, but still desirous of doing something, we determined to administer 
ergot, regardless of the rigidity of the os uteri. Several twenty grain doses 
were accordingly put into the mouth, but from the inability to swallow, very 
little, if any, was conveyed to the stomach. No uterine contractions resulted 
from this experiment. The paroxysms continuing to recur with unabated fury, 
I proposed as the only resource left to make an effort to deliver her. This my 
colleague in the case assented to, though reluctantly, as he considered it, if not 
impossible without certain death, to say the least of it rash and useless. I 
determined, however, to make an effort. Not having with me my obstetrical 
instruments, I was under the necessity of making a small crotchet for the 
purpose, out of the spindle of a cotton spinning wheel, such as is used in 
many families in the southern and western parts of the United States. As 
some of the readers of the American Journal of Medical Sciences may not 
be familiar with this domestic machine, I will describe that part of it which 
I used on this occasion as well as on others of a like emergency, when time 
was not allowed to procure more suitable instruments. It is a small round 
iron spike, from twelve to fourteen inches long, gradually tapering off from 
about the middle to a point at one end, while the other half remains of a 
uniform size, say one-fourth of an inch in diameter. The hook was readily 
made by heating the sharp point to a red heat, and bending it exactly as I 
wished. For the purpose of perforating the head of the fostus, I wrapped 
with tape the blade of a common dirk knife to within half an inch of the 
point. With these rude instruments I prepared for the operation, by placing 
the nates of the woman on the edge of the bed, with a chair and an assistant 
on each side to support the legs, (the usual position in this country for turn- 
ing). With the index finger of the left hand I soon found the os tincae, and 
cautiously but firmly thrust it into the uterus. The second finger by dint of 
perseverance, was likewise forced in by the side of the first. This effected 
a slight dilatation of the passage, and after ascertaining pretty satisfactorily 
that the •foetal head presented, I withdrew my fingers and carried up the 
point of the knife, carefully guarded with my finger until it reached the head, 
which I pierced readily by acting on the handle of the knife with my right 
hand exterior to the vulva. After perforating the head, I introduced the 
hook, and with some difficulty fixed the point in the bones of the cranium. 
These were, however, so soft as to yield under the slightest force. I suc- 
ceeded ultimately in fixing the point among the bones at the base of the scull. 
The last situation enabled me to use as much force as I pleased, but bearing 



1843.] Harris on Puerperal Convulsions. 61 

in mind the delicacy of the parts thus rudely assailed, I did not exert it 
beyond what I supposed would have been the natural expulsive power of 
the uterus, under ordinary circumstances in abortion, at the fifth or sixth 
month of pregnancy. Though occasionally interrupted by the recurrence 
of the fits, the efforts at delivery were kept up at short intervals for several 
hours, when finally the os uteri yielded, and I succeeded in extracting the 
foetus and secundines. Little or no hemorrhage ensued. The woman was 
then placed back on the bed in what appeared to be a truly forlorn and 
hopeless condition. Blisters and warm applications were immediately 
applied to the extremities, which were now cold and clammy. As is 
usually the case, she had two or three fits after delivery, but they were less 
severe and occurred at longer intervals. She remained in a comatose state 
nearly twenty-four hours, frequently without any pulse at the wrist, or the 
ability to swallow either nutriment or medicine. Gradually, however, reac- 
tion came on, the breathing became less stertorous, the pulse slower and fuller, 
the surface warmer, the face less livid, and the eyes more natural in appear- 
ance. In this situation she remained for several hours, and finally waked 
up as if from a sound sleep, uttering moans and inarticulate cries of pain and 
anguish. Consciousness having returned, she was soon able to converse a 
little with her anxious friends, and take a little fluid nourishment, but the 
complete restoration of all her faculties was retarded for several days, in 
consequence of the severe shock which the brain had received. Mild laxa- 
tives with an occasional mercurial purgative, a nutritious but not stimulating 
diet, frictions on the surface, with quiet but cheerful company, soon restored 
her to perfect health. As far as I was able to ascertain, neither the uterus 
nor its appendages sustained the slightest injury from the operation. She 
has since been pregnant three or four times, but has not as yet brought forth 
a living child. Generally she has an abortion about the fifth or sixth month, 
preceded by giddiness and pain in the head, and on one occasion slight con- 
vulsions, which ceased after the expulsion of the foetus, but a partial paralysis 
remained in one arm and hand for six or eight months afterwards. 

The result of this case proves, I think beyond all question, that we are 
not only justifiable, but in duty bound, when all else fails, to force our way 
into the uterus and remove the offending cause. The practicability of this 
too much dreaded operation, without serious or permanent injury to the 
organ, is likewise demonstrated in the following case. 

I was called in the month of February 1839, with two other medical gen- 
tlemen, to see Mrs. , with puerperal convulsions, pregnant with her 

fifth child, and about thirty years of age. Naturally of a thin, nervous 
habit, she had never enjoyed robust health, and for several years previous to 
the attack, had been declining in strength and vigour. She was in the latter 
part of the fifth or first part of the sixth month of gestation. She had been 
labouring under the disease eight or ten hours when I first saw her, and had 
had probably a dozen severe paroxysms. The os uteri was undilated, and 
No. XI.-— July, 1843. 5 



62 Harris on Puerperal Convulsions. [July 

we were unable to discover any indications oflabour. After bleeding freely 
and finding no relief, it was proposed to deliver her at once. This I accom- 
plished in nearly the same manner as in the other case. She had only one 
fit afler the extraction of the fcetus, but remained in a state of almost hopeless 
insensibility for many hours. The general aspect of the ease was very 
similar to the one already detailed both before and after delivery; but it could 
not be viewed otherwise than as a more hopeless one, as this lady had neither 
the youth nor vigour of constitution of the other. The next day after the ope- 
ration she became rational, but was unable to articulate distinctly. The 
following evening fever came on, attended with a low muttering delirium, 
and a slow but full pulse. There was no tenderness or swelling of the 
abdomen, nor were the vaginal discharges at all different from that which 
usually follows abortion. There was, however, a retention of urine for 
several days, which compelled us to use the catheter. In order to lessen 
the violence of the reaction, she was bled from the arm and cupped on the 
temples, Gold applied to the head, and the bowels evacuated. Her case con- 
tinued on for six days, with some slight remission of the symptoms in the 
forenoon, but a high fever with wandering delirium in the evening. During 
all this time she enjoyed not one hour's refreshing sleep, nor did one-sixth 
of a grain of the sulph. morphia which we ventured to give her, produce 
more than an unquiet stupor. She would occasionally, in the morning, con- 
verse for a few moments on the subject of her children, or domestic con- 
cerns; at all other times she appeared unconscious of, or indifferent to what 
was passing around her. There was evidently in this case pressure on the 
brain, either from congestion or effusion, and the treatment pursued was 
strictly in accordance with this view of its pathological condition. She died 
on the seventh day. Had delivery been resorted to sooner, possibly the 
result might have been different. 

We find that the os tincae, though closed and rigid, will, by persevering 
efforts, generally admit one and sometimes two fingers, which will enable 
us to perforate the foetal head, if presenting, without wounding the uterus. 
This being done, and a proper degree of tractive force applied, the passage 
will generally dilate and allow the foatus to be extracted. It is admitted, I 
believe, by most of the standard authorities on the subject of parturition, that 
the child being forcibly impelled by the contractions of the uterus at the full 
period of utero-gestation towards the os uteri, contributes powerfully to 
dilate this opening, by overcoming the resistance of its circular fibres. Is it 
not probable, therefore, that if an equal degree of force be applied directly to 
the head of the child, and kept up at proper intervals for a reasonable length 
of time, that the same effect will be produced? Unaided by the concurrent 
action of the uterus itself, I grant that we might not so readily succeed; but 
it rarely happens that this sensitive organ fails to second our designs. 
Roused up by the rupture of the membranes, and the tractive efforts of the 



1843.] Harris on Puerperal Convulsions, 63 

operator, the contractions of the body and fundus, contribute more or less to 
the dilatation of the os uteri, and the ultimate delivery of the foetus. 

Not having seen a case of convulsions of the epileptic or apoplectic form, 
earlier than the fifth month, I am not prepared to give any positive opinion 
as to the practicability or utility of extracting the ovum in the first period of 
pregnancy. But so firmly convinced am I of the importance of the ope- 
ration in such cases, that I should not hesitate one moment, other things 
having failed, to make the attempt. I have frequently seen this disease in 
the latter stages of pregnancy, and during labour at the full term of gestation, 
and I have not yet succeeded in checking it even until after delivery, either 
by the natural powers of the uterus, or by an operation. 

In thus presenting to the public my views, in reference to this formidable 
malady, based on an experience so limited, I can only hope to direct the 
attention of others to the subject, rather than expect an imitation of my rash- 
ness. If I have subjected myself to the imputation of having violated 
an established rule of practice, in the two cases reported, I have at least the 
consolation of knowing that the bold innovation of forcibly entering the 
uterus and delivering the fetus, saved the life of one patient, and did not 
injure the person of the other. It is only as a pis-aller that I can recommend 
this course, and I venture to affirm, that if timely resorted to, it will, under 
guidance of reason and the promptings of ingenuity, result very often in the 
preservation of human life. 

[Every proposition for the relief of so terrible a disease as puerperal con- 
vulsions is deserving of a respectful consideration, and therefore we have 
given place to the preceding well drawn up paper. The cautious practitioner 
will however doubtless require evidence of greater success from the practice 
advocated by our respectable correspondent, than has been adduced, and will 
duly weigh the consideration whether the forcible dilatation of the os uteri is 
not likely to be productive of more injury than the delivery will be of 
benefit. 

Dr. Churchill, the author of one of the best works on diseases of women, 
and an experienced practitioner, remarks on this subject, "I believe there is 
no dispute that, until labour sets naturally, interference would be injurious; 
so that in convulsions during gestation, we have nothing to do with the 
uterus, but must confine ourselves to the treatment of the convulsive dis- 
ease.*' — Diseases of Females, Am. Ed. p. 403. 

Dr. Rigby, equally high authority, states: " The practice in former times 
of dilating the os uteri, introducing the hand and turning the child, has been 
long since justly discarded, for the irritation produced by such improper 
violence would run great risk of aggravating the convulsions to a fatal 
degree." — System of Midwifery, Am. Ed. p. 385. 

Mr. J. T. Ingleby entertains similar views. " From the seventh to the 
ninth month," he observes, "delivery, when it is expedient, may certainly 



64 Harris on Puerperal Convulsions. [July 

be accomplished, but every objection which attaches to artificial delivery at 
the full terra of utero-gestation, applies with peculiar force to the performance 
of it, if undertaken before the term is completed, since the cervix uteri will 
not have undergone its full development. In numerous instances death has 
speedily followed artificial delivery; in others, the event has not been so 
immediately fatal. In an instance of very recent occurrence, the comatose 
state in which the patient died, did not take place for many hours after de- 
livery; she was in the eighth month of pregnancy, and labour succeeded the 
artificial evacuation of the liquor amnii. Even admitting that the con- 
vulsions which arise previous to labour depend primarily upon the condition 
of the uterus, it is important to recollect that labour is not always necessary 
for their removal, and that whether delivery be effected artificially, or by the 
violence of the paroxysms, the convulsions may continue in full force, not- 
withstanding the evacuation of the uterus; possibly indeed, the impression 
previously made upon the brain may be increased by the efforts which 
attend delivery." — Facts and Cases in Obstetric Medicine, p. 31. 

Again, he says, "It has been already stated that convulsions sometimes 
cease under natural and spontaneous labour-pains, nevertheless it is equally 
true that manual interference is, at the moment, calculated both to renew the 
paroxysm and render it more violent: thus Denman found the mechanical 
dilatation of the os uteri productive of these effects, and the best informed 
Writers, including Chaussier, fully confirm his statement. The principle of 
forwarding the dilatation of the os internum by means of the fingers, can only 
be commended when the orifice is in a soft and yielding condition; under 
contrary circumstances, the practice cannot fail to be injurious." — Op. cit. 
p. 33. 

Mr. Symonds, in a paper on puerperal convulsions (Lancet, 8th Feb. 1834), 
after detailing the particulars of four cases successfully treated — first, by de- 
pletion, cold to the head, blistering, the warm bath, and camphor and opium 
— concludes in the following words: ** Instructed by my own experience, and 
fortified by the authority of such writers as Denman, Blundell, and Gooch, 
I would say with the latter, take care of the convulsions, and let the uterus 
take care of itself." In this as a general principle Mr. Ingleby says that he 
quite concurs, and adds, "but exceptions to it may arise. When the attack 
appears during actual labour, our line of practice is clearly defined; we must 
moderate excessive action, and deliver on the first favourable moment. But 
should the convulsions precede labour, the practice pursued by Dr. Jos-eph 
Clarke (very similar to that recommended by La Motte) is the most rational 
that can be followed, viz. to trust to nature's efforts, aided by medical treat- 
ment, until the patient's life appears to be immediately endangered by the 
continuance of the disease, and then to interfere in the speediest and safest 
manner to promote delivery. The circumstances which justify interference 
demand an impartial and dispassionate consideration, and should embrace 
the state of the uterus, the presentation of the foetus, the period of gestation, 



1843.] Harris on Puerperal Convulsions. 65 

and the violence of the symptoms. An apprehension lest the patient may- 
die undelivered, has often proved an incentive for undertaking delivery at any 
risk, and, doubtless, the interests of the mother alone ought to decide so 
momentous a question; indeed, under severe and frequent paroxysms, espe- 
cially of the tetanic kind, the child is frequently still-born. In Collins's 
cases, 14 of 32 children, including two twin births, were born alive. Of 43 
cases, including a twin birth, which occurred under Dr. F. H. Ramsbotham's 
observation, 21 of the infants survived. The death of the child is considered, 
by this gentleman, to depend rather upon a defective utero-placental circula- 
tion, than upon direct pressure; but the result may be occasioned by either 
cause. 

" The want of success in delivering generally arises from one of two causes; 
the first — delivering too early, before the uterine orifice has undergone suf- 
ficient relaxation; the second — postponing the delivery until effusion has 
taken place, or a fatal impression been made upon the brain. Previous to 
delivery being attempted, sufficient relaxation of the uterus must therefore be 
obtained by bleeding or emetic medicines in nauseating doses, purgative ene- 
mata, and perhaps the application of belladonna to its orifice, otherwise we 
incur the risk either of an apoplectic seizure, or a laceration of the uterus or 
vagina.* This precaution has less regard to the degree of dilatation of the 
os uteri, (for the orifice is not unfrequently more or less open for many days 
before labour,) than to its state of softness; and if a decided impression be 
made upon it during the paroxysm, the sooner delivery is accomplished the 
better. Although the uterine orifice often becomes relaxed earlier than we 
might a priori infer, a moderate degree of resistance is, in every delivery, 
both to be expected and desired: but a forcible entry into the uterus must be 
discountenanced by every rational practitioner. Ashwell considers that we 
may always dilate the uterus with the fingers: a statement which I cannot 
assent to, and it is with marked propriety that Collins strongly cautions the 
practitioner to 'avoid hasty measures for the delivery of the child.' " Op. 
cit. p. 35, 36, 37. 

All these considerations should be duly weighed, and we would particu- 
larly recommend to the junior practitioner a careful perusal of the admirable 
remarks of Mr. Ingleby on puerperal convulsions, in the work from which 
we have just quoted. — Editor.] 

* Of five fatal cases recorded by Collins, three were complicated with laceration of the 
vagina. 



66 Paiicoast on Staphyloraphy. U^Y 



Art. VI. — On Staphyloraphy. By Joseph Pancoast, M. D., Professor 
of Anatomy in Jefferson Medical College, Lecturer on Clinical Surgery 
at the Philadelphia Hospital, etc. 

This operation is an invention of modern surgery — though the idea of re- 
uniting the two edges of a fissured velum palati was entertained by the older 
surgeons, and is said to have been successfully performed by M. Le Monnier, 
in 1764. To Graefe of Berlin, and Roux of Paris, who performed their 
first operation of the kind in 1816-17, are we indebted for the example 
which introduced the operation into general use. 

A congenital division of the palate, a fissure resulting from a wound of the 
organ, or a destruction of a part of the substance by ulceration impairing the 
clearness of articulation, are the common causes, which require the perform- 
ance of this operation. 

In simple staphyloraphy the principle of the operation is the same as in 
simple harelip, viz: to remove the margins of the fissure with a cutting in- 
strument, and to hold the raw edges in contact with each other till there is 
time for union to take place. But in cases where the fissure of the palate 
is too large to admit of the edges being brought into contact at all, or without 
being placed in such a degree of tension as to render union impossible, some 
modification of the plastic art is required in addition, to which the term 
staphyloplasty is applied. This may consist in a partial division of the two 
sides of the cleft palate, near their bony connection, so as to admit the middle 
strips to be readily brought together; or by the raising of flaps from the sides 
or the roof of the mouth, which are to be turned over and fastened by suture 
in the middle line. The plan of partial division, is especially applicable 
where the sides of the fissure cannot well be brought together, not so much 
in consequence of loss of tissue, as from the long continued action of the 
palate muscles, which have retracted the corresponding halves of the palate, 
till they have become partially lost in the mucous covering of the sides of the 
throat. 

The raising of the flap has been applied to cases where the loss of tissue 
is greater; but the attempt has not been attended with success, such as to 
render it worthy of repetition. The liability of the flap to sloughing, the 
imperfect and ill-shaped velum which it forms even if union should take 
place, and the danger of producing necrosis in the bone from which the cover- 
ing has been stripped, are objections of much moment to this mode of opera- 
tion. 

The following observations will illustrate my mode of proceeding; 1st, 
in simple staphyloraphy; and 2d, where in addition is required, an incision 
of the sides of the palate or some other process of staphyloplasty. 



1843.] Pancoast on Slaphyloraphy . 67 

Case I. — Marian Giberson, of Monmouth county, New Jersey, a strong 
healthy girl of 16, with a congenital fissure of the soft palate, of medium size, 
—about half the dimensions of the one shown in fig. 1, which impaired her 
speech and interfered somewhat with deglutition, was referred to me August 
14th, 1841, by Dr. Millar, of that state, for the purpose of having the opera- 
tion of staphyloraphy performed. 

For a week or more previous to the operation, care was taken to prepare the 
patient so as to facilitate the process, by pressing upon the tongue, touching 
the soft palate and pharynx with the handle of a spoon, till the irritation could 
be borne without exciting cough or producing nausea. The patient was seated 
in a chair in front of a large window. Seating myself opposite I then pro- 
ceeded to the first part of the operation, assisted by Dr. Moehring, of this 
city. I took hold of the divided uvula on the right side, with a pair of 
Assalini's forceps, holding it lightly on the stretch, and passed Wenzel's 
cataract knife (the handle of which was made three inches longer than 
usual), through the velum, just far enough from the edge to remove the 
whole rounded border, as I severed it rapidly up to the apex of the fissure. 1 
then withdrew the instruments, and allowed the patient to wash out the mouth 
with alum water. The incision not having extended quite down to the free 
end of the uvula, there was no floating point to irritate the passages, and the 
hemorrhage that followed was soon checked. 

I repeated the operation in the same manner on the opposite side, at this 
time running up the knife so as to meet the other incision at the top of the 
palate; and carrying the knife again down, I cut through the free edge of 
the uvula, so as to leave the forceps attached to the loosed marginal slip. By 
retracting the forceps the loosened piece was drawn out, nearly straight, 
and its attachment to the uvula of the right side removed with the knife.* 
After well rinsing her mouth out with alum water, till the hemorrhage was 
in a great measure checked, the patient was ready for the second part of the 
operation, the introduction of the ligatures. 

Six stout, short, curved needles, lance shaped at the point, were arranged 
in a cushion in two rows, within reach. Three were threaded with long 
stout silken ligatures, of which the knot was to be made, and three with a 
fine silk thread, to be employed only for a temporary purpose, so as to ena- 
ble me to enter the needles on both sides from before backwards. 

Physick's artery forceps and the common dressing forceps made long in 
the handles, were the only instruments used in passing the needles. The 
three needles armed with the thick ligatures were first passed on the left side, 
one near the base of the uvula, one near the middle and one near the top of 
the fissure. 

* In the following case I found so much irritation and congh produced, that I was 
obliged to remove the instruments, and let the patient again rinse out her mouth, before 
the V shaped piece was detached from the uvula of the right side. 



68 



Pancf>ast on Staphyloraphy. 



[July 



The needle held in the Physick artery forceps, was presented with the 
point perpendicular to the membrane, the handle being carried to the oppo- 
site corner of the mouth for this purpose. When the needle had pierced per- 
pendicularly the membrane, the handle of the forceps was carried across the 
mouth to the other corner, and the needle pushed on, when from its curved 
shape the point came into view in the fissure, and was seized with the dress- 
ing forceps held in the other hand for the purpose. The needle was then with- 
drawn, bringing one end of the ligature with it. The sharp edged needle being 
presented in this way, the velum will be found sufficiently tense without being 
stretched or even held with an instrument for the purpose, to allow the ligature 
to be readily passed. By this means we avoid one great source of irritation in 
this part of the operation, viz: the introduction of an additional instrument, 
and the disposition to cough or choke, when restraint is made on the velum. 
The needle held in the dressing forceps, was first carried obliquely down- 
wards and backwards, till it was freed from the palate, and then brought 
out heel foremost through the fissure. It was then removed and the two 



Fig. 1, 



loose ends of each ligature knotted 
so as to prevent the ends of dif- 
ferent ligatures being confounded 
together. From time to time, the 
throat was rinsed with the astrin- 
gent wash, and the mucus which 
accumulated on theligatures wiped 
away. The three needles with 
single threads were passed on the 
left side, in the same manner and 
without difficulty. It now re- 
mained to bring the end of the 
thick ligatures which had been 
carried to the back part of the 
palate on the right side, through 
|v the punctures which had been 
made with the needles on the left. 
This was readily effected by knot- 
ting together the two back ends 
of each corresponding pair of 
ligatures, which were long enough 
to be drawn out by the mouth for 
the purpose, flattening the knot 
with a squeeze of the forceps, and 
pulling upon the single thread, so as to carry the knot and the back end of 
the ligature of the opposite side with it, the end of a forefinger being pressed 
upon the velum as the knot was passed with a slight twitch through the 
puncture. The double ligature being now passed through both sections of 




1843.] 



Pancoast on Staphyloraphy. 



69 



the velum, the glairy mucus was wiped away from the threads, the 
ends of which were assorted and held in due order between the fingers 
of an assistant, one of whose hands was passed from behind on either side 
of the face for the purpose. 

The third step of the operation, the tying of the ligatures, and the closure 
of the fissure was next performed. This was readily done by carrying the 
two forefingers back in the mouth, so as to close the knots firmly. The 
threads were cut off with scissors curved on the flat close to the knot as each 
respective one was tied. The lower ligature was first knotted and the upper 
one last. The entire operation lasted but 38 minutes. The usual after 
treatment was pursued, as will be fully detailed in connection with the fol- 
lowing case. The patient could not be restrained from drinking, taking 
food, and talking occasionally beyond the first 24 hours. On the removal 
of the ligatures, union had taken place, in about two-thirds the extent of the 
fissure. A small hole remained above which was subsequently closed by 
touching with caustic; and a small gap about an eighth of an inch long, at 
the side of the uvula, which as it seemed of little importance, and would not 
close under the caustic, was not interfered with. 



Case IT. — Cathe- 
rine Abel, a healthy 
girl of this city, aged 
21, has a congenital 
fissure of the palate 
of unusually large 
size.* It is about 
two inches in length, 
extends up to the 
bony palate, and is 
about an inch in 
width at its widest 
part. She has a 
younger sister and 
two brothers, the 
sister suffering un- 
der the same afflic- 
tion as herself. The 
accompanying cut is 
an exact representa- 
tion of the palate, ta- 
ken by Mr. Schultz. 

The operation for 
closure of the fis- 



Fig. 2. 




* For the notes of this case I am indebted to Dr. George Newbold, the house surgeon 



70 



Pancoast on Staphyloraphy. 



[July 



sure, was performed before the class of the Philadelphia Hospital, Feb. 7, 
1841. The previous preparation of the patient, the excision of the edge of 
the fissure, and the introduction of the ligatures was much in the same 
manner as above described, for simple suture.* From the very large size of 
the opening, four sutures were made in this case, and it would probably 
have been better had five been employed. As the edges of the fissure 
could not be approximated by simple suture, and it was determined to make 
a partial division of the base of each half of the velum, so as to enable the 
ligatures to draw the edges of the middle opening together, four ligatures 
of the common saddlers' silk were passed double and drawn subsequently 
through on the other side with as many temporary single ligatures, which 
were passed from before backwards on the opposite side for that purpose 
alone. These double ligatures were ultimately secured in the manner 

of the common looped 
F 'g- 3 * bandage, one loose end 

of the ligature being 
passed through the 
loop of the opposite 
side, before the knot 
was formed. By this 
measure, which is one 
of great convenience, 
there is much less dis- 
position in the liga- 
tures to slip, and there 
is no necessity of 
holding the knot either 
with the forceps, or in 
using the complica- 
ted serre-nceud during 
the process of tying. 
The knots were so ar- 
ranged that two were 
on one side of the fis- 
sure, and the remain- 
ing two on the other, 
as seen in the cut. 




in attendance at the time. Another female infant of the same parents, still born, had a 
fissure extending through the soft and hard palate of the lip. It may be worth while to 
observe, in connection with this peculiarity, that all the members of the family except the 
father seem endowed with an ordinary share of intelligence. 

* In my first operation of this kind, I introduced the ligatures before the removal of 
the rounded edges of the fissure. But the threads offer some embarrassment to the 
knife, and I now pursue the plan as described in the text. 



1843.] 



Pancoast on Staphyloraphy. 



71 



When the knots were prepared for tying, but before they were finally se- 
cured, Wenzel's cataract knife was passed from before backwards, through the 
attached sides of the palate, in the line designated by the cut, to enable the two 
halves of the velum to come together in the middle line, as well as to divide 
the insertion of the palate muscles so as to prevent their straining the sutured 
edges of the palate asunder. Considerable hemorrhage followed this division, 
arrested however in a few moments by gargling with an alum wash. The liga- 
tures were then finally knotted, and the loose ends detached. The patient bore 
the operation with uncommon fortitude and self-control; her mouth was large 
and kept well opened, so as to afford great facility in the performance of the 
operation, which was completed, and the patient ready to be removed from 
the room in twenty-nine minutes from the commencement of the operation. 



Fig. 4. 



The usual course of treatment was 
pursued. The patient placed in bed 
with the face downwards, so as to let 
the blood and mucus which flowed 
for some hours be discharged without 
effort. A compress was applied below 
the chin, and a bandage passed round 
the head and jaw to keep the latter at 
rest. The patient not to communicate 
with any one except by signs or by 
writing; xxx gtt. tinct. opii was given 
by the mouth, and xx gtt. acet. opii 
in an ounce of mucilage to be given at 
the end of every four hours by enema 
to lull the patient, and keep down ir- 
ritation. Nothing to be taken in the 
way of diet, for three days, except a 
little mucilage or barley water, and 
that only when urgently demanded. 
A small piece of ice to be left to dissolve in the mouth from time to time, to 
keep down the sensation of thirst. 

Feb. Sth.morning. — Last night rested tolerably well; complains this morn- 
ing of pains in the region of her throat and in her head; some troublesome 
cough has also supervened, she having been entirely free of it previous to 
the operation. Ten leeches directed to be applied to the throat, black drop 
enema to be continued. 

Evening. — Cough and pain subsided to a great degree; quite easy during 
most of the day. 

10/A. — Feeling of much soreness in the fauces, without absolute pain. 
Cough has again become more troublesome so as to render very uncertain 
the success of the operation. A purgative enema with 30 gr. assafoetida, to 
be given. After its action, the black drop enema to be resumed. 




72 Pancoast on Staphyloraphy . [July 

l\th. — Cough so considerable during the night as to disturb the patient's 
rest — a good deal of ropy mucus discharged from the fauces. To day re- 
moved the two upper ligatures. The lower one was removed on the fifth day, 
when it was found to have partially cut out. Union took place only for about 
quarter of an inch just above the middle of the fissure and near the apex of 
the uvula, leaving a small hole above, and a gaping opening below. Union had 
taken place throughout in the lateral incisions. When the tough mucus from 
the edges of the fissure was wiped away, the ununited parts were seen cover- 
ed by weak grayish granulations. To stimulate and give strength to these a 
wash of infus. cincho. with sulph. cupri gradually increased in strength to be 
applied two or three times daily. At the end of three weeks the upper orifice 
had closed up by granulations. The lower opening had cicatrized at the edges 
without union, leaving the patient still with a fissure in the palate, though very 
considerably reduced in size, the union between the two sides of the uvula 
having been broken up. Six weeks from the time of the first operation, 
the parts having, it was believed, become sufficiently restored to their natural 
condition, the operation was repeated in order to close the remainder of the 
fissure. The edges were shaved off, the ligatures applied and knotted; but 
the parts, in consequence of the great original deficiency of the palate, were 
placed in an extreme degree of tension. To take off this tension, which 
seemed to forbid union by first intention, the lateral incisions were again 
made, though to a less extent than before. There was considerable irrita- 
bility of the fauces, with a slight disposition to nausea, and the operation, 
though much less extensive than the first, occupied about three quarters of 
an hour. The after treatment was much the same as before, except that she 
was allowed to take chicken water in small quantities, four times in the 24 
hours, and twice a day the edges of the fissures was touched with a solution 
of gr. x. sulph. zinc, in an ounce of rose water, applied with a camel's hair 
pencil, to give tone to the raw surfaces, and prevent the reaccumulation of the 
viscid mucus which appeared to have acted injuriously in the former operation. 
The plan answered well. The cough which supervened on the second day 
was much less troublesome than on the former occasion. On the removal of 
the ligatures complete union had taken place in the lower half of the wound 
(and in the lateral incisions), leaving a small oval opening just below the 
middle of the palate. The astringent wash was continued upon the sides of 
the opening, which was changed after a few days for a solution of argent, 
nitrati, gradually increased in strength from 3 up to 20 gr. to the ounce. 
The parts however cicatrized over, with little contraction of the orifice, 
leaving a rounded hole about a quarter of an inch in diameter. Suspending all 
applications for eight days, so as to allow irritation to subside, I removed the 
edges of this small opening with a club-foot knife, and introduced two looped 
ligatures, so as to cross each other opposite the middle of the opening; on 
tying these, the edges of the orifice, though somewhat puckered, were brought 
completely in contact. The needles were all entered in front with Physick's 



1843.] Pancoast on Staphyloraphy. 73 

forceps as before, and detached and brought out with the heels foremost 
through the opening, with a pair of minute ear polypus forceps. This 
was a delicate and somewhat difficult operation. Complete union was found 
to have occurred on the removal of the ligatures, except a small point in the 
centre the size of a duck shot, which closed in a few weeks under the use 
of a lunar caustic solution. The patient was ultimately discharged 
completely cured of one of the most extensive congenital fissures of the 
palate that I have ever witnessed; and without the least impairment of 
her general health. The velum was well shaped but tense. From her 
habit of speaking deep in the throat and through her mouth only, and from 
the rigidity of the palate, consequent upon the effusion of lymph in the line 
of incision and the places of puncture with the needles, the improvement in 
her articulation was at first hardly at all obvious. As the effused lymph of 
the cicatrices, which were almost of cartilaginous hardness, was removed, 
and the velum became soft and pliable, her speech gradually improved, and 
at the present time, though not perfectly free from the original peculiar note, 
improperly called nasal, it is such as to excite but little observation, and ren- 
ders her capable of reading aloud with considerable distinctness. 

Remarks. — These two cases of staphyloraphy will serve to illustrate the 
mode of curing this distressing deformity, in the moderate degree in which 
it usually presents itself, and in that state of extreme widening, which pre- 
sents the greatest possible difficulty in the cure. Though there are many 
difficulties to encounter in the after treatment, that may render the opera- 
tion fruitless, as the neglect on the part of the patient to observe absolute 
silence, the occurrence of paroxysms of coughing, sneezing, etc., yet 
when the patient is docile, and the simple plan above described is em- 
ployed, it will not be found one of any peculiar difficulty, to any person ac- 
customed to the performance of such as require some nicety of touch. I 
can readily conceive however, from the delicacy of the operation, and the 
length of time required to perform it, that great dexterity and skill on the part 
of the surgeon, and firm resolution on the part of the patient, will all be 
needed, as described by writers, when the complicated and cumbersome 
instruments frequently advised are employed, five of which were used 
by Graefe merely for tying the knot. The most difficult part of the opera- 
tion is said by Roux to be the excision of the edges of the fissure. But 
this is dependent on the method in which it is done, and will especially be 
found the case, where the ligatures are first completely passed, the loops de- 
pressed in the throat, and the edges made raw with the long angular scissors, 
as practised by this surgeon. The leaden ligature of Dieffenbach, the simple 
long curved needle set in a handle used by many surgeons, the ingenious 
modifications even of the old port-aiguille by Messrs. Dupierris and Guyot, 
cannot be compared with the instruments I have described above, in respect 



74 Lopez's Case of Spiders discharged from the human Eye. [July 

to the facility and rapidity with which the ligatures can be passed — in reality 
the only difficult part of the operation. 

The artery forceps of Physick, which is not represented sufficiently curved 
in fig. 3, has also been successfully employed by Prof. Mutter in several 
cases of suture of the palate. 



Art. VII. — Spiders discharged from the Eye. Hysteric Monomania. By 
A. Lopez, M.D., Mobile, Ala. 

I was requested on the 5th of February, 1840, to visit a young lady, from 
whose mother I received the following statement. The patient had left the 
city of Charleston, S. C. (at which place I then was), to visit a friend who 
resided in the country. On the night of the 2t)th January, while conversing 
in bed, she was sensible that some object had fallen from the ceiling of 
the apartment, upon her cheek, just below the inferior lid. This caused her 
to apply the hand briskly and forcibly in order to brush off, what she sup- 
posed to be some one of the many insects so common in country houses, 
upon which, the friend with whom she slept observed, that as the room was 
much infested with spiders, it was probable that the object which had fallen 
was one of them. In the course of the night she was awakened by a feeling 
of intense pain in her left eye, which continued at intervals until morning, 
when, upon examination, the eye was discovered to be highly inflamed and 
lachrymose. Ordinary domestic means were applied, and during the morning 
feeling an intense degree of itching and irritation, she rubbed the lids together 
upon the ball and removed two fragments which were readily recognised as 
the dismembered parts of a spider. Her alarm in consequence became very 
great, and was much heightened when the same thing was repeated in the 
afternoon. She left for home and arrived in Charleston on the 2d February. 
During the voyage her mind was much perturbed and under considerable 
excitement from the event, and when I paid my first visit on the 5th, the 
date mentioned in the early part of my statement, the following was her con- 
dition: the right eye unaffected; the left, turgid, inflamed and weeping; and 
there had been removed from it that morning, a spider, imbedded in a 
mucous covering. It was entire with the exception of two legs. The two 
preceding days before I had seen her three others had been removed and 
were now exhibited to me. I immediately submitted the eye to as close an 
examination as the irritable condition of the parts permitted, without being 
enabled to discover the minutest portion of any foreign substance. In order 
however to combat the pain and inflammation I ordered leeches, saline-anti- 
monial medicines, and evaporating lotions. I thenceforward visited her daily 
until the 19th, and at every visit, I removed' either an entire or dismembered 



1843.] Lopez's Case of Spiders discharged from the human Eye. 75 

spider from the same eye. Before proceeding it will be well to mention 
that during the interval between the 5th and 19th, I invited to an examination 
of the case, Professors Geddings and Dickson, and Doctors Bellinger and 
Wurdeman. Dr. Dickson on one or two occasions also removed these ob- 
jects from the patient's eye. I made, assisted by Prof. Geddings, the most 
minute scrutiny with a view of discovering, first, whether there could pos- 
sibly exist a nidus within the orbit for these animals; secondly, whether a 
sac containing their ova was there concealed; and thirdly, if any communi- 
cation between the eye and nose could account for their appearance. For 
these purposes, the superior and inferior palpebrse were everted with great 
care, traversed thoroughly with a blunt probe, and afterwards I threw injec- 
tions around the internal lining, but all to no avail. The anterior and posterior 
nares were closely examined by strong light, both of the sun and candle, yet 
we could not perceive the slightest trace of any means by which either ova, 
insect or nidus could be retained. 

The sensations always precursory to their removal were, a sense of burn- 
ing in the ball, a pricking of the superior lid, proceeding more or less severely 
around the orbit, until it assumed a fixed pain within the lower lid, upon the 
eversion of which by myself, if present, or by her mother, in my absence, the 
spider, always dead, would be discovered enshrouded in its mucous bed, and 
removed by means of the finger or probe. I now resume the order of their dis- 
charge. From the 19th they were removedyrom both eyes, and so continued 
until the 23d, when again they became confined to the left, and afterwards 
from each eye alternately until the 5th of March, when a truce was had until 
the 10th. During this interval, the eyes resumed their normal condition, but 
again on the 10th the inflammation was renewed and the discharge of spiders 
recommenced, the right eye being now chiefly the depository. Up to the 
date, during which time my visits were unremittingly made, none other than 
general observations were kept, but, the spider-making power appearing so 
inexhaustible, a more circumstantial diary was thought necessary. 

March \Qth. Two spiders. 

llth. Two. Pain over right orbitar region passing gradually over the 
frontal sinus to the left. Sharp pricking pains upon pressure. 

\2th. Previous to my visit, one from the left eye, which was much less 
inflamed than the right. 

ISth. Eyes much improved in appearance. One discharged since my 
last visit, and another just previous to my departure this morning. As this 
discharge served greatly to perplex the views at which I shall arrive before 
I conclude this paper, it may not be irrelevant to notice it. I have men- 
tioned the scrupulousness with which the eye and its appendages were ex- 
amined in order to elicit, if possible, any clew by which to unravel this 
enigma, and the fruitlessness of those exertions. It appears then, that on the 
day of this visit (the 13th) a spider was removed before my arrival. A ser- 
vant was despatched for it to a neighbour's whither it had been sent for exa- 



76 Lopez's Case of Spiders discharged from the human Eye. [July 

mination. Some time elapsed before her return, during which time I sat 
in such a relative position to the patient as to preclude all possibility of de- 
ception, and I had this day, as was my wont at every visit, made a careful 
examination of the eye without discovering a vestige of any kind of substance. 
Upon the return of the servant I arose to depart, at which moment the 
patient complained of pain, and in a few seconds, by turning down the lower 
lid I removed another spider. 

15th. Eyes extremely healthy and clear. On the 13th just after my 
visit, the mother removed three spiders, two entire and one broken; also a 
putrid substance, the precise nature of which I could not define. No others 
discharged to date. 

17th. None since 15th. Right eye more affected; upper lid much irri- 
tated and swollen. Left eye healthy. 

18th. Right eye still inflamed — discharged a portion of web from the 
inner canthus. 

19th. Eyes the same — another piece of web. 

20th. Eyes perfectly natural. After my departure on the 19th, there was 
removed a sacculum containing ova. 

27th. None since 20th until to-day. The left eye being* inflamed and 
painful she was advised by a friend to insert an eye stone, which at its exit 
protruded one spider of the long-legged kind, entire. 

April 6th. None since 27th ultimo. Eyes healthy and generally im- 
proved in their appearance. 

13th. None since 6th. Eyes healthy; has used them since my last visit, 
in sewing and reading without inconvenience. 

May 14th. None since 13th of April. Eyes healthy until a few days 
past; to-day they are weak, lachrymose, and slightly injected. They how- 
ever improved under remedial measures, and the case terminated. 

The total number of spiders removed from commencement were between 
forty and fifty. During the progress of this very singular case, the treat- 
ment was regulated according to the greater or less degree of local or general 
disturbance. The patient was restored to good health, and continued so un- 
interruptedly to the date of my leaving Carolina in November, 1840. 

I have presented the facts as succinctly as possible, and here perhaps, in 
the opinion of many, it should rest; but other considerations may offer them- 
selves to warrant a further notice. They are these: 1st, a case so anoma- 
lous and of so unusual occurrence, could not well exist, without necessarily 
exciting an intense degree of public curiosity, and in fact, becoming, as it 
did, a subject of general notoriety and discussion in the various public presses 
of the union, all of which however were strictly unprofessional, as this is 
the first entire and correct statement yet made on the subject by myself. 
2dly, the character and respectability of the patient as well as her mother, 
being familiarly known to me for many years, preclude the remotest suspi- 
cion of any desire to impose, or to acquire a spurious notoriety on the part 



1843. j Lopez's Case of Spiders discharged from the human Eye. 77 

of the daughter, or of the countenance of fraud by the mother; 3dly, the 
pathological history of the patient, which I will proceed to give, and which 
has induced me to distinguish this case as one unequivocally of Hysteric 
Monomania. 

In adopting this rationale I am of opinion that I conform more strictly to 
the category within whose scope are embraced so many equally singular and 
otherwise inexplicable perversions of the nervous system, and under the 
influence of which the most remarkable anomalies have been produced. I, 
moreover, am disposed to regard it rather as a melancholy, though interesting 
feature of disease* than a subject of levity to be classed among the nine-day 
wonders of everyday report. The father of the patient was a man of pecu- 
liarly nervous temperament and excitability. The patient from her child- 
hood exhibited a due inheritance of that temperament, which became more 
strongly developed at that age, which, in females so strikingly calls into 
action the consentaneous play of every nervous affinity. The establishment 
of the catamenial period, corresponded with this complication. Her natural 
disposition was variable, at times cheerful, sometimes gloomy, but more 
commonly timid and reserved. 

In 1839 I attended her for an attack of chorea, during which many pecu- 
liarities were observable, and a few months preceding the invasion of the 
case now under consideration, she was under my care for a neuralgic affec- 
tion, terminating in a tremulousness of her upper extremities corresponding 
with what Good in his Neurotica recognizes as " synclonus tremor ," except 
that here the morbid action is exhibited on attempt at voluntary motion, 
whereas in this case it was independent of such causes. In the presence of 
these facts, to wit, the entire confidence entertained not only by myself but 
all others, in the strict veracity and irreproachable integrity of the parties; 
the predisposing and salient qualities in the idiosyncrasy of the patient, and 
the indisputable, though too frequently unexplained effects resulting from a 
morbid condition of the nervous system, — effects impressing their astounding 
influences not only upon the physical but also upon the psychological nature 
of man, — can we, without becoming amenable to the charge of an indifference 
incompatible with the proper spirit of inquiry which is so peculiarly the 
province of medical philosophy, refrain from devoting a little time to the 
investigation of this case. 

Previously to any considerations touching the mental agency involved 
in this history, I will refer in abstract to a few instances, which if not even 
in strict analogy, are nevertheless not devoid of interest, either as objects of 
science or curiosity. 

1. In the " Memoir 'es de la Societe Medicate" (Annee 5me. p. 181,) 
M. Silvy relates a case in which an immense number of pins and needles 
were swallowed, and their exit from parts remarkably singular. These were 
doubtless swallowed under an erratic condition of the mind. 2. In the Med. 
Ck&r. Rev. vol. vii, No. 22, Oct. 1825, p. 559, will be found the extraor- 
No. XL— July, 1843. 6 



78 Lopez's Case of Spiders discharged from the human Eye. [July 

dinary " Copenhagen Needle Case" in which it is stated that a young 
woman from Aug. 1807 to Dec. 1823, discharged from nearly every part of 
her body 400 needles. This case is reported conjointly by Professor 
Heckoldt and Dr. Otto. In 1825 she was living and in good health in 
Frederick's Hospital, at Copenhagen. No account is given by which we 
are to infer that so immense an amount of needles were accidentally intro- 
duced, and the presumption is legitimate that they were either swallowed or 
thrust in under a state of mind beyond the patient's control. These are in- 
stances which would seem to owe their existence to influences such as con- 
stitute the pathological features of the case under review. They are only a 
few from the many with which mecfical history abounds. Nor are these 
records silent with regard to insects and larvse being discharged from the 
human body, and from places so unusual as to excite surprise; and while I 
refer to a few of the most prominent, I do not conceive their 'characters 
parallel with my case, because in the former there are palpable grounds for 
explanation, whereas, in the latter there is one of two modes alone, by 
which to obtain a solution, — either gross fraud and premeditated concert, or a 
morbific condition dependent upon extreme exaltation of the nervous system. 
I will, nevertheless, briefly condense a few of the cases referred to. 

In 1828, M. Cloquet reported to the Philomathic Society of Paris, the 
case of a rag-gatherer who in a state of intoxication laid himself down to 
sleep near some dead horses. He slept for twenty-four hours. On 
awakening he felt as if he were swelled out with much unusual pain. On his 
return home, a number of blisters arose about his head, and worms crawled 
out of his nose and ears, and other natural openings of his body. He went 
to the Hospital St. Louis. More came from his head when the swellings 
were lanced. His skin produced them every instant. The nurse collected 
three plates full. The conjecture was that the flies from the dead horses laid 
their eggs in the pores of the man's skin during sleep, as well as in the 
natural openings of his body, and that warmth hatched the eggs which pro- 
duced the worms. — Am. Journ. Med. Sci., No. 3, May 1828, p. 228. 

Animals are frequently found in situations of the human body, for whose 
location it would be difficult to account. The doctrines of equivocal and 
spontaneous generation have been taxed through all the bearings, and still 
leave us as much benighted as ever. I will merely refer to the several 
authorities, and give their cases in brief. Worms in active motion under 
the conjunctiva. Blot, of Martinique, removed by incision two from a 
similar position in the eye of a negress. They were thread shaped, 38 
millimetres long,"\vith a black protuberance adapted for suction. The worm 
lay on the outside of the eye, and sometimes turned around a portion of 
the cornea, causing stinging pains and nervous symptoms from fear. The 
patient, an African, was unable to give any account of herself or the liability 
of her country people to this disease. 

Bajou, of Cayenne, in 1768, observed a worm in serpentine motion in 



1843.] Lopez's Case of Spiders discharged from the human Eye. 79 

the eye of a negress; upon incision being made it removed, but was 
secured by forceps and dislodged. He saw another case in 1771. {Jim. 
Journ. Med. S'cu, May 1840, p. 194.) The Lond. Med. Gaz. Aug. 1833, 
records a case of a little girl, aetat. six, under whose conjunctiva and resting 
upon the sclerotica there was found a cyslicercus cellulosa perfect in all its 
parts. — See Jim. Journ. Med. Set., May 1840, p. 194. 

Some years since the Baltimore Sun related the case of an insect resem- 
bling a snake in the eye of a horse. It grew in two months from a half 
inch to 3£ or four inches in length. It moved with great rapidity and 
incessantly. 

Dr. Yule, in the Edin. Philos. Journ., July 1825, p. 72, records 
cases of insects in the human stomach: — One, of a countryman, from 
whose stomach, after several weeks of intense suffering, there was ejected 
a large hairy caterpillar, supposed to be of the common Dragon fly. 
The opinion is that it must have lived several weeks in the stomach and 
grown to its full size. 

Dr. Reeve mentions the fact of larvae inhabiting the human stomach. He 
cites a case, where the larvae of the musca domestica or common house fly, 
were voided by a girl. — New England Med. and Surg. Journ., Jan. 1821. 

Kirby and Spence relate a case where several beetles were vomited by a 
boy. 

In the Am. Journ. Med. Sci. No. xlii, Feb. 1838, p. 473, will be fo^ind 
a case of a beetle discharged from the urinary bladder. 

It now remains to attempt some explanation as to the means by which the 
spiders obtained their " local habitation" in the eyes of my patient. As" 
might be supposed, conjectures were not idle, and the reasons assigned 
assumed their complexion in proportion as the credulity or scepticism of 
individuals prevailed. Those who yielded to the first, of course resorted to 
the intervention of miraculous agency, while the latter class believed it to be 
an artful endeavour to impose upon the community. I need not reiterate 
how unjust and unphilosophical such suspicions must appear under the 
historical features of this case. The only attempt to explain it by a natural 
and direct probable cause, was published by a Mr. Meddler, of Erie, Penn- 
sylvania. In a letter addressed to the postmaster of Charleston, he gives 
the natural history and habits of the wood-spider, which, he says, unlike the 
rest of that class of insects who propagate their young from eggs, " bring 
them forth in perfect form, 11 and the female carries them about, attached to 
the extremity of the tail. Mr. Meddler thinks, therefore, that it was one of 
this class which fell upon the young lady's cheek, and 'that the effort to 
brush it off, separated the young from the point of attachment, upon which 
they took different directions, some into the eyes and others into the nostrils, 
whence they " could easily pass 11 to the eyes, and become killed there by 
the touch. He also thinks that the spiders discharged from the eyes " were 
at different stages of maturity and not of different species." 



80 Lopez's Case of Spiders discharged from the human Eye. [July 

Now, Mr. Meddler errs in every particular. The wood-spider " bring 
forth their young in perfect form." We have shown that one of the articles 
removed on the 20th March, was a sacculum containing ova. Again, 
his idea of their passage into the eye at the moment of accident is disproved, 
because I have stated the extreme care with which I repeatedly examined 
that organ and all its appendages; and surely if the extraordinary number 
discharged from first to last had been lodged therein, they could not have 
escaped observation. They were not in the nostril, for I have also said that 
due exploration was there made: moreover, the communication between the 
nose and eyes even in a healthy condition, could not possibly have admitted 
the passage of bodies as large as many of these spiders were, much less 
under the high state of inflammation and swelling in which they were almost 
constantly found. Lastly; Mr. Meddler, deriving his history of the case 
solely from newspaper reports, originating with persons unacquainted with 
its character and progress, errs in thinking that the spiders were only "at 
different stages of maturity," and not of different species. The spiders re- 
moved from the eye were subjected to close microscopic examination by 
myself assisted by several professional gentlemen accustomed to scientific 
investigations, among whom was the Rev. Dr. Bachman, whose re- 
putation precludes all doubt, and we discovered at least three different 
species, distinguished by the anatomical classification of Latreille, Wal- 
kenar and Hentz. But even supposing them to have been lodged " in 
perfect form," the fact that they were subjected to a residence in depraved 
secretions unfit to preserve the lives of insects, forbids the belief that they 
could have reached the different stages of size and maturity which they 
presented, much less so then could we suppose them to have been hatched 
by incubation either in the eyes or nostrils. I am then constrained t* 
discard from my mind the presumption that they were lodged and perfected 
previously to their discharge, or that they were placed there by the patient 
in a healthy condition of feeling and witb a desire to impose. 

The only suggestion left for my adoption is this: That from all the pre- 
ceding history of my patient, there existed a want of nervous integrity, so 
operating upon the mind as to produce the form of disease which I have dis- 
tinguished in my text as Hysteric Monomania; and I am induced to think 
that the various types of mental irregularities, which an unbalanced nervous 
system is so familiarly known to produce, sustain the belief. It is needless 
on this occasion to investigate the diversified operations of the human mind 
in its physical and pathological relations, or to refer to the multiform phases 
It is capable of assuming under the excitement to which it is subjected by the 
agents which are perpetually at work upon its impressionable nature; suffice 
it to say, that the history of the different forms of insanity, from the highest 
degree of concentrated fury to the most subtile shade of the mind's day-dream, 
present arguments and examples sufficiently numerous to render my view of 
this case at least plausible. 



1843/] Spackman's Case of Carcinomatous Tumour. 81 

At the incipiency of the case, I do not for an instant doubt the presence of 
those fragments of spiders, and perhaps one or two entire, but my opinion 
is, that subsequently, terror, superinduced upon the idiosyncrasy described, 
dethroned the judgment; hallucination usurped its seat; a morbid concatena- 
tion was excited, and the patient under the control of this influence was 
urged irresistibly to introduce them from day to day, until the morbid series 
was exhausted. I cannot express myself more forcibly than by adopting 
the language of M. Ollivier addressed to the court at Paris, in behalf of a 
young girl arraigned for the murder of an infant. She confessed to have 
given it ten pins to swalloio from time to time. M. Ollivier said, " he was 
inclined to attribute the present act to one of those unaccountable perverse 
impulses which are not unfrequent in certain females, more especially about 
their menstrual periods." (Lancette Francaise, 1839). M. Dupuytren says, 
" I have seen at the Hotel Dieu, a great number of women and children, 
who had been affected with the strange ?nania of swallowing pins and 
needles.' 1 '' He then gives the case in detail, and concludes by saying, "on 
examining the body after death, several hundred pins and needles were found 
scattered through the viscera, muscles, cellular substance, &c." 

I will, lastly, merely refer to that extraordinary form of insanity described 
in the Journal de Progres, for 1828, under the tide of Periodical Vino- 
Mania. It is reported by M. Pierquin who says, " The disorder commenced 
fifteen years ago in the shape of an irresistible impulse to swallow wine day 
and night without the possibility of satiety. 'The paroxysms last from two 
to three months, with an interval of equal duration, when it returns again 
without any prodrome that might indicate its approach." 

I here close this case, extraordinary in its character under any aspect, and 
if my view of it be a correct one, it will afford another to the many which 
are to be found in nearly every work professing to analyze the yet inscru- 
table character of the human mind. 

Mobile, Ala., April 26, 1843. 

N. B. The spiders are in my possession, and were exhibited with a statement to the 
Medical Society of this city. 



Art. VIII. — Carcinomatous Tumour connected with the Stomach simu- 
lating Aneurism — Disease of the Aortic Valves, fyc. — Death, Autopsy, 
with Remarks. By George Spackman, M.D. 

I was requested, on the 13th of December, 1842, to visit Mrs. L., aged 
52 years, of middle stature, with black hair and eyes, and rather corpulent. 
She had been in bad health for many years, though seldom confined to the 



82 Spackman's Case of Carcinomatous Tumour. [/"ly 

house. On .the left side of the upper lip was an ulcer the size of a penny, of 
an indolent character, which had been there fifteen years, not increasing 
much until the last year. The patient informed me that she had been treated 
for disease of the liver, and sometimes for dyspepsia. She now complained 
of want of sleep and constant vomiting, with no pain. In this state she 
had been for ten days previous to my seeing her: at that time the pulse was 
frequent but feeble; her tongue clean and moist; her bowels constipated; 
urine scanty and thirst constant, with an excessive secretion of mucus, re- 
sembling ptyalism, though no mercurial fcetor could be detected, and the 
gums were not swollen. Pressure on the epigastric region gave no pain, 
the countenance of the patient depicted great anxiety, and her skin was of a 
dull white hue. I directed sinapisms to the region of the stomach, and a 
solution of muriate of morphia, one grain to the ounce of water, a tea- 
spoonful every two hours until sleep was induced; gum water and sago 
being given as nourishment. 

14th, 9 A. M. Patient slept well all night; the vomiting has ceased; 
some sago has been taken; the bowels not having been moved for three 
days, I ordered calomel gr. iij. pil. iv, one every hour, to be followed by 
small doses of magnesia usta, until they were moved. 

15//i, 10 P. M. Bowels moved three times; vomiting returned; pulse 80, 
feeble; skin rather hot; patient complains of pain in the head, back, and 
left leg; no pain in the stomach; pressure on the spinous processes of 
lumbar and dorsal vertebra gave some pain. I ordered a large sinapism to 
be applied down the spine and a spice plaster to the epigastrium, directing 
the patient to take lime water and milk, a tablespoonful of each every hour, 
chipped ice, iced gum water, and morphia solution at night. 

16th, 9 A. M. Stomach quiet; sleeps middling well; pain in the back and 
leg better; no headache; pulse feeble; 78 in the minute. Directed essence of 
beef, and sago for her diet. 

17th. She has retained all she took yesterday, and is sitting up out of 
bed; thinks she is much better; looks better; no medicine appears to be 
required; sago and beef-tea continued; tea and crackers. 

18th. Did not see her till evening; she said the beef-tea did not agree 
with her as well as heretofore, that she had vomited several times; was free 
from pain, and slept none. Prescribed tinct. lupulinae twenty drops; tine, hy- 
oscyami 40 drops every two hours; oysters, soft part; cream with milk and 
lime water; chicken water as a nourishment, and an enema to open the bowels. 

19th, 4 P. M. Patient better; stomach settled; bowels opened by the 
enema; she slept tolerably well, but complains of being very weak, and of 
a trembling and moving in the stomach like worms, with a throbbing sensa- 
tion in that organ; she has some palpitation of the heart; I made no alteration 
in the treatment, except that I directed the use of a teaspoonful of the solu- 
tion of muriate of morphia at bedtime, to be repeated every three hours until 
she slept. 



1843.] Spackman's Case of Carcinomatous Tumour. 83 

20th. She continues about the same. 

2\st. Vomiting returned; pain in the back and leg; none in the stomach; 
no fever; pulse as before. All the remedies used thus far have produced no 
effect. Directed nit. argent, gr. iss., muc. gum arab. 3iss: aq. 3'j; a tea- 
spoonful every two hours; blister over the stomach. Saw her again at 11 at 
night; and she was no better. I directed an anodyne enema; | drop of 
creasote every hour. 

22d, 9 P. M. No better; vomits every thing; complains of no pain in 
the stomach; pulse 90 and feeble, has had no sleep and is thirsty. Ordered 
to take chipped ice and soda powders; 1 1 at night is no better. 

23d. Dr. C. W. Pennock was called in consultation; he made a minute 
examination of all the cavities and organs, and inquired, into the history and 
symptoms of the case, and furnished me with the following note: — The skin 
of an ash hue, drj r and harsh; on the right cheek near the angle of the mouth 
is ulcerated from one to four lines in depth, with uneven jagged edges, its 
surface presenting pale, reddish-gray granulations; countenance anxious; 
complains of no pain, but some uneasiness is experienced upon pressure 
being made upon the intervertebral space of the middle dorsal vertebras; slight 
oedema of the legs. Thorax is well developed; the percussion throughout 
resonant, and beneath the left clavicle it is preternatu rally so; respiration 
normal, with the exception of the upper third of the left lung, where the 
vesicular murmur is very feeble. Heart by percussion is of natural size, 
the rhythm of movement natural, the sounds at the apex are normal, but a 
slight saw sound is heard over the aortic' valves. 

Abdomen. The liver enlarged, extending as indicated by percussion two 
inches below the right hypochondrium, and the left lobe occupies the upper 
portion of the epigastric region; immediately below is a hard mass four by 
four inches, extending to the umbilicus. A sense of oppression or suffocation 
is induced by pressure upon this mass; a strong impulse over the course of 
the aorta synchronous with the pulsation at the wrist exists, but no ab- 
normal murmur attends this impulse. 

24th, 10 A. M. Dr. C. W. Pennock in consultation — another minute 
examination was made. I am indebted to my friend Dr. Pennock for the 
following note: — "The abdominal tumour is much less than yesterday. Tt is 
now confined to the epigastric region; the impulse or upheaving movement 
over the central portion of the tumour is very forcible, but it diminishes late- 
rally, and is not felt on its borders; in a word, there is no expansive move- 
ment. The diagnosis presented is not an aneurismal tumour, but a scirrhous 
mass connected with the pyloric extremity of the stomach, together with an 
enlargement of the left lobe of the liver; the aortic valves of the heart carti- 
laginous, with probably some ossific deposit." Patient appeared much 
better; slept well; had no vomiting; had taken some beef-tea and sago; 
pulse weak, not exceeding 80 in a minute; countenance and intellect good; 
she attributed her improvement to quack medicines; Stuckert's nervous 



84 Spackman's Case of Carcinomatous Tumour. [July 

cordial, which she took without our knowledge. To test the efficacy of 
this medicine, we allowed her to continue it, stopping all other treatment, and 
left the case. I did not see her again until the 28th, when I was sent for at 
eleven in the evening. She had been vomiting blood and a green pus-like 
matter, since eight o'clock, and had ejected about a pint and a half. She had 
fainted several times; had no pain; a clear mind; a cool skin, and a frequent 
pulse. As there was no vomiting on my arrival, stimulants of brandy and 
ammonia with sinapisms over the stomach and extremities were ordered, and 
I directed in case vomiting returned, acetate plumbi gr. v. every hour, 
nourishment, soup, &c. At 3 A. M. of the 29th, vomiting returned with 
violence, a large quantity of blood was thrown up, she fainted and died. 

Autopsy 36 hours after death, present Drs. C. W. Pennock, W. Brinckle, 
and Spackman. 

Moderate emaciation; skin, as in life of an earthy hue. Some serous in- 
filtration of the ankles and legs. 

Chest. The lungs upon opening the thoracic cavities were found to be 
natural, with the exception of the upper lobe of the left, which was emphy- 
sematous, the air vesicles being much enlarged. The heart coincided in size 
with that indicated by percussion of the thoracic parietes in life; the walls of 
the left ventricle were slightly thickened; all the valves natural, with the ex- 
ception of the semilunar valves of the aorta, which were cartilaginous with 
some spiculae of bone near their margins. 

Abdomen. Opening the cavity of the abdomen, the liver was found to be 
much enlarged, especially its left lobe, which occupied the upper third of 
the epigastric region; immediately beneath and behind the left lobe was a 
rounded, irregular, lobulated mass of 4 by 4 inches, lying upon, and imme- 
diately in front of the abdominal aorta, but not connected with it. This 
abnormal growth commenced at the pyloric orifice of the stomach, occupying 
one-half of the lesser curvature of the stomach, and was stiongly attached and 
united to the liver at the great portal sinus. Upon cutting into the tumour 
it was found to be carcinomatous. The whole of the internal structure was 
dyed with extravasated blood, which when washed ofT, showed that internally 
the surface of the tumour was of a slight bluish-white colour, very firm, 
hard, striated, fibrous, and creaked when cut by the scalpel. Interspersed 
through this stiucture, were some ten or twelve masses of the size of filberts, 
filled with a brain-like substance, of the consistence and colour of thick 
cream. The tumour, by ulcerative absorption, had eroded a large cavity in 
the left lobe of the liver, from which it could be only separated by the scalpel, 
and was found to have penetrated into the large branches of the vena portarum, 
and that these vessels had emptied themselves through the softened ence- 
phaloid portions of the tumour into the stomach. The liver around the 
tumour presented the appearance of the scirrhous transformation, and was 
generally cirrhosed. The stomach contained a pint of clotted blood, the 
mucous coat was of a slate colour, and generally thickened, mammelous. 



1843.] Thompson's Case of Gun-shot Wound. 85 

Around the pyloric opening is a carcinomatous band, half an inch in thick- 
ness, and nearly two inches broad. This abnormal formation appears to be 
a transformation of the cellular and muscular coats, and was in intimate con- 
nection with the tumour previously described. 

Some small hard roundexl masses of a light blue colour were observed in 
the spleen presenting a striated appearance when cut into. The mesenteric 
glands were also hardened, and presented a similar appearance to the masses 
in the spleen. 

The kidneys were of a fawn colour and granulated; some of the iubuli 
uriniferi were obliterated. Intestines, and the other viscera not examined. 

Remarks. — This case presents several points of interest. In the first 
place, the fact of the existence of a carcinomatous formation of the size of 
that which has been described, unattended by pain, is very surprising, and 
shows that pain is not a necessary or invariable attendant on carcinoma. 
Again, the existence of the cephaloid, brain-like masses, in the midst of the 
scirrhous mass, is extremely interesting, as it conclusively shows, that the 
two affections or lesions, depend on the same pathological conditions, in 
different stages of development. The immediate cause of death, by hemor- 
rhage into the stomach from the vessels of the liver, through the softened 
cephaloid portions, was very remarkable. 

But the point of greatest interest is that which points out the means of 
differential diagnosis of scirrhous or hardened tumours, accompanied with 
pulsation, from those tumours dependent upon aneurism. In this case, a 
tumour lying in contact with the abdominal aorta, received the impulsive move- 
ment of that vessel; but this pulsative movement was only felt in a small part 
of the tumour: it was felt forcibly over the central portions, but not towards 
the sides of the tumour; it was not an expansive impulse, and it was for the 
want of this latter characteristic, that the diagnosis, which was ultimately 
verified, was founded. 



Art. IX. — Gun-shot Wound. Extensive laceration of the Brain, ivithout 
loss of consciousness, or impairment of mind. By J. H. Thompson, 
M.D. of Salem, N.J. 

Monday, Feb. 13th, 1843. Mr. Win. L. Johnson, aetat. 22, in attempting 
to shoot a bullock on his father's farm, which is about two miles from this 
town, was wounded by the bursting of the gun, a fragment of which struck 
him in the median line at the*root of the nose. I saw him in about 
twenty-five minutes after the occurrence. The hemorrhage, which was said 
to have been profuse, had nearly ceased. At the moment of the accident he 
was prevented from falling by a person near him. He then walked into the 



86 Thompson's Case of Gun-shot Wound. QJuly 

house, a distance of about 40 yards. I found him, although suffering ago- 
nizing pain, in the full possession of his mental faculties, which he had not 
indeed for a moment lost. Considerable tumefaction had occurred in the 
injured parts. The wound resulting from the accident commenced a little 
above the transverse suture, and extended directW down the middle of the 
nose. It was three quarters of an inch in length, by one quarter in breadth. 
The nasal bones were completely demolished, the frontal sinuses were laid 
open, and the upper turbinated bone was torn off. This much of the injury 
could be distinctly seen. The missile after entering had taken an oblique 
direction behind the right eye. Its ultimate course could not be accurately 
traced, owing to the extreme sensibility of the wounded parts; nor indeed 
was it deemed proper to persevere in the attempt, since it soon became evi- 
dent that the foreign body had penetrated so deeply as to render it highly 
probable, that more injury than benefit would result from the search. The 
right eye protruded more than half an inch beyond its ordinary level. This 
protrusion was an immediate consequence of the accident, and therefore led 
to the supposition that the optic nerve was destroyed. The patient referred 
all his pain to the rigrrt eye. The sensibility of this part was so acute, that 
the slightest touch — even a drop of water falling upon it, brought on spas- 
modic action of the whole muscular system, and rendered the dressing of the 
wound a task of great difficulty. Dr. Swing, an experienced practitioner, 
residing at Sharpstown in this county, was called in consultation with me, 
and continued to attend the case until its termination. Several loose frag- 
ments of bone were removed from the wound, and cold water dressings were 
applied. It is not necessary to enter further into the treatment than to say, 
that the strictest antiphlogistic plan was adopted and rigidly pursued. Dur- 
ing the first and part of the second day, this amiable and unfortunate young 
gentleman retained the perfect possession of his senses. He answered all 
questions readily and with entire consistency — knew his friends — called 
repeatedly for different members of his family — made use of the most tender 
and endearing expressions towards them — in short, his mental faculties ap- 
peared to be unimpaired. There was no paralysis manifested until a few 
hours before death, when the left arm became motionless. Delirium came 
on, on Tuesday afternoon, and continued with short intervals until the termi- 
nation of the case. Suppuration was speedily established; several consider- 
able fragments presented themselves, and were removed. At the second 
dressing, a small quantity of cerebral substance issued from the wound. 
Death occurred on Friday morning, four days after the reception of the in- 
jury. Permission for a post-mortem examination was granted, on condition 
that we would make no incisions, nor in any way disfigure the body. We 
were therefore limited to a mere inspection of the wound. This is to be 
regretted, since it would have been interesting to have ascertained with pre- 
cision, the exact nature and extent of the injury which had been inflicted. 
Tumefaction having subsided, the wound now presented a very different ap- 



1843.] Thompson's Case of Gun-shot Wound. 87 

pearance. It measured one inch and an half in length, and an inch in breadth. 
A fissure commencing a little to the right of the median line, extended per- 
pendicularly about two inches up the os frontis. As before mentioned, the 
frontal sinuses were opened; two or three considerable fragments of the inter- 
nal table of the os frontis were depressed. The wound was filled with the 
softened substance of the brain, and with pieces of bone. As well as could 
be ascertained by the introduction of a finger, all the bones entering into the 
composition of the orbit, with the exception perhaps, of those forming the 
anterior part of the floor, were broken up. The right eye was completely 
torn loose from all its attachments to the posterior part of the orbit. Through 
a large opening formed by the fracture of the orbitar plates of the sphenoid 
and os frontis, the finger could be passed into the skull. As far as it 
could be reached in this way, the brain was in a pulpy condition. No foreign 
body could be detected. A probe, however, at length made it apparent. It 
proved to be the whole breech-pin of the gun. The large end, or that part 
which is screwed into the barrel, was over or upon the petrous portion of 
the temporal bone, the small end was near the opening which its passage had 
made in the bones of the orbit. The weight of this piece of iron (which is 
now in my possession) is two ounces; it is two inches and three quarters in 
length. Its extraction was attended with considerable difficulty. It could 
not in fact be removed until we had taken away, with strong forceps, the 
depressed portions of the os frontis. 

Here was a most extensive laceration of the brain from a foreign body 
which remained imbedded in it, large fragments of bone were depressed, 
and in all probability spiculse were driven into the cerebrum, yet none of the 
ordinary signs of such an injur}'' were present. There was no loss of con- 
sciousness — no symptoms of compression — no paralysis until a few hours 
before death, — and until delirium came on as a consequence of inflammation 
of the brain, the operations of the mind were unimpaired. It is presumed 
that in so dreadful an injury as this, the case would necessarily be considered 
hopeless, although Larrey, Dupuytren, and indeed all surgeons relate instances 
of recovery after more or less extensive injury of the brain. There are upon 
record at least two examples of wounds from precisely the same cause as the 
one which came under my observation. The first is related by Dr. Rogers, 
(Vide Am. Journal of Med. Sci., for 1828. The account is extracted from 
Med. Chirurg. 7rans.) In this case the breech-pin of the gun remained in 
the left hemisphere of the brain for 27 days. The patient recovered with 
the loss of the sight of the left eye, and with his mental faculties unimpaired. 
In the second case both hemispheres were wounded to the depth of an inch 
and an half by the breech-pin of a gun, which struck the subject of the injury 
in the middle line of the frontal bone. (Vide Am. Journal of Med. Sci. y 
for 1830, where the account is taken from the Edinburgh Medical and Sur- 
gical Journal.) In this case also, the patient perfectly recovered " without 
the slightest alteration in mental power." 



88 Wharton on Sphacelation of the Male Organs. QJuly 



Art. X. — Sphacelation of the integuments of the Male Organs of Genera- 
tion, successfully treated. By W. L. Wharton, M. D., Surgeon, U. 
S. Army. 

James Wallace, aged 31, carpenter by trade, temperate man, solicited 
my assistance at "Fort Gibson," Ark., in August, 1840. Has been work- 
ing amongst the " Cherokees" for the last few months, and the previous 
week, has had connection with a " squaw" during her period of menstrua- 
tion, neglecting the necessary precaution of ablution. 

I found on examination complete phimosis, total obstruction of the passage 
of urine, great distension of the cellular structure of the penis, and the scro- 
tum enlarged to a degree as almost to prevent his walking. This condition 
has existed three days. Failing in the first 12 hours to remove the phimosis 
by ordinary means, I had resort to a division in part, of the prepuce, at the 
same time relieving the distended scrotum by puncturing. 

The subsequent treatment proving ineffectual in checking the irritation, 
the progress of the case terminated in a few days in sphacelation of parts of 
the prepuce, glans penis, cellular structure of the penis, (with an opening 
into the urethra, or its upper surface, about one inch in rear of the glans, 
through which the urine freely passed,) and of the entire scrotum, followed 
almost immediately by sphacelation of the integuments of the right inguinal 
region. 

As may be imagined, the horrible appearance of the patient was enhanced 
by the quantity of maggots attacking the sphacelated parts. 

Doubtful at first of the success of any treatment which might be adopted 
for the restoration of the parts, I had the gratification to perceive the degree 
of irritation thus far, was sustained" by the patient without much inconveni- 
ence, affording, at least, assurance of his strength of constitution. 

Premising the treatment at this juncture with an aperient to remove costive- 
ness, my next object was to restore as speedily as possible the urine to its* 
natural passage. This I happily attained in a reasonable time, by a catheter, 
of a size that, whilst its introduction could be readily effected, its perma- 
nency as long as required, did not cause irritation or inconvenience, aided 
of course by local applications to the orifice in the urethra. 

Glad to discover at this stage, that the parts in the vicinity of the disease 
were assuming a healthy condition, my attention was directed to the consti- 
tutional treatment of the patient, my principal reliance being opium, which 
though occasionally exhibited at the commencement, was now steadily ad- 
ministered in increased quantities, with the addition of more nutritious diet, 
and occasionally wine. This treatment of the case, though protracted about 
five weeks, was eventually successful, resulting in restoration of part to the 
inguinal region, and covering to the testes, with loss of portions of the pre- 
puce, glans penis, and cellular structure of the penis. 

Though unconnected with the case, I will allude to the fact, that no portion 
of the profession have a greater field for the treatment of ulcers, than those 
belonging to the " military" and "naval service." This, as readily appears, 
arises from the materiel in part constituting the ordinary "soldier and sea- 
man." From much attention to the treatment of ulcers, more especially 
those of the lower extremities, I have found nothing so materially retard 
their cure, as the hairs on, and about them. I could mention many cases, 
in which after untiring efforts to heal an ulcer, the simple removal of the 
hairs matted on the surface thereof, has been followed by a speedy cure. 



1843.] Shipman on Poisoning with Lead. 89 

A late distinguished "surgeon," of the "United States Navy," employed 
for the cure of the inert ulcer, particularly of the lower extremities, an ordi- 
nary domestic poultice, rendered stimulating by the addition of some spirituous 
liquor. 

Fort Leavenworth, Mo., Nov. 23, 1842. 



Art. XI. — Poisoning ivilh Lead. Bv A. B. Shipman, M.D. of Cortland- 

ville, N. Y. 

On the night of the 8th January, 1842, I was called to the village of 
M'Laen, Tompkins Co., to consult with Drs. Hall and Chapman, in relation 
to some cases of poisoning with lead in the family of Mr. Horace Baker. 

The history of the ceases, as given by the physicians and family, is as fol- 
lows: about six weeks previously some new cider was poured into a wash 
tub which had been newly painted with white lead and linseed oil, inside 
and out, and the family, consisting of the man, his wife, three or four children 
from the ages of six to two years, and a hired man began drinking* it. The 
cider was drunk at meals, the most of it by Baker and his hired man, 
and the least by Mrs. B. and children. The use of it was persevered 
in for nearly four weeks. The family remarked that after a few ilays the 
cider had a smart pungent flavour, then became dead and flat, and after a few 
days more became more lively, but rather hard. The first effects were per- 
ceived in the children, particularly a small boy who had taken quite libe- 
rally of it, and began about two weeks after first commencing its use. His 
mother perceived that his gait was awkward and that he frequently tumbled 
down in crossing the floor, and that he staggered and complained that it hurt 
him to walk, and that his feet pained him, especially the bottoms of them. 
Soon the other children complained in a similar manner; they also com- 
plained of feeling sick at the stomach; cutaneous eruptions made their ap- 
pearance on the legs, arms and face of a vesicular character. 

The next taken was Baker, then his man, and next Mrs. Baker; as their 
symptoms were nearly alike, I shall describe them in common. The first 
symptom was slight nausea which continued several days, with a load at the 
pit of the stomach, then a soreness and tenderness of the soles of the feet, 
when first getting out of bed in the morning, so much so as to be unable to 
walk without first rubbing them, and then there were pains in the limbs which 
they supposed was rheumatic; cutaneous eruptions also made their appear- 
ance. The soreness in the. soles of the feet disappeared in the course of the 
day, after taking exercise and getting warm. The next symptom was 
severe colic, pains fn the bowels which took place several days subse- 
quent to the affection of the feet and legs, and from four to five weeks after 
first commencing the use of the cider. Being now satisfied that the cider 
caused the difficulty, its use was abandoned and a physician called who 
treated them with bleeding, cathartics and anodynes. The symptoms were 
obstinate, and continued so with little abatement for four weeks. The 
bowels were obstinately costive, tongue dry, with a dark streak in the centre; 
abdominal muscles retracted and rigid; anorexia, with little fever and 
scarcely any disturbance of the circulation. Mrs. Baker soon recovered, not 
having taken much of the cider, as did also the children. But Baker and 
LaJd his hired ma i were a 'ong ti ne in getting well, and even at this time 



90 Shipman on Poisoning ivith Lead. [July 

are troubled with colic, and pains in the soles of the feet, with cutaneous 
eruptions. Venesection and anodynes with cathartics of sal. epsom and ol. 
ricini constituted the treatment. Alkalies and mucilages were also freely 
used. A hired girl who lived in the family and who did not use any of the 
cider, was the only one who escaped a fit of sickness. 

The pain and soreness in the soles of the feet were peculiar, and were 
the first and prominent symptom in every case, and the cutaneous erup- 
tions were also peculiar. The above is an example of the slow and gradual 
introduction of lead into the system, and its effects were in proportion to the 
quantity imbibed. 

I fear that acetate of lead is not used by medical men as an internal 
remedy in hemorrhages and other complaints, where it is recommended in 
books, with that caution which the nature of the article requires. By many 
it is a kind of cure-all for hemorrhages of every kind, diarrhoea, &c. It 
is a remedy which may induce a worse train of evils, if used without proper 
precautions, than the disease for which it is prescribed. A deplorable case 
fell under my observation some years since which I am induced to believe 
was wholly caused by the injudicious use of acetate of lead. A lady setat. 
about 35, mother of five children and of a good constitution, suffered abor- 
tion in the third month. The placenta was retained three or four days and 
some considerable hemorrhage followed. To restrain it, the acetate of lead 
was given freely every two or three hours. I was called on the 4th day 
and removed the placenta, when the hemorrhage ceased, and although she 
had not lost blood enough to sap the foundations of life — yet she never re- 
covered. Complete prostration of the powers of digestion, obstinate con- 
stipation, and spasms of the bowels and abdominal muscles with colicky 
pains, the gums became spongy and ulcerated; and before she died vibices 
and spots like purpura hemorrhagica made their appearance. She lingered 
three months, and died a painful and miserable death. 

The past summer a young lady setat. 16, of a delicate constitution and 
nervous temperament, had been troubled with profuse menstruation, at times 
amounting to menorrhagia for many months; I had always been successful 
in controlling it with the persesquinitrate of iron and kino; being absent when 
she was taken, a young practitioner was called in who gave her Dover's 
powder and acetate of lead. After taking several doses, the hemorrhage 
ceased, but violent pain in the bowels came on attended with obstinate vomit- 
ing, spasms in the arms and legs, constipation and fever, with most exqui- 
site tenderness of the bowels, which continued several days. Large doses 
of morphine and fomentations to the bowels with mercurials finally relieved 
her, and she has nearly recovered her accustomed health. 

In 1838, I was called to attend a lady, 47 years of age, who had been 
troubled for three years with uterine hemorrhage, and had been taking the 
acetate of lead and opium for the last two or three months — the hemorrhage 
had been less since the use of the remedy, but severe and constant pain in 
the bowels with much tumefaction, and prostration of the digestive powers 
was the result: a discontinuance of the lead and a substitution of the perses- 
quinitrate of iron with laxatives of the syrup of rhei, restored her to comfort- 
able health, and she has remained so to this time. 

In an alarming hemorrhage where it is necessary to use prompt and effi- 
cient aid, a dose or two of the acetate well guarded with opium may be 
advisable, and is probably the best means we possess. But where the case 
is not urgent, and its use persevered in for some time, I do believe from what 
I have witnessed that it should not be employed. 



1843.] 91 






BIOGRAPHY. 



Art. XII. — Biography of Thomas C. James, M. D. By Hugh TJ. 
Hodge, M. D., Professor of Obsterics, etc. in the University of Penn- 
sylvania. Read before the College of Physicians of Philadelphia. 

Some years have now elapsed since we were deprived of one of the or- 
namcnts of our profession — the late venerable President of this College, 
Dr. Thomas Chalkley James. His death, though at last sudden, had 
been long expected by himself and friends from the evident decline of his 
health, and from the premature approach of those infirmities which too 
surely indicate the decline of life. 

We all knew him. We all loved and respected him. It could not be 
otherwise. The senior members of this college viewed him as a friend 
and brother, who had always been their chosen companion and their fel- 
low labourer in all the duties of this society, and of the profession to which 
they were alike devoted. The younger members looked on him with 
love and veneration, for he had been their medical teacher — their friend, 
their counsellor, and, as far as practicable, their benefactor. His example 
had always been presented, as most worthy of imitation. And, when he 
departed, they felt, and still feel, as if one important link in that golden 
chain which binds this generation to the past, was, unfortunately for them, 
severe:!. 

The college lost one whose devotion to its interests had been sincere 
and long continued; and whose virtues, age, and experience had deservedly 
placed him in the most prominent station in its power to bestow. 

To his immediate survivors, it would therefore be useless to depict the 
character of our lamented president; but for our successors, and for pos- 
terity, the record should be made, not only that justice should be shown 
to him who always rendered ample justice to others, but that his example, 
virtues, and piety, should still benefit the profession which he adorned; 
and be presented to succeeding physicians as objects worthy of imita- 
tion. 

The most striking trait in the character of Dr. James was unfeigned 
modesty and diffidence. His conversation, his intercourse with his 
friends, with professional brethren, and even with students of medicine, 
his whole deportment indicated, that he did not rest upon his own senti- 
ments with that implicit confidence which would induce him to promul- 
gate his opinions, or to insist on their correctness or importance. He paid 
great deference to the opinions of others, and would hence submit to the 
guidance of those of an opposite temperament, really believing they must 
be better informed than himself. This native modesty, pervading his 
whole intellectual and moral nature, had the most decided influence on his 
professional course, and on his present and future reputation. 

Nevertheless, Dr. James, however reluctant he might be to promulgate 
his sentiments, or even to express an opinion, possessed a mind too pow- 
erful and too well furnished not to form positive opinions on almost every 



92 Memoir of Thomas Chalkley James, M. D. [J u ty 

subject to which it was directed, whether in literature or science. Those 
only who enjoyed his confidence, who were admitted into the favoured 
precincts of his private friendship, could discover how positive and correct 
were his sentiments; how discriminating his opinions, respecting men and 
things; and yet, how anxious to avoid having his views known, whether 
for praise or criticism. 

As a man Dr. James was also remarkable for great dignity, combined with 
mildness of disposition and gentleness of manners. He was entirely free 
from any thing approaching hauteur or stateliness; yet no one could look 
on him without feelings of respect, which were excited by his venerable 
appearance and by the native simplicity of his manners. He was affable 
and condescending to all, and never, in the latter years of his life, manifested 
undue excitement under the most trying circumstances. This gentleness 
of character was greatly the result of his own efforts; for gifted by nature 
with a warm heart and a sprightly imagination, he was prone in early 
life to be excited, when any dear friend or darling opinion was assailed. 
In subsequent years he had so fully obtained the government of his pas- 
sions, that no one even suspected that he could ever have been under their 
influence; a victory this, more difficult of achievement than those which 
have conferred celebrity on many of the heroes of the world. 

This self-command w r as the result of high moral and christian principles. 
As a young man, when his feelings and passions were ardent, he is 
believed to have been uniformly correct in his conduct and moral prin- 
ciples. Subsequently there can be no doubt that he was governed by the 
high principles of Christianity. To this important subject he devoted 
much attention. He studied the Bible as the source of all correct know- 
ledge on religious subjects, not only in his native language, but in the 
original Hebrew and Greek, and in the Latin, French, and German 
versions. He examined the various readings, the commentaries of dif- 
ferent authors, and the creeds of different sects of Christians. He ventured 
even within the perplexed mazes of theology, and endeavoured to elicit 
information and sound doctrine from the obscurities of theological meta- 
physics. His mind, however, was too strong to become confused by 
sophisms, and his heart too sincere in the love and pursuit of truth, to be 
lost in this extensive investigation. He returned from these excursions 
ladened with good fruit; and, after much inquiry among the living and the 
dead, he rested with child-like confidence, his hopes of immortal hap- 
piness on the simple declarations of the Bible. Frequently in the con- 
fidence of friendship has he confessed to the writer his great and over- 
whelming sense of the depravity of human nature; that he had no 
confidence in his good intentions, feelings, or actions; and that all his 
hope of pardon .and happiness rested on the merits and sacrifice of an 
Almighty Saviour. This solemn declaration was reiterated in the most 
impressive manner to his family and physicians, a short time previous to 
his dissolution, and was almost the last effort of that excellent man, whose 
life in the eyes of his fellow-men was irreproachable, but who regarded 
himself as vile in the sight of a Holy God. 

His life was governed by these principles. In conjunction with the 
diffidence and modesty of his character, they gradually separated him from 
the general intercourse of society. Although naturally of warm feelings, 
of ardent attachments, devoted to his friends, disposed to be s.ocial, and 
happily gifted with convivial talents, abounding with anecdote and infor- 
mation, Dr. James, in the latter periods of his life, studiously avoided all 






1843.] Biography of Thomas Chalkhy James, M. Z). 93 

social meetings. The collisions of sentiment, the scintillations of wit, as 
well as the ruder shocks which occasionally result from opposition of 
opinion in mixed societies, were too powerful for his refined taste and 
sensibilities. He was fond of reading and study, of examining intricate 
subjects in the quietness of his study, surrounded by the recorded facts 
and opinions of the mighty living and dead, and of thus forming slowly, 
but carefully, his own opinions. He devoted every moment to the acqui- 
sition of knowledge, which could be spared from the arduous duties of his 
profession, and from that delightful intercourse with his family to which 
he looked for substantial happiness. 

His main objects of pursuit were of a practical character, especially 
those which related to the duties of his profession and the demands of 
religion, but he always, especially in his youth, manifested a love for 
literature. He was fond of the belles lettres. In the early periods of his 
professional career he indulged a strong native taste and a sprightly imagi- 
nation, not only in rapidly ranging over the products of kindred minds, 
but in becoming himself a writer, even of poetry, and, in the opinion of 
partial friends, with no ordinary success, but never so much to his own 
satisfaction as to allow his name to be publicly connected with any of his 
productions. Several effusions emanating from a true poetic fancy, and 
suited to the circumstances of the day, became exceedingly popular, and 
gave him a publicity he studiously avoided. In the magazines of the day 
are to be found some sprightly and beautiful verses, entitled the •* Glow 
Worm," " The Eagle of Freedom," " The Country Meeting." A friend 
and cotemporary states that he well remembers the last mentioned pro- 
duction — that it was very much admired, and passed through all the 
magazines that were published, for several succeeding years. On the 
same authority it may be mentioned that in 1794 Dr. James accompanied 
the Western expedition as Surgeon of the " M'Pherson Blues," and on his 
return presented his friend with a copy of a very animating song which he 
wrote on a drum-head, at a time when great gloom pervaded the corps. 
It had a fine effect on their spirits — was set to music, and was sung 
through the camp for a long period. 

Under the signature of P. D., he published in the Port Folio for 1801, 
versified translations of the Idyls of Gessner, which were regarded by 
good judges to be entitled to " much and some to high praise for poetical 
merit," as well as exhibiting his accurate knowledge and fine perception 
of the German language and idiom. 

The imagination of Dr. James was, however, restrained by strong good 
sense, and by devoted attention to practical duties. Nevertheless literature 
was his delight and recreation. He kept pace with the publications of the 
day, and amidst the interruptions and toils of an arduous and self-denying 
profession, succeeded in gratifying his taste and refreshing his spirit by 
continual recurrence to these fountains of unalloyed pleasure. These in- 
tellectual gratifications were derived, not merely from publications in his 
native language, but from those in Latin, Greek, French, and German, 
with all which his knowledge was considered as so intimate that he could 
fully appreciate their merits and enjoy their most delicate allusions: thus 
keeping up an active interest in the republic of letters, and a peculiar 
fitness for intelligent and cultivated society. 

Intimately associated with these intellectual gratifications, was the inte- 
rest he manifested in the history of his native state, in the character and 
No. XI.— July, 1843. 7 



94 Biography of Thomas Chalkley James, M. D. [truly 

conduct of the earlier settlers, in the product of the soil, and especially in 
the richness and variety of its mineral productions. He was among the 
first to perceive and rightly to estimate the great value of the coal forma- 
tions — so numerous and varied in Pennsylvania — having commenced 
the use of anthracite coal in his own house as early as 1804, and having 
published* a memoir on its original discovery. He was among the 
founders of the society for commemorating the landing of William Penn, 
and also of the Historical Society of Pennsylvania. To these he devoted 
much of his leisure, took a warm interest in their success, and rejoiced in 
every new development of the original character and policy of the early 
settlers, in every discovery relating to the physical and moral character of 
Pennsylvania. 

It does not appear that Dr. James ever devoted much attention to the 
exact sciences. He was in tiie proper meaning of the term a Philosopher, 
- — a lover and a supporter of science; — but, irrespective of those branches 
which are involved in his profession, he left to others minuteness of 
detail, and contented himself with mastering the general principles, and 
lending his influence for the support of scientific men and institutions. 
Being early made a member of the American Philosophical Society, he at 
one time attended its meetings, acted as its secretary, and was interested in 
their transactions; but afterwards he but seldom appeared, and, it is believed, 
never contributed any paper, except on medical subjects, to their publica- 
tions. 'He preferred the seclusion of his study to the bustle of the society, 
and the lighter walks of literature to the rougher paths of science. 

It is as a medical practitioner that Doctor James was best known to this 
community, and especially to the members of this college. In this cha- 
racter, who has not known and admired him? Who is not ready to 
present him, as regards his disposition, his virtues, his sentiments, his 
manners and deportment, as a model for the young physician? His 
whole conduct proved that he was governed by those high-elevated senti- 
ments, which result from an enlightened and gifted mind, — sustained by 
all that virtue and religion impart, to purify and exalt the human character. 
As a physician, he was especially distinguished for the benevolence and 
kindness which characterized his intercourse with his patients. He was 
anxiously devoted to their welfare, sympathized with them in their suffer- 
ings, and laboriously exerted himself at all seasons to remove or meliorate 
their trials, not only by administering the usual professional remedies, but 
by inspiring confidence, elevating their hopes and expectations, changing 
the current of morbid thoughts and feelings by his cheerfulness, intelli- 
gence, extensive information; by the pleasant and elevated tone of his 
conversation, abounding in humour and anecdote, calculated to lead off the 
mind diseased from the contemplation of its sufferings, to more delightful, 
if not engrossing subjects; and to afford the stimulus of hope — so powerful 
in resuscitating the depressed energies of body as well as mind. The 
benevolence of his disposition was also manifested in his gratuitous and 
disinterested services to those unable to reward his attentions by any other 
recompense than the overflowings of a grateful heart: and, not unfre- 
quently, by services to those who in the hour of health and of prosperity, 
remember, not even with gratitude, the devotion and anxieties of that man, 
who under Providence restored them from the brink of the grave, to life, 
health, and happiness. In all such cases, it was the uniform practice of 

* In vol. ii. p. 154, part I. of the Trans, of the Historical Society. 



1843.] Biography of Thomas Chalkley James, M. D. 95 

Dr. James to submit to injustice, rather than have any unholy passions 
excited in his bosom by the wickedness of others. 

In his attentions to patients he was unremitting and persevering, even 
when the infirmities of declining health might afford a suitable excuse. 
When the extent of varied character of his practice is considered, when 
it is known that much of his time was occupied with obstetrics, and, of 
course, that his hours of rest and sleep, as well as those allotted to recrea- 
tion or business, were thus encroached upon, it will be found no mean 
praise that none complained of his remissness or neglect. The wonder is, 
that business such as his could have been, in any manner, suitably trans- 
acted. 

Although Dr. James was remarkable for the kindness of his feelings, and 
the suavity of his manners towards his patients; although the benevolence 
of his character may have occasionally inclined him to be too lenient in 
enforcing his prescriptions; yet he never compromised the dignity of his 
profession. None of the modern forms of empiricism, however supported 
by nominal physicians, received any countenance from him. His appear- 
ance, manners, conversation, sentiments, — all evinced the instructed and 
polished practitioner, who never condescended to the minor arts, by which 
lesser minds attempt to advance their temporary popularity, forgetful of 
their permanent interests and of the welfare of the profession. Dr. James 
at once cast his professional interests on his moral and intellectual charac- 
ter; he maintained, steadily, but quietly, and without offence, his personal 
and professional dignity, and with a result, every way encouraging to the 
young practitioner. He did not, it is true, at once command an extensive 
practice; but he gradually, but surely, fixed on himself the confidence of 
the community in his integrity, virtue, benevolence, intelligence and pro- 
fessional attainments, — a confidence eventually manifested by an over 
abundant practice; a confidence which gained strength with his years, 
until the withering hand of time, rendered, in his case, more influential by 
watchings, anxieties and fatigue, advised him, as well as others, that his 
course was to close sooner than his friends anticipated. 

As a practitioner, he was remarkable for his knowledge, and for his 
judgment in the selection and application of remedial measures, rather than 
lor the novelty or boldness of his piescriptions. He was well read in his 
profession, learned in the opinions and practices of others, well imbued 
with all that collateral information, so important for all professional men, 
especially for the physician; and interested in every thing suited to advance 
the interests of the profession, to enlarge the boundaries, or to increase the 
efficiency of medical science. He was a scientific physician; not governed 
simply by authority, or by the experience of himself or others, but regu- 
lated by principles derived from anatomy, physiology, and pathology. He 
was, however, a practical physician; that is, he was never led astray, or 
unduly influenced by novelties, by specious theories, by the crude notions 
of men of talent or genius, but always adhered to those principles and re- 
medies, which, while they were sustained by scientific rules, had received 
the testimony of experience in their efficiency. Hence he was not one of 
the pioneers of the profession — not one who was remarkable for the novelty 
of his views, the importance of his discoveries, or the boldness of his prac- 
tice, — but he was numbered among that most respectable and useful class, 
who, by the exercise of a discreet judgment, under the guidance of science 
and experience, profited by the discoveries of others, perhaps of more 



96 'Biography of Thomas Chalkley James, M. D. [J"ty 

genius, and of more energy and enthusiasm; and at the same time avoided 
the errors into which such geniuses often fall, and the mischief they not 
^infrequently produce. 

As an obstetrician, he was chiefly known to the inhabitants of this city 
and of our country; and great are the obligations under which society is 
placed to him and a few of his cotemporaries who, by their talents, edu- 
cation, learning, manners and accomplishments elevated and adorned a 
department of the profession which had been unaccountably neglected, and 
was, in this country especially, in a degraded condition. 

As a practitioner of obstetrics, Dr. James manifested the same kindness 
and benevolence of disposition, the same prudence, discretion and judgment 
for which he was distinguished as a physician, and which gave him an 
eminent station as an accoucheur. As an operator, he was also skilful and 
prudent: occasionally also bold and decisive when the circumstances of 
the case demanded his assistance. His natural diffidence of himself, his 
fear of responsibility, his deference to the opinions of others, pre- 
vented however his obtaining that self-command and that composure 
essential for greatest eminence in the operative department of obstetrics. 
Nevertheless a large proportion of our physicians resorted to him for 
assistance in cases of difficulty and danger with the happiest results. 

As a teacher of obstetric science, his success was also great. Com- 
mencing a system of instruction when no medical school patronized this 
department of the profession, when the prejudices of the community were 
greatly in opposition, and when even practitioners of medicine thought 
any peculiar tuition on this subject unnecessary, Dr. James succeeded in 
securing the attention of a very respectable portion of the pupils who then 
resorted to Philadelphia for medical instruction, and soon obtained an influ- 
ence in favour of tokology, by which the practice was rendered more 
efficient and extensive, and the importance of the science suitably acknow- 
ledged by the establishment of an independent professorship. Occupying 
the situation of professor, he was well and advantageously known to the 
full classes which annually resorted to the University of Pennsylvania. 
In him, they beheld the accomplished obstetrician, one whose mild, so- 
ciable yet dignified deportment, not only gained their respect but their 
affection; who not only secured for himself attention and confidence, but 
for his science, the devotion and interest which it so richly deserved. 

As a lecturer, it is not pretended that Dr. James was perfect; the critic 
might say that from the native peculiarities of his character, especially 
from that modesty and self-diffidence, that respect to the opinions of others, 
even of mere tyros in their profession, he wanted that boldness and deci- 
sion, that spirit and enthusiasm, that air of originality and self-confidence 
so interesting and impressive in a teacher, so calculated to fix attention 
and impart instruction. Nevertheless he was an excellent teacher. His 
lectures were handsomely and classically written; they were copious, 
abounding in matter, rich in illustrations, and indicating a mind of a supe- 
rior cast, well cultivated and enriched with literary, as well as scientific 
attractions. If he wanted originality, he was well versed in the opinions 
and discoveries of others; if he was deficient in spirit and boldness, his 
compositions evinced great taste, much reading and laborious attention to 
his subject, so that every lecture was a full and satisfactory essay on the 
subject, treated with suitable references to acknowledged authorities. His 
delivery, it may be inferred, was not very impassioned; he wanted more 



1843.] Biography of Thomas Chalhley James, M. D. 97 

energy, and more vigour in his voice and composition, yet he was always 
interesting from the mild dignity of his appearance and manners, and from 
the good sense and superior mental and moral character which marked the 
man and his productions. 

Hence he was a successful teacher. This is not the proper occasion 
to analyze the doctrines which he taught, or to examine the medical and 
chirurgical treatment which he recommended in the practice of obstet- 
rics. Suffice it to say, that receiving his early impressions from distin- 
guished English teachers, his views were founded mainly on British ob- 
stetrics. He examined, however, the productions of the French and other 
continental schools, followed their writers into that scientific detail, and 
those minute instructions regarding the mechanism of labour and the treat- 
ment of parturition therewith necessarily connected, which has distin- 
guished the French obstetrician, and so elevated the science of tokology. 
Profiting by all this accurate information, Dr. James still in his teaching 
and his practice, yielded to the influence of the English rather than of the 
French#uthorities, either from the influence of early impressions, or from 
a decided conviction of the superiority of the former. 

Unfortunately for the medical profession, as well as for the greater 
perpetuity of Dr James's reputation, he has not appeared before the 
public as a medical writer. The results of his accurate observation and 
extended experience have, with some minor exceptions, perished with 
him. Dr. James has published few opinions on professional subjects. 
This is to be regretted, for it seems hardly possible that the experience 
of a long life, devoted to the observation of disease, to the details of a 
profession so varied, yet so imperfect, as that of medicine, should not have 
furnished abundant material for the improvement of his science as well 
as for the amelioration of human suffering, especially when elaborated by a 
mind so well constituted and liberally furnished. Our regrets are unavail- 
ing, but this negative example should induce all of us who are actively 
engaged in professional duties to make that record of our experience and 
observations, which when age or ill health prevent active exertion, may 
be promulgated as our mite to the cause of science and the interests of 
humanity. 

The excellence of Dr. James's feelings, the exercise of his benevolence 
and his christian charity were not limited, however, by the duties of his 
profession. He was a promoter as well as a patron of many benevolent 
institutions. He was, as early as 1801, made physician to the Welsh 
Society; was for some twenty-five years on duty as a physician to the 
Pennsylvania Hospital, and was among the founders of the Union Bene- 
volent Society, which has been productive of so much moral as well as 
physical good to the poor of our city, whose means and influence are still 
increasing. Over this society Dr. James acted as president until the period 
of his death, giving impetus to its first and feeble efforts by his liberal con- 
tributions, and by the weight of his personal and professional character. 
He was also a warm friend of the negro. Actuated by a sound judgment 
and christian feelings, he*ardently desired his emancipation from moral as 
well as physical slavery: of course not that sudden emancipation which 
would send him forth upon the world as an infant or a child, incapable of 
providing for present or future wants; or as a savage, hungry, and re- 
vengeful; with his hand against every man, and every man against him. 
No: but for that gradual emancipation, which would first diminish the 
intellectual and moral darkness in which his brother was enshrouded, and 



98 



Biography of Thomas Chalhley James, M. D. [Juty 



then would knock off fetter after fetter, from the enslaved limb of the 
African, until lie could with confidence and exultation bid him walk forth 
a freeman; free from physical restraints to his body; free above all things 
from the slavery of ignorance and vice. Such were the views of Dr. 
James; hence he early lent his influence to the society (formed chiefly 
among Friends, and having for a long time the late excellent VVm. Rawle 
as its president,) for the abolition of slavery in Pennsylvania. In perfect 
consistency with these views he was among the first members, and for a 
considerable time the president of the Pennsylvania Colonization Society, 
believing that the true interests of the black would by this institution be 
most efficiently promoted. Perhaps it is known generally, that at that 
period, more than at present, these were not the general impressions re- 
specting the Colonization Society, especially among the society of Friends, 
who regarded the system of colonization with a jealous eye, as calculated 
to strengthen, not to weaken slavery in these United States. Dr. James 
was, therefore, unpleasantly situated with his most intimate friends and 
his religious society. He acted on this occasion in obedience#0 those 
feelings and principles which always governed him. He resigned " to 
please friends," anxious to avoid any thing which would gender strife or 
bad feelings, to avoid "even the appearance of evil;" although his own 
sentiments, as declared to the writer, remained unaltered. Another ex- 
ample in which the amiability, timidity, and modesty of his character, 
prevented him from taking that bold stand in which his influence would 
have been great, and, in the opinion of many, for nothing but good. 

Dr. James lent also the great weight of his character to the active mea- 
sures adopted for the suppression of lotteries, but his modesty was again 
shocked in being made president of the society for their suppression. He 
did not live long enough to see the triumph of these benevolent principles 
by which he and his colleagues were actuated, in the abolition of this 
nefarious business by the constituted authorities of the state. 

Such was the character of our late president, modest, retiring, distrustful 
of his own abilities; willing at all times to avoid responsibility, seldom 
acting therefore boldly and decidedly; but, nevertheless, a man of superior 
talents, well cultivated, with ardent feelings and social propensities, in love 
with literature and science, eminently prepared for the social circle, for 
literary and scientific society, and for the active, iaborious, and exhausting 
duties of the medical profession. As a physician, especially as an obste- 
trician, a noble example of the profession, venerable, not only for his 
appearance, but for his real excellencies. He was beloved and respected 
by all. His manners were courteous, affable, to the high and the low, to 
the learned and the unlearned, to the experienced practitioner in medicine, 
who came to solicit his advice, and to the student who was anxious to 
imbibe his sentiments on all subjects. Every word and look intimated the 
delicacy and puritv of the inner man, whose mind was stored with know- 
ledge, and whose heart was overflowing with kind feelings. " His cha- 
racter," says an intimate friend, Mr. Anthony iMorris, " belongs to that 
distinguished class in which the virtues appear more from a habit of doing 
every thing in the spirit of Christianity, than any thing in the spirit of the 
world. There was no display, but a consistency and conformity in every 
thing to the mind, and manners, and habits of the christian gentleman." 

It would be interesting, if practicable, to trace the gradual development 
of such a character from infancy to old age, to discover, if possible, the 
circumstances which favoured its growth, and to draw philosophical de- 



1843.] Biography of Thomas Chalkley James, M. D. 99 

chictions for (be improvement of the present or succeeding generations. 
Such hopes are vain, or nearly so; man is born with his peculiarities, 
with specific and yet complex sensibilities, and however similar the cir- 
cumstances of life and education of two or more individuals, entirely dif- 
ferent characters result. This is experience, ancient and modern, in 
opposition to the theories of philosophers. Still, our interest for the early 
history of the great ones of this world is not diminished, and when little 
can be learnt, as in the present instance, the disappointment is felt. 

The ancestors of Dr. James were originally from England, and on both 
sides were connected with the society of Friends. His maternal grand- 
father was Thomas Chalkley, (for whom the Doctor was named,) who 
for many years exerted by his talents, eloquence, excellencies and un- 
tiring industry, a most extensive influence among Friends in Europe and 
America. His life and correspondence have been published, and indicate 
the superiority and excellence of his character. 

His father, Mr. Abel James, was for many years one of the leading 
merchants in Philadelphia, and very successful. From a character pub- 
lished in the Columbia Magazine, for 1790, we learn that he was of an 
active, enterprising spirit, well prepared to devise plans for mercantile 
advancement, but disposed to leave to others the practical details and the 
efficient execution. Eventually however, he failed, and soon after, in the 
year 1790, Oct. 27th, died apoplectic, leaving his affairs in a state of de- 
rangement. His widow, with a spirit worthy not only of her pious ances- 
tor, Thomas Chalkley, but of that christian religion which she professed, 
gave up all her own private property, inherited from her parents, and never 
involved in the business of her husband, for the satisfaction of his creditors. 
Fart of her property was eventually restored, there being more than suffi- 
cient for the liquidation of the debts. 

Of such parentage was our friend and president: not usually termed 
noble, but far superior to that ancestry too often termed noble, which has 
no recommendation but external honours and decorations. Dr. James was 
born in Philadelphia, Aug. 31st, 1766, and was the youngest son. He 
was well educated after the manner of Friends, especially at their school, 
under the superintendence of Robert Proud, the historian of Pennsylvania. 
No doubt can exist, that his love of literature and of books in general, must 
have been at this period manifested, as his proficiency was early evinced,, 
and a superiority over his cotemporaries in this respect existed, which 
could not otherwise be explained. He commenced and prosecuted the 
study of medicine under the direction of that eminent practitioner, Dr. 
Adam Kuhn, a disciple of Linnaeus, whose opinion always carried weight 
among his medical brethren, and who had the honour of educating some of 
the first physicians of our country. In 1787, at the age of twenty-one, he 
received the certificate of bachelor in medicine from the University of 
Pennsylvania, of which his preceptor, Dr. Kuhn, was a distinguished pro- 
fessor. It was about this period that his father's affairs became deranged, 
and the desire of the son to have a complete medical education, then not 
to~be procured m America, seemed to be thwarted. He did not despair, but 
through the influence of friends, procured in the fall of 1788, the situation 
of a surgeon in the Sampson, a mercantile vessel, to the Cape of Good 
Hope and Canton, and by the results of this tedious voyage, was enabled 
to carry his anxious wishes into complete execution. His voyage was 
productive of no remarkable incidents, but gave opportunity for reading 



100 Biography of Thomas Chalkley James, M. D. [July 

and reflection, which was fully embraced, as well as for the exercise of his 
passive virtues. He returned home early in the summer of 1790, and soon 
afterwards completed his long contemplated preparations for finishing his 
medical education in Europe. After receiving advice and instructions from 
his experienced friends and preceptors, Dr. Adam Kuhn and Dr. Wistar, 
he sailed for London in the fall of the year. A short time before the death 
of his beloved and respected father, the intelligence of this melancholy 
event reaching him not very long after his anival. 

In London he found his countryman and fellow student, Dr. P. S. 
Physick, a pupil and an assistant of the celebrated Mr. John Hunter, pur- 
suing his studies in St. George's Hospital. By Physick's advice, Dr. 
James entered (May 30, 1791,) as a house pupil of the Story-street Lying- 
in Hospital, under the care of Drs. Osborne and John Clarke, the two 
leading obstetric practitioners and teachers in London. In this institution 
he had soon the pleasure of receiving as a companion, his friend Dr. J. 
Cathrall, who was also with him at Canton. The winter of 1701-2. was 
spent in London chiefly in attending lectures, and also as an attendant at 
St. George's Hospital. When relieved from professional studies for a 
short period, he availed himself of his letters of introduction, especially to 
the connections of his mother's family, and partook of the hospitality which 
was freely and cheerfully extended to him. He speaks in his letters with 
gratitude, of the attentions he received from friends, and also from that 
ornament of our profession, Dr. Lettsom, who treated him very kindly, 
and proffered him letters of introduction to Paris. 

After much deliberation respecting the relative advantages of spending a 
winter in Edinburgh or Paris, and after consulting by letter his friends on 
this side of the Atlantic, he finally followed the example of Drs. Physick 
and Cathrall, and went to Edinburgh in the spring of 1792. Here he re- 
mained and attended the lectures during the succeeding winter, in com- 
pany with Dr. Hosack of New York, and Dr. Ruan, one of our fellow 
members, whose acquaintance with Dr. James commenced at Edinburgh. 

It does not appear that Dr. James graduated at Edinburgh, in imitation of 
his friends, Dr. Wistar and Physick, being content with the honours of 
his own University in Philadelphia, then in its infancy. In the month of 
June, 1793, Dr. James, accompanied by Dr. Ruan, arrived at Wiscasset, 
in the then district of Maine. They reached Philadelphia a short time 
only before the terrible and then unknown epidemic, the yellow fever, 
visited this city. Dr. James had hardly time to receive the congratulations 
of his anxious friends, when the fatal scourge appeared, bringing dismay 
and terror, even to the boldest spirits. Before time was afforded him for 
exerting his talents and acquired knowledge for the benefit of others, he 
himself became a sufferer and for some time was disabled. He probably 
had but a slight attack, for in a letter dated Philadelphia, Sept. 20th, 1793, 
to his mother, he makes no mention of his own health, while he alludes to 
the dismal scenes which his family and professional duties had made too 
familiar. In the violent disputes which unfortunately existed among the 
leading physicians of the day, respecting the source and nature of the epi- 
demic, Dr. James, as might be supposed from his character, took little part. 
He however decidedly avowed himself as agreeing with Kuhn and Wistar, 
to whom his predilections and attachments had formerly been fully ac- 
corded. Still so slightly was he tinctured with prejudice, that when Kuhn 
and Wistar were absent from the city, he solicited the assistance of Dr. 



1843.] Biography of Thomas Chalkley James, M. D. 101 

Rush for a sick relative, as we learn from the above-mentioned letter to his 
mother. 

The winter dissipated the epidemic;, and of course the fears, although 
not the sorrows of the inhabitants of Philadelphia. Dr. James undertook 
the more regular business of his profession, but did not yet feel himself 
settled; for the ensuing year we find him acting surgeon to the " M' ''herson 
Blues, on the Western Expedition," as already mentioned. 

On his return from this military expedition, he opened his office and 
became a candidate for professional business and reputation in this city, 
under the most favourable prospects of success. The yellow fever had 
greatly thinned the ranks of the profession. Dr. Way and Dr. Carson had 
lately died. Dr. Dunlap, vvhp was extensively and almost exclusively de- 
voted to obstetrics, was advancing in years, and depended much, says Dr. 
' Ruan, on Dr. James, whilst his competitors, although numerous, were about 
his own age, and perhaps none of them possessed the advantages which 
Dr. James enjoyed. With the talents, attainments, extensive and com- 
plete medical education at home and abroad, now extending to at least eight 
years of preparation, was conjoined great personal attractions. His figure, I 
am informed by one who, although his junior, became acquainted with him 
about this time, was nearly perfect; his features handsome, his expression 
open, candid, cheerful; his manners pleasant, and his conversation, when 
he felt unrestrained, was of the most elevated character, abounding, as a 
friend and relative informs me, with information, cheerful, occasionally 
eloquent, and always replete with anecdotes well selected, and garnished 
by the corruscations of a poetic imagination. His family connections were 
of the most influential character; while his medical friends, Kuhn and 
Wistar, were the ornaments of the profession, and exerted an influence not 
second to those of any of their cotemporaries. Thus favoured by natural 
endowments, mental and corporeal, supported by family and professional 
influence, and blessed by providential arrangements, great expectations 
were entertained of Dr. James; his society was sought for; a connection 
with him was by all esteemed desirable, and his success in his profession 
was regarded as certain and rapid. These favourable presages were however 
not realized. His morbid sensitiveness, and his dread of responsibility, pre- 
vented his taking the lead in the professional race for reputation and prac- 
tice. He drew back under a mistaken notion of inferiority and unsuitable- 
ness. His friends however, acted judiciously and decidedly. They made 
him assume his proper station, and gradually bring his strength into compe- 
tition with that of his cotemporaries. This alone was necessary; he gained 
confidence, so that in the course of a few years he ventured to teach, as 
well as to practice his profession, and, having about this period married 
Miss Hannah Morris, (a lady connected with one of the first families in 
Pennsylvania, eminently adapted by her mild, but decided character, her 
judicious, yet cheerful disposition to meet the peculiarities of Dr. James's 
character,) his success became certain, business rapidly increased, and his 
time became fully occupied with patients and pupils, all of whom admired 
and loved him. 

In 1802, Nov. 17th, Dr. James, in conjunction with the late Dr. Church, 
commenced his first regular course of lectures on obstetrics. It was al- 
together a private course, entirely unconnected with the University or any 
corporate institution, resting for success on the merits of the lecturers alone. 
It was quite successful, commencing with twenty pupils, who had th,e 



102 Biography of Thomas Chalkley James, M. D. [Juty 

good sense to devote time to this neglected department of medical science. 
This was not the first effort to teach obstetrics in our country; for some 
lectures were delivered by Prof. Shippen in the University of Penn- 
sylvania, and Dr. Devvees lectured prior to this period in 1797; but it 
seems to have been the first regular and sustained effort; the commence- 
ment of that chain of circumstances which has elevated the science of 
Obstetrics to a co-ordinate rank with the other medical sciences, in the 
opinion and confidence of the community through the whole extent of our 
country. To render his teaching useful, Dr. James, assisted by Dr. Church, 
not only employed the usual modes of illustration, but zealously endea- 
voured to instruct practically, as well as theoretically. For this purpose 
his influence and exertions prevailed in having a " lying-in ward" (the first 
in this city) established at the Almshouse, over which he presided as at- 
tending accoucheur. To each case of labour was admitted not only the ' 
resident pupils of the house, but three of those attending the lectures, so 
that in succession all were furnished with cases, the peculiarities of which 
were duly explained. 

The first course of lectures terminated on the 2d March, 1803, the 
second commenced May 10th of the same year. So that two courses were 
delivered every year for three years. On the death of Dr. Church, which 
occurred about this period, Dr. James associated Dr. Chapman with him- 
self, lecturing with him during the winter of 1807-8, and subsequently as 
a private and public teacher. 

In 1808 Dr. Shippen died, and Dr. Wistar was appointed his suc- 
cessor, as Professor of Anatomy and of Midwifery. Dr. Wistar imme- 
diately perceived that these two departments of medical science ought to 
constitute two distinct professorships. On the 3d of January, 1809, he 
communicated these sentiments to the Board of Trustees, but it was not 
until the llth of April, 1810, that the Board took action on this important 
proposal of Dr. Wistar, and declared by resolution that there should be a 
separate Professorship of Midwifery in the University of Pennsylvania; 
but singular as it now seems, they did not render it obligatory on the 
student to attend the lectures, nor did they place the Professor on an 
equality with his colleagues. 

For this new and important station — important, not only for the ex- 
pected incumbent, but for the interests of science and the cause of 
humanity, several candidates were immediately presented, and supported 
warmly by their respective friends and admirers. Dr. James had for his 
opponents Dr. Wm. P. Dewees, who had been practising midwifery 
since the year 1793 in Philadelphia with great success, and whose reputa- 
tion as a practitioner was then at its height. Also, Dr. N. Chapman, much 
younger than his rivals, but whose talents and attainments, whose vivacity, 
humour, and other social qualities, united with an excellent education in this 
country, polished by a visit to Europe, and with the influence of many 
and devoted friends, had attracted in a few years the admiration of our 
community. The election by the Trustees was made June 29th, 1810, 
and terminated in the elevation of Dr. T. C. James as Professor of Mid- 
wifery in the University of Pennsylvania, with the understanding that 
he should be assisted by Dr. Chapman. This was a most important 
epoch, not only in the life of Dr. James, but in the history of Medical 
Science, particularly of obstetrics in the United States. 

The first course of lectures in the University was commenced by the new 



1843.] Biography of Thomas Chalkley James, M. D. 103 

Professor in November, 1810, and although supported, not by any positive 
regulations on the part of the trustees, but merely by the indirect influence 
of the school, and by the personal character of the teachers, was attended 
by a large proportion of the medical students then assembled in Phila- 
delphia. 

In May, 1813, the medical profession lost one of its brightest ornamenls, 
Dr. Benjamin Rush, the Professor of the Theory and Practice of Medicine, 
whose life and opinions have become identified with the history of 
medicine in our country. He was succeeded by Dr. Benjamin Smith 
Barton in the practical chair, on the 14th July, 1813; while the chair of 
Therapeutics and Materia Medica, vacated by the resignation of Dr. Barton, 
was assigned to Dr. Chapman, on the 13th Aug., 1813, and Dr. James 
was left the Professor of Obstetrics without an assistant. On this interesting 
event, the following resolution was unanimously passed by the Board of 
Trustees in Oct., 1813: — " Resolved, that hereafter the Professor of Mid- 
wifer}- shall be a member of the Medical Faculty, and shall have all the 
power, authority, and privileges, belonging to a professorship in the said 
Faculty, and that no person shall be admitted hereafter as a candidate for 
the degree of Doctor of Medicine in this University, unless he shall have 
regularly attended the lectures of the said Professor for two years, pro- 
vided, &c." 

This triumph of truth and humanity over ignorance and prejudice may 
be considered as complete. Obstetrics was confessedly equal to the other 
practical branches of medical science; and its practitioners and teachers 
were authoritatively pronounced on a par with those of Surgery and the 
Practice of Medicine. The battle had been fairly fought and won, and 
Dr. James who, we have seen, contributed so much to this happy issue, 
received now the reward so eminently due to modest worth, superior 
talents and attainments, united with persevering industry. 

Large classes annually resorted to Philadelphia, and profited by the 
lectures and demonstrations of the various professors, which were contin- 
ually rendered more pointed and instructive, by the reiterated experience 
in the difficult art of teaching, and by the adoption of all the real improve- 
ments promulgated here or elsewhere. 

At this interesting period of the history of medicine in our country, it 
was the lot of many members of this society, and of the writer of this 
memoir, to form a professional, and afterwards a friendly acquaintance 
with the professor of midwifery. Some fifty years had passed over his 
head. Age had made an undue impression, owing perhaps partly to ori- 
ginal temperament, but more to mental and corporeal exertion, to anxiety, 
to loss of sleep and necessary exposure. He was partially bald, his hair 
whitened, and his form originally so perfect, was now somewhat bent, but 
his ruddy and healthy aspect, his fine countenance, his diffident yet re- 
fined manners, his affability, his condescension to medical students, his 
great intellectual and moral worth, excited feelings of affection and venera- 
tion in the minds and hearts of all. 

Dr. James continued to lecture without assistance, to the increasing 
classes of the University until 1821, when, with the desire of relieving 
himself of a portion of his duties, but especially with the wish of rendering 
the course more valuable, he requested the assistance of the then adjunct 
professor of anatomy, Dr. Horner, in demonstrating the anatomical portions 
of the lectures, and in exemplifying to the sub-classes, the mode of per* 



104 Biography of Thomas Chalkley James, M. D. [July 

forming obstetric operations. Soon, however, the lamentable fact began 
to be apparent to Dr. James, as well as to the pupils, that his physical 
powers were failing. A nervous tremour was occasionally observed in the 
lingers of the right hand; gradually but very slowly, it extended to the mus- 
cles of the right arm; and in a few years involved all his nervous and mus- 
cular system, exciting the symptoms of a premature old age, and indirectly 
becoming the cause of his death. Soon after, his voice began to fail, so 
that great attention was requisite to hear him during the lecture. He ap- 
plied to the trustees for an assistant to his chair. In consequence of this 
suggestion, the following resolution was passed on the 18th of October, 1825: 

" That an Adjunct Professor of Midwifery be appointed, who shall hold 
his appointment so long as Dr. James continues to be Professor of Mid- 
wifery: Provided that the expenses of the student shall be in no manner 
increased by such appointment, and that such an Adjunct Professor shall 
have no vote in the Faculty of Medicine, except in the absence of the Pro- 
fessor af Midwifery to whom he is adjunct." 

On the 15th of November, 1825, Dr. William P. Dewees was unani- 
mously elected adjunct professor under the foregoing resolution, and im- 
mediately entered on the duties of his new situation. 

With this valued reinforcement, Dr. James continued for some years 
longer to exercise his duties at the University and in private practice, but 
the annual increase of his nervous tremours seemed continually to diminish 
the strength of his voice and the activity of his body. Eventually, most 
of the lectures having been in the year 1833-34 delivered by Dewees, Dr. 
James in justice alike to his own character, to Dr. Dewees, and the Uni- 
versity, resigned in the month of June, 1834, his professorship, of which 
he in a great measure, may be considered the founder, and the reputation 
of which he sustained for the long period of twenty-four years. 

We have already intimated the manner in which those duties were dis- 
charged, with how much affability and dignity combined, with what purity 
of diction his instructive lectures were delivered, and how the love and 
veneration of the students were extended to one to whom the profession 
and the public were so much indebted. 

During his professional career, he became engaged also with many 
private and public institutions as physician in ordinary, or as consulting 
physician; among others, with the Welsh Society, St. George's Society; 
also with the Philadelphia Dispensary, where for many years he was con- 
sulted by the attending physicians, many of whom, with much gratitude, 
bear testimony to the value of his assistance, and to the readiness and cheer- 
fulness with which it was at all times rendered. As formerly remarked, 
he might be regarded as the founder of the " Lying-in department" of the 
Philadelphia Almshouse Infirmary, over which he presided until about the 
year 1807, endeavouring to render it practically important for students of 
medicine. In 1807, (Jan. 26,) he was appointed Physician to the Penn- 
sylvania Hospital, as successor of Dr. J. Redman Coxe, and on the 25th 
of June, 1810, was translated at his own request to the station of obstetric 
physician. The duties of this appointment he continued to discharge with 
scrupulous attention and punctuality, until the 26th of November, 1832. 
He watched over not only the interests of his immediate department, but 
the other portions of the establishment, and paid great attention to the me- 
dical library of the hospital, the improvement and increase of which he 
facilitated very much by his advice and recommendations. At his resigna- 



1843.] Biography of Thomas Chalkley James, M. D. 105 

tion, the board of managers made the following minute on their records: 
"A letter from Dr. Thomas C. James was received, resigning the station 
of obstetric physician afler twenty-five years service most acceptably in 
this institution. The managers, on parting officially from the Doctor, tender 
him their acknowledgments for his long, faithful, and useful labours, and 
assure him of their cordial regard, and best wishes for whatever may con- 
tribute to his future happiness. The secretary is requested to furnish Dr. 
James with a copy of this minute." 

In the Philadelphia Medical Society, Dr. James was an honorary member, 
but the exciting character of its debates never seemed to suit the quiet 
tenor of his feelings, and he rarely, at least of late years, attended its meet- 
ings. To the College of Physicians he was much attached. Its quiet and 
dignified course well suited the peculiarities of his character. Within its 
precincts, he was sure to meet with his cotemporaries and personal friends, 
or with those who were gratified in numbering themselves among his 
pupils and admirers; and he there never anticipated that rude collision of 
sentiment, which, although it may occasionally elicit the spark of genius, 
too frequently generates the fires of envy and passion. He was elected 
Fellow of the College on the 6th of October, 1795, and in July, 1796, he 
succeeded Dr. Samuel P. Griffitts as secretary. The duties of that office 
he discharged for six years. In 1809 he was made treasurer, and continued 
as such for seventeen years; at the expiration of this period in 1826, he 
became vice-president, and finally in March, 1835, he was unanimously 
elected president as the successor of Dr. Parke. We all remember the 
interest which he took in the affairs of the college, the pleasure with 
which he attended its meetings, and the suavity and dignity with which he 
presided over its deliberations. Great however, as was his confidence in 
his associates, and anxious as he was for the improvement of medical sci- 
ence, he was unwilling to present his sentiments in written communica- 
tions to the society. With perhaps one exception, the papers he read were 
rather the history of facts than the detail of opinions. On the 9th of April, 
1804, he presented the history of a case of hydatids. On the 4th of Sep- 
tember, 1810, he gave the details of a case of premature labour, artificially 
induced by himself, in the case of a contracted pelvis, after the expiration 
of the seventh month, with the gratifying result of safety to mother and 
child. This is the first record, we believe in this country, of the scientific 
performance of this operation, for which much credit is due to Dr. James, 
especially as in America and Europe generally, it is still viewed with 
suspicious eyes, although in Britain, it is regarded as an established ope- 
ration in certain defined cases. 

On the 7th of August, 1827, he read a paper on extra-uterine pregnancy, 
in which he seemed anxious to establish the opinion from the historical 
detail of cases, that ventral or abdominal pregnancy never originally oc- 
curred; that tubal or uterine pregnancy had previously existed in cases 
where the child was found in the cavity of the abdomen; the tube or uterus 
having been ruptured or ulcerated, so as to allow the escape of the 
foetus from its original location into the peritoneal cavity. His reasoning 
from the anatomy and functions of the parts concerned, from the mode in 
which the foetus is sustained, and especially from the facts on record was 
ingenious and powerful; but facts subsequently detailed seem to confirm 
the opposite opinion, however improbable, that the ovum may be depo- 



106 Biography of Thomas Chalkley James, M. D. [July 

sited in the peritoneal surface and there be developed with its contents, in 
some instances, even to the usual period of utero-gestation. 

Connected with his efforts to favour the beneficial influence of the 
college, and the progress of medical science in our country, was the 
establishment and support of a most valuable periodical work, termed as 
evincive of its character the Eclectic Repertory, commenced in the year 
1811, and carried on for eleven years with great advantage to students^and 
practitioners of medicine. Although chiefly eclectic from foreign books and 
journals, many valued domestic and original monographs and cases were 
admitted, which enhanced the interest and importance of the publication. 
The names of the editors whose disinterested labours and judicious efforts 
were for a long time lent to this undertaking have not been published, but 
were known to most of the members of the college. They were Drs. 
Hewson, Parrish, Otto, James. The latter is well known to have spent 
much time in selecting and preparing suitable materials, although he did 
not frequently contribute original matter to its pages. 

Such are the most important and interesting facts which we have been 
able to procure, respecting the public and professional duties of our late 
President. There is another series of facts which might be brought into 
view as exceedingly interesting, but which have only an indirect bearing 
on his character before the world. We allude to hia private, his do- 
mestic history; but this is and ought to be a sacred subject, to be touched 
by no foreign hand. Suffice it to observe, that what Dr. James was abroad, 
he was at home, excepting that when in company with friends and rela- 
tions, reserve would be banished and his warm, full heart, would overflow 
in confidential and familiar intercourse with his family and friends. 

Thus blessed in his domestic relations, in his social circle, and in the con- 
fidence of the public as a practitioner and teacher of medicine, the moderate 
expectations of Dr. James were abundantly gratified; he had all that this 
world could bestow to render life happy and useful. He, however, felt 
and acknowledged that more was requisite to satisfy the wants of man, 
and he early found that religion alone can give zest to temporal enjoyments, 
and dissipate the dread of a future state of. existence so natural to the 
human soul. In this state of mind, looking forward to an eternity of in- 
creasing knowledge, holiness, and happiness, he died July 5th, 1835; 
leaving us, his surviving friends, and the medical profession, a bright ex- 
ample of the accomplished physician and the Christian gentleman, who 
always preferred the useful to the brilliant, and who, however others may 
have surpassed him in originality of thought and boldness of execution, 
was inferior to none in that pure morality, that unsophisticated integrity, 
that sound discriminating judgment, so essential for the practitioner of 
medicine; which exalt and dignify the professor, and render him a blessing 
to the community. 



1843.] 107 



REVIEWS. 



Art. XIII. — Traite Pratique de la pneumonie aux differ ens ages et dam 
ses rapports avec les autres maladies aigues et chroniques. Par A* 
Grisolle, D. M. P. Medecin 1U1 Bureau Central des Hopitaux et Hos- 
pices civils de Paris, &c, &c. &c. 

S. Practical Treatise on Pneumonia, as it occurs at different ages, and 
considered in its connections with other acute and chronic diseases. 
By A. Grisolle, D. M. P. &c. Paris, 1841, 8vo. 747 pages. 

This treatise, devoted to the consideration of one of the most frequent 
and fatal diseases to which we are subject, is the result, we are told, of 
six years persevering labour. It contains a summary of 373 cases, ob- 
served and recorded by Dr. Grisolle in the Paris hospitals. By far the 
greater number were cases of primary pneumonia; 69 however were met 
with in individuals already labouring under some acute or chronic affection. 
Dr. G. has made use also from time to time of materials derived from other 
sources, and examined the principal works of ancient and modern writers 
on the same subject, not confining himself to the office of a mere historian, 
but endeavouring to appreciate their value, arid to point out the fallacy of 
certain doctrines. Without further preface let us proceed to a more de- 
tailed consideration of the disease, and first of the 

Pathological Jinatomy. The anatomical characters of an inflamed lung 
are first described under the three heads of engorgement, red hepatization 
and purulent infiltration. According to Stokes, the stage of engorgement 
is preceded by one of injection and dryness; but as this view, however 
theoretically probable, is not satisfactorily established by direct observa- 
tion, our author adopts the ordinary division, and considers the state of 
engorgement as the first stage of the disease. In the second stage the 
lung becomes impermeable to air, resisting and heavy. In one case ob- 
served by our author the increase of density was such that the weight was 
ten times as great as that usually assigned to a healthy lung. Such instances, 
of course, are rare, and for their production require that nearly the whole 
lung should be hepatized. The state usually styled splenization, is also 
considered by our author as dependent upon inflammation, and belonging 
to this stage. In support of this conclusion he mentions having met with 
six cases presenting the symptoms of acute pneumonia along with the 
characteristic physical signs of the second stage, where the only lesion 
found to account for the phenomena was splenization of the lung. This 
condition is also sometimes found in connection with ordinary hepatiza- 
tion. After describing with great clearness the anatomical characters of 
the three degrees of ordinary acute pneumonia, their extent, &c. he goes 
on to speak of the lobular or disseminated form, so frequently though not 
exclusively met with in early childhood, in which the anatomical lesions, 
instead of occupying continuously a certain portion of the lung, are found 
scattered throughout it, isolated lobules being the seat of the affection. 
Why this form should especially occur in infancy is not satisfactorily 
determined. In connection with this form of the disease is noticed ano- 



108 Reviews. [July 

ther described by Andral under the name of vesicular pneumonia, charac- 
terized by a number of red granulations disseminated throughout the pul- 
monary tissue, an appearance which our author has not met with. 

He observes farther that the researches of MM. Rilliet and Barthez 
seem to show that this lesion described by Andral is nothing more than 
vesicular bronchitis, in which a portion only of the pulmonary vesicles 
being inflamed and becoming distended by a puriform liquid, the lung 
appears studded with a number of gray or yellow granulations, resembling 
tubercles, but distinguishable from them by the circumstance that when cut 
into, they give exit to a puriform liquid and then collapse. This lesion is 
evidently the same with that noticed by Dr. West of London, in a late 
interesting report upon the pneumonia of children,* under the title of 
vesicular pneumonia or bronchitis. Like the gentleman just mentioned he 
considers the lesion to have its seat in the extreme pulmonary vesicles, a 
fact which he says may be readily ascertained by tracing a minute bron- 
chus to its termination in one of these little sacs. Dr. West further ob- 
serves that it is a frequent complication of lobar and lobular pneumonia; 
but seldom constitutes the chief lesion. He mentions but one instance in 
which it was not surrounded by some other form of pneumonia. 

The much greater frequency of inflammation in the right than in the 
left lung, seems now well established by a mass of facts. This preference 
for the right side exists throughout all periods of life. Various explana- 
tions of this circumstance have been offered; some supposing that it was 
to be accounted for on the ground that persons more commonly lie upon 
the right side, others attributing it to the more forcible use of the right 
arm. It has also been accounted for by supposing a greater functional 
activity of the right lung, owing to its receiving a larger amount of blood 
than the left; but our author observes that the volume of the right lung is 
also greater, and probably its capacity. He thinks it more natural to 
attribute the greater frequency of pneumonia on the right side to the differ- 
ence in volume and capacity between the two lungs, since the greater the 
size, the more extensive must be the surface exposed to the action of 
morbific causes. To our minds this is hardly a sufficient reason, unless 
we admit at the same time a greater functional activity, in the production 
of which several of the circumstances above mentioned may concur. 

In reference to double pneumonia, our author's observations are in 
accordance with the experience of those who believe it to be a rare occur- 
rence. He found it in the proportion of one to sixteen of the whole num- 
ber of cases. Of course it is understood that this applies to the lobar 
pneumonia of adults; that of infants as well as lobular and metastatic 
pneumonia generally, being very commonly double. 

That the lower lobes are more frequently the seat of inflammation than 
the upper is fully confirmed by our author's observation, in whose cases 
the proportion was as 4 to 3. Various circumstances however modify this 
law, particularly the extremes of life and certain epidemic constitutions. 
Thus in infancy and old age the upper lobe would seem to be equally or 
even more frequently affected than the lower, and in certain epidemics 
there is an evident tendency to attack the upper lobes. The greater com- 
parative frequency of inflammation of the upper lobe at the extremes of 
life than during the intermediate period, is a strong if not a conclusive 

* The British and Foreign Medical Review, April 1843. 



1843.] Grisolle's Treatise on Pneumonia. 109 

objection to the opinion that the preponderance of inflammation of the lower 
lobe in adults is to be attributed to the influence of gravity in favouring 
congestion of blood, since this force should on the contrary exert its great- 
est power at those periods of life when the vital force was least capable of 
counteracting it. 

As regards the precise anatomical element of the disease, Dr. G. is of 
the mind that nothing positive can be asserted. It has always appeared 
to him that both the vesicles and the intermediate tissue were equally in- 
volved when the inflammation was established, and that the distinction of 
vesicular and intervesicular pneumonia was not borne out by facts. He 
inclines to the opinion indeed, that the vesicles are the especial or at least 
primitive seat of the inflammation which then extends to the cellular tis- 
sue, and that the independent affection of the latter has not been satisfac- 
torily made out. 

If from the primary idiopathic pneumonia of adults, we turn our atten- 
tion to the secondary form of the disease, we find that several of the laws 
above mentioned no longer hold good. Thus the preponderance is no 
longer in favour of the right side, and the simultaneous affection of both 
lungs, instead of being a rare, is here a frequent occurrence. 

Most competent observers are agreed in regarding true pulmonary ab- 
scess as a consequence of pneumonia, to be very rare. But a single 
instance has been met with by our author, whose description of this lesion 
is based upon twenty-two cases of it, derived from various sources. Having 
completed the description and pointed out the danger of mistaking collect- 
ions of pus between the pulmonary lobes, in tubercular cavities, &c. for 
true pneumonic abscess, he goes on to speak of consecutive and metastatic 
abscesses, and lastly of gangrene, a lesion which he has never met with 
amongst those who have fallen victims to acute idiopathic pneumonia. 

Having finished the description of the various anatomical characters pre- 
sented by the inflamed pulmonary tissue, he then passes to the considera- 
tion of the concomitant lesions of the pleura, bronchial tubes, heart, sto- 
mach, &c. Dilatation of the bronchial tubes was not met with, and he is 
inclined to think, that, in infancy where this lesion appears to be a fre- 
quent one in connection with pneumonia, it is less the result of the latter 
disease than of the bronchitis which so often complicates pulmonary 
inflammation in children. 

Dr. West states in the paper before quoted that he has frequently met 
with dilatation of the bronchi in children affected with pneumonia, and 
that it was especially marked in those cases where the inflammation had 
supervened upon whooping cough. The dilatation, he says, bore no pro- 
portion to the amount of fluid contained in the tubes, and hence he thinks 
that some other theory than that of mechanical distension must be resorted 
to in order to explain it. 

In common with most recent writers of authority, our author regards 
chronic pneumonia as a very rare affection, having met wilh but three 
examples of it. That this lesion should ever have been regarded as fre- 
quent is clearly owing to its having been confounded with other alterations, 
particularly the tuberculous. 

The account of the anatomical characters is concluded by a notice of the 
peculiarities presented in cases of secondary pneumonia. Where inflam- 
mation of the lung comes on in the course of another disease, the changes 
No. XL— July, 1843. 8 



1 1 Reviews. [Juty 

which the organ undergoes are much the same as when the affection is 
primary. It much more commonly, however, assumes the lobular form, 
which among adults is indeed almost always secondary, and amongst 
infants very commonly so, as where it follows whooping cough, bronchi- 
tis, &c. Splenization too, is a lesion more frequently met with in the 
course of other diseases than as a primary alteration. By Louis, this 
lesion is not considered as dependent upon inflammation, a view in which 
our author does not coincide. Dr. G. indeed thinks, as before observed, 
that like hepatization, it marks the second stage of inflammation of the 
lung, being met with generally in individuals previously debilitated, where 
the liquids are more under the influence of gravity, and consequently en- 
gorge and macerate the tissues, and thus modify the common characters of 
inflammation. The facts adduced seem fairly to justify the inference. 

Causes. — The etiology of pneumonia forms the subject of the second 
chapter, where the facts going to show the influence of various circum- 
stances and conditions in its production, are carefully detailed and con- 
sidered. In estimating the influence of age he has been careful to take 
not merely the absolute number of deaths at different ages, but has com- 
pared them with the corresponding population. Although the disease 
occurs at all periods, of life even in the fetal state, it is particularly common 
in children up to six years of age, after which it diminishes very much 
until puberty, when it again increases in frequency. After thirty years of 
age it again diminishes until sixty, from which period it becomes very 
common and is, says our author, the most frequent as well as the most 
fatal of all the acute diseases of advanced life. 

That women are more subject to pneumonia than men, seems well es- 
tablished and is generally admitted. Dr. G. agrees with those who 
attribute this, not to any special predisposition in the male constitution, 
but to the difference in the occupation and mode of life of the two sexes, 
and cites several instances where, when similarly exposed, women were 
found equally liable to the disease with men. 

The opinion that a first attack predisposes to a second, is confirmed in 
the pages before us, and it would seem also that the inflammation is most 
likely to occur on the side first affected. 

We will not, however, follow our author seriatim in his examination of 
the probable influence of a variety of circumstances, such as the different 
professions, climate, season, &c. He has collected together with great 
care many of the facts already known, bearing upon these questions, to 
which he has added the result of his own observations. Exposure to cold, 
atmospheric vicissitudes and sudden check of perspiration, are usually re- 
garded as the great causes of pneumonia. Some, indeed, have gone so far 
as to assert that cold is the exclusive or almost the sole cause of the dis- 
ease. Our author strongly opposes this view, and whilst he admits the 
reality of the influence of cold in certain cases, he thinks that its effects 
have been very much exaggerated. He could find no sufficient evidence 
of the operation of cold in inducing the attack in more than about one- 
fourth of the cases observed by himself, a statement nearly in accordance 
with the experience of several other writers. He cautions his readers 
against admitting with some physicians, that, in those cases where the 
patient cannot recall any particular exposure to cold previous to the attack, 
ihis cause may still be regarded as having been operative, since the pa- 
tients may have neglected to notice impressions which they nevertheless 



1843.] Grisolle's Treatise on Pneumonia. Ill 

experienced. Such a mode of reasoning 1 lie thinks altogether illogical, and 
especially inadmissible where the etiology of disease is concerned, since it 
is here not allowable for us to regard any cause as really operative, save in 
those cases where its action ean be separately traced in that particular in- 
stance. But is this really so? are we obliged before we can affirm, for 
instance, that smallpox is uniformly or very generally contracted by expo- 
sure to the emanations from the bodies of those affected with it, to point 
out the time and circumstances of the exposure in each individual Instance? 
Must we limit the operation of contagion to those cases where the patient 
can recall the precise time, place, and circumstances under which he was 
exposed to it? Are we not quite as sure that it is equally operative in 
thousands of cases where the patients are perfectly unconscious of how the 
exposure took place? Most certainly we are; and yet we are told that in 
the case of pneumonia it is unscientific to admit the operation of cold as a 
cause, except in those cases where the patient can recall precisely as above 
mentioned, the mode in which he was exposed to it. But it will be said 
we can readily imagine an individual to be exposed to the effluvia of a 
contagious disease without his being conscious of it. And may we not 
imagine the same thing as regards exposure to cold, a check of perspira- 
tion, or the like? Certainly we may, and not only so, but we must admit 
such a result to be of necessary occurrence, so long as the mass of man- 
kind have not leisure to note every change of temperature, every draft of 
air to which they may be exposed, the impressions produced by them 
upon the body, its varying susceptibility to their influence from the state 
of the cutaneous surface, &c. Upon the whole then, we think, that a 
conclusion the reverse of our author's is the true one, and that it is abso- 
lutely unreasonable to limit the operation of a given cause to those cases in 
each of which its operation can be separately and independently shown. 
Admitting this, then, let us see what are the positive arguments in favour 
of giving to the influence of cold in the production of pneumonia a greater 
extension than Dr. G. seems disposed to assign to it, and to do this we 
need not travel beyond the tine of facts which he has himself so accurately 
laid before us. In the first place, it is admitted that in almost every case 
where the action of an exciting cause can be made out, this cause is found 
to be cold. But in three-fourths of the cases no exciting cause could be dis- 
covered, by which, however, the reader must not infer that many of those 
patients did not themselves think that they were indebted for the attack to 
a check of perspiration, but only that they could not give such an account 
of the time, place, and circumstances, as would render the point clear. 
There is strong presumption then at the very start in favour of the idea 
that many of these latter cases were brought on by cold, since this cause 
is not only shown to be capable of producing the effect, but is almost 
the only one to which an attack can ever be directly traced. 

Let us now see how far an examination of the conditions which are 
treated of under the head of predisposing causes will confirm this view. 
In the first place it is unquestionable that pneumonia prevails to a greater 
extent in northern and temperate climates, especially when they are sub- 
ject to sudden changes of temperature, than in the equatorial regions. 
This general influence of a severe climate and atmospheric vicissitudes is 
admitted by our author, but at the same time he is disposed to lay great 
stress upon certain apparent exceptions. Thus, if we admit that the great 
prevalence of the disease in Canada and New Brunswick is attributable to 



112 Reviews. [Juty 

these causes, how, he asks, can we account for its great frequency at Ber- 
muda. Now, supposing 1 that this and other similar objections were well 
established and not to be accounted for by any local atmospheric conditions 
with which we are acquainted, they would still be too insignificant in 
extent, to throw any doubt upon the value of the general law already 
alluded to. But in truth we suspect that these exceptions are neither so 
well made out nor so altogether unaccountable as might at first sight ap- 
pear. As regards Bermuda, we have no documents before us which enable 
us to speak with certainty; but as regards Malta, to which our author also 
alludes as an exception, we have before us the recent work of Dr. Davy, 
Inspector General of Army Hospitals, who endeavours to show that the 
native population of the latter island in reality suffer comparatively little 
from pulmonary diseases, and that the troops both here and in other parts 
of the Mediterranean suffer less than in England, a difference which he 
attributes to the difference of climate. The greater frequency of these 
diseases among the troops at Malta than among the native population 
may be attributed to their dissipation, to severe sentinel duty exposing 
them to the night air, and generally to exposure to more considerable 
vicissitudes of temperature than might be expected in so mild a climate, 
which is subject however in the winter season to such strong winds, as to 
render it objectionable as a winter residence. We do not wish to lay too 
much stress upon these statements, but they may serve to show that until 
the subject is much more thoroughly investigated, we cannot admit the 
supposed frequency of pneumonia in certain limited localities in rather warm 
climates, as any argument against the proposition that it is a disease es- 
pecially frequent in cold and variable climates. Indeed our author, as 
already observed, does not deny this, but is merely disposed, we think, to 
lay more stress upon the above-mentioned exceptions than they deserve. 
Still, however, he thinks that it is rational to attribute the general rarity of 
pneumonia in the West Indies to their uniformly high temperature, and 
the almost complete absence of barometric variations; an opinion especially 
justified by the fact that in one of these islands (Jamaica), where the air 
is more moist than in the others, and the atmospheric vicissitudes very 
frequent, pneumonia also is more prevalent than in most other intertropical 
countries. But pneumonia is not only a disease especially frequent in 
northern and variable climates, but is vastly more common in winter and 
spring when the temperature is low and variable, and the winds high and 
piercing, than in the summer and autumn months. Further, it is most 
frequent during the prevalence of northerly winds, a fact confirmed by our 
author's observation in Paris. Finally, in those professions where indi- 
viduals are exposed to great fatigue and vicissitudes of temperature, pneu- 
monia is two and a half times more frequent than amongst those differently 
situated in these respects. Upon the whole, then, if we reflect that the 
attack could, in one-fourth of the cases, be distinctly traced to cold, that 
this cause is of universal though unequal influence, and that whether in 
reference to climate, season, or the other circumstances above mentioned, 
the prevalence of the disease as a general rule, is evidently in a great 
degree proportionate to the extent and severity of this influence, it seems 
sufficiently evident that we are quite justified in extending its operation 
beyond the cases mentioned, and that of the remaining three-fourths, a 
large proportion were really induced by it. Of course it is understood that 
by the word cold in the above connection, we do not refer to absolute 



1843.] Grisolle's Treatise on Pneumonia. 113 

temperature merely, but to the effect produced upon the system by a re- 
duction of temperature, which may be favoured, retarded, or prevented, by 
a variety of circumstances, such as the state of the system generally, of the 
skin in particular, of the air in reference to dryness or moisture, &c. In 
extending the operation of cold beyond the limits to which our author would 
restrict it, we are but supporting what has been sustained by some of the 
best authorities of former times, and very generally held to be correct, and 
what moreover would scarcely, we think, have been called in question at 
the present time, but for a tendency in the minds of some, to require a 
degree of positive arithmetical demonstration which is not to be looked 
for in the solution of this and many other questions. We have already 
extended our remarks rather far upon this subject, or we might observe, 
that although we fully agree with our author as regards the necessity of 
a careful interrogation of patients, with respect to the circumstances of 
their attack, in order to arrive at the truth, it is worthy of attention on the 
other, that by too great a severity of examination, peisons in the lower 
walks of life may be readily confounded; and again, although some may 
be disposed from prejudice to attribute their attack to check of perspi- 
ration, without sufficient evidence, the reverse of this is true of others, who 
will often deny some imprudent exposure, which in private practice other 
members of the family are able fully to establish. Hence it is not im- 
possible that of the cases before us, a larger number might with propriety 
have been considered as directly traceable to cold. Be this as it may, we 
will conclude with a few remarks upon two other points interesting in this 
connection. Our author observes, that since men engaged in rough occu- 
pations and exposed to the weather, are most liable to pneumonia, we 
should expect to find it particularly rife among sailors, who on the con- 
trary, whilst at sea, appear to be remarkably exempt from it. This ex- 
emption he is disposed to attribute rather to the regular life which they 
lead when at sea, than to the diminished influence of cold. When our 
author has once had personal experience of a sea voyage, we are sure that 
he will lay less stress upon the first, and also that he will become convinced 
of what at present he is evidently not aware of, though matter of common 
observation among seafaring men, that there is something in salt air pre- 
servative from cold. Every one under these circumstances has noticed 
how freely he may expose himself to wind and weather, cold and moisture, 
with scarcely a fear of these consequences, such as coryzas, sore-throat, or 
rheumatism, which would most certainly be his recompense for indulging 
in such imprudences on shore. In connection with this fact then, which 
we think will scarcely be contested by any experienced individual, the 
comparative exemption of persons at sea from pneumonia, instead of 
being calculated to throw any doubt over the opinion that cold is its 
principal cause, is on the contrary highly confirmatory of it. 

Again, although it is granted that, as a general rule, those trades which 
require great exertion, and also exposure to the weather, offer, as before 
mentioned, far more numerous examples of pneumonia than those of an 
opposite description, it would seem that the rule is liable to certain excep- 
tions. Thus it appears by the statement of Parent Duchatelet, that of 670 
men engaged as porters, and interrogated by him on this point, one only 
had had pneumonia. A similar statement is made by Thackrah, as quoted 
by our author in reference to bricklayers, founded upon inquiries made 
among 32 individuals of this trade. As these persons are much exposed 



114 Reviews. [Juty 

to the weather, some perhaps might be disposed to regard the above state 
rnents as good arguments in favour of our author's opinion that the influ- 
ence of cold has been greatly exaggerated. In this point of view however, 
such statements should be received with much caution. Numerous cir- 
cumstances, affecting the mode of life, &c. of particular elasses in parti- 
cular places, the estimation of which requires often the most intimate 
acquaintance with their social condition, might render such a conclusion 
totally inadmissible. A mode of life remarkably favourable to health in 
other respects, might more than counterbalance the injurious influence or 
exposure. Again, we must consider what is the kind of exposure, whether 
it is uniform or occasional, of long or short duration, accompanied by severe 
or moderate exercise, and so on. Now, we well know that moderate ex- 
ercise and uniform exposure to the weather, are the best prophylactics 
against the influence of cold, and this is probably one great reason why 
pneumonia was so rarely found among the persons mentioned. Be this 
as it may, such limited statistical data, whatever may be their local value, 
are entirely nugatory with reference to the general proposition in question, 
supported as it is by such various and accumulated evidence, and confirmed 
by the common sense of mankind in every age. Finally, it has been said 
that since persons are so often exposed to cold, or have the perspiration 
checked without experiencing an attack of pneumonia, we must, in order 
to explain this as well as the different results to which it gives rise at dif- 
ferent times, suppose a certain pre-existing organic disposition in the indi- 
vidual, wherever disease results. On this account, says our author, "I 
think that M. Chomel is perfectly right in maintaining that occasional 
causes have only a secondary influence in the production of pneumonia. 
That this affection, like most other internal diseases, results from an internal 
condition, the essence of which escapes us." That there is much truth 
in this view, though at the present time, we think greatly exaggerated, we 
will admit; but as for the conclusion that causes called occasional, and 
especially cold, exert only a secondary influence, it does not at all follow 
from the premises. As well might we say in the case of a fractured limb 
from a fall, that inasmuch as so many persons tumble down without break- 
ing their limbs, the fall is of secondary consequence in such cases. Who 
does not see that a variety of circumstances affecting both the state of the 
individual and the mode in which the injury took place may increase or 
diminish its effects, as well as determine the character of that effect, 
without admitting for an instant the absurdity of its being any other than 
the principal cause. In short, there is nothing irrational or inconsistent 
with facts in maintaining that, whilst cold is the principal cause of pneu- 
monia in a large proportion of cases, its influence is greatly favoured by a 
number of predisposing and concomitant circumstances, the importance of 
which we would not depreciate, as for instance an epidemic constitu- 
tion, which at times appears to be strongly operative. 

In addition to the circumstances already alluded to, many other causes of 
pneumonia are stated by authors; most of these Dr. G. finds unsupported 
by any positive facts, or exerting a very circumscribed influence. 

We now pass to the third article of the chapter on etiology, in which is dis- 
cussed the subject of secondarv pneumonia. It is liable to occur in the course 
of most acute and chronic diseases. Its extreme frequency in the course of 
measles, whooping cough and other infantile diseases is well known. It 
is also met with in adults in the course of typhoid fever, phthisis, organic 



1843.] Grisolle's Treatise on Pneumonia. 115 

affection of the heart, lung 1 , liver, &c. In some instances, as when it 
follows upon capillary bronchitis, whooping cough, &c, the production of 
pneumonia can be explained by the direct transmission of inflammation to 
the substance of the lungs or by their congestion. In most cases however, 
Dr. G. thinks that we must look for some other influences. Fever and 
debility are in his opinion the two conditions which play the principal part 
in the production of secondary pneumonia. Of the two, he regards de- 
bility as the most important, and as the one principally operative in the 
production of pneumonia, in cases of organic affection of the heart, liver, 
lung, &c. It may act by favouring passive congestion of the lungs, or by 
rendering the individual more sensible to the ordinary causes of the disease. 
Along with debility, a long continuance in the horizontal position is also 
calculated to favour congestion in the most dependent portions, since as the 
powers of life diminish, gravitation, like the other physical laws, begin 
to resume their control. In this way the production of secondary pneu- 
monia in cases of typhoid fever and analogous affections, is sufficiently ex- 
plicable, but in other cases, as for instance, in organic affections of the 
heart, where secondary pneumonias are very common, it seems to us that 
we must have recourse in addition to pulmonary irritation and congestion, 
the presence of one or both of which can scarcely be questioned. In the 
concluding article of the present chapter, we are told that of 201 patients 
who were able to give satisfactory information on this point, 76 were 
labouring under a cough, when the attack of pneumonia commenced. Of 
these the cough had existed for years in 23, but in the remaining 53 the 
catarrhal affection was recent, not dating in any case beyond three weeks 
or a month. Acute pulmonary catarrh then preceded the attack in full 
one-fourth of the cases, and we are further told that in four out of five of 
these the pneumonia supervened without the occurrence of any appre- 
ciable accidental cause. In a few of these cases, our author thinks that 
we may attribute the pneumonia to an extension of the bronchial inflam- 
mation, though in most cases the latter should be regarded as predisposing 
merely to the former, by rendering the system more liable to be influenced 
by the common causes of pulmonary inflammation. Be this as it may, 
however, if we reflect that cold is the common cause of acute pulmonary 
catarrh, that the pneumonia supervened rapidly upon the latter in so large 
a proportion of cases, and that of these but few are included in the category 
of those regarded by our author as distinctly traceable to cold, we shall 
find another and most convincing argument for extending very greatly the 
number of the latter. In short, from whatever point of view we look at 
this important question, we find the commonly received opinion to be fully 
supported; and if we have extended too much our remarks upon the sub- 
ject, our excuse must be found in the fact that within a few years past there 
is an evident tendency to attack upon insufficient grounds, certain gene- 
rally received opinions, based upon common observation and sanctioned 
by the authority of the best practical minds in the profession. We highly 
approve of the present accurate methods of observation and numerical ana- 
lysis, and for this reason we do not wish to see them abused, and it does 
seem to us that in reference to the opinion in question they have been so. 
Statistical data, insufficient, imperfect and inconclusive, as well as a too 
exclusive and rigid line of observation, have been appealed to in order to 
overturn it; and this course, we believe, has been in great measure dic- 
tated by an unwarrantable indisposition to admit the truth of conclusions 



116 Reviews, [July 

which have been arrived at by common observation without the aid of 
statistics. Whatever value we may attach to numbers, we do not agree 
with those who think, that, on many points at least, general observation, 
unaided by them, is far more likely to lead into error than truth. Such 
an assertion appears to us to involve the position, that the Creator has so 
constituted us, that in the ordinary course of human life, a large part of 
the conclusions to which we arrive on most subjects, must of necessity be 
false; a worse than absurd idea, which we would not for a moment enter- 
tain. 

Symptoms. — Several of the subsequent chapters are devoted to the his- 
tory of the symptoms, which are most minutely described, and contem- 
plated in numerous points of view. For example, in the section devoted 
to dyspnoea and accelerated respiration, after describing what he had ob- 
served in reference to the character, frequency, &c, of these symptoms, 
he enters into an examination of certain opinions which have been ad- 
vanced in regard to them. Thus it has been supposed that they were 
partly owing to the pain in the side, but on selecting '62 patients of about 
the same age, and in whom the disease was about equally severe, one-half 
of whom had severe pain in the side, the other half none or scarcely any, 
it was nevertheless found that the dyspnoea and frequency of respira- 
tion were about the same in each. Even in those cases where the pain in 
the side is very severe, our author is of the mind that it is not so much to 
this that the symptoms in question are owing, as to the lesion of the lung 
itself. 

Again, it has been said that pneumonia of the summit gives rise to more 
severe dyspnoea than that of the base of the lung. To determine this point, 
our author chose as above, 44 patients of about the same age, and in whom 
the disease was about equally severe, in one-half of whom the upper lobe 
was affected, and in the other half, the lower, whilst nevertheless the 
dyspnoea and frequency of respiration were about the same in all. Of 
course, the conclusion is obvious, that the seat of the pneumonia could 
have had but little influence upon the severity of the dyspnoea or the fre- 
quency of the respiratory movements. As a general rule, these symptoms 
were found to be in proportion to the extent of the inflammation. Excep- 
tions to this rule however, were frequently met with, and although some 
of them could be accounted for, as for instance, when a pneumonia of mo- 
derate extent was accompanied by extreme dyspnoea owing to its being 
complicated with capillary bronchitis, most of them were entirely inexpli- 
cable. 

In this way each symptom connected with the chest is successively 
considered, after which the physical signs are taken up, one or two points 
merely in reference to which we shall notice. First, with respect to the 
configuration of the chest, we are told that in scarcely any case was any 
alteration observable, and further, that both the diseased and sound side 
were equally dilated during inspiration, except in some cases where the 
pleuritic pain was very severe. This last observation is strikingly at 
variance with the experience of Dr. Williams, who tells us that, *' in the 
staae of hepatization, the lung being nearly inexpansible, the corresponding 
walls of the chest are nearly motionless." 

Dilatation of the chest would seem to be the necessary consequence of 
extensive hepatization, and yet this has been denied on the ground of 
positive observation. With a view to this, our author measured with line 



1843.] Grisolle's Treatise on Pneumonia. 117 

and compass the chests of four patients, and obtained only purely negative 
results. He soon, however, gave up the investigation, for being obliged to 
conduct it when the disease was at its height, most of the patients suffered 
so much as to be unable to preserve the same position for a sufficient 
length of time, a circumstance calculated to give rise to serious mistakes. 
Further, he very justly remarks, that "the fatigue of the examination, and 
the danger incurred by the patients from being a long time exposed to the 
air, imperatively demanded that he should give up such investigations, 
which, at last, however curious, were of no practical value." Such a re- 
flection is highly to the credit both of the humanity and common sense of 
our author, who, it should also be observed, was, notwithstanding the 
fruitlessness of the above attempts, able to arrive at a positive result by the 
ordinary inspection of two cases, in which the summit of the right lung 
was the seat of hepatization, which had evidently occasioned a corres- 
ponding dilatation of the anterior superior portion of the right chest. 
Hence, he does not hesitate to admit that an inflamed lung, independently of 
all pleuritic effusion, may give rise to a partial or general dilatation of the 
corresponding side of the chest. 

It has been supposed that the vibratory movement of the thoracic walls 
when the patient is speaking, was more marked opposite the hepatized lung 
than on the opposite side. On the contrary, however, Dr. G. found that 
in eight of ten cases where this point was attended to, the thoracic vibra- 
tions were either entirely absent, or equally felt on both sides, whilst in 
the two remaining ones the difference in favour of the hepatized portion 
was inconsiderable. It would seem, therefore, that as a diagnostic sign, this 
fremitus or vibration could not be much relied on. In the second article, 
the general symptoms connected with the circulatory and other organs 
are described. Among other points we observe that he has found that the 
urine became precipitable by nitric acid about the time of convalescence. 
In the (ew fatal cases however, in which the urine was examined, no pre- 
cipitate was met with. These results nearly coincide with those obtained 
by Martin Solon, and confirm the general correctness of the opinion ad- 
vanced by the latter, that the precipitate in question is indicative of the 
crisis of the disease, and of very favourable prognosis. We notice par- 
ticularly our author's confirmation of this conclusion, because doubts have 
been thrown over their correctness by the statements of a recent writer, 
whose investigation as regards the urinary secretion would seem to have 
been of a most elaborate kind. 

The symptoms of primary pneumonia having been disposed of, the 
modification which they undergo when the disease is secondary are next 
pointed out. Some of these symptoms indeed may be altogether wanting 
when pneumonia occurs in the course of a severe disease, which has 
greatly diminished the strength and deadened the sensibility of the patient, 
whilst others are rendered more obscure. Thus pain in the side, instead 
of being an almost constant attendant upon the disease, as in primitive 
pneumonia, seemed altogether wanting in a large proportion of cases, 
whilst in others it was of less severity, and this as a general rule in pro- 
portion to the advanced age and debility of the patient. Dyspnoea and ac- 
celerated respiration were nearly always present, but were remarkable in 
this, that their severity was often out of all proportion to the extent of the 
inflammation. That a very limited inflammation occurring in the course 
of organic disease of the heart, emphysema, &c, should give rise to ex- 



118 Reviews. \J U ^Y 

cessive dyspnoea is easily understood, but it is not to such cases only that 
the remark applies, for Dr. G. tells us that in nearly every case of purulent 
resorption, the respiration became very difficult and was extremely 
accelerated, notwithstanding that nothing more was found after death than 
a few indurated spots (noyaux) scattered here and there through the lungs. 
The same is said to be true of glanders, &c. It may be doubted, however, 
how far in some of these cases we are justified in considering the dyspncea 
as strictly a symptom of the pneumonia. May it not rather be viewed as 
dependent upon a disorder of the pulmonary functions, depending perhaps 
upon the circulation of a poisoned blood, and not necessarily connected 
with inflammation. Cough is mostly present, but like the pain in the side 
it is as a general rule less severe in proportion as the patient is debilitated. 
Sometimes it is so slight and comes on at such rare intervals as scarcely to 
attract attention. The expectoration is less characteristic, and even the 
physical signs, though possessing, in our author's estimation, as much 
value as in the primitive form, are often less marked and sometimes 
altogether wanting. 

The progress and termination of the disease form the subject of the sixth 
and seventh chapters. Coincident with the resolution of the attack, there ap- 
peared some of those phenomena usually regarded as critical, in thirty-four 
out of one hundred and thirty cases in which the date of the commence- 
ment of the attack could be determined, and where all the phenomena 
throughout its course had been studied. Perspiration was most commonly 
met with, sometimes alone, at others combined with spontaneous deposits 
in the urine. Sometimes there was an herpetic eruption about the mouth. 
Twice our author has met with epistaxis twelve and twenty-four hours 
before convalescence, and in one case only a critical discharge by stool. 
The rarity of the latter he attributes to the fact that all the patients had 
used laxatives or taken the tartar emetic draught, so that it was impossible 
to tell how far diarrhoea might be owing to an effort of nature, or to the 
medication employed. He adds: — 

" I believe with Baglivi, that if crises are less frequent now than they 
formerly appeared to be in Greece, it is probably in consequence of the more 
energetic treatment which is now employed in acute diseases. The great phy- 
sician just cited, adds, that amongst the country people who use no medicine, 
crises by sweat, abdominal discharges, the kidneys and other natural passages 
occur regularly. I believe that this opinion of Baglivi lias perhaps some founda- 
tion; for having studied the course of pneumonia in ten patients who recovered 
under a nearly expectant method of treatment, critical pnenomena were met with 
in one half of them; four had copious sweats; one had an abdominal flux; the urine 
was examined in only one of these patients, and in that case the nitric acid pro- 
duced a most abundant coagulum. It is probable that the same would have 
been found true of nearly all the others, at least what has been heretofore stated 
makes the supposition allowable."— P. 223. 

The reader will recollect that it has been already mentioned, that in 
almost every case where this point had been accurately investigated, the 
urine of those who recovered was found to precipitate by the addition of 
nitric acid, near the time of convalescence. Upon the whole, then, there is 
abundant evidence of a natural connection, either as cause or effect, be- 
tween certain discharges and convalescence. As for the disease, however, 
being more likely to give way on particular days, our author thinks such 
a doctrine altogether inadmissible. 

In the eighth chapter, the various complications of pneumonia, as 



1842.] Grisolle's Treatise on Pneumonia. 119 

pleurisy, pneumothorax, bronchitis, &c. are brought under review; after 
which the different forms of the disease, viz. bilious, typhoid, &c; the 
phenomena of convalescence, the causes of death, &c. are considered in 
successive chapters. 

The influence exerted by pneumonia in causing or modifying other affec- 
tions forms the subject of the twelfth chapter. According- to our author's 
observation, pulmonary consumption does not often follow pneumonia, and 
even when it does, he thinks that the latter is to be looked upon more as an 
accidental than a proximate cause. When tubercles already exist, how- 
ever, he admits that they are sometimes accelerated in their course by an 
attack of inflammation, though even this result, he thinks, is met with only 
in the minority of cases. In the greater number of instances, the pneu- 
monia developed around the tuberculous masses is dissolved in a moderate 
length of time without any aggravation of the primitive disease, a circum- 
stance in which it differs greatly from pleurisy, which is rarely. completely 
cured, when it occurs in the course of consumption. He admits also the 
truth of the opinion that organic affections of the heart are sometimes 
owing to pneumonia, but thinks at the same time that such a result is not 
frequent. 

Neither the author nor any of the French physicians, so far as the 
former is aware, have ever met with cases of general dropsy which could 
be referred to pulmonary inflammation, which is believed to be capable of 
giving rise to the former, by Abercromhie and other pathologists. 

Treatment. We pass over the chapters on diagnosis and prognosis, 
and proceed to the last, which is occupied with the treatment. Our anther 
commences by reminding his readers that the history of symptoms, which 
he had laid before them, was calculated to convince them that the dif- 
ferences presented by the disease under different circumstances of age, 
constitution, epidemic influence and the like, were such that the same 
method of treatment could not be applicable to all. Such an opinion, he 
says, could only be sustained by empirical practitioners, who would reduce 
the difficult science of indications to the knowledge of a receiptor formula, 
which they blindly employ in all cases, thinking merely of the local in- 
flammation, and regardless of those features of an attack which stamp its 
general character in other respects and demand a modification of treatment. 
The idea that any particular method of treatment, whether that by san- 
guine depletion or any other, is necessarily applicable to all cases, is 
altogether false. The capital point in the treatment consists in such a 
wise appreciation of those individual and general conditions which modify 
so deeply the aspect and character of diseases, as shall enable us to adapt 
our remedies with the greatest advantage to the peculiarities of each case. 

The principal remedies employed are successively examined, and their 
influence appreciated by an appeal to the results of our author's own cases, 
in connection with those of other writers, some of whose statements are 
amply and freely commented upon. 

The loss of blood is first noticed. From the earliest ages, this agent 
has been generally regarded as the most efficacious; by some it has been 
carried to an unwarrantable extreme, and by others been as unjustly ne- 
glected, so that, says our author: — 

41 The history of the past teaches us that neither excessive bleeding nor the 
expectant plan of treatment have met with such marked success as to bring 
about the exclusive adoption of either the one or the other, A knowledge of 



120 Reviews. [July 

this should preserve humanity from new experiments; but unfortunately the 
human mind profits little from the experience of the past. Thus Bordeu pre- 
dicted nearly a century ago, that individuals would again arise and revive old 
errors, some of whom would bring into vogue again the excessive use of bleeding, 
whilst others would proscribe it altogether. Bordeu was right, for the period 
predicted by this great physician has arrived. We now see men who, faithful 
to the practice of Izes, like him, bleed beyond measure; and on the other hand 
those who, flying to an opposite extreme, discard altogether the loss of blood in 
the treatment of pneumonia, and adopt a merely expectant course. Such ex- 
clusive and opposite opinions upon the treatment of a disease so well understood 
as pneumonia, are deplorable, for these contradictions in practice are among the 
most powerful arguments employed by those who are unwilling to concede that 
the science of medicine is possessed of any degree of certainty; but let every one 
cease tr. reproach medicine with errors which are exclusively chargeable upon 
those who are controlled by hypotheses (medicins systematiques). In order to 
contribute my mite towards preserving our successors from such periodical 
anarchy, I proceed to lay before the reader what, in my opinion, may be ex- 
pected from the emplo} r ment of bleeding in the treatment of pneumonia." 

Most of our readers, we doubt not, will join us in affixing the seal of 
approbation to our author's general views on the subject of therapeutics, 
and it is to be hoped that his contributions in reference to the question 
before us may have their just influence. But, so long as the human mind 
remains the same, so long as there exist ardent enthusiasts to be thrown 
into ecstasies by plausible dogmas, or the stupidly incredulous who are 
ready to doubt the most ordinary truths, it is to be feared that we shall still 
witness the same extremes of folly, not merely in reference to pneumonia 
and depletion, but to other diseases and other remedies. 

In the first place our author considers the question of the utility of 
bleeding in pneumonia; in other words, whether it is preferable to bleed 
the patient or abandon him to the efforts of nature. For this purpose he 
compares two series of cases of a mild form of the disease occurring in 
young subjects, in one of which moderate depletion was resorted to in 
the early stages, whilst in the other the efforts of nature, aided only by 
repose and diet, pectoral drinks and rarely a laxative, were trusted to. The 
result, as might be expected, was much in favour of the former, both as 
regards relief of symptoms and the duration of the attack. Another cir- 
cumstance corroborative of this, and absolutely conclusive as regards the 
importance of early attention and treatment in general, is stated in the 
chapter on prognosis. It is there mentioned, that whilst of the patients 
admitted during the first three days of the attack only a thirteenth part died, 
of those who entered from the seventh to the tenth day, a third to a half 
died, there being a gradual increase of mortality from the third to the 
seventh clays. 

He next goes on to inquire whether bleeding should be practised in all 
cases, reminding us that although some regard the loss of blood as a spe- 
cific to be always resorted to, really sound practitioners at all times have 
admitted that in a large number of pneumonias, sanguine emission could 
not be resorted to without danger, let the quantity be ever so small. He 
does not agree with those who proscribe bleeding altogether in infancy and 
old age, but concludes that it should be more sparingly and cautiously em- 
ployed at these periods of life. A constitution debilitated by privation, 
excesses or other causes, as is well known, entirely contraindicates or 
admits of but a limited resort to depletion and that for the most part 
locally. In certain epidemics too, bleeding is absolutely contraindicated, 



1843.] Grisolle's Treatise on Pneumonia. 121 

being often followed by the most alarming symptoms. Such consequences 
were observed by our author in some cases during the prevalence of the 
last epidemic of grippe at Paris. With few exceptions, he thinks that 
general bleeding is injurious in secondary pneumonia. As regards the 
presence or near approach of the menses, being, as some suppose, a formal 
contraindication to bleeding, he thinks the opinion not only erroneous but 
of dangerous practical tendency. Whenever symptoms demand the remedy 
we must resort to it, without reference to the menstrual flow, and in this 
view, he supports himself by the high authority of De La Mott and J. 
Frank. In cases of pregnancy, also, he says that we should not be de- 
terred by the fear of bringing, on abortion, for surely this result is more 
likely to follow the pneumonia if we allow it to go on unchecked. The 
fear of taking blood whilst the patient is in a state of perspiration, he thinks 
also unfounded, and says that he has never seen any unpleasant results fol- 
low such a course, an opinion which he also sustains by an appeal to the 
authority of Frank. Of course, as a general rule, the strength of the pulse, 
and the more or less inflammatory or typhoid character of the symptoms 
must be our great guides, whatever other condition may be present. 

The question next considered is, whether we must bleed at all stages 
and in every degree of pneumonia. That the remedy is vastly the most 
efficacious when early resorted to is unquestionable, but it would be extreme 
to follow the advice of those who would restrict its use to the first four or 
five days, from an idea that when expectoration was about becoming estab- 
lished it was no longer demanded or might even be injurious. Indeed it 
may be resorted to whenever the symptoms demand its use, without re- 
ference to the period of the disease. When, however, the disorder has ar- 
rived at the third stage, and the greater part of the diseased portion of lung 
has passed into the state of purulent infiltration, our author has seen the most 
disastrous results from the loss of blood, and is inclined to proscribe it under 
these circumstances. 

As regards the mode in which blood should be drawn, we are told that 
a large opening should be made in the vein where the fever is intense, as 
in this way the fever, oppression and cephalalgia will be best relieved; 
whilst on the other hand the pain in the side, which may still persist or 
even be aggravated, will be best relieved by local depletion, and especially 
by scarified cups. It is also well understood that local depletion must 
be resorted to rather than general, in patients debilitated by age, privations, 
or other causes. As regards the quantity of blood to be drawn and the 
frequency with which the operation should be repeated, no general rule 
can be laid down, and after examining the evidence of some of the chief 
authorities from the time of Hippocrates, Dr. G. concludes that sound prac- 
tical men never thought of laying down fixed rules in reference to these 
points, but at the same time that as a general rule, while they bled mode- 
rately they proportioned the amount drawn to the strength of the patient 
and the severity of the disease. A few, however, in the present day — wit- 
ness the pupils of Rasori and Tomasini in Italy, and Bouillaud in France — 
detract enormous quantities of blood, repeating the operation several times 
a day during the first few days, and, in a more routine manner than sound 
practical distinction would seem to warrant. The practice of the Italians 
our author does not criticise, having no means of comparing its results with 
those obtained by other methods in the same climate. He freely criticises, 
however, the evidence on which M. Bouillaud supports the claims of his 



122 Reviews. \Ju\y 

method, and arrives at the conclusion that this physician neither cures his 
patients more quickly or in larger proportion, than his fellow practitioners 
who pursue a different course. 

Our author next proceeds to point out the results of the moderate and 
rational bleedings which he advocates. The amount taken being pro- 
portioned to the circumstances of the case, varied from six or eight ounces 
to ten pounds, not exceeding in mostcases however, more than two pounds. 
The cases are divided into two series, in the first of which are included 50 
patients, in whom the disease had not advanced beyond the first stage, 
and whose average age was 40 years. Of these 50 patients, five, or one 
tenth, died. In 32 of them, no other active treatment was had recourse to, 
except a mild laxative and very rarely a blister, whilst in most of the re- 
maining 18, the bleeding, after having been repeated as often as the strength 
of the patients would admit, was followed by the use of tartar emetic in 
large doses. The patients who died lost upwards of four pounds of blood 
each, so that the fatal termination could hardly be attributed to a too spa- 
ring use of the lancet. The second group, in whom the disease had ad- 
vanced to its second stage, comprises 182 patients, whose average age was 
35 years. Of these, 32 died, or more than a sixth. Of the 150 who re- 
covered, there were 69 in whom bleeding alone was resorted to, or else 
merely combined with some mild laxatives or a blister. In all the remain- 
ing 81 some antimonial preparation was employed, sometimes as an eme- 
tic, more commonly with the view of acting as a contra-stimulant, in which 
case it was resorted to after depletion, and sometimes not until the latter 
had been pushed as far as the strength of the patient would admit. Be- 
sides the more general result of mortality, duration, &c. JVI. Grisolle 
studies the influence of bleeding upon each symptom in particular. In a 
few instances, pain in the side yielded completely to one or two bleedings, 
but of the other prominent symptoms, none were completely removed in 
this way. A comparison of his success, with that of M. Bouillaud, leads 
him to the conclusion that the excessive loss of blood advocated by this 
gentleman has led to no more favourable results than that which follows a 
more rational and moderate course, and in fact that M. Bouillaud has use- 
lessly abstracted two pounds of blood on an average from each of his 
patients. At the same time, such immoderate depletion, even if merely 
useless at the time, must, it is reasonable to conclude, be ultimately disad- 
vantageous to many patients. 

We now proceed to the treatment of pneumonia by tartar emetic in 
large doses. M. Grisolle first gives an abstract of the evidence on this 
point furnished by previous writers from the time of Rasori, from which 
it is to be inferred that the remedy, given in large doses as a contra-stimu- 
lant, either alone or combined with sanguine depletion, has been followed 
by the most happy effects. He then proceeds to examine his own cases 
in reference to this point. He has in all 154 cases in which tartar 
emetic was given, according to the plan of the Italian school. These 
he divides into three series. The first contains 44 cases treated ex- 
clusivety by tartar emetic, without the previous or concurrent use of other 
active means. The second includes 80 cases in which bleeding had 
been first employed, but without any marked influence upon the disorder, 
and where the remedy was administered before the strength of the patient 
was so far reduced as to render further loss of blood improper. The 
third series contains 30 cases, where bleeding had been freely resorted 



1843.] Grisolle's Treatise on Pneumonia. 123 

to, but where at the same time the disease had made such progress, and 
the prostration was such as entirely to forbid further depletion, and the 
tartar emetic was given as a last resort. 

In the first series, the mean age was 37 years, the constitution weak or 
of only moderate strength in the greater number, and the disease in all of 
sufficient severity to render the result doubtful. The treatment was com- 
menced at different periods from the second to the ninth day; on an ave- 
rage, about the fourth day. Six grains was usually given in the course 
of the first day, and the remedy subsequently continued in doses varying 
from 6 to 12 grains in the 24 hours, either alone, or combined with the 
syrup of poppies where its first effects had been very violent. The period 
during which its use was continued, varied from one to ten days, the 
average length of time being three days and a half; about 20 grs. of the 
emetic having been given altogether in most of the cases. In all these 
cases the primary effects of the medicine were experienced, purgation for 
the most part predominating over emesis, complete tolerance however 
being established in many after the third or fourth day. Of the 44 cases 
thus treated, 6 died, or rather less than one in seven. The condition of 
those who died, however, was not favourable, their mean age being over 
fifty, and the treatment not commenced till after the fifth day, one of them 
also being affected with such violent delirium, that the diagnosis was ren- 
dered difficult, and the remedy continued for only two days. Still, how- 
ever, the result of these cases is not such as to establish the propriety of 
substituting tartar emetic for the lancet under similar circumstances. It 
should, however, be observed that bleeding was not resorted to in these 
cases, because the resistance of the pulse was less than usual, leading our 
author to suppose that not more than one or two bleedings could probably 
have been practised, and therefore inducing him at once to resort to the 
treatment above described. Under such circumstances we should have 
preferred moderate blood-letting, frequently repeated doses of calomel and 
opium or Dover's powder, with a resort to blisters, where the symptoms 
would admit of their use. Be this as it may, let us continue to accompany 
Dr. Grisolle in watching the immediate effects of the antimony upon the 
principal symptoms. These, i. e, the pain, the respiratory movements, 
the character of the pulse, of the expectoration, and the auscultatory phe- 
nomena, were most frequently improved, or even entirely gave way, within 
' the first or second day after its administration. The rapidity with which 
these and other symptoms such as headache &c. were relieved by the 
tartar emetic is very remarkable, especially when we observe that even in 
a majority of the fatal cases, this happy influence at the start, was also ob- 
servable. In these latter cases however, it should be noted, that notwith- 
standing the improvement t)f certain symptoms, the countenance was still 
indicative of severe disease, the skin had become more hot and arid, and 
the examination of the chest showed an extension of the disease. 

In the second series, including 80 patients, whose mean age was 35£ 
year?, the pneumonia was severe in all. At the time when the antimony 
was first given, it had reached in every instance the second stage. Bleed- 
ing had been first resorted to during the first 24 or 48 hours after their ad- 
mission into the hospital, which was on the average, about the fifth day of 
the disease. The loss of blood however, which varied from one to three 
pounds, had never arrested the disease, and the state of the pulse was such 
as to admit of further depletion. The tartar emetic was then given much 



124 Reviews. [July 

in the same way as in the preceding series. The number of deaths were 
ten, i. e. about one in eight. The same rapid melioration of the symp- 
toms was met with as in the first series, a very great improvement being 
observable in the course of the first two days, in two-thirds of the cases. 

To the third series belong 30 cases, whose mean age was 49 years, and 
who like the preceding, took the tartaiised antimony after several bleed- 
ings had been already practised, but with this difference, that further 
bleeding was inadmissible, the disease being far advanced (10th day), the 
pulse soft, the strength exhausted, and one half of the cases indeed, in a 
desperate condition. Of these 30 patients, 18, or nearly two-thirds, died. 
This result, says our author, speaks much less against the efficacy of tartar 
emetic than against that of bleeding, which, although freely resorted to as 
early as the fourth day, did not prevent the disease from making steady 
progress. He attributes indeed most of the recoveries to the tartar emetic, 
the administration of which was followed by a rapid melioration in nine 
cases, where life was in imminent danger. 

Upon the whole Dr. Grisolle thinks that the good effects of tartar eme- 
tic in large doses, upon pneumonia, are indubitable. Under its use, the 
mortality was diminished, the most distressing symptoms relieved with 
unusual rapidity, the convalescence prompt and the strength soon re- 
established. Asa general rule, however, he prefers that one or more bleed- 
ings should be first resorted to, as being most likely to ensure a favourable 
result. 

Various conditions of course would contraindicate the use of antimony, 
such as acute inflammation of the stomach or intestines, chronic diarrhosa, 
&c. On this account we must be cautious about using it in the pneumo- 
nia of consumptive patients, as the tuberculous disease of the intestine 
might be aggravated and fatal consequences follow. The mere presence 
however, in ordinary cases, of some diarrhosa and abdominal tenderness, 
does not forbid its use, the number of stools not being increased by it, but 
on the contrary often diminished. 

Several unpleasant effects, the most common of which is an inflamma- 
tion, followed by a pustular eruption or even ulceration, of the mucous 
membrane of the mouth and fauces are sometimes found to follow its use. 
In fatal cases these pustules have been met with in the cesophagus, but in 
our author's experience, not beyond the cardia. In a single instance 
only, he found on the large curvature of the stomach an ulceration which 
seemed to have been occasioned by the antimony. Our author gives one 
case in which the most alarming symptom and death followed its admin- 
istration, and remarks that there are some facts which go to show that at 
times the system appears to be poisoned by it. This effect is shown, 
not by superpurgation, but by the symptoms^of collapse, a small pulse, 
hippocratic countenance, &c. As regards the mode of action of tartar eme- 
tic, Dr. Grisolle thinks that we cannot attribute its good effects to mere 
revulsion, to its emetic and purgative operation, for in cases where no 
evacuations follow its administration, the same rapid melioration of the 
symptoms is still met with. Indeed it is not reasonable to suppose that so 
active a substance should operate merely as an evacuant, when it is ab- 
sorbed and mixed with the torrent of the circulation. That it is absorbed, 
seems to have been positively proved by Orfila, who in analyzing the 
principal viscera, especially the secretory organs, of those who died of 
pneumonia after using tartar emetic in large quantities, has been able to 



1843.] Grisolle's Treatise on Pneumonia. 125 

procure the metallic antimony. He has also found it in the urine both of 
those who experienced the evacuant effects and of those who did not. 
We may conclude then that it operates in part by the altered nutrition of 
the tissues, consequent upon its absorption, though at the same time, its 
evacuant effects are not to be lost sight of. As regards the intimate nature 
of the action which it exercises on the tissues, or even which of these is 
especially influenced by it, we are in entire ignorance. Still, the occur- 
rence of the symptoms of collapse, the complete relaxation and loss of 
muscular power manifested in cases where the remedy has not operated at 
all as an evacuant, point out sufficiently a powerful action on the nervous 
system. 

As regards the other preparations of antimony, particularly Kermes mine- 
ral and the white oxyde, Dr. Grisolle is of the mind that their good effects in 
pneumonia have been much exaggerated by some, and that although some- 
times useful, they should never be substituted for tartar emetic, except in 
cases where the digestive organs are the seat of some serious disease which 
the latter might aggravate. 

Besides antimony, several other articles have been employed as contra- 
stimulants, particularly acetate of lead, digitalis and prussic acid. After 
making a few observations upon these, Dr. Grisolle goes on to say a {ew 
words in reference to the alterative method of treatment, under which head 
he speaks of calomel. He describes the mo tie in which it is administered 
by English practitioners, but declines expressing an opinion as regards its 
value, either alone or combined with opium, as he had never seen it used, 
and did not like to try it himself, not being conversant with any positive 
fact in its favour. At the same time, he calls upon English physicians to 
publish their experience on this point, taking care to study the question 
upon those exact medical principles which are necessary in the present 
day, in order to convince men of well constituted minds. This we should 
be glad to see; but if Dr. G. means at the same time to have it inferred 
that at present the English and American practitioner can appeal to no 
such evidence in favour of the utility of calomel as would be convincing to 
a man of sound mind, we think he is mistaken. What, indeed, is the 
ground upon which the utility of tartar emetic is mainly established? Cer- 
tainly, not the diminished mortality, for this varies so little from what is 
met with under other methods of treatment as to bring no conviction to the 
mind. In fact, the mere comparison of mortality in different series of 
cases, in order to determine the value of a particular remedial measure, 
even when every effort is made to have the different series, as far as pos- 
sible, properly comparable, by taking into account age, sex, constitution, 
severity of disease, &c, is to our minds the most unsatisfactory and per- 
plexing of all methods; for there still remain such a number of modifying 
circumstances which cannot be appreciated, as to leave the result altoge- 
ther doubtful, except under particular circumstances, and where the differ- 
ence of mortality is very great. What then, we repeat, is the ground upon 
which the value of tartar emetic is mainly established? Certainly on this, 
that the force of the principal symptoms yields very generally and very 
promptly to its use. Now, although we grant that it would be satisfactoiy 
to know more accurately how often and how promptly the relief of parti- 
cular symptoms takes place after the use of calomel, we utterly deny that 
numbers are necessary to determine the general fact; for, were this indeed 
requisite, we could feel confidence in the use of scarcely any remedy 
No. XI.— July, 1843. 9 



125 Reviews. [July 

which we possess, anil on similar principles we should be led, on all ordi- 
nary subjects of common observation, into the most narrow-minded and 
desolating scepticism. Before leaving the subject, it may be well enough 
to say, that in this city calomel is not usually given in as large doses as 
that described by our author. With us, one or two grains, or even a frac- 
tion of a grain frequently repeated, and combined with opium, or Dover's 
powder, is commonly found sufficient. Of course, no sensible man would 
think of trusting to it to the exclusion of bleeding, or indeed regard it in 
any other light than as one among a number of efficacious remedies, espe- 
cially applicable under certain circumstances and in certain cases, but by 
no means equally serviceable or even proper in all. After a few remarks 
upon the evacuant plan of practice, the various adjuvants, such as diet, 
position, drinks, baths, narcotics, &c, are next introduced to notice. 

Opium in moderate doses he thinks may always be resorted to with 
safety to procure relief in cases where the pain in the side persists, the 
cough is very troublesome, the patient restless and unable to sleep, even 
if the fever should be severe. He has never observed suppression of ex- 
pectoration or increase of fever, or cerebral symptoms from its use. A 
warm bath is sometimes very serviceable, especially in the latter stages 
of the disease, where the patient is convalescing, but the skin continues 
hot and dry and the pulse frequent. Its effect is to dissipate the acrid heat 
of the skin, and restore its suppleness and moisture. 

In common with several French writers, Dr. Grisolle is disposed to 
proscribe almost entirely the use of blisters in the treatment of pneumonia. 
They were applied to the chest 12 or 24 hours before death in 4 fatal 
cases, and several days previously in 8 others; also in 26 cases which 
recovered, in 5 of them a little before the end of the sixth day, and in the 
others when the disease was on its decline, on an average about the eighth 
day. In but four of these cases was any amendment observed to follow 
the application, and ev^n when it did so, our author is doubtful how far it 
could he attributed to the blister. Moreover, the duration of the disease 
did not seem to be shortened in consequence, or a fatal termination pre- 
vented. In a former part of the work, however, when speaking of the 
doubtful propriety of bleeding in the last stage of the disease, he recounts 
the history of an individual who was almost expiring when he first saw 
him, the pulse being nearly insensible, the extremities cold, <fcc, to whom 
he administered tartar emetic in large doses, and at the same time applied 
a very large blister. By these means a most unlooked-for amendment 
took place; in 15 hours the pulse had acquired both fulness and resistance, 
the strength was increased, the countenance more natural, and the expec- 
toration much improved. It was now thought that bleeding might be use- 
ful, and unfortunately 12 ounces of blood were drawn, when the alarming 
symptoms returned, and the patient died in three hours. Certainly in this 
case the fatal termination cannot be attributed to any want of efficacy in 
the blister, to which, on the contrary, the previous amendment was proba- 
bly, in great degree, attributable, an amendment too which in all likelihood 
would have been followed by recovery, had not blood unfortunately been 
drawn. Whilst, however, Dr. Grisoile is not disposed to concede to blis- 
ters any decided efficacy as a general rule, he admits that they are service- 
able in one condition, and that is where, during convalescence, pain in the 
lower part of the chest still persists, notwithstanding previous depletion; 
for this pain, he says, is generally dissipated under their use. Had the 



1843.] Grisolle's Treatise on Pneumonia. 127 

condition, of their application, as understood with ns, been appreciated and 
acted on, we cannot help thinking that more extended good effects would 
have been observed. We allude especially to reserving their application to 
that period when the system is brought to what is called the blistering point, 
where the heat of skin has subsided, and the pulse has lost its resistance. 
Be this as it may, it will be difficult to convince practitioners in this coun- 
try that they have not repeatedly witnessed the good effects of blistering, 
especially in cases where the disease, although partly overcome, is not 
rapidly advancing towards resolution, or when from the advanced stage of 
the disease, or other causes, the strength of the patient will not admit of 
depletory measures. 

We will not follow our author in his observations upon the treatment of 
particular symptoms, the modifications requisite in the bilious and other 
forms of the disease, &c, but must bring our remarks, already perhaps too 
much extended, to a conclusion. The work closes with some just obser- 
vations upon the general considerations which should guide our treatment, 
and a summary of its result in the cases before us. We are reminded that 
the physiognomy of the disease varies greatly; that no one treatment is ap- 
plicable to all, but must be modified to suit particular circumstances and 
individual peculiarities; that at times, especially during the prevalence of 
an epidemic influence, it is requisite that the physician should have his 
mind less occupied with the mere inflammatory nature of the disease, than 
with the presence of certain symptoms, which give to the attack a peculiar 
aspect and demand a special treatment. Such is the case in bilious and 
typhoid pneumonias, when the symptoms indicative of these several condi- 
tions predominate; and here, says Dr. G., we have a new proof of the ne- 
cessity in practice of recollecting that all diseases which are characterized 
by a common lesion, are not on that account to be regarded as identical 
and treated in the same way. The general condition of the system must 
be our great guide in acquainting us with the proper indications for treat- 
ment. The plan of practice to which he gives the preference in the main, 
consists in abstracting blood until the hardness or resistance of the pulse is 
reduced, and then resorting to tartar emetic before the strength is so far 
reduced as to render further bleeding improper. A combination of general 
and local bleeding is to be preferred, the latter being most serviceable in 
relieving pain in the side, especially when performed by means of cups. 
The mortality among the patients treated after this manner was only one 
in eight. Sometimes, however, it was found necessary to abandon this 
method, and resort to evacuants, or tonics or stimulants, as the peculiarities 
of the case might require. We have already alluded to the two prominent 
circumstances in which the practice usually adopted with us differs from 
the above, viz: in a resort to calomel and opium, and blisters, not by any 
means to the exclusion of tartar emetic, which however is commonly given 
in smaller doses, sometimes alternated with the calomel, and occasionally 
abandoned entirely to give place to the latter, which in some cases is de- 
cidedly preferable. Amongst children, indeed, were we obliged to confine 
ourselves to one or the other, we should choose calomel as being the most 
generally serviceable, and subject to the fewest inconveniences. 

In conclusion we would observe, that the work of M. Grisolle is most 
complete, and must be highly serviceable as a book of reference. We say 
this, because the work is too voluminous to admit of its being read by the 
generality of medical men. It contains however, upon every question, a 



128 Reviews. [July 

vast body of information, well arranged and digested, where the reader 
will find a history of opinions and statements given forth by previous wri- 
ters, accompanied by a full and rigid criticism, and tested by an analysis 
of the facts within the author's reach. With a few of his conclusions, as 
the reader has noticed, we do not feel disposed entirely to coincide; but as 
a general rule he has shown great caution and a sound discriminating judg- 
ment in appreciating his own observations as well as the statements and 
opinions of others. If he has occasionally attributed to a few numerical 
data a force and conclusiveness in reference to their bearing upon certain 
questions, which they do not really possess, he seems in the main to be 
well aware of the abuses to which the numerical system is liable, and to 
have been careful to avoid them. Thus in the chapter on treatment, instead 
of being doomed to the perusal of a mass of numerical details in reference 
to series of cases not properly comparable, and from which no satisfactory 
conclusion can be derived, we find merely a comparison of the mortality, 
duration of disease, &c, in different series of cases, where the severity and 
stage of the disease, the age of the patients and other circumstances were 
more or less similar, and further the free admission that in certain cases the 
results are still to be received with caution, owing to inappreciable differ- 
ences, as for instance of epidemic constitution or the like. We cannot 
conclude without expressing the gratification which we have felt in the 
perusal of M. Grisolle's work, the main feature of which is that it contains 
a summary of our knowledge, with a careful examination of the facts and 
statements on which this is based, the whole completed by a rigid appeal 
to the author's own experience. Such works are greatly to be desired at 
the present time; and although the author may succeed in bringing out no 
striking novelty, he may have the satisfaction of knowing that he has as- 
sisted in sifting the true from the false, and in settling medical opinion on 
true grounds. T. S. 



Art. XIV.— Traite du Namollissement du Cerveau. Par Max. Durand- 
Fardel. Ouvrage couronne par l'Academie Royale de Medecine. 
8vo. pp. 526: Paris, 1843. 

A Treatise upon Softening of the Brain. By Dr. Max. Durand-Far- 
del. Paris, 184 3. 

The following question was proposed by the French Academy of Medi- 
cine: " What are the different varieties of softening of the nervous centres, 
its causes, symptoms, and appropriate treatment?" To this question M. 
Durand-Fardel succeeded in furnishing the most satisfactory answer, so 
that his essay does not come before us entirely upon its own merits, but 
bearing the imposing imprimatur of the most eminent medical association 
in Europe. But, perhaps the very fact that the work was prepared for 
contesting a prize which was to be awarded on a particular day, may have 
obliged its author to deal too rapidly with the valuable materials lie had 
collected. Perhaps the very profusion of cases which he had to analyze, 
may have made him somewhat inattentive to style and logical arrangement. 
This want of clearness and precision, not so much in particular passages 
as in the general conduct of the work, may possibly prevent the author 
from receiving full justice in the abstract it is proposed to give of his trea- 



1843.] Du rand-Fardel's Treatise upon Softening of the Brain. 129 

tise. We trust, however, that the importance of the facts and views to be 
presented will be distinctly made out through all the imperfections, as 
well of the original work, as of this notice. 

In English medical literature there is hardly any complete dissertation 
upon softening of the brain. Even the excellent article upon the subject 
by Dr. Carswell, in the "Cyclopedia of Practical Medicine," is little 
more than a sketch, whose outline and principal features are copied from 
the portraitures of the French pathologists. The latter observers have 
taught us nearly every thing that we know about cerebral softening, and 
to one of them we owe the present work, in all respects the most com- 
plete that has been written upon the subject. 

M. Durand-Fardel, in attempting the solution of the very obscure ques- 
tions presented to him, has generally taken for his guide the light of nature 
as revealed in well-observed facts. So far as he has adhered to this plan, 
his conclusions seem to be irresistible; where he has abandoned it for 
hypothetical reasoning, he may have made some shrewd guesses, but has 
not established any valuable truth. Of 126 cases narrated, with* more or 
less details, in the body of the work, the greater number were observed by 
the author himself. In collecting data for the elucidation of any point, he 
has gleaned his materials from every authentic source; and where these 
were wanting, has given the opinions of the most distinguished writers 
in connection with his own. We may, therefore, look upon the treatise 
before us as embodying, both in fact ?.nd hypothesis, every thing which is 
known or maintained in regard to softening of the brain at the present day. 
With these prefatory remarks we pass to the proper subject of this notice, 
and, following the arrangement adopted by our author, consider, first, the 
pathological anatomy of acute softening of the brain. 

This lesion most frequently exists in the convolutions of the brain, but 
is very rarely found limited to the cortical substance. The latter appears 
to be its ordinary starting place, whence it subsequently invades the deeper 
portions of the organ. Yet it is occasionally confined entirely to the cen- 
tral or medullary matter. The extent of the morbid change is infinitely 
variable; sometimes it is found involving the whole cerebral surface, and 
sometimes occupying a space not larger than a pea. 

The consistence of the diseased portion may vary from that of a firm 
jelly to the least cohesion compatible with organization. It is important not 
to mistake for a morbid change the natural softness of the base of the brain, 
and especially of those portions of it which lie on the sphenoidal wings. 

In acute softening a red colour is observable in the first stage, and is 
succeeded by yellowness at a later period of the disease. The redness may 
be due to vascular injection, (which is rarely seen except in the medullary 
substance,) to bloody infiltration, or to an imbibition of blood, which shows 
itself almost exclusively in the cortical substance, and imparts a ruddy 
tinge to the whole extent of the softening. Each of these conditions must 
have been preceded by vascular injection. The redness, then, may be 
looked upon as the effect of inflammation, especially since it is accompa- 
nied, in the beginning, by swelling, adhesion of the membranes, etc. 
When a patient survives the 1 acute stage, and dies after the disease has 
become chronic, this redness no longer exists. Hence the division into 
red and white softening by some pathologists who studied the lesions of 
the disease without regarding iheir duration or the symptoms with which 
they severally coincided. Of 120 patients affected with softening of the 



130 Reviews. [Juty 

brain, and observed by M. Durand-Fardel, all who died within a month 
from the first attack, except two only, presented the redness here described 
as characteristic of the acute form of the disease. By uniting his cases 
with those of other observers, it appears, that out of more than 200 there 
were only three of recent date, in which neither redness, yellowness, jior 
suppuration could be found, and only four chronic cases which offered any 
redness at all. The yellowness is not caused, as some have supposed, by 
the presence of pus; it is merely a sign that where it exists there has been 
blood, just as the same colour indicates the same mode of production in 
the resolution of ecchymoses, and around the little clots of blood which 
we find in encephaloid tumours. 

When the superficial portions of the brain are the seat of acute soften- 
ing, the cortical substance swells, so that, on removing the skull-cap, the 
membranes are found tense, and under them the convolutions appear flat- 
tened. In chronic softening, exactly the reverse takes place — the brain 
contracts upon itself. 

Although the membranes, and the cerebral substance directly in contact 
with the softened portion, sometimes present the signs of great vascular 
injection, the remoter parts of the organ appear to share very little in this 
condition. Even the arachnoid is rarely inflamed, except within the limits 
just alluded to. 

Symptoms of acute softening of the brain. — Cases of acute soften- 
ing are separable into two groups; the one, which may be called apo- 
plectic, marked by a sudden or rapid onset, with weakening or abolition 
of the functions of the brain, such as occurs in cerebral hemorrhage; the 
other characterized by a gradual increase of symptoms, such as belong to 
meningeal inflammation, and which may be termed ataxic. But since 
the anatomical lesion is, in both cases, the same, we are forced to infer that 
the same physical condition of the brain may or may not be attended by 
evident symptoms, according to circumstances which we have no means of 
appreciating. Nor does either of the above forms maintain its original 
characters throughout the disease. The one beginning suddenly with an 
apoplectic seizure, may subsequently present a gradual decline of power 
in the functions of the brain; the other may at first be slow and insidious 
in its progress, and abruptly terminate with'all the symptoms of apoplexy. 
The first variety is, however, by far the most frequent, especially in per- 
sons above sixty years of age. Thus of 137 cases, 79 began suddenly. 
Of 29 patients in whom the attack was of this sort, 1 1 only had not reached 
their 60th year; while 24 out of 32 belonging to the other class were under 
that age, and 6 of them under 20 years of age. 

Let us now consider the symptoms more in detail; and, first, the de- 
rangements of motility. 

In nearly every case of softening of the brain there is paralysis, usually 
limited to one side of the body, or to a single limb. Whether complete or 
not, it is sometimes accompanied by contraction, which may be very slight, 
or so considerable as to be overcome with great difficulty. This state is 
not to be confounded with mere stiffness of the joints, which may exist 
upon the sound side; nor yet with voluntary, or automatic flexion of the 
limbs. Instead of paralysis, there may be convulsions simulating epilepsy, 
or tetanic contraction, or merely a tremulous state of the muscles. The 
decay of muscular power commonly keeps pace with that of the mind. 
The prevalent opinion that contraction of the limbs, with rigidity, is nearly 



1843.] Durand-Fardel's Treatise upon Softening of the Brain. 131 

constant in this disease, is unsupported by the experience of M. Durand- 
Fardel, who has readied the same conclusion as M. Rostan, namely, that 
this symptom occurs only in a minority of the cases of softening of the 
brain. 

The sensibility of patients labouring under the apoplectic form of this 
disease can hardly be determined with any degree of certainty. How is 
it possible to distinguish involuntary movements from such as are induced 
by pain, or the cries extorted by suffering from the inarticulate sounds 
which patients in the condition supposed address to those around them? 
Another source of error is in the movements produced through the excito- 
motory system, movements which the experimenter indeed causes, but of 
which the patient is unconscious. The loss of sensibility is, however, 
generally in proportion to that of motion, but is never observed inde- 
pendently of the latter, in this disease, as it so frequently is in affections of 
the spinal cord. Certain modifications of sensibility sometimes accompany 
the onset of the disease, such as numbness like that produced by a blow in 
the course of a nervous trunk, a tingling, or prickling in the face or the 
extremities, or a deep-seated coldness in the paralyzed limbs, or in those 
which are about to be affected with paralysis. 

Headache, which is so common in chronic, is much less frequent ill 
acute softening. It offers no peculiarity either of type or situation. 

The mind presents some striking and interesting phenomena in acute 
softening of the brain. Sometimes a few days before the attack there 
seems to be a certain dulness or confusion of ideas, the disposition is 
irascible, or prone to sadness. When the progress of the disease is slow, 
the mental faculties grow weaker and weaker, until at last the patient 
seems quite besotted, or sinks into coma. In other instances, on the 
contrary, there is a wandering and excitement of ideas, with loquacity, or 
at times a more tranquil delirium, showhig itself in acts rather than in 
words. All these, and similar symptoms, have been ascribed by writers 
of high respectability to inflammation of the membranes of the brain; but 
on reviewing the cases of acute softening collected by the author of the 
work before us, there would seem to be no good reason why these symp- 
toms should be referred to the trifling and circumscribed injection of the 
arachnoid or pia mater, rather than to the more considerable lesion of the 
instrument of thought itself. 

The expression of the face often furnishes important indications in the 
disease under consideration, and deserves a careful study in patients of 
advanced age. Sometimes may be remarked a fixed look of surprise, or 
of indifference, sometimes one of dulness or fatuity. In other cases there 
is a remarkable mobility of feature, and an expression of wildness or 
wandering. It is of consequence to note the earliest departure from sym- 
metry in the face. When one eyebrow is slightly raised and the mouth 
a little drawn towards the same side while the patient is speaking or 
laughing, or when the eyelid of the opposite side veils the eyeball, as if it 
were heavier than usual, there is strong reason to apprehend the imminence, 
if not the actual commencement, of softening of the brain. It is proper to 
remark, however, that in old persons the mouth is usually drawn towards 
the side on which the teeth are least numerous. When, instead of simple 
paralysis, there is permanent muscular contraction, the mouth is often 
drawn towards the affected side. A similar observation is applicable to 
the strabismus which occurs in this disease, A profuse discharge of glairy 



132 Reviews. [July 

mucus from the eyes and mouth frequently accompanies the other symp- 
toms, diminishing and increasing with them. 

The speech is altered materially in this disease: there may be merely a 
certain thickness of speech, or, vocal articulation may be impossible. Some- 
times the sense of the meaning of words is lost, while the faculty of articu- 
lating is preserved, the patients uttering a string of incoherent words, 
with singular volubility. Occasionally all power of uttering even the natu- 
ral cries seems extinguished, and the most perfect, and apparently obstinate, 
silence is maintained, even in the absence of coma. 

The state of the pupils does not throw much light upon the nature of 
the cerebral lesion, although our author thinks that when they are con- 
tracted there is more reason to suspect hemorrhage, than softening of the 
biain. It should be borne in mind, that in old persons a contracted state 
of the pupils is not only very common, but quite consistent with perfect 
health. 

Vomiting is a symptom sometimes observed at the commencement of 
an attack, but seems to depend upon accidental circumstances, such as 
repletion of the stomach, &c. Occasionally deglutition is rendered impos- 
sible by paralysis of the pharyngeal muscles. Retention of urine is a com- 
mon symptom in this disease, and one which the practitioner should never 
neglect. The same caution may be given in regard to the gangrenous 
spots which are apt to form on parts of the body subjected to pressure, 
such as the sacium and the heels. 

The duration of acute softening in fatal cases appears to be from one to 
thirty days. Out of fifty-nine patients, however, forty-three died before 
the ninth day, and nine only survived the twentieth day. 

The diagnosis of acute softening of the brain from hemorrhage of that 
organ, is that which it is of the greatest interest to determine. The apo- 
plectic form already described, presents peculiar difficulties to the observer, 
inasmuch as it is, like true apoplexy, preceded by a congestion of the 
brain, which may of itself give rise to nearly all the symptoms of either 
disease. Even the paralysis is not an exception to this statement, it may 
accompany a coup de sang, as well as a real extravasation of blood upon 
the surface, or into the substance of the brain. It has been said that if the 
mind is unaffected by a sudden attack of hemiplegia, we may be sure that 
the disease is softening, and not hemorrhage, of the brain. But although 
we may be warranted in presuming that such is the case, we eannot-posi- 
tively assert that it is so. There are facts on record to prove that the con- 
trary is sometimes true. If after the symptoms of an apoplectic fit the 
paralyzed limbs are affected with twitching, or for a time recover a por- 
tion of their power, there is every probability that the attack is not hemor- 
rhagic. 

It has been maintained that permanent muscular contraction is an in- 
fallible sign of softening of the brain. Now it appears from an analysis of 
forty-seven cases of acute softening with paralysis, reported by MM. 
Rostan, Andral, and Durand-Fardel, that muscular contraction with rigidity 
existed in thirteen of them only; while in twenty-nine cases of cerebral 
hemorrhage the same symptom occurred nineteen times, that is to say, in 
a much larger proportion. In all these latter cases the hemorrhage broke 
into the ventricles. The first notice of this important fact is due to M. 
Boudet, and from it our author deduces the following proposition. Since 
ventricular apoplexy cannot take place without giving rise to unequivocal 



1843.] Du rand-Fardel's Treatise upon Softening of the Brain. 133 

signs of compression of the brain, we may conclude that when muscular 
contraction with rigidity is accompanied by slight apoplectic symptoms, 
there is sufficient ground for suspecting the existence of cerebral softening. 

The ataxic form of the disease under consideration may be mistaken 
for meningitis, on account of the delirium which is common to both. So 
far as regards persons of advanced age, there is every probability that in 
them delirium arises from the former, rather than the latter disease, which 
is rare in the decline of life. The loss, and the perversion of muscular 
power are not unfrequent symptoms of meningeal inflammation, but when 
these are confined to one side of the body they afford sufficient reason for 
suspecting a lesion of the substance of the brain itself. When an attack 
of paralysis comes on during delirium, it may almost certainly be attributed 
to softening. 

Chronic softening of the brain. — This resembles acute softening, in 
at first consisting merely in diminished cohesion of the cerebral substance, 
but is distinguished from it by the absence of redness. Inflammation of 
the brain but rarely gives rise to suppuration, except in cases of wounds 
of that organ, and disease of the cranial bones. When the brain suppurates, 
the pus is collected in abscesses easily distinguishable from the disor- 
ganized substance of the brain by the creamy consistence and the greenish- 
yellow or grayish-white aspect of their contents. In proportion as the soft- 
ening becomes chronic its inflammatory hue disappears, and blood-vessels 
can no longer be readily detected in it. They are first lost sight of in the 
centre of the diseased portion. Chronic pulpy softening, (or that of M. 
Durand-Fardel's first stage,) may be met with in any portion of the brain, 
but least frequently upon the surface of the convolutions, owing to the readi- 
ness with which they yield to the disease. Its consistence is always least 
at the centre of the degenerated part; sometimes it is as fluid as thin pap, 
so that when deeply seated, its fluctuation may be distinctly felt upon the 
surface of the brain. 

The second stage comprises peculiar alterations in the cortical, as well 
as in the medullary matter. The former of these presents upon the surface 
of the convolutions, and sometimes dipping between them, certain yellow- 
ish plates {plaques), about the size of a half dollar. They have a flabby 
feel, but are much more coherent than the healthy substance of the brain. 
They do not seem to be composed of distinct fibres, the most perfect 
among them resembling softened leather. Blood-vessels can rarely be 
traced in them; but, generally, their surface, under the pia mater, is co- 
vered with a delicate cellular film in which a fine vascular injection may 
be detected. They are commonly not quite as thick as the cortical sub- 
stance. The pia mater can usually be stripped off without lacerating them, 
but sometimes the adhesion of that membrane is so strong as to resist sepa- 
ration, and then the plates are either torn, or dragged away entire. There 
is often found around them a degree of softening, and sometimes true chro- 
nic ulceration with loss of substance, either limited by the thickness of the 
cineritious, or encroaching on the medullary, matter. 

M. Durand-Fardel deserves the credit of having first described this in- 
teresting lesion with minuteness, although it had been previously figured 
by M. Cruveilhier in his great work on Pathological Anatomy. 

The second stage of softening in the medullary substance is called by 
our author cellu/ar infiltration. At this point in the progress of the 
disease, the medullary pulp disappears, to a greater or less degree, and is 



134 Reviews. [[July 

replaced by a loose cellular tissue containing - , in the irregular cavities 
formed by its meshes, a turbid whitish liquid, generally holding in sus- 
pension flakes of disorganized brain. The seat of this alteration is in the 
central portion of either hemisphere, in the corpora striata, or in the 
cerebellum. Its volume may not exceed that of a filbert, or it may occupy 
the whole extent of two lobes. The cellulur tissue concerned in this 
lesion appears to be .nothing more than the cellular "woof" of the brain 
dissected or left bare by the dissolution of the proper substance of the 
organ. This tissue is sometimes very soft, and sometimes so dense as to 
offer a resistance like that of fibrous texture. The latter condition indi- 
cates a tendency to induration which is the only sort of cure possible in 
organic changes so far advanced. The contained fluid bears a strong 
resemblance to lime-water, and is entirely distinct from pus in all its phy- 
sical qualities. The brain around these cavities is generally soft, or pulpy, 
of a white or yellowish hue, and more or less vascular, but never of an 
uniformly rosy tint. 

The third stage is marked by the absorption of the fluid just described; 
the cellular tissue, becoming condensed, lines an empty cavity, or forms 
the centre of a cicatrix made by the 'contraction of the surrounding por- 
tions of the brain. This is not properly a stage ot softening, but rather 
the process of its cure. 

Symptoms of chronic softening. — It is needless, upon the present 
occasion, to insist upon the obscurity which still invests the study of cere- 
bral symptoms. Our just appreciation of symptoms generally, depends 
•upon our means of examining into the condition of the organs, upon our 
knowledge of their functions in health and in disease, and of the morbid 
changes which occur in them. But, as regards the brain, it is inaccessible 
tofall our methods of exploration during life: of its physiology we know 
next to nothing; its very anatomy is unsettled; its organic alterations are 
sometimes revealed by no disorder of function; and its functions may be 
wholly perverted without the least change in its structure, so far as the 
assisted senses can discover. It would be, therefore, unwise to consider 
the symptoms presently to be detailed, as necessarily belonging to the 
disease under consideration; this latter has been too recently a subject of 
serious and separate study, to permit our pointing out the link which con- 
nects its lesions with its apparent symptoms, and that too, were it even 
possible to remove the difficulties already suggested. Cases of chronic 
softening may, however, be arranged in several groups according to the 
symptoms which accompany their commencement. The first of these, 
in the order followed by M. Durand-Fardel, is gradual and progressive 
softening. In this form, the patients, who are generally advanced in life, 
begin to complain of uneasiness; of numbness about the head; and then 
of headache which is usually frontal; they are apt to faint or fall from 
vertigo. This condition may last for several years, but sometimes after a 
few months, or even days, new and more characteristic symptoms appear. 
These are numbness of the fingers or toes, and a prickling of the skin as if 
ants were running over its surface. These symptoms usually affect only 
one side of the body. They may precede or accompany the headache, 
and, with it, are often sufficient to indicate softening of the brain, espe- 
cially of the form we are now considering. Then succeeds feebleness of 
the limbs: the foot is dragged in walking, and the hand lets fall the lightest 
bodies. Oftentimes, at this stage, the fingers cannot grasp any object 



1843.] Durand-Fardel's Treatise upon Softening of the Brain. 135 

unless it is in direct contact with the palm of the hand; as soon as this 
contact ceases, the fingers remain fixed and motionless as before. In cer- 
tain cases muscular contraction with rigidity comes on, first showing itself 
in the hand or elbow, and then extending to the whole of one side, but 
varying in degree from time to time, until it becomes permanent. Coinci- 
dent with this contraction of the limbs, the mouth is drawn towards the 
paralyzed side: the corresponding eye remains half open, and becomes 
inflamed. There is a peculiar look of dulness, astonishment, or indiffer- 
ence; and, at an advanced stage, there are fits of weeping, or sobbing, with- 
out apparent reason. From the very commencement of these symptoms 
the memory begins to fail, the judgment loses its accuracy, and the under- 
standing its perception of ideas. The sight grows dim, and the sense of 
touch dull; the speech is embarrassed either from forgetfulness of words, or 
from the control of the tongue being lost, and the voice becomes singularly 
monotonous. With the progress of the disease the paralysis maybe com- 
plete, and accompanied with a total loss of sensibility. Then the headache 
usually diminishes, but the limbs may still be racked with the most acute 
and lancinating pains. The mind may fall into a state of perfect demen- 
tia, while in some cases its faculties seem unimpaired when all the other 
functions of the brain are at an end. The patients lose the power of 
retaining their excretions, sink into marasmus, and die either from gan- 
grene about the sacrum, or from hypostatic, or intercurrent, pneumonia. 

The earlier symptoms of the second or apoplectic form of chronic 
softening have already been described while treating of the acute stage of 
the disease. But when the patient survives the sudden attack, and the 
disease becomes chronic, there is, in many cases at least, a progressive ame- 
lioration of all the symptoms. The mind may gradually recover its clear- 
ness if not its original vigour; the speech may be partially restored; the 
paralysis may diminish. When the power of using the limbs returns, it is 
almost always preceded and accompanied by a lively, and sometimes pain- 
ful, prickling sensation in the palsied extremities These pains, and tingling 
sensations, when well marked, always indicate cerebral softening. If they 
are perceived immediately after the apoplectic fit, we may infer that the 
latter is due to a primitive softening; if they do not come on till later, there 
is reason to think that they depend upon a consecutive softening of the brain 
around a clot, or hemorrhagic cavity. 

The third form is that in which patients affected with chronic softening 
die with well-marked symptoms of acute disease of the brain. In these 
cases an examination after death reveals only the lesion peculiar to the 
chronic affection, and nothing which goes to explain the symptoms of the 
final attack. 

The fourth or latent form of the disease. Softening is occasionally 
met with in dissecting the brains of patients who during life had never 
presented any symptoms referable to cerebral disease, or who at some 
remote period may have had such symptoms for a time, and subsequently 
enjoyed uninterrupted health. The brain is in this respect like the 
orgafis of the trunk, which may be extensively diseased without betraying 
the change, by any modification of their functions. They, especially, 
who are used to examine the bodies of old persons and children, must be 
frequently surprised at meeting with a large number of organic lesions 
of which no symptoms existed during life. 

Diagnosis. — Chronic softening of the brain is most likely to be con- 



136 Reviews. [July 

founded with apoplectic cysts, or tumours of the brain. In regard to dis- 
tinguishing- it from the former of these, M. Durand-Fardel informs us that 
he finds great difficulty. This difficulty seems to be insuperable; for both dis- 
eases own the same origin, namely, cerebral congestion; the symptoms of 
their attack are in many cases identical; and in their progress the one may 
arise to complicate the other. Indeed until our acquaintance with cerebral 
pathology shall be perfected, there can be little practical good in making 
refined distinctions between these two diseases, since we have no more 
efficient weapons with which to combat the one than the other. The re- 
marks which have already been made respecting the diagnosis of acute 
softening, and the sketch of the symptoms of chronic softening, must 
suffice, for the present, upon this head. 

The phenomena depending on tumours of the brain are fortunately 
rather more susceptible of distinction from those to which softening of that 
organ gives rise. We say fortunately, because the latter disease offers 
many more chances of recovery to the patient than the former, and neither 
prohibits, nor entirely discountenances, judicious treatment. From a de- 
tailed analysis, by M. Durand-Fardel, of sixty-eight cases of tumours in the 
brain, we extract the following propositions. Headache occurred much 
more frequently in these cases than in those of cerebral softening; in the 
former too, it was intense, extorting loud cries during the paroxysms; 
besides which it was usually confined to one side of the head. In sixteen 
cases, headache was the only symptom until within a few days of the 
patient's death. Six times, there was, in addition to the headache, a 
gradual loss of vision, without paralysis, except in one case where the 
paralysis supervened a long time after the blindness. Frequently there 
was feebleness or some other alteration of the sight. These symptoms 
certainly present a strong contrast to those of chronic softening, and 
especially as regards the one last mentioned. Our author declares that he 
knows of no case of complete loss of vision which could be attributed to 
softening of the brain. The other symptoms were, for the most part, 
common to the two diseases, although in the cases of cerebral tumours, 
the convulsions were often unaccompanied by paralysis. If, then, we 
should observe a violent headache limited to one side of the head, with or 
without vomiting, with blindness or disorders of vision unaccompanied by 
paralysis, we may not indeed be certain that these symptoms are caused 
by a tumour in the brain, but we may feel sure that they are not the effect 
of softening. If, however, in addition to these signs, there should be 
paroxysms resembling epilepsy, without paralysis in the intervals between 
them, the chances would be in favour of the existence of a tumour, espe- 
cially if the mind and the speech were unaffected. 

Curability of softening of the brain. — It has been stated, in the 
remarks upon acute softening, that (except when suppurative) it differed 
from the chronic form in the absence of disorganization. Now it must 
be admitted that so long as a tissue preserves its organization it may 
return to its natural condition without retaining any trace of the modifi- 
cations it has undergone. Thus there can be no question that inflam- 
mations of the brain, caused by wounds of the head, and which must 
represent the first stage of softening, have been entirely cured. Our 
author asserts his conviction that many cases of sudden congestion of the 
brain, of apoplexy, and of delirium, which have been arrested in their 



1843.] Durand-Fardel's Treatise upon Softening of the Brain. 137 

progress by judicious treatmnt, have really been instances of the cure of 
cerebral softening. 

When the chronic affection exists under the form of a pulpy softening 
.without redness, it is in a state of transition between the acute form, and 
the advanced stages characterized by the yellow plates, or by cellular 
infiltration. There is every reason to believe that the former may persist 
for many years, during which time the symptoms it has occasioned 
undergo a sensible improvement. The state of the cerebral substance, in 
this form of the disease, does not admit of its return to a normal condition; 
but since the lesion of the part ceases to advance, and it is, so to speak, 
isolated, by its very want of a circulation, from the healthy portion of the 
organ, there appears to be no reason why it should not remain permanently 
stationary, without interfering materially with the functions of the brain. 

After the disease has reached the stage of cellular infiltration, it may, 
judging from the evidence furnished by pathological anatomy, be cured in 
one of three ways. 1st. The cellular tissue which lines and partially fills 
the cyst becomes harder: some points in it, indeed, seem fibrous and 
almost cartilaginous. The spaces between the meshes of the cellular 
tissue, enlarged by a hardening of the latter, or by commencing absorption, 
are filled with serosity, or with the lime-water liquid already described. 
The adjacent substance of the brain is found healthy, or a little hardened, 
or slightly softened, and usually without change of colour. 2d. The 
portion of the brain presenting the cellular infiltration is absorbed, leaving 
a circumscribed cavity, with white, and more or less hardened walls, con- 
taining serosity or a liquid resembling lime-water, and situated in the in- 
terior of the brain or opening outwardly. 3d. This cavity, if it be small, 
may contract and become obliterated, leaving in its place a white, stellated, 
or linear, cicatrix. 

The causes of death in persons affected with softening of the brain are 
to be found usually in some accidental complication rather than in the 
original disease, although the influence of the latter may be the remote 
cause of such complication. The brain, the lungs, or the skin may be the 
seat of the fatal attack. Sometimes, although rarely, a fit of apoplexy 
brings the disease to a sudden termination; more frequently there is in- 
flammation of the brain around a chronic softening. Acute meningitis may 
supervene, or an exhalation of blood " into the cavity" (?) of the arachnoid. 
It is usual to attribute the death of persons with softening of the brain to 
serous infiltration of the pia mater, or to a chronic meningitis, of which 
it is said this infiltration, and the whitish spots and thickening of the 
arachnoid, are the evidences. M. Durand-Fardel is of opinion that these 
appearances are no more morbid than are the milky spots in the heart, 
the adhesions of the pleurae, or those of the gall-bladder, and asserts them 
to be quite common in old persons who have died of any disease other 
than one of the brain. 

Hypostatic pneumonia is a frequent cause of death among patients 
affected with softening of the brain. This is an inflammation of the lungs 
produced by an accumulation of blood in the most dependent part of those 
organs, in persons of feeble powers of life. The symptoms to which it 
gives rise are often so indistinct as to create no suspicion of its existence; 
thus, a change in the expression of the face, dryness of the tongue, and 
weakness of the pulse, may be the only signs of the insidious attack, signs 
which are by no means pathognomonic of inflammation of the lungs. The 



138 Revieivs. QJuly 

physical indications are quite uncertain; and there is rarely any dyspnoea, 
or peculiar expectoration, or stitch in the side. If, indeed, the congestion 
which always precedes the more active disease comes on rapidly, we 
may have all the familiar phenomena of asphyxia. 

Death frequently occurs, in the disease we have been studying, from 
gangrene of the skin over the sacrum or the heel. It is important to bear 
in mind that, in this disease, the recuperative powers of nature are so fee- 
ble, that we have nothing to expect from them, and but little from art. 
When once the gangrene has commenced, its course can rarely be arrested. 
Hence the precept to protect the parts exposed to injury from pressure, 
and to examine them carefully from time to time. 

The Prognosis of cerebral softening might very well have been con- 
sidered under the head of the curability of the disease, but we prefer fol- 
lowing the arrangement of subjects adopted by our author. The prognosis 
made in this disease will depend upon the views entertained in regard to 
its nature. If it is to be looked upon as a specific lesion, or a sort of gan- 
grene of the brain, as some writers teach us, it would be almost a waste of 
time to study it minutely. But if it is nearly always an inflammatory dis- 
ease, and in most respects resembling diseases of that class, there is no 
reason why it should not, like them, be curable. It is certainly a very- 
serious affection;— serious on account of its seat, of the rapidity with which 
it someiimes runs its course, and on account of the disorganization which 
it produces in the most important organ of the economy. But why should 
it stand alone amongst diseases not characterized by malignant degenera- 
tion with the fatal stamp of incurability upon it? It has never hitherto 
been so thoroughly studied, its true nature has never before been so nearly 
demonstrated; and it is not right that we should now inflexibly hold opi- 
nions in regard to it, which our ignorance of its history may once have 
justified. After all, this question can only be settled by a more minute and 
accurate study of the morbid anatomy of the disease, and a correct refer- 
ence to its several lesions of the symptoms observed during life. One 
obstacle to harmony of opinion upon this subject has, we think, been 
removed by M. Durand-Fardel, since he has proved that many cases of 
cerebral disease where recovery has taken place, and which have been 
looked upon as meningitis, congestion, <fcc, were in reality cases of # soft- 
ening of the brain. It may, however, be proper to state here, that M. 
Rostan, who first explored the intricacies of this disease, and who, at the 
conclusion of his original researches, saw no reason to doubt the possi- 
bility of its cure, has recently declared, that with twenty years of addi- 
tional experience, he now considers the malady as " infallibly fatal." 

In an elaborate chapter on the nature of cerebral softening, our author 
passes in review all the theories and hypotheses which pathologists have 
built up or imagined to account for the phenomena of the disease. It is 
an instructive chapter; for it shows the prodigious activity of scientific men 
in patching up the showy monuments of their inventive genius, and their 
amazing contempt of that slow and laborious process which alone has ever 
added a single shrine to the temple of science. M. Durand-Fardel, not 
content with establishing, or rather with»stating what was already estab- 
lished by his cases, treats his readers to some specimens of his skill in 
hypothetical reasoning. It is needless to say that in this respect he is on 
an equality with his rivals, and that his labours are attended with neither 



1843.] Durand-Fardel's Treatise upon Softening of the Brain. 139 

more nor less important results than theirs. In criticising their specula- 
tions he is much more successful than in confirming his own. 

The remote or predisposing causes of softening of the brain are but lit- 
tle understood. It is commonly looked upon as a disease peculiar to old 
age; but while it is true that by far the greatest number of its victims are 
among the aged, yet it destroys many both in childhood and in adult life. 
It has, sometimes, been attributed to a feeble state of health, and to decre- 
pitude, but our author conceives this opinion to be erroneous. In his own 
experience he has met with a great many cases in persons of previously 
excellent health, and in some who were fleshy, or who had what is called 
the apoplectic constitution. M. Rostan, Crawford, and other writers rank 
amongst the predisposing causes all that promote or determine congestion 
of the brain, and, no doubt, with good reason, so far as in matters of this 
sort reasoning from analogy, or a priori, can be called good. Neverthe- 
less, cases of cerebral softening in old persons have been observed, in 
which neither the influence of such causes, nor of any others, could be 
distinctly made out. An examination of this point in a more extensive 
series of cases is greatly to be desired. 

Treatment. — If it be true that vascular congestion in every case pre- 
cedes the disorganization of the brain which has here been considered, 
there must, doubtless, be a period, however brief, in which active treat- 
ment may prevent the development of the disease. Again, when softening 
has once commenced, it is still susceptible, in almost every stage of its 
progress, of undergoing certain modifications, after which the symptoms 
of the malady may gradually disappear, or be replaced by an " infirmity," 
perfecly compatible with life and tolerable health. The important fact to be 
constantly borne in mind, is, that when softening is once developed, it does 
not increase in extent, and may therefore, under favourable circumstances, 
go through the several processes peculiar to its mode of cure. We may 
consider it as proven, that nature sometimes cures this formidable disease. 
But how shall art imitate her model? Experience has not yet informed 
us; and until the answer of this only legitimate oracle shall be rendered, we 
must content ourselves with applying to the treatment of this disease the 
methods which are obviously suggested by the knowledge we have of its 
pathology. A, S. 



140 [July 



BIBLIOGRAPHICAL NOTICES. 



Art. XV. — An experimental and critical inquiry into the Nature and Treatment of 
Wounds of the Intestines. By Samuel D. Gross, M. D., Professor of Surgery 
in the Louisville Medical Institute. — (West. Journ. Med. Surg., Jan., Feb., 
March, 1843.) 

Without being of very common occurrence in civil practice, wounds of 
the intestines are nevertheless of very great interest to the surgeon, as well 
from their danger, as from the various methods which have been recommended, 
and the difference of opinion which exists, on the subject of their proper treat- 
ment. In the paper before us, we are furnished with the results of upwards of 
seventy experiments upon dogs, performed with a view to elucidate the pro- 
cess employed by nature in repairing wounds of these parts, and determine the 
value of the different methc\ls of treatment which have been proposed, as well 
as with an account of the researches of those who have preceded the author in 
the same field of inquiry. 

The mode of reparation in wounds of the intestinal canal, as well as the steps 
employed by nature in disposing of the ligature when applied to them, are now 
well understood. W T hen a small round cord is drawn tightly around an intestine, 
results nearly similar to those produced by a like application to an artery will 
occur — the. mucous covering being completely divided, with oftentimes a partial 
division of the muscular and cellular coats. If this operation be done on a living 
animal inflammation soon follows, lymph is deposited upon the peritoneal sur- 
face around the parts embraced by the ligature, while ulceration takes place 
in those pressed upon by it, and it soon falls into the cavity of the intestine, and 
is discharged with the faecal matter. The period required for the process to be 
completed is of course variable, the size of the ligature, the degree of tightness 
with which it is drawn, the thickness of the gut, the age, and state of the gene- 
ral health, all affecting it. In one experiment of Prof. Gross, the ligature, which 
was round and narrow, had by the third day found its way through more than 
one half of the circumference of the tube, while in another animal, which died 
from the effects of the operation thirteen hours later, the cord had escaped into 
the bowel, and was found at the distance of several feet from the point of in- 
jury, and in both instances an abundant deposit of lymph had re-established the 
continuity of the canal. 

When a ligature is applied firmly to the edges of a small wound precisely 
similar effects are produced, though here, from the cord embracing a larger sur- 
face of intestine, reparation takes place more slowly than in the former case. 

When the wound is left to nature, or when sutures are employed, the process 
of reunion is the same. In both cases the consequent inflammation gives rise to 
an effusion of plastic lymph, and generally to an adhesion between the injured 
gut and the neighbouring parts. From what he has noticed in dogs, Dr. G. be- 
lieves that in eight out of ten cases there is an attachment of the omentum to 
the edges and surface of the wound, though probably, he thinks, this occurrence 
is less rare in man, from the epiploon in him being much smaller than in the 
lower animals. 

The mode in which the ligature is thrown off in the interrupted and continued 
sutures of course varies. Where the cords are cut off close, experiments are de- 
tailed confirmatory of those of Smith, Thomson, Travers, and Cooper, to show- 
that they invariably drop into the intestinal canal and are discharged; but if, on 



1843.] Gross on Wounds of the Intestines. 141 

the other hand, the extremities are left hanging from the external wound, they 
will be discharged outwardly. 

In regard to sutures, the conviction arrived at by Dr. Gross as the result of his 
numerous experiments is, that there are but two which should ever be thought 
of in the management of wounded intestine, viz. the continued and the inter- 
rupted, on which point most practical surgeons will fully coincide with him. 
The continued or glover's suture, is perhaps the oldest of the methods proposed 
for the treatment of wounded intestine. The mode of application of this suture 
is so well known as to preclude the necessity of any description of it here — we 
will only remark that the needle should be introduced throughout at the same 
distance from the edge of the divided surface, and that great care should be taken 
to place the stitches at such distances one from the other as will effectually 
guard against the occurrence of faecal effusions. A caution given by Dr. Gross 
is not to draw the thread so tightly as to give the lips of the wound a puckered 
appearance — an occurrence which he believes calculated to interfere with the 
adhesive process, and with most other writers of the present day, he advises the 
ends of the suture to be securely fastened, either by a knot, or by passing them 
under an adjoining loop, after which they are to be cut off close to the gut, into 
the interior of which, as has been already observed, the thread employed ulti- 
mately finds its way by ulceration. The reduction of the prolapsed fold after 
stitching is of course to be made in the gentlest manner, and the outer wound is 
afterwards to be carefully closed. 

The results of the experiments of Dr. Gross are very favourable to the use 
of this suture as well in longitudinal as in transverse and oblique wounds; they 
were seventeen in number, and in no one of them did the operation prove fatal 
to the animal. "In eight the needle was carried th/ough the whole thickness 
of the bowel, and in five, the everted mucous membrane was pared off on a 
level with the surrounding surface; in eight, the suture was introduced through 
the fibrous lamella, or between the muscular and mucous coats; and in one, 
through all the layers of the tube, except the peritoneal. It is worthy of remark 
that the caliber of the tube was not sensibly diminished by the operation in any 
of the experiments. 

" Of these three methods, that of introducing the suture through the cellulo- 
fibrous lamella is the least objectionable, as it enables us to bring the serous 
surfaces into more accurate apposition. When the needle is conveyed through 
all the tunics, there must necessarily be some degree of puckering, whereby the 
mucous lining will be forced between the lips of the wound, if not beyond the 
level of the peritoneal membrane. By such an arrangement the adhesive pro- 
cess would be retarded, and if the stitches were to lose their hold, or if the bowel 
should not become glued to the neighbouring parts, faecal effusion might occur, 
followed by its whole train of evil consequences." 

For the employment of this suture we have the high authority of Travers and 
Larrey, and Sir A. Cooper was favourable to it, though like Baron Larrey he 
believed the danger to be increased by cutting it off close to the bowel, and 
advised the end of the ligature to be brought out at the external orifice. The 
principal advantages which it offers are, that it is easily, and quickly per- 
formed, and that it closes very firmly the wounded part. Five cases are cited 
in the paper, which the author states are the only ones known by him to have 
been communicated to the profession, in which the continued suture was employed 
in the human subject. These are quoted from Travers of Lisbon, Glandor- 
pius, Charliar and Larrey, and of these five, one died. With a little research, 
other recoveries of this description might easily be adduced. 

The interrupted suture is also of great antiquity. The most important cir- 
cumstance in its application is to place the stitches sufficiently near each other 
to prevent the escape of the faecal or other matters. In fourteen animals ex- 
perimented upon with this suture, two were fatal, one from peritonitis and the 
other without obvious cause. In thirteen of these the suture was carried through 
all the tunics, and in one through the cellulo-fibrous lamella. Five cases are 
No. XL— July, 1843. 10 



1 42 Bibliographical Notices. [J"ty 

appended from authors in which the treatment with the interrupted suture was 
attended with happy results in the human subject. 

The method of joining together the two ends of a divided bowel by introducing 
the superior into the inferior portion of it and retaining it there by means of a 
suture as done by Rarndohr, or the looped suture of Le Dran, the suture " a points 
passes" of Oertrandi — where the thread is passed through and not over the lips 
of the wound, the method of the "Quatres maitres" viz. that of stitching the 
divided ends of the bowel over a piece of the trachea of a calf or other animal, 
a cylinder of isinglass, of elder wood,' of pasteboard, or other like substance, as 
well as that proposed by Palfin and advocated by J. Bell and Scarpa, of securing 
the edges of the solution of continuity in the intestine at their centre by a simple 
slip knot, and after bringing out the ends at the external opening attaching them 
by adhesive strips to the parietes, are all methods which time and again have 
exercised experimenters. Instances too may be cited, (and where may not 
exceptional cases be adduced to support any mode of practice in medicine), of 
the success of each of the modes of treatment enumerated, upon the human sub- 
ject, as well as upon animals. Lavielle, Pitcher, and others have succeeded 
with that of Rarndohr, Le Dran, and Palfin, have each reported cures by their 
methods, while Duverger has succeeded with that of the "Quatres maitres," but 
notwithstanding the ingenuity with which all these have been urged, and the 
hecatombs of animals that have been slaughtered to show their little danger or 
their peculiar adaptation to the end for which they are employed, the slow and 
imperfect adhesion to which they give rise, the danger of breaking up the adhe- 
sion upon the removal of the threads, the difficulty of effecting what is proposed, 
or their total inefficiency to prevent faecal effusions, sufficiently explains the 
causes of their rejection. 

Of the more modern methods, most which have been proposed will we fear 
share the fate of those that have been already enumerated. Jobert, in wounds 
involving the entire circumference of the gut, dissects off the mesentery for 
several lines from each extremity of it, and after attaching a couple of loops to 
the upper and inverting the coats of the lower end of the bowel, passes an armed 
needle from within outwards through the doubled wall of the lower end, and 
then by pulling gently at the threads gradually drags down the upper into the 
lower portion in such a way as to bring the two serous surfaces of the bowel into 
contact, when havino- restored the bowel into the abdominal cavity, the ligatures 
are twisted and brought out at the lower angle of the wound. Lembert advises 
the sewing up of the wound by a sufficient number of interrupted sutures passed 
so as to include only the muscular and peritoneal coats, and carefully inverting 
their edges before the tightening of the knots. Denans recommends the introduc- 
tion of hollow metallic cylinders into the intestinal tube with the view of keeping 
more effectually in contact the serous surfaces of the divided ends of the gut. 
Raybard proposes to produce a temporary obliteration of the wound, and to main- 
tain the intestines in close contact with the walls of the abdomen, and for this 
purpose introduces a ligature armed with two sharp needles through a light and 
smooth wooden cylinder into the intestine, where it is fastened by carrying the 
needles from within outwards through the lips of the wound about aquarter of an 
inch from its margin. The extremities of the ligature, twisted together, are then 
passed by means of a crooked needle through the muscles of the belly, at a little 
distance from the edge of the outer opening, the bowel reduced, and the thread 
drawn upon by the surgeon until the injured partis placed in apposition with the 
abdominal parietes; the ligatures are then separated and tied over a small com- 
press lying parallel with the inner lips of the wound. Amussat, Thomson, and 
Choisy, have each recently proposed modifications of the method of Rarndohr, 
but the same objections urged against the earlier of the proposals we have noticed 
are equally applicable to all these, and but few who have examined with care the 
methods we have alluded to, and none, we think, who have seen much of this 
class of injuries in the human subject, will be likely to practise them. The 
murderous cruelties which we have witnessed, and which it is well known are 
constantly performed by M. Amussat and his clique upon the inferior animals, 



1843.] Gross on Wounds of the Intestines. 143 

should be alone sufficient to make one wary in giving trial to any proposal in ope- 
rative medicine emanating from such source. 

Upon the subject of the treatment of wounded intestine there are some points 
in which we do not entirely coincide with Professor Gross, and upon which, as 
being likely to lead in our opinion to a false prognosis, and erroneous practice, 
we beg to offer a remark or two. Speaking of the dilatation of the outer wound 
in cases of injury to the intestine unaccompanied with protrusion, and of the 
necessity in some cases of resorting to such practice, he says: — "Let us, for the 
sake of being more fully understood, suppose a case: A man, after having in- 
dulged in a hearty repast, receives a penetrating wound in the abdomen from 
the thrust of a dirk or knife; the bowel is pierced, or, it may be, nearly divided, 
and there is a copious discharge of fap,cal matter, both externally and into the 
peritoneal cavity, as is evinced, in the latter event, by the excruciating pain, the 
gastric oppression, and the collapsed condition of the sufferer. Here the most 
prompt and decisive measures must be resorted to, or the person will perish from 
peritoneal inflammation with as much certainty as if his skull had been frac- 
tured and a portion of his brain let out." 

" By the above procedure, which, under the circumstances pointed out, I should 
never hesitate to pursue, the patient is not placed in a worse condition than a 
female who has undergone the Ca?sarian section, or a person whose abdomen 
has been ripped up in the first instance; recovery from both of which is not, as 
is well known, of unfrequent occurrence." " The truth is, the fatality of penetra- 
ting wounds of the abdomen has been greatly overrated. Injuries of this kind 
have been a sort of bugbear with surgeons and physicians, not so much from 
,what they themselves have witnessed as from what they have heard from others; 
and hence a prejudice has arisen against the infliction of wounds and even 
punctures upon the peritoneum which has 'grown with our growth and strength- 
ened with our strength' until it has become almost impossible to eradicate it." 

The opinion is generally held thatfsecal effusion is not a common consequence 
of penetrating wounds, and that it can rarely occur except where the bowel is at 
the moment full, and the wound extensive; and notwithstanding the experiments 
upon animals cited by Dr. Gross to support the contrary belief, we think Mr. 
Travers has conclusively proved its general correctness by reference to the ex- 
aminations of cases of this kind which have occurred in the human subject — a 
method which, to our mind, is more conclusive than any experiments upon 
brutes. Mr. Travers too has adduced experiments to prove this point which are 
at variance with those of Dr. Gross. The latter gentleman we are led to believe 
from what is stated, though on this point he is not explicit, opened the abdomen, 
dragged out the intestine, wounded, and returned it, while the former simply 
plunged a sword into the bellies of the animals selected, thus making an injury 
precisely similar to those met with in the human subject. But admitting effu- 
sion into the peritoneal cavity to happen in a case where the external opening 
was of small size, how is it to be ascertained'? It must be a point of extreme 
difficulty if not altogether impossible to determine certainly the fact, and most 
assuredly, the occurrence "of excruciating pain, gastric oppression, and a col- 
lapsed condition," are not alone to be depended on for it, for all of these we have 
seen occur in an extreme degree in a wound not affecting the intestine. But 
even were effusion known to be present, in case the injury had been made by a 
thrust with a long and sharp instrument, as a dirk, a small sword, or a bayonet, 
would it not be well to caution the practitioner against a resort to the practice, as 
in all of these instances it would be probable that several folds of intestine had 
been wounded, the whole of which could not be secured, and any attempt to do it 
would but aggravate the sufferings, and hasten the end of the patient. Where 
there is a copious discharge of faecal matter externally, sound surgery altogether 
forbids a search after the wounded bowel for the purpose of ligaturing it. All 
persons so wounded who are left to nature do not invariably die, any more than 
do all those who meet with fractures of the skull and losses of portions of the 
brain. Rare though they be, yet any treatise on military surgery will show in- 
stances of cure after both the one and the other injury. 



144 Bibliographical Notices. QJuly 

That a patient, by dilatation of the wound under such circumstances, is not 
placed in a worse condition than a female after the operation of the Caesarian 
section, is another position that we cannot admit — the wound of the intestine 
vastly aggravates the case. Recoveries too after this very formidable operation, 
or after having had the abdomen ripped up, cannot be said to be frequent, even 
under favourable circumstances. Michaelis has collected the reports of two 
hundred and forty-eight cases of the Caesarian operation, of which one hundred 
and forty proved fatal; and Dr. Churchill asserts that the operation was done 
three hundred and sixteen times between the years 1750 and 1841, with a mor- 
tality of 52.8 per cent, and it is matter of notoriety that many unfortunate cases 
have occurred which have never been noticed in print. Small wounds of the pe- 
ritoneum, as those made with a penknife, or in the operations for hernia, or tap- 
ping, generally do well, but as a class they must always excite the most serious 
apprehensions, and when extensive, or accompanied with a wound of the small 
intestine, a fatal termination of them should be given as the common rule of 
prognosis, and the recoveries be looked upon as the exceptional cases. We are 
led to suspect that the views of Dr. Gross on this point may possibly have had 
some«bias from the happy results he constantly observed to follow his experi- 
ments upon brutes. What he has himself stated in another part of his memoir 
(p. 208) in regard to the comparative results of operations upon animals and 
upon man, appears to contradict, in some degree, the assertion made in this 
place, relative to the unfrequent occurrence and little danger attendant upon ab- 
dominal wounds, and expresses so well our own views that we cannot do better 
than repeat it. " It should not be forgotten that an operation which is perfectly 
successful upon an inferior animal, may, when performed upon the human sub- 
ject, be followed by the worst consequences. In the one, disease is exceed- 
ingly rare; in the other, it is not only frequent, but capable of assuming a vast 
variety of forms, and of sapping the foundations of life when least expected. 
In the one, peritoneal inflammation is not only uncommon, but, when developed, 
seldom attains any considerable height; in the other, it is not only easily excited, 
but extremely apt to terminate fatally." G. W. N. 



Art. X VI.— 1 . The Annual Report of the Court of Directors of the Western Lunatic 
Asylum, to the Legislature of Virginia, for 1842, pp. 62. 

2. The Annual Report of the Rhysician and Superintendent of the Eastern Asylum, 
in the city of Williamsburg, Virginia, for 1842, pp. 38. 

3. Twenty-sixth Annual Report of the state of the Asylum for the relief of Persons 
deprived of the use of 1 heir Reason, pp. 28. 

4 State of the New York Hospital and Bloomingdale Asylum, for the year 
1842, pp. 32. 

5. Sixth Annual Report of the Trustees of the Vermont Asylum for the Insane, pp. 1 6. 

6. Tenth Annual Report of the Trustees of the Slate Lunatic Asylum at Worcester, 
December, 1842, pp. 110. 

The season for the publication of the annual reports of the institutions for 
the Insane in the United States, has again passed, and copies of those documents 
from all the Asylums at which they are issued, with but two exceptions, are now 
before us : — they are richly laden with the results of the experience of another 
year; they bear evidence of advancement in a knowledge of the disease upon 
which they treat; they are well adapted to the dissemination among the commu- 
nity of more accurate ideas in regard to the most unfortunate malady which 
" flesh is heir to." Several of them were noticed in the last number of this 
Journal. A brief review of the others, the titles of which are above, will now 
occupy our atteation. Before proceeding, however, to the prosecution of this 
object, we wish to point out an error which, though of no great magnitude, is 
of sufficient importance to justify a rectification. 

In the Report of the Maine State Asylum, we observe the phrase "». Tuke, 



Men. 


Women. 


Total. 


58 


41 


99 


47 


6 


53 


105 


47 


152 


17 


9 


26 


13 


2 


15 


1 




1 


74 


36 


110 


13 


6 


19 


4 


3 


7 



1843.] Insane Asylum Reports. 145 

the venerable physician of the York Retreat, England " and in several other docu- 
ments, tire gentleman therein mentioned has been spoken of as Doctor Tuke. 
Samuel Tuke is not a physician, but a Tea-merchant in the city of York. He 
has long been connected with the Retreat, as a manager, and hence has been 
enabled to prosecute those observations the valuable results of which have been 
imparted to the profession. 

1. The legislature of Virginia, during its session for 1842, made an appro- 
priation of $22,000 for the support of the " Western Asylum.'" and another of 
$24,000, for the erection of three additional buildings to that establishment, one 
for the accommodation of forty -five female patients, and two others, — "lodges" 
— for sixteen patients, each. These buildings have been commenced, and are to 
be completed on or before the first day of July, 1844. 

The following are the statistics of this asylum for the year 1842. 

In the Asylum at the commencement of the year, 
Admitted during the year 

Whole number " " " " 

Discharged " " " " 

Died " " « " 

Eloped " " " " 

Remaining at the end of the year 

Of those discharged, there were recovered 

" " improved and unimproved 

The discrepancy of numbers between men and women arises from the fact that 
the accommodations for the former are much more extensive than for the latter. 
The departments will be nearly equalized by the construction of the edifices 
afore- mentioned, the necessity of which appears urgent, inasmuch as the number 
of female applicants waiting for admission is " upwards of eighty." 

Of the 152 patients, but 21 had been insane less than one year, and 22 from 
one to three years, the remainder having been so during different periods, from 
three to thirty years. The Superintendent urges upon the legislature the im- 
portance of authorizing a discharge of harmless incurables, to make room for 
cases of recent origin. So long as the accommodations are insufficient for all the 
applicants, the arguments in favour of this course are too obvious to require 
repetition. 

In an article on "Medication" Dr. Stribling deplores the ignorance of medical 
men "in the general" in regard to Insanity. — "There is one evil," says he, 
"resulting from this want of information, of so frequent occurrence and so mis- 
chievous in its character, that we cannot, even at the risk of being deemed pre- 
sumptuous, refrain longer from raising our voices against it, and calling upon 
physicians throughout the commonwealth to halt in a course which but too often 
aggravates, and that in a ten-fold degree, the horrors of a malady for the relief of 
which their interposition has been sought. It rarely happens that a patient is 
brought here, after having been previously under the care of a medical practi- 
tioner, in regard to whom it cannot be said that he has been ' well bled, blistered 
and purged? So indiscriminate and universal is this practice, and to such an 
extent is it frequently prosecuted, that it numbers among its victims those 
labouring under every form, degree, and duration of insanity! But those who 
are most exposed to it, and in the greatest degree injured by it, are individuals 
afflicted with active mania. Here the practitioner rarely fails to attribute the 
usual consequences which result alone from nervous excitement, to inordinate 
arterial action." Dr. S. recognizes exceptions to this rule, but in all cases to 
which it is applicable recommends the use of cold applications to the head, 
warm pediluvia, a gentle laxative and narcotics. " As a general rule," he pro- 
ceeds, "we prescribe what would be equivalent to 100 drops of laudanum, to be 
repeated at intervals of six hours, and the dose to be cautiously increased until 
a decided effect, either for good or harm is produced. * * * After narcotics have 
been used for a season, we combine with these some mineral tonic, and have 
often found the most beneficial effects to result from the combination.— Iron in 



Men. 


Women. 


Total, 


60 


37* 


97 


13 


14 


27 


73 


52 


125 


11 


6 


17 


5 


10 


15 


57 


36 


93 


10 


5 


15 


1 


1 


2 



148 Bibliographical Notices. [J u ty 

some one or other of its preparations, is usually prepared for this purpose." 
The Report contains a detail of several cases which have been treated in the Asy- 
lum and a valuable article on "Simulated Insanity." We regret to learn that 
the health of Dr. Stribling is in a precarious state, and trust that its renovation 
may still secure, for years to come, his valuable services to the institution with 
which he is connected. 

2. — In the Eastern Asylum, of Virginia, the number 
of patients at the commencement of the year was 
Admitted during the year 

Whole number " " " ." 

Discharged " " " " 

Died " " " " 

Remaining at the end of the year 

Of the discharged there were Restored 
44 " Unimproved 

Of thirteen recent cases admitted between the 1st of Jul} 7 1841 and the corres- 
ponding day of 1842, twelve were discharged restored. After some remarks 
upon this result, and the introduction of the per centum of cures in some other 
asylums, the Superintendent, Dr. Gait, says, " I am led to believe that there is 
no insane institution, either on the continent of Europe, in Great Britain or in 
America in w T hich such success is met with as in our own." Granting to the 
Dr. that this inference is derived from fair and accurate premises, such as would 
place the institution under his direction upon an equality with the others which 
are the subjects of comparison, we must still be permitted to believe, and we 
think the Dr. will himself coincide with us in the opinion, thatthe experience of 
but one year, is altogether inadequate to justify a conclusion so general and so 
positive. — He cannot be unaware of the fact that numerous contingencies, en- 
tirely beyond the control of the Physician, may materially effect the proportion 
of cures, and that though they may combine in his favour one year, and raise 
that proportion to its maximum, their influence may be opposing the next, and 
diminish the number restored to its minimum. Dr. Bel!, of the McLean Asy- 
lum, who deprecates the division of patients, in statistical reports, into " old" 
and "recent," says: " During some years, as in 1838 for illustration, we have 
had so entirely the co-operation of friends in a due perseverance, that we should 
have been able to report the recovery of 100 per cent, of cases presumed to be 
recent." — This result exceeds that of the Eastern Asylum by 7 T ^ per cent. 
Again, says the same writer, " the records of this Asylum justify the declaration 
that all cases certainly recent, that is whose origin does not either directly or 
obscurely run back more than a year, recover under a fair trial. This is the 
general law; the occasional instances to the contrary are the exception." 

Now, one reason why the institutions for insane do not report from year to 
year a greater proportion of cures of the ''recent" cases treated in them, is found 
in the fact that those cases have not all been submitted to "a fair trial" — some 
of them being prematurely removed, and others having been received but a short 
period, perhaps but a few days previous to the time of making the report. These 
disadvantages did not exist in the cases reported by Dr. G. — since they all re- 
covered with the exception of one who died, and since his report was made 
six months after the expiration, of the year during vjhich they were admitted. Not- 
withstanding these evidences of dissimilarity of condition in his objects of com- 
parison, we grant, what cannot be dented, that the success of the Dr. was 
eminent, and sincerely hope that it may continue to be no less so in future years. 

In a long article on "Treatment," it is stated that the principal medical agents 
relied upon in that asylum are " narcotics, tonics, purgatives, counter-irritants 
and baths." Opium is more used than any other article of its class. The 

* These numbers are as they are given in the report. There is a discrepancy of one, 
as will be seen upon adding the two items. 



1843.] Insane Asylum Reports. 147 

maximium dose is from six to twelve grains, and that of either of the salts of 
morphia from two to three grains three times a day. " We have also employed 
opium," says the Report, "in a manner which we believe is peculiar to our- 
selves; that is, mixing- it with tobacco and causing the patient to smoke it.' 
We very much doubt whether this method of administration will be found as 
useful as those already in vogue. Sulphate of quinine is the most used as a 
tonic, and blisters on the back of the neck as counter-irritants. Much benefit 
has been derived from the use of the shower and the warm bath, the former in 
the morning the latter at night. 

The remainder of the Report is occupied with remarks upon the various sub- 
jects usually discussed in documents of the kind. The whole indicates fami- 
liarity with most of the standard authorities upon insanity, and a laudable zeal 
in the undertaking in which its author is engaged. We cannot, however, in 
justice to the writer or to ourselves forbear to notice what we think must be 
evident even to the superficial reader, that it is written in a style too desultory, 
ideas very remotely connected with each other either by analogy, association or 
induction, being placed in such juxtaposition or succession as is only justified 
by one of those forms of relation. 

3. At the *'» Asylum for the Relief of Persons deprived of the use of their Rea- 
son," near Frankford, Pa. the number of patients Men. Women. Total, 
at the commencement of the year was 29 29 58 

Admitted during the year 12 13 25 

Whole number " " " 41 42 83 

Discharged during the year, 32; Died, 5; Remaining at the end of the year, 46. 
Of those discharged, 10 were restored, 6 much improved, 4 improved, and 12 
unimproved. Of those remaining 3 were restored. The report of the physicians 
is brief, but contains judicious remarks upon the " Supposed cause," its dura- 
tion, and forms, and upon recoveries, discharges, and deaths. 

4. The Reports of the New York Hospital and the Bloomingdale Asylum are, 
as usual, combined, the latter institution being a branch of the former. 
The number of patients in the Bloomingdale Asylum, Mea - 

January 1st, 1842, was 

Admitted during the year 

Whole number " *' 4t 

Discharged, cured " s; " 

44 " improved 
** " by request 
Died u u u> 

Eloped " 4t " 

Remaining, Jan. 1st, 1843, 

Total 126 93 219 

Recent cases admitted, from 1823 to 1842 inclusive, 1394; Of which, discharged 
cured, 10G4; old cases admitted, 1065; cured, 131. Whole number admitted from 
1821 to 1842, inclusive, 2G34; of which were cured, 1255; died, 247. 

The Report of Dr. Wilson contains observations upon the utility of asylums, 
an exposition of some of their advantages, and a short account of the institution 
with which he is connected. — The last mentioned is here extracted: 

The Bloomingdale Asylum " is the Insane Department of the New York 
Hospital, the governors of which institution, at an early period of its existence, 
were induced to appropriate apartments for the insane in the Hospital, as there 
existed no institution in the State for the reception and cure of that description 
of patients; but as the building was not designed far that purpose, the accommo- 
dations were found to be extremely inconvenient and inadequate, and the appli- 
cations for insane persons constantly increasing, it was resolved, in 1806, to 



Men. 


Women. 


Total. 


78 


55 


133 


48 


58 


86 


126 


93 


219 


29 


26 


55 


9 


6 


15 


22 


9 


31 


4 


3 


7 


1 





1 


61 


49 


110 



148 Bibliographical Notices. [Juty 

erect, with legislative aid, a separate building, to be exclusively appropriated to 
the reception of that unfortunate class of persons. The governors immediately 
proceeded to lay the foundation of the proposed edifice, denominated the 4 Lu- 
natic Asylum,' which was completed at an expense of about fifty-six thousand 
dollars. It was opened for the reception of patients on the 15th of July, 1808, 
when nineteen were removed from the Hospital and forty-eight more were ad- 
mitted, making the whole number sixty-seven. This building was the first edi- 
fice erected in the United States expressly for the reception and curative treat- 
ment of insane patients. It continued to be used for that purpose until the 
governors, actuated by the desire of accommodating the still increasing number of 
applicants, of removing them from the noise and excitement inseparable from 
their location in the midst of the city, and of introducing a course of moral 
treatment, more extensive than had hitherto been practiced in this country, 
purchased in 1815, the beautiful grounds now occupied by the institution, and 
erected thereon the principal edifice. It was completed in 1820, and opened 
for the reception of patients in June, 1821, when it received the name of Bloom- 
ingdale Asylum. 

" Previous to the removal of the Asylum from the e\iy , fifl cenhundred and fifty- 
three patients were admitted — of whom seven hundred and four recovered, artd 
fifty-two were removed to Bloomingdale. The present location is about seven 
miles from the city, near the Bloomingdale road, and from its elevated situation 
affords one of the most extensive and delightful views to be found in the 
country. 

" The principal edifice is of stone, 211 feet in length and GO feet in depth, of 
three stories in height above the basement, and is divided into a centre building 
and two wings. The wings are arranged, in each story, with a large hall 
through the whole length, and the dormitories and sitting-rooms are on either 
side. There are also two additional buildings, each about sixty feet by forty feet, 
three stories in height, and with internal arrangements similar to those of the 
main building, for the accommodation of the more noisy and boisterous patients. 
The cost of all the buildings and improvements, with fifty acres of land, has 
been about $180,000. 

"The government of the institution is confided to a Standing Committee of 
the Board of Governors of the New York Hospital. This committee visit the 
Asylum weekly, and report monthly their proceedings to the Board of Governors. 
Under their direction the physician, warden, and matron discharge the various 
duties appropriately devolving on each. 

"The means employed in this Asylum for the recovery of those placed under 
its charge, are much the same as are provided in all similar institutions in our 
country." The account does not particularize those " means," but from per- 
sonal observation during an afternoon very agreeably and usefully passed in a 
visit to this Institution a few months since, we believe them to be as extensive 
and as judiciously selected and applied as at any other asylum in the United 
States. 

5. Since the Annual Report for 1841, of the Vermont Asylum for the Insane, 
that Institution has been enlarged by the addition, or "the completion" of a 
wing; thus furnishing more extensive accommodations and increasing "the 
facilities for a better classification of the patients." At the commencement of 
the year the number of patients was ------- 95 

Admitted during the year, ------- 101 

Whole number, - ...-*-- 196 

Discharged, - . - __..._ 77 

Died, - 6 

Remaining at end of year, - - - - - - - 113 

Of the discharged there were recovered, ----- 49 

" " " " " not recovered, - 28 

Whole number admitted since opening of the Asylum, - - - 424 



1843.] Insane Asylum Reports. 149 

Whole number recovered, - - - - - - 179 

« " Died, ------ - 21 

Discharged not recovered, - - - - - - - 111 

The number of patients admitted was greater than during any previous year. 
Two cases recovered which were of six or eight years standing. In one of them 
the principal means employed to effect a restoration was "constant and useful 
labour." No suicide has ever occurred in this asylum. The Institution is fur- 
nished with a library of 400 volumes, for the use of the patients; and a cabinet 
of minerals has been commenced. It is presumed that the annals of history, 
whether written or unwritten, can furnish no parallel to this asylum in regard to 
the publication of a newspaper wholly conducted by lunatics. "The Asylum 
Journal," commenced by the patients about a year since, is managed with no 
inconsiderable ability. Dr. Rockwell has furnished this year, as he has in his 
previous reports, an excellent example of the multum inparvo. 

6. During the past year, the establishment of the Massachusetts State Lunatic 
Hospital has been improved by the erection of a new barn and the conversion of 
the old one "into a building two stories high with a room for an engine, and a 
shop for carpenter and cabinet work on the lower floor, and with a shoemaker's 
shop, and a shop for the manufacture of mattresses on the second floor." The 
trustees, in the Report before us, urge upon the State legislature the necessity 
of enlarging the hospital, on account of its present incapacity to accommodate 
nearly all the applicants for admission. "There are only 229 rooms for the 
accommodation of patients, and there has been no time during the year when 
they have not all been occupied, and most of the time there have been more 
patients than rooms.*** There have been during the year, one hundred and fifty- 
seven applications in behalf of persons who were not admitted at the time when 
the applications were made, and one hundred and thirteen of them have not been 
admitted at all. 

"The tru'stees therefore are of the opinion that accommodations for at least 
one hundred and fifty more patients should be provided. ****The mostadvisable 
plan seems to be to add two wings, one to the north and one to the south, so 
joined to the existing building that the present kitchens may serve also for the 
additions." Agreeably to these suggestions, the legislature, during its recent 
session, authorized the proposed enlargement. 

The number of patients has been greater than in any preceding year. There 
were in the Hospital on the 1st of 
December, 1841, 
Admitted during the year, - 
Whole number, - 

Discharged, 

Died, - ------ 

Remaining November 30th, 1842, 
Of those discharged there were recovered, 
" " " " " improved, - 
" " " •' " incurable, 

" During the past season," says the Report, "erysipelas with tendency to sup- 
puration and gangrene, has been somewhat prevalent in this vicinity, and a few 
cases have occurred among our patients, none of which have proved fatal. Three 
or four of these cases had extensive suppuration, and were quite severe, but the 
free application of nitrate of silver arrested the progress of the inflammation. In 
three cases, in the incipient stage of the disease, the free use of the caustic, so 
as to destroy the scarf skin, entirely arrested the progress of the inflammation, 
and the case was ended at once." 

" In every department of industry the labour has been more productive than 
in any former year. The products of the farm have greatly increased, and me- 
chanical employments have engaged a greater number of workmen, with greater 
comfort than heretofore. More than §1000 worth of shoes have been made s 



Men. 


Women. 


Total. 


116 


116 


232 


107 


91 


198 


223 


207 


430 


96 


83 


179 


3 


9 


12 


124 


114 


238 


44 


44 


88 


13 


12 


25 


39 


27 


66 



150 Bibliographical Notices. [July 

yielding- a nett profit of $1 25/ ? ff to the Institution. Many useful articles are made, 
and all repairs of furniture for the establishment are done in the carpenters' and 
cabinet shops, and one patient has " prepared all the hair and made and repaired 
all the mattresses necessary for the season." " Of the fifty tons of hay gathered 
this season, seventy-five per cent, of it was probably mowed, made and gathered 
in by the patients. From twenty to thirty workmen were often in the field at 
one time, all busily employed." "At one of my daily visits to the hay-field," 
says Dr. Woodward, "1 found four homicides mowing together, performing their 
work in the best manner, and all cheerful and happy." Other departments of 
labour, the usual course of amusements, and the meetings for worship have 
been continued as usual. Of the 430 patients in the hospital during the year 
" nearly four hundred have attended the chapel exercises more or less." A 
valuable Meteorological Journal is appended to the Report. 

Ten years having elapsed since the Institution at Worcester went into ope- 
ration, Dr. W. has taken the present occasion to enter more extensively than 
heretofore into general data — data which can be satisfactorily attained only by 
the collection of a large number of cases. Hence this Report is more valuable 
than any by which it has been preceded. We proceed to select some of the most 
important information. 

During the ten years the whole number 

of patients admitted was 
Whole number discharged, 
Died, 

Eloped, - 
Discharged, recovered, 
Cases, which, when admitted were 

of less duration than one year 
Of which recovered, - 
Died, 
" Remaining in Hospital, 

Winter, - 
Spring, - 

Summer, - 
Autumn, - 

1557 1204 676 114 

Cases in which the disease arose - Single 823 

from physical causes, - - 703 Married, 584 

" Moral 459 Widowers, 50 

44 Unknown, - - - - 395 Widows, 100 

1557 1557 

On page 53 of the Report there is an interesting table, being the first attempt 
that we have seen, to ascertain by statistical investigation, the relation between 
occupation or employment, and the causes of insanity. The conclusion derived 
therefrom is, that " intemperance is the bane of the active, and the ' secret vice' 
of the sedentary occupations." 

Dr. W. thus refers to the new doctrine of " Millerism," as a cause of mental 
alienation. "Some new views of religious truth have recently disturbed many 
persons who have deep solicitude for their future well-being, and have brought, a 
number of patients under our care. Some of those views are greatly calculated 
to alarm those who entertain them, and 1 fear that, for some months to come, 
this agitation of the public mind may, in this and other communities, add many 
to the list of the insane." " Religion, in any view of it, is a solemn subject of con- 
templation. No individual can feel indifferent to it who has a rational mind, and 
feels his responsibility to God for the actions of his life. But it is particularly de- 
sirable that all consideration of it should becalm and dispassionate, that we should 



Men. Women. 


Total. 


806 751 


1557 


621 579 


1200 


67 47 


114 


_ 


4 


- 328 348 


676 


699; More than one year, 


856 


535; Of which recovered, 


141 


32; « Died, 


82 


40; " Remaining, 


198 


Admitted. Discharged. Recoveret 


I. Died. 


- 324 227 138 


24 


434 325 164 


27 


- 406 339 174 


34 


393 313 200 


29 



Marasmus, 


25 


Epilepsy, 


14 


Consumption, 


10 


Apoplexy and Palsy, 


10 


Suicide, 


7 


Disease of Heart, 


7 


Cholera Morbus, 


4 


Hemorrhage, 


4 


Inflammation of Brain, 


4 


" of Bowels, 


3 


Mortification of Limbs, 


3 


Dropsy, 


3 


Chronic Dysentery, 


3 



J843.] Insane Asylum Reports. 151 

live it, in our several spheres of duty, rather than seek new dog-mas which dis- 
tract the mind and unfit it for the high responsibilities of this life, or for suitable 
preparation for the elevated pleasures of a future existence." 

Of recoveries, there has been a greater number in patients between 40 and 50 
years of age, than of those in any other decennium of life. 

Twenty-two patients have recovered who had been insane from 5 to 10 years; 
6 who had been insane from 10 to 15 years, and one who had been insane be- 
tween 15 and 20 years. 

The following table exhibits the diseases which have proved fatal, and the 
number of patients who have died of each of them. 

Diarrhoea, 2 

Dysenteric Fever, 2 

Disease of brain from intemperance, 2 
Lung Fever, 2 

Bronchitis, 2 

Erysipelas, 2 

Old Age, 1 

Gastric Fever, 1 

Congestive Fever, 1 

Land Scurvy, 1 

Disease of Bladder, 1 

Total, 114 

In the two cases of death resulting from bronchitis, the disease was of the 
chronic form and followed wounds of the trachea made in attempts at suicide. 
Of 167 patients in whom there was a propensity to suicide, but 7 have suc- 
ceeded in effecting the destruction of life, and neither of these has been within the 
last eighteen months. " In some families," says the Report, " there is a strong na- 
tural propensity to suicide, no love of life, and no firmness to bear the calamities 
incident to it. One patient under our cure had twenty male relatives, more or less 
nearly connected with him, who had committed suicide. Suicide is also contagious 
or epidemic. In institutions for the insane, there are periods when we have 
great solicitude on this account, and other periods when we have comparatively 
little. In the community such cases rarely occur alone. Suicide is often im- 
pulsive, the means at hand often excite an irresistible desire, or equally repulsive 
dread; in the one case the means are applied, in the other cautiously put away 
or avoided. I have often had patients give me knives, scissors, cords, &c, 
fearing they might be tempted to use them, yet sometimes these same indivi- 
duals will secret them about their persons or rooms." 

In an interesting article on " Recommittals," it is stated that " there have 
been 308 persons in the hospital who have had more than one attack of insanity; 
many of these had been periodical for years before they were committed to our 
care. One hundred and eighty-nine that had been discharged have been recom- 
mitted, and a few of them more than once. Of the recommitted, 68 had reco- 
vered and 121 had not recovered. Of the 68 who had recovered, the cases of 
49 are arranged in a tabular form, so as to exhibit " the length of time they were 
confined at each period, the length of time they were well and with their friends, 
the time each was in confinement during the whole period after he was com- 
mitted, and the proportion of time they were insane, " after they first entered 
the hospital. "The remaining 19 cases have not been kept in remembrance, and 
their history is not fully known." Of the aforesaid 49 cases, it appears that 39 
have been in the hospital twice, 6 three times, and 3 Jive times each respectively, 
and 1 eight times.'''' In neither of these cases was the patient admitted twice in 
the same year. 

In regard to those cases in which the disease appears to occur more than once, 
the Report states as follows: "The rule which we have adopted has been to con- 
sider all recurrences within a year (after apparent cure) relapses, and recurrences 
after longer periods, new attacks. We may make a few exceptions to both of 
these rules." The distinction appears to us to be judicious, and removes thepoa- 



1 52 Bibliographical Notices. [July 

sibility of the same patient being reported as cured tjince during the same year, 
a contingency the probability of the occurrence of which has been advanced as 
an argument against the accuracy of the statistics of insanity. 

The article now under consideration is one of the most valuable portions of 
the Report, and we regret that our limits prevent the propriety of copious extracts. 
One only must suffice. It presents a fearful picture, the more so, as coming 
from one whose experience and observation has been such as to convince us that 
it is no fairy sketch of the imagination. " Political strife, religious vagaries, 
over-trading, debt, bankruptcy, sudden reverses, disappointed hopes, and the 
fearful looking for of judgments which are to dissolve the natural elements of 
time, all seem to have clustered together in these times, and are generally influ- 
enza! in producing insanity. The hospitals are filling up most fearfully with 
the victims of these evils, and the predisposed and periodical are, in great num- 
bers, plunged by them into the vortex of disease." 

Twenty-four pages of the Report are occupied with an essay on "Impulsive 
and Homicidal Insanity," including a history of fifteen cases of actual homicide, 
and of five others in which attacks with deadly weapons were made, but which 
did not result in fatality to life. The prominence of the subject of insanity in 
its connection with criminal jurisprudence, induces us to extract the following 
remarks. 

44 In general, homicidal insanity is impulsive; in a few cases only, so far as I 
have known, has there been any considerable premeditation of the act, even in 
cases of supposed command from powers which the insane individual felt bound 
to obey. The command and the execution of it are b'oth impulsive, and gene- 
rally follow one another in such quick succession, that the opposing influences 
are not aroused to interfere and prevent the deed." 

"Seven of the fifteen cases of homicide that have been in the hospital, were 
not considered insane before they committed the act. They were at work at. their 
several employments, were not observed by those associated with them to have 
any evidence of alienation of mind, knew as well as others right from wrong, 
how to manage their affairs and conduct their business well. The first overt 
act of insanity was the homicidal act, and that was impulsive. Yet in all these 
cases, the symptoms of insanity have been clear and decisive since the patients 
came to the hospital. 

44 In this connection it may not be improper to say, that of all the cases that 
have come to my knowledge, and I have examined the subject with interest for 
many years, I have known but a single instance in which an individual arraigned 
for murder, and found not guilty by reason of insanity, has not afterwards shown 
unequivocal symptoms of insanity in the jails or hospitals where he has been 
confined; and I regret to say, that quite a number who have been executed have 
shown as clear evidences of insanity as any of these. In a large proportion of 
the cases, the insane man is desirous to keep the evidence of his mental aliena- 
tion out of sight rather than to present it, while he who feigns insanity generally 
presents it in caricature. 

44 1 am aware that the plea of insanity is often made in criminal trials, and 
may be made so often as to excite public prejudice; but till the subject is better 
understood, it cannot be too frequently or too thoroughly investigated. The old 
boundaries have been or will be broken down, and new principles will govern 
courts and jurors, in deciding upon the lives of their fellow men. 

44 The abstract principles of right and wrong are as well understood by a large 
proportion of the inmates of insane hospitals, as in the community at large. 
Even in sane communities, the question of right and wrong is every day consi- 
dered by courts and jurors, and how often are they unable to agree as to what is 
right, or decide what is wrong! In many cases of controversy the parties are 
often both honest in their opinion of right, though diametrically opposite to 
each other. Shall more be required of insane than of sane men, in such circum- 
stances?" • 

We extract two of the cases reported, one of them from the aetual homicides, 
and the other from those in which the attempt proved unsuccessful. 



» 
1843.] Insane Asylum Reports. 153 

Case I. — "A — L — was tried for the murder of his wife in 1833. He was 
acquitted on the ground of insanity, and ordered to be committed to the State 
Lunatic Hospital, into which he was admitted in February, 1834. 

" L — had for years been subject to depression of spirits and turns of great 
despondency, in which every evil that could befall him was apprehended. He 
sometimes kept his bed at such times, refused to take his food, was irritable and 
ill-natured, could not bear contradiction or opposition of any kind. When well 
he was an industrious man, a miller by trade, a good husband and kind father. 
A day or two previous to the homicide, he had one of the turns of gloom and 
depression. In these paroxysms he sometimes contemplated suicide, and at 
this time particularly. His pistol was loaded ready for the dreadful act at any 
moment when he should feel sufficiently desperate. 

" He came into the house where his wife and one or more children were sitting 
together; she had put away the powder and emptied the pan, fearing he might 
injure himself. Very soon after he came in, he took the pistol, examined 
it, and finding no priming, asked his wife in a peremptory tone for the powder 
horn. Instead of informing him where it was, she said entreatingly, "If you 
have no regard for your own life, do think of your poor children." In a moment 
he presented the pistol to her breast, and snapped it. It went off and killed her 
immediately. He then seized a razor, ran to the barn and cut his own throat. 
The wound was not mortal and he was immediately arrested. At his trial the 
jury rendered a verdict of not guilty, by reason of insanity. 

" My impression has always been, that L — did not intend to kill his wife 
one moment before the dreadful deed was irrevocably done. He thought of 
using the pistol for himself, but finding that his wife had taken away the powder 
to prevent the act he contemplated, he became irritated, and her reply to his 
inquiry excited an impulse that resulted in the fatal homicide. 

L — was a good patient while in the hospital, but, especially in the early part 
of his residence here, had occasional periods of gloom which would induce him 
to be dull, ill-natured, and sulky. He would then lie in bed and take no food 
for some days. At these times he was jealous, irritable and passionate, and 
sometimes thought his food was poisoned. When he got over these turns he 
would be very comfortable. He improved favourably, and after three or four 
years was discharged, recovered. We have from time to time heard that he has 
continued well since he left the hospital. His temper is irritable and he was 
always impulsive." 

Case 11. — "The husband of Mrs. H-— B — was intemperate and neglected 
his family. Mrs. B— was an excellent woman and an exemplary christian. 
She became depressed, but not so much so as to be considered dangerous. She 
contemplated suicide for some time, but suddenly was impelled to take the lives 
of her children, to save them from the cruelty and neglect of a drunken father. 
With a razor she inflicted dreadful wounds on a little boy ten years old, cut the 
muscles and tendons of the neck so effectually as to destroy all power of raising 
or holding up his head. The boy escaped from her grasp and hid among the 
vegetables in the garden, and thus saved his life. On the neck of the little girl, 
two years old, she inflicted twenty gashes, and would certainly have killed her 
if she had not been rescued from her hands. A neighbouring woman who had 
heard the cries of the children, went to their relief; she was seized by the dis- 
tracted woman and cut badly upon the cheek before she could escape from her 
grasp. Two young men then came to their assistance, and she was arrested, 
secured, and soon brought under our care. 

" For a long time she appeared uneasy, was easily agitated, and yet said little 
or nothing. Her countenance was wild and phrenzied, everything startled her, 
yet she was mute and apparently unconscious where she was, or what she had 
done. Some weeks after she came to the hospital, having had intelligence from 
her family, I informed her that 1 had heard from her friends, and that they were 
all comfortable. She seemed greatly agitated, and came to me a few minutes 
aft-rwards, her eyes swimming with tears, and said most imploringly, " Will 
you protect me!" I promised her my protection, told her she was entirely safe 



154 Bibliographical Notices. [July 

and need fear no injury, while she was in my care: she was pacified and sat 
down calmly and quietly. Her recovery was slow, but she improved favourably, 
not however without many turns of agitation and alarm, which led me to sup- 
pose that the dreadful reality of her wounded and suffering children continually 
haunted her mind. She now conversed some, worked daily, but said nothing 
of her children, nor did she make any inquiries concerning them. Fortunately 
the children got well; and their recovery perhaps saved her from perpetual in- 
sanity. 

" One day, while she was in her room quietly engaged in her work, a wild 
and mischievous insane girl, in a moment of excitement, called her a 'mur- 
derer.' The effect was electrical, she was agitated and distressed beyond mea- 
sure; she screamed and wrung her hands in agony, exclaiming, 'Am I a mur- 
derer'?' It was a long time before she could be appeased; she was answered 
that she had killed no one, that her family were well, and that there was no 
reason for the offensive language used to her. 

" When told what had really happened, she said that she had a dreamy recol- 
lection of something of the kind, that she feared something had been done by 
her, but hoped that, among other imaginations, this was also one. The recovery 
of the children was favourable, and our patient improved regularly until she was 
entirely well. She has since been with her family, in all respects as well as 
before this attack of insanity." P. E. 



Art. XVII. — On Gravel, Calculi and Gout: chiefly an application of Professor 
Liehig^s physiology to the prevention and cure of these diseases. Ey H. Bence 
Jones, M. A., Cantab., Licentiate of the College of Physicians, Fellow of the 
Chemical Society. London, Taylor and Walton. 1842, pp. 142. 

To review a work professing to apply professor Liebig's views in physiology 
to the causes and treatment of urinary disorders, is a task, at the first glance, 
almost appalling to any but a professed chemist; and we were not altogether free 
from a feeling of hesitation in attempting it. To unravel the vast and changing 
series of newly described and named organic compounds, with all the algebra of 
their striking and characteristic formulae, seemed indeed rather a labour for one 
employed in analytical investigations than of a practitioner in medicine. Yet 
on the other hand, the very nature of the new doctrine calls upon medical men 
to make themselves acquainted with that which bids fair to explain so many 
important points in physiology and pathology, and to a-dd the daring hope of a 
large accession to our means of successful practice in curingand preventing 
disease. Either the physician must travel out of the record of his former pro- 
ceedings, and assume the responsibility of pronouncing opinions in chemistry, the 
science so long existing exclusively by the labours of his predecessors, and 
which may be said to have been discovered by them, or he must now expect to 
find the chemist adopting a parallel course, and becoming his competitor in the 
practice of medicine and hygiene. It is impossible, indeed, to do justice to the 
various important diseases which complicate or produce weak health, without the 
full employment of this philosophy, so characteristic of the age. 

With these views, we enter upon the labour with a feeling of necessity and 
duty; and must view it in a medical and not a chemical point of view. Still, 
however, for those who are enabled to pursue it with adequate labour, the face 
of Organic Chemistry appears to us to present a far less disheartening aspect 
than in former years. The very circumstance of an enormous extension in 
amount of inquiry and knowledge has had in this science, the same result as in 
so many others; that of affording more general rules and an ampler and more 
extensive induction. That which before appeared, at least to us, as a vast field 
of detached and apparently unconnected detail, growing naturally out of the 
labours of the apothecary or the manufacturer, and diversified to a degree 
which has often astonished philosophers, fatiguing to the memory, and incapable 



1843.] Bence Jones on Gravel, Calculi and Gout. 155 

of being used without indexes, now begins to bestow upon the intellect the 
hitherto vainly hoped for enjoyment of the contemplation of principles. Laws 
of nature, of vast scope, of curious and wonderful applicability; connections 
between facts apparently the most remote; clear and intelligible correlations be- 
tween things that formerly seemed only to approach each other by the forced 
compression of proximity, and in regard to which the wonder only seemed to 
be how nature could possibly place together things so unlike, and with such 
a total absence of analogy or connection in the human mind; such are among 
the increased attractions of the more modern science, and might well repay us, 
were we to consider this as an evil, for the increased amount requiring to be 
studied. Here and there, too, an instance occurs in which advancing knowledge 
has overleaped the great, the grand difficulty, the impossibility of reconstructing 
any of the products of the vegeto-animal kingdom with materials derived from 
unorganized nature. And, to crown all, the feature, alarming to the student, of 
a new algebra applied to chemistry, has like other algebra, the character of a 
beautiful art, simple, clear, intelligible to those who study its symbols, and only 
intricate in the wonderful extent of what it teaches, the unexpected and important 
discoveries to which it has given rise, and the prodigious power and facility 
which it adds to the art of thinking. The finest and most important results of 
the modern notation have been those which became at once and of necessity 
visible the moment a question was fairly expressed in characters. For these 
improvements the world is indebted to many labourers; among the most brilliant 
of whom, and most likely to be often remembered by posterity, is undoubtedly 
the professor of Giessen. We thankfully join in the applause of an admiring 
world; but we should never forget, amid the enthusiasm of popular approba- 
tion, our duties to those who have served mankind, though not now the subject of 
the shout; and our best gratitude and praise belong to the names of a Chev- 
reuil, who first gave Organic Chemistry its impulse in the direction of its present 
splendour, of a Wcehler, who first artificially composed an organic compound, 
and of a Berzelius, whom vast powers of intellectual combination and original 
suggestion could not tempt, by their so often " fatal facility," to hold himself 
excused from the most indefatigable labour in the details. The present is also 
the fitting moment to welcome the rising fame of a Mulder, whose genius and 
industry bid fair to revive, in chemistry, the ancient glories of Holland. From 
the land of Boerhaave, the Delta of our modern Egypt, there has arisen a 
name justly foreshowing the most invaluable improvements and brilliant dis- 
coveries, and in a field emphatically useful to the whole human race. And in 
the present inquiry we have to thank it for the important observation which 
forms the basis of Professor Liebig's comprehensive and farsighted views — 
and which could only have been made by a rare combination of minute and ac- 
complished skill with clear powers of abstraction — the chemical identity, in nutri- 
tion, of albumen, fibrine and caseine; alike throughout the animal and vegetable 
world. 

Mr. Jones is, as we have above represented him, a graduate in the arts; and 
was a pupil of Professor Liebig. His name is to be seen attached to some of the 
analyses published by his preceptor. The present publication owes its origin 
to a suggestion made in the Quarterly Review; and Mr. J. has placed the pas- 
sage in his title-page. The first and larger portion of the work treats, in 88 
pages, on the Uric Acid Diathesis, on Gout, and on the Oxalic Acid and Phos- 
phatic Diatheses. In the second part, which treats of Calculus, he has" very 
closely adhered to the manual of Professor Berzelius; giving manfully the opi- 
nions of another where he thought them better adapted to the purpose than his 
own. It is the earlier part which developes the views of his now celebrated 
teacher. In this, if our impressions be correct, Mr. Jones need be under no 
anxiety as to his success; the inquiries and genius of the distinguished professor 
of Giessen bidding fair to assume a position, in this all important branch of Sci- 
ence, almost equal to that of the works of Lavoisier in the chemistry then known 
to mankind. We have been told by a celebrated poet that ha awoke one morn- 
ingand found himself famous. It is not reasonably to be doubted that the 
6udden and brilliant celebrity of Dr. Liebig with u3 was preceded by a long 



156 Bibliographical Notices. [July 

career of labour and reputation in his own country; but as respects America and, 
we fancy, England, his name may be said to have exploded from obscurity to 
unexampled, and to all appearance enduring fame, by the simple publication of 
his two memoirs on Animal and Vegetable Chemistry as applied to Physiology. 
The moment before, he was lost amid the numerous list of learned and intellec- 
tual German professors; the next, he had won if not the highest at least the most 
widely diffused and brilliant reputation of the age; and it was apparent that he 
was, at once and for ever, established as one of the great and commanding repu- 
tations of chemical history. Albumen, flbrine and caseine are, then, in their 
composition and as regards nutrition, the same; and that is to be understood as 
including the substances known by the same name in the vegetable world. The 
definitions given by Dr. Liebig for flbrine and gluten do not coincide with 
those which have been commonly given by the English chemists; and the usage 
of Dr. L. seems to be prevailing. These substances all consist of proteine, 
with variously superadded amounts of sulphur and phosphorus; the total of these 
two last, together with the oxygen, being always the same. Proteine, which is 
not named from Proteus, indicating change, but from wganve*, "I take the first 
rank," is composed of carbon 48 atoms, nitrogen G, hydrogen 36, and oxygen, 
14. In forming albumen and fibrine, there are added phosphorus and sulphur, 
and in forming caseine, sulphur; while the differences in the action of these bo- 
dies may be further explained by the differences in the order of arrangement of 
their atoms. The gelatinous portions of our composition, as cartilages, tendons, 
arteries, &c, contain these four leading substances with little important differ- 
ence. These bodies constitute the great mass of the materials which make up 
our organs; and the other compounds are incidental, and comparatively sparing 
in amount. They are also so far detached in their chemical history as to be capa- 
ble of being studied separately from the above; thus removing a great mass of 
complicated inquiry from the great central accumulation of the science. The 
bodies composed of proteine obviously furnish the principal portion of the 
nourishment; and we here have an exemplification of the law of nature by which 
the food of animals, the chief and almost entire substance of their bodies, is 
separated from the earth by plants; while to the more complicated organization 
is left the elaboration of this into the products purely animal. Plants prepare 
the nutriment; animals consume the structures in which it is contained. Plants 
require the materials of decaying organization for their growth; animals elabo- 
rate the nutriment they receive into forms calculated, principally from their 
complexity, for accelerated decay. In regard to variety of compounds, and 
difference of external appearance, the excess is, we believe, on the side of Plants. 
We have said that animal compounds are, in proportion to their greater com- 
plexity, prone to dissolution. This takes place from heat, moisture and oxygen; 
of which the oxygen of the air, so necessary to our existence, is the chief; as also 
from the catalytic action of many of those substances, unfriendly to life, which 
we denominate poisons. Against this incessant action, the vital power offers a 
perpetual resistance; yet, in its regular expenditure by the operations of the or- 
gans, particularly the muscles, tolerates the process; and it is thus that the inces- 
sant wear and tear of the body converts carbon into the carbonic acid of the lungs, 
and the remainder of our tissues generally into uric acid. The vital power is de- 
bilitated by muscular action and by cold; and the activity of oxygen is augmented 
by an increase in the amount of the gas presented to the lungs. In the two last 
named cases, this amount is increased by the acceleration of respiration, and by 
the greater density of a cold air, and its greater freedom from dilution with watery 
vapour. Hence these agents augment the production of uric acid; but the presence 
of an excess of oxygen converts this substance into urea, with other soluble mat- 
ters; which are then regularly expelled by the uiine. This takes place in an active 
respiration of pure air and the carnivorous animals afford a convenient illustra- 
tion; the hot-blooded tribes, as the feline animals, habitually undergoing this 
process, while, in those with cold blood, as the boa constrictor, the uric acid 
escapes from the cloaca in the form of urate of ammonia. The use of iron pro- 
motes the absorption of oxygen, by sensibly augmenting the amount of the 
globules of the blood; whieffare vehicles, transporting oxygen from the lungs 



1843.] t Bence Jones on Gravel, Calculi and Gout, 157 

to the capillary reticulations; and that of non-nitrogenous food (fat, starch, &c), 
lends to retard the changes produced by oxygen, by furnishing, to employ its 
activity, a larger amouut of carbon, and in a state possessing for it a greater 
chemical affinity; while, at the same time, they cannot be made to yield nourish- 
ment for albumen, to supply the waste of that substance in the organs. In 
pulmonary consumption, the wasting of the body is achieved by excessive 
oxygenation; our authors here lending the sanction of modern chemistry to the 
practical views of Dr. Beddoes. 

In the gelatinous tissues, as in gouty joints, according to Professor Liebig, the 
changes must take place at their surface only. Mr. Jones remarks that it is in 
tissues of slow sanguineous circulation that we should more frequently expect 
the uric acid to be left without further oxygenation; and hence the production of 
gouty concretions. 

Dr. Jones then proceeds to show, by formulas, that in case of a want of oxy- 
genation from the lungs, the gelatinous tissues may develope urate of ammonia 
by their simple decomposition; liberating oxygen, and, at the same time, fat, and. 
choleic acid, which last would be conveyed to the bile. Thus: 

Gelatine=C 32 N 5 H 27 O l2 ") CC ]0 N 5 H ,0 6 =Urate of ammonia. 

— 40xygen= 4 5~tC 22 H 20 O 2 =Fat. 

C 32 N 5 H 2 ,0 8 C 32 N 5 H 27 8 

Or, in health, by another process, a little oxygen and some water can be ab- 
sorbed, and the products be urea, fat, carbonic acid, and ammonia. 

Gelatine=C 32 N,H 27 O l2 "j {° Z2 ^ S 20 ° 2== ^ at - . 

a \kt . u r, 1 I } N H , =Ammonia. 

4 Water= H 4 4 S=\ C 4 N 5 H ;:0 4 =2 Urea. 

2 0xygen= O , J ^ * 8 Q 12 =6 Carbonic acid. 

C 32 N 5 H 31 0~ C 32 N 5 H 31 ]8 

Chondrine can furnish oxygen to a diminished oxygenation, and the residue 
be converted into urate of ammonia and choleic acid. Thus, 

Chondrine=C 48 H 40 N 6 O 20 ~> _ CC 10 H 7 N 5 6 =Urate of ammonia. 
— 30xygen= O 3 3 £C 38 H 33 N 1 1 =^Choleic acid. 

C 48 H 40 N 6 O~ ' C 48 H 40 N 6 O 
Uric acid, being an extremely complex substance, readily undergoes changes 
under the action of oxygen, heat and water, which render it soluble, and more 
fitted for expulsion in the urine. These can be imitated in the laboratory; and 
there is no doubt that, under a proper and free habit of oxygenation in the body, 
they take place within it. Thus we shall exemplify, in the following formulae, 
that a small addition of oxygen may convert uric acid into urea and alloxan; a 
little more will change the alloxan into a fresh portion of urea, with an excess 
of carbon and oxygen; a further oxygenation will convert the materials of this 
excess into oxalic acid, and a still further, into carbonic acid. 

4 U ^«1= C - N ^8 : ? = £C 8 N 2 H 4 O 10 =a„oxar 



C 



These equal C 2 N 2 H 4 2 =urea 

C 6 O 8 ^=2urea+C 6 

C 2 N 2 H 4 2 =urea 



C ]0 N 4 H 8 O ]2 

But C 6 8 +0=3 (C 2 3 )=3 oxalic acid. 
And C 6 8 +0 4 =6 (C0 2 )=6 carbonic acid. 
In confirmation of this, the guano, the celebrated manure of the sea islands of 
Chili, referable to the excrement of birds, and of consequence, containing their 
urine, as is the case in that class of animals, was found to undergo an analogous 
No. XI.— July, 1843. 11 



158 Bibliographical Notices. [July 

change. Its urate of ammonia, by length of time, exposure to moisture, and 
the action of its own impurities, was converted into oxalate; the article being 
found in progressive stages. The theorem is as follows; being considered hy- 
pothetical. 

O fi =2 oxalic acid. 



Uric acid=C 5 H 2 N 2 3 } f"C 4 6 =2 ox; 

4 Water= H 4 ° 4 > = ") H 6 N 2 =2 am 
Oxygen= O ) CC 2 =1 car 



mmonia. 
bonic acid, 



C 5 H 6 N 2 8 C £ H 6 N 2 ( 



It is thus inferred that the presence of uric acid in the urine, instead of urea 
and the other compounds enumerated, is evidence of an imperfect action of oxy- 
gen upon the animal system. The quantity of uric acid excreted by the kidneys 
will therefore depend partly upon the quantity produced within the body, and 
partly upon the proportion of it, which is changed to the above forms before its 
expulsion. It is evident that oxygen must be the principal agent in effecting 
these changes; and the heat and moisture, as well as the alkalies, secondary. 
The attempt to prevent uric acid from being formed having been thus abandoned, 
as a vain attack upon a physiological and necessary process; the task next re- 
mains to facilitate its solution and discharge. 

The freer action of oxygen is to be promoted, first, by giving a large supply of 
this gas. This is to be effected, first, by exercise. Every action of the muscu- 
lar apparatus, so lively as to give rise to a quicker respiration, is necessarily fol- 
lowed by the presentation of an increased amount of oxygen to the blood in the 
lungs; and this is a primary medicinal means. The effect is also promoted by 
a colder air, in w 7 hich, from its greater density, a larger portion of the atmos- 
pheric fluid is made to enter into a given bulk inhaled by the subject. Finally, 
medicines may act for this purpose. One, and the most direct, of these is the 
use of water holding nitrous oxide gas in solution, as a drink; which Mr. J. 
believes to he a very useful practice. Another class of remedies is the ferru- 
ginous family of preparations. With our old chemical ideas, we would not 
immediately see how these are to act. The recommendation of these is an in- 
ference from the theory of the professor's, in which he views the red globules of 
the blood as a means of transferring the oxygen required for the purposes of life 
from the lungs to those points in the capillary system where they were to ex- 
change it for carbonic acid gas. Thus, the bright, arterial blood is furnished 
with globules containing the sesquioxide of iron; while, in the capillary system 
or intercapillary texture, this is converted into carbonate of the protoxide; a 
black substance which harmonizes with the colour of the venous blood. We 
may misunderstand Professor Liebig; but we believe he associates the respec- 
tive colours of venous and arterial blood with those of the compounds of iron of 
which we have spoken. Several allusions would give this impression, but we 
do not feel any of them an exact committal. Of the visible effect of ferruginous 
medicines in augmenting the red portion of the blood, Dr. L., in common with 
every practitioner of experience, justly entertains no doubt. Whether the ideas 
above expressed in regard to the mode in which the red matter acts, be contested 
by physiologists, or not, these will undoubtedly assent to the fact of a close as- 
sociation between the quantity and rapid circulation of this substance and the 
amount of oxygen consumed in respiration. Hence, no theory compatible with 
modern views on this point can weaken the presumption in favour of the utility 
of chalybeate remedies to promote oxygenation of the materials of the body. 

The effect of diet on the gouty and uric acid diatheses has always fixed the 
attention of physicians. The inferences which flow from the views of organic 
chemistry on this point, are very important; and are calculated to produce, if 
conceded to be correct, a very considerable change in our ideas respecting the 
treatment of these states of the system. They appear to me to explain much of 
the difficulty in which this important subject has been involved; the results of 
experience differing, as is well known, from most of the explanations founded 
upon our knowledge as it existed at the time. When uric acid has been ob- 
served in the urine, or about the joints of gouty persons, it has been the general 



1843.] 



Bence Jones on Gravel, Calculi and Gout. 159 



custom to limit the consumption of animal food, with the view of preventing ple- 
thora; which was taken to be the predisposing cause of gout, and which, if we 
allow the proposition a fair construction, and give to its defence the benefit of 
the same new lights of science which we should be so ready to employ for its 
destruction, is really so. Certainly, the accumulation of matter which has 
finished its duties in the animal economy, and is difficult of discharge from the 
want of sufficient oxygenation, is a plethora, and one of the worst kind. On the 
other hand, daily and hourly experience dictated and enforced the necessity of 
abstaining from acids; the sufferings of the patients frequently inducing them 
to take the subject into their own hands; and, by the chemfsts of the time, the 
prevalence of uric acid concretions, in gout, and of a gravel consisting mostly of 
the same materials, tended to confirm what was thus prompted by experience. 
A new indication arose; to deny animal food with the view of withholding the 
materials which went to constitute this animal acid; and at the same time, many 
considered the inducements for doing so strengthened by the generally beneficial 
effect of abstinence upon all inflammatory affections; particularly those so acute 
as active gout. The result showed that the restriction afforded no benefit com- 
mensurate with the suffering inflicted; and from this cause, and from the occur- 
rence of symptoms of nervous excitement or debility, it became necessary, in 
instances of continual recurrence, to infringe the restriction. The local actions 
of gout were considered as inflammation; and it was deemed an explanation to 
compare them with other inflammations; while no reason was perceived, among 
any of these analogies, for the bad effects of acids, above alluded to, or for that 
so frequently encountered in the use of a reduced diet. Wines were prohibited, 
as being contraindicated by inflammation; while it was forcibly seen and felt 
that their injurious agency bore no proportion to the degree of stimulation they 
produced; and it was found, on trial, to our surprise, that brandy was more use- 
ful and less injurious than wine, and the ill quatyy of wine seemed regulated 
by the degree of acidity and not that of stimulation. We seem thus to have 
been engaged in a perpetual struggle between the inferences drawn from the 
imperfect lights of the age, and the teachings of experience. 

Certainly, if organic Chemists can show us how to reconcile difficulties like 
these, on subjects so important to human life and enjoyment, they are truly 
benefactors to mankind, and to that fraction of its interests comprised in medical 
science. In examining Dr. Liebig's definitions, we are struck with the differ- 
ence in his manner of applying it to medicine from what we have been some- 
times accustomed to witness. After becoming endowed with a mass of brilliant 
ideas, he does not, as has been in some instances the case, it may be in the lati- 
tude and longitude in which these comments are penned, insist on new model- 
ling all medicine upon the strength of the new views, and begin by endeavouring 
to destroy the credit of all that has gone before. Instead of decrying the results 
of past experience, he has used them as evidence of truth, and has tested his 
chemical doctrines by their correspondence. Unless his inferences agreed with 
the observations of the best physicians, they were wrong; and must share the 
fate of all other conclusions in science founded upon an insufficient comparison of 
facts. 

Vegetable and animal matters which contain a large portion of carbon, and no 
nitrogen, (fat, starch, sugar, wine, beer, alcohol, also gum, bassorin and pectin,) 
have a much greater affinity for oxygen than the nitrogenous compounds; and 
unite with it in preference to them. Now, if the chemistry of the present age 
be correct, it is not from the food that the uric acid is produced at all; it is the 
product of the wear and tear of the tissuesand fluids, and is composed of the mat- 
ters no longer fitted for the service of vitality. In the view of Professor Liebig, 
it is a regular step, intermediate between the natural living condition of proteide 
substances and the urea of the kidneys. Whether fresh nitrogen be furnished or 
not, the elimination of uric acid, altered or otherwise, will still go on at the ex- 
pense of the body, until death be either threatened or perhaps actually produced, 
as in the case of some experiments. The albuminous matter must be supplied, 
either from the animal or vegetable kingdom. Our practice, while forbidding 



160 Bibliographical Notices. [3 u ty 

meats and soups, has been, in comfortable ignorance of tins yet unexplored 
mystery of nature, to add a very proper quantity of nitrogenous matter in the bread 
and other articles, to which no one has thought of objecting; thus violating our 
own rule for the benefit of the patient. On the other hand, in administering the 
non-niirogenous and carbonaceous matters enumerated above, whether vegetable 
or animal, we furnish a mass of substances which, by their nature, and in an 
increased degree by the chemical effect of quantity, take the preference of the 
uric acid in oxygenation, furnish the animal heat in the lungs and the carbonic 
acid for elimination, and leave a restricted amount of oxygen for the proper 
"preparation" of tfae "morbific mailer" to be discharged. How curiously the 
inquiries of modern science sometimes lead us back to those well-known results 
of experience, observation and sagacity among our predecessors, which we have 
sometimes been told to laugh at! To check the unnecessary expenditure of oxy- 
gen upon matter which can only be used for the repair of the cellular, tendinous, 
bony, and other gelatinous tissues, we are not to forbid nitrogenous food, either 
vegetable or animal, but to furnish enough for the proper support of strength; 
but we are to limit the use of non-nitrogenous and carbonaceous articles, and 
that as severely as is compatible with the patient's comfort. 

Next after these indications comes a confirmation, we will not say from the 
last new theory, but from the most refined and perfect scientific investigation, 
of another result of the old, rational-empiric method of philosophizing; another 
product of the experience of ages; we mean purging. At no time, perhaps, since 
the popularity of the doctrine of excitement, which we date from Cullen, have 
the minds of physicians been free, on this point, from perpetual vacillation be- 
tween the influence of experience and daily observation. When the beneficial 
effect of purging was to be explained only as revulsive, its reputation was sub- 
ject to continual assaults growing out of theoretical views. One set assailed 
it as debilitating, and greatly limited its use. Another pleaded that it produced 
a dangerous counter-irritation in organs essential to life; and that the treatment 
of diseases of irritation by such means was a mere game of "double or quits." 
We have even heard it gravely objected to by men of venerable years, because 
it was disgusting and vulgar! In vain did men, as long ago as Glisson, point 
out the nature of the portal circulation; and urge the improbability that so many 
"effete matters," "impurities," and, it may he, "putrid matters," were ab- 
sorbed back into the system without having a share in the production of the 
various disorders which followed intemperate eating and costiveness. The erro- 
neous theory went on injuriously, while practitioner after practitioner was com- 
pelled, by the useful results of this ancient practice, to return to its use; and not 
unfrequently founded a reputation upon its consequences. This was, among 
others, pre-eminently the case with the late Mr. Abernethy. 

The bile, according to Professor Liebig, is produced in amounts altogether 
disproportionate to those discharged from the bowels in combination with the 
faeces. This excess, in the course of healthy nature, is reabsorbed, and contri- 
butes to furnish a large amount of carbon for respiration. By removing this in 
large quantity, we leave the oxygen to complete the preparation of uric acid. 
Dr. Liebig considers urine and bile as each other's complement; both, when added 
together, deducting oxygen and water, added in the formation of the organs 
from the blood, amounting to the materials of the blood. Bile is qhiefly composed, 
according to Demarcay, of an acid called cho/eic united with soda. The formula 
of choleic acid is only empiric, or formed from ultimate analysis; positive proof 
not having been yet obtained of the immediate compounds which unite to form 
this substance. It is C, 6 N 2 H 66 22 . Inspection will at once exhibit the large 
proportion of carbon and hydrogen contained in this oily substance. 

Perspiration, which evacuates either acetates, lactates, or both, rids the body 
of much carbon; and the exposure of the skin to the air gives rise to a further 
degree of oxygenation; Dr. Liebig, in this, agreeing with the experiments of 
various physiologists, and with the general inference from comparative anatomy. 

Having thus completed our survey of the means for extending the effect of 
oxygen upon the tissues and fluids, the indication next in importance is to keep 



1843.] Bence Jones on Gravel, Calculi and Gout. 161 

the uric acid, if its changes cannot be completed, in a state admitting of solution 
in the blood and urine, to facilitate its removal; and this is to be done by water 
and alkalies. Here we find inferences drawn from the acknowledged successes 
of the practice of Priessnitz, and of mineral waters, including travelling; certainly 
the most fashionable methods of treatment in this age. The effect of the mineral 
waters, among the principal localities of which our author gives some discrimi- 
nating criticisms, is to be ascribed to the combined agency of watery dilution, 
of the alkalies contained in them, of purgation, of air, and of exercise; all which, 
as we have seen, act together, in several ways, for the same end; producing a 
combined influence which he considers very efficacious. In the water cure of 
Priessnitz, are combined the dilution, the life in the open air, the exercise and the 
exposure of the skin to oxygenation. The external application of moisture, 
practised by him, is viewed by Mr. Jones as facilitating the escape of carbonic 
acid from the body, by means of the solubility of that gas in water. The use of 
alkalies need not be simple; the stomach, when fatigued with them, may enjoy 
the variety afforded to its nervous sensibility by those compounds which become 
alkaline in passing through the body, though not originally so. Among these 
are cream of tartar, notwithstanding its acidulation, together with the alkaline 
citrates and oxalates; the acids of all these being converted into the carbonic by 
oxygenation, before they make their appearance in the urinary cavities, and the 
last named acid not depriving them of their alkaline energy. It must be granted, 
however, as an objection, that these must consume a little oxygen. Hot rooms 
should be avoided. Warm climates are probably as favourable as cold ones; 
from the diminution of appetite and the increase of perspiration. The sesqui- 
oxide is, in Dr. Liebig's opinion, the best preparation of iron; but not in very 
large doses. The present reviewer does not wish frequently to give his own 
experience, which on this point is rather large; but he thinks the difficult solu- 
bility of this substance has made it far inferior to the protocarbonate, in his trials; 
or even to the old impure mixture which contains the latter. Bread should be 
used sparingly, and potatoes and rice avoided, on account of the large proportion 
of starch they contain. Beans and peas are better, from containing albuminous 
matter. Fruits, particularly apples and pears, are objectionable, on account of 
the starch and sugar they contain. Fat is altogether improper, as non-nitroge- 
nous. Butter, for the same reason, should be employed sparingly; but, the patient 
abstaining from fat, a little butter may be permitted. Jellies and gelatinous 
syrups should be only partially used; as they are insufficient for nourishing the 
albuminous tissues and fluids, though quite competent to supply the gelatinous 
parts of our bodies. 

When water containing nitrous oxide in solution, and known in London by 
the name of oxygenated water, is not to be had, distilled water is the most pro- 
per. After this, the next best course is to select the fluid from a healthy spring, 
and have it boiled for several minutes with a few grains of potash or soda, to 
precipitate the native salts of lime. The alkalies added become sulphates or 
chlorides, and in this state, may be taken without inconvenience. The best purges 
are calomel, aloes, colchicum and colocynth; and blue pill is often useful as an 
alterative. Courses of mercury should be avoided, unless in cases of necessity. 
Sudorifics are occasionally very useful; and, in general, the cold bath is a valu- 
able remedy. By its cooling action on the skin, the cold bath acts to depress 
the vital energy of that membrane, accelerates the decomposition of its albumen 
and other components at the time; and, when this process is finished, leaves the 
central parts of the system to the undivided benefit of all the oxygen inspired. 
With all respect to the distinguished professor from whom it is understood to 
emanate, we believe in the tonic power and utility of the cold bath; but this 
theory of its action appears to us strained, and too complicated. From our expe- 
rience of physiology and pathology we should not think the vital activity of the 
body capable of being safely reasoned on in this manner; which seems to us 
better 6uited to the addition and subtraction of the beautiful chemical formulae 
we have above cited. The application of alkaline baths, even to the feet, renders 
the urine alkaline. This is on the authority of Mr. Rehberger, cited by Pro- 



162 Bibliographical Notices. [July 

fessor Liebig. Mr. Jones then proceeds to urge that the use of common salt 
greatly increases the action of oxygen on the tissues, and finishes the chapter by 
a neat contrast of the gouty diathesis with scorbutus; which he conceives to be 
an opposite state of the system. In scorbutus, from the long continued action of 
fatiguing muscular exertion, of fresh air, and of salt, and from the privation 
of carbonaceous food, the action of oxygen upon the albuminous tissues and 
fluids has been carried to a long continued excess. The result, is a destructive 
waste of the tissues and blood, accompanied by excessive brightness of the 
colour of the sanguineous fluid, and quite sufficient to account for all the other 
symptoms of that formidable affection. 

Having been thus far rather full in our analysis, and been obliged frequently 
to include gout in our remarks, we can be brief in examining the chapter on that 
especial subject. Mr. Jones considers it, as uniformly the consequence of a long 
continuance of the uric acid diathesis. He quotes many authorities in illustrating 
this point; and incidentally informs us, from Dr. Liebig, that death has some- 
times followed the practices of Priessnitz, at Grseffenburg. The treatment we 
have given requires little modification other than what is obvious to the practi- 
tioner. In inflammation, according to Dr. Liebig, there is a more rapid con- 
sumption of the textures; while, in the gouty subject, the oxygenation being 
imperfect, the uric acid produced is discharged with difficulty; and the relief 
afforded when the escape of this substance is at last effected, is strikingly ob- 
vious to every practitioner. 

The questions why uric acid is not found in the blood, and whether it be 
formed in the organs, and undergo its change into urea there, or whether it be 
first produced in a different form and conveyed to the kidneys, there to assume 
its acid character, are stated and acknowledged not to be yet answered. The 
author predicts that chemistry will in time solve them. He cites the observa- 
tion of urea in the blood in Bright's disease, as an argument in favour of uric 
acid being probably passed through the blood in its proper character after being 
formed in the tissues. Part of this we should think was already answered, by 
the fact alluded to by Professor Liebig, and so familiar in its effects to the un- 
fortunate sufferers from gout, of the deposition of this substance on the surface 
of the ligaments of the joints in the form of gouty concretions. 

The nature and treatment of the oxalic acid diathesis, may be inferred from 
what we have thus far described; reference being had to the formulas which ex- 
hibit the generation of the substance from which it is named by the oxygenation 
of uric acid. In the oxalic, oxygenation has been carried further than in the uric 
tendency; but it is still incomplete. The number of cases suffering by it is really 
very small; though the production of this substance contributes to the formation 
of a great proportion of the urinary calculi. There is no use in attempting to 
prevent the organism from receiving supplies of lime; the thing is impossible; 
but our most earnest attention should be directed to preventing the formation of 
the oxalic acid; and the remedies required, acting by oxygenation, are nearly the 
same with those we have above indicated. 

The phosphatic diathesis may be either false or true. In the true, in conse- 
quence of a general state of the system, the urine becomes alkaline, and the 
phosphates are deposited as an effect of this. In the false, local circumstances 
in the urinary organs produce the same effect by converting the urea into car- 
bonate of ammonia, incurring the absorption of a little water. In both, a white 
deposit occurs, easily soluble in any dilute acid, but insoluble by heat or alka- 
lies. It is not uncommon to see a layer of crystals on the surface of the water, 
presenting a prismatic appearance, and composed of the phosphatic salts. 

Phosphorus, phosphoric acid, lime and magnesia are carried into the circula- 
tion by both food and drinks. Between vegetable and animal albumen no dif- 
ference can be observed in the presence and relative amounts of sulphur, phos- 
phorus and phosphate of lime. The organic acids existing in vegetables are 
combined with much lime and magnesia; and are accompanied by phosphates, 
carbonates, sulphates and chlorides of the same bases. Most seeds contain 
phosphates, and the cerealia, in particular, phosphate of magnesia. The con- 



1843.] Bence Jones on Gravel, Calculi and Gout. 163 

cretions of chaff of oats found in the alimentary canal of horses are cemented 
together with these substances. An enormous specimen of this class, formerly 
in the museum of the Pennsylvania Hospital, was presented to the writer of 
these notes, when that establishment was dissolved, by the committee in charge 
of it; and has been left as a loan in the hands of Professor Gibson. Of several 
articles examined by Dr. Liebig with this reference, the largest proportion of 
the phosphates was found in potatoes; next came black bread; the grain of 
wheat was found to furnish considerably less; milk much less; and fresh beef 
very little. We do not quite understand our author at pages 78 and 79 on this 
subject. Perhaps he means that the graminivora discharge these matters in 
their urine only at intervals. They must employ a great portion of them in their 
bones, &c; nor does it seem very physiological to imagine that this particular 
tribe of animals is distinguished by a power of using over again matters which 
have once served their turn for the functions of life, and never been expelled. 
Still less does it seem probable that the brain should be selected for such a nu- 
trition. Again, whether the phosphates be used for many or few textures of the 
body, they must, according to all physiology, find a discharge at last; and Mr. 
Jones must discover an outlet for them; as the brain could not go on indefinitely 
accumulating phosphates. This is, however, a trifling "macula" in a brilliant 
and useful work. In animals of a rapid oxygenation, the production of the 
phosphates from oxygenation of albumen is proportionally great; thusy^^ths 
of the urine of the lion consists of them; and phenomena somewhat analogous 
are produced by high aeration in the human subject. A man was brought to St. 
George's Hospital with a severe injury received while engaged in active labour. 
His urine contained a considerable amount of phosphates. Under bleeding, rest, 
and a fever diet, it had next day nearly disappeared. These facts are ascribed 
to the action of a high oxygenation upon the phosphorus of the albumen. Salts 
of lime are probably conveyed to the kidneys as carbonates; and meet with 
phosphoric acid in these and the appended organs. In the absence of this acid, 
the carbonate of lime is sometimes excreted. Much reason exists for thinking 
that all mucous membranes have a tendency to secrete the phosphates, or the 
carbonate of lime. We have mentioned concretions, cemented by phosphates of 
lime and magnesia, from the alimentary canal of horses. The tartar deposited 
in the teeth contains 75 per cent, of phosphate of lime. A calculus from the 
sublingual gland was almost entirely composed of it. The calcareous concre- 
tions of tubercles consist of phosphate and carbonate of lime; substances which, 
as pointed out by the anatomist, abound in the puruloid matter of these bodies. 
Concretions of the prostate gland consist almost entirely of the salts alluded to. 
The mucus of the urinary organs is a great source of phosphate of lime: as the 
mucus of all mucous membranes is found to contain salts of lime, and generally 
phosphates. If the urine be alkaline, these are precipitated; if acid, they are 
held in solution. 

A curious instance of the catalytic power of presence is exhibited here; and is 
necessary for the comprehension of the medical part of the case. The phos- 
phates already formed in the vesical mucus act as a ferment upon the urea, 
causing it to change into carbonate of ammonia, thus rendering the urine alka- 
line; upon which, not only the phosphates of the mucus, but those previously 
dissolved in the urine, are rendered insoluble, and form deposits. In the healthy 
state, this change takes place after some hours exposure to the air; but when the 
membrane has been inflamed, and the secretions consequently increased on its 
surface, the process is more rapid, and is liable to be completed before the ex- 
pulsion of the fluid. In cases of retention of the urine, both the length of time 
and the inflammatory irritation tend to produce this effect. It is not uncommon 
to find that the portion of the urine most in contact and commixtion with the 
mucus undergoes the change first. The formula in which the change into carbo- 
nate of ammonia takes place, is as follows. 

Urea=C 2 N 2 H 4 2 ") C C 2 C 4 =2 carbonic acid, 

2 water= H 2 C 2 5 c N 2 H 6 =2 ammonia. 



C 2 N 2 H 6 4 C 2 N 2 H 6 4 



1 64 Bibliographical Notices. QJuly 

Mr. Jones speaks in strong- terms of the expectations to be entertained from 
the approaching publications of M. Dumas on the changes which the mucus 
undergoes in these cases. 

In instances of great weakness, and where the spinal cord has been injured, 
the urine is found to be alkaline. In great weakness, the sulphuric and phos- 
phoric acids are discharged in very small quantities; and carbonate of lime ap- 
pears. In this case, the proper decomposition of the albumen is retarded. In 
instances in which the spinal cord has been injured, so as to produce paralysis, 
retention of the urine is the source of some production of ammonia; but the effect 
produced is more frequent than this will account for. Mr. Jones is of opinion, 
we presume after Professor Liebig, that ammonia is generated in the natural 
decompositions within the body; an occurrence difficult of investigation. Be- 
sides the ammonia contained in the triple phosphate, lactate and muriate of 
this alkali are believed by Professor Berzelius to exist in the urine. It is finally 
observed that action of the brain accelerates decomposition in its substance, and 
must necessarily disengage phosphoric acid. 

The treatment of the phosphatic diathesis consists almost altogether in making 
and keeping the urine acidulous. The vegetable acids must be given, without 
partially combining them with alkali; as is done in cream of tartar; and this 
must be recollected. In such a case, as we formerly observed, they are com- 
pletely converted into carbonates, and evacuated in a condition in which they 
exhibit the alkaline agency of those compounds. When given uncombined, on 
the other hand, they pass into the urine, not only without neutralization, but, 
what is very singular, without being further oxygenated; and although with 
less of the acidifying principle, exhibit, as is well known, more of the acid re- 
action. It is possible to lessen the amount of phosphates received into the sys- 
tem by abstinence from those substances which contain a large proportion of 
them. Such are brown bread and potatoes; and the patient should employ 
peas, beans and rice instead of them. As inflammations of the urinary organs 
and obstructions to the passage of the urine are among the most powerful 
causes of the local or false phosphatic diathesis, this consideration forms ast.rong 
additional inducement for persevering efforts to cure, and failing or during these, 
to palliate such affections. 

Upon our author's chapter on the stone we shall not pause. Thirty pages 
constitute the extracts from Berzelius; and are given, almost verbatim, in the 
neat translation of our townsmen, Mr. Boye and Dr. Learning. The remaining 
thirteen relate to attempts to remove the stone. We do not observe any appli- 
cation of Dr. Liebig's views in either of these parts. The prospect of success 
by dissolving the calculus is discouraging as ever. Three favourable cases are, 
however, enumerated. Borax is most used, in Germany, as a solvent to act 
through the general fluids; and the benzoic acid, suggested by Dr. Ure, is not 
viewed favourably by Messrs. Garrod and Keller. Alkaline drinks are unques- 
tionably palliative; but these act by causing a phosphatic deposit, so as to coat 
the stone with a less irritating substance; and this is perhaps right, as is suggest- 
ed by Sir Aslley Cooper. The presence of a nucleus stimulates the deposition, 
even if the solution be not quite saturated. Among injections for the purpose 
of dissolving the stone, acids largely diluted seem more promising than alka- 
lies; but their agency seems to take place almost exclusively on the animal 
cement, and but very little on the crystalline, matter. B. H. C. 



Art. XVIII. — The Kidneys and Urine. By J. J. Berzelius. Translated from the 
German by M. H. Boye and F Leaning, M. D. Philadelphia. Lea & Blan- 
chard, 1843, pp. 179. 

Little seems necessary to be said in the way of expression of opinion on the 
merits of any work of Professor Berzelius. It comes from one of the Di mnjo- 
rum gentium; and the established reputation is' sufficient. Mr. Berzelius never 



1843.] Berzelius on the Kidneys and Urine. 165 

touches any thing but with the hand of a master. The publication of this trans- 
lation is rendering a substantial service to American medicine; as we had nothing 
of easy access on the subject, according to the belief of the present writer, 
since the edition of Prout's earlier work by the late Professor Samuel Colhoun; 
and it is much more than time to give us some account of the movements, in 
this respect, of the severer forms of recent modern chemistry. The treatise of 
Bence Jones is rather theoretical and argumentative; the present extract from 
Berzelius is strictly descriptive and didactic, and communicates, among other 
things, the practical instructions in examination of the urine of which we most 
feel the need. The physiological theory of this secretion intimated by the edi- 
tors of the present volume is the same generally received by the chemists of the 
time, and among others, by Mr. Jones: we, therefore, need not repeat it. It is 
dismissed by Professor Berzelius in a single sentence (p. 27); a fine specimen 
of a great man who confines himself strictly to his proper, peculiar business. 
A concise and neat description of the organs is first given; in the course of which 
he makes the following anatomical observations. On being pounded in a mortar, 
the substance of the kidney of a horse was almost entirely reduced to a fluid, 
inclusive of fine particles that passed through a linen strainer. The solid matters 
left behind could not be distinguished chemically from the coats of an artery; thus 
proving by the present method, in addition to the well known mechanical and 
microscopic means, that the organ was almost altogether constituted of vessels. 
Around these, however, existed a fatty and albuminous matter, capable of being 
separated by the above process, and faintly imbued with lactic acid. No fibrine 
was found in the kidneys; nor was urea encountered; at which last Professor 
Berzelius expresses his surprise. He had prepared the kidney by first inject- 
ing the artery as far as possible with distilled water introduced with a hydraulic 
pressure; and by many washings of the slices into which he subsequently divided 
it, with ice-cold water; but he had not succeeded in introducing the water of his 
injections into the cellular substance. 

Our author shows us by his example, that a man of high scientific distinction, 
who will never be accused of not informing himself of "the latest improve- 
ments," by no means thinks it beneath his dignity, or a waste of his time, to 
give a careful historical retrospect of the inquiry he has himself so effectually 
advanced. Van Helmont examined the urine with care in his essay on calculous 
affections. Twenty-five years later, Brandt and Kunkel made the brilliant dis- 
covery of phosphorus by obtaining it from the urine. Boyle, Bellini, Boer- 
haave and Marggraf made more or less elaborate inquiries into its composition; 
and a minor degree of importance is conceded to Pott, Haupt, Schlosser, 
Schockwitz, Beyman, Klaproth, and others unnamed. Rouelle, junior, next 
studied the organic elements of this fluid, but did not succeed in separating 
them: — he called them, as a totality, the soapy extract of the urine. Reexa- 
mined the saline matters, and compared the human urine with that of herbivo- 
rous animals, in which last he notes the absence of the phosphates, but found 
the carbonate of lime. To Scheele is attributed the discovery of uric, or lithic 
acid, which latter name our translators have retained; and Scheele also found that 
the urine contained phosphate of lime dissolved in excess of acid. Cruikshank, 
in the investigation of diabetic urine, made so many advances, that, in the opi- 
nion of Professor Berzelius, our knowledge of the nature of urine ought to be 
dated from his work. His experiments were published in Rollo's treatise on 
diabetes mellitus. Mr. Cruikshank was the discoverer of urea, succeeded in 
obtaining it in a crystalline form, and noted its precipitation by nitric acid. He 
further pointed*but a good method of ascertaining the relative quantity of ingredi- 
ents in the urine; besides investigating various modifications of this fluid, as those 
occurring in fever, dropsy and dyspepsia. The detailed analysis of the urine, by 
Fourcroy and Vauquelin, dates three years later; and Mr. Berzelius throws out a 
broad insinuation to the discredit of the allegation of Fourcroy, that he and his as- 
sociate had been acquainted with the principal facts noted by Cruikshank at an 
earlier period than the latter. To Fourcroy and Vauquelin is due the first good 
investigation of the effects of putrefaction on the urine; and Thenard demon- 



166 Bibliographical Notices. [July 

strated the existence of another acid in that fluid, besides the lithic and phos- 
phoric. This, according to him, was the acetic, bat, in the conviction of 
Professor Berzeiius, the lactic. The latter, finally, himself, made evident the 
presence of an extractive matter having a great resemblance to that derived from 
the liquids contained in flesh. Dr. Prout is not here enumerated as a discoverer; 
he is cited, however, in various places throughout the work, as an observer and 
analyst, and always with great respect. 

The writer of this sees no benefit likely to accrue from inserting in these 
pages any abstract of Professor Berzelius's chemical description of the urine. 
The achievement is scarcely possible. Professor Berzelius's style is concise; 
and nothing is to be spared. To form or approach an adequate estimate of the 
subject, it is necessary to have recourse to the original, and to bestow patient 
labour upon it. We shall note some of the points most likely to be borne in the 
memory of a practitioner of medicine not already conversant with this branch of 
inquiry. 

After the rather free employment of mercurial ointment, the urine contains 
mercury, and becomes alkaline; and its sediment, dried, and distilled with pow- 
dered charcoal, yields globules of the metal just named. Nitre, ferro-prussiate 
of potassa, and other salts, are found in the urine, and after the use of a large 
quantity of a preparation of iron, a faint bluish or greenish tinge has sometimes 
been found in this fluid, from the formation and union with iron of a portion of 
ferrocyanic acid, derived from materials within the body. After oxalic or tar- 
taric acids have been taken by the mouth, the urine, when cool, deposits oxalate 
or tartrate of lime, and this is increased by the addition of chloride of calcium. 
Tartaric, as well as citric and malic acids, render the urine acid. After the use 
of infusion of galls, that fluid gave dark coloured precipitates with the salt 
of iron. Succinic acid appears in the urine; and benzoic, as explained by Pro- 
fessor Woehler, in an addition which Messrs. Boye and Learning introduce 
as a foot note, is transformed into the hippuric. This is alluded to in the work 
of Mr. Bence Jones, reviewed in the present number. After the use of 
iodine, the iodides of sodium and ammonium appear. Alkaline carbonates, bo- 
rates, silicates, chlorates and nitrates were always found to pass into the urinary 
fluid; as was also sulpho-cyanide of potassium. Red ferro-prussiate was converted 
into ordinary ferro-prussiate. Sulpho-hydrate of potassium was partly discharged 
unchanged; but principally converted into sulphate of the same base. Salts of 
vegetable acids with potash and soda were converted into carbonates; and the 
urine showed alkaline properties and effervesced with acids. The same thing 
frequently happens atter the free use of certain fruits; as apples, cherries, straw- 
berries and raspberries, from these containing acid malate or citrate of potassa. 
This explains the utility of such fruits in cases of uric acid gravel. Students of 
an older date will recollect the often repeated case of Linnaeus, said by him- 
self to have been cured of an attack of gout by strawberries. The colouring and 
aromatic principles of plants enumerated as passing by the urine, we will not 
copy. Articles which will not pass by the urine, are alcohol, ether, camphor, 
empyreumatic animal oil, musk, the colouring matter of cochineal, litmus, sap- 
green (from the fruit of rhamnus catharticus), alkanet, oxides of tin, and pre- 
parations of lead and bismuth. The same is alleged of mineral acids; which, it 
is stated, never render the urine acid. (p. 108.) This last remark, which differs 
from Bence Jones, ought to be well understood. Dr. Prout recommends the 
use of mineral acids, as antalkaline; and mentions the use of them in one of his 
cases; though, in this instance, the remedy is said to have disagreed with the 
patient. {Nature and Treatment of Stomach and Urinary Diseases? 285-293.) 

We have not space for the phenomena produced by disease, nor can we do 
justice by abridging them. Professor Berzeiius agrees with the Hippocratic 
description of the urine in fevers; and differs from M. Becquerel. (p. 109. See 
this Journal, Jan. 1842, pp. 161, 162.) Severe vomiting is followed by the 
elimination of a small excess of phosphate of lime. (p. 111). In rheumatism there 
is, as theory would lead us to anticipate, a considerable excess of lithic acid; 
an argument, if the views of Professor Liebig and Mr. Bence Jones be correct, 



1843.] • Goldsmith on Lithotripsy. 167 

in favour of the treatment of that disease by purging-, found so successful in 
practice. It is unnecessary for us to add that we omit much that possesses 
great interest and value. The treatment for prevention of calculus (p. 158) 
harmonizes well with the chemical views generally entertained. Professor 
Berzelius thinks that trials of injections to dissolve the stone ought still to be 
persevered in. In general, the best injection is a tepid solution of one part of 
carbonate of potassa with from 90 to 100 parts of water, and a little mucilage; 
as it acts on all kinds of calculi, and caustic potassa operates too severely on the 
membranes. Borax may be used when the calculus is ascertained to consist of 
uric acid. He suggests the chlorohydric acid, with a large quantity of mucilage, 
for calculi consisting of phosphate of lime and cystine. 

Of the rules for examination of the urine in medical practice we shall not 
venture on giving any account. We are informed that Messrs. B. and L. origi- 
nally made this translation for their private use; but it has been published with 
the object of encouraging and enabling physicians in practice to establish the 
habit of examining the urine chemically. For this we are sure it is well suited; 
while our abstracts could be of no use. It is in general the only volume from 
which American practitioners, remote from cities, can obtain this invaluable 
information. We can recommend the publication in the strongest manner. No 
question exists of the merit of the original. The translation is neat and clear; 
and unusually well executed for this really difficult department of medical litera- 
ture. The volume is handsome, and got up in a liberal style of execution. 

B. H. C. 



Art. XIX. — Lithotripsy; or, the Breaking of Stone in the Bladder. By Alban 
Goldsmith, M. I)., late Professor of Surgery in the Medical College of 
Ohio, and the College of Physicians and Surgeons New York. New York, 
1843, pp. 24, 8vo. 

This purports to be an abstract from the lectures of the author, delivered while 
holding the Professorship of Surgery in the Medical College of Ohio and the Col- 
lege of Physicians and Surgeons in New York. Of the work, it is sufficient to say 
that it is "only intended for general distribution," and that whether we consider 
its scientific or literary claims, it is about on a par with Mr. Swaim's book of 
cures. Its sole object is to puff and advertise its author; and every friend to the 
respectable institutions mentioned, as well as every right-minded member of our 
profession, must feel gratified to think that previous to his publication, Dr. Gold- 
smith had left his high estate and was no longer connected with them. Publi- 
cations such as this, and the disgusting picture pamphlets which it is now the 
order of the day to circulate as standing advertisements for operations, though 
they may for a time have effect with " the many," and bring money to the 
pocket, cannot we think but lead to loss of reputation and contempt among all 
upright and honourable professional men. We long deemed it proper to pass 
unnoticed the pamphlets of those who were thus led astray, but when we see 
them fearfully increasing, and see too, men who occupy high places degrading their 
stations and the whole profession by employing collectors to scour our lanes and 
alleys for cases, and countenancing secret remedies, we think it right to direct 
attention to the system, in the hope of effectually and at once subduing it. A 
vain hope we cannot think it, and confidently look forward to the time when 
medical advertisers, whether for the cure of stone, strictures, deformities, or 
coughs, and whether by means of newspapers, pamphlets, medical journals, 
envelopes, or collectors, shall receive all that reward and renown to which they 
are justly entitled. G. W. N. 



1 68 Bibliographical Notices. [July 

Art. XX. — Physical Diagnosis and Diseases of the Lungs. By Walter Hayle 
Walshe, M.D., Professor of Pathological Anatomy in University College, 
London; Physician to the Hospital for Consumption and Diseases of the Chest; 
Member of the Medical Society of Observation of Paris, etc. Philadelphia: 
Lea & Blanchard, 1843. 

This work is in one volume duodecimo, including 380 pages and a copious 
index. It is especially intended by its author as a manual for students, in their 
investigations of physical diagnosis, as applied to diseases of the respiratory 
organs. There are, however, but few practitioners who might not derive much 
useful information, and many practical hints from a careful perusal of its pages. 

The first part of the work includes all the physical signs derived from auscul- 
tation, percussion, inspection, manual examination and mensuration of the chest, 
both in the healthy and diseased condition of the lungs; and these different sub- 
jects are handled in a concise and masterly manner. 

In treating of inspection or ocular examination of the chest, particular allusion 
is made to the numerous deformities of the chest which occur unconnected with 
pulmonary disease. "It is obvious that the chief, almost the sole, clinical im- 
portance attached to these "physiological" departures from regular form, con- 
sists in the chance of their being confounded with, or mistaken for, alterations 
of shape dependent on disease. Their frequency indicates the necessity of being 
acquainted with them; in 197 cases there existed 251 examples of natural hete- 
romorphism; 144 of these occurring in 111 subjects who had had thoracic dis- 
ease; 107 in 86 individuals who had all their lives been perfectly free from such 
disease." p. 157. 

The section devoted to mensuration is remarkably complete, and contains much 
valuable and practical information. Mention is made of the unequal dimensions 
of the two sides of the chest; the right side exceeding the left, by half an inch 
in right-handed individuals. Practical rules for the performance of mensuration, 
and the most appropriate instruments, together with those precautions which are 
essential for the prevention of error, are fully detailed in the same chapter. 

The degree of clearness, duration of sound, the amount of resistance experi- 
enced by the fingers in the act of percussion, and the relative importance of these 
different phenomena, are described, and illustrated by familiar facts. 

One of the varieties of sound mentioned by the author as derived from percus- 
sion, is the " wooden." The wooden character is very closely allied to that of the 
sound yielded by mediate percussion of a common table, and distinctly conveys the 
idea of hardness. The duration of the sound having this character is commonly 
less than in the natural state, and the sense of resistance experienced by the 
fingers is usually great. The author then refers to the physical cause of this 
sign. "I am inclined to think, from the experience I have hitherto had on the 
subject, that when well marked it may be considered almost a conclusive sign of 
a thick and dense stratum of fibrous substance in the pleura, binding the lung and 
parietes together. No amount of fluid in the pleural cavity, or of consolidation 
of the lung itself, seems capable of producing it to a marked amount; but all 
descriptions of consolidation, when false membrane is present in abundance, pro- 
duce it more or less." p. 177. 

The most interesting part of the work is to be found under the head of " Aus- 
cultation." The various improvements in this department of physical diagnosis 
are referred to, and due credit is faithfully given to the different authors by whom 
they were first noticed. 

When treating of the respiratory murmur during expiration, Dr. Walshe uses 
the following language: "To the late Dr. Jackson, jun., of Boston, U. S., be- 
longs the honour of conceiving the value and extent of information which might 
be obtained from its analysis. In a most ingenious paper, read in 1832 before 
the Medical Society of Observation of Paris, that zealous inquirer forcibly drew 
attention to the subject." 

The author's views are highly independent, and he does not hesitate to ex- 



1843.] Walshe's Physical Diagnosis and Diseases of the Lungs. 169 

press them fully', even when they differ with high authorities; nor is the work 
deficient in ingenuity and originality of conception. That the expiration is na- 
turally louder and more prolonged under the right than the left clavicle, is fully 
believed by many accurate observers; but our author does not subscribe to this 
opinion, nor is he disposed to admit that "the excess of caliber of the right 
bronchus over the left" is sufficient to account for such dissimilarity in the local 
signs. 

No one of the signs derived from auscultation has given rise to more discre- 
pancy of opinion as to its physical cause, than the crepitant rhonchus. The 
opinion most commonly adopted, is, that the passage of air through a viscid 
fluid contained in the air cells, fully explains the peculiarity of this rhonchus. 
Dr. Walshe's view upon this subject is certainly highly ingenious. " It seems 
to me most probable that, 1st, The phenomenon occurs in the parenchyma of the 
lung itself, especially in those portions of it immediately contiguous to, and 
actually forming the walls of, the ultimate terminations of the bronchi; whether 
these terminations be globular sacs open at one point of their periphery only, or 
otherwise constituted: 2ndly, That its physical cause is the sudden and forcible 
expansion of that parenchyma, glued together, as it were, by the viscid exuda- 
tion with which it is infiltrated. Each single crepitus or click would thus sig- 
nify the expansion of a cell, and be produced by the unfolding and surrounding 
glutinous tissue necessary for that expansion. Thus conceived, as respects its 
mechanism, the chief phenomena of the crepitant rhonchus become perfectly in- 
telligible; its dryness and sharpness; the sensation of minute size attending the 
sounds of which it is composed; the similarity to the sound of minute rupture of 
tissue, and the total absence of the bubbling character; its occasionally accom- 
panying the entire inspiratory act, and sometimes appearing only at its close, 
according as the infiltration of viscid lymph less or more completely prevents 
expansion of the vesicles. We can, on this supposition, also readily understand 
why crepitation should exist in the inspiration only; though the rapid and abrupt 
unfolding of the glutinous mass be productive of crackling noise, it is very un- 
likely that the comparatively slow and equable restoration of the tissue to its 
previous collapsed state, would be thus productive, — indeed the presumed phy- 
sical cause of crepitus has ceased to exist: on the other hand, there is no reason 
why in the ordinary theory crepitation should not as regularly exist, though not 
with the same loudness, in expiration as in inspiration." pp. 241-2. 

The second part of the work is in a tabular form, and contains a full exposi- 
tion of the causes, and locality of the different physical signs. The names of 
the diseases in which the various signs are most commonly observed, are also 
carefully enumerated. 

The third part, comprising about one-half of the volume, forms a commentary 
upon the two preceding divisions. Under this head various " debateable points" 
are impartially discussed, and copious references made to the views entertained 
by different acknowledged authorities. It is to be regretted that "all disquisi- 
tion upon the acoustic principles regulating the production and transmission of 
sounds," have been scrupulously avoided by our author when treating of the 
mechanism of the various physical signs. An unwillingness to increase the size 
of the book, "or deprive it of the simple practical character," are the reasons 
assigned for this omission. 

We have thus endeavoured to give a general idea of the plan of the present 
work; but it would be impossible in a short notice like the present, to do justice 
to the various points of interest contained in the commentary. Before closing, 
we would strongly recommend this little volume to students and the profession 
at large, as a useful guide and book of reference. W. P. 



170 Bibliographical Notices. [July 



Art. XXI. — A P radical and Theoretical Treatise on the Diagnosis, Pathology, and 
Treatment of Diseases of the Skin, arranged according to a Natural System of 
Classification, &c. By Erasmus Wilson, Lecturer on Anatomy and Phy- 
siology in the Middlesex Hospital School of Medicine, &c. Philadelphia. Lea 
& Blanchard, 1843, 8vo. pp. 370. 

The possession of a well-considered and systematic classification has been 
found to be so indispensably necessary to a successful prosecution of the study 
of the diseases of the skin, that much effort has been made by successive ob- 
servers to establish one which shall meet every want. The greatest diffi- 
culty, however, has hitherto been met with in arranging the various forms into 
distinct natural groups, and as a consequence the artificial system of Willan, 
which is as perfect as an artificial system can be, has long remained in favour. 
Undismayed by the unsuccessful efforts of his predecessors to substitute for this 
a natural classification, Mr. Wilson has, in the work of which the title is placed 
at the head of this notice, presented us with one "in which he has endeavoured 
to avoid the objections which may be urged against the artificial arrangement," 
and claims for it the name of "The Natural System." 

"The basis of the Natural System of classification rests upon Anatomy and 
Physiology, and herein lies its strength, its simplicity, its easy application, and 
its truth. The dermis and its dependencies, its glands, and its follicles, are the 
undoubted seat of all the changes which characterize cutaneous Pathology. 
These then constitute my four Primary Divisions: — 
I. Diseases of the Dermis. 
JI. Diseases of the Sudoriparous Glands. 

III. Diseases of the Sebaceous Glands. 

IV. Diseases of the Hair and Hair follicles." 

In the First class, under its five Secondary Divisions, 

1. Inflammation of the Dermis. 

2. Hypertrophy of the Papillae of the Dermis. 

3. Disorders of the Vascular Tissue of the Dermis. 

4. Disorders of the Sensibility of the Dermis. 

5. Disorders of the Chromatogenous Function of the Dermis, 

is arranged almost the whole circle of Cutaneous diseases. Indeed, if we ex- 
cept Acne and Sycosis, which are placed among the diseases of the sebaceous 
glands, and Favus, properly studied among the diseases of the hair-follicles, all 
the important and serious alterations and affections of the skin are grouped 
together among the Diseases of the Dermis. 

There is one point which we cannot pass over without an expression of surprise; 
it is in reference to the strange notions of our author respecting the nature and 
origin of Variola. We will first advert to the position which he has assigned 
to it and its commonly received kindred affections Vaccinia and Varicella in his 
Natural System. 

The first division of the disease of the dermis, namely, inflammation of the 
dermis, is separated into two groups, "such as are characterized by inflammation 
of the Dermis and mucous membranes with constitutional symptoms of a specific kind; 
and such as consist simply of inflammation of the dermis without constitutional 
symptoms of a specific kind, the mucous membranes being less conspicuously 
disordered." 

Under the former of these groups are placed Scarlatina, Rubeola, Variola and its 
kindred affections. Now while we cheerfully accord with our author in this col- 
location, on the ground that there is an advantage in studying together what are 
usually termed the Eruptive Fevers, from their resembling each other in many 
particulars, yet upon the basis assumed by Mr. Wilson, that they are " diseases 
originating in the same morbid contagion, the differences between them depend- 
ing on modifications either of the physical or of the vital conditions of the system 
by° which the contagion is received," we must protest against it, until something 



1843.] Wilson's Treatment of Diseases of the Skin. 171 

more positive in support of such a doctrine is advanced than the bare assertion 
of the writer. 

The general principles of the classification in other particulars appear to be 
sound, and much credit is due to the author for having- left unchanged the com- 
monly received name's of the cutaneous diseases. There is no innovation here; 
and the student has only to classify his ideas under new heads, without being 
compelled to burthen his memory with new terms. 

But we must now proceed from the preface, which contains the author's remarks 
upon his Natural System and upon those advocated by other writers, to a brief 
examination of the other contents of the work. The first chapter is devoted 
to a consideration of the Anatomy and Physiology of the skin; it is a full and 
complete ac«ount of the various parts of which this tissue is composed, and of 
the interesting functions which it performs. In the descriptions, which are me- 
thodical and distinct, the author has freely availed himself — as by the way is 
the case throughout the book — of the recent analyses and microscopical inves- 
tigations which have been so carefully made in En'gland, France, and Ger- 
many, but more particularly in the last. 

Having thus prepared the ground, Mr. Wilson enters upon the study of the 
different diseases under their respective groups or divisions. . Suffice it to say, 
that the account of the history, diagnosis and treatment of the diseases under 
consideration is practical and full. In some few points of practice, however, he 
appears to have arrived at conclusions which are not, we believe, in accordance 
with the generally received opinions of medical men, at least in this country. 

The subject of vaccination as a means of protection against small-pox is care- 
fully examined, and our author adds his testimony to the experience of others in 
insisting upon a careful performance of this operation. Among the elements 
which constitute a perfect vaccine vesicle, he lays it down as essential that it 
should be allowed to run its course unmolested for the purpose of extracting 
lymph. This we fear is too often neglected, and the safety of many who were 
supposed completely protected, is thus endangered. Re-vaccination is relied 
upon as the best, and an efficient test of the excellence of the previous vaccina- 
tion; and is recommended "as a simple and harmless operation, producing a mild 
and trifling indisposition when- the system is unprotected, but no effect whatever 
when the organism is safe." The only question is relative to the length of time 
during which vaccination affords protection, as no positive law can be estab- 
lished here. Mr. Wilson recommends that it should be repeated every five, or 
seven, or ten years, according as the individual manifests a susceptibility for its 
reception. 

A short chapter is devoted to Syphilitic eruptions, and the work concludes 
with an historical and descriptive account of the acarus scabiei or itch-animal- 
cule, and of the acarus follicu brum , of which a drawing is given, an insect, 
which in his researches "relative to the cause of acne, Dr. Gustav Simon of 
Berlin, had the good fortune to discover in the sebaceous substance with which 
the hair-follicles are so commonly filled, particularly on the face, — even in cases 
where the skin presents all the characters of perfect health." 

Before closing this notice, we would advert to a matter of some moment; it is 
that the corrections of the press have not been as carefully made in this work, as 
they usually are in those emanating from the publication office of the enterpris- 
ing firm which stands sponsor here. Two of these errors are calculated to 
lead to important misconceptions. We refer to one, page 116, paragraph 162 
— Mr. Wilson is made to say, by the omission of a little particle, "Recurrence 
to the primary lymph from the cow appears to me to be the only objectionable 
method of improving the current lymph, &c." Now his opinion is directly the 
contrary. Again, page 223, paragraph 403 — " Several cases of psoriasis have 
followed the employment of the liquor hydriodatis arseniciet hydrargyri" — when 
it is evident from what follows that our author means to speak of cures. The 
last, however, occurs in the original work. 

In conlusion, we can recommend this book to the profession as a useful and 
practical work. C. R. K. 



172 Bibliographical Notices. [July 



Art. XXII. — Mental Hygiene; or, an Examination of the Intellect and Pamons, de- 
signed to illustrate their Influence on Health and the Duration of Life. By Wil- 
liam Sweetser, M. D., late Professor of the Theory and Practice of Physic, 
&c, New York: J. & H. G. Langley, 1843, pp. 270, 12mo. 

We have here an agreeable, well written, and carefully digested treatise on 
one of the most interesting branches of medical inquiry; the influence of mind 
upon matter, or, in other words, of the intellect and the passions upon the func- 
tions and health of the body. Our author has sought to awaken attention, and 
to direct it when so excited, to the investigation of the important truths which 
are embraced in mental hygiene, and has brought to his assistance much apt and 
well arranged illustration, though, perhaps, not as recent as he might have ob- 
tained. 

The work is divided into two parts. The first, is occupied with an examina- 
tion of the intellectual operations in their relation to the functions of the body 
and of their effect upon the general health. Dr. Sweetser shows the importance 
of a proper cultivation of the intellect, and also that the evils resulting to the 
constitution from intellectual exertions, excepting when these are carried to too 
great an extent, are not the consequence of the mere intellectual effort, but depend 
upon the passions which are found almost invariably to mingle their poison 
with the draughts of knowledge which the student seeks to drain, or upon an 
inattention to the proper rules of exercise and diet, so essential to the maintenance 
of healih. Indeed, abundant proof exists, that the votaries of science and of 
knowledge are, cseter is paribus, among the longest-lived of the human race. 

In the second portion of the book, the passions are shown in their effects upon 
the health. They are divided into the pleasurable, the painful, and the mixed, 
and are studied at much length under these several heads. We cannot close 
this brief notice better than with this general proposition deduced by the author 
from his examination of the passions: "Having reference only to the laws of 
our present organization, it seems to me that no truth can be more plain than 
that pure and well-regulated moral affections are essential to the greatest good 
of the entire animal economy, that the turbulent and evil passions must necessa- 
rily corrupt the sources of our physical, moral, and intellectual health, and thus 
be followed by the severest penalties to our whole nature." C. R. K. 



Art. XXI II. — Meteorology; comprising a description of the atmosphere and its phe- 
nomena, the laws of climate in general, and especially the climatic features pecu- 
liar to the region of the United States; with some remarks upon the climates of 
the ancient world, as based on Fossil Geology. By Samuel Forry, M. D. 
Extra New World, New York. J. Winchester, 1843. 

The object of Dr. Forry in this work is to give a general view of Meteorology, 
in its relation to the laws of climate, and at the same time to present some in- 
teresting researches respecting climatology, both in its general aspect, and, more 
particularly, in its peculiar bearings upon the region of the United States. 

The readers of this journal are already well acquainted with the labours of 
the author in this department of science, the results of which he has formerly 
laid before them in several able papers. It is, therefore, sufficient to mention 
here, that Ihese deductions and others of a more general nature are contained 
within the pages of the work before us, and that the whole matter has been 
arranged in a form which will render it particularly valuable to the general 
reader. It is well known, that the medical board of the army has compiled for 
the use of the officers at the different military stations throughout this extensive 
country, a series of directions to which they must conform and by which they 
are to be guided in making meteorological observations. But it so happens that 
the central portions of the Union are almost entirely without military posts, 



1843.] Thomson's Conspectus of the Pharmacopoeias. 173 

which are arranged along two lines, following the sea-ccast and the Mississippi. 
So that the observations, perfect as far as they go, must be to a certain extent 
defective as regards the central States. Individuals scattered throughout these 
must, therefore, be induced to lend their aid, to fill up the chain. 

In furtherance of this object, we think that the book before us will have a 
good effect. By rendering the subject interesting and by setting forth the results 
already obtained, at the same time that the method of reaching them is simply 
yet sufficiently explained, we doubt not that many will be induced, from reading 
the book, to apply themselves to the collection of facts; more particularly so, as 
there are really no very serious obstacles to deter them from it. 

The concluding chapter contains an account, from the pen of Dr. C. A. Lee, 
of the climates of the ancient world, for which the materials are drawn from 
fossil geology. C. R. K. 



Art. XXIV. — A Conspectus of the Pharmacopoeias cf the London, Edinburgh, and 
Dublin Colleges of Physicians, and, of the United Slates Pharmacopoeia, being a 
Practical Compendium of Materia Medica and Pharmacy. By Anthony Todd 
Thomson, M. D., F. L.S.&c. The second American edition, much enlarged 
and improved. Edited by Charles A. Lee, M. D. From the thirteenth 
English edition, 12mo., New York, 1843. J. & H. G. Langley. 

The author of this work, Dr. Thomson, has long laboured in the department 
of materia medica, and among the numerous authors who have contributed to its 
improvement, may at the present time be regarded as a patriarch. His works 
are generally very voluminous, but in the present instance, he has abandoned 
his wonted course, and by considerable pains-taking, has given to the public what 
may be termed a labour-saving production. The arrangement of the volume is 
alphabetical, and it comprises the different articles and their preparations. Each, 
article is designated by the name it possesses in the Pharmacopoeias, and there 
are indicated in succession, its natural history, its source, the portion of the world 
whence derived, its composition, properties, operation, use, dose, and officinal 
preparations. To chemical substances are added the incompatibles. Under 
each preparation, to be found in its appropriate position, is given the mode of 
obtaining it with the formula which has been directed by the London Pharma- 
copoeia usually. 

Upon the plan specified, the main body of the work has been executed, but 
preceding it is an introduction, which is a condensed pharmaceutical essay., and 
following it is an alphabetical exposition of poisons, the analysis of urine, the 
art of prescribing medicines, with prescriptions and dietetic preparations, tables 
of chemical affinity, &c, weights and measures, directions for preparing baths, 
and the composition of the most noted mineral springs. 

With regard to this little production, we fully endorse what is stated by the 
American editor in his preface, that "it is in reality a complete summary or 
comprehensive epitome of the science of pharmacy and materia medica; com- 
prising an amount of information altogether unparalleled, we believe, in so small 
a space." His labours have been directed to supplying such deficiencies as ap- 
peared to him to exist, and "advantage has therefore been taken of the recent 
publication of the new edition of the United States Pharmacopoeia, and its im- 
proved processes and new preparations, together with its nomenclature, will be 
found embodied in these pages." The indigenous articles of the United States 
have been added. J. C. 



No. XI,— July, 1843. 12 



174 Bibliographical Notices. U u ty 



Art. XXV. — Transactions of the Medical Society of the State of New York. Vol. 
V. Part III., 8vo. Albany, 1843. 

This, like its predecessors, is an interesting contribution to our sciences. The 
contents are the Annual Address (an excellent one) of the President; an admirable 
exposition of that transcendentalism of humbuggery — Homosopathy, by Dr. 
Blatchford; an interesting- paper on Insanity, by Dr. Coventry; Medical and Topo- 
graphical Sketches of Binghamton and the surrounding country, by Dr. N. S. 
Davis; and an abstract of the proceedings of the society at its annual session in 
February, 1843. 



Art. XXVI. — Fifty-sixth Annual Beport of the Regents of the University of the 
State of New York, made to the Legislature March 1, 1843. Albany, 1843. 
pp. 316, 8vo. 

This is an interesting document. It contains a general view of the matters 
contained in the annual reports made to the Regents by the several colleges and 
academies of the state — showing the financial condition of, courses of study in, 
number of students in, &c. each of these institutions. Also an abstract of the 
returns of Meteorological observations for the year 1841, made by the academies 
in the state. 

There are four medical colleges in the state, and the number of pupils the past 
session, was 667. 



Art. XXVII.— Quarterly Summary of the Transactions of the College of Physicians 
of Philadelphia, February, March, April, 1843. 

This number of the Transactions of the Society contains the annual reports 
" on the Diseases of Women," and "on the Diseases of Children." The for- 
mer is by Dr. Jos. Warrington, and the latter by Dr. D. F. Condie. They are 
both interesting papers, the latter particularly, but they contain no facts of im- 
portance that have not already appeared in this journal, and we need not there- 
fore give an analysis of them. 



Art. XXVI II. — A Practical Treatise on the Management and Diseases of Children. 
By Richard T. Evanson, M. D., Professor of Med. in the Royal College of 
Surgeons, Ireland; and Henry Maunsell, M. D., Professor of Political Med. 
in the Royal College of Surgeons, Ireland. Second American edition, from 
the fourth Dublin edition, with Notes by D. Francis Condie, M. D., F. C. P. 
P., Mernb. A. P. S., &c. Philadelphia. Ed. Barrington & Geo. W. Haswell. 

This work has been remarkably successful in Great Britain, having gone to a 
fourth edition in less than six years, and will, we are sure, meet with favour in 
this country. "It embraces," as the editor correctly observes, "a very full 
account of the principal affections peculiar to the early period of existence — the 
phenomena of which are described with great accuracy, while the views advanced 
in relation to their pathological, as well as the directions given for their thera- 
peutical management, are evidently the result of extensive personal observations, 
and a careful study of the views and experience of the best modern authorities." 

The principal additions of the editor are to the sections devoted to the subjects 
of gangrene of the mouth in children, and to cholera infantum. The brief notice 
of the former in the original " being extremely incomplete, and withal somewhat 



1843.] Graves' Clinical Medicine, 175 

confused," the editor has "appended an account of the symptoms, etiology, and 
treatment of this important malady, derived from his own observations, and 
those of the principal European writers who treat especially of the disease. A 
similar course has been pursued in relation to the account of cholera infantum, 
contained in the same chapter; a disease of which Dr. Evanson has evidently 
seen but little, and which he has strangely confounded with another and very 
different disease of the digestive organs." 

These additions are well drawn up — they show the editor to be not only 
familiar with infantile diseases from extensive experience, but that he is also 
well acquainted with the literature of the subject, and will lead the profession to 
expect much from the original work which is announced as in preparation by 
him for early publication. 



Art. XXIX. — Dissertation on the Diseases of the Maxillary Sinus. By Chapin 
A. Harris, M. D., D. D.S., Prof, of Practical Dentistry in the Baltimore 
College of Dental Surgery; Member of the Medical and Chirurgical Faculty 
of Maryland; Corresponding Member of the Western Academy of Natural 
Sciences, &c. &c. Philadelphia, Lea & Blanchard, 1843, pp. 165, 8vo. 

This Memoir was read before the American Society of Dental Surgeons, at 
their third annual meeting held in Boston in July last. The author was led 
to its preparation, from a belief, which appears to us to be well founded, that a 
short and at the same time comprehensive treatise on the morbid affections of 
the maxillary sinus, would not be altogether unacceptable to the members of the 
Dental profession. 

The author, after some general observations on the morbid affections of the 
antrum maxillare, treats in succession of the inflammation of its lining mem- 
brane, of a purulent condition of its secretions and engorgement, of abscess, of 
ulceration of the lining membrane, of caries, necrosis and softening of its bony 
parietes, of tumours of its lining membrane and periosteum, of exostoses of its 
osseous parietes, and of wounds of its parietes and foreign bodies in it. 

In discussing these various affections the author has displayed very great re- 
search, and adduced numerous cases illustrative of the different forms of disease 
from the various periodical journals, as well as from some of the older writers, 
whose works are not easily accessible. 

This volume will not only be of value to the dentist but also to the surgeon, 
some of the affections originating in the maxillary sinus often involving the 
whole upper-jaw, and requiring not unfrequently the extirpation of the parts 
involved. 



Art. XXX. — A System of Clinical Medicine. By Robert James Graves, 
M. D., M. R. J. A., one of the Physicians to the Meath Hospital and County 
of Dublin Infirmary, &c. &c. Dublin, 1843, pp. 937, 8vo. 

We congratulate the profession upon the appearance of the valuable clinical 
lectures of Professor Graves, revised and systematically arranged by the author. 
The lectures on fever have in this volume been completely remodelled, and those 
on typhus fever have "assumed an entirely new form." 

"For many years," Dr. G. observes, "several of the doctrines I promulgated 
respecting fever, were opposed to those taught by other lecturers and generally 
advocated by authors; and consequently I was then obliged to dwell on such 
disputed questions at greater length than perhaps their intrinsic importance 
would now seem to warrant; formerly I stood almost alone in resisting the in- 
flammatory theory of fever, as successively brought into fashion by Armstrong, 
Clutterbuck and Broussais, and my opinions respecting contagion, the use of 



176 Bibliographical Notices. [July 

mercury, purgatives, of wine, diet, &c. were different from those then generally 
entertained: and therefore it was that such topics occupied so considerable a 
space in the original lectures, and are treated of at some length in the present 
volume. While engaged in the task of preparing for the press, I have consult- 
ed many of my medical friends, both in Dublin and the Provinces, on various 
subjects, and by this means having been enabled to avail myself of the experi- 
ence of others where my own was deficient, much valuable information has 
been gained, and the courtesy of my professional brethren has produced com- 
munications which will no doubt be received by the public with a degree of 
favour proportioned to the gratitude the author feels to his friends for their 
valuable assistance." 

Besides the clinical lectures, this volume contains observations on the nature 
and treatment of various diseases, being a republication of the papers published 
by the author at different times in the Dublin Medical Journal. 

Our Journal has already been enriched with some of the valuable materials 
contained in this work, and we shall hereafter draw still further from the same 
source. 



Art. XXXI. — The Horse. By William Youatt. A new edition, with nume- 
rous Illustrations, together with a General History of the Horse, &c, and 
an Essay on the Ass and the Mule. By J. S. Skinner, Editor of the Turf 
Register, &c. Philadelphia, Lea & Blauchard, 1843, pp. 448, 8vo. 

Veterinary medicine does not come within the strict scope of this Journal; 
nevertheless there are many of our readers who are doubtless interested in the 
subject, and we would call the attention of those to the work of Mr. Youatt, which 
comes out with high sanction, being published under the superintendence of the 
Society for the diffusion of useful knowledge. 

The first edition of this work was published in 1831, and met with great suc- 
cess. The considerations which led to the present edition are the following, as 
stated by the secretary of the committee in the preface. 

" Veterinary science has, however, made great progress in the last twelve 
years; the structure of the horse, the injuries and diseases to which he is sub- 
ject, and the treatment, of these, have been investigated, in this country and 
abroad, with much diligence and success, both at colleges and in societies 
devoted to the cultivation of veterinary knowledge, and by practitioners whose 
education and experience render their observations worthy of great respect. 

" In these circumstances, the society entrusted to the author the preparation 
of a new edition of this treatise; and he has subjected it to so complete a re- 
vision, as to render it in many respects a new work. This remark applies 
especially to the chapters relating to the diseases of the horse." 



1843.] 



177 



SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On Fissiparous Generation. — Dr. Martin Barry, in a memoir read to the 
Royal Society on the 16th of February last, observes that the blood corpuscle and 
the germinal vesicle resemble one another in the circumstance of an orifice 
existing in the centre of the parietal nucleus of both. He pursues the analogy 
still further, conceiving that as a substance of some sort is introduced into the 
ovum through its orifice, which the author terms the point of fecundation, so 
the corpuscles of the blood may undergo a sort of fecundation through their 
corresponding orifice; and also that the blood-corpuscle, like the germinal vesicle, 
is propagated by self-division of its nucleus; a mode of propagation which he be- 
lieves to be common to cells in general. The nucleus of the germinal vesicle, or 
original parent cell of the ovum, gives origin, by self-division, to two young per- 
sistent cells, endowed with qualities resulting from the fecundation of the parent 
cell; these two cells being formed by assimilation, out of a great number of mi- 
nuter cells which had been previously formed. This account of the process 
which takes place in the reproduction of the entire organism, explains, accord- 
ing to Dr. Barry, the mysterious reappearance of the qualities of both parents 
in the offspring. 

Certain nuclei, which the author has delineated in former papers as being 
contained within and among the fibres of the tissues, he conceives to be, in like 
manner, centres of assimilation, from observing that they present the same sort 
of orifice, that they are reproduced by self-division, and that they are derived 
from the original cells of development; that is, from the nuclei of the corpuscles 
of the blood. He considers that assimilation of the substance introduced into 
the parietal nucleus of the cell is part of the process which propagates the cell; 
that the mode of reproduction of cells is especially fissiparous, and that the pro- 
cess of assimilation prepares them for being cleft. 

A pellucid point is described by the author as being " contained in a certain 
part of the cell-wall, and as representing the situation of a highly pellucid sub- 
stance, originally having little if any colour." This substance, which he consi- 
ders as being primogenital and formative, he denominates hyaline, and ascribes 
to it the following properties. It appropriates to itself new matter, thus be- 
coming enlarged; then divides and subdivides into globules, each of which 
passes through changes of the same kind. Under certain circumstances, it 
exhibits a contractile power, and performs the motions called molecular. It is 
the seat of fecundation, and it is by its successive divisions that properties 
descend from cell to cell, new properties being continually acquired as new- 
influence? are applied; but the original constitution of the hyaline not being 
lost. The main purpose for which cells are formed is to reproduce the hyaline; 
and this they do by effecting the assimilation which prepares it to divide; such 
division being thus the essential part of fissiparous generation. 

The remaining part of the paper is occupied with a detailed account of these 



178 Progress of the Medical Sciences, [Juty 

processes as they occur in the development of the ovum, and also in the changes 
exhibited by the corpuscles of the blood, in which fissiparous reproduction also 
lakes place, and the red blood-discs are converted into fibrin, and thus give ori- 
gin to the various tissues of the organs. The same theory of fissiparous repro- 
duction he also applies to the formation of the muscular fibre, in connection with 
his belief that it is composed of a double spiral filament. Contractile cilia, he 
supposes, are also formed by the elongation of nuclei, the filaments proceed- 
ing from them in opposite directions. The author considers, lastly, the subject 
of the fissiparous reproduction of the infusoria, and particularly of the volvox 
globator, the chlamido-monas, baccillaria, gonium, and the rnonadina in general; 
and applies the same theory to gemmiparus reproduction, and to the so-called 
spontaneous generation of infusoria and parasitic entozoa. — Proceedings of the 
Royal Society, 

2. Blood Corpuscles. — T. Wharton Jones, Esq. in a paper read to the Royal 
Society (Dec. 8, 1842) pointed out what he conceives to be important errors in 
the series of papers by Dr. Martin Barry, which have lately appeared in the 
Philosophical Transactions. He alleges that Dr. Barry had generally con- 
founded the colourless corpuscles of the same fluid; each of which latter kind 
consists of a vesicle or cell, with thick walls, but in a collapsed and flattened 
state, having therefore a biconcave form, and in consequence of its thick wall 
being doubled on itself, presenting under the microscope a broad circumferential 
ring, which is illuminated or shaded differently from the depressed central por- 
tion, according to the focal adjustments of the instrument: while the colourless 
corpuscles, on the other hand, are of a globular shape, strongly refractive of 
light, and granulated on their surface, and are of a less specific gravity and of 
somewhat larger size than the red corpuscles. 

Mr. Jones regards as wholly erroneous the notion which Dr. Barry entertains 
that a fibre exists in the interior of the blood corpuscle; and that these fibres, 
after their escape from thence, constitute the fibres which are formed by the 
consolidation of the fibrin of the liquor sanguinis. The beaded aspect presented 
by the double contour of the thick wall of the red corpuscle when it had been 
acted upon either by mechanical causes or by chemical reagents, of which the 
effect is to corrugate the edge, and to bend it alternately in opposite directions, 
has, Mr. Jones thinks, given rise to the illusive appearance of an internal 
annular fibre. The appearance of flask-like vesicles presented by some of the 
red corpuscles, with the alleged fibre protruding from their neck, Mr. Jones 
ascribes altogether to the effects of decomposition, which has altered the mecha- 
nical properties of the corpuscle, and allowed it to be drawn out, like any other 
viscid matter, into a thread. In conclusion Mr. Jones remarks, that if these 
statements of Dr. Barry should be recognized as fundamental errors in his pre- 
mises the whole reasonings built upon them must fall to the ground. — Proceed- 
ings of the Royal Society, No. 56. 

3. Structure and Composition of Nerves. — Dr. James Stark, in a paper read be- 
fore the Royal Society in January last, gives the results of his examinations, 
both microscopical and chemical, of the structure and composition of the nerves, 
and concludes that they consist, in their whole extent, of a congeries of mem- 
branous tubes, cylindrical in their form, placed parallel to one another, and 
united into fasciculi of various sizes; but that neither these fasciculi nor the 
individual tubes are enveloped by any filamentous tissue; that these tubular mem- 
branes are composed of extremely minute filaments, placed in a strictly longitudinal 
direction, in exact parallelism with each other, and consisting of granules of the 
same kind as those which form the basis of all the solid structures of the body; 
and that the matter which fills the tubes is of an oily nature, differing in no 
essential respect from butter, or soft fat; and remaining of a fluid consistence 
during the life of the animal, or while it retains its natural temperature, but be- 
coming granular or solid when the animal dies, its temperature is much reduced. 
As oily substances are well known to be nonconductors of electricity, and as the 






1843.] Anatomy and Physiology, 179 

nerves have been shown by the experiments of BischofF to be among the worst 
possible conductors of this agent, the author contends that the nervous energy 
can be neither electricity, nor galvanism, nor any property related to those pow- 
ers; and conceives that the phenomena are best explained on the hypothesis of 
undulations or vibrations propagated along the course of the tubes which com- 
pose the nerves, by the medium of the oily globules they contain. He traces 
the operation of the various causes which produce sensation, in giving rise to 
these undulations; and extends the same explanation to the phenomena of vo- 
luntary motion, as consisting in undulations, commencing in the brain, as deter- 
mined by the will, and propagated to the muscles. Fie corroborates his views 
by ascribing the effects of cold in diminishing or destroying both sensibility and 
the power of voluntary motion, particularly as exemplified in the hybernation of 
animals, to its mechanical operation of diminishing the fluidity, or producing 
solidity in the oily medium by which these powers are exercised. — Proceedings 
of the Royal Society, No. 56. 

4. On the special Function of the Skin. By Robert Willis, M. D. — The pur- 
pose which is answered in the animal economy by the cutaneous exhalation has 
not hitherto been correctly assigned by physiologists. Dr. Willis believes it 
to be simply the elimination from the system of a certain quantity of pure 
water; and he considers that the saline and other ingredients which pass off at 
the same time by the skin, are in too inconsiderable a quantity to deserve being 
taken into account. He combats, by the following arguments, the prevailing 
opinion, that this function is specially designed to reduce or to regulate the ani- 
mal temperature. It has been clearly shown, by the experiments of Delaroche 
and Berger, that the power which animals may possess of resisting the effects 
of a surrounding medium of high temperature, is far inferior to that which has 
been commonly ascribed to them; for, in chambers heated to 120° to 130° F., 
the temperature of animals is soon raised 11°, or even 16° above what it had 
been previously, and death speedily ensues. The rapid diminution, or even total 
suppression of the cutaneous exhalation, on the other hand, is by no means fol- 
lowed by a rise in the temperature of the body. In general dropsies, which are 
attended with a remarkable diminution of this secretion, an icy coldness usually 
pervades both the body and the limbs. A great fall in the animal temperature 
was found by Fourcauld, Becquerel and Breschet to be the effect of covering the 
body with a varnish impervious to perspiration; and so serious was the general 
disturbance of the functions in these circumstances, that death usually ensued 
. in the course of three or four hours. 

The question will next arise, how does it happen that health, and even life, 
can be so immediately dependent as we find them to be on the elimination of 
so small a quantity of water as thirty-three ounces from the general surface of 
the body in the course of twenty-four hours'? To this the author answers, that 
such elimination is important as securing the conditions which are necessary 
for the endosmotic transference between the arteries and veins of the fluids 
which minister to nutrition and vital endowment. It is admitted by physiolo- 
gists that the blood, whilst still contained within its conducting channels, is 
inert with reference to the body, no particle of which it can either nourish or 
vivify until that portion of it which has been denominated the plasma has trans- 
uded from the vessels, and arrived in immediate contact with the particle that is 
to be nourished and vivified: but no physiologist has yet pointed out the efficient 
cause of these tendencies of the plasma, first, to transude through the wall of its 
efferent vessels, and, secondly, to find its way back again into the afferent con- 
duits. The explanation given by the author is that, in consequence of the out- 
going current of blood circulating over the entire superfices of the body perpe- 
tually losing a quantity of water, by the action of the sudoriparous glands, the 
blood in the returning channels has thereby become more dense and inspissated, 
and is brought into the condition for absorbing, by endosmosis, the fluid per- 
petually exuding from the arteries, which are constantly kept on the stretch by 
the injecting force of the heart. 



180 Progress of the Medical Sciences. [Juty 

Tn an appendix to the paper, the author points out a few of the practical ap- 
plications of which the above-mentioned theory is susceptible. Interference 
with the function of the skin, and principally through the agency of cold, he 
observes, is the admitted cause of the greater number of acute diseases to which 
mankind, in the temperate regions of the globe, are subject. He who is said to 
have suffered a chill, has, in fact, suffered a derangement or suppression of the 
secreting action of the skin, a process which is altogether indispensable to the 
continuance of life; and a disturbance of the general health follows as a neces- 
sary consequence. Animals exposed to the continued action of a hot, dry at- 
mosphere, die from exhaustion; but when subjected to the effects of a moist at- 
mosphere, of a temperature not higher than their own, they perish much more 
speedily, being destroyed by the same cause as those which die from covering 
the body with an impervious glaze; for, in both cases, the conditions required 
for the access of oxidized, and the removal of deoxidized plasma, are wanting, 
and life necessarily ceases. The atmosphere of unhealthy tropical climates 
differs but little from a vapour hath at a temperature of between 80° and 90° 
F.; and the dew point in these countries, as, for example, on the western coast 
of Africa, never ranges lower than 3 or 4 degrees, nay, is sometimes only a 
single degree below the temperature of the air. Placed in an atmosphere so 
nearly saturated with water, and of such a temperature, man is on the verge of 
conditions that are incompatible with his existence; conditions which may be 
easily induced by exposure to fatigue in a humid atmosphere, under a burning 
sun, or other causes which excite the skin, while they prevent the exercise of 
its natural function. The terms miasma and malaria may, according to the au- 
thor, be regarded as almost synonymous with air at a temperature of from 75° 
to 85° F., and nearly saturated with moisture. — Proceedings of the Royal So- 
ciety, No. 56. 

5. On the import and office nf the Lymphatic Vessels. By Robert Willis, M. D.-— 
That absorption is the especial office of the lymphatic vessels was, until very 
lately, a universally received doctrine in physiology: but it is now admitted that 
if they exercise this faculty, it can be only to an inconsiderable extent; and phy- 
siologists of high authority have even denied that they possess any absorbing 
power at. all. This last is the opinion of Magendie, in which Dr. Willis con- 
curs. So lately as 1841, Rudolph Wagner asserted that "neither anatomical 
or physiological considerations render any satisfactory account of the import and 
office of the lymphatics," which, thus shorn of their ancient office, were repu- 
diated as a superfluous apparatus in the animal mechanism. The grand organs 
of absorption Dr. Willis believes to be the. veins; and a principal object of this 
paper is to point out the mode in which they acquire this remarkable faculty. 
The principal condition which this faculty of imbibition implies, is a difference 
of density between the contents of the vessels which are to absorb, and the con- 
tents of those which furnish the matter to be absorbed. If the several consti- 
tuent materials of the body, both fluid and solid, were to remain in the same 
unaltered state, both chemically and physically, there could be no interchange 
among them: in order that mutual penetration may take place between two ele- 
ments, the one must differ from the other: that which is designed to absorb 
must be, with relation to that which is to be absorbed, more dense; that is, must 
contain a smaller quantity of water in proportion to its solid ingredients. For 
the continuance of the delicate processes concerned in the access and removal 
of the nutrient fluids, it is necessary that a difference should be established be- 
tween the arterial and the venous blood in respect to density. This purpose Dr. 
W. conceives is accomplished by the abstraction from the former of a portion of 
its water by the sudoriparous glands of the skin on the one hand, and by the 
lymphatic vessels on the other. 

That the separation of the lymph from the blood is calculated to increase its 
density, is proved by its chemical analysis; lymph containing from 96 to 97 per 
cent, of water, and blood from 77 to 82 per cent. Dr. W. regards this separa- 
tion of lymph from the blood as the result of a purely vital process of the same 



1843.] Anatomy and Physiology. 181 

nature as that by which the saliva and the watery portion of the urine are se- 
creted from the circulating mass. He considers that his views are supported 
by the anatomical distribution of the lymphatic system: for on the principle that 
organs are found in the vicinity of the places where their office is wanted, the 
office of the lymphatics must be general, inasmuch as the system is general. 
These vessels may, in fact, be regarded as the essential element of an universally 
distributed gland. The mode in which the lymphatics are finally connected 
with the blood-vessels appears also to indicate that the object in view is to keep 
their watery fluid separate from the blood as long as possible; for, as is well 
known, they do not transfer their contents into the neighbouring veins, but pour 
their whole fluid into the superior vena cava at the moment it is about to enter 
into the heart. 

The remarkable manner in which the lymphatic system is developed in some 
of the lower tribes of animals whose bodies are incased in an impervious cover- 
ing, such as turtles-, lizards and serpents, is adduced in farther consideration of 
Dr. W.'s views. He regards the serous membranes as contrivances for the 
accommodation of a great number of lymphatics; and the intimate connection 
which the function of these vessels has with the life and nutrition of internal 
organs, he thinks is shown by the remarkable amount of disturbance consequent 
on inflammation, or other morbid condition of serous membranes. Finally, Dr. 
W. adverts to the influence which the difference of endosmotic capability en- 
gendered by the abstraction of a certain amount of water in the course of the 
circulation (first between the blood corpuscles and the plasma in which they 
swim, and then between the liquor sanguinis and the containing channels) must 
have on the capillary circulation, which he conceives it is calculated to facilitate. 
Proceedings of Royal Society, March 16, 1843, No. 56. 

6. Mechanism of Digestion — In our precedingnumber, page 432, we gave an ac- 
count of the interesting memoir of MM. Bouchardat and Sandras, on digestion, 
communicated to the French Academy of Sciences towards the conclusion of last 
year.. On the 30th of January of the present year, a very interesting report was 
made to that learned body on the memoir in question, by a committee consisting 
of MM. Payen, Magendie, Flourens, Milne-Edwards and Dumas. 

The chemical experiments of this committee have established a new and very 
remarkable fact, consisting in the action exerted by water, acidulated with muri- 
atic acid, on fibrin, albumen, casein, gluten, and fibrous tissues. All these sub- 
stances swell, become translucid, and some of them dissolve. The addition of 
six parts of acid to ten thousand of water, suffices to produce this reaction. 

The authors have, however, gone too far in considering the muriatic acid as 
the only agent in the solution of azotised alimentary substances. In fact, while 
fibrin, under its influence, merely becomes excessively tumefied, the addition of 
a few drops of runnet suffices to dissolve it completely; consequently, muriatic 
acid is not the only solvent in the gastric juice. We must also probably take 
into account the animal substance termed pepsin, detected in the stomach by 
MM. Schwann and Deschamps, and obtained in an isolated form by Wasmann. 

It seems probable, according to the experiments of the authors of the memoir, 
that the neutral azotised animal substances, when dissolved in the stomach, pass 
directly into the veins. 

Gluten is acted on in the same way. Starch and fecula are changed partially 
or entirely in the stomach, into lactic acid, and are absorbed in that state. 

The fats evidently resist the action of the stomach. They pass into the intes- 
tinal canal. The committee regard the fats as the chief agent in the production 
of the chyle. — Lond. and Edin. Month. Journ. Med. Sci., April, 1843. 

7. Worms in the Blood of a Dog. — MM. Gruby and Delafond exhibited to the 
French Academy of Sciences, January 30th, 1843, filiform worms which were 
found alive in great numbers in the blood of a dog. At the subsequent meeting 
(Feb. 6th), MM. G. and D. communicated the following details relative to the 
case. 



182 Progress of the Medical Sciences. [July 

The worms had been seen circulating 1 in the blood of a dog. The body of the 
worm is transparent and colourless. The anterior extremity is obtuse, and the 
posterior, or caudal end, terminates in a very minute filament. At the anterior 
part, a minute short furrow could be observed, which was regarded as the mouth. 
The movements of these animals are very lively; and they lived so long as ten 
days after the blood in which they were contained had been drawn from the 
animal, and deposited in a vessel at a temperature of 15° Cent. On examining 
a drop of blood under the microscope, these hasmatozoa were seen swimming 
about with an undulatory movement among the blood globules, curving, twirl- 
ing, and twisting themselves about with great vivacity. Blood taken from the 
coccygeal arteries, external jugular veins, capillaries of the conjunctiva, &c, 
contained them. During twenty days, the capillaries of different parts of the 
skin and mucous membrane of the mouth were opened, and the haematozoa were 
constantly found in the blood which flowed from these wounds. 

The diameter of the blood-globules of the dog is from seven to eight milliemes 
of a millimetre; that of the worm from three to five milliemes. Its size is there- 
fore no obstacle to its circulating everywhere with the blood. 

Notwithstanding the innumerable quantity of these worms circulating in the 
blood of this animal, it seemed to enjoy excellent health. Twelve months ago 
MM. Gruby and Delafond examined the blood of from seventy to eighty dogs, 
without finding any worms; and since the discovery of them in the present case, 
they have been equally unsuccessful in fifteen others. — Land, and Edin. Month. 
Journ. Med. Set., Ap. 1843. 

8. Structure of ike Teeth. — A report on Mr. A. Nasmyth's paper on this sub- 
ject was read to the French Academy of Sciences, 5th December last, by M. 
Serres, in his own name, and in that of MM. Dutrochet and Flourens. 

According to some authors, the teeth are composed of solid fibres, variously 
arranged, and according to others, of tubes. With the exception of Malpighi, 
most anatomists deny the existence of areolae in the dental tissue, but both A. 
Nasmyth and Owen regard them as the specific character of this texture, and 
admit also the cellular arrangement in the enamel. Several preparations were 
presented to the commission by Mr. A. Nasmyth to prove this structure in the 
teeth. In examining these preparations by means of a microscope from 200 to 
400 diameters, the areolae were discovered in the ivory, and they were seen to be 
of different shapes and sizes according to the species of both examined, showing 
that this appearance could not be owing to any optical illusion. Mr. A. N.next 
enters into a consideration of the nature of the fibres of the teeth, whether they 
be tubular or solid. After mentioning the names of many authors who have 
espoused both sides of the question, he declares that the enamel contains no tubes, 
but the commission are of opinion that Mr. A. Nasmyth's preparations do not 
overturn the statements of Leeuwenhoeck and other anatomists, who admit the 
existence of tubes. Mr. A. N. has, however, clearly demonstrated the cellular 
structure of the enamel, which has not been distinctly done since the time of 
Eustachius, in the sixteenth century. Before his investigations nothing was 
known of the formation of the solid part of the tooth, and he refuted the idea 
that the permanent teeth were produced from the roots of the milk ones. The 
different theories of the formation of the teeth are then touched upon, and Mr. A. 
Nasmyth tries to show that a similar organization exists in the enamel, ivory, 
and bulb. Having found the cellular structure in the two first, he was led to 
look for it in the third, and his attempts were successful. In his preparations it 
has not always the same appearance, being reticulated in some, and vesicular, or 
approaching it, in others. A like structure was found in preparations made by 
the reporters themselves. 

To our knowledge, continued M. Serres, no one has ever produced a more 
perfect set of preparations than that which Mr. A. Nasmyth has laid before the 
commission; and in studying and comparing them with the drawings which have 
been published from the times of Malpighi and Leuwenhoeck, to those of Ret- 
zius and Owen, and also with those which we ourselves have presented to the 






1843.] Anatomy and Physiology. 183 

Academy,we are enabled to say, that they contain almost the whole microscopic 
history of the dental system of the mammiferae from the pulp to that of the ivory 
and enamel. — Lond. andEdin. Month. Juurn. Med. Sci., Jan. 1843. 

9. Structure of the Uterus. — M. Jobert conceives that the peritoneum is united 
to the surface of the uterus by true muscular fibres; and that the uterus consists 
of a single muscle, whose fibres, arranged in super-imposed layers, run in the 
following directions: — 

1. The superficial longitudinal fibres, which may be called median, as they 
occupy the central raphe of the body of the uterus, rarely exist on its anterior 
surface; they are constantly found on its posterior aspect, where they consist of 
two thin super-imposed layers, commencing at the fundus of the uterus, and run- 
ning to the uterine extremity of the vagina, to which they are attached, with the 
exception of a few which terminate on the neck of the uterus above the opening 
of the vagina. They adhere on the one hand to the peritoneum, on the other to 
the oblique fibres. 

2. The superficial fibres of the anterior wall of the uterus form a layer covered 
by the peritoneum and lying on the deep fibres; they are so disposed that they 
do not embrace the entire surface of the wall of the uterus which they concur in 
forming, but they cross, before they reach the round ligament of the opposite 
side. Some of its fibres enter into the composition of the round ligament, while 
others pass behind it and terminate on the sides of the organ where they decus- 
sate with those from the posterior surface. 

3. The remaining superficial fibres appertain to the tubes and to the ligaments 
of the ovaries; they are only apparent during pregnancy. Some arise from the 
fundus of the uterus, adhere to those which belong to the tubes, and run to the 
anterior part of the ligament of the ovaries, being slightly twisted on themselves; 
others more numerous, at first divergent, arise from the posterior surface of the 
fundus of the uterus, and also run to the ligament of the ovary. Finally, some 
transverse fibres, arising from the posterior surface, constitute the inferior 
portion of the organ. 

The neck of the uterus is composed of the same tissue as the body. The 
fibres composing it represent semicircles, and decussate without intermixing in 
the direction of the commissures. This semi-annular arrangement is more 
evident when the female has borne children, and when the orifice of the uterus 
is transverse. Are the fibres of the neck of the uterus confounded with those 
of the vagina] M. Jobert thinks they are. — Lond. and Edin. Month. Juurn. Med. 
Sci., April, 1843. 

10. Respiratory Capacity of the Lungs.— M. Bourgery read to the Academy of 
Sciences on the 23d January last, a memoir on the relations between the inti- 
mate structure and the functional capacity of the lungs in the two sexes and at 
different ages. By means of a hydro-pneumatic apparatus, the author has con- 
structed a table of the numerical value of the respiration in seventy individuals 
— fifty males and twenty females — and the following are the results which he 
obtained: — 

1. Ceteris paribus, the respiration is more energelic, the younger and thinner 
the subject. No other condition of strength or health is equivalent to the in- 
fluence of youth. 

2. At the same age, the volume of the respiration of the male doubles that of 
the female; this is a fundamental difference between the two sexes, and suffices 
to explain the superiority of the vital acts in the male. 

3. The plenitude of respiration in both sexes occurs at the age of thirty, and 
corresponds to the complete development of the capillary air-vessels of the 
lungs. In a well-made man, aged thirty, the amount of a forced respiration is 
from 2.50 to 4.30 litres, and in the females from 1.10 to 2.20 litres. In a boy 
of fifteen, it is 2 litres; in a man, aged eighty, it is only 1.35 litres. Thus the 
respiratory power of a strong man at thirty represents that of 



184 Progress of the Medical Sciences. [Juty 

two feeble men, 
or two boys, aged fifteen, 
or two strong women, 
or four weak women, 
or four boys, aged seven, 
or four old men, aged eighty-five, 
And the respiratory power of a strong woman, aged thirty, is equal to that of 
one feeble man, 
or one boy, aged fifteen, 
or two feeble women, 
or two boys, aged seven, 
or two men, aged eighty-five. 

4. The volume of air required by an individual in an ordinary respiration aug- 
ments gradually with the age. The relations between the ages of seven, fifteen, 
twenty, and eighty, are geometrical, and represented by the numbers — one, two, 
four, eight. An adult man habitually respires four times as much as an infant, 
and twice as much as a female of fifteen. An old man respires twice as much 
as an adult. This progressive increase is the consequence of the diminution of 
the energy of the pulmonary sanguification — that is to say, this faculty dimi- 
nishes from infancy to old age, in a ratio represented by fractional numbers, the 
inverse of those above given, 1, |,|, i. 

5. During a forced respiration, the aerial capacity of the lungs, or their per- 
meability to air, presents two periods, — the one ascending from infancy to thirty 
years, — the other descending from thirty years to old age. The first augments 
in a regular relation of one, two, three, from seven to fifteen and thirty years; 
the second diminishes from three to two and a half from thirty to fifty years, 
and from two and a half to one and a half from fifty to eighty years. 

In youth, the respiration is tripled in twenty-three years, and augments one- 
ninth in each year. From the adult age it diminishes in twenty years two-fifths, 
or one-hundredth in a year. From fifty to sixty it diminishes but one-fifth in 
ten years, or one-fiftieth in each year. From sixty to eighty it falls almost one- 
half more, or one-twentieth in each year. 

6. Thus the respiration at any given age may be more or less developed in 
any subject compared with another, but the rate of diminution is constant in all, 
and in a nearly equal proportion. The diminution of the respiratory faculty 
must play a considerable part in the gradual extinction of the vital forces as age 
advances. 

7. In proof of this last proposition, the relation of a forced and ordinary respi- 
ration diminishes with the age. It is as one to twelve, at three years of age, as 
one to ten at fifteen years, as one to nine at twenty years, as one to six at twenty- 
five and thirty years, as one to three at sixty years, as one to one-half or one- 
third at eighty years; whence it follows that in youth there is an immense 
respiratory power in reserve for any violent exertion; while in old age the sub- 
ject is at once out of breath. 

The respiratory faculty is impaired by the capillary rupture of the aerial and 
sanguiferous canals, improperly called emphysema of the lung. This rupture 
accompanies more or less, but inevitably, every great respiratory effort. Though 
it appears to be a senile earing of the lung, it nevertheless commences in infancy, 
and gradually augments with the age, from the mere reiteration of the function 
of respiration. All the diseases of the lung, however temporary, hasten this 
species of disorganization. 

The ultimate result of senile emphysema, uncomplicated with any other dis- 
ease, is to assimilate the cavernous lung, and imperfectly sanguifying respiration 
of old age to the locular lung and incomplete respiration of the reptrle. 

As disease, like old age, causes an augmentation of ordinary, and a diminution 
of forced respiration, this difference affords a new means of diagnosing pulmo- 
nary affections. — Land, and Edin. Med. Juurn. Med. Sci., April, 1843. 

II. On Menstruation.— M. Raciborski, in a letter to the French Academy of 



1843.] Anatomy and Physiology. 185 

Medicine, details the results of his researches on menstruation, of which the fol- 
lowing 1 are the most important. 

1. There exists the most intimate connection between the Graafian vesicles 
and menstruation. When these vesicles arrive at their full development men- 
struation commences, and when they are destroyed menstruation ceases. 

2. At each menstrual period a follicle projects like a nipple on the surface of 
the ovary, where it afterwards bursts, without requiring for that purpose an erotic 
excitation. 

3. The rupture of the follicles in general appears to take place just at the 
period when the menstrual discharge is stopping. 

4. The ovaries do not act alternately, as has been affirmed; they do not seem to 
be under any fixed law as to this. — Edin. Med. and Surg. Joum., April, 1843, 
from Bull, de PAcad., Jan. 1843. 

12. Chemical Theory of Nutrition. By MM. Dumas and Cahours. — For a con- 
siderable period chemists have noticed in animals the existence of three neutral 
azotized principles, remarkable, either on account of the number of properties 
which are common to all, or on account of their abundance in the fluids or solids 
of the animal economy, or by their presence in all the essential ingredients of 
our food. These matters are albumen, fibrin, and casein. The albumen existing 
in the white of the egg, the fibrin forming the coagulable portion of the blood, 
the casein constituting the animal part of milk. In a physiologico-chemical 
essay, read to the Academy of Sciences about eighteen months ago, by MM. 
Boussingault and Dumas, it was endeavoured to be proved that albumen, casein, 
and fibrin existed in plants; that these matters passed ready formed in the bodies 
of the herbivorous animals, from whence they were transferred into those of the 
carnivorse; that plants alone possess the power of forming these three products, 
which animals separate either for the purpose of assimilating to their own 
bodies, or to destroy them, according as the wants of their system demand. 
MM. Dumas and Cahours, in the present memoir, have extended these principles 
to the formation of the fatty matters, which, they state, take their origin in 
plants, but in animals undergo a species of combustion, or remain as transitory 
parts of the body. They have also urged the necessity of grouping together all 
the organic bodies which possess the property of passing into the state of lactic 
acid during fermentation, and which, as sugar and starch, form an essential in- 
gredient in the food of man and the lower animals, and are only produced in 
plants by the powers of vegetation. 

The details of these views, and the conclusions drawn from them, may be 
thus shortly stated. 

The vegetable kingdom produces or forms the neutral azotized principles, 
the fatty matters, sugar, starch, and gum; the animal kingdom, on the other 
hand, consumes these. The first decomposes the carbonic acid, water, and am- 
moniacal salts formed by the second; which in its turn absorbs oxygen for the 
disengagement of these. The animal produces or gives out heat and electricity; 
the vegetable, on the other hand, absorbs them. The vegetable is a decomposing 
apparatus which forms new products, and is fixed in one spot; the animal is an 
oxidizing apparatus, endowed with locomotive powers. 

" If, as we hope," continues MM. Dumas and Cahours, " physiologists re- 
cogonise with us that plants are destined to create albumen, fibrin, casein, but 
that animals only modify these matters, assimilate them, or destroy them, but 
cannot create them, we shall esteem ourselves happy, after having been the first 
to publish such opinions, to be also the first to furnish to science the rigorous 
analysis of these substances, so often studied for some years past. To avoid con- 
fusion, however, it ought to be stated, that, in so far as albumen is concerned, 
this opinion was previously announced by MM. Prevost and Le Royer, in their 
Memoir on Digestion; but it ought also to be stated that they did not adduce 
sufficient proofs to convince physiologists. More- lately the same opinion was 
entertained by Mulder, who, reasoning simply on the identity of composition, 
which he established to exist between vegetable and animal albumen, did not 



186 Progress of the Medical Sciences. [July 

hesitate to conclude that the albumen of the herbivorous animals was procured 
from the vegetable which served them as nourishment. 

" A granivorous bird finds in grain all the elements necessary for its nutrition. 
A dog finds in bread the matters which its organization requires for the purpose 
of life and of growth. A cow which is giving milk not only finds in barley and 
oats the matters requisite for its own existence, but also the substance by means 
of which the casein is formed, which is found in its milk. The cerealia ought, 
therefore, independent of the amylaceous or sugary matters they contain, to 
furnish to the animal organization the neutral azotized substances which every 
animal body consists of, and which we have seen that the animal body cannot 
create. The analysis of corn, or the flour formed of it, is quite conclusive on 
this point. If we take some flour, and after forming it into a consistent paste, 
wash it slowly under a fine stream of water, there remains in the hand a grayish- 
coloured tough elastic paste, of a faint odour, which constitutes the gluten of the 
old chemists. The turbid water which ran off carried with it the fecula, a few 
flakes of gluten, and all the soluble matters. But if this liquid is left in repose, 
and be decanted, so as to procure it free of the fecula which is deposited, it is 
only necessary to boil it to recognize in it the presence of albumen. On the 
other hand, if we take the gluten, as it remained in the hand after the washing, 
four distinct substances, at least, may be recognized in it. In fact, if we boil 
this substance first with absolute alcohol, and then in proof spirit, we obtain a 
fibrous, grayish-coloured residue, which may be named vegetable fibrin. The 
alcoholic liquors allowed to cool furnish a substance possessing those properties 
which we assign to ordinary casein. If the alcoholic liquors are then concen- 
trated and allowed to cool, pultaceous substance is formed, which presents all 
the characters of albuminous matters, but which, on account of some special pro- 
perties, deserves more particularly the name of gluten. Along with this gluten 
is deposited a fatty matter, which is easily removed by means of ether, and 
which does not differ from the ordinary oils or fats, or rather from butter, which, 
it resembles in its point of fusion. 

"The analysis of the flour of the cerealia thus enables us to ascertain the pre- 
sence of, 1. albumen; 2. fibrine; 3. casein; 4. gluten; 5. fatty matters; G. fecula, 
dextrin, and glucose. 

" We therefore regard it as proved that the food of animals includes the first 
four of these substances, that is to say, the azotized substances, or at least some 
of them. We admit that in those cases where the fecula, dextrin, and sugar 
disappear from the food, they are replaced by fatty matters, as we see occurs in 
the food of the carnivorous animals. In fine, we see that the association of 
neutral azotized principles with fatty, sugary, or starchy principles, constitutes 
the almost entire food of all herbivorous animals. 

" Does it not follow T from this that there are two fundamental principles in 
nutrition, viz. 1. That neutral azotized and organized matters are indispensable 
as articles of food in the nutrition of animals; and 2. That animals can, to a 
certain extent, subsist without taking fatty matters, or without taking starchy or 
saccharine principles, provided that in the one case the fatty matters shall be 
replaced by a proportional quantity of starch or sugar, or in the other by fatty 
substances] 

"The indispensable necessity which all animals are under to take with their 
food those neutral azotized principles which exist in their organization, almost 
of itself demonstrates that they are incapable of creating these substances. But 
to render this fully apparent, it is only necessary to follow these neutral azotized 
principles when introduced into the stomach, and see what is their final desti- 
nation. It is tolerably easy to prove that these substances are found essentially 
represented by the urea, which, in man and the higher animals, constitutes the 
essential principle of the urine, and by the uric acids in birds and reptiles, a sub- 
stance which takes the place of the urea in thern. Without counting the excre- 
ments, an adult man absorbs daily a quantity of neutral azotized matter capable 
of representing about four drachms of azote, a quantity which is found entire in 



1843,] Materia Medica and Pharmacy. 187 

the eight drachms of urea, which are passed with the urine voided during the 
twenty-four hours. 

" Leaving out of question all those phenomena which pass in the interior of 
the organs, and considering only the balance of the ingesta and egesta, we find 
that a man gives out in urea nearly all the azote which he took in under the 
form of a neutral matter. Is it not, therefore, reasonable to conclude, that the 
neutral azotized matters of our food serve to procure this urea, and that the whole 
industry of the animal organism is limited either to the assimilation of this 
azotized matter, when the wants of the system require it, or to convert it into 
ureal" — Ibid, from Comptes Rendusde VAcad. des Set., Nov. 28, 1842. 

13. Urea in healthy Blood. — M. Franz Simon has always been able to detect 
the presence of urea in the blood of patients labouring under Bright's disease. 
To exhibit this principle two or three ounces of blood are precipitated by means 
of alcohol, and when the liquid is filtered, the filtered fluid is evaporated in the 
vapour bath to the consistence of a syrup. Fresh alcohol is poured on this, the 
clear liquor removed, evaporated, and the process again repeated, till the anhy- 
drous extract dissolves completely in alcohol without leaving any residue. It is 
then evaporated to dryness, dissolved in distilled water, filtered to remove the 
fat, and evaporated to the consistence of a syrup. A little is then put on glass, 
a drop of cold nitric acid added, and it is allowed to rest till a saline crust forms. 
When this crust is examined by means of a microscope, the rhomboidal tabular 
crystals, of which the nitrate of urea is composed, are easily recognized. 

By this means M. Simon has not only detected the presence of urea in the 
blood of cholera patients, but found also that it exists in all healthy blood; but 
in the healthy blood it exists in very small quantity. — Ibid, from Annales des Set, 
Nat., Dec. 1842. 



MATERIA MEDICA AND PHARMACY, 

14. Ferruginated Pill rf Mercury. By G. F. Collier, M. D. — The varying: 
and unsatisfactory quality of our "blue-pill" has for many years attracted at- 
tention. In my second edition of the " London Pharmacopoeia" I gave the 
outline of a formula for preparing it with sesquioxide of iron; the further expe- 
rience of years enables me to offer this preparation to the profession as a boon to 
them and to the public, for it may be proved that the iron enters along with the 
mercury into the blood, and saves the wear and tear of the human body under 
its use. I will not, at this time canvass, because I doubt, the probability of the 
sesquioxide (in double equivalents) yielding up one atom of its oxygen to the 
mercury, as is the opinion of several chemists to whom 1 have submitted this 
compound. I am aware that other peroxides, when moist, will similarly combine 
and divide meicurial globules; and I will not now enter upon the series of in- 
complete experiments instituted by myself to prove that mercury will amalga- 
mate with other metallic oxides, and in this state form double or triple salts with 
acids. I shall now keep only to the practical utility of rny compound, and to 
its importance as a great remedial improvement. 

In the spirit of a pharmaceutical chemist I should either exclusively manu- 
facture and sell it over my own counter, or I should take out a patent for it; in 
that of a manufacturing chemist I should do the like, or keep it a secret and save 
a fortune by it; were I of the new school of "snmmi auctores" I should throw 
the mere shadow of it, chemical, mestnerical, magnetical, and homceopathical, 
into a modest pamphlet, proving that the era of medicine truly commenced in 
1843, and that up to that time all were shadows, clouds, and darkness. 1 shall 
content myself with publishing the recipe, and recording a brief statement of my 
experience. 



188 Progress of the Medical Sciences. [Juty 

B. — Ferri sesquioxydi, gi; 
Hydrargyri, gij; 

Confect. rosa? Gallicse, giij. Contere donee globuli non 
amplius eonspieiantur. 
It is made in five minutes; common blue-pill demands a week. The globules 
are not visible, even by the microscope. It is uniform in its appearance and 
effects. It makes a smoother pill, retaining its form more permanently. It 
salivates in a few days in the usual doses. The presence of the iron prevents the 
wear and tear of the human body under the effects of the mercury. It is par- 
ticularly eligible for the strumous, the irritable, and for reduced anemial consti- 
tutions requiring mercury. The powers of life are not so much (scarcely at all) 
prostrated under its use. Its resolvent power is greater than that of mercury 
alone, especially with respect to buboes. Practitioners will at all events know 
what they are using; at present they have for blue-pill all manner of alloys and 
sulphurets, — mercurial-zinc pill, mercurial-sulphur pill, &c. &c. &c. 

Five grains of sesquioxide will suffice to amalgamate and divide a large 
quantity of mercury, but I propose the larger proportion as a remedy. — Lancet, 
March 11, 1843. 

15. Cannabis Indica. — The No. of the Provincial Medical Journal, for March 
18th, 1843, contains an interesting paper on this article, read before the Royal 
Medico-Botanical Society by W. Ley, Esq. "The hemp plant, Cannabis 
Sativa," the author observes, " is well known; it is supposed to be a native of 
Persia; it grows wild on the mountains of Asia, but is not confined to them. 
When cultivated for its fibre it is sown so closely that it spends itself in long 
shoots. When a single plant is grown it shoots out its branches close to the 
soil luxuriantly, and attains a height of four, five, or six feet. The leaf re- 
sembles that of the common nettle. It exhales a powerful narcotic odour, and 
the branches are glutinous to the touch, with a resinous secretion. For medicinal 
purposes the garden hemp is used. In the East the plants are directed to be set 
at least nine feet apart, to allow them the full benefit of heat, light, and air. 
When the seed is formed, the plant is in the greatest perfection. The resinous 
exudation of the leaves is then collected and sold as churrus; or the shoots, 
from which the resin has not been collected, are cut and dried, and sold as gunjah. 

" In England it has been used medicinally, but its use is quite forgotten. In 
an old act of Henry the Eighth, which is still in force, hemp is forbidden to be 
soaked in ponds or running streams where cattle drink. The seeds are men- 
tioned by old medical writers. By modern writers it is treated as having no 
effect; yet botanists speak of it as a violent poison, and of the water in which it 
has been soaked, producing its effects almost as soon as drank. Herodotus, 
speaking of the customs of the Scythians, says they have among them a species 
of hemp, resembling flax, except that it is both larger and thicker; of this the 
Thracians make themselves garments. The Scythians take the seed of this 
hemp and throw it upon red hot stones; immediately a perfumed vapour ascends 
stronger than from any Grecian stove. This is to them in the place of a bath, 
and it excites from them cries of exultation. Hemp seeds are also mentioned 
by Galen as promoters of hilarity and enjoyment. These properties are forgotten 
among us, if they really exist; yet throughout the East the resin of the plant 
maintains a very high credit. It is of the resin that this paper treats. 

" It is noticed by many Arabian, Persian, and Sanscrit writers, and is in popular 
use as an intoxicating agent from the furthermost confines of India to Algiers. 
When the dry leaves are mixed with tobacco, and smoked, 'intoxication ensues 
almost instantly, with heaviness, laziness, and agreeable reveries; but the person 
can be readily roused, and is able to discharge routine occupations.' If the 
resin be swallowed, almost invariably the inebriation is of the most cheerful 
kind, causing the person to sing and dance, to eat food with great relish, and to 
seek aphrodisiac enjoyment. The intoxication lasts about three hours, when 
sleep supervenes. No nausea or sickness of the stomach succeeds, nor are the 
bowels at all affected; next day there is slight giddiness and much vascularity 



1843.] Materia Medica and Pharmacy. 189 

of the eyes, but no other symptom worth recording. These effects are produced 
on carnivorous animals generally; but on graminivorous they are less marked. 
In the colder climate of this country the effects are much modified. I fear, too, 
that a vegetable production sent to this country from Calcutta, and not imme- 
diately used, has been deteriorated by age. The stimulating effect has been very 
much less marked; the few persons who have felt the dreamy exhilaration have 
made no outward manifestation of it. The dose to produce stupor must be much 
larger. The appearance of catalepsy, which was occasionally produced in India, 
has not been produced here. The subsequent effects are depression of spirits 
and relaxation of the muscles in a remarkable degree; yet the litheness attending 
that relaxation, the free perspiration on the skin, and the increase of appetite, 
have made some old rheumatic persons speak of it as of the elasticity of youth. 
Most frequently the depressing effects cause a great disinclination in the patient 
to continue its use. The remedy was introduced to our notice by Dr. O'Shaugh- 
nessy. 

"The hemp resin has no taste, and little smell. In the East it is stimulating 
to intoxication, and to aphrodisia; it raises the pulse, excites warmth, makes the 
breathing more slow, does not check secretion; it allays irritation and pain, but 
less generally than opium; it causes general depression, sleep, relaxation of the 
muscles in a remarkable degree. The patient lies in one position, indisposed to 
move; the face loses its expression, the jaw falls, there is difficulty of breathing; 
it is as though the air was drawn through cotton, it feels dry; the expectoration 
and perspiration are increased; the bowels are not affected except there may be 
an unpleasant feeling of heat — a forcing of the sphincter ani, as if it could not 
retain the contents of the rectum; yet with evacuation— which is in such case 
particularly easy — or no evacuation, the forcing continues. These symptoms 
will continue while the muscular relaxation lasts. Sleep, or rather repose, would 
continue during the whole time unless the avocations of the day or mental 
activity forbid it; no unpleasant feelings succeed, and the appetite improves. 

"Opium is usefulto increase the heat of the surfaces, to restrain over-secretion, 
to diminish pain and irritation; but it is in spasmodic and convulsive diseases 
that opium is most evidently useful. In tetanus it has occasionally succeeded 
when given in very large doses. In hydrophobia 180 grains have been given in 
the space of twelve hours without apparent effect. 

"The amount of benefit we may derive from the hemp, when experience has 
more fully proved its efficacy, is yet to be seen. In cholera it has allayed sick- 
ness, cramp, and purging; it produced rapidly an improved condition of skin 
in warmth and perspiration; it raised the pulse. In rheumatism it relieved the 
pain and swelling more quickly and satisfactorily than I have seen by any other 
medicine. In spasmodic and convulsive diseases hemp is most eminently useful. 
In tetanus it has been the means of cure in the majority of cases, both in men 
and in horses. It has relieved hydrophobia of much of its horror, but did not 
avert the fatal termination. In common with opium it is useful in chorea, spas- 
modic asthma, delirium tremens; and I believe that whenever opium is useful 
hemp also will show that it has some power. Time mu-st draw a more perfect 
comparison. 

" In dangerous doses the effects of opium are — increasing stupor, loss of motion, 
and of sensibility, respiration slow, muscles relaxed, pupils- contracted. The 
progress of the poison is marked by the increasing relaxation of the muscles, 
and the falling of the features from that cause, until the depression of death 
arrests progress. In dangerous doses the effects of hemp are not known, because 
the largest doses have not proved dangerous; in this is its great superiority over 
opium. When opium begins to kill, hemp exerts a beneficial influence. The 
stupor, loss of motion and sensibility, slow respiration, relaxed muscle, fallen 
feature, when produced by hemp are not the prognostications of death; by their 
agency we promote cure. The falling jaw and relaxed features, so fatal as the 
effect of opium, may be in hemp the result of a moderate dose; it is by sustaining 
these relaxing doses that an absorbent effect is attained. By this influence we 
relieve muscular spasm with oreater mildness and more certainty; under it we 
No. XL—July, 1843. 13 



190 Progress of the Medical Sciences. [July 

produce absorption from bursa?, from the sheaths of tendons, and from the joints. 
It is no slight thing to say of a new remedy that it will in any degree bear com- 
parison with opium. It is a triumph in therapeutics to establish, as I do not 
doubt we shall be able, that this new remedy will effect by moderate doses, and 
safely, what our heretofore strongest power could only attempt with danger — 
that, going further, this acquisition will prove itself a direct antidote — the first 
of its class — to strychnine, one of the most violent poisons nature affords. This 
language may be strong; but, being founded on evidence, is not too strong, until 
it is contradicted by further investigation. To promote that, Dr. O'Shaughnessy 
has brought with him to this country a considerable quantity of the dried plant. 
He has placed it in the hands of Mr. Squire, to be by him prepared; it will there 
be within the reach of all, and, allowance being made for the age and voyage, his 
name is an assurance that the preparation he makes will be as good as any phar- 
maceutist in this country could supply. The question of the effects of the plant 
grown in this country is still to be tried; the experiments hitherto made are in- 
conclusive. In any experiment that may be made it must be borne in mind that 
the water in which hemp is steeped has the credit of being a poison in this 
country, and in India also. 

"The introduction of the plant into use as an intoxicating agent, in the East, 
would appear to contradict this opinion. The fresh leaves were eaten; and sub- 
sequently a beverage having the emerald green colour of the leaf was a favourite 
mode of imbibing its virtues." 

16. Medicinal Properties of Indian Hemp. — A paper on this subject was read 
before the Royal Med. Chirurg. Soc. on the 9th of May last, by John Clendin- 

NINC, M. D. 

The author commenced his paper with general observations on. the importance 
of narcotics, but especially of opium, in the treatment of disease. After having 
referred to numerous examples of the successful use of opium in acute and 
chronic disease, he adverted to the inconvenience occasionally attending the 
employment of opiates, especially to the derangement of the stomach and bowels 
and kidneys, and the vertiginous and other painful conditions of the nervous 
system they so frequently produce. He then stated that, in his experience, 
those inconvenient effects had occurred so frequently, and been found in many 
cases so difficult to c-bviate, without the abandonment of the use of a class of 
remedies of the utmost importance in a large number and variety of diseases, 
that he had been recently induced to make trial of the extract of hemp, recom- 
mended by Dr. O'Shaughnessy, of Calcutta, as a substitute for opium in nu- 
merous instances. The author's object in making this communication was to 
bring under the notice of the society the results he had obtained, as in his judg- 
ment important to be made generally known, with a view to further and more 
extended trials by other practitioners, more especially at this moment, when 
there was some prospect of a new edition of the London Pharmacopoeia, upon 
which he understood a committee of the Royal College was actually engaged. 

The author then -gave. details of eighteen cases, from a much larger number, 
in which he had given trial to the new remedy with satisfactory results. 

These trials included cases of acute and chronic disease, in persons of both 
sexes, and persons of very various ages. The number of cases detailed, although 
necessary to substantiate the claims advanced by the author in favour of the 
new narcotic, was yet such as to preclude any analysis of them in this place. 

It will be sufficient to say generally, \hat the indications for its use in these 
cases appear to have been more especially to relieve neuralgic pain; to relieve 
irritation and spasms of chronic bronchitis, of rheumatism, &c; and to subdue 
sleeplessness or disturbed rest from whatever cause, if not arising from inflam- 
mation in the head. The author found the remedy highly useful in checking 
cough in phthisis, and cramp and irritation in the limbs, &c, in rheumatism, 
without any interference with the digestive processes, or intestinal action or 
secretions, yet with an anodyne and hypnotic effect not less uniform than that 
of opium. He gave it trial also in several cases of low fever, characterized by 



1843.] Materia Medica and Pharmacy. 191 

spots, tremors, and delirious restlessness, and with very good effect; it repressed 
delirium and conciliated repose, and thus secured that tranquillity and refresh- 
ment, the proper effects of sleep. He reported, also, some instances of successful 
use of hemp extract, as a pure anodyne, to secure sleep, by suppressing pain, 
arising in one case from a cut, in another from a violent purgative, and in a 
third from rheumatic irritation of the meninges. 

The author concluded his paper by a resume of the objects of his trials, and 
the results and conclusions he had attained. 

He stated that his experience had satisfied him that the hemp extract was 
possessed of medicinal properties sufficiently energetic and uniform to entitle it 
to admission into our national pharmacopoeia amongst our most useful narcotics; 
and that as a substitute for opium, especially in cases for which that drug was 
unsuited, owing to idiosyncrasy, or to the presence of active indigestion, or the 
nervous temperament, he had found reason to place much confidence in the ex- 
tract, and to regard it as a remedy exceeding in value that of any other narcotic, 
or combination of narcotics, with which he was acquainted.— Prow. Med. Journ. 
27th May, 1843. 

17. Remarks on the Pathogenic Action of the Ioduret of Potassium. By M. 
Ricord. — The extraordinary results obtained by the use of the ioduret of potas- 
sium in the treatment of syphilis, and the general employment of this remedy by 
the great proportion of physicians who attend specially to venereal diseases, 
have induced me to point out some of those effects produced by it, which may 
become causes of error in the course of the treatment, or constitute real complica- 
tions, which may modify or arrest the cure. % 

I have already made known the circumstances in which the ioduret- of potas- 
sium ought to be employed — that is to say, at what period of the syphilitic dis- 
ease it is most likely to be serviceable, and of which it is in a sort the specific. 
I have also stated the doses and pharmaceutical preparations to which the pre- 
ference should be given. In order to complete the history of this powerful 
therapeutic agent, I am now about to speak of its pathogenic action. In the first 
place, let me say that the ioduret of potassium has a very marked action on the 
secretions in general, which it excites and increases greatly. Its effects on the 
skin, mucous membranes, and kidneys, are very remarkable; the circulation and 
the blood itself are sometimes influenced by it, as also the nervous and the mus- 
cular systems; but there exists in the production of these phenomena a certain order 
*f frequency, in accordance with which we shall now study them. At the same 
time, 1 must observe that, although what I am about to advance is drawn from a 
great number of observations, 1 yet give it with a certain degree of reserve, ex- 
pecting from time, and the experience of other practitioners, either the confirma- 
tion of my remarks, or, on the other hand, advantageous modifications thereof. 

Action on the Skin. — The skin is incontestable one of the tissues the most 
easily influenced by the ioduret of potassium. Nothing is more common, in fact, 
than to see patients under its influence affected with different eruptions, and more 
especially with eruptions of the psydracious form, somewhat resembling the 
pustules of acne, with this difference, that they are not confined to the parts 
habitually affected with acne; thus they are found not only on the face and 
shoulders, but on every part of the body without exception. 

There is scarcely any form of acute eruption of the skin which the ioduret of 
potassium cannot induce, according to the predisposition of the patient. In the 
one case we may have an eczema, in the other herpes, while in others it may 
cause simple erythema. I have recently had under my care at the hospital two 
patients, in whom, at two different periods, there appeared an eruption of 
papulous erythema on some parts, of erythema nodosum on others, and, in a 
patient affected with cancer of the face, to whom the ioduret of potassium was 
given in rather large doses, it on several occasions caused an eruption of impe- 
tigo on the hairy scalp, and of a rupia, offering the characters of a cachectie 
rupia, on the legs and forearms — symptoms which disappeared as soon as the 
remedy was omitted, and showed themselves again when its use was resumed. 



192 Progress of the Medical Sciences. U^Y 

I have seen the ioduret of potassium several times give rise to a genuine purpura 
hemorrhagica. I have seen it produce on three several occasions, after a fort- 
night's use, a genuine spotted disease on the legs of a gentlemen, for whom 
I prescribed it; and in the case of a lady, for whom, with the sanction of Pro- 
fessor Cruveilhier, I ordered it, for the removal of very serious tertiary symp- 
toms of syphilis, it caused, towards the termination of the cure, a petechial 
eruption on the lower limbs, unattended, however, with danger. Some patients 
have experienced only a feeling of heat and pricking of the skin, attended at 
times with more or less pruritus. The importance of knowing these different 
effects of the ioduret of potassium on the skin will be readily acknowledged, in 
order that they may not be confounded with the symptoms for the removal of 
which the remedy is given, and especially in order that it may be abandoned at 
once in those who have analogous diseases, or such predisposition that the 
ioduret of potassium may either exasperate or develope these affections. 

Action on the Digestive Functions. — I have ascertained, and the greater number 
of those who have experimented with the ioduret of potassium agree with me on 
this point, that the functions of the digestive apparatus are increased in activity, 
and are better performed; the individuals get an appetite, and embonpoint is an 
ordinary consequence of its use. 

Nevertheless, there are circumstances in which this medicine may produce 
injurious effects on the digestive canal. One of the most remarkable and most 
constant is a pain situated in the great cul-de-sac of the stomach, and which, by 
the manner in which the patients complain of it, might be mistaken at first for 
pleurodynia of the left hypochondrium. This pain may be sometimes very 
severe, without there b«ng any increase of thirst, disorder of the appetite, coating 
of the tongue, or any reaction of the circulation. Pressure does not increase the 
pain; the function of digestion has not any influence on it; it seems to be due 
entirely to a gastralgia. In some persons the appetite, which at first is increased 
solely to a satisfactory condition, becomes excessive, exaggerated, and absolutely 
morbid. We have had patients in the hospital that double rations did not satisfy. 
In a few cases the use of the ioduret of potassium is followed by phlegmasia 
either of the stomach alone, or of the entire intestinal canal, attended with 
vomiting and diarrhcea, and, in fact, all the phenomena of poisoning. Never- 
theless, the most frequent result of the action of this agent on the intestinal 
mucous membrane is the production of a sero-mucous flux, and we shall find that 
it has an analogous effect on the other mucous membranes. 

Ptyalism. — While speaking of the pathogenic action of the ioduret of potassium 
on the alimentary canal, I must mention a phenomenon I have often met with — 
I mean a peculiar salivation caused by this medicine. In many persons it causes 
a real ptyalism, which may be as great and as severe as the most marked mer- 
curial ptyalism. It is important to be aware of this peculiar phenomenon, in 
order that it may not be confounded with an analogous one caused by mercury, 
especially in those cases where the two remedies are administered conjointly. 
It will be sufficient to point out the characters proper to the ptyalism from iodine, 
•without mentioning those caused by mercury, in order that they may be distin- 
guished from each other. 

The salivation to which the ioduret of potassium gives rise very much re- 
sembles that of pregnant women. In these cases the saliva has very little 
viscidity; it seems to come not only from the cavity of the mouth, but to be also 
the product of a kind of regurgitation. The mucous membrane of the mouth may 
be rather irritated, and (edematous, but there are not any signs of inflammation, 
as in mercurial stomatitis, nor is there observed any tendency to the ulceration 
peculiar to the latter. In the majority of cases even it is impossible to discover 
any appreciable alteration of tissue. The salivary glands are not the seat of 
any tumefaction, nor is there any peculiar odor from the breath. The patients 
complain that the saliva has a saltish taste, resembling that of the ioduret of 
potassium. 

Action on the Kidneys. — The secretion of urine is often increased by the ioduret 
of potassium, the augmentation under certain circumstances constituting a true 



1843.] Materia Medico and Pharmacy. 193 

pathological condition; 1 have had a patient in the venereal Imspital affected 
with diuresis from the use of this remedy. Each time it was administered, the 
emission of urine was materially increased; the patient has passed from forty to 
fifty quarts in the course of the twenty-four hours, drinking in the same pro- 
portion. Each time that the ioduret of potassium was suspended, this accidental 
supersecretion ceased, but it was reproduced as soon as its use was resumed. 
In this case, as in those where the urinary secretion was infinitely less, and in 
those where it was not in the least augmented, it did not present any notable 
change, with the exception that it was found to contain the ioduret of potassium. 

Action on the Circulation. — The circulatory action has not appeared to be sen- 
sibily influenced by the ioduret of potassium; in general the pulse has been 
neither accelerated nor rendered slower. Under some circumstances we have 
had reason to believe in a peculiar action on the circulation, because certain 
persons who laboured under febrile excitement previous to the administration of 
the remedy, have had the febrile symptoms lessened or removed while it was 
used; in these cases I believe the modification of the circulation was not caused 
by the ioduret of potassium, but depended solely on the removal of the cause, 
of which the fever was only a symptom. In some persons, however, as a rare 
exception to the rule I have just laid down, the circulation has been increased in 
activity; but here again it is less by the direct action of the medicine on the cir- 
culation, than by the irritation it has produced in the alimentary canal, whether 
it has originated a gastro-enteritis, or that it has been given to persons whose 
digestive apparatus was already in a disordered condition. 

While noticing the action of the ioduret of potassium on the blood itself, it 
Has appeared to us, as was mentioned when speaking of its effects on the skin, 
that it renders the blood less plastic, and thus gives rise to hemorrhages. 

We have seen nasal and pulmonary hemorrhages, and even sometimes hemor- 
rhage from the intestines, during the administration of the ioduret of potassium 
in persons whose blood was already impoverished, either from chlorosis, scurvy, 
or scrofula, or from an old taint of syphilis in the constitution which has injured 
it seriously. 

Action on the Conjunctiva. — Following the phenomena just mentioned is one 
which is often met with, and which may cause much alarm to those medical 
men who are not in the habit of using the remedy in question. This phenomenon 
is its action on the conjunctiva. 

The conjunctiva may be affected alone, or else together with the mucous mem- 
brane of the nasal fossae or of the bronchia. The conjunctiva of one or both eyes 
is often seen to be affected in persons who are under the influence of the ioduret 
of potassium. This attack commences by a more or less general and more or 
less rapid vascular injection, to which is speedily added a tumefaction of the 
mucous membrane, and an infiltration, generally well marked, of the sub-mucous 
cellular tissue, which give rise to considerable chemosis of the eye and oedema 
of the eyelids. The species of ophthalmia, which may be named the catarrho- 
cedematous, presents the peculiar indication of the general effects of the ioduret 
of potassium on the mucous membranes — that is to say, the secretion is in- 
creased without any tendency, or very little, to suppuration. It has appeared to 
me, that in the great majority of cases these symptoms showed themselves when 
the use of the remedy was commenced, rather than when it had been admin- 
istered a long while. I may add, that when it has once occurred, it is rare to 
see it attack the party a second or third time. It is very important to be aware 
of this effect of the ioduret of potassium on the eyes, because the peculiar oph- 
thalmia it causes may be mistaken for a symptom of syphilis, more especially 
for gonorrhoea! ophthalmia, with which it has some analogy. 

Action on the Respiration. — I have noticed under certain circumstances some 
very remarkable effects of the ioduret of potassium on the respiratory apparatus. 

In a certain number of individuals from the first week of medication, and in 
others only after a much longer period, a peculiar coryza is noticed, which may 
be mistaken for a simple coryza, or for an exacerbation of the syphilitic symp- 
toms affecting the nasal fossae. In the particular cases of the action of the 



194 Progress of the Medical Sciences. [Juty 

ioduret of potassium on the Schneiderian membrane, there happen the symptoms 
of the simple coryza, the mucous secretion being considerably increased, but 
with this peculiarity, that the discharge has much less viscidity, and has not 
any tendency to pass to suppuration. This rheum caused by the ioduret, to use 
a common expression, does not ripen, and even if, previously to the use of the 
remedy, there existed a purulent secretion from the nasal fossa?, unless it de- 
pended on caries of the bones, it will soon diminish under its influence, and 
sometimes disappear. 

Action on the Bronchia. — In some cases, but not so numerous as the preceding 1 , 
the effects just described as occurring on the pituitary membrane, take place 
with the bronchial. The symptoms of a peculiar kind of bronchitis then show 
themselves; the cough is very slight, and there is rarely present symptomatic 
fever, but the patients generally experience a well marked difficulty of breathing, 
and bring up a large quantity of expectoration, similar to that observed in the 
first period of simple bronchitis. There is also this particular attendant circum- 
stance, that the expectoration ceases as it began — that is to say, without passing 
to the purulent state. The stethoscopic phenomena, and those furnished by per- 
cussion, are the same, or nearly so, as in simple bronchitis. 

Jiction on the Nervous System. — A less frequent effect, but still one requiring to 
be noticed, as occurring among persons to whom the ioduret of potassium has 
been administered, is a degree of cerebral excitement which has occasionally 
shown itself; symptoms of slight congestion, which have given rise to a con- 
dition analogous to that of the intoxication produced by alcoholic drinks. It has 
been already noticed by authors, and has received the name of the iodic intoxi- 
cation. In these cases, we have also observed in some patients, a certain iri* 
fiuence of the medicine on the agents of locomotion; some have been affected 
with spasms, and even a degree of subsultus tendinum. Dr. Guillon told 
me that a professional friend of his thought he had observed a double amaurosis 
in a man while under the influence of the ioduret of potassium. The man's wife 
was similarly affected. Statements of this kind, however, require a severe 
analysis before they are received. 

Jiction on the Gcni to-urinary Organs. — The action of the ioduret of potassium, 
it has appeared to me, is also directed upon the mucous membrane of the urethra. 
I have, in some cases, had reason to attribute to this medicine the return of ill- 
cnred gonorrhoeas, or the exasperation of one already existing, so much so that 
if a patient be labouring under blenorrhagia, more especially if it be at all ap- 
proaching the acute state, I consider it a counter-indication to the use of the 
remedy. Still there maybe certain cases of blenorrhcea in which advantage 
may be derived from the use of the ioduret of potassium. 

The remarks that have just been made respecting the action of this remedy on 
the urethra are equally applicable to the mucous membrane of the vagina and 
uterus. In some patients, labouring under uterine or utero-vaginal catarrh, and 
treated with the ioduret of potassium, I have seen the morbid secretion very con- 
siderably increased; it follows, therefore, that the existence of an acute utero- 
vaginal catarrh, or of one approaching the acute state, equally constitutes a coun- 
ter-indication to its use. 

If I were now to state the proportion in which the various maladies of which 
I have spoken occur, relative to the number of patients to whom I have admi- 
nistered this potent therapeutic agent, I should say that it is certainly a very 
small one; and I may add, that hundreds of patients take the ioduret, and are 
successfully treated by its use, without the occurrence of any of the pathologi- 
cal conditions I have described. I should also mention that there is not one of 
these maladies, even of those the most severe in appearance, which continues 
more than a week after the suspension of the medicine, or the modification of 
the dose. I have, hitherto, only met with five or six patients with whom I have 
been obliged, ultimately, to relinquish the medicine, on account of the constant 
pathogenic effects which it produces; in a great many, however, I have been in- 
duced to modify the doses, or to suspend the use of the medicine for a time, on 
account of the occurrence of the effects to which I have just drawn the attention 



1843.] Materia Medica and Pharmacy. 195 

of practitioners, and which, like those caused by mercury, ought to serve as 
guides. In the employment of the ioduret of potassium we should adopt this 
common principle — to give the medicine in doses sufficient to modify and cure 
the complaint, without producing any of the annoying effects previously men- 
tioned. 

Besides, my experience enables me to establish as a positive practical fact, 
that the morbid phenomena, which depend purely and solely on the action of 
the ioduret of potassium, do not require for their removal in a few days any 
other treatment than the suspension of the medicine, or the diminution of the 
doses in which it is administered. The pathogenic effects of this remedy are 
less permanent and persistent than those produced by mercury; they cease al- 
most as soon as the cause that produced them is removed. 

Although this sketch is doubtlessly very incomplete, it will serve, I trust, to 
point out several counter-indications, to which, hitherto, sufficient attention has 
not been paid. It will also show that in some circumstances, before adminis- 
tering the ioduret of potassium, certain complications must be removed, and cer- 
tain predispositions combatted, which might, otherwise, have the effect of pre- 
venting the proper action of the remedy. Besides, a thorough knowledge of the 
therapeutic and pathogenic action of the ioduret of potassium will encourage 
timid practitioners to employ it in proper and sufficiently large doses, while it 
will serve to restrain those who unfortunately are inclined to use it in excessive 
quantities. 

Jt is by proceeding in this manner that we are enabled to ascertain the doses 
in which the ioduret of potassium ought to be given. In the majority of cases 
it may be administered in the dose of a scruple and a half in the course of the 
day, that quantity being given at thrice, and, generally speaking, the same dose 
must be given for five or six days to judge of the effects produced. If the symp- 
toms do not improve, and none of the affections that have been mentioned show 
themselves, each dose may be increased ten grains, making three scruples in 
the day, to be continued for five or six days, and then, according to the effects 
produced, the dose may be increased in the same proportion, or remain in statu 
quo, or, if requisite, diminished. My experience being now very extensive on 
this point, I may say that it is rarely necessary to exceed three scruples in the 
day; that six scruples should be the maximum, and that it is exceedingly rare 
to be obliged to give less than a scruple and a half in the twenty-four hours. 

I use the following syrup freely in private practice: — 

Syrup of sarza, 500 scruples; 

Ioduret of potassium, 16 scruples. Mix. 
Of this the dose is at first three teaspoonsful in the day, then six, nine, and 
twelve. The medium dose is six spoonsful three times a day. 

When it is requisite to administer mercury at the same time with the ioduret 
of potassium, I prefer giving them separately, either in the form of pill or syrup. 
In the first place, because the prescription may require to be frequently changed; 
one of the two drugs requiring, perhaps, to be omitted, or the dose lessened or 
increased, thus causing the loss of the medicines previously prepared; and, also, 
because patients do not bear so well the compounds of the ioduret of mercury 
and potassium as they do these iodurets administered separately, with intervals 
of one or two hours between each. 

The remarks I have just made respecting the ioduret of potassium are appli- 
cable, in a great measure, to the ioduret of iron, a powerful remedy, which I 
have employed for many years, and from which I have derived great advantage. 
I should give it the preference to the ioduret of potassium, if its chemical com- 
position were in general more regular and fixed. But 1 must say that at pre- 
sent, in the great majority of cases tried upon a very large scale, the ioduret of 
potassium has furnished me with the most favourable results. If the ioduret of 
iron ought to be preferred in some cases, although it is much less easily borne 
by patients, it is in those where there are scorbutic complications in anemic in- 
dividuals — in those who are commonly said to have poor blood — in those cases, 
in fact, where chalybeates are indicated— and in those where the ioduret of po- 



196 Progress of the Medical Sciences. [July 

tassium is followed by well-marked anti-plastic effects. — Prov. Med. Journ. 
March 18th, 1843, from Bull, de Therap., Sept. 1842. 

18. New Caustic. — M. Payan, senior surgeon to the Hotel-Dieu of Aix, speaks 
favourably of a new caustic paste made with the sulphate of copper. A suffi- 
cient quantity of the sulphate, reduced to powder, is mixed up with the yolk of 
an egg - , so as to form a soft paste of a deep green colour. It is applied on a 
piece of lint, and when removed does not leave behind it the loss of substance, 
or unsightly scars, which commonly follow the use of other escharotics. In 
illustration of the efficacy of this remedy, M. Payan relates the case of a soldier, 
affected with malignant pustule of the cheek. A circular piece of diachylon was 
placed on the cheek, and a hole, about the size of a two-shilling piece, cut in 
its centre; through this the caustic was applied on a bit of lint. For five or six 
hours the patient experienced some degree of pain, but this was not very severe, 
and subsided; the caustic was removed at the expiration often hours, when the 
surface of the pustule presented a blackish gray colour; the adjacent parts were 
somewhat swollen and red. The local inflammation being thus modified, the 
eschar was allowed to come away of itself, and at the end of three weeks the 
wound was completely cicatrised, with scarcely any mark-, save a very slight 
depression in the centre. M. Payan concludes that this caustic might be advan- 
tageously employed in certain cases of lupus; but it does not appear that he 
speaks from actual experience of its efficacy in this disease. — Prov. Med. Jour. 
April 22, 1843, from Bull. Gen. de Therap., Dec. 1842. 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

19. Calculus in Appendix Vermiformis.— In our No. for January last, there is 
recorded by Dr. J. F. Peebles a very interesting case of calculus in the appendix 
vermiformis. Two cases of a similar character have been recorded in the recent 
Nos. of the Prov. Med. Journ. The first case is related by F. J. Butler, 
Esq. The subject of the case was a lad eight years of age, who complained 
on the 8th Feb. of being rather unwell, and four days afterwards when Mr. Butler 
was called in, he found the child suffering from frequent bilious vomiting; great 
thirst; considerable heat of skin; frequent, but soft and compressible pulse; pain 
in the right thigh and groin, increased upon pressure; and slight tenderness of 
the abdomen. A calomel purge, with effervescing saline medicine, was given, 
and fomentations were directed to be applied to the thigh and abdomen. 

12. Has passed a restless night, the pain in the thigh and groin being rather 
increased; no relief from the bowels; the sickness and all the other symptoms 
are much lessened; tenderness of the abdomen very slight. Ordered a warm 
bath; scammony, two grains; calomel, one grain. A pill to be taken every second 
hour. 

13. Has had a more comfortable night; pain in the thigh and groin lessened; 
heat of skin subsided; pulse 98, soft, and rather feeble; thirst considerable; no 
return of sickness; bowels not acted upon. To have a common enema at once; 
five grains of purgative pill every second hour. 

14. Ten, A. M. Slept but little; abdomen more tender upon pressure, and 
somewhat distended; countenance anxious; pulse quick, small and weak; pain 
in groin and thigh much the same; no relief from bowels. Cathartic mixture, 
one ounce, every second hour until the bowels are well opened; a blister to the 
abdomen. 

Five, P. M. The bowels have been freely relieved; the tenderness and tension 
of the abdomen is greatly lessened: pulse much the same; in every other respect 
improved. Arrow-root with brandy. 

15. After the last visit considerable and rather sudden prostration came on; 
the pulse being quick, small, and very feeble; countenance much more anxious; 



1843.] Medical Pathology and Therapeutics. 197 

abdomen a good deal distended; skin bedewed with a clammy perspiration, 
which, with the other symptoms, led to the supposition that some intestinal 
lesion had taken place. Ammonia, &c, was given constantly. 

Nine, P. M. Has rallied considerably since the afternoon, but the skin is still 
covered with perspiration, and all pain and tenderness has subsided, indicating 
a speedy dissolution; is perfectly sensible. 

16. He slept the greater part of the night, and expired about nine o'clock, A. 
M., without a sigh, remaining quite sensible till the last moment. 

Post-mortem Examination. — Abdomen a good deal distended; upon removing 
the parietes the contents presented a mass of inflammation, the whole being glued 
firmly together, in their natural position, by layers of half-organized lymph, whilst 
the viscera were much reddened and injected, especially in the right iliac fossa, 
where a portion of intestine of much darker hue than the rest quickly attracted 
our notice. Upon further examination, this proved to be the appendix vermi- 
formis coeci, which was much enlarged and thickened, being larger than the 
little finger; and in its upper half were two circular perforating ulcers, close 
together, with rounded edges, through which had escaped two small bodies about 
the size of large peas, of a light brown colour, and rather nodulated surface, 
which proved to be calculi, and corresponded with one other which remained 
within the appendix. In the immediate neighbourhood of the appendix, but 
perfectly distinct from it, in the root of the mesentery, was situated a small 
abscess; whilst the cavity of the abdomen contained about two pints of very of- 
fensive purulent matter, with flakes of lymph floating in it. No other calculi 
were discovered in the intestinal canal of gall-bladder. 

On analysis the calculi were found to be composed of inspissated mucus, 
fatty matter, and oxalate of lime in small proportion. — Prov. Med. Journ., 25th 
March, 1843. 

The second case is recorded by W. C. Worthington. The subject of it was 
a lad eleven years of age, who was attacked after swallowing two-thirds of a pint 
of plums with their stones, with pain in his abdomen, accompanied with retching. 
The following day Mr. W. was consulted, the patient then complained of great 
increase of pain; the abdomen had become tumid, and exquisitely tender Hpon 
pressure; frequent vomiting; bowels costive; and tongue coated with white fur; 
pulse small and rapid; countenance pale and expressive of great suffering. These 
symptoms were regarded as indicating acute enteritis, brought on by the in- 
temperance of the preceding day. The remedies usual in such cases were had 
recourse to. Leeches, calomel, purgative enemata, &c, were all tried in turn, 
but without affording any relief to the suffering patient. He lingered till the 
following day, when a sudden cessation of pain took place, succeeded by 
collapse and death. 

Autopsy ; sixteen hours after Death. — On laying open the abdomen, which was 
very much swollen, a considerable quantity of muco-purulent fluid escaped, 
containing flocculi. The convolutions of the bowels presented one agglutinated 
mass, the product of acute peritonitis. After unfolding these parts, with a view of 
ascertaining more clearly if any of the detained plum-stones had proved a source 
of inflammatory irritation in the course of the intestinal canal, two only were 
detected, lying loosely in the transverse arch of the colon. On arriving at the 
coecum, it presented marks of having been the seat of a more intense degree of 
inflammatory action than the adjoining viscera. The peritoneal surface was 
covered with an exudation of albuminous lymph, and the appendix adhered to 
the adjoining part. This process had also become gangrenous, which had given 
rise to a ragged perforation within an inch of its apex. Nearer to the ccBCum 
could be felt a concretion, which at first was supposed to have been a plum-stone 
that had found its way within the appendix, but upon exposing it to view it was 
discovered to be a calculus, of a grayish colour, about three-quarters of an inch 
in length, and of an oblong shape.— Ibid, April 8, 1843. 

A case of calculus in the appendix vermiformis is related by Waldron, in the 
Midland Med. and Surg. Reporter, vol. ii. p. 463; and another by Mr. Wickham, 
in the Lond. Med. and Phys. Journ., 1827, vol. iii p. 505. 



198 Progress of the Medical Sciences. \Ju\y 

20. Emphysema of the Lung as a cause of Sudden Death. — A memoir on this 
subject by M. Prus was read to the French Academy, on the 21st of February 
last, which gave rise to an interesting discussion, of which we give the follow- 
ing report. 

"-M. Louis did not consider the disease, termed emphysema of the lung, as 
capable of causing more than certain inconveniences, serious, without doubt, but 
not attended with immediate danger. He did not think that sudden death from 
this malady was a fact so well established as M. Prus seemed to suppose. Be- 
sides, it was well known that sudden death occurred during numerous diseases, 
without our being able to account for it by the state of the organs. M. Louis 
considered pulmonary emphysema to consist in hypertrophy of the pulmonary 
vesicles, but he only regarded this as a presumption, very probable, no doubt, 
but certainly not incontestably established. 

"M. Dupuy maintained that he had ten years since proved that emphysema 
of the lung occupied the interlobular cellular tissue. He established that fact 
beyond doubt, by dissecting emphysematous lungs previously dried, and thus 
ascertained that there was extravasation of air outside the air-vesicles. 

" M. Bouillaud agreed in M. Louis's observations respecting sudden death. 
He had observed in cases of emphysema the most intense fits of suffocation, 
occasionally wearing the most alarming aspect, but they never proved really 
dangerous. 

" M. Ollivier d'Angers said, that as the possibility of sudden death, from em- 
physema of the lung, had been doubted, he would mention a case which had 
been seen. Two brothers-in-law, one small and feeble, the other athletic and 
robust, quarrelled. The latter received a blow, but was restrained by the con- 
sideration of his superior strength from avenging. He was a person of violent 
passions, but succeeded, by an extreme effort, in mastering his rage, and had 
scarcely walked forty paces from the scene of the quarrel, when he fell down 
dead. M. Ollivier next day examined the body juridically. There was no sign 
of putrefaction, and what chiefly attracted attention on opening the thorax, was 
the protrusion of the lungs. On examination, M. Ollivier satisfied himself that 
air was effused into the interstitial cellular tissue. M. Ollivier did not of course 
know what was the previous condition of the lung. M. Ollivier considered that 
it was unquestionable that most (1) cases of sudden death arose from a lesion of 
the lungs. He had seen several such cases. For example, a man being ex- 
pelled from his lodgings by his landlord, rushed at him, but fell dead in so 
doing. On dissection, the lungs were gorged with blood, which escaped at each, 
stroke of the scalpel. 

<k M. Velpeau was surprised that no allusion had been made to M. Lombard's 
theory, that emphysema of the lung was caused by the destruction of the inter- 
vesicular septa. 

t; M. Bouillaud conceived that the seat of pulmonary emphysema might be 
elucidated in a few words. Emphysema from a violent effort was of a traumatic 
origin, and had no analogy with the medical disease now under consideration, 
which was a spontaneous disease of essentially slow formation. The distinction 
between dilatation of the air-cells and extra-vesicular effusion of air, was not, as 
some seemed to suppose, impossible. Laennec had made the distinction, and 
described the two cases as two very different species; and they can be perfectly 
distinguished in the dead body by persons accustomed to such researches. As 
to the cases of sudden death, M. Ollivier does not differ from me and M. Louis. 
We have not absolutely denied the possibility of the event; and the case men- 
tioned by M. Ollivier is clearly one of traumatic emphysema from rupture of the 
tissue of the lung. 

M M. Blandin said that the anatomical seat of emphysema of the lung could 
not be determined until the normal structure of that organ was exactly known. 
But the most eminent anatomists are not agreed as to whether the pulmonary 
tissue consists of isolated vesicles or of cells communicating with each other. 
M, Blandin, nevertheless, thought that pure and simple dilatation of the vesicles 
most probably existed. In fact, in the dead body, we could not by pressure 
expel the air from the ampullae which constituted the emphysema. 



1843."] Medical Pathology and Therapeutics. 199 

" M. Ferrus said the two questions raised by M. Prns's memoir were, — Can 
pulmonary emphysema alone cause death] and, Can it cause sudden death! 
Laennec did not consider pulmonary emphysema as a cause of death, but with 
his usual sagacity, he remarked, that most commonly some other serious disease 
was associated with this malady. He did not, however, consider interstitial 
emphysema to be so serious a disease as many physicians suppose it to be. 

"• M. Ferrus said, that, in his opinion, emphysema of the lung was a cause of 
asthma, but that evidently some other cause must be usually admitted as the 
cause of the emphysema, and this other cause, distinct from the emphysema, 
was, M. Ferrus considered, a nervous affection. 

" It is only thus that we can explain the sudden deaths which have been attri- 
buted to emphysema. Thus, if we analyse the case mentioned by M. Ollivier 
d'Angers, we shall find that death cannot be attributed to the emphysema, if we 
examine the cadaveric alterations detected. But if, on the other hand, we attend 
to the symptoms, we shall find that the individual presented all the characters 
of the nervous temperament, and it must be particularly recollected that the 
patient expired during a vivid moral emotion, in a fit of violent passion. No 
doubt the emphysema exerted an important influence, but it certainly was not 
the only cause of death; the fatal event can only be explained by a nervous 
lesion. There i-s no difficulty in understanding how a disturbance of the nervous 
function may cause both. It is well known how great an influence a disturbance 
of innervation exerts on sanguification; by merely suspending, or even impeding 
the play of the respiratory muscles, it causes asphyxia from deficiency of air. 
Laennec remarked this fact, which M. Ferrus dwelt on, because of its imporant 
bearing on the point under consideration. 

"M. Rochoux said, that by a strange confusion of terms, two very distinct 
diseases were confounded under the name of pulmonary emphysema. One of 
the diseases thus confounded consisted in dilatation of the pulmonary cells; the 
other in infiltration of the air between these cells. M. Rochoux thought that 
the term, pulmonary emphysema, should be restricted to the first of these affec- 
tions. Emphysema always co-existed with other affections more or less serious, 
many thence thought that these latter affections were the cause of death; but this 
was a point by no means completely decided, and which required farther inves- 
tigation. M. Rochoux concluded by saying that the examination of a section of 
a dried lung evidently showed that the pulmonary cells communicated with each 
other. 

" M. Poiseuille observed, that, in ordinary respiration, a portion only of the 
lung was penetrated by air, and concerned in sanguification; and that it was only 
under peculiar circumstances of forced respiration, that the whole of the bron- 
chial ramifications were employed in this function. Every circumstance which 
diminishes the aerial surface of the lungs, correspondingly lessens the area of 
sanguification; but it is obvious that this area cannot be indefinitely diminished, 
and if it falls below a certain limit, which it is not easy to define, death must 
be the result. He had ascertained, in the lungs of old people, that eight or ten 
vesicles were replaced by a single one, whose surface was three or four times 
smaller than the sum of the surfaces of the vesicles from which it was formed. 
This fact has been also ascertained by M. Bourgery. In pulmonary emphysema, 
caused by dilatation of the pulmonary vesicles, the aerial surface of the lung 
must consequently be greatly diminished, and sanguification must, therefore, 'be 
interfered with, and may become insufficient for the sustentation of life. In 
inter-vesicular emphysema, the air is not free as in the case of simple dilatation 
of the vesicles, and interferes with the collapse of the lungs, and thence there is 
always more or less dyspnoea, because the air confined in the cellular tissue 
compresses the pulmonary vesicles, and therefore diminishes the aerial capacity 
of the lung. But air extravasated into the cellular tissue of the lung has another 
and very peculiar effect; for, by compressing the capillary vessels of the lung, 
it obstructs the passage of the blood from the pulmonary artery into the pulmo- 
nary veins. Thus M. Poiseuille having distended a lung with air, without ren- 
dering it emphysematous, noted the time in which a given quantity of serum, 



200 Progress of the Medical Sciences. [J u ty 

placed in the pulmonary artery, was expelled under a given pressure on the 
right auricle; and having subsequently distended the lung with air, so as to 
render the organ emphysematous, ascertained that it allowed a passage to only 
the half, the third, or a quarter the quantity of liquid, according as the emphy- 
sema was more or less considerable. M. Poiseuille, from the foregoing con- 
siderations, was inclined to think that, in the case mentioned by M. Ollivier 
d'Angers, in which inter-vesicular emphysema was eminently developed, death 
was caused, on the one hand, from the obliteration of a great number of the 
pulmonary vesicles, and on the other, from obstruction of the capillaries of the" 
lungs. 

" M. Bouvier observed that there was a common cause of error in determining 
the situation of the emphysema of the lung. It is often thought, that air is in- 
filtrated into the cellular tissue of the lung, because it can be pressed from one 
vesicle to another, or even from lobule to lobule. This, however, is a very de- 
ceptive test, for the air frequently passes, not through the ruptured septa of the 
vesicles, but through a bronchial tube common to several vesicles or to several 
lobules. 

" M. Royer-Collard observed, that it was important to advert to the physio- 
logical mechanism of pulmonary emphysema. Most physicians suppose, that 
the gaseous infiltration that characterizes emphysema of the lung is always pro- 
duced by a respiratory effort. This opinion was, M. Royer-Collard thought, 
unfounded, though no doubt it was true in some instances, as there are several 
cases recorded in which emphysema of the lung has been caused by hooping- 
cough, the presence of a foreign body in the larynx, or difficult parturition: in 
such cases a respiratory effort was obviously the cause of the emphysema. M. 
Prus maintains, that disease of the heart does not usually correspond to the 
general symptoms which accompany pulmonary emphysema. M. Royer-Collard 
had made inquiries on this point from several physicians attached to hospitals 
and asylums for old persons, and particularly from their intern pupils, who were 
in the constant habit of examining the bodies of the persons who died in those 
institutions; and all agreed in stating, that they had not observed any striking 
connection between these two affections. M. Royer-Collard by no means denied, 
that a relation existed between diseases of the heart and emphysema of the lung; 
but he maintained, that it was by no means so frequent as was commonly sup- 
posed. On the other hand, ninety out of one hundred old persons, probably even 
more, affected with emphysema of the lung, have previously laboured under 
chronic bronchitis. It has been thence inferred, that the expiratory efforts and 
cough have caused dilatation and rupture of the pulmonary cells. This was pre- 
cisely the point which M. Royer-Collard disputed. He thought that the same 
thing occurred here that occurred whenever the capacity of a canal was dimi- 
nished, — viz., that the substance retained in consequence of that diminution, 
gradually dilated the cavity in which it was contained. Thus, in stricture of 
the urethra, and of the intestinal tube, the portion of these canals, respectively 
situated above the obstructed point, become dilated. Farther, the expiratory 
power of the lung was much feebler than its inspiratory power, and, therefore, 
an excess of air remained in the cells, which gradually dilated and ruptured 
them, and finally became infiltrated into the cellular tissue. Such was the view 
M. Royer-Collard took of the mechanism of senile emphysema. The cells were 
not, he conceived, ruptured by a sudden violent effort, which lacerated the ves- 
sels, as air forced in by a bellows would; they were gradually distended by the 
prolonged confinement of air, and their parietes, having partially lost their elas- 
ticity, at length gave way. It may be objected to this theory, that the bronchial 
ramifications frequently present no narrowing, and that often, even when catarrh 
has existed for a long period, no tumefaction, or other alteration of the bronchial 
mucous membrane can be detected. How, then, it may be asked, can the air 
be detained in the air cells? The answer is easy. Alteration of the bronchial 
mucous membrane is by no means necessary to the existence of contraction of 
the bronchial ramifications. They become contracted, as Laennec well remarked, 
by the mere accumulation in them of the fluid they secrete, which mechanically 



1843.] Medical Pathology and Therapeutics. 201 

obstructs the free exit of the air. It is obvious that this kind of obstruction may 
occur in bronchia] tubes that are actually dilated. We know, however, from 
the researches of M. Louis, that dilatation of the bronchial tubes occurs rarely, 
and when it has been observed, it did not correspond to the portion of the lung 
affected with emphysema. Another consideration strengthened this theory, and 
at the same time aided in the discrimination of senile from accidental pulmonary 
emphysema, — viz., that the modification of the lung, which occurred in emphy- 
sematous persons advanced in life, was in reality a mere exaggeration of the 
natural condition of the lung in old age. Physiology tells us, that as man runs 
through the different phases of his existence, the functions in general, and the 
secretions in particular, are displaced, pass from one organ to another, and 
change their form and nature. In old age, the aqueous secretions are, in par- 
ticular, singularly diminished in quantity. The skin becomes dry, and exhales 
but a moderate quantity of that vapour which comes off with the carbonic acid; 
dry chronic eczematous, and other cutaneous affections, are of frequent occur- 
rence. The diminished quantity of the humours of the eye causes flattening of 
the cornea. The gastric and intestinal fluids become less abundant, the liquid 
portion of urine is diminished in quantity proportionably to its solid contents, 
and the secretion of bile is lessened. The menstrual and spermatic secretions 
are also diminished in the two sexes respectively, and, finally, the pulmonary 
exhalation is considerably lowered in quantity. Most of these secretions are, 
however, evolved in another shape. On the skin, we find an augmentation of 
the inspissated secretion of the follicles, of the wax of the ear, of conjunctival 
mucus, and of the scales of the epidermis. In the intestinal canal, the secretion 
of mucus is increased, while the bile, though lessened in quantity, is thicker and 
more viscid. The urine deposits more sediment, and has a stronger smell; and 
the bronchia] mucus, which more particularly bears on the present question, is 
always secreted much more copiously than at the earlier periods of life. Such 
is the natural condition of things in old age, — a condition which may be termed 
the state of health. If, then, this condition is not disturbed, the foregoing con- 
siderations explain why it is that expiration is accomplished with a certain 
amount of difficulty, whence results the detention of a certain excess of air in the 
air-cells, which consequently become slowly distended, but not ruptured, so as 
to permit the air to escape into the cellular tissue. It is an ascertained fact, that 
the air-cells are always more dilated in old persons than in the adult; the super- 
abundance of mucus may not be the only cause of this dilatation, but it is cer« 
tainly one of its causes. 

" But suppose that any cause— exposure to cold for example — acts not directly 
on the bronchial mucous membrane, but affects the skin, so as to lessen the 
small amount of aqueous exhalation it still secretes, an augmentation of the 
bronchial mucous secretion, in other words, a catarrh must inevitably result. 
This is an inevitable result of the law of the equilibrium of organs, as it has been 
termed by M. Geoffroy Saint-Hilaire, a law which establishes so intimate a cor- 
relation of action between the external and internal skin, and between the pul- 
monary and cutaneous secretions. The morbid state in question is then merely 
an exaggeration of the state of health. The natural condition of old age is only 
relatively a state of health, or should rather be termed a normal cachexia; con- 
sequently, there is but a step from the natural state to disease, and when this 
step is made, expiration becomes still more impeded, and rupture of the air-cells 
readily occurs. From these considerations M. Royer-Collard considered that 
we must admit a decided difference between senile and accidental pulmonary 
emphysema. The etiology, progress, duration, and the mechanism of the forma- 
tion of the two affections differed. Accidental pulmonary emphysema did not 
seem to be always produced in the same way. The rupture of the pulmonary 
vesicles was sometimes caused by a forced inspiration, sometimes by a violent 
expiration. M. Royer-Collard had lately seen a curious case connected with 
this point. A young man lately returned from the East, had contracted the habit 
of smoking after the Turkish manner, which consists in inspiring the tobacco 
smoke by means of a violent inspiration, so that it penetrates into the bronchial 



202 Progress of the Medical Sciences. [July 

tubes, where it is retained, occasionally so long- that the individual speaks and 
drinks, and does not expel the smoke till after the lapse of five, six, or even ten 
minutes after its ingestion. Obviously such a practice should cause just the 
same consequences as ingestion of air into the lunges, and destroy the delicate 
parietes of the air-cells, and sifch was the result in this case. Another case of 
pulmonary emphysema resembles senile emphysema in its mechanism — that is 
the emphysema almost constantly observed in persons that have been hanged or 
drowned. There a mechanical obstacle opposing the expulsion of the air accu- 
mulation in the lung, rupture of the vesicles necessarily results. M. Royer-Col- 
lard considered that these views were important, both as leading 1 to a more just 
view of the mode of formation of pulmonary emphysema in different cases, and 
as indicating a rational method of treating the affection. Accidental pulmonary 
emphysema may be cured; several unexceptionable cases of its cure have been 
recorded. In an adult, otherwise in good health, bleeding would be especially 
useful, as it would favour the absorption of the gas from the tissue of the lung-. 
In old persons the treatment should be rather preservative than curative. In the 
first instance, it is indispensable to avoid every influence capable of exciting 
catarrh. It is to be observed, that senile pulmonary emphysema is infinitely 
more frequent in hospitals and among the poor, than amongst the better classes. 
When catarrh does occur, it should be briefly treated by the method of deriva- 
tion; the skin should be excited by friction, by sudorifics, topical irritants and 
blisters, purgatives should be administered to excite a flow of mucus from the 
intestines, the patient should be kept in an atmosphere of mild equable tempera- 
ture, and tonics should be given to support the strength. The reason that pul- 
monary catarrh and emphysema were so frequent among the inmates of Bicetre 
and Salpetriere was that they were insufficiently clothed and warmed. The 
greatest difficulty was experienced in obtaining for these poor creatures flannel, 
wine, or other necessaries which they required. Every physician who had ever 
been attached to those institutions had loudly remonstrated on this subject. On 
the other hand, those affections are much less frequent and serious at the Hotel 
des Invalides, because the diet is better, and the establishment is in every respect 
more comfortable and more regularly conducted. 

41 M. Piorry had no doubt that air could cause death by entering the blood 
through the ruptured inter-vesicular septa. He had in experiments on living 
animals ascertained that this occurred. It was also incontestable that the bron- 
chial mucus could produce dilatation of the air-cells, by obstructing the bronchial 
tubes in which it accumulates. The good effects of tartar emetic in such cases 
confirmed the truth of this view. M. Piorry had always observed that its admi- 
nistration gave immediate relief in nine cases out of ten. The rarity of emphyse- 
matous dyspnoea in summer, as contrasted with its frequency in winter, was 
explained on the same principle — that is to say, by the infrequency of bronchitis 
in fine w 7 arm weather. 

"M. Blandin could not accede to the assertion that death might result from 
air becoming mixed with blood in the lungs. M. Roux had mentioned a case 
in which this was alleged to have occurred, and to have caused death. In that 
case a body was brought to the dissecting-room, the external appearance of which 
seemed to indicate that the subject had met with some violent death. Bichat 
opened the cranium in the presence of M. Roux, and, to his astonishment, found 
all the arteries of the brain distended with air. On inquiry it was ascertained 
that the individual had died while making a violent and prolonged effort, and 
Bichat concluded that the effort had caused rupture of the septa of the air-cells, 
whence air passed into the blood and caused death. M. Blandin conceived that 
nothing could be concluded from this case, because the details respecting the 
previous history of the patient and the mode of death were very imperfect, and 
because neither M. Bichat nor M. Roux had ascertained that the patient was 
really affected with emphysema; it was not known either whether the elastic 
fluid contained in the vessels of the brain was air or some other gas. M. Piorry's 
experiments were also inconclusive, because efforts produced artificially and 
violently on animals had no relation to the occurrence of slow and spontaneous 
emphysema in man." — Lond. and Edin. Month, Journ. Med. Sci. April, 1843. 



1843.] Medical Pathology and Therapeutics. 203 

21. Case of Paralysis without loss of Sensation, from disease of the Cervical Me* 
dulla. By John Webster, M. D. — Mr. G., aet. 36, had, in 1836, a phagedenic 
ulcer of the left leg 1 , which got well after some months; but it igain broke out 
in 1839, when he had also a large chronic ulcer on the posterior pharynx of 
some duration, but not of a syphilitic character. He had pains in the head, 
with very costive bowels, during the greater part of the year 1839; in January, 
1840, epileptic attacks, with very slow pulse, now supervened; and in the spring 
following, Mr. G. had spasmodic contractions of the lower limbs, accompanied 
by a sense of weakness in the back; and latterly he lost the use of his legs, and 
ultimately the entire control over every muscle situated lower than the neck. 
During the last twelve months of the patient's life, the whole body was para- 
lysed, excepting the head, neck, and diaphragm, by which breathing was en- 
tirely carried on, and not by the muscles of the chest. However, sensation re- 
mained perfectly natural throughout the entire surface of the body; and towards 
the termination of the disease, the patient's feelings were even more acute than 
usual, and he could always tell, on the slightest touch of a bystander's finger, 
the exact spot to which it was applied. Severe spasmodic twitchings of the 
legs and arms were now more frequently noticed than before, and these were 
sometimes so violent as almost to throw the patient off his couch. The extremi- 
ties were often very cold, but occasionally they felt also burning hot, with a 
sensation of excessive coldness in the epigastrium. The urine was drawn off 
by the catheter for many months, but latterly it passed involuntarily, as the 
faeces did likewise. All the symptoms continued unabated in violence to the 
last, and the patient died in July 1842, but retaining his intellectual faculties 
perfect until the last. 

Treatment. — Medicine had very little influence in arresting the disease, al- 
though the treatment may have relieved the severity of some of the symptoms. 
The remedies consisted principally of purgatives, mercury, sarsaparilla, hydrio- 
date of potassa, strichnia, and morphia to procure sleep or allay spasm. Other 
means were also used, but the treatment which appeared to produce the most 
benefit was active purging, and the tincture of cantharidis taken as a diuretic; 
at the same time that a copious discharge was kept up for many months con- 
secutively from two large issues on the nape of the neck. 

Jlutopsy. — Nothing particular was found in the head, excepting that the arach- 
noid membrane over the pons varolii adhered to the parietal layer of that tissue, 
and about two ounces of serum were found in the ventricles; but there was no 
tumor or change of structure either in the brain or in the cerebellum. The tho- 
racic and abdominal viscera were healthy, with the exception of the bladder, 
which was much contracted in size, thickened in its coats, whilst the omentum, 
and some of the small intestines, adhered to its surface. On opening the spinal 
canal, the theca, corresponding to the three or four lower cervical vertebrae, was 
much distended; the arachnoid cavity was filled with lymph, and there were ad- 
hesions of the membranes to the chord, which appeared firmer at the anterior 
than at the posterior portion, and the parts were inseparable. The cord itself 
was longer than usual at this particular point, felt soft and pulpy to the touch, 
and on being divided it was found to be in an almost diffluent state, infiltrated 
with serum, but of a natural colour. For the extent of half an inch above this 
point the chord exhibited a dusky red colour, but there was no difference ob- 
servable betwixt the two columns, both being alike softened and discoloured; 
the parts above and below being perfectly healthy, and of a natural appear- 
ance.— Lond. Med. Gaz. Nov. 1842. 

22. Leucorrhasa cured by Iodine. — M. Cn. Van Steenkiste has published the 
details of two cases of leucorrhoea treated with iodine injections, in the " Annales 
de la Societe Medico-Chirurgicale de Bruges." The first case in which he tried 
it was that of a sempstress, twenty-two years of age, of a scrofulous constitu- 
tion, who had laboured under leucorrhoea three years. The discharge was thick 
and abundant, and of a milky or slightly yellow colour. The patient presented 
all the symptoms of anaemia; the mucous membrane of the vagina was very pale 9 



204 Progress of the Medical Sciences. [Juty 

the cervix uteri red and tumefied. The genitals were excoriated. An injection, 
containing four scruples of iodine, sixty of alcohol at 25°, and 125 of common 
water was ordered for her, of which about thirty scruples were thrown up into 
the vagina. Heat and irritation were immediately experienced in the parts, and 
the discharge ceased entirely for three hours, returning then in larger quantity 
than ever, accompanied for a few minutes with very severe pain in the genitals, 
headache, and general spasms. These symptoms soon disappeared, and the 
discharge did not again return till the next day, when the same quantity of 
iodine was injected, less severe symptoms following its use. The catamenial 
secretion, which had been absent seven months, appeared towards evening, and 
continued for three consecutive days, unaccompanied by any other discharge. 
On its cessation, the leucorrhoea again showed itself, but less in quantity than 
before. M. Steenkiste, desirous of retaining the iodine more in contact with 
the vaginal mucous membrane than it had been previously, introduced a specu- 
lum, with the assistance of which he filled the vagina with five pieces of charpie, 
soaked with the iodine, and left them there, intending to remove them in an 
hour's time. Four of these pledgets were expelled by pains which came on in 
the interval, and when the surgeon sought to withdraw the fifth he could not 
introduce the speculum, the vagina was so contracted. The cure thus induced 
has been permanent, and the catamenia have again appeared. The second case 
was equally satisfactory. — Frov. Med Jour. April 22, 1843. 

23. Stammering.— Dr. Abercrombie read a paper on this subject to the Medico- 
Chirurgical Society of Edinburgh in January last. When his attention was 
first directed to the subject, he stated, the following facts attracted his notice: — 

I. He observed that stammerers never stammer in singing. 

II. The individual on whom his first observations were made, did not stam- 
mer when he was obliged to speak in a louder tone of voice than usual, as when 
conversing in the midst of a noisy crowd, or in a carriage on a rough road. 

III. The precentor of a church came under his notice who stammered in com- 
mon conversation, but showed no hesitation when reading out the line, as it is 
called, which was done in a peculiar high-pitched tone of voice, such as is 
usually employed by precentors for that purpose. 

IV. He found that stammerers have no difficulty in performing any of those 
movements of the lips and the tongue, by means of which the consonant sounds 
are produced, when they are directed to make these movements simply, that is, 
without any reference to speech. 

V. He observed, that in some stammerers, the difficulty is not confined to the 
consonant sounds, in which the peculiar action of the organs of speech is more 
directly exerted, but extends to other sounds, in which these organs are little, if 
at all concerned, such as the simple aspirated h, as in the words happiness, holi- 
ness, &c. In one individual, indeed, who was treated successfully, he found 
that he often hesitated at such words as these, long after he had overcome every 
difficulty respecting the consonants. 

By such facts as these he was led to the conjecture, that the affection does not 
depend upon any defect in the organs of speech, properly so called; but is rather 
connected with a deficiency in the management of the voice; and he thought it 
would be found, that, when a stammerer gets into that peculiar state of hesita- 
tion, which is so familiar to every one who has witnessed it, he is endeavouring 
to speak when he has no voice; that is, when the lungs have become emptied of 
air, or nearly so. 

According to these views, the principles on which the cure of the affection 
may be accomplished, appeared to be the following: In actually accomplishing 
a cure, every thing depends upon the perseverance of the patient himself after 
the principles have been explained to him. 

I. To direct the attention of the individual to the three distinct parts, of which 
the function of speech consists, viz. 

1. A full and continuous current of air proceeding outwards from the lungs. 

2. The formation of this into inarticulate sound, or voice, by the action of the 
larynx. 



1843.] Medical Pathology and Therapeutics. 205 

3. The formation of this into articulate sound, or speech, chiefly by certain 
movements of the lips and the tongue. 

He soon perceives that he has no difficulty in performing any of these actions, 
when they are thus made separate objects of attention; and in this manner he is 
led to understand that his affection does not depend upon any defect in any of 
the organs of speech, or a difficulty of performing any of the processes of which 
the function consists; but in a certain want of harmony^among these processes, 
which has grown into a habit. He is easily made to perceive, for example, that 
he has no difficulty in performing that motion of the lips by which is formed the 
sound of the letter b, then why should he have any difficulty in saying bee, boy, 
bell, &c. When the formation of each letter is thus made a separate object of 
attention, or a distinct voluntary act, it is remarkable to observe how the diffi- 
culty seems to vanish; and by continued attention in this manner, the habit is 
gradually broken, in as far as concerns this part of the process. 

II. The second, and principal part of the treatment is, to exercise the indivi- 
dual in the habit of never attempting to speak without having a full and strong 
current of voice. He may be made sensible of the effect of this, by making 
him read in a strong loud tone of voice, as if he were calling to a person at a 
distance,— or in a tone resembling singing or chanting, — or in the peculiar tone 
of a precentor, in reading out the line, which has been already referred to. When 
he has thus been made to understand the principles on which the removal of the 
affection fs to be conducted, the farther treatment consists in a course of exer- 
cises calculated to give him a full command of his voice, and so to correct the 
habit which he has acquired, of speaking, or attempting to speak, without suffi- 
cient voice. For this purpose he should be made to read aloud, several times 
a-day, from an author whose style is somewhat declamatory. In doing so, he 
should be made to read in a high-pitched tone, and to stop frequently and take 
a full breath, so as to have the voice thrown out with a force beyond what is 
required for ordinary reading or ordinary conversation. With this view it is 
necessary to make him stop and take a full inspiration much more frequently 
than would be required by another person: for it is in this part of the process 
that we are to trace, in a great measure, the bad habit which he has acquired, 
and the opposite habit which he is required to cultivate. In particular, when- 
ever he feels the tendency to hesitate at a word; he is to be taught to stop in- 
stantly, take a full breath, and then try it again. He will be immediately sen- 
sible of the effect; and a succession of voluntary efforts of this kind will be gra- 
dually formed into a habit, calculated to correct the injurious habit, in which, I 
believe, we are chiefly to trace the pathology of stammering. 

In a note appended to this paper, Dr. Abercrombie remarked, that since his 
observations were written, he had found that the same principle, respecting the 
influence of respiration in this affection, had been pointed out by Dr. M'Cormack 
of Belfast, in a small volume published in 1828. — London and Ed. M. J. Med. 
Sci., March, 1843. 

24. Decrement of Weight in Phthisis. — Dr. Robert Williams, physician to 
St. Thomas's Hospital, in a paper read to the Royal Medical and Chirurgica\ 
Society, stated that some years ago he began a series of experiments on possi- 
ble remedies in phthisis, and in making these experiments he determined on 
weighing the patients, considering that an increase or decrease of weight would 
afford a better criterion of amendment, or otherwise, than the fallacious hopes 
with which nature cheers the individual in this desolating disease. The num- 
bers weighed were few, perhaps eight, unexpected difficulties having occurred, 
and the experiments being prematurely terminated in some cases by the patient 
leaving the hospital. One general law, however, was observed in all, viz., that 
the loss of weight was not continued but intermittent; or, the patient being 
weighed weekly, and as nearly as possible under the same circumstances, 
showed an alternate increment and decrement generally of one or more pounds 
on each alternate week. The decrement, however, usually exceeded the incre- 
No. XL— July, 1843. 14 






2C6 Progress of the Medical Sciences. [July 

ment, and consequently every few days an increasing balance was left against 
the patient. 

The only inference which Dr. W. is able to deduce from tbe singular law of 
the alternate increment and decrement of weight in phthisis, is, that it may afford 
.an explanation of the buoyant feelings of the patient, who must necessarily feel 
his symptoms ameliorated, and his health improved every few days. It is evi- 
dently the measure of the last flickerings of the vital principle, but how the 
lamp of life is fed is, perhaps, beyond our power of explanation. — London and 
Edin. Month. Journ. Med. Sci., March, 1843. 

25. Strumous Peritonitis. — The March number of the Dublin Journal of 
Medical Science, contains communications from Sir Henry Marsh and Dr. Fleet- 
wood Churchill, on a form of peritonitis occurring in persons of a strumous 
diathesis, to which the above title has been given.* Strumous inflammation of 
the peritoneum with effusion may present itself either as an acute or chronic 
disease; the latter, which is the more frequent form, may be an evident conse- 
quence of the former, or it may occur without our being able to recognize any 
preceding acute stage, coming on so gradually, in fact, that the nature of the 
complaint may not be discovered until it is fully developed. As M. Duges 
observes, ''there may be occasional pains, colics, irregular attacks of diarrhoea, 
emaciation, paleness, for weeks or even months before the disease is established, 
while from the earlier and more prominent symptoms being referable tb the mu- 
cous membrane of the intestinal canal, the real affection may be overlooked, and 
the fatal results attributed to the diarrhoea. 

Bad diet, cold, privations, excesses, dentition, constipation, &c, have been 
mentioned as exciting causes of this variety of peritonitis; but the principal one, 
in Dr. Churchill's opinion, is an extension of irritation from the intestinal mu- 
cous membrane. It also occurs as one of the sequelas of febrile diseases, such 
as scarlatina, measles, &c. Sir H. Marsh observes, that it frequently arises 
without the intervention of any well-marked exciting cause, and sometimes sets 
in either gradually or abruptly, during the progress of some other disease. The 
age most obnoxious to its supervention is between early childhood and puberty, 
and for a few years after that period; it is rarely met with in infancy or after the 
age of thirty. It is almost confined to children of a strumous habit and lymph- 
atic temperament; and it is frequently complicated with, and is perhaps a 
consequence of, mesenteric disease. 

The symptoms of the acute form are, wandering pains in the abdomen, in- 
creased on pressure, and gradually becoming more severe, with hot and dry 
skin, scanty, high-coloured urine, small and very frequent pulse, and extreme 
distress and anxiety, rapidly followed by effusion into the cavity of the perito- 
neum. In the chronic variety the mode of invasion varies widely; in one class 
of cases the patient labours under diarrhoea for a considerable time with or with- 
out pain; the appetite is pretty good, the temperature natural, and the pulse 
quiet; but at length— it may be weeks or months — complaints are made of a 
sensation of pricking, or of paroxysms of pain and a feeling of tightness in the 
abdomen, which, upon examination, is found to be more or less swollen. In 
other cases there is a certain amount of pain from the beginning, occurring in 
paroxysms with perfect intervals, and though at first limited to one part of the 
abdomen, yet by degrees spreading over and occopying the whole; or again, 
there may not be any complaint of pain, merely a feeling of distension, with 
variable appetite, irregular bowels, and progressive emaciation. In many cases, 
indeed, the early symptoms are so slight that no attention is paid to them until 
the emaciated appearance of the patient excites alarm. The abdomen, on exa- 
mination, is probably found tumid, and in some degree tender in parts. Dr. 
Gregory states that tenderness on pressure is probably felt from the commence- 

* This is the disease well known to the French pathologists under the name of tuber, 
cular peritonitis, and which led Dr. Hennis Green to give the name of luLercular 
meningitis to the analogous affection of the brain in children. — Eos. 






1843."] Medical Pathology and Therapeutics. 207 

ment. As the disease advances, the patient complains of pain occurring- in 
paroxysms, beginning in some one part of the abdomen, and gradually spreading 
over the entire, and increasing in frequency and in severity according to the 
duration of the disease. ' This state is accompanied by a certain amount of ten- 
derness on pressure, and more or less uneasiness in walking or even standing 
erect. This is followed by a feeling of distension and enlargement of the abdo- 
men, with fluctuation more or less evident on careful percussion. The enlarge- 
ment of the abdomen is not always equable; in some cases, especially in the 
commencement, the umbilical region protrudes. As the effusion increases, the 
entire abdomen enlarges, loses its softness, and becomes tense and hard, though 
occasionally unequally so, and its integuments hot and dry. In some rare cases 
the intestinal canal preserves its integrity for a long time; the tongue is pretty 
clean, the appetite much as usual, the bowels regular, or perhaps rather consti- 
pated; but in the large majority of cases we find the tongue white, loaded, and 
flabby; more or less thirst; the appetite irregular and fastidious, sometimes in- 
creased, more frequently impaired or lost altogether; the bowels relaxed or con- 
stipated, perhaps alternately; the stools foetid, and of whitey-brown or bluish 
colour. The quantity passed sometimes in the twenty-four hours, without the 
aid of medicine, is enormous. Dyspnoea may be induced either by the quantity 
of the abdominal effusion or by accompanying hydrothorax; the pulse is increased 
in frequency, but diminished in strength and fulness; the urine is scanty, the 
skin hot, and there are distinct evening exacerbations of a fever of the hectic 
character. It is hardly necessary to add that so formidable and long-continued 
a disease is attended with great emaciation and exhaustion. As it progresses, 
the local symptoms are aggravated; the quick pulse and fever, with exacerba- 
tions, more remarkable; the weakness and incapability of exertion more exten- 
sive; the patient, in short, is utterly worn out. 

The course of the disease is generally very long; it may terminate, first, in 
resolution, secondly, in a circumscribed collection of the effused fluid and its final 
evacuation with more or less subsidence of the original affection, and, thirdly, in 
death. The majority of the cases terminate fatally at different intervals from the 
commencement of the attack. Instead of diminishing, the symptoms progres- 
sively increase in intensity. The abdomen becomes very tense and tender, the 
fever high, the pulse very quick and feeble, the thirst considerable, the diarrhoea 
persistent, the exacerbations severe, the emaciation and exhaustion extreme. The 
countenance becomes sunken, the extremities cold, the surface covered with a 
clammy sweat, and occasionally dotted with petechias, and at length, after a 
prolonged period of suffering, death closes the scene. The appearances pre- 
sented after death are, more or less severe effusion into the peritoneal cavity, 
with shreds of lymph floating therein. The intestines are agglutinated together, 
and sometimes to the peritoneum, which membrane is occasionally thickened 
and partially injected, and sometimes studded with miliary tubercles, or has 
tubercular matter deposited on it. The mesenteric glands may be healthy, 
or they may be enlarged, and contain tubercular matter. In two of Sir H. 
Marsh's cases there were collections of a thin pus mixed with curdy matter, 
one of these in one case communicating with the bowel by an ulcerated perfora- 
tion, and containing a dark-brown fluid, having a very evident feculent odour. 
Dr. Gregory observes that the mucous membrane of the bowels, particularly of 
the small intestines, appears ulcerated in various places, and at these points of 
ulceration the convolutions of the intestines communicate, so that instead of 
forming one line of canal, as they will continue to do even in advanced stages 
of chronic peritonitis, they constitute a mass of tubes communicating freely with 
each other, and with the thickened and ulcerated peritoneal membrane by innu- 
merable openings. 

Th,e prognosis in the majority of cases is unfavourable. Where the peritoneum 
alone is affected, the patient has certainly a chance of recovery, but if the mesen- 
teric glands, or the mucous membrane of the intestines or pleura be involved, the 
case will probably terminate unfavourably. 

The treatment should consist in the application of leeches to the abdomen, 



208 Progress of the Medical Sciences. [July 

when admissible, poppy fomentations, the use of the warm bath, and the em- 
ployment of mercury so as to affect the gums. It may be exhibited internally 
or by inunction; in many cases the latter is preferable, as, when diarrhcea occurs, 
the bowels are too irritable. A scruple of mercurial ointment should be gently 
rubbed in over the abdomen, thighs, legs, back, &c, until the gums are touched. 
Flying blisters to the abdomen are also useful. The diet must be bland and 
unstimulating. — Prov. Med. Journ., April 15, 1843. 

2G. Delirium Tremens cured by Ammonia. — Dr. Scharn extols highly the 
powers of the liquor ammonia? pyro-oleosus, or the liquor ammonias succinatus, 
in the treatment of delirium tremens, and asserts that under its influence, " the 
most violent madman, uncontrollable by the united efforts of four men, is 
brought, in the course of a (ew hours, from his state of excitement, and restored 
to rational existence." — Land, fy Edin. Month. Journ. Med. Sci. May, 1843, from 
Caspar's Wochenschrift, No. 5, 1843. 

27. Urea discovered in the Blood of individuals labouring under Inflammation 
of the Lungs. By Dr. F. Simon. — Having taken the coagula of six bleedings 
performed upon males and females, labouring under inflammation of the lungs, 
with a view to procuring a quantity of hcemato-globulin, Dr. Simon found that, 
by treatment with aether, alcohol, &c, and, finally, the addition of nitric acid to 
the syrup alcoholic extract, and desiccation under the air-pump, he procured a 
crop of crystals, which, under the microscope, presented themselves as an aggre- 
gate of rhombic tables, and which he discovered to be nitrate of urea. — Ibid., 
from Muller's Archiv., No. 1, 1843. 

28. Spontaneovs Rupture of the Spleen. By Dr. Alle. — A robust man, 50 years 
of age, had suffered from intermittent fever many years ago, from which, how- 
ever, he had long recovered completely. In the course of the few last years, he 
became subject to "stitch in the side" when he walked quickly; he had an at- 
tack of rheumatic fever in the spring of 1840; in the autumn of the same year 
he began to suffer extreme annoyance from a sense of burning heat in the soles 
of the feet, which, although he was not otherwise ill, kept him confined to his 
chamber through the winter. In January, 1842, he first complained o( burning 
pain in the region of the spleen, and Dr. Alle was summoned. The patient had 
a sallow look, no preper appetite, and his nights were sleepless; the urine was 
high-coloured; the bowels confined; there was burning pain in the region of the 
spleen, which was increased on pressure. The whole left side of the abdomen, 
from the hypochondrium downwards to the crest of the ilium, was extremely 
hard, without any irregularity; the feet were livid, and the burning of the soles 
still continued. There was little or no proper pyrexia. After three weeks of 
simple antiphlogistic and resolvent treatment, the patient complained one day at 
noon of a feeling, as if something had given way in his abdomen, and then of 
severe abdominal pain, and of sickness and vomiting. Before Dr. Alle could 
be fetched, the patient was moribund, and in about twelve hours expired, with 
every indication of extravasation of blood into the cavity of the abdomen. 

The post-mortem examination, in fact, showed that the greatly enlarged and 
hardened spleen had literally burst, and given occasion to a fatal hemorrhage 
into the general cavity of the abdomen. The organ appeared to be composed of 
lobuli, of the size of hazel nuts. — Lond. §r Edin. Month. Journ. Med. Sci., March 
1843, from Oder. Med. Wochens, No. 51, 1842. 

[Two other cases of spontaneous rupture of the spleen are recorded in our No. 
for Oct. 1842, p. 369.] 

29. Supposed Antivariolous Properties of Tartar Emetic Pustules. — M. Lichten- 
stein has published a curious article on this subject in " Hufland's Journal." 
His attention having been excited by the similarity of appearance between the 
smallpox and tartar emetic pustules, he was led to make some experiments on 
the properties of the latter. Clear lymph, taken from the pustules produced by 



1843.] Medical Pathology and Therapeutics. 209 

friction with the tartar emetic ointment, was introduced, in the usual manner, 
underneath the epidermis of persons who had not heen vaccinated. It gave rise 
to pustules which it was impossible to distinguish from those produced by vac- 
cine matter. The lymph of the tartar emetic pustules was inoculated from indi- 
vidual to individual, and invariably gave rise to pustules of the same form, and 
attended by the same symptoms. 

Since the year 1836 the author affirms that he has practised thirty-one vac- 
cinations and re-vaccinations with the matter from tartar emetic pustules; the 
persons thus vaccinated were placed in intimate relation with individuals af- 
fected with smallpox during an epidemic of that disease, and they all escaped 
contagion. 

Many further experiments will be required before the conclusions of the au- 
thor can be admitted.— Prov. Med. Jour?i. Nov. 5, 1842. 

30. Death from enlarged Bronchial Glands. — Dr. Golding Bird has recorded 
in the London Medical Gazette, (Nov. 1842,) a case in which death appears to 
have resulted by the constriction of the left bronchus by two enlarged bronchial 
glands, so as to prevent ingress and egress of air to the left lung, the right being 
so full of tubercles as to be incompetent to the task of arterializing the blood. 
Dr. Bird states that he has seen three other cases in which death occurred in 
the course of phthisis, where the disorganization existing was not sufficient to 
account for the fatal termination, and in which pressure on the left bronchus 
existed; in two the constriction was produced by enlarged bronchial glands, and 
in one by an aneurismal tumour. 

31. On the Epidemic Smallpox at Loreze in 1836, and the protective power of 
Vaccination. — By M. Millon. Every individual who had not been vaccinated 
was affected sooner or later with the smallpox; and in them the disease lasted 
from fifteen to twenty-five days. This difference in the duration of the disease 
depended on the mildness or severity of the case. It was invariably remarked 
that the milder the case, and the fewer the pustules, the sooner did the disease 
run its course; while, on the other hand, the more severe the attack, the longer 
was it of running its course, the longer was its duration. Many who had not 
previously been vaccinated were induced to be so during the prevalence of the 
epidemic, and the disease was invariably rendered milder in consequence. 

The circumstance of having been previously vaccinated did not appear to 
exempt the individuals from being variously affected with varieties of the small- 
pox. Thus, most of those previously vaccinated had the chickenpox eruption, 
a few others the varioloid eruption. It was very difficult to distinguish between 
the varioloid eruption and the smallpox during the first days of the disease. 
By the seventh or eighth day, however, the distinction was easy, as the vario- 
loid eruption began to dry up, while the smallpox ran on to suppuration. These 
eruptions are, therefore, essentially the same, says M. Millon, the difference 
arising from the disease in the one case running its natural course, in the other 
being modified by vaccination, or transformed into the vaccine form. Vaccina- 
tion, therefore, like inoculation, has created a new variety of smallpox. This 
conclusion is arrived at from comparing the appearance of the eruption after 
inoculation, and that after vaccination, when it assumes the varioloid form, 
which, he states, are not to be distinguished from each other. As inoculation 
with the smallpox gives no greater security than vaccination, and besides, has 
the great inconvenience of keeping up and propagating a highly contagious 
disease, besides being every now and then attended with considerable mortality, 
M. Millon strongly advocates the superior advantages of vaccination, which, 
if it does not always preserve from attacks of smallpox, what is more essential, 
it always or almost always deprives it of all danger. He adds the following 
important fact from his own observation. When by chance a person who has 
been vaccinated dies during an attack of smallpox^ it frequently happens that 
this takes place during the feverish stage, or on the first appearance of the 
eruption, so that there is every reason to believe the same person would have 



210 Progress of the Medical Sciences. [July 

equally fallen a victim to any other feverish disorder, while in smallpox the 
chief mortality occurs during- the suppurative stage. — Ed. Med. fy Surg. Journ. 
April 1843, from Bull, de VMad. de Med. Oct. 1843. 

32. Confluent Smallpox in a new-born child. — M. Gerardin exhibited a child to 
the meeting- of the French Academy of Medicine, born five days previously with 
a full eruption of confluent smallpox in a state of suppuration. The mother 
was healthy and had no complaint. About eight or ten days before her confine- 
ment she had visited a friend in the Hospital of La Pitie, near whom lay a 
person affected with smallpox. She herself suffered nothing in consequence 
of this visit, but the foetus in ulero had apparently been affected with the disease 
in consequence. — Ibid. Jan. 1843. 

33. Universal Suppuration of the Cerebrospinal Membranes, without any corre~ 
sponding symptoms. By Professor Wagner of Vienna.— Jacob Eichinger, a sol- 
dier in the 4th Light Infantry Regiment, had enjoyed good health during the 
seven years that he had been in the service. On the 17th of November, 1839, 
he was suddenly attacked with symptoms of gastric derangement, which in- 
creased on the following day, and compelled him to go to bed, at about a quarter 
to twelve, A. M. He fell asleep, and awoke in an hour delirious. Convulsions 
soon supervened; the man became comatose, and, although the most active 
antiphlogistic treatment was had recourse to, he died on the following day, No- 
vember 19th, at half-past four in the morning. 

The body was examined on the 29th. The cranial bones were remarkably 
thin, and the right side of the skull somewhat prominent. The whole of the 
superior surface of the cerebral hemispheres was covered with a layer of yellow 
fluid pus, and appeared somewhat flattened; no trace of the arachnoid could be 
found at this part. The pia mater was highly congested, and infiltrated with 
pus in its prolongations between the convolutions; the substance of the hemi- 
spheres was very much softened, and contained numerous points of blood when 
cut through; the lateral ventricles empty, and their walls softened in the highest 
degree; the pineal gland was very mu*h enlarged, and did not contain any calca- 
reous matter. The inferior surface of the cerebrum, and the whole of the cere- 
bellum, were covered with pus, and extremely soft; the arachnoid here also 
appeared to have been destroyed; the base of the cranium was bathed in pus; no 
fluid in the third or fourth ventricles; the pineal gland much injected. Tlie 
inner surface of the trachea was of a light red colour, but the bronchi was 
healthy. There were some adhesions between the pleurae, and the substance of 
the lungs was much congested; a few tubercles in the upper part of the left 
lung. The heart -was very large, soft, and loaded with fat, but not diseased. 
In the abdominal cavity nothing worthy of notice was found. The bladder con- 
tained about half a pint of turbid urine. The fibrous membrane of the spinal 
marrow was much injected, and the cellular membrane particularly so; its whole 
surface, and especially opposite the cauda equina, was bathed in the same kind 
of purulent matter as the brain; there was no trace of the serous membrane, and 
the substance of the spinal marrow itself was converted into a thin, pultaceous 
matter. 

Remarks. — This remarkable case is almost unique in the annals of medical 
science. Pathologists must decide whether the inflammation commenced in the 
arachnoid membrane, or extended to it from the softened nervous tissue, or whe- 
ther both states were simultaneously produced by one and the same cause. But, 
however this may be, we cannot but be struck with surprise that such extensive 
softening of the cerebro- spinal nervous mass, and universal suppuration of its 
serous membrane, should have existed without the production of any symptoms 
to indicate such extensive disease. Particular inquiries were made in the regi- 
ment in which the man had served, and it was ascertained that during the seven 
previous years he had enjoyed excellent health, having continued to do his duty 
as a soldier without interruption. It was only two days before his decease that 
gastric and convulsive symptoms made their appearance, and quickly terminated 



1843.] Medical Pathology and Therapeutics. 211 

in coma and death. — Prov. Med. Journ., Dec. 3, 1842, from Ostr. Med. Wuch., 
Nov. 4, 1842. 

34. Typhus Mdominalis. — Much new light has been lately thrown upon the 
pathology of this form of disease (typhus) hy the researches and observations 
of Professor Rokitansky, and which have been made known to the profession 
in this country by my friends and colleagues in Vienna, Drs. Drysdale and 
Russell, in their valuable article on the Pathology of Typhus, in the note to 
" Fletcher's Elements of General Pathology." From this we leain that "the 
Typhus process is characterized in an anatomical point, of view by the deposi- 
tion of a peculiar morbid product, which forthwith undergoes a distinct series 
of peculiar changes. The seat of this process is various, and depends upon the 
specific relation of the general process to certain organs. The tissues most sub- 
ject to this deposition are the mucous membrane and the lymphatic glands; and 
in Austria, at least, where the observations were made, the mucous membrane 
of the ileum {ilio-typhus) is most frequently affected, but it also occurs in the 
bronchia and lungs, (when in this seat constituting most probably the exanthe- 
matic typhus,') ar»d also, though very rarely, in the colon (colo-fyphus)." 

Let us examine its changes in the intestines — the most frequent seat of the 
process. First, the stage of congestion, corresponding to the period of irritation 
and catarrhal or gastric symptoms. " It exhibits a congested state of the ves- 
sels, or succulent condition of the mucous membrane, particularly of the villous 
coat extending over the greater part of'the ileum, hut better marked at particular 
spots — especially near the ccecum; the mesenteric glands are slightly swollen, 
their vessels are gorged with blood, their substance soft and elastic, and their 
colour dark. 

" In the second stage (the stage of deposition of the morbid product, i. e. typhus 
infiltration, which is in respect to the degeneration its crude stage) the congested 
stage moderates to a certain degree, and is reduced to several spots corresponding 
to the Peyerian glands, and a few solitary follicles. Here it appears in the form 
of round elliptic 'plaques,' varying from half a line to three lines in thickness, 
which are formed by the deposition of a peculiar substance in the Peyerian plexus 
and submucous cellular tissue. On a more close examination the degeneration 
is found to be so deposited in the submucous tissue of the follicles, that the 
deepest layer of that tissue, immediately covering the muscular coat, remains 
free from infiltration. It very seldom reaches beyond the bounds of the follicular 
apparatus. 

"The mesenteric glands are now more swollen, so as to reach the size of a 
bean or hazel nut. blue, or grayish-red, tolerably consistent, and apparently in- 
filtrated with lardaceous substance. 

"The commencement of the third stage (that of intumescence, softening and 
throwing off of the degeneration) is indicated by a return of the congestion in 
the ileum in a violent degree. The vessels, especially the veins, both in the 
mesentery and in their ramifications in the intestines, are gorged with dark-violet 
viscid blood, and the tissue of the mucous membrane presents again a swollen 
appearance, more especially in the villi, which yield a grayish-white turbid fluid 
on pressure. 

" But the most remarkable change takes place in the typhus-plaques and mes- 
enteric glands, which beeome sp,ongy and turgescent. These changes may take 
place in either of the following ways. The deposit assumes the appearance of 
a grayish marrow-like substance, and is then, along with the covering of the 
mucous membrane adhering to it, converted into a dirty yellowish-brown eschar; 
which, shrinking together from all sides, gradually loosens itself at the margin, 
splits into various directions, breaks off from the deepest stratum of the submu- 
cous cellular tissue, and is carried off all at once, or by a repeated recurrence of 
the process; or the deposit degenerates into a loose, vascular, blood-streaked, 
bluish-red, luxuriant fungoid structure, which becomes a special source of pro- 
fuse intestinal hemorrhages, and is generally thrown off piecemeal without scab- 
bing. 



212 Progress of the Medical Sciences. [Juty 

"The mesenteric glands now reach their greatest volume, attaining the size 
of a pigeon's, and near the ccecal valve not unfrequently that of a hen's egg. 
Their substance is injected, tolerably consistent, but changes into a grayish-red, 
loose pulp, frequently presenting the appearance of evident extravasation of 
blood. It is then soft and elastic, or frequently gives rise to the sensation of 
fluctuation. 

"In the fourth stage, after this deposition is thrown off, a loss of substance of 
the internal substance of the gut remains, which represents the proper typhus 
ulcer. It is unnecessary to go more into the detail or the appearance of these 
ulcers, which have been so frequently described and are so well known. At this 
stage the morbid product has been thrown off; the mesenteric glands diminish 
forthwith in volume by the removal of the infiltrated morbid matter, but they 
remain still somewhat larger than natural, and retain a reddish colour and their 
increased vascularity. 

" When the typhus process localizes itself in the bronchial mucous mem- 
brane, the phenomenon presents a considerable difference. It appears always in 
the form of a diffused intense congestion, with dark-coloured swelling of the 
membrane, and copious secretion of a gelatinous, occasionally dark blood-streaked 
mucous, and is principally developed in the bronchial ramifications of the inferior 
lobe. It appears, therefore, in this situation to be always arrested in the stage 
of typhus congestion, and never comes to any manifest production of that morbid 
product in the tissue of the bronchial mucous membrane, which is produced in 
such abundance in the follicular apparatus of the intestinal mucous membrane in 
abdominal typhus. Thus in the primitive broncho-typhus the general affection 
is localized in the bronchial mucous membrane alone, to the exclusion of all the 
other mucous membranes, even that of the intestines, with which the typhus 
process in general has the greatest affinity. In many cases indeed the latter 
exhibits a recognizable, but always subordinate secondary affection of the folli- 
cles, in which the neighbouring mesenteric glands participate; and it would often 
be difficult to recognise the affection as typhus, were it not for the other attendant 
changes which mark the disease — viz. the peculiar engorgement of the spleen 
and congestion of the pyloric extremity of the stomach, the condition of the 
blood, and the typhus nature of the affection in general, but more especially the 
change in the bronchial glands. This change is the same as that which the 
mesenteric glands undergo in the ilio-typhus. They are swollen to the size of a 
pigeon's or hen's egg, reddish-blue, spongy, friable, soft, and infiltrated with the 
peculiar typhus product. 

"This form is frequently combined with pneumo-typhus and typhus pleurisy, 
and is undoubtedly the pathological cause of the exanthematic contagious typhus, 
and most probably also of the Irish and North American typhus, which com- 
monly run their course without abdominal affection. 

" Sometimes the typhus affection of the lungs is better pronounced than that 
of the bronchia; but the former never occurs independently of the latter. 

" Besides these primary seats of typhus deposition it may be deposited in 
many other organs as a secondary formation, giving rise to many complications, 
which, though very interesting in a practical point of view, would lead to too 
much detail were we to notice them here. 

"Third. The typhus matter has, even at its origin, but much more in the 
transformations it undergoes, the greatest analogy with the cancerous degenera- 
tion, and more particularly with the medullary cancer. 

"Fourth. The local typhus process is an inflammation, not however of a 
healthy character, but of a typhus character; and this unhealthiness is given, 
according to Rokitansky, by the peculiar diseased state of the blood. Lastly, 
Rokitansky is of opinion that when the local process is not met with in the 
mucous membrane of the intestines or in any other mucous membranes, it may 
have run its course in the blood without localizing itself at all." — " Rokitansky' 's 
Handbuch der Paihologischen Anatomie^ 

A perusal of the foregoing remarks shows that its post-mortem appearances 
resemble very closely the Parisian form of the disease. The Viennese patholo- 



1843.] Medical Pathology and Therapeutics. 213 

jjists, however, consider it a dyscrastic affection, depending- entirely upon the 
formation and subsequent changes of the peculiar substance called "typhus mat- 
ter," similar in nature to medullary-sarcoma. — Wilde's Jluslria. 

35. Engorgement of the Uterus. — In a pamphlet published by Dr. Clement 
Oluvier, of Angers, on the treatment of prolapsus,uteri, he speaks strongly 
against the use of differently shaped pessaries, which are employed indiscrimi- 
nately, without paying attention to the cause of the prolapsus, which, according 
to Dr. Ollivier, is nothing more than an engorgement. Thence arise the symp- 
toms which are constantly observed, and which are attributed to any cause other 
than the presence of a foreign body, and its contact with a painful and inflamed 
surface. 

M. Ollivier considers that one of the most frequent causes of this affection in 
young girls, with whom it is very rare, is masturbation. He says, that one of 
the most frequent causes of chronic engorgement of the uterus in virgins, or wo- 
.men who do not have any communication with men, is masturbation, which, by 
gradually inducing disorder in the uterine functions, gives rise at first to spasm 
of the organ, which affects the secretion of the menstrua; on the other hand, this 
excitement, if frequently repeated, finally brings on a more or less intense san- 
guineous congestion, which gives rise to a kind of impermeability of the uterine 
parenchyma, caused by a slight inflammatory affection; then the dysmenorrhcea, 
at a later period, becoming habitual, induces amenorrhcea, which ultimately de- 
termines more dangerous diseases. Sterility is always an inevitable result, un- 
less the diseased state of the uterus being arrested, allows those portions of the 
viscus which continue healthy to perform their functions; the catamenia may- 
then reappear, but are almost always accompanied by uterine colics; the matrix 
may recover its powers of conception, but during gestation a period arrives when 
the uterus, not being able to enlarge freely, on account of the inflammatory action 
it has undergone before conception, reacts upon the product it contains, and 
almost always determines an abortion; in this way the pregnancies of women 
affected with morbid conditions of the uterus almost always terminate. 

Masturbation, in causing a disordered condition of the entire uterus, produces 
more frequently an engorgement of the body of the organ rather than of the neck, 
whilst an exactly contrary condition obtains in women who have connection 
with men. In virgins the affection of the body of the uterus is more frequently- 
found, that of the cervix uteri more rarely. 

M. Ollivier mentions, among other causes of engorgement of the uterus, the 
irritation of the sexual organs by primary connection, a cause of irritation of the 
organ the more dangerous, that it has hitherto escaped the notice of medical 
men, either because they do not attach sufficient importance to it, or because 
women conceal from them the knowledge of their illness, notwithstanding the 
sufferings they endure. 

The dysmenorrhcea, which almost always follows abortions, is the result of 
an inflammatory engorgement more or less considerable, and susceptible of cure; 
this engorgement is the cause of the sterility that follows miscarriages. The 
frequency of these inflammatory engorgements observed by the vulgar has ren- 
dered abortions more dangerous in their eyes than a delivery at the full period; 
when they take place during the first pregnancy, they are the more frequently 
to be attributed to a too great sensibility of the uterus, as yet unaccustomed to 
the sensations produced by coition. It is this sensibility which gives rise to 
consecutive inflammatory symptoms; under other circumstances this uterine 
sensibility causes the disorders which precede menstruation. 

M. Ollivier attributes the sterility which occurs to most women in large 
towns, after their first and second labours, to a similar cause. The editors of 
the Journal de Medicine et de Chirurgie Pratiques observe, with respect to this 
opinion, that they agree with M. Ollivier, that the engorgement of the uterus 
may sometimes prevent conception, but that another cause for this pretended 
sterility in great towns, and Paris especially, must be sought for. Considera- 
tions of a different kind will explain the small number of children found in fami- 



214 Progress of the Medical Sciences. U U ^Y 

lies, whose pecuniary means are not in just relation with their daily expenses. — 
Prov. Med. Journ. Nov. 19, 1842. 



SURGICAL PATHOLOGY AND THERAPEUTICS AND OPERATIVE 

SURGERY. 

36. Researches on the Decomposition and Disintegration of Phosphatic Vesical 
Calculi; and on the introduction of Chemical Decomponents into the living bladder. 
By S. Elliott Hoskins. — The object of these researches was the discovery of 
some chemical agent, more energetic in its action on certain varieties of human 
calculi, and less irritating when injected into the bladder, than any of the fluids 
hitherto employed. 

These indications not being- fulfilled by dilute acids, or other solvents which 
act by the exertion of single elective affinity, the author investigated the effects 
of complex affinity in producing decomposition, and consequent disintegration of 
vesical calculi. 

For this purpose an agent is required, the base of which should unite with the 
acid of the calculus, whilst the acid of the former should combine and form solu- 
ble salts with the base of the latter. The combined acids would thereby be set 
free in definite proportions, to be neutralized in their nascent state, and removed 
out of the sphere of action, before any stimulating effect could be executed on the 
animal tissue. These intentions the author considers as having been fulfilled 
by the employment of weak solutions of some of the vegetable super-salts of 
lead; such as the super-malate, saccharate, lactate, &c. The preparation, how- 
ever, to which he gives the preference, is an acid-saccharate, or, as he calls it, a 
nitro- saccharate if lead. 

This salt, whichsoever it may be, must be moistened with a few drops of 
acetic, or of its own proper acid, previous to solution in water, whereby alone, 
perfect transparency and activity are secured. He further states, that the de- 
composing liquid should not exceed in strength one grain of the salt to each 
fluidounce of water, as the decomposing effect is in an inverse ratio to its strength. 

Having by experiments, which are fully detailed, ascertained the chemical 
effects of the above class of decomponents on calculous concretions out of the 
body, the author briefly alludes to the cases of three patients, in each of whom 
from four to eight ounces of these solutions had been repeatedly, for weeks to- 
gether, introduced into the bladder, and retained in that organ without inconve- 
nience, for the space of from 10 to 50 minutes. — Proceedings of the Royal So- 
ciety, No. 5G. 

37. Nitric Acid in Hemorrhoids. — Dr. Houston has published an interesting 
communication in the March number of the Dublin Journal of Medical Science, 
in which he points out the peculiar forms of hemorrhoidal affections, to which 
he conceives the use of nitric acid as an escharotic is especially applicable. The 
external hemorrhoid, an offset from the dilated veins about the lower part of the 
rectum and anus, admitting, during the early period of its existence, of the ready 
ingress and egress of blood from those vessels, and afterwards being found as a 
shut sac, lined with a fine serous membrane, analogous to that forming the inner 
coats of the veins, and containing a small clot of blood, or else consisting of per- 
manent tumours of greater or le'ss magnitude, and of complex cellular texture, 
which, by forming adhesions to the mucous membrane or skin, and bursting 
there under circumstances of congestion, and also by becoming occasionally the 
seat of acute inflammation, may "produce all the inconveniences of a "fit of the 
piles," and must be regarded, as long as they continue to swell and bleed, as re- 
maining in communication with the°deeper varices from which they originally 
sprung, admits of removal by cutting instruments, although such operation may 
be attended with considerable and even profuse hemorrhage, controllable, how- 
ever, by the ligature, styptics, or actual cautery. Accordingly, excision or 



1843. J Surgery. 215 

destruction with the red hot iron are unhesitatingly resorted to, whenever the in- 
conveniences attendant on such affections require a radical removal for their cure. 

The form of hemorrhoidal tumour, for the relief of which Dr. Houston advises 
the application of nitric acid, is that state of the mucous membrane to which the 
term vascular tumour, has been applied. He regards it as an affection of the 
mucous membrane and submucous tissues exclusively, having for its basis a 
knuckle or bunch of varicose veins, or else being a distinct and independent 
growth, the result of some other irritation in that region, but giving rise ulti- 
mately to the formation of a varicose condition of the diseased part. These 
tumours vary in size and number in different patients. They may be so nume- 
rous and so large as to cause, by their protrusion through the anus, a permanently 
widened state of that aperture, and an habitual prolapsus, not only of the diseased 
growth, but also of a portion of the bowel, or they may be very few in number, 
and very small in size. In the early period of the affection the tumours are so 
soft, compressible, and free from pain, as scarcely to be discoverable by the 
finger when introduced into the rectum, but when of long standing, and especially 
when they have been permitted to remain down for protracted periods at the 
water-closet, they acquire an increase of firmness and a tenderness which render 
them easily detectable by such manipulations, and give them a tangible and 
permanent character. The dragging and pressure to which they are subjected, 
in being pushed out and squeezed by the sphincter in defecation, likewise render 
them prominent, and give them often a pedunculated or polypus-like form. The 
surface of the tumour is either granulated like a strawberry, or of a villous aspect. 
It is of a red colour, and when protruded from the anus, bleeds from every pore, 
the blood discharged being always of an arterial red colour; if it has previously 
laid in the bowel for some time, it acquires a dark red colour, and even a grumous 
character. 

There are two varieties of organic lesion known under the name of vascular 
tumour — the one called " erectile," from its supposed resemblance to conge- 
nital affections of this class; the other, a congested, hypertrophied, and tender 
state of the membrane, the result of irritative or inflammatory action. The first 
form, which may be regarded as a sort of aneurism by anastomosis of the small 
vessels of the mucous membrane and submucous tissue exclusively, differs from 
ordinary naevi in not being necessarily congenital, but resembles them too much 
in its persistent tendency to increase in growth. It may be independent, from 
the first, of varices of the general veins about the anus. The second variety is 
of a chronic inflammatory nature, and may be best described by comparing it to 
the red, villous, tender, hemorrhagic surface exhibited by the mucous membrane 
of the eyelids, in old cases of chronic conjunctivitis. The destruction of the 
morbid growth is the only means of relief for both these varieties, as they neither 
have any disposition or power to undergo a spontaneous cure; and this Dr. Hous- 
ton proposes to effect by the methodic application of nitric acid, instead of having 
recourse to the knife or ligature, the use of which, in very many cases, is neither 
necessary nor safe. 

The properties of pure nitric acid, as an escharotic, point it out, in theory, as 
an agent fitted to take the place of these over severe remedies, in cases where a 
superficial destruction of the part to be removed is all that is required; and the 
application of it to practice has fully proved its efficiency as a substitute. This 
acid, at the density of 1,500, destroys on the instant the vitality of that part to 
which it is applied, by the production of a chemical decomposition of its solid 
and fluid elements. The depth of the slough, which is to follow, may be regu- 
lated in some degree by the quantity of acid laid on the part; and its extent, 
laterally, may be limited by instantly smearing the whole over with olive oil, 
which neutralizes its further corrosive powers, by combining and forming with it 
a new, but no longer escharotic compound. The separation of the slough, after 
the nitric acid, leaves a healthy suppurating surface, which contracts and heals 
over very quickly, the tender, tumid, bleeding surface being removed with little 
pain and no danger, while, by the cicatrization and consequent bracing up of the 
general mucous membrane which follow the removal of the relaxed and diseased 



216 Progress of the Medical Sciences. [Juty 

part, the other varices are supported and reduced in bulk, and ulcers, or even' 
fissures, are healed. The resumption of the natural action of the bowels, and 
the general improvement in health which follow the application of the acid to a 
single vascular hemorrhoid, even where several are left behind, show an improve- 
ment in the state of the rectum generally, greater than could be supposed to arise 
from the simple abstraction of one from among the number. The relief, too, 
which the bowel gains by the removal of such a source of local irritation 
contributes, no doubt, in a prominent degree, to the production of the same good 
results. 

The application of the acid may be made in the following manner: — Let the 
patient strain, as at the night-chair, so as to bring the tumours fully into view; 
and while they are so down, let him either lean over the back of a chair, or lie 
down in the bent posture on the side on which the disease exists, with the but- 
tocks over the edge of the bed. The finger must not be passed into the rectum 
before the operation, as it will so compress the tumours as to diminish their bulk, 
and prevent the necessary steps being taken. When the patient is so placed, 
let a piece of wood, cut into the shape of a dressing case spatula, be dipped into 
the acid, and then, with as much of the acid adhering to it as it will carry with- 
out dripping, let it be rubbed on the tumour to the extent desired, its effect being 
shown by the part being changed to a grayish-white colour. One or more appli- 
cations of the acid are needed, according to the depth of the slough required, 
after which the whole is to be smeared with olive oil. The prolapsed parts 
should then be pushed hack within the sphincter, the patient put to bed, and an 
opiate administered. The pain is at first sharp and burning, but goes off in two 
or three hours, and does not return again in the same form. A general uneasi- 
ness about the anus on motion, together with a slight sense of heat, fulness, and 
throbbing, are felt for a few days, and there may be some slight feverishness. 
The symptoms following the application are usually so mild as not absolutely 
to require confinement to bed for more than a few hours, although, for many 
reasons, such confinement may often be desirable. On the third or fourth day 
a purgative draught should be administered, when the bowels will be found to 
yield to the medicine, generally without either pain or prolapsus of the rectum. 
The progress after this to healing is rapid, and free from any disagreeable symp- 
toms. 

This highly interesting and graphic communication is illustrated by cases. — 
Prov. Med. Journ., April" 15, 1843. 

38. Ruplure of the Internal Jugular Vein into an Mscess. — Alexander King, 
Esq. of Glasgow, records in the Land, and Edin. Monthly Journ. Med. Sci.,~ 
(March, 1843,) an interesting example of this occurring in a boy four years of 
age. This child had been attacked with scarlet fever, followed by a diffused 
swelling on the right side of the neck, below the lobe of the ear, considerably 
impeding deglutition and respiration, and giving rise to an incessant tickling 
cough. 

The swelling remained stationary for some days, but eventually evinced a 
tendency to suppurate, and after the application of a poultice it pointed and 
burst, leaving an opening into which a No. 8 catheter could be introduced. 
A quantity of pus was discharged; the swelling gradually subsided, and every 
thing seemed to proceed to a favourable termination for three days, when blood 
was observed by the nurse running down the patient's breast from underneath 
the dressings, and on removing them two jets were forcibly propelled. 

A few minutes afterwards Mr. King saw the patient with Mr. Brown, the sur- 
geon who had been previously in attendance. On removing the cloths which 
had been applied to arrest the hemorrhage, they found blood still flowing in a 
free stream from the opening already described; the walls of the abscess were 
very tense, about the size of a hen's egg, which, according to the mother's ac- 
count, was larger than before the abscess first gave way. It occasioned con- 
siderable difficulty in breathing, and gave rise to occasional severe paroxysms 
of couo-hino-, durino- which it became excessively firm and prominent. 



1843.] Surgery, 217 

Pressure on the carotid did not, in any manner, alter the state of the tumour, 
and pressure directly applied to its walls immediately brought on a fit of cough- 
ing, but did not appear to displace any of its contents. The pulse was extremely 
quick and feeble, and occasionally intermitting; the countenance was pale and 
blanched. Uncertain from what source the blood escaped, it was resolved to 
apply a compress and bandage to support its walls, and allow coagulation to take 
place, but it was found that when the bandages were applied tightly, the child's 
breathing was considerably impeded, and almost incessant coughing took place, 
so that it became necessary to apply them less accurately than was desirable. 

During the afternoon, hemorrhage again occurred, and required Mr. Brown to 
apply additional compresses. At mid-day on Sunday, the tumour had increased 
in every direction, and more compresses were needed to suit the altered circum- 
stances of the case. 

At seven o'clock the same evening the tumour having still further increased, 
it was agreed to remove the compresses and bandages, so as to ascertain ex- 
actly the state of the tumour, and if it gave way, to restrain the hemorrhage by 
making pressure on the injured vessels with the finger, and afterwards secure 
it with a ligature. 

When the bandages were partly removed, the child was seized with a violent 
paroxysm of coughing, during which the anterior wall gave way, to the extent 
of two square inches. A thin coagulum, about the size and thickness of a crown 
piece, was ejected, followed by an immense gush of blood. 

Mr. King instantly introduced the first two fingers of his right hand into the 
opening, and surrounded the fingers and tumour with cloths, and very little 
blood was afterwards lost, although Mr. K's. fingers could not get either to the 
upper or lower orifices, in consequence of the lower part of the tumour being 
covered by the parotid gland, and sterno-cleido-mastoid muscle. 

When Mr. K's. fingers were first pressed into the abscess, he felt blood flow 
freely downwards from above, and propelled upwards with great force, during 
each forcible expiration. A state of syncope followed in a few seconds, and the 
child expired shortly afterwards. 

Dissection, ten hours after death, — The swelling had entirely disappeared, and 
the skin, which had previously covered the tumour, had contracted in every 
direction, so that it could hardly be conceived that so much distension had ever 
existed. 

On dividing the integuments, from the lobe of the ear to the middle of the 
neck, it was found that the tumour, to a certain extent, had been divided into two 
sacs, which communicated very freely. The one extended below the digastric 
muscle and parotid gland to the base of the skull; the other having the parotid 
gland for its posterior wall, the sterno-mastoid muscle for its external, the pla- 
tysma fascia? and skin for its anterior. On cutting through the substance of the 
parotid, which was sound and healthy, and the posterior belly of the digastric 
muscle, a very distinct view of the source of the hemorrhage was obtained. 
Nine-tenths of an inch of the external wall of the internal jugular vein, com- 
mencing two lines below the base of the skull, and extending downwards, was 
completely removed, as if by a sharp scalpel. The internal wall, and even the 
margins of the opening, were perfectly healthy, and of the normal pearly white 
colour. The common carotid, at its division, was exposed by removing a little 
healthy cellular structure, and showed no appearance of disease. The walls of 
the abscess were examined in every direction, and found to be healthy, and an 
incision, two lines in depth at any point, displayed the surrounding structures in 
a natural state. 

Permission could not be obtained to make further examination. 
Mr. K. does not consider " that the child's life could have been saved, even if 
we had possessed the fore-knowledge of the state of parts, which were displayed 
on dissection. 

" A ligature could not have been applied between the laceration and the base 
of the skull, even granting that the internal jugular vein could be tied with im- 
punity. 



218 Progress of the Medical Sciences. U u ty 

" On our first visit, the tumour had exactly the appearance of a neglected 
abscess. The distension and colour of the integuments would have induced us 
at once to give relief by an incision, had not the small opening, referred to, 
existed, and had such a mistake been committed, I do not think the hemorrhage 
could have been even temporarily arrested, in consequence of the attenuated 
condition of the walls. The case presents a striking proof of the danger likely 
to. occur, from rashly opening abscesses in the vicinity of important vessels; and, 
in the locality of this tumour, it is feared that strumous abscesses are every day 
laid open, after a very cursory examination." 

Prof. Fergusson relates a similar case, in which the child also died from 
hemorrhage, and on dissection, the hemorrhage was found to have taken place 
from an, ulcerated opening in the lingual artery, near its origin from the carotid. 

39. Pathology of fracture of neck of the Femur.— Prof. Hargrave exhibited to 
the Surgical Society, Ireland, at their meeting on the 8th of April last, a specimen 
of ununited fracture of the neck of the femur, which he found in the dissecting 
rooms of the College school. It was taken from a male, aged between sixty and 
seventy, and occurred in the left thigh; the limb was from two to three inches 
shorter than the sound one, the motions of which were very free: the capsule of 
the joint was very thick for its whole extent; the two obturator muscles were 
very strong and attached to their usual parts; their augmented strength was evi- 
dently for the purpose of preventing the external part of the fracture being carried 
during progression and standing, upwards and outwards. This is the second 
example Professor H. met with of the value of these muscles in a nearly similar 
pathological condition of the neck of the femur. On opening the capsule poste- 
riorly, not a vestige of the neck of the femur remained; the head of the bone was 
closely confined in the cotyloid cavity by the lig. teres, which was shorter than 
usual, also much stronger; the external surface of the head of the femur towards 
he inferior part presented a small porcellanous deposit, and from the centre of 
the external surface a strong short band of fibrous structure passed downwards 
and outwards to be attached to the internal surface of the capsule; besides this 
strong band, two smaller ones extended from the edge of the head of the femur 
to corresponding parts of the capsular ligament: the articular aspect of the head 
of the bone presented a slightly nodulated appearance, which was deprived of 
cartilage, and covered by a thin lamina of the ivory deposit. This portion of 
the bone, from the nature of its fibrous attachments, was tolerably firmly fixed 
in its articular cavity. That part of the femur corresponding to the site of the 
external end of the neck of the bone was irregular in its aspect, and about one- 
third of it covered by the porcellanous deposit; in the movements of the limb it 
must have played upon a part of the head of the bone, chiefly where it was 
covered by the kind of deposit already mentioned. Professor H. considered this 
a rare specimen of the ununited fracture of this part of the femur, as there is no 
specimen in the museums of the College similar to it; there was one in which a 
strong fibrous band extended from the head of the bone to the near branch of the 
neck still existing. To sum up the peculiarities of this morbid specimen, not a 
vestige of the neck of the bone remained; the head of it was confined closely in 
its cavity by the ligamentum teres, and the fibrous bands extending from the 
external surface of the head to the capsule. Professor Hargrave expressed an 
opinion, that in future such extreme examples of the absorption of the neck of 
the femur would be very rare, in consequence of the improved plans of treatment 
now pursued for this kind of fracture, which, if followed up with care, would 
end in osseous union of it, or certainly union of so fir ma character as will continue 
to the patient the almost perfect use of the limb, and scarcely any deformity. 
Three, if not four, examples of this kind of fracture have been treated in the city 
of Dublin Hospital during the last four years with the most perfect success. — 
Dublin Medical Press, April 19, 1843. 

40. Glossitis in an Infant. — Surgeon Koettl relates a case of glossitis in an 
infant only nine days old. The affection having resisted the application of 



1843.] • Surgery. 219 

leeches to the sides of the windpipe and other treatment, the child's mouth was 
opened and a longitudinal incision made along the dorsum of the tongue. This 
was followed by free bleeding, and in two hours the tongue was reduced to half 
its former size. The patient recovered. — Oester Med. Wochens. No. 47, 1842. 

41. Hunter's Operation for Aneurism. — Mr. B. Phillips has collected from 
various works, 389 cases of aneurism treated by Hunter's method, of which 277 
were cured. 

Cases. Cures. 

Subclavian, - - - - - 80 - - 46 

External iliac, -----79 ---62 
Carotid, ------ 74 - - - 59 . 

Femoral, 113 - - -77 

Humoral, 30 - - - 24 

Various, - - - - - 13 - - - 9 



389 277 



— AmoWs Hunterian Oration, 1843. 



42. Aneurism.— Dr. J. Adair Lawrie, Prof. Surgery, Anderson's University, 
Glasgow, has examined the records of the Glasgow Infirmary, and finds that 
from the opening of the hospital in 1794, to 1st Jan. 1842, a period of forty-six 
years, there have been 23 operations "of aneurism for disease." Of these 
23 cases he has been able to procure more or less accurate details of 17, from 
which he has constructed the following table: — 

" 1. Sex. — i)f the 17, 13 were males, and 4 females, being in the proportion 
of 4{ to 1; giving a large proportion of females. Dr. Hodgson makes the pro- 
portion one in thirty-four. Dr. Hope says that, in external aneurisms, it has not 
exceeded in his experience 'one in fifteen to twenty.' 

"2. Age. — Excluding the two congenital cases, the ages range from 18 the 
youngest, to 65 the oldest. There is one under 20; two between 20 and 29; 
eight between 29 and 40; three between 39 and 50; one above 60. These ages 
are younger than is generally supposed; the explanation is to be found in the 
causes of the disease, or at least of the cases which form the table. 

" 3. Causes. — Of the 15 cases not congenital, eight were attributed to violence, 
either in the form of blows on the artery, as in cases 5 and 13, or from exertion 
or sprains: this combined with the ages and sex would show that external 
aneurisms are likely to be most frequently met with in those in the prime of life, 
whose occupations are fatiguing and laborious, and not in those whose arteries 
are diseased by age. 

*' 4. Vessels affected. — Of the 17 cases, 3 occurred in the vessels of the head, 
neck, and upper extremities, (viz. 1 temporal; 1 sub-clavian; 1 brachial and 
vessels of forearm); 14 in those of the lower extremity; viz. 1 profunda femeris; 
2 femoral, and 11 popliteal; showing a great disproportion between disease of 
the vessels of the upper part of the body requiring, or admitting of operation, 
and those of the lower. Of the lower vessels the popliteal is by much the most 
frequent cause of operation. This is doubtless attributable to the position of 
this artery relatively to the knee-joint. Something may also be owing to its 
being imbedded in cellular tissue, at some depth under the facia, and hut loosely 
supported by the muscles. Of 10 of the popliteal aneurisms in which the limb 
is stated, 7 were in the left, and 3 in the right. This may have been accidental; 
but so far as it goes it may appear an objection to the opinion, that the cause of 
these aneurisms is rather to be sought for in the effect of violence than in disease 
in the vessels, inasmuch as the right knee is fully as much exposed to injury 
and over-exertion as the left. It may however admit of explanation, in what [ 
believe to be very frequently the case, that the ligaments of the .left knee 
are more lax than those of the right, allowing the joint to be thrown unduly 
backwards, and thereby causing a greater strain on the parts placed posterior 
to it. 



220 



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"5. Mortality. — Of the 17 cases, 4 
were fatal; being deaths to recoveries as 
1 to 4£; of these 17, the results of two 
are uncertain, and in one the operation 
failed, the patient's life having- been 
saved by amputation; consequently in 

5 cases out of 15 the operation failed, 
the proportion being as 1 to 3 — a much 
greater mortality than I expected. The 
causes of death were, 1st, serous ef- 
fusion into the cerebral cavities, in the 
case of ligature of the subclavian (No. 
'2). This was doubtless owing to the 
increased quantity of blood transmitted 
along the carotids, and suggests in cases 
of this kind, especially when the patient 
is advanced in years, the propriety of 
venesection before and after the ope- 
ration; shaving the head, keeping it high 
and cold, and using those means which 
experience has shown to be best adapted 
for lessening the quantity of blood in 
circulation through the brain. 2d. Case 
4, ligature of the external iliac, died of 
inflammation of the tissues in the neigh- 
bourhood of the wound of the operation. 
3d. Gangrene occurred in three case3 
(8, 9, 12) of ligature of the femoral for 
aneurism of the popliteal. In all am- 
putation was performed, two died and 
one recovered/' 

Dr. Lawrie also gives the preceding 
table of seven cases of Traumatic 
Aneurism. 

Of these 7 cases one was in the carotid 
and six in the brachial. Of the latter, 5 
followed venesection, and one an injury; 

6 recovered, and one died; but in one 
the patient was saved by amputation. 

" In the 24 cases given in the above 
tables, secondary hemorrhage took place 
in 5 (more than 1 in 5); in three from 
the wound of the operation, in one from 
the bursting of the sac, and in one from 
the original wound. In two amputation 
was performed — one died, and one re- 
covered. In one the wound was re- 
opened and fresh ligatures applied with 
success. In two pressure was trusted 
to with success. So far as these sta- 
tistics go, they teach us to give pressure, 
as firm as safety will allow, one fair 
trial, that failing, to secure the vessel, 
as above advised. Amputation can 
seldom be justified for uncomplicated 
hemorrhage, and should only be per- 
formed when all other means have been 
fairly tried and have failed." — Lond, 
Med. Gaz., Jan. and Feb., 1843. 



No. XI.— July, 1843. 



222 Progress of the Medical Sciences. [July 

43. Osteosarcoma of Thigh-bone.— Jlmputalion.— Two cases of this have been 
communicated to the Royal Medico-Chirxir gical Society by R. A. Frogly, Esq. 
The first is that of a female, aged twenty-six, who had a tumour of the thigh, 
which measured, in its greatest diameter, thirty-five inches and a half, and 
reached from* with in an inch of the trochanter to the knee-joint. It began in 
the summer of 1829 with a pain in the condyle of the femur, and in May oF the 
following year a tumour had formed, of the size of the half-closed hand. It 
continued gradually to enlarge, without pain or discoloration of the skin, or 
materially impeding the motions of the limb, till March, 1843, when the limb 
was amputated. Owing to the close proximity of the upper part of the tumour 
to Poupart's ligament, it was anticipated that it migiit be necessary to disar- 
ticulate the bone at the hip-joint; but in the course of the operation, when the 
two lateral flaps had been made, the femur was found in a healthy condition 
below the lesser trochanter, and it was sawn through at this point. Mr. Lane, 
who assisted, commanded the blood-vessels by pressure with his fingers on the 
external iliac artery, so that scarcely any arterial liEemorrhage took place. 
What little occurred was immediately arrested by another assistant grasping 
the flap until as many as ten ligatures were applied. After the operation the 
patient caused much alarm by falling into a faint, in which she gasped as in 
articulo mortis; but she was soon restored from this condition. The stump 
healed favourably, and there has been no return of the morbid growth. A longi- 
tudinal section having been made of the thigh-bone and tumour, it was seen to 
consist chiefly of a whitish, elastic, hard tissue, resembling cartilage, but rather 
more transparent. /.There was very little deposit of osseous structure in it, and 
the tumour appeared more connected with the periosteum than with the bone 
itself, which could be readily distinguished in the morbid mass from preserving 
its sound condition. Numerous cysts, communicating with each other and 
with a large central cavity, were developed in the tumour, and these contained 
several pints of a yellow, tenacious, honey-like fluid. 

The second case is that of a married lady, aged thirty-seven, who had, also, 
a tumour of the thigh. The swelling was first observed eleven years ago, 
as a hard lump, about the size of half a walnut, situated on the inner condyle of 
the femur. When seen by Mr. Frogly, five or six years after its commence- 
ment, it had not increased perceptibly in size; but in five years more it had 
acquired considerable magnitude, and had extended up the thigh. Finding that 
it made more rapid progress, so that it measured, at its largest part, twenty inches 
and a half in circumference, while the thickness of the limb below was only 
twelve inches, she consented to undergo amputation, which was performed in 
August, 1848, and the slump healed by the first intention. Upon making a 
section of the thigh-bone and tumour it was remarked that the morbid growth, 
although smaller than in the preceding case, presented the identical appear- 
ances both in position and structure which have been described in this case. — 
Prov. Med. Jour. April 22, 1843. 

44. Treatment of Aneurism by the method of Br asdor.— -The following are the 
conclusions of a paper read by M. Diday to the French Academy of Medicine, 
September 13, 1842. 

1st, In every aneurism of the innominata, it is necessary to tie both the carotid 
and the subclavian; in those cases where it may have appeared that success lias 
followed the ligature of one of these branches, it has been found that the inno- 
minata was either not involved, or that the cure was not complete. 

2d, The ligature of both branches at the same time is assuredly the most ac- 
tive of all methods; the dangers of the operation have been much exaggerated, 
for analogy and experience ever prove, that the circulation is still carried on in 
the upper extremity, after both branches have been tied. Most fear is to be 
apprehended from hemorrhage and inflammation of the sac. In the present 
state of the science, M. D. would not disapprove of a surgeon performing this 
operation, but he would not recommend it himself, even although it has been 
successfully done. 



1843.] Surgery. 223 

3c?, When both branches of the innominata are to be tied, and are to be oblite- 
rated, the surgeon ought to begin the treatment by throwing a ligature round the 
patent one. 

4th, But in this case, it is necessary to distinguish real from apparent oblite- 
ration of the vessel, caused by pressure of the aneurism on its origin. This 
distinction is important, as our treatment is different. Experience has shown in 
three cases, that when in one branch, where suspension of the circulation only 
exists, and the other branch has been tied, the same good results do not fol- 
low as when there is real obliteration, but that, on the contrary, the operation 
has some serious disadvantages. 

5th, When before the operation both branches appear equally permeable, we 
must endeavour, by observing in what direction the tumour is advancing, when 
the pulsations appear strongest, and by alternate pressure, first on the one and 
then on the other, to decide which of the two ought to be tied first. In cases 
of doubt, we ought to commence with the carotid. Experience has proved this; 
besides, it is established statistically, that the ligature of the carotid is an ope- 
ration just half as dangerous as that of the subclavian or axillary arteries. 

6th, As a general rule, the second ligature should be applied as soon as the 
effects of the first have ceased, i. e- when the tumour is no longer diminishing; 
if the pulsations reappear after they had suspended, we ought to hasten the ope- 
ration as much as possible, and if the carotid has been the first tied, it should 
not be delayed beyond the time, when the fear arising from imperfect circulation 
has been removed. This fear will be found illusory when we consider the nu- 
merous facts which prove the great rapidity of the re-establishment of the circu- 
lation after ligature of the carotid. 

1th, When the carotid has been tied after the jmethod of Brasdor, hasmorrhage 
has been only observed twice from the wound. In both cases it was from the 
upper part of the vessel, and in both it was attributed to the ligature having 
been placed too near the bifurcation of that vessel. 

8^, Alterations in the coats of the artery appear to be equally common in the 
upper and in the lower part of the primitive carotid. We ought then, cseteris 
paribus, to place the ligature as far as possible from the bifurcation of that ves- 
sel, as, towards that point, there is equal chance of finding the coats diseased as 
lower down, besides having less risk of haemorrhage from the upper extremity. 
— Lond. $r Edin. Month. Juurn. Med. Sci., January, 1843. 

45. Structure of Neuromatous Tumours in stumps. — Dr. Bennett exhibited to 
the Anatomical Society of Edinburgh, February 8, 1843, a neuromatous tumour 
about the size of a hazel nut, which had been removed from the stump of a 
patient of his by Mr. Spence. It had caused the individual great agony, which 
was entirely removed by the operation. On making a section through the 
tumour, it was found to be composed of a dense white substance, of cartilaginous 
consistence. Examined microscopically it was seen to be made up of numer- 
ous bands of fibres, enclosing an amorphous structure. The bands were com- 
posed of from twenty to forty filaments crossing and recrossing each other, and 
terminating in loop?. This filamentous structure differed in its arrangement 
from any other which Dr. Bennett had hitherto examined. About three-eighths 
of an inch of the nerve, to which the tumonr was attached, had been removed 
with it, and this presented the same structure as that of the tumour. No remains 
of nervous tubes could anywhere be detected. 

Mr. Spence considered that these tumours, on the ends of divided nerves, 
were not necessarily productive of pain in the stump. They existed on the cut 
extremities of nerves in every case, and only give rise to pain when exposed to 
pressure, when partially implicated in a firm cicatrix, or when thinly covered 
and thus exposed to the effects of atmospheric changes, or other external causes. 
When thickly covered by the soft parts it was seldom they gave rise to painful 
symptoms, though of large size. Mr. Spence, in support of these statements, 
exhibited a preparation of the nerves from a stump of the \eg, where, although 
a neuromatous tumour existed on every nerve, the only one which had ever 



224 , Progress of the Medicul Sciences. [July 

given rise to pain bad been situated between the cicatrix and end of the fibula. 
He also showed several drawings of stumps which he had dissected, where the 
neuromata were very large, and yet had occasioned no pain. — Land, ty Edin. 
Month. Journ. of Med. Set., April, 1843. 

46. The Starch Apparatus for Fractures. — M. Seutin, the inventor of the 
starch apparatus for the treatment of fractures, has recently visited Dublin, 
where be has explained and demonstrated the application of his bandage. One 
great objection had been, that the apparatus, when once put on, remained a hard 
case round the limb, allowing no room for the necessary degree of tumefaction, 
and consequently endangering the safety of the member by inducing gangrene; 
and that, as the parts were hid from view, no timely warning was afforded of 
such accidents. As the starch bandage was used, there was much truth in this 
objection; as M. Seutin now uses it, the occurrence of such dangers is obviated. 
He first applied a calico roller, moderately firm, round the leg; no starch was 
put on the inside of this bandage, as it would stick in the hairs, and prove un- 
pleasant to the skin when it hardened. After it was applied some starch was 
smeared along its surface; wherever pressure was wished to be avoided pledgets 
of soft lint were put; a soft pasteboard splint, a little starched on the inside, 
was then placed on each side of the leg, and then one behind, the part about the 
heel and the hollow of the tendo Achillis being well stuffed with lint; a paste- 
board splint *was also then put in front. These were secured by a bandage 
smeared with starch, the end of the bandage being turned down and stuck in 
front, so as to be easily found. More starched bandage was applied, till the 
whole was a firm and smooth case. This should be left for twenty-four hours: 
when it has become quite dry, ii is then slit down along the whole front of the 
outside, in the space between the tibia and fibula, down to the end of the foot. 
When the sides of this opening are held aside, the state of the limb can be 
examined. If it is found to press too much on any part, a little lint can be 
inserted, so as to raise the apparatus from the place pressed on; should it be 
desirable, any part of it covering a wound, &c. can be cut away, to allow the 
proper dressings to be applied, and the discharge to be removed. 

Long bandages are preferred wherever it is requisite to establish a regular 
compression, and that the lifting up of the injured part cannot entail inconveni- 
ence to the patient, sharp "pain, derangement in the coaptation, &c. Short 
bandages are reserved for contrary cases; they are disposed generally in three 
planes; it is between the layer in contact with the skin and the middle layer 
that the pasteboard splints are generally placed; short bandages are especially 
employed in lesions of the pelvic extremity. The length or breadth of the 
bandages is proportioned to the part which ought to be covered with them. 
Folds should be repeated as seldom as possible, and never on bony eminences 
or excrescences, which should be defended by layers of wadding, lint, or some 
other such material, besides the bandage. 

It is important to leave uncovered the ends of the fingers or toes, whose vari- 
ations of colour and of temperature furnish a sufficiently just measure of the 
analogous changes of the other parts of the limb covered by the bandage. 

The compression exerted by this apparatus ought never to reach to that degree 
of violent constriction which practitioners, as little familiarized with M. Seuiin's 
method as with the general principles of compression, have believed to be 
necessary for the resolution or prevention of inflammation. Compression, as 
understood by M. Seutin, ought to stop at a gentle methodical pressure, suffi- 
cient to moderate the afflux of blood, but not to stop it — a pressure which, in 
many circumstances, at the instant of its application, is only retentive, and which 
never acts on the soft parts, so as to be able to induce mortification in their 
tissues. The pressure should always be made to act from the extremities to the 
centre as evenly as possible, care being taken to avoid its immediate action on 
bony or tendinous prominences, excrescences, &c. 

The starch apparatus dries in the course of from thirty to forty hours after its 
application, but its desiccation may be aided by the employment of artificial 






1843.] Surgery. 225 

heat if needed, which, however, is better avoided if possible. Unless the 
patient complain of pain, or much uneasiness in the injured limb, or the surgeon 
entertain fears on the state of the soft parts, it would be as well to defer the 
section of the bandage to the second or fourth day, when, if the apparatus fulfil 
the views proposed, it is made secure again with a starched bandage; if it exer- 
cise too much pressure, the edges must be separated, the interval being filled up 
with a little softened pasteboard; the exterior surface is then to be smeared with 
starch, and the apparatus surrounded by a starched bandage, very little com- 
pressed. Folds and plaits that press the skin irregularly are to be removed; 
the pieces that exercise injurious local pressure are to be wet slightly with 
water; pieces of lint are to be inserted where necessary, and the whole to be 
surrounded by the starch bandage, care being taken to make a daily inspection 
to see that all is right. If the apparatus appear defective in any particular, it 
should be removed, having been previously wet with tepid water, and replaced 
by another, less objectionable. — Dublin Juurn. Med. Set-, Nov. 1842. 

47. Bare Cases of Strangulated Hernia. — M. Gerdy has met with two very 
curious cases of strangulated hernia. In the first the constriction took place in 
a narrow canal of seven or eight centimetres long, which existed along the 
course of the superior-strait of the pelvis, and of the external iliac artery. The 
patient died after the operation. In the second, the hernia occurred on a level 
with the anterior superior spinous process of the ilium; it lay betwixt the ex- 
ternal and internal oblique muscles, and was complicated by the presence of the 
testes, the adhesions of which to parts around, had, in fact, opposed the farther 
downward passage of the small intestines, which had therefore mounted above 
the iliac spine. — L. §r E. M. Journ. Med. Sci., May, 1843, from V Experience, 
Jan. 12, 1843. 

48, Vesico-Vaginal Fistula. — The Archives Generates dc Medecine, for March, 
contain a very lengthy but interesting communication on the treatment of vesico- 
vaginal fistula, with the detail of two successful cases, by M. Lallemand, of 
Montpellier. The first case is that of a lady, twenty-three years of age, labour- 
ing under this affliction from the use of instruments in her first labour. The 
fistula was situated about three and a half inches from the orifice of the urethra; 
its transverse diameter was about an inch and a half, the two lips being separated 
to the extent of half an inch, and the posterior one masked by a fold of the 
vesical mucous membrane an inch long, one third of an inch high, and one fourth 
of an inch thick. The greater part of the circumference of the vagina behind 
the fistula was blocked up and narrowed by semicircular, thick, and hard cica- 
trices, into which the first phalanx of the index finger could not be passed, 
whilst -the index and medius fingers together could be passed into the bladder 
through the fistula. 

The first step directed by M. Lallemand under these distressingcircumstane.es, 
was the dilatation of the vagina by large bougies, and afterwards by conical 
gum elastic cylinders, which unfortunately proved, on the patient's return to 
Montpellier in two months' time, to have been misapplied, inasmuch as the 
fistula was much increased in size, and the vaginal contraction in the same state 
as previously. M. Lallemand, after having then for a few days attempted to 
dilate the vaginal passage, on the 22d of February, 1836, applied the actual 
cautery on the flap of vesical mucous membrane which blocked up the posterior 
lip of the fistula, so as completely to destroy it. The sloughs separated in a 
few days, and the anterior lip having been brought into the same state by the 
appli ation of the nitrate of silver, the entire edges of the fistula being fresh 
and bleeding, the hooked catheter (sonde- air -igne) was immediately applied, a 
task of some difficulty on account of the depth of the fistula and the impossi- 
bility of introducing the finger beyond the contraction of the vagina; the vesico- 
vaginal parietes consequently not being supported, were pierced by the hooks 
with difficulty, and it could not be ascertained whether they were at a proper 
distance, from the posterior lip of the fistula. If they had been too near, the 
soft parts would have been torn; and if too far, the cervix uteri might have been 



226 Progress of the Medical Sciences. QJuly 

injured. Guided, however, by the marks engraven on the stem of the instru- 
ment, the hooks were confidently forced in, and the instrument being slowly 
drawn, the fistula could be felt with the index of the other hand to be gradually 
closing; the movable plate was then wrapped up with lint, and the spring- work- 
ed until the coaptation was complete. The instrument was then perfectly fixed 
by its own mechanism. It was withdrawn five days afterwards, and a common 
elastic cUheter passed for a few days, after which the patient made water as 
usual. Four weeks after the operation, the parts were examined with the spe- 
culum, when a transverse band of a bright red colour, half a line wide and more 
than an inch long, was seen on a level with the contracted part of the vagina, 
the cicatrices of which prevented the extremities of the band being seen. The 
patient, being now able to retain her water for three or four hours, left Mont- 
pellier, to which she returned in the following spring, complaining of fluor albus, 
the discharge being very liquid. Lallemand at first thought the cicatrix had 
given way in some part, but this was proved not to be the case by a very careful 
exploration; there were found two small and tortuous canals on either side of 
it; the cauterization of which arrested the discharge. The bladder was kept 
empty for several days after the application of the actual cautery. The patient 
recovered perfectly, and the catamenia, which had been absent from the time 
after confinement, soon reappeared, and resumed their natural course. 

In the second case, the vesico-vaginal fistula, which was also caused by the 
use of instruments, was situated about three inches posterior to the meatus 
urinarius, having a transverse diameter of nearly one inch and a half, and nearly 
an inch in the antero-posterior direction. The vagina was contracted by two 
thick cicatrices, but not sufficiently to prevent the passage of the finger beyond 
the posterior lip of the fistula. The right lower extremity was partially para- 
lytic and contracted. The operation was performed as in the preceding case, 
the edges of the abnormal communication between the bladder and vagina having 
been freshened by the actual cautery and the subsequent removal of the sloughs, 
the parts were brought into coaptation by the hooks of the sonde-airigne, which 
was kept in for several days, and then replaced by a common elastic catheter. 
The state of the parts was examined a few weeks afterwards with the aid of 
the speculum, when the fistula was found to be closed, except in the centre, 
where there was an interval of a line in extent, which soon healed under the 
application of the nitrate of silver. The patient was dismissed, cured of her 
infirmity, three months after the performance of the operation. 

The proceeding thus advised by Lallemand requires much care in order not to 
involve any part of the uterus, for a case is recorded by him, in which the hooks 
having been applied to the part of the bladder covering the womb, and in all 
probability into the womb itself, pain in the pelvis, speedily extending over the 
whole abdomen, set in, and notwithstanding the removal of the instrument, 
symptoms of gastro-enterilis and hepatitis with delirium became manifest, and 
although the patient for a time survived the attack, she gradually sunk into a 
state of exhaustion and marasmus, with disturbance of the intellectual functions, 
and died in the course of the ensuing year. On examination of the body, 
traces of chronic peritonitis, disease of the liver, and effusion of serum within 
the cranium were discovered; although the womb was not found to be the seat 
of organic changes, M. Lallemand is convinced from the symptoms, that it was 
the source of the complicated diseases which destroyed his patient, and in this 
opinion he was confirmed by the results of another case which terminated fatally 
in eight days, the autopsy presenting similar appearances to those in the pre- 
ceding case. In those cases, therefore, where the fistula is situated on a level 
with the cervix uteri, it is advisable to attempt a cure only by means of cau- 
terization made with great care, and renewed at long intervals. 

The employment of the sonde-airl^ne is not adapted for those cases of fistula 
where the opening is so exceedingly small that it can be closed by the swelling 
induced by the cauterization of the parts, or where the fistula is of such a size 
as to occupy the larger part of the vesico-vaginal septum, so that the edges of 
the fistula could not be brought into contact, or finally where a healthy charac- 



1843.] Surgery. VL1 

ter of inflammation cannot be excited so as to ensure reunion. As a general 
rule, the chances of success are in the inverse proportion to the duration of the 
infirmity, because, according to the length of time the diseased state has existed 
is the degree of irritation and unhealthy inflammation about the parts, and the 
disordered condition of the general health, consequently the less likelihood is 
there of a pure and proper character of inflammatory action setting in, and the 
consequent formation of a firm cicatrix. 

It is a task of exceeding difficulty to freshen the entire circumference of the 
fistula with cutting instruments; some points will escape division, or not be cut 
with uniformity, while at the same time if a cutting instrument be used effec- 
tually, a greater portion of the soft parts is removed, and the opening conse- 
quently made larger, without any special advantage, than when cauterization is 
had recourse to. Swelling of the adjacent part is not occasioned, as when the 
latter process is employed, the tumefaction being of service in rendering the 
coaptation more easy and more complete. The actual cautery should be had 
recourse to whenever it is requisite to destroy certain parts and to remove ine- 
qualities, especially when the opening is very large, or masked and sinuous, so 
that its course cannot be followed with a stick of nitrate of silver. The in- 
strument should be of an olivary shape, not more than a line in diameter in the 
most enlarged part, and the stem still thinner. Probes of different sizes and 
shapes should be used for the tortuous canals. The inferior paries of the vagina 
must be protected from the influence of the cautery by the demi-speculum, and 
the upper part by a large spatula made with an elbow, that there be not any 
shadow cast by the hand of the assistant. The spatula will serve at the same 
time to bring the diseased parts into view. 

The sonde-airigne is preferable to the surare in every case where the fistula is 
transverse, or can be brought into that form, which can almost always be done 
when the operation is possible. Out of twenty-one cases, M. Lallemand has 
only met with one oblique and irregular fistula, the reunion of which could not 
be effected from behind forwards. If the sutures are not sufficiently tightened, 
or become relaxed by the slow section of the parts engaged, the lips of the 
fistula gape, and the operation must be repeated, for there is not any means of 
increasing the compression. It is not so with the sonde-airigne, as the pressure 
with it can be increased or decreased at pleasure, nor can the edges of the wound 
get out of place, they being kept in situ by the hooks of the instrument, which, 
at the same time, retain the instrument itself in a state of immobility. It has 
been employed by M. Lailemand in fifteen cases, and he has been successful 
with it in nine, not always at the first operation, but at the utmost in two, but 
the most frequently the application of caustic has been sufficient to effect a cure 
afterwards.— Prov. Med. Juurn. April 8, 1843. 

49. Cancer of the Mamma: statistics of the disease: treatment by compresses of 
kydriodate of potass, §rc. — M. TANCHou.read to the French Academy of Sciences 
on the 14th November last, a communication in relation to the prevention of the 
cancerous degeneration. He supposes that diseases of the mamma increase in 
proportion as civilization advances; and he has attempted to show this by a 
series of tables. In the department of the Seine, in 1830, 668 died from cancer: 
in 1840,889, being an increase of from 1-96 to 2*40 per cent, on the total mor- 
tality during that period of 382,851 individuals. In Paris alone, in 1830, 595 
fell victims to this disease; while in 1840 there were 779, giving a mortality of 
2 54 per cent, on the deaths; while in the rest of the department, the deaths 
were — in 1830, 73; in 1840, 110; or 1-63 of the total number. M. Tanchou con- 
demns excision, as well as the employment of caustic as a substitute for this 
treatment. He recommends several methods, and among others, that by com- 
pression: the compresses to be formed of the hydriodate of potass, five parts; 
sponge in powder, tan parts; the hydrochlorate of ammonia, fort)' parts; and the 
hydrochlorate of sodium, ten parts; or a powder composed of powdered sponge, 
twenty parts; nitrate of potass, and Florentine iris, of each one part. Thirty 
people have been treated in this way, all of whom appeared to have derived 



228 Progress of the Medical Sciences. [Juty 

considerable benefit from it. In some, the gland bas been entirely removed, but 
in the greater number, remains of it have been visible aftprwards. In none, was 
the knife deemed necessary, although in some of the cases an operation had 
been proposed before the commencement of M. TVs treatment. — Lund, ty Edin. 
Month. Journ. Med. Sci., January, 1843. 

50. Imperfect Luxation of the Radius. — Dr. Goyrand, of Aix, has published, 
in the Annates de la Chirurgie Frangaise et Etrangere, two instances of a 
displacement of the head of the radius, not described in surgical works, but of 
frequent occurrence among children. 

On the 9th of September a little girl, three years old, while walking on an 
unequal pavement, was nearly falling, when her mother caught her, and kept 
her up by the right hand. The child immediately screamed out, and could not 
use the limb; she was brought directly to M. Goyrand. The forearm was flexed 
to one-fourth its full extent, the hand was in pronation, and dependent, the limb 
motionless, and there was neither deformity nor swelling at the elbow. Any 
attempt to bring the hand into supination caused the child to scream. M. Goy- 
rand took the right elbow in his left hand, pressing his thumb at the same time 
on the anterior face of the head of the radius, and having the child's hand in his 
own. He then extended the forearm, and exercising rather powerful traction, 
principally upon the radius, while he carried the hand in supination, then, push- 
ing the head of the radius backwards with the thumb, he suddenly flexed the 
limb, and the displacement was reduced. The pain the child was suffering 
from was instantly removed, and the little patient could use the hand to carry a 
piece of cake, which was given her, to her mouth. 

The second case so completely resembled this, that it is only mentioned to 
state that the reduction was as easy and sudden as in the preceding. 

In 1837, M. Goyrand published a communication in the Gazette Medi- 
cate, on this injury, from which it appears that it is an incomplete luxation of 
the superior extremity of the radius, forwards. Jt is met with only in very 
young children; it is observed most frequently from the age of eighteen months 
to three years, when falls are frequent, and to prevent them, children are caught 
by the hand, or else the child is lifted up by the limb to carry it over the kennel. 
The upper extremity, thus placed in pronation, supports the whole weight of 
the body; the weakness of the ligaments and muscles at that age favours the 
separation of the articular surfaces; a luxation does not take place, and conse- 
quently there is not an appreciable change in the shape of the elbow, but the 
extremity of the radius, separated at first from the small head of the humerus, 
from the traction exerted on the forearm, is carried forwards by the rapid con- 
traction of the biceps, and there results a change of the articular relations suf- 
ficient to explain the appearance of the phenomena by which this injury is gene- 
rally accompanied. 

A significant crackling noise warns the surgeon when the articular surfaces 
have regained their respective positions. The pain is immediately removed, 
and the use of the limb is so perfectly restored, as to prevent any necessity for 
consecutive treatment — Prov. Med. Journ. Nov. 19, 1842. 

51. Staphyloraphy. — The Dublin Journal of Medical Science, for January last, 
contains an account of three casos, in which the operation for uniting the cloven 
soft palate was performed successfully. The operator in the first case was Dr. 
Cusack, surgeon to Stevens' Hospital, in the two others Sir P. Crampton. Dr. 
Cusack's patient was a medical student, eighteen years of age, labouring under 
a congenital fissure of the soft palate. For some time previous to the operation 
he was directed to employ measures to diminish the irritability of the fauces, 
the existence of which constitutes one of the principal difficulties, and in the 
removal of which he was perfectly successful. 

Dr. Cusack proceeded as follows: — With the aid of a simple forceps and 
curved needles, three ligatures were passed at equal distances from each other 
through the soft palate, the lowest being at the base of the uvula; a double- 



1843. J Surgery. 229 

edged knife was then introduced about a line from the margin of the cleft, and 
the same distance from the apex of the triangle; on each side in succession, the 
incisions being terminated above. After the lapse of a short time, during which 
the patient took some light nourishment, the edges of the wound were approxi- 
mated, and the ligatures tied with a surgical knot; one of them, however, 
having been cut, as it was supposed, too closely, unravelled, and was replaced. 
Some slight haemorrhage followed, with teazing cough, and a few hours after 
the operation all the ligatures had become unravelled, and were, of necessity, 
replaced by two others at points more remote from the margins of the fissure. 
They were each secured by a simple knot. No untoward symptoms occurred 
afterwards, and on the fifth day the ligatures were cut, the palate being perfect, 
the only remaining defect being a bifid uvula, a condition commonly met with 
in persons who articulate with perfect distinctness. 

Sir Philip Crampton's patients were a boy of twelve years of age and a 
young lady aged sixteen. The peculiarity in the treatment of these cases con- 
sisted, first, in the manner of securing the ligature; and secondly, in the man- 
agement of the patient after the operation. The difficulty of tying the second 
knot on the ligature, without suffering the first to become opened by the strong 
retraction of the edges of the fissure effected by the muscles of the palate, has 
always been acknowledged. This difficulty, however, was effectually removed 
by an ingenious contrivance of Mr. Maclean's; after the ligatures had been 
passed through the palate at the distance of a quarter of an inch from the cut 
edge of the fissure, and brought out at the mouth, their ends were passed 
through a small perforated metallic bead, such as are used in making purses; 
the bead was then pushed down along the ligatures, closing them as it de- 
scended, until it touched the approximated edges of the wound; it was then 
compressed with a pair of strong, blunt-pointed forceps, and the ligatures were 
thus firmly secured without a knot at the required degree of tension. The 
other and most important peculiarity in the treatment consisted in allowing the 
patients an ample supply of soft food during the whole period of the treatment. 
Boiled bread and milk, custard, soup, and jelly, were given twice or thrice a 
day, and the patients were not confined to their*beds, Sir Philip Crampton con- 
ceiving that the total privation of all nourishment for five days, so strongly 
insisted on by Roux, was not only unnecessary, but in the highest degree un- 
favourable to the successful issue of the operation, as it must cause a state of 
constitutional disturbance highly unfavourable to the establishing of the healthy 
process of union by the first intention, in proof of which the observations of 
Messrs. Manoury and Thore, house-pupils at the Hotel-Dieu, where Roux's 
operations were performed, are quoted; they state that they have seen delirium 
and severe nervous derangement follow such protracted abstinence from food. — 
Prov. Med. Jour. March 25, 1843. 

52. Staphyhraphy in cases of Cleft, Palate. By M. Roux. — The velum palati, 
like the upper lip, may be affected by a species of congenital malformation, which 
consists in fissure or separation of the lateral portions, along the median line. 
This division may be simple — that is, confined to the soft parts; or complicated — 
that is, extending more or less to the hard palate, or even comprising the alveolar 
processes of the superior maxillary bone and the upper lip. Artificial reunion 
of the velum palati has been chiefly applied to the congenital disease; but it is 
equally suited to accidental malformations arising from ulceration, wounds of the 
mouth, or certain operations for the extraction of polypi, foreign bodies in the 
pharynx, &c. 

In some cases the disease is confined to simple bifurcation of the uvula; in 
others, which is less common, a part of the soft palate only is divided; in ordi- 
nary cases the fissure extends to the whole of the soft palate. M. Roux lately 
saw rather a rare example in the son of a German physician; the soft and hard 
palates were separated, but there was no hare-lip; the velum palati, however, 
was imperfectly united by a thin transparent membrane, evidently formed by the 
mucous membrane. Although the fissure always exists on the median line, the 



230 Progress of the Medical Sciences. [Juty 

two sides of the palate do not always present the same degree of thickness or 
breadth — a circumstance which may cause some trouble in fixing the needles 
properly. On the other hand the palate may be in various states which are more 
or less favourable for the success of the operation. It may be solid, thick, and 
capable of supporting the sutures well; or it may be thin, membranous, and semi- 
transparent. The degree of separation varies much; sometimes it is produced by 
simple bifurcation of the posterior nasal spine; sometimes by complete separa- 
tion of the two sides of the roof of the mouth. In the latter case the cavity of 
the mouth communicates freely with that of the nares and pharynx. 

As to solutions of continuity arising from wounds, we can readily conceive 
that they must be extremely irregular and of various forms, according to the 
causes which have produced them. The same remark applies to deformities 
from syphilis or scrofulous ulcerations, and the latter are much more frequent 
than has hitherto been supposed, their ravages being erroneously attributed to 
secondary syphilis. 

Having thus briefly noticed the anatomical varieties of cleft palate, it may be 
well to enumerate, as briefly as possible, the inconveniences which arise from 
this deformity. In new-born children it gives rise to great difficulty, or even 
impossibility, of drawing the breast, according to the extent of the fissure. When 
the velum palati alone is cleft the child may be able to suck; but even then, 
whenever he is placed in a horizontal position, deglutition becomes extremely 
difficult; some assistance, however, may be rendered by placing the infant erect, 
and by pressing the bosom. When the hard palate and lip are divided the child 
is incapable of sucking, and must be supported by artificial means. As the in- 
dividual advances in life much inconvenience may arise from a difficulty of pro- 
nouncing words intelligibly, and the voice is always nasal and disagreeable; 
certain guttural sounds can never be produced. The English physician on whom 
M. Roux performed his first operation pronounced the th like s, and spoke more 
distinctly in French than in English. "Verba naribus egredientia videbantur." 
Amongst minor inconveniencies may be reckoned the impossibility of blowing, 
of drinking in the horizontal position, playing wind instruments, &c. &c, a great 
tendency to reject all fluids through the nares. 

A remarkable fact, which should have been noticed before, is that the two 
sides of the velum approximate each other, or come into contact during efforts at 
deglutition; it was this fact which first led M. Roux to the idea of uniting them 
by suture. 

Staphyloraphy is an extremely delicate operation; it requires so much docility 
and patience on the part of the individual operated on that it should not be at- 
tempted before the age of fifteen or sixteen; but this period may be slightly 
advanced or deferred, according to the determination and courage of the patient. 
The operation may, indeed, be performed at any period of life; and the earlier it 
is done the less chance we have of being foiled by a vicious habit of pronuncia- 
tion; but experience shows that the chances of success are not sufficient to war- 
rant us in undertaking it before the period just mentioned. 

In cases of cleft palate complicated with fissure of the hard palate and upper 
lip, the hare lip should be united at as early an age as possible. 

The instruments employed during the operation are known to all surgeons. 
They are few and simple; flat ligatures, formed of two or three threads, and 
fixed in the needles, needle-carriers (parte- aiguilles), hooked forceps, common 
forceps, a probe-pointed bistoury, and a pair of long-bladed curved scissors, &c. 
The most convenient needles are from 0.44 to 0.88 of a line in breadth, slightly 
enlarged near the eye; of a parabolic form, the curve being 0.88 of a line and the 
branch which supports the eye being about six or seven lines longer than the 
other branch. 

The patient is placed on a low seat; the ligatures are inserted from below up- 
wards at equal distances; generally three in number, commencing from behind 
and at from 3.5 to 3.9 lines from the edges of the fissure. When the point of 
the needle has passed clearly through, the needle-carrier is opened, and the liga- 
ture disengaged by the forceps. The three ligatures being thus placed, the sur- 






1843.] Surgery. 231 

geon proceeds to refresh the edges of the fissure. The inferior part of the velum 
is seized by the hooked forceps, and the excision which has been commenced 
with the scissors is finished with the bistoury; the flap or portion of tissue thus 
removed is about 1.7 to 2.2 lines broad. The ligatures are now tied in the same 
order that they were placed; the first knot being held by the ring-headed forceps, 
until the second one is fastened. 

Such is the usual course of proceeding, but in cases of division of the hard 
palate the following modification is made: — When the edges of the fissure have 
been refreshed, the soft parts are divided transversely by an incision which runs 
along the posterior edge of the palatine bones. This aids very considerably the 
extensibility of the two sections of the velum palati, and enables the surgeon to 
unite them without using the slightest force. 

Every circumstance which may impede the union of the parts must be care- 
fully avoided. The patient must observe complete silence, and avoid every ex- 
citement; he must not swallow his saliva, and even food must be abstained from, 
the ill-effects of abstinence being counterbalanced, if possible, by nutritious ene- 
mata. It must be confessed, however, that the latter are very efficacious sub- 
stitutes for food, and few patients can support absolute privation from it. In 
two cases the want of food gave rise to severe agitation and delirium; on the 
whole it may be prudent to let the patient have some liquid sustenance in small 
quantity. 

The immediate results of the operation are a sense of tension in the back of 
the mouth, and sometimes smart pain extending into the ear. The ligatures 
should be removed on the fourth or fifth day; the inferior ligature the last in 
cases of simple fissure, but first in the complicated form. Sometimes we can 
remove the ligatures on the fourth day; sometimes the inferior or superior one is 
left in for a day longer, according to the distinction just made. The thread is 
simply taken hold of by a forceps, and cut through. The patient should have 
some broth before the ligatures are divided. During the next few days he must 
preserve silence, and take nothing but broth. 

The following analysis of nine cases operated on during the course of the year 
1841 will serve to furnish some idea of the results of this operation: — 

Case I. — A patient, twenty years of age, had a fissure involving the hard and 
soft palates and the upper lip. The hare-lip had been operated on some years 
previously by M. Sanson. A considerable interval separated the two segments 
of the roof of the mouth in nearly its whole extent; the velum pendulum was 
thick and strong. The operation was simple: M. Roux divided the velum trans- 
versely near the edge of the palatine bones. The patient was examined five 
months after the operation, and found to be in a most satisfactory state. The 
fissure was very considerably reduced, appearing merely as an oval aperture; he 
could now speak distinctly, whereas before he could not pronounce words intel- 
ligibly. 

Case II. — This case was analogous to the preceding one. M. Roux had 
operated on the patient for hare-lip when he was five years old, and the effect of 
that operation was to diminish the interval between the lateral portions of the 
hard palate. Ten years afterwards, in April, 1841, staphyloraphy was performed 
with complete success. 

Case III. — This was the case of a girl, twenty-one years of age. The lip was 
intact, and the fissure occupied the soft palate only. The operation lasted about 
half an hour; its results were satisfactory, a small aperture only remaining, which 
will probably close up with time. 

Case IV. Vassel, thirty-one years of age, was admitted into the 

Hotel-Dieu on the 4th of July, 1841. He was born with simple cleft palate; 
there is, however, a slight notch in the posterior nasal spine; the lateral seg- 
ments of the velum are of equal thickness, but the left is narrower than the 
right. 

The operation performed on the 5th of July, presented nothing remarkable, if 
we except some difficulty in fixing the left portion of the superior ligature. When 
the threads were drawn together, a small aperture remained, which it was ira- 



232 Progress of the Medical Sciences. [July 

possible to obliterate by tightening the upper knot. On the following day, in 
spite of injunction, the patient talked constantly and drank frequently. On the 
9th the ligatures were removed; union had taken place at a small point only, near 
the middle of the fissure. This was M. Roux's hundredth operation. 

Case V. — Maret, was admitted into the Hotel-Dieu on the 8th of July, 

and the operation performed on the 20th. This was a case of fissure extending 
through the whole of the palate and upper lip. M. Beclard had operated for the 
hare-lip when the patient was seven years old, but the operation was only suc- 
cessful in part. The edges of the wound had united by the second intention, but 
the anterior portions of the hard palate had been so completely approximated, 
that there was not the slightest interval between the incisor teeth. The left side 
of the velum was narrower than the right; both were thick and well organized. 
On the 24th, the two inferior ligatures were removed; reunion had not taken 
place at the lowest points. On the 25th, the superior thread was removed, and 
here union was perfect. He left the hospital on the 28th. 

Case VI. — A young man, twenty-two years of age, had simple fissure of the 
velum, with bifurcation of the posterior nasal spinous process. The operation 
was performed on the 20th of July, 1841. The two superior ligatures were re- 
moved on the fourth day, and the inferior one on the fifih. Complete union had 
taken place, but the cicatrix gave way opposite the lower thread, in consequence 
of violent coughing. There likewise remained a very small oval aperture from 
the bifurcation alluded to. On the 13th of August it became necessary to apply 
a fresh ligature over the inferior portion of the velum. 

Case VII. Mas, twenty years of age, a musician, was operated on at 

the Hotel-Dieu, on the 24th of August. The case was one of simple fissure of 
the soft palate. Four days afterwards the ligatures were removed and complete 
union had taken place. The cicatrix was firm on the 29th, when the patient 
was allowed to speak and eat. On the 31st nothing remained, except an oval 
aperture of 0.8 to 1.3 of a line in diameter, from bifurcation of the posterior nasal 
process. 

Case VIII. — The operation in this case was performed in London, in the 
month of September, 1841, on a man, thirty-five years of age, not for congenital 
malformation, but for loss of substance from syphilitic ulceration. The opera- 
tion failed. 

Case IX. — This operation also failed; it was performed on a tailor, named 
Hurel, eighteen years of age. The ve3um palati was thick and short, divided 
in its whole length; the posterior moiety of the hard palate was likewise fis- 
sured. On the 1st of November, 1841, two sutures only were inserted, as the 
palate was narrow; the edges of the wound were easilj refreshed and the trans- 
verse incision made without difficulty. There was some trouble in tying the 
inferior knot, because the uvula was constantly driven against it, by the base of 
the tongue. The two threads were removed on the 5th, when it was found that 
the middle portion of the wound only had united. The voice, however, was less 
disagreeable. On the 7th, the whole of the cicatrix gave way while the patient 
was coughing. 

From the preceding observations, it appears that of the nine cases just related, 
five were examples of complete and complicated fissure of the palate, cases in 
which the prognosis is always unfavourable. In three of those five cases the 
result was as favourable as could be expected; intone of the remaining two the 
operation completely failed; in the other a partial benefit resulted. Four cases 
were examples of simple fissure, although in two there was bifurcation of the 
posterior spinous process, which is always followed by the persistence of a 
small aperture. This latter can only be removed by having recourse to palato- 
plasty, and seldom if ever closes of its own accord. Finally, of two of the most 
simple cases, one failed, while the other was only partially successful. Of the 
nine patients operated on, one was a female; their ages varied from 15 to 35; the 
majority of cases (5 in 9) occurred between 20 and 22 years. 

Although the operation is, in itself, attended with no danger, yet in 3 of the 
105 cases it was followed by death. In one, severe inflammation of the pharynx 



1843.] Ophthalmol) gy. 233 

set in, and extended to the air-passages. The second was a young Englishman, 
who died with irregular nervous symptoms. The last case occurred in the 
daughter of an eminent English nobleman, who was carried off soon after the 
operation by phthisis. In 1828, M. Roux had performed 40 operations for cleft 
palate; 19 were cases of simple fissure, and of these 13 were successful, G unsuc- 
cessful; 21 were cases of complicated fissure, of which 12 failed, and 9 suc- 
ceeded. In 1834 he had performed 68 operations, in 1842, 105. 

The general result was, success in two-thirds of the cases of simple fissure; 
and in one-third only for cases cr complicated fissure. This is not so favourable 
a result as that obtained from the earlier operations, but as it is drawn from a 
large number of cases, it probably gives a fair estimate of the chances of success 
or failure of the operation. — Prov. Med. Journ., December 24, 1842, from Gaz. 
Med. de Paris, No. 30. 

53. Syphilitic Rhagades of the Sole of the feet and Toes. — Dr. Herschman re- 
commends the following salve as ofgreat efficacy in allaying the pain and pro- 
moting the healing of the fissures. 1£. — Unguent. Lytharg. 3j., Hydrarg. Praecip. 
alb. gr. x.— Bj. M.—Oest. Med. Wochens., No. 51, 1842. 



OPHTHALMOLOGY. 

54. Structure and mode of action of the Iris.— A paper on this subject, by C. R. 
Hall, Esq., was read to the Royal Society, Feb. 9, 1843. After reciting the 
various discordant opinions entertained at different periods by anatomists and 
physiologists, relative to the structure and actions of the iris, the author proceeds 
to give an account of his microscopical examination of the texture of this part 
of the eye in different animals. He considers the radiated plicae, which are seen 
in the uvea in the mammalia, as not being muscular; but he agrees with Dr. 
Jacob in regarding them as being analogous in structure to the ciliary processes. 
The white lines and elevations apparent on the anterior surface of the human 
iris he supposes to be formed by the ciliary nerves, which interlace one with 
another in the form of a plexus. The iris, he states, is composed of two por- 
tions; the first consisting of a highly vascular tissue, connected by vessels with 
the choroid, ciliary processes, sclerotica and cornea, and abundantly supplied 
with nerves, which, in the human iris, appear, in a front view, as thread-like 
stria?; and which are invested, on both surfaces, by the membrane of the aqueous 
humour. They are more or less thickly covered with pigment, which, by its 
varying colour, imparts to the iris on the anterior surface its characteristic hue; 
and, by its darkness on the posterior surface, renders an otherwise semitrans- 
parent structure perfectly opaque. The second component portion of the iris con- 
sists of a layer of concentric muscular fibres, which fibres, in man, and mam- 
malia generally, are situated on the posterior surface of the pupillary portion of 
the iris; but which, in birds, extend much nearer to the ciliary margin, and con- 
sequently form a much broader layer. In fishes, and in some reptiles, they do 
not exist at all. 

The author then proceeds to inquire into the bearings which these conclusions 
have on the physiology of the iris. He thinks that the phenomena of its mo- 
tions can receive no satisfactory explanation on the hypothesis of contractility 
alone, or on that of the antagonism of two sets of muscular fibres, the one di- 
lating, the other of contracting the pupil. He is convinced that the contraction 
of the pupil is the effect of muscular action; but does not consider the knowledge 
we at present possess is sufficient to enable us to determine the nature of the 
agent by which its dilatation is effected. He, however, throws it out as a con- 
jecture, that this latter action may be the result of an unusual degree of vital 
contractility, residing either in the cellular tissue, or in the minute blood-vessels 
of the iris. It is from elasticity, he believes, that the iris derives its power of 
accommodation to changes of size, and its tendency to return to its natural state 



234 Progress of the Medical Sciences. QJuly 

from extremes, either of dilatation or contraction; but beyond this, elasticity is 
not concerned in its movements. — Proceedings of the Boy a I Society, No. 56. 

55. Lachrymal Calculi. By M. Desmarres. — An old woman, 66 years of age, 
who had swelling of the joints of the fingers and toes, the result of gout, had 
suffered for two years from lachrymation of the right eye, which was succeeded 
by a discharge of purulent matter. On examining the eye, the conjunctiva and 
sclerotic were injected, the superior lachrymal puncture was healthy, while the 
inferior one was dilated to three tmies its natural size; from this there flowed a 
sero-purulent matter, which was not increased by pressure over the sac. A.n 
indolent tumour, of the dimensions of a small nut, occupied the situation of the 
lachrymal sac; the conjunctiva was raised by it; the skin over it was of the natural 
colour, but that of the cheek was excoriated in several places, by the constant 
irritation of the tears, and discharge. Upon introducing a probe into the lower 
punctum, a hard resisting body was felt. About two months after M. D. first 
saw the patient, the inconvenience arising from the tumour was so great that she 
determined to have it removed. This was easily accomplished, by means of a 
director placed in the lower punctum, and inserting on it one blade of a pair of 
scissors, and cutting with them the superimposed textures towards the inner 
part of the eye. The concretion, about the size of the green pea, immediately 
fell out; some yellow sandy matter was then removed from the bottom of the 
incision, and the walls of the sac and duct cauterized. The wound was quite 
healed in twenty-four days, when all the unpleasant symptoms for which the 
operation was performed had disappeared. 

The following analysis of the stone was obtained by M. Bouchardat: — 

Concrete albuminous matter, . . .25 parts. 

Mucous matter, . . . . 18 " 

Fat, ..... Traces. 

Carbonate of lime, . . . . 48 " 

Phosphate of lime and magnesia, . . 9 " 

Chloride of sodium, . . . Traces. 

Its weight was 4 centigramives, and its sp. gr. 1*14. 

— Lond. §r Edin. Month. Journ. Med. Sci., March, 1843, from Gaz. Med. de Paris, 

December 3, 1842. 

56. Turpentine in Hemeralopia. — Charles Kidd, Esq., relates in the Dublin 
Medical Press for 10th May, 1843, two cases of Hemeralopia which had proved 
refractory to various remedies, and which were cured by the following mixture: 
R 01. Terebinth, ol. Ricini aa ,^j; Mist. Camphora 5iv; Liquor polassa gj; Tr. 
Opii gtt. x. Ft. Mist. A large table-spoonful every morning and night. 



MIDWIFERY. 

57. Abdominal Puerperal Neuralgia — Dr. Golding Bird, in a communication 
published in the January number of the Edinburgh Monthly Journal, draws the 
attention of the profession to a peculiar form of neuralgia arising from uterine 
irritation after parturition, which rather closely simulates the characters of 
puerperal peritonitis, and has often, as he believes, been mistaken for it. He 
narrates three cases in illustration of his remarks, in each of which the com- 
plaint was apparently removed by remedies, which certainly could not have 
cured the puerperal inflammation. He observes that at a time, varying from a 
few hours to a few weeks, after parturition or miscarriage, we occasionally find 
excessive irritation of the uterus, attended with intense neuralgic pain over the 
abdomen, and a suppression of the lochial discharge manifested, producing, as 
might be anticipated, a disordered state of every function of the body, and 
giving orgin to a set of symptoms often mistaken and treated for puerperal fever 
or peritonitis. In the first case narrated by Dr. Bird, that of a woman whose 



1843.] Midwifery. 235 

nervous system had been from the commencement of menstruation always more 
or less deranged from an irritable state of the uterus and its attendant, hysteric 
epilepsy, forty-eight hours after the termination of labour, the peculiar set of 
symptoms indicative of intense uterine irritation supervened. The suppression 
of the lochia and urine, the position of the patient in bed, the pulse, state of the 
tongue, skin, and abdominal tenderness, all preceded by rigors, appeared to 
indicate that much-dreaded disease, puerperal peritonitis; but the incoherent 
screams, the wild and unmeaning expression of countenance, the tossing of her 
arms, and the constant shifting of her position in bed, as well as the crying out 
on the mere approach of the hand to the abdomen, and the pain occurring in 
paroxysms, pointed out, on the other hand, the existence of excessive irritation, 
and unmasked the true character of the disease. The result of the treatment by 
the use of fomentations, purgatives, and opiates, fully justified the prognosis. 
Still, however, a degree of uterine irritation persisted, evidenced by pains about 
the loins, hips, and pubes. The bowels were next allowed to become consti- 
pated for two days, the consequence being the re-occurrence of rigors, cessation 
of uterine discharge, and an apparent attack of intense pleurisy. A careful ex- 
amination of the symptoms, however, demonstrated the neuralgic character of 
the complaint, and she was again relieved by purgatives and opiates, by which 
the discharge of numerous scybalous masses was obtained. 

The second case occurred in the person of a young woman, who, from the 
commencement of her first menstruation, had been the subject of those pains 
characteristic of uterine irritation, and which became more severe at each men- 
strual period. The bowels were habitually constipated, and she always suffered 
more or less from leucorrhceal discharge. The attack was induced by exposure 
to a draught of air, whilst in a state of perspiration, eleven days after parturition, 
and in its symptoms resembled puerperal peritonitis, for which i't was mistaken 
by a practitioner who had been called in before Dr. Bird saw her. Fomenta- 
tions and saline aperients speedily removed the complaint. 

Dr. Bird, aware that the objection might be urged, that these cases of neu- 
ralgia arose from intestinal irritation, observes that we have equal evidence of 
derangement of every function of the body; the secretions of the skin and 
kidneys are in most instances deficient, those of the liver and mucous surfaces 
are always more or less vitiated, and the bowels, though often constipated, are 
occasionally acting too energetically, or in some cases are tolerably regular; but 
the uterine functions are, as far as Dr. Bird has seen, invariably affected, the se- 
cretion being either entirely arrested or becoming very foetid and viscid. He does 
not consider it reasonable to suppose that a slight constipation — a symptom of 
such frequent occurrence during the puerperal state — could develope so serious a 
train of symptoms, unless some other function was so manifestly imperfect as 
to produce a generally irritable condition of the nervous system, and thereby 
render the body obnoxious to attacks of disease from exciting causes, which, in 
the ordinary state, and when free from such depressing influences, would be 
almost without action upon it. He regards the depressed state of the nervous 
system produced by the irritable condition of the womb, as the predisposing 
cause of these attacks, and any slightly deranged function, whether of the skin, 
liver, or bowels, will act as an exciting cause upon such a deranged state of the 
system, and develope in full force the severe neuralgic attacks under consider- 
ation. 

With regard to the diagnosis of these neuralgic affections, the comparison of 
the different symptoms presented by the patient will generally bethe best guide 
of the practitioner. Every symptom of genuine peritonitis may be present in 
these attacks, but not at the same time; again, the accession of the pain in pa- 
roxysms, the screaming out ere the hand is in contact with the abdomen, or 
when it has barely touched the parietes; the fact of our being often able to apply 
considerable pressure without pain, when the patient's attention is arrested by a 
sudden exclamation, an abrupt query, or her infant's cries, will generally enable 
the practitioner to detect the true natuie of the disease. The excessive depres- 
sion of spirits, and often the strange and groundless delusions of the patient — 



236 Progress of the Medical Sciences. [Juty 

the accession of an occasional hysteric convulsion — will also assist in forming 
a correct diagnosis, a task at all times of no small difficulty in these cases. 

There is one very curious circumstance connected with this suhject, that 
when a rumour has been spread abroad of a patient having died of puerperal 
fever, almost every other woman in the neighbourhood who happens to be con- 
fined is seized with the symptoms just narrated with greater or less severity, an 
effect somewhat analogous to that produced on the nervous system of some 
women who see another the subject of hysteric fits. — Prov. Med. Journ. March 
18, 1843. 

58. Rupture of the Uterus. — Dr. Mitchell's contributions to obstetric medicine, 
published in the January number of the Dublin Medical Journal, contain the 
details of a case of rupture of the anterior wall of the uterus, which terminated 
successfully. The treatment chiefly relied on consisted in the sustained admin- 
istration of opium. The patient was a woman, thirty-eight years of age, the 
mother of six living children. When admitted into the Southeastern Lying-in 
Hospital, of which institution Dr. Mitchell is the master, the os uteri was found 
dilated as large as a penny piece, the head presenting, and the pains recurring 
about every ten minutes. She was admitted on the night of the 18th of Sep- 
tember, 1842, and at seven, A. M., of the following morning, Dr. Mitchell was 
summoned to be in attendance in consequence of the pupil being alarmed at the 
great prostration of strength which had ensued. Stimulants were given, and, 
in consultation with Dr. Beatty, it was at once determined to extract the child. 
On attempting to effect this with the forceps, the head receded, so that it was 
thought advisable to use the perforator, which was done according to Dr. M'- 
Keever's plan — that is, not to apply it at the most depending part of the presenta- 
tion, but to one side; so as to press the part as it were against the pelvis of the 
mother, and thus prevent the recession of the child through the rent. The head was 
afterwards extracted without much difficulty with the crotchet, the uterus acting 
in the expulsion of the shoulders and body. The placenta was extracted 
immediately, and a rent perceived at the junction of the anterior part of the 
cervix with the os uteri. The uterus contracted firmly, and no intestine what- 
ever escaped through the fissure. The internal administration of opium in the 
solid form was immediately commenced, a grain being given every hour. To- 
wards evening small doses of calomel were combined with it, and the abdomen 
steeped with hot water and turpentine, in consequence of impending symptoms 
of peritonitis. The inflammatory indications, with the exception of considerable 
irritability of stomach, were speedily checked; but severe diarrhoea set in, and 
continued nearly throughout the treatment. In other respects the patient had 
scarcely a bad symptom after the first severity of the accident had been subdued. 
On the sixteenth day, a discharge of about two pints of extremely foetid, muco- 
purulent fluid took place from the vagina, and nearly to the same extent the 
following day, but less foetid in appearance. After that it gradually diminished 
in quantity, and was very trifling when she was dismissed on the thirty-first day 
after the accident. 

Opium in this case was relied on from the commencement; it was adminis- 
tered at the suggestion of Dr. Beatty, who had previously witnessed its good 
effects in a case of rupture of the uterus, occurring likewise in the anterior wall 
of the cervix. With respect to its action in these cases, it is well known that 
it exerts a powerful influence in allaying or diminishing muscular contraction, 
and is thus supposed to be of use in cases of rupture of the intestine; at least 
this is the view taken of it by Dr. Hart, who, at page 30G of the fifth volume of 
the Dublin Hospital Reports, after speaking of the impropriety of giving purga- 
tives, as by their action they would tend to increase the peristaltic motion of 
the intestines, and thus produce a greater effusion of the intestinal contents, 
says, instead of purgatives, then it would appear more proper to give large doses 
of opium with a view of suspending peristaltic motion, could this be accom- 
plished, and the inflammation moderated, by general and local bleeding, and 
counter-irritants, as sufficient time might be gained for the formation of adhe- 



1843.] Midwifery. 237 

"sions around the wound in the intestine, &c. In Dr. Mitchell's case, although 
the uterus contracted firmly immediately after the extraction of the child, yet as 
soon as the opium had been taken in sufficiently numerous doses it became 
relaxed, so much so indeed as to appear as large as when impregnated, and this 
dilated condition it did not lose until the tenth day, showing that the opium acts 
in a similar manner in both cases. Another remarkable similarity produced by 
its use in the two accidents, rupture of the uterus and of the intestine, is that in 
both it appears to lose its narcotic and astringent properties, as shown by the 
case of a man admitted into the Meath Hospital labouring under symptoms of 
peritonitis, from ulcerative perforation of the intestine, to whom 105 grains of 
opium, exclusive of that in the injections, were administered without the patient 
experiencing the slightest coma, headache, or delirium; diarrhoea also setting 
in severely for three or four days. Dr. Mitchell's patient, who presented some- 
what similar symptoms, took altogether 53 grains of solid opium, and nearly 
400 drops of laudanum. 

Dr. Murphy observes, with respect to the causes of rupture of this organ, that 
a perfectly healthy uterus is rarely ruptured, except from external injury; that 
in most of the instances where it occurs it may be traced to morbid lesions 
either previously existing, or produced by inflammation; and even in some cases 
where this cannot be satisfactorily proved from inspection, the history would 
seem to indicate it, and that rupture may occur in cases where the labour is not 
unusually prolonged, nor the pains violent; on the contrary, it has happened where 
the pains were weak and the progress of labour in every other respect favourable. 
The prior history in Dr. Mitchell's case is such as to give rise to the belief 
that some morbid action had been going on previously in the uterus, as about 
three months before her labour took place the patient applied to him, complaining 
of great and incessant pain in the lower part of the abdomen, together with a 
discharge of a thin, fetid fluid from the vagina on two occasions, about a fort- 
night elapsing between each discharge. She described the sensation of the 
child as if it were standing upright, the pressure being in front, to which she 
referred the pain. It is a remarkable fact, that in cases of rupture the greater 
number occur in persons who have borne several children previously, and in 
w 7 hom consequently the womb may have been injured or debilitated in the pre- 
vious labours. — Prov. Med- Journ., April 8, 1843. 

59. Prolapsus of the Uterus reduced after sixteen years' 1 continuance. — M. Durant 
records an interesting case of this in the Transactions of the Medical Society 
of Ghent. The womb protruding beyond the external parts, and covered by 
the inverted vagina, presented a globular tumour, round and contracted at its 
origin into the form of a circular appendix. The os uteri was clear at its inferior 
part. The tumour at its middle part was fifteen and a half inches in circum- 
ference. Its external surface was brownish red, and covered with crusts and 
ulcerations. The long continuance of the affection had seriously injured the 
general health of the patient — she was pale and emaciated, and subject to 
sleeplessness, and cramps of the stomach. 

M. Durant, before attempting reduction, kept the patient on light diet, and 
at rest in bed in a proper position; at the same time dressing the tumour with 
opiated emollient fomentations. Its surface speedily softened, and the crusts 
fell off, leaving superficial sores. After six days of this treatment, the operation 
was performed. It having been ascertained that the rectum and bladder were 
empty, the patient was placed in the position most advantageous for the entrance 
of the womb. M. D. then introduced the right forefinger into the os uteri, and 
burying it, pushed upwards in the axis of the tumour, which itself was placed 
in the axis of the true pelvis— then retaining the uterus in its place with the 
left hand, withdrew the finger, and, repeating this manipulation with gentleness, 
just as one turns the finger of a glove outside in, accomplished the reduction in 
less than half an hour. He then inserted into the vagina a sponge, cut into 
the form of a cylinder, and saturated with an emollient decoction, the thick end 
being highest up, and a cord attached to the other, for the purpose of removing 
No. XL— July, 1843. 16 



238 Progress of the Medical Sciences. [Juty 

it at pleasure. This sponge-pessary was retained in its place by means of com- 
presses, anil the T bandage. The patient did well, speedily gaining flesh and 
strength. During the after-treatment, which continued for about six weeks, 
emollient and astringent lotions were employed, and an ordinary-sized caoutchouc 
ring-shaped pessary was used, the saturated sponge and the injections being 
passed through its centre. — Land. Med. Caz., April, 1843, from Journ. de Mid. 
et dc Chirurg. Prat. 

GO. .dbscess in the Walk of the Uterusyhy Frederick Bird (related at the West- 
minster Medical Society). Mrs. G. aged 37, had, previously to the last three 
years, enjoyed general good health, menstruating regularly. At this date she 
married, and was soon afterwards attacked with acute deep-seated pain in the 
hypogastric region, radiating to all parts of the pelvis, and increased by mictu- 
rition and defecation. Those symptoms were associated with general constitu- 
tional disturbance, and, in fact, with all the ordinary symptoms of inflammation 
affecting the uterus. She passed through the usual forms of treatment, and 
although the more urgent symptoms were mitigated, yet she continued to suffer 
during the three following months from occasional pain in the region of the 
uterus, always produced by attempts at expelling the contents of the bladder or 
rectum, the discharge of faeces being also sometimes effected with great difficulty. 
An internal examination made at this period detected the uterus lower in the 
vagina than usual; there existed marked enlargement of that organ, the chief 
increase in size being found to occupy the posterior wall; the os and cervix uteri 
were painful to the touch and tumid. 

Shortly after the vaginal examination had been made about half an ounce of 
pus suddenly escaped from the rectum, and she experienced immediate relief 
from her former symptoms. She now became the subject of diarrhoea, generally 
passing from six to eight evacuations daily, each of which contained more or 
less purulent matter; pain in micturition was no longer felt, but she invariably 
suffered greatly when passing motions. The diarrhoea could not be arrested by 
any of the remedies employed; her general health, nevertheless, slowly im- 
proved, and she went into the country, where she remained during the succeed- 
ing two years, little or no variation in her symptoms having occurred. The 
diarrhoea, and with it the discharge of pus from the rectum, continued; on some 
occasions more than a pint of pus has been thus evacuated during twenty-four 
hours, and she observed that whenever the pus failed to be discharged so freely 
as usual the local pain became aggravated. During the whole of this period 
menstruation had been very irregular, generally occurring at intervals of eight or 
nine days, accompanied by much lumbar pain and the passage of coagula. 

After the lapse of the time mentioned she again applied to Dr. Bird, suffering 
from nearly all her previous symptoms, and, in addition to them, profuse mo- 
norrhagia; the pain in the region of the uterus was extremely acute, increased 
by the passage of the freces and by pressure on the lower part of the abdomen, 
to which became added a neuralgic condition of the genital organs, the slightest 
pressure upon which produced extreme suffering; so great was the pain thus 
excited that she was accustomed to employ a mechanical contrivance to prevent 
the bed-clothes from touching the pubes. A vaginal examination was, with 
much difficulty and pain, again made; the uterus was found to be nearly in the 
same state as before, excepting that it had become quite immovable, appearing 
as if impacted in the pelvis, just as may be observed in some forms of malig- 
nant, disease affecting that organ. No benefit resulted from medical treatment, 
occasional relief only being afforded by large dos^s of opium and the external 
application of belladonna. 

She continued to suffer from frequent discharges of blood from the vagina, and 
from all her former symptoms, until the lapse of six weeks, when she sank ex- 
hausted by the extreme suffering produced by her disease. 

Jl post-mortem examination was made twenty-four hours after death. On 
laying open the abdomen the omentum, small intestines, and all the pelvic vis- 
cera, were found agglutinated together by peritoneal adhesions of old date. On 



1843.] Midwifery. 239 

raising the uterus it was seen to be firmly attached by its upper and posterier 
portion to the rectum; it presented an irregular form, having the fundus enlarged 
to about thrice its natural size. A longitudinal section showed this enlargement 
to have been produced by an abscess seated in the substance of the wall of the 
fundus uteri, the cavity of which contained about an ounce of dark thick pus; 
the walls of the abscess varied in thickness from one to three quarters of an 
inch, the thinnest portion being nearest to the cavity of the uterus. A commu- 
nication by means of a short sinus could be traced passing from the cavity of 
the abscess to the adherent portion of the rectum, and opening into that intestine 
by an aperture sufficiently large to admit of the passage of a thick probe, and 
evidently of old formation. No communication existed between the uterine 
cavity and that of the abscess. The os and cervix presented no evidence of 
malignant disease. The Fallopian tubes and ovaries were adherent to the ute- 
rus, and could with difficulty be distinguished. The uterus had never been im- 
pregnated. 

He (Dr. B.) had been induced to bring the case before the notice of the society 
cheifly from the rarity of such forms of disease; very few cases had as yet been 
described, and those which he had hitherto met with in the works of Madame 
de Boivin and others were complicated with carcinoma or other malignant 
disease of the uterus. In the instance he had related no evidence of such disease 
existed, but it was clearly a case of inflammation of the substance of the uterus 
terminating in the formation of abscess. It was difficult to account for the neu- 
ralgic state of the generative organs, unless the immovable and apparently im- 
pacted condition of the uterus might be received as sufficient to produce such an 
effect by mechanically pressing upon the surrounding nerves, an idea favoured 
by the fact that at the earlier period of the case, when the uterus was not thus 
fixed, the pain was limited to that viscus and did not extend to the external 
organs. 

* # * The preparation was exhibited to the society, where Dr. Chowne stated 
that he had never seen a similar case. The uterus and its appendages, he said, 
were in that conglomerated state which is usually observed in women who had 
led an irregular life, and which was, probably, in them, dependent upon early 
and excessive excitement. This adhesion of the ovaries, Fallopian tubes, &c, 
in prostitutes, had been noticed also in France. Perhaps, he added, in Dr. 
Bird's case, this condition might have been the result of the disease under which 
the patient laboured. On the same occasion another member of the society, 
Dr. Reid, said that he also was unacquainted with the record of any similar 
case, excepting those related by Madame Boivin, and thought the disease must 
be a remarkably rare one. — Lancet, 28th Jan, 1843. 

61. Statistics of Deliveries. — Mr. Wilde, in his recent work on Austria, gives 

the following interesting tables of 25,906 deliveries, and 26,149 births, in the 

Imperial Lying-in Hospital in Vienna, (the Gebaranstalt) for the eight years 

ending the 31st Dec. 1840. 

f Single births 25,638. 

I Twins, 248 times — 496, or 1 in 105-43. 

Children -{ Triplets, 5 " — 15, or 1 in 5229-8. 

I % 

L Total births, 26,149. 

c • oo cio u- tu * ^Boys, 11 ,717 > Proportion of Males 
Sex in 23,513 births* < n; i-/ n car c ♦ mni? i fAA '- t ; 

' £ Cf iris, 11,6963 to 100 Females 10017. 

Sex of Still-born C Boys, 48 } 

Children in 2,201 J Girls, 45 f Proportion of Males 

births. ") — C to 100 Females 106-66. 

v. Total 93 ) 

* This affords another very remarkable instance of the laws that are supposed to 
regulate illegitimate births, viz.: — that females are either equal to, or predominate over, 
male births; for of 21,212 children born in the seven years prior to 1838, the sexes 
were in the proportion of 10,581 males to 10,628 girls. 



240 Progress of the Medical Sciences. \J^\y 

Total still-born in 23,413 births, 939, or 1 in . 24-92. 

Died before the ninth day, in 23.222, 1,482, or 1 in . 15-66. 

Spyps in 95 of thpso $ Bo y s > 49 l Proportion of Males 

fcexes in 95 ot these <; Gh] ^ ^ ^ {q wq Femaleg 1Q6 . 52 

Abortions and Premature deliveries } P „, , • O oio 
• rke *ac c 674, or 1 in J8-13. 

in 25,705 cases. ... 3 



1 Th 


3 3rd month, 


2 


1 


4th " 


2 


In 196 cases of Abortions and Pre- t 
mature Deliveries there occurred in i 


5th " 


3 


6th « 


25 


i 
i 


7th " 


54 


J 


8th " 


110 


Table showing the number and variety 


of presentations in 


25,449 


ingle births: — 






Breech, 


448, or 1 in 56 8. 




Face, 


190, or 1 in 133-94. 




Feet, 


133, or 1 in 191-34. 




Funis, 


133, or 1 in 191.34. 




Of 133 Funis? With head, 


97, or 1 in 2-37. 




cases in 26, 149 5 With other parts, 


36, or 1 in 3-69. 




Transverse position, 


94, or 1 in 270-73. 




Placenta, 


35, or 1 in 727-11. 




Of 35 Placenta ? Complete, ... 


20, or 1 in 1-75. 




Presentations 5 Partial, 


15, or 1 in 2-33. 




Turning, 140 times, or I in 186-77. 




Forceps used, 359 


do. or 1 in 72-83. 





Perforation, 

Cesarean Section ~) . j t ■ rm» or 

ft ■ n -.u • c 4 do. or 1 in 6537-25. 

after Death, 5 

Ruptured Uterus, 7 do. in 21,001 cases, or 1 in 3000-14. 

Convulsions, 34 do. in do. do. or 1 in 617*67. 

Extra-Uterine fcetation once in 25,906 conceptions. 

Spontaneous Turning, once in 26,149 births. 

Monstrous Births, 68 in 23,222, or once in 341-5. 

Mortality of Mothers 755 in 23,312, or one in 30-87. 

62. Statistics of Monstrosities. — The following table exhibits the number and 
variety of monstrosities in 23,413 births in Austria: — 

Club foot - - - - 16 or once in 1463-31 

Hare lip 

Simple ditto ... 

With cleft palate - 

Spina bifida - 

Hydrocephalus - 

With six fingers - 

Imperforate anus - 

Hemicephalus ... 

Acephalus -# - 

With umbilical hernia - 

Without eyes - 

Wanting superior part of vertex 

With lenticular cataract 

Wanting one upper extremity 

With plurality of fingers and toes 

Hydrocephalus with spina bifida, 
and closed anus - 

Club foot and closed anus 
— Wilde's Austria. 



20 


" 


1170-65 


9 


(( 


2601-44 


11 


a 


2128-45 


5 


(t 


4682-6 


6 


tt 


390216 


3 


(C 


7804-33 


2 


u 


11706-5 


1 


ft 


23413. 


1 


a 


23413. 


1 


a 


23413. 


2 


i< 


11706-5 


1 


<t 


23413. 


1 


it 


23413. 


2 


it 


11706-5 


5 


(< 


4682-6 


1 


u 


23413. 


1 


it 


23413. 



1843.] 



Medical Jurisprudence and Toxicology. 



241 



63. Statistics of Still-born Births.— The following table exhibits the number, 
sexes, and proportion to the living births, of still-born births in seven years in 
the Austrian dominions: — 



LOCALITY. 



Vienna - - - - 

Linz - - - - 

Gratz ... _ 
Laibach - - - - 
Trieste and District 
Innsbruck - - - 
Prague - - - 

Brunn - - 

Lemberg - - - 
Zara ... 

Milan - - - 

Venice - - - - 

Total, 

•Wilde's Austria. 



no 

-5 


STILL-BORN. 






CD 


6 




« 




TO 
CD 


cci 


s 




13 


in 
QJ 


cd 






cd 


o 
H 


3 


CD 
ft* 




<D 


o 


101,167 


2027 


1614 


1713 


1928 


3641 


5,942 


160 


130 


180 


110 


290 


12,847 


163 


119 


178 


104 


282 


3,426 


54 


44 


67 


31 


98 


20,351 


88 


43 


28 


103 


131 


2,099 


33 


20 


33 


20 


53 


30,309 


813 


572 


733 


652 


1385 


11,659 


117 


78 


111 


84 


195 


18,762 


368 


241 


308 


301 


609 


2.922 


74 


65 


75 


64 


139 


43,466 


915 


462 


1101 


276 


1377 


25,663 


457 


440 


528 
3055 


369 
4042 


897 


278,613 


5269 


3828 


9097 



Proportion of 

Stilt born to 

Living Infants, 

as 1 to 



27-78 
20 48 
45 55 
34 95 
155 35 
39 60 
21-88 
59 78 
3080 
2102 
3156 
28 60 



30 62 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

64. Kakodyle. (Cacodyl.) — This remarkable substance deserves some notice, 
from its toxicological characters, and a brief statement of its nature and com- 
pounds will not therefore be misplaced. 

When equal weights of acetate of potash and arsenious acid are submitted to 
dry distillation, a remarkable liquid is obtained, which is called liquor of Cadet 
or alcarsin. It is distinguished by its insupportable odour and spontaneous in- 
flammability in air. The mode of its formation and the oxidability of alcarsin, 
induced the idea that it belonged to the acetyl series and contained arseniuretted 
hydrogen. Berzelius, however, deeming this improbable, presumed alcarsin to 
be the oxide of a compound radical, which he named cacodyl, in referatice to its 
repulsive odour. Bunsen has adopted ihe same theory, and has devoted much 
time to an investigation of this class of bodies, of all of which the sensible pro- 
perties are offensive and dangerous. He succeeded in isolating cacodyl, the 
supposed radical of the series. 

This substance is an ethereal limpid liquid of a nauseous odour, and takes 
fire spontaneously in air and in chlorine gas with the formation of a cloud of 
white smoke, and which consists of water, carbonic and arsenious acids. 

If air be gradually admitted, thick white clouds are evolved, and oxide of 
kakodyle and kakodylic acid are formed. If the supply of oxygen he insufficient 
for complete combustion, a secondary product is formed, termed by Bunsen, 
erytharsin; this is deposited, mixed with a black foetid layer of arsenic. 

Oxide <f Cacodyl (alcarsin,) as already described, is a violent poison when 
taken internally. 

Cacodylic acid (formerly called alkargen by Bunsen) crystallizes in large 
colourless prisms. It is inodorous, and in a toxicological point of view, is a 
very remarkable substance. 

" For although it contains more than 72 percent, of arsenic and oxygen in 
the same proportion as arsenious acid, it does not exhibit the least poisonous 
properties. Eight grains dissolved in water were injected into the jugular vein 



242 Progress of the Medical Science*. [Juty 

of a rabbit, but produced neither death nor indeed any symptom of a poisonous 
action This unexpected fact is in perfect concordance with one which has not 
as yet been regarded, but which is evident in the pharmaco-dynamical properties 
of organic bodies, and on w r hich is founded one of the characteristic distinctions 
between the inorganic bodies and those produced by the interference of vitality. 
If namely, certain matters are added to inorganic bodies, their pharmaco- 
dynamical effects are thereby somewhat altered, but not destroyed. If on the 
contrary, they combine together to form organic substances, these properties are 
completely lost. Copper, lead, mercury, and barium do not lose their poisonous 
qualities, whatever the soluble compound may be in which they are present. 
Carbon, hydrogen, nitrogen, and oxygen, which in strychnine, atropine and 
coniine, form the most violent poisons, are altogether harmless in the compounds 
of proteine. This fact receives a beautiful confirmation from the kakodylicacid; 
arsenic, as if combined by organic affinity, has become a harmless body. Kako- 
dylic acid contains to one atom of radical, four atoms of oxygen, of which one 
atom is combined with hydrogen to form basic water, which cannot be drawn 
out by heat, but only by stronger bases." (Bunsen.) 

Chloride of Kakodyle is a colourless ethereal liquid which does not fume in the 
air, but is converted at a little above 212° into a colourless vapour, which in- 
flames in the air. Its odour is extremely penetrating and stupifying. 

Cyanide of Kakody I is produced by the distillation of concentrated hydrocyanic 
acid, or of a solution of cyanide of mercury wilh oxide of cacodyl. It crystallizes 
in fine prisms, highly limpid, which emit a strong and insupportable odour. It 
is insoluble in water, and is declared to be the most poisonous of the compounds 
of cacodyl. 

1 have consulted for the above, Graham's Chemistry, the Reports of the British 
Association for 1840 and 1841, and the London, Edinburgh, and Dublin Philoso- 
phical Magazine for March, 1843. T. R. B. 

65. Insurance on Lives. — It is now quite common, in cases of life insurance, 
to make an exception as to suicide. In the case of Borrodaile v. Hunter and 
others, tried before the English Court of Common Pleas, in December, 1841, 
the action was brought to recover the sum of J21000, on a policy effected by 
the Rev. Wm. Borrodaile on his own life in the London Life Association. 

It was shown, that on Friday, the 16th of February, 1838, the assured was 
seen to deposit his hat and cloak in one of the alcoves of Vauxhall Bridge, to 
cross to the Battersea side and climb over the parapet, and having gradually 
crept along to where the water was deepest, threw himself into the river, and 
was drowned. 

It was shown, that the unfortunate gentleman, until within a short time of his 
death, wa^ a man of remarkable energy and activity, cheerful in disposition, 
pious, exemplary in his dealings, and affable in manner and address. Unfor- 
tunately he became surety for a tax collector named Foster, who in November, 
1837, made default, and from that time the assured was observed to be an altered 
man. He appeared to labour under great depression, was subject to fits of 
absence, lost his appetite and apparently, in some degree his memory; spoke 
little, and did not like to be left alone. He would stay up late at night, instead 
of going to bed about eleven, as was his usual custom; would observe, he could 
not bear to go to bed; if he did, he could not sleep, and even if he did sleep it 
was still worse. He appeared to feel bitterly his embarrassment through Foster, 
and once observed to that person's wife, " Oh, Mrs. Foster, I am in such trouble, 
that L know not sometimes where 1 am going, or what 1 am doing." 

Pie appeared to have a presentiment of what might happen, and therefore 
begged that his brother-in-law would accompany him to London, observing that 
he did not know what he might do if left alone. He became remiss in the exer- 
cise of family prayer, in which he had been before most regular, and latterly he 
abstained from it altogether. He, however, continued to perform his other duties. 

Being vicar of Wandsworth, he performed his duty at the Parish church on 
the Sunday preceding his death; he read the service on the Wednesday fol- 



1843.] Medical Jurisprudence and Toxicology. 243 

lowing-, and on the Thursday, attended a Board of Guardians of the Clapham 
Union, where he remained from eleven to four, and in the evening attended a 
reading society, of which he was a member. 

On the Friday, (16th,) he appeared more cheerful than ordinary, and rallied 
his brother-in-law, who was a few minutes behind the breakfast hour, upon his 
sluggishness, saying, he hoped his early rising would not do him harm. Mr. 
Borrodaile ordered the servant to prepare his clothes for travelling on the next 
day to Worthing, where his wife and children were staying, and desired her 
(trie servant) to get a steak for dinner at six o'clock. He then went out, telling 
his brother-in-law he was going to the Union and thence to London, where he 
should call on his brother., but he never returned. 

The defence in this case was, that the insured died by his own hand, in con- 
travention of the stipulation in the policy. It was also contended by the de- 
fendants, first, that there was nothing to show aberration of intellect on the part 
of the insured, and secondly, if there were, the simple fact of the party dying by 
his own hand would vitiate the policy. 

" In this case, there could be no dispute as to the facts, but the question re- 
solved itself into a dry point of law on the finding of the jury, whether a party 
who dies by his own hand, unconscious of right and wrong, thereby avoids the 
policy." No witnesses were called by the counsel for the defendants. 

Mr. Justice Erksine told the jury that in his opinion, the true construction of 
the policy was, that where the assured intended to destroy himself, and had at 
the same time a sufficient mind to take his own life, the case would be brought 
within the condition of the policy. His lordship referred to the various circum- 
stances of this extraordinary and important case, and concluded by observing: 
"There could be no doubt that the assured throwing himself into the water 
was his own voluntary act, but whether he had the will to destroy himself, 
knowing what the consequences of throwing himself into the water would be, 
was a question which he must leave to them to decide upon the evidence." 

The jury found that Mr. Borrodaile threw himself into the water, intending to 
destroy himself, adding that previous to that time there was no evidence of 
insanity, but they were told by the judge, that they must take the act itself into 
consideration in connection with Mr. Borrodaile's previous conduct,and then say 
whether they thought at the time he was capable of knowing right from wrong. 
They retired again, and on their return stated "that Mr. B. threw himself from 
the bridge with the intention of destroying himself, but that he was not capable 
of judging between right and wrong." 

The verdict was then entered for the defendants, with leave to enter it for the 
plaintiff. 

On the 30th of January 1842, Sir Thomas Wilde accordingly moved to enter 
the verdict for the plaintiff, contending that the verdict was in facta finding that 
Mr. Borrodaile was non compos mentis, and argued that the condition in the 
policy, by which it was provided that the policy should be void in the event of 
the party dying by his own hand, must be construed to mean "in the event of 
the party's becoming feto de se." The court granted a rule to show cause. 
On the 6th of June, Mr. Sergeant Channel contended that the finding of the jury 
was, that Mr. B„ threw himself from the bridge, intending to destroy life and 
knowing that the act would destroy life, therefore if the assured by his own 
agency produced death, the policy was void, and the verdict ought to remain with 
the defendants. On the other hand, it was urged, that the legal result of the 
verdict excluded intention in any sense which could make the policy void, and 
that it was equivalent to a verdict of non compos mentis. 

The court took the case for consideration, and their final decision is not stated. 
— Jlppendix to the Treatise on Annuities in the Library for the diffusion if Useful 
Knowledge. 

In May 1843, their lordships gave judgment in this case, and there being a 
difference among them, they now delivered their opinions seriatim. The result 
was, that the rule was discharged, and the verdict remains for the defendants — 
London Atlas, May 13, 1843. T. R. B. 



244 Progress of the Medical Sciences. U u ty 

66. Chloride of Gold as a test of certain vegetable Alkalies, {Morphine, Brucine, 
Strychnine.} — MM. Larocque and Thibierge have found the perchloride of gold 
a more decisive test of certain vegetable alkalies than the double chloride of 
sodium and gold. The following are the colours of the precipitates, which it 
produces with the salts of the annexed alkalies dissolved in water. 

Quinine, buff coloured. 

Cinchonine, sulphur yellow. 

Morphine, yellow, then bluish, and lastly violet. In this last state, the gold 
is reduced, and the precipitate is insoluble in water, alcohol, the caustic alkalies, 
and sulphuric, nitric and hydrochloric acids; it forms with aqua regia, a solution 
which is precipitated by protosulphate of iron. 

Brucine, milk, coffee, and then chocolate brown. 

Strychnine, canary yellow. 

Veratrine, slightly greenish-yellow. 

All these precipitates, with the exception mentioned, are very soluble in alco- 
hol, insoluble in ether, and slightly soluble in water. {Journal de Chimie Medi' 
cqle, October 1842.)— Land., Edin. and Bub. Philos. Mag., Dec. 1842. 

67. Detection of Opium. — MM. Larocque and Thibierge also detail various 
experiments on the modes of detecting opium, proposed by Dr. Christison, and 
they mention that their results differ much from his. They state that these dif- 
ferences may arise from three causes. 1. The inequality of the composition of 
the opium of commerce. 2. The analytical process employed by Dr. Christison, 
which consists in decomposing the meconate of lead by sulphuretted hydrogen; 
this, the authors show, frequently masks the meconic acid, and that it could only 
be detected by decomposing the meconate of lead with dilute sulphuric acid. 3. 
The variable nature of the liquids with which opium is mixed. 

The following are some of the conclusions arrived at as the results of their 
experiments. 1. By the aid of reagents, it is possible to determine the presence 
of morphine, strychnine, and brucine in substances which, after being mixed 
with the salts of these alkalies, have undergone the vinous, acetic or putrefactive 
fermentation. Orfila has already shown that the putrefactive fermentation does 
not alter morphine. Merck detected the three alkaloids, after they had been 
exposed to fermenting animal and vegetable matters during twenty days, and 
our authors found similar results on adding salts of brucine to blood, and allow- 
ing it to putrefy, and again mixing the different alkaloids with sugar and yeast, 
and testing after the fermentation had been completed. 2. Iodic acid should be 
employed with great caution as a test of morphine, since if crystallized, or in 
the form of a concentrated solution, it is susceptible of being decomposed by 
neutral azotized bodies. 3. The reagents, on which the greatest reliance may 
be placed, as tests of morphine, are nitric acid, neutral perchloride of iron and 
perchloride of gold. 4. By the use of reagents, morphine which has been mixed 
with beer, soup or milk, may be detected. 5. It is also easy to prove by reagents 
the presence of meconic acid in soup or milk, especially when the meconate of 
lead is decomposed by dilute sulphuric acid. — Ibid. 

68. Action of Alkaline Chlorides on Mercury and Mercurial Compounds. — I have 
noticed in the previous volume, the experiments of M. Mialhe on the action of 
alkaline chlorides on calomel, and also mentioned, that their results have to a 
certain extent been denied by Lepage. M. Mialhe has continued the investi- 
gation on other mercurial compounds and the metal itself, and the products ob- 
tained are such, that (if found to be accurate) they will deserve the attention of 
every practitioner of medicine, and aid materially in explaining the modus operandi 
of mercury, in its diversified modes of prescription. 

A solution of sixty parts of common salt, and sixty of sal ammoniac is termed 
by Mialhe, the assay liquor; in this, sixty parts of the mercurial compounds were 
digested during 24 hours, at the temperature of the air, (59° to G8° Fan.,) and in 
the heat of a stove, 104° to 123°. 



In the air 1.1 part; by heat 1.9 


part. 




Temp, of the Air. 




Stove heat, 


0.4 part 


- 


1.3 part. 


0.7 " 


- 


1.4 " 


0.8 " 


. 


1.1 " 


0.4 " 


- 


0.8 " 



1843.] Medical Jurisprudence and Toxicology. 245 

In Protobromide of Mercury \ at the temperature of the air, the corrosive subli- 
mate produced, was 0.6 part; by the heat of the stove 1.5 part. 

Protiodide of Mercury in the air, 0.5 part; and by heat 0.6 part. 

The solution acts on this with the least intensity. 

Binoxide of Mercury, although scarcely soluble in water, yet in the air 4.7 
parts, and by heat 15.4 parts^ 

Black Oxide of Mercury. 
Protosalts of Mercury. 
Protonitrate, 
Protosulphate, 
Protoacetate, 
Prototartrate, 
Bisalis of Mercury. 

Biniodide, - . - 11.0 « - - 19.3 " 

All the salts of binoxide of mercury when in contact with the alkaline chlo- 
rides, immediately yield corrosive sublimate and a new alkaline salt by double 
decomposition. 

Turbith Mineral. At the temperature of the air 11.2 parts; stove heat 22.8 
parts. 

Pertartrate of Mercury. Air 31.2 parts; heat 36.2 parts. 

Bicyanide of mercury and pernitrate of mercury are also each converted 
into corrosive sublimate. 

Our author further states that he had nearly concluded his experiments, when 
it occurred to him to try whether mercury itself would not be acted upon by this 
class of substances, -and he found that this was the fact. The metal itself treated 
with the assay liquor, gave by stove heat 0.4 part of sublimate, and when this 
experiment was repeated with the mercury finely divided by mucilage, it yielded 
0.7 part of sublimate. 

The following experiments show the relative energy of the alkaline chlorides. 
120 parts of hydrochiorate of ammonia, and 30 parts of calomel were placed in 
an open bottle containing 1000 parts of distilled w T ater, the temperature of which 
was gradually raised to 122 Fah., and kept at this heat for half an hour; the 
sublimate produced amounted to 0.9 of a part. The experiment repeated with, 
the following salts gave the annexed quantities of sublimate. 

Chloride of Sodium, 0.4. 

Chloride of Barium, 0.4. 

Chloride of Potassium, 0.3. 

"In concluding his experiments, M. Mialhe remarks that the reactions which 
he has pointed out take place at common temperatures, but better at the temper- 
ature of the body. All of them are produced in a short time, and some occur 
instantaneously, the greater part requiring only a few hours' contact for action. 
As then the different fluids contained in the human body, contain oxygen, chlo- 
ride of sodium and hydrochiorate of ammonia, accompanied or not with hydro- 
chloric and other acids which may facilitate their action, it follows that all the 
chemical phenomena produced under the circumstances described, occur in the 
human body when any mercurial preparation whatever is introduced into it; these 
always produce a certain quantity of corrosive sublimate in which their medici- 
nal properties reside, and this fact explains, in the opinion of M. Mialhe, the 
hitherto unexplained physiological action and therapeutic properties of metallic 
mercury when introduced into ihe animal economy. {Annates Be Chim. et Be 
Phys.—Lond., Edin. and Bub. Philos. Mag., for Dec. 1842, and Jan. 1843. 

T. R. B. 

69. Beath by Suffocation. — At the March Assizes at Lincoln, in England, Tho- 
mas Johnson, alias Henry Hensey,. was indicted for the wilful murder, at Croft, 
on the 12th of February, of Elizabeth Evison. From the evidence it appeared 
that the deceased was an aged person, about 70, living at the time of the occur- 
rence, with her sister, who was nearly of the same age, in a lonely cottage, a 
short distance from the village of Croft. On Sunday, the 12th, they were both 



246 Progress of the Medical Sciences. [July 

well and walking about as usual. They slept in the same room up stairs, in 
separate beds, and retired to rest about eight o'clock. They were disturbed 
not very long afterwards, by a man breaking in at the windows of their chamber. 
He proceeded to obtain a light by means of a lucifer match, and then with some 
muslin, to tie together their hands and feet very tightly, and to fasten their arms 
under their shoulders equally tightly to the bedsteads, so that they could not 
move hand or foot, or at all help themselves. He then tucked the clothes closely 
over their heads, and proceeded to rob them of some money, silver spoons, &c, 
and then decamped by the street door, leaving it open and the women in the 
state just described. This was on Sunday night. They remained in this con- 
dition, both being almost suffocated, until the forenoon of Monday, when the 
deceased, who had been moaning during all this time, and frequently said she 
must be suffocated, expired. The sister could undertake to mark the time of 
the death by the cessation of the moaning and the breathing, as being in the 
course of the forenoon of Monday. She herself remained in this horrible state 
almost momentarily expecting the same fate, until Tuesday morning, when she 
heard some one near and cried out for help. This was a poor boy, begging, who 
gave the alarm to other persons, and the one sister was found cold and stiff, while 
the other was extremely exhausted. 

The evidence produced left no doubt of the guilt of the prisoner. He was 
convicted and sentenced to death. — Lond. JJtlas, March 11, 1843. T. R. B. 

70. Probable Case of Super foliation in a bilocular Uterus. By M. Billengren, 
(L' Experience, Nov. 24, 1842.) — The following is the first case, I apprehend, 
on record, of two foetuses positively known to have been born from a divided 
uterus, and is therefore extremely interesting. "A woman, forty years of age, 
who had borne several children, about the sixth month of pregnancy, began to 
suffer from uterine hemorrhage. It was arrested for a few days, but soon re- 
turned, gave rise to uterine contractions and the expulsion of a foetus, which, 
from its appearance, could not be more than a three months' foetus. On exa- 
mining the uterus, another foetus was discovered, which was extracted by means 
of the forceps. This foetus was well developed, had the appearance of a seven 
months' foetus, was alive, and lived for some time. Each of these foetuses had 
their separate placentas, which strongly adhered, requiring the introduction of 
the hand for their removal. By this means it was ascertained that the uterus 
was divided into two cavities, beginning just within the lips of that organ, and 
that each of these cavities contained a placenta. From the inequality in size of 
the two foetuses, and their appearance, the author states that he was forced to 
admit this as an undoubted case of superfoetation, though somewhat similar cases 
have been usually described as those in which one foetus has, at a certain period, 
been arrested in its development." — Edin. Med. and Surg. Juurn., January, 1843. 

T. R. B. 

71. Deaf and Dumb Witness. — In the case of James Whyte, charged, in April, 
1842, at the Circuit Court of Justiciary held at Stirling, in Scotland, with rob- 
bery, the principal witness, James Shaw, was called, and one of the crown wit- 
nesses, named M'Farlane, having been sworn to act as interpreter, M'Farlane 
deposed that he had known Shaw from his earliest years, had been on intimate 
footing with him, and was, on that account, able to communicate with him bet- 
ter than any other person whom he knew; that Shaw was not born deaf, but be- 
came so from disease, about the age of seven years; that he had been stone deaf 
ever since, and had lost, in a great measure, the faculty of speech; that he could 
talk a little, but, so very inarticulately that none but those who were in the habit 
of communicating with him could understand his meaning; that the mode of 
communicating with him was partly by signs and partly by the motion of the 
lips. The interpreter having been desired by the court to repeat the oath to the 
witness, after communicating with hiin, stated, that though he believed Shaw 
to be naturally honest and trustworthy, he found it impossible to convey to his 
mind any idea of an oath; that the subject of their communications had always 



1843.] MedicalJurisprudence and Toxicology. 247 

been about ordinary country matters, and that as Shaw had received no educa- 
tion whatever, it was his decided opinion that he could not comprehend the obli- 
gation of speaking the truth. 

In these circumstances the court held that the witness could not be sworn, and 
he was accordingly rejected.— -Lond. and Edin. Month. Journ. of Med. Sci., May, 
1843. T. R. B. 



MISCELLANEOUS. 

72. M. Gibert's letter on the late Epidemic in Paris. — "I was present lately," 
writes this intelligent physician to his friend Dr. Cayol, ' k at a meeting of our 
hospital physicians, when various questions connected with the reigning epide- 
mic—during last summer and autumn in Paris — formed the chief topic of con- 
versation; one of the gentlemen told us that, in a hospital which contains 230 
beds, he had upwards of 60 cases of typhoid fever under his care at one time; 
another said that he also had had a great number, and had not lost a single case 
out of several hundreds; a third communicated the important information that, 
provided no active treatment was employed, and the expectant method chiefly 
trusted to, nearly all the cases might do well; while a fourth added, that he 
thought mild laxatives in many instances useful. All agreed in denominating 
the disease as typhoid fever. 

" But, although this name may have been brought into fashion by a school 
which is willingly satisfied with words in place of things, who is there but will 
not admit that the appellation is ill chosen at best, and that in particular it can- 
not be properly applied to the epidemic now prevailing in this metropolis] For 
in what does this epidemic really consist'? In fevers induced by the high and 
continued heat of an unusually warm summer, which has partaken in many 
respects of the character of a tropical season. Now these fevers (generally of 
a mild form, as already said) assume very rarely the proper typhoid character, 
but usually either a bilious, mucous or a catarrhal form; in some cases, the fever 
is inflammatory and continued; occasionally it is more or less remittent; and 
still more rarely has it any thing of an adynamic or putrid character — the very 
character, be it observed, to which the term of typhoid would be least inappli- 
cable. 

"All these forms of febrile disease are evidently attributable to the mode of 
reaction in individual cases — a reaction, which manifests itself in different ways, 
according as the constitution of the patient is either sanguineous, bilious, or 
nervous. 

" I have several patients at the present moment, in the Hospital St. Louis, 
affected more or less severely with the epidemic. In some it has been only an 
ephemeral fever, which passed off by sweating in the course of two or three 
days; while, in others, the fever has been of a catarrhal character; cough, nausea, 
slight diarrhoea, and a white coating of the tongue, being the most prominent 
symptoms. In one of the patients, the disease assumed the ataxic form, charac- 
terized by restlessness, delirium, paralysis of the bladder, and constipation of 
the bowels. In a few cases, the symptoms have been more or less remittent. 
Now I ask, is it not prudent to retain the old classic names of these various 
forms of fever, rather than to blend them all together under a single appellation, 
typhoid? — which, as far as the present epidemic is concerned, is unquestionably 
the least applicable and proper of all. Is there not a great practical advantage 
in retaining appellations, which in themselves suggest therapeutic indications? 
and has it not been clearly shown that the pretended successes of certain statis- 
tic physicians, who have boasted of their having lost scarcely any patients under 
such and such a course of treatment, may be at once traced to the erroneous use 
of this phrase, typhoid fever?" 

M. Gibert closes his remarks by stating that unquestionably the "medecine 
expectante" was, on the whole, the most safe and judicious mode of treating 
the late epidemic in Paris. In those cases, where the fever had somewhat of an 



248 Progress of the Medical Sciences. [Juty 

ataxic or remittent character (usually without any shivering at the commence- 
ment of the paroxysm), he administered quinine with decided benefit; and in a 
few, where the vascular action was excessive, he had recourse to moderate 
depletion of blood. — Med. Chirurg. Rev. April 1843, from Revue Medicate. 

73. Results of the Re-Vaccinations made in the Prussian Jlrmy during the Year 
1841. — In Prussia every child is obliged to go to school, but before being ad- 
mitted, a certificate of vaccination must be produced by the parents. In 1833, 
an order was issued, that each soldier entering the army should be re-vaccinated, 
which has been in force ever since, and a report of the re-vaccinations has been 
annually sent to the war-office by the military surgeons. The following table 
is for 1841. During the course of the year, 44,941 men were re-vaccinated, of 
whom 36,182 had well-marked cicatrices on the arm; 6193 had pits, but less 
distinct; and in 2567 there were none visible. In 23,383 soldiers, the pustules 
formed regularly;, in 8635 irregularly; while they completely failed in 13,523. 
These last were again vaccinated, when the operation succeeded in 2254, and 
failed in 9468. 

After vaccination, from 1 to 5 pustules were observed in 11,174 men. 
6 — 10 " " 6,513 " 

" 11—20 " » 4,838 " 

" « 21—30 " " 855 " 

Among those vaccinated in 1841, 2 were affected with varicella, and 8 with 
varioloid disease. That vaccination sometimes only succeeds after having been 
several times had recourse to, was observed in this as well as in former years. 
The proportion of cases in which this occurred was as 19 to 100. A soldier who 
had been three times vaccinated during the three previous years, and always 
unsuccessfully, had six well-marked pustules after the operation was performed, 
which would show that some temporary influence had formerly prevented their 
formation. The influence of re-vaccination in the diminution of variolous affec- 
tions in the different military hospitals is most remarkable. In 1841 there were 
only 50 cases, of which 15 were varicella, 34 modified, and 10 true smallpox. 
Three died; of these, one had not been vaccinated on his admission into the 
army, as his vaccine certificate showed that the operation had been done shortly 
before he joined; the second occurred in a recruit who had not been re-vaccinated; 
and the third was in a non-commissioned officer who had been re-vaeeinated 
some years before, but without success, before the order for re-vaccination was 
issued, the different barracks used to be a prey to varioloid disease; it has now, 
however, disappeared. — Lund. & Edin. Mun. Juurn. Med. Set. March, 1843, from 
I? Emm. Med. and Berlin Med.* %eit. May, 1843, 



1843.] 249 



AMERICAN INTELLIGENCE. 

Remarks on Typhus Fever, as it prevailed in Delaware Co., Penna, 
By William E. Haines, M. D., of Springfield, Delaware County. 

The difference of opinion among physicians respecting the cause and 
nature of typhus fever induced me to note some cases which have occurred 
in my own practice within the last eighteen months. During- the time that 
there were a great many persons attacked with bilious remittent fever, as 
also some with intermittent, there were a number of cases possessing many 
features peculiar to themselves, which finally put on the character of typhus 
fever. 

The first case I will mention was a young married woman of delicate 
constitution, taken ill in the fall of 1841; found her with an accelerated but 
weak pulse, skin hot generally over the body, but feet cold, thirst urgent, 
complained of being very weak, tongue dry, and brown, with confused in- 
tellect. The foregoing symptoms I had met with in a number of cases of 
bilious remitting fever after the disease had progressed for some time; but 
so much appearance of typhus I had not before seen in the commencement 
of any case. As there did not appear to be sufficient cause for bleeding, 
ordered pediluvium, hydrarg. submurias gr. vi., to be followed in three hours 
by infusion of senna. The symptoms were improved by the action of the 
medicine, although now, tenderness of the abdomen was manifested, for 
which warm herb poultices were used; if they are not to be had, I found 
warm moist poultices of any kind greatly preferable to sinapisms or any 
thing which will simply irritate the surface. She took small portions of 
calomel and ipecac, at short intervals, followed every other day by castor 
oil to open the bowels; remedies were used to keep up as nearly as possible 
an equable state of circulation; and as a gentle stimulant infusion of rad. 
serpentaria was given, she had frequent haemorrhage from the fauces during 
convalescence. 

A man past middle age, who had formerly been of intemperate habits, 
but for some time previous to his illness had quit the use of intoxicating 
drinks, sent for me. I found him with a slow full pulse, roused with diffi- 
culty and very peevish; tongue brown and dry, no tenderness of the abdo- 
men, but a fetor arising from the breath which I observed to attend in a 
greater or less degree every patient who was ill with this form of disease. 
Considering the age and habits of the man I did not bleed him, but gave 
him calomel gr. x., to be followed in two hours by infusion of senna; ordered 
his feet to be immersed in warm water made strong with mustard, and 
when the medicine began to operate on the bowels to apply a sinapism to 
the nape of the neck. I found him the next day very much relieved; di- 
rected a mild liquid diet, left a small portion of calomel and ipecac, to be 
given in the evening, and followed next morning by castor oil. He con- 
tinued to improve, and I saw him but once after. 

The history of the following case possesses pecular interest. The patient 
was a man about sixty years of age, of delicate constitution, had been living 
with and assisting in nursing a brother who had quite recently returned 



250 American Intelligence. [July 

from a fatiguing journey, and was taken ill immediately on getting home, 
and died within a week after his arrival, of what 1 suppose, from the 
description given, was typhus fever. There were several more cases in the 
immediate vicinity equally fatal, which received the very expressive title 
of Black tongue fever or Black fever. A few days after the death of his 
brother the individual before alluded to sent for me, said his symptoms 
were very similar to those of his brother, that he was very anxious to be 
removed, and should die if left there. 1 procured him an asylum in a house 
not more than a mile and a half from where he was staying. His symp- 
toms, which were those described in case 2d, excepting his pulse was 
quick and corded, thirst urgent and tenderness of the abdomen on pressure, 
were considerably mitigated by the change; the treatment was mild 
throughout, relying chiefly on a small portion of blue mass at night, and 
castor oil every other day; used an infusion of rad. serpentaria as common 
drink, as it had no unpleasant effect on the bowels. His disease was re- 
mitting in its character, and continued more than four weeks, his hearing 
was impaired and his nervous system generally very much shocked, had 
epistaxis frequently during his confinement and convalescence. 

A child aged twelve, was living in a family who followed the Thomsonian 
plan of treatment, and in which there had been two deaths with what they 
called Black fever. After she was taken sick, her mother wished her 
brought home, which instead of being in a more healthy district, was the 
contrary. I found her almost insensible to every thing around her. It 
was with difficulty I could obtain any answer to my queries; her pulse 
was quick and vibrating, tongue covered with a brown crust, and dry, 
sordes on the teeth, bowels tender to the touch; directed a warm bath and 
revulsives to the feet and bowels, a dose of calomel to be followed in two 
hours by an infusion of senna, at the same time leaving her small portions 
of calomel and ipecac, to be given after the effect of the senna had subsided, 
at intervals of three hours. It was several days before I could perceive 
much improvement; however, contrary to the expectations of every one 
who saw her, she slowly recovered. 

Two female members of a family had taken a long walk, and both re- 
turned home sick, but did not apply for any medical advice for several 
days, and when I saw them one was much worse than the other, having 
high fever, with constant delirium and all the other symptoms attending 
this form of ftver, whilst the other one had a slight attack, the fever re- 
mitting for a few days, but soon began to decline, whilst the former was ill 
for weeks. Her attack being so violent, she was bled and treated more 
actively than most of the others. Extensive suppuration took place from 
the glands of the groin after she began to improve. 

An elderly woman was taken ill with all the symptoms of ague which 
continued for three days, when it assumed a remitting form. This case 
was very tedious, there being irritation of the mucous surfaces generally, 
with a pulse quick and soft, urgent thirst, tongue brown and dry, almost 
constant delirium for two weeks. Her nervous system was a good deal 
shattered, had hemiplegia which lasted for two days, then gradually 
yielded, and she finally recovered. 

I shall notice particularly but one more case, that of a man about middle 
age, robust and active when in health, of temperate habits, had not been 
well for some days, but thought he would get better in a little time, until 






1843.] American Intelligence, 251 

the disease had a more alarming hold of him than almost any I had met 
with. 1 found him resisting with all his power the progress of the malady, 
sitting in a reclining posture, with a belief there was not much the matter 
with him. Pulse slower than natural, expanded but not very strong, 
stiength very much prostrated, tongue a chocolate colour and dry, skin 
hot, thirst urgent, no tenderness of abdomen; brain much oppressed, would 
fall asleep while you were conversing with him. no pain complained of any- 
where; the peculiar breath before alluded to could not be mistaken in this 
case; indeed, I think I could pronounce on the character of the disease by 
that symptom alone. His speech was much affected, when he made an 
effort it was with difficulty he could articulate with sufficient distinctness 
to make himself understood; this was the case with many of the other 
patients. Although there was great prostration of strength at the time, 
in consequence of the symptoms of cerebral oppression, I determined on 
bleeding him, which relieved him considerably, his pulse became stronger 
and more frequent, said his head felt better, yet had not complained of it 
in the least, previously. Sinapisms were applied to his feet and cold vine- 
gar and water to his head. As he had taken an active dose of senna the 
day before, and the alvine discharges being dark, I gave him small doses 
of calomel frequently repeated, to be followed by castor oil; in a short time 
I could perceive tenderness of the abdomen, for which the same remedies 
were used as before mentioned with good effect; so long as this con- 
tinued his fever was high, but they subsided pari passu; the cerebral ob- 
struction was not entirely removed until he was convalescent. He was 
recovering finely, being able to leave his room, when he was seized with 
diabetes mellitus, which carried him off in a few days. 

From observation in this form of {ever, 1 am persuaded a very active 
course of treatment is not generally required; there is danger in depleting 
freely and also in stimulating too early, whilst perhaps some vital organ 
is in a state of great congestion, simply because the strength is much pros- 
trated and the energies of the system sunken. If thev would not bear 
bleeding, I generally found purging of use if resorted to early in the at- 
tack. Close attention was required to notice if any unfavourable change 
was taking place, to apply a remedy and endeavour to prevent any organ 
from becoming unduly affected. It was of no use to attempt to cut short 
the disease by active remedies when it became fixed. It had a certain 
course which was of shorter duration in some cases than others, or it passed 
through the different stages more rapidly. 

Since the foregoing was written, I have had two cases of Pneumonia, 
which possessed many of the symptoms of typhus fever. They were 
cases of typhoid pneumonia, since which there 1ms been no case of typhus 
fever, although there were a few a short time previous: I believe it is 
generally acknowledged that the typhoid symptoms of this form of pneu- 
monia so closely resembling typhus fever, are owing to atmospheric influ- 
ences. About the year 1813, it followed closely after typhus fever, and 
in this instance bilious and typhus fever existed at the same time in the 
same neighbourhood, and even in the same family, a short time elapsing 
between, the latter frequently putting on the remitting form, or else reco- 
very took place soon after the removal of the internal congestion. There 
was a tendency to great prostration in most cases of indisposition without 
regard to the nature of the attack within the period mentioned. There 
was no instance of one person having taken the disease from another, 



252 American Intelligence. [July 

unless they had become a member of the family and were living with them 
at the time. Neither do we find many physicians who are willing to sub- 
scribe to the contagious character of the disease from their own experience. 
Why need we therefore ascribe to typhus fever the direful attributes of a 
contagious disease, whilst bilious fever and typhoid pneumonia are viewed 
as an ordinary epidemic, dependent on malaria for their origin? The 
arguments which are brought forth to sustain the contagious nature of 
typhus fever, are those which would apply with equal force to bilious fever 
and ordinary dysentery of temperate latitudes, though it would make but 
little difference in the treatment of the malady, yet the moral influence 
which the doctrine of contagion carries with it into society is of great 
moment. 

2d Mo. 1843. 

The Mulatto a Hybrid — probable extermination of the two races if the 
Whites and Blacks are allowed to intermarry. By J. C. Nott, M. D., 
Mobile. 

The reader will probably be astonished at this late day to see so novel 
an assertion as that the mulatto is a hybrid; but I hope he will read and 
ponder upon the facts given below before he concludes that it has no foun- 
dation in reason. 

A writer in the Boston Medical and Surgical Journal, under the signa- 
ture of " Philanthropist," has made the following important and interesting 
statements: — 

" From authentic statistics and extensive corroborating information, 
obtained from sources, to me of unquestionable authority, together with 
my own observation, I am led to believe that the following statements are 
substantially correct. 

1st. " That the longevity of the pure Africans is greater than that of 
the inhabitants of any other part of the globe." 

2d. " That the mulattoes, i. e. those born of parents one being African 
and the other Caucasian or white, are decidedly the shortest lived of any 
class of the human race." 

3d. " That the mulattoes are no more liable to die under the age of 
25* than the whites or blacks; but from 25 to 40, their deaths are as 10 to 
1 of either the whites or blacks between those ages — from 40 to 55, 50 to 
1— and from 55 to 70, 100 to 1." 

4th. " That the mortality of the free people of colour in the United 
States, is more than 100 per cent, greater than that of the slaves." 

5th. " That those of unmixed African extraction in the " free states" 
are not more liable to sickness or premature death than the whites of their 
rank and condition in society; but that the striking mortality, so manifest 
amongst the fiee people of colour, is in every community and section of the 
country, invariably confined to the mulattoes." 

The following extracts are from the same writer: — 

" It was remarked by a gentleman eminent for his intellectual attain- 
ments and distinguished for his correct observation, and who had lived 
many years in the Southern States, that he did not believe he had ever 
seen a mulatto 70 years of age." 

* This does not. accord with my observation at the South, where a Inrge proportion 
of the mulatto children die young, and where abortions amongst the mothers are 
common. 



1843.] American Intelligence. 253 

" From a correspondence published in the ' Boston Statesman' in April 
last, is taken the following statistics: — ' In a population (coloured) of 
2,634,348, (including the free blacks) there are 1980 over 100 years of 
age; whereas there are but 647 whites over 100 years of age in a popula- 
tion of 14,581,000.' It so happens we have before us a pamphlet pub- 
lisdeh in 1827 by Dr. Niles, then a citizen of New York, now resident 
and well known in Paris, in which he gave a comparative statement of the 
mortality of the cities of Philadelphia, New York, and Baltimore, deduced 
from the official reports of the boards of health of the respective cities, 
from which it appears that in the years 1823-4, 25 and 26, the deaths 
were as follows: — 

In New York. In Philadelphia. In Baltimore. 

'Whites, 1 in 40.15 1 in 31.82* 1 in 44.29 

Free Blacks, 1 in 18.S8 1 in 19.91* 1 in 32.02 

Slaves, 1 in 77.88' 

" In Boston the number of deaths annually among the coloured popula- 
tion is not far from 1 in 15. There are probably fewer of pure African 
descent among the coloured population of Boston than any other city in the 
United States/' 

"The same comparative mortality between the mulattoes and blacks 
exists in the West Indies and Guiana, where unfavourable social causes do 
not operate against the mulattoes, as in the United States." 

The extracts above are from the November No. 1842, of the Boston 
Journal. I am rejoiced to see light breaking from this point of the com- 
pass, as the writer cannot be charged with sectional prejudice, or the in- 
fluence of self-interest. 

I have myself been actively engaged in the practice of medicine for the 
last fifteen years in the South, and in situations where the population is pretty 
equally divided between the blacks and whites. I was soon struck by cer- 
tain facts connected with the mulattoes, and my attention since has been 
turned to their peculiarities. My observation has led me to the following 
conclusions:— 

1st. That the mulattoes are intermediate in intelligence between the 
whites and blacks. 

2d. That they are less capable of endurance and are shorter lived than 
the whites or blacks. 

3d. That the mulatto women are particularly delicate— are subject to 
many chronic diseases, and especially derangement of the catamenia, pro- 
lapsus uteri, leucorrhcea, and other diseases peculiar to females. 

4th. That the women are bad breeders and bad nurses — many of them 
do not conceive at all — most are subject to abortions, and a large portion 
of their children die at an early age. 

5th. That the two sexes when they intermarry are less prolific, than 
when crossed on one of the parent stocks. 

6th. That the above facts apply with more force to the Terceroons and 
Quarteroons than to Mulattoes. \ 

7th. That during the severe epidemics of Yellow fever in Mobile in the 

* [These statistics are incorrect. The actual mortality in Philadelphia as shown by 
Dr. Emerson, (see the No. of this Journal for Nov. 1831,) is for the whites 1 in 42.3, and 
for the blacks 1 in 21.7. — Editor.] 

t Under the general term Mulatto, I shall for brevity include, Terceroons, Q,uarte- 
roons, Quinteroons, &c. # 

No. XL— July, 1843. 17 



254 American Intelligence. [July 

years 1837, '39, and '42, I did not see a single individual attacked with 
this disease, who was in the remotest degree allied to the Negro race — I 
heard, however, of one or two cases in the practice of others. 

I have thus far laid down what I believe to be truths — though the gene- 
ral rules, strong as they are, will be found subject to many exceptions. If 
true, they open to the philosopher and philanthropist a wide field for explo- 
ration. I will here attempt nothing more than to throw out some materials 
for reflection. — I am well aware that my assertions would have much 
greater weight, if they were supported by statistics; but the habits and 
condition of the Mulattoes in the South render it extremely difficult to 
obtain satisfactory statistics — they would rest upon my veracity alone. In 
the Northern cities ample materials exist, for investigating this subject, 
and I hope it will be taken up by some one who will do it justice. 

The space here allowed would not permit, nor does my present purpose 
require, that I should enter fully into the discussions on the natural history 
of the human race, or the many definitions which have been given of the 
term species. The Caucasian, Ethiopian, Mongol, Malay, and American 
may have been distinct creations, or may be mere varieties of the same 
species, produced by external causes acting through many thousand years; 
but this I do believe, that at the present day the Anzlo-Saxon and Negro 
races are, according to the common acceptation of the terms, distinct spe- 
cies, and that the offspring of the two is a Hybrid. 

Look first, upon the Caucasian female with her rose and lily skin, silky- 
hair, Venus form, and well chiseled features — and then upon the African 
wench, with her black and odorous skin, woolly head and animal features — 
next compare their intellectual and moral qualities, and their whole ana- 
tomical structure, and say whether they do not differ as much as the swan 
and the goose, the horse and the ass, or the apple and pear trees. How 
all this comes to pass is not for me to say — it has pleased the Creator, at 
some period of time, so to make or change them. The American Indian 
too, though living in all latitudes and in a savage state; besides his hair, 
beardless chin, well shaped foot and leg, and tawny skin, has many other 
peculiarities which are just as striking. 

I have said that the Mulatto is a Hybrid. By this term is understood 
the offspring of two distinct species — as the mule from the horse and the 
ass. This is a very curious subject, on which much might be said; but 
I have space for but a very kw general remarks. There are a great 
variety of hybrids running through the whole chain of animated nature, 
from man down through both animal and vegetable kingdoms. Some 
hybrids do not breed, as the mule. There are instances of their having 
propagated when crossed back on one of the parent stocks. There are 
other hybrids which do propagate perfectly, as the offspring of the he-goat 
and ewe — the goldfinch and Canary birds, the Cygnoides (Chinese goose) 
and common goose, &c. &c. 

Hybrids when bred together have a tendency to run out and change 
back to one of the parent stocks. This has been remarked of the Mulat- 
toes in the West Indies, and there are now in Mobile families of children 
from the same parents, some of whom are nearly white and others nearly 
black, and there is every reason to believe that the mothers have been 
faithful to their husbands. 

A general law laid down by naturalists is, that the hybrid derives its 



1843.] American Intelligence. 255 

size and internal structure principally from the mother, and a striking ex- 
ample is given in the mule. The mule, or offspring of the mare and jack, 
is a large and powerful animal, having the internal organization of the 
mother. The Bardeau, on the contrary (the offspring of the stallion and 
jenny), is a small and comparatively worthless animal. 

As many of these hybrids are governed by different laws, is it not rea- 
sonable that the human hybrid may also have its peculiar laws — may not 
one of these laws be (which might be inferred from the foregoing data) that 
the Mulatto or Hybrid is a degenerate, unnatural offspring, doomed by na- 
ture to work out its own destruction? 

The statistics given by " Philanthropist" prove that the Mulattoes are 
much shorter lived, and it is a common subject of remark in the Southern 
States, that they are more liable to be diseased, and less capable of en- 
durance than the whites or blacks of the same rank and condition. What 
then could we expect in breeding from a faulty stock — a stock which has 
been produced by a violation of nature's laws, but that they should become 
more degenerate in each successive generation? We know that the parent 
will transmit to the child not only his expression, external form, character, 
temperament, &c, but even diseases through many generations, as gout, 
scrofula, consumption, &c; why then may not that defective internal or- 
ganization, which leads to ultimate destruction, exist in the Mulatto? 

Estwick and Long, who are high authorities, in their histories of Ja- 
maica, both assert unhesitatingly, that the male and female Mulatto do not 
produce so many children together, as if they were united respectively to 
negresses or Europeans. 1 am, too, credibly informed that these facts 
are verified in New Orleans, and that in that city there are many instances 
where families have run out so completely as to leave an estate without an 
heir to claim it. # 

It has been asserted by writers, that when the grade of Quinteroon is 
arrived at, all trace of black blood is lost, and that they cannot be distin- 
guished from the whites. Now if this be true, most of the Mulattoes must 
cease to breed before they arrive at this point of mixture; for though 1 
have passed most of my life in places where the two races have been 
. mingling for many generations, I have rarely if ever met an individual 
tainted with black blood, in whom I could not detect it without difficulty. 
These higher grades should be extremely common if the chain was not 

k broken by death and sterility. How else can the fact be accounted for? 
Virey, a distinguished French naturalist, states, that the connections be- 
tween Europeans and the women of New Holland are very seldom prolific! 
This looks very like some difference in species. 
There are also some curious facts connected with the brain and intellec- 
tual faculties, which bear strongly on the question of distinct species. 
It is well settled by anatomists and physiologists, that the brain of the 
Negro compared with the Caucasian, is smaller by a full tenth, that its 
nerves are larger, the head differently shaped, the facial angle less, and the 
intellectual powers comparatively defective. In the white race the fact is 

* I would here remark, that there is a mixed race in New Orleans and Mobile, of 
French and Spanish blood with the negro, which presents a very different appearance 
from the chalky Mulattoes of the Atlantic States. They have a redder skin than the 
latter, are more robust, healthy, and superior in every respect. My remarks are meant 
to apply particularly to the Anglo-Saxon cross. 



256 American Intelligence, [Juty 

notorious that the child derives its intellect much more from the mother 
than the father. It is an old remark, that a stupid mother never produces 
an intelligent family of children. Look the world over, and ask who are 
the mothers of the eminent men, and it will he found that there are few 
exceptions to the rule, that the mothers are above and most of them far 
above mediocrity; but this law is reversed when the white man is crossed 
upon the negress, or Indian woman — in the offspring the brain is enlarged, 
the facial angle increased, and the intellect improved. Every observer in 
the South will tell you that the Mulattoes have more intelligence than the 
blacks, and we know that the leading men amongst the Indians are the 
mixed class. 

The Mulattoes do not make good slaves, and are always leaders in in- 
surrections. 

BufTbn and other naturalists assert that in Hybrids the head resembles 
the father. In the mule it resembles the ass — in the bardeau it is long, 
lean, with short ears like the horse. This law holds in other hybrids, and 
bears strongly on the question before us. 

Lawrence, than whom there is no better authority, says, " the intellec- 
tual and moral character of the Europeans is deteriorated by the mixture 
of black or red blood; while on the other hand an infusion of white blood 
tends in an equal degree to improve and ennoble the qualities of the dark, 
varieties." • 

These remarks, though hastily drawn up, are the result of many years' 
observation; and I am satisfied that full investigation will show that they 
are substantially true. Every intelligent reader will see the many impor- 
tant bearings of this subject, and I hope it will fall into the hands of some 
one who has more ability and more leisure to bestow on it. If I can start 
the ball my object is accomplished. 

Cave of Artificial Anus. By fl. G. Wharton, M. D., of Grand Gulf, 
Mississippi. 

I was called in August, 1841, to see a negro child five or six days old, 
belonging to Mr. D. G. Humphreys, whose umbilical cord had sloughed 
off close to the abdomen, leaving a circular opening at least one and a half 
inches in diameter, penetrating through the abdominal parietes and a cor- 
responding portion of the intestinal canal. The gut adhered firmly to the 
circumference of the abdominal opening, and the bowels were evacuated 
exclusively through this channel. I could not ascertain what was the 
cause of the sloughing. Its general health was good, though it suffered a 
good deal from occasional paroxysms of pain proceeding apparently from 
the irritation of the ulcerated opening. The inner surface of the exposed 
portion of the intestine was of a very deep red, owing probably to its exposure 
to the external air. I ordered simple poultices of powdered slippery elm, 
made with the infusion of oak bark, to be constantly applied with a tolerably 
firm bandage, and emollient and oily enem;-.ta several times a day, to excite 
the action of the lower bowels. This last means afforded great relief to 
the pain, and after a few days fecal matter was discharged in small quanti- 
ties, per anum. The local applications were occasionally varied; and 
under this treatment the umbilical opening gradually contracted, so that in 
three or four months it had become quite small, only a small quantity of 
the fluid portion of the fecal matter passing through it. 1 then touched 



1843.] American Intelligence. 257 

it with argent, nit., which formed an eschar, and I supposed it had 
healed long ago, as I ordered it to be touched occasionally. At present 
(May, 1843), however, there still remains a small circular ulcerated sur- 
face, very red, about two lines in diameter, from which there is a slight 
oozing of the watery part of the contents of the intestinal canal. This cir- 
cular ulcer is surrounded by a large circular cicatrix, showing the original 
seat, though contracted about one third of the primary opening. I ordered 
the application of the nit. argent., and had the child watched so as to prevent 
his rubbing off the eschar, which seems to be the cause of its not having 
closed up before now. The child is large for its age, and perfectly healthy. 

Opeationsfor Fissure of the Soft, and Hard Palate. — There is a very interesting 
paper on this subject in the last No. of the New England Quarterly Journal of 
Med. and Surg, by Dr. J. Mason Warren. The author, after briefly noticing 
the different forms under which the fissures of the palate may present them- 
selves, and giving a slight sketch of the operations which have been proposed 
for their relief, relates the following case, which illustrates the method practised 
by him. 

"The patient was a young man, 25 years old, with a congenital fissure of 
the soft and hard palate, the bones being separated quite up to the alveolar pro- 
cesses, with a deviation to the left side. On looking into the mouth, the whole 
posterior fauces were exposed, with the opening's of the eustachian tubes and 
the bottom of the nasal cavity of the left side distinctly visible. The speech of 
the patient was rendered so indistinct, by this misfortune, that it was with the 
greatest difficulty that he could make himself understood. Deglutition had 
always been imperfectly performed, liquids, particularly, being swallowed with 
much difficulty, and often regurgitated through the nose. At the first glance 
the soft parts were scarcely perceptible, being almost concealed in the sides of 
the throat from the action of the muscles. On being seized by a forceps they 
could be partially drawn out, though with great resistance. So far as any of 
the old methods were applicable to the relief of this extensive fissure, the 
patient was beyond surgical aid. I determined, however, to put in practice the 
operation which had before appeared to me practicable. 

"The patient was placed in a strong light, his mouth widely opened, and the 
head well supported by an assistant; with a long, double-edged knife, curved 
on its flat side, 1 now carefully dissected up the membrane covering the hard 
palate; pursuing the dissection quite back to the root of the alveolar processes. 
By this process, which was not effected without considerable difficulty, the 
membrane seemed gradually to unfold itself, and could be easily drawn across 
the very wide fissure. A narrow slip was now removed from the edges of the 
soft palate, and with it the two halves of the uvula. By this means a continu- 
ous flap was obtained, beginning at the roots of the teeth and extending back- 
wards to the edges of the velum palati. Finally, six sutures were introduced, 
on tying of which the whole fissure was obliterated. The patient was directed 
to maintain the most perfect quiet, and to abstain from making the slightest 
efforts to swallow even the mucus which collected in the throat, which was to 
be carefully sponged out as occasion required. 

"The following day he was doing well. He complained of some pain, or 
rather a sensation of excessive emptiness of the bowels, which was relieved by 
the use of a hot spirituous fomentation. On the third day, a slight hacking 
cough commenced, owing to the collection of thick ropy mucus in the throat 
and air-passages. The cough was temporarily relieved by an injection of a 
pint of oat-meal gruel into the rectum; during the night, however, it again 
increased so much as to tear away the upper and lower ligatures. I now al- 
lowed him to take liquid nourishment, which at once quieted the irritation of 
the throat. The other four ligatures were removed on the following days, the 
last being left until the Cth after the operation. This patient returned home 



258 American Intelligence. \Ju\y 

into the country at the end of three weeks, a firm fleshy palate being formed 
behind, and half the fissure in the bony palate obliterated. 

" In the following spring I again operated on the remaining fissure in the 
hard palate, and succeeded in closing about half the extent of it, the tissues 
yielding with some difficulty, owing to the inflammation caused by the former 
operation. The small aperture which remained I directed to be closed by a 
gold plate. His speech was very much improved at once as well as the powers 
of deglutition, and he will, no doubt, ultimately, as the soft parts become more 
flexible, to a great degree recover the natural intonations of the voice." 

Since performing this operation, Dr. W. says, "that he has had occasion to 
repeat it in thirteen different cases, which with one exception have terminated 
successfully, either in the closure of the whole fissure, or of both hard and soft 
palate, or so far that the aperture which remained in the bones could be easily 
closed by an obturator fitted to the adjoining teeth." 

Dr. W. offers the following remarks on various interesting circumstances 
which have been presented, both in the forms of this affection, and in the 
method of operation. 

" 1st. As regards the fissure itself. Tn all patients which have thus far come 
under my notice, the direction of the fissure has been towards the left side of 
the jaw; and with infants on whom I have been called to perform the operation 
of hare lip complicated with the above malformation, the jaw has been in- 
variably divided to the left side of the median line. I have observed aiso, in 
simple hare-lip, that the preference is to the left side of the face, and to this I 
have seen but a single exception. It will be generally found in those cases 
where the fissure of the maxillary bones is complete, that the bones forming the 
roof of the mouth are forced upwards, as it were, the palatine process of the 
superior maxillary bone of the right side being continuous with the vomer. This 
circumstance much increases the difficulty of the operation in this region, 
making the mucous membrane less accessible, which when detached and 
dragged into the horizontal line of course loses its support from the bones be- 
hind, at least this will be the case where the obliquity of the bones is con- 
siderable. 

" It would naturally be supposed, that from the want of protection to the 
mucous membrane" lining the nostrils and posterior fauces, and the immediate 
contact, of air and of foreign substances, the patient would be more liable to 
inflammatory affections of these parts; this, however, on inquiry, was not 
found to be the case, none of them being more than ordinarily liable to catarrhal 
attacks. 

"Operation. — The following is the method I have usually adopted. 

"The patient is placed on a low seat, in a strong light, his head firmly sup- 
ported on the breast of an assistant, who raises or depresses it as circumstances 
may require. He is directed to keep the jaws widely separated, to retain any 
blood which may collect as long as possible, so as not to embarrass the operator, 
and restrain all efforts at coughing. To do this will require constant warnings 
and encouragement on the part of the surgeon, as there is a natural tendency to 
close the mouth as soon as any pain is felt, or there arises any collection of 
blood or mucus in the fauces which interferes with respiration. The use of a 
speculum, as directed by some operators, is altogether inadmissible; it not only 
obscures the light, but also prevents the proper manoeuvres of the instruments. 
The mucous membrane of the hard palate is now to be carefully separated from 
the bones with a long, double-edged bistoury, curved on its flat side, and is 
rather pealed than dissected off, from the difficulty of making any sawing 
motion with the knife in this confined situation, the obstacles always being 
greater in proportion to the obliquity of the palatine vault. As the dissection 
approaches to the connection of the soft parts with the edges of the ossa palati, 
where the muscles are attached and the union most intimate, great care must be 
taken or the mucous membrane will be perforated, and from these causes 1 have 
found this part of the operation to be the most embarrassing. As soon as this 
dissection is terminated, it will generally be found that by seizing the soft 



1843.] American Intelligence. 259 

palate with a forceps it can be easily brought to the median line. Tf the fissure 
is wide, and this cannot be effected, I have found the following course to be 
invariably "followed by success. The soft, parts being forcibly stretched, a pair 
of long, powerful French scissors, curved on the flat side, are carried behind the 
anterior pillars of the palate; its attachments to the tonsil and to the posterior 
pillar are now to he carefully cut away, on which the anterior soft parts will 
at once be found to expand, and an ample flap be provided for all desirable 
purposes. 

"The edges of the palate may now be made into a raw surface by seizing 
them on either side with a hooked forceps and removing a slip with the scissors 
or a sharp-pointed bistoury. Our next object is to insert the ligatures, and for 
this purpose an immense armory of instruments have been invented. After the 
trial of nearly all of them I have found the most simple to be the most effectual. 
A small curved needle being armed with a strong silk thread, confined in a 
forceps with a movable slide, is introduced to the upper edge of the fissure, the 
needle being carried from before backwards on the left side, and from behind 
forwards on the right, or vice versa. In this manner, three, four or more liga- 
tures may be successively introduced. The patient is now requested to clear 
his throat of mucus and blood, the ligatures are wiped dry and waxed, and tied 
with deliberation, beginning at the upper and proceeding gradually downwards, 
waiting a little between each ligature, in order to allow the throat to accom- 
modate to this sudden and almost insupportable tension of the soft parts. No 
forceps are required for holding the first knot while the second is tied; the 
object is better effected by using the surgeon's knot, that is, by making two 
turns of the thread instead of one, and by enjoining perfect quiet on the patient 
for the moment, until the second knot is tied. It has been advised by some 
surgeons to wait a certain length of time, after the cutting part of the operation, 
before inserting the ligatures; five or six hours for instance, to allow all bleed- 
ing from the wound to cease This appears to me a useless prolonging of the 
patient's suffering, and entirely unnecessary. I have never seen, in a single 
instance, either in the operations of surgeons abroad or in my own experience, 
any hemorrhage, that a little iced water, or the pressure for a short period with 
the finger, would not easily arrest. The after treatment will not here require 
any notice, as it has been sufficiently noted in the previous detail of the cases. 

"In all the operations of this kind which I have lately had occasion to per- 
form, the ligatures have been removed at the end of 48 hours, or at the farthest 
three days, and to this circumstance may be partly attributed the successful 
termination. If the threads be allowed to remain until the 4th. 5th, or 6th day, 
as recommended and practised by Roux, the apertures left by them will be of 
such magnitude as almost to approach each other, and to weaken the parts so 
as to cause a separation on any untoward motion of the patient." 

In regard to the best plan to be pursued when we are called on to advise upon 
the affection at the time of birth, Dr. W. observes: — "At this early period, 
nothing of course can be done in the way of a surgical operation on the palate; 
much, however, may be affected by a judicious plan of treatment, to reduce and 
even close the aperture in the bones, and reduce the fissure of the soft palate to 
a simple state, and thus give the patient a better chance for recovering his 
voice as he advances in life. Our object may be effected in two ways: 1st, by 
the early operation of the hare-lip, with which the fissure of the bones is gen- 
erally complicated; 2d, by the use of mechanical means. 

" For some years I have been accustomed, even in cases of simple hare-lip, to 
recommend the operation to be done earlier than is usually laid down by sur- 
gical writers, and lately, since the attention of the profession has been called to 
the subject by the excellent paper of Dr. Peirson, of Salem, have performed it 
as soon after birth as possible. The advantages of this early operation will be 
at once seers — the pins may be removed in 48 hours, and the child is able to 
nurse as soon as the mother is ready to receive it at the breast. If the palate is 
fissured the advantages are doubled, and it is surprising with what rapidity the 
edges of the bones are approximated when muscular action of the lips is brought 



260 American Intelligence, QJuly 

to bear on them. It is also a question to determine whether the teeth would 
ever approximate if the hare-lip was allowed to remain." 

The expediency of an early operation for hare-lip is also advocated by Mr. 
Houston of Dublin, whose interesting observations on the subject we published 
in our No. for July, 1842, p. 118, et seq. 

Treatment of Vascular Nsevus. — Prof. N. R. Smith, of Baltimore, has de- 
vised the following method of treating vascular neevus. He saturates a thread 
with a saturated solution of caustic potash. This is dried by a fire, and a 
needle being armed with it, the base of the tumour is transfixed with the needle, 
and the thread quietly drawn through the part. This is repeated in different 
parts of the tumour. Dr. S. states that he has now under care a case treated 
by this plan, and the tumour is rapidly wasting, without any distressing symp- 
toms having occurred. — Maryland Med. and Surg. Journ., March, 1843. 

Contagiousness of Puerperal Fever. — Dr. Oliver W. Holmes, in a paper, in 
our cotemporary the New England Quarterly Journal of Medicine and Surgery, 
(for April 1843), has adduced a very strong array of evidence, to show that the 
disease known as puerperal fever is so far contagious as to be frequently carried 
from patient to patient by physicians and nurses. In addition to a great number 
of facts collected from various sources, and some of which have been already 
presented in this Journal, Dr. H. gives the three following statements which 
are now for the first time made public. All the cases referred to occurred 
within the state of Massachusetts, and two of the three series in Boston and its 
immediate vicinity. 

"•I. The first is a series of cases which took place during the last spring in 
a town at some distance from this neighbourhood. A physician of that town, 
Dr. C, had the following consecutive cases. 
No. 1, 
2, 
3, 
4, 
5, 
6, 
7, 
44 These were the only cases attended by this physician during the period 
referred to. ' They were all attended by him until their termination, with the 
exception of the patient No. 6, who fell into the hands of another physician on 
the 2d of May. (Dr. C. left town for a few days at this time.) Dr. C. attended 
cases immediately before and after the above-named periods, none of which, 
however, presented any peculiar symptoms of the disease.' 

44 About the first of July, he attended another patient in a neighbouring village, 
who died two or three days after delivery. 

44 The first patient, it is stated, was delivered on the 20th of March. 4 On 
the 19th, Dr. C. made the autopsy of a man who died suddenly, sick only 48 
hours; had oedema of the thigh, and gangrene extending from a little above the 
ankle into the cavity of the abdomen.' Dr. C. wounded himself, very slightly, 
in the right hand during the autopsy. The hand was quite painful the night 
following, during his attendance on the patient No. 1. He did not see this 
patient after the 20th, being confined to the house, and very sick from the wound 
just mentioned, from this lime until the third of April. 

44 Several cases of erysipelas occurred in the house where the autopsy men- 
tioned above took place, soon after the examination. There were also many 
cases of erysipelas in town at the time of the fatal puerperal cases which have 
been mentioned. 

44 The nurse who laid out the body of the patient No. 3, was taken on the 
evening of the same day with sore throat and erysipelas, and died in ten days 
from the first attack. 

44 The nurse who laid out the body of the patient No. 4, was taken on the 



delivered March 


i 20, died March 24. 


44 


April 


9, 44 April 14. 


a 




10, 44 " 14. 


it 




11, 44 44 18. 


u 




27, 44 May 3. 


tt 




28, Had some symptoms, recovered. 


u 


May 


8, Had some symptoms, also recovered. 



1843.] American Intelligence. 261 

day following with symptoms like those of this patient, and died in a week, 
without any external marks of erysipelas. 

" No other cases of similar character with those of Dr. C. occurred in the 
practice of any of the physicians in the town or vicinity at the time. Deaths 
following confinement have occurred in the practice of other physicians during 
the past year, but they were not cases of puerperal fever. No post-mortem 
examinations were held in any of these puerperal cases." 

Some additional statements in this letter are deserving- of insertion. 

" A physician attended a woman in the immediate neighbourhood of the cases 
numbered 2, 3 and 4. This patient was confined the morning of March 1st, 
and died on the night of March 7th. It is doubtful whether this should be con- 
sidered a case of puerperal fever. She had suffered from canker, indigestion 
and diarrhoea for a year previous to her delivery. Her complaints were much 
aggravated for two or three months previous to delivery; she had become greatly 
emaciated, and weakened to such an extent, that it had not been expected that 
she would long survive her confinement, if indeed she reached that period. 
Her labour was easy enough; she flowed a good deal, seemed exceedingly 
prostrated, had ringing in the ears, and other symptoms of exhaustion; the pulse 
was quick and small. On the second and third day there was some tenderness 
and tumefaction of the abdomen, which increased somewhat on the fourth and 
fifth. He had cases in midwifery before and after this, which presented nothing 
peculiar." 

"It is also mentioned in the same letter, that another physician had a case 
which happened last summer and another last fall, both of which recovered. 

"Another gentleman reports a case last December, a second case five weeks 
and another three weeks since. All these recovered. A case also occurred 
Very recently in the practice of a physician in the village where the eighth patient 
of Dr. C. resides, which proved fatal. 'This patient had some patches of ery- 
sipelas on the legs and arms. The same physician has delivered three cases 
since, which have all done well. There have been no other cases in this town 
or its vicinity recently. There have been some few cases of erysipelas.' It 
deserves notice that the partner of Dr. C, who attended the autopsy of the man 
above-mentioned and took an active part in it; who also suffered very slightly 
from a prick under the thumb nail received during the examination, had twelve 
cases of midwifery between March 26th and April 12th, all of which did well, 
and presented no peculiar symptoms. It should also be stated, that during 
these 17 days he was in attendance on all the cases of erysipelas in the house 
where the autopsy had been performed. 

"I owe these facts to the prompt kindness of a gentleman whose intelligence 
and character are sufficient guaranty for their accuracy. 

"The two following letters were addressed to my friend Dr. Storer, by the 
gentlemen in whose practice the cases of puerperal fever occurred. His name 
renders it unnecessary to refer more particularly to these gentlemen, who on their 
part have manifested the most perfect freedom and courtesy in affording these 
accounts of their painful experience. 

" 'Jan. 28, 1843. 

u ]j # m* 'The time to which you allude was in 1830. The first case was 
in February, during a very cold time. She was confined the 4th, and died the 
12th. Between the 10th and 28th of this month, 1 attended six women in 
labour v all of whom did well except the last, as also two who were confined 
March 1st and 5th. Mrs. E., confined Feb. 28th, sickened, and died March 8th. 
The next day, 9th, I inspected the body, and the night after attended a lady, 
Mrs. B., who sickened, and died 16th. The 10th, I attended another, Mrs. G.» 
who sickened, but recovered. March 16th, I went from Mrs. G.'s room to attend 
\ Mrs. II., who sickened, and died 21st. The 17th, I inspected Mrs. B. On 
1 9th, I went directly from Mrs. H.'s room to attend another lady, Mrs. G., who 
\lso sickened, and died 22d. While Mrs. B. was sick, on 15th, I went directly 
jrom her room a few rods, and attended another woman, who was not sick* 



262^ American Intelligence. [Juty 

Up to 20th of this month I wore the same clothes. I now refused to attend any 
labour, and did not till April 21st, when having thoroughly cleansed myself, I 
resumed my practice, and had no more puerperal fever. 

" 'The cases were not confined to a narrow space. The two nearest were 
half a mile from each other, and half that distance from my residence. The 
others were from two to three miles apart, and . nearly that distance from my 
residence. There were no other cases in their immediate vicinity which came 
to my knowledge. The general health of all the women was pretty good, and 
all the labours as good as common except the first. This woman, in conse- 
quence of my not arriving in season, and the child being half born some time 
before I arrived, was very much exposed to the cold at the time of confinement, 
and afterwards, being confined in a very open, cold room. Of the six cases, you 
perceive only one recorded. 

" ' In the winter of 1817, two of my patients had puerperal fever, one very 
badly, the other not so badly. Both recovered. One other had swelled leg, or 
phlegmasia dolens, and one or two others did not recover as well as usual. 

" 'In the summer of 1835 another disastrous period occurred in my practice. 
July 1st, I attended a lady in labour, who was afterwards quite ill and feverish; 
but at the time 1 did not consider her case a decided puerperal fever. On 8th, 
I attended one who did well. On 12th, one who was seriously sick. This was 
also an equivocal case, apparently arising from constipation and irritation of the 
rectum. These women were ten miles apart, and five from my residence. On 
15th and 20th, two who did well. On 25th, I attended another. This was a 
severe labour, and followed by unequivocal puerperal fever, or peritonitis. She 
recovered. August 2d and 3d, in about twenty-four hours I attended four per- 
sons. Two of them did very well; one was attacked with some of the common 
symptoms, which, however, subsided in a day or two, and the other had decided 
puerperal fever, but recovered. This woman resided five miles from me. Up 
to this time I wore the same coat. All my other clothes had frequently been 
changed. On 6th, I attended two women, one of whom was not sick at all; but 
the other, Mrs. L., was afterwards taken ill. On 10th, I attended a lady, who 
did very well. I had previously changed all my clothes, and had no garment on 
which had been in a puerperal room. On 12th, I was called to Mrs. S., in 
labour. While she was ill, I left her to visit Mrs. L., one of the ladies who 
was confined on 6th. Mrs. L. had been more unwell than usual, but I had not 
considered her case any thing more than common till this visit. I had on a sur- 
tout at this visit, which, on my return to Mrs. S., I left in another room. Mrs. 
S. was delivered on 13th with forceps. These women both died of decided puer- 
peral fever. 

" * While I attended these women in their fevers, I changed my clothes, and 
washed my hands in a solution of chloride of lime after each visit. I attended 
seven women in labour during this period, all of whom recovered without 
sickness. 

" ' In my practice I have had several single cases of puerperal fever, some of 
whom have died, and some have recovered. Until the year 1830, I had no sus- 
picion that the disease could be communicated from one patient to another by a 
nurse or midwife; but I now think the foregoing facts strongly favour that idea. 
I was so much convinced of this fact, that I adopted the plan before related. 

" ' I believe my own health was as good as usual at each of the above periods. 
I have no recollection to the contrary. 

" ' I believe I have answered all your questions. I have been more particular 
on some points, perhaps, than necessary; but I thought you could form your 
own opinion better than to take mine. In 1830, I wrote to Dr. Channing a 
more particular statement of my cases. If I have not answered your questions 
sufficiently, perhaps Dr. C. may have my letter to him, and you can find your 
answer there.'* 

* In a letter to myself, this gentleman also stated, " I do not recolWt that there was 
any erysipelas or any other disease particularly prevalent at the time." 



1843. J American Intelligence. 263 

" 'Boston, Feb. 3, 1843. 

"III. 'My Dear Sir, — I received a note from you last evening, requesting 
me to answer certain questions therein proposed, touching- the cases of puerpe- 
ral fever which came under my observation the past summer. It gives me 
pleasure to comply with your request, so far as it is in my power so to do, but 
owing to the hurry in preparing for a journey, the notes of the cases I had then 
taken were lost or mislaid. The principal facts, however, are too vivid upon 
my recollection to be soon forgotten. I think, therefore, that I shall be able to 
give you all the information you may require. 

" 'All the cases that occurred in my practice took place between the 7th of 
May and the 17th of June, 1842. 

" 'They were not confined to any particular part of the city. The two first 
cases were patients residing at the south-end; the next was at the extreme north- 
end, one living in Sea street, and the other in Roxbury. The following is the 
order in which they occurred: 

" 'Case 1. Mrs. was confined on the 7th of May, at 5 o'clock, P. M., 

after a natural labour of six hours. At 12 o'clock at night, on the 9th, (thirty- 
one hours after confinement,) she was taken with severe chill, previous to which 
she was as comfortable as women usually are under the circumstances. She 
died on the 10th. 

" ' Case 2. Mrs. was confined on the 10th of June, (four weeks after 

Mrs. C.,) at 11, A. M., after a natural, but somewhat severe labour of five 
hours. At 7 o'clock on the morning of the 11th she had a chill. Died on the 
12th. 

" ' Case 3. Mrs. , confined on the 14th of June, was comfortable until the 

18th, when symptoms of puerperal fever were manifest. She died on the 20th. 

" ' Case 4. Mrs. , confined June 17th, at 5 o'clock, A. M., was doing 

well until the morning of the 19th. She died on the evening of the 21st. 

" 'Case 5. Mrs. was confined with her fifth child on the 17th of June, 

at 6 o'clock in the evening. This patient had been attacked with puerperal fever 
at three of her previous confinements, but the disease yielded to depletion and 
other remedies without difficulty. This time, I regret to say, I was not so for- 
tunate. She was not attacked, as were the other patients, with a chill, but com- 
plained of extreme pain in abdomen, and tenderness on pressure, almost from 
the moment of her confinement. In this, as in the other cases, the disease re- 
sisted all remedies, and she died in great distress on the 22d of the same month. 
Owing to the extreme heat of the season, and my own indisposition, none of the 
subjects were examined after death. Dr. Channing, who was in attendance 
with me on the three last cases, proposed to have a post-mortem examination of 
the subject of case No. 5, but from some cause which I do not now recollect, it 
was not obtained. 

" ' You wish to know whether I wore the same clothes when attending the 
different cases. I cannot positively say, but 1 should think I did not, as the 
weather became warmer after the first two cases; I therefore think it probable 
that I made a change of at least a part of my dress. I have had no other case 
of puerperal fever in my own practice for three years, save those above related, 
and I do not remember to have lost a patient before with this disease. While 
absent, last July, I visited two patients sick with puerperal fever, with a friend 
of mine in the country. Both of them recovered. 

" 'The cases that I have recorded were not confined to any particular consti- 
tution or temperament, but it seized upon the strong and the weak, the old and 
the young — one being over 40 years, and youngest under 18 years of age.***** 
If the disease is of an erysipelatous nature, as many suppose, contagionists may 
perhaps find some ground for their belief in the fact that, for two weeks previous 
to my first case of puerperal fever, I had been attending a severe case of erysi- 
pelas, and the infection may have been conveyed through me to the patient; but 
on the other hand, why is not this the case with other physicians, or with the 
same physician at all times, for, since my return from the country, I have had a 



264 American Intelligence. E^ty 

more inveterate case of erysipelas than ever before, and no difficulty whatever 
has attended any of my midwifery cases.' 

" I am assured, on unquestionable authority, that ' About three years since, a 
gentleman in extensive midwifery business, in a neighbouring State, lost, in the 
course of a few weeks, eight patients in child-bed, seven of them being un- 
doubted cases of puerperal fever. No other physician of the town lost a single 
patient of this disease during the same period.' And from what I have heard in 
conversation with some of our most experienced practitioners, I am inclined to 
think many cases of the kind might be brought to light by extensive inquiry." 

Caesarian Section on a Dwarf. — This case is recorded by Dr. Cyrus Falconer 
in the Western Journal of Medicine and Surgery for May last. 

The patient was only three feet six inches in height, wjth ill-proportioned 
form. When seen by Dr. F. she had been in labour upwards of fourteen hours; 
the left foot of the foetus was presenting at the os externum. On examination, 
Dr. F. found that " the sacrum projected towards the pubis so as to give the 
superior strait the character of a fissure; the antero-posterior diameter being cer- 
tainly not over one inch and three-fourths. The leg of the presenting foot occu- 
pied the full breadth of the fissure, affording an evidence but too conclusive that 
nature was not competent to the delivery. The os uteri was well dilated, and 
the pains incessant and severe." 

The Cesarean section was resolved upon, and executed in the following man- 
ner: — A somewhat oblique incision was made, "beginning at the upper part, 
near the margin of the linea alba, crossing towards its centre in the descent 
towards the pubis," this being necessary "in order to get an opening large 
enough to extract, the foetus." When the peritoneum was opened, much diffi- 
culty was experienced in preventing the escape of the intestines. The uterus 
beino- then divided, the foetus was exposed, its back presenting to the incision. 
"Although," says Dr. F., "I began rny incision considerably above the umbi- 
licus, such was the relative size of the child that I found it impracticable to 
extract it, until I had extended the opening in each direction; approaching nearly 
to. the cartilage of the lower true rib above, and the pubis below. During my 
efforts to accomplish the delivery, considerable extravasation took place. The 
relative size of child and mother can only be conceived by the reader, when he 
remembers the height of the mother — three and a half feet — and learns that the 
child was about the ordinary size, weighing, by conjecture, from seven to eight 
pounds. 

" I at length succeeded, by grasping the thighs, in elevating the breech, and 
delivered the child, as in a breech presentation; it soon cried lustily, and was 
separated from the cord. The uterus now contracted powerfully, the placenta 
was expelled, the extravasated blood removed as much as possible, and we then 
proceeded to dress the wound. 

"Four or five points of the interrupted suture were employed — long adhesive 
strips were applied between the sutures, leaving a space at the lower portion, 
for the escape of any discharge that might accumulate. A broad compress was 
next applied, and the whole covered with a broad, firm bandage, tolerably tight. 

" During the operation, the patient made very little complaint; she now said 
she felt very comfortable, and expressed much gratification at being relieved by 
an amount of suffering so much less than she had apprehended. An anodyne 
was administered, and finding her, at the end of a couple of hours, still com- 
fortable and inclined to rest, 1 left her." 

Before morning, however, inflammation was developed, and the patient died 
on the eighth day. 

"The child did well, and is now a vigorous, healthy, and well-formed little 
girl." 

Influenza. — This epidemic is, at the present moment, prevailing over the 
whole of the eastern and middle States of the Union. A ve.ry large portion of 
the population have been affected or are now suffering from it. In Albany a 
correspondent writes to us that four-fifths of the inhabitants have had it; and iu 



1843. J American Intelligence. 265 

the city of New York it has prevailed to such an extent, we learn, as to seriously 
delay or suspend most business operations. Great numbers have suffered from 
the disease in Philadelphia, where it seems not yet to have reached its height. 

So far as our observation has extended, the disease, though often threatening 
in its symptoms, has been extremely manageable. 

Its onset is usually very sudden, sometimes with a chill, but most usually 
with the ordinary symptoms resulting from what is popularly termed having 
"taken cold." In most cases the disease assumes a catarrhal character— and 
then it is ushered in with coryza, cough, and very violent oppression of the 
chest; or the larynx is affected and the oppression is of a croupy character. In 
other cases rheumatic symptoms predominate, and the patient has the most 
severe pain in the back and hips, — lumbago and sciatica. In other cases again 
the head suffers most, and there is severe headache, injection of the conjunctiva, 
and more or less photophobia; whilst in others, again, there is hemicrania, severe 
pain in the ear, &c, the pains being of a neuralgic character, and these neuralgic 
pains are also experienced in some cases in the limbs. In some instances the 
digestive organs seem to bear the onus of the disease, and the patient has nausea, 
severe pain around the body just below the margin of the diaphragm, pains in 
the bowels, and occasionally diarrhoea. Finally, in other cases these affections 
are variously combined, at times one and at others another predominating, and 
even alternating in the same patient. 

The pulse, even in the most severe cases, is little affected, the heart not sym- 
pathizing with the suffering of the other organs. The skin is generally warm 
at first, and sometimes dry, but perspiration is in the latter cases easily excited, 
and from the commencement, in most instances, there is very profuse sweating. 
The patient usually complains throughout the progress of the disease, of a 
feeling of lassitude and debility. 

The disease sometimes runs its course in a few hours, in others it is protracted 
to five or six days, or perhaps longer. 

As already intimated, the disease is very controllable by proper remedies. 
We have seen the oppression of the chest when most severe and threatening, 
and also the pain in the back and loins, promptly relieved by a mustard plaster. 
In other cases cups were required, which always were productive of the desired 
result. 

In many cases a mild laxative, followed at night by a mustard pediluvium 
and Dover's powder, are the only remedies necessary. The cough, when 
troublesome, is relieved by the ordinary expectorants and sedatives. — Medical 
News, July, 1842. 

Necrology. — Departed this life, in Baltimore, on the morning of the 2d of 
January, 1843, after a sudden and very brief illness, Professor Nathaniel 
Potter, M. D., in the 74th year of his age. 

Dr. Potter was a native of Caroline County on the Eastern Shore of Mary- 
land. The greater part of his long and useful life was passed in Baltimore, 
where he early achieved the eminent position in the medical profession which 
he retained to the last, and to which he was justly entitled by his natural 
abilities and by his literary and scientific acquirements. Soon after settling in 
this city, he exerted himself, in association with the late Dr. Davidge and others, 
as one of the most active agents in establishing the Medical Department of the 
University of Maryland. In this institution, he filled with distinguished honour 
for more than thirty years, and up to the time of his death, the chair of the 
Theory and Practice of Physic. In private and domestic life, Dr. Potter mani- 
fested many amiable virtues which will be remembered with affectionate 
fondness by his family and friends. As a practitioner of medicine, he was re- 
markable for promptitude and integrity of judgment, and for the boldness and 
energy of his remedial measures. As a teacher, he was perspicuous and im- 
pressive, displaying in his lectures extensive knowledge and great practical good 
sense, rendering his subject pleasing and attractive by his native power of wit, 
and illustrating and enforcing his doctrines by the ample resources of a profound 
and elegant erudition — The Maryland Med. and Surg. Journ., March, 1843. 



266 



American Intelligence. 



[July 



UNIVERSITY OF PENNSYLVANIA. 

At a Public Commencement held the 31st day of March, 1843, in the 
Hall of the Musical Fund Society, the following gentlemen received the 
Degree of Doctor of Medicine at the hands of the Rev. John Ludlow, 
D. D., Provost. 

An address was then delivered by Dr. Hugh L. Hodge, Professor of 
Obstetrics. 



NAME. 

Arrington, Thomas C. 
Ashlon, Samuel K. 

Baker, Charles L. 
Ballard, Charles E. 
Barnes, William E. 
Beaumont, George H. 
Berkeley, Richard F. 
Best, John Milton, 
Birekhead, Edward F. 
Bird, John Francis, 
Boone, Jesse T. 
Bowling, William E. 
Bradley, Samuel 
Brandon, James C. 
Briggs, Etheldred E, 
Burgess, Jesse 
Burgin, George H. Jr. 
Burwell, George N. 
Butterfield, Ralph 
Byrd, Flavius A. 

Campbell, Alexander H. 
Gary, Walter 
Cheatham, William A. 
Clawson, Isaiah D. 
Coleman, William H. 
Conway, James H. 
Cooper, Thomas B. 
Coryell, Richard H. 
Curtis, Benjamin W. 

Davis, Charles H. 
Dougal, James 
Duffield, Samuel E. 

Eddins, Simeon J. 
Elliott, James L. 



RESIDENCE. 

North Carolina, 
Philadelphia, 

Pennsylvania, 

North Carolina, 

Pennsylvania, 

Pennsylvania, 

Virginia, 

Kentucky, 

Virginia, 

Philadelphia, 

Ohio, 

Kentucky, 

South Carolina, 

Mississippi, 

Virginia, 

Pennsylvania, 

Philadelphia, 

New York, 

Massachusetts, 

Alabama, 

Pennsylvania, 
New York, 
Tennessee, 
New Jersey, 
Alabama, 
Virginia, 
Pennsylvania, 
New Jersey, 
Maine, 

Virginia, 

Pennsylvania, 

Pennsylvania, 

Alabama, 
Pennsylvania, 



Fessenden, Benjamin F. North Carolina, 

Finney, Oswald B. (M. D.) Virginia, 



Gayle, Matthew 
Gower, James 
Grantland, Fleming T. 
Grigg, Jacob 

Hadley, John L. 
Haines, Alfred C. 
Hall, William P. 
Harper, Thomas S. 



Alabama, 
Tennessee, 
Georgia, 
Pennsylvania, 

Tennessee, 
Ohio, 
Virginia, 
Pennsylvania, 



SUBJECT OF ESSAY. 

Dysentery. 
Cholera Infantum. 

Poisoning by Arsenic. 

Cinchona. 

Cholera Infantum. 

Human Heart. 

Acute Hepatitis. 

States of the System. 

Gout. 

Health and Education of Females. 

Prolapsus Uteri. 

Dyscnt. Byliosa. 

Acute Gnstritis. 

Scarlatina. 

Colica Biliosa. 

Scarlatina. 

Medical Physiognomy. 

Artificial Pupil. 

Intermittent Fever. 

Inflammation of the Eye. 

Angina Pectoris. 

Dysentery. 

Acute Arthritis. 

Topical Depletion. 

Congestive Fever of the South. 

Menstruation. 

Path, of Blood. 

Scarlatina. 

Catarncnia. 

Hemorrhages. 

Dysentery. 

Arsenic. 

Hydrops Abdom. 

Phys. and Path, of Blood. 

Ung. Hydrarg. Nitr. 
Jaundice. 

Nephritis. 
Calorification. 
Typhus Fever. 
Apoplexy. 

Typhus Fever. 

Fever. 

Wounds of Thorax and Abdomen. 

Coryza. 



1843.] 



American Intelligence. 



267 



Harris, William A. 
Harrison, Benjamin S. 
Harvey, El wood y 
Harwell, Rufus S. 
Hinton, Samuel A. 
Holstein, George W. 
Housekeeper, Benjamin 
Hunter, William G. J. 

Jenkins, Wiley 
Jones, Benjamin F. 
Jones, John R. 

Kemper, Charles R. 
Kerr, John J. 

Laird, Thomas H. 
Leggett, Nazareth 
Lehman, John C. 
Lindsley, John B. 
Lyman, George H. 

Maccoun, Robert T. 
M"Guire, Robert L. 
Martin, Gabriel S. 
Mason, TJiomas W. 
Mayburry, William. 
Mercer, Thomas S. 
Merritt, John 
Metcalfe, John T. 
Miller, Henry C. 
Moor, George W. 
Morrison, William O. 
Morton, Thomas M. 
Moss, Robert P. 
Murray, Robert 
Musgrave, George J. 

Nash, Clurin V. 
Newkirk, Nathaniel R. 
Nichols, Charles H. 



Philadelphia, 

North Carolina, 

Pennsylvania, 

Tennessee, 

Virginia, 

Pennsylvania, 

Philadelphia, 

Tennessee, 

Mississippi, 

Alaba:na, 

Pennsylvania, 

Virginia, 
Philadelphia, 

Virginia, 
North Carolina, 
Philadelphia, 
Tennessee, 
Massachusetts, 

Pennsylvania, 

Virginia, 

Georgia. 

Alabama, 

Pennsylvania, 

Maryland, 

Delaware, 

Mississippi, 

South Carolina, 

Massachusetts, 

Louisiana, 

Kentucky, 

South Carolina, 

Maryland, 

North Carolina, 

Alabama, 
New Jersey, 
Rhode Island, 



Iodide of Potassium. 

Blood-letting. 

Gonorrhoea. 

Acute Bronchitis. 

Fractures. 

Datura Stramonium. 

Dropsy. 

Abortion. 

Pernicious Intermittent Fever, 

Trachitis. 

Scarlatina. 

Iodide of Potassium. 
Management of Children. 

Antimonial Preparations. 
Spontaneous Hemorrhages, 
Pertussis. 
Inflammation. 
Thcrap. of Water. 

Chorea. 

Dyspepsia. 

Abortion. 

Acute Hepatitis. 

Delirium Tremens. 

Intermittent Fever. 

Acute and Chronic Hepatitis, 

Coxalgia. 

On Remittent Fever. 

Scrofula. 

Phys. and Path. Lymph. System, 

Sympathy. 

Diabetes Mellitus. 

Lead Colic. 

Hydrocephalus Internua. 

Delirium Tremens. 

Homceopalhy. 

Omnivorous Nature of Man. 



Parham, Edward H. M. 
Pearson, Richmond N. 
Penniman, Jesse A. 
Pepper, Lawrence S. 
Pope, John T. 

Race, Henry 
Raines, William N. 
Reynolds, Thomas 
Rickards, William M. L. 
Rogers, John C. 

Sargent, Fitzwilliam 
Saunders, Thomas J. 
Schanck, John S. 
Shivers, James K. 
Simmons, Edward L. 
Singleton. Spyers 
Slemmer, Henry T. 
Stabler, Richard H. 
Stockwell, Nathaniel 
Stribling, Magnus W. 



Virginia, 
North Carolina, 
Massachusetts, 
Philadelphia, 
North Carolina, 

New Jersey, 
Virginia, 
North Carolina, 
Delaware, 
North Carolina, 

Philadelphia, 
New Jersey, 
New Jersey, 
Philadelphia, 
Virginia, 
North Carolina, 
Pennsylvania, 
Dist. of Columbia, 
Mississippi, 
Virginia, 



Leucorrhcea. 

Chronic Muco-enteric Inflammation, 

Sources of Error. 

Pneumonia. 

Dyspepsia. 

Influence of Mind, &c. 

Hydrops. 

Anchylosis. 

On Bilious Remittent Fcver> 

Neuralgia. 

Nitrate of Silver. 

Cholera Morbus. 

Articular Rheumatism. 

Pleurisy. 

Remitting Fever. 

Koino Miasma. 

Diarrhoea. 

Arsenic. 

Congestive Fever. 

Foetal Circulation. 



26S 



American Intelligence. 



Taylor, Charles H, 
Thomas, Jason B. 
Trick nor, Francis O. 
Twitchell, George B. 
Tyler, John W. 

Upshur, George L. 

Walke, Sydenham 
Walker, William 
Wall, Robert E. 
Wellford, Robert 
Wilson, John J. 
Wilson, John R. 
Wilson, William B. 
Wolff, Samuel 



Pennsylvania, 

Massachusetts, 

Georgia, 

New Hampshire, 

Virginia, 



Viroi 



na, 



Virginia, 

Tennessee, 

Virginia, 

Virginia, 

Pennsylvania, 

Virginia, 

Pennsylvania, 

Pennsylvania, 



Contagions Diseases. 

Menstruation. 

Atmospheric Air. 

Necrosis. 

Acute Dysentery. 

Topical Depiction. 

Wounds. 

Struct, and Funct. of Iris. 

A sthma. 

Hasmorrh. Diathesis. 

Scarlatina. 

Opium. 

Inflammation. 

Marsh x\Iiasmata. 



Anderson Bagley, of Virginia, Essay on Fractures of the Thigh, is also entitled to a 
Degree, but from an accidental informality, whereby his name was not in time for the 
Board of Trustees in issuing their Mandamas, the conferring of the Degree is post- 
poned to next July. 



At the Commencement held in July, 1842, the Degree of Doctor of Medicine was 
conferred upon 

South Carolina, 
Pennsylvania, 
New York, 
Virginia, 



Benjamin F. Nicholls, 
Washington G. Nugent, 
Thomas S. Roycroft, 
Reuben J. Thomas, 



Pleuritis. 

Dropsy following Scarlet Fever. 

Dyspnoea. 

Acute Hepatitis. 



Total, 1 18. 



W. E. HORNER, Dean of Medical Faculty. 



New Works. — Churchill's Midwifery, edited by Prof. Huston, and illustrated 
with numerous wood cuts, in the same style of execution as those in Wilson's 
Anatomy, and Fergusson's Surgery; Carpenter's Physiology, with additions by 
the author, and edited by Dr. Clymer; Graham's Chemistry, edited by Dr. 
Bridges; Wilson Philip on Indigestion; and Brodie on the Diseases of the Joints, 
will be issued by Messrs. Lea & Blanchard, we are informed, in the course of 
the present month. 

The following works are announced as in preparation for early publication by 
the same. — A Treatise on the Diseases of Children, by D. F. Condie, M. D.; 
a Medical Formulary, by Joseph Carson, M. D.; also Wilson's Practical and 
Surgical Anatomy, revised, &c. 



CLINICAL INSTRUCTION 

To a private class will be given at the Pennsylvania Hospital, during the summer months, by the gen- 
tlemen having charge of the house during this period. 

In the course of instruction propoeed, students will be trained in the practical study of disease at the 
bed-side during the daily visits to the wards, and also have a series of lectures delivered on some of the 
most important subjects presenting themselves in the practice of the house. Auscultation, Fevers, Frac- 
tures, and Diseases of the Genito urinary organs, will receive particular attention. 
From April to July MEDICINE Dr. Pepper. 

" SURGERY Dr. Norris. 

From July to November . . . MEDICINE Dr. Stewabbso\. 

" SURGERY Dr. E. Peace. 

Fee for the Course, including the privilege of attending the practice of the house 

for one year $30 

For those already holding the ticket of the house 20 



THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES 



OCTOBER, 1843. 



Art. I. — Observations on Cerebral Auscultation. By S. S. Whitney, 
M. D., of Newton, Mass. 

Whenever new doctrines or new theories are held up for public con- 
sideration, whatever relation to science they may seem to bear, their decla- 
ration should be received, only after a most rigid and careful examination of 
the principles upon which they are based. The progress of science and 
sound philosophy need no other, and should sustain no other material within 
its noble superstructure, than that which has passed the severest test of 
experiment and of fact. Could the real interests of science be promoted by 
any other, or by more partial means, even then a proper respect for the 
usages of age, and for opinions which have been long received and enter- 
tained, would seem to allow of no milder alternative. 

Yet, on the other hand, a too obstinate and inflexible adherence to doc- 
trines, because they bear the "impress of age," would as certainly retard the 
progress of true philosophy, as that laxness of reason, which would allow 
every induction of sense to be counted of equal weight to the most obvious 
and practical truths. So far, therefore, as the means are within our reach 
and can be made available, every thing relating to science or philosophy, 
should be made as plain and unequivocal as experiments and matters of fact 
can render it. 

Perfect precision, in investigating the causes of phenomena which are 
continually varying, is not easily attained; and although we may not expect 
every science to be made an " exact science," nor every phenomenon to be 
as constant and unalterable in its phasis as the "nine digits" of enumeration, 
yet we are to expect that out of the confused and huddled mass of pheno- 
mena which ages of conjectural observation have scrambled together, a more 
No. XII.— October, 1843. 19 



282 Whitney on Cerebral Auscultation. [Oct. 

sincere and enlightened regard for its true object will discover and arrange 
the elements of a purer and more chastened philosophy. This, indeed, in 
many instances, has already been accomplished; and whenever the period 
shall arrive, in which it shall become universal in its application, a new and 
important era will have dawned upon every branch of science: but upon 
none a brighter, and one of more importance in its application, than upon 
that which is so intimately connected with the physical constitution of 
man; for over none, has fancy thrown such a complicated and inexplicable 
network of theory, conjecture and strange deductions of sense, as it has 
over that branch of philosophy which should discover to us the true patho- 
logical and physiological principles of the human body. 

In the perfectly healthy and normal conditions of the organs of the human 
body, every one has, in its structure, functional and local developments, 
something in which it is peculiar, and which is characteristic of itself. This 
is an axiom in physiology, which has been too long received, and is too 
obvious to admit of doubt. It is equally true, if not so universally admitted, 
that any derangement or deviation of these organs from their natural con- 
dition, is manifested by signs which are peculiar and characteristic of' such 
deviation. It may, therefore, be laid down as a principle of pathology, that 
every disease is marked by some sign which is pathognomic of its real 
character; something in which it is unique; something, in respect to which 
it is unlike, and by means of which, it is signalized from all other diseases. 

In many, perhaps in a majority of cases, these characteristic features of 
disease are well defined and easily recognized, and the phenomena which 
accompany them are plain and well marked, while there are other cases, in 
which every thing is obscure, confused, scarcely able to be comprehended, 
and still less to be appreciated. Still the existence of such peculiarities is 
none the less real, because they are not so easily recognized. 

In many diseases this peculiarity is manifested by the development of a 
single and unequivocal phenomenon. In many others, by a variety or series 
of phenomena, all of which are positive and perfectly distinct. In others 
again, this peculiarity only manifests itself through phenomena which are 
purely negative, and there are still others, in which we are only able to dis- 
tinguish them from those of a similar character, by the different shades of 
their similar phenomena. Hence the extreme difficulty, in frequent in- 
stances, of arriving at a perfect and correct diagnosis of disease, and the 
occasion of the various and conflicting opinions which oftentimes arise in 
regard to the one and the same object. It is the little and foolish things in 
these cases, which too often confound the wise, and in the search after patho- 
logical truths, "the less weighty matters of the law" are too apt to be over- 
looked for its "more signal and manifest display." 

Such is the case, particularly, in regard to the means which have been 
most relied on, in diagnosticating the various affections of the brain and 
appendages. The question, here, has been, not what the lesion actually 



1843.] Whitney on Cerebral Auscultation. 283 

was, but what, in the end it would prove itself to be; and the feeling of 
anxiety has been, not so much to forestall the development of particular 
symptoms, as to see to what end such symptoms might eventually lead. 

The fact is, just in proportion to the minuteness and accuracy of the know- 
ledge which we possess, of the relations and the sympathies which exist 
between one organ and another, and of the healthy and due performance of 
the functions of those organs, just in that proportion shall we be able to 
decide upon any departure of those organs from their legitimate state. 

At the present moment, it must be confessed, diseases of the brain are to 
be regarded as not only the most difficult, but as the most obscure class of 
lesions in the great nosology of man. A little more than a quarter of a cen- 
tury ago, when fancy built her hypotheses and conjecture in a degree took 
the place of observation and fact, before the new revelation had been made 
to science by means of such physical signs as are brought to light by aus- 
cultation and percussion; the same remark, with equal truth, might have 
been applied to diseases of the heart and lungs. But now, so far from this 
being the fact, the very reverse is indeed the truth, and instead of being the 
"most difficult" and most obscure, diseases of the heart and lungs, with the 
grand rationale of physical signs by which they are elucidated, are as easily 
recognized, and with as much certainty and precision defined, as the most 
simple lesion of the human body; and this too, apart from the ancient regime 
of rational signs, by which we have been wont to investigate disease. 

It was the remark of a distinguished pathologist, " that the nature of the 
organs within the thorax and their disposition, render it almost impossible, 
that physical signs should ever be of any avail in developing the nature and 
character of these diseases;" and yet how wide from the truth has the sequel 
of a few years proved this opinion to be. 

Instead of their disposition within the thorax, and the structure of these 
organs, offering any hindrance to the application of the natural principles 
of philosophy to them, an apparatus could scarcely be devised, which, by 
its disposition and structural arrangement, could more correctly, and with as 
much simplicity, demonstrate the principles of hydraulics and pneumatics, 
as the heart and lungs. And singular as it may appear, long after the art 
of auscultation and percussion had survived its infancy, not a feAv were to 
be found, to whom the possibility of detecting and distinguishing diseases 
in the chest, one from another, by means of a purely mechanical process, 
was a chimera, too absurd to merit a moment's consideration; and yet with 
all the objections which have been urged so unfairly against it, and the hin- 
drances which prejudice and envy have opposed to its progress, the rapid 
advances which it has made, and its now almost universal acceptation, is a 
most signal triumph of the truth of the adage, " magna est Veritas, et prae- 
valebit." 

It has also been asserted, " that there are no physical signs applicable to 



284 Whitney on Cerebral Auscultation. [Oct. 

the brain, and from the circumstances in which the organ is placed, it is to 
be feared that none will ever be discovered." 

It is indeed true, " that there are no physical signs applicable to the 
brain," such as are dependent on a cause similar to that of the act of inspi- 
ration and expiration of the lungs, or perhaps of the systole and diastole of 
the heart, while in their healthy state; for the brain, in its normal condition, 
can of itself develope no physical phenomena. The thing is incompatible 
with a physiological state of the organ. 

There are, however, certain conditions of the brain, in which a new order 
of things has been discovered to take place; and the very fact that it is 
known, and can be shown to exist only in certain derangements of that 
organ, while in its physiological condition, signs which are purely negative 
in their character are developed, proves the former to be, not only a physical 
sign, but a sign which is most surely pathognomic of some derangement of 
the organ itself. 

Such then, being the case, can it be shown that the organs within the 
cavity of the cranium are "so disposed" as to render the art of auscultation 
or percussion in any way available, and that these physical signs are 
applicable to the brain? The very thought ought to commend itself to the 
consideration of every true lover of science. 

Heretofore, and even at the present moment, the diagnosis of diseases of 
the brain rests solely upon the plausibility of physiological and pathological 
induction. But inductive signs are known to vary, and to vary exceedingly 
in organs of the most simple structure, from the force of the slightest varia- 
tion of circumstance. How infinitely more complex and variable then, 
must they be when dependent upon the mere breath of circumstance, over 
an organ of such exceedingly complex structural organization, as that of the 
brain! Yet in regard to this organ, although we may never, perhaps, attain 
to that degree of precision, I might say physical certainty, which has been 
attained, in regard to diseases of the organs of the thorax, may we not 
rationally anticipate, that, with what industry and perseverance can accom- 
plish, and with what may be accomplished by a newer and more rational 
method of investigating its diseases, our knowledge may be as certain, and 
our diagnosis of the diseases of the brain, in a degree, may be made with as 
much precision, as that of the heart and lungs? 

If, indeed, such a hope is held out to us, is the duty not an imperative 
one, that when we enter upon the investigation of a class of diseases, so 
numerous in their relations, and so important in their results, as those of the 
brain, it should be done with a boldness which nothing can intimidate, 
while at the same time we watch with a jealous eye, every thing which 
would tempt us to overreach the bounds of well-ascertained and well-estab- 
lished facts? And if by any means, whatsoever they may be, we may be 
able to reduce and simplify the phenomena of disease, to discriminate be- 
tween the real and apparent signs, and to set a mark upon those particular 



1843.] Whitney on Cerebral Auscultation. 285 

ones which look out from amidst the surrounding darkness, as beacon-lights, 
to warn us of the dangers which are at hand, so far do we elevate and extend 
the limits of that science, which, in its beneficence, would embrace every 
member of the great family of man. 

Such were some of the reflections indulged in, after having read, a number 
of years since, some observations upon a new method of exploring the dis- 
eases of the brain. I mean that of "cerebral auscultation." 

A summary notice of the discovery of a new auscultic phenomenon, as 
connected with certain diseases of the brain, and a brief resume of its most 
prominent features, was first made by the author of the above-mentioned 
" observations," to the Boston Society for Medical Improvement, in the 
summer of 1833. Further observations were made, and a more extended 
view of the subject was subsequently communicated to the same society in 
March of 1838. The same paper was published the following August, as 
the readers of this Journal will recollect, under the title of " Observations 
on Cerebral Auscultation, by J. D. Fisher, M. D. of Boston." 

I was particularly struck at that time with the observations contained in 
that paper, in consequence of my attention having been directed to the sub- 
ject of the lesions of the great nervous centre, from reading the researches of 
Abercrombie, MM. Lallemand, Rostan, and some others of the more notable 
French writers upon this subject. Since that time I have noted as well and 
as accurately as circumstances would admit, every incident worthy of notice, 
which would tend to throw any further light upon the subject of cerebral 
auscultation. 

The cases which I shall hereafter describe, have been those, with a single 
exception, which have occurred within my own practice, and from having 
had a frequent opportunity of seeing them, day after day, under every variety 
of condition and circumstances, I can certify to the accuracy and truthful- 
ness of the details. 

In a strictly physiological state of the brain, as has already been observed, 
no physical signs are developed, except such as are dependent on causes 
which are extraneous in their operation to any of the functions of that organ; 
such, for instance, as the sound of respiration, of deglutition, the sound of 
the voice and heart as heard through the medium of the brain. 

There are, however, other sounds which are manifest only in certain 
pathological conditions of the brain, and which are dependent upon causes 
within the brain itself. These are the physical signs so far as they are 
known, of certain diseases of the cerebral organs, and as such they will here- 
after be spoken of. Before entering upon the history of these last-mentioned 
symptoms, it may be proper to say a few words, first, in regard to the normal 
cephalic sounds. For a more particular and detailed account of these sounds 
the reader is referred to the article on " Cerebral Auscultation," in the August 
No. of this Journal for 1838. 

In auscultating the heads of healthy children, four very different and per- 



286 Whitney on Cerebral .Auscultation. [Oct. 

fectly distinct bruits, are heard passing through the brain. They are evidently 
the sounds which are produced by the act of respiration and deglutition, by the 
impulse of the heart and the voice. 

The one which first attracts the attention, is that which is produced "by 
the impinging of the air against the walls of the nasal cavities during the act 
of respiration." It commences and terminates with the respiratory act, and 
in this respect, is peculiar and easily recognized. This sound has been 
denominated " the cephalic sound of respiration." 

" The second sound which strikes the ear, is one whose impulse seems to 
be transmitted from a distance. It is evidently that of the heart, and is a soft 
mellow sound, resembling that produced by softly palpating the cheeks when 
distended with air." This sound is synchronous with the action of the heart, 
and " varies in frequency and intensity, as the contractors of that organ vary 
in rapidity and power." This has been called the "cephalic sound of the 
heart." The sharp, piercing, and vibratory sounds which accompany the 
act of crying or speaking, and which can be so distinctly heard over every 
portion of the skull, has been termed the " cephalic sound of the voice" It 
varies somewhat in its tone at different parts of the head, being the least shrill 
and piercing at the unclosed fontanelle. The other sound which attracts 
attention, and the only remaining one of the normal sounds of the head, 
attends the act of deglutition. It is a dull, massive, liquid sound, and so 
peculiar, that when once recognized, it never can be mistaken for any other 
bruit. This is the " cephalic sound of deglutition." 

Such are the bruits, which are heard in the heads of infants before the 
closure of the fontanelle. As age advances, and the density of the brain and 
cranium increases, these sounds become somewhat modified. The change 
which some of them undergo in the numerous lesions of the encephalon, is 
however, exceedingly slight: still others are so manifestly changed in their 
character, as to become symptoms of cerebral disease. 

Beside a modification of the " cephalic sound of the heart," under the 
influence of certain diseases of the cranium, to a consideration of which this 
paper is more particularly devoted, I shall have occasion, hereafter, to speak 
of an equally striking modification of the "cephalic sound of the voice," 
which is found to accompany, and which I think is characteristic of & par- 
ticular affection of the brain. It resembles, as nearly as the nature of the 
organs could admit, the sound which is known to accompany the effusion of 
fluid between the two pleurae of the lungs, and is never heard, except in 
those diseases of the brain which are attended with a similar effusion between 
the membranes by which this organ is enveloped. It is, indeed, no more 
nor less than a simple fegophony of the brain; and as such, I doubt not, but 
that hereafter it will be found a valuable acquisition to the category of signs, 
which belong to this obscure and difficult class of lesions. During nearly 
five years, in which the observations herein detailed, have been made, I have 
noticed the " cephalic bellows-sound, or some modification of it, in no less 



1843.] Whitney on Cerebral Auscultation. 287 

than eight different and perfectly distinct lesions of the brain. In some of 
these, it has been a well-marked, constant, and invariable symptom; in 
others it has been less so, while in all it has been sufficiently striking to 
render it a valuable and independent physical sign. 

The different diseases in which this symptom has been present and cha- 
racteristic, I have arranged, and shall speak of them in the following order: 

1. In simple congestion or irritation. 

2. In acute inflammation of the brain, with or without effusion. 

3. In chronic hydrocephalus. 

4. In acute or local compression of the brain. 

5. In induration, or scirrhous transformation of the substance of the cere- 
bellum. 

6. In ossification of the arteres of the brain. 

7. In aneurism of the basilar artery. 

8. In aneurism, and certain hydrocephaloid diseases. 

The first instance in which I was able satisfactorily to determine the 
presence of the " cephalic bellows-sound," arising from simple irritation or 
congestion of the brain, was in the following case, transcribed from my note 
book for 1839. 

Case I. — July 10th, I was called to visit a child of Mr. L., aged 18 
months. This afternoon on awaking from its sleep, in the absence of its 
mother, it had crept from its place of rest, which was a high-post bedstead, 
and had fallen to tne floor. In its passage its head came in contact with the 
corner of a small wooden foot cricket, producing a manifest contusion of the 
integuments over the right frontal bone, and depriving it of all con- 
sciousness. 

When I arrived, the child was in a state of apparent insensibility. Its 
inspirations were long, surreptitious, and somewhat convulsive in character. 
Countenance pale and cadaverous, with the eyelids closed, and the eyeballs 
rolled upwards; extremities cold and clammy, with scarcely a perceptible 
pulse at the wrist. The pulsations of the heart were feeble and preter- 
natural ly slow. 

On auscultating the head, which I did for the purpose of satisfying myself 
of the presence of this new and singular phenomenon of the brain, no 
" cephalic bellows-sound" was heard; not a sound was communicated to the 
ear, but the unnatural and convulsive sound of respiration. Thinking that 
the feebleness of the arterial pulsations mioht be the cause of the absence of 
this sound, frictions with warm and stimulating applications were directed to 
be applied to the extremities, with the intention of relieving the smothered 
condition of the internal vessels, by increasing the activity of the capillary 
circulation without. The pulsations of the arteries of the extremities, head 
and neck were soon very perceptible, and on applying the ear again to the 
head, a short and abrupt sound, synchronous with the action of the arterial 
pube, was immediately communicated to it. 

This was the "cephalic bellows sound," and is perfectly distinct from 
the " cephalic sound of respiration," heard on my first auscultation. This 
sound, which was at first rather faint, increased in intensity and distinctness 
as the natural warmth and vitality of body was restored. Friction was 



288 Whitney on Cerebral Auscultation. [Oct. 

directed to be continued, and some active internal remedies were prescribed. 
On the following morning, July 11, the child, after having passed a rest- 
less and troublesome night, awoke to consciousness. From its appearance, 
however, it was evident there still remained no inconsiderable degree of dis- 
turbance of the functions of the brain. There was a strong febrile action 
about ihe system; skin dry and hot; tongue and mouth parched, and accom- 
panied witti extreme thirst. Head and face hot and flushed, and the integu- 
ments over the contused portion, tender and swollen. The eyes were dull 
and heavy, and there was a strong tendency to stupor and drowsiness. 
The pulsations of the carotid and temporal arteries of the injured side, 
were violent and rapid: less so on the left. 

Such were the apparent external physical signs. On ausculting the head, 
the " cephalic bellows sound" was found much more distinct than on the 
preceding evening. It is short, abrupt, but does not so much resemble the 
" coarse, rasp-like sound," as mentioned by Dr. Fisher and which accom- 
panies certain lesions of the heart, as the soft, diffusive sound, which is pro- 
duced by drawing the finger suddenly over the surface of a piece of fustian 
or velvet. This sound is perfectly in unison with the arterial pulsation, and 
occurs 130 times in a minute. 

Cataplasms of mustard were ordered to the extremities, a powerful purge 
was administered, and three leeches applied to the right temple. 

July 11, afternoon. Medicine has operated six times; blood still running 
from the leech bites; countenance more natural; though still pale; eyes look 
brighter and more intelligent; movements around him noticed; skin warm 
and moist, and urine evacuated freely for the first time since the injury. 
Cephalic bellows-sound still heard, but not so distinctly as at the morning 
visit. In fine, this singular and evidently abnormal sound, and the first I 
had ever noticed in a purely functional disturbance of the brain, grew fainter 
and fainter, until about the third day from the injury, it had entirely dis- 
appeared, and the little patient had regained the natural vigour both of body 
and mind. 

Case II. — The second case of simple cerebral congestion which occurred 
to me, and in which the similar auscultic phenomenon was observed, was that 
of a young girl, aged 2 years. This patient, by being thrown from a car- 
riage with its mother, had received an injury upon the head, similar to the 
one mentioned above. I saw her about two hours from the occurrence of 
the accident, and although not actually deprived of its senses, yet the singu- 
lar and somewhat erratic movements of the child, coupled with the fears and 
apprehensions which the excitement of the moment had aroused in the 
minds of both parents and friends, demanded of their medical adviser a more 
careful, attentive, and serious consideration of the case. There were no 
external marks of injury upon the child, either about the body or head, not 
even the slightest abrasion of the skin could be found, and had not the age 
and the intelligence of the child removed it far above the reach of suspicion, 
I should have looked upon it merely as a case of hysteria. 

Apart from this, however, there was evidently some functional disturbance 
of the brain. When left undisturbed, there was a disposition on the part of 
the child to fall asleep; upon being aroused, however, the countenance main- 
tained an appearance of intelligence, although the eye had rather an uncer- 
tain and vacillating look and movement. 

On ausculting the head, I directly caught a cephalic murmur, very much 
resembling that described in the previous case, and though less distinct, yet 



1843.] Whitney on Cerebral Auscultation. 289 

like that, it was short, abrupt, and in frequency corresponded with the pul- 
sation of the heart and arteries. 

The next day the child had recovered from the immediate effect of the 
fall, and the "cephalic bellows-sound" had disappeared. 

Case III — Was that of a young girl, aged 4 years. This patient, in the 
month of January 1842, while on her way to school in company with her 
brother, a little older than herself, in attempting to cross over a small plat 
of ice, slipped, fell, and in her fall brought her head with her whole force 
in contact with the ice. The blow, at the time, appeared to occasion only 
a momentary loss of sense. She was assisted up by her little brother, and 
proceeded immediately to school. During school hours, she was observed 
by her instructress frequently to fall asleep, and once or twice on being 
questioned, she complained of "dizziness in the head," and of the "school- 
house turning round." 

I was called to see her in the afternoon of the same day, and found her 
labouring under all the common symptoms of a severe cerebral congestion. 
Her sleep was deep and heavy, almost lethargic, and was interrupted every 
now and then, with a low muttering moan, and frequent restless and uneasy 
movements of the head and limbs. 

On applying my ear to the head, I at once recognized the cephalic mur- 
mur which I had previously noticed in similar cases of congestion of the 
brain. I think it was not so plain and distinct in this case as in other cases 
in which I had observed it, where the anterior fontanelle remained un- 
closed. It was distinct enough, however, to be readily recognized by one 
or two individuals present, who had never before practised auscultation. 
As in the cases already cited, the sound was short, abrupt, and synchronous 
with the motion of the heart and the action of the arterial pulse. A strict 
antiphlogistic treatment was prescribed, and cupping to the amount of two 
or three ounces from each temple. The sudden abstraction of blood from 
the head by means of the cupping-glass, seemed to afford almost instanta- 
neous relief, and yet I must confess, I could not perceive that the distinct- 
ness and length of the bellows-sound were at all diminished. A second 
application of the cups was made on the following morning, which, beside 
the relief it brought to my little patient, evidently very much diminished the 
intensity of the cephalic murmur. In short, just so far as the functions of 
the brain, from day to day, regained their natural and healthy action, just 
so far did this pathognomic symptom of their disturbance also die away. 

Case IV. — This, the last case which I shall detail under the present head, 
I notice more on account of its singular and fatal termination, than for any 
marked auscultic phenomenon which it developed. I transcribe it as 
recorded in my Note Book of Cases for 1841. 

March 16th. I was called to see the daughter of Mr. C, a little girl 3 
years of age, who had been labouring under a violent attack of hooping- 
cough, during the preceding four or five weeks. Generally speaking, she 
had five or six severe fits of "coughing" during the twenty-four hours. These 
paroxysms, sometimes longer, and sometimes shorter, averaged from five 
to ten minutes in duration. For the last four or five days, they seemed to 
have increased both in length and severity, and once or twice, after a very 
severe and protracted fit of coughing, a sort of tetanic rigidity of the muscles 
of the face and neck had been observed by her parents. It was the appear- 
ance of this last symptom which had given occasion for my visit, On 



290 Whitney on Cerebral Auscultation. [Oct. 

entering the room I found my little patient in the midst of a severe parox- 
ysm of cjughing, with her countenance bloated, her "face black and full of 
blood." 

"Tier eye-balls farther out than they were wont, 

Staring full ghast'y, like a strangled man, 

Her hair uprearrd, her nostrils stretched with struggling, 

Her hands abroad displayed as one that gasped 

And tugged for life, and was by strength subdued-" 

With her tongue spasmodically protruded, and accompanied with a copious 
secretion of a frothy saliva; with every muscle convulsed and every nerve 
strained to its utmost tension; she looked the very impersonation of a " living 
asphyxia," in the last struggle to rend asunder the throttling embrasure, 
which death was not in vain endeavouring to throw around her. 

I could not help noticing the untoward severity of the paroxysms; and 
although accustomed to look upon this disease as one comparatively free 
from all danger, I was deeply impressed with the conviction, that death had 
already set his seal upon my patient, and the grave marked her out for its 
prey! 

After the paroxysm had subsided, and as soon as the little sufferer had 
obtained a [e\v moments' repose from this struggle between life and death, I 
carefully applied my ear to the coronal portion of the head, and, beside the 
hurried and laboured sound of respiration, I at once detected a perfectly 
audible and distinct " cephalic bellows-sound." It did not differ from the 
same sound as described in the foregoing cases, except that it was more 
continuous, the sounds running into each other, and scarcely leaving a per- 
ceptible interval between. The sound evidently diminished in intensity 
during the thirty-five or forty minutes to which my visit was protracted; but 
it had not at the end of that time entirely disappeared. 

Till within the last two or three days, the child, as I was informed, had 
maintained its accustomed spirits and playfulness during the intervals of the 
paroxysms. Since then she had become exceedingly nervous and irritable 
in her disposition, little inclined to play, but rather averse to see amuse- 
ment, and much inclined to sleep. 

Besides the probability of this temporary congestion of the brain, accom- 
panying each paroxysm of the cough, there were also present some une- 
quivocal signs of no inconsiderable bronchial affection. A deep and sono- 
rous rhonchus, interrupted here and there by a slight mucous rale, was heard 
throughout both lungs. The lungs resounded well on percussion, except 
near the posterior portion of the right one. 

Once or twice, for a few moments preceding a fit of coughing, I was in- 
formed that the respiration had been exceedingly laborious, and accompanied 
with that peculiar dry and stridulous sound which is so characteristic of 
croup. Pulse frequent, tongue coated; skin dry and hot. Antimony and 
paregoric, with a powerful purge of calomel, were prescribed, and a pedi- 
luvium at night, with poultices of mustard to the feet and legs. A small vesi- 
cating plaster was also applied over the posterior portion of the right lung. 

17th. Morning. Sleep has been more quiet through the night, and 
less interrupted by coughing; respiration is also freer and more natural; 
otherwise, the child is much the same as yesterday. Chest still resonant 
on percussion, except over the inferior portion of right back; mucous rhon- 
chus still heard throughout both lungs. Pulse still frequent, skin hot, cheeks 



1843.] Whitney on Cerebral Miscultation. 291 

flushed, tongue coated, and the lips dry and parched. Bellows-sound in- 
audible. 

Continue antimony and paregoric, with oleum ricini ^ss, to be repeated 
in three hours if necessary. 

In the evening was again present during a very severe paroxysm of 
coughing, which was followed by a distinct and well marked bellows-sound, 
which entirely died away again within the lapse of twenty-five or thirty 
minutes. Bowels had been moved five or six times during the day, which 
seemed to afford a little temporary relief. Blister had extensively vesicated 
the surface, under the influence of which the irritation about the lungs had 
somewhat subsided. 

ISth, \9thi and 20fh, much the same, excepting the length and vio- 
lence of the paroxysms of coughing, which of the two, had rather increased. 

21s/. Early this morning I was hastily summoned to attend the child — 
as the messenger informed me, "in a fit." I immediately repaired to the 
bedside of my little patient, and was much surprised to find it labouring 
under the usual symptoms of a decided cerebral apoplexy. The acces- 
sion of the fit, I was told, occurred during a moment of strangulation which 
accompanied an unusually long and severe fit of coughing. The urgency of 
the case, together with the grief and anxiety of its friends, seemed to admit 
of not a moment's delay either for inquiry or examination. That was 
demanded, and that only, which would afford instantaneous relief, and res- 
cue the little sufferer from the jaws of death. 

A free discharge of blood was made from an opening in the temporal 
artery of the left, and the jugular vein of the right side. After the bleeding, 
ice was ordered to be applied to the head, accompanied internally with an 
active purge, to be followed with enemata of castor oil and spirits of tur- 
pentine. 

On ausculting the head at this moment, contrary to every expectation, I 
was unable to detect any sound, except the long and stertorous sound of 
respiration. A similar result followed the third and fourth subsequent 
examination, which were made during the deep, lethargic sleep into which 
the child had so suddenly fallen. In about seven hours from the time of its 
attack, the powers of life seemed to rally again. Consciousness in a degree 
returned, though not sufficiently clear, I think, to recognize the coun- 
tenances of her afflicted parents. She has had no paroxysms of coughing 
since this evident attack of apoplexy; and I now notice for the first time, a 
slight contraction of the muscles of the right side of the face. There was 
found on a further examination, an evidently palsied state of the whole of the 
left side of the body. The sensibility of this side, though much diminished, 
was not, however, entirely lost. The foot was slightly turned inward, and 
the muscles of the arm affected in such a manner as to draw the thumb and 
fingers of the left hand towards its palmar surface and each other. 

During a visit this evening, my attention was again directed to the dis- 
covery of whatever physical sign might be developed within the cranium. 
The paryoxysms of coughing had returned during the latter part of the 
afternoon, and had continued more or less frequently during most of the 
evening. 

On ausculting the head immediately succeeding a coughing fit, I again 
detected a very distinct and audible murmur, varying somewhat in its cha- 
racter from the pure bellows-sound of the head. It was less circumscribed 
in its locality and duration than that sound, and was more a dull, impulsive, 
muffled murmur, and withal a sound «« sui generis," 



292 Whitney on Cerebral Auscultation. [Oct. 

I had scarcely time to satisfy myself of the real character of the murmur, 
when a sudden accession of coughing, with a momentary sense of suffoca- 
tion, put a period to the existence of my little patient. 

Examination of the body sixteen hours after death. 

External appearance of the body is natural, except the integuments about 
the head, face, and neck: these appear bloated and swollen. 

Head. — The membranes of the brain natural, except the pia mater and 
arachnoid, which are somewhat congested. Eleven or twelve whitish and 
rather opaque granulations are clustered together about the posterior part of 
the arachnoid, near the longitudinal fissure; there are also some very slight 
traces of effu