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

THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC H.AYS, M.D., 

PRTjIiOW of the college op physicians of PHILADKLPHIA : MEMBER OF 

THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, AND OF THE AMERICAN 

PHILOSOPHICALSOCIETY ; associate fellow of THE AMERICAN 

ACADEMY OF ARTS AND SCIENCES, 

&C.&C.&C. 



ASSISTED BY 

I. MINIS HAYS, M.D. 



NEW SERIES 
VOL. LXXIII. 




PHILADELPHIA: 

HENRY C. LEA 

1877. 



Entered according to the Act of Congress, iu the year 1877, by 

HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 




PHILADELPHIA: 
COL li INS, PHTNTKR] 

705 Jayne Street. 






TO READERS AND CORRESPONDENTS. 

All communications intended for insertion in the Original Department of this 
Journal are only received for consideration with the distinct understanding that 
they are sent for publication to this Journal alone, and that abstracts of them 
shall only appear elsewhere subsequently, and with due credit. Gentlemen 
favouring us with their communications are considered to be bound in honour 
to a strict observance of this understanding. 

Contributors who wish their articles to appear in the next number are re- 
quested to forward them before the 1st of February. 

Compensation is allowed for original articles and reviews, except when illus- 
trations or extra copies are desired. A limited number of extra copies (not 
exceeding /////) will be furnished to authors, provided tlie request for them 
he made at the time the communication is sent to the Editors. 

The following works have been received : — 

Hauptmomente in der Geschichtlleheu Entwickelung der Medicinischen Therapie 
von Dr. Jul. Petersen. Kopenhagen: And. Fred. Host k Sohn, 1877. 

Klinik der Pailiatrik. Von Dr. Ludwig Fleischmann, Decent au der Universtat. 
11. Der Erste Zahndurclibruch des kindes nebst einer Geschichtlicben Einleitung. 
Wien : Wilhelm BruumiUler, 1877. 

Sauerstoff und Ozou, ihre Bedentung fiir die Diiltetik und Heilkunde. Von Ge- 
bruden Zenz. Berlin. 

Surgical Observations on Gunshot Wounds of the Hip-Joint. By B. Von Langen- 
BECK, Prof, of Surgery iu Univ. of Berlin. Translated by Jas. F. West, F.R.C.S., 
Birmingliara. 

A Case of Double Optic Neuritis without Cerebral Tumour. Case of Large Cere- 
bral Tumour without Optic Neuritis, and with Left Hemiplegia and Iraperception. 
By J. Hughltngs Jackson, M.D. 

Medical Science in relation to the Voice as a Musical Instrument. By Lennox 
Browne, F.R.C.S. Edin. London, 1876. 

Medical Hints on the Production and [Management of the Singing Voice. By 
Lennox Browne, F.R.C.S. Edin. London, 1876. 

Chemistry: General, Medical, and Pharmaceutical, including the Chemistry of the 
U. S. Pharmacopoeia. By John Attfield, Ph.D., F.C.S., Prof, of Practical Chemis- 
try to Pharmaceutical Society of Great Britain, etc. Seventh ed., revised from the 
sixth (English) edition by the author. Philadelphia: Henry C. Lea, 1876. 

A Treatise on the Theory and Practice of Medicine. By John Syer Bristowe, 
M.D. Lond., F.R.C.S., Phys to St. Thomas's Hospital, etc. Edited, with Notes, 
by James H. Hutchinson, M.D., Physician to the Pennsylvania Hospital. Philadel- 
phia: Henry C. Lea, 1876. 

A Century of American Medicine: 1776-1876. By Edward H, Clarke, M.D., 
late Prof, of Materia Medica in Harvard University; Hp.nry J. Bigelow, M.D., 
Prof, of Surgery in Harvard University, etc. ; Samuel D. Gross, M.D., LL.D., 
D.C.L. Oxon., Prof, of Surgery in Jefferson Med. Coll., Phila. ; T. Gaillard Tho- 
mas, M.D., Prof, of Obstetrics, etc. in Coll. of Phys. and Surgeons, New York, etc.; 
and J. S. Billings, M.D., Librarian to the National Medical Library, Washington, 
D. C. Philadelphia: Henry C. Lea, 1876. 

Epitome of Skin Diseases, with Formulge. For Students and Practitioners. By 
Tilbury Fox, M.D., F.R.C.S , Phys. to Dep't for Skin Dis. in Univ. Coll. Hosp., and 
T. C. Fox, B.A. (Cantab.). Philadelphia: Henry C. Lea, 1876. 

Principles of Human Physiology. By William B. Carpenter, M.D., F.R.S., 
F.L.S., Registrar to the University of London, etc. Edited by Henry Power, M.B. 
Lond., F.R.C.S. A new American, from the eighth revised and enlarged English 
edition, with Notes and additions by Francis G. Smith, M.D., Prof, of Institutes of 
Medicine in Univ. of Penna. Philadelphia : Henry C. Lea, 1876. 



8 TO READERS AND CORRESPONDENTS. 

Observations on the Diseases of the Rectum. By T. B. Curling, F.R.S., Consult- 
ing Surgeon to the London Hospital. Fourth ed., revised and enlarged. Philadel- 
phia: Lindsay & Blakiston, 1876. 

The Physician's Visiting List for 1877. Philadelphia: Lindsay & Blakiston. 

Nutrition in Health and Disease. A Contribution to Hygiene and to Clinical 
Medicine. By James Henry Bennet, M.D., M.R.C.P. Lond. Second edition. 
Philadelphia: Lindsay & Blakiston, 1876. 

Clinical Studies, illustrated by cases observed in Hospital and Private Practice. 
By Sir John Rose Cormack, K B., F.R.S.E., Phys. to Hertford British Hospital of 
Paris. 2 vols. Philadelphia: Lindsay & Blakiston, 1876. 

Cyclopasdia of the Practice of ^ledicitie. Edited by Dr. H. Von Ztemssen. 
Vol. VL — Diseases of the Circulatory System together with the chapters on Whoop- 
ing Cougli, Diseases of the Lips and Cavity of the Mouth, and Diseases of the Soft 
Palate. Vol. VII. — Diseases of the Chylopoietic System. Albert H. Buck, M.D., 
New York, Editor of American edition. New York: William Wood & Co., 1876. 

Ophthalmic and Otic Memoranda. By D. B. St. John Roosa, M.D., Prof, of 
Ophthalmology and Otology in Univ. of City of New York, and Edward T. Ely, M.D., 
Assistant to the Chair of Ophthal. and Otol. Univ. of City of N. Y. New York : Wil- 
liam Wood & Co., 1876. 

Tablets of Anatomy and Physiology. By Thomas Cooke, F.R.C.S. New York: 
William Wood & Co. 

Contributions to Reparative Surgery. By Gurdon Buck, M.D. New York: 
D. Appleton & Co., 1876. 

Compendium of Histology. Twenty-four Lectures, by Heinrich Frey, Professor. 
Translated by George R. Cutter, M.D., Assist. -Surgeon N. Y. Eye and Ear In- 
firmary, etc. New York: G. P. Putnam's Sons, 1876. 

The Use of the Spectroscope in its Application to Scientific and Practical Medi- 
cine. By Emil Rosenberg, M.D. New York: G. P. Putnam's Sons, 1876. 

A Series of American Clinical Lectures. Edited by E. C. Seguin, JNI.D. No. 20 — 
The Hypertrophied Prostate, by Robert F. Weir, M.D., Lecturer on Genito-Urinary 
Diseases in the Coll. of Phys. and Surgeons, N. Y. No. 21 — Points on the Surgery 
of Childhood, by J. H. Pooley, M.D., Prof, of Surgery in Starling Med. Coll., Co- 
lumbus, Ohio, No. 22 — Spinal Irritation; its Pathology and Treatment, by Wil- 
liam A. Hammond, M D., Prof, of Dis. of Mind and Nervous System in Univ. of 
City of New York. New York: G. P. Putnam's Sons, 1876. 

The Anatomy of the Head, with six Lithographic Plates, representing Frozen Sec- 
tions of the Head. By Thomas Dwight, M.D., Prof, of Anatomy at Medical School 
of Maine, etc. Boston: H. 0. Houghton & Co., 1876. 

The jNledical Staff' of the United States Army, and its Scientific Work; an Address 
delivered to the International Medical Congress at Philadelphia, Sept. 6, 1876. By 
Surgeon J. J. Woodward, U. S. Army. Philadelphia, 1876. 

Naval Medical Schools of France and England. Reported to the Bureau of Medi- 
cine and Surgery by Richard C. Dean, Med. Inspector U. S. N. Washington, 1876. 

Micro-Photographs in Hij-tology, Normal and Pathological. By Carl Seiler, M.D. , 
in conjunction with J. Gibbons Hunt, M.D., and Joseph G. Richardson, M.D. 
Vol. II., No 6 Philadelphia: J. H. Coates & Co , 1876. 

A Treatise on Hernia; with a New Process for its Radical Cure, and Original Con- 
tributions to Operative Surgery, and New Suigical Instruments. By Greensville 
Dowell, M.D., Prof, of Suigery in Texas Med. Coll. Philadelphia: D. G. Brinton, 
1876. 

On Coughs, Consumption, and Diet in Disease. By Horace Dobell, M.D., 
F.R M.C.S., etc. Philadelphia: D. G. Brinton, 1876. 

Public Libraries in the United States of America; their History, Condition, and 
Management. Special Report, Department of the Interior, Bureau of Education. 
Parti. Washington: Government Printing Office, 1876. 

Johns Hopkins Hospital: Reports and Papers relating to Construction and Or- 
ganization. No. 2, with Plates. 

The Ovulation Theory of Menstruation ; will it stand ? By A. Reeves Jackson, 
A.M., M.D. New York, 1876. 

The Use and Value of Arsenic in the Treatment of Diseases of the Skin. By L. 
Duncan Bulkley, A.M., M.D. New York, 1876. 

The Treatment of the Insane. By Dr. Nathan Allen, of Lowell, Mass. Albany, 
1876. 



TO READERS AND CORRESPONDENTS. VJ 

Vaginnl Ovariotomy. By Clifton E. Wing, M.D., Boston. Cambridge, 1876. 
Salicylic Acid ; the Experience of Maine Physicians in its use. Reported by 
Frederic Henry Gerrish, M.D., of Portland. Portland, 1876. 

Degenerations of the Placenta as a Cause of the Death of the Child. By Charles 
A. Leale, M.D. New York, 1876. 

Bloodletting in Puerperal Eclampsia, Pathology and Therapeutics; the Old and 
the New. By Henry Fraser Campbell, M.D , of Augusta, Geo. New York, 1876. 
A Case of Exophthalmic Goitre. By J. P. Thomas, M.D., Pembroke, Ky. Louis- 
ville, 1876. 

On the Treatment of Chancroids by the Actual Cautery. By Henry G. Pifeard, 
M.D. New York, 1876. 

A Lecture on Specialism in Medicine. By E. D. Foree. M.D. Indinnapolis, 1876. 

Argument in favour of a Contagious Diseases Act; its present state. By E. T. 
Easley, M.D., Little Rock, Ark. Louisville, 1876. 

Hints towards a Better Knowledge of some of the Methods of and Substances used 
in Specific Medication. By Edward R. Mayer, M.D., of VVilkesbarre, Pa. 

On the Reciprocal Relations of an Efficient Public Health Service and the Highest 
Educational Qualifications of the Medical Profession. By Stephen Smith, M.D. 
Cambridge, 1876. 

Remarks upon the Nature of the Diphtheritic Poison, and its Treatment by so- 
called Disinfectants. By Beverley^ Robinson, M.D. New Y^ork, 1876. 

The Collateral Circulation in Aneurism : Report of the Successful Ligation of the 
Innominate, the Common Carotid, the Vertebral, and the Internal IVIanimary Arte- 
ries, in a case of Right Subclavian Aneurism. By A. W. Smyth, INI.D. New Or- 
leans, 1876. 

The Treatment of Antefiexions of the Uterus. By Ely Van de Wabker, MD. 
New York, 1876. 

Report on the Registration of Prevalent Diseases. By Dr. H. W. Draper. M.D. 
Boston, 1876. 

Preventing the Extension of Syphilis. By J. K. Black, M.D., of Newark, Ohio. 

The Management of the Insane without Mechanical Restraints. By J. L. Bo- 
dine, M.D., of Trenton, N. J. 

The History of Spontaneous Generation. By Edward S. Dunster, M.D. Ann 
Arbor, 1876. 

On Masturbation and Hysteria in Young Children. By A. Jacobi, M.D. New 
York, 1876. 

A New Method of Treating Hemorrhnge after Abortions and at Full Time, when 
due to Uterine Inertia. By H. Otis Hyatt. M.D. New York, 1876. 

Diphtheria. By Dr. J. H. Gilman, of Lowell. 

The Medical Libraries of Boston. By James R. Chadwick, M.D. Cambridge, 
1876. 

Transactions of the Texas State Medical Association, April, 1876. Marshall, 1876. 

Transactions of the Medical Society of the State of Pennsylvania, 1876. 

Transactions of the New Hampshire Medical Society, Concord, June, 1876. Con- 
cord, 1876. 

Transactions of the Colorado State Medical Society, 1876. Denver, 1876. 

Proceedings of the Medical Society of the State of Oregon, 1876. Porthuid, 1876. 

The Proceedings of the Medioal Society of the County of Kings, Brooklyn, N. Y. 
October, November, December, 1876. 

Annual Report of the Surgeon-General United States Army, 1876. 

Report of the Board of Health of Philadelphia, 1875. Philadelphia. 1876. 

Report of the Births, Marriages, and Deaths in the City of Providence for 1875. 
By Edwin M. Snow, M.D., Supt. of Health and City Registrar. Providence, 1876. 

Report of the State Lunatic Hospital of Pennsylvania. Harrisburg, 1876. 

Report of the Northern Hospital for the Insane of the State of Wisconsin, 1876. 
Madison, 1876. 

Report of the Alabama Insane Hospital at Tuskaloosa, 1876. Montgomery, 1876. 

Report of the Massachusetts Sohool for Idiotic and Feebleminded Youth, 1876. 
Boston, 1877. 



10 TO READERS AND CORRESPONDENTS. 

The following Journals have been received in exchange: — 

Deutsches Archiv fur Klinische Medicin. Bd. XVIII., Heft 2, 3, 4. 

Archiv der Heilkunde, Bd. XVII., Heft 6. 

Archiv fiir An.itomie, Phj^siologie und Wissenschaftliche Medicin, 1876. No. 3. 

Centralbliitt fiir die Medicinische Wissenscbaften. Nos. 37 to 48. 1876. 

Allgemeine Wiener Medizinische Zeitung. Nos. 38 to 48. 1876. 

Deutsche Medicinische Wochenschrift. Nos. 36 to 47. 1876. 

Nordiskt Medicinskt Arkiv. Bd. viii. Tredje Haftet. 

Upsahx Lllkareforenings Forhandlingar. Bd. xii., No. 1, 

Bibliothek for Lasger. Bd. VI., Heft 4. 

Anuali Universali di Medicina e Chirurgia. Ottobre, Novembre, 1876. 

Giornale Ituliano delle Malattie Venneree e della Pelle. Ottobre, 1876. 

L'Imparziale. Nos. 18 to 23. 1876. 

Lo Sperimentale. Settenibre, Ottobre, Novembre, 1876. 

Correio Medico de Lisboa. No. 24, 1876. 

Archives Generales de Medecine. Octobre, Novembre, Decembre, 1876. 

Annales de Dermatologie et de Syphiligraphie, Tome VII., No. 6. 

Annales des Maladies de I'Oreille et du Larynx. Aout, Novembre, 1876. 

Revue des Sciences Medicales en France et de I'Etranger. Octobre, 1876. 

Gnzette Hebdomadaire de Medecine et de Chirurgie. Nos. 36 to 48. 1876. 

L'Union Mgdicale. Nos. 108 to 142. 1876. 

Le Progres Medical. Nos. 38 to 49. 1876. 

Le Mouveraent Medical. Nos. 38 to 49. 1876. 

Revue Scientifique de hi France et de I'Etranger, Nos. 12 to 23. 1876. 

L'Annee Medicale. Nos. 10, 11. 1876. 

The British and Foreign Medico-Chirurgical Review, October, 1876. 

The Lancet. October, November, December, 1876. 

The Medical Times and Gazette. October, November, December, 1876. 

The British Medical .Journal. October, 1876. ^ 

The London Medical Record. October, November, December, 1876. 

The Sanitary Record. October, November, December, 1876. 

The Practitioner. October, November, December, 1876. 

The Obstetrical Journal of Great Britain and Irelaiid. Oct.,' Nov., Dec, 1876. 

The Journal of Anatomy and Physiology. October, 1876. 

Edinburgh Medical Journal. October, November, December, 1876. 

The Dublin Journal of Medical Science. September, October, November, 1876. 

The Indian Medical Gazette. September, October, November, 1876. 

Canada Medical and Surgical Journal. October, November, December, 1876. 

The Canada Medical Record. September, October, November, 1876. 

The Canadian Journal of Medical Science. November, December, 1876. 

The Canada Lancet. October, November, December, 1876. 

L'Union Medicale du Canada. October, November, December, 1876. 

The usual American exchanges have been received ; their individual acknowledg- 
ment we are compelled to omit for want of space. 



Communications intended for publication, and books for review, should be sent 
free of expense, directed to Isaac Hays, M.D., Editor of the American Journal of the 
Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as 
above, and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 
King William Street, Charing Cross, London, will reach us safely and without delay. 

All remittances of money and letters on the business of the Journal should be ad- 
dressed exclusively to the publisher, Mr. H. C. Lea, No, 706 Sansom Street. 

The advertisement sheet belongs to the business department of the Journal, and 
all communications for it must be made to the publisher. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. CXLY. NEW SERIES. 

JANUARY, 1877. 



ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Rupture of tlie Healthy ffisopliaiius. By Reginald H. Filz, M.P., 
Assistant Professor of Pathological Anatomy in Harvard University. . 17 

II. A contribution to the Study of Animal Temperature. Preliminary 
Note. By Roberts Bartholow. M.D., Prof, of tlie Theory and Practice 

of Medicine and of Clinical Medicine in the Medical College of Ohio. . 36 

III. The Treatment of Certain Injuries of the Head, accompanied by 
Lesions of the Brain and its Membranes. With illustrative cases. By 

W. B. Rodman, M.D., of Frankfort, Ky. . . . . . 39 

lY. The Disproportion between the Power of Hearing the Tick of a 
Watch and the Human Yoice ; with remarks on hearing better in the 
midst of noise. By D. B. St. John Roosa, M.D., Professor of Ophthal- 
mology and Otology in the University of the City of New York, Sur- 
geon to the Manhattan Eye and Ear Hospital. . . . . .50 

Y. On the Development of the External Ear Passages. By David Hunt, 
M.D., of Boston, Mass 58 

YI. Remarks on some of the Rarer Syphilitic Neuroses of the Eye, illus- 
trated by cases. By Charles S. Bull, M.D., Ophthalmic Surgeon to 
Charity Hospital, Assistant Surgeon to the N Y. Eye Infirmary. . . 62 

YII. On the Mechanism of Occipito-posterior Positions of the Yertex. 
By H. G. Landis, A.M., M.D., of Niles, Ohio. (AVith four wood-cuts.) 71 

YTIl. A Case of Addison's Disease. By William Pepper, A.M., M.D., 
Prof, of Clinical Medicine in the University of Pennsylvania. . . 75 

IX. A Case of Sarcomatous Tumour mistaken for Popliteal Aneurism. By 
Erskine Mason, M.D., Surgeon to Bellevue and the Roosevelt Hospitals. 
(With a wood-cut.) 85 

X. Partial Aphasia without Appreciable Lesion of Island of Reil. By 
Horatio C. Wood, Jr.. M.D., Professor of Materia Medica and The- 
rapeutics, and Clinical Professor of Diseases of the Nervous System, in 

the University of Pennsylvania. ........ 89 

XT. The Relations of Blepharitis Ciliaris to Ametropia. By D. B. St. 
John Roosa, M.D., Professor of Ophthalmology and Otology in the 
University of the City of New York, Surgeon to the Manhattan Eye 
and Ear Hospital. . . . . . . . - . . . .92 

XII. Pulsating Tumour of Orbit resembling true Aneurism; Ligation of 
Common Carotid; subsequent Removal of Tumour; Recovery. By G. 
E. Frothingham, M.D., Professor of Ophthalmology, University of 
Michigan. (With two wood-cuts.) .......,, 97 



12 CONTENTS. 

ART. PAGE 

Xni. On a Modified mode of detectinsf Paralysis of the Ocular Muscles. 
By H. Culbertson, M.D., Professor of Ophthalmology in the Columbus 
Medical College, Ohio ' . . . .100 

XIV. Treatment of Fracture of the Femur. By Ferd. Brother, M D., of 
Bunker Hill 111. (Wit!» a wood-cnt.) 108 

XV. On the Identity of the Rod Blood Corpuscles in different Races of 
Mankind. By Joseph G. Richardson, M D., Microscopist to the Penn- 
sylvania Hospital 112 

XVI. Ophthalmic Contributions. By George Strawbridge, M.D., of Phila- 
delphia. (With a wood-cut.) ........ 11.5 

XVII. Extraordinary Case of Urinary Calculi. By J. R. MacGregor, 
M.D., of New York City . .120 

XVIII. Aphonia of Ten Months' Duration from Paralysis of the Aryte- 
noideus Proprius Muscle, with Concomitant Heart Disease (Aortic Ob- 
struction); voice restored by the direct application of electricity to the 
vocal cords. By Beverley Robinson, M.D., one of the Physicians to 
Charity Hospital, New York 123 

XIX. Conversion of Face Presentation into one of Vertex by Aid of Knee- 
elbow Position. By J. R. Humphrey, M.D.,of ynickersville, Virginia. 126 

XX. Report of a Case of Multiple Emboli caused by Organic Disease of 
the Heart, and producing Nutritive Changes; Atrophy of one Arm and 
Gangrene of one Leg. By AV. H. Webb, M. D , of Philadelphia. . . 128 

XXI. Pelvic Adhesions in "Ovariotomy. By Walter F. Atlee, M.D., of 
Philadelphia. . _ . . . . _ 131 

XXII. Case of Rabies Felinje, treated with Woorara and Morphia ; Death 

on fifth day. By Ira B. Read, M.D., of New York 136 

XXIII. A New Anthropometer, or a simple Apparatus for Determining 
the Inequalities of the Length of the Legs. By B. F. Gibbs, M.I)., Sur- 
geon U. S. Navy, and Fleet Surgeon South Pacific Station. (With two 
woodcuts.) 139 

XXIV. Description of an Apparatus devised by Dr. Thomas G. Morton 
for Measuring any Irregularity in the l^ength of the Lower Extremities. 
By Stacy B. Collins, M.I)., Assistant Surgeon of the Orthopcedic Hos- 
pital, Philadelphia. (With a wood-cut.) 144 

XXV. A New Method of Double Staining. By W. F. Norris, M.D., 
Clinical Professor of Ophthalmology in the University of Pennsylvania, 
and E. 0. Shakespeare, A.M., M.D., of Philadelphia 146 

XXVI. Absence of the Uterus, with a previous History of Chronic In- 
version of this Organ, which was mistaken for Polypus, and removed by 
Ligature. With remarks. By W. R. Whitehead, M.D., of Denver, 
Colorado. 151 

REVIEWS. 

XXVIT. A Practical Treatise on Materia Medica and Therapeutics. By 
Roberts Bartholow, M.A., M.D., Professor of the 'I'heory and Practice 
of Medicine and of Clinical Medicine, and formerly Prof, of Materia 
Medica and Therapeutics in the Medical College of Ohio, etc. etc. 8vo. 
pp. 537. New York : D. Appleton & Co., 1876 155 

XXVIII. A Treatise on the Science and Practice of Midwifery. By W. 
S. Playfair. M.I)., F.R.C.P., Professor of Obstetric Medicine in King's 
College ; Physician for the Diseases of Women and Children to King's 
College Hospital : Examiner in Midwifery to the University of London, 
etc. etc. With two plates, and one hundred and sixty-six illustrations 

on wood. 8vo. pp. 576. Phila. : Henry C. Lea, 1876 164 

ANALYTICAL AND BIBLIOGRAPHICAL NOTICES. 

XXIX. Guy's Hospital Reports. Edited by H. (i Howse, M.S., and 
Frederick Taylor, M.D. Third Series. Vol. XXL 8vo. pp. xx., 469. 
London : J. & A. Churchill, 1876 178 



CONTENTS. 13 

ART. PAGE 

XXX. Transactions of American State Medical Societies. 

1. Proceedings of the Connecticut Medical Society, May, 1876. 8vo. 

pp. 157. 

2. Transactions of the Medical and Chirurgical Faculty of Maryland, 

April, 1876. 8vo. pp. 165. 

3. Transactions of the Iowa State Medical Society 1872 to 1876 inclu- 

sive. 12rao. pp. 224. 

4. Transactions of the State Medical Society of Arkansas, 1875-6. pp. 

100. Little Rock, Ark., 1875. 

5. Transactions of the Medical Association of the State of Alabama, 

April, 1876. 8vo. pp. 270. 

6. Trans, of the South Carolina Med. Association, April, 1876. pp. 91. 

7. Trans, of the Med. Assoc, of the State of Missouri, April, 1876. pp.79. 

8. Trans, of the Med. Soc. of the State of Cal., April, 1876. pp. 168. 

9. Trans, of the Medical Society of New Jersey. May, 1876. pp. 314 
10. Transactions of the Medical Society of the State of Pennsylvania, 

May and June, 1876. pp. 386 188 

XXXI. A Practical Treatise on the Diseases, Injuries, and Malformations 
of the Urinary Bladder, the Prostate Gland, and the Urethra. By 
Samuel D. Gross, M.D., LL.D., D.C.L. Oxon., Prof, of Surgery in Jeffer- 
son Medical College, Phila. Third Edition, revised and edited by 
Samuel W. Gross, A.M., M.D.. Surgeon to the Philadelphia Hospital. 
8vo. pp. 574. Philadelphia : Henry C. Lea, 1876. .... 194 

XXXII. De I'Exstrophie de la Yessie Envisagee specialement au point 
de vue du Traitement Chirurgical. Thfese pour le Doctorat en Medecine, 
presentee et soutenue par Rodolfo Valdevieso, Docteur en Medecine des 
Facultes de Pennsylvanie et de Paris, etc. etc. Paris, 1876. 

Exstrophy of the Bladder, considered specially with regard to Surgical 
Treatment. Thesis for the Degree of Doctor of Medicine, presented and 
defended by Rodolpho Yaldevieso, Doctor of Medicine of Pennsylvania 
and Paris, etc. 8vo. pp. 76. With four lithographic plates. Paris, 1876. 200 

XXXIII. Yital Motion as a Mode of PhysicaTMotion. By Charles Bland 
Radcliffe, Doctor of Medicine, Fellow of the Royal College of Physi- 
cians of London, etc. etc. 8vo. pp. vi., 252. London: Macmillan & Co., 
1876 202 

XXXIY. A Treatise on the Theory and Practice of Medicine. By John 
Syer Bristowe, M.D. Lond., F.R.C.P., Physician to St. Thomas's Hos- 
pital, etc. Edited, with notes, by James H. Hutchinson, M.D., one of 
the Attending Physicians to the Pennsylvania Hospital, etc. 8vo. pp. 
xxxii., 1089. Philadelphia: Henry C. Lea, 1876 206 

XXXY. The proper status of the Insane and Feeble Minded. By John 
Ordronaux, LL.D., State Commissioner in Lunacy. 8vo. pp. 48. . . 208 

XXXYl. Cyclopaedia of the Practice of Medicine. Edited by Dr. H. 
Yon Ziemssen, Professor of Clinical Medicine in Munich, Bavaria, y o\. 
XI. Diseases of the Peripheral Cerebro-spinal Nerves. By Professor 
Wilhelm Heinrich Erb, of Heidelberg, Baden. Translated by Mr. Henry 
Power, of London, England. 8vo. pp. xiii., 623. 

Yol. YI. Diseases of the Circulatory System; together with the Chapters 
on Whooping-cough, Diseases of the Lips and Cavity of the Mouth, and 
Diseases of the Soft Palate. By Prof. Rosenstein, of Leyden; Prof. 
Schroetter, of Yienna ; Prof. Lebert, of Yevay ; Prof. Quincke, of Berne ; 
Dr. Bauer, of Munich ; Dr. Stefifen, of Stettin ; Prof. Yogel. of Dorpat; 
and Prof. Wagner, of Leipsic. 'JVanslated by George W. Balfour, M.D., 
of Edinburgh ; Edward D. Geoghegan, M.D., of Lond. ; Thomas Dwight, 
M.D., of Boston ; J. Haven Emerson, M.D., and George C. Wheelock, 
M.D., of New York ; and J. Solis Cohen, M.D., of Philadelphia. Albert 
H. Buck, M.D., New York, Editor of American Edition. New York : 
William Wood & Company, 1876 212 



14 CONTENTS. 

ART. PAGE 

XXXYII. What is the best Treatment in Contracted Pelves? Part II. 
Is Craniotomy, Cephalotripsy, or Cranioclasm preferable to the C^esa- 
rean Section in Pelves varyinof from one and a half to two aud a half 
inches? By Isaac E. Taylor, M.D., President; and Emeritus Professor 
of Obstetrics and Diseases of Women and Children, in Bellevue Bospi- 
tal jMedical College. 8vo. pp. 64. ....... . 215 

XXXVIII. Catalogue of the Models of Diseases of the Skin in the Museum 
of Guy's Hospital. By C. Hilton Facge, M.D., Assist. Phys. to and Lec- 
turer on Pathology at the Hospital; formerly Demonstrator of Cuta- 
neous Diseases. 8vo. pp. xxxii., 269. London : J. & A. Churchill. 1876. 216 

XXXIX. The Anatomy of the Head, with six lithographic plates, repre- 
senting frozen sections of the Head. By 'I'homas Dwight, M.D., Pro- 
fessor of Anatomy at the Medical School of Maine, etc. etc. 12mo. 
Boston : H. 0. Houghton & Co., 1876 218 

XL. Memoires sur la Galvano-caustique Thermique par le Docteur A. 
Amussat fils. 8vo. pp. 125. Paris : Germer Baillifere, 1876. , . 219 

XLI. Compendium of Histology. Twenty-four Lectures. By Heinrich 
Frey, Professor. Translated by George R. Cutter, M.D., Assistant 
Surgeon N. Y. Eye and P^ar Infirmary. Illustrated by 208 engravings 
on wood. 8vo. pp. viii., 274. New York : G. P. '^utnam's Sons. 1876. 219 

XL! I. A Manual of Midwifery. By Alfred Meadows, M.D. Lond., F.R.C.P., 
Lecturer on Midwifery and the Diseases of Women and Children at St. 
Mary's Hospital Medical School, etc. Second American, from the third 
London edition, revised and enlarged, with one hundred and forty-five 
illus. 8vo. pp. 490. Phila. : Lindsay & Blakiston, 1876. . . .220 

XLIII. Illustrations of Clinical Surgery. By Jonathan Hutchinson, 
F.R.G.S. Fasiculus lY. Folio, pp. 64-87. Philadelphia : Lindsay cSc 
Blakiston, 1876 221 

XLIY. The Theory and Practice of Medicine. By Frederick T. Roberts, 
M.D , B.Sc, M.R.C.P., Assistant Physician and Assistant Teacher of 
Clinical Medicine at University College Hospital, etc. etc. Second 
American from the last London edition. Revised and enlarged. 8vo. 
pp.920. Philadelphia: Lindsay & Blakiston, 1876. . . . .222 

XLV. Chemistry; General, Medical, and Pharmaceutical; including the 
Chemistry of the U. S. Pharmacopoeia. By John Attfield, Ph.D., F.C.S., 
etc. Seventh edition, revised from the sixth (English) edition, by the 
Author. 12mo. pp. 668. Philadelphia : H. C. Lea, 1876. . . .222 

XL VI. Observations on Diseases of the Rectum. By T. B. Curling, 
F.R.S., Consulting Surgeon to the London Hospital. 4th edition. 8vo. 
pp. xvi.. 244. Philadelphia: Lindsay & Blakiston, 1876. . . .223 

XLVII. Hay-Fever, or Summer Catarrh ; its nature and treatment. By 
Geo. M. Beard, A.M., M.D. 12mo. pp. 266. N. Y. : Harper & Bro- 
thers, 1876. 223 

XLVIII. Annual Report of the Surgeon-General, U. S. Array, 1876. . 225 

XL[X. A Century of American Medicine. 1776-1876. By Edward H. 
Clarke, M.D.; Henry J. Bigelow, M.D. ; Samuel D. Gross, M.D., LL.D., 
D.C.L Oxon.; '1\ Gaillard Thomas, M.D.; and J. S. Billings, M.D., 
Washington, D. C. Royal 12mo. pp. 366. Philadelphia: Henry C. 
Lea, 1«76 226 

L. The Medical Men of the Revolution, with a Brief History of the Medi- 
cal Department of the Continental Array, etc. By J. M. Toner, M.D. 
8v6. pp. 140. Philadelphia, 1876 227 

LI. Public Libraries in the United States of America ; their Flistory, Con- 
dition, and Management. Special Report, Department of the Interior, 
Bureau of Education. Part I. 8vo. pp. 1187. Washington: Govern- 
ment Printing Office, 1876 227 

LII. Transactions of the College of Physicians of Philadelphia. Third 
series. Vol. 11. Svo. pp. Ixviii., 186. Philadelphia, 1876. . . . 228 



CONTENTS. 



15 



QUAKTERLY SUMMARY 



IMPROYEMENTS AND DISCOYERIES IN THE 

MEDICAL SCIENCES. 



Anatomy and Physiology. 



. 229 



230 



PAGE 

1. Reflex Movements of the Cra- 
nial Dura Mater. By M. Boche- 
fontaine. . 

2. Nervous Apparatus of the 
Lung. B}^ Dr. Wra. Stirling. . 

3. Effect of Esmarch's Apparatus 

Materia Medica, General Therapeutic 

6. Salicylic Acid. By Mr. J. A. 
Erskine Stuart. . . .232 

7. Action of Alteratives. By Dr. 
T. Lauder Brunton. . . .233 

8. Action of Gelseminum Semper- 
vireus. By Dr. Sidney Ringer 
and Mr. Wm. Murrell. . . 233 

9. Action of Alcohol on the Brain. 
By Mr. T. C. Kingzett. . . 234 

10. Action of Strychnia applied 
directly to the Integuments of 
the Nostrils in Man. By Dr. 
M oiler 235 

11. Bromide of Potassium as a 
Caustic. By M. Peyrand. . 235 



PAGE 

on the Circulation. By Dr. 
Gamgee. ..... 230 

4. Intestinal Secretion and Move- 
ment. By Dr. McKendriclj. . 231 

5. Clinical Confirmation of Dr. 
Ferrier's Researches. . . 231 

AND Pharmacy. 

12. Action of Pilocarpin on the 
Submaxillary Gland of the Dog. 
By Mr. J. N. Langley. . . 235 

13. Second Series of Experiments 
on the Biliary Secretion of the 
Dog. By Prof. Rutherford and 
M. Yignal 236 

14. Anaesthesia by Intravenous In- 
jection of Chloral. . . . 237 

15. Symptoms resulting from 
AniESthesia by Ether in Young 
Subjects. By Dr. Leon Tripier. 238 

16. On the Employment of Iron in 
the 'J'reatment of Chlorosis. By 
Dr. Dujardin-Beaumetz. . . 238 



Medical Pathology and Therapeutics, and Practical Medicine. 



17. Hemorrhagic Diathesis. By 

Sir Wm. Jenner. . . . 239 

18. Phosphorus in Leucocy- 
thi3emia. By Sir Wm. Jenner. . 241 

19. Tlie Blood in Anaemia. . . 241 

20. Treatment of Acute Rheuma- 
tism by Salicin. By Dr. T. 
Maclagan. .... 242 

21. Cold-Bath Treatment of En- 
teric Fever. By Dr. John 
McCombie 243 

22. The Relation of Algous Vege- 
tation to Malaria. ByDr. Lanzi. 243 

23. Nitrite of Amyl in Ague, etc. 

By Surgeon W. B. Saunders. . 244 

24. Chloral in Infantile Convul- 
sions. By Lowenstamm. . . 244 



25. First Dentition in its Causal 
Relation to Disease. By Dr. 
Lederer. ..... 244 

26. On the Use of Sulphate of Iron 

in Diphtheria. By Dr. Fera. . 245 

27. Carbolic Spray in Bronchial 
Catarrh. By Dr. Moritz. . .245 

28. Phthisis with Rapid Contrac- 
tion of a Cavity. By Dr. Theo- 
dore Williams. .... 245 

29. Thoracic 'I'umour simulating 
Aortic Aneurism. ByDr Finny. 246 

30. Symptomatic Hepatic Fever 
from Occlusion of Hepatic Duct. 248 

31. Primary Cancer of the Spleen. 250 

32. Peritonitis in Children. By 

Dr. Kersch 250 



Surgical Pathology and Therapeutics, and Operative Surgery 



33. The Open Treatment of 
Wounds. By Dr. Bulow. . 251 

34. Sulphiteof Soda as a Dressing. 

By Dr. Minnich. . . .251 

35. New Method of Wound-drain- 
age. ByMr. Chiene. . .252 

36. Scalds by Steam. By In- 
spector-General Smart. . . 253 



37. Ranula treated by Injection of 
Chloride of Zinc. JBy Prof. 
Panas 255 

38. Gastrotomy for Stricture of 
OEsophagus. By M. Verueuil. . 255 

39. Treatment of Spasmodic Stric- 
ture of the CEsophagus. By Dr. 
Morell Mackenzie. . . .256 



16 



CONTENTS. 



PAGE 



40 Supra-pubic Cystotomy, By 
M. A. Amussat. 

41. Effects of the entry of Air into 
the Veins. By M. Gouty. 

42. A Form of Chronic Inflamma- 
tion of Bones (Osteitis Defor- 
mans). By Sir James Paj^et. . 

48. 'I'rephining-. By M. Sedillot. 

44. Fracture of the Cranium with 
Depression; symptoms of com- 
pression ; cure without trepan- 
By M. Berger. 



257 



259 



259 
260 



261 



PAGK 

45. Injuries to the Shoulder. By 

Dr. 'iM. Schuller. . . .262 

46. Excision of the Elbow-joint. 

By Surgeon-Major J. H. Porter. 262 

47. Subcutaneous Division of the 
Neck of the Femur for Anchy- 
losis of the Hip-joint. By Mr. 
Wm. Adams. .... 263 

48. Separation of the Spine of the 
Tibia. By Prof. Dittel. . . 265 

49. Suture of the Sciatic Nerve. 
By Dr. Langenbeck. . . . 266 



Ophthalmology. 
50. Modified Operation for Cata- { 51. Causes and Origin of Near- 

ract. By M. Galezowski. .266 1 Sight. By Prof. Arlt. . .267 

Midwifery and Gynecology. 



52. The Mechanism of Spontane- 
ous Version. By Dr. Geneuil. . 268 

53. Enemata of Chloral in Natural 
Labour. By M. Polaillon. .268 

54. Extra-Uterine Foetation ; Re- 
moval by Abdominal Section of 
a Living Foetus ; Recovery of 
Mother and Child. By Mr. 
T'homas R. Jessop. . . . 268 

55. The Originator of the Double- 
curved Midwifery Forceps. By 
Dr. McClintock. . . .270 

56. On the Action of Midwifery 
Forceps as a Lever. By A. L. 
Galal.in 270 

57. Local Treatment of Puerperal 
Fever. Dr. Fritsch. . . 271 



58. Pathology of Membranous 
Dysraenorrhoea. . . .271 

59. Coesarean Section for Cicatri- 
cial Obliteration of Vagina. By 
Dr. Galabin 271 

60. Subperitoneal Fibroid Tumour 
of the Uterus removed through 
an Incision in the Posterior 
wall of the Vagina. By R. 
Stansbury Sutton. . . . 272 

61. Treatment of Inverted Uterus 
by Elastic Ligature. By Dr. 
Aries 273 

62. Removal of Inverted Uterus 
by the Elastic Ligature. By 
Prof. Courty 273 

63. Dermoid Ovarian Cysts. By 

Dr. Thos. Griffiths. . . .274 



AMERICAN INTELLIGENCE. 

Original Communications. 



Sub-peritoneal Fibroid Tumour 
removed by Abdominal Section. 
By C. B. King, M.D. 

Case in which an India-rubber 
Nursing-tube was Swallowed by 
an Infant. By James Bordley, 
M.D 

Description of an Improved 
Barnes's Dilator. By T. P. 
Seeley, M.D 



277 



278 



Supplemental Report of a Case of 
Ovariotomy. By J. P. Orr, M.D. 

Circulation of the Blood Subjec- 
tively Seen. By C. B. White. 
M.D 

Autopsy of the Body of J. W. 
Wilkie, M.D., late Superintend- 
ent of the Auburn Asylum for 
Insane Convicts. By D. Dimon, 
M.D 279 



278 



279 



Domestic Summary. 



Amputation at the Hip-joint. By 
Dr. Erskine Mason. . . .280 

Lister's Antiseptic Method in Ova- 
riotomy. By Dr. J. M. Sims. . 283 

Cold Bathing in the Treatment of 
Summer Diarrhoeal Affections of j 

Infants. By Dr. C. G. Comegys. 284! 

Successful Treatment of Vascular j 

Tumours by Injection with the | 



By 



Fluid Plxtract of Ergot 
Dr. Wm. A. Hammond. . 

Ergot in the Treatment of Pur- 
pura. By Dr. L. D. Bulkley. . 

Experimental Study of the Process 
of Repair. By Dr. I. N. Dan- 
forth 

On the Effect of the Bipedal Posi- 
tion in Man. Dr. H. Allen. 



285 



285 



286 



288 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JANUARY 1877. 



Art. I. — Rupture of the Healthy CEsophagus. By Reginald H. Fitz, 
M D., Assistant Professor of Pathological Anatomy in Harvard Uni- 
versity. 

The recent occurrence of a case of rupture of the oesophagus, in the 
practice of Dr. George 0. Allen, of Boston, has led to as thorough a 
research as possible into the literature of the subject. The results of this 
investigation have seemed such as to render it desirable to call renewed 
attention to this lesion, of which our knowledge has been enlarged by the 
detailed report of this case, upon the consideration of which the present 
article is based. 

It is to be stated at the outset, that by the term rupture of the oesophagus 
is meant a complete, defined solution of continuity, extending through the 
walls of this tube, and occurring during life. 

This, of course, may be produced in various ways. The cases are 
sufficiently numerous where, in the progress of an abscess in the vicinity 
of the gullet, perforation of the latter eventually takes place. In this 
series may also be included the advance of cavities from the air passages 
and from the bronchial glands. Somewhat analogous are the instances 
of an aneurism of the aorta, or of its primary branches, which in time 
reaches the oesophagus, and the invervening tissues give way. The per- 
forations caused by sharp and pointed foreign bodies, by the rude 
introduction of tubes, bougies, and the like, are also left out of con- 
sideration ; so, too, the sloughings produced by caustics, which may be 
accidentally or intentionally swallowed, and those resulting from the 
progress of morbid growths. Only that form of rupture is to be considered 
which takes place in persons previously healthy, especially in those in 
whom there is no evidence of any local disease of the oesophagus or of 
No. CXLY.-Jan. 1877. 2 



IS FiTZ, Rupture of the Healthy (Esophagus. [Jan. 

the surrounding parts. This possibility remains, and, as the evidence to 
be presented shows, there exists the certainty that a previously healthy 
oesophagus may be suddenly ruptured by muscular action. 

Such a proposition is by no means a novel one, and has been made 
much more often than it has been proven. Limited as the literature of 
this subject is, it evidently contains numerous errors of observation and 
conclusion which almost warrant tlie scant attention, and more frequent 
omission, which are to be noticed in most of the text-books, whether old 
or recent, clinical or anatomical. The descriptions of the causes, symp- 
toms, and their sequence, the nature of the lesion and its immediate effects, 
may be regarded as traditions, to be believed in, perhaps, because it is 
worth no one's while to contradict them ; and worth no one's while, 
because the matter has never been thought of. 

The following case may therefore be regarded as one of exceptional 
interest and importance : cf interest, from the rarity of its occurrence, its 
clinical obscurity, and the long duration of life in the presence of so serious 
an injury; of importance, from its tolerably uncomplicated character, the 
thoroughness of its description, and the unquestioned nature of the lesion. 

Dr. Allen writes as follows: — 

"Mr. , 31 years of age, was engaged in mercantile pursuits. His 

general condition was that of debility, due to the long continued and 
excessive use and abuse of alcoholic stimulants. A year previous to his 
last illness he had an attack of delirium tremens while in Washington, 
and, upon his partial recovery and return home, was under my charge for 
a while, affected with obstinate gastritis, but from which he eventually 
recovered. In December, 1 875, he suffered from another attack of gastritis, 
though the threatening delirium was averted by the free use of stimulants. 
He recovered from this attack in about a week. Dui'ing this sickness, and 
the previous one, a persistent and distressing symptom was the vomiting 
of blood, which in variable proportions formed a [tart of every discharge 
from the stomach. For years he was in the habit of cutting his food into 
small pieces, and he ate slowly, but never complained of pain or difficulty 
in swallowing. 

"I was called to see him about 9 P.M., January 26, 1876. Before 
seeing him, was told that, while at supper, about three hours previous, he 
suddenly became partially strangled by some article of food lodging 'some- 
where in his throat.' His countenance did not become blue, nor was there 
any difficulty of respiration. 

"Every resource of domestic surgery was employed to afford him relief, 
and after an hour of great discomfort and intense anxiety, he succeeded, 
by a concentration of his entire muscular energy, in ejecting tiie obstructing 
fragment. This proved to be a piece of hard, tougli, gristly meat, nearly 
circular in shape, about an inch in length, and rather more than half an 
inch in diameter. It came from his mouth with the noise and force as if 
' propelled from a pop-gun ;' he sank back upon the sofa exhausted, and 
almost immediately ejected a moderate quantity of clotted and liquid blood. 
His attendant then noticed a 'swelling' at the angle of the lower jaw, on 
the left side, followed by a corresponding swelling on the right ; these 
were soon united by a swollen isthmus across the upper part of the trachea 



1877.] FiTZ, Rupture of the Healthy CEsophagns. 19 

and the larynx. He was now undressed and put to bed, in a completely 
exhausted condition, complaining of thirst but not of pain. Fluids were 
easily swallowed, and without discomfort. Cold water applications were 
made about his throat, but, the prostration continuing, and the swelling 
rapidly increasing, I was called to see him. 

"I found him lying on his back, with a pale face and anxious counte- 
nance; the eyes were closed, the lids twitching and trembling. The 
respiration was nearly natural, though slightly hurried ; pulse 90, and 
small ; skin moist. He complained of no pain, but had sliglit tenderness 
on pressure on the left side of the trachea, just over the clavicle. He was 
somewhat restless, and there was slight nausea. He had vomited but 
once, this an hour after the food was expelled, and the vomit contained 
no blood. There was drowsiness, but inability to sleep. The swelling 
was then extending upon both sides of the face, both cheeks being con- 
siderably puffed out. I learned that in his efforts at expelling the meat, 
the lungs were fully inflated, and then, the muscles being tense, violent 
expulsive efforts were made, during which he became 'red in the face.' 
These efforts were not suggestive of vomiting, nor was there any complaint 
of nausea. Tliere was an occasional slightly bloody expectoration. A 
few minutes before the meat was ejected, the patient removed his collar 
and loosened his shirt, on account of a feeling of constriction. The 
swelling of the face came on very rapidly after the food was raised. Fain 
in the left chest was then complained of, but there was no evidence of any 
sudden tearing of the tissues in this region. 

"A quarter of a grain of sulphate of morphia was given him, and a 
sinapism applied over his stomach. 

''Jan. 27. Was called during the night. The swelling had increased ; 
both cheeks were puffed out; the whole neck and ujiper part of the chest 
were also swollen, pitting on pressure, the pits slowly disappearing upon 
the removal of the fingers. 

" During the day the swelling continued to increase, extending down the 
arms to the hands and fingers. The swollen face was hard and tense, with 
a dark, erysipelatous look and feel. He complained of occasional sharp, 
migratory pains in the right side, and in tlie u))per part of the back. 
Fulse 100, and full ; surface of the body dry and hot ; tongue moist, and 
coated with a thin, white fur. There is constant thirst. The contents 
of the stomach are frequently ejected, and blood is occasionally vomited. 
He swallows without diiliculty and without pain. There is tenderness on 
pressure iii the neck, and upon both sides of the trachea. There is no 
cough, but a constant expectoration of thick, tenacious mucus, sometimes 
mixed with blood Bowels have not been moved; urinates naturally. 

"Bismuth and morphia were ordered, witii ice; small quantities of beef- 
tea and milk, and cooling lotions externally. 

" 28//?. The patient was seen several times during the day and night. 
His condition this morning is not materially changed, except that he 
suffers less pain, and has less irritability of the stomach. He slept at 
intervals, for a few minutes at a time, during the night. Fulse 100, 
and small ; skin dry; thirst continuous ; bowels have been moved; urin- 
ates without difficulty; is quite weak. The emphysematous nature of the 
affection is fully developed ; the whole subcutaneous cellular tissue of the 
body appears to be undergoing the process of inflation. The face, eye- 
lids, neck, the upper part of the chest in front, and the entire back, are 
swollen ; the scrotum is enormouslv distended, and the inflation extends 



20 FiTZ, Rupture of the Healthy Q^]sophagus. [Jan. 

to the middle of the thiglis. Everywhere, upon slight pressure, the sharp, 
crackling sound, indicating the presence of air, is heard and felt. On 
account of the sudden onset and rapid progress of the emphysema, the 
relations of the parts have been so changed that the precise nature and 
locality of the lesion which permits the admission of air into the subcuta- 
neous cellular tissue have not been determined. Notwithstanding the great 
extent of this inflation, the action of the lungs is but little impeded, and 
respiration is performed with but little difficulty, though with a slightly 
accelerated rapidity. Orthopnoea was never present. 

"2dth. Condition about the same as yesterday. The swelling does not 
increase, and has even diminished on the face and arras ; the scrotum also 
is less distended than yesterday. The nausea has nearly disappeared, 
though alcoholic stimulants induce it. He is still quite weak, and is 
nervous and restless. Hoffmann's anodyne is more efficient in relieving 
pain and in quieting restlessness than any other article that has been 
used. 

" With the assistance of Dr Joseph Stedman, a more thorough exami- 
nation of the ])atient was attempted, with the hope of fixing the locality of 
the lesion, but without satisfactory result. A general supporting treat- 
ment is pursued. ]n the evening symptoms of delirium tremens mani- 
fested themselves. 

"80//?, S\sf, Feb. 1. The patient passed through an ordinary attack of 
delirium tremens, falling into a deep, stertorous sleep during the night of 
the 1st. During these three days the emphysema has remained without 
marked change, and the jiatient has comi)lained of no pain except in the 
stomach. He swallowed without difficulty whatever was given him in 
the way of medicine or nourishment. His bowels have been opened daily. 
The respiration for the most i)art easy, and only sligiitly hurried. There 
is a profuse mucous expectoration, occasionally tinged with blood. Pulse 
to-day 112. There is considerable exhaustion, but stimulants and nourish- 
ment can be taken and retained. 

" M. Patient is weaker, was restless, and slei)t but little during the 
night, and is occasionally delirious ; but his delirium is easily quieted, and 
his attention fixed for a short time. Pulse 120-130, small, and weak; 
respiration hurried ; lias but little constant pain ; three bloody dejections 
during the afternoon and evening. Daring the day he had three attacks 
of cramp or spasm, each lasting about half an hour, immediately preceded 
and associated with a flushing of the face. A sharp, excruciating pain 
accompanied these, referred to the region of the heart and stomach. The 
attacks began with a trembling in all the limbs, and a quivering of all 
the flexor muscles; these gradually and slowly contracted, until it ap- 
peared as if the extreme limit of flexion had been reached. The extremi- 
ties were firmly held in this position, and no force that it was desirable to 
apply would overcome this fixed rigidity of the muscles. Gradually, how- 
ever, the rigid muscles would relax, and at the end of half an hour a con- 
siderable degree of mobility in the limb was re-established ; though, after 
the first attack, the rigidity did not entirely disappear. 

"The patient did not lose consciousness in these attacks, and while they 
lasted he was constantly turning his head from side to side, his countenance 
at the same time expressing mingled pain and terror. The rigidity was 
somewhat more marked upon the left than upon the right side. The 
breathing became short and quick, a desire for more air was constantly ex- 
pressed, and the pulse was small and rapid; vomiting did not occur. As 



1817.] FiTZ, Rupture of the Healthy (Esophagus. 21 

the attacks passed off, a cold perspiration, commencing upon the forehead 
and gradually extending over the entire body, followed. 

" The patient was seen and examined in the evening by Drs. F. I Knight 
and J. Stedman, and a subcutaneous injection of a quarter of a grain of 
morphia was given him later. 

",3r7. The patient slept quietly during the night, waking three or four 
times for a moment, but immediately falling off to sleep ; was awake in 
the morning, and was quite rational. He took nourishment and stimu- 
lants, but was extremely weak and prostrated. He died quietly and easily 
at 9 A. M., being seven and a half days after the beginning of his dis- 
ease." 

The autopsy was made, forty-eight hours after death, by Dr. Fitz. There 
was marked rigor mortis ; the subcutaneous tissue of the neck and anterior 
portions of the trunk emphysematous; a livid patch on the right side of 
the neck, said to have made its appearance after death. 

Head not opened. Anterior mediastinum emphysematous, independent 
of the conditions produced on removal of the sternum. The valves and 
cavities of the heart apparently normal, its muscular structure pale, with 
the microscope found to contain numerous granules, many of which did 
not disappear on the addition of acetic acid, and were apparently fat and 
pigment. The left pleural cavity was obliterated by old adhesions, which 
were emphysematous, and the costal pleura contained numerous bullae 
distended with air. On the right side the posterior lateral and inferior 
portions of the lung were adherent to the thoracic walls by recent fibrinous 
adhesions, and numerous ecchymoses were present in the thickened, in- 
jected, and opaque pleura. In the apex of the right lung a cheesy nodule 
was found imbedded in dense fibrous tissue, and a similar mass was present 
in the lower part of the left upper lobe in front. The lungs were cede- 
matous, and posteriorly injected, the lower lobes being moderately col- 
lapsed. The pulmonary arteries contained post-mortem clots. 

The organs of the thorax and neck were removed in continuity. 

In front and to the right, at and below the bifurcation of the trachea, 
was found a longitudinal rent of the oesophagus two inches in length, 
extending through all its coats. Its edges were sharply defined, and gave 
no evidence, microscopically or otherwise, of a pre-existing ulcerative or 
degenerative process. A communication was thus established between 
the oesophagus and a sinuous cavity in the posterior mediastinum on the 
right, which extended between the oesophagus and trachea in all directions, 
and behind the former to a limited extent. This cavity was of the volume 
of a small lemon, was crossed by fibrous trabecular, and filled with clotted 
blood. Its walls, neither soft nor pulpy, were of a greenish hue, and the 
thickened and reddened left pneumogastric nerve could be seen projected be- 
hind. The tissues of the posterior mediastinum on the left side were spongy 
and stained with blood. The pleura covering the cavity mentioned* on the 
right side was adherent to the opposed upper lobe of the lung, the adhe- 
sions being recent, discoloured, and offensive. The posterior wall of the 
trachea, corresponding with the cavity, was of a greenish colour ; other- 
wise there was nothing abnormal here from the epiglottis downwards. 
■ The inner surface of the oesophagus, from the bifurcation of the trachea 
to the cardiac orifice of the stomach, was of a greenish colour, its epithe- 
lial layer in general slightly flocculent, occasionally thickened in patches, 
and entirely absent over a space an inch in diameter below the rent, the 
exposed surface being smooth and shining ; its walls of normal consistence. 



22 FiTZ, Rupture of the Hea]t])y (Esophagus. [Jan. 

The apjiearances presented by the stomach were those of chronic ca- 
tarrhal gastritis, and there was no indication of postmortem softening. A 
black grumous material, probably metamorphosed blood, was found in the 
small and large intestines. The spleen was enlarged and softened — acute 
splenic tumour; the kidneys gave evidence of cloudy swelling, and the 
liver was fatty infiltrated. 

In brief, it may be stated that a young man, without any pre-existing 
stricture or ulceration of the oesophagus, becomes choked by a piece of 
meat. During the violent efforts made to expel the same, a rupture of the 
air passages takes place, apparently on the left side, and an emphysema 
arises, which rapidly extends into the neck, but which does not attract 
attention till just before the meat is expelled. A rupture of the oesopha- 
gus also occurs, which becomes evident only after death. 

In consideration of the symptoms of this case it is evident that there 
is nothing in the earlier history of the patient to call attention to disease 
of the oesophagus or its immediate vicinity. The attacks of gastritis, 
associated with delirium tremens, are very common events in the life of a 
drinker, and the existence of a chronic gastric catarrh was rendered certain 
by the appearance of the mucous membrane of the stomach. 

The vomiting of blood is mentioned in connection with these attacks. 
As a matter of inference it seems more than likely that the blood should 
have come from the lungs, in different parts of which the results of a 
previous inflammation were found, and an inflammation of such a character 
as is very generally associated with hcBmo[)tysis. Even if this blood did 
not come from the lungs, its having appeared at all is of little or no value 
in throwing light on the lesion now being considered. 

The impaction of a bit of food in the oesophagus, and its remaining 
there an hour, apparently gave ri^e to neither nausea nor vomiting. The 
expulsive efforts did not suggest vomiting; it was a straining, rather, 
which took place, from the description, such as might occur during defeca- 
tion or parturition. It is evident that the stomach played but little direct 
part in this process, at the most serving as a reservoir for air, as an explo- 
sive sound attended the ejection of the bolus, without being followed by 
the escape of food. 

It seems further as if the spitting of blood, which took place during 
the hour of anguish, was rather to be attributed to the straining efforts 
than to any local changes in the oesophagus. The redness in the face, 
spoken of, suggests a similar condition of the mucous membranes, and capil- 
lary haemorrhages might readily arise from the bronchial or pharyngeal 
surfaces. That bloodvessels were ruptured in the air passages at this 
time is also suggested by the continued mucous expectoration tinged with 
blood, observed for some days afterwards. The blood in quantity, clotted 
and fluid, which followed the escape of the meat, was a})pareutly from a 
different spot, presumably from the ruptured oesophagus. 



1877.] FiTZ, Rupture of the Healtby (Esophagus. 28 

It is evident from the emphysema that tissues were actually torn during 
these straining efforts. Although those attending the patient first ob- 
served the swelling of the face and neck after the food was expelled, it 
seems not unlikely that the feeling of constriction from the shirt collar 
and band may have been an earlier symptom of this condition. It might 
be thought that this emphysema was due to the escape of gas or air from 
the stomach through a rent in the oesophagus, made below the meat while 
it was still impacted. Opposed to this view is the fact, that, during the 
violent straining and the obstruction of the oesophagus, the emphysema 
was not noticed, but constantly progressed after the oesophagus was open 
and the respiration relatively quiet. It seems most likely, therefore, that 
a rupture of the air passages was the cause of the emphysema at the 
outset, as it evidently was later, also that this rupture took place on the 
left side independently of the tear in the oesophagus, from the fact that 
the sub-pleural tissues and the pleural adhesions on this side alone were 
infiltrated with air, and there was an absence here of evidences of recent 
pleurisy. An additional argument might be derived from the external 
swelling being first noticed on the left side of the neck. It appears that 
a double rupture must have occurred within the lung in the first place to 
permit the air to pass upwards and make its way beneath the costal pleura, 
and secondly through the pleura that the adhesions might become emphy- 
sematous. 

The time when the rupture of the gullet took place is not so apparent. 
The sole sign of its occurrence is the hemorrhage ; the manner of the 
escape of the food is also somewhat indicative. Were the rupture present 
in its totality before the food was expelled, the emphysema should have 
occurred earlier from the stomach, and a large rent in the pleura would 
be expected. It might even be expected that food should have been found 
in the pleural cavity as a result of the extreme muscular force employed. 
It would also have been probable that the obstructing piece itself would 
have been forced through the rent, and thus hemorrhage, even vomiting, 
have preceded the actual escape of the fragment, and then the decided ex- 
plosion could scarcely have taken place. 

It may have been that the tearing of the oesophageal wall had begun 
before the expulsion of the food, as clotted blood followed it, but that the 
rupture as a whole occurred at the time of the expulsion seems most pro- 
bable, from the negative evidence already presented. 

The collapse following the escape of the food is in part to be referred 
to the preceding exhaustion, mental and physical, and in part to the hem- 
orrhage, which continued till the time of death, as evinced by the bloody 
stools during life, the presence of metamorphosed blood in the intestines, 
and of clotted blood in the mediastinal cavity. That no large bloodvessels 
were ruptured, seems indicated by the small amount of blood raised imme- 
diately after the removal of the meat, and from the fact that the contents 
of the stomach vomited an hour later contained little or no blood. 



24 FiTZ, Rupture of the Healthy (Esophagus. [Jan, 

It is a matter of considerable interest and of decided value that the only 
pain complained of at the outset was in the left chest after the removal of 
the obstruction, and which was very likely of a similar character to the 
tenderness on pressure over the clavicle, due to the emphysema. The 
sharp migratory pains on the right side, noticed on the following day, 
were more likely to have been occasioned by the beginning of the recent 
pleurisy eventually demonstrated. 

Of the subsequent symptoms occurring in this case, there are scarcely 
any which may be considered as calling direct, exclusive attention to the 
oesophagus. There is neither severe localized pain nor difficulty in swal- 
lowing. Fever, diminishing nausea, and irritability of the stomach, with 
sensitiveness to pressure in the epigastrium, and complaint of occasional 
pain in the stomach, are noted. Blood makes its appearance in the vomit, 
the alvine dejections, and in the expectoration. The spasms of the flexor 
muscles towards the end of life are apparently of a tetanic character. 
The simultaneous disturbance of respiration suggests a similar condition 
of the respiratory muscles. Without considering this group of symptoms 
at length, it may be stated that the close proximity of the pneumogastric 
and sympathetic nerves to the ascertained lesion, afford opportunity for 
the transfer of an existing peripheral irritation, and the former nerve 
trunk was seen to give evidence of pathological changes in the form of 
enlargement and injection deserving the name of neuritis. 

It has already been stated that but few cases of this affection have been 
recorded, and that most of these are to be considered as doubtful in their 
nature. Some of the references have been copied by one author from 
another, apparently without any effort being made to examine the record 
of the original observation. In the present inquiry the original source of 
information has always been sought for, and in most cases found. The 
success of this effort is largely due to the courtesy of those in charge of 
that extensive collection of medical works, the Library of the Surgeon - 
General's Office at Washington, to whom ray thanks are most gratefully 
rendered. 

The oldest case mentioned, that which, with but few exceptions, among 
writers, is quoted as the type of the class, lacks so much that is desired, 
that the diagnosis is not only not proven, but may well be regarded 
as incorrect. This assertion necessarily premises that the following 
extracts contain the essential features of the original account of Boer- 
haave.^ The case is referred to somewhat quaintly by Van Swieten,^ as 
follows : — 

" We have a surprising observation given us by the celebrated Boerhaave, 
which is, perhaps, the only one published, namely, the illustrious Baron Was- 

1 Atrocis nee descripti prima morbi historia. Lugd. Batav., 1724. 

2 The Commentaries up )n the Aphorisms of Dr. Herman Boerhaave. By 
Gerard Van Swieteu, M.D. 2d edition. London, 1765. Vol. ii. p. 112. 



1877.] FiTZ, Rapture of the Healthy (Esophagus. 25 

senaer, Lord Hioh Admiral to the Eepublick, after intense straining in vomit- 
ing-, broke asunder the tube of the oesophagus, near the diaphragm, so that, 
after the most excruciating pains, the aliments which he swallowed passed, 
together with the air, into the cavity of the thorax, and he expired iu twenty- 
four hours." 

Lieutaud^ records the same case, but somewhat more in detail. 

From him it appears that the Admiral, who was more than fifty j^ears old, 
suffered an annoyance at the pit of the stomach three days after feasting sump- 
tuously. During the efforts to obtain relief by vomiting, the sudden pain, "as 
from some rupture or tearing," occurred. " During the progress of the affec- 
tion, he was constantly tortured with extreme pains. In the mean time the 
increased suffering threatened syncope ; there was neither fever, cough, nor 
difficult breathing. The vehemence of the pains prevented any motion of the 
body, and there was scarcely any remission from their great severity. They 
seemed to be seated primarily within the chest near the diaphragm, thence 
extended to the back and Ihronffhout the entire chest. Finally the strength 
gave way, and he died suffocated, the horrid symptoms continuing. Nothing 
noteworthy was found in the abdomen; a large amount of gas escaped from 
the first incision into the pleural cavity. The lungs and heart were unaffected. 
A marked and unusual smell came from the chest, as if proceeding from some 
putrid fluid iu which the posterior parts of both lungs were bathed ; this fluid, 
amounting to six pounds, did not differ in the least from the contents of the 
stomach. The body having been thoroughly cleansed, there was found a trans- 
verse rupture through the oesophagus near the diaphragm." 

A transverse rupture near the stomach, permitting the escape of fluid 
into both pleural cavities, and the association with evident decomposition, 
are strongly suggestive of cadaveric softening. Death within twenty-four 
hours after the sudden intense pain and subsequent torture, without cough, 
dyspnoea, or evidences of pleurisy, is not indicative of a pre-existing rup- 
ture of the oesophagus, which should permit the contents of the stomach 
to enter the pleural cavities. Cadaveric softening might have taken place 
in connection with tlie rupture of the gullet, but evidence of the ante- 
mortem nature of the latter is wanting. The possibility of the existence 
of angina pectoris, perforating ulcer of the duodenum, even of a dissecting 
aneurism, might be considered, and neither the symptoms nor the post- 
mortem examination permit a differential diagnosis to be made. 

Ziesner^ is credited by some with a case of this affection, and he de- 
scribes, in 1732, "a rare disease of the oesophagus." The case is appa- 
rently one of puerperal fever, with purulent inflammation of the kidneys, 
ovary, and liver. An abscess of the size of a butternut had broken into 
the oesophagus. The fifth and sixth vertebrae, near which the abscess was 
situated, were eroded. 

More than fifty years after the occurrence of Boerhaave's case, there is 

published by Mr. John Dryden,^ Surgeon in Jamaica, "An account of a 

Rupture of the OEsophagus from the Action of Yomiting." 

A strong, healthy man, on the morning after a debauch, on account of 
nausea drank plentifully of warm water to induce vomiting. He always 
guarded against emetics, and strained hard during their use, feeling sore and 
weak for some time after. 



1 Historia Aiiatomico-Medica. Toraus secundus, p. 311. Parisiis, 1767. 

2 Haller's Disputationes ad Morboriim, etc. Lausanuse, 1760. Vol. vii. p. G29. 

3 Medical Commentaries. Edinburgh, 1788, p. 308. 



26 FiTZ, Kupture of the Healthy Oesophagus. [Jan. 

Durinsf his straininof lie felt somethui.fi: g'ive way internally, with the sensa- 
tion as if liquid had been injected into the thoracic cavity. A slight amount 
of blood was raised, and acute pain was felt in the repion of the stomach and 
abdomen. 'J'he vomiiino: then ceased, and was followed by thirst, g^reat heat 
in the stomach and thorax, constipation, and restlessness. Emphysema of the 
neck soon appeared. In the afternoon the pain was most severe on the left 
side, 'j'he brealhino- then became laborious ; he was unable to chanofe his 
position without feelinp" that his lungs were compressed and the fear of suffo- 
cation. Death occurred at 10 P. M. On opening the thorax air escaped, and 
a gallon of fluid was removed from the left side, nearly two quarts from the 
right. There was a longitudinal rent in the oesophagus above the diaphragm 
large enough to admit two fingers, and the contents of the stomach had entered 
the thorax and compressed the lungs. 

This case is somewhat peculiar, and by no means satisfactory. The 
sudden, tearing pain, as in Boerhaave's patient, the sensation of injected 
fluid and slight hemorrhage, seem suggestive. The referring the pain to 
the abdominal region scarcely comports with the supposed lesion. The 
emphysema is more than likely to have been the result of a laceration of 
the air passages, and it may have been this which caused the sudden sen- 
sations at the outset. The same suspicion of post-mortem softening arises 
here; quantities of fluid in both jileural cavities too great to have been 
the result of pleuritic effusion within ten hours, and also stated to have 
come from the stomach. It is further to be considered that the patient 
lived in a hot climate, where the elevated temperature would favour a post- 
mortem softening of the oesophagus, and the character of the rent is not 
sufficiently described to determine its nature. 

ReiPs name is mentioned in connection with this subject, but in the 
work' referred to no case was found bearing upon the point. Kade'^ 
states, however, that this author had spoken of the conditions in 
describing the disease of a certain Goldhagen. Kade's^ case (probably 
the same) of rupture of the oesophagus is described in a thesis presented 
by him for the degree of Doctor of Medicine. 

He reports the case as one of gangrene of the oesophagus : — 

The patient fell sick with ' malignant nervous fever,' which caused gan- 
grene of the oesophagus by metastasis. Throughout the entire course of the 
disease there was no complaint of pain in swallowing. On the 11th day of the 
disease, frequent drowsiness and weakness supervened, and the patient died 
after a few days. 

The oesophagus, from the diaphragm to the pulmonary veins, was in a 
"gangrenous" condition, destroyed throughout its entire circumference, 
with but a few fibrous connections here and there; so that food and 
drink entered the thoracic cavity. From the admirable drawing accom- 
panying the thesis, as well as from the text, it is evident that the gangrene 
was a simple post-mortem softening of the oesophagus. 

Sedillot has been supposed to have contributed to the knowledge of this 

1 Memorabilium Clinicorum. Halae, 1790, vol 1., fasc. i. 

2 De Morbis Ventriculi. Halae, 1798, p. 17. 

3 Op. cit., p. 16. 



18*17.] FiTZ, Rupture of the Healthy (Esophagus. 27 

subject, because he published^ a case of stricture of the oesophagus, fol- 
lowed by rupture of the canal and a consequent gangrenous abscess. The 
introduction of a probang seems to have played an important part in the 
production of the result. 

The next record of a case of rupture of the oesophagus in consequence 
of vomiting is that of Guersent."^ 

A girl of seven years, whose previous health had been good, after a diarrhoea 
of several days' duration, was seized with vomiting a short time after dinner. 
During the subsequent two clays there was nocturnal fever, mild delirium, 
thirst, drowsiness, and involuntary fetid yellow dejections. The drowsiness 
then continued, and nausea was complained of. Suddenly a violent convulsion 
occurred, during which the tonjz-ue was protruded, and the skin became a dark- 
red colour. Great feebleness followed. Guersent saw her some hours later, 
when her face was a violet colour, the skin being hot and dry, the pupils 
dilated, and the jaws set; convulsive movements of the lips were also noticed. 
The pulse was full and frequent, the respiration natural, although there was 
an occasional cough. 'J'he application of leeches was followed by a diminution 
of the drowsiness, though the other symptoms continued. An emetic was 
administered, and the child made vain efforts to vomit. The pulse now fell 
rapidly, the extremities became cold, the respiration disturbed, and swallowing 
was painful. Partial convulsions occurred during the night; towards morning 
the skin became of a violet colour, the pulse failed, and the patient died. 

At the autopsy the cerebral vessels were found to be engorged ; a rent two 
centimetres long was found in the right pleura some five centimetres above 
the diaphragm. Pressure upon the stomach caused the escape of a fluid 
through this rent into the right pleural cavity, which contained a brown fluid, 
in which were green flocculi. The edges of the rent in the oesophagus gave 
no evidence of suppuration or of preceding alteration, and the stomach and 
oesophagus were healthy, without any trace of inflammation. 

It is evident that an acute febrile disease was present, in which dark-red 
discolouration of the skin was prominent. Nausea, vomiting, and diar- 
rhoea had existed for two days before the convulsions began. Painful 
swallowing was noticed only just before death. The clinical history sug- 
gests rather a case of scarlet fever than one of rupture of the oesophagus, 
and the condition found after death is much more likely to have been the 
result of cadaveric softening than of a rupture. 

Guersent mentions the occurrence of two analogous cases — that of 
Boerhaave already quoted, and one " in the second volume of the Journal 
of Desault will be printed in detail with the conclusions of the author in 
the early volumes of the Memoir of the Society.'' 

The cases of Boerhaave and Dryden are alluded to by Monro,^ who states 
that Dr. Carmichael Smyth had communicated to him a similar case. He 
also speaks of having seen a preparation of the oesophagus of a child in 
which was a considerable longitudinal rupture. Such statements of course 
can have no weight where any sort of criticism is attempted. 

' Recneil Periodique de la Societe de Medecine de Paris, 1799, t. vii. p. 194. 

2 Bulletin de la Faculte de Medecine de Paris, 1812, t. i. p. 73. 

3 The Morbid A,natomy of the Human Gullet, Stomach, and Intestines. Edin- 
burgh, 1811, p. 311. 



28 FiTZ, Rupture of the Healthy (Esophagus. [Jan. 

Bouillaud^ reports a case as one of rupture of the oesophagus, where 
the diagnosis is evidently so incorrect that a summary of the main points 
is alone desirable. 

A man, 20 years of age. had a purulent discharge from the right ear since 
he was eight years old. There was some gastric disturbance for six weeks 
previous to his entrance into the hospital, and he had been confined to Ids bed 
four days immediately preceding his admission. His chief symptoms were 
chills, fever, headache, delirium at night, and repeated vomiting. There fol- 
lowed increasing weakness, intermitting right hemiplegia, dilated pupils, inco- 
herent speech, alternating drowsiness and excitement, involuntary dejections, 
collapse and death ten days after his arrival at the hospital. 

The autopsy showed caries of the middle ear. injected cerebral membranes, 
and much opaque fluid in the lateral ventricles, with softened brain substance. 
Four perforations were found in the splenic region of the stomach, a wounded 
perforation of the oesophagus a little above the cardia, also a rent an inch and 
a half long, through which part of the contents of the stomach entered the 
pleural cavity, which also contained gas. Gas and fluid were found too in the 
abdomen. 

Under the title "Observations on the Digestive Solution of the CEso- 
phagus," King' publishes the report of a case by Mr. Comley, with the 
results of his examination of the stomach. He expressed himself unable 
to say, "if there be a rupture, where the post-mortem solution ends, and 
where laceration begins. I think, the probabilities considered, there was 
no rupture." Habershon^ offers the same case as warranting the belief 
that rupture of the oesophagus may take place during life. As this case 
was not originally presented as one of rupture, and as, after carefully ex- 
amining the original record, there appears to be no good reason for doubt- 
ing Mr. King's opinion, it seems unnecessary to call any further attention 
to the report. This paper, and another by him in the preceding volume 
of the Reports, deserve special mention for calling attention to the fre- 
quency of cadaveric softening of the oesophagus, and its relation to the 
similar condition of the stomach. Since its date, much more care seems 
to have been exercised in the observation of suspected cases, and an opinion 
is not arrived at without very cogent reasons. 

A paper by Yigla* on perforations of the oesophagus may here be alluded 
to as containing a very extensive series of cases, original and collected 
from various sources, with the conclusions at which he arrived. Among 
these there are none which can properly be included under rupture 
from muscular action, but all are perforations associated with various 
pathological conditions, and from foreign bodies, or are cases of post- 
mortem softening. 

1 Archives Generates de Medecine, 1823, t. i. p. 531. 

2 Guy's Hospital Reports, 1843, 2d series, vol. i. p. 113. 

3 Pathological and Practical Observations on Diseases of the Alimentary Canal, 
etc., Am. Ed., Philadelphia, 1859, p. 52. 

* Archives Geuerales de Medecine, 1846, 4th series, t. xii. p. 15. 



1877.] FiTZ, Rupture of the Healthy O^^sophagus. 29 

The following statement by Oppolzer' is of decided interest, but of slight 

value from its brevity. 

" I have seen only one case of rupture of the healthy oesophagus. The 
patient had strained herself in ironing, and died of hemorrhage into the medi- 
astinum The symptoms are uncertain, but point in general to a 

severe affection. A violent pain suddenly occurs on vomiting, blood is vomited, 
there is anxiety and a sense of oppression from the entrance of food and drink 
into the mediastinum. The disease may be suspected when suddenly, during 
vomiting, a violent pain arises in the course of the oesophagus, vomiting can no 
longer take place, and when earlier disturbances were present." 

This case is referred to later^ in about the same terms. The symptoms 
and means of diagnosis as recorded by Oppolzer are mentioned as possibly 
being the result of his own observation in the case referred to. They carry 
less weight, however, as Boerhaave's case is accepted in the same article. 

This brief record cannot, therefore, be considered as of any value for 
purposes of generalization, and if its statements conflict with those of more 
fully recorded and better authenticated cases, they must necessarily be set 
aside. 

Meyer^ publishes a case which he regards as one of rupture of the 
oesophagus from violent efforts in vomiting, there being no evidence of 
preceding ulceration, abscess, or gangrene. Not having been able to ob- 
tain the original account of this case, the following statement* is inserted, 
which is "as complete as possible." 

"A shoemaker, thirty-eight years of age, a drinker, on account of having 
taken lye when a child, had suffered since then from difficulty in swallowing; 
the food would stop near the pit of the stomach, and violent efforts were re- 
quired for its dislodgment. Of late this difficulty had increased. February (?) 
1, 1858, while at dinner, a piece of sausage stuck in the usual place. Yiolent 
efforts were made to remove the food, during which his anxiety became so ex- 
treme that he ran outdoors. Repeated attempts at vomiting were made; about 
a cupful of bright red blood followed, but the sausage could not be raised. 
Anxiety, a feeling of oppression, and epigastric pain became so extreme, that 
the patient returned to his house. About an hour after the beginning of the 
attack, a swelling appeared in the right side of the face. A physician, thinking 
the food to be still impacted, gave an emetic, and introduced a probang', without 
any benefit, for the patient did not vomit, and his difficulties increased, 

" He was received into the hospital on the 2d of July, at noon. His condition 
then was as follows: He could be put to bed only in the upright position, with 
the body bent forwards. The face was pale, slightly cyanotic. There was em- 
physema of the right side of the face, of the neck, of the entire front of the chest, 
the sternum excepted. There was a clear resonance on percussion of the chest, 
and an abnormally diminished resistance. Behind, on the right, there was 
diminished resonance from the ninth rib downwards, above this point it was 
normal; behind, on the left, percussion was impossible, on account of the em- 
physema. There was good vesicular respiration everywhere, except behind at 
the base, where the breathing was indistinct. Local fremitus indistinct below 



' Wiener Mediziuische Wocliensclirift, 1851, p. 65. 

^ Oppolzer's Vorlesungen iiber specieile Pathologie und Therapi©, voa Stoffela* 
Erlaiigeu, 1872, vol. ii. p. 150. 

3 Medicinisclie Vereinszeitang in Preussen, 1858, Nos. 39, 40, 41. 
* Caustatt's Jahresbericlit, 1858, vol. ill. p. 334. 



30 FiTZ, Rupture of the Healthy (Esophag'us. [Jan. 

and behind. Respiration 40. Impulse of the heart feeble, but in the usual 
place. Sounds distinct. Rulse small, soft, 142. The patient complains of a 
very violent squeezing pain, which proceeds from the base of the ensiform car- 
tilage to a spot one-half an inch below its point, thence extends backwards to 
the spine. This pain is increased by attempts to sit upright, or to bend back- 
wards. The spine is not sensitive to pressure. Diagnosis : Rupture of the 
oesophagus; moderate pleuritic effusion in the right pleural cavity, probably in 
the left likewise. Emphysema of the skin dependent upon the rupture of the 
CESophagus. 

"Sinapisms and ice to the chest, also ice internally gave no relief; the emphy- 
sema increased, the pains in the chest and along the spine became more severe; 
fluids could be swallowed, but only in small quantities, on account of the ex- 
treme desire for air. Swallowing produced a feeling of compression near the 
cardia. At 2 P. M. on the 3d the patient died, the disease having lasted fifty 
hours. 

''A ufopsy. — The oesophagus free throughout almost its entire extent. A gap- 
ing, ulcerated surface one and one-fourth inch long and three-eighths of an inch 
wide was observed three inches above the cardia, in the anterior wall of the 
cesophagus; the edges were tolerably smooth, in places sharply defined as if 
the ulcer had been cut out. The mucous membrane more extensively destroyed 
than the muscular coat, from which it could be easily raised, and its edges were 
not thickened. 

"The submucous tissue in the vicinity of the ulcer was of ordinary con- 
sistence, and not specially thickened. The muscular coat was distinct to the 
very edge of the ulcer, in the alcoholic preparations showing the same colour 
and configuration as in the other healthy portions, and the microscopical exa- 
mination, though not showing distinct muscular elements, yet establishes the 
identity with tlie healthy portions. The coats in the immediate vicinity of the 
ulcer are not softened. The rest of the oesophagus is somewhat widened ; above 
the cardia it is somewhat narrow, but without distinct cicatricial tissue, the 
muscle here being hypertrophied. 

"The mucous membrane below the great gaping wound presents numerous 
small, linear, yellow streaks from one-half a line to two lines long, which are 
parallel to the long axis of the gullet. With the microscope these are found to 
be composed of an amorphous substance, without epithelium. The subjacent 
mucous membrane is normal. 

" A large gangrenous cavity extended forwards from the perforation into the 
posterior mediastinum, separating the oesophagus from the cardia upwards for 
five and one-half inches from its surroundings ; it contained dead tissue, and 
numerous particles of food, and its wall gave no evidence of a chronic thicken- 
ing. 'Inhere was exudation, etc., in both pleural cavities. The stomach and in- 
testines were distended with gas, etc." 

A dissertation upon rupture of the oesophagus is published by Grrara- 
matzki/ and is extracted by Gerhardt.'^ The subject is illustrated by a 
case occurring in Ley den's clinic, regarded as one of spontaneous rupture 
in a previously healthy person. 

" An English machinist, John Mudd, thirty-five years old, six weeks ago suf- 
fered for some time from gastric disturbance, from which he recovered. June 
15, 1867, after carousing the night before, he was seized at 7 A. M. with vomiting, 
mixed with blood, violent pains in the stomach, coldness of the extremities, and 
a collapsed appearance — with repeated vomiting again after nine o'clock. After 
this second attack of vomiting, which was also bloody, the neck began to swell. 
The patient ascended the steps of the hospital without assistance, and spent 

' Ueber die Rupturen der Speiserohre. Konigsberg, 1867. 

2 Jabresbericht der gesammten Mediciu. Virchow und Hirsch, 1867, vol. ir. 
p. 144. 



187*7.] FiTZ, Rupture of the Healthy (Esophagus, 31 

the rest of the time bent forwards in an easy chair, till his death at 6.30 in the 
evening'. His face expressed anxiety and pain, there were frequent groaning, 
emphysema of the cheeks, eyelids, neck, and front of the chest, somewhat more 
marlied on the right, but the arms and sides were free from it. Violent pain 
and increased dyspnoea resulted from swallowing. Percussion and auscultation 
gave no special information. In the afternoon decided collapse supervened, 
cold sweats, pulseless extremities, a bending back of the head, increasing cya- 
nosis, and asphyxia. At the autopsy there was found a double pneumothorax, 
and in each pleural cavity were six to eight ounces of a reddish fluid, in which 
were solid particles and fat drops. The tissues of the anterior and posterior 
mediastina were tilled with air. Above the cardia was a cavity of the size of a 
walnut formed from a greenish-black, frangible tissue, which communicated 
with the pleural cavity by a large hole, through the pleura, of the size of a four- 
groschen-piece. On the other side there was a wound, through the wall of the 
oesophagus, five centimetres long. This was longitudinal, like a tear, with sharp 
edges, and encroached upon the stomach below. A similar wound, extending 
only to the submucous tissue, was found upon the anterior wall of the cardia, 
for the most part within the cavity of the stomach. These wounds of the 
oesophagus were attributed by Leyden to some foreign body which had been 
swallowed, and were considered to be explanatory of the illness six weeks before. 
It was left undecided whether the vomiting on the morning of the last illness 
was the cause of the perforation or a symptom of it." 

Strictly speaking, this can hardly be regarded as a pure case of sponta- 
neous rupture of the oesophagus from muscular action, Leyden's opinion 
that a rupture had occurred, necessarily carries great weight, though the 
description of the opening into the pleural cavity suggests cadaveric soften- 
ing rather than rupture. If the vomiting and the rupture occurred simul- 
taneously, as is suggested, and the contents of the stomach had then 
entered the pleural cavity or cavities, pneumothorax should have made 
itself manifest before the autopsy took place ; but no special information 
was obtained by auscultation and percussion. Even supposing it to be 
one of sudden rupture, the assumed previous injury to the oesophagus from 
a foreign body would remove it from the more spontaneous forms in 
healthy gullets. A further possibility may be entertained that this was a 
case of combined rupture and post-mortem softening. A microscopical 
examination of the edges of the wound might have been of considerable 
service in eliminating post-mortem agencies, though the presence of the 
contents of the stomach in the pleural cavities gives opportunity for the 
dissolving material to act upon the edges of an actual rupture. 

Finally Charles^ reports a case of "Rupture of the CEsophagus ; with 
Remarks thereon." 

'* The patient was a man, 35 years of age, who from infancy had been occa- 
sionally distressed with difficulty of swallowing. He was of intemperate habits, 
and had been drinking to excess for a few days before his death, and it was 
suspected that some of the whiskey had been medicated. At 8 P. M., after a 
light dinner and while exercising a horse, he felt something give way inside of 
him during attempts to vomit. He reached the house with difficulty, and fell on 
the floor in great agony. 'J'he pain, first felt in the region of the left kidney, 
ascended towards the stomach and back of the chest, became more severe, and 
there was much retching. Dyspnoea and thirst ensued, the patient became 



• Dublin Quarterly Journal of Medical Science, 1870, vol. 1. p. 311. 



82 FiTZ, Rupture of the Healthy (Esophagus. [Jan. 

delirious, the pulse, previously stroug, suddenly failed, and death took place 
seven and a half hours after the vomiting first appeared. The autopsy was 
made twenty-nine hours after death, the weather being tolerably warm, and on 
turning the body dark fluid escaped from the mouth. At the left side of the 
oesophagus, near the posterior wall, a longitudinal rent was found, an inch and a 
half in length, extending from immediately below the cardiac orifice of the 
stomach upwards. This led into a space in the posterior mediastinum which 
contained black grumous matter like that in the stomach. The space commu- 
nicated with the left pleural cavity by a round opening, through which the con- 
tents of the stomach could be pressed into the left pleural cavity. The left 
pleura was blackened along the lower two-thirds of the posterior mediastinum, 
and the left pleural cavity contained two quarts of dark offensive fluid contain- 
ing starch and oil. In the right pleural cavity there was found a quart of fluid 
appearing like bloody serum. The mucous membrane in the cardiac end of the 
stomach was very soft and of a dark hue." 

That post-mortem softening was present in this case is evident, and is 
admitted by Dr. Charles. He thinks, however, that a rupture of the oeso- 
phagus preceded death. The opinion seems to be based mainly upon the 
sensation of internal laceration, the appearance of the rent, a theory of its 
causation based upon an analogy with doubtful cases of laceration of the 
stomach, and the knowledge of previously recorded cases, among which 
Dryden's occupies a prominent place from its obvious resemblance. 

A subjective sensation becomes of real value only when its cause is made 
clear, and this is plainly in dispute. The intense pain complained of was 
not referred at first to the oesophagus, where the tearing is assumed to have 
taken place, but to the left kidney. If the injury had occurred during 
the early vomiting, a sufficient time intervejied to permit evidence of inflam- 
mation of the pleura covering the mediastinal cavity. The appearances of 
the edges of the wound would evidently depend largely upon the length of 
time they were in contact with the gastric fluids, as well as on the degree 
of concentration of the corroding agents. Hemorrhages into the medi- 
astinum, and the vomiting or raising of fresh blood, both likely to have 
taken place, were not observed. The nature of the laceration of the 
stomach referred to, may be regarded as equally, if not more, in doubt 
than the condition in question. If Dryden's case can be considered in 
dispute, as well as some of the others referred to, Dr. Charles's case must 
be considered as still in doubt. 

The disturbing element in most of these cases is evidently the softening 
of the stomach and oesophagus. 

Previous to the year 1786, when Hunter published his observations on 
the self-digestion of the stomach, the possibility of a perforation of this 
organ otherwise than as a result of pathological conditions was not thought 
of. It is consequently very evident why Boerhaave and Dryden should 
not have considered this feature differentially. The latter ought to have 
done so ; the fact that he did not suggests that Hunter's observations were 
not familiar to him. Even after these had been published, there were 
many authorities, French and German particularly, who disputed his views- 
and spoke of softening of the stomach as a disease. The value of King's 



1877.] FiTZ, Rnptnre of the Healthy (Esoplingns. 33 

papers, already referred to, was very direct, therefore, in calling renewed 
attention to Hunter's work, and in showing that the oesophagus was 
exposed to the same alteration. 

The most important contribution to this subject since Hunter's time is 
unquestionably that of Elslisser (1846), who showed experimentally and 
otherwise that an acid fermentation of the contents of the stomach was 
the main element in producing the softening and perforation. Among 
recent authorities who advocate an ante-mortem softening of the stomach 
and oesophagus is Hoffmann.^ He maintains as of this nature the brown 
form of gastro-malacia, that which is observed among adults, though .met 
with in children also, and regarded by most observers as not differing from 
the gelatinous form except in the presence of injected bloodvessels. 

He considers that a number of cases observed by him elevate this opinion 
to a certainty. He further maintains that this form of softening, usually 
if not always, is the result of a hemorrhagic infarction, the presence of 
acid gastric fluids causing a maceration of the altered parts. As the cases 
reported are regarded as including a pre-existing localized pathological 
process as a cause for the rupture, their consideration does not fall within 
the province of this paper. 

The number of indisputable cases of rupture of the oesophagus under 
the conditions mentioned, may be considered as two, possibly three: those 
of Meyer and Allen, and those of Grammatzki. The similarity of the 
symptoms in the last case to those in the others is unmistakable, and their 
occurrence in a future one would point very strongly to the lesion in ques- 
tion. At the same time the case is not sufficiently fully reported in the 
abstract, nor is it sufficiently freed from the suspicion of post-mortem 
changes, to permit its use in the further consideration of this subject. 

As the cases of Meyer and Allen are, therefore, the only ones (Oppolzer's 
being merely an allusion) from which a knowledge of this class of spon- 
taneous ruptures could be obtained, it follows that the statements to be 
found in the text-books and elsewhere, previous to 1858, are to be consid- 
ered as essentially theoretical. It may be said that they are based upon 
errors of observation, insufficient testimony, and superficial generalizations. 
That such a statement can be made indicates merely that in some respects 
the opportunities for criticism are greater now than was the case twenty 
years ago and earlier. It may also be regarded as premature that an at- 
tempt should here be made to present the history of an affection which has 
offered so few opportunities for its study. This article is intended mainly 
as a means of assistance for those who may hereafter acquire an interest 
in the subject, and who may find it difficult to obtain some of the neces- 
sary data. 

Rupture of the healthy oesophagus in a person free from disease may 

1 Virchow's Archives, 1868, xliv. p. 352, and 1889, xlvi. p. 124. 
No. CXLV.—Jan. 1877 3 



34 FiTZ, Rupture of the Healthy (Esophagus. [Jan. 

take place as a rare occurrence. Such ruptures are quite independent of 
and distinct from the lacerations and other traumatic injuries produced by 
the contact of unyielding foreign bodies. The rupture takes place between 
the bifurcation of the trachea and the diaphragm, in the anterior or 
lateral walls of the cesophagus, and corresponds in direction with the 
long axis of this tube. Such rents lie wholly within the thoracic cavity, 
are from one to two inches in length, and are distant from, rather than 
near to, the cardiac orifice of the stomach. Tiiough it is not impossible 
that the tearing of the tissues may extend through the pleurae, one or 
both, sucli an event is very unlikely and of doubtful occurrence. There are 
two factors essential: the impaction of a foreign body in the oesophagus, 
and the exei'cise of great muscular force in the attempts to remove it. 
There is no good reason for considering that the act of vomiting can in 
any way produce this result, nor is it essential that the foreign body 
should remain in contact with the oesophageal wall long enough to give 
rise to inflammation from pressure. The fact of muscular action alone 
being sufficient as the active agent is of considerable value from a medico- 
legal point of view, in those cases where the introduction of a probang or 
a bougie may be asserted as the cause of the rupture. 

Those persons in whom this lesion has been met with have been drinkers, 
and have suff'ered from various disturbances of digestion. There is no 
reason to suppose, however, either that the excessive use of alcohol as 
such, or the digestive disturbances have been special predisposing causes of 
any marked importance. 

Soon after the impaction of the foreign body, as a piece of meat or a 
bit of sausage, and the unsuccessful attempts at its removal, intense anx- 
iety becomes evident on the part of the patient. Yiolent straining efforts 
are made to expel the obstructing body. The chest is fully inflated, and 
powerful efforts are made by the respiratory muscles. More or less blood 
is ejected during this period, either mixed with saliva and mucus, or 
raised in considerable quantities as a bright red fluid. In the course of 
an hour usually an emphysema makes its appearance in the neck and face, 
which probably comes from a rupture of the air passages during the vio- 
lent straining. The htemoptysis is probably from a similar source. 
The impacted substance is either eventually expelled or makes its way 
downwards ; if expelled, it may be immediately followed by a decided ex- 
plosive sound, though not necessarily by the contents of the stomach. 
The regurgitation of fluid and clotted blood, umixed with air or food, after 
the evident displacement of the foreign body, gives evidence of a laceration 
of the oesophageal wall, though the extent of the same cannot be deter- 
mined. 

Pain is not a very prominent early symptom. When present it is referred 
to the region of the stomach, and later to the emphysematous parts. It 
has not been found to be of a tearing character, nor is suddenness one of 



ISTT.] FiTZ, Rupture of the Healthy (Esophagus. 35 

its features. A varying degree of epigastric pain and tenderness continues 
during the subsequent course of this affection, extending from the ensi- 
form cartilage to the spine, and increased on bending backwards. Pains 
of another character, sharp and stabbing, supervene where the pleura 
becomes inflamed, as it may, from the extension of the inflammation from 
the mediastinum, either by continuity of tissue or as a result of lacera- 
tion. 

Nausea and vomiting are not prominent features, though blood is occa- 
sionally vomited, either pure or mixed with the contents of the stomach. 
Liquids may be swallowed without pnin, though a feeling of constriction is 
at times excited by their passage downwards. The patient falls into a 
condition of great exhaustion after the violent straining, from which he 
rallies in the course of twenty-four hours, when fever is evident. The 
emphysema advances, the patient has difficulty in breathing, there may be 
orthopnoga even, also slight cyanosis, and death may occur within fifty 
hours, or may be postponed for seven or eight days. When the disease 
assumes a protracted course, it is essentially a gangrene of the medias- 
tinum combined with gangrenous pleurisy ; tliere are continued fever, great 
prostration, mild delirium, pains in the stomach and chest, and bloody 
stools after a time. Tetanic convulsions may occur if the inflammation in 
the mediastinum involves the nerves along the spine. 

Many of the symptoms occurring in these cases are apparently those 
resulting from the emphysema. At tiie outset there is little to call di- 
rect attention to the oesophagus except the impaction of the food and the 
eventual hemorrhage, and nothing to determine absolutely the fact of a 
complete rupture at the time of its occurrence. Later the symptoms are 
essentially those of a septicasmia. The diagnosis is likely to be attended 
with considerable difficulty, and death is the result. 

Hamburger says-: — ^ 

" We must admit that up to the present the diagnosis is first made upon the 
corpse, and often contrary to all expectation, '• to which it can be added that 
even then the diagnosis may be attended with very great difficulties." We be- 
lieve, however, that, by auscultation of the oesophagus during the act of swal- 
lowing, the most valuable assistance may be obtained. The place where the 
perforation has occurred may be exactly designated when the difficulty in 
swallowing is relieved, and the fluids swallowed reach a certain point only, 
beyond which they cannot be recognized. ISometimes a slight blowing sound 
is heard at this point on swallowing. 'J'his method is applicable only to those 
cases where the rent is sufficiently large to permit the liquids to pass through. 
If the opening is too small for this, there is then no communication, and the 
rupture runs a latent course." 

This suggestion is of value in so far as it offers a new application of 
the auscultatory method, and it has apparently proven satisfactory in 
certain cases of perforation. The objection raised by Oppolzer, that the 
usual condition of the patient is not likely to permit the employment of 

' Klinik der (Esophagus Krankbeiten. Eriangen, 1871, p. 189. 



36 Bartholow, The Study of Animal Temperature. [Jan. 

this means of diag:nosis, is hardly applicable to eases of the character here 
referred to. He also suggests, as a precaution, that only small quantities 
of fluid should be swallowed. The patient, however, is either inclined to 
take fluid in small quantities, or else suffers no apparent inconvenience from 
larger amounts. 
Boston, Nov. 1876. 



Art. II. — A Contribution to the Studi/ of Animal Temperature. Pre- 
liminary Note. By Roberts Bartholow, M.D., Professor of the 
Theory and Practice of Medicine and of Clinical Medicine in the Medi- 
cal College of Ohio. 



o 



In some " experiments of control" during a course of investigations 
into the actions of antipyretic medicines, I ascertained that the tempera- 
ture of rabbits confined in a Czermak's support declined sensibly. If com- 
plete immobility of tlie animal be secured, the rectal temperature begins at 
once to lessen, and in an hour the declination has reached easily measurable 
proportions. After some hours the decline of temperature is very marked. 
The observations were taken with an Arnold's clinical thermometer, which 
are, I am informed by the maker, compared with the Greenwich standard. 
Such comparative tests as I applied indicated that the thermometer used 
was fully up to the average of accuracy of the most carefully constructed 
clinical thermometers. The Czei-mak's support, made in the usual way, 
held the rabbit quite immobile. The temperature of the laboratory and 
of the rabbit's rectum was taken before the animal was placed in the 
apparatus. It was found that the rabbit's temperature declined in a 
nearly uniform ratio. 

Eocpt. 1. Babbit of four months; weight 34 ounces. Temperature of the 
air 8uo F. 'J'emperature of the rectmn 102° F. Fastened in the support. 

At the end of the first hour the rectal temperature was 1 01^.5 

At the end of the second hour " " " 101° 

At ihe end of the third hour " " " 100° 

At the end of the fourth hour " " " 99° . 

When released from confinement the rabbit crouched in a corner, the limbs 
being stiff and swollen. At the end of the first hour of freedom, when the 
rabbit had recovered in large part from the immediate effects of the confine- 
ment, the temperature of the rectum had risen to 102°. In oscillating from 
the lowest point the temperature did not stop at the normal, but passed to the 
other side, reaching in three hours 103°, and in six hours 103°. 5. At the ex- 
piration of twenty-four hours, when I had arranged to repeat the experiment 
with the same animal, I found the temperature still at 103°. 

Eocpt. 2. hjame rabbit as in preceding observation. Temperature of the air 
82°. Rectal temperature 103°. Fastened in the Czermak support. Not- 
withstanding the abnormal elevation of temperature, the decline in body-heat, 



1877.] Bartholow, The Study of Animal Temperature. 37 

under the influence of complete immobihty, was in nearly the same ratio as 

before. 

In one hour the rectal temperature was .... 102° 
Tn two hours " " " . . . . lOlo 

In three hours " " " . . . . 100^ 

In four hours " " " . . . . 99° 

After release from confinem.ent, in an hour the rectal temperature was 
102O.5 ; in three hours was 103° 

A number of experiments of the same kind with rabbits yielded the 
same results. Observations with pigeons also demonstrated that com- 
plete immobility of the body causes a decline in the temperature of birds. 
A pigeon may be secured v/ithout injury by folding the wings, extending the 
legs, and then wrapping it in strong paper, leaving a sufficient orifice for 
the admission of air. The temperature was taken by introducing the 
thermometer deeply into the gullet. 

Expt. 3. Pigeon, fully grown, prepared as above described. Temperature 
of the air 81°. Temperature of the gullet 107^. 

In one hour the temperature of the gullet was . . 106^.5 

In two hours " " " . . 106° 

In three hours " " " . . 105O 

In four hours '' " " . . 104O..5 

After an hour of freedom the temperature of the gullet was found to be 107°, 
or normal. So decided a fail of temperature did not take place in all cases, 
due, I think, to the great freedom allowed the head and neck in order to secure 
the admission of air. The decline in temperature was never less than one de- 
gree, and usually reached two degrees. 

The fact being ascertained that immobility of the body causes a decline 
in the body temperature, it is obviously necessary to take this result into 
account in studying the action of antipyretic medicines. Dr. J. L. An- 
derson, my assistant, and I have made a number of observations to ascer- 
tain the gross effects of immobility and of the action of the antipyretic 
medicine. 

Exj)t. 4. Rabbit; weight 66 ounces. Rectal temperature 102°. Adminis- 
tered, subcutaneously, fifty minims of the official tincture of digitalis. Placed 
in the support. 

In an hour the rectal temperature was .... 98°.5 
In an hour and a half the rectal temperature was . . 98° 
In three hours " " " . . 97°. 8 

Expt 5. Rabbit; weight 64 ounces. Rectal temperature 102°. Injected 
under the skin 20 minims of the officinal tincture of aconite root. Placed in 
the support. 

In ten minutes the rectal temperature was . . . 101°.5 

In twenty " " " "... 101°. 2 

In forty " " " "... 100°.6 

In an hour " " "... 98°.5 

Expt. 6. Rabbit ; weight 64 ounces. Rectal temperature 102°. Injected, 
subcutaneously, five minims of the officinal tincture of veratrum viride. Placed 
in support. 

In twenty minutes the rectal temperature was . . 100° 

In forty *' •' - u _ ^ ggo 

In an hour " " " . . 97°.5 



38 Bartholow, The Study of Animal Temperature. [Jan. 

Expt. 7. Rabbit; weight 70 ounces. I'emperature of the air 76°. Rectal 
temperature 103°. Injected, subcutaneously, twenty grains of chloral. Placed 
in the support. 

In one hour the rectal temperature was .... 101° 

In two hours " " " . . . . 99° 

In three hours " " " . . . . 96° 

In six hours " " " . . . . 93° 

Expf.Q. Rabbit; weight 64 ounces. 'J'emperature of the air 71°. Rectal 
temperature 102°. Injected under the skin twenty grains of chloral. Placed 
in the support. 

In one hour the rectal temperature was ; . . . 98° 
In two hours " " " . . . . 96° 

In three hours " " " . . . . 95° 

It is, of course, perfectly well known that the temperature of rabbits 
may be reduced by chloral very much below the point mentioned above. 

It is a very curious fact that an agent like atropia, which increases the 
action of the heart, and raises the arterial tension, causes a decline of 
temperature in the rabbit, if administered in sufficient quantity to produce 
paralysis and consequent cessation of voluntary movement. I am in- 
debted to ray assistant, Dr. Anderson, for a number of observations made 
in my laboratory with atropia. I select one experiment to illustrate this 
point. 

Expt. 9. Rabbit; weight 64 ounces. Temperature of rectum 102°. Tem- 
perature of air 78°. Injected under the skin one-half grain of atropia. Al- 
lowed to run about the laboratory. 

In one hour the temperature of the rectum was . . 103° 
In one and a half hours the temperature of the rectum was 103° 

The rabbit was then fastened in the support. 

In thirty minutes the rectal temperature was . . . 102° 

In fifty " " " "... 10I°.5 

In an hour " " "... 101° 

In one and a half hours the rectal temperature was . 100°..5 
In four hours " " " . 98° 

Expt. 10. Rabbit; weight 62 ounces. Temperature of the rectum 103° 
Temperature of air 78°. Injected, subcutaneously, two drachms of alcohol. 

In five minutes the rectal temperature was . . . 104° 

In fifteen " " " "... 103°. .5 

In forty-five minutes the rectal " "... 102° 

In an hour " " "... 101° 

My notes say that in five minutes there was "muscular paresis with excite- 
ment," and this corresponded to the maximum elevation of temperature. 
AVhen " complete muscular relaxation" ensued, "with dilated pupils," the tem- 
perature declined. 

It appears to be established, from the foregoing facts, that any agent 
producing complete muscular relaxation, whatever its mode of action in 
other respects, causes a decline in temperature ; and the more complete 
the immobility consistent with the maintenance of respiration and cir- 
culation, the more decided the reduction of the body-heat. It must be 
obvious to every intelligent reader that I do not mean to include in the 



1877.] Rodman, Treatment of Injuries of the Head. 39 

above formula all antipyretics, for the mode in which these agents depress 
temperature varies greatly. 

The lowering of the temperature oaused by the maintenance of an im- 
mobile condition of the body is overcome by artificial heating. For the 
purpose of this inquiry I employed a hot-air chamber, large enough to 
contain the rabbit support and an apparatus for maintaining a uniform 
heat. The temperature of the chamber was registered by a thermometer 
projecting into the interior, the scale being external. The results were so 
uniform that I need not now occupy space in detailing the individual ob- 
servations. The experiments as narrated above were first made, and then 
without delay the rabbits were placed in the hot-air chamber, the thermo- 
meter in situ. The temperature of the hot-air chamber was usually 130°. 
Several observations were made with the air of the chamber at 160°. The 
rise of temperature which followed the introduction of the animal into the 
hot air was more rapid when the temperature of the hot-air chamber was 
at the maximum. The results of heating were constant, and I state the 
averages : — 

In fifteen minutes the temperature rose . . . 0° 5 
In thirty minutes " " *' . . .2° 

In one hour '' " '' . . . 3°.5 

In two hours '' '' *' . . . 1° to 2° 

above normal. 

The same results were obtained when the temperature had been reduced 
by the antipyretics, as detailed above. When the temperature had, by 
artificial heating, been raised to normal, it declined again when the rabbit- 
was placed, still in the support, in the external air. 
120 West Seventh Street, Cincinnati, 0. 



Art. III. — The Treatment of Certain Injuries of the Head, accompa- 
7iied by Lesions of the Brain and its 3Iemhranes. With illustrative 
cases. By W. B. Rodman, M.D., of Frankfort, Ky. 

Since surgery has been an art, its authors, teachers, and practitioners 
have differed widely in their views of the proper treatment for the various 
wounds of the skull. The subject of simple fracture with depression (with 
or without symptoms of compression of the brain) has been an especial 
ground of contention. I believe that most surgeons are agreed on the 
treatment of compound fracture of the skull with depression, but very few 
of them dare to treat a simple fracture as they would a compound one. 
They fear that hemorrhage, inflammation, erysipelas, and encephalitis in 
its various forms, will supervene if an incision is made when the fracture 



40 Rodman, Treatment of Injuries of the Head. [Jan. 

is simple. My object in writing this paper is to show that these clangers 
are more traditional than real ; that more lives have been sacrificed and 
minds left permanently impaired from fear of making an incision, so that 
the actual condition of the bone might be thoroughly known ^nd thereby 
remedied, than have been lost from an opposite course of treatment ; that 
even conservative, or rather 7ion-operative surgery may be carried to an 
extreme ; that the danger of making a compound out of a simple fracture 
has been greatly overrated by the older v/riters, and that we of the present 
day have blindly accepted their views as infallibly correct. 

No doubt that Cooper, Abernethy, Dupuytren, and others wrote as their 
reasoning from observation of cases prompted them. They saw compound 
fractures of the skull and those simple fractures made compound by the 
surgeon do badly. 

These men treated all injuries of the head when brain trouble existed, 
or was apprehended, by general bleeding, comparative starvation, tartar 
emetic, and calomel. Under this plan, even the simplest wound of the 
scalp would be predisposed to slough, to take on a low grade of inflam- 
mation, or be attacked by erysipelas. Let us see for one moment if these 
dangers are common under a more rational treatment, I grant that 
bruised, lacerated, or punctured wounds of the scalp will take on just 
such action as wounds of the same character in other parts of the body. 
But are these the wounds a surgeon would make in incising the scalp in 
his endeavour to learn the exact condition of the broken bone beneath ? 
What is the usual consequence of an incised wound of the scalp? Union 
by first intention if properly treated. 

On page 15, Part 1st, Surgical Histori/ of the War of the Rebellion, 

this language will be found: — 

"Of the two hundred and eighty-two cases of incised wounds of the scalp 
above recorded, six terminated fatally An examination of the re- 
cord in each individual case indicates .... that three died from some 
form of encephalitis, directly resulting from the injuries received." 

As others were discharged for mental aberration, vertigo, imperfect 
vision, headache, persistent pain at the seat of injury, it is reasonable to 
suppose that in these cases there was something more than a simple in- 
cised wound of the scalp ; in other words, that the three who died, and 
those who suffered, as mentioned above, had their skulls fractured by the 
sabre, which inflicted the incised scalp wounds. The three other deaths 
are recorded as having occurred from causes totally independent of the 
wounds received. This statement does not show that an incised scalp 



wound is such a dreadful affair. 



1 The case of Harrison Gr. Campbell (page 4) will appear remarkable to those 
who so firmly believe that scalp wounds are particularly liable to erysipelas. This 
man ha<i a scalp wound. Erysipelas attacked the left leg (upon which there was 
no wound), and from this part extended to his body, other leg, throat, and face. 
He died without the scalp wound ever having become erysipelatous. 



1877.] Rodman, Treatment of Injuries of the Head. 41 

It may be said that an incised wound of the scalp, without a fractured 
skull, is a very simple affair ; but that when it accompanies or complicates 
a fractured skull it renders the latter more dangerous. How so ? Is there 
any special danger in the scalp wound per se? Is there here any hidden 
source from which innumerable agents may spring, bringing in their train 
erysipelas, inflammation, abscess or hernia of the brain ? I contend that 
an incised wound made by the surgeon for the purpose of ascertaining the 
exact condition of a fractured skull is harmless. If the fracture is not 
extensive, or depressed enougli to require trephining, or raising, or remov- 
ing the fractured bone, the simple incision can do no harm. If the reverse 
be the case, I pity the patient who falls under the care of the surgeon too 
timid, too faint-hearted to make the necessary incision, even if he renders 
a simple a compound fracture. 

It is proper at this point to discuss the opinions and teachings of Gross 
and Erichsen (who have probably more influence over the practice of sur- 
gery in America than any other writers or teachers). 

Gross (Syst. Surgery, 1872, vol. ii. p. 133-4), speaking of the treatment 
of compression of the brain by depressed bone, says: — 

"When compression is produced by depression of bone, attended with com- 
pound fracture, immediate recourse should be had to trephining 

The question is still an open one as it respects the treatment of compression 

from depression attended with simple fracture I am disposed to 

regard operative interference as justifiable only in the event of extensive de- 
pression, and I should adopt this plan whether the symptoms of compression 
were urgent or not, on the ground that the patient would be much less likely to 
suffer from subsequent cerebral disorder." 

Page 146, under the head of Simple Fracture with Depression and 

Symptoms of Compression, he says, speaking of delay and immediate 

operative interference : — 

" Unfortunately experience, always the best guide in such matters, has 
not fully decided the question as to which of these two plans should be pre- 
ferred But I am decidedly in favour of immediate trephining, on 

the ground that while the operation adds but little to the risk^ of the case, the 
patient has a much better chance of prompt recovery. As long as the bone is 
depressed, even supposing that the compression is removed, there is danger of 
inflammation of the brain and its envelopes, to say nothing of the occurrence of 

epilepsy and other nervous affections My opinion then is, that 

operative interference, early and efficient, is, as a rule, the only proper plan to 
be pursued under such circumstances." 

If Prof. Gross intends to convey the idea that he would not operate 
when he says, as above quoted, "I am disposed to regard operative inter- 
ference as justifiable only in the event of extensive depression, and I should 
adopt this plan, whether the symptoms of compression were urgent or 
not," etc., there is a decided conflict in his opinions. The sentence is, at 
least, ambiguous. 

1 The italics are mine. 



42 Rodman, Treatment of Injuries of the Head. [Jan. 

Page 146, 1st line, speaking of simple fracture with depression of bone 
(without symptoms of compression), he says: — 

"Upon this subject (treatment) surgeons have been divided in opinion, some 
favouring, others condemning operative interference; favouring, because of the 
dreaded primary and secondary effects ; condemning, because a simple fracture 
is thus converted into a compound one." 

Dr. Gross would here be guided by the degree of depression ; if slight, 
would not interfere ; if very decided, he would. He closes this paragraph 
with these remarks : — 

"A man labouring under such an affection [depressed bone] is never free 
from danger; he may get well, or be well to all appearance, and yet be only 
partially cured, subject, at any moment, to have his life and mind imperilled 
by the "broken bone. It is like the sword of the tyrant suspended over the 
head of his subject." 

What is the treatment almost universally recommended in compound 
fracture with depression of bone, with or without symptoms of compres- 
sion ? To relieve the depression at once by trephining, if this be neces- 
sary, but at any hazard to elevate or remove all depressed bone. Yet if 
depression occur in a simple fracture, it must be let alone, unless it is evi- 
dent that the patient will die, and that soon ! It is asking too great a 
risk of the surgeon to make a simple incision down to the fractured bone, 
and see the exact condition of it; for, by so doing, he is making a com- 
pound fracture out of a simple one, and there is danger of inflammation! 

It took the profession nearly one hundred years to learn that hot drinks 
and starvation would not cure a fever patient. How long will it take 
them to find out that a simple fracture of the skull should be treated as a 
compound one; and that a depression of bone under a scalp intact, is as 
dangerous, if let alone, as the same amount of depression under a cut six 
inches long ? 

The special dangers of compound fracture are said to be shock, inflam- 
mation, and fungus of the brain. Probably if an even number of fractures, 
both simple and compound, were analyzed, shock would be found to pre- 
dominate in the latter ; not because they are compound merely, but because 
there would be naturally in compound wounds more injury to the skull 
bones independent of the scalp wound. The compound fractures of the 
skull are, in civil practice, rarely accompanied by clean incised wounds, 
but the scalp wound is generally lacerated, bruised, or punctured. This 
class of wounds almost invariably suppurate, and thereby they might, to 
a slight extent, prejudice the chances of recovery by interfering with the 
brain. But a simple incised wound should heal by first intention, and in 
no wise interfere with the perfect recovery of the brain and its membranes. 
Will any one contend that a simple incised wound is, in itself, the least 
responsible for fungus cerebri? Unless there is decided depression of bone 
and some laceration of dura mater, fungus will hardly occur. In the event 
that there is suflicient depression of bone and laceration of dura mater, to 



IStT.] Rodman, Treatment of Injuries of the Head. 43 

let the brain escape beneath the scalp, I Tenture to say that death is inevi- 
table, unless the bone is raised ; and this cannot be done without an incision, 
which makes a compound out of a simple fracture. I think it would do 
well to put these imaginary horrors of compound fracture along with that 
which the laity so much dread, viz., "taking cold in the cut." 
Erichsen, Philadelphia, 1869, page 347, says: — 

"If there be no wound in the scalp, but the occurrence of symptoms of com- 
pression and the e^xistence of some irregularity of the skull at the seat of injury 
lead the surgeon to suspect a depressed fracture, he should make a crucial or 
T-shaped incision down upon the part in order to examine the bone, and if this 
be found depressed to elevate or remove it." 

Page 348, fourth line: "In those rare cases in which there is depressed frac- 
ture without symptoms of compression or even a wound of the scalp, the line 
of practice is still unsettled as to whether the depressed portion of bone should 
be left where it is, or an attempt be made to elevate it." 

Erichsen, in these last-mentioned cases, seems biassed by the opinions 
of Cooper, Abernethy, and Dupuytren, who adopt the expectant plan, 
but he does not adliere strictly to their advice, but remarks further on : 
"I think, however, this expectant practice should not be followed too 
implicitly, but that we must be guided by the circumstances of the par- 
ticular case." I would say in all cases of doubt as to whether there was 
depressed bone or not, make an incision — it can do no harm — having done 
this, treat the fracture as you would a compound one — there is no doubt 
about the treatment then, because all are agreed on immediate interference 
in compound fractures. I know, or at least have reason to believe, that 
persons (especially children) have fully recovered without depressed bone 
being raised ; but this result is an exception to a very general rule. In 
adults it occurs but very rarely. 

Although my experience is rather limited, I will relate a series of cases 
which have made an indelible impression on my mind, and have strength- 
ened my convictions as to the proper treatment of skull fractures: — 

Case I. — John Newman, age 16, was thrown from a horse on April 
22d, 1876. Falling, he struck violently upon the left side of his head on 
a round stone in the bed of a branch. This was four miles from Frank- 
fort. I saw him at 9 A. M., one hour and a half after the accident. He 
had symptoms of concussion of the brain, would answer when spoken to, 
and several times, with assistance, arose from a lounge and walked across 
the room to a fireplace and vomited. When asked what hurt him, he said 
his head, and would put his hand over the injured part. I found a great 
puffy tumour of the scalp, almost as large as one's hand, extending from 
the left ear to within a short distance of the sagittal suture, and almost 
as broad as long. There was no wound of the scalp. The scalp tumour 
was puffy, yet firm; so much so that 1 was unable to feel whether the skull 
bone was broken and depressed. From his condition I concluded that he 
could be carried to his own home, two miles nearer town, and I directed 
that this should be done on a litter. In the mean time I returned to town 
for instruments and assistance. When I reached him the second time I 
found that he had been brought the distance of two miles in a buggy, and 
not on a litter as I had directed. He had, however, rallied so much from 



44 Rodman. Treatment of Injuries of the Head. [Jan. 

the concussion that he was able to talk, and to hold a conversation with 
the priest durinp^ the rite of extreme unction. 

Notwithstanding this was a simple fracture with no symptoms of com- 
pression, and although I was unable after careful manipulation to detect 
any fracture, I determined to cut down upon the bone at once. Chloro- 
form having been sparingly administered, I made an incision extending from 
the ear to within two inches of the sagittal suture. When this incision 
was carried to the bone, or rather where the bone had been, there was such 
vc terrific gush or spurt of blood and brain that I thought the boy would 
die then and there. I thought that the middle meningeal artery or the 
lateral sinus, or both, had been ruptured. (A fissure in the bone ran 
across the course of the lateral sinus, and a large branch of the menin- 
geal artery was ruptured.) Having made a T-shaped incision and re- 
flected the scalp, an enormous fracture came into view. Two pieces of 
broken bone, each as large as tiie bowl of a teaspoon, were projecting 
perpendicularly into the brain from the anterior edge of the fracture. 
They had lacerated the dura mater fearfully, and had crushed out nearly 
half an egg-shell full of brain. Several other pieces, much larger in the 
aggregate than the two together, mentioned above, were removed. One 
large piece, not being entirely detached, was raised and left. The sur- 
face thus left unprotected by bone was at least two and a half inches in 
diameter. Of course no trephining was necessary. The sharp points of 
bone being removed with the pliers, the periosteum and dura mater having 
been rej^ilaced as well as possible, I closed the incisions with sutures exce})t 
enough immediately over the ear for the purpose of drainage. The wound 
was tlien dressed with cold water. No ligatures for the arteries of the 
scalp were necessary. The boy was then left, and his father ordered to 
give him 20 grs. of potass, bromid. every two hours if he should become 
restless or complain of headache. He did well for ten days, having 
suffered slightly with symptoms of cerebral irritation, which were easily 
controlled by the potass, bromid. There was very little purulent dis- 
charge, and this came through the upper part of the wound where the 
sutures were, the lower part, without sutures, having healed by first inten- 
tion in two days. There was up to this time every indication of a favour- 
able result. 

May 1st, I for the first time noticed indications of fungus of the brain. 
The sutures had been pulled loose and the incisions made to gape by an 
ugly pulsating tumour forcing its way through the wounded scalp. (The 
incision into the scalp indirectly caused the fungus — for if the incision had 
not been made the boy would have died before the fungus could have 
formed!) When I attempted to use compresses they gave such pain that 
I had to abandon them. The wound was syringed out with a carbolized 
solution, and in two or three days (during which time there were symp- 
toms of decided cerebral irritation) the compresses were again applied, and 
this time could be borne. The fungous tumour, the size of a pullet's e^g, 
decreased, the wound in the scalp rapidly cicatrized, and the boy is now 
entirely well. During the latter part of June, contrary to my advice, he 
passed a very creditable final examination in his school. His mind is as 
clear as ever. 

This case is a remarkable instance of decided depression of bone and 
extravasation of blood without a single symptom of compression. It also 
illustrates to what a fearful extent bone may be broken, dura mater lace- 



181Y.] KoDMAN, Treatment of Injuries of the Head. 45 

rated, and brain literally crushed, without the- scalp being in the least 
wounded. I will state here that I could easily feel the petrous portion of 
the temporal bone when I was exploring the wound for loose fragments 
from the fracture. 

Does any one pretend to say that I did wrong in operating so soon on 
this boy? Should I have waited until symptoms of compression came on 
before making the exploratory incision — for such it was in the beginning? 
But for the course pursued death would in all probability have resulted. 
Yet this case was treated contrary to the rules laid down in the text-books. 
It was a simple fracture, without apparent depression, and with no symp- 
toms of compression. 

Case IL — Lee Frazier, age 13, was struck over the left temple by the 
butt-end of a base-ball bat on the afternoon of Sept. 16, 1810. He was 
brought to my office, a distance of two blocks from where he was injured, 
and I saw him a few minutes after the occurrence. Symptoms of concus- 
sion predominated over those of compression, which latter were very slight. 
There was a cup-shaped depression on the left side of the head just the 
size of the end of the bat with which he had been struck. As the fracture 
was simple and the symptoms of compression but slight, it was determined 
to wait until the demand for operative interference should become more 
urgent. The next morning, instead of a depression there was a puffy 
scalp tumour over the seat of fracture, and the boy was comatose. I made 
a crucial incision large enough when the flnps were reflected to expose the 
whole fracture. As the bones were fearfully crushed, no trephining was 
necessary. 1 began to remove pieces of bone, and continued until I was 
alarmed at the tremendous gap I was making in the skull. Most of the 
squamous portion of the temporal, a large piece of the parietal, including 
the anterior -in fe^'ior angle, part of the frontal, and part of the great 
wing of the sphenoid were loose and had to be removed. Pieces which 
were only partially detached were raised and left. The dura mater was 
slightly lacerated, much less than would be expected under the circum- 
stances. The brain did not seem to be injured at all. Sutures having 
been used, the wound was dressed with cold water and a compress applied. 
The boy became conscious soon after the Oj)eration, and made a perfect 
recovery without a single unfavourable symptom. I attribute the non- 
formation of fungus 10 the fact that there was but slight laceration of 
dura mater. 

This boy should have had immediate attention, due regard being had 
for the shock and concussion which existed at the time. I think now that 
I took a great risk in allowing him to remain in his condition for fifteen 
hours, as he might have died during that time. In the Am. Joiirn. Med. 
Sciences for July, 1876, p. 292, there is the report of a case by Dr. Turner, 
of Dakota, which illustrates the danger of too long delay. His patient 
m\^\\i possibly have been saved by proper treatment instituted soon enough ; 
but I must confess that it would require a bold surgeon to have performed 
the necessary operation in view of the modern and ancient teaching on 
this subject. The proper treatment was decided on, viz., to make au 
exploratory incision and be guided by the result; but the works on surgery 



46 Rodman, Treatment of Injuries of the Head. [Jan. 

being rather timid in advising this course, Dr. Turner waited until death 
was upon his man. I venture to say that if he has another case resembling 
this he will make an incision at once, and if necessary trephine, elevate 
depressed bone, or, if extravasation of blood is supposed to be the cause 
of the compression, remove it at all hazards. Death is almost certain 
unless this plan be followed. 

I might mention here a singular fact. Dupuytren was one of the 
strongest advocates of the expectant or let-alone treatment in simple 
fractures of the skull with depression. Yet, believing that a patient had 
an abscess of the brain, he trephined, and when even the dura mater was 
punctured and no pus flowed, he was bold enough to plunge his bistoury 
into brain substance itself and thus achieve a wonderful cure. 

The following cases show the danger of the non-operative treatment : — 

Case III. — In 1869 I was sent for by the attending i)hysician to see 

J E , aged 8 years, in an adjoining county. The messenger, a 

negro, said he had been kicked in the head by a horse, but gave no further 
particulars. When I arrived there were five other physicians in the house. 
I learned that the boy had been injured tiventij-eight dai/s before. There 
was slight " concussion" at the time of the injury, but the doctor had appre- 
hended nothing serious up to the last four or five days, when the boy began 
evidently to grow worse. On examining him we found a scalp wound about 
one and a half inch long over the right frontal eminence. This wound 
had healed by granulations, which then looked pale and flabby. Not one 
of us could tell by physical examination whether there was a fracture of 
the bone with depression. The attending doctor said he didn't know, as 
he had not examined when the wound was oj)en, and he had seen no symp- 
toms indicative of depressed bone. (He had probabl}^ consulted some 
work on conservative surgery, which told him never to interfere unless 
there were symptoms of compression.) The boy's pulse was over 130, 
his tongue coated, bowels irritable. He was partly delirious, and had 
decided photophobia. I expressed tlie opinion that there was irritation or 
inflammation of the brain resulting probably from depressed bone or a 
small abscess, and I proposed to open the wound and make the examina- 
tion thorough. Only one physician agreed to my opinion ; the others said 
that it would make matters worse by any interference. They finally con- 
sented, "as the boy would die anyhow," that I might be allowed to see the 
nature of the injury. (I was granted permission to make something on 
the order of an ante- post-mortem examinalton rather than a surgical 
operation.) I made a crucial incision, and removed two pieces of de- 
pressed bone half the size of the bowl of a teaspoon. The brain looked 
disorganized, and there was a slight sero-purulent discharge through the 
wound. He died two days after tiie operation. 

I have no doubt that this patient could have been cured if the exact 
nature of the injury had been fully ascertained when first received, and the 
offending pieces of bone promptly removed. As I did not operate until 
the secondary effects of the injury had occurred and he was evidently 
doomed, it cannot be said that the operation of reopening the wound 
killed him. 



1877.] Rodman, Treatment of Injuries of the Head. 47 

Case IY. — Hugh C , aged 5 years. Some time in May, 1876, I 

was called to see this child, who was having severe muscular spasms, eon- 
fined to the left side. He had been vomited and purged before I reached 
him. The warm bath and cold to the head seeming to have no effect, I 
used chloroform by inhalation, which stopped the spasm. Not being able 
to trace the convulsion to the usual causes, and observing the unilateral 
character, I pressed my inquiries, and learned that six weeks before he had 
been struck over the right frontal eminence by a piece of brick, which 
made a punctured wound of the scalp down to the bone. The family 
physician coming in, I advised that the child be given large doses of the 
bromid. potass., and if the spasms were not controlled by this treatment, I 
would certainly trephine over the wound. I told him what I supposed to 
be the cause of the convulsions. He agreed with my views. About two 
weeks after my first visit I was called again, and found the child in the 
same condition as when I first saw him. I learned that he had taken the 
remedies, but that the spasms had occurred more frequently and with 
greater intensity. 1 ngain suggested trephining, and the attending phy- 
sician tried to persuade the parents to consent. They thought, however, 
that the remedy was too severe, and their child might "outgrow" his 
trouble. He died. I believe that there was here a fracture of the internal 
table of the skull, and that a splendid opportunity to save a life by tre- 
phining was lost. No poiit-mortemi j^ermitted. 

Case V. — John J ', aged 21, walked into my office as if in perfect 

health. When asked what brought him, he said, " Oh, nothing much. I've 
got a knife blade in my head; I want you to take out." A few hours 
before he had been stabbed through the left side of the frontal bone about 
a half inch from the coronal suture and an inch to the left of the median 
line. He said his head pained him some little, but the closest observation 
revealed no symptom that the man was hurt. The blade was the large 
one of a " Congress knife." On examination I found it broken ofi' to the 
shank, and firmly fixed in the skull, only the eighth of an inch remaining 
above the bone. I made a crucial incision, and dissected the scalp from 
around the blade. In spite of all my efforts with instruments (shoemaker's 
pinchers and others), the blade could not be moved. I suggested trephin- 
ing. My father, thinking this operation too dangerous and unnecessary, 
suggested that he could chisel enough of the skull away from the blade to 
enable us to remove it. This he proceeded at once to do; the fellow in 
the mean time sitting in a chair and taking the whole proceeding very 
quietly. The man did well for three days, and in six he was dead. 

What killed him ? The blade penetrating the brain ? No ; the blade 
had fractured the internal table, and although the chisel had removed 
enough to release the knife, it had not taken away a few sharp spicula of 
bone which were then inflicting a mortal injury on the man's brain. It 
may be interesting to contrast the last case with the following : — 

Case Yl. — Nelson Finney, a coloured man, aged 25 years, having in- 
sulted a. damsel of his persuasion at a dance, was immediately felled to 
the floor by a skillet, an old frying skillet, which is so common an article 
over our " Sunny South." The woman held it by the long handle, and 
struck Finney with such force as to bury one of the legs at least one and 
a half inches into his brain. He was struck over the left temple. The 
blow was received about midnight. Next morning when called to see him 



48 Rodman, Treatment of Injuries of the Head. [Jan. 

I found him comatose, with a punctured fracture as described. The neces- 
sary incisions having been made, it was found im})ossible to remove or 
raise the bone without first using tlie trephine. This instrument was used 
at once; then there was no trouble in removing thirteen small pieces of 
l)one, some the size of a finger-nail. The dura mater and brain were lace- 
rated of course, some of the latter escaping. Notwithstanding these in- 
juries, the man recovered without an alarming symptom. 

I do not cite these last cases to prove my point with respect to the 
treatment of simple fracture with depression, but I go further and state, 
that frequently a life is sacrificed through the timidity of the physician 
even when operative interference is unquestionably sanctioned by the text- 
books. It is too often the case that the operation of trephining and the 
raising of depressed bone is deferred until the patient is moribund, or, as 
more frequently happens, is left to the expectant treatment because there 
are no immediate or urgent symptoms. As Chelius remarks, secondary 
effects come sooner or later, and it is then too late for any operation to be 
of service. I do not believe that one in ten will recover fully in mind and 
body when these secondary symptoms have supervened, no matter what 
treatment may be adopted. In nineteen cases of fractured skull {Surg. 
Hint, of the War of the ReheUion), when there were secondary complica- 
tions, ten died, eight ended in permanent disability, and one fully recovered. 

There is described in most surgical works a peculiar condition of the 
scalp, which, to a novice, seems a depression of bone in the centre of the 
scalp tumour. This depression is supposed to be caused by the driving 
forcibly together of the tissues of the scalp. Blood is extravasated around 
this point, and gives the scalp a puffy appearance, but, being unable to 
force itself between the tissues in the centre, these remain comparatively 
depressed. WHienever this condition exists, and the physician is in doubt 
as to its exact nature, an incision should be made down to the bone. If 
this be found fractured, treat as a compound fracture; if no fracture is 
present, no harm is done. The incision merely enables the scalp to get rid 
of the effused blood, and the sooner to regain its normal condition, 

No rules of treatment can be laid down from the observation of a 
limited number of cases such as I have reported. I have given only a 
part of those which have come under my observation, having selected 
those which seem to me illustrative of the opinions I have advanced. 

However, as experience is said to be a safe guide, let us analyze 105 
cases of fractured skull reported on pages 67, 68, and 69 of Surg. Hist, of 
the War of the Rebellion, 1st Part. These fractures resembled those seen 
in private practice, and resulted from falls, railway accidents, blows with 
bludgeons and the butts of muskets, etc. 79 were treated without operative 
interference; 43 died, 54.4 per cent. 26 were operated on; 14 died, 60.8 per 
cent. This comparative mortality looks at first glace as if the views of 
Cooper, Abernethy, and other advocates of the non-operative plan, were cor- 



187*7.] Rodman, Treatment of Injuries of the Head. 49 

rect, but a careful analysis will show the reverse of this. Of the 79 who were 
not oi>erated on, 28 had fracture without injury to the brain or its membranes, 
and all of these latter are reported as having recovered except one, who died 
from laceration of the testes. These men of course required no operative 
treatment. There were therefore 51 who had injury to the brain or its 
membranes from fracture of the skull who received no operative treatment, 
and 43 died, a per cent, of 84.3. Of the 26 who received operative treat- 
ment 14 died, 60.8 per cent. With the fact that those operated on were 
probably much more seriously injured than those not, the difference in 
favour of the operative treatment becomes the more evident. To sum up, 
out of 51 men with injury to the brain and its membranes treated ex- 
pectantly, 43 die, 8 recover, whether fully or not is not stated. Out of 
26 men who received operative treatment (and who were probably much 
more seriously injured) 14 die, 9 certainly recover, and 3 probably recover. 
Non-operative treatment 84.3 per cent, die; operative 60.8. These facts 
speak out unmistakably. Of 58 cases in which compression of the brain 
supervened immediately or soon after the injury 46 died, 3 unknown, 3 
completely recovered, 6 partially recovered. As only 14 of those operated 
on died, it follows that 32 men who had compression of the brain died 
without operative interference. 

I repeat that persons, even adults, may recover •from depressed bone 
without an operation to relieve them, but the instances on record are so 
rare, and they are such remarkable exceptions to the general rule, that they 
by no means warrant us in waiting for urgent symptoms before exploring 
by incision or even operating. 

I cannot understand why a simple fracture should not be treated as a 
compound one. When there is the slightest doubt as to the nature and 
extent of the injury, let us imitate the example of the law, "give our 
patient the benefit of the doubt," by incising at once; after this has been 
done, treat the fracture (if there be one) as a compound fracture is treated 
by almost all surgeons. I suggest, however, that no more be done after 
incision in simple fracture than is recommended for a fracture compound 
from the beginning. 

I did not, neither do I now, intend to discuss the subject of trephining, 
but I cannot refrain from expressing the opinion that the rules for tre, 
pinning laid down by Chelius {Syst. Surgery by South, vol. i. pp. 456 and 
457, ed. 1847) are correct and safe. The following sentence is very ex- 
pressive : " Trepanning is not to be considered in itself a dangerous ope- 
ration, it is so esteemed because most commonly it is employed when the 
diseased changes have already become great, or severe injury has been 
produced by external violence." 

No. CXLY.— Jan. 1877. 4 



60 RoosA, On the Power of Hearing. [Jan. 



Art. IY. — The Dispj^oportion between Ihe Power of Hearing the Tick of 
a Watch and the Human Voice; with remarks on hearing better in 
the midst of noise} By D. B. St. John Roosa, M.D , Professor of 
Ophthalmology and Otology in the University of the City of New 
York, Surgeon to the Manhattan Eye and Ear Hospital. 

It has long been known that the power of hearing the tick of a watch 
is not always in exact proportion to the capability of hearing the human 
voice. Some few persons, for example, hear the tick of a watch at what 
is fairly considered a normal distance, while they hear conversation very 
badly; while, on the other hand, what proves to be a much larger class 
hear and distinguish the notes of the human voice much better than they 
count the tick of a watch. With a view to determine, with some approach 
to exactness, the degree of this disproportion, which so many of us have 
found to exist, I have lately instituted an examination of the cases of loss 
of hearing in both ears that have presented themselves to me, and have 
arranged the results in a table, which I desire to present to the Society, 
with a few remarks upon the general subject thus presented. I am aware 
of the comparatively slight importance of the subject, but I hope the few 
facts shown may, atleast, turn the attention of some observers, so that a 
careful working up of the questions involved may finally accomplish some- 
thing for otological science. It is hardly necessary to say that I have 
made no examination when one ear alone is affected, because our means of 
excluding one ear, while the other is tested, are so imperfect as not to be 
relied upon. Cases where the watch is not heard at all have also been ex- 
cluded, for in a number of such cases there may be a great difference in 
auditory power, while the watch test merely shows that they are alike in 
not being able to hear its tick. The w^atch used in this test should be 
heard by an average ear, in a moderately quiet place, forty inches. Nor- 
mal hearinGr would, therefore, be expressed by the fraction — 

' Read before the New York Society of Neurology. 



isn.] 



RoosA, On the Power of Hearing. 



51 



Table showing the Disproportion between the Power of Hearing the 
Tick of a Watch and the Human Voice. 




' In corroboration of the Case No. 9, I append the results of an examination by 
ray friend, Dr. P. W. Cremin, under whose care the patient afterwards came. 
H. D. watch. Voice. 

72 

^2 4 feet. 

After treatment for about three weeks, for the watch the hearing was the same, 
and for the voice six feet. 



52 



RoosA, Oi) the Power of Hearing. 



[Jan. 











Hearing distance for con- 










versation, the • patient 


No. 


Sex and 


Disease 


Hearing distance for 


being with the back to 




age. 




the watch. 


the speaker. 


17 


Male 


Chronic catarrh mid- 


S 


Conversation with ease 




41 


dle ears. 


at 40 feet. 


18 


Male 


Chronic catarrh mid- 


^ pressed 
^- 40 ^' 40 


Conversation at 40 ft. 




45 


dle ears. 




19 


Male 
54 


Chronic catarrh mid- 
dle ears, with inspis- 
sated cerumen left 
side. 


4 pressed 

^- 40 ^- "40-^ 


Loud conversation at 

45 feet. 


20 


Male 
70 


Chronic catarrh mid- 
dle ears. 


^ pressed ^ laid 
^' 40 ^- 40 


Conversation at 30 ft. 

j 


21 


Female 


Chronic catarrh mid- 


^- 40 ^- 40 


Voice with difliculty 




16 


dle ears. 


at 10 feet. 


22 


Male 


Chronic catarrh mid- 


^- 40 ^'- 40 


Conversation at 40 ft. 




50 


dle ears. 




23 


Male 


Chronic proliferous in- 


R -^ L f 


Conversation at 30 ft. 




32 


flammation middle 
ears, with impacted 
wax Inft side. 


''• 40 ^- 40 




24 


Male 


Chronic suppuration 


contact 
R- "40 


Ordinary conversation 




36 


middle ears. 


at 18 feet. 








^ on mastoid 










I- - 40- - 




25 


Female 
24 


Chronic catarrh mid- 
dle ears. 


3 4 

R- 40 L. ^Q 


Conversation at 10 ft. 


26 


Male 
74 


Chronic catarrh mid- 
dle ears ; excessive 
nasal catarrh. 


laid i 

^- ~40~ ^- 40 


Conversation at 40 ft. 


27 


Female 


Suhacute catanh mid- 


2 4 
^•40 ^-40 


Ordinary conversation 




■ 15 


dle ears, and of post- 


at 30 "feet. 






pharyngeal space. 






28 


Male 


Chronic catarrh mid- 


li pressed 
^•40 ^- 40 


Conversat"on at 20 ft. 




71 


dle ears, with se- 








condary changes in 










cochlea. 






29 


Male 


Chronic catarrh mid- 


R '^ L 1^ 


Conversation at 30 ft. 




44 


dle ears. 


"^^ 40 ^' 40 




1 30 


Female 

22 


Subacute catarrh mid- 
dle ears, with im- 
pacted cerumen. 


1^ 3 

After removal of 
cerumen and in- 
flation 

12 30 

^- 40 ^' 40 


Conversation at 26 ft. 

Conversation at 35 
feet. 


31 


Male 


Chronic catarrh both 


R. I 


Conversation at 20 ft. 




38 


ears. 


L. pressed 




32 


Male 


Chronic suppuration 


R '' T -- 
^' 40 ^- 40 


Conversation at 30 ft. 




13 


middle ears. 




33 


1 Male 
21 


Chronic catarrh both 
middle ears, with 


^1 ^ pressed 


Loud conversation at 
8 feet. 


^- 40 ^- 40 






secondary disease of 








1 


nerve. 






34 


Male 


Affection of cochlea 


laid 1 

^- 40 ^-40 


Conversation at 50 ft.. 




33 


from exposure to 


general conversa- 






long-continued and 




tion with ease. Does 






violent cannonading 




not hear high notes 
well. 



isn.] 



RoosA, On the Power of Hearing. 



53 













Hearing distance for cou- 












versatiou, tlie patieat 


No. 


Sex aad 


Disease. 


Hearing distance for 


being with the back to 




age. 




the watcli. 




the speaker. 


35 


Female 


Chronic proliferous in- 


R. I3 L. 


5 


Conversation with 




■ 17 


flammation middle 


40 


some difficulty at 






ears. 






30 feet. 


36 




Chronic proliferous in- 


R.^L. 


laid 


Loud conversation at 




"34" 


flammation middle 


40 


6 ft. 






ears, with secondary 












affection of laby- 












rinth. 








37 




Chronic proliferous in- 


R.^ L. 


laid 


Distinct voice at 2 ft. 




"37" 


flammation middle 


40 








ears. 






, 


38 


"se" 


Chronic catarrh mid- 
dle ears, with nearly 


R i"^ T 
R. 4Q L. 


laid 
40 


Voice at 34, aftef use 
of artificial mem- 






entire loss of both 


After use of 


arti- 


brana tympanorum. 






membranse tympan- 


ficial membranes 








orum. 


R ^ L 


laid 




















tx. ^^ Ij. 


40 





The tests with the voice were made in a furnished room, fifty feet long, 
the face of the person addressed being turned away from tlie speaker. 

It is certainly important to secure a good test or standard of a function. 
Without this there can be no exact idea as to the amount of disease in 
a given organ. For the eye, as is well known, this has been achieved, 
and the benefit in the exactness with which a loss of function is estimated 
in ophthalmic practice is everywhere appreciated. For the ear we have 
as yet no accurate tests which are adapted for the records of the consult- 
ing room. In ordinary life, however, we have no difficulty in determining 
who of our associates do not hear well, and in our social companionships 
we immediately form an opinion as to whether our friends are or are 
not hard of hearing, and just about how much their hearing is impaired. 
But when it comes to the matter of making a scientific record, we are 
usually reduced to the statement that a patient hears the watch that is 
normally heard at a given distance so much less, and sometimes it is added 
that a voice, about whose quality we know nothing, is heard in a loud 
tone, at a certain number of feet, in a whisper at such a distance, and so 
on. Could anything be more inexact? Of the two tests, perhaps, on the 
whole, we should, at first view, prefer the tick of a watch. But when we 
find that this in many cases is no index whatever of the power to join in 
general conversation, or to hear the words of a public speaker, in fact, that 
it tells very little of the patient's auditory power under the very circum- 
stances for which we are most concerned about him, we are at a loss as to 
what tests to apply. It was, indeed, a great gain to exact methods of 
examination when the power of hearing the watch was indicated by a frac- 
tion, the denominator of which expressed the distance at which its tick 
could be heard by persons with normal hearing power, while the numerator 



54 RoosA, On the Power of Hearing. [Jan. 

expressed the actual distance at which it was perceived (Prout) ; for, in 
the improvement of a case, the increased capacity to hear the watch often, 
but not always, goes jjari passu with the power of hearing conversation. 
The watch, however, is no such test for auditory power as is a series of 
test types for that of vision. In the latter case, the ability to measure 
the smallest visual angle capable of allowing an image to be formed upon 
the retina, gave Snellen the opportunity to make test types that determine 
visual capability with an accuracy that very well expresses the actual 
power of the patient for the very things for which he needs eyes. Conse- 
quently, from our examination in the consulting room, we may determine 
with exactness about how much the patient will be embarrassed by his 
loss of function in the intercourse of daily life. The watch forms no such 
test; and after applying it we know very little as to how well a patient can 
hear the human voice. 

From an exclusive use of it, many of us have grown into a combination 
of methods, so that we now record, not only how far a watch is heard, 
but also how far the voice. A comparison of the vast difference in the 
tones excited by the mechaiiism of a watch and that of the larynx, will at 
once strengthen the general conviction that the former forms no adequate 
or exact test of practical hearing power. The sound of a watch, that we 
call its tick, is produced by the striking of a little hammer upon the apex 
or side of the tooth of a ratchet wheel, and it is, therefore, a simple un- 
varying tone, modified as to quality by the mechanism, while the sounds 
produced by the vocal chords, and rcenforced by the resonating cavities of 
the nose and mouth, may pass through a range of musical notes, which, 
as in the case of the celebrated Parepa Rosa, compassed three full octaves.^ 
A mere regular sound, such as that of the watch, is certainly in no sense 
to be compared with the music of the human voice. If, however, the 
power of hearing the watch tick were even proportional to the power of 
hearing conversation, it would be an approximately exact test. If we 
could say that a person who hears a watch that ought to be heard at forty 

30 
inches, say thirty inches, or who has a hearing power of — , has an amount 

of hearing as adequate to the work of life as 1-, Snellen, is for vision, the 

80 

statement would give us a definite idea of just how much the hearing is 
impaired. But the table I have read shows that the power of hearing the 
tick of a watch stands in no exact or determinable proportion to the 
power of hearing conversation. Moreover, I believe a comparative exa- 
mination will show that the test of the voice of one person addressed par- 
ticularly to another who is waiting to hear it in a quiet room, no matter 
what kind of a tone is employed, will also be found, on any comparison 

' Flint's Physiology, Secretion, Excretion, etc., p. 503. 



18t7.] RoosA, On the Power of Hearing. 55 

with what is demanded of an ear, utterly inadequate to give an idea of the 
true amount of auditory power. A healthy ear, as is well known, can appre- 
ciate, — and probably the daily demands of life in the varied noises we live 
among, requires such an appreciation — from seven to eleven octaves. It is 
impossible then for the different tones of an instrument capable at its bes^ 
of reaching but three octaves to form a sufficient test. Perhaps an audi- 
tory test will yet be found in a musical instrument, and music boxes and 
sounds are sometimes employed by aurists. But up to this time we seem 
to be limited to the ungracious task of criticizing old methods without 
suggesting a better one. A case that illustrates the inadequacy of the 
voice, employed in the manner I have indicated, as a test for hearing power, 
is the following : — 

A gentleman consulted me a few days since, who could hear the watch 
only when laid on the right ear and one-fourth inch' from the left. 
He could hear conversation in an ordinary tone with his face away from 
the speaker, fifty feet. This kind of discrepancy my previous examinations 
prepared me for ; but I was not quite prepared for the fact that with this 
capability for hearing a voice addressed to him, and for which he was 
waiting, he did not hear readily the conversation of a gentleman with 
a good clear voice standing within three feet of him, and whose face was 
turned towards him. The patient complained that he could not hear 
common conversation, and that even when sitting in an orchestra chair of 
a theatre he could with difficulty follow a play. My tone in talking to the 
patient was what I should call a little above an ordinary one for con- 
versation; and by all ordinary comparison, a man who could hear such a 
voice fifty feet, ought to be able to hear conversation near at hand with 
ease. This patient was incapable of distinguishing well the conversational 
tone, no matter how near he was to the speaker, while one pitched above 
that he heard at a fair distance. 

One practical deduction from these tables has occurred to me, and that 
is that those cases are least amenable to treatment in which the watch is 
heard relatively better than the voice. This deduction, however, is one 
that I cannot demonstrate to be correct. I do not know whether the 
power of hearing the watch and conversation goes on improving in a con- 
sonant manner as recovery takes place from acute disease, but my impres- 
sion from the observation of a large number of cases is, that it usually 
does, and that we do not find this disproportion in any striking degree, 
except in cases that have become chronic from acute suppuration, and in 
the insidious forms of disease of the ear that are never acute, and which 
are known as chronic catarrhal, and proliferous inflammations of the 
middle ear. Cases of chronic suppuration exhibit the disproportion, but 
patients suffering from these affections usually hear the voice relatively 
better than the watch, a very happy circumstance for them. Indeed, were 
it not for the dangers incident to loss of the drumhead, chronic suppu- 
ration would be much to be preferred to chronic catarrh or proliferation. 
I think we may explain the apparent fact that there is not such a dispro- 



56 EoosA, On the Power of Hearing-. [Jan. 

portion between the power of hearing the tick of a watch and the voice in 
acute cases, by the fact that there is in these cases a more uniform and 
general pressure exerted upon all parts of the cochlea and the rods of 
Corti, or the terminal auditory apparatus, than in the chronic cases, where 
we have reason to believe, from our scanty patliological investigations, 
localized or isolated changes may occur, and thus, of course, an unequal 
amount of pressure be exerted by sonorous waves. 

■ The disproportion between the power of hearing the watch and the voice 
becomes very marked in those interesting cases of hearing better in the 
midst of noise, that were described by Thomas Willis in the seventeenth 
century. Although the power of hearing the voice is much improved in 
many partially deaf people, while in a rail car or a stage coach for exam- 
ple, or when a drum is beaten near them, as in Willis's case, the power of 
hearing the watch, or of hearing the outside or general noise, that of the 
wheels or the engine, is not ini})roved. This fact has not been always ap- 
preciated in the study of this subject. The phenomenon of hearing better 
in the midst of noise also occurs in subacute cases of catarrh, from which 
complete recovery occurs. This fact has also, I think, not always been 
recognized in the theories that have been propounded for the explanation 
of this phenomenon. Relaxation of the drum membranes, rigidity of the 
base of the stapes, which is the pathological theory at the base of many 
of these explanations, will hardly be sui)posed to occur very markedly in 
subacute cases of catarrh of the middle ear. The following case illustrates 
this subject, and, perhaps, may in some degree lead to the elucidation of 
the problem that has employed several minds. 

A man of thirty-six years of age presented himself at my office, saying 
that he had suffered in)j)airment of hearing as a child from an ulcerative 
process in both ears. Being a paper manufacturer, he was much accus- 
tomed to have bits of paper in his hand, and occasionally he would use 
them to quiet unpleasant or tickling sensations in the auditory canal. He 
thus learned that if he put the paper in far enough, and struck the right 
point, he could hear better. Discovering this, he continued to employ 
this method for years, and he came to me to know if some better artificial 
drumhead could not be devised, and also "to instruct the facuKy.''^ I 
found both drumheads gone, scarcely a rim remaining; the mucous mem- 
brane of the tympanic cavity was swelled and hypersecretive. The ossicles 
could not be seen. The artilicial drumheads of Toynbee improved his 

hearing from - — to -, and from thirty-four to fifty feet, and more. The 

interesting fact he stated to me is, that when he improved his hearing for 
the voice, it was only of use in moderately quiet places; that is to say, if 
be went into a rail car, he needed no help, he could hear the conversation 
as well, if not better, than those who had healthy ears; but he could not 
hear the wheels, the engine: in short, the waves of sound from a distance, 
or the undulations not produced by the human voice did not seem to reach 
his nerve. When he used his artificial drumhead, like ordinary people, he 
had some difiiculty to hear, on account of the surrounding noise. 



1877.] RoosA, On the Power of Hearing. 57 

Dr. A. H. Buck/ in a review on the progress of otology, has suggested 
a new explanation for this phenomenon of hearing better in the midst of 
noise, which he does not claim as his own, but which I am unable to find 
in any other place. He assumes the pathological condition in these cases 
to be one of rigidity, either of the ligament which holds the base of the 
stapes bone, or of the memhrana iympani secundaria. He then supposes 
that wave sounds of sufficient strength are put in motion by the noises of 
these noisy places to set the stapes in motion, while it could not be set in 
motion by the waves produced in ordinary conversation. Once in vibra- 
tion this ossicle, which is termed the key to the auditory chamber, can per- 
form, with a certain degree of freedom, the subordinate vibrations called 
into existence by the conversation which is carried on near by. 

The facts in the phenomenon of hearing better in the midst of noise are: 
A certain number of people whose hearing is impaired hear better in a 
noise than they do in a quiet place, and not only that, but they hear belter 
than people whose hearing poioer is no7inal. As to the pathology of these 
cases, we know that this condition obtains in acute, subacute, and chronic 
affections, suppurative and nonsuppurative, of the middle ear, but not in 
all the cases of these affections, and that it does not occur in diseases of 
the nerve. The improvement in hearing power in noise seems only to 
extend to the human voice. The tick of a watch is not heard better or 
further in a noisy place than in a quiet one, as I have taken pains to 
ascertain. Indeed, it is not heard as well. Dr. Buck's explanation does 
not seem to me adequate to explain all these facts. In the first place, we 
can hardly suppose " rigidity of the ligament that holds the base of the 
stapes bone, etc.," to be the pathological condition in acute or subacute 
catarrh. In these cases, as I have said, as well as in the chronic forms of 
disease where rigidity may be supposed, the phenomenon of hearing better 
in noise occurs. Secondly, the improvement resulting from ''setting the 
stapes in motion" ought to affect other sounds than those of the voice, 
which it does not. 

It will be observed that the patient whose case I have reported, states 
that he could not hear the outside sounds as well as people with good ears. 
He proved this by the fact that when he put in his artificial drumheads, 
and became like other people, he was so much disturbed by the sound of 
the wheels, engine, etc., that he could not hear conversation as well as 
when they were out and he was comparatively deaf. In his case at least 
a kind of Daltonism of the ear, an insensibility to certain sounds, was pro- 
duced. Perhaps, then, the elevation of the pitch of the voice, or what is 
the same thing, the increase in the number of vibrations in a given time, 
with a change in quality of the voice of the speaker, taken together with 
the insensibility to outside sounds, enabled this patient to hear better in a 

' New Yolk Medical Record, July 5, 1875. 



58 Hunt, Development of External Ear Passages. [Jan. 

noise. If we can successfully imitate this increase in pitch and this as- 
sumed change in quality, in a quiet place, of course such patients should 
hear as well there also. This experiment is necessarily a difficult, but 
probably not an impossible one. I hope other cases, and the carrying out 
of the experiment suggested, will finally enable us to explain what is now 
only a puzzle to most of those who investigate aural disease. 



Art. Y. — Oil the Development of the External Ear Passages. 
By David Hunt, M.D., of Boston, Mass. 

The history of embryology contained but little of interest, as far as the 
development of the ear was concerned, until von Baer published his classi- 
cal observations in 1828. In tlie seventeenth century a number of the 
most excellent observers busied themselves with the anatomy of the ear, 
and at the same time were more or less engaged in those studies of de- 
velopment which have made the century an epoch in the history of em- 
bryological research ; still we miss anything like an earnest attempt to 
account for the origin of the intricate parts contained in the organ of 
hearing. 

Early in the present century von Baer and Iluschke may be said to 
have placed the study of the development of the ear upon a solid basis. 
The plan of their work is still good, and as far as the meatus and Eusta- 
chian tube is concerned, the details have scarcely been added to. 

It so happened that the formation of the ear became a subject of con- 
troversy between von Baer and Huschke ; the former, misled by the 
seeming analogy between the otic and optic vesicles, described the ear as 
an offshoot from the brain. ^ 

Huschke attacked this view,^ and proved that the otic vesicle is an in- 
volution of the tegumentary layer of the embryo. At the same time von 
Baer stated an opinion as to the development of the meatus and Eusta- 
chian tube^ that was opposed by Huschke ; here also the latter has been 
declared the victor, but I believe incorrectly. 

Huschke's'^ views now prevail, and have been supported by Valentin,^ 
Rathke,^ and Bischoff.^ 

1 Ueber Entwickelungsgescbiclite der Tliiere Konigsburg, 1828 ; Erster Tbeil, 
p. 30. 

2 Isis von Oken, 1831, beft. 8-10, seite 951. 

3 Op. citat., Part I. pp. 77, 106, 122, 131, and Part II. p. 116. 

4 Op. citat., vol. XX. p. 401, 1827; p. 162, 1828; p. 951, 1831. Merkel's Ar- 
cbiv fiir Anatomie und Pbysiologie, 1832, p. 40. 

5 Lehrbucb der Pbysiologie des Menscben, Braumscbweig, 1847. 

6 Anat. Pbysiol. Untersncbungen iiber den Kiemenapparat, 1832, p. 119 and 120 

7 Entwickelungsgescbicbte des Huiide Eies. Braumscbvreig, 1815, p. 109. 



ISI'r.] Hunt, Development of External Ear Passages. 59 

As evidence of the confusion which exists on the subject, it may be 
stated that Kolliker, in the new edition of his Entwickehnigsgeschichte 
des Menschen und der hoheren Thiere (Leipzig, 1876), describes the first 
cleft as closed in an embryo of ten days (p. 300) and open in another at 
the same age (p. 253), and Mr. W. K. Parker^ describes the cavity of 
the auditory vesicle as the first branchial cleft. 

One cause of the confusion which has heretofore existed in the descrip- 
tions of the mode of closure of the first branchial cleft, has been that 
the stages of development of the embryos under examination have been 
too far apart; another frequent cause has been the advanced stage of 
development of the embryos. I have selected a series of ten embryos, 
representing as many stages of development, the smallest measured three- 
eighths of an inch in length, the largest seven-eighths of an inch.^ 

In an embryo three-eighths of an inch long the ends of the first and 
second branchial arches have united in the median line, and a bridge of 
tissue joins the first and second pair at this place of union ; the first fissure 
is now surrounded with tissue, and is much longer than the second, the dif- 
ference being greater in embryos one-eighth of an inch longer ; the cause 
of this apparent increase in length is the budding of the superior max- 
illary process of the first arch, this process is accompanied by a swelling 
or puffing up of the root of the arch, the boundary between the plateau 
thus formed, and the neighbouring tissue forms a furrow that appears to 
be a continuation of the first branchial cleft.^ 

This continuation of the cleft has a direction nearly at a riglit angle 
with the course of the original fissure, that is, it bounds the end of the 
first arch while the cleft bounds its lower margin; it gives the embryonic 
mandible the shape of the adult lower jaw, the original fissure bounding 
the inferior border of the body, and the continuation that we have just 
described the posterior border of the ramus; this appearance is very 
striking in an embryo four-eighths of an inch long. 

In one sense this furrow is a part of the first branchial fissure, that is, 
it borders the first branchial arch. I do not propose to discuss the 
question, but wish particularly to call attention to it as a secondary for- 
mation. 

1 On the Structure and Development of the Skull of the Pig. Philosophical 
Transactions, vol. 164, part 1, 1876. 

2 The embryos were all from the pig ; the descriptions apply to specimens 
hardened in Milller's fluid and alcohol. The measurements were made from the 
tip of the snout to the tuberosity of the ischium. I would express my thanks to 
Messrs. John P. Squire & Co., of Boston, for the liberality with which the re- 
sources of their large establishment have been placed at my disposal. 

3 It seems to me that Kolliker has cut this furrow in the section which we have 
referred to (figure 220, page 300 of his Entwickelungsgeschichte) ; this accounts 
for the depression in the ectoderm, and at the same time explains the contradic- 
tion there noticed. 



60 Hunt, Development of External Ear Passages. [Jan. 

In an embijo foiir-eigbtbs of inch long the second branchial arch has 
undergone a marked change in its sliape, it appears shorter; instead of 
its previous form, like that of a tapering finger, it is more pyramidal, the 
base being quite broad ; on the margin of the arch bordering the first 
cleft there is a little projection into the fissure; on close examination a 
little circular nodule is seen situated at just this point, the contour of the 
nodule is not very sharp, it is more easily distinguished with the aid of 
Briicke's glasses; this projection on the second arch is to be intimately 
connected with a slight process from the inferior maxillary process of the 
first arch, or mandible, which is the point that we have compared to the 
angle of the lower jaw in the adult. 

In an embryo five-eighths of an inch long the cleft is wholly closed on 
the ventral surface of the embryo; the remainder of the cleft is a shallow 
depression, the posterior wall of which is thicker and more elevated than 
the anterior. From the former wall there is a small, pointed projection 
into the shallow fossa; it is the representative of the circular nodule above 
referred to. A little ridge is also seen making into the depression from 
the opposite (anterior) wall almost opposite the point of origin of the 
projection just described; this is the transformed projection from the in- 
ferior maxillary process of the first arch, the same that was compared to 
the angle of the jaw. The ridge bounding this depression sweeps in a 
curved line, concavity upwards, from the projection first described across 
the site of the former cleft to the second projection. The depression or 
fossa runs out superiorly into a little slit, which is the remains of the 
furrow that apparently formed a continuation of the first cleft. The slit 
is as shallow as the depression; they are both lined l)y the common in- 
tegument. The most careful inspection fails to discover any communica- 
tion with sub-tegumentary tissue. 

In an embryo eleven-sixteenths of an inch long, a little hole about the 
size that would have resulted from the prick of a })in has formed in the 
antero-inferior portion of the fossa; the projection that has formed from 
the nodule on the second cleft has increased in size, and is distinctly 
pointed, but the puffy, thick ridge forms but a blunt point; the slit has 
become shorter and broader, so that now it resembles the remainder of 
the depression. 

In an embryo three-fourths of an inch long the fossa is nearly round, 
and its superior and inferior wall make nearly symmetrical curves in pass- 
ing over to the borders of the pointed projection, spoken of in the de- 
scription of the embryo eleven-sixteenths of an inch long; this projec- 
tion has become thinner, and its apex has commenced a curve which 
points forward; the meatus is more easily distinguished. 

In an embryo seven-eighths of an inch long no mistake is possible; the 
" pointed projection" is the auricle which points forward over the shallow 
concha (depression or fossaj in the antero-inferior angle, of which the 



18Y7.] Hunt, Development of External Ear Passages. 61 

meatus is seen burrowing into tissue, that at a previous period composed 
the root of the first branchial arch. 

It will be seen that we regard the concha as the only opening remain- 
ing from the closure of the first branchial cleft, and this opening is 
entirely superficial; the ridge forming the auricle is the same evidently 
as that which Valentin' describes as forming the external meatus. It has 
suggested itself to me that the slit described as extending upward from 
the depression which forms the concha might explain the little pointed 
projection on the helix described by Darwin ; if it does, this projection has 
its origin in a defective obliteration of the slit, and it is not a rudiment 
of the apex of the originally pointed auricle of the lower animals. 

The early development of the Eustachian tube can be studied on sec- 
tions made in a plane anterior to the otic vesicle, and nearly parallel with 
the genera] direction of the branchial fissure. The section should incline 
anteriorly, as it passes downward so as to cut the first arch at an oblique 
angle. In such a section the commencement of the Eustachian tube is 
seen as a slight depression in the roof of the pharynx. In an embryo 
nine-sixteenths of an inch long, a section in the same plane will show that 
this involution has become deeper, that it points outward and upward, 
and that it lies in the tissue in which the base of the skull is developed. 
In an embryo eleven-sixteenths of an inch long the relations are plainer, 
since the connective tissue surrounding the auditory sac has been trans- 
formed into cartilage. At this stage of development, the Eustachian tube 
is easily distinguished ; its course is nearly parallel to that of the cochlea, 
which as yet is not spiral. A nearly vertical section just anterior to the 
otic vesicle will pass through meatus and tube so as to show the end of 
the Eustachian tube overlapping the inner end of the meatus ; this rela- 
tion is still plainer in an embryo a little larger where the involution form- 
ing the meatus is deeper. In an embryo seven-eighths of an inch long, 
the drum is easily distinguished as a layer of connective tissue bounded 
below by the meatus which forms its dermoid surface, above by the Eusta- 
chian tube which forms its mucous surface. From this description it will 
be seen that the membrana propria of the drum is a section of em- 
bryonic connective tissue. At this stage of development the long pro- 
cess of the hammer is imbedded in it; this description of its formation 
also accounts for the position and thickness of the embryonic tympanum. 

The hammer and anvil form in the connective tissue above and poste- 
rior to the site of the drum ; the stapes at first appears to be located in 
the vestibule rather than in the tympanic cavity; not free in its cavity, 
however, for it is connected with its wall.^ 

' Entwickelungsgescliichte <les Menschen (Berlin, 1835), p. 216. 

2 I do not think that the stapes forms by a process of gemmation from the car- 
tilage of the vestibule, as Mr. Parker states; it seems to me to originate iude- 
pendently, in connective tissue, like the other ossicles. 



62 Bull, Syphilitic Neuroses of the Eye. [Jan. 

This position of tlie stapes accounts for the statement generally given 
by authors, that it forms at a later period than that at which the other 
ossicles form ; it appears later in the tympanic cavity, but I think that 
its formation begins at about the same time with that of the hammer and 
anvil. The outer wall of the Eustachian tube lines the drum, and covers 
in the long process of the hammer; the inner wall shuts the stapes from the 
tympanic cavity ; the body of the hammer and the anvil lie above the end 
of the tube in the connective tissue from which they are formed; it seem.s 
that the formation of the ossicula is directly connected with the forma- 
tion of the mastoid cells; the growth of the bones is accompanied by an 
absorption of the connective tissue around them, so that later when ossi- 
fication takes place in this tissue, there are only bands composed of a few 
embryonic cells, and their processes remaining, as a result we have the 
thin, bony plates, that bound the cavities in the mastoid process. 



Art. YI. — Reniai^ks on some of the Barer Syphilitic Neuroses of the 
Eye, iUui<traled by cases. By Charles S. Bull, M.D., Ophthalmic 
Surgeon to Charity Hospital, Assistant Surgeon to the N. Y. Eye 

Infirmary. 

Though syphilitic affections of the nervous system constitute a field 
which of late years has been assiduously and carefully worked, yet we all 
must admit that cases are by no means unfrequently met with, which, in 
the obscurity of their symptoms, or the rapidity or slowness of their 
course, or in the results yielded by treatment, differ so markedly from what 
WPS expected, that we hesitate in our generalizations, and are almost pre- 
pared to doubt what we have hitherto regarded as established facts. Yet, 
although such cases necessarily make us careful in diagnosis, it will not 
do to err on the side of caution, lest we meet with unfortunate therapeu- 
tical results. In many neuroses of the eye, we rarely or never meet with 
any really definite sign which would immediately prove its syphilitic 
nature. Though the simultaneous occurrence of different symptoms in a 
given case enables us to make a true diagnosis of syphilitic nerve disease, 
yet in them all we must depend more or less upon the patient's history for 
aid. The manner in which symptoms occur, their arrangement in point 
of time, may sometimes help us materially in coming to a diagnosis, and 
even to a knowledge of the particular nature of the lesion in an individual 
case. It is of some importance to know whether a lesion is due to the 
presence of a gummy tumour connected with the nerve tissue, or to pa- 
thological changes in the bloodvessels or surroundings of the brain tissue. 
The cases which illustrate these remarks all pointed to the existence of 



187T.] Bull, Syphilitic Neuroses of the Eye. 63 

some central cerebral lesion as the seat of the trouble, and therefore all 
consideration of peripheral nerve lesions will be omitted. Of course, we 
all know that paralyses of individual cranial nerves may be caused by dis- 
ease in the same side of the brain or its membranes, or even of the skull. 
Optic neuritis, followed by atrophy, or simple wdiite atrophy of the optic 
nerve, without any preceding inflammatory action in the nerve, may occur 
from disease on one or both sides of the brain, and may affect one or both 
eyes, but does not materially help us in locating the lesion without the 
aid of some other symptoms. Of course, we may meet with neuroses of 
syphilitic origin, situated in the eye and its appendages, without any 
accompanying symptoms of brain trouble; but, generally speaking, these 
make their appearance in the course of the disease, and far oftener pre- 
cede all localized eye trouble. I believe it is generally admitted that the 
symptoms of syphilitic brain disease are of two kinds, transient and per- 
manent, but I do not think that the same fact has been noticed in syphilitic 
neuroses of the eye, especially when they affect the integrity of the muscles. 
Another fact taught us by experience is, that it is next to impossible to 
lay down any rules for the order of occurrence of the various nerve lesions. 
They may occur at any period of the disease, and on more than one occa- 
sion I have seen them preceding the cutaneous eruption. Generally speak- 
ing, the symptoms at first are but slight, and very often transient, but nofc 
uncommonly they are persistent, and tend to increase in severity, I 
think, also, that it may be said that no period is too late for the occur- 
rence of a syphilitic neurosis, for in one of the accompanying cases, seven- 
teen years elapsed between the occurrence of the primary lesion and the 
appearance of the nervous symptoms. 

The two conditions of nerve disease of syphilitic origin, which are 
illustrated by the cases to be detailed, and to which I wish to call atten- 
tion, are optic neuritis and paralysis of one or more of the muscles of the 
eyeball. Both these conditions are common enough, as the result of 
syphilitic lesions, but these cases are very peculiar in certain of their cha- 
racteristics, and therefore worthy of special attention. The protean 
nature of the syphilitic poison is brought home to every practitioner occa- 
sionally with special force, but tiiis very fact should prevent us from 
stamping the effects of syphilitic lesions with something peculiar and un- 
mistakable in themselves. 

In respect of the pathology of syphilitic neuroses our knowledge is still 
in an unsatisfactory state. We know in the early stages there is an affec- 
tion, generally inflammatory, always proliferative, of the connective tissue 
of nerve structure, or of their vessels. Of course, the progress of such an 
affection involves secondarily the nerve structure pro[)er, but only second- 
arily. Whether the syphilitic poison primarily produces some change of 
nerve tissue, which is sufficient to cause nerve symptoms, is still a matter 



64 Bull, Sypliilitic Neuroses of the Eye. [Jan. 

simply of inference. The primary changes have not yet been recognized 
by microscopical examination. 

'Now, among the obscurer neuroses of syphilis we may rank motor de- 
fects in the ocular muscles ; and under this head I include tremor and 
muscular weakness, as well as actual paralysis. These phenomena are 
sometimes fugitive and unsettled in position, and although disappearing, 
they often relapse again and again, and are less easily overcome as the 
relapses increase in frequency. A muscular tremor or nystagmus may 
precede an attack of paralysis of the muscles of the eye, though the pre- 
monitory symptom is more often a weakness or lessened power of action. 
Still, a paralysis of one or more ocular muscles coming on gradually, is a 
much rarer form of neurosis than where the paralysis supervenes sud- 
denly. 

Binocular or compound paralyses of the ocular muscles of syphilitic 
origin are of diagnostic importance in affections of the brain. Some forms 
of binocular paralysis may be distinguished by rapid development and 
favourable prognosis, and these may be caused by a local basilar meningi- 
tis, or even periostitis, rather than by any direct gummy deposit. We 
look for a common central focus of origin in these cases of bilateral, sym- 
metrical disturbance of innervation, for a peripherical cause for each 
paralysis is of very rare occurrence. Of course, in these cases of paralysis 
of one or more ocular muscles of central origin, we meet also with neu- 
roses of other parts of the body, such as hemiplegia, convulsions, and 
amblyopia or amaurosis. In the examination of these cases the use of 
the ophthalmoscope is indispensable, but at the same time we should 
guard ourselves against assuming that atrophy of the optic disk in a 
syphilitic patient proves that the atrophy was caused by the syphilitic 
poison alone, for other constitutional causes frequently come into play. 

Though, as before stated, syphilitic neuroses may occur at almost any 
period, yet the early nervous symptoms are usually slight and compara- 
tively transient ; and of these it must be confessed that we know but little 
of the pathological changes which have taken place. The paralysis most 
often occurs suddenly, and is usually incomplete, being more often a weak- 
ening or partial loss of power, rather than actual paralysis. The central 
process here is irritative or mildly inflammatory, and yields readily to 
proper treatment. Occasionally, however, grave neuroses are met with 
in the early stages of syphilis, such as complete paralysis of several of the 
cranial nerves, associated with convulsions and hemiplegia, and these 
often resist all treatment, and become permanent. These may be due to 
extensive periosteal or meningeal inflammation, with marked exudation of 
granulation tissue which becomes vascularized, or to actual gummy de- 
posits in and around the sheath and connective tissue framework of nerves. 
Post-mortem examinations have taught us that these growths are most 
often found just on or behind the optic chiasm, in the pons and in the 



1877.] Bull, Syphilitic Neuroses of the Eye. 65 

cerebellar peduncles, though they may be met with at almost any point. 
Where the paralyzing lesion is a meningitis, either of the dura mater or 
arachnoid, it is the same as any other meningeal inflammation ; it is 
scarcely necessary to say that meningitis in a syphilitic patient has no 
feature distinguishing it as of syphilitic origin. 

In regard to optic neuritis or neuro-retinitis, it is usually taught that 
syphilis does attack the optic nerve, and this not very uncommonly. 
Again, optic neuritis in a syphilitic patient follows usually the same course 
as optic neuritis in other patients, and ends in one of two ways, that is, 
it is recovered from, or, what is much oftener the case, ends in atrophy, 
despite all treatment, and this within no very long space of time. But 
during the last three years I have seen three cases in which optic neuritis 
occurred in syphilitic patients, in which the vision failed up to a certain 
point and then remained stationary, but in which the ophthalmoscopic 
signs of neuritis remained unchanged for nearly two years. These were 
all well-marked cases, in which the active inflammatory action was present 
during a long period of time, with neither diminution nor improvement 
of vision in spite of all treatment, though the other symptoms of syphilitic 
disease had all yielded to the remedies employed. This is a somewhat 
startling and very unusual fact, that a nerve of special sense should retain 
its functions to a certain extent unchanged in spite of an inflammatory 
process which tends to atrophy. This is a point which I do not recollect 
to have seen or heard mentioned until Dr. Mathewson, of Brooklyn, spoke 
of a similar case at the last International Ophthalmological Congress, held 
in New York in September, 1876. 

Case I. Neuro- Retinitis of three years^ duration — Wm. H. B., agt. 
38, first seen by me September 7, 1874. Primary lesion eighteen years 
before, which, according to his account, was followed only after a very 
long interval by constitutional lesions of skin, mucous membranes, and 
scalp. About five years after initial lesion, had diplopia, which was cured 
after six weeks' treatment. Fourteen months before I saw him his vision 
began to fail, for which he consulted an oculist, who told him he had in- 
flammation of both optic nerves. Was treated for some months, and 
process apparently stayed, though vision was not improved. About two 
months before I saw him vision again began to fail. On examination 

20 
y = oc. utr., pupils very small and sluggish. Field of vision con- 

centrically limited and reduced to very small dimensions, most marked in 
left eye. Only very slight disturbance in colour-sense; recognizes all 
colours in field but light green ; very well-marked neuro-retinitis ; conside- 
rable swelling of disk (Hg^g) ; oedema of retina; enormous retinal veins. 
No other sign of constitutional syphilis after careful and extended exam- 
ination. No cardiac disease, and no signs of renal trouble. Urine nor- 
mal. Treatment consisted in three leeches to each temple, atropia, mercu- 
rial inunction, potass, iodidi grs. xv, ter die. On third day leeching 
repeated, and potass, iod. increased to grs. xx. Leeches repeated three 
times subsequently, and mercury and potass, iod. pushed for three weeks, 
No. CXLY.— Jan. 1877. 6 



66 Bull, Syphilitic Neuroses of the Eye. [Jan. 

when patient began to have some dyspeptic symptoms, and drugs omitted 
for one week. Recommenced with potass, iod., and rapidly increased 
dose to grs. 50 ter die. Vision improved somewhat in R. E., so that 

could read — +, but remained unchanged in L. " This patient was 

L 

under constant treatment for nearly seven months, but no further improve- 
ment ever appeared. The field of vision remained the same, and the 
neuritis was unchanged. He has been seen at intervals of two or three 
months ever since, and was last seen in August of this year. Yision was 

20 
then -^^, field the same, and the same ophthalmoscopic picture of marked 

L-A.X 

neuritis. By dilating the pupil, at the extreme equatorial region of the 
fundus, signs of atrophic choroiditis begin to show themselves. No other 
signs of any syphilitic trouble, and no head symptoms at any time. 

Here was a case of syphilis with a long interval between primary lesion 
and first appearance of constitutional symptoms ; the first syphilitic 
neurosis, diplopia, after five years, and then perfect freedom from any 
constitutional trouble for thirteen years. Then optic neuritis in both eyes, 
with failing vision, lasting for three years, without any change either to- 
wards recovery or atrophy, and without any head symptoms whatever. 
That the optic nerve fibres should have retained even partial integrity in 
spite of the long-continued neuritis and accompanying pressure, without 
becoming atrophied, is certainly very remarkable, and leads us to entertain 
a higher opinion of the capacity to resist disintegration, which the optic 
nerve must possess. It is perhaps almost equally remarkable that there 
should have been no tendency to recovery in spite of long-continued treat- 
ment, and in view of the improvement and eventual disappearance of all 
the other symptoms. The course pursued by the disease, and the absence 
of all symptoms pointing to intracranial lesions, render almost impossible 
any localization of the original cause. In spite of the occurrence of the 
diplopia, the optic neuritis may have been of peripheral origin, and located 
in the intraocular end of the nerve. If the"origo mali" were within 
the cranium, it may have been a low form of meningitis at the base, 
around or immediately in the neighbourhood of the optic chiasm, where 
any irritation or exudation might affect one or both third nerves and one 
or both sixth nerves as well as the optic nerves, though this seems highly 
improbable. 

Case II. Optic Neuritis of nearly two years^ duration. — Jane R., set. 
27, first seen Sept. 14, 1874. Contracted syphilis from her husband six 
years ago, primary lesion being on labia minora, followed by enlarged in- 
guinal glands ; but sore healed under local treatment. No constitutional 
symptoms till nearly three years later, when an eruption appeared on face 
and left arm and hand, and soon spread over whole body. This lasted 
for nearly a year, and was followed by well-marked alopecia, which even 
afifected the eyebrows. About ^ue months before she applied at the eye 
infirmary for advice she began to suffer from left hemicrania, which at 
first was transient and not severe, but gradually became constant and, at 



18^7.] Bull, Syphilitic Neuroses of the Eye. 67 

times, very severe. One month later she had left ptosis, vision began 

to fail in the left eye, and she complained of seeing double. She has had 

five miscarriages ; the first three were girls, and the fourth a boy, all 

aborting at the sixth month. The fifth miscarriage was a two months' 

foetus. The sixth child was a boy, carried to full term, and is now an 

apparently healthy child of ten months of age. Examination showed 

some slight ptosis of left upper eyelid, and some slight paresis of left 

internal rectus muscle, but nothing abnormal demonstrable in the ocular 

20 
muscles, and patient has no diplopia. Pupil normal, R. E. Y. =— — 

A.XX. 

20 
L. E. Y. = — . No limitation of field. Ophthalmoscope showed well 

L 

marked optic neuritis in L. E., with considerable swelling of disk and 
adjacent retina, and very much engorged and pulsating veins. In R. K. 
no decided neuritis, but whole fundus injected and hypergemic. No dis- 
turbance in colour sense. In L. E , swelling most marked on nasal side 
of papilla. Hemicrania very violent, and occasional attacks of vertigo. 

Treatment. — Mercurial inunction night and morning (5ij each time), 
and potass, iodidi, grs. xx te?' die. After first week inunction was 
stopped, and potass, iod. given in grs. xl doses three times a day. To- 
wards the end of the third week the hemicrania entirely disappeared, and 
there were no further attacks of vertigo. The dose was then gradually 
diminished and mercurial inunction again commenced, but there was 
no improvement in vision and no change in appearance of fundus. This 
patient still occasionally presents herself for inspection, and was last seen 
about three months ago. At that time the optic disk was still in the 
same condition as it was when first seen nearly two years before, but 

20 
vision had sunk somewhat and was only -1— by good illumination. 

LXX 

Here was an interval of three years between occurrence of primary 
lesion and appearance of constitutional symptoms. First occurrence of 
neurosis 5 J years after initial lesion, hemicrania being left-sided and 
pointing to central lesion. The ptosis and diplopia, and later the optic 
neuritis pointed to a localized trouble, confined to left side, and was prob- 
ably a gummy new growth, somewhere in neighbourhood of anterior part 
of middle fossa, on left side, and in front of optic chiasm, assuming as an 
anatomical fact that decussation of optic nerve fibres in chiasm is partial 
and not complete. In this case also the paralytic symptoms and hemi- 
crania rapidly disappeared under use of large doses of potass, iodid,, but 
optic neuritis remained unchanged for nearly two years, and vision also 
was the same as at first examination. 

Case III. Neuro- Retinitis, oc. utr. — James M., cet. 45, first seen Dec. 
8, 1875. Initial lesion of syphilis eight years ago, with enlarged inguinal 
glands, and five weeks subsequently a cutaneous eruption on face, neck, 
and hands. Recovered from this and had no further symptoms of consti- 
tutional trouble for more than seven years. About eight months before 
he applied for treatment his vision began to fail, at first in the L. E., but 
soon also in R. E., and in a few days he was attacked with diplopia, and 
he said his L. E. diverged. Yision grew worse very slowly, but the di- 
plopia after a while, owing to treatment probably, began to improve, and 



08 Bull, Syphilitic Neuroses of the Eye. [Jan. 

at present there is no trace of it. About four weeks before I saw him he 

began to complain ©f a sense of weight and fatigue in back, most marked 

in cervical region, and a numbness and coldness of R. foot, beginning in 

toes, and gradually creeping up until it has almost reached the knee. 

The foot and leg feel very heavy, and he has considerable difficulty in 

walking. No apparent loss of power in legs or arms, and no painful 

sensations in extremities. No point of tenderness in spine. Examination 

20 
of eyes shows Y. = ., no limitation of field of vision, no disturbance 

LXX 

of colour-sense, motility normal ; but well-marked neuro-retinitis in both 
eyes, with swelling of papilla, and a sodden-infiltrated retina. 

Treatment. — Mercurial inunction twice daily, and potass, iod. grs. xx 
ter die, with ol. morrhu?e and iron, as patient was markedly cachectic. 
This treatment was cari'ied out for nearly four months and the potass, 
iod. was increased to 5j doses, with an amelioration in the condition of 
the spine and also some improvement in power of sensation of right leg. 
But the neuro-retinitis remained strangely and obstinately unchanged 
throughout, though I thought I could detect some diminution of retinal 
infiltration. This patient was seen last week and a careful examination 
showed the same amount of vision, and absolutely no change in the con- 
dition of the fundus. But the spinal symptoms had entirely disappeared, 
and the sensation and power in leg and side were normal. 

This patient escaped all constitutional symptoms except a mild eruption, 
for seven years, and then the first neurosis was optic neuritis, which was 
binocular, and was soon .followed by paralysis of left third nerve. Then 
came the signs of sensory paralysis of right lower extremity. The order 
of occurrence of these symptoms points to a lesion, probably a gumma, in 
or just outside the left optic thalamus, involving or pressing upon per- 
haps the left cms cerebri, pressing upon and paralyzing the left third 
cranial nerve, yet not completely, for there was no ptosis. The left optic 
tract had probably previously been involved and had set up neuritis in 
both optic nerves ; lastly came the signs of anaesthesia in the right foot 
and leg. 'Still it is possible that there was a second lesion in this case, in 
the spinal cord, which pressing upon the posterior columns or posterior 
roots of the spinal nerves, could have caused the symptoms complained of. 
The optic neuritis in this case also showed a marked tendency to resist 
treatment, and remain unchanged for a long period of time. 

Case I Y. Farati/si.^ of both Third Gimnial Nerves, and of Right 
Sixth Cranial Nerve; Optic Neuritis. — Herman M., set. 36. First seen 
May 22, 1876. Primary lesion five years ago, rapidly followed by consti- 
tutional symptoms, most obstinate being rheumatoid pains, which, at first 
transient and slight, soon became very severe and almost constant. No 
syphilitic neuroses of any kind till November, 1875, four and a half years 
after initial lesion, when had sudden paralysis of all branches of left third 
nerve, with ptosis and dilated pupil. Under proper and well-directed 
treatment, was entirely cured in February, 1876. In March, 1876, began 
to suffer from severe right hemicrania, and neuralgia of neck and right 
side of face and right arm. In a few days there suddenly occurred com- 
plete paralysis of third nerve in both eyes, except that there was no ptosis, 
and also paralysis of right sixth nerve or abducens. He was again put 



1877.] Bull, Syphilitic Neuroses of the Eye. 69 

under treatment, by his physician, and again amelioration set in, but the 
muscles, though regaining some of their power, still remained paretic, and 
his vision began to fail. When I saw him in May, the right motor oculi 
had regained considerable power, but the abducens was still completely 
paralyzed. In the left eye the improvement in the third nerve was much 
less advanced, though the internal rectus had considerable motion. Both 
eyes were slightly prominent, and the ocular conjunctiva hypersemic, and at 
the canthi chemotic. For last two weeks patient has had considerable 
difficulty in swallowing, and all liquids showed a tendency to regurgitate 
through nostrils. Soft palate and superior constrictors of pharynx found 

20 ... * 

paretic on examination. Y. = — oc. utr., no limitation of field, no dis- 

L 

turbance of colour-sense, double optic neuritis, most marked in riglit eye 
with infiltration of disk and retina. After three months' treatment l)y in- 
unction and potass, iod., there was a small improvement in condition of 
all muscles of both eyes, except right abducens, which remained immovable. 
The neuritis had nearly subsided, but vision remained unimproved, though 
optic nerves showed no tendency to pass into atrophy. But the paretic 
condition of the palate and pharyngeal niuscles disappeared entirely. 

In this case the localization of the cerebral lesion is a matter of great 
difficulty and uncertainty. The right hemicrania, with paralysis of right 
third and sixth nerves, would point to the right side of the base as the seat 
of the trouble, and if the lesion extended over the median line, it would 
explain the paralysis of the left third nerve. But the paralysis of the 
palatal and pharyngeal muscles is of obscure causation, If the base of 
the brain were the seat of somewhat extensive meningitis, or even of 
gummy infiltration, this might extend far enough to involve the facial 
nerve. But in this case we would probably meet with other symptoms of 
facial paralysis to help us in our diagnosis which did not exist here. The 
persistence of the paralysis of the third nerves, and the right sixth nerve, 
shows that positive degeneration had taken place in the nerve fibres, while 
the improved vision and subsidence of the optic neuritis prove that the 
conductibility of these fibres is still intact. In any event the case is of 
interest from its obscurity. 

Case Y. Total Paralysis of all the Ocular Muscles. — Y. T., «t. 28 
single, first seen in February, 1874. Primary lesion in August, 1873, 
and secondary symptoms followed, though none of them well marked. 
In November, 1873, after considerable pain in temporal and occipital 
regions, she noticed a drooping of both upper eyelids, which rapidly 
went on to double complete ptosis. Also noticed that when lids were 
raised she saw double, and that the eyeballs were almost immovable 
in every direction. The pupils were also dilated When first seen in 
February, 1874, she had constant pain in supraorbital regions, complete 

20 
immobility of eyes, ptosis and dilated pupils, Y. =^- oc. utr., no limita- 

oc 

tion of field of vision. General hyperaemic condition of fundus, and a low 
grade of retinitis in both eyes. Yeins engorged and pulsating, retinaa 
sodden and cedematous. General condition of health good. Remained 
under treatment for several months, during which time she was almost 



70 Bull, Syphilitic Neuroses of the Eye. [Jan. 

constantly under the influence of mercury and potass, iodid. The vision 

20 
improved somewhat so that she could read — - — but no change appeared 

in the muscles or fundus of either eye. In June, 1875, she again applied 
for treatment, and was taken into the N. Y. Eye Infirmary. An exam- 
ination at that time showed still almost complete immobility of eye- 
balls, though there was some slight motion upwards, indicating that 
superior recti had regained some power. But the other muscles were 
motionless, nor was there any improvement in the ptosis. Pupils 
moderately dilated and immovable. Fundus still hyper^emic and retina 

9A 

cederaatous, but no perceptible charge in optic nerves. Y. = " . 

On this occasion patient remained under continuous observation and treat- 
ment for a full year. There resulted considerable improvement in the 
ptosis and a slight improvement in the external recti muscles, so that 
there was a slight motion outwards of eyeballs, as well as upwards. 
Yision, however, remained the same, and there was no perceptible change 
in the fundus. All head symptoms had ceased, and the patient had 
learned to suppress the annoyance caused by the di!)lopia. 

Here again we meet with an obscure condition of the optic nerves, 
with tendency to permanent amblyopia. Merely a low grade of 
retinitis, with but little exudation, clear media, no signs of atrophy, and 
yet marked diminution of vision, which remained unchanged for over a 
year. The central lesion was probably a more or less diifuse gummy 
infiltration of slow growth, accompanied possibly by a low grade of 
inflammatory action, but by no head symptoms except frontal headache. 
The marked resistance to treatment is of interest as showing that even 
the long-continued use of potass, iod. in syphilitic neuroses, will sometimes 
fail of benefit. 

From these cases it may be seen that syphilitic neuroses show a marked 
tendency to relapse, when they belong to the class of later manifestations. 
Another characteristic that may be affirmed of them, I think, is that the 
later they occur, the more unfavourable is the prognosis. The formation 
of a distinct gummy tumour, or even of a mere gummy infiltration of a 
nerve or its envelope, too often leads to actual disorganization ; for though 
they may be absorbed by proper treatment, as they undoubtedly often are, 
yet they constantly tend to form again. I have learned to expect a 
recurrence, even in spite of long-continued treatment. 

One word in regard to the treatment of these cases of muscular 
paralysis by electricity or galvanism. In the two cases of ocular 
paralysis just detailed, both the induced and galvanic currents were 
faithfully employed for a long period, but without avail, though the 
galvanic current produced contractions in the paralyzed muscles. It may 
possibly aid internal medication in some cases, but in the two above 
mentioned the mischief had occurred too long before, and the loss was 
irremediable. 

47 East Twenty-third Street, New York, Oct. 18, 187G. 



18*17.] Landis, Occipito-posterior Positions of the Vertex. tl 



Art. YII. — On the Mechanism of Occipito-posterior Positions of the 
Vertex. By H. G. Landis, A.M., M.D., of Niles, Ohio. (With four 
wood-cuts.) 

In a paper published in this Journal for April, 1876, I have endeavoured 
briefly to point out a more exact correspondence between the foetal head 
and the pelvic passages than has been heretofore taught ; and also to 
exhibit the great simplicity of the pelvis and of the mechanism of labour 
as well, when the former is regarded as a double canal. These statements 
w^ere substantially limited to occipito-anterior positions of the vertex. It 
now remains to be seen in what manner occipito-posterior positions 
conform to these views, and what further light on pelvic anatomy a study 
of their mechanism may furnish. At first sight there appears to be no 
reason why the same mechanism will not answer for both anterior and 
posterior positions. If the calibre of the tube, so to speak, is elliptical 
in outline, it might be supposed that either pole of a projectile having an 
elliptical transverse section might be placed to one side. But we notice 
at once that the foregoing is only a half truth. The passage is "rifled," 
and the projectile constructed to fit this adaptation. In other words, all 
parts of the pelvis are not equally resistant, and all parts of the head are 
not equally yielding. To state a conclusion in advance, for the sake of 
calling attention to it more prominently, we find that anterior rotation is 
determined by the coincidence of the most resistant parts of the pelvic 
canal with the most unyielding and incompressible parts of the foetal 
head. These parts are respectively the ischial spines and the parietal 
protuberances. When these points of mutual resistance do not conflict, 
as in a roomy pelvis, or with a small head, posterior rotation is as likely 
to occur as anterior rotation ; that is, the elliptical section of the head 
may traverse the same simple spiral course as in an occipito-anterior posi- 
tion, the poles of the ellipse being reversed. This latter condition is 
sometimes artificially produced by the compression of the forceps when 
applied to the sides of the child's head, in which case also posterior rotation 
may occur. We will suppose a head descending in the right occipito- 
posterior position. After becoming demi-flexed, it follows the line leading 
from the pectineal eminence to the ischial spines, substantially as in an 
occipito-anterior position. No special difiSculty occurs until it nears the 
ischial spines, at which point the double character of the canal ceases 
{vide Fig. 12). Here the right parietal boss is just behind the left ischial 
spine, and the left boss is just in front of the right spine. Before posterior 
rotation can be completed, these two protuberances must ride over the 
spinous processes; and if each is of normal prominence, the more energetic 
the expulsive force the more difficult will this feat become. This, then, 
is the reason why another direction must be taken. In the mean time 



Y2 



Landis, Occipito-pofcterior Positions of the Vertex. [Jan. 



there is an arrest of the head. By reference to the diagram (Fig. 1), it 
will be seen that anterior rotation involves the transfer of the head from 



Fig. 1. 



Fig. 2. 





the right to the left canal, for this is what is meant by stating that after 
anterior rotation the labour is terminated, as in a second position of the 
vertex. The diagram (Fig. 1) is outlined from Hodge's section of a pelvic 
cast,^ showing the plane of the second parallel, which being a little above 
the plane of the ischial spines does not give exactly the true state of affairs 
under consideration, but purposely exaggerates the divergence of the canals 
for the purpose of making the fact of the transfer clearer. The real con- 
dition is midway between this and that represented in Fig. 2, which is 
similarly outlined from Plate III., Fig. 21, of Hodge, which shows the 
plane of the ischial spines, or the third parallel. The line CD will 
represent the antero-posterior diameter of the head before rotation. When 
this is complete, the line C D will have changed, not to E G, but to E F, 
for it is obviously impossible for C D to turn in its entirety, especially 
when we remember that the true pelvic outline is more nearly as in Fig. 2. 
It is also obvious that the diameter E F is not the same quoad the head 
which occupied the line C D. But, as is well known, continued ^^e^ioTi of 
the head has brought a nearly circular plane of the child's head, viz., the 
cervico-bregmatic, coincident with the plane of the ischial spines, or a little 
above. Continued expulsive force, therefore, acting on a head in compelled 
arrest, results in extreme flexion, and this presenting a circular instead of 
an elliptical plane, there is no longer any impediment to anterior rotation; 
and the position becoming an anterior one, descent proceeds naturally. 
Neither is the extreme flexion any longer required, for E F may now be 
extended to E G. In fact, after passing the plane of the inferior strait, 
extension is required. 

This, then, may be regarded as the first or most natural mechanism of 
delivery in occipito-posterior positions. If, however, the ischial spines 
and parietal protuberances do not offer sufficient mutual resistance, the 
occiput may remain posteriorly placed throughout, which may be regarded 



System. Plate III. 20. 



18*7t.] L AND I s, Occipito-posterior Positions of the Vertex. 73 

as the second method of delivery. As before stated, compression by the 
forceps may result in overcoming this resistance, and determine the 
posterior rotation. In seven cases of occipito-posterior positions delivered 
by the forceps, of which I have notes, three resulted in anterior rotation; 
in none of vrhich was there any more compression used than was necessary 
to prevent the instruments from slipping. In three of the other cases the 
disproportion was decided, and considerable compression being used, com- 
plete posterior rotation occurred. In the remaining case the occiput 
remained posteriorly until an unusually large head had fairly passed 
through the inferior strait, and was distending the perineum to a 
dangerous extent ; in fact, a slight tear had begun, and a large surface of 
the vertex was in full view. I then removed the forceps, and allowed two 
pains to pass unassisted. I then placed the thumb of the left hand on the 
posterior fontanelle, and the middle finger a little back of the anterior 
fontanelle, against the overlapping sutural cdgt ; and with the next pain 
endeavoured to force anterior rotation. Though it was an instinctive 
experiment rather than an attempt well founded in reason, the result 
justified the trial, for before the pain ended anterior rotation had occurred, 
and the head had glided over the perineum. A similar case to the fore- 
going is narrated by Cazeaux (5th Am. edition, p. 32t), in which the 
occurrence was spontaneous. We have, then, a third possible method 
to wit, anterior rotation on the perineum. A fourth mechanism, which 

Fiff. 4. 





E "^> ^ -^ B 



Outline of foetal head, f, Foramen maguum ; Outline of superior strait. 

0, Occipital pole. 

in point of frequency, might rank second or even first, is anterior rotation 
at the brim, and before the head has really engaged in the initial strait. 
In ten cases without instrumental interference, of which I have notes, six 
rotated anteriorly at the brim. It must be added, however, that in several 
of these, internal or external manipulation, or both combined, were 
employed to further the natural efforts. The following facts seem to 
afford a partial explanation of the manner in which this rotation takes 
place. Fig. 3 is designed to represent diagrammatically the outline of the 
foetal head, or rather of that plane section thereof which is coincident with 



14 Landis, Occipito-posterior Positions of the Vertex. [Jan. 

the initial plane of the pelvic canal at the beginning of labour. It may 
be well to remark here, that the outlines of the foetal head and of the dried 
foetal skull are two very different things, which apparently are sometimes 
confounded. The former is regular in outline ; in the latter, the more 
ossified portions stand out in relief. The foramen magnum, F, is seen to 
be appreciably nearer the occipital pole, a fact which is stated also by 
Schroeder {Manual, p. 77). Hodge appears to have thought otherwise, 
but the fact is so patent to any one who will look at a foetal head in demi- 
flection, that it is unnecessary to speak further of it. On reflection it will 
appear that this proximity increases directly with the degree of flexion. 
Now the axis of the shoulders (B C) passes through the foramen at a 
right angle. Let us apply this section to the pelvis. Fig. 4 is an outline 
of the so-called superior strait. The dotted lines complete the elliptical 
outlines of the initial planes of the two canals of which the pelvis is made 
up {vide former article). If the head is so situated that the occipital 
])ole of the section represented in Fig. 3 is opposite B, being thus in the 
1st occipito-anterior position, the long axis of the shoulders is placed over 
the diameter E F, and ready to be coincident with that ample diameter 
after the descent of the head. If, however, the section is reversed, and 
the pole is placed at A, the head being thus in the right occipito- 
posterior position, the axis of the shoulders lies over the line D C. Thus 
the right shoulder impinges on the lower lumbar vertebra, which may 
serve the purpose of directing the shoulder on one side or other of the 
promontory. If the shoulder should slide to the right (towards A), a 
little reflection will show that the head will have difficulty in maintaining 
its posterior position from the increased twist in the neck. As soon, then, 
as flexion has continued long enough to bring the cervico-bregmatic plane 
of the head coincident with the initial plane of the pelvis, anterior rotation 
takes place. If, however, the shoulder should slide to the other side, and 
the shoulders thus lie in the transverse diameter of the brim, with the back 
posteriorly, anterior rotation becomes evidently impossible by any means 
compatible with the integrity of the neck, so long as this position of the 
shoulders is maintained. This would lead to the practical conclusion that 
no attempt to assist occipito-posterior positions in any case should be 
made until the status of the shoulders is determined, seeing that they have 
an important relation to the permanence of this position. Independently 
of this movement of the shoulders upon the promontory, the mere grasp 
of the uterus upon the child's body is sufficient to insure continuance of 
the original position until external manipulation is put in practice. 
Finally, since the posterior position is necessarily more difficult than the 
anterior, owing to the relation which the shoulders occupy to the head, 
two things must be borne in mind in attempting to make a favourable 
change. First, as the canal is substantially of elliptical outline throughout, 
the head cannot turn until it presents a circular plane whose diameter 



18TT.] Pepper, Case of Addison's Disease. t5 

corresponds to the shortest diameter of the elliptical plane in which the 
turning is to be made. Flexion, therefore, is the first requisite in all 
methods. Secondly, to make the rotation feasible, and with safety to the 
child, the shoulders must also be rotated, so that the child's back shall 
present anteriorly. 



Art. YIII. — A Case of Addison^ s Disease. By William Pepper, A.M., 
M.D., Prof, of Clinical Medicine in the University of Pennsylvania. 

Since Addison, in 1855/ published his classical account of a peculiar 
form of anaemia attended witli bronzing of the skin, this subject has 
attracted much attention, a considerable number of cases have been placed 
on record, and many memoirs have been written upon it. Comparatively 
little has been added to his admirable description of the symptoms and 
course of the disease, and the following brief summary of the leading and 
characteristic features may still be quoted : " Antemia, general languor 
and debility, remarkable feebleness of the heart's action, irritability of the 
stomach, and a peculiar change of colour in the skin." It is certainly a 
rare form of disease in this country, if we may judge by the great rarity 
with which it appears as a cause of death in the mortality reports, and by 
the small number of cases which have been placed on record by American 
authors. Thus of 230 cases of Addison's disease tabulated by Greenhow 
in the last edition of his monograph on this subject, only 10 are quoted 
from American sources. However, since the causes of Addison's disease, 
as far as we are acquainted with them, are equally operative here as in 
other countries, it seems more probable that the apparent frequency of 
its occurrence in England, especially in London, is partly due to the great 
degree of attention which the subject has there received and to the greater 
readiness with which it would consequently be recognized. I have myself 
met with three perfectly developed cases of this disease ; one of these is still 
living, in the second year of its course; the other two have terminated 
fatally. In one of the latter, an autopsy could not be obtained ; but in the 
remaining case a careful examination was made, and, in consequence of the 
rarity and importance of such complete observations, I have felt justified 
in publishing the notes of the case at full length. In addition to these 
three cases, I have met with several others in which a peculiar discolora- 
tion of the skin, similar to that in Addison's disease, occurred in con- 
junction with some of the general symptoms of that affection ; but in 
which, either by the recovery of the patient and the disappearance of the 

' On the Constitutional and Local Effects of Disease of tlie Supra-renal Cap- 
sules, Syd. Soc. Ed. of Addison's Works, p. 291. 



T6 Pepper, Case of Addison's Disease. [Jan. 

symptoms or by actual post-mortem examination, it was shown that the 
fibro-caseous degeneration of the supra-renal capsules, which is regarded 
by many as the characteristic lesion of Addison's disease, did not exist. 
This does not include cases attended with discoloration of the skin of a 
different character from that present in Addison's disease (vagabondism, 
chronic phthisis, chronic hepatic disease, chronic malaria, etc.) ; of these 
I have observed a considerable number. In the present article I wish 
merely to place upon record the complete case above referred to, leaving 
for discussion in a second article, to appear in the following number of 
this Journal, the interesting questions connected with the nature of this 
affection, and with its relations with disease of the supra-renal capsules and 
also with some seemingly analogous forms of disease. 

Mr. C. L., set. 40 years, has enjoyed good health, and has followed the 
life of a farmer. His only known hereditary tendency is to nervous dis- 
ease, one of his aunts being insane, a sister highly eccentric and hypochon- 
driacal, and two of his own children having suffered during their early 
years with eclampsia. He himself is a man of nervous temperament, but 
cheerful and even humorous in disposition. 

He had never suffered from syphilis, scrofula, rheumatism, or malaria. 
He states that for years he has found such work as diorging potatoes, etc., 
almost instantly cause marked pain across the small of the back. He 
never met with any injury. More than four years before I first saw him, 
he began to notice gradually increasing weakness, occasional vertigo, and 
steadily deepening discoloration of the face, groins, and hands. He con- 
continued to pursue an outdoor life with much exercise for about a year, 
when he found it necessary to accept a position in a railway office. His weak- 
ness, however, continued, though not steadily, to progress, so that of late, on 
getting through his day's work in the office, he has been entirely exhausted. 
He feels his legs ache after a few minutes' walk. There was also decreas- 
ing power of resisting cold. Occasionally also, while warm and within 
doors, he has noticed that his thumbs and some of his fingers and toes 
grow numb. During the past two or three years, he has had occasional 
spells of marked nervousness, attended with impaired sleep and disturbing 
dreams ; at times also he has suffered from depression of spirits. He has 
never noticed any febrile action. There has been scarcely any loss of 
flesh ; he has always been a man of spare habit; height about 5 ft. 10 ; 
weight 138 to 144 lbs. His appetite has been very variable; two years 
ago it was voracious, but for the past year it has been growing capricious, 
and he has often experienced nausea and epigastric uneasiness or actual 
pain. This has sometimes been caused even by drinking a little water. 
There have also been occasional attacks of gastric disturbance, attended 
with the vomiting of much bilious matter. The bowels have usually been 
costive. The urine has varied in quantity, at times being dark-reddish and 
usually depositing a sediment. The only pain which he has complained 
of has been deep seated in the lumbar region, and dull and aching. He 
has also occasionally suffered from attacks of profuse sweating. The 
discoloration of skin first appeared in the face, and has subsequently 
involved other parts of the surface, as will be hereafter described. The 
increase in debility has not been uniform, but from time to time there has 
been temporary improvement, so marked in character as to raise delusive 



1877.] Pepper, Case of Addison's Disease. 77 

hopes. He tried hydropathy for some time, with apparent relief to the 
profuse sweating ; and subsequently he has used iron, strychnia, and quinia, 
with temporary benefit. 

He had. been about two weeks before consulting me, October 22, 
1869, upon a holiday trip of several weeks, before which he had been 
very much run down, but while away from work he regained health and 
strength and became able to walk considerable distances. Upon returning 
to Philadelphia, he unfortunately immediately resumed his full duties, and 
very soon began to run down again. This expressed itself chiefly by a 
growing sense of muscular debility, which became so great that, for a few 
days before visiting me, he found the exertion of walking even a single 
square fatiguing. After his first visit to me, he continued to go to his 
office, avoiding all walking and standing as much as possible, for three 
or four days, when he found that it had become absolutely impossible for 
him to continue this, and voluntarily took to his bed. 

His condition on my first visit, Oct. 27, 1869, was noted as follows : — 

There is marked discoloration of the face and neck from about one inch 
below the line of the hair (about the line to which the hat reaches), down 
to the line of the collar. The colonr is less deep over the central parts of 
the forehead, and under the cover of the arch of the eyebrows than over 
the cheeks and nose. It is most intense over the neck, skirting the line of 
the scalp, and extending down to the base of the neck. The colour of face 
and neck is of a quite deep brown with a slight yellowish tinge, or almost 
like mahogany. 

There is slight discoloration of the skin in the axillse, especially on 
the folds of the armpits; so, too, in the popliteal spaces it is slight, and 
most marked along the external and internal hamstring tendons. 

There is also a streak of similar discoloration, rather light in degree, 
over the lower dorsal and lumbar spinous processes. The skin over both 
groins, the upper part of the inner aspect of the thighs, and over the 
genitals at times presents a uniform and comparatively slight discolora- 
tion, but at other times irregular splotches of discoloration have appeared, 
even darker than on the face, but have not been permanent. 

The hands are deeply discoloured, the colour extending a short distance up 
the forearms, gradually fading. The matrix of the nails is not discoloured, 
but, on the contrary, they are unusually white, so that the nails contrast 
curiously with the fingers and hand. The discoloration does not extend 
to the palmar surface, but terminates abruptly along the middle of the 
lateral aspects of fingers and hand. The nails have been brittle for a long 
while, and the skin is very dry, stiff, and somewhat scaly. 

The colour is almost uniform where it is most dark, and in all parts is 
lighter towards the edges of the discoloured areas, where also there are 
little spots of lighter colour breaking its uniformity No patches of deeper 
colour are present on the discoloured [)arts, nor any dead white patches of 
vitiligo. 

It is thus seen that the abnormal deposit of pigment has occurred most 
markedly at those parts where there is usually more or less coloration 
from exposure to the sun. The other points of its deposit are those where 
there is naturally a tendency to its production, as the neighbourhood of 
the genitals, the axillse and popliteal spaces, and along the spine. 

In connection with the effect of exposure, he states on inquiry that until 
manhood he was much freckled, but since the disappearance of the 
freckles at that time, exposure to the sun has never redeveloped them. 



78 Pepper, Case of Addison's Dit^ease. [Jan. 

It may here be stated that six weeks after this time (December 6, 1869) 
after constant confinement to bed, and when all bleaching influence of 
confinement might well be supposed to have occurred, discoloration is 
still marked, as will be further described below. 

The conjunctivae are perfectly clear. There is no positive discolora- 
tion of the mucous membrane of the lips, mouth, or tongue. 

His muscular strength is very much impaired. There is utter loss of desire 
for effort, so that he lies contentedly in bed day after day without ever ex- 
pressing the least desire to rise even for a moment. Indeed the mere effort of 
sitting up in bed wearies him much, and when he gets out of bed to sit in an 
easy chair while the bedclothes are being changed, he slips down on to floor. 
The power of grasping with his hands remains fair. As he lies in bed he is 
not conscious of any sense of weakness or exhaustion ; but, as nearly as he 
can express it, is merely utterly devoid of that instinctive sense of muscu- 
lar tonicity and tendency to muscular movement which exist so markedly 
in vigorous and muscular subjects. 

So great did his exhaustion appear to his family that, on my entering 
the house, his wife informed me that she believed he was in the early stage 
of an attack of typhoid fever. He also complained that in turning in bed 
or making any sudden movement, he frequently had pain in the muscles 
or joints, as though he had strained himself. 

He is now bright, cheerful, and contented. There is no disturbance of 
special senses or failure of mental power. He frequently wakes at night, 
and fancies some one entering the room, but instantly dispels this illusion, 
and soon gets to sleep again. His nervous condition is very much better 
than formerly, for he has at times been subject to severe attacks of insomnia, 
with great agitation. Electro-muscular sensibility and contractility unim- 
pairecT. There is no incoordination of movement, though lately his hand- 
writing has been cramped and awkward. 

There is not the slightest febrile action. Temperature of extremities 
is reduced, and he constantly keeps bottles of hot water in bed with him. 
Respiration quiet and regular. Pulse rather small and compressible, about 
eighty in minute. Heart's sounds rather feeble, but normal. The tongue 
is clean, v/ell shaped, and moist. Appetite capricious and not vigorous. 
Digestion fair, but readily deranged by any irregularity in diet. Bowels 
constipated, but rarely requiring use of laxatives. Abdomen rather 
scaphoid — indolent. Emaciation not at all marked. Urine free, rather 
dark coloured, often throws down deposits (urates?). In two specimens 
I found a specific gravity of 1016; no albumen; rather high coloured; on 
standing in moderately warm room, threw down rhombs of reddish-yellow 
uric acid in abundance. 

He was put on use of pil. ferri iodidi, gr. j, t. d. p. c, and pill containing 
quinine sulph. gr. jss, acid, arsenios. gr. :^\, ext. Ignatias, gr. ^, t. d. a. c. 
and magneto-electric faradization, applied morning and evening (fifteen 
minutes each). One pole was ap})lied over spine, along dorsal region, and 
over kidneys, and the other around the space below the ensiform cartilage 
down nearly to umbilicus. 

Diet. — Beef-tea, whiskey, fsj, Madeira wine, fjij, q. d., cream, 0|, and 
other articles of digestible, nutritious nature. 



I 



99.10 11 A.M. 


99.4^ 9 P. M 


98.6 9i " 


100 8i " 


98.4 8 " 





98.4 8i " 


99.6 8:i " 


98.4 8 " 


99 8 " 


97.8 8i " 


98.8 8 " 


98.2 8^ '* 


99.6 8 " 



18t7.] Pepper, Case of Addison's Disease. 79 

Temperature in Axilla. 

Nov. 16 . . . 

" 17 . . . 

" 18 . 

" 19 . 

" 20 . 

" 21 . 

" 22 . 

Nov. 22. Treatment steadily continued, and some slight improvement 
has certainly occurred. Remedies have agreed perfectly with him. He 
has had an attack of vomiting and looseness of bowels, evidently caused 
by slight indiscretion in diet, and readily checked. Temperature is now 
better, and maintained with less artificial aid. Amount of iodide of iron 
doubled. 

21th. Slight improvement continuing. Some slight gain in muscular 
power. 

Stopped pills of quinia, Ignatia, and arsenic, and ordered pil. argent, 
nitratis, gr. ^, t. d. p. c. Continues pil. ferri iod. gr. ij, t. d. Diet con- 
tinued. Cream reduced to Oss. Daily faradization continued. 

In addition to otiier improvement noted, he is gaining flesh, temperature 
more steadily maintained, appetite more uniform and vigorous. 

There has been slight lowering of the colour line on forehead, and slight 
diminution in colour of portion of forehead, and also of part of nose. The 
hands have grown lighter, and skin much more supple, and less dry and 
scaly. Gets out of bed more willingly and walks a few feet. Pulse stronger 
and about seventy-two. 

Bee. 6, 1869. Treatment has been steadily continued, remedies (silver and 
iron) agreeing excellently. He is less sensitive to electric currents, owing 
probably to increase in fat, which is very positive. Yery slight change in 
colouration of face; hands are lighter, and skin more soft and supple. 
During the past few weeks there have been noticed, for the first time, 
small dark spots appearing on hands, like dark-brown freckles. There is 
also a little ring of brown coloration around a number of the orifices of 
hair follicles. 

His appetite is uniform and good, and digestion good, and bowels 
regular. Irregularities in diet give him nervous and restless nights. 
Muscular strength has increased so much that for past week he has been 
out of bed twice every day to walk a little; and to-day, for first time, he 
got out of bed and went down stairs to dinner, being out of bed one and 
one-half hours. He was a good deal fatigued afterwards. 

From this time he steadily progressed for several weeks, eating well, 
maintaining his temperature perfectly, gaining flesh slightly, and strength 
very positively, so that on Christmas day he rode one-half mile to dine 
with his mother, and returned without any excessive fatigue. Another 
day he walked a short distance in the warm sunlight. A few days after 
this, however, he had a sudden attack of digestive disturbance, entirely 
causeless, unless it be that he had over-exerted himself. He vomited 
frequently, had some diarrhoea, and w^as much prostrated. It became 
necessary to feed him on small quantities of beef-tea, brandy, and cream, 
and milk and lime-water, given at short intervals. He rallied from this 
but did not regain his former point of strength, but gradually lost ground. 

The discoloration of the face remained at the same limits, but there was 
a slight decrease in the depth of the colour. The other patches of dis- 



80 Pepper, Case of Addison's Disease. [Jan. 

coloration (axilla, groins, etc.) became lighter. The dark spots which had 
appeared over the discoloured skin on back of hands grew smaller and 
lighter; and, indeed, the whole shade of colour of back of hands grew 
lighter, so that the abrupt line of demarcation, before descril^ed as visible 
on the sides of the hands, became less marked. 

His temperature continued to keep up quite well. His pulse gradually 
became rather smaller, weaker, and, at times, rose from seventy-two to 
eighty -four. He was never subject to either palpitation of the heart or 
dyspnoea, and had no cough. 

His muscular strength gradually failed, and again he ceased to have any 
desire to leave bed, took no exercise, and was much fatigued by sitting up 
while his bed was being made. He com|)lained less of pain caused by 
sudden movements, though when questioned he said he still strained him- 
self quite frequently. He also lost flesh slowly and assumed a more anaemic 
appearauce. The skin was usually dry, but he sweated at times over fore- 
head and flexures of joints, axillse, etc. He had noticed no change in 
natural odour of axilhe. 

His appetite was very capricious, and he wearied of almost every article 
of food after using it a few times. Beef-tea alone he invariably relished. 
His appetite was also very irregular. At the fixed meal times he would 
often be utterly without desire for food, while at varying intervals he would 
be seized with a sudden sense of faint sinking at epigastrium, craving food 
instantly. This sensation would be relieved by almost anything taken, 
cold water, beef-tea, etc., apparently by the mere presence of the article. 
At other times he would have a well-defined desire for some special article 
of food, and yet before the ^tw minutes requisite to prepare it had passed, 
he would be utterly unable to take it. Still again he would be seized with 
sudden aversion to food as he saw it carried toward him, or as the smell 
of it reached him, and he would be obliged to have it placed aside for a 
while: These nervous impressions were, at times, associated with nausea 
and a desire to vomit; but more frequently were not so. He also expe- 
rienced at times what seemed a spasmodic contraction of the oesophagus, 
accompanied by slight gagging, but rarely causing actual vomiting. 
Quite frequently the mere contact of solid food in his mouth, still more 
t!ie effort of chewing it, would excite this gagging. He vomited compara- 
tively rarely; when he did so, it was often without nausea, but seemed 
excited by the mere presence of food, and occurred instantly on arrival of 
food in the stomach, and was followed by relief. The matters vomited 
usually consisted of food taken, mixed with mucus and glairy fluid; at 
times yellowish, bilious fluid was rejected. Occasionally the reflex irrita- 
bility of oesophagus and stomach would be so great, that the presence of 
a tooth brush in his mouth would cause gagging, though never actual 
vomiting. 

His tongue was always moist; epithelial coat somewhat thick and 
roughish. 

Bowels inclined to be costive, apparently from atony of muscular coat, 
readily relieved by rhubarb, gentian, and belladonna. The abdomen was 
usually retracted to slight degree. No abnormal aortic pulsation ; no 
tumour. 

There was distinct, quite marked tenderness over lower part of the 
epigastrium, including an area fully 2X2, midway between umbilicus and 
xiphoid cartilage, and extending rather more to left of median line than 
to right. This tenderness was more marked for pressure by small 



18t7.] Pepper, Case of Addison's Disease. 81 

objects, as tip of finger, than by larger objects, as palm of hand. There 
was also marked reflex irritability of abdominal ranscles : thus tickling 
the skin at the end of 10th rib caused unusually marked contraction of 
rectus of that side. 

Urine usually seemed quite healthy ; it varied from time to time in its 
colour, and in amount of deposit thrown down on standing. 

His mind remained entirely bright, and all its faculties good. His 
spirits gradually became somewhat depressed, and he grew nervous and 
even irritable to a slight degree. His sleep was variable, at times quite 
sound, at others broken and restless. 

The use of faradization became irksome to him, and, as it evidently was 
no longer productive of any benefit, it was discontinued. 

He took quinine sulph. gr. ij and strychnia^ sulph. gr. 4V @ ^t ^^efore 
meals. After a little while this became intolerable, and was stopped. 

He then took pepsin and quinia before meals ; bismuth subnitr. gr. xv ; 
pulv. aromat. gr. v after meals. This suited him for awhile, but soon 
disagreed with him, and he continued to take only the powders of bismuth, 
which always suited and relieved him. 

He also resumed nitrate of silver in pill form after meals, but after a 
few weeks, during which it seemed to benefit him, he had a bad spell of 
vomiting, and took a violent repulsion to it. 

After this a mixture of cod-liver oil (containing phosphorus gr ^^ 
and ether gtt. v to f^ss), made up with aromatics, was tried in very small 
(f5j) doses, but after a few days became repulsive and nauseating to him. 

About this time, March 1, 1870, he had marked gastric disturbance, and 
lost one or two meals every day for several days. His temperature fell, 
so that for a whole day he was quite cool up to the thighs, and required 
frictions and hot applications to maintain temperature. He was exces- 
sively prostrate, only able to lift himself in bed ; he was also highly rest- 
less and nervous, alternating with great languor and drowsiness. 

He was restricted to bismuth powders, milk and lime-water in very 
small quantities, brandy and cream, beef-tea, every half hour through day 
and night. He slowly reacted ; the intervals were increased ; and in four 
days he was so much improved as to be able to begin with simple food at 
meal times, taking the other preparations at intervals. He complained of 
eructations of gas tainted with food eaten before, and wine of pepsin at 
meal times was again tried. Amount of brandy given was about i5iss @ 
ij q. d. 

After the attack of vomiting, with marked prostration and tendency to 
collapse noted above, he did well for a few weeks, wiien, without apparent 
cause, he was seized with diarrhcea, vomiting, and rapid and extreme 
prostration. The matters vomited were, as before, the ingesta, and subse- 
quently fluid tinged with bile. The stools were small, serous, attended 
with some cuttiiig pain at time of discharge, and followed by great sense 
of exhaustion. All desire for or relish of food was lost. There was great 
restlessness, and at times almost hysterical irritability, leading to painful 
agitation, even with paroxysms of crying. The pulse became threadlike, 
very feeble, about 108 ; the temperature rapidly fell. The mouth was very 
dry, lips parched and cracked. A small bed-sore formed over sacrum. 
Abdomen was retracted, not painful on pressure, save at one spot over 
greater curvature of stomach. Pulsation of aorta abnormally marked. His 
voice became thin, very feeble, and almost whispering, and that condition, 
though it improved as he rallied, continued to a certain extent until his 
No. CXLV.— Jan. 1877. 6 



82 Pepper, Case of Addison's Disease. [Jan. 

death. There was now occasional dyspnoea with sense of breathlessness. 
External warmth was applied, and cloths wrung out of hot brandy and 
water laid on abdomen. All food suspended, save milk f^iss, lime-water 
f^ss, brandy f^j q. q. h., and chlorodyne gtt, xv t. d. ordered. This latter 
had the happiest effect, securing rest, and allaying abdominal distress and 
diarrhoea. 

After a week he again began to improve markedly, showed desire for 
food, and slept well, had regular and healthy stools, and improved in 
strength. He still, however, suffered from abdominal uneasiness. 

Soon after another attack, alike causeless, of diarrhoea and severe 
abdominal pain, with but little vomiting, set in and speedily reduced him 
lower than he had been at ajiy previous time. Chlorodyne failed, and he 
was ordered morph. sulph. gr. j\ -, acid, sulph. aromat. gtt. xv ; curacoa 
^5j ; sj^'- aurantii cort. fjss ; aq. aurantii tior. f^ijss. — Ft. sol. S. q. q. h. 

This speedily checked vomiting and diarrhoea, and relieved somewhat 
the abdominal pain, although this continued in less degree. He reacted 
very slowly, remaining very feeble, with scarcely any appetite: there was 
occasional vomiting, sudden, unattended by nausea. 

No more aphtli^e formed on lips or tongue. Mouth continued very dry. 

He had been for several weeks troubled with occasional cough, and 
some mucoid sputa, and there were the physical signs of partial consoli- 
dation of the extreme apex on both sides. Heart sounds very feeble, but 
without murmur ; pulse very small, weak, 84 @ 100. Temperature quite 
well maintained. Mind entirely clear, and at times interest in outside 
affairs was active, and he expressed hopes of recovery, though he knew 
incurable nature of his afi'ection. 

Aljdomen markedly retracted, and pulsation of aorta excessive. No 
marked abdominal tenderness. 

Discoloration of skin did not increase at all, so that it was materially 
less than at an earlier stage of the disease. Skin was usually dry, and 
but rarely was there any actual sweating, and then usually confined to the 
head. Tiiere was no discoloration of the mucous membrane of mouth. 
Conjunctivge continued pearly white. His emaciation steadily progressed, 
though it never reached an extreme degree. 

He remained in about this condition from early part of April until 
night of April 25, when, after sleeping for several hours quietly, he awoke, 
stating that he felt very strangely, and sick all over; made a liasty, auto- 
matic movement to throw off bedclothes, and died instantly without a 
groan or struggle. 

Autopsy, tIrL7iy'Six hours after death. — Body in ice, and well pre- 
served. Brain and cord not examined. There was a fair amount of fat 
in abdominal walls and mesentery ; but there was but little in subcuta- 
neous tissue elsewhere, as over thorax. 

Thorax. — Lungs : At the apex of each lung was a patch of fibroid 
induration, involving the upper half of each upper lobe. The pleura over 
these was thickened, and closely adherent to costal pleura. Upon making 
a section of this part of lung, tissue was found dense, homogeneous, 
and fibroid in character, and presenting on each side a small cavity :|" 
in diameter, filled vAth. whitish, cheesy material, with a few calcareous 
granules imbedded. On microscopic examination this cheesy material 
presented a few altered epithelial forms, and very numerous closely packed 
cells, round, oval, or shrivelled, with their nuclei usually obscured by re- 



187t.] Pepter, Case of Addison's Disease. 83 

fracting granular contents, though in some cases a single, double, or tre- 
foil nucleus was visible after treatment with acetic acid. 

The rest of the lung tissue was crepitant and healthy. No pleural 
effusion ; but pleurae were throughout both sides quite closely adherent 
by delicate connective tissue. 

lieart. — Pericardium healthy; no effusion. Heart small and flabby. 
Cavities contained small coagula, succulent and osdematous, of a peculiar 
whiteness, and with these some little fluid blood. Walls of heart were 
thin, especially that of right ventricle, where the layer of muscular tissue 
did not actually exceed V" in thickness in places. The tissue was rather 
friable and pale. On microscopic examination the muscular fibrils seemed 
to be decidedly smaller and thinner than normal. In addition, there was 
marked diminution in transverse striation, and, in some fibrils, distinct 
granular degeneration ; and, in tissue of walls of left ventricle, streaks of 
refracting granules in the substance of the fibrils. The amount of blood 
in the tissues and vessels was very small. 

Liver. — Of normal size and healthy appearance. 

Spleen. — Slightly enlarged, with unusually distinct trabeculag ; but with 
soft, rather pale pulj). 

Kidneys. — The kidneys were of normal size ; capsules healthy, and not 
too adherent. The only change in the organs was slight granular fatty 
degeneration of the epithelium. 

Supra-7^enal Capsules. — The fat and connective tissue around both was 
much indurated, so as to require careful dissection to separate. This was 
evidently due to a subacute inflammatory process. The right capsule pre- 
sented a triangular shape, the lower portion being thick and swollen, 
while the upper end was thin, flat, and somewhat tongue-shaped. On 
making a longitudinal section the normal a})pearances were found to be 
entirely lost. At the lower end the capsule invested an ovoid mass, 
rather more than ^'^ in diameter, of firm, fibroid, cheesy appearance. 
This was readily enucleated, owing to softening of its superficial layer, and 
left the investing fibrous capsule quite empty. Microscopically exam- 
ined, this nodule consisted of sparse fibrous tissue, numerous imperfectly 
developed fibre-cells, and very numerous round, oval, or angular cells, 
with refracting granular contents concealing the nucleus, and which were 
apparently retrograde lymph cells. There was much free fat in granules 
and globules. On incising the upper and more thin part of the organ, 
the contents of the fibrous capsule were found to be partly a milky fluid 
and partly soft, slightly shreddy, pultaceous particles. In the firmer tissue 
surrounding these soft collections were small calcareous fragments. The 
fluid presented many cells like those described above, very fatty ; much 
free oil, and some fragments of crystals of cholestearine. The pultaceous 
soft particles of tissue contained similar elements, a certain amount of 
fibrous tissue, and, in addition, quite numerous very large compound 
granule cells. It was impossible to say whether these were mere fortui- 
tous aggregations of fatty and albuminous granules, or whether they were 
due to the fatty degeneration of the large nerve-like cells which normally 
are present in the central portions of the supra-renal capsules. All traces of 
the pigment usually present had disappeared; and so also it was impossi- 
ble to trace the separation originally existing between cortex and medulla. 
The left supra-renal capsule was much smaller than the right, and formed 
a puckered, indurated fibroid nodule. 

Stomach. — Moderately distended with gas. It contained about three 



84 Pepper, Case of Addison's Disease. [Jan. 

ounces of turbid fluid, beef-tea and milk mixed, with a few lumps of curd 
floatiui^ in it. Towards the pyloric end of stomacli tliere was an area 
about 3^' in diameter, over wliich tlse raucous membrane was studded with 
small yellowish-,2:ray bodies, which a microscopic examination proved to 
be enlarged follicles distended with granular matter, and small cells 
closely packed together. Elsewhere the mucous membrane was pale, 
slightly softened, but essentially healthy. 

Intestines. — The ileum was small, and rather contracted. There were 
no traces of peritonitis. The peritoneal surface of the ileum presented 
a curious mottling with numerous dark-purplish spots of various sizes, 
from a mere minute point to ^''' in diameter. There was a slight ele- 
vation of the peritoneum at these spots, and upon incising them they 
were found to be due to the effusion of dark and still fluid blood in the 
subperitoneal connective tissue. These ecchymoses were quite plainly 
visible from the mucous or inner surface of the intestines, and in some 
places they caused slight elevations of the mucous membrane. In some 
ii'.stances, upon incising the spot, the blood was found to have been 
effused into the submucous connective tissue; though far most fi'equently it 
was into the subperitoneal tissue. These ecchymoses were very numerous 
throughout the greater part of the ileum ; a few were found in the duodenum, 
and a very few also along the colon. The mesenteric and mesocolic glands 
were slightly enlarged, and one or two of them presented collections of 
black pigment, as though some ecchymosis of their tissue had occurred. 
There was no ulceration of any part of the intestine or enlargement of the 
solitary or agminated glands. 

Sympathetic Nerve. — The abdominal sympathetic, including the ganglia 
and the branches going to the supra-renal capsules, were dissected with 
great care. The parts presented their normal size, appearance, and con- 
sistence, and upon prolonged microscoj)ic examination appeared cjuile 
healthy. The nerve cells, in particular, were typically healthy for the 
most part, and only here and there was there even a suspicion of an ex- 
<:ess of granular pigmentary matter in them. 

It appears, tlien, to sum up this extended report, that a strong and 
healthy man, doing farm work, notices dull, deep-seated pain in the loins 
on exertion, and gradually increasing weakness without apparent cause. 
He occasionally has vertigo, and, before long, observes a peculiar brownish 
discoloration of the face, hands, groins, and genitals. The weakness and 
discoloration slowly increase for four years, attended with the evidences 
of ansemia, a very feeble pulse, and with irregular appetite and frequent 
gastric disturbance. This increase is not steady and uniform, but from 
time to time there is apparent improvement, always followed, however, by 
a return, in aggravated form, of the symptoms. There is no fever, chronic 
diarrhoea, albuminuria, disease of tlie lungs or heart, enlargement of liver, 
spleen, or lymphatic glands, nor any other apparent cause for the progres- 
sive failure of strength ; nor is there any marked degree of emaciation. 
Finally, so great does his debility and loss of energy become, that he is 
confined to bed, and every exertion causes faintness and exhaustion. He 
still has occasional spells of improvement in strength, but these are soon 
interrupted by apparently causeless attacks of vomiting and diarrhoea. He 



1877.] Mason, Tumour Mistaken for Aneurism. 85 

becomes intensely anagmic without extreme emaciation, and finally dies 
suddenly after a slight exertion, about four and a half years from the 
time when distinct symptoms were first observed. 

At the post-mortem examination the supra-renal capsules are found in 
an advanced stage of fibroid and caseous change ; there is extreme anaemia 
of all the tissues; the heart is slightly fatty; the spleen somewhat en- 
larged; the glands of the stomach are enlarged, and ecchymoses are found 
under the peritoneal coat of the small intestine. The lymphatics are not 
involved; and the abdominal ganglia of the sympathetic are healthy. 



Art. IX — A Case of Sarcomatous Tumour mistahen for Popliteal 
Arieuris7n, By Erskine Mason, M.D., Surgeon to Bellevue and the 
Roosevelt Hospitals. (With a wood-cut.) 

It is not the most pleasant doty for any of us to tell, let alone publish, 
our mistakes — either as to diagnosis or the treatment of our cases. Were 
we not so backward in this respect, I cannot l}ut feel that probably we 
would advance our science and art quite as much as is done by publishing 
only those cases in which we have been more successful. In this way, 
at least, we may often prevent others unwittingly committing the blunders 
we ourselves have made. Indeed, it is only too often we hear the remark 
made of some that "we only hear of their successful cases." 

The difficulties which often surround the diagnosis of aneurismal 
tumours are well known, and cases are recorded where our most astute 
diagnosticians have taken malignant growths for aneurisms, and aneurisms 
for other morbid growths. The symptoms of both are so clearly set forth 
in works that all have access to, that at first sight the student might fail 
to see how error could arise. In practice, however, how often are we 
assailed by doubts ! 

In the case we report, to our mind certainly all the signs of aneurism 
were well marked, and in tliis view we were confirmed by others ; yet the 
result proved how great was our mistake. Even now, after a careful 
review of the case, we do not see how we could have arrived at any other 
conclusion than the one we did ; and, though deeply deploring our error 
of diagnosis, we cannot but feel that, in a case presenting the same 
features as this one did at first, we would have no rule to guide us from 
falling into a similar error ; unless, it is true, we should resort to an 
explorative puncture, and this certainly would not be judicious practice 
in every case of suspected aneurismal tumour, especially where all symp- 
toms appeared so clear. Without further comment, therefore, we give 
the full history of our case, believing that it will prove of interest and 



SQ Mason, Tmnour Mistaken for Aneurism. [Jan. 

instrnetion to those interested in the study of aneurisms or morbid 

growths. 

C. "Wagner, 03t. 24, German, upholsterer, was admitted into my service 
at Roosevelt Hospital March 15, 187 G. Patient gave his history as 
follows: Five months before entering the hospital, he began to suffer 
from pain in his left knee; this occurring after a hard day's work, and 
gradually increasing in severity. Seven weeks before I saw him, the 
joint began to " swell behind," and soon after tliis he could not walk 
without a cane, and then suffered great pain in the attempt. Outside the 
hospital it had been regarded as rheumatic, and for this affection he had 
received treatment ; at another time he was sujjposed to be suffering from 
hip-disease. He does not remember at any time of having received an 
injury, but says that of late his work hns been that of putting down car- 
pets, and that in this way he might have strained the joint. His family 
history is not good, being of a phthisical stock. 

On admission, there was discovered in the left popliteal space a saccu- 
lated oval-sliaped tumour, two and a half inches in its vertical and two 
inches in its transverse diameters. Circumference of affected knee is 
fourteen inches — healthy knee twelve and three-quarters inches; affected 
limb just below the knee ten and a quarter inches — sound limb just below 
the knee eleven and a quarter inches. The temperature of affected knee 
is greater than that of the healthy one, while the temperature of the sound 
leg is greater than that of the affected leg. Besides the tumour occupy- 
ing the ))opliteal space before described, there is another, apparently an 
off'-growth from it, about the same size extending downwards towards the 
head of the tibula and upwards along the tendon of the biceps, which 
appears to be a partially consolidated aiieurismal sac. There is no 
enlargement of the inguinal glanrls. The limb is semiflexed, and any 
attempt to straighten the limb causes considerable pain. General con- 
dition of patient good. 

Upon careful examination, the tumour is observed to have a distinct, 
eccenti'ic pulsation, vvhicli separates the hands wlien placed upon it. The 
pulsations of the tibials on this side are considerably feebler than upon the 
opposite limb. Upon auscultation, there is heard a loud <ind distinct 
hruit. Pressure upon the femoral diminishes the size of the tumour, and 
at once suspends the bruit. My diagnosis was at once popliteal aneu- 
rism ; but having recently had my attention drawn to the difficulties 
which may surround the diagnoses of aneurism, by a paper on this sub- 
ject, was more careful in my examination of tliis case than perhaps I 
otherwise should have been. The case v^as examined repeatedly both by 
myself and my colleagues of both the medical and surgical staff, and the 
opinion of all regarded it as a case of aneurism ; and this, too, was the 
opinion of others not connected with the staff who examined the case. 

I determined to try the action of flexing the leg, and, if tliat did not 
succeed,, then pressure, before resorting to the ligature. The treatment 
was accordingly begun on the afternoon of March 17th, about three 
o'clock. The leg was placed at right-angles with the thigh, and main- 
tained in this position by straps of adhesive plaster. This partially con- 
trolled the pulsation, the position soon becoming painful, he was given 
a dose of chloral. 

\^th, 9 A. M. P. 120; T. 98^. Pulsation somewhat less, but dis- 
tinct; flexion was now increased, and 5'j of (U. S. P.) sol. morph. sulph. 
given to relieve pain. 6 P. M. P. 100; T. 98j. 



187t.] Mason, Toraour Mistaken for Aneurism. 87 

Idth, 9 A. M. P. 102; T. 99^. At 3 P. M., pulsation still continu- 
ing, I had digital compression made over the femoral below Poupart's 
ligament, in addition to the flexion of the knee ; this was kept up for 
three hours and a half by relays of students. 6 P. M. P. 102 ; T. 99. 

20^/^ 9 A. M. P. 108; T. lOQi 6 P. M. P. 90; T. 99i. Still 
pulsation in the tumour. 

2lst, 9 A. M. P. 90; T. 99|. The tumour still pulsating flexion was 
now stopped, and digital compression made by students for about two 
hours; during this time the patient fainted twice. Three hours later 
compression was again used, this time, however, l)y an artery compressor, 
and kept up for about an hour; owing to pain, however, it was discon- 
tinued ; pulsation had greatly diminished. After removal of the tourni- 
quet, flexion was again resorted to, and this time increased so that the 
heel almost touched the buttock. The following morning, though there 
wa'A still some fluctuation, the tumour was harder. 

23d P. 86 ; T. 100. 9 A. M. Digital compression was again em- 
ployed for about six liours, which resulted in sh'ghtiy diminishing tiie 
force of the pulsation ; leg again flexed. 6 P. M. P. 84 ; T. 98^}. 
Compression was kept up also by the compressor at intervals till one 
o'clock on the morning of the 26th, when it was discontinued owing to 
the pain it produced. When I saw him that morning the tumour was 
certainly harder; pulsation less, yet still very distinct ; the kiiee was 
quite painful, and there was also more swelling about it. The patient 
being desirous to change his position, I let him get out of bed and sit 
np for a while on the 30rh. Pulsation and bruit were now as distinct as 
ever. During this treatment by flexion, which the patient bore with 
great fortitude, it will be noticed how little variation was noted either in 
pulse or temperature. Morphia or chloral was administered from time 
to time to relieve pain and induce sleep at night. 

On the 31st of March, at half-past r.wo, in the presence of a class of 
students, assisted by Dr. Markoe, I ligated the femoral in Scarpa's space. 
All pulsation immediately ceased upon tightening the ligature, and 7iever 
afterwards was observed. Patient had some pain in the knee after the 
ligature, but was more comforta!)le than before for some days ; the liga- 
ture came away on the 13th of April. 

May 1. Dr. Weir took charge of the service; the patient was now 
suffering great pain in the knee ; the tumour had increased in size ; the 
integument was slightly reddened ; fluctuation was discovered over the 
inner side of the tumour above the condyle of the femur. Supposing the 
sac was suppurating, an aspirator was used, and a little blood and pus 
withdrawn, and poultice applied. 

23^ A sharp-pointed bistoury was introduced, which let out a small 
quantity of bloody pus. 

25th. The following note is made : There is a large oval swelling just 
above the inner condyle; tumour has increased greatly in size, and 
around the joint the circumference is sixteen inches. The swelling com- 
mences at the head of the tibia, and rises to its greatest diameter at the 
condyles, and gradually shades off directly along the course of the 
femoral artery, and to about six inches above the condyles. It greatly 
simulates a neoplasm. The pain is intense, chiefly extending down the 
outer side of the thigh and leg. Pain in the tumour is described by the 
patient as of a "bursting" character. He requires large doses of mor- 
phia to quiet the pain. 



88 Mason, Tamour Mistaken for Aneurism. [Jan. 

June 5. Fluctuation is distinct on tlie upper border of the tumour on 
tlie inner aspect of the X^*^ ; and a dischar^'e of serum and bloody pus is 
issuing from the puncture made a few weeks ago. 

8(!/?. Discharge continues about the same ; no change in the patient. 

19^/?.. A spontaneous opening occurred just above the punctured open- 
ing, through which an abundant discharge of pus escapes. Patient is 
fast losing strength. 

22t/. Dr. Weir amputated the limb in the middle third of the thigh. 
There was a greater number of arteries required the ligature, and of 
larger size than is usual in this amputation. The stump treated openly. 
7 P. M. Patient had a chill. 

23c?, 8 A. M. He had another chill, and looks badly ; stump looks 
sloughy. 

24//i. Passed a more comfortable night; appetite im})roving. 

26^/^ ^\ A. M. Had a slight chill, but looks !nuch better than he did 
a few days ago. The flaps have retracted, exj)osing the bone. 

28^/i Complains of a feeling of chilliness, but had no distinct chill. 

29ifA, 7 A M Had a severe chill; a hypodermic injection of morphia 
seemed to control it. 

o^th. Patient had two or three chills during the day. 

July 2. Feels better, though liad a chilly sensation during the day. 

3c/. Had a very severe chill last night, and hypodermic injections of 
vrater appeai'ed to control them as well as the morphia. 7 P. M Had 
a severe attack of vomiting, and complained of pain in the back and 
shoulders — this was controlled by a hypodermic injection of 20 m, of 
water. 

\th. Stump doing nicely — bone protruding. 

^ih. He suffers from bed-sore over the sacrum, which gives him much 
pain, for the relief of which he sat up in a chair nearly all day. 

10//?. There is a slight improvement in his general condition ; stump 
looks well ; an abscess just two inches below Poupart's ligament was 
opened. 

\^th. Is not so well ; bed-sores give him much ti'ouble, and for relief 
he often stays in a rocking-cliair all night. 

IG/Zi. Looking badly and losing ground. 

30/A Has considerable cough ; examination revealed phthisis. His 
cough continued to give him great trouble, and he died exhausted by his 
cough atid dyspnoea August 5th. 

The following description of the post-mortem and microscopic exami- 
nations of the specimen has been kindly prepared for me by Dr. Heine- 
mann, Assistant Pathologist to the hospital: — 

June 26. Appearance of limb after amputation. On the inner aspect 
of the lower end of the thigh, and filling up the greater portion of the 
popliteal space, is a large mass of new tissue, resembling in its regular 
contour and apparent gross structnre the sac of an aneurism laid open, 
v/ith its contents. This mass seemed to be composed of a succession of 
layers, like the organized fibrinous layers of an anenrismal clot. The 
tissue was of a firm consistency, of a dirty brownish-red colour, and 
coated here and there with pus, with blood, and broken-down tissue. 

On passing the finger through an artificial opening made in the lower 
portion of the popliteal space, it entered a cavity which passed forward 
to the shaft of the femur. This cavity was partially filled with detritus 
of broken-down tissue. The lower end of the shaft of the femur was 
found fractured. 



isn.j 



Wood, Partial Aphasia. 



89 



On making a longitudinal median section, involving the shaft of the 
femur and of the tibia, the following appearances were presented, as 
described by Dr. F. Delafield : — 

" There is a tumour occupying five inches of the lower end of the 
femur; the tumour has completely replaced the medulla of the bone, and 
at a point four inches from 
the lower end of the bone 
has completely destroyed its 
shaft, so that there is an 
oblique fracture. The tu- 
mour has grown backwards, 
so as to form a circumscribed 
tumour the size of a goose's 
e^g in the popliteal space. 
On the anterior and lateral 
surfaces of the femur is a 
periosteal tumour five inches 
long and two inches thick. 
The popliteal artery runs 
over the tumour in the pop- 
liteal space. 

' ' Microscopic Examin a- 
tion. — The periosteal tumour 
consists of an abundant re- 
ticulated and fibriilated 
stroma, with a large number 
of cells. The cells are round, 
oval, fusiform, irregular, 
many large, some giant cells. 
The medulla of the shaft is 
replaced by new tissue, also 
the medulla of the cancellous 
bone forming the lower end 
of femur. This new tissue 
has more basement substance 
and fewer cells than the peri- 
osteal tumour. The shaft of the bone is destroyed by the new growth 
followin<^ the Haversian canals." 




"^^S 



A. Supposed aneurism ; b b. Secondary growth ; p. Popli- 
teal artery ; f. Femur; t. Tibia. 



Art. X. — Partial Apha.na tuithout Ajjpreciable Lesion of Island of 
ReAl. By Horatio C. Wood, Jr., M.D., Professor of Materia Medica 
and Therapeutics, and Clinical Professor of Diseases of the Nervous 
System, in the University of Pennsylvania. 

James D ., set. 33, presented himself at the University Hospital 

Dispensary, June 11, 1875. He stated that he had been for a long time 
under treatment at the Orthopaedic Hospital, without considerable im- 
provement, but had discontinued his visits there for some time. Subse- 
quently a history of his case was kindly furnished by Dr. Geo. S. Gerhard 



90 Wood, Partial Aphasia. [Jan. 

of the Orthopedic Hospital staff ; this is here inserted instead of the crude 
and very imperfect account given by the patient's friends. 

"Was admitted as out-patient Oct. 28, 1874. Served in army during war in 
infantry, and was once slightly wounded. He never had any symptoms of lead 
poisoning, but had chancre in 1863. He never had any secondaries, and was 
always perfectly well until two months ago (end of July^, when he was suddenly 
taken with present difficulty of speech. He was formerly addicted to sprees, 
but since early part of Jnly has been temperate. He has not had vision dis- 
order or vomiting, but has suffered, and still suffers, from frontal headache. 
General health good. Weight 155 pounds. Mother says he is silly, and acts 
queerly as he never did before, and that his mind is feeble. 

"There is marked difficulty of speech (indeed this is the most prominent fea- 
ture of his case), but there is no actual loss of memory for words. For instance, 
he related all the details connected with his killing a snake ten years ago. The 
story was told in a very slow and embarrassed way, but no loss of memory for 
words was observed during its narration. Grip of right hand feebler than left. 
An irregular and indistinct blue line on the gums. Eye ground normal. Or- 
dered pot. iod. gr. X, t. d. 

''Jan. 2, 1875. Appears to be somewhat better. Continue treatment. 

"26lli. Improved greatly for some time, so that he was able to resume his 
work, but now worse again, and the relapse appeared to follow neglect in taking 
the iodide. 

"i^e/;. 8. Iodide increased to gr. xx, t. d. 

"15^/k Speech difficulty becoming more marked. Iodide increased to gr. 
XXV, t. d. 

''I9th. Iodide stopped. 01. morrhuje and phosphorus gr. j'g t. d. ordered. 

''March 8. Oil and phosphorus stopped on account of causing nausea. 

" 19^/i,. Intellection more sluggish. Elix. quin., strych. et ferri, f^j t. d. or- 
dered. 

"29th. Pain in head somewhat better. 

"May 7. Very drowsy and mind more sluggish than ever. No paralytic 
symptoms. Elixir stopped and zinc phosphide ordered. Able to take care of 
himself. Goes about city alone. 

"lOth. Ordered hydrarg. chl. corros. gr. y\- t. d. Zinc stopped. 

"17//i. Keturned to report no change. Left off attendance." 

When the patient offered himself at the University Hospital he was 
decidedly worse than at the time he ceased his visits at the Orthopedic 
Hospital. There was not, hov»'ever, any distinct paralysis; there was 
general mnscnlar weakness, but not more than is often seen in chronic dis- 
orders ; the chief complaints were of a persistent severe frontal headache, 
with marked paroxysmal exacerbations. There had been no fits, bnt there 
was a very decided, although not complete, aphasia. The patient was 
entirely unable to give any account of himself, or to frame any connected 
sentences. When asked whether he had ever had the "bad disease," he an- 
swered with great slowness and effort " war — rotted me — bitch ;" meaning 
that he had got the disease from a woman whilst in the army. The spe- 
cial senses were unimpaired. Ophthalmoscopic examination showed com- 
plete absence of choked disk or descending neuritis ; there was some nenro- 
retinitis, which was pronounced by Dr. Wm. F. Norris to be probably the 
result of the existing high degree of myopia. 

Large doses of iodide of potassium were prescribed and the patient sent 
home. That evening, or tlie next one, he was seized with violent con- 
vulsions, with delirium and unconsciousness. A neigiibouring practitioner, 
having been called in, pronounced the case one of strychnia poisoning, 
and treated it as such for four days, when I was called in. At this time 
there was furious delirium, with constant screaming and fighting, but no 
convulsions. The case was pronounced meningitis, and a fatal prognosis 



1811] Wood, Partial Aphasia. 91 

given. The man was sent on the 18th to the hospital, where, under 
active blistering, the free use of calomel and bromide of potassium, he got 
better, but never became rational. About 11 o'clock in the morninp^ of 
the 29th, he fell into a sleep, which deepened into a stupor, in which 
he died about four o'clock in the next afternoon. 

His pupils were widely dilated and immovable during his stay at the 
hospital, but on ophthalmoscopic examination nothing more decided than 
some retinal congestion could be detected. 

The notes of the post-mortem, as follows, are extracted from the hospital 
register : — 

"Examination made eight hours after death: Dura mater yerj thick 
and opaque. Very great increase of cerebro-spinal fluid. 

'' Arachnoid c]o?^e\y adherent over upper surface of brain, opaque and 
thick with spots of very great thickness here and there. 

" Consistency of hra.in about normal to touch. Great thickening and 
exudation of lymph behind the optic chiasm. Lobes closely agglutinated 
by exudation. Left side externally seemingly normol. Softening of 
extreme anterior apex of middle lobe on right side, Idand of Reil seem- 
ingly normal, though membranes over it thickened. Lungs normal. 
Heart healthy. A very large ante-mortem clot in the pubuonary artery, 
also one in left ventricle " 

The brain was put in alcohol, which failed to keep the inner portions 
of the organ. The exterior cortical layer was fortunately well preserved, 
and good sections of the left Island of Reil were made in the Pathological 
Laboratory of the University, under the superintendence of Prof. Tyson. 
Prof. Tyson stated that he was unaljle to find any disease in the Island of 
Reil, and a section sent to Prof. Fitz, of Harvard University, elicited the 
following note : — 

"Your section arrived in good condition. I found occasional pigment 
granules in the perivascular spaces — a rare glistening round or oblong homo- 
geneous body suggestive of a corpus amylaceum. Also rare, was an apparent 
increase of nuclei in certain adventitite. 

" None of these appearances were sufficient in quantity or quality to suggest 
disorganization of the cerebral substance in the respective section." 

Remarks. — The chief interest of the case just narrated centres in two 
points, the absence of choked disk with general and local meningitis, and 
the presence of aphasia, without detectable alteration of the Island of 
Reil. The diagnostic importance of choked disk, so far as my experience 
goeSj is not su})reme. I have seen what was apparently it in a patient in 
whom no other distinct evidences of brain lesion could be found during a 
scrutiny extending over several months, and I have generally found it 
absent in such cases of brain tumour as presented any diagnostic difficulties, 
the diagnosis in one of these cases being confirmed by an autopsy, made 
two days after the ophthalmoscopic examination by Prof. Norris and 
myself. I do not mean to deny the usual diagnostic import of choked 
disk when present, but it seems to me in some cases impossible to dis- 
tinguish it from ascending neuritis, and its absence appears to be of no 
value in proving the non-existence of cerebral growths, or even of menin- 
gitis. 

The controversy as to the localization of function rages so fiercely that 



S2 RoosA, Blepharitis Ciliaris and Ametropia. [Jan. 

the present case will probably be seized npon at once, I have therefore 
had the matter carefully verified, and it seems to me thoroughly estab- 
lished that there was no appreciable lesion of the Island of Reil. This 
does not, however, to my mind disprove the theory of speech localization. 
The aphasia, according to the statement of the friends of the patient, had 
come on gradually. It was far from complete, althougli very marked. 
It is well known that the Island of Reil receives much of its blood sujiply 
from the superjacent meninges. These meninges were very much thick- 
ened, and it is perfectly possible that there should have been an interrup- 
tion of circulation sufficient to interfere with the function of the [)art, but 
not sufficient to alter its structure in a degree to be appreciated by our 
present methods of examination. 



Art. XI. — The BeloAioim of Blepharitis Ciliaris to Ametropia} By 
D. B. St. Johx Roosa, M.D., Professor of Oi)hthalraology and 
Otology in the University of the City of New York, Surgeon to the 
Manhattan Eye and Ear Hospital. 

It is a well-recognized fact that certain forms of conjunctival inflam- 
mation arise from uncorrected errors of refraction. I do not think it is 
generally conceded, however, that blepharitis ciliaris often stands in the 
saine relation to ametropia. The principal text-])ooks do not give any 
prominence to the sul)joct either in the discussion of blepharitis or 
ametropia. Most, if not all of them, are silent upon the subject. Bonders 
does not, I think, even allude to b1e[)liaritis as one of the results of un- 
corrected strain of the accommodation. In the chapter on Blepharitis in 
Saemesch's Hand-Buch, by Professor Michel, the subject is not mentioned. 
Schweigger in his hand-book is also silent upon the point. The same 
may be said of the treatises of Wecker, Stellvvag, and Soelberg Wells. I 
mention these facts because in speaking of the causal connection of 
blepharitis with ametropia to some of my professional friends, I found 
them under the impression that the subject had already been distinctly 
enough mentioned in the text-books. However much may have been 
known and said upon the subject in the practice of eye infirmaries, very 
little has as yet found its way into the literature of ophthalmology. 

I therefore present a few statistics as to the connection between diseases 
of the hair follicles and tarsal glands and the various forms of ametropia. 
They are all the cases observed by me in private practice during the last 
eighteen months. I have attempted to keep a similar record in the Man- 
hattan Eye and Ear Hospital, but there are some omissions in these statistics 

1 Read before the luteinatioual Congress of Ophthalmology, September, 1876. 



187*7.] RoosA, Blepharitis Ciliaris arid Ametropia. 93 

— that is, the refraction has not been determined in all the cases; I liave 
therefore, not placed them among my private cases. I will say, however 
that, so far as they go, in the opinion of the House Surgeon, Dr 
Cheatham, they confirm the results of ray own statistics. My conclusions 
are as follows: — 

I. Ametropia seems to be the condition of most eyes affected with 
blepharitis ciliaris. 

II. When the blepharitis is associated with errors of refraction, the 
cure of the edges of the lids is very much fncilitated by and sometimes 
depends upon correction of the ametropia. 

III. Paralysis of the accommodation by the use of atropia will usually, 
with no other treatment, very much relieve the blepharitis that is associated 
with ametropia. 

lY. Patients suffering from blepharitis associated witli ametropia will 
often ignore any other affection of the eyes than that of the edge of th# 
lids, and deny tiiat they suffer from asthenopia or conjunctivitis, com- 
plaining only of the discomfort and disfigurement produced by the disease 
— and this when the error of refraction is so mnrked that we would 
naturally expect quite serious consequences from its non-correction. 

y. Tlie form of blepharitis to which my statistics refer is not a mere 
irritation of the eyelids, such as often accompanies a catarrhal conjunc- 
tivitis, but a true hypersecretion of the hair follicles and tarsal glands, 
attended by the formation of crusts, ulcerated points, and hyperemia. 

yi. Hypermetropia is the error of refraction most frequently associated 
with blepharitis ciliaris. 

I frankly admit that the number of cases I am now able to present does 
not absolutely prove that blepharitis ciliaris is very frequently caused by 
ametropia, although I cannot escape the conviction that this is the case. 
The number is large enough, however, to show a remarkable coincidence 
at least, and to stimulate others to inquiry in the same direction. 

Case I. Mr. U., set. 17. Complains of blepharitis, which he has had 
three or four years. Sometimes has had slight pain in eyes after reading. 
Accommodation and muscles normal. Refraction, emmetropic. V= I. 

Case II. Mr. D., set. 26. Has had blepharitis and asthenopia for past 
three years; complains chiefly of the blepharitis. Has derived no benefit 
from treatment, which has been from competent surgeons, who have not 
attempted to prescribe glasses. Refraction, mixed astigmatism, both 
eyes. Under atropia — 

R. E. with -f j\ Y — 4V "'^''= -'S- 
L. E. - + ^:,'\-:k'V=U- ^ 
Ordered above glasses; also cleansing of lids with a solution of bicarbonate 
of soda in water, and the application of red oxide of mercury ointment. 
Patient reports six months later : Uses eyes with comfort, and has scarcely 
any blepharitis. Says that redness of the lids returns whenever he leaves 
off his glasses for a few days. Four nionths later the lids are entirely 
well. 



94 , RoosA, Blepharitis Ciliaris and Ametropia. [Jan. 

Case III. Miss A., !«t. 18. Has had asthenopia and blepharitis since 
childhood. Accommodation and muscles normal. Refraction, compound 
hypermetropic astigmatism, both eyes. Under atropia — 

R. E. r=u with + 3V C + TsV "1^= i§- 
L. B. V = IS with + sV C + sV " I" = il 

This patient was freed from the blepharitis, etc., by the glasses. 

Case IY. Miss U., a?t. 15. Complains only of blepharitis. Refrac- 
tion, hypermetropic -^^ with each eye. Result of treatment unknown. 

Case Y. Mrs. F., ^t. 28. Complains of blurring of distant vision, of 
fatigue in eyes after use, and of blepharitis. Accommodation and muscles 
normal. Myopia, ^\ right eye, ^^ left eye ; ordered -^jj for both eyes. 
Four months later reports herself entirely well. 

Case YI. Mr. D., set. 23. Has had blepharitis and styes for past two 
years. Some asthenopia for past six months. A. normal. Vz=l. In- 
sufficiency interni, 6^ at 12'^ and 4° at 15^ Refraction, emmetropic. 
No record of treatment or course. 

^ Case YII. Mr. Y., ajt. 28. Complains of blepharitis. V= 1. Re- 
fraction, H. J^, both eyes. After declining glasses for a year nearly, 
with constant relapses, is now wearing ^\j with evident progress in the 
cure of the blepharitis. 

Case YIII. Mr. W., jet. 28. Blepharitis and asthenopia past two 
years. A. normal. Refraction, compound myopic astigmatism, both 
eyes — 

R. E. with —J^C — ^k'V=^^l 
L. E. with —^C — A''V= |g. 
Ordered these glasses. Patient not heard from since. 

Case IX. Mr. D., set. 28. Complains of blepharitis; has had it four 
or five years. Refraction, H. J-^, both eyes. V =1. 

Case X. Mr. J., ^t. 36. Complains of blepharitis, which he has had 
for several years. A. and muscles normal. Refraction, simple myopic 
astigmatism 5^, both eyes. 

Case XI. Mr. B., eet. 28. Complains of "gritty" sensations about 
eyes, and blepharitis. Refraction, H. 2^;^, both eyes. V=l. One 
month after, this patient was greatly relieved of his symptoms. 

Case XII. Mr. A., get. 23. Complains of indistinct vision and of 
blepharitis. Refraction, simple hypermetropic astigmatism /^, each eye. 
F=fg. This patient is relieved by the treatment, but a complete cure 
has not been effected. 

Case XIII. Miss C, set. 15. Complains of blepharitis. Refraction, 
hypermetropic, both eyes. Declines to wear glasses. 

Case XIY. Master U., set, 10. Complains of blepharitis and asthenopia. 
Refraction, H. |, each eye. R. E. F=§J. L. E. F = f|}. The glasses 
cause some improvement, but the patient was seen but twice or three 
times after they were prescribed. 

Case XY. Miss C , set. 16. Blepharitis since a small child. Treated 
without success for a year at an eye institution. 

Refraction, R. E. H. j\ F= |{} +. 

L. E. H. ^V^=t^-+. 
This patient was very much improved, as to the blepharitis, under the use 
of atropia, in connection with the same treatment that had been previously 
employed. She passed from observation before she was entii^ely well. 



18tt.] KoosA, Blepharitis Ciliaris and Ametropia. ^ 95 

Corneal opacities prevented better result from the correction of the hyper- 
metropia, and the glasses had not been ordered when last seen. 

Case XYI. Mr. T., set. 35. Complains of blepharitis, which he has 
had since 1858; also of asthenopia. A. normal. 
Refraction, R. E. M. ^V V=l. 
L. E. M. J^ V=l. 
Insufficiency of recti interni, 7° at 12^'. This patient was seen once after 
glasses were ordered, and was then impro.ved. He had had the usual 
local treatment for years. 

Case XVII. Mr. A., aet. 24. Complains of having had blepharitis for 
past three years ; asthenopia for same period. A. normal. Refraction, 
M. -^^, both eyes. V=l. Insufficiency interni recti, 5° at 12^^ The 
patient went to Europe before the benefit from glasses could be tested. 

Case XYIII. Mrs. L., set. 32. Has had asthenopia, slight blepharitis, 
and muscae for some time. Unable to do any fiiie work for past two 
months. A. and muscles normal. V=l. Refraction, emmetropic. This 
patient is suffering from mental worry, and the eyes but index the whole 
nervous system. The refraction was tested under atropia. 

Case XIX. Mrs. B., set. 44. Complains of blepharitis. Refraction, 
emmetropic, V=l. Presbyopia, Jg. 

Case XX. Mr. B. complains of blepharitis. A. and muscles normal. 
Refraction very slightly hypermetropic by ophthalmoscope ; not tested 
with atropia. F= 1. Xo note of a second visit. 

Case XXI. Miss L., set. 21. Complains only of blepharitis, which 
she has had over a year. Refraction, mixed astigmatism, both eyes — 
R. E. with _ ^1^ f + ^1^ ° F =r |g — . 

L. E. with-V.T + ^^^^^^lg — 

This patient's blepharitis was considerably improved by the use of 
atropia for two or three weeks, while the refraction was being tested. 
There were also evidences of old iritis in her case. She passed from 
observation almost immediately after the refraction was determined. 

Case XXII. Mary P., set. 5. Her mother states that she has had 
blepharitis for the past eighteen months, and she now has a marked affec- 
tion of her lids. The refraction is hypermetropic in both eyes -^^. On 
account of the youth of this patient, none but local treatment was advised 
until she should begin to study. 

Case XXIII. Mr. R., set. 21. Has had asthenopia and blepharitis of 
the left eye for the past eighteen months. Blepharitis in right eye for 
the past three months. A. and muscles normal. Refraction, H. -^\, both 
eyes. V=l. Ordered -|- ^V- 

Case XXIY. Master E., a3t. 12^. Complains of having pains in his 
eyes occasionally, and of blepharitis. 

Refraction, M. ^L, L. E. 
M. i, R. E. 
Choroiditis. 

Case XXY. Master F., set. 6. Has had blepharitis for several months. 
Refraction, emmetropic by ophthalmoscope. Atropia not used. Local 
treatment advised. 

Case XXVI. Mr. M., ait. 21. Blepharitis for the past year. Has had 
a good deal of treatment, but without benefit. A. normal. Insufficiency 
of internal recti, 4° at 12'^ Refraction, M. ^^g, both eyes. 

Case XXVII. Miss M., set. 13. Has had blepharitis since a small 
child. Has been treated frequently, but never permanently cured. Some 



9G RoosA, Blei>liaritis Ciliaris and Ametropia. fjan. 

asthenopia after pro]onG:ec] use of eves. Refraction, H. y^^, both eyes. 
V=l. 

Case XXYIII. Miss S., aat 25. Has had blepharitis and asthenopia 
for five years. A. and muscles normal. Refraction, compound hyper- 
metropic astigmatism, both eyes — 

R. E. with4-3VC + 4^^^T^^=M. 

Ordered the above glasses. No local treatment for lids. Patient reports 
four months later that asthenopia is entirely relieved, and that the 
blepharitis has disappeared. 

Case XXIX. Mr. C, get. 20. Asthenopia for two years. Quite severe 
blepharitis for the sauie ]ieriod. Kefraclion, compound hypermetropic 
astigmatism, both eyes. IJnder atro[)ia — 

R- E. + 4's C + r a-^is 900 V=U-i-. 
L. B. -f ^1^ 3 + ^V axis 91)0 ¥=-- f-§. 

Case XXX. Mr. C, tet. .39. Complains of blepharitis. Has had 
slight asthenopia in the evening, but he is only annoyed by the redness of 
his lids. Refraction, slightly hy{)ermetropic in both eyes by ophthalmo- 
scope, i — jV- Ordered -\- 4^0 for reading. No other treatment. One 
month later tlie lids looked better, but not entirely well. 

Case XXXI. Master U., set. 12. Has had blei)haritis for the past 
four years. He has been treated by the usual remedies, but never cured. 
Has asthenojjia and a mild form of palpebral conjunctivitis. Refraction, 
H. ^Q, each eye, under atropia. 

Summary. — Whole number of cases reported, 31. 

Complained of blepharitis alone, 1.5, or about 50 per cent. 

Complained of blepharitis and asthenojtia, 1 G. 

Cases having refractive error, 26, or 83y^y per cent, nearly. 

Cases, emmetropic, 5, or about 16 ^^ per cent. 

Hypermetropia ....... 13 

Myopia ......... 5 

Hypermetropic astigmatism ..... 1 

j\Iyopic astigmatism ...... 1 

Compound hypermetropic astigmatism ... 3 
" myopic astigmatism .... 1 

Mixed astigmatism ....... 2 

Emmetropia ........ 5 

81 

The refraction in these thirty-one cases was tested under atropia when- 
ever it was allowed. I cannot accept statistics on this subject for myself, 
that are not made up in this way. For I am led to believe, from some 
considera]3le observation, that even experienced and competent observers 
sometimes declare an eye emmetropic which they have examined with the 
ophthalmoscope, without atropia, when the use of the mydriatic will show 
hypermetropia of more than a sixtieth. If every one of my cases had been 
tested under atropia, the percentage of hypermetropia would perhaps have 
been increased. 



1877.] Frothingham, Pulsating Tumour of Orbit. 97 



Art. Xll. — Pulsating Tumour of Orbit resembling true Aneurism; 
Ligation of Common Carotid; subsequent Removal of Tumour; Re- 
covery. By G. E. Frothingham, M.D. , Professor of Ophthalmology, 
University of Michigan. (With two wood-cuts.) 

In March, 1872, I was called to see Mrs. J. B., set. 35 years, residing 
in Chelsea, Michigan, and suffering from exophthalmia of left eye. The 
history of the case was briefly as follows: Three years before I was called, 
she had noticed a slight protrusion of the eye. As it was not attended 
with any pain or serious discomfort at first, she did not consult a physi- 
cian. The prominence of the eye gradually becoming more marked, she 
consulted at different times several surgeons, but did not remember what 
diagnosis was made by any of them. At the time I saw her the eye was 
very much protruded, and moved perceptibly with each pulsation. Upon 
applying the ear over the temple or eye, a loud bruit, just such as is 
heard in aneurism, was detected; and with a stethoscope the bruit was all 
the more distinct and characteristic. Upon compressing the common 
carotid the bruit ceased, and the eye could be made to recede in the socket, 
but not to its normal position. Upon pressing the finger in at the outer 
angle of the orbit, at a point where the tumour showed slightly, it could 
be felt as a soft, elastic, pulsating tumour, just like a true aneurism with 
a thin sac. 

There was no dilatation of the pupil. The sight in the protruding eye, 
though much diminished, was sufficient to distinguish readily the features 
of persons several feet distant, when the lid was raised so as to uncover 
the pupil. In the usual position the cornea was completely covered by 
the upper lid, which was much thinned, and overlapped the eye. After 
a careful examination 1 diagnosed true aneurism of the orbit, although 
the insidious approach and slow growth of the tumour pointed to aneurism 
by anastomosis, or some form of pulsating tumour. 

Later in the month she was examined by Prof. T. A. McGraw, then 
occupying the chair of surgery in this University. After a thorough 
examination he also diagnosed true aneurism. 

After having tried compression without success, I advised ligation of 
the common carotid. The patient at first objected, but after a few weeks, 
the tumour increasing rapidly, and great discomfort being experienced 
from the noise in the head, she consented to the operation, which I per- 
formed on the 29th of May, 1872, assisted by Dr. F. K. Owen, of Ypsi- 
lanti, and Drs. Gates and Ackley, of Chelsea, 

The efffect of the operation was immediate cessation of the bruit and 
pulsation in the tumour, which diminished considerably in size, the eye 
receding to a corresponding extent. The pulsation ceased for fourteen 
days. It then began to return, but not with any considerable force, and 
not to the extent of producing any noise or uncomfortable sensation that 
disturbed the patient. 

The ligature came away on the eighteenth day, and the patient recov- 
ered slowly from the eff'ect of the operation, suffering from giddiness and 
other cerebral symptoms for several weeks afterward. 

Although the pulsation returned in the tumour, the ligation of the 
artery had the effect of retarding its growth, so that the symptoms did not 
No. CXL7.— Jan. 1877. 7 



9S 



Frothingham, Pulsating Tumour of Orbit. [Jan. 



a.G^aiu become urgent until the latter part of August, 1875. The patient 
visited me several times in the interval between the ligation of the artery 
and the date above mentioned, and was examined in my presence by seve- 
ral surgeons, all of whom declared the pulsation and bruit to be like that 
of true aneurism. Among those who thus examined the patient was my 
colleague, Prof. Maclean, who, as a private pupil of the late Prof. Syme, 
had early been made familiar with all forms of aneurism, and whose practice 
since his graduation, chiefly surgical, had kept his ear trained to the nicest 
distinctions. 

The exophthalmia increasing quite rapidly, the patient again consulted 
me in the latter part of September, 1875, and, upon examination, I found 

that the tumour had considerably 
increased, the eye presenting the ap- 
pearance shown in Fig. 1, copied from 
a photograph taken at that time. 
The tumour had now projected so 
far beyond the lower margin of the 
orbit that it could be more thoroughly 
examined, and, although it was very 
elastic, and became greatly reduced 
in size by pressure, I became satisfied 
that it was not a true aneurism, but 
one of those vascular tumours com- 
monly known as "aneurism by anas- 
tomosis." 

The eyeball was almost completely 
covered by the upper lid, which was 
much thinned and expanded, so as to 
cover the eye like a hood ; whenever 
it was raised it had to be held for- 
ward, or it would slide completely 
back and leave the whole eyeball 
uncovered. The vision in the eye was sufficient to enable the patient to 
count fingers at about six feet distance. 

I advised at this time the removal of the tumour, feeling confident that 
it could be safely jierformed. Tiie patient, feeling very anxious to be re- 
lieved, readily consented ; but as the weather then was very warm, desired 
to postpone the operation until it was cooler. To this 1 consented, and 
the patient left for home. For some reason she did not again return till 
November. The tumour had not materially changed in appearance from 
that presented at the examination in September. On the 3d of Novem- 
ber, assisted by my colleagues. Profs. Maclean and Herdman, I proceeded 
to perform the operation, having made preparation for any modification that 
might be ciilled for by the condition of the tumour, that might be ascer- 
tained after a more thorough exploration, which could be made after 
enucleation of the eyeball. 

The patient having been chloroformed, an exploring trocar and canula 
was plunged into the tumour ; and upon withdrawing the trocar the blood 
flowed in regular jets in a sp'eam the full size of the canula The eye was 
now enucleated, and, on pressing the finger well back, the posterior por- 
tion of the tumour could be felt. It was thus ascertained that the tumour 
lay wholly within the orbit, and was fed by large vessels entering through 
the spheno-raaxillary fissure, which was so much enlarged that the finger 




1877.] Frothingham, Pulsating Tumour of Orbit. 



99 



Ficr. 2. 



could be readily passed into it, and by thus exercising pressure on the 
vessels all pulsation in the tumour could be stopped. 

The tumour was now rapidly enucleated, the pedicle cut with the curved 
scissors, an assistant being ready to compress the vessels at once. The 
hemorrhage, as expected, was very profuse, filling the orbital cavity and 
flowing in a large stream down the cheek in the brief time required for the 
assistant to pass his finger into the fissure and compress the vessels. A 
compress moistened with a solution of Monsel's styptic was now pressed 
down upon the bleeding vessels, the orbit tamponed, and the patient placed 
in bed. Some fever and headache followed the operation, but the recovery 
was rapid, the patient returning home on the 17 ih of November, and soon 
the recovery was complete. 

The tumour, upon examination, was found to consist of two portions. 
There was a more dense portion and on the inner and upper side a large 
mass of convoluted and sacculated vessels, held together by connective 
tissue, and loosely connected by the 
same tissue to the more solid por- 
tion of the tumour. 

This more solid portion differed 
from the other simply in having a 
greater quantity of connective tissue, 
which was also more dense in its 
character. It was permeated freely 
by bloodvessels, and in structure ap- 
peared much like a sponge. A thick 
slice allowed the light to shine 
through, revealing cavities of irregu- 
lar form and size, with which the 
bloodvessels freely communicated. 
A careful microscopic examination 
showed it to be composed of blood- 
vessels and condensed connective tis- 
sue. Fig. 2 represents the appear- 
ance presented by a section of the 

tumour, made after eight months, the tumour being much shrunken by 
the action of the alcohol in which it was preserved. 

This case is of interest as illustrating the difificulty attending the diag- 
nosis between aneurism and other pulsating tumours situated in the cavity 
of the orbit. 

This was, perhaps, more strikingly illustrated by the case in which 
Bowman ligated the common carotid for a supposed aneurism of the orbit, 
but which proved to be neither an aneurism nor vascular tumour of any 
kind. In his case the diagnosis of aneurism was concurred in by several 
eminent and experienced medical gentlemen, no one doubting the existence 
of aneurism. But the patient dying from the effect of the ligation, a post- 
mortem showed that no aneurism existed anywhere in the cranium or orbit, 
nor was there any vascular disease within the orbit. The only condition 
that could be found to explain the exophthalmia, bruit, and pulsation, was 
inflammation of the cavernous sinus and occlusion of the ophthalmic vein 
where it entered that sinus. The swollen walls of the sinus, by partially 




100 



CuLBERTSON, Paraljsis of the Ocular Muscles. 



[Jnn. 



compressing the internal carotid, probably gave rise to the bruit, and the 
occlusion of the vein, by preventing the free return of venous blood, pro- 
bably gave rise to the pulsation of the eyeball, and its protrusion from the 
orbit. 

Perhaps the tendency at the present is too strongly inclined to regard 
all deep-seated pulsating tumours of the orbit as true aneurism, and I 
report this case chiefly to add to the statistics of this class of tumours, 
for I am fully convinced that, until a more thorough and extensive study 
of the subject shall develop more accurate diagnostic distinctions than are 
at present known, mistakes in diagnosticating these tumours must occa- 
sionally happen. 



Art. XIII. — On a Modified Mode of detecting Paralysis of the Ocular 
Muscles. By H. Culbertson, M.D., Professor of Ophthalmology in 
the Columbus Medical College, Ohio. 

In considering this subject, one of the sources of confusion is the 
necessity of describing the position of the false images and of the 
meridians for each eye. This we would avoid by adopting a uniform 
method of investigation for either eye, and which is as follows : — 

A diagram like that below. Fig. 1, is drawn on card-board, which should 
be about 21 inches square and perforated with an opening in the centre, 
half an inch in diameter. 





Fig. 1. 






Superior 


Region. 






Temporo- 


Naso- 




o 


superior 
quadrant. 


superior 
quadrant. 


o 
Pi 


15 

;-. 
o 

2 


Teraporo- 
inferior 


Naso- 
inferior 






quadrant. 


quadrant. 






Inferior 


Region. 





This diagram is intended to be viewed when inspecting the left eye. 
When examining the right eye the lateral regions will be reversed. 
(See Fig. 2.) 

These diagrams may be made on opposite sides of the same card-board, 



187t.2 CuLBERTSON, Paralysis of the Ocular Muscles. 



101 



and the side employed which corresponds to the right or left eye when 
the patient is placed in front of the figure for examination. 





Fig 


. 2. 






Superior 


Region. 






Naso- 


Temporo- 




3 


superior 


superior 


fl 


O 






o 


CD 

C4 


quadrant. 


quadrant. 






Naso- Temporo- 
inferior inferior 
quadrant. quadrant. 

Inferior Region. 

i 


1 

Ph 

a 



The diagram intended for the right or left eye should be placed in front 
of a lamp, its centre on a level with the eye, before the patient, and 
usually three or four feet from the party to be inspected. It may be 
necessary to change the antero-posterior axis of the eyeball, by inclining 
or turning the head, to discover the false image in paralysis of some of 
the muscles of the eye. 

The eyeballs examined are also, in imagination, divided into the same 
regioyis and quadrants, represented on the card-board, Figs. 1 and 2 ; 
and these regions and quadrants are supposed to move with the eyeballs. 
Thus Fig. 3 is a front view of these divisions. The section above the 

Fig. 3. 




102 CuLBERT SON, Paralysis of the Ocular Muscles. [Jan. 

horizontal plane is the siq^ernor region, and that below this the inferior 
region for either eye; that to the left of the vertical plane a a, for the 
left eye, the temporal region, and that to the right of a a (for the same 
eye) the 7iasal region; d, represents (left eye) the temporo- superior 
quadrant; e, the temporo-inferior quadrant; c, the naso-superior 
quadimnt ; and/ the naso-inferior quadrant. 

The divisions for the right eye will be as follows: that to the left of 
a a the nasal 7^egion, and that to the right of a a the temporal region; 
d, represents the naso-superior quadrant ; e, the naso inferior quadrant ; 
c, the temporo-superior quadrant; and/", the temporo-inferior quadrant. 

The vertical plane in either eye is supposed to fall within the apex of 
the cornea anteriorly, and to pass through the macula lutea posteriorly. 
The horizontal plane is imagined to run below the apex of the cornea io 

Fig. 4. Fig. 5. 




front, and to intersect the macula Intea behind. Fig. 4 represents a 
lateral, and Fig. 5 a posterior, view of the horizontal plane. 

After having determined which is the eye affected, the proper diagram 
is placed in front of the corresponding eye, and the investigation pro- 
ceeded with. 

To determine the Eye Affected. — The patient in front of the card-board, 
Fig. 1, will see two images of the central perforation. Suppose the 
marginal (the least distinct) or false image* be seen in the temporo- 
superior quadrant. If a prism of the proper degree of refraction be 
placed with its base over the false image, and its axis parallel to a right 

' The most certain mode of determining which is the false image is to place a 
pointer in the hand of the patient. On pointing to the position of the false image, 
the pointer will not pass through the card-board, but, on directing it upon the 
central image, the pointer will pass through the central perforation of the card- 
board. 



187*7.] CuLBERTSON, Paraljsis of the Ocular Muscles. 103 

fine intersecting the true and false images, the two images will be united. 
But if the prism be carried before the opposite eye, its base and axis in 
the same direction as above (the several regions depicted in P^ig. 1 being 
transported, in imagination, with the prism), the images will be further 
separated. Hence we may conclude that eye affected before which the 
prism is placed, the base over the false image and its axis parallel with a 
right line drawn through the true and false image, and which, thus placed, 
fuses these images; and that, if the prism be thus placed before the sound 
eye, the images will be separated.^ 

The reason for this is as follows: We know by experiment that the 
central is the true and most distinct image; and that the falae image is 
in the region or quadrant in which is found the paralyzed muscle; and, 
further, to correct this, the base of the prism must be placed in the region 
or quadrant in which is located the paralyzed muscle. When so placed 
the glass, if of proper refracting power, will effect fusion of the images in 
the diseased, but not in the sound, eye; in which latter it will only pre- 
vent a normal state, or separate the images. 

Paralysis of Individual Nerves or Muscles. — In the plan herein pro- 
posed it should be remembered that sometimes the regions and quadrants 
will be so largely displaced as to falsify this method of investigation. 
But, as it is evident the same difficulty would obtain by any method of 
detecting ocular i)aralysis, no greater objection can be had against this 
plan than to those heretofore proposed. 

Paralysis of the Third Nerve. — The apex of the cornea is drawn 
slightly into the temporo-iiferior quadrant by the external rectus and 
the soperior oblique muscles. In the complete form of this paralysis, the 
snuscles paralyzed are the levator palpebrarum, the internal, the superior, 
and the inferior recti ; and the inferior oblique, the ciliary, and the 
sphincter popillas muscles. 

The rays of light impress the retina in tlie temporo-inferior quadrant. 
The false image will be seen in the naso-superior quadrant; by virtue of 
the law of inversion of retinal images, and also that the aiigle of reflection 
is equal to that of incidence, the media being the same; or in the region 
of the eyeball, in which is found the greatest number of paralyzed muscles. 
The eye lags when moved towards the superior, the inferior, and the 
nasal regions. 

' In determining wliieh is the affected eye, it is essential that the base of the 
prism be not reversed in the horizontal or vertical meridians. For it is evident 
that this would destroy the value of the test. For instance, suppose the false 
image is seen to the lefi of the vertical line, i. e., in the tempor(d region, and when 
the prism is placed base in the temporal region, axis horizontal, the images are 
fused. But if the base be now placed (in fi-ont of the right eye) towards the 
right temporal ref^ion, axis horizontal, the iihages will be united. This, however? 
violates the rule, the base being carried towards the true image. The plan le- 
quires that the base of the prism should always be towards the false image. 



104 CuLBERTSoN, Paraljsis of the Ocular Muscles. [Jan. 

In uniting the true and false image, the prism should be placed with its 
base over the false image, and its axis parallel with a line drawn through 
the true and false image, and the base in the naao-superior quadrant ; or 
the base in the region of greatest paralysis. 

Paralysis of the Internal Rectus. — Here the apex of the cornea ia 
drawn into the temporal region, in the horizontal meridian, by the external 
rectus muscle. As the only muscle paralyzed is the internal rectus, there 
is no inclination of the vertical meridian. The rays of light enter the eye 
in the nasal region, in the horizontal meridian, and the retina is impressed 
in the same meridian in the temporal region ; and hence the false image 
will appear in the nasal region, or in the same region in which is found 
the paralyzed muscle. The eye will lag when the wand is moved towards 
the nasal region, or that in which is found the paralyzed muscle. 

The prism should be placed (in fusing the images) with its base in ihe 
nasal region, its axis corresponding with the horizontal meridian. 

Paralysis of the External Rectus. — Paralysis of this muscle causes 
the internal rectus to turn the corneal apex into the nasal region, in the 
horizontal meridian ; and the rays of light will reach the retina in the 
nasal 7'egion, in the horizontal meridian. Hence the false image will be 
seen in the horizontal meridian and in the tem^joral region, or in the 
region in which is found the paralyzed muscle. 

As the movement of the eyeball is in the plane of the controlling muscle, 
the internal rectus, the false image will not be inclined. The eye will lag 
when moving the object towards the temporal region, or in the direction 
of the paralyzed muscle. The prism should be placed base in the temporal 
region, and axis horizontal. 

Paralysis of the Superior Rectus. — Paralysis of this muscle enables 
the action of the inferior rectus and of the inferior oblique muscles to turn 
the apex of the cornea into the inferior region, and slightly into the 
temporo-inferior quadrant. The retina will be impressed in the temporo- 
inferior quadrant, and, therefore, the false image will be projected in the 
naso-superior quadrant, a little above the horizontal and near the vertical 
meridian, or towards the region of the eye in which is found the paralyzed 
muscle — i. e. — superior region. The eyeball will lag when an object is 
moved towards the naso-sup)erior quadrant, or towards the region in 
which is found the paralyzed muscle. The prism should be placed base 
in the naso-superior quadrant, near the vertical meridian. 

Paralysis of the Inferior Rectus. — Paralysis of this muscle enables the 
superior rectus to roll the apex of the cornea into the naso-superior quad- 
rant, thus causing the rays of light to impinge on the retina in the naso- 
superior quadrant. Hence the false image will be projected in the tem.- 
pjoro-inferior quadrant near the .vertical meridian : or in the region in 
which is found the paralyzed muscle. The eye will lag when the object is 
moved towards the temporo-inferior quadrant, or the region paralyzed. 



18Tt.] CuLBERTSON, Paraljsis of the Ocular Muscles. 105 

The prism should be placed, base in the temporo-inferior quadrant, near 
the vertical meridian. 

Paralysis of the Superior Oblique. — By paralysis of this muscle and 
the action of the inferior oblique, the apex of the cornea is turned into 
the naso-superior quadrant. Hence the rays of light will impress the 
retina in the naso-superior quadrant, and the false image will be seen in 
the temporo-inferior quadrant. But the inferior rectus inclines the verti- 
cal meridian above into the te^nporo- superior quadrant, and thus the 
retina would be impressed still further outwards in the naso-superior 
quadrant; hence the false image will be projected further inwards in the 
tempo7'o-inferior quadrant: or in the region, in which is found the para- 
lyzed muscle. 

The eyeball will lag towards the naso-inferior quadrant, and the prism 
should be placed with the base in the temporo-inferior quadrant. 

Paralysis of the Inferior Oblique. — By paralysis of this muscle and 
the action of the superior oblique, the apex of the cornea is turned into 
the naso-inferior quadra7it. Hence the rays of light will impress the 
retina in the naso-inferior quadrant, and the false image will be seen in 
temporo-inferior quadrant. But the superior rectus inclines the vertical 
meridian above into i\\Q naso-superior quadrant, and thus the retina would 
be impressed still further inwards in the naso-inferior quadrant; hence 
the false image will be seen still further outwards in the temporo-superior 
quadrant; or in the region in which is found the insertion of the para- 
lyzed muscle. The eyeball will lag towards the naso-superior quadrant, 
and the prism should be placed base in the temporo-superior quadrant. 

Conclusions. — 1st. That in paralysis of the ocular muscles, the apex 
of the cornea will be carried towards the 7'egion m which is found the 
controlling muscle. 

2d. That in moving an object before it, the eye will lag towards the 
region in which is found the paralyzed muscle. 

3d. That if the movement of rotation is strictly within the plane of the 
controlling muscle, no effect will be had upon the inclination of the false 
image. 

4th. If the movement of rotation is not within the plane of the con- 
trolling muscle, the false image will be inclined. 

6th. The false image will seem to be located in the region in which is 
found the paralyzed muscle. 

6th. That in the treatment of the disease by prisms, the base of the 
latter should be placed in the region in which is located the paralyzed 
muscle, and its axis parallel with a line drawn through the false and true 
image. 

*7th. To induce the same effect, artificially upon the rays of light, as 
produced by paralysis of the ocular muscles, the apex of the prism should 
be placed over the muscle assumed to be paralyzed. 



106 CuLBERTSON, Paniljsis of the Ocukr Muscles. [Jan. 

8tli. Although in paralysis of the superior and inferior recti, the false 
images are seen in the quadrants, yet they are located so near the verti- 
cal line or plane, that practically they naay be regarded as situated in that 
plane, and in the superior and inferior regions. Hence in general terms, 
it may be stated, that in paralysis of the recti, the false image will be seen 
in the regions, and in the vertical or horizontal meridians; while in 
paralysis of the obliqui and of the third nerve, the false image will be 
located in the quadrants. 

Illustrative Cases. — Case I. J. B.,?et. 47. Primary position in front 
of card-board for left eye He sees th.e false image in the vertical meri- 
dian in the superior region. The prism placed in front of the left eye 
base in superior region and axis corresponding with a right line drawn 
through the true and false images, unites these images, but placed before 
the right eye in the same position as before the left, separates the images. 

The wand moved a little below the .horizontal meridian develops two 
vertical images, the false one above and to the right (his) or in the naso- 
superior quadrant. Moved into the nasal region, the images become plainer 
and a very little further apart. Moved into the temporal region, the 
images quickly unite. Moved above or below, the images are quickly fused. 
There is no ptosis, the pupil is active, and accommodation is normal. 

Diagnosis. — Paralysis of the third nerve, the superior rectus most 
affected, the internal rectus next most impaired. Originally all the 
branches of this nerve were paralyzed, but improvement has resulted, and 
renders the diagnosis less distinct. Even now there is limited impairment 
of the inferior rectus. 

Remark. — This man has hemiplegia of the right side, from which he 
has recovered partially. 

Case II. J. T. ; adult; equivalent to paralysis of the left internal rectus. 
He has an ulcer upon the apex of the left cornea, which causes the left 
eye to turn outwards, that the inner clear portion of the cornea may 
transmit light. This induces diplojn'a. 

In front of the card-board for the left eye he detects the false image in 
the nasal region and in the horizontal meridian. The light impresses the 
retina in the temporal region, and hence the false image seems to be in 
the nasal region, or in the region in which is found the muscle (internal 
rectus), the action of which is affected as though defective in its opera- 
tion, but is not paralyzed. 

When the wand is carried before him into the extreme temporal region, 
he sees two erect images on the same level. He sees the same in the same 
positions in front of him, but nearer together. When the wand is carried 
into the nasal region, the images are easily fused. 

A prism of 10° jdaced in front of the left eye, its base in the nasal re- 
gion and over the false image and in the horizontal meridian, unites the 
images; but when the prism is carried l)efore the right eye, its base and 
axis in the same direction, the images are separated. 

Remark. — This man's eyes were under the influence of atropia when 
examined. 

Case III. Miss E. H., set. 10. On bringing finger close to her eyes in 
the horizontal meridian, the apex of the right cornea turns outwards, or 



I 



181T.] CuLBERTSON, Paralysis of the Ocular Muscles. lO'J 

into the temporal region of the card-board for the right eye. On placing 
the base of the prism 3° over the false image, and in front of the right 
eye, the base in the nasal region, and its axis in the horizontal meridian, 
the images are fused, but before the left eye they are more widely sepa- 
rated when the prism is placed, before that eye, its base and axis un- 
changed in direction. 

In this investigation the patient was necessarily placed within about 
four inches of a small card-board with only a dark central spot and a 
horizontal and vertical line upon it, in discovering the diplopia. 

The light impressed the retina in the temporal region, and hence the 
false image will be seen in the nasal region, or in the region in which is 
found the relaxed muscle. 

Diagnosis. — A case of insufficiency of the right internal rectus — mus- 
cular asthenopia. 

Remarks. — Her general health is impaired and catamenia deranged. 
She has amenorrhoea. 

Case IY. A male adult, set. 25. On holding the finger close to his 
eyes, the patient sees two images on the card-board for the left eye. The 
false one in the nasal region, horizontal meridian. The base of the prism 
placed over the false image in the nasal region in front of the left eye 
unites them, but in front of the right eye it separates them. 

Diagnosis. — Asthenopia and myo[)ia with insufficiency of the left in- 
ternal rectus. 

Treatment. — Guy e 24'' — glasses for distance and near vision, with 
which he read No. 1 Galezowski at 12''. 

Remark, — This man has a very prominent nose and quite full eye. 

Case Y. H. J., set. 29, a male. The history of the case revealed that 
some months previously he received a blow upon the right temple. With 
the card-board for the right eye in front of the right eye, he detects the 
false image in the temporal region in the horizontal meridian. A prism 
of 9° placed in front of the right eye, base in the temporal region, and 
axis horizontal, fuses the images ; but placed in front of the left eye, base, 
and axis in the same direction, separates them. The eye lags when the 
wand is moved into the temjjoral region. Secondary deviation of left eye 
greater than the primary. No diplopia to the nasal side of the vertical 
meridian. 

Diagnosis. — Paralysis of the right external rectus from rheumatism. 

Treatment. — Prism 9^^, applied as above over right eye, and gave pot. 
lodidi 5j ; vini colchici |ss ; tr. guaiac. ^iss ; fl. ext. nucis vomicae 5ss. 
M. Teaspoonful after meals. Result, recovered. 

Case YI. Miss E. C. ; set. 19. Card-board for left eye. Sees 

false image in the temporal region horizontal meridian. A prism of 10° 
placed in front of left eye, base over false image, axis horizontal, fuses 
images, and in front of right eye axis and base in the same direction, 
separates them. Eye does not lag in any direction. At the margin of 
the superior, inferior, temporal, and nasal regions the false image dis- 
appears, while the true remains. At the usual distance in reading diplo- 
pia is not observed. Primary and secondary deviation are equal. Closing 
left eye the right remains fixed on the object. On closing the right eye 
the left turns into the temporal region, and on opening, then, the right 
eye, the left turns back into its usual position into the nasal region. 

Diagnosis. — Concomitant convergent strabismus of the left eye. 



108 Brother, Fracture of the Femur. [Jan. 

Remarks. — Although this is a case of strabismus and not of paralysis, 
it is included as a part of this subject. It is evident that were the left 
external rectus divided and its insertion brought forward, normal vision 
would be restored, and in fact this has been several times successfully ac- 
complished by Dr. Yieusse. See Recueil d^Ophth., 1875, p. 330. 

Case VII. A. P. Mulligan, male, aged 41. Card-board for left eye. 
False image in nasal 7^egion, prism, placed base in nasal region, axis hori- 
zontal, in front of left eye fuses the images ; base and axis in same direction 
in front right eye separates them. Images are separated when wand is 
carried towards the nasal region, and united when moved into the tempo- 
ral region. 

Diagnosis. — Paralysis of the left internal rectus from rheumatic thecitis. 

Treatment. — Prism 10^ placed base in ??<2saZ ret/zo«, axis horizontal ; 
also pot. iodidi, comp. syrup sarsap., and vini colchici. 

Result, recovered, 

The publication of this method has been delayed in order to gain addi- 
tional cases for illustration. But as it is thought that others can add 
these and better test the value of this plan of diagnosis than we, it is be- 
lieved best to publish now. The plan requires to be thoroughly tested by 
the many competent to do it in the ophthalmological profession, and if it 
is found truthful and useful, or erroneous and worthless, we rest satisfied 
with the result. 

Zanesville, Ohio, May, 1875. 



Art. XI Y. — Treatment of Fracture of the Femur. By Ferd. Brother, 
M.D., of Bunker Hill, 111. (With a wood-cut) 

It is simply our purpose in this article to discuss the indications to be 
fulfilled, and the best means of obtaining the most favourable results in 
fracture of the femur. 

The matter of greatest importance in treatment of all fractures is, first, 
''that the result should be a perfect limb. Secondly, the greatest comfort 
to the patient while being treated." 

With the testimony almost universal, that lack of perfection of limb is 
the general result in oblique fractures of the femur, is not the inference 
natural that none of the methods in general use are adequate to attain the 
much-desired result? Admitting the truth of this proposition, the ques- 
tion then presenting is, is the fault in the principle of treatment, or its 
application? I contend that it is in the latter chiefly. 

What is the principle involved in the treatment of every fracture? It 
is overcoming muscular contraction by continuous extension. This and 
nothing more. 

By a close study of those cases where lateral supports alone are used to 



1817.] Brother, Fracture of the Femur. 109 

preserve the apposition, this fact is revealed, that the ends of the bone are 
the prime factors in maintaining extension, if it (extension) is an accom- 
plished fact. Is it accomplished and sustained in oblique fractures of the 
femur by this means? What is the experience in the use of the lateral 
splint, of every character, when depended on for extension ? After the 
attempted reduction by more or less, and generally very much manual ex- 
tension, the supports are carefully and firmly adjusted, the perineal or 
axillary counter extension arranged, extension from the foot made, and if 
manual effort has been continued until immediate contractility has been 
overcome, the patient is left in good shape, and the surgeon lays the flat- 
tering unction to his soul that he has effected, and will be able to preserve 
good apposition, and shall have a correspondingly good limb as a result. 
The next visit reveals the fact that the yielding extending agents, together 
with the mobility of the points of counter extension, have permitted the 
oblique ends of the bone to glide past each other, and the limb is short- 
ened; dislike to believe it as mnch as we may, the stubborn fact is tliere. 
The extending bands are tightened ; and this is done day after day, and 
time after time, until union has become so firm as to be unyielding. For- 
tunately experience demonstrates that repeated movement does not prevent 
bony union, of which the lower animals afford us frequent illustrations. 
But it is my intention to discuss mechanical principles only — not patho- 
logy. The inability to overcome muscular contraction is only one of the 
objections to the long splint. Experience demonstrates the greater the 
possibility of overriding of the bone in proportion to the increased amount 
of soft tissues intervening between the lateral supports ; to overcome this 
tendency increased compression is applied. Compression necessarily im- 
plies an interrupted circulation, inducing atrophy of the parts, and im- 
peded repair of the injured structures. We may enumerate among other 
objections the excoriations so universally attending the use of the perineal 
bands — the compulsory position producing bed-sores — the difficulty in at- 
tending to the calls of nature — and the lack of relation of the ends of the 
bone, if the fracture is in either the upper or lower third. If of the upper 
third, the psoas and iliacus muscles tilt the upper fragment forward and 
outward; if of the lower, the gastrocnemii pull the fragment backward. 

If it be a fact that continuous extension, i. e., overcoming muscular 
contraction, is the groundwork of all successful plans of treatment of frac- 
tures, the question of vital importance is, how can this extension be best 
made and maintained ? 

There is no apparatus with the workings of which I am familiar, pos- 
sessing as many points of excellence, as few faults, and productive of better 
results than the wire suspension splint devised by Prof. Jno. T. Hodgen, 
of St. Louis; and were it better known and understood it could not fail 
to be appreciated. The apparatus is a combination of the principles of 



110 



Brother, Fracture of the Femur. 



[Jan. 



Smith's anterior, Swinbnrn's or Jobert's extension, and the strip bandage 
support. 

It consists (see figure) of a one-fourth inch iron rod of sufficient length 
to perniit its being bent into two parallel arras connected by a cross or 




Explanation of Fuu'ke. — k, k, k, k, ParaUel bars to which muslia strips are pinned; x, Wire 
bow ; E, E. D, D, Sliding hooks to which cords are attached ; p, Adhesive strap and blocli attached 
to H, H, cross bar; B, Suspending cord; m, Means of tightening same; A, Pulley in the ceiling. 
Near the middle of the thigh, a strip is unpinned, oxhibiting ease of examination or dressing com- 
pound fracture. 

foot bar. These arms are bent at an oblique angle at the knee, and should 
reach from the pubes and hip to some six inches beyond the foot, the cross 
or foot bar should be four or five inches long. For suspension and exten- 
sion, four small hooks with loops to slip over the bars are necessary, as 
also a wire bow, eight or ten inches long, with loop at each end to slip on 
the upper ends of the splint to separate them; with the pulley and cords 
the apparatus is complete. 

Application. — My plan is to have the patient laid obliquely across the bed, 
with the leg of the injured thigh projecting over the edge. An adhesive 
strap, four or five inches wide, si)lit so as to avoid the malleoli, is applied 
on the lateral aspects of the \^^ to the knee, providing a loop across the 
foot, into which the usual block is fitted to prevent pressure of the ankle. 
The roller, having been previously applied to the foot, is now carried 
smoothly to the knee. A half dozen muslin strips, three or four inches 
wide, and of sufficient length to encompass the thigh, are passed between it 
and the bed. The splint, with the wire bow adjusted, is placed in front of the 
limb, the upper ends thereof at the pubes and hip supported by one assist- 
ant; the opposite end of the splint and the foot are steadied by another. 
The ends of the muslin strips, previously passed, are then pinned to the 
bars, care being taken to make the tension as uniform as possible; the leg 
is then supported in the same manner. The adhesive strap and block are 



1877.] Brother, Fracture of the Femur. Ill 

then fastened by a cord to the cross or foot bar, thus attaching the limb 
firmly to the splint, which is supported until the patient is righted in bed, 
and is then suspended from the pulley previously so placed in the ceiling 
that the suspending cord may have an oblique direction, by means of which 
obliquity extension may be maintained. 

To prevent the patient slipping down in bed, and thus lessening the ex- 
tension, blocks three or four inches thick may be placed under the posts at 
the foot of the bed, though this is not absolutely necessary, as the patient 
soon realizes the fact that the lack of extension permits the sharp ends of 
the bone to impinge the soft tissues, causing pain, as also that his pushing 
himself up in the bed relieves the difficulty. Thus, by the patient's com- 
fort, we have extension assured. 

Having alluded to one of the objections made, I will take up a few 
others which have been raised. Hamilton, in his last edition of Fractures 
and Dislocations, p. 443, says : " Whatever the advocates of flexion in 
fractures may say to the contrary, they are never able, in this position, to 
employ effective extension and counter-extension ;" and that " a careful 
examination of all the double inclined planes, including Smith's and 
Hodgen's suspending apparatus, will convince any experienced observer 
that such is the fact •" and " whatever other excellences they may possess, 
this does not belong to them." 

I think, if Prof. Hamilton had taken the trouble to adjust a Hodgen's 
splint with a spring balance attached between the cross-bar and the foot, 
he would not have expressed the above opinion. 

On the other hand, I have been credibly informed of a surgeon of some 
repute, who, having been induced to try this apparatus, found he had 
adjusted it with so much extension as to be unendurable. 

Educated, as we nearly all have been, "to set" the fracture, it is natural 
that objection should be made to this appliance on the score that there is 
no provision made for this manipulation. 

Unless profound anaesthesia is produced, it is very seldom that the ends 
in oblique fracture can be placed in perfect apposition, and retained until 
the retentive apparatus is applied. Nor does the necessity exist for this 
great amount of pulling ; as the fact is well known that a small amount 
of force continuously applied will overcome muscular contractility, and 
retain its control, which is more than any given amount of force applied 
for a short time can do. 

Another fault found is the freedom of motion, rendering the possibility 
of displacement greater. The only risk I can see is, that of the patient's 
sliding down in bed; the suffering entailed, as previously alluded to, warns 
against an attempted repetition ; while the general freedom of motion is 
an advantage over all other appliances. It is almost impossible to dis- 
turb the axis of the limb; so the patient can sit up, move to either side 



112 EiCHARDSON, Red Blood Corpuscles. [Jan. 

of the bed, lift himself on the bed-pan, and lie almost on his side, without 
disturbing the relation of the fracture or causing pain. 

The last objection I shall notice is — '* it affords inadequate support 
along the centre of the shaft, in consequence of which the limb is apt to 
unite with a backward curve or angle." Is there any appliance for treat- 
ment of fracture of the femur which is not open to the same objection, or 
in which there would be less atrophy of the soft tissues permitting the 
backward curving ? Certainly in none is the tendency to the defect as 
easily overcome as in this, where the mere tightening of a few. strips 
will give the support in the right place; and, being in view, the right 
place is known. 

Now for a few of the advantages of this apparatus. It is easily made, 
cheap, quickly applied, and not painful. In its use no excoriations or 
ulcerations of the soft parts, as the perineum, heel, or knee, can follow. 
Through the freedom of motion permitting the patient to lie down or sit 
up, and change his position, the general health is better preserved; while 
at the same time bed-sores are almost impossible, and the calls of nature 
can be conveniently attended to. The site of fracture being open to in- 
spection, we can be sure of apposition without disturbance of dressings to 
make examination. There is no compression of the vessels, hence circula- 
tion and nutrition go on uninterruptedly, repair is best provided for, and 
risk of non-union diminished. Requiring no setting of the bone, the 
powerful pulling, with risk of injury to the soft parts, is avoided. In 
compound fractures, dressings can be applied and renewed without dis- 
turbance of the limb, thus reducing the sulferings of the patient to the 
minimum, while cleanliness is easily maintained. These are advantages — 
nay, requisites — not possessed by any other apparatus ; and while it is 
not claimed for this that in every respect it is better than all others, I 
prefer it, in a greater number of cases, to any I have seen in use, and 
would bespeak for it a candid, impartial consideration, and a fair trial by 
my professional brethren. 



Art. XY. — On the Identify of the Bed Blood Corpuscles in different Races 
of Mankind. By Joseph G. Richardson, M.D., Microscopist to the 
Pennsylvania Hospital. 

Exact measurements of the red blood disks of man and of those of the 
ox, pig, cat, horse, deer, and sheep (from which I contend the human 
blood globules can with certainty be discriminated) have acquired so much 
importance through recent discussions upon the diagnosis of blood stains, 
that I trust the subjoined investigations will prove valuable to the medical 
and legal professions. 



1877. J Richardson, Red Blood Corpuscles. 113 

I present in them the commencement of an extended series of observa- 
tions upon the identity or diversity of blood corpuscles from the genus 
Plomo in different races and under various conditions of sex, age, habits of 
life, hygienic influences, disease, etc., and also of those from the animals 
enumerated under similarly diverse circumstances ; they constitute more- 
over some of the first medical results of our Centennial Exhibition, which 
by attracting to Philadelphia visitors from every quarter of the glol)e has 
rendered it possible for me to procure well-authenticated specimens of blood 
from many different nations. 

The samples were each procured by myself from the individuals mentioned 
(sometimes only through much persuasion), by puncturing a finger with the 
quick stab of a cataract needle, pressing out a small amount of blood, ap- 
plying a clean slide to the apex of the drop, and then spreading out the 
portion of fluid which adhered to the glass, with the end of another slide, 
according to Prof. Christopher Johnson's excellent method. 

The measurements were all made with a -j--^ immersion objective and 
by the aid of a cobweb micrometer eye-piece, giving when thus combined 
a power of 1800 diameters. The value of the degrees of the eye-piece 
micrometer with this objective, at the cover correction employed, was 
determined by a stage micrometer kindly compared for me by my friend 
Col. J. J. Woodward, of Washington, D. C, with one carefully tested by 
the standard in the U. S. Coast Survey Office, and which he has pro 
nounced practically correct. 

Instead of measuring all corpuscles, deformed or otherwise, in two 
directions, as proposed by Dr. Woodward {Phila. Medical Times, vol. 
vi. p. 457), I prefer to determine the size of unaltered, i. e., circular cor- 
puscles only. By this plan, which I believe is that of our highest authority 
upon the subject. Prof Gulliver, we obtain the dimensions of nearly normal 
cell elements, such as are exhibited in Dr. Woodward's beautiful photograph 
of fresh blood {Army Med. Miiseuni, No. 861, new series), where, as in 
fluid preparations, but little variation in size exists among the corpuscles ; 
and escape being misled by pathological specimens similar to those dis- 
played in photograph No. 836, of the same invaluable series. 

Since the chief cause of marked variation in magnitude as well as of 
distortion in shape among blood disks spread out upon glass is, I think, 
their mutual attraction and repulsion during the process of drying, my 
investigations were made upon portions of slides where the corpuscles were 
very sparsely disseminated, and then, to secure the most infallible accuracy 
for my deductions, as the preparation was moved along, I measured every 
isolated circular red disk, which came into the field of the microscope. 
In doing this I cautiously avoided recording those which manifested even 
slight departures toward an oval form, and by several experiments learned 
that the deviation corresponding to a transverse diameter of 1-3030 and 
a conjugate of 1-2857 of an inch was recognizable by a single glance. 
No. CXLY Jan. 1877. 8 



114 Richardson, Red Blood Corpusoles. [Jan. 

One hundred corpuscles in each specimen were measured and the dimen 
sions as I read them off in millionths of an inch noted down generally by 
• an assistant. These memoranda, with the preparations to which they 
refer, are carefully preserved for examination by any experts who may 
desire to convince themselves respecting the substantial foundation of fact 
whereon I base the following conclusions : — 

Drop 1. Obtained Oct. 11, 1876, from Mr. I., member of the Japanese 
Centennial Commission. Average diameter 1-3212 of an inch, maximum 
1-2777, minimum 1-3737. Of the 100 corpuscles, 8, or 8 per cent., were 
less than 1-3448 of an inch ; 10 per cent, were more than 1-3030, and 
the remaining 82 per cent, were between tliese two sizes. 

Drop) 2. Senor F. C, set. 30, born in Valencia, member of Spanish Cora- 
mission. Average 1-3226, maximum 1-2777, minimum 1-3571. Eighty- 
nine per cent, ranged between 1-3448 and 1-3030 of an inch in diameter, 
whilst 6 per cent, fell below the former and 5 per cent, exceeded the latter 
magnitude. 

Drop 3. Mr. A. M., about 38 years of age, born in Yerviers, Belgium 
Delegate. Average 1-3203, maximum 1-2777, minimum 1-3846. Eighty- 
eight per cent, ranged between 1-3448 and 1-3030, whilst 7 per cent, fell 
short of and 5 per cent, exceeded these sizes. 

Drop 4. Herr E. G., about 40 years old, born in Zurich, member of 
Swiss Commission. Average 1-3203, maximum 1-2857, minimum 1-4000. 
Eighty-two per cent, ranged between the above-named limits, while 7 per 
cent, fell short of, and 11 exceeded them. 

Drop 5. R. E., set. 29, l)orn in Constantinople, member of Turkish 
Commission. Average 1-3197, maximum 1-2777, minimum 1-3846. 
Eighty })er cent, ranged between the limits mentioned, whilst 4 were less 
and 16 more than these measurements in their diameter. 

Drop 6. J. P. R., set. 25, born in Copenhagen, a^/«c/?e of Danish 
Commission. Average 1-3257, maximum 1-2857, minimum 1-4000. 
Eighty-two per cent, between limits mentioned, 12 below and 6 above them. 

Drop 7. Herr G. K., set. 27, born in province of Vladimir, member of 
Russian Commission. Average 1-3190, maximum 1-2857, minimum 
1-3571. Ninety-one per cent, between above-named limits, 2 below, and 

7 above them. 

Drop 8. C. H., set. 35, born in Cliristiania, attache of Norwegian Com- 
mission. Average 1-3252, maximum 1-2857, minimum 1-4000. Eighty- 
six per cent, fell between sizes named, 10 below, and 4 above them. 

Drop 9). Dr. J. L., set. 33, born in Kongsbacka, member of Swedish 
Commission. Average 1-3254, maximum 1-2777, minimum 1-3737. 
Eighty-two per cent, fell between sizes named, 13 below, and 5 above them. 

Drop 10. Sig. V. F., about 35 years old, born in Bologna, member of 
Italian Commission. Average 1-3272, maximum 1-2777, minimum 
1-4000. Eighty-three per cent, of the measurements lay between dimen- 
sions above stated, 10 fell below, and 7 surpassed them. 

Drop 11. M. P. P., set. 67, born in Bordeaux, member of French Com- 
mission. Average 1-3239, maximum 1-2777, minimum 1-3737. Eighty 
per cent, were found to be within the limits specified, 12 fell beneath, and 

8 exceeded them. 

Drop 12. I. L., set. 52, dark mulatto, born in Delaware, U. S. Average 
1-3229, maximum 1-2857, minimum 1-3856. Eighty-three per cent, fell 
within limits noted, 11 below, and 6 above them. 



1877.] Strawbridge, Ophthalmic Contributions. 115 

Drop 13. E. M., set. 48, Cherokee Indian, born in Florida, U. S. 
Average 1-32 15, maximum 1-2857, minimum 1-4000. Eighty-three per 
cent, fell between limits stated above, 10 fell below, and t exceeded them. 

Dy^op 14. J. R., set. 40, white male, born in Pennsylvania, U. S., of 
English parentage. Average 1-3191, maximum 1-2777, minimum 
1-3846. Eighty-five per cent, came within limits mentioned, 6 fell below, 
and 9 above them. 

Combining these deductions, we find that of the whole 1400 corpuscles 
each separately measured, the average was 1-3224 (.007878 mm.), the maxi- 
mum 1-2777, and the minimum 1-4000 of an inch ; 1158 or 83 per cent, 
measured between 1-3448 and 1-3030 of an inch in diameter, and conse- 
quently under a power of 200 would appear about the same magnitude; 
118 or about 8 per cent, were less than 1-3448, and 124, or nearly 9 per 
cent, were more than 1-3030 of an inch in diameter. The total number 
of corpuscles 1-4000 of an inch across was 6, or less than one-half of one 
per cent. The total number 1-2777 of an inch in diameter was 10, or less 
than one per cent. 

The somewhat smaller averages of the Italian, Swedish, and Norwegian 
specimens are perhaps due to slight accidental variations in spreading out 
the layers of blood for examination, and cannot be accepted, at least without 
further research, as indicative of either personal or national peculiarities. 

Such minute differences indeed must be expected with our present 
methods of observation, and it seems to me that, taken as a whole, my 
results powerfully confirm the Scriptural declaration, that the Lord ''made 
of one blood all the nations of the earth." 



Art. XYI, — Ophthalmic Oontrihutions. By George Strawbridge, 
M.D., of Philadelphia. (With a wood-cut.) 

I. Modified Flap Extraction Operation. — In a report of some forty 
recent cases of cataract extractions, published in the Philadelphia Medical 
Times of February 19, 1876, I referred very briefly to an operation which 
was designated as the "Modified Flap Operation." Since then my ex- 
perience in this operation has been considerably enlarged, and with most 
gratifying results. If a circle be drawn having a radius of 6 mm., {vide 
Fig.), it will closely represent the size of the cornea. Now, if the line 
5 c? be drawn tangent to the vertical diameter of the cornea, ^ ^ -, 
as represented by the circle, and the lines h a and d ehQ 
drawn tangent to the horizontal diameter, two triangles a 
will be formed by the intersection of these three lines, a h t 
and e d t, which triangle practically represents the most 
available ground for the puncture and counter-puncture of any incision 
that may be made for lens extraction. In fact, the puncture and counter- 



116 Strawbridge, Oplithalmic Contributions. [Jan. 

puncture must closely follow the lines a h and e d io form an openinp: 
sufficiently large for the lens exit. (The same rule would hold good for 
the inferior operation.) 

The centre of an incision, whether a flap or a lineal cut, should be 
tangent to the corneal margin, for two important reasons: The greater 
completeness of the iridectomy, a proceeding generally admitted as 
greatly increasing the success of the operation ; and, secondly, the 
greater ease attending the lens removal and the escape of any cortical 
remnants that may be left. 

In regard to the puncture and counter-puncture. The nearer the 
points h and (/are approached, the greater the risk of ciliary inflamma- 
tion ; while, on the other hand, the points a and e necessitate a large 
corneal flap, and great risk of corneal suppuration. Therefore the points 
p and c have been chosen as midway between these two dangers; they 
being at a distance of 0.5 mm. from the corneal border, and 3 mm. be- 
low a line tangent to the superior corneal border. 

Method of Operation. 1st Stage. — A Graefe knife, held horizontally, 
enters the eyeball at a point 0.5 mm. from the corneal border and 3 mm. 
below a line tangent to the superior corneal border. The counter-punc- 
ture is made at a corresponding point on the other side of the cornea, 
and the incision completed so as to form a tangent to the superior corneal 
border, the eyeball being held by fixation forceps. This incision forms 
an opening of 10-11 mm., amply sufficient for the exit of any lens — the 
ordinary lens diameter being 9-10 lum,, ajid thickness 4 mm. 

2d Stage. Iridectomy. — If the patient is quiet, the forceps are removed, 
and the iridectomy made in the ordinary manner, but of moderate size. 

3d Stage. Laceration of the Capsule. — The attempt is always made 
to remove with the lens a triangular piece of the anterior capsule. The 
cystotorae is passed down the anterior chamber to the middle of the lower 
edge of the pupil, and freely incises the capsule as it is drawn from this 
point upward along the inner pupillary edge. It is then again passed 
to the central point of the lower pupillary edge, and drawn upward 
along the outer edge of the pupil, and the triangle completed by a hori- 
zontal sweep of the cystotome along the upper border of the lens. This 
triangle of capsule often comes away with the lens, and lessens greatly 
the necessity of secondary operations. 

4th Stage. Lens Delivery: accomplished by gentle continuous press- 
ure on the cornea at the junction of the middle and lower thirds with a 
Daviel spoon, and the lens remnants removed by gentle inward and upward 
pressure of the lower lid on the cornea, the finger being used for the 
purpose. 

Advantages of this modification — 1. The lessened risk of ciliary in- 
flammation as compared with the Graefe-Litiear method, and the less pro- 
bability of corneal suppuration as compared with the corneal flap. 



1871] Strawbridge, Oplitlialmic Contributions. lit 

2. The removal of the forceps, after the completion of the cut, avoids 
all pressure on the eyeball during this critical time. 

3. The removal of the capsule triangle greatly lessens the number of 
secondary operations. 

II. Needle Operations in Cases of Retinal Detachment. — In my opera- 
tions I have followed Bowman's plan of tearing the retina with two 
needles, but have used needles of unequal size — one quite large, the 
second one very 6ne— for the double purpose of making a communica- 
tion between the vitreous chamber and the sub-retinal pouch, and also 
of allowing the sub-retinal fluid to drain out through the sclerotic open- 
ing made by the passage of the large needle. 

If the position of the effusion permitted, as was usually the case, the 
region of the eye punctured has been from a quarter to half an inch be- 
hind the cornea, and between the straight muscles ; the needles being 
thrust vertically in toward the centre of the eyeball, passing through the 
detached retina, and then tearing it by crossing or separating the needles 
the forceps being but seldom used. Generally there has been subcon- 
junctival effusion immediately after the puncture; the vitreous humour 
often showed a considerable amount of cloudiness, but lasting only a short 
time, and in some instances the retinal tear could be distinctly seen with 
the aid of an ophthalmoscope. No great amount of irritation followed 
any of these operations, atropia locally and a pressure bandage being 
used for forty-eight hours afterwards. 

Case I. — Mr. J. E,, set. 43, applied September 3d, 18t5. Right 
eye ; cataract of four years' standing, following retinal separation. No 
light perception ; refraction of eye, high grade of myopia. Left eye, 
myopia = ^. Retinal separation in its entire upper and outer 
parts. Visual field lost except in a very small upper portion, where he 
counted the fingers with great difficulty. Separation of eight days' 
standing, the visual field could only be determined by the finger test, as the 
amount of vision did not admit of the use of a perimeter. The first and 
second operations did not produce any change, they being made within 
one week of each other, as so little irritation existed. The third opera- 
tion yielded good results. The retinal tear could be now for the first 
time distinctly seen ; also considerable amount of fluid drained from the 
sclerotic opening immediately after the withdrawal of the needle, followed 
by low tension of eyeball. I am inclined to believe that the two preceding 
operations did not tear the retina, as the ophthalmoscope was carefully used 
to detect it without avail. The patient could read type— Jaeger No. 3, 
Retinal separation had disappeared, and the visual field was restored. 
Very little reaction was caused by the puncture, beyond slight vitreous 
humour cloudiness lasting a very short time. This inij^rovement lasted 
twelve weeks, when the separation again took place, but in the 
lower half of the retina. A fourth operation restored vision to read- 
ing moderate print. This improvement lasted eight days, when separa- 
tion took place at the same point. A fifth and sixth operation caused a 
replacement lasting about eight days after each, when it again re- 
appeared, always now in the lower half. The seventh operation was 



118 Strawbridge, Ophthalmic Contributions. [Jan. 

made on January 8th, 1876, followed by rapid replacement and restora- 
tion of vision to reading power Jaeger 8, for distance Y= ^W, which has 
lasted np to present time, October 23d, 1876 — over eight months. At 
examination made a few days since, I could detect the separation again 
commencing in the lower half. 

A more discouraging case than this could not be supposed. One eye 
entirely lost, the second eye reduced to barely light sensibility as count- 
ing of the fingers was most imperfectly done, where useful vision has been 
given for a term extending over a year, and with a prospect of its being 
still further prolonged. 

The reaction from these repeated operations was very slight. 

Case II.— Miss M., ast. 30, a])plied July 8th, 1875. Left eye: En- 
tire retinal separation of two years' standing. No light perception. 
High grade of myopia. Kigliteye: M=^. Retinal separation upward and 
outward comprising one-third of retina of two weeks' standing, with 
entire defect in corresponding visual field. Read Jaeger No. 11. 

Jul?/ 14. Operation on upper outer quarter, with two needles. Great 
leakage into conjunctival sac. 

15//<t. Restoration of visual field. Reads large print. 

21th. Visual field good. Reads Jaeger 5. Can see the tear in the 
retina by aid of ophthalmoscope. 

8l5^. Improving. Reads Jaeger 3. Good visual field. 

August 8. Reads Jaeger 2. 

April 6, 1876. Seen M. last time. No retrograde either in visual 
field or reading power, nor could any separation be detected with the 
ophthalmoscope. No amount of irritation was caused by the operation. 

Another most unpromising case. One eye lost, and all conditions 
tending to same result in second eye. 

In these two cases it was not ditficult to decide as to the propriety of 
an operation. There was all to gain in both of these cases, but I would 
not be willing, as long as one eye was preserved, to risk the operation on 
the second eye, for fear of sympathetic trouble ; but in cases where vision 
remained in one eye only, and that in such peril, I think the operation 
to be strongly indicated. Both Graefe and Bowman, from their experi- 
ence, concluded that the operation, carefully made, was a safe proceed- 
ing. As to permanent results, their experience showed improvement 
lasting from one month up to several years, in many cases ; in others, 
very little profit, but no serious harm from the operation. It must also 
be considered that these are desperate cases, where little can be hoped 
for, from non-interference. 

For information concerning the literature of the subject, the reader is 
referred to Sichel, Cliniqne Eurojyeene, 1850, No. 29. Kittel, AUgemeine 
Wiener Medicinische Zeitung, 1860, No. 23. V. Graefe, Arcliiv j. Oph- 
thal., vol. ix. p. 85, 1863. Bowman, Ophlhal. Hospital Reports, May, 
1864. L. Y. Wecker, Text-book. 



18*77.] Strawbridge, Ophthalmic Contributions. 119 

III, Optical Delusions in the Insane — probably caused in some cases 
by disease of the Macula Lutea. — The ch'nical history of this case is in- 
teresting from the fact that the optical phenomena were probably caused 
by disease of the macula, retinitis macule ; and as these were a most 
prolific source of annoyance and distress to the person, he considering 
them originating from a diseased mind, the recognition of their probable 
source, as being in the macula and not the brain, proved the greatest 
relief and comfort to the patient. 

Mr. C, agt. 69, a victim of self-abuse from twelve years of age up to 
time of his married life ten years later; also, a moderate user of alcohol. 
Shortly after his first marriage, owing to anxiety caused by the sickness of 
his wife, and want of sufficient means of support, he became troubled with 
mental hallucinations, and was in constant fear of receiving harm from mem- 
bers of his wife's family, owing to his imagined want of care for his wife. 
This disordered state of mind lasted nine months, during which time his wife 
died. He then sufficiently recovered to resume his business, and married 
a second time. Worry from pecuniary troubles caused a return of his 
old hallucinations for some ten months, when he again recovered and 
kept well until the death of his second wife, which loss entirely upset 
his mental powers for some months, then for a year had a compara- 
tively clear mind, followed by an attack of religious excitement, imagin- 
ing himself to be an Anti-Christ. Gazing for some ten minutes one day 
on the sun, thinking it to be a divinity, he noticed immediately after- 
wards a black spot. This condition lasted constantly for two weeks. 
Then from this spot appeared light seintilhitions, changing into light 
circles, and nine months later changing into a face, having a hideous 
grin, and constantly mocking him. During this time the eyes were sen- 
sitive to light, and painful from exposure or any amount of work. From 
that time up to the present this face has been his constant companion, 
and is a constant source of terror to him — as he of course attributes its 
origin to a diseased mental condition, and its continual presence a con- 
stant proof of his incurability. 

Status Presens of the Eyes. — Right eye, vision = fg. Visual field 
greatly lessened in extent, particularly in vertical meridian, with small 
central scotome, also sensitive to light. 

Ophthalmoscopic Examination — Atroi)hic excavation in the temporal 
side of optic papilla, with a greenish rim around the outer half of the 
sclerotic foramen, the arteries small and some tortuosity of the retinal 
veins. The macula appears as an ellipsoid figure filled with distinct black 
dots; in some places several of these dots appear to coalesce, forming 
small black patches. The change is most marked, and would be con- 
sidered as caused by inflammation in the retina and choroid at this part, 
(Retinitis Maculse), and readily accounting for the central scotome. 

Left eye shows the same changes that have been described as existing 
in the right eye. 

From the fact of the existence of this marked macula change, with the 
accompanying central scotome, I felt warranted in telling the patient 
that most probably the existence of his tormenting companion — the face 
with the hideous grin — was due to ocular disease rather than of brain 
origin, thereby greatly relieving his distress. Of course it is impossible 
to speak with certainty in u case of this kind, but at the same time the 



120 MacGregor, Case of Urinary Calculi. [Jan. 

above explanation seems, under these existing conditions, at least to 
be probably the correct one. 

I have endeavoured to enlarge my experience since meeting with this 
case, but find that insane patients with optical delusions are the rare 
exception, and I must content myself at present with the history of this 
one case. 



Art. XYII. — Extraordinary Case of Urinary Calculi. By J. R. 
MacGregor, M.D., of New York City. 

The following case is brought to the notice of the profession, under 
the belief that it presents some rare and remarkable features. 

It is not unusual to see in pathological collections, specimens of calculi 
that are noticeable either for size or number, or perhaps both ; but the case 
about to be narrated may be safely asserted to be, in both the qualities 
mentioned, as well as some other peculiarities, if not unique, at least 
extremely uncommon. 

I was called in May last to see Mrs. B., aged 63, married, who was 
suffering from symptoms referable to the bladder, among which, pain and 
difficulty in urinating were prominent, and accompanied with considerable 
constitutional disturbance, manifested by fever and nausea. Her general 
condition was enfeebled, and she had been in poor health for several 
years. According to her own statement, she had not at any time ex- 
perienced an attack of kidney colic. I was shown a box containing 
upwards of three hundred calculi, varying in size from that of an ordinary 
shot, up to a large bean ; these she had passed by the urethra during the 
past four years. They were of various shapes, and from attrition, had 
been worn down, presenting facets beautifully polished ; many of them 
assumed a cuboidal form. In colour they varied from a yellowish-brown, 
to that of fawn mixed with gray, and were more or less mottled. 

A vaginal examination revealed the presence of a hirge number of 
apparently the same kind of concretions, seemingly occupying nearly the 
whole cavity of the bladder, and the mass from its bulk pressing down 
upon the superior wall of the vagina, encroaching upon its calibre, and 
altering the direction of the urethra so much, that a catheter to be intro- 
duced required to be pointed markedly downwards. 

Two or three days of appropriate treatment rendered her condition 
sufficiently comfortable to warrant an operation for extraction ; and after 
a gradual dilatation of the urethra by means of large-sized bougies, which 
process occupied a period of four days, the blades of a pair of uterine 
dressing forceps were introduced into the bladder, and a finger of the left 
hand passed into the vagina as a guide ; none of the stones, however, could 
be seized, and after repeated and protracted efforts to no purpose, the 
operation for the time was relinquished. The cause of the failure will be 
apparent in the su!)sequent history of the case. 

The degree of pain and general distress following the attempt at re- 
moval so discouraged the patient, that during the whole summer she could 



187Y.] MacGregor, Case of Urinary Calculi. 121 

not be prevailed upon to submit to a second operation, and, as before, she 
continued to pass calculi at short intervals, 

A visit to the country of some three weeks, undertaken with a view of 
improving her health, resulted in no benefit, and her condition became so 
miserable, that on the 19th of September, she voluntarily came to my 
office and proposed submitting again to an operation. Arrangements 
were accordingly made, and two days subsequently, a second effort was 
attempted, in which I had the valuable aid of my friend, Dr. W. H. Stud- 
ley, of this city. 

Anaesthesia was produced at first by chloroform, and afterwards kept 
up by ether; dilatation of the urethra was initiated by the introduction 
of a large gum-elastic bougie ; this was rej^laced by one of flexible metal, 
calibre No. 26, American scale, which rendered it not difficult to insert a 
two-bladed anal speculum into the urethra. The blades were expanded 
cautiously and gradually, and in the course of twenty minutes, the urethra 
became sufficiently distended to admit a steel scoop without removing the 
speculum ; no calculi, however, could be engaged, and, moreover, it was 
noticed that the metallic sound of contact with them was absent. The specu- 
lum was then withdrawn, and the finger of the operator passed into the blad- 
der: it was then discovered that the calcarous collection was apparently 
inclosed in a cyst, but as far as the finger could reach, no opening communi- 
cating with the cavity of the bladder was discoverable. At this juncture, a 
hasty consultation was held, in which it was decided to make an opening 
through the wall. This was accomplished with some difficulty, and the finger 
then could be brought in direct contact with the concretions, and a couple 
somewhat larger than a graiu of corn were extracted; examination then 
revealed the presence of a stone of large dimensions, which had been con- 
cealed by the smaller ones, and prevented the further removal of the latter 
by their retreating behind it out of reach. It was impossible to estimate 
the bulk of the former, but from the size of the presenting part, it was 
evidently too large to admit of removal, and all farther attempts were 
abandoned. 

During the operation, the anfesthetics had acted very kindly ; respi- 
ration and the action of the heart went on regularly ; but, while recovering 
from insensibility, sudden and alarming syncope came on, in which both 
respiration and pulsation ceased: active measures were promptly resorted 
to, which succeeded in a short time in restoring her. 

The local pain referable to the urethra and bladder subsequently was 
considerable ; in this, aside from the administration of anodynes, she de- 
rived the most relief from vaginal injections of hot water. The urine 
drained off continuously by drops. 

The patient did not fully react from the effects of the operation ; symp- 
toms of peritonitis soon developed, with protracted vomiting and increasing 
prostration. Death took place on the 23d, 48 hours after the operation. 

Post-mortem, 72 hours after death.— This, from reasons not necessary 
to state, was more limited in extent than was desirable. Rigor mortis 
well marked : some tumefaction of the abdomen. On exposing the ab- 
dominal cavity, the small intestines, presented numerous inflammatory 
patches of an arborescent form, upon some of which were thin layers of 
exudation lymph ; these here and there had agglutinated the intestines 
together. The amount of intestinal distension was only slight. The 
same inflammatory process had extended to the peritoneum of the abdomi- 
nal walls. Occupying the ordinary position of the bladder, which it was 



122 MacGregor, Case of Urinary Calculi. [Jan. 

at first supposed to be, was a large tumour, reacbiug nearly to the umbili- 
cus, and presenting much the appearance of an enlarged uterus during 
gestation. This mass contained the calculi, and on removal, proved to 
be the left kidney; the pelvis of which had become thickened and distended 
into an enormous sac. The body of the organ had undergone little or no 
structural alteration ; it had changed shape, however, being flattened out 
on its transverse diameter, evidently from gradual accommodation to the 
enlarged pelvis. Its secretory function was apparently unimpaired; several 
ounces of urine escaping from the sac when opened. At the lower portion 
was an opening about an inch in length, corresponding to a similar one 
through the superior portion of the bladder ; these were made at the ope- 
ration for removal during life. 

The sac contained upwards of five hundred and twenty calculi, of a size 
varying from that of a mustard seed to an almond, and a very large one, 
which in its recent state weighed /i/h/-o??e ounces ; it was oval in shape, 
with the lower portion posteriorly bevelled off nearly to an edge, and 
polished by friction with the smaller ones: most of the latter were in this 
portion of the sac; a few, however, were in the superior part, and the 
upper end of the stone presented a small area of surface similarly polished. 
Its dimensions were, length, 6f inches ; greatest circumference, 16f inches; 
circumference around the transverse diameter, 121 inches. The compo- 
sition is supposed to be (no section as yet having been made) uric acid, in 
alternate layers with earthy phosi)hates: that part of its surface which was 
in contact with the smaller calculi, presents the brown colour characteristic 
of uric acid, and the rest of the surface nearly white with phosphatic in- 
crustation ; in which are thickly imbedded crystals of the ammoniaco- 
magnesian phosphate. The smaller calculi, upon section, show finely 
alternating layers of uric acid and phosphates; the nuclei being composed 
of the former substance. 

In considering the features of the foregoing case, the writer is fully 
aware that, had the actual condition been known as revealed by the 
autopsy, surgical interference would have been unjustifiable; and in this 
connection, the question might possibly arise, could it not have been fore- 
told ? He can only answer, that with the light that was in him, every 
endeavour was made to comprehend all that could be known in a case beset 
with hidden danger ; in his opinion of such a nature as it would be rea- 
sonable not to look for, even if, a priori, it would be regarded as possible; 
and in the judgment formed, he was fortified by that of a gentleman in 
whose opinions, from long experience, he has learned to place the greatest 
reliance. That part of the history to which this question refers, could 
have been conveniently omitted, but not without detracting much from the 
instructive value of the case. Recognizing, therefore, the })rinciple that 
the facts of important cases belong to the profession, he has ventured to 
include the whole, at the risk, perhaps, of adverse criticism. 

153 East 83d Street, " 



18T7.] Robinson, Aphonia of Ten Months' Duration. 123 



Art. XVIII. — ApJwnia of Ten Months^ Duration from Paralysis of the 
Ay^ytenoideus Proprius Muscle, with Concomitant Heart Disease 
{Aortic Obstruction) ; voice restored by the direct application of elec- 
tricity to the vocal cords. By Beverley Robinson, M.D., one of the 
Physicians to Charity Hospital, New Yorlv. 

L. S., eet. 42, single, residing at Sharon, Connecticut, was placed under 
my care on May 22, 18*16, through the courtesy of Dr. C. R. Agnew of 
this city. 

She has always enjoyed good health. Four years ago, in consequence 
of prolonged exposure to cold, she suddenly lost her voice. Two or three 
months afterwards it came back spontaneously. In the month of August, 
1875, her voice again disappeared, and still apparently from the effects of 
a cold. This time she did not recover it, and she consulted a physician, 
who considered her case to be one of functional aphonia, and made exter- 
nal applications of the faradic current to the throat. This treatment 
remained without effect. 

Actual state. — Patient speaks in a whisper; no local pain over or in 
the larynx; antecedent history good; general health excellent; hearing 
impaired for some years. 

Pharynx. — Slight catarrhal condition. 

Larynx. — In phonation inter-ligamentous portion of glottis approxi- 
mates well. Inter-arytenoid portion does not reach the median line, but 
leaves a triangular open space, with base of triangle looking posteriorly 
towards wall of pharynx. Inter-arytenoid fold slightly thickened; ven- 
tricular bands somewhat congested. 

Treatment. — Application to larynx of ferri perchlor. (Sij-'Sj)- Caps, 
cubebse (10 grs.), six a day. Troch acid, benzoici one t. in die. 

31ay 25. The faradic current w^as applied for the first time to the aryte- 
noideus muscle, and continued every other day until June 9. 

June 1. The medicine above mentioned was omitted, and -^^ grain of 
strychnia with a grain each of pyrophosphate of iron and quinia was ad- 
ministered tliree times a day, and local applications of a solution of nitrate 
of silver (gr. xx-3j) were made twice to the larynx from May 25th to 
June 9th 

^th. Could speak throughout the day in a moderately good tone of 
voice and without great effort. During the night, however, she loses her 
voice, and is unable to talk louder than a whisper on awakening in the 
morning. Treatment by faradic electricity and strychnia is continued. 

Ibth. The following notes were taken : Yoice continues to improve, 
although still weaker than formerly. She does not lose it in the night, 
and on rising can talk tolerably well. At first, however, she is obliged to 
make more effort to articulate distinctly than afterwards. When my 
patient lost her voice last August (ten months ago) she felt a dull pain 
situated profoundly at the base of the neck, just above the clavicle, on the 
left side. At present she has another focus of pain in the left mammary 
region. The pain here is very similar in character to that still persisting 
at the base of the neck. Pain in the regions named is much augmented 
by even slight pressure. By palpation and percussion nothing abnormal 
is discovered, and no swelling is noticeable. Auscultation shows normal 
respiration, but reveals a distinct, rather rough bruit at the base of the 



124 Robinson, Aphonia of Ten Months' Duration. [Jan. 

heart, accompanying the first sound, and propagated into the arteries of 
the neck. The diagnosis of "aortic obstruction" is made, and, upon in- 
terrogating my patient, T find she has had latterly slight swelling of the 
feet and ankles at bedtime, and occasional palpitations. Since she has 
been under my care she has had several attacks of faintness without appa- 
rent cause, and resembling incomplete syncope. Previously she never had 
had anything of the sort. 

Inasmuch as she is a large, robust, vigorous woman, of sanguineous 
temperament, I thought the tonic remedy she had been taking, by ray 
orders, might have something to do in the causation of these attacks, and 
therefore prescribed elixir of calisaya with quinia in tonic doses. 

A few days later my patient left town, after having visited Dr. Agnew, 
and made known to him the iaiproved condition of her throat, and I heard 
nothing from her until September 9th, when she wrote to me: — 

" T have not forgotten to let you know of my welfare, and I think you will be 
glad to hear that ray voice is now as strong as ever. I can talk, laugh, call, 
read aloud, and use it as other people do, without any inconvenience. But it 
is only recently that it has regained its fall strength, a,nd the improvement has 
been very gradual, so 1 have delayed waiting till I could announce its entire 
restoration. The heart trouble has been much better, so that sometimes for 
weeks 1 have had scarcely a twinge of the old pain, but this week it has shown 
that the foe is still lurking in ambush, and ready for a spring if opportunity 
offers. However, rdo not apprehend any serious difficulty, though, perhaps, 
some annoyance." 

The special interest of this case consists in the connection which may 
possibly be established between the loss of voice and the valvular affection 
of the heart. Yery many instances have been reported already by laryngo- 
scopists of so-called hysterical, or functional aphonia. In some of these, 
hysteria was made apparent, through its usual symptoms; in others, there 
was no substantial reason for making this diagnosis. Frequently the loss of 
voice was traceable in its origin to a cold; but the cold had long since dis- 
appeared, and aphonia persisted. And, under these circumstances, a whis- 
pering voice has remained for months and years, in spite of much and 
various medication. When, however, the faradic current has been applied 
directly to the vocal cords, the voice has sometimes returned in its normal 
strength, after one or two applications of electricity, or again it has come 
back by degrees, and only after persistent treatment of several weeks. 

These two categories of cases have, nevertheless, been included in one 
overcrowded and questionable division of *' cases of functional aphonia." 

From this section, or class, it is time to separate cases where a probable 
physiological ex])lanation may be given of a chronic morbid condition. 
In my patient, although there were no physical signs of aneurism, and but 
moderate enlargement of the heart, there was notable aortic obstructive 
disease, which is frequently accompanied by change of the cardiac muscle 
in the vicinity of the affected valves and orifice. 

Now, this outgrowth is especially due to the production of fibrous tissue, 
which takes place in the more or less hypertrophied left ventricular walls. 
This heterogeneous development, by its nature, teiids towards contraction, 



187V.] Robinson, Aphonia of Ten Months' Duration. 125 

and after this manner will exercise pressure upon vessels and nerves. 
What are the peripheral extremities of nerve in the heart structure, which 
may be affected? 

Evidently the branches from the great cardiac plexus, which derives its 
origin from the pneuraogastric, and from the cervical ganglia of the sym- 
pathetic. In certain cases, therefore, of sudden loss of voice, organic dis- 
ease of the heart may be an efficient cause of its production, and the pre- 
sence of "cold" merely a predisposing one. 

The modus operandi must seemingly be that of reflex paralysis effected 
through certain motor fibres of either vagus. One or more of the intrinsic 
muscles of the larynx may be affected. And the extent and duration of 
the loss of functional power in the vocal organ will, no doubt, depend 
upon the area and amount of pressure exercised within the cardiac walls 
upon nerve structure. It is a well-corroborated fact that the effects 
produced in the action of the vocal cords by pressure due to aneurismal 
tumours of the aorta, are proportioned to the degree in which the vagus, 
or its most important branch (recurrent nerve), becomes involved. At 
times, complete and lasting loss of voice is the consequence. Again, the 
voice comes and goes in a very intermittent and sudden manner. These 
are /acte, and for lack of a better explanation we interpret them to mean, 
in their causation, at least, a more or less complete suppression of nerve 
force generated, occasioned by remote pressure. Thus it may be in in- 
stances of aphonia, brought on in reality, by intra-cardiac change, and 
irritation or pressure of nerve fibres originating directly in the great car- 
diac plexus. Whenever the pressure is slight the voice may be restored 
by one or two direct applications of the faradic current to the vocal cords; 
whenever the pressure is considerable the voice can only be re-established 
(if it be at all possible) by degrees, and after somewhat prolonged use of 
electricity. And the fact of the restoration of the voice for several weeks 
or months is no proof that it will not disappear once more for a time, and 
again return. In questioning a patient with intra-cardiac trouble and loss 
of voice, we should be careful not to be misled by certain symptoms, which 
may be present at the beginning of the aphonic state. Such patients may 
presume they have taken cold, and may even come to the hospital to be 
treated for an affection of the air passages. 

Paroxysms of pain, together with cough, croup-like in character, and 
dyspnoea, due to spasm of the bronchial muscular fibres, may all complicate 
the loss of voice when peripheral nerve fibres of the cardiac plexus are 
irritated. And yet in these symptoms we have not those which are neces- 
sary to the existence of a bronchial inflammatory trouble. Again, my 
explanation of such cases of aphonia, as our preceding history presents an 
example, differs but little from that of aphonia occurring in the incipient 
stage of tubercular disease of the lungs, without any change of the laryn- 
geal mucous membrane. Loss of voice is then ''caused apparently by a 



126 Humphrey, Face Presentation. [Jan. 

reflex irritation of the laryngeal nerves, due to disturbance of the peripheral 
branches of the pnenmogastric by the tubercular processes in the lungs." 

Further, I would remark that my interpretation of so-called functional 
aphonia, when heart disease is manifest, is far less liable to objections, and, 
indeed, far more probable as regards its pathology than interpretations 
which trace connection between aphonia by paralysis of intrinsic laryngeal 
muscles and remote organs, animated by nerve trunks of very different 
origin from those which govern vocal function. 

I shall not dwell upon the existence of pain in my case at the base of 
the neck, and over the priecordial region, further than to refer to the fact 
that this symptom, winch first mauife.sted itself at the period,when the voice 
was lost for the second time, is also fairly attributable to a similar cause 
for its production, and this appears to me to strengthen my explanation 
of the etiology of the loss of voice. 



Art. XIX. — Conversion of Face Presentation info one of Vertex hy Aid 
of Knee-elboiv Position. By J. K. Humphrey, M.D., Snickersville, 
Virginia. 

On Nov. 11, 1876, at 11,30 A.M. I was called to attend Mrs. S., ast. 
20, prim! para. She stated that she had had pain since early in the morning. 
There was great anterior obliquity of uterine ovoid. Examination re- 
vealed OS partly dilated, and head on a level with brim of pelvis, present- 
ing by the face in mento-posterior position. It was decided to be best to 
wait and let the labour take its natural course, viz., rotation of chin to the 
front. At 2.30 P. M. the condition of things was much the same, with 
rupture of membranes added, so I determined to make an effort toward 
converting the face presentation, if possible, into one of the vertex. Hav- 
ing been led to regard the genu-pectoral position with favour as an 
auxiliary in certain cases of podalic and cephalic version, a trial was made 
of it in this case, but owing to insufficient dilatation of os, it had to be 
abandoned. 4.30 P. M., Dr. R. Hoge in consultation. Examination 
now showed that the os was more fully dilated, and that the chin had 
rotated toward the sacro-iliac junction. The pains at this time were 
tolerably strong, and we waited awhile to see what the powers of nature 
would accomplish unaided. Between 5 and 6 o'clock — the woman had 
changed her position in the mean time — the chin was found facing almost 
directly the anterior surface of the sacrum, and not engaged in the exca- 
vation. The intervention of art seemed to be now called for; so at my 
proi)osal we decided to try, for the second time, conversion of the pre- 
sentation to one of the vertex. Accordingly we placed some pillows 



1877.] Humphrey, Face Presentation. 127 

under our patient's knees, at the same time letting her breast and head 
rest on the bed ; thus bringing her body at an angle of about 60° with 
the horizon, and her buttocks well to the edge of the bed, I then with 
little difficulty introduced ray hands into the uterus, and getting my fin- 
gers well over the vertex, succeeded in flexing the head on the breast and 
bringing it into left occipito-anterior position. The case afterwards did 
well but progressed slowly, terminating at 2 A. M. that night. 
Cazeaux/ in treating of mento-posterior position, says :— 

" It is well known that a spontaneous delivery in face-positions requires that 
they should be converted into mento-pubic ones, but this process of rotation, 
which is easily effected in the mento-anterior varieties, that is to say, in the 
cases where the chin v/as primitively in relation with some part of the anterior 
half of the pelvis, is much more difficult in the mento-posterior positions, and 
sometimes even it does not take place at all." 

He then gives a hypothetical case of mento-posterior position, very 
closely resembling the case just related; and recommends its conversion 
into one of the occiput, laying down for that purpose a rule for intra- 
uterine manipulation which was followed in the present instance; after 
which he passes upon it this withering condemnation : — 

" I am now convinced that this manoeuvre will rarely prove successful, there- 
fore it should be attempted very carefully and pelvic version substituted for it 
without much delay." 

It must be remembered, however, that the manceuvre given by Cazeaux 
was intended by him to be used in the dorsal position of the w^oman, as 
he has not hinted at any other. It is the writer's conviction that Cazeaux, 
had he used the procedure in connection with the knee-elhow position of 
the woman, would have had less cause to be dissatisfied with it. He (the 
writer) believes that in mento-posterior positions where rotation fails to 
take place or does so very slowly, and even in other face presentations, 
if the pelvis is not of ample proportions, it would very generally be wise 
to make use of it; feeling confident that it would often substitute an easy, 
natural labour for one tedious and painful, not to say dangerous, to 
mother and child. 

He also ventures to state, judging from his own case, that, by aid of 
gravitation conferred by the knee-elbow position, the accoucheur will be 
able to eflfect a change of presentation with comparative ease to himself 
and his patient. 

^ Ther. and Prac. Midwifery, 5th Amer. ed., p. 845. 



128 Webb, Case of Multiple Emboli. [Jan. 



Art. XX. — Report of a Case of Multiple Emboli caused by Organic 
Disease of the Heart, and producing Nutritive Changes ; Atrophy of 
one Arm and Gang^rme of one Leg. By W. H. Webb, M.D., of 
Philadelphia. 

Miss G-., 49 years of age ; her constitution and general health had been 
tolerably good until about fifteen years ago, when she noticed that she had 
attacks of numbness of both arras, which were relieved by frictions, and 
would pass off in a few days, to recur in from three to six months. She 
was also affected during this time with dyspepsia and attacks of nausea. 
Her father and two paternal uncles died of heart disease, the former quite 
suddenly and without premonition ; her mother is still living and is de- 
mented. During September, 1874, she was troubled with nausea, vomit- 
ing, and palpitation, with difficulty of breathing, which prevented her from 
assuming the recumbent posture for several weeks; there was svvelling of 
both feet and ankles during this time. About June 15, 1875, she was 
again attacked with nausea, vomiting, palpitation, and dyspnoea, which 
continued some six weeks, after which she enjoyed tolerably good health 
until the latter part of December, 1875, when, in getting out of bed, she 
found that her left arm was powerless, and was very painful for several 
days thereafter. Power gradually returned, and in about a week she had 
control of her arm, but the use of it was defective, and sensation was im- 
paired. 

About the middle of January, 1876, she was attacked with a severe 
pain in the right hypochondriac region, which came on suddenly and 
lasted about two hours; no jaundice followed, but the next day she was 
paler than usual. On February 1, 1876, she was seized with severe 
pain in the left leg, lasting some hours and leaving the foot cold and numb, 
which was relieved after considerable friction had been employed. There 
was no discoloration of the limb. 

When I saw the patient, March 22, 1876, she was in bed complaining 
of nausea, shortness of breath, and palpitation. She was very thin, which 
was her habit, her colour sallow ; expression anxious ; pulse 120, irregular, 
intermittent, and jerking ; without fever. No pulsation was perceptible 
in either the radial or ulnar arteries of the left arm, the temperature of 
which was less, and the arm was also much smaller than the right one, 
about as six is to eight. Her respirations were 30 ; tongue slightly 
coated; appetite variable; bowels consti})ated ; urine ofsp.gr. 1010, and 
free from albumen. Menstruation ceased about two years ago. Percus- 
sion showed no increase of cardiac dulness. On auscultation, a faint 
systolic murmur was noticed; the first sound was rather dull and pro- 
longed, the second sound lacked sharpness and distinctness, and sometimes 
was not discernible. The heart's impulse was strong, not forcible, and 
was not extended. Diagnosis. — Valvular disease of the heart. 

March 25. The patient complained of severe pain in the right leg, the 
intensity of which was in the popliteal space, and continued with more or 
less severity, when on the morning of the 28tli inst., it was noticed that 
the leg and foot were of a dark-purplish colour, extending to within two 
or three inches of the knee and forming an irregular line at that portioji 
of the limb. Frictions and other remedial agents were resorted to in 
order, if possible, to establish collateral circulation, but proved of no 



isn.] Webb, Case of Multiple Emboli. 129 

avail. The pain was now confined principally to the popliteal space, and 
became excruciating upon the slightest pressure being made in that region, 
though at times the whole limb was painful, the pain being shooting in 
character. The next day the leg from the knee down was cold, and sen- 
sation as well as motion was entirely destroyed, though she complained of 
its feeling very heavy, and in order to obtain ease, she would sit up in bed 
with the limbs flexed, the body bent forward with the head resting upon 
the knees, and in this position she was comparatively free from pain, and 
could obtain some sleep. It was now noticed, that when the finger was 
placed just above the superior margin of the sixth rib, and on a line drawn 
half an inch to the right of the left nipple, the intercostal muscles being 
very thin, the apex beat [ictus] could be distinctly felt, and within the area 
covered by the end of the middle finger this ictus w^as found to be wander- 
ing; that is, it would not occur twice in succession in the same spot, and 
was not influenced by respiration. The leg and foot now became oedema- 
tous, and a bulla began to form on the calf of the leg. 

April 3. The pulse was 90, but in other respects the irregular action of 
the heart was the same ; the pulse in the left radial artery was detected 
for the first time, notwithstanding it was diligently sought for every day 
previously; it was very soft and easily compressible. She complained of 
difficulty of breathing and a constriction of the chest. Her appetite was 
very good. 

lith. The bulla had gradually increased in size to the capacity of 
about three fluidounces, when it was accidentally broken by the patient in 
getting out of bed, discharging a dark-coloured fluid ; the same character 
of fluid continued to ooze more or less for some days, when it became 
somewhat thicker in quality and of a putrescent odour, making it neces- 
sary to use powerful disinfectants in the room. 

20^/l The heart's action remained the same. The discharge from the 
leg was now, and had been for several days past, of a dark-greenish colour, 
and in consistence resembled pus. The toes and a portion of the foot 
were dried and very hard, and resembled those often seen in the anatomical 
room. She was comparatively free from pain in the limb during the day, 
but towards evening it was quite severe, rendering it necessary to give 
morphia sulph. gr. J hypodermically to procure rest. Her appetite was 
very good. 

26^/i. A consultation was had with Prof. Da Costa. On his attention 
being called to the peculiar action of the apex beat, he was of the opinion 
that it was due to a clot in one of the cavities of the heart. 

May 1. The pulse was 100, small, feeble, irregular, and intermittent; 
about 4 o'clock P. M., for several days past, she has had attacks of nerv- 
ousness which were always accompanied by extreme restlessness, for which 
ext. valerian fld. 5ss, and spts. aeth. com p. 5j» were given p. r. n. with 
benefit. She was also now troubled with a severe burning sensation in 
the eyes. Additional treatment, stimulants and generous diet. 

Ibth. Since the last notes of the case her complexion changed very 
much, being now of a yellowish hue. The restlessness was now and had 
been more severe for several days past; the pulse 100, not so feeble as on 
the 1st inst., the heart's action remained the same ; the oozing from the 
leg was not so profuse, and was now mixed with pus which was profuse, 
the latter coming from the line of demarcation. She complained of in- 
tense pain which was referred to the calf of the limb, shooting to the toes, 
the latter being dried, shrivelled, and so hard that an indentation could 
No. CXLY.— Jan. 187t. 9 



130 Webb, Case of Multiple Emboli. [Jan. 

not be made in them with the finger nail. She seemed quite refreshed in 
the mornings, especially so after a hearty breakfast. The hypodermic use 
of morphia was continued every night. 

June 1. The patient had been troubled with nausea and considerable 
headache, and also a burning sensation of the cutaneous surface of the 
whole body for some days past. The sloughing process at the line of 
demarcation was now quite rapid, and she insisted that most of the pain, 
which was almost constant, was below the point of vitality. The irregular 
action of the heart was the same; bowels obstinately constipated; appe- 
tite very good. The bowels were relieved by enemata. 

\btli. The burning sensation of the skin has been absent for the past 
two weeks. The pain in the limb was now more severe than ever, and 
she stated that it extended into the toes, which were as hard as marble. 
It was evident that the sciatic nerve had sloughed oft' just above the divi- 
sion of the internal and external popliteal nerves, as the bones just below 
that point were exposed to view when the pus was removed, and they 
were necrosed and eroded for a considerable distance around. 

July 1. The pain in the limb had not been so severe for the past few 
days; she complained now of nausea, and eructations of a very fetid 
odour, resembling that emanating from the diseased limb. The fibula 
was eroded through, and the tibia could very easily be broken off at the 
point of erosion. The heart's action was now so tumultuous that the 
pulse could not be counted, and pulsation of the vessels of the neck was 
quite perceptil)le ; the patient becoming exceedingly restless towards eve- 
ning and quite impatient until she received a hypodermic injection of 
morphia. 

13//?. Stercoraceous vomiting set in about 4 P.M., and continued at 
intervals until 7 J o'clock P.M., when she died of exhaustion. 

With the kind assistance of Dr. A C. W. Beecher, who also saw the 
case several times during life, the autopsy was made twenty hours after 
death : rigor mortis fairly marked, body considerably emaciated, left arm 
much atrophied. The suppurative action at the line of demarcation of 
leg had extended so far into the bone that in manipulating the body, the 
gangrenous limb broke off through the bone at that point, so that spon- 
taneous amputation was rapidly going on and would have been completed 
in a very few days had the j)atieiit lived. The thoracic cavity was opened, 
the right pleura contained about a pint of serum, and the cavity ex- 
tended about one and a half inches above the clavicle of that side, pro- 
bably due to the upward pressure of the lung when encroached upon 
by the fluid. In the left cavity but little fluid was found ; there were 
present many old adhesions ; the lungs of both sides appeared to be 
healthy. The heart occupied its normal position, was somewhat etdarged, 
and the pericardium was adherent to the heart throughout, except where 
it covered the roots of the great vessels. Section of the heart showed 
somewhat thin and flabby walls, the right side presented nothing abnormal 
at the tricuspid valves, but the semilunar (pulmonary) valves were some- 
what thickened. Tlie left side showed a large calcareous deposit upon the 
posterior leaflet of the mitral valve, which extended into the substance of 
the auriculo-ventricular septum ; the valves were thickened and stiff. The 
aortic valves were slightly thickened, the Aurantian corpuscles contained 
calcareous matter ; the aortic orifice was narrowed by adhesion of a por- 
tion of the margins and sides of two of the valves^ evidently from inflam- 
matory action ; one of the leaflets was fenestrated. In the appendix 



18Yt.] Atlee, Pelvic Adhesions in Ovariotomy. 131 

auriculae of the left side was quite a large plate of inflammatory lymphous 
deposit, which evidently was quite old, as it required considerable force for its 
detachment. The aorta bore evidences of atheromatous deposit, its inner 
coat was deeply stained with the colouring matter of the blood. About three 
inches of the left brachial artery were removed, its calibre was occluded in 
the upper portion and the vessel generally was smaller than normal ; the 
inner coat was separated from the middle coat and resemWed one tube 
contained loosely inside of another. The femoral artery of the right 
thigh was removed from about the middle of Scarpa's triangle to a few inches 
below the profunda, and was found to be smaller in size than normal, but 
its calibre was not occluded. The inner surface of the vessel was deeply 
coloured with the colouring matter of the blood, and was very rough, 
apparently from lymphous exudation. Its coats were separated in the 
same way as the brachial. 

The popliteal artery was removed, and where it entered the gangrenous 
leg had been spontaneously divided, its coats were also separated like the 
other vessels examined. 

Remarks — Nutritive changes due to emboli must be a result of ex- 
tremely rare occurrence, for, after looking carefully over the various medical 
journals — the Medical Times and Gazette, Edinburgh Medical Journal^ 
the Lancet, and American Journal of the Medical Sciences, the reports 
of the London, Guy's, St. George's, and St. Bartholomew's Hospitals — 
nothing was found bearing upon the subject, neither do I find reference 
made to it by Hayden or Balfour in their recent works on the heart. 

Equally rare must be the cases of wandering ictus or apex beat, as no 
reference to it could be found in the literature above referred to, but then 
this may be accounted for, in part, by the fact that cases are not often seen 
where the intercostal muscles are so delicate and thin as was the case just 
recorded. 



Art. XXI Pelvic Adhesions in Ovariotomy. By Walter F. 

Atlee, M.D., of Philadelphia. 

I have seen recently a very interesting and very remarkable case of 
ovariotomy in the practice of my father, Dr. John L. Atlee, of Lancaster, 
which is worthy of record, as showing the best course to follow when in 
attempting to remove an ovarian tumour we find the cyst has inseparable 
adhesions to important organs in the pelvis. 

In the well-known works on ovarian tumours and ovariotomy by 
Peaslee, Spencer Wells, and Dr. Washington L. Atlee, the proper 
course to follow when this complication is encountered is not definitely 
pointed out The reason is, that such cases are rare. In an extended 
search I have met with the following only : — 

In Mr. Spencer Wells's "Fifth Series of One Hundred Cases," in vol. 
Ivi. of the Medico- Ghirurgical Transactions, among the cases appended in 
which ovariotomy was commenced but not completed are the following : — 



132 Atlee, Pelvic Adhesions in Ovariotomy. [Jan. 

No. 2. Multilocular cyst emptied and partly removed ; the remainder 
adherent to rectnm, uterus, and pelvis generally, stitched to the opening 
in the abdominal wall, which was partly left open for drainage. Died 
on the tenth day. 

No. 3. A burst cyst, and ovarian fluid free in the peritoneal cavity 
partly removed ; the lower segment of the cyst generally adherent be- 
hind the uterus stitched to the lower edges of the wound and drained. 
Died on third day. 

No. 5. Peritoneal fluid removed ; bunches of the grape-like cysts 
drawn out. Part of a large cyst firmly adherent in the pelvis not sepa- 
rated, but secured outside by a large clamp. Died eleven days after. 

In his Diseases of the Ovai^ies, vol. i. page 220, the same distinguished 
surgeon relates a case (Case LXXXVL) where the tumour adhered so 
closely to the left iliac fossa that it was impossible to separate it safely ; 
the adherent part was secured for the moment with a clamp, and the 
cyst cut away ; before closing the external incision, Mr. Wells transfixed 
and tied the portion of cyst which had been left adherent to the left iliac 
fossa and sigmoid flexure of the colon, leaving the ends of the ligatures 
hanging out of the lower angle of the wound. Some time in May (the 
operation was performed on the 6th of March) the discharge, according 
to Mr. Teale, was feculent for two days. The ligatures came away May 
31st, and after this the patient considered herself as well. She came to 
London in October, and except a very slight oozing of pus from the 
lowest point of the cicatrix, appeared to be perfectly well. 

In vol. Iv. of the Medico- Chirurgical Transactions is an article by 
Mr. Timothy Holmes, on the Surgical Treatment of Suppurating Ovarian 
Cysts, and on Pelvic Adhesions in Ovariotomy. The author says : — 

" xinother interesting question in ovariotomy, illustrated by this case, is how 
to manage cysts which are so adherent in the pelvis that they cannot be pulled 
away without too much danger. In this instance any persistent attempt to 
have dissected or torn the mass away from the pelvic outlet would probably 
have ended in laceration of the ureters or great veins, and might, after all, have 
been futile. The alternatives are to pull the cyst as far as possible out of the 
abdomen, and apply a clamp to its neck ; or, to apply a clamp temporarily, cut 
away the cyst, sear the cut edges with the cautery, and return the mass into 
the abdomen ; or, instead of the cautery, to use ligatures for the purpose of 
restraining hemorrhage from the cut edges of the cyst; or, finally, to stitch the 
edges of the cyst to the wound in the abdomen, and leave the cavity of the cyst 
exposed. 

"I have no doubt of the superiority of the first method when it is practi- 
cable; that is, when the neck of the cyst is thin enough to be embraced in the 
clamp. The internal surface of the cyst is thus brought into contact, and may 
adhere and obliterate the cavity, as seems to have occurred in our patient. If 
this does not take place, at any rate the resulting inflammation, during the 
healing of the wound, will probably exclude the mass from the peritoneal 
cavity just as effectually as if the edges were stitched to the wound ; whilst the 
plan is free from the dangers incurred by leaving the remains of a suppurating 
cyst free in the pelvis, and those resulting from the irritation of ligatures in 
the pelvic cavity. Mr. Wells related a case of this kind, in which the con- 
tinued presence of the ligatures set up abscess, which burst into the rectum 
and produced fecal fistula {Diseases of the Ovaries, vol. i. p. 220; Glasgow 
Medical Journal, February, 1868, p. 381). 



18*77.] Atlee, Pelvic Adhesions in Ovariotomy. ]33 

"The case before us was an example of complete, and, I must allow, unex 
pected success. I expected that when the clamp and pins had been removed 
a suppurating sinus would be left proceeding from the interior of the cyst 
which would only gradually dry up, if at all." 

The patient, nearly a year after the operation, had remained well ; 
the sides of the sac which had suppurated having united when pressed 
together, and obliterated what remained of the sac. In this case the sac 
adhered on the left side so firmly to the brim of the pelvis, that it could 
not be extracted without too great risk to the iliac vessels and bladder. 
I would remark here, that Mr. Wells relates his case in such a way that 
I do not learn that fecal fistula resulted. In his case, as told before, he 
transfixed the portion of the cyst adherent to the left iliac fossa and sig- 
moid flexure of the colon, and tied, leaving the ends of the ligatures 
hanging out of the lower angle of the wound ; after a time, according to 
Mr. Teale, there was a feculent discharge /or two days. 

The case of my father, which has been the occasion of this article, I 
now give in his own words : — 

" Early in February, 18-tfi, I was called to see Miss A. M. W., aged 
42, tall in stature, and somewhat emaciated, in consultation with Dr. I. 
M. Dunlap, of Manheim, in this county. She was represented as labour- 
ing under an enlargement of the abdomen, which he supposed was caused 
by an ovarian cyst. At my visit, to our surprise no abdominal tumour 
could be. found. It appeared that on the day previous to ray visit, and 
after an external examination of the abdomen by Dr. D., she had had a 
very copious discharge of urine from the bladder, amounting to several 
pints, and that during the night the abdominal enlargement had disap- 
peared. 

"An examination of the vagina discovered the os uteri in the left and 
posterior portion of the pelvis, barely tangible with the point of the 
finger, and apparently firmly fixed in that position. The brim of the 
pelvis was filled with a firm mass, and the fundus uteri could not be felt, 
nor could I introduce the uterine sound to ascertain its position. An 
examination, per rectum, showed that all the parts in the brim of the 
pelvis were occupied by a mass of abnormal matter, firm and unyielding. 

"On the nth February I visited the patient again, and found the 
abdomen considerably enlarged, especially on the left side, with evidence 
of fluid on percussion. This fluid was encysted ; but within it I found 
a tumour as large as a cocoa-nut, elastic and firm, into which I introduced 
a French exploring trocar, and drew off about six ounces of a viscid 
semi-transparent, yellowish fluid, which strongly coagulated with heat, 
and also with nitric acid. The pelvic cavity was in the same condition 
as before. Soon after leaving the patient that evening, she commenced 
discharging large quantities of urine, amounting to at least seven or 
eight pints during the night, and the abdominal enlargement again sub- 
sided. The urine discharged was free from any trace of albumen. This 
state of things continued more or less frecpiently during the months of 
March, April, May, and June, more especially at and near the time of 
her menstrual periods. In the mean time the cyst which I had tapped 
became gradually enlarged, and having no doubt respecting its character 
as ovarian, preparations were made for its removal on the 20th of July. 



134 Atlee, Pelvic Adhesions in Ovariotomy. [Jan. 

The inducement for this was that her health was gradually declinino:, the 
emaciation increasing, and exercise and labour of all kinds very fatiguing. 
She was also extremely anxious for the operation. On that day, as- 
sisted by my son, Dr. John L. Atlee, Jr., Dr. Welchens, and also by Dr. 
Wilson, and in the presence of Drs. Dunlap, Sr, and Jr., Parry, and 
Mr. Heinitsh, I proceeded to the operation after the usual preliminary 
preparations. On opening the abdomen in the linea alba to the extent 
of four or five inches, the cyst wall presented itself, of the usual cream 
colour and thickness. There were no adhesions between the upper por- 
tion of the cyst and the abdominal wall. It was then tapped with a large 
trocar, and about four pounds of a highly albuminous and viscid fluid 
removed. In passing my hand down between the cyst wall and abdomi- 
nal peritoneum, I found the inferior third of the ovarian cyst very firmly 
adherent to all the viscera of the pelvis, and impossibility of removing 
it without endangering the integrity of the bladder, uterus, lower colon, 
and rectum, and also the pelvic bloodvessels. Grasping the cyst firmly, 
I could have elevated the patient from the table, so intimately did it 
adhere. 

" The question here arose : What should be done ? To return the 
whole cyst into the abdomen and close the wound would, even if the pa- 
tient recovered from the immediate effects of the operation, entail upon 
her a continuance of her disease, and necessarily shorten her life. I 
therefore concluded to brii.g out as large a portion of the cyst as pos- 
sible, surround it with the clamp, and cut it off, trusting that by a 
very careful attention to closing the abdominal walls accurately around 
the cyst by the interrupted suture, the necessary peritoneal inflammation 
which would result would seal the peritoneal coat of the ovary to that 
lining the abdominal wall, and in a day or two seal up the general peri- 
toneal cavity. This was then done, and after the usual attention with 
compresses and bandages the patient was put to bed. Without entering 
into details, I will only say, that at no time did any untoward symptoms 
arise. There was the usual moderate reaction which always occurs in the 
most favourable cases of ovariotomy. On the 24th of February, fifth day, 
the clamp was removed, and I then found that the general cavity of the 
abdomen was completely secured by the union of the surfaces above 
mentioned. No adhesion whatever had occurred between the opposing 
surfaces of the membrane lining the interior of the cyst ; and there was a 
very considerable discharge of fluid from its cavity. To lessen this there 
was a daily application of a saturated solution of nitrate of silver applied 
to the whole interior surface by means of a bushy camel's-hair pencil, fol- 
lowed by solutions of carbolic and salicylic acid, alternately, as seemed 
most needed to prevent septicsemia. About this time I was informed 
for the first time that in November, 1875, while attending to business in 
Philadelphia, on a cold, damp day, she felt chilly, and stood for some 
time over a heat-register; soon after which she had a severe chill, fol- 
lowed by high fever and severe pain in the lower portion of the abdomen, 
back, and thighs, making it necessary to return home. Her legs 
became so stiff and swollen that she could scarcely walk ; had coldness 
of the lower extremities, while she perspired over the rest of the body. 
Two weeks after this she had an attack of pleurisy, which lasted two 
weeks. She then felt a bearing-down pain in the bowels. 

"On the 10th January, 1876, she first perceived the tumour in the 
abdomen, and sent for the family physician, Dr. Dunlap, who continued 



ISn.] Atlee, Pelvic Adhesions in Ovariotomy. 135 

to treat her with anodynes to relieve pain, and alterative treatment until 
I was sent for. 

'* It was only now that I was able to comprehend the mystery in her 
case, and the peculiar circumstances connected with the occasional en- 
largement of the abdomen and its disappearance. She must have had a 
very serious attack of pelvic cellulitis in November, followed by copious 
extravasation of coagulable lymph, which sealed all the parts together, 
as if a pot of glue had been poured into the pelvic cavity. In addition 
to this I think there must have been a formation of false membrane con- 
nected with the surface of the peritoneum, under which there was a 
secretion of serous fluid, which every now and then was ruptured, and 
the contents, passing into the general cavity of the peritoneum, were 
absorbed and discharged by the kidneys. In no other way can I account 
for the immense discharges of urine (from seven to twelve pints in a few 
hours) which so frequently occurred. It is also most probable that pre- 
vious to her visit to Philadelphia in November cystic development of 
the ovary had already commenced, which, if it did not invite the pelvic 
cellulitis, was influenced to a more rapid development by it. 

" The progress of the case, after the use of the caustic, has been very 
gradual. By degrees absorption of the lymph effused has been going on, 
until the viscera of the pelvis have been restored to their normal con- 
dition. An examination in the latter part of August showed the uterus 
in its normal position, and a finger introduced into the bottom of the 
cyst readily perceived the fundus, which could be freely moved up and 
down between the opposing fingers. As absorption went on, the cyst- 
wall gradually became separated from the adjacent parts in the interior 
of the wound, and was strangulated by ligature and removed. 

" She returned home on the first of September, with her health and 
strength greatly improved, feeling, as she said, perfectly well, except 
somewhat weak, and entirely free from pain As the whole of the cyst- 
wall had not been removed, and occasioned a purulent discharge from 
the wound, she was requested to visit me once in two or three weeks for 
further examination. Her last visit occurred on the 31st October, when 
I found a mass of cyst-wall as large as an eg^j;, which I strangulated 
with a double canula and wire, and wiiich came away November 2d, 
leaving the bottom of the wound ahiiost entirely free from abnormal 
tissue, and the external wound very small and not interfering with her 
general health," 

The study of these cases, I think, will lead to the conclusion that in a 
case of ovariotomy where pelvic adhesions were very firm, the proper 
course to pursue would be not to stitch the cyst to the abdominal wound, 
but to pull the cyst as far as possible out of the abdomen, and apply a 
clamp, cut it off, and close the wound beneath the clamp with the greatest 
care. We may trust that there will be union between the opposing 
peritoneal surfaces ; and, whether, as in Holmes's case, the sides of the 
sac adhere immediately, or, as in my father's case, the process is more 
gradual, the ultimate result will be entirely satisfactory. 



136 Read, Case of Rabies Felince. [Jan. 



Art. XXII. — Case of Rabies Felinse, treated with Woorara a77d Mor- 
phia ; Death on fifth day. By Ira B. Read, M.D., of New York. 

On Sunday evening, July 16, I was called to see Mrs. H., German, 
fet. 32. I found her in a very nervous and excitable condition, but per- 
fectly rational. The pulse was 112; temperature 102°; tongue moist 
and clean ; respiration normal ; slight perspiration. The eyes were glar- 
ing, and there was an expression of countenance denoting extreme anxiety. 
There was great hyperaesthesia of the face and neck, as shown by the 
irritation caused by the flies which swarmed in the room, and by any cur- 
rent of air that passed over her. She said she '' did not feel sick, but she 
could not eat or drink, and she was afraid." She refused to make any 
attempt to swallow either food or drink ; and the mere mention of water 
would cause her to start back with a wild expression of countenance, and, 
with the lips tightly closed, there would be a spasmodic action of the 
muscles of deglutition for a minute or two, when she would become more 
quiet. When a cup of water was offered her, she would spring forward 
and dash it to the floor, complaining that it was not right to give it to 
her when we knew she could not swallow it. 

On further inquiry I learned the previous history of the case, as fol- 
lows : On Thursday, June 15, while weeding in the garden, a cat had 
sprung from the weeds and fastened its teeth in the woman's neck. She 
was very much frightened, and immediately proceeded to the nearest phy- 
sician, who cauterized the wounds, which healed rapidly. During the 
succeeding three weeks she experienced no inconvenience, either mentally 
or physically, from the bite ; but, during the week previous to my seeing 
her, she had been rather melancholic, "downhearted," as her friends ex- 
pressed it, losing her appetite, and frequently expressing her fears as to 
the result of the bite of the cat ; and finally, on Saturday evening, July 
15, she had refused to eat or drink, and, as I was told, presented much 
the same appearance as when I first saw her. 

At this stage of the investigation I learned that the woman had that 
day been seen by another physician, and I refused to have anything further 
to do with the case till he could be consulted, or till they could tell whose 
services were required. The next morning I was sent for to take charge 
of the case, and found the patient in about the same condition as on the 
night before. The pulse was 96 ; temperature 102j° ; respiration quite 
normal, but slightly laboured — which I may here say continued to be the 
ease throughout the course of the disease. At 10 A. M. of the Itth, I 
gave hypodermically ten drops of Magend. sol. morph. sulph., and also 
gave per rectum 5ss hydrate of chloral. At 5 P. M. I injected twelve 
drops Magend. sol., and also ten grs. chloral. Pulse 130; temperature 
103°. There was marked increase of the aerophobia, and great restlessness. 
The right arm and leg were in constant motion. The left side was com- 
paratively quiet, but suflSciently active to show there was no paralysis. 
In her right hand she held a handkerchief, with which she was continu- 
ally brushing away the flies, and would not suffer any one to do this for 
her, as she was afraid too great a breeze would be produced. I noticed 
that she often used the handkerchief when there was no fly near her, but, 
if one did light on her face, she was much more decided in her movements, 
and the muscles of the face would act spasmodically, and the head turn 



1877.] Read, Case of Rabies Felinse. 137 

with a quick jerky motion from side to side. At 7 P. M. I found her in 
the same restless condition, and I injected fifteen drops Magend. sol. She 
could swallow nothing, and had the same dread of water as before. She 
complained of great thirst, and piteonsly asked if I thought she "could 
swallow by to-morrow." I induced her to try to swallow a little " sarsa- 
parilla beer." As I approached her with the glass, she watched it steadily, 
as if making up her mind to make the attempt at all hazards. Suddenly 
she grasped the glass with both hands, carried it hurriedly to her mouth, 
and with a great shudder and a deep spasmodic inspiration she gulped 
down one swallow. But the effort was so great she would try no more. 

At 9 A. M. of Tuesday I found her with all the symptoms somewhat 
exaggerated. Pulse 92; temperature 103°; tongue slightly coated. Had 
no sleep during the night. Complained of being very warm. Bears light 
well, and has at all times. Having lately read in the American Journal 
Dr. B. A. Watson's report of a case of hydrophobia successfully treated 
with woorara, I determined to try it. Having after considerable search 
obtained some, I dissolved some of it in water and alcohol, and at 11 
A. M. I injected -^^ gr., the pulse being at 140 and the temperature 104°. 
At 3 P. M. the pulse was 160; temperature 102^°. She drank a little 
of the beer, with but little eflbrt, and said it tasted good, and expressed 
herself as confident that she would find relief. There was no abatement 
of the movements of the right arm and leg. I now injected fifteen drops 
Magend. sol,, and soon after -^^ gr. of the woorara. At 6 P. M. the 
extremities were much below the normal temperature, a slight departure 
from which I had noticed on my previous visit. The pulse and axillary 
temperature were the same as at 3 o'clock. She now drank more of the 
beer. This was done with some difficulty, but was attended by no con- 
vulsions, I now again injected ^^ gr. woorara. Her husband presently 
came in drunk, which excited her very much, and it took some time to 
get her quiet. At 8 P. M. the pulse is 130 ; temperature not recorded. 
She is much more quiet. Has taken a little beef-tea and more of the beer. 
The pupils are much contracted, probably from the influence of the mor- 
phia. I gave her twenty grains chloral, and left the following to be given 
at 1 A, M. : chloral, gr. xx ; woorara, gr. Jg ; morph. sulph. sol. mag. 
gtt. xij. — M. 

The next morning I learned that she had rested well till 12 o'clock. 
At 1 the medicine was given, also more beef-tea and beer. She was 
rather restless till morning. I saw her at 7, and found the extremities 
cold, pulse feeble, and the patient evidently dying. She could not swallow, 
and refused to make any attempt. Up to within ten minutes of her death, 
which occurred about 10 A. M., the muscles would twitch if a fly lit on her 
face, or a current of air swept across it. She died without a struggle or 
spasm. 

The case was seen by three other physicians, Drs. Gregory, McLean, 
and Rhodenstein, who all concurred in the diagnosis of hydrophobia, to 
which conclusion I was led by the symptoms as herein given. In taking 
a retrospect of the case, we find, first, the bite of a cat, not known to be 
rabid, as it was killed soon after, but presumably so ; then, after the 
lapse of three weeks, the patient became melancholic, with loss of appetite, 
and a fear of the result. All this, to be sure, might be the result of 
over-wrought nerves and a hysterical condition. But, to my mind, the 



138 Read, Case of Rabies Felinse. [Jan. 

result in this case proves something more than hysteria. There was the 
constant dread of water and food, the extreme hypersesthesia of the face 
and neck, and tlie aerophobia. There was a constant tendency to, and a 
moderate exhibition of, spasmodic action of any muscle of the body that 
was called into use. But during the whole period of the disease there 
were none of the terrible convulsions which I have seen in other cases. 
While some, as Dr. Watson's case, for example, will eat and drink during 
almost the whole course of the disease, my patient from the first refused 
to take anything into her mouth, with the exception of the beer and beef- 
tea already mentioned. There was a constant accumulation of mucus in 
the throat, which increased on the third and fourth day. This was nearly 
all wiped from the tongue with a handkerchief or ejected on to the floor. 
In the record of this case, I do not find much that is different from other 
cases of hydrophobia. It is in the consideration of the treatment that the 
interest lies. If we have found in woorara a remedy for this dreadful dis- 
ease, then indeed we are called on to rejoice, and render immortal the name 
of him who first discovered its power. I have recorded the case because 
it seems to me that the unsuccessful as well as the successful results should 
be given in making up our estimate of any course of treatment. Then, 
under due consideration and fair and friendly criticism, the want of success 
will attach to the physician or to the remedy, as is right. In this case 
some temporary benefit seemed to be derived from the action of the mor- 
phia in producing a quiet state. But this seemed to have no control 
over the aversion to food or liquids ; and it was only when the patient 
seemed to be under the influence of the woorara that she could swallow 
without much difficulty. And it seems to me that the subtle and powerful 
influence of that poison which produces the condition known as hydro- 
phobia is to be met and overcome only by some agent equally subtle and 
powerful. Have we this agent in vv^oorara ? I should certainly give it 
further trial if called on to meet other similar cases, giving it in slightly 
increased and more frequent doses. 

[A case of hydrophobia resulting from the bite of a cat is related by MM. J. 
L. Prevost, Chief Physician to the hospital at Geneva, and Toloz, the interne 
of his service [Gaz. Med. de Paris, No. 26, 1876). The patient was treated 
by intravenous injections of chloral, which afforded relief to the sufferings, but 
did not prevent a fatal termination. Cases of hydrophobia produced by the 
bites of cats have been published by Balzac in his History of Hydrophobia 
(Tours. 1810) ; and more recently by M. Bouley [Did. Enci/dop.). See Gaz. 
Hebdom., Aug. 11, 1876.— Ed.] 



IbYT.] GiBBS, A New Anthropometer. ■ 139 



Art. XXIII, — A New Anthropometer, or a simple Apparatus for Deter- 
mining the Inequalities of the Length of the Legs. By B F. Gtbbs, M.D., 
Surgeon XJ. S. Navy, and Fleet Surgeon South Pacific Station. 
(With two wood-cuts.) 

In a case of fracture of the femur, on board of the U. S. Flagship 
"Richmond," at Talcahuano, Chili, on the tth of March, 1875, and 
which was treated on board ship, there was some shortening. The re- 
sults of the use of the tape-measure were unsatisfactory. The man was 
coloured, and no marks could be made on the skin with the nitrate of 
silver, at the points usually selected for comparative measurements of 
the two limbs. The difference given by the tape was a half of an inch, 
which was contradicted by the man's very steady walk. As I had taken 
much pains in the treatment of this case, and had used the ordinary Lis- 
ton's splint, in connection with canvas stretched over a wooden frame for 
handling the patient, I was desirous of finding as accurately as possi- 
ble the exact difference in the length of the legs. 

I accordingly devised a very simple apparatus for measuring the ine- 
qualities of the length of the legs, which can be made by any skilful car- 
penter, and which is fully represented in the annexed diagrams, Figs. 1 and 
2. It mainly consists of three parts, viz. : A board one inch thick, five 
feet long, and twenty-two inches wide ; two sheet-iron hooks, e and r, Fig. 
1 ; and a sliding square, c. The board has a longitudinal slit or open- 
ing exactly in the median line, one and a half or two inches wide, and 
beginning at twelve inches from the upper or pelvic end. The back of 
the boards (as it will be made of two ordinary boards) is supplied with 
six battens, to preserve the rigidity of the apparatus and integrity of the 
open slit, and which are represented by the transverse dotted lines. 

The transverse piece o is placed so as to be rectangular to the median 
line of the board, and is screwed firmly to tlie slide d, which by careful 
adjustment is made to move accurately in the longitudinal slit. Toward 
the upper part of this slit there is also another slide, A, to which is at- 
tached a small piece of board placed upright, and of the following di- 
mensions, viz. : six inches long, seven inches deep, and one inch thick, 
and marked b. This is a perineal block which is intended to finish the 
adjustment of the median line of the pelvis to that of the board. 

The hook-like pieces made of sheet- or boiler-iron, figured in the dia- 
gram, Fig. 1, as E and f, have a pivotal centre, as represented in the 
perspective view of the same in Fig. 2, at which point they are secured 
to the board by a single "wood-screw." The latter figure also shows 
the iliac blocks, which are cut from a white pine board one inch thick, 
and screwed to the sheet-iron, the screws entering from the under face. 



uo 



GiBBS, A New Arithroporaeter. 



[Jan. 



Of the irregular-shaped pieces of sheet- or boiler-iron, an outline of which 
is represented in Fig. 1, there are two, one for each hip. These sheet- 



Fig. 1. 



Fig. 2. 





iron pieces I have called for conveni- 
ence iliac hooks, a, b, c, e, and the 
pieces of wood represented attached 
to them, A, B, D, in Fig. 2, the iliac 
or hip blocks. These being attached 
to the board by the screw mentioned, 
which is also the fixed centre of a 
circle, and which is located near the 
end of the broad part of the hooks 
(e, Fig. 2), it is evident that the other 
ends of the hooks, and the iliac blocks 
attached, describe the circles. The 
value of the whole apparatus depends 
upon the establishment of these two 
centres. The circles which are produced, with these points as centres, 
v/hen described on the board with a pair of dividers, must cut each other 
at exactly the same point in the median line of the board, and which is 
a simple matter of measurement. The whole of the iliac hook and 
block, as represented in Fig. 2, would go on the left-hand side of the 
board, if one were standing at its foot and looking towards its upper or 
pelvic end. 

The broad parts of the iliac hooks are two inches wide and eight 
inches long. The narrow parts of the same (a, b, c, Fig. 2) are one 



1877.] GiBBS, A New Anthropometer. 141 

inch wide and seven inches long. In cutting these from the sheet-iron, 
this narrow part, A, B, c, Fig. 2, must stand at an angle of 45 degrees 
with the broad part, and as represented by the diagram, Fig. 1. The 
perpendicular edge of the block, b, d, represented in Fig. 2, bears a con- 
stant parallel relation with the perpendicular edge of the block on the 
opposite side of the board. The base of the block A, B, in Fig. 2, is 
not intended to be as long as the whole length of the narrow part of the 
hook, because the free end b, c, Fig. 2, in passing beneath the pelvis 
gives greater solidity to the apparatus in final adjustment. The perpen- 
dicular edges of these two blocks are intended to press against the iliac 
crests on each side, as the body lies in proper position horizontally on 
the board. Both hooks and blocks are easily made, and adjusted as 
follows : — 

The object to be achieved in attaching the whole thing represented in 
Fig. 2, to the board above described, is, that the pivotal screws shall be 
placed in certain points in the board, so that when this part of the appa- 
ratus, right and left, shall describe sufficient parts of circles in being moved 
toward the median line, the iliac faces of the blocks, standing perpendic- 
ular to the surface of the board, shall exactly meet at a point in this 
median line which is exactly equidistant from either one of the screws. 
Under these conditions, the apparatus is in perfect adjustment. 

The points at which the pivotal screws are fixed in the diagram. Fig. 
1, are six inches from the median line of the board, and twelve inches 
from its pelvic or upper end. A line drawn through these two points 
across the board at right angles with the middle line of the board, will 
mark the first of a series of peg holes, the first two of which are placed 
a half an inch from the ends of this line, or the outer edges of the board. 
These holes are continued in a semicircle, made a half an inch apart, 
and numbered up to 20. The radius of this, a part of a circle, is the dis- 
tance to the above first peg-hole. These holes are numbered, so that each 
two of corresponding numbers on either side, shall be exactly the same 
distance from the median line of the board. 

Having now the board with the iliac blocks, perineal block, and slid- 
ing square, all of which could be made by a skilful carpenter after secur- 
ing first the iron hooks, almost as quickly as it has taken to describe 
them, we have to discover the application by adjusting the body of the 
person to be examined. This is done by drawing widely apart the iliac 
hooks, and directing hina to sit on the upper end of the board so that the 
iliac crests shall be five or six inches below the upper end of the board. 
With one or two movements up or down, to right or left, done by the 
person himself, the iliac blocks are easily adjusted so that their perpen- 
dicular faces shall press equally against the iliac crests, and if the body is 
in the median line of the board, the pegs will occupy holes of corres- 
ponding numbers on each side, securely fastening the faces of the blocks. 



142 GiBBS, A New Anthropometer. [Jan. 

These blocks, in their perpendicular position, will be found to form an 
angle with the line of the iliac crests of about 30 degrees, so that in no 
instance can there be a failure in finding a bony point of resistance. The 
crest-blocks being adjusted, the perineal slide and block is pushed up, 
which further secures the body in the median line. 

We have now^ the pelvis in a rectangular position, as well as the heads 
of the femurs and the trochanterian prominences, if the parts are normal. 
It may just here be as well to meet a possible objection to this apparatus 
by noting that it is seldom a deformity of the pelvis is sustained in the 
iliac bones, even in abnormal structures in which there has occurred dis- 
ease of the bones later in life. In those female pelves which have never 
been fully developed, the deformity almost always exists in the ischium 
or pubis, and seldom in the heavier ilium. That distance may be con- 
sidered as constant in the skeleton, between the upper edge of the aceta- 
bulum and the crest of the ilium, as in any other part of the osseous tissues. 
This constancy is indeed practically admitted by the custom of taking 
the anterior superior spinous process of the ilium for one of the reliable 
points for tape measurements in any comparison of the legs. 

If the pelvis and heads of the femur are caused to assume, by this ap- 
paratus, a perfectly transverse position on the board, they are of necessity 
in a rectangular position with the sliding square at the lower end of the 
board, as well as with the lower extremities, if there is no abnormal ine- 
quality in the length of the limbs. The legs being now separated so 
that the heels rest just external to the blocks, represented on the trans- 
verse slide, and which places the heels ten inches apart, there will be 
seen at once any inequality, if such exists. The plantar surfaces being 
so soft as to yield readily to the pressure of the transverse square, a 
more perfect compai'ison of the length of the limbs may be made by 
having the person to wear a pair of snugly-fitting shoes having the same 
thickness of soles. The toes naturally fall outward when the feet are 
placed against the square, but they should be held fixed as nearly at right 
angles as possible with the line of the leg, so that only the heels come in 
contact with tlie square. 

A difference of an eighth of an inch can easily be seen with this appa- 
ratus. With one more perfectly constructed, having metallic guides, set 
screws, peg-holes, etc., even much greater accuracy can be achieved. 
Any one having used this apparatus would be exceedingly unwilling to 
go back to the guess-work of the tape measurement in which no two 
people will secure similar results from the same experiment. The statis- 
tics of fracture of the femur would at once be more valuable, if the meas- 
urements were taken by an apparatus of this description, and the com- 
parative values of the different modes of treating fracture of the femur 
could then be decided as they only can by a more uniform system of 
measurement. 



1877.] GiBBS, A New Anthropometer. 143 

The accuracy of this instrument, if carefully constructed, may be fur- 
ther relied on in matters of diagnosis, and more particularly in that of 
fracture of the neck of the femur. Not a few good surgeons in their 
professional lives have been puzzled in making a differential diagnosis 
between fracture of the neck of the femur and dislocation of the hip 
joint. Nothing would seem easier, and yet fracture of the neck has oc- 
curred without shortening or eversion of the foot. Intra-capsular frac- 
ture of the neck of the femur is known in one way by observing the 
trochanter to move on a shorter radius than on the sound side. This is 
the case whether there be shortening or not. Hence, one of the points 
in making this diagnosis is to observe whether the trochanter approaches 
the median line of the body in the direction of the axis of the neck of 
the femur. The diagnosis in case of impacted fracture is difficult where 
there is no perceptible shortening, no crepitus, no eversion or abduction. 
The rectangular position of the pelvis in such cases, when placed on this 
apparatus, will have exact relations with the ends of the lower extremi- 
ties, and most extraordinary advantages wil! be found for determining the 
existence of this fracture. 

The adjustment for this purpose is easily made by properly placing the 
body on this apparatus so that there will be a correspondence of middle 
lines, and the trochanters shall be equidistant from the centre. If in the 
measurement with a carpenter's square and rule, there should be seen a 
marked difference in the distance of the trochanters from the median 
line, or the same thing from the outer edges of the board, the existence 
of a fracture would be clear. It would show that there was a shortening 
of the neck of the femur, and this without any shortening of the length 
of the limb. 

It was exactly this kind of measurement, as a means of diagnosis, 
which was brought forward at a meeting of the Royal Medical and 
Chirurgical Society, Dr. C. J. B. Williams in the chair, and published 
in the Lancet for 13th of February, 1875. A paper was introduced 
by Mr. Thomas Bryant on the diagnostic value of the Ilio-femoral Tri- 
angle in cases of injury of the hip in impacted fracture, and in intersti- 
tial absorption of the head of the femur. This paper set forth the 
means of constructing this right angled triangle. Its reliability as a 
means of diagnosis seemed to have been in direct proportion to the ac- 
curacy with which a line could be let fall perpendicularly from the ante- 
rior superior spinous process of the ilium, to another line which was 
practically drawn from the great trochanter of one side to that of the 
other. The outer ends of this transverse line, on each side, between the 
intersection of these perpendiculars and the trochanteric processes, if 
there were found a normal condition of the parts, should be found equal. 
Of course the two remaining sides of the two triangles should be equal. 
Tiie proof of an abnormal condition of the parts is decided by this test, 



144 Collins, Morton's Apparatus. [Jan. 

when there is found a difference in the length of the base lines above re- 
ferred to. In healthy adults, Dr. Bryant found the normal length of this 
base line two and a half inches, and in cases of impacted fracture, it 
might be from one-half to one inch less. 

The least reflection it seems to me ought to show that all this triangu- 
lation of the surgical region is attended with great uncertainty when 
performed by unsiiilful hands, and even with the greatest accuracy, the 
same person would not probably secure the same results upon two con- 
secutive trials on account of the uncertainty of the " fixed points." TvTo 
sliill is required to fix the pelvis on the apparatus in hand, and the same 
results can be secured consecutively with very little care, as the rectangles 
formed are purely mechanical. 

The careful admeasurement of a number of sound men with a view of 
testing the normal symmetry of the two sides resulted in showing the per- 
fect accuracy of my rather crude apparatus. When the pelvis was placed 
in position, the sliding square showed no difference in the length of the 
limbs. This was a multiplied test for the instrument. On the other 
hand, the case of fractured femur, mentioned at the beginning of this 
paper, showed that tlie treatment had resulted in shortening of a little 
over one quarter of an inch, instead of one-half inch, as three different 
surgeons had concluded from the most accurate tape measurement. In 
conclusion, I would recommend surgeons who have occasion to use this 
kind of anthropometry, to prepare this rigid apparatus, and use it in 
preference to the tape measurements, made from badly defined anatomi- 
cal points. 



Art. XXIV. — Description of an Apparatus devised hy Dr. lliomas G. 
Morton for Measuring any Irregtdarity in the Length of the Lower 
Extremities. By Stacy B. Collins, M.D., Assistant Surgeon of the 
Orthopa3dic Hospital, Philadelphia. (With a wood-cut.) 

In attempting to accurately estimate the shortening which may take 
place after fracture, coxalgia, etc., it seems necessary to have — First, a 
simple instrument that can be used on a patient in bed without disturb- 
ing any applied apparatus. Second, to have it of material which cannot 
be stretched. Third, to have both limbs measured from one fixed point, 
thus avoiding inaccuracies resulting from obliquities of the pelvis, dififer- 
ences in height of the iliac bones, and similar causes. Fourth, to have 
an instrument that not only shows the inequality, but accurately mea- 
sures it at the same time. 

To meet these requirements, Dr. Morton, one of the surgeons of the 
Pennsylvania Hospital, introduced into that institution several years 



isn.] 



Collins, Morton's Apparatus. 



145 



since an apparatus which, with some late improvements, I shall now 
describe. 

It consists of two parts. First, a frame with movable arras, intended 
to hold the body and legs in exactly the same right line, or, in other 
words, to make the patient lie perfectly straight ; and, secondly, a measur- 
ing rod extending from this which passes between the legs, and by means 
of two short arms touches the internal maleoli at 
exactly the same relative point at the same time 
on both sides. When this is done the measure- 
ment is accomplished, as a scale on the extended 
rod at once shows and records any existing dif- 
erence. (See accompanying figure.) 

The frame consists of three small steel bars, 
each three feet long, lying parallel to each other, 
and joined at the ends by means of two steel cross- 
bars at right angles to the others, and nine inches 
long. This makes a rectangular frame nine inches 
by thirty-six inches, and divided into two equal 
parts by the third long bar running longitudinally. 

From each side of this frame three arms ex- 
tend, which, when it is in position on the person 
to be measured, drop perpendicularly, and by 
means of a right and left hand screw, held in 
position by the central bar, can be extended or 
contracted through brass boxes playing on the 
outside bars, so as to grasp the body firmly. 

The boxes through which the arms run can be 
moved along the frame so as to clasp the person 
at any desired point, or in the case of children, 
allow all the arras to be moved toward one end, 
thus practically shortening the frame. It is evi- 
dent that if this apparatus is laid on the body, 
and the arms screwed up so as to hold it tightly 
under the armpits, at the hips, and about the 
knees, any lateral motion is impossible, and the 
body is held immovably straight. This is neces- 
sary, because we have found from many experi- 
ments that the slightest deviation from the 
straight line at once produces an apparent short- 
ening in the limb opposite to the side to which 
the body is bent. A hinged bar drops from the 
centre of the lower end of the frame, and extends 
between the legs. Over this runs another bar 
which can be pushed up or down as the length 
No. CXLY.— Jan. 187T. 10 



146 NoRRis, Shakespeare, Double Staining. [Jan. 

of the legs requires, and held in any desired position by means of a screw 
at the top. From either side of this outer bar extend short arms, which 
by means of an elbow with a long fenestra fitting on a steel button can 
be moved for a short distance up or down, a screw forming the top of the 
button allowing it to be fixed firmly at any spot, while small pointers, 
attached to the arms, and sliding up and down with them, run over a 
scale on the upper face of the outside bar, and show any existing short- 
ening to the one-sixteenth of an inch. 

The manner of using this apparatus is sufficiently simple, and when it 
is carefully made all sources of error (save possibly that from an actual 
attempt to deceive) seem to be eliminated. 

Let us suppose the case of a patient lying in bed with extension ap- 
plied. We don't wish to get him out of bed or disturb the apparatus, 
at the same time we are desirous of knowing whether we have sufficient 
weight applied, and the limb accurately adjusted in length. The clothes 
are turned back, and the frame is placed over him, so that one pair of 
arms clasps him under each axilla. The second pair firmly holds his 
pelvis a little below the iliac crests, while his legs are strongly pressed 
out on each side, above the knees, against the third pair of arms, which 
are approximated so as to allow about two inches between the ankles. 
Now the sliding bar is moved down a convenient distance, and one of the 
small arms is brought against the lower edge of one malleolus, and the 
other is moved upward or downward into a corresponding position on the 
other side. The body is now held immovable, any shortening can be at 
once diagnosed, and its amount read from the scale without further 
trouble. 



Art. XXV. — A Nevj Metliod of Double Staining. By W. F. Norrts, 
M.D., Clinical Professor of Ophthalmology in the University of Penn- 
sylvania, and E. 0. Shakespeare, A.M., M.D., of Philadelphia. 

The great progress made of late years in minute anatomy is largely due 
to the successful use of new reagents, which, having special affinities for 
certain tissues or parts of tissues, by their action upon them, produce such 
changes of consistence and of colour, as to give us an optical dissection or 
separation of them from surrounding tissues, and thus enable us minutely 
to study their distribution and structure. The uses of nitrate of silver in 
the study of the lymphatic system, of perosmic acid in the study of the 
retina, and of chloride of gold in the study of the nervous system, are 
striking examples of the above assertion, and are familiar to all practical 
microscopists. It was, therefore, with great interest, that during the past 



1877.] NoRRis, Shakespeare, Double Staining. 147 

year we read a "technical notice"^ from the pen of F. Merkel, on a new 
method of double staining. The author, by using a mixture of indigo- 
carmine and carmine, found, that in sections of brain, "everything was 
coloured red except the marrow sheath and the red blood corpuscles, the 
former being usually coloured blue, and the latter green." He recommends 
this fluid for tracing out the roots of nerves, but laments that he could 
only obtain this colouring of the blood corpuscles in the brain substance, 
"and that in other organs they either are not coloured at all, or very faintly 
and irregularly." He found, however, that the mixture was also advan- 
tageous in the study of ossification ; all fully developed bone staining blue, 
while everything else coloured red — "it shows beautifully how even ossifying 
osteoblasts colour red, while in the transition to older bone substance 
gradually, and at first, indistinctly, the blue colour comes out." 

Encouraged by such brilliant results, we endeavoured to use the same 
reagents, and after repeated trials have adopted another mixture of the 
same colourmg agents which differs essentially from that of Merkel, in 
that it works uniformly and readily in all tissues of the body, and after a 
year's trial we confidently recommend it to our brother microscopists. 

We will first give the formulae for its preparation, detail the manner of 
using it, and then describe some of the results in various tissues of the 
body. 

Red staining fluid. Blue staining fluid. 

Carmine 5ss. Indigo-carmine 3ij'^ 

Borax 5ij- Borax Jij- 

Distilled water f^iv. Distilled water f^iv. 

In each case the ingredients are thoroughly mixed by trituration in a 
mortar ; after standing the supernatant fluid should be poured off and 
preserved for use. The sections, when cut, should, if the specimens have 
been hardened in either bichromate of potassa, picric acid, or chromic 
acid, be thoroughly washed in water until that fluid ceases to be tinged with 
the hardening agent f they should now be placed for a few minutes in 
alcohol, and then be immersed from 15 to 20 minutes in a mixture of equal 
parts of the red and blue fluids, afterwards transferred without washing to 
a saturated solution of oxalic acid, and allowed to remain in it rather less 
time than in the staining fluid. When sufficiently bleached, the sections 
should be washed in water till every trace of oxalic acid is removed, for 
its presence impairs the brilliancy and permanence of the double staining. 

* Anatomische Untersuchungen aus dem Anatomischen Institut zu Rostock, 
1874, pp. 98-99. 

2 So-called Indigo-carmine is really a sulpliindigotate of potassium. Its 
chemical formula is CgH^NOSO.^OK. 

3 Immersion of the sections in alcohol immediately before staining is not essen- 
tial to the success of the process, but we think renders the colouring more uni- 
form. 



148 NoRRis, Shakespeare, Double Staining. [Jan. 

Previous staining of the tissue with carmine in the ordinary method, does 
not prevent a successful double staining by subsequent immersion in the 
mixed fluid. Sections stained in the manner above described are best 
mounted for permanent preservation either in balsam or damar. 

Connective Tissue. — The wavy fibrillse of dense connective tissue, as 
found in tendons, in the dura mater, etc., stain blue, while the nuclei on and 
between the fibres stain red. The cells of the inter-muscular connective 
tissue stain red, and their processes either remain uucoloured or present a 
faint tinge of the same colour. 

Cartilage. — Hyaline cartilage shows a blue parenchyma with imbedded 
cells, which, with their nuclei, stain red. Exceptionally, however, we 
found the protoplasm blue, with a red nucleus and blue nucleolus. 

Bone stains in a manner similar to cartilage, the osseous lamellae 
colouring blue, while the cells lying in the lacunae are red, and the cells of 
the marrow stain apple-green. 

Teeth. — Sections of the jaw and teeth of the white rabbit, decalcified and 
hardened by immersion in a saturated solution of picric acid, when stained 
by this process, present a most variegated and brilliant coloration. The 
cells of the pulp cavity stain red with a slight tinge of blue, their nuclei 
deeper red, and the odontoblasts between them and the dentine appear as 
long green cylinders with red nuclei. The dentine itself is bright red 
slightly tinged with blue, and the prisms of the enamel take a bright apple- 
green colour, while the intervening substance has a delicate reddish tinge. 

Striated Muscle. — Each primitive fibre of striated muscle appears under 
a low power as a stripe of blue-green colour, sometimes with predominance 
of one colour, and sometimes of the other. Under a higher power the 
sarcolemma shows of a faint bluish tint with red nuclei, while the sarcous 
elements are blue-green, and the intersarcous material sometimes of a faint 
reddish hue, and sometimes of a faint blue-green. In embryonal tissue, 
the latter usually stains pink. The cells of the inter-fibrillar connective 
tissue stain, with cell contents and nuclei red, and the processes, if they 
are coloured, exhibit a fainter shade of the same colour. 

UnstiHated Muscle, in masses, appears of a bright apple-green or green- 
ish-blue; examined with a higher power, the protoplasm of the cell only is 
seen to be of this tint, while the nucleus is red, and the nucleolus, where it 
does not appear as a mere black spot, shows a blue colour. 

Bloodvessels are very beautifully demonstrated by this new method of 
staining. In many parts of the body, particularly in the central nervous 
system, the staining of the small vessels is such that under a low magni- 
fying power an appearance of a complete vascular injection is presented. 
If there happen to be a natural injection in areas more or less extended, 
the latter offer a most beautiful example of variety of colour, and at the 
same time a very desirable degree of differentiation of structures. The red 
blood disks crowding the lumen of the vessels are usually of a strong apple- 



1877.] NoRRis, Shakesteare, Double Staining. 149 

green colour. The nuclei in the capillary walls are bright carmine, the 
wall itself having a slight tinge of bluish-purple. The connective fibres 
adjacent are stained a deep blue. The connective tissue nuclei are every- 
where a brilliant red, as are also the nuclei of the lymph corpuscles, whether 
they be within or without the bloodvessels. The elements of vessels of 
larger calibre stain as they do in other tissues. Using a medium-sized 
artery for illustration, the endothelium of the interior shows the nucleus 
red, and cell-contents a scarcely perceptible tinge of blue which is most 
distinct where the plate is seen in profile. The so-called elastic or limiting 
layer of the intiraa stains blue, as do also the elastic plates and fibres 
between the different laminae of the muscular or middle coat. The nucleus 
of the unstriated muscle cell colours red, and the cell-contents, blue-green. 
The vasa-vasorum and the nervi-vasorum stain as these structures do 
in other locations. The same is true of the fibrous bundles, elastic fibres, 
muscle-cells, and connective tissue corpuscles of the adventitia. 

The skin, after hardening by means of picric acid or Miiller's fluid, in 
thin sections, is a brilliant object. The corium, with its vessels and nerves, 
its cellular, adipose, and muscular tissue, scattered through a purely fibrous 
groundwork, displays all these different structures in the manner indicated 
for each one of them elsewhere. The epithelium of the surface is usually 
tinted in the following manner : The cells of the deep columnar layer 
have their nuclei reddish, and their cell-contents greenish, if there be pig- 
ment ; bluish, if there be none. The cells of the mucosa have more red 
in their nuclei and more of blue in their cell-contents, while the corneous 
layer usually colours greenish-blue or green. 

The hairs and hair follicles are excellently differentiated. The external 
and middle layers of the hair follicle are purple, with the nuclei of their 
cells deep red. The hyaline membrane of the follicle is of a light trans- 
parent blue. The cellular elements of the outer sheath of the hair are 
stained in a manner similar to that which characterizes the corresponding 
layers of the surface epithelium, the amount of red increasing as the 
root of the follicle is approached. The layers of Henle and of Huxley are 
observed as one united corneous membrane of a bright blue, or greenish- 
blue without any mixture of red. Below the position of the ducts of the 
sebaceous glands, the cuticle of the hair appears reddish, the colour becom- 
ing more decided towards the root of the hair. A little above the bulb 
the cortical portion of the hair is bright green, while the medulla is of a 
much darker hue. For some distance above the papilla the medullary cells 
are distinctly seen with bright red nuclei and faint blue, or purplish cell- 
contents. The cells of the papilla itself have less of the blue and more of 
the red colouring, while the cells of the cortical portion of the bulb have 
more of the blue and less of the red. The cells, both of the sweat and 
sebaceous glands, are very distinct, and have their cell-contents blue or 
greenish, the nucleus reddish, and the nucleolus sometimes blue. 



150 NoRRis, Shakespeare, Double Staining. [Jan. 

Nervous System. — The ganglion cells of the spinal cord and brain, 
with their processes, stain usually purple (mixed blue and red tint). Their 
nuclei colour red, while the nucleoli in well-stained specimens appear blue. 
In sections of the spinal cord the marrow sheath colours blue or green, 
and the axis cylinder red. In longitudinal cuts the latter can often be 
traced for considerable distances. In the nerves the marrow sheath and 
axis cylinders stain in the same manner as in the spinal cord. In the 
optic nerve, however, owing to the extreme minuteness of the axis cylin- 
ders, it is difficult to determine their colour. In transverse sections they 
appear as minute, reddish-black points, surrounded by a green-blue marrow 
sheath. The connective tissue between the bundles of nerve fibres stains 
blue, as do also the walls of the bloodvessels, while the nuclei both of the 
vessels and neuroglia stain bright red. 

Owing to the blue staining of the marrow sheath the roots of the cra- 
nial nerves may readily be followed considerable distances in the brain and 
medulla oblongata. 

Kidney. — The capsule stains as does the other similar fibrous envelopes. 
The nucleus of the epithelium lining the tortuous tubes colours red, while 
the surrounding cell-contents are greenish-blue, approaching to green. 
In the epithelium of descending arm of loops of Henle, the nucleus is dis- 
tinct and bright red ; cell-contents blue. In the recurrent arm, from the 
bend of the loop, the staining gradually passes from that which charac- 
terizes the epithelium of the descending arm to that of the previously de- 
scribed convoluted tubes. The staining of the epithelium of the collect- 
ing tubes differs but little in character from that of the convoluted tubes. 
There is somewhat less of the green ; the cell being less granular, the 
nucleus is more distinct and of a brighter red. The vessels, blood-disks, 
and nerves stain as in other tissues. The general picture presented by 
a low magnifying power is very striking. The glomeruli appear as purple 
islands in a sea of bluish-green, which is checkered irregularly by the pur- 
plish lines which represent the capillary network. 

The Liver. — The capsule and its projections into the parenchyma of 
the glands take a staining similar to that which has been already de- 
scribed for fibrous tissues in general. The bloodvessels are well seen, 
even the delicate wall of the finest radicles of the hepatic veins, with its 
alternate nuclei, is easily recognized. The epithelium of the gall-ducts, 
from the ductus interlobularis to ducts of the largest lumen, are very dis- 
tinct ; the nucleus red, and the cell-contents blue or bluish-green. The 
gland cells of the lobuli stain much like secretory cells elsewhere, with a 
bright-red nucleus, and cell-contents blue or greenish. 

The Spleen (of the white rabbit). — The fibrous elements of the capsule 
are stained as usual ; the smooth muscular elements have their rod-shaped 
nuclei red, and their nucleoli perhaps blue, although the latter point is 
difficult to determine. The trabeculse traversing the spleen pulp, consist- 



J 



18t7.] Whitehead, Absence of the Uterus. 151 

ing of similar elements, is similarly coloured. The arterial and venous 
walls, much thickened by the inward prolongations of the capsule, stain 
in an identical manner ; the red blood-corpuscles, in' their lumina, appear- 
ing deep apple-green. The lymph cells of the pulp have their nuclei 
red. The free red blood-corpuscles are stained green or bluish-green. 
The lymphoid cells, containing red corpuscles within their body, show 
these red disks greenish or bluish, while at the same time their own proper 
nuclei are red. Under a lower power, the Malpighian corpuscle, in its 
outer portion, shows reddish-purple, in its inner portion a purplish-red. 

Stomach and Intestine. — The cells of the peptic glands stain, with their 
cell-contents, blue or green, and nuclei red. The capillary vessels are 
everywhere beautifully distinct, with their purple walls and brilliant car- 
mine nuclei. The smooth muscular elements are as in other organs. The 
fibrous tissue between the bundles is usually purple. 

The villi of the intestines, especially where the bloodvessels are en- 
gorged, are beautiful specimens of the variegated colouring and excellent 
differentiation which are obtained in epithelium, connective tissue, and 
vessels, by the use of this new method of double staining. 

The Lungs, after this double staining, present a beautiful picture. 
Take for illustration the lungs of a cat which has been killed by stran- 
gulation. The capillaries with their purple tinted walls and bright red 
nuclei are distended with blood, which has its usual apple-green hue. 
The large flat cells of the alveoli show in their cell-contents a faint blue, 
which does not at all mask the carmine of the nucleus. The arteries and 
veins are stained as usual. The cell-contents of the columnar epithelium 
of the bronchi and trachea stain greenish-blue, while the nucleus is always 
red, and the cilise are tinged faint blue-green. 



Art. XX YI. — Absence of the Uterus, ivith a previous History of Chronic 
Inversion of this Organ, which was mistaken for Polypus, and removed 
by Ligature. With remarks. By W. R. Whitehead, M.D., of Denver, 
Colorado. 

The removal of the uterus is of sufficient interest, under any circum- 
stances, to merit grave consideration ; but when the result of an error of 
diagnosis, every physician will be painfully impressed with the necessity 
of a careful and accurate physical examination, before attempting to per- 
form on the uterine organs, operations of such capital importance. This 
duty is also made imperative, from the fact that some eminent and usually 
judicious surgeons have related, that this accident has occurred in their 
practice. I believe, therefore, that the following case will be thought 
worth recording ; — 



152 Whitehead, Absence of the Uterus. [Jan. 

Mrs. Hattie S., set. 28, living a few miles from Denver, accompanied by 
her husband, consulted me at my office, on the 25th of last July. Mr. S. 
remarked that his wife had long been a sufferer, and had undergone much 
treatment for disease of the womb, and been sul)jected to two or three 
operations on this part, and that unless I thought I could cure her, he did 
not wish me to undertake her case. I assured Mr. S. that 1 endeavoured 
to practise my profession conscientiously, and was indisposed to make 
hasty promises of cure, especially in uterine diseases. This led to a few 
questions, and a digital and bimanual examination of the pelvic organs, 
and a recognition of her condition, which was further explained by a more 
detailed account of her previous history. 

Mrs. S. menstruated at twelve years of age, and at thirteen was mar- 
ried. Her husband was killed a week after her marriage. Five and a 
half years afterward, she was married to her present husband. About 
six months after her second marriage, and before coming to Colorado to 
live, she had a miscarriage at the fourth month ; and she got up within 
three days after her sickness. It was not until a month afterward, that 
she noticed blood to flow freely from her, and then she said, ** it flowed all 
the time, and very badly, and continued so more or less for four years." 
She came under the observation of a number of Denver physicians, one of 
whom was Dr. R. G. Buckingham, an eminent and much respected physi- 
cian, and our present mayor. In 1868, Dr. F. J. Bancroft, a prominent 
physician of Denver, and Dr. A. L Justice, formerly a practitioner of this 
city, attended her. Dr. Bancroft informed me to-day, that he and Dr. 
Justice diagnosed an intra-uterine fibroid tumour, having a large pedicle 
which was attached to the fundus, and that they constricted the pedicle 
with silver wire by means of a double canula. He also remarked that the 
fibroid sloughed and came away in small pieces a few days afterward; but 
that a meddlesome nurse repeatedly pulled at the ligature, and caused inver- 
sion of the uterus. He further stated that very soon afterward, another 
physician was called to attend the case. The patient stated that this phy- 
sician, and to whom Dr. Bancroft alludes, placed a loop or ligature of 
wire or thread around the tumour and strangulated it, and that something 
came away. Finally, about the last of August, 1873, another practitioner 
of this city, with an assistant, used ligatures and instruments, and re- 
moved from her what seemed to be a tumour. From that time she ceased 
entirely to menstruate ; but has had more or less leucorrhcea, and been 
under treatment for supposed uterine disease up to the time I saw her. 

A digital examination revealed that the os was slightly patulous, and 
the lips of the cervix enlarged and indurated. Nothing by a mere digital 
examination led me to suspect a very unusual condition of the parts. 
However, by the bimanual exploration, I could not detect the body of the 
uterus in its normal position, or in a position of flexion or version. I 
passed a catheter into the bladder, and the index finger into the rectum, 
and found the body of the uterus to be absent; introduced the speculum 
and found the os to be rather everted; introduced into the cervical canal 
the uterine probe, which could be made to enter only three-quarters of an 
inch ; removed the speculum, and again introduced the probe into the 
cervical canal, and the index finger into the rectum, and approaching the 
end of the probe and the index tinger, found in place of the uterus an in- 
durated mass of only slight thickness interposed between the probe and 
finger. Both she and her husband seemed much astonished when, after 
my examination, I remarked that she had no womb, and that the supposed 



ISYT.] Whitehead, Absence of the Uterus. 153 

tumour which was taken from her was the uterus. I told Mr. S. that I 
could do nothing more for his wife than to relieve her of the leucorrhoeal 
discharge, and for which I prescribed some powders of alum and sulphate 
of zinc to be used in vaginal injections. 

There were some points of rare interest observed in this case, one of 
which was the freedom from severe bleeding until a month after the mis- 
carriage, and which was suggestive of the production of inversion a con- 
siderable time subsequent to the premature labour. Leblanc, referred to 
by Thomas, and mentioned by Courty,^ cites a case of inversion reduced 
with facility very soon after labour, and which was reproduced ten days 
afterward, and restored with difficulty. It seems to me, as Thomas ob- 
serves, quite impossible to admit the occurrence of inversion of an undi- 
lated uterus; and that pregnancy, or hydrometra, or retained menses, or 
an intra-uterine fibroid, or some other similar dilating cause, must pre- 
viously exist. Thus is explained the occurrence of inversion at variable 
intervals of time after pregnancy, or in women who have never been preg- 
nant. When inversion is due to a fibroid tumour, as Courty^ very pro- 
perly observes, such a tumour, or a polypus, with or without pedicle, is 
the more readily mistaken for inversion, as each is capable of causing it, 
and thus complicate the inversion. But it is well known that the 
diagnostic signs of a fibroid or polypus are usually sufficiently manifest if 
the proper exploration is made. By the aid of sponge-tents the interior 
of the uterus can be explored for small intrauterine fibroids. With a No. 
6 gum-elastic catheter, with a wire in it, and used in the manner Sims has 
pointed out, the uterus can be effectively explored for the largest fibroids. 
If the tumour be a polypus, and occupy the vagina, by the aid of the com- 
mon uterine probe, and conjoined manual and digital examination, fibroids 
or polypi may nearly always be distinguished from inversion. 

On practising the bimanual exploration on Mrs. S., had I possessed no 
knowledge of her antecedent history, and carelessly, as has often been 
done, confined my examination to a mere digital exploration, her condition 
would have remained undiscovered. There was, however, no peculiar 
merit in resorting to the bimanual examination; it is an omission not to 
do it. Had this examination been ever so carefully made, and without a 
knowledge of her previous history, I should have been liable to mistake 
her case for congenital absence of the uterus. Five or six years ago I 
was invited, with the late Prof. J. C. Nott, by Prof. Isaac E. Taylor, of 
New York, to examine at his office a fine-looking young woman, with every 
external appearance of splendid physical development, who had congenital 
absence of the uterus, and who presented very much the same degree of 
rudimental development of the cervix that was found in the case of Mrs. 
S. after the loss of her uterus, but without, however, the patulous os and 
indurated cervix. 

1 Maladies de I'Uterus, etc. Paris, 1866, p. 804. 2 Op. cit. p. 793. 



154 Whitehead, Absence of the Uterus. [Jan. 

Prof. Willard Parker's case of inversion mentioned by Thomas, which 
occurred during a violent effort in rolling ten-pins, and which was mis- 
taken for polypus, and which, after removal, proved to be the uterus, with 
its tubes and ligaments, was not only an instructive warning against pos- 
sible errors of this kind, but also shows the suddenness with which inver- 
sion may occur even years after pregnancy. Not less instructive was the 
case of Prof. Budd, of New York, an eminent and skilful gynsBcologist, 
also mentioned by Thomas, and who was fully alert to the importance of 
not mistaking a partial inversion for polypus, yet by error removed one 
horn of the uterus with a part of the corresponding Fallopian tube and 
ligament, for a supposed intra-uterine polypus. 

Formerly, removal of the uterus was much practised for inversion of 
this organ, but in this country at least the intentional extirpation or re- 
moval of the uterus for inversion has become quite exceptional, and been 
replaced by more conservative methods. The procedures of Tyler Smith, 
of White of Buffalo, of Noeggerath, and especially of Thomas, of New 
York, are well known. Marion Sims, a decade ago, in his work on 
Uterine Surgery, p. 134, remarked, in alluding to the success attending 
his own efforts and those of others, at restoration of the uterus, that he 
would hesitate a long time before removing another inverted uterus. So 
that the merit of success in a case of this kind, which is procured at the 
price of depriving a young woman of one of the most important organs 
of reproduction, would not justify a deliberate removal of the uterus for 
inversion, without repeated and intelligent trials of the known methods 
of reduction. Courty's method is well v/orth essaying, but is not so ex- 
tensively known as that of White or Thomas, but is briefly described by 
the writer in a review of Courty's work, and is to be found in the number 
of the American Journal for January, 18'?2, p. 15t. 

An interesting question may arise regarding one of the modes of the 
mechanism of inversion ; and which is, How far will pressure on the 
fundus during labour, to facilitate expulsion of the child, aid in causing 
inversion ? I have always regarded this pressure, judiciously practised, 
as an invaluable aid during manual or instrumental delivery ; and Barnes 
and others make favourable mention of it. Recently I had a case of par- 
tial inversion immediately following the expulsion of the child; the ex- 
treme shortness of the cord, together with pressure on the fundus during 
the last and rather ineffectual contractions of the uterus, were the cause. 
The uterus was immediately and readily reduced; but there was a tendency 
to recurrence, and I thought it necessary to give a large dose of ergot, 
and place the patient for an hour in the postural position on her elbows 
and knees, before I felt satisfied that the inversion would not be repro- 
duced. To this, it is hardly necessary to add, that proper watchfulness 
was exercised during the convalescence. 



1871.J 155 



REVIEWS 



Art. XXYII. — A Practical Treatise on Materia Medica and Thera'peu- 
tics. By Roberts Bartholow, M.A., M D., Professor of the Theory 
and Practice of Medicine and of Clinical Medicine, and formerly Prof, 
of Materia Medica and Therapeutics in the Medica] College of Ohio, 
etc. etc. 1 vol. 8vo. pp. 537. New York : D. Appleton & Co., 1876. 

A RECENT English review of the Memoir of the late Norman Macleod, 
D.D., commences thus: "This" — the Memoir — "is a really good book, 
and, even in its present shape, a popular book, which does honour to its 
subject, and to its author, in their several degrees. It is, however, so 
good, that we wish it were made better." Similar language may be justly 
applied to the treatise of Dr. Roberts Bartholow on Materia Medica and 
Therapeutics, which lies before us. It is so good that it ought to be 
better, and we wish that it were made better. The merits, which give to 
it a high place among works of the class to which it belongs, and which 
justify the wish, if not the demand for greater excellence than it now 
possesses, will be apparent as we proceed. 

Works on Materia Medica and Therapeutics have multiplied so largely 
within the last few years, that we are compelled to inquire into the reason 
or necessity for their increase; and to demand of each new book, that 
treats of this subject, a justification of its appearance. When Rufus 
Choate was asked by a young lawyer, fresh from the lectures of Story 
and Greenleaf, if there was any chance for a new-comer among the 
crowded competitors of the Boston or New York bar, the great advocate 
replied: there is always room on the front seats. So there is always 
room for new books on the front seats of our libraries. We welcome to 
these seats every new-comer that is worthy, and gladly place him on 
shelves reserved for the elect, or in the niche which holds our favourites, 
inspirers, and instructors. At the present time an unusually cordial wel- 
come awaits any new book on Materia Medica and Therapeutics, that 
comes to the profession freighted with recent acquisitions and needed 
knowledge. If the new claimant only presents us with traditional 
opinions and traditional superstitions, if he only serves up a re-hash of 
old views in new covers, yesterday's baked meats on to-day's fresh plates, 
the more sternly he is rebuked by that neglect of his book which is its 
severest condemnation, the better. If, on the contrary, he has anything 
to offer which is not only new, but important, his work will be heartily 
welcomed, however great and imposing may be the crowd through which 
it has to make its way. Dr. Bartholow unhesitatingly claims for his book 
a place among the second of these two classes. He says : — 

" It may well be inquired why I have ventured to add a new book to those 
already existing in this department of medical knowledge. A belief, which I 
trust will not be regarded as egotism, that 1 have earned the right to address 
the medical profession, has moved me to the preparation of this work. Several 
years a teacher of Materia Medica and Therapeutics, I have necessarily 



156 Reviews. [Jan. 

formed opinions as to the kind of information which should be contained in a 
treatise on this subject. As far as such a course of experiment is practicable, 
I have demonstrated in my lectures the actions of remedies on animals. I 
have conducted in my private laboratory many independent investig'ations, and 
have contributed in this way, I submit with diffidence, some orij^inal knowledge 
to the subject of therapeutics. The information thus acquired has been sup- 
plemented by thirty-two years of clinical experience as a practitioner of medi- 
cine. Under these circumstances I am induced to believe that my professional 
brethren and medical students will hold that I am entitled to a hearing." 

This is the language of courageous self-confidence. If there are those 
who can not applaud its delicacy, there are none who will deny its frank- 
ness. Dr. Bartholow does not misjudge his ])osition in using it. He is 
well known as a zealous student of medical science, an acute observer, a 
good writer, a skilled practitioner, and an ingenious, bold, though some- 
times reckless investigator. His present book will receive the cordial 
welcome which it deserves, and which the honourable position that he has 
won, entitles him to demand for it. 

The last quarter of a century, and particularly the last ten or fifteen 
years, have witnessed a marked change in the character of the works on 
materia medica that have appeared durijigthis period, in comparison with 
those of any previous date. The change is an important and auspicious 
one, but it is only the commencement of still greater change that is yet 
to come. The change to which we refer is twofold in character. It 
concerns, first, the limits or boundaries of the science, which have been 
latterly greatly enlarged, so as to include many other agencies than drugs ; 
and it concerns, secondly, the method by which the action of remedies 
on the human system is investigated, and their consequent therapeutic 
employment. 

Until within a recent period, treatises on materia medica and thera- 
peutics have been confined almost exclusively to a description of drugs 
and of their therapeutic apjilication. They have, moreover, been written 
almost exclusively from a clinical standpoint, and have made very little 
account of the physiological action of medicinal agents. Illustrations 
of the truth of this remark abound in the medical literature of this 
country and of Europe. 

Nearly the whole of Pereira's treatise, a monument of marvellous in- 
dustry and knowledge, is devoted to drugs. The first part of the first 
volume refers, it is true, to light, air, climate, exercise, diet, mental influ- 
ence, etc., as agencies wliich modify the course of disease, and consequently 
have some therapeutic power ; but the account of these important agents 
is so brief and meagre, that the impression which the student derives from 
the perusal of Pereira's great work is that drugs are the most important 
part of the ormamenia medicoriim, and that all other remedies are com- 
paratively insignificant. A similar impression is produced by the study 
of the Materia Medica of Trousseau and Pidoux. Yet the CUnique 
Medicale testifies, from beginning to end, that Trousseau constantly and 
successfully employed many other agents than drugs in the treatment of 
disease. In like manner, Oesterlen's work presents us with a discussion 
of the action and use of drugs alone, and thus indicates that the German 
school of medicine, like that of England and of France, was not at the 
time he wrote emancipated from the notion that the physician's materia 
medica was confined to what the pharmacist j^repares, and the druggist 
dispenses. Stille's admirable treatise resembles, in this respect, the works 
that we have mentioned of his transatlantic colleagues, and proclaims 



1877.] Bartholow, Materia Medica and Therapeutics. 157 

that American medicine attaches more importance to drugs than to other 
agencies. 

We do not wish to depreciate the value of drugs as remedial agents. 
They hold an important place in therapeutics from which they can never 
be dislodged. They are not, however, the sole, not even the chief reli- 
ance of the physician. They are auxiliaries to other and more potent 
forces, whose subtle influences, unperceived and unrecognized by the 
unintelligent and the vulgar, are often decisive of the issues of life and 
death. Every physician acknowledges the power of these agents, and, as 
far as it is possible for him to do so, utilizes them for the benefit of his 
patients in the hospital and in the sick room. Kemedies which possess such 
an influence, and which the wisest physicians employ to as great an extent 
as possible, not only ought not to be excluded from works on materia 
medica, but should receive an ample discussion in them. It is not difficult 
to point out these extra-pharmaceutical remedies, nor to discern their 
character. The experience of every practitioner makes him familiar with 
them. Possibly there are physicians who use them unconsciously. They 
may be distributed into three classes. The first class comprises mental 
influences, that is the action of the mind upon the body ; or, in more pre- 
cise language, the influence of the cerebral ganglia upon the other gan- 
glia of the nervous system, and through the latter upon the functions and 
organs, by which physiological and pathological processes are more or 
less modified. All forms of mental influence belong to this class. They 
are subjective remedies, and maybe appropriately designated as subjecta. 
The numerous works upon the mutual action of mind and body, which 
have appeared of late years, especially those of Brodie, Feuchsterleben, 
Maudsley, Bain, Tuke, and others, testify to the physiological and thera- 
peutical power of this class, but most writers on materia medica either 
do not mention it at all, or content themselves with the briefest possibly 
allusion to it. To the second class belong all the circumstances or con- 
ditions which surround a patient, and to a greater or less extent affect him 
as causes of disease, or means of relief. These are known as circumscripta, 
or the patient's surroundings. They are the character, exposure, ven- 
tilation, and drainage of the chamber and of the house or hospital in 
which a patient is placed, and the occupation, clothing, exercise, habits, 
climate, and other like circumstances that beset him. These are usually 
called hygienic influences, and are discussed at length by writers on 
hygiene. They cannot, however, be disconnected from practical thera- 
peutics. They are often the most potent agents, not only in the causa- 
tion and prevention of disease, but in the treatment of it. The efficacy 
of change of air in the management of pertussis and cholera infantum, 
of ventilation and bathing in scarlet fever and typhoid fever are familiar 
illustrations of this truth. The diet of a patient forms the third great 
class of remedies. This is technically called dietetica. Its physiological 
importance has always been known. Man must eat, or die. Its thera- 
peutical importance — its direct and intelligent application to the treat- 
ment of disease — has only been recognized of late years, and its full im- 
portance is not yet fully appreciated. If now to these three classes, all 
of which eminently belong to the medical material, or materia medica of 
the practitioner, we add a fourth, drugs, or medicamenta, we have a 
notion of the whole territory which materia medica properly comprises. 
Subjecta, circumfusa, dietetica, and medicamenta are the four great 
departments which form the practitioner's complete outfit. This is the 



15S Reviews. [Jan. 

armory from which he draws all his weapons. It is a dwarfed and imper- 
fect materia medica which is limited to the last of these four classes. 

Intelligent physicians have always and everywhere, practically, if not 
theoretically, recognized the therapeutical importance of these four classes 
of remedies. Unfortunately professors in our medical schools, who have 
been charged with the duty of teaching materia medica, and writers, who 
have undertaken to expound it in text-books and learned treatises, have 
commonly discussed drugs alone. Hence the almost universal impression 
that physicians are limited, or limit themselves in the treatment of dis- 
ease to the exhibition of drugs. In answer to the question, what was 
your treatment, most persons, medical or non-medical, expect only a cata- 
logue of the medicines administered. 

Treatment and drugging are too often synonymous. Dr. John Ware 
successfully resorted to the first class of agents to which we have referred, 
the subjecta, when he prescribed a dose of volition in a case of hysterical 
aphonia. Put will enough into your throat, and not drugs, was his pre- 
scription, and you will speak. I will try, was his patient's courageous 
and confident answer ; and she, who had not spoken for months, and for 
whose relief iron, electricity, counter-irritation, and the like had been 
tried in vain, by an effort that forced the blood to her head and crim- 
soned her cheeks and ears, sent a volitional stimulus to her glottis, which 
made her voice roll out like a blast from a trumpet. The paralysis 
was relieved and did not return. Abernethy, the most eminent and per- 
haps the roughest English physician of his time, selected a remedy from 
the second class, the circumfusa, in the case of an American clergyman, 
who had crossed the Atlantic to consult him, when he cut short the 
patient's laboured and querulous description of dyspepsia, blue devils, and 
hard parish work, with the curt advice, "damn your parish, go home and 
build a barn." The clergyman was scandalized and confounded, but like 
Naaman the Syrian, who concluded to wash and be clean, the American 
doctor of divinity swallowed his anger, and went home and built a barn. 
He was rewarded for his good sense by recovery. Sydenham, who fully 
appreciated the comprehensive character of a rational materia medica, 
and frequently employed non-pharmaceutical remedies, illustrated the 
importance of our third class, dietetica, when he ordered, in place of 
drugs, a roast chicken and a pint of canary for a patient, whose story 
is graphically told by John Brown in that delightful book, Horse Sub- 
secivte. Felix ille is the natural and just comment of the genial Edin- 
burgh doctor on the patient's good fortune. 

Dr. Bartholow's treatise has the merit, and a great merit it is, of in- 
cluding diet as well as drugs. Under the head of agents used to promote 
constructive metamorphosis, about thirty pages are devoted to a discus- 
sion of aliments, of special plans of diet, of alimentation in disease, and 
of water. This is too brief for so important and comprehensive a sub- 
ject, but it is excellent as far as it goes It contains a large amount of 
valuable matter which is apt to be neglected by the profession. As we 
have already intimated, this section of our author's work is a move in 
the right direction, and we wish that he had ventured further in the same 
path. If he had added an account of the physiological and therapeutical 
action of the mind and of surrounding influences to his account of diet 
and of drugs, if he had given us, as he is admirably qualified to do, a 
discussion of the subjecta and circumfusa in his materia medica, as well 
as the dietetica and medicamenta, he would have presented to the medical 



1811.] Bartholow, Materia Medica and Therapeutics. 159 

world the most complete treatise on the subject, considered from the 
point of view which we have indicated, that has yet appeared. 

This enlargement of the boundaries, or rather of the territory of materia 
medica, which has rendered the science more comprehensive, and at the 
same time more rational, constitutes only one part of the twofold change 
to which we have referred, as characteristic of recent progress in this 
department of medical inquiry. The other part of the change, the second 
characteristic, which the recent progress of scientific inquiry has developed, 
and which differentiates the materia medica of to-day, not only from that 
of the distant past, but from that of a past quite near to us, is to be found 
in the method by which the action of medicines on the human system is 
investigated, and their therapeutic applications inferred. 

In the remote and mythical age of medicine, the sick, and especially 
those who were afflicted with unfamiliar or unknown maladies, were car- 
ried on their beds into the streets, with the hope that some passing 
traveller might recognize their diseases and suggest appropriate remedies. 
Such was the origin of clinical observation and teaching. From that 
early time, rife with superstition, error, and empiricism, down to a recent 
period, clinical observation has been relied upon as the only source for 
ascertaining the therapeutic action of remedies, and as the sole arbiter 
of their therapeutic value. In the trial of the remedial action of medi- 
cinal agents, and especially of drugs, it has usurped, or been allowed to 
assume all the functions of counsel, expert, jury, and judge. Not only 
has this been done, but the remedies employed have more often been 
selected by whim, superstition, or unfounded theory than by sound deduc- 
tion or rational empiricism ; and their therapeutic value has been more 
frequently decided, simply by the issue of the cases in which they were 
used, that is, by the single fact of death or recovery, than by their influ- 
ence in modifying the natural course of disease. Clinical observers 
too often reasoned, post hoc, propter hoc. Science could not accept such 
reasoning. In the mean time the other physical sciences, which had 
become more exact in their methods, more precise in their results, and 
more confident in their tone, advanced with unexampled rapidity. It 
was evident that therapeutics must imitate them, and take a new depar- 
ture, or, renouncing all scientific aspirations, must be content with the 
position of a nurse, or descend to the role of a conjurer. The choice was 
soon made, and almost as soon as it was made the effect was seen in 
grander results and more rapid progress. 

The urgent demand or fundamental necessity of scientific therapeutics 
was for an accurate determination of the physiological action of remedies. 
This, so far as drugs were concerned, implied two distinct lines of inquiry ; 
first, an investigation into the course or progress of a drug through the 
system, by which its mysterious and tortuous windings through the secret 
channels, fluids, and organs of the economy, from ingestion to complete 
elimination or destruction, should be traced and ascertained, and all its 
metamorphoses and combinations in the body be determined with as much 
exactness as in the chemist's laboratory ; and second, an investigation 
into the behaviour of the system as the drug passed along, or a determi- 
nation of the organic and functional modifications, which accompany every 
step of the passage of the drug from its entrance into the system to its 
exit. Clinicians were content with the fact, that when chlorate of potash 
was administered, stomatitis was relieved more rapidly than when the 
chlorate was not used ; and they accordingly advised the chlorate of 



160 ' Reviews. [Jan. 

potash in cases of aphthae. The scientific therapeutist was not content 
with this statement. He insisted upon lino wing, first, what became of 
the chlorate of potash in the stomach ; when and how it was absorbed ; 
whether it remained unchanged in the blood, or not ; when it left the blood 
and where it went; by what organs and in what condition it was elimi- 
nated ; he demanded in short, that every grain taken into the system should 
be accounted for. He insisted upon knowing, secondly, how the stomach 
beliaved while the chlorate of potash was there ; how the blood was 
affected by its presence; what influence, if any, was exerted by it upon 
the functions of the system ; and how the salivary glands and kidneys, 
and other organs, engaged in the process of elimination, were affected by 
the labour which was imposed upon them. Possesssed of this knowledge, 
the scientific practitioner is in a position to employ the chlorate of potash 
intelligently, and to determine whether the relief which it affords to sto- 
matitis is, or is not, counter-balanced by physiological damage inflicted 
elsewhere. 

Investigations of this character are among the most abstruse and diffi- 
cult of any that the physicist is called upon to make. They require for 
their prosecution the most delicate instruments, the nicest manipulation, 
and a profound acquaintance, not only with physiology and its cognate 
branches, but with chemistry, mathematics, and many other departments 
of knowledge. To all this, the successful student of physiological materia 
medica must add a long and severe training in the art of original research, 
and must possess what may be termed the faculty of philosophical imagi- 
nation, or in other words, a genius for devising new and conclusive ex- 
periments. It is as difficult a task, and as lofty an intellectual achieve- 
ment to trace a particle of strychnia from the stomach through the blood 
to its oxidization in the ganglia of the nervous system, or to its elimina- 
tion by the kidneys, and to ascertain how, when, and in what proportion 
nerve tissue is changed, and the functions of the economy modified by its 
presence, as to sweep the heavens for comets, explore the rings of Saturn 
by spectrum analysis, or calculate the force that " binds the sweet influ- 
ence of the Pleiades" and "guides Arcturus with his sons." 

Notwithstanding these inherent difficulties, physiologists and clinicians 
have courageously attempted to solve the problem of the physiological 
action of medicines, and to obtain results as definite and accurate as those 
of chemistry or mathematics. We do not assert that such definite and 
accurate results have yet been attained, but it may be safely affirmed, 
that the researches of Bidder and Schmidt, Kolliker, Bernard, Schiff, 
Helraholz, Anstie, Binz, M. See, H. C. Wood, Jr., our author, and 
others have made an auspicious commencement, and one which promises 
results of incalculable importance to the future of medicine. What has 
been accomplished is reflected by recent works on materia medica, and 
has already wrought a notable change in the treatment of disease. War- 
ing's treatise was one of the first in the English language to recognize 
the importance of the new departure, and to utilize the knowledge of the 
physiological action of drugs, that had been acquired at the time of its 
appearance, for the benefit of a sound therapeutics. Nothnagel has gone 
further than Waring in the same direction. The acceptance with which 
the Therapeutics of Sydney liinger was received at the time of its publi- 
cation, and the popularity which it still enjoys in England and this coun- 
try, in spite of its obvious imperfections, may be fairly attributed to the 
fact that its therapeutics is professedly based upon the explanation which 



18Tt.] B A RTHOLOW, Materia Medica and Therapeutics. 161 

it gives of the physiological action of the remedies it describes. The 
recent admirable work of Dr. H. C. Wood, Jr., teaches and, we may 
justly add, demonstrates the importance of supplementing the clinical ob- 
servation of the therapeutic application of drugs by an investigation into 
their physiological action. Dr. Bartholow's Materia Medica is another 
illustration of the same thing. His work does not ignore or depreciate 
the value of the empirical facts of a well-grounded and rational profes- 
sional experience, but, as far as possible, it bases the therapeutical action 
of remedies upon their physiological behaviour. It would be an easy and 
grateful task to quote largely from our author in confirmation of this 
statement, but it is far better to refer the reader to the book itself. We 
cannot refuse, however, to call attention to the articles on alcohol, digi- 
talis, belladonna, opium, and aliments as excellent examples of a clear 
and condensed presentation of recent acquisitions with regard to these 
agents, and of the relation of their physiological power to their thera- 
peutical employment. 

At the present time, when the discussion of the physiological action of 
alcohol, its position as a food or poison, as an unmitigated curse to 
humanity, devised by the devil, or as a blessing to the race, sent of God, 
is carried on by both parties, teetotallers and pro-alcoholites alike, with 
the utmost partisan acerbity, each advocating its own side, by partial 
statements, half truths and special pleading, it is refreshing for those who 
believe in the truth, the whole truth, and nothing but the truth, as the 
most efficient agent of reform, to meet with an impartial summary of the 
case, as far as known to science at present, and a judicial opinion upon it 
like the following: — 

"The disposition of alcohol in the organism is a subject which has gone 
through several revolutions of opinion. At present the weight of authority 
and the deductions of experiment are in favour of that view, which maintains 
that, within certain limits (one ounce to one and a half ounces of absolute alco- 
hol to a healthy man), alcohol is oxidized and destroyed in the organism, and 
yields up force which is applied as nervous, muscular, and gland force. The 
amount of alcohol ingested in excess of this oxidizing power of the organism, 
is eliminated as alcohol by the various channels of excretion — by the lungs, 
skin, kidneys, etc. As alcohol checks tissue metamorphosis, and thus dimi- 
'nishes the evolution of heat and force, it might be expected that the products of 
its own oxidation would supply the deficiency; but this is not the case. Alco- 
hol is a useful food in the small quantity which increases, but does not impair, 
digestion, which quickens the circulation and gland secretion, but does not over 
stimulate, and which is within the limit of the power of the organism to dispose 
of by the oxidation processes. This amount has been pretty accurately shown, 
as stated above, to be one ounce to one ounce and a half of absolute alcohol for 
a healthy adult in twenty-four hours. All excess is injurious. North pole 
voyages, military expeditions (experiences in India and the Ashantee march), 
and the diminished power of resistance to cold shown by drunkards, have con- 
clusively demonstrated that alcohol does not supply the place of other foods; 
and that those habituated to its use, damaged as they are in their vital organs, 
do not possess the same endurance of fatigue, and the same power of resistance 
to external morbific influences as do the healthy. Furthermore, clinical expe- 
rience has amply proved that topers do not bear chloroform well, that they 
succumb more quickly to injuries and surgical operations, and that they possess 
much less power of resistance than the temperate to the inroads of acute dis- 
eases. While these facts rest upon the soundest basis, it is equally true that 
alcohol is, within certain limits, a food; and that the organism may subsist for 
a variable period on it exclusively." (pp. 308-9.) 

No. CXLY.— Jan. 187 1. 11 



162 Reviews. [Jan. 

We had occasion at the beginning of this notice to remark that Dr. 
Bartholovv's work was so good that it onglit to be better, and we justified 
the criticism, by showing that while he has interpreted the science of ma- 
teria niedica more liberally than to make it only a descriptive catalogue 
of the articles on the druggist's shelves, he might have legitimately gone 
further than he has done in this new direction, and have added a discus- 
sion of mental and hygienic remedies to his account of aliments and drugs. 
We now repeat the remark in connection witli his presentation of the 
physiological action and therapeutical ap[)lication of medicines. He has 
discussed this part of his subject so well as to make us wish it had been 
possible for him to do it better still. The two distinct lines of investiga- 
tion, which lead up to a knowledge of the physiological action of medi- 
cines, have previously been referred to, and the two distinct classes of 
fucts which are thereby revealed, one belonging to the progress of drugs 
through the body and their metamorphoses, and the other, to the reaction 
of the economy upon the drugs as they pass along, have been indicated. 
That an accurate notion of how and when a drug passes into and passes 
out of the body, and of the phenomena accompanying its mysterious march, 
is necessary to a scientific therapeutics, is implied all through Dr. Bar- 
tholow's treatise, but the subject is not presented so clearly and promi- 
nently as to compel the attention of the reader. So far as it is possible 
to do so, each drug should be described in this way, and the practical 
therapeutical corollaries, which flow from such knowledge, should be 
api)ended and enforced. It is important, for example, that the practi- 
tioner should know, with regard to any given dose of bromide of potash 
which he prescribes, how long it remains in the stomach after ingestion, 
and in what form it leaves that organ, how the stomach is affected by its 
entrance into the gastric territory, its residence there, its departure there- 
from, and the inferences to which these facts lead. In like manner, with 
regard to the blood, the brain, the nervous system, the heart, the capilla- 
ries, the kidneys, and all the functions and organs of the system, he desires 
the most precise information, that science can impart, as to how and when 
the dose he prescribes will affect them. Let us not be misunderstood. 
We do not assert that in the present condition of physiological science, 
it is possible for any one to render a complete account of all the particu-. 
lars we have mentioned; but it is clear that as many of them should be 
given as possible, and they should be presented in separate paragraphs, 
and under distinct headings, so as to emphasize their importance. 

There is another subject, and an important one, to which our standard 
works on niateria medica give too little attention. It is the potency of 
different doses, or the physiological effect of variation in dose. The 
French call this dosage, a term for which, unfortunately, there is no 
single equivalent in the English language. Dosing conveys the idea of 
improper or excessive medication, while dosage means not merely the 
adaptation of the dose to the age, idiosyncrasy and pathological condition 
of the patient, but to the particular physiological result which the 
prescriber wishes to bring about. It is probable that practitioners 
recognize the fact that the number of minims or grains, which the United 
States Bispensatoinj, or any other work on materia medica, gives as the 
dose of a drug, by no means represents its physiological power. A small 
dose given frequently, that is, repeated at short intervals, of almost any 
drug, will affect the economy differently from a single legitimate dose. 
Doses, administered in such a way that each repeated dose enters the 



i 



1877.] B A RTH GLOW, Materia Medica and Therapeutics. 163 

blood before the previous one is eliminated, produce a contiuued physio- 
logical action, which cannot be obtained by tlie exhibition of a single 
dose, or of the frequent dose, or of a toxic dose. The practical importance 
of all this is obvious. But although such is obviously the case, no work 
on materia medica should leave it unexplained. It should be enforced as 
a part of the description of the physiological action of every drug. We 
might quote many passages from Dr. Bartholow's book to show that he 
is fully aware of the therapeutical value of dosage, but lie has generally 
restricted himself to the old orthodox fashion of giving under the head 
of "dose" the average quantity that is proper for administration. 

We have extended these remarks so far as to leave very little space for 
any detailed account of the treatise on which we have commented. For- 
tunately only a few words are necessary for this purpose. 

The work, comprised within the limits of a single volume of five hundred 
and thirty-seven pages, is divided into three parts. The first part, con- 
sisting of sixteen pages, describes briefly the modes in which medicines 
are introduced into the organism. The second ])art, which forms the 
bulk of the work, is devoted to a discussion of the actions and uses of 
remedial agents. The third part gives an account of topical remedies. 
No scientific classification of the materia medica is possible in the ])resent 
state of science. Writers are therefore justified in adopting any classifi- 
cation that happens to suit their fancy, or in adopting none at all. In 
fact there are about as many ditferent classifications as there are different 
writers upon this subject. Our author has devised a new one, which has 
at least the merit of simplicity, though it is of very little practical value. 
He divides remedial agents, excluding topical remedies, into four classes: 
1. Those used to promote constructive metamorphoses. 2. Those used 
to promote destructive metamorphoses. 3. Those used to modify the 
functions of the nervous system. 4. Those used to cause some evacua- 
tion from the body. Under the first head, or constructive agents, are 
placed aliments, iron, quinia, vegetable bitters, water, pe])sine, oils, fats, 
acids, and the like. Under the second head, or destructive agents, are 
placed alkalies, iodine, mercury, antimony, colchicum, and their congeners. 
Agents which modify the functions of the nervous system are divided into 
those which excite the functional activity of the general nervous system, 
like electricity and nux vomica; those which excite the activity of the 
cerebrum, like camphor and valerian; those which diminish or suspend 
the functions of the brain after antecedent excitement, like alcohol, ether, 
and opium; and those which depress the motor functions of the spinal 
cord and sympathetic, like conium, aconite, and veratrum viride. Evacu- 
ants are divided, in accordance with their prominent physiological actions, 
into emetics, cathartics, urino-genital remedies, and so on. Under topical 
remedies are placed antiseptics, counter irritants of all sorts, and emol- 
lients. In describing each article, a definite and systematic order is 
followed, which contributes not less to the clearness than to the concise- 
ness of the description. There is first the technical name of the article 
to be described, with a brief and comprehensive definition of it, and its 
average dose. This is followed by a list of preparations into which the 
article enters, and their doses. Its antagonists and incompatibles are 
mentioned next, and these are followed by a brief account of the agents 
that aid its remedial actions, or its synergists. Its physiological action 
is then described, to which are appended its various therapeutical appli- 
cations. A list of the authorities referred to, concludes the account of 
each separate article. 



164 Reviews. [Jan. 

We are glad to notice tliat a large number of medicines whose virtues, 
to say the least, are of doubtful importance, but to which the superstitions 
and whims of the past attributed a fictitious value, are not to be found 
in Dr. Bartholow's list of remedies. Another class of agents, whose 
power to affect the economy is undoubted, but which, as the profession 
have learned by sad experience, are more likely to do harm than good, 
like antimony and colchicum, are described with commendable brevity. 
Siill another class of agents, like aconite and belladonna, with whose 
names the profession have been familiar for ages, but of whose virtues it 
has taken little note, are brought into prominent notice, and described 
as they should be at considerable length. Ample space, moreover, is 
given to those few agents which have been, and always will be chief 
among drugs — opium, iron, bark, alcohol, and two or three others. 

Classical authorities tell us that ^sculapius, the mythical father of 
medicine, who brought down from gods to men a knowledge of the 
healing art, flourished about three thousand years ago. If the account 
current between drugs and humanity from that nebulous age till now 
were closed to-day, and the former credited with all the lives they have 
saved, all the pain they have alleviated, and all the good they have done, 
and charged with all the deaths they have caused, the distress they have 
produced, and the harm they have wrought, we fear that humanity, on 
looking at the result, would cry out, away with all doctors' stuff; sink it, as 
Dr. Oliver Wendell Holmes proposed, to the bottom of the sea. While 
we rejoice that the prescribing of drugs is only a small part of a physi- 
cian's duty, we also rejoice that the account to which we have referred is 
not yet closed. When another three thousand years have passed, the sum- 
ming of it up will show a ditferent result. Humanity will then accept 
drugs and gladly give them place as assistants, not disturbers of nature's 
healing laws. The book which has here been reviewed, and whose last 
leaves we now turn over, is an auspicious harbinger of that better day in 
the future, whose dawning we can see, but whose full effulgence a distant 
posterity alone will witness. E. H. C. 



Art. XXVIII. — A Treatise on the Science and Practice of Midwifery. 
By W. S. Playfair, M.D., F.R.C.P., Professor of Obstetric Medi- 
cine in King's College; Physician for the Diseases of Women and 
Children to King's College Hospital ; Examiner in Midwifery to the 
University of London, etc. etc. With two plates, and one hundred 
and sixty-six illustrations on wood. 8vo. pp. 576. Philadelphia: 
Henry C. Lea, 1876. 

Were Siebold, the historian of obstetrics, continuing his great work 
in these times, he would find himself kept busy chronicling the numerous 
text-books and new editions which now follow each other in rapid succes- 
sion ; he would doubtless pause to inquire whether, in view of the great 
excellence of some of the later ones, there was really need for any more. 
This question was evidently in the mind of the author of the work we now 
undertake to examine, for although not stating it, yet in his preface he 
virtually answers it. He finds justification for the publication of his work 
in the rapid progress made of late in this branch of medical science, in 



18tt.] Playfair, Science and Practice of Midwifery. 165 

the fact that there is no department of medicine " in which modern views 
of practice differ more widely from those prevalent only a short time ago." 
He boldly states that "on certain important points he hns recommended 
a practice which not long ago would have been considered heterodox in 
the extreme, and which even now will not meet with general approval." 
A book which introduces itself to us in such a manner, which claims to 
be " an epitome of the science and practice of midwifery which embodies 
all recent advances," challenges the attention of all. To the student and 
practitioner, the appearance of such a work cannot but be an event of the 
greatest interest, while it imposes upon us the duty of inquiring how the 
self-imposed task has been performed, and whether the standard set up 
has been reached ; for not all that is nev/ is good, and as to the matter 
of writing a satisfactory text-book, it is far more frequently attempted 
than achieved. 

After a careful examination of the work, an examination begun under 
the conviction that we already had a text-book of obstetrics that is entirely 
satisfactory, we feel compelled to render judgment in favour of the author. 
In our opinion he has been decidedly successful in his undertaking, liaving 
produced a most excellent manual for the student, and a most valuable 
work of reference for the practitioner. Several characteristics of the 
work justify us in pronouncing this opinion. There is throughout that 
plain and clear statement of fact which is peculiarly appropriate for a 
scientific treatise ; there is no useless verbiage, and no encumbering 
rhetorical ornament. We mark this especially in chapters on such 
important and practical subjects as the signs and symptoms of pregnancy, 
on hemorrhage after delivery and on placenta pragvia, which we consider 
admirable and excellent. The work contains full information upon sub- 
jects not generally found in text-books, such, for instance, as sudden 
death during labour, pregnancy complicated with ovarian tumour, con- 
joined and locked twins. We find, too, that it presents the most recent 
advances in the science of which it treats. There are the latest discoveries 
in regard to the anatomy of the ovary ; the relation of the time of con- 
ception to menstruation ; among the signs of pregnancy not only Rasch's 
test by fluctuation from the abdomen to the vagina, but the far more 
practical one of intermittent contractions of the uterus, recently brought 
prominently forward by Braxton Hicks, a sign which is said to be always 
discoverable, and one upon which the author places a high value. We 
find noticed, also, the operation of gastro-elytrotomy, and the induction 
of premature labour in placenta pra3via is advocated. In another point 
we think there is especial excellence. The author possesses that judicial 
tone of mind so ne(;essary when subjects are under consideration upon 
which our knowledge is yet incomplete, and upon points in regard to 
which practical men are not yet in agreement. He states the case, and 
sums up the argurrient in such cases with admirable good judgment, 
clearness, and precision. Again, there is an entire absence of that devo- 
tion to, or partiality for, pet theories, which is the greatest enemy to 
scientific teaching, as it is to scientific investigation. The author has no 
hobbies to ride, but manifests throughout that true spirit of science which 
seeks only to know the truth, and nothing but the truth, and which will 
be content with nothing less than the v/hole truth, or the nearest possible 
approach to it. 

We are aware that this is no scant praise, and it behooves us to show 
that we are justified iu rendering it. This, we think, we can do by 



166 Reviews. [Jan. 

glancing at some few portions of tlie book, giving preference to those of 
a practical character; and we shall, at least, afford an opportunity for our 
readers to form an independent judgment. 

Passing over the anatomical and physiological portions we first stop 
at the two chapters on Diseases of Pregnancy, a subject which is exceed- 
ingly well treated, considering the limited s))ace at disposal in a volume 
of this size. We find here a decided judgment in favour of the produc- 
tion of premature labour for albuminuria, a doctrine which is not yet 
generally accepted, but one which has of late rapidly made progress, 
and now seems to be finally adopted. In this country it has been advo- 
cated by Elliott and T, G. Thomas, and has been made the subject of an 
elaborate paper by Dr. S. C. Busey.* 

"The propriety of this procedure in the albuminuria of pregnaiacy, has of 
late years been much discussed; and I believe that, having in view the 
undoubted risks which attend this complication, the operation is unquestionably 
indicated, and is perfectly justifiable in all cases attended with symptoms of 
gravity. It is not easy to lay down any definite rules to guide our decision, 
but 1 should not hesitate to adopt this resource in all cases in which the amount 
ot albumen is considerable and progressively increasing, in which treatment has 
failed to lessen the amount; and, above all, in every Ciise attended with 
threatening symptoms, such as severe headache, dizziness, or loss of sight. 'J'he 
risks of the operation are infinitesimal compared to those which the patient is 
running, in the event of puerperal convulsions supervening, or chronic Bright's 
disease becoming established. As the operation is seldom likely to be 
indicated until the child has reached a viable a^e, and as the albuminuria 
places the child's life in danger, we are quite justified in considering the mother's 
safety alone in determining on its performance." (p. 184.) 

But a few years since we were so unfortunate as to meet with a case of 
pregnancy complicated with a large ovarian tumour, and could find no 
counsel excei)t from some scattered articles in journals. Here we have 
the results of the recent study of ovariotomy fully presented, and although 
the extract is long, we give the author's remarks entire, from their great 
practical value, and because it well illustrates his style. After stating 
that of thirteen cases of labour complicated with ovarian tumour, collected 
by himself, far more than half proved fatal ; he continues : — 

"It is obvious, then, that the risks are so manifold, that in every case it is 
advisable to consider whether they can be lessened by surgical treatment. The 
means at onr disposal are either to induce labour prematurely, to treat the 
tumour by tapping, or to perform ovariotomy. The question has been particu- 
larly discussed by Spencer Wells, in his work on Ovariotomy, and by Barnes, 
in his Obstetric Operations. 'J'lie former holds that the proper course to pursue 
is to tap the tumour when there is any chance of its being materially lessened 
in size by that procedure, but that when it is multilocular, or when its contents 
are solid, ovariotomy should be performed at as early a period of the pregnancy 
as possible. Barnes, on the other hand, maintains that the safer course is to 
imitate the means by which nature often meets this complication, and bring on 
premature labour without interfering with the tumour. He thinks that 
ovariotomy is out of the question, and that tapping may be insufficient, and 
leave enough of the tumour seriously to interfere with labour. So far as 
recorded cases go, they unquestionably seem to show that tapping in itself is 
not more dangerous than at other times, and that ovariotomy may be practised 
during pregnancy with a fair amount of success. Wells records six cases which 
were surgically interfered with. In one, tapping was performed ; and in five, 
ovariotomy; and all of these recovered; the pregnancy going on to term in 



Reprint from National Medical Journal. 



1877.] Playfair, Science and Practice of Midwifery. 167 

four, and the fifth beinj^ combined with the C^esarean section. On the other 
hand, five cases were left alone, and either went to term, or spontaneous 
premature labour supervened; and of these, three died. The cases are not 
sufficiently numerous to settle the question, but they certainly favour the view 
taken by Wells rather than by Barnes. It is to be observed that, unless we 
give up all hope of saving the child, and induce abortion at an early period, the 
risk of induced premature labour, when the pregnancy is sufficiently advanced 
to hope for a viable child, would be almost as great as that of labour at term ; 
for the question of interference will only have to be considered with regard to 
large tumours, which would be nearly as much affected by the pressure of a 
gravid uterus at seven or eight months, as by one at term. . . . 'J'he success 
of ovariotomy during pregnancy has certainly been great, and we have to bear 
in mind that the woman must necessarily be subjected to the risk of the opera- 
tion sooner or later, so that we cannot judge of the case as one in which even a 
successful abortion terminates the risk. Even if the operation should put an 
end to the pregnancy — and there is at least a fair chance that it will not do so — 
there is no certainty that that would increase the risk of the operation to the 
mother, while as regards the child we would only then have the same result as 
if we intentionally produced abortion. On the whole, then, it seems that the 
best chance to the mother, and certainly the best to the child, is to resort to 
the apparently heroic practice recommended by Wells. 1'he determination 
must, however, be to some extent influenced by the skill and experience of the 
operator. If the medical attendant has not gained that experience which is so 
essential for a successful ovariotomist, the interests of tlie mother would be 
best consulted by the induction of abortion at as early a period as possible. 
One or other procedure, however, is essential ; for, in spite of a few cases in 
which several successive pregnancies have occurred in women who have had 
ovarian tumours, the risks are such as not to justify an expectant practice. 
Should rupture of the cyst occur, there can be no doul3t that ovariotomy should 
at once be resorted to, with the view of removing the lacerated cyst and its 
extravasated contents." (pp. 197-9.) 

The chapter upon the Management of Labour presents some pointsS of 
great practical interest. The author teaches, of course, the usual Eng- 
lish obstetric position of the patient, on the left side, and well says, " it 
would be useless to insist on any other, even if it were advisable." The 
fact is, this is not a matter of reason, but is a firmly rooted national custom, 
and as such is most tenaciously clung to. Almost every nation lias its 
peculiar and favourite position in labour, and what is very singular, each 
stoutly maintains that its position is tiie best and insures an easier process 
of part\irition.^ But we cannot for the life of us see how the position 
general in this country, on the back, "certainly leads to unnecessary ex- 
posure of the person," a statement which the author makes twice, and 
that, too, when he recommends this position for passage of the catheter ! 
If ru[)ture of the perineum be favoured by dorsal delivery, that is a far 
more serious matter, and deserves attention. The author quotes the 
statistics of Schroeder to support this view, but we cannot think them 
enough to settle the question, although certainly enough to indicate that 
further accurate information is desirable upon tliis point. W^hen, how- 
ever, the author claims that the position on the side is svperior to that 
on the back for forceps operations, as he does, and uses, too, the instru- 
ment having the double curve, we take issue with him, or at least point 
to it as a wonderful instance of the effect of early education and long 
habit. AVith these his claim may possibly be true, but for the student 
and the beginner we do not see how there can be a question. 

' Ueberdie La2;e uud Stelluug der Fran wahrend der Geburt bei verscliiedenen 
Vol.kern. Von Dr. H. H. Tlosri, Leipsic, 1872. 



168 Reviews. [Jan. 

The manan^emeiit of the perineum during the closing stage of parturi- 
tion is a subject upon which tliere has been a great cliange of opinion 
witliin about a decade, brought about chiefly by the writings of Graily 
Hewitt and Leishnian. We find the author in general agreement with 
these opponents of perineal support, although not going so far as to incul- 
cate leaving the perineum entirely alone. He corrects the usual and 
general mode of procedure, and says : " The less pressure that is applied 
directly to the perineum the better. Nor is it either needful or advisable 
to sit by the patient with the hand applied to the perineum for hours, as 
is so often practised." This reaction against extreme doctrine based upon 
exaggerated fears and erroneous views is not, however, new, but revived, 
for it was held by Mende, and Ritgen, and others, and Wigand dis- 
tinctly taught that pressure upon the perineum was likely to do more 
harm than good, and that to restrain too rapid advance the force 
should be applied to the head itself,^ and he must have been one of 
the tirst objectors to the practice, since sujiporting the perineum did not 
become general until during the latter half of the last century.^ The 
author mentions, with commendation, Dr. Goodell's plan of inserting two 
fingers into the rectum, hooking up the perineum and drawing it for- 
wards towards the pubes. " I have followed this plan frequently, and 
believe that it admirably answers its purpose," at the same time admits 
that it is " repugnant both to the practitioner and patient." Assistance 
rendered in this way is a procedure which especially excited the ire of 
Osiander, probably because Stein had recommended it I^ He terms it 
" den alien garstigen Handgritf," for it was even then " old," having been 
recommended by Smellie; and again, " der ehelJiafte Handgritt" says 
that he who practises it will always be told that he has " got into the 
wrong place !"* and relates much of injury done especially by midwives 
in making use of it. However, we learned early in life to attach some 
value to assistance rendered in this way, more however by pressing the 
head forwards and compelling it to hug the pubic arch, from the number 
of times it was communicated to us by older men, as a great discovery 
they hnd made, worthy of being kept a profound secret ! 

Finally, how much of the error relating to this matter has originated in 
a misuse of words ? " Support" implies the expenditure of strength, 
Avhich is wrong; the author says " the term * suj)|)orting the perineum' 
conveys an unquestionably erroneous idea," and he is right. It has 
always seemed to us that had the phrase been framed " ivatching the 
perineum," it would have been far clearer and better, for that is what 
the student should be taught to do. One great danger to the perineum 
is undoubtedly from precipitate labours, but they are not common. In 
ordinary cases there can be no danger of rupture until the last moment of 
extreme extension has arrived, and just then such aid may be given as is 
required. Leishman puts the matter in its true light, although he does 
not formally propose the term we have suggested, when he says that the 

' Geburt des Mensclien, by Nsegele ; ii. 544, Berlin, 1820. 

2 Lei.sliiTian, Meclianism of Partui'ition ; System of Midwifery, Amer. ed. p. 277. 
Goodell, Management of the Peiineum during Labour, Amer. Jouru. Med. Sci., Jan. 
1871 ; one of the best historico-medieal essays ever produced in tliis country. 

3 Handbucli der Entbindungskunst, ii. pp. 159, 225. 

* Whioli will not happen unless the practitioner resorts to it too soon. It can- 
not b" of service until the perineum is so distended that the sensibility of the parts 
is obtunded. 



187T.] Playfair, Science and Practice of Midwifery. 169 

proper manao;ement of tliis stage "consists in watching the amount of 
pressure to which the perineum is being subjected."^ 

We do not find here any recognition of what we believe to be the truth, 
that the quality of the tissues has much to do with this accident. In the 
language of Hecker, " Sometimes a perineum is met with that tears lilve 
tinder."^ Baker Brown, in his Surgical Diseases of Women (2d ed. 
p. 4), teaches nearly the same doctrine.^ The limited experience we have 
had with this lesion, certainly favors the view that this is a most important 
factor. 

Probably upon no part of the management of natural labour has doc- 
trine varied so much as in regard to the third stage. The do-nothing 
policy reached its extreme point under Willinm Hunter. He was a firm 
believer in the omnipotence of "nature," and he therefore left the expul- 
sion of the placenta entirely to the natural powers, and taught this 
practice in his lectures. We are told that under one of Dr. Hunter's 
pupils, a patient retained the placenta thirteen days, and in another 
eleven days, to be expelled in a state of putrefaction. But two or three 
fatal cases, which took place in Hunter's own hands, finally caused him 
to change his views and his teachings.^ Since then, manual extraction 
after short delay, may be stated to be the general plan pursued. It is a 
notable fact, too, that tlie assistance rendered has obscured, we may even 
say falsified, the natural process of events. Tlie profession is indebted 
to Dr. Matthews Duncan for recently calling attention to the real pro- 
cess of placental delivery, and the understanding of this, with the method 
of expression taught by Credo, has established the latest and most im- 
proved method of placental delivery, which is entirely physiological and 
above all eminently preventive of some of the worst sequences of labour. 
Dr. Playfair is a warm advocate of Crede's method, and expresses the 
fullest confidence in its efficacy. After tracing the natural process, as 
taught by Duncan, he describes and illustrates the ordinary mode of de- 
livery by traction on the cord, in which it "passes through the os very 
much in the shape of an inverted umbrella," obstructing the passages, 
and tending to produce hemorrhage. He then gives directions for effect- 
ing expulsion by means of abdominal pressure, and says: — 

"In nineteen cases out of twenty the finger need never be introduced into the 
vagina after the birth of the child, or the cord touched." (p. 263.) 

"The cardinal point to bear in mind is that the placenta should be expelled 
from the uterus by a vis a tergo, not drawn out by a vis afroJtte." (p. 202.) 

In the chapter on Hemorrhage after Delivery he again impresses the 
importance of this mode of delivery: — 

"It is a curious fact that post-partum hemorrhage is much more common in 
the practice of some medical men than in that of others ; the reason being that 
those who meet with it oi'ten are careless in their management of their patients 
immediately after the birth of the child. 'J'hat is just the time when the assist- 
ance of a properly qualified practitioner is of value, much more so than before 
the second stage of labour is concluded; hence, when I hear that a medical 

' System of Midwifery, second Am. ed., p. 278. 

2 Schroefler's Manual of Midwifery, p. 306. 

3 "Some may imagine that sncli an accident at parturition ought not to occiir 
in the hands of a careful practitioner — an inference, liowever, not countenanced 
by the records of obstetric medicine. It has occurred in the practice of the best 
accoucheurs, and some of its causes can neither be obviated nor removed." (p. 3.) 

' Merrimau: Synopsis of Difficult Parturition, 1820, p. 145. 



170 Reviews. [Jan. 

man is constantly meetinq;' with severe post-partum hemorrhaf^e, T hold m3'self 
justified, ipsa fudo, in inferrin": that he does not know, or does not practise, the 
proper mode of managing the third stage of labour." (pp. 273-4.) 

This is sound doctrine; these are words of wisdom. Let the student 
and young practitioner bear thein in inind; he may be sure that in pur- 
suing" this plan he takes the surest means of preventing some of the worst 
complications of the puerperal state. 

Continuing the sul)ject of expression brings us to tlie chapter on Pro- 
longed Labour, where we find this ])rocedure applied for the expulsion 
of tlie child, an application of the method due rather to Kristeller than 
to Crede, although, like so many other things in medicine, it was used, or 
proposed, by others before, as Busch and Von Ritgen.^ In the opinion 
of the author this is an addition to our resources of very considerable 
value, and one which, we are told, is beginning to be used in English 
practice. 

" Crede maintains that it is possible to efTect the complete expulsion of the 
child by properly applied pressure, even when the pains are, entirely absent. 
Strange as this may appear to those who are not lamiliar with the effects of 
pressure, I believe that, under exceptional circumstances, when the pelvis is 
very capacious, and the soft parts otier but slight resistance, it can be done. 
I have delivered in this way a patient whose friends would not permit me to 
apply the forceps, when I could not recognize the existence of any uterine con- 
traction at all, the foetus being literally squeezed out of the uterus. It is not, 
however, as replacing absent pains, but as a means of intensifying and prolong- 
ing the effects of deficient and feeble ones, that pressure finds its best applica- 
tion." (p. 312.) 

The indications and contra-iudications are then given : — 

"If the uterus seem unusually tender on pressure, and, a fortiori, if the 
tonic contraction of exhaustion be present, it is inadmissible. So, also, if there 
be any obstruction to rapid delivery, either from narrowing of the pelvis, or 
rigidity of the soft parts, it should not be used. The cases suitable for its ap- 
plication are those in which the head or breech is in the pelvic cavity, and the 
delay is simply due to a want of sufficiently strong expulsive action." (p. 312.) 

This process of aiding labour is so manageable, and so nearly resembles 
the natural process, that he gives it the j)reference to ergot, a drug which 
finds no more favour at his hands than its merits, or demerits we should 
say, entitle it to. It is very briefly treated of, indeed, occupying less than 
a page. He points out, however, the dangers which accompany its ad- 
ministration, both to the mother and child, although he says nothing of 
its influence in causing irregular contraction of the nteiMis, thus produc- 
ing hour-glass contraction and retained placenta, which we believe to be 
the most frequent, if not the most serious, of its evil effects. However, 
he justly, almost entirely, banishes it from practice as an oxytocic, but 
counsels its use for promoting uterine contraction after delivery. 

This introduces us to the subject of instrumental assistance in laboui 
and the author's position is betrayed at the outset by the quietus hegiv 
to one of the time-honoured maxims of the profession, a maxim which h„^ 
been quoted and misquoted times without number, which has ever been 
the bugbear of timidity, the shield of ignorance, the prolific parent of 
innumerable sins of omission : " Meddlesome miduufenj is bad^ 

"When this proverb is applied to restrain the rash and uninstructed inter- 
ference of the ignorant, it is of undeniable value ; but when it is quoted to 

' Suchard : De I'Expressiou Uterine Appliquee au Fcetus. Paris, 1872. 



es 
las 



18TY.] Playfair, Science and Practice of Midwifery. Ill 

prevent the scientific action of the experienced, who hnow precisely when and 
why to interfere, and who have acquired the indispensable mechanical skill, it 
is sadly misapplied." 

And now why did not the author finish off ''Nature^'' while he was 
about it ? Why not give the covp de grace to that personification, which, 
like the above maxim, is used as a refnge and defence for ignorance and 
incompetence ? That same " Nature," whose powers are so trusted and 
relied upon to escape from diflicnlties, who is looked up to and invoked 
as the sovereign and benign disposer of events, gives us the frightful 
hemorrhage of placenta prajvia, and the disaster of shoulder presenta- 
tions, under which dispensations we have no respect for her authority, do 
not wait on her movements, and do not hesitate to trespass on her do- 
main. 

Tiie varying fortunes of the forceps as an aid in labour would make one 
of the most curious chapters in the history of medicine. They have 
passed from the highest esteem to the deepest reprobation, have been 
resorted to witli a frequency beyond all justification, and have been neg- 
lected until the resultijig mortality excites our horror. Thus Zeller iiad 
10,454 cases of labour without using the forceps once !^ and Boer, 29,961 
cases, with only 119 forceps deliveries.^ On the other hand, Osiander, 
who carried the use of this instrument to the greatest extreme, used the 
forceps 1016 times in 2540 deliveries, or once in every 2 4 cases !'^ In 
England the forceps had their origin, and it is a gift to suffering woman 
of wliich she may be justly proud. Yet there, and throughout Great 
Britain, the reputation of this instrument has, in times past, fallen quite 
as low if not lower than in any other country, and its use been restricted 
within limits so narrow as to excite the utmost surprise, especially in 
view of the eminently practical character of the people. No less an 
autliority than Wm. Hunter, according to Leishman,* rejected them en- 
tirely. Dr. Clarke, whose mastership of the Rotunda Lying-in Hospital 
closed in 1193, says: "Wherever labour is protracted to a dangerous 
length by unusual resistance, there is nothing but mischief to be expected 
from their application. ... I am persuaded a fair opportunity of ap- 
plying forceps with good effect will not occur to a rational practitioner 
in one thousand cases !"^ Writing of the earlier part of the present 
century, Beatty says that for " a period of full forty years this instrument 
was banished from practice through the whole of tliis country. The feel- 
ing was so strong against its employment, and the leaders of the outcry were 
so powerful, that no one dared to question the authority by which it was 
condemned." Under Dr. Labbatt, at the Rotunda, it was not used once 
in 2I,86t labours, and under Collins, only 24 times in 16,654 cases. 

Osborn,® who was the especial advocate of the forceps, as against 
Denman and the vectis, who wrote that " there never was an instrument 
invented more ingenious in the original contrivance, more simple in the 
structure, better adapted, or more capable to overcome evei'y possible 
resistance, to answer every beneficial intention, and to guard against 
every possible injury either to mother or child," laid down rules for the 

' Siehold : Geschichte der Gehurtsliulfe, ii. 449. 

2 Abe<:g : Zur Geburtshiilfe u. GynakologaB, Berlin, 1868. 

3 Siebo'ld, ii. 604. 

* Meclianisin of Parturition, p. 43. 

5 Beattj, Contributions to Medicine and Midwifery, Dublin, 1866, p. 5. 

s Essays on the Practice of Midwifery, London, 1792, pp. 57, 59, 88. 



1^2 Reviews. [Jan. 

use of it which are nothing less than barbarous. The forceps were not 
to be applied until symptoms had occurred to " demonstrate that the 
living powers of the whole body, or vis vitce, are greatly reduced, if not 
irrecoverably exhausted!" — one of the symptoms being "continued ces- 
sation of the labour-pains for several hours, at the end of the third or 
fourth day !" 

It may be said that we have cited extreme cases ; but their number 
counters the objection. Nor can it be denied that neglect of, if not direct 
hostility to this instrument has been a marked characteristic of British 
midwifery, one which has more than once called forth the merited reproach 
of other nations. Now, however, the current of doctrine and of practice 
has changed. Within a few decades past the cause of the forceps has 
been advocated by some most intelligent and active workers, not all of 
them occupying high positions, or filling chairs in metropolitan schools ; 
the advantages of the instruments have been insisted on, its dreaded 
dangers shown to be imaginary, and it has been used so frequently that 
it now^ occupies its true position as the most beneficial and harmless in- 
strument in the obstetrician's armamentarium. The struggle has been a 
long and severe one between the conservatives who would only resort to 
the instrument when failure of the natural powers was unequivocally 
demonstrated, and those who maintained that they should be used in 
anticipation of the evils resulting from delay. With the latter we find 
the author teaching plainly the doctrine that " the mere prolongation 
of labour is in itself a serious thing." This is quite different doctrine 
from that taught by Osborn/ that " in these [severe and long-continued] 
cases, the tediousness and painfulness of the labour, however irksome to 
bear, have a considei"able share in insuring the future security and perfect 
recovery of the patient !" — quite different from that taught by even so 
late a writer as Murphy, that "the mere protraction of labour is no 
justification for interference."" 

Tiie author is in company then, we are happy to say, with all the 
leading British teachers and authorities of the present day upon this 
point ; and we may now say that the reproach is removed of neglecting 
one of the most glorious of her contril)utions to medical progi-ess, and 
one of the most efficient instruments for the preservation of tlie life of 
both mother and child. 

"It is now recognized as an axiom by the most experienced teachers that, 
when we are once convinced that the natural etlbrts are failing, and are unlikely 
to effect delivery, except at the cost of long delay, it is far Better to iiiterlere 
soon rather than late, and thus prevent the occurrence of the serious symptoms 
accompanying protracted labour." (p. 313.) 

We have here no directions for waiting until the head has rested a 
certain number of hours on the perineum ; no admonitions not to 
operate until an ear can be felt, or until certain that absolutely no pro- 
gress is being made, but, 

" What has to be done, I conceive, is, to watch the progress of the case 
anxiously after the second stage has fairly commenced, and to lie guided by an 
estimate of the advance that is being made and the character of the pains, 
bearing in mind that the risk to the mother, and still more to the child, increases 
seriously with each hour that elapses. If we find the progress slow and 
unsatisfactory, the pains flagging and insufficient, and incapable of being 
intensified by the means indicated, then, provided, the head be low in the pelvis. 



Op. cit. p. 54. 2 Lectures on Midwifery, 2d ed. 1862. 



18Yt.] Playfair, Science and Practice of Midwifery. 113 

it is better to assist at once by the forceps, rather than to wait until we are 
driven to do so by the state of the patient." (p. 315.) 

He is careful to point out that the use of the instrument, w^ien the 
head is low down and when it is arrested in the cavity of the pelvis, or 
at the brim with, possibly, an undilated os are two very different matters. 
In the latter case : — 

" The application of the forceps is an operation requiring much dexterity 
for its proper performance, and must never be undertaken without anxious 
consideration. It is because these two classes of operations have been con- 
fused together, that the use of the instruments is regarded by many with such 
unreasonable dread," 

Of the numerous instruments in existence, "so numerous as to make 
it almost appear as if no one could practise midwifery with the least 
pretensions to eminence" (and in this country often without even that), 
" unless he has attached his name to a new variety of forceps," he prefers 
Simpson's. He, therefore, abandons the short forceps altogether, an 
instrument which has been most conservatively clung to in England 
from the time of Denman, and together with such fellow-teachers of his 
country as Barnes and Meadows, prefers the long and double curved 
instrument as suitable for all cases and all emergencies, which the short 
straight forceps is not. The objection that they are too powerful he well 
meets by the remark that "the existence of power does not involve its 
use, and the stronger instrument can be employed with as much delicacy 
and gentleness as the weaker," and quotes a paragraph from Hodge to 
the same import. 

The short forceps having been abandoned, he also abandons the rule 
that the blades of the instrument be applied to the sides of the child's 
head, and as this is a question which still divides obstetricians, we give 
his own words in regard to it. 

"It is admitted that in the high forceps operation the blades must be intro- 
duced in the transverse diameter of the pelvis, without relation to the position 
of the head. On the continent it is generally recommended that this rule should 
be applied to all cases of forceps delivery alike whether the head be high or low, 
and 1 have now for many years adopted this plan and passed the blades in all 
cases, whatever be the position of the head, in the transverse diameter of the 
pelvis, without any attempt to pass them over the bi-parietal diameter of the 
child's head. Dr. Barnes, in his standard work on Obstetric operations, points 
out with great force that, do what we will, and attempt as we may. to pass 
the blades in relation to the child's head, they find their way to the sides of the 
pelvis, and that the marks of the fenestrge on the head always show that it has 
been grasped by the brow and side of the occiput. Of the perfect correctness 
of this observation I have no doubt; hence it is a needless element of 
complexity to endeavour to vary the position of the blades in each case, and one 
which only confuses the inexperienced practitioner, and renders more difficult 
an operation which should be simplified as much as possible." (p. 432.) 

The author finds in the greatly diminished infant mortality which 
attends a more frequent resort to the forceps, one of the strongest argu- 
ments in favour of the views he holds as to the instrument. We cannot 
agree with him, when he states that this is a point which ''has been 
little dwelt on." That the forceps is the child's instrument, that it 
will rescue many infants otherwise still-born, was taught by Meigs^ in our 
country, more than twenty years ago ; it was not only taught but 

1 Obstetrics ; the Science and the Art, 2d ed., 1852, pp. 539, 540. 



174 Reviews. [Jan. 

reiterated, and impressed in tlie strongest language possible, as worthy 
of tlie utmost attention of the student. It was, too, the first step in 
advance towards i)lacing the instrument in the position it now occupies. 
And now tiiat this great change lias been effected in Englisii midwifery, 
it is but just and right that lie and others should have credit for it, or 
at least it should l)e known that the doctrines as to the forceps, to which 
the English have now attained, have been current with us for a genera- 
tion. 

There are some excellent remarks upon the dangers of the forceps ; in 
most cases of injuiT from them he believes that "the fault lay not in the 
instrument, 1)ut in the hand that used it." In regard to the production 
of vesico-vaginal fistula, he gives some instructive statistics which seem to 
prove in the clearest manner, that in the large majority of cases this nn- 
hapi)y accident may be directly traced to the bad practice of allowing labour 
to drag on many hours in the second stage without assistance, and not to 
premature instrumental interference." This had been shown by Emmet, 
in this country, and Jobert de Lambelle maintained that vesico-vaginal 
fistula is always the result of prolonged labour and is never produced by 
the forceps.^ Although not supported by statistics this doctrine is not 
new; it was presented by Osiander and by the elder Dubois.'-^ 

The choice of treatment, as between version and forceps, in cases in which 
the pelvis is contracted has been and still is, as the author well remarks, 
" one of the most vexed questions in midwifery," and in view of the 
recent discussion upon the subject here, we can by no means fail to give 
his position in regard to it. We think, he here shows again that sound 
judgment and freedom from partisanship which win our confidence for him 
as a guide where authorities differ and opinions are conflicting; he states 
the question briefly and clearly, and makes some admirable remarks upon 
the necessity of giving time for the process of moulding the child's head 
to go on, and the mistake of interfering too soon. The instrument being 
generally considered applicable to all cases where the diameter of tlie 
conjugate is about 3j inches, he says : — 

" It is very likely that the forceps do not act equally well in all cases. 
When the head is loose above the brim ; when the conli-action is chiefly limited 
to the antero-posterior diameter, and there is abundance of room at the sides 
of the pelvis for the occiput to occupy after version ; and when, as is usual in 
these cases, the anterior fontiinelle is depressed, and the head is placed in a 
very oblique position, it is probable that turning may be the safer operation 
for the mother, and the easier performed. When, on the other hand, the head 
has engaged in the brim, and has become more or less impacted, it is obvious 
that version could not be performed without pushing it back, which may neither 
be easy nor safe. It is probable, also, that in the generally contracted pelvis, 
in which the contraction is not limited to the conjugate diameter, and in which 
the head enters in an exaggerated state of flexion, the posterior fontanelle 
beins" much depressed, the forceps are more suitable." (pp. 354-5.) 

"That delivery is often possible by turning after the forceps and the natural 
powers have failed, and when no other resource is left but the destruction of 
the child, must, I think, be admitted by all; for the records of obstetrics are 
full of such cases." (p. 355.) 

" 'i'he original choice of turning is a more difficult question to decide. My 
own impression is that the forceps will generally be found to be the preferable 
operation of the two, except, perhaps, when the head refuses to enter the brim, 
and cannot be sufficiently steadied by external pressure to admit of the easy 



' Joulin : Traite des Accouclienients, p. 1070. 

2 Haudbucli der Eubtiu dungskuudt, vol. ii. p. 143. 



187t.] Playfair, Science and Practice of Midwifery. 1Y5 

application of the instrument. An arf^nment used by Martin, of Berlin, in 
reference to the two operations, should not be lost sip^ht of, as it seems to be a 
valid reason for si^'iDrT ^ preference to the forceps. He points out that mould- 
ing may safely be applied for hours to the vertex ; but that when pressure is 
applied to the important structures about tlie base of the brain, as, after turn- 
ing, moulding cannot be continued beyond five minutes without proving fatal. 
Tiiis, however, is no reason why turning should not be used after the forceps 
and the natural efforts have proved ineffectual." (p. 356.) 

Closing what we have to say of the forceps, we must criticize some of 
the illustrations. Generally through the l)ook they are good, and the 
two plates, after Braune, are excellent, even in the reduced scale in which 
tliey are compcdied to appear. But some of the diagrams ai-e very wide 
of the mark indeed. Jn Fig. 152, for instance, the instrument has the 
head only between the tips of the blades, a grasp which would not "hold" 
under any traction at all, and one with which any considerable pressure 
must sink the ends of the blade into the scalp. Fig. 153 calls to tnind 
the artist (!) who placed under his production, " This is a horse !" that 
there might be no mistake! It is said that the figure represents the 
handles of the forceps turned upwards towards the mother's abdomen as 
in the termination of the delivery, but it does not do so. The handles 
project nearly in the axis of the woman's body, nor could they turn up 
towards the abdomen with the position given to her and to the operator's 
hand, which is over the blades, instead of under, as it must be at that 
stage of the extraction. 

We cannot continue the subject of obstetric operations. The chapter 
which follows, on the destruction of the child by craniotomy or eviscera- 
tion, as the case may be, is equal to any of tlie others. At the begin- 
ning, he frankly admits that the frequency with which it has been resorted 
to, " constitutes a great blot on British midwifery." The crochet for 
extraction, he designates as an " obsolete instrument," the craniotomy 
forceps being in evei'y respect preferable, and he thinks Simpson's cra- 
nioclast, an instrument that has never conquered for itself an established 
position, the best of these. The most noteworthy feature of this cliapter 
is his high estimate of the cephalotribe, which has never been a favourite 
in England, and which has received but little countenance until within 
about the last decade. In all cases, except those of extreme contraction, 
he advises the use of this instrument immediately after perforation. We 
do not find Braun's hook, for decaj)itation, noticed among the instruments 
for embryulcia ; one of the few omissions of novelties in the work. 

The subject of anaesthesia in labour is very briefly disposed of, for the 
most excellent reason that, so far as chloroform is concerned, there is no 
longer any argument "required to establish its being a perfectly legiti- 
mate means of assuaging the sufferings of childbirth." This is now, we 
believe, the almost unanimous position of all English-speaking authorities 
upon this subject, and we record it with the satisfaction one may be sup- 
posed to feel who has seen it, from the beginning, win its way in spite of 
prejudice, and in the face of opposition, and who has disappointed many 
solemn prophecies of disaster, to the infinite disgust of the prophets. 
Quite as much space is taken up with the consideration of chloral as 
with chloroform, and the practitioner will find full information as to the 
administration of this more recent anaesthetic, and the cases to which it 
is adapted. The author estimates its value very highly, and has seen no 
evil result from its use. 

Part V. of the work is on the Puerperal State, and contains chapters 



176 Reviews. [Jan. 

on the management of the lying-in woman and of tlie infant, together 
with the puerperal diseases and their treatment. There is much here 
worthy of notice had we not already exceeded our limits. It would be 
scarcely just, however, not to give the author's position in regard to the 
vexed question of puerperal fever, which of late has attracted so much 
attention and excited so much debate. Briefly, then, he denies the ex- 
istence of a peculiar and specific puerperal fever, and looks upon the dis- 
ease as a septicaemia differing in the local manifestations of the constitu- 
tional affection. Indeed, he calls it "puerperal septicsemia," and says — 

*' The whole tendency of recent investigation is daily rendering it more and 
more certain that obstetricians have been led into error by the special virulence 
and intensity of the disease, and that they have erroneously considered it to 
be something special to the puerperal state, instead of recognizing in it a form 
of septic disease, practically identical with that which is familiar to surgeons 
under the name of pyasmia or septicaemia." (p. 516.) 

He is very far from maintaining that our knowledge is complete upon 
this subject; says that the theory of septicaemia '' otfers a far better ex- 
planation of the phenomena observed, than any other that has yet been 
advanced;" that much investigation is yet necessary, and "if any real 
advance is to be made, it can only be by adopting an humble attitude by 
admitting that we are on the threshold of the inquiry; and by a careful 
observation of clinical facts, without drawing from them too positive de- 
ductions." 

This view of the nature of the disease having been accepted, that it 
may spread by infection follows as a matter of course, and there are some 
interesting pages upon the origin of the disease, both autogenetic and 
heterogenetic. Any decomposing organic matter being capable of de- 
veloping the morbid train of action, and the hands of the practitioner 
being one of the most frequent modes of conveyance of the poison, one 
of the most interesting, and indeed solenr.n questions, immediately arises 
as to how much of this is avoidable or unavoidable, and what course 
the practitioner should pursue in regard to withdrawing either from obstet- 
rical practice, or from other cases when they are of such a nature as likely 
to imperil puerperal women under his care. When duty and interest 
clash, the decision is not easy ; it is still more difficult when duty in one 
direction militates against duty in another. Ui)on this point, of so great 
practical interest, we quote the admirable remarks of the author in full. 

"This question naturally involves a reference to the duty of those who are 
unfortunately brought into contact with septic matter in any forms, either in a 
patient suffering from puerperal septica3niia, zymotic disease, or offensive dis- 
charges. The practitioner cannot always avoid such contact, and it is practi- 
cally impossible, as Dr. Duncan has insisted, to relinquish obstetric work every 
time that he is in attendance on a case from which contagion may be carried. 
Nor do 1 believe, especially in these days, when the use of antiseptics is so well 
understood, that it is essential. It was otherwise when antiseptics were not 
employed; but I can scarcely conceive any case in which the risk of infection 
cannot be prevented by proper care. The danger I believe to be chiefly in not 
recognizing the possible risk, and in neglecting the use of proper precautions. 
It is impossible, therefore, to urge too strongly the necessity of extreme and 
even exaggerated care in this direction. The practitioner should accustom him- 
self as much as possible to use the left hand only in touching patients suffering 
from infectious diseases, as that which is not used, under ordinary circum- 
stances, in obstetric manipulations. He should be most careful in the frequent 
employment of antiseptics in washing his hands, such as Condy's fluid, carbolic 
acid, or tincture of iodine. Clothing should be changed on leaving an infec- 



1817.] Playfair, Science and Practice of Midwifery. lit 

tious case. Much more care than is usually practised, should be taken by 
nurses, especially in securing perfect cleanliness in everything brought into 
contact with the patient. When, however, a practitioner is in actual and con- 
stant attendance on a case of puerperal septicaemia, when he is visiting his 
patient many times a day, especially if he be himself washing out the uterus with 
antiseptic lotions, as it is frequently advisable for him to do, it is certain that 
he cannot deliver other patients with safety, and he should secure the assist- 
ance of a brother practitioner ; although there seems no reason why he should 
not visit women already confined in whom he has not to make vaginal examina- 
tions." (pp. 525-6.) 

One part of the book we marked for especial comment, but must forego 
the pleasure. It is the succeeding chapters on Puerperal Yenous Throm- 
bosis and Embolism, Arterial Thrombosis and its resulting gangrene, with 
sudden death during labour from these and other causes. It is a subject 
which the author has made a special study ; in regard to some portions 
of it, he has new views to offer, and the whole is very fully and excel- 
lently treated. 

Doubtless we have extended our notice of this work enough and made 
extracts sufficient to enable our readers to judge for themselves as to its 
merits. We are satisfied that they will agree with our high estimate of 
it as an admirable text-book for the student, and work of reference for 
the practitioner. They will also find that it is a complete embodiment of 
recent progress in this branch of medical science. As to the heterodox 
teaching, or that not yet generally accepted, to which the author alludes 
in his preface, that is a matter more concerning English midwifery ; so 
far as instrumental interference with labour is concerned, the work will be 
found in accord with accepted doctrines here. 

In closing, we may note a more frequent quotation of American authors 
than usual in English books, and an acquaintance even with our journal 
literature. We find quoted besides Meigs, Hodge, Bedford, Thomas, 
Sims, Barker, and other standard authorities, allusion to the waitings of 
Goodell, Penrose, Engelman, Whittaker, and Minor. There are some 
notable omissions, however. The work is doubtless too recent to con- 
tain anything of the labours of the lamented Parry in the chapter on 
extra-uterine pregnancy, or Skene's successful case of gastro-elytrotomy ; 
we could hardly expect an allowance of the claims of Wright of Cincin- 
nati, as to cephalic and bimanual version ; but we certainly expected to 
see the name of Dr. Isaac Taylor in connection with the changes the 
cervix undergoes during pregnancy, of Dalton in connection with the 
corpus luteum, and White of Buffalo with the reduction of chronic inver- 
sion of the uterus. J. C. R. 



No. CXLY.— Jan. isn. 12 



178 [Jan. 



ANALYTICAL AND BIBLIOGRAPHICAL NOTICES, 



Art. XX^X.— Gui/\s Hospital Reports. Edited by H. G. Howse, M.S., and 
Fredkrick Taylor, M.D. Third Series. Yol. XXI. 8vo. pp. xx., 469. 
London : J. & A. Churchill, 1876. 

The current volume of this valuable series contains, as usual, about an equal 
number of medical nnd surgical papers, and in accordance with our custom we 
ehall consider these separately, calling attention first to those of special interest 
to the physician. 

In the remarks which precede the reports of Cases illustrating the Diuretic 
Action of the Resin of Copaiba, Dr. Frederick 1'aylor extols the valuable 
therapeutic properties of this drug, especially in the treatment of the various 
forms of dropsy, believing that it is to the resin and not to the oil, as is gene- 
rally supposed, that the balsam owes its power of increasing the secretion of 
the kidneys. The resin was given in more than sixty cases treated in the wards 
at Guy's by Dr. Taylor and his colleagues. They include cases of (1) hepatic 
dropsy; (2) simple peritoneal effusion; (3) cardiac dropsy; (4) anasarca and 
ascites secondary to emphysema and bronchitis ; (5) pleuritic effusion ; (6) renal 
dropsy. As a result of its administration in favourable cases the quantity of 
urine was quickly increased, the specific gravity being at the same time much 
lowered ; this result being frequently produced in cases in which digitalis and 
other diuretics had been given without effect. The diuresis, however, subsided 
immediately upon the withdrawal of the drug. In some of the cases the resin 
did not increase the flow of urine. In most of these the kidneys were extensively 
diseased, but even in these cases there was no evidence that positive harm fol- 
lowed its use. 

It may be well to remind our readers that the urine of persons taking this 
drug yields a precipitate on the addition of nitric acid, closely resembling that 
produced by albumen, but care will generally enable us to distinguish one from 
the other. From twelve to fifteen grains may be given in emulsion thrice daily. 

Considerations on the Cures in Insanity is the title of a long paper by Dr. 
George H. Savage, who bases his statistics on the annual returns of Bethlem 
Hospital during the last ten years, from 1865 to 1874 inclusive. The paper 
has evidently been very carefully prepared, and will, we have no doubt, be con- 
sidered a valuable one by alienists, but it would be impossible to present our 
readers with an abstract of it in the space at our command. As the general 
practitioner is more apt to see cases of insanity at the beginning than at any 
other time, we will quote the following paragraphs for his benefit : — 

" It is to be observed that cases get well in much larger proportion if they 
have been sent to an asylum early. This is a most vital point, and one that we 
are never tired of bringing before the public and the general practitioner. It 
is false economy — if done for economy — to keep a patient in a workhouse or 
in a private house when he is distinctly insane. My experience completely cor- 
roborates that of Dr. D. H Tuke, at ' The Retreat,' that over seventy per cent, 
of cases admitted within three months of the first attack get well ; whereas of 
sufferers from a first or other attack admitted to an asylum treatment twelve 
months after the onset not twenty per cent, get well." 



1877.] Guy's Hospital Reports. 179 

Dr. James F. Goodhart's paper On Meningeal Hemorrhage is foimded upon 
forty-nine cases, thirty-six of which are from the post-mortem records of Guy's 
Hospital for the last twenty-one years. 'I'he rest he has collected from the 
Transactions of the Pathological Society of London. Eight out of the forty- 
nine cases are probably, he says, due to iajury, and are therefore not available 
as to the cause of spontaneous meningeal hemorrhage. The remaining forty-one 
show that in twenty there was renal disease, associated in thirteen instances 
with hypertrophy of the heart; in two more it is probable that the same condi- 
tions existed, and in six others there was hypertrophy of the heart without renal 
disease. Thus twenty-eight out of forty-one, two-thirds of the whole number, 
occurred with a state of the kidney or heart which is known to bring about an 
increase of the blood pressure in the arterial system. To this, therefore, he 
ascribes the principal influence in the production of the hemorrhage. He 
believes that the miliary aneurisms of the cerebral vessels, to which MM. 
Bouchard and Charcot have called attention, are caused by this high tension 
and its consequent hypertrophy. That similar aneurisms are not found so 
frequently in other parts is easily accounted for, he says, by the fact that there 
are few vessels so little supported by surrounding tissues as are those of the 
brain. 

The symptoms of meningeal hemorrhage appear to be absolutely wanting in 
pathognomonic significance. Coma was present in fourteen of the cases ; it 
was generally profound, and ushered in death, but in some it was only partial, 
and in three was temporarily recovered from. Convulsions, contrary to what we 
should expect, do not appear to be a common symptom, having been noted in 
only twelve of the cases. Rigidity is even less frequent, having occurred in 
only four cases. Headache in the occipital region, and pain in the back of the 
neck were marked symptoms in only four cases. Delirium was occasionally 
noticed, as also were irregularity of the pupils, stupidity, and incoherence. 
Sudden death occurred in four cases. The author says that the one symptom 
which more than any other would lead him to suspect meningeal hemorrhage is 
" a permanent or rather persistent stupidity after an injury or following upon 
some convulsive seizure." 

The prognosis in meningeal hemorrhage is grave. There is good reason for 
thinking, however, that recovery occasionally takes place. To relieve the 
high tension which is so prolific a source of cerebral hemorrhage, no remedy 
is so effectual, in the author's opinion, as free purgation. H should be resorted 
to both as a means of prevention, which, if carefully guided, may avert the 
dangers of an impending stroke, and which, even when the seizure has come, 
may yet do much good by lessening the blood pressure, and so avert further 
bleeding. For the same reason venesection will occasionally be useful, especi- 
ally where after a hemorrhage the pulse keeps hard. Ice should be at the same 
time applied to the head, and the head and shoulders be raised. If there is 
hypertrophy of the heart, the tincture of aconite may be given in small doses. 

The reader will find in Dr. Paul Henry Stokes's paper On the Use and 
Administration of Sedatives, many valuable hints in the treatment of disease. 
It is not of a nature to be readily analyzed, and we must therefore content 
ourselves with this brief reference to it. 

We learn from the Fifth Annual Report of the Guy's Hospital Lying-iri 
Charity ; collated from the Records, by A. L. Gallabin, M.D., that the dis- 
trict comprised by the Charity lies within a radius of about a mile from the 
hospital, and that the patients are attended at their homes by the students; 
the assistant obstetric physician being, however, sent for to superintend all 



180 Bibliographical Notices. [Jan. 

cases in whicli any obstetric operation is required. 'J'he report embraces a 
period of twelve years from October, 1863, to the end of September, 1875. 
During this period 23,591 women were delivered of 23,811 children; of whom 
22,838 were born alive, and 973 were stillborn ; the proportion of the sexes 
being 100 males to 88 females. The death-rate in children shows, Dr. Gallabin 
says, a progressive improvement. In the present report it is only 4.08 per 
cent. ; in the last report of nine years it was 4.6; while in the preceding 
twenty-one years it was 5.2. The mortality among the children in cases of 
pelvic, arm, transverse, or funis presentation, is, however, high. Taking foot 
and breech presentations together, the children stillborn are in the proportion 
of 1 to 2.5. 

Of twin cases there were 220, or about 1 in 107 of the whole number of 
women delivered. In 84 cases the children were both males, and in 61 both 
females. Only one case of triplets is noted; 86 cases of face presentation 
occurred, and in 7 of these the children were stillborn. All were delivered by 
natural efforts, except one, which was extracted by version, and was living. 
The number of cases in which the funis presented was 62 ; 8 of the children 
were living, and 54 stillborn. The brow presented in 16 cases, and 14 of the 
children were born alive. The upper extremity presented in 61 cases, in 9 of 
which the funis was also prolapsed. There v/ere 16 transverse presentations, 
two of them complicated by prolapse of the funis. Taking the whole 77 cases 
together, 12 were completed by natural efforts, the children being stillborn in 
7 cases. In the remaining 65 cases the presentation was rectified by podalic 
version ; 15 of the children only being born alive. 

Out of the 23,591 deliveries included in the present report, 121 protracted 
labours were terminated by forceps ; or 1 in 197, or about 0.51 per cent. The 
foetal skull was opened in 18 cases, or 1 in 1310, or about 0.07 per cent. Seven 
•cases of rupture of the uterus or vagina are recorded, or 1 in 3371 deliveries. 
Caesarean section was performed after death in one case, but the child was not 
«aved. Delivery after the occurrence of the rupture was effected by the for- 
ceps in four cases ; by version in one ; and by version, followed by craniotomy 
in one. All the patients died, but one of them lived as long as four days after 
delivery. In one case the uterus became spontaneously inverted two days 
after delivery, and the patient quickly died of hemorrhage. 

Post-partum hemorrhage directly caused death in eleven cases. In nine 
cases a solution of perchloride of iron was injected into the uterus; but the 
measure, the author tells us, was never adopted until the effect had first been 
tried of introducing the hand into the uterus, clearing out the clots, and com- 
pressing it between the internal hand and the other hand applied externally to 
the abdomen. In all instances the iron injection stopped the bleeding, but in 
two the patients sank under the effects of the hemorrhage about an hour after ; 
and one woman died from septicaemia on the twenty-sixth day. No successful 
instance of transfusion is recorded. Forty-one cases of placenta praevia occur- 
red, six of which were fatal to the mother. Of the children, 10 were living ; 
31 were stillborn, 'i'he placenta was adherent, and required the introduction 
of the hand into the uterus for its removal in 75 cases ; or 32 per cent, of all 
the cases. 

28 cases of eclampsia are recorded, or 0.12 per cent., or 1 in 842. In refer- 
ence to the connection betwean albuminuria and this complication, we find the 
author expressing himself as follows : — 

" Since it has been recently urged by some that the importance of albuminu- 
ria in connection with eclampsia has been overrated, and that uraemia is only 
one of several common causes which may produce such a result, it may be of 



187*7.] Guy's Hospital Reports. 181 

interest to note that, of all cases durino^ the last forty years in which the urine 
was examined, it remained free from albumen in only two." 

Out of 23 cases of eclampsia in which chloroform was administered often 
for many hours consecutively, there were five deaths, which is a decided im- 
provement upon the death-rate under the old plan of treatment by venesec- 
tion. 

Three cases of puerperal mania occurred, all of which terminated fatally. 
Death took place from puerperal peritonitis and other forms of septicasmia in 
thirty-four cases, two of which are reported under the head of post-partura 
hemorrhage, and two under that of adherent placenta. Nine cases of zymotic 
disease occurred, including five of variola, in one case terminating fatally ; 
and one each of the following diseases — typhoid and typhus fever, scarlatina, 
and erysipelas— all ending in recovery. The number of deaths among the 
mothers was 106. 

A Case of Nitro-Benzol Pohoiniig, reported by Thomas Stevenson, M.D., 
occurred through the fault of a physician, who wrote his prescription so illegi- 
bly that nitro-benzol was substituted for rectified benzol, the drug intended to 
be given. The patient took about 23 minims of the poison in the course of 
about forty-eight hours. When first seen by a medical man the surface of his 
body was bluish-purple, and cold, and the pulse could not be felt at the wrist. 
The heart could be heard beating faintly and irregularly. The lower jaw was 
rigidly closed, but the limbs were flaccid, and dropped powerless when raised. 
The pupils were widely dilated. No breathing could be perceived. The treat- 
ment consisted in the application of sinapisms to the chest, and abundant 
friction of the limbs for two hours. Later, a secondary current from a mag- 
neto-electric machine was sent through the hands and upper limbs. Still later, 
brandy was administered, and ammonia inhaled. In about six hours from the 
time the patient was first seen he had begun to react, and the next day was fairly 
convalescent. Nitro-benzol was detected in his urine. Dr. Stevenson calls atten- 
tion to the close resemblance of the symptoms in this case to those produced 
by prussic acid. 

Appended to the paper is the prescription, beautifully lithographed, through 
the misreading of which the case occurred; and also another prescription by 
the same physician. They are, as Dr. Stevenson says, curiosities in the way 
of illegibility. 

Under the heading, Remarks on fiome of the Paroxysmal Neuroses, Dr. C. 
Hilton Fagge discusses a group of diseases, including migraine, paroxysmal 
vertigo, and mania, epilepsy, and tetany, all of which have, among other cha- 
racters in common, a tendency to recur paroxysmally at more or less regular 
intervals, the persons who suffer from them being at other times in apparently 
good health. Another important character of these diseases is, that they are 
essentially innate and hereditary. In different members of the same family the 
inherited tendency may, however, show itself in different ways, one child being 
epileptic, another asthmatic, a third subject to migraine, etc. Still another 
feature which is common to them is, their tendency in the same patient to 
undergo metamorphosis in course of time. This is particularly the case, the 
author says, with epilepsy ; its attacks being liable to be replaced by vertigo, 
catalepsy, mania, or even other forms of nervous disturbance. Dr. Fagge 
enters very fully into a discussion of the pathology of epilepsy, migraine, and 
paroxysmal vertigo, during the course of which he subjects the views of Drs. 
Hughlings-Jackson, Liveing, Latham, and Meniere, to a searching criticism. 
We are, unfortunately, unable to follow him through this, and will therefore 
quote only his conclusions in regard to epilepsy : — 



182 Bibliographical Notices. [Jan. 

"To sum up, I would adopt the language of some modern writers, and say 
that epilepsy is ' dependent upon an unstable condition of the nerve tissue in 
some portion of the nervous system, permitting occasional discharges.' 'J'his, 
in reality, is not stating more than that the disease is a nerve storm. And 
just as in migraine teichopsia may be followed in succession by numbness in 
the fingers, by headache, by vomiting, by sleep. So in epilepsy, tonic spasms 
give place to clonic convulsions; and these, again, to stupor or coma. To me 
it appears more satisfactory to refer this sequence of phenomena to the gradual 
extension of some morbid condition from one part of the nervous centres to 
another, than to ascribe it to modifications in the blood supply." 

Dr. Pavy, in his article On the Recognition of Sugar in Healthy Urine, 
gives us the details of a process by which he has succeeded in demonstrating 
the existence of sugar in normal urine. Two or three quarts of healthy urine 
are first treated with the neutral plumbic acetate, until a precipitate is no 
longer produced, for the purpose of ridding it of urea, uric acid, and other in- 
gredients. Sugar is not carried down by lead in an acid solution, but if the 
supernatant liquid is now siphoned and treated with ammonia and plumbic 
acetate, it falls with the lead as a definite compound, consisting of two atoms 
of sugar and three of oxide of lead. After thoroughly washing the precipitate 
to free it of the ammonia, it is treated with sulphuretted hydrogen, which dis- 
places the lead. The product is then subjected to filtration, and after washing 
the filtrate, the lead washings, which will contain any sugar that may have been 
present, are brought to a small bulk by evaporation over a water bath. De- 
coloration is next effected by animal charcoal, which has been thoroughly 
purified from lime. Reduced to a concentrated form, the product is now 
ready for the apjdication of the various tests. 

With a specimen of the product obtained by the above process, Dr. Pavy 
obtained, with Moore's test, a dark-brown coloration. The bismuth (Bottger's) 
test became black. The copper solution gave a copious precipitate of orange- 
yellow reduced oxide. As long as the solution has an acid reaction, fermenta- 
tion cannot be excited in it; but it is readily produced if it be brought to the 
neutral state before the addition of ye;!St. As the result of his experiments, 
Dr. Pavy has reached the conclusion that healthy urine contains about half a 
grain (.565 grain) of sugar to the pint. 

In conclusion, the author says : — 

" I regard the fact that sugar is susceptible of recognition in healthy urine 
as of the highest importance with reference to the glycogenic theory. It tells 
strongly against the validity of this doctrine. I strenuously contend that there 
is no active destruction of sugar carried on in any part of the circulatory sys- 
tem. If sugar reach the general circulation, whether from the liver or by 
artificial introduction from without, it is to be discovered in the blood of all 
parts of the system. Under natural circumstances, the blood contains only a 
minute proportion of sugar ; and still, from this minute proportion, the urine 
acquires a recognizable saccharine impregnation. Such being the case, what, 
it may be asked, might be reasonably looked for if sugar were constantly being 
discharged from the liver, as is maintained under the glycogenic theory?" 

J. H. H. 

Excluding Dr. Steele's statistical report, the surgical portion of this volume 
comprises but about one-fourth of its bulk ; and of that portion we now pro- 
ceed to furnish our readers an analytical abstract. 

The first article is On Fractures of the Thigh, from the pen of Mr. J. Cooper 
FoRSTRR, and under this caption he gives a summary of his experience, extend- 
ing through more than thirty years, in the treatment of fractures of the shaft 
of the thigh-bone. While expressing great impartiality in regard to the dif- 



1811.'] Guy's Hospital Reports. 183 

ferent plans of treatment which have prevailed during the last quarter of a 
century, Mr. Forster shows a decided preference for the Hodgen splint, claim- 
ing that by its use are combined all the advantages of the inclined plane, with 
its relaxed muscles, and those of the straight splint, with its fixed joint sur- 
faces and extension. As Hodgen's splint is but little used in this country, it 
is, perhaps, well to state the points of difference between it and the well-known 
splint of Dr. N. R. Smith, of which it is a modification. Dr. Smith fastened 
the splint to the limb by a roller closely applied, and extended the splint upon 
the pelvis, thus confining the hip-joint. Mr. Hodgen attaches strips of cloth 
to the lateral bars of the splint, and does not allow it to extend above the hip, 
the limb is then placed in the splint, resting upon the strips of cloth, thus 
reviving the method of action belonging to the double inclined plane. Mr. 
Forster swings the limb, as did Dr. Smith, so as to obtain some extension 
directly from the thigh, and also applies adhesive plasters and a weight. That 
this compound method is an efficient one can be readily seen, and, we have no 
doubt, may be exceptionally useful. In the great majority of cases, however, 
we think simple extension by a weight, with lateral compression by sand bags, 
will be found to give quite as good results as those recorded in the table which 
concludes Mr. Forster's article. Experience has pretty well demonstrated the 
fact that some muscular extension conduces to the steadiness of a limb, and 
there would seem to be little advantage in reviving the inclined plane, with its 
muscular tremors and startings, excepting where there is special intolerance 
of other methods. It is proper here to state that Mr. Forster looks upon the 
smaller weight required, from the absence of friction between the limb and the 
surface of the bed, as a decided advantage. It is very common to cast sus- 
picion upon the accuracy of the measurements where the results obtained by 
different plans of treating fractures of the thigh-bone are under discussion, but 
among competent and careful surgeons one man may be presumed to be about 
as apt to be correct as another, so that we do not hesitate to aver, that we 
have seen as little average shortening after the use of the old apparatus, known 
in this country as Physick's Desault, as is obtained by any other plan, although 
we have long since adopted the sand bags and weights as more comfortable to 
the patient, less troublesome to the surgeon, and attended with equally good 
results. 

A very readable paper On Causes of Preventable Blindness is contributed 
by Mr. 0. Higgens. Three causes are mentioned— granular ophthalmia, puru- 
lent ophthalmia, and undetected glaucoma, which are treated successively and 
in some detail. Granular ophthalmia is seen most frequently among those 
whose hygienic surroundings are unfavourable, and is confined to those in 
whom the characteristic anatomical changes, known as granulations, are pre- 
sent on the lids. Tliese cases always extend through long periods of time, 
despite any treatment which may be adopted, yet the practitioner is encouraged 
to believe that faithful and persevering attention will generally be followed by 
improvement, and the disastrous injury to vision, so common a result of neglect 
or inefficient treatment in these cases, be averted. The treatment by astringents 
and mild caustics, combined with general remedies, advised by Mr. Higgens, 
does not differ from the standard practice among ophthalmic surgeons. 

Purulent ophthalmia is the second among the preventable causes of blind- 
ness referred to in this paper. Prompt and vigorous treatment by strong 
caustic applications frequently used, with hourly cleansings by astringent 
lotions, is strictly according to the canon. It is worthy of especial notice that, 
according to our author, general depletion is scrupulously to be avoided in 
this highly inflammatory disease, although we believe that most ophthalmic 



184 Bibliographical Notices. [Jan. 

surgeons, while agreeing with Mr. Higgens on the value of tonics and stimu- 
lants, place more dependence upon local depletion than he seems to do. 

That portion of the paper which speaks of undetected glaucoma as a very 
frequent cause of blindness is of great value, for the failure to recognize this 
condition is too common among general practitioners, and from such failure 
serious evils very often follow. When a patient over fifty presents himself 
complaining of impaired vision, with a somewhat dilated and immovable pupil, 
it is not safe to make a diagnosis of unripe cataract merely because we notice 
that the pupil has lost its pure blackness ; the tension of the ball should be 
carefully examined, and a comparison made with the unaffected eye, or with 
that of the observer, and, if increased hardness is found to exist, the diagnosis 
should be at once made positive by the ophthalmoscope, or the patient sent to 
one expert in such cases. 

A noticeable feature in this paper, and one worthy of high praise, is the 
comparative absence of special technical terms, so that it appeals directly to 
the average medical man, who can read it without finding that he has a new 
vocabulary to learn. In the judgment of the writer there is hardly a greater 
error into which an author can fall than to indulge largely in technical terms 
when addressing the general reader. Even so eminent a writer as Mr. Thomas 
Carlyle would probably have exerted a wider and more permanent influence 
had he confined his genius within the limits of a more ordinary phraseology 
and style than that in which his thoughts have been given to the world, and 
Mr. Emerson, probably, would be longer remembered had he been less 
Emersonian. While the scientist must perforce sometimes resort to those 
terms which have sprung into being with the advances they represent, yet the 
simpler his language, and the plainer his style, the more readily will he find 
readers. High science, like high art, is only appreciable by a very few. Such 
papers as this one by Mr. Higgens are much needed at the present day, and 
ought to be largely appreciated, even though they may contain nothing abso- 
lutely new ; for, while specialists are often criticized for the narrowness of their 
work, the every-day physician or surgeon is too apt to allow himself to go 
uninformed of the progress made in the separate departments of medical 
science. 

The remaining contribution to Ophthalmic Surgery is a short paper on 
Retinitis Pigmentosa, being the ninth series of a descriptio7i of the appearances 
of the human eye in health and disease as seen hy the ophthalmoscope, by Mr. 
C. Bader. Mr. Bader's pictures are too well known to the readers of Guy's 
Reports to need commendation. It is sufficient to say that the lithograph is 
well executed, and the short account of the disease it represents distinct and 
lucid, so that this number will be regarded as a worthy member of the series 
in which it finds a place. 

Between the two ophthalmic papers is a Contribution to Dental Pathology, 
by S. James A. Salter, M.B., P.R.S. The subject of hypertrophied dilated 
tooth-fangs is first discussed in connection with an article published in the 
volume of the Reports for 1868, describing a case which was the third one 
upon record. At that time Mr. Salter predicted that the cases published by 
Tomes and Forget would prove to be identical in nature with his own, and a 
re-examination of the specimens has verified the statement, and they have been 
proved to be enlarged and dilated fangs. Another case is now narrated, which 
occurred in the practice of Mr. Bryant, making the fourth one recorded. The 
patient from whom the specimen was obtained was a boy, aged eleven years, 
with the notches of inherited syphilis upon his incisors. For three years there 
had existed a growth, probably an epulis, over the socket of the left central 



1811.2 Guy's Hospital Keports. 185 

incisor. Upon removal of the incisive bone with the overlying soft parts by 
operation, the left central incisor was found to have an expanded fang, furnish- 
ing a beautiful example of the " odontome radiculaire," with the pulp as yet 
uncalcified. Mr. Salter thinks that the abnormal size of the fang acting as an 
irritant may have had some connection with the growth of the epulis ; he also 
propounds the question whether the syphilitic dyscrasia which existed, was in 
any way chargeable with the altered form of the fang. As will be seen, the 
number of recorded cases of this character is as yet too few to admit of 
generalizations. 

The next case was one occurring in a girl of thirteen. A semisolid tumour 
of the right superior maxillary bone existed, filling up the space between the 
cheek and the gum, and causing the hard palate to project downwards, while 
both the lateral incisor and canine of that side were absent. Upon making 
an incision within the mouth a cavity was opened, projecting from the external 
wall of which were two osseous masses, that upon removal proved to be the 
missing teeth, amorphous and hardly recognizable. A speedy recovery ensued. 
Mr. Salter gives an interesting account of the histology of these masses; he 
also indulges in some criticism of M. Broca's classification of such tumours, 
preferring the one adopted by himself, Wedl, and Virchow. For the details 
of the discussion we must refer the reader to the original article, which con- 
cludes with an account of a deformed second upper molar in which the three 
fangs were almost entirely fused. The paper is illustrated with several wood- 
cuts. 

The next two surgical papers are by an author whose name will awaken the 
memories of a generation almost past; they are entitled Statistics of Amputa- 
tions and On the Treatment of Ulcers hy the Local Application of a Weak 
Continuous Electric Current, by C. H. Goldtng-Bird, B.A., M.B. The first 
article is intended as a continuation of Mr. Bryant's tables published in vol. 
xlii. of the Medico- Chirurgical Transactioiis. It includes the record of 
results obtained in Guy's Hospital during the fifteen years subsequent to those 
with which Mr, Bryant dealt. Since Norris first published his statistical 
tables, the contributions to our knowledge of the average results of most of 
the major operations in surgery have been sufficient to pretty much establish 
laws, and the tables before us, while helping to make the subject complete, do 
not diff'er in conclusion from those which accord with the experience of most 
large hospitals. We shall not attempt to condense what is already condensed, 
but pass on to the second paper, which narrates some experiments instituted, 
together with the results in some cases of treatment based upon the conclu- 
sions arrived at by experiment. 

To an indolent ulcer a silver plate was applied, and to a neighbouring raw 
surface one of zinc, and the two plates united by a copper or silver wire. 
The raw surface was obtained by first blistering and then removing the 
cuticle, and this was found to be necessary, as when the epidermis was 
unbroken, no galvanic action was induced. When, however, the cutis was 
removed in the manner stated, a current between the two plates was at once 
established, and it was found that an eschar was gradually produced under the 
zinc from the nascent chloride of that metal there developed, while the ulcer 
under the silver plate was stimulated into healthy action. After a few days' 
use of the plates the galvanic action became feeble or ceased altogether, the 
density of the eschar formed under the zinc interrupting the current, while the 
tenderness and swelling in the locality became so considerable as to require a 
change in the position of that pole of the battery. To avoid this undue action 



186 Bibliographical Notices. [Jan. 

it was found desirable to move the zinc plate to a fresh surface every day. 
When, however, the ulcer under treatment had a dense lardaceous base, by 
applying the zinc plate directly to it, the caustic action of the chloride could 
be taken advantage of and the sore led to take on healthy action upon the 
separation of the slough. 

To obviate the inconvenience produced by the decomposition of the zinc plate, 
nn(\ the suffering attendant thereon, Mr. Golding-Bird resorted to experiments, 
and found tliat he could obtain the beneficial results of the galvanic current 
without drawback by the use of a small independent battery, with silver 
electrodes. For walking cases an efficient battery was obtained by inclosing 
plates of zinc and silver foil in lint, separated from each other by the same 
material, moistened with salt and water. When patients were confined to bed 
a one-, two-, or three-celled sulphuric acid battery was used. In either case the 
silver electrodes were applied one to the sore and one to an adjacent part. 
By the experience thus obtained it was found that equal effects were produced, 
whether the fluids of the patient formed part of the battery, or if he were 
subjected to the current of one entirely external to himself. 'I'he experience 
of Mr. Golding-Bird, together with that of others, leaves no room for doubting 
the efficiency of electrolysis in the treatment of indolent ulcers, while it is 
admitted to be equally certain, that, like other stimulating dressings, it is only 
valuable for a limited period of time. Experience has also taught many sur- 
geons to regard almost in the light of law, the fact, that variety is the spice of 
life for an ulcer. 

A Case of Fracture of the Skull, followed hy a Collection of Cerebrospinal 
Fluid Beneaili the Sccdp, Recovery, by R. Clkment Lucas, B.S., is next 
in order, and transcribing the title seems almost to have effected an analysis of 
the article. The case was, however, an interesting one, and of such rarity as 
to warrant the presentation of some of its details. A child two and a half 
years old fell from a window to the ground, a distance of eighteen feet, and 
had some slight cerebral symptoms immediately after the accident. When 
first brought under observation, three weeks after the receipt of the injury, the 
child was peevish, fretful, and lacking in animation, though presenting an intel- 
ligent expression. In the left temporal region were two circumscribed tumours, 
of the shape and size respectively of a pullet's egix, and a walnut, connected 
together, extending from within an inch of the orbit nearly to the posterior 
margin of the parietal bone. The lateral bulging was sufficient to press down- 
wards and outwards the pinna of the ear; they were both fluctuating, but 
without pulsation, though becoming more tense when the child cried, and the 
contents of one could be pressed into the other through the narrow isthmus 
which united them at about the junction of the temporal and parietal bones. 
The temperature and pulse were normal, and no discomfort appeared to attend 
manipulation of the swellings. Mr. Lucas punctured one of the tumours with 
an aspirator, drawing off two ounces of fluid, which in appearance, and upon 
analysis, seemed identical with the cerebro-spinal fluid. Upon the subsidence 
of the tumours, which occurred at once, a depressed, stellated fracture of the 
skull in the region of the lateral fontanelle was very apparent, and it seemed 
as if the Wormian bone had been driven in. There was no corresponding 
absence of bone on the opposite side. Within a few hours the tumour filled 
up again and then gradually subsided. Three months afterwards there was a 
small circumscribed swelling back of the ear, containing about one drachm of 
fluid, and the depression over the site of the Wormian bone could still be felt. 
The child continued strong and well nourished, but had neither spoken, nor 
attempted to walk since the accident. 



1811.'] Guy's Hospital Reports. 18t 

Gases presenting a group of symptoms like the above are rare. Mr. Pres- 
cott Hewett, in Holmes' Surgery, speaks of ten cases in which effusion of 
cerebro-spinal fluid accompanied compound fractures, which, however, like 
those in which large amounts of fluid escape from the ear, have no resemblance 
to the one recorded by Mr. Lucas. Mr. Warrington Haward and Mr. Erichsen 
each narrate a case in which this fluid accumulated beneath the scalp in simple 
fractures; in both cases the tumours were tapped, and the patients died. The 
case recorded by Erichsen occurred in a hydrocephalic infant, those of Messrs. 
Haward and Lucas in normal children. Mr. Lucas is inclined to think that 
the best treatment in these cases is to let them alone, and in thus furnishing a 
criticism upon his own course, renders comment by us unnecessary. He also 
very justly questions the permanence of the recovery which appears to have 
taken place in his patient. 

A perusal of Dr. Keen's paper upon chloral as a preservative, published in 
this Journal, July, 1875, induced Mr H. Gr. Howse, M.S., to make a trial of 
that agent, and a Note on the use of Chloral for the preservation of subjects and 
anatomical preparatzo7is gives his conclusions as to its value. Half a pound 
of chloral proved in his hands a tolerably efficient preservative for winter sub- 
jects, but inferior to glycerin and arseniate of soda as recommended by himself 
in volume xvii. of the Reports, although he thinks the translucency of the tis- 
sues so objectionable when this last method is resorted to does not obtain when 
chloral is used. In summer his experience leads him to regard Keen's method 
as unreliable. Mr. Howse, however, thinks that very possibly the difference 
which exists between the climate of Great Britain and that of the United 
States may account, in some measure, for the different results obtained by Dr. 
Keen and himself. For the preservation of urine, or small specimens, he thinks 
a solution of chloral is very useful. 

The usual Statistical Analysis of the Patients treated in Guy's Hospital, 
by J. C. Steele, M.D., concludes the volume. In this article, as in its fellows, 
there will be found much subject for thought, with suggestions which shotild 
be of service to all those connected with the management of large hospitals. 
It is short and condensed, and will well repay perusal by those belonging to 
the class referred to above. ^J'he tables are hardly as well arranged as those 
which emanate from St. Bartholomew's Hospital. 

Taken as a whole, the surgical papers of this volume do not seem to be up 
to the average of those which have hitherto made this the best, as it is the 
oldest series of hospital reports. S. A. 



Bibliographical Notices. [Jan. 



Art, XXX. — Traiisart/ojis of American State Medical Societies. 

1. Proceedings of the Connecticut Medical Society, May, 1876. 8vo. pp. 157- 
. 2. Transactions of the Medical and Chirargiccd Faculty of Maryland, April, 
1876. 8vo. pp. 165. 

3. Transactions of the Iowa State 3Iedical Society, 1872 to 1876 inclusive- 

12mo. pp. 224. 

4. Transactions of the State Medical Society of Arlcansas, 1875-6. pp. 100. 

Little Rock, Ark., 1875. 

5. Transactions of the Medical Association of the State of Alabama, April, 

1876. 8vo. pp. 270. 

6. Transactions of the So'uth Carolina Mediccd Association, April, 1876. 

pp. 91. 

7. Transactions of the Medical Association of the State of Missouri, April, 

1876. pp. 79. 

8. Transactions of the Medical Society of the State of California, April, 

1876; pp. 168. 

9. Transactions of the Medical Society of Neiv Jersey, May, 1876 ; pp. 314, 

10. Transactions of the Medical Society of the State of Pennsylvania, May 
and June, 1876. pp. 386. 

1. We observe that an attempt is makiiij^ in the Connecticut Society to elicit 
the opinions of physicians all over the State, by circular letters of inquiry, espe- 
cially respecting the prevailing beliefs and ideas concerning diphtheria. Re- 
plies have not been at all as numerous as might have been hoped. They indicate, 
however, a belief in the distinct nature of the disease, in its constitutional 
character, and in the need of supporting treatment. Tincture of iron is the 
one tonic almost unanimously trusted. 

Dr. Paddock, of Norwich, describes a human monstrosity in which the two 
eyeballs, partly conjoined, were placed in one central orbit, and the nose, want- 
ing in the natural position, was represented by a fleshy appendage to the fore- 
head above the eye. The child was born alive, but died almost immediately. 

An article on Jjaryngeal Phthisis by Dr. Chamberlain, and two or three brief 
papers and obituaries, with some essays which possess little novelty, complete 
this publication. The work is neatly printed and has two or three coloured 
lithographs of pathological specimens. 

2. In the transactions of the Maryland Faculty we find the orthodox, and 
much to be dreaded, annual oration. This time, however, we meet with an 
agreeable surprise. Dr. Roberts Bartholow discusses, in a very pleasant and 
instructive manner, the Degree of Certainty in Therapeutics. While thoroughly 
alive to the worthless nature of much so-called evidence as to the virtues of 
drugs and other means of treatment, the orator takes no dismal or faithless view 
of the physician's armament. Both aims and results of treatment are more 
definite and more certain than of old. The value of physiological experiment 
on animals in determining the action of drugs is highly appreciated, and de- 
fended from its adversaries. 'I'he humiliating errors and uncertainties of empi- 
rical therapeutics are well set forth. The supposed virtues which medical 
experience has attributed to drugs should be tested by physiological experi- 
ment. 

A Report on Surgery from a standing committee, notes the advanced ideas 
and improved methods of the day. The author of this report, Prof. Christo- 



1877.] Transactions of American State Medical Societies. 189 

plier Johnston, relates a case of vesical exstrophy in which he operated essen- 
tially by the method of Wood. After etherization — 

" A great umbilical flap was brou;:(ht down over the bladder, the skin sur- 
face lying under, and this was covered by two wing flaps, one from either 
groin, which met in the middle line, and were secured to the first oblong 
flap. The space left by the umbilical flap was almost effaced by drawing 
together the integuments of opposite sides, and which had been dissected up ; 
while the spaces left by the wing flaps were obliterated by a gliding of the skin 
which lay beyond the groins, made free underneath, aud attached to the outer 
border of the wing flaps, now fixed in their new situation by silver andiron 
wire. As tension strained the lateral flaps, a crescentic incision was made 
beyond each groin to reduce it. After the operation the little patient suffered 
exceedingly, principally on account of scalding by the urine ; but in about five 
weeks he was able to return home greatly benefited, the operation having 
proved a success, perfect with the exception of a small loss of substance at the 
lower edge of the umbilical flap. In its present condition the child will remain 
until cicatrization shall have completed its contraction, whereupon a second 
operation will be attempted, having for its object the formation of a sort of 
roof for his urethral groove. A3 things are, however, the urine escapes over 
aud around the penis only, and he is able to wear advantageously a railroad 
urinal." 

In supplemental reports, some account is given of recent progress in oph- 
thalmology, the contra-indications to the enucleation of ruined eyes are pre- 
sented, and the treatments of orchitis and urethral stricture are discussed. 

Prof Abram B. Arnold contributes a paper upon Phthisis. This is chiefly a 
sketch of the different views of this disease held at different times, tracing espe- 
cially the changes in medical opinion which have occurred during the last few 
years. 

In a report from a committee or section on Psychology and Physiology, Dr. 
Conrad treats of Insanity in its Financial Relations to the States. The Doctor 
modestly states that his special experience has been of limited extent and dura- 
tion. This very plainly appears in his paper. 

Dr. J. E. Gibbons describes a cure of empyema by aspiration, in a child of 
less than four years. During nine months, thirteen pints of matter were drawn 
off, in five tappings. 

Cases of obscure abdominal disease are reported by Dr. W. C. Yan Bibber. 
A few cases of cure of peripheral paralysis are presented by Dr. John Van 
Bibber to illustrate the importance of treatment addressed to the muscle. In 
the January number of this Journal (p. 228), we referred to his valuable sugges- 
tions as to "elastic relaxation." By this means, by massage, by position, by 
electricity, the circulation and nutrition of paralyzed parts can be maintained, 
and recovery rendered more speedy and more complete. 

Prof Frank Donaldson presents an analysis of Thirty-seven Operations of 
Thoracentesis by Pneumatic Aspiration. His experience is every way favour- 
able to the safety and great value of this treatment. 

3. The pamphlet of the loiva Society is largely composed of brief essays or 
addresses. Some bear the aspect of being written because the writers were 
appointed to prepare something, rather than because they had anything especial 
to say. A good deal of information is conveyed, but very little not to be found 
in the text-books. 

A case of hernia of the ovary is reported by Dr. Benj. McCluer. The organ 
protruded through the saphenous opening, and was removed on account of 
pelvic and abdominal pains, and some inflammatory symptoms at the periods of 
menstruation. No ill results followed its removal. 



190 Bibliographical Notices. [Jan. 

Dr. Ady reports a case of extraordinary prostration, apparently from malarial 
poisoning, in which the disposition and the ability to breathe were at first greatly 
lessened and at last destroyed. From five or six respirations a minute, the 
breathing gradually failed, in spite of all efforts to arouse and stimulate, till in 
an hour it had wholly ceased. The patient, at first responding to loud orders, 
sank into profound insensibility. The pulse at the wrist ceased. Feeble motion 
of the heart only remained. Artificial respiration produced, in a minute, a gasp- 
ing inspiration, and a fluttering at the wrist. Half a drachm of aqua ammoniae 
with as much water was injected into cellular tissue above the clavicle. No 
obvious result appearing, in a few minutes one drachm of tincture of cantharides 
was injected below the collar-bone. This seemed soon to raise the pulse. Arti- 
ficial respiration was kept up to supplement the natural, which, however, soon 
became more frequent, and in an hour was normal. Large doses of quinia were 
given, and no subsequent paroxysm occurred. Twenty-four hours previously, 
he had experienced an attack almost as alarming. Abscess and sloughing fol- 
lowed the ammonia injection, but no trouble resulted from the cantharides. 

Dr. Drake reports two cases of adenia or Hodgkin's disease. Both died. 

Dr. Farnsworth sets forth the duty of the State in connection with the public 
health. He exhibits with considerable force the need existing in his State of 
proper sanitary supervision, and public enlightenment. 

4. In a report upon the health of Little Rock we find the negro population 
referred to as furnishing four or five times their proper proportion of deaths. 
Consumption is said to be peculiarly fatal among them. The writer adds that 
"it was very seldom observed" while they were in slavery. Another writer 
mentious the extreme rarity of erysipelas among negroes. 

Dr. Shibley believes gossypium to be far superior to ergot in promoting ex- 
pulsive uterine efforts, but inferior in arresting bleeding. 

Dr. Welch removed by aspiration twenty-eight ounces of pus from the peri- 
cardial sac. Great relief followed, but death occurred a few days later. 

A number of brief reports of cases are given, of which we need name only 
one of extra-uterine pregnancy, in which the foetus was retained thirty years, 
and one of coredialysis. Others are interesting and instructive, but present no 
points of especial novelty. 

5. From the proceedings of the Alabama Association we learn that although 
the legislature a year ago constituted that body a State Health Board, it made 
no appropriation for expenses. The society now asks for further legislation 
appointing a health officer. Vigorous efforts continue to be made to obtain 
the passage of a proposed act to regulate and elevate the practice of medicine. 

Two long and elaborate papers constitute the bulk of this volume. The first 
is a prize essay on the Pathology and Treatment of B right's Disease, by H. D. 
Schmidt. One especial aim of the writer is to compare the organic changes in 
this disease with those observed in yellow fever. He strives to show, more- 
over, that in the cases of Bright's disease arising in his section of country, 
malaria is an efficient cause — setting in motion the train of morbid actions 
which finally results in the affection of the kidney. It is the author's observa- 
tion of the disease, under his own peculiar climatic conditions, that gives the 
essay its chief value, though the entire paper exhibits evidence of study and of 
original research. 

Under the name of hemorrhagic malarial fever, Dr. R. D. Webb presents a 
minute description of the disease often designated as malarial haematuria. 
Whatever may be the fact in Europe, the malarial fever, with hemorrhagic ten- 



187T.] Transactions of American State Medical Societies. 191 

dencies, observed in the Southwestern States, is the same disease, whether the 
effusion takes place in the kidneys, stomach, bow els, gums, nose, womb, blis- 
tered surfaces, or the substance of the tissues. Th e writer does not, however, 
mean to deny that hsematuria is the most common and characteristic symptom 
of the malady. But not being constantly present the symptoms should not be 
taken as the name of the disease. Yellowness of the skin and excessive nausea 
are symptoms almost uniformly present. The paroxysms and remissions which 
mark the malarial origin are commonly, though not invariably, quotidian. 
Suppression of urine sometimes occurs after two or three paroxysms, and is 
apt to result in death from uraemic poisoning. If the disease is not checked 
before the fifth paroxysm profound and fatal prostration appears. 

From the suddenness of the cutaneous discoloration, and absence early in the 
disease of any tokens of suppression or reabso rption of bile, Dr. Webb believes 
it to be due to effused hgematin and not to biliary pigment. 

I'he disease is by no means confined to persons debilitated by repeated attacks 
or continued influences of a malarial character. It attacks people in good 
health, and even those who have never before suffered from the effects of miasma. 

The author doubts if the forms of disease with renal liemorrhage described 
by European writers are identical with the one here described. His comparison 
of the different features of various haeraaturial diseases and his whole examina- 
tion of the symptoms, pathology, and causation of the malady, as observed in 
Alabama, are full, able, and instructive. 

6. The present publication of the South Carolina Society has little matter 
calling for notice. A fatal case of epithelioma of the vocal chords ; one of 
trephining the cranium, with relief to paralytic and convulsive symptoms; an 
amputation for femoral aneurism ; and a case of paroxysmal hsematuria, are re- 
ported. 

7. The Missouri Transactions conta,in a few reports of cases having some 
points of interest. One account of an operation for the relief of neuralgia by 
the removal of the infra-orbital nerve and Meckel's ganglion, illustrates the 
danger of chloroform as an auEesthetic. Two or three times the dissection had 
to be suspended to bring the patient to life, as, whenever rendered insensible, 
he ceased to breathe, 'i'his unpleasantness led to a hasty termination of the 
operation, apparently without removing the ganglion. The object of the ope- 
ration, however, was to a considerable degree attained. Dr. Prewitt reported 
the case, after hearing the presidential address, which contained an account of 
several cases of Nerve-section for Neuralgia, 

The cases of President Hodgen, above mentioned, were, two of the second 
branch of the fifth nerve, four of the third branch, and two of nerves of the 
lower extremity compressed by abnormal growths. 

In describing a case of blepharospasm. Dr. Dickinson gives a curious history 
of permanent disturbance of the nervous system following stroke by lightning. 

Dr. Steele treats of torticollis in a very practical and sensible manner. He 
describes a device for obtaining elastic extension, by sticking plaster and India- 
rubber bands, which seems likely to be of use in connection with other treat- 
ment. 

8. Most of the papers in the California publication are quite brief and not 
especially noteworthy. They exhibit, however, a commendable pride and 
interest in the honour and the advancement of the profession. A committee 
upon Medical Education, reporting through Dr. Montgomery, advocates a 



192 Bibliographical Notices. [Jan, 

higher standard of acquirements than is required and attained by most of our 
medical schools. 

Obscure forms of epilepsy and the responsibility of epileptics, are treated 
in a paper by Dr. Shurtleflf, 

Dr. Dubois describes some convenient devices for applying water in motion, 
for the purpose of reducing the bodily heat in febrile states. 

We notice from the minutes here printed, that female physicians have been 
admitted as members of the Society. 

9. The large and handsome volume published by the New Jersey Society is 
more than half filled with reports from county societies. Diphtheria appears 
to be the only disease that has been unusually prevalent throughout the State. 
One practitioner claims to have treated one hundred and fifty cases, out of a 
population of eight hundred souls. 

Dr. J. S. Cook contributes an interesting essay upon climate. 

In a paper by Dr. B. R. Bateman, upon Mental Pathology and Criminal 
Law, is a somewhat violent but very loose attack upon the plea of insanity as 
offered in criminal cases. Indignation at the setting at large of a homicide 
acquitted on this plea, is perfectly natural and proper. But surely the fear of 
this result should not prevent an expert from giving evidence, nor induce a 
jury to ignore it. It is not allowable to do one wrong in order to avert another. 
As to a certain case cited by the writer, we are forced to believe that he was 
not cognizant of the very strong evidence of insanity which was placed before 
the jury. 

The attention of the district medical reporters having been directed espe- 
cially to the true therapeutic value of mercury, and to the usefulness of topi- 
cal applications in malignant sore throat, we find a somewhat general and 
differing expression of opinion on these points. We judge that mercurials are 
much used and highly prized by the profession in New Jersey, but administered 
with a much more sparing and discriminating hand than was the practice in 
former years. The discussion of the mode of action of mercury, and its use 
in various conditions, is quite full and instructive. 

Among a number of interesting reports of cases, we find one of paralysis 
and gangrene attributed to embolism, in patients who had formerly suffered 
from acute rheumatism. Dr. G. T. Welch reports a case of membranous 
enteritis. Fatal chorea in a girl of eighteen, is reported by Dr. A. W, Rogers. 
Dr. D. A. Currie describes two cases of abscess of the larynx. 

10. In the minutes of the annual meeting of the Pennsylvania Society we 
find a draft of a law to be proposed for passage by the State Legislature, in 
place of the Act passed in 1875 for the regulation of medical practice. The 
latter enactment was so unskilfully drawn as to be practically inoperative. 
There is also presented an exact statement of the facts in connection with the 
attempt recently made to force homoeopathic affiliations upon the stafi" of the 
Harrisburg Hospital. 

A committee appointed to prepare a petition to the Legislature for addi- 
tional provision for the insane of the seven southeastern counties near Phila- 
delphia, make a powerful statement of the existing need, and a moving appeal 
for justice and mercy. 

In the Address on Obstetrics, Dr.R. Davis describes a new method of dealing 
with placenta proevia. It was suggested by the partial-detachment process of 
Dr. Barnes. The separation is to be made towards the nearest or the least 
firmly adherent edge of the placenta, and that, when reached, is to be brought 



187*7.] Transactions of American State Medical Societies. 193 

down and fully engaged in the os. The other segment of the placenta is not 
to be detached. The membranes being ruptured, labour proceeds without 
serious hemorrhage, without the necessity of version, and with diminished 
danger to the child. The procedure is claimed to be identical with that which 
takes place when Nature, unaided, deals successfully with this complication. 

The i^ddress in Surgery, by Dr. T>. Hayes Agnew, is full of wise suggestions 
and sound judgments. After full and careful trial. Dr. Agnew gives his earnest 
approval to the antiseptic treatment of wounds, as advocated by Lister, of 
Edinburgh. He warns his hearers, however, that, to avoid disappointment and 
failure, even the apparently trivial details must be carefully attended to. A 
new and simple apparatus for treating the fractured patella is suggested and 
pictured in this paper. 

The proofs of the agency of water and of milk in conveying the germs of 
disease, form the principal subject of the Address in Hygiene, by Dr. Benjamin 
Lee. 

In the Alleghany County Society report we find narrated a sad story of 
culpable blundering, by which the youthful inmates of a so-called reform school 
were poisoned by polluted water. What amount of skill and tact in the 
supremely difiQcult work of moral reform can be expected, or could be efficient, 
in the presence of such murderous stupidity? 

The Berks County report is principally occupied with an analytical exami- 
nation of the facts in regard to a recent severe epidemic of scarlatina in 
Reading. The report was prepared by Dr. W. F. Muhlenberg, and is a valu- 
able contribution. 

Dr. Herr, of the Lancaster County Society, reports a case of well-marked 
scurvy arising in a woman who persistently refused vegetable diet, though living 
amidst an abundance of such food. 

Dr. Rothrock, after practising for nearly half a century in Mifflin County, 
not only believes in a "change of type," from sthenic to asthenic, some thirty 
years ago, but also thinks that the last five years have seen a reaction commenc- 
ing towards the former condition. The great diminution in the prevalence of 
miasmatic and typhoid fevers, dating from 1850, is, he tells us, connected in 
the popular mind with the opening of the Pennsylvania Railroad. 

Dr. Hiram Corson, of Montgomery County, makes a vigorous plea for vene- 
section in commencing pneumonia. 

The report of the Philadelphia County Society, besides mortuary tables, 
contains a map so tinted as to exhibit the varying mortality from typhoid fever 
in different districts. This is very curious and suggestive. The entire Dela- 
ware River front is deeply coloured. It will be remembered that sewers pour 
their contents into the docks, and that portions of the water supply are derived 
from that stream, while the tidal movements tend to diffuse its pollutions in all 
directions. A deeply-tinted belt also crosses the city, filling the space from 
river to river between Market and Spruce streets. A similar space directly 
north seems unusually free from the disease, especially at its eastern portion, 
where it makes a slight break in the otherwise continuous fever-line of the 
Delaware. We observe, however, a marked discrepancy between the figured 
mortality of some wards and the tints imparted to them on the map. The 
eighth, with a mortality less than the twenty-fourth (3.54 per 10,000 living, 
against 3.72), is made much darker. If we change the tint of the former 
ward to that even of the latter, the dark helt across the city disappears. There 
would seem to have been some error here. Tints and figures (mean, 6.53) 
agree, however, in showing the greatest mortality from typhoid in the wards 
No. CXLV— Jan. 1877. 13 



194 Bibliographical Notices. [Jan. 

inclosed by the Germantown Koad, Lehigh Avenue, and the Delaware, and 
traversed by Aramingo Creek. In West Philadelphia "Mantua" and the 
Twenty-fourth Ward bears to " Hamilton Villag-e" and the Twenty-seventh the 
favourable relation of 3.72 to 5.11. In the latter ward, the colour seems to 
deepen along Thomas's Run, Cobb's Creek, and at Darby. The wards con- 
taining Chestnut Hill, Germantown, and Frankford, exhibit the smallest mor- 
tality. Those containing Manayunk and the Falls make a much less favourable 
showing. B. L. R. 



Art. XXXT. — A Practical Treatise on the Diseases, Injuries, and Malforma- 
tions of the Urinary Bladder, the Prostate Gland, and the Urethra. By 
Samuel D. Gross, M.D,, LL.D., D.C.L. Oxon., Prof, of Surgery in Jefferson 
Medical College, Phila. Third Edition, revised and edited by Samuel W. 
Gross, A.M., M.D., Surgeon to the Philadelphia Hospital. 8vo. pp. 574. 
Philadelphia: Henry C. Lea, 1876. 

It is now some twenty-t,wo years since the last edition of this work appeared. 
In the present issue a number of changes are to be found. Among them are 
the omission of ninety-two pages on the anatomy of the urinary organs, and of the 
chapters on worms in the bladder; foetal remains in the bladder; serous cysts 
and hydatids; hair and air in the bladder. Also the chapters on urinary deposits, 
on cystic disease of the prostate, and on inflammation of Cowper's glands have 
been either entirely cut out or relegated to subordinate positions under more 
general heads. There have been added as new material, chapters on rupture of 
the bladder, and evidently with the idea of rendering completeness to the work 
on vesico-vaginal fistula, and on prostatorrhoea. 'J'hese, with the chapters on 
the malformations of the prostate, on the injurious effects of operations on the 
urethra and on prolapse of the mucous membrane of the urethra in the female, 
constitute the main ditlerences in the table of contents between the earlier edi- 
tions and the one now put forth. 'I'o assist him in bringing the subjects treated 
up to date, the venerable author has called in the able services of his son. Dr. 
S. W. Gross, who not only has acted as general editor, but has contributed 
valuable chapters on the tumours of the bladder and of the prostate gland. 

In these latter, in addition to the consideration of the fibrous and myomatous 
tumours of the bladder, the editor devotes considerable space to an excellent 
resume of the subject of the so-called villous growths or papillary fibromas, 
based upon the analysis of twenty cases of this affection. Its usual site in the 
vesical triangle, its comparative painlessness, absence of secondary glandular 
enlargements, and its occurrence either in infant or adult subjects under forty- 
four are well brought out in a table in contrast to the symptoms presented by 
carcinoma, with which it is frequently confounded, and due importance is given 
to the value of the .microscopical examination of fragments, not epithelium, dis-. 
charged with the urine. A table of sixteen cases wherein removal of tumours 
of the bladder by operation was performed, four of which occurred in males, 
closes the chapter. The neoplasms of the prostate are also fully detailed, and 
the description of carcinoma of this gland may be considered the best in our 
language. 

'J'he limits of a review of a work that has reached its third edition does not 
permit an extended analysis, hence we must pass over the chapters on cystitis, 
retention, etc., to those on lithotripsy and lithotomy. These are well written, 



1871.] Gross, Diseases of the Urinary Organs. 195 

and are the most satisfactory in the whole volume. Credit is given Santorio 
for his invention of the lithotrity canula in 1626, and to Cuicci for the "tena- 
cula tricuspis" which he describes in his " Fromptuarium Chirurgicum" 
published in 1679, and in which instrument, it will be recollected, he had such 
faith that it was three times used upon himself. 

In the 1613 cases of lithotripsy collected by the author, it is shown in sup- 
port of the views of Vandyke Carter, that 1067 had nuclei of uric acid or of 
the urates, 317 of oxalate of lime, and 183 of phosphates, though neither 
Carter's explanation of the spontaneous fracture of calculi nor his investiga- 
tions with those of Rainey and Ord upon the importance of colloids in the for- 
mation of calculi are referred to. 

For sounding. Dr. Gross recommends the position on the left side of the 
patient, which certainly is much less serviceable to most surgeons than the right 
side ; and it is noticed that no mention is made of the manoeuvre of, after a 
stone is first seized with the lithrotrite, sounding with the calculus in its jaws 
in order to detect the presence of other calculi. While the points to be ob- 
served in lithotripsy are well and clearly given, yet the old rules are enjoined, 
viz. : " that any chronic cystitis that may exist should be met by appropriate 
measures until the bladder is enabled to hold about four ounces of urine with 
comfort, and preliminary injection of the bladder will (then) be ren- 
dered unnecessary." 

Thompson, it is known, advises the operation even when only one ounce of 
urine is contained in the bladder, and with others condemns the preliminary 
injections. 

The same injection of the bladder is advised and resorted to by Dr. Gross 
prior to lithotomy, " in old subjects affected with excessive irritability of the 
bladder with a constant desire to micturate." It is proper to allude in this 
report to the vast personal experience of W. Poulett Harris, in 365 lithoto- 
mies, who speaks in this way concerning this injection : " No injection should 
be given when the bladder is so irritable as to be incapable of re- 
taining any fluid, but the operation may be proceeded with, and will be found 
almost as easy and successful as if the bladder contained fluid." Other au- 
thorities entertaining these ideas might be quoted. The comparative results 
of the cutting and crushing operations in the hands of the same surgeons, 
gives a mortality of 1 in 11.55 for lithotrity and of 1 in 3.74 for lithotomy. 
Thompson's own statistics give a mortality for lithotrity of 1 in 17,11, and 
for lithotomy of 1 in 4.82 cases. A knowledge of the former success is per- 
haps of more service to the general surgeon than Thompson's results. No 
record is presented of Dr. Gross's own efforts in lithotrity, though in connec- 
tion with lithotomy we learn that this operation has been done by him 140 
times ; 74 times in adults with 11 deaths, and 66 times in children with one 
death. 

Prof. Gross, with many other surgeons, fails to perceive the advantage of 
Dolbeau's perineal lithotrity. It is, however, to be regretted that Dolbeau's 
excellent forceps for crushing an extra large calculus should not have been 
depicted rather than the one shown on p. 255. The convenience of Prichard's 
anklets renders them so much superior to the old-fashioned fillet that their 
omission naturally excites comment. 

The following directions raise a query : "A stone may be entangled in the 
folds of the mucous membrane, or it may be spasmodically grasped by the 
bladder. ... In the latter case the surgeon desists for a few minutes, until 
the organ relaxes its convulsive grasp, when the foreign body is seized and 



196 Bibliographical IN'otices. [Jan. 

extracted. Should the Bpasm be severe and refuse to yield, it may be over- 
come by anseslhetics." Does Prof. Gross operate without the use of anaes- 
thetics? A reference to a previous page is necessary to correct this impres- 
sion. The article on lithotomy concludes with a table presenting the mor- 
tality met with in the various methods of this operation. Unfortunately no 
distiriction is made between impubic and adult patients. The figures given 
are as follows : — 

Lateral operations, 10,150 cases; 1 death in 9.11 cases. 

Bilateral " 536 " 1 " 13.07 " 

Median " 350 " 1 " 10.93 " 

Recto-vesical " 83 *' 1 " 5.18 " 

Supra-pubic " 465 " 1 " 3.44 " 

It will be found that in the consideration of the inflammatory complications 
of operations on the urinary organs. Professor Gross advises, in accordance 
with his well-known views, the use of the lancet, and in the immediate after- 
treatment of lithotomy or perineal urethrotomy omits the useful caution of 
suspending the scrotum. His directions for the treatment of calculi in females 
are practical, and he indorses the dilatation process of Simon, the rules for 
which are fully given in the chapter on tumors of the bladder. 

In Chapter XL on foreign bodies in the bladder, Denuce's paper is quoted; 
but the point that Foucher reiterates is somewhat obscured ; it is, that in a 
total of 127 ca&es, lithotomy was resorted to, prior to 1839, 100 times, and ex- 
traction 27 times ; but, that since that period, owing to the use of the lithotrite 
and the improvement in instruments for extraction per vias naturales, lithotomy 
was done only in 21 cases, and extraction in 101, in a total of 122 cases. 

Space is insufficient to dwell upon the chapter on rupture of the bladder, 
save that attention is called again to the advisability of resorting to the lateral 
section of the prostate as for lithotomy which has been successfully done by 
Walker and Erskine Mason. In the fistulas. Chapters XIV. -XV., communi- 
cating with adjacent organs, as vesico-vaginal, vesico-rectal, etc., but three or 
four lines are given to the vesico-intestinal communications; nor is any allusion 
made to the use of coloured injections, as milk, ink, etc., as aids in the diagnosis, 
nor of colotomy as a mode of relief. 

In the description of the diseases of the prostate, Dr. Gross's work is again 
characterized by a large experience and much personal investigation. The 
satisfactory presentation of the disease styled prostatorrhoea, by Dr. Gross in 
1860, but according to Bumstead described in 1853 by Adams, and by Led- 
wich in 1857, is worthy of notice. Under this head are embraced those dis- 
charges, not seminal, that result from a "preternatural afflux of blood to the 
prostate and neck of the bladder, or to the posterior portion of the urethra. 
For treatment Goulard's extract, with the wine of opium in the proportion of 
two drachms of each to ten ounces of water, applied three [sic] times a day by 
means of the catheter syringe, is preferred." " In obstinate cases cauterization 
of the prostatic portion of the urethra or even of the entire length of the canal 
may be necessary, the operation being repeated once a week." The other and 
milder measures suggested will, it is to be hoped, obviate the risks attendant 
upon either of the above somewhat severe procedures. 

The results obtained from the examination of 289 men past fifty years of age, 
are interesting as showing that about one in every five were afiected with senile 
hypertrophy of the prostate, a less proportion than that given by Thompson. 
The results obtained by Iversen in his observation of 210 persons of all ages 
are, however, not referred to, though that author is quoted (but with name 



1877.] Gross, Diseases of the Urinary Organs. 197 

misspelt), in connection with his observations on prostatic calculi, which, en 
passant, are not due according to that observer to an amyloid transformation 
of the epithelial cells, as is stated on p. 477 of the present volume. To the 
statement that in hypertrophy of the prostate, in "no instance, however, has 
the development of glandular elements been demonstrated," some exception 
must be taken. Though rare, it does exist. Thompson records such with the 
microscopical appearances. Iversen ascribes the hypertrophy to a myo-adeno- 
matous hyperplasia, and Rindfleisch says, that the hypertrophy arises from a 
"fibro-muscular overgrowth of the peritubular stroma of single segments of the 
gland with a coincident elongation and multiplication of the tubules them- 
selves." 

The description of the symptoms and effects of the disease are fully and ex- 
plicitly given and the treatment also. The latest wrinkle, so to speak, of Heine's 
injections into the glandular substance of tincture of iodine, is detailed. Its 
risks, it is said, must be borne in mind. Recent reports from Vienna show that 
it has proved too hazardous to justify its continuance; in fact Heine's own 
reports are not encouraging. The treatment suggested by Iversen, based upon 
Ilildebrandt's success in uterine tumours, of the injection of ergotine, is not re- 
ferred to, though the internal use of ergot to increase the expulsive power of the 
bladder is advised. It would have been appreciated by the surgical public had 
Prof. Gross, in speaking of the value of the supra-pubic opening, or the removal 
of an enlarged middle lobe, or cystotomy, in the severest forms of hypertrophy, 
expressed more clearly which of these operations was most to be recommended, 
as his personal experience in such cases has probably been unequalled by any 
one on this side of the Atlantic. 

In fact, it is in this very particular that the present work is disappointing. 
There is much that is of value as a compilation from both author and editor, 
but more dogmatic statements on doubtful points would have been preferred 
by the profession at large, and from a surgeon of Dr. Gross's eminence was 
naturally to be looked for. 

The portion assigned to the diseases and injuries of the urethra opens with a 
hiatus. Not a word is assigned to the subject of gonorrhoea! or other inflam- 
mations of this canal. In other respects, its malformations, diseases, and in- 
juries are fully treated. 

Where the urethra is lacerated to any extent, the following most sensible advice 
is given, and, as it is too seldom acted upon, it is quoted at length. " The only 
rational treatment is to make a free incision into the part, to afford a free exit to 
the urine, which will otherwise be sure to insinuate itself rapidly into the connec- 
tive tissue of the perineum and scrotum. The operation is conducted upon the 
same principles as that of external urethrotomy, without a guide. If the urethra 
be completely and cleanly divided across, its ends should be approximated with 
a single suture, and union be favored over a soft gum catheter. . . Under 
ordinary circumstances a catheter need not be retained in the bladder." 

In so recent a work as this the consideration of penile fistula ought cer- 
tainly to have embraced Szymanowski's remarkably successful plastic method 
for the closure of such openings. The pages occupied by the subject of stric- 
ture are of special importance in relation to the confirmation that is given to 
Thompson's localization of such affections. Of 173 strictures occurring in 100 
living subjects, 44 per cent, were found in the bulbo-membranous region ; 28 per 
cent, in the spongy urethra, and 28 per cent, within two and a half inches of 
the meatus. These results, it will be seen, though differing in percentages, 
confirm Thompson's statements. The statistics of Otis, quoted in a subsequent 



198 Bibliographical Notices. [Jan. 

paragraph by the editor, are, as has been shown elsewhere, not sufficiently 
accurate to allow of deductions being drawn from them. 

The impassability of strictures to instruments, though permeable to urine, is 
reaffirmed by the author, who has, we learn, performed perineal section (?'. e. with- 
out a guide) 26 times. By reference to Thompson's work on structure of the 
urethra, 3d ed., 1869, it is to be noted with some surprise perhaps, that up to 
that time that surgeon has never performed this operation — for impermeable 
stricture — a condition considered by him to be extremely rare. Dr. Gross 
gives, unfortunately too briefly, details of a case, one out of four that he has 
met with, of truly impermeable stricture, but the cause of the occlusion is not 
stated. This is unfortunate, as Thompson, it will be recollected, insists that 
these are always of traumatic origin. 

Dr. Gross advises for the detection of a stricture the use of " a common 
silver catheter, large enough to fill without distending the meatus." In a 
similar way the bougie a boule is recommended. 

Prior to the treatment of a stricture, or as the author expresses it, to the 
" permanent cure" of a stricture, he advises if the urethra is irritable the use 
of sounds and soothing injections; also, he says, " Great benefit may be derived, 
especially if the part be studded with granulations, from cauterization with 
nitrate of silver. The operation is performed with the porte caustique . . . 
the caustic is brought fairly in contact with the affected surface by a rotary 
movement of the instrument. . . . Too much stress cannot be placed upon 
this preliminary treatment; indeed, I should consider it highly culpable to 
neglect it under any circumstances." 

In this respect it must be stated that the accepted practice of surgeons 
varies much from that enumerated above. Indeed, it may be said, that the use 
of caustic applications to the urethra is felt to be rarely necessary in this or 
any other difficulty of the urinary passages. 

In the reasoning that naturally follows the question as to the method of 
treatment to be adopted in a case of stricture, the consideration of the normal 
size of the urethra comes up, and both the author and editor give their adher- 
ence to the views of Dr. Otis on this subject. The editor in a foot-note lends 
confirmatory evidence to the correctness of the estimate of the relation sup- 
posed to exist between the circumference of the penis and the urethral calibre. 
Proper value is given to the urethrometer as a means to be resorted to in 
the estimation of the capacity of the urethra in each individual case, though 
dissent must be made to the rules set forth in the otherwise fair representation 
of the present views on this point, viz., " that the circumference of the bulbous 
portion is greater by two millimetres and a half than that of the spongy portion, 
and that the canal should be dilated as can easily be done to twice that extent, 
which represents its real size when it is ordinarily stretched." The difference 
between the spongy portion and the bulbous portion is really much greater than 
this. According to measurements given by Dr. Sands, in the discussion on 
gleet before the New York County Medical Society, January, 1876, there existed 
between the circumference of the spongy and bulbous portions a difference 
averaging in the cadaver of about 1.3 mm., and in the discussion that followed 
it was shown that the difference between the two portions in the living subject 
amounted to an average of nearly 10 mm. Hence, in carrying out the prin- 
ciple of restoring the urethra by section to its normal calibre, the risk of such 
deep incisions must be kept in view and not lightly resorted to, especially as 
on page 491 we have recorded two deaths following urethrotomy in patients 
whose strictures admitted instruments of the size No. 16 of the French scale. 



1811,] Gross, Diseases of the Urinary Organs. 199 

" Gradual dilatation is in the end considered very unsatisfactory, relapse being 
the rule, and is only applicable to very recent cases." Rupture is strongly advised 
by the consecutive use of conical sounds of increasing size; six in number are 
used, running from No. 11 at the point of the smallest to 30 of the French 
scale in the shaft of the largest, beyond which he rarely has occasion to go. 
Richardson's divulsor is also decidely commended as more useful than Holt's. 
It is interesting to note that of this operation, now falling into desuetude by 
reason of its frequent relapses as well as by its greater mortality' over internal 
incision, he says : — 

*' The operation of rupture with either of these instruments may be said to 
be absolutely free from danger, unless there is advanced renal disease. It is 
never followed by serious hemorrhage, and what bleeding there is usually 
promptly ceases spontaneously. I have never known it to give rise to any 
untoward symptoms. ... I do not hesitate to give it my unqualified approval. 
Internal incision is, however, preferable when the disease is seated at or near 
the meatus and in the spongy portion anterior to the curve, and when the new 
deposit is thick and dense." 

Of the latter operation, he says on the next page: '' I have performed the 
operation too frequently not to be convinced of its superiority, as to enduring 
results, over all other plans," and sums up further on, without statistical proof, 
however, as follows: "If all resisting bands have been thoroughly divided, 
and a bougie of the size of the natural calibre of the urethra slips easily, by its 
own weight, into the bladder, without meeting the slightest impediment to its 
insertion or withdrawal, after the wound has healed. I have every reason to 
believe that recontraction need not be feared, and that the subsequent methodical 
use of the steel bougie may be dispensed with, except at long intervals, as a 
matter of precaution." 

A new urethrotome by the editor is brought favourably to notice for division 
of strictures of moderate calibre. Trelat's is advised for tight stricture, but no 
mention is made of Maisonneuve's urethrotome, which is the one in common 
use both here and abroad. The credit of the tunelled sound is given to Gouley. 

This is also the dictum of Geo. A. Otis in the second volume of the Surgical 
Bis^ory of the War of the Rebellion, who shows, moreover, that the idea of the 
tunelled instrument originated with Desault. 

Want of space compels us to pass over the remaining chapters, but, in con- 
cluding, it must be said, that notwithstanding the peculiarities that have just 
been noticed, the present work of Prof. Gross must be held in great esteem 
and value by the practitioner, not only for the richness of its compilations, but 
also for its many other and varied excellences. It suffers, however, it must be 
confessed, to a moderate extent by the necessary comparison it sustains with 
the more practical and logically arranged volumes of Thompson and of Van 
Buren and Keyes on similar subjects. R. F. W. 



' Grant oil Diseases of the Bladder, 1876, states, p. 272, that many deaths have, 
I believe, occurred. Mr. Teevau says, fifteen in number of this operation which 
have not been included in the reports of cases hitherto published. 



200 Bibliographical Notices. [Jan. 



Art. XXXIT. — De rExstropJu'e de la Vessie Envisag^e sp^ci'alement au point 
de vue du Traitement Chirurgical. Th^se pour le Doctorat en Medeeine, 
presentee et sontemie par Rodolfo Valdevieso, Doctenr en Medeeine des 
Facultes de Pensylvanie et de Paris, etc. etc. Paris, 1876. 

Exslropln/ of the Bladder, considered specially with regard to Surgical Treat- 
ment. Thesis for the Degree of Doctor of Medicine, presented and defended 
by RoDOLPHO Yaldevieso, Doctor of Medicine of Pennsylvania and Paris, 
etc. 8vo. pp. 76. With four lithographic plates. Paris, 1876. 

Perhaps nothing shows to greater advantage the progress of modern sur- 
gery than the operations devised and executed by bold and thinking men for 
the radical cure or the relief of vesical exstrophy. The wretchedly pitiable 
condition of the subject of this sort of infirmity had for centuries appealed to 
the sympathies of the learned and the skilful in the medical profession, and 
yet, until a very recent time, aid was withheld from the apparent thanklessness 
of the task. 

Teratology, however, seems not only to have pointed to a correct under- 
standing of so remarkable a deviation from the normal as extroversion, but it 
also, doubtless, suggested the earliest surgical operation ever practised, and 
which had for its object the radical cure of exstrophy through the establish- 
ment of what may be regarded as a higher grade of deformity, namely, that 
abnormal state in which " the ureters have been found entering the rectum, 
and discharging the renal secretion entirely by that channel." Failure in this 
direction forced the operator to be content with procuring relief for bis client 
instead of continuing fruitless efforts towards reconstruction; so that nowa- 
days the surgeon, with more modest aspirations, has at his command a guiding 
principle which is hardly clouded by the varying circumstances of degree, age, 
or sex. 

It is also observable that the surgi<.'al mind is prone to grapple with the 
difficult, and taxes its energies to the utmost to reach the thule of its aspira- 
tions; and success adds vigour to the effort, and paves the way to future pro- 
gress. So it has always been in our profession ; therefore we may not wonder 
at the increasing desire of surgeons to treat of the exstrophic error of nature, 
and to make accessions to the number of cases in which treatment has brought 
about a favourable result. The brochure of Dr. Valdevieso is to be noticed 
as an evidence of the former. With an excellent knowledge of his subject, of 
which his first impressions were formed in this country, the author opens his 
Introduction with the words of Nelaton in his Surgical Pathology : " The 
treatment of exstrophy of the bladder is essentially palliative;" but only to 
contrast the state of surgery in France before 1857 with its condition in our 
own time, when the same cannot be said, for " surgeons have striven to afford 
permanent relief in this painful infirmity." 

I^hen follow general considerations upon exstrophy of the bladder; and in the 
matter of etiology the author adopts the views of Mr. Herrgott, who expresses 
his "belief that exstrophy of the bladder results from the 'non-reunion, of the 
pubic bones, and. consequently, from the separation of the abdominal muscles." 
This opinion will hardly be shared by anatomists, who would rather regard, 
■with Isidore G. Saint Hilaire, "the divers complications of extroversion of the 
bladder as being in some way inherent, and as accompanying it in the majority 
of cases, but in some as a constancy ;" and believe that such anomalies as 
spina bifida, acephalia, exomphalos, imperforate anus with incomplete forma- 



187t.] Yaldevieso, Exstrophy of the Bladder. 201 

tiou of the intestine, together with all ordinary complications of exstrophy, 
result, more or less conspicuously, from arrest of development.' And they 
will further agree with the same author that in the separation of the lateral 
halves of the external genital organs and of the abdominal muscles of the two 
sides, there is a remarkable concordance, which explains perfectly the connec- 
tions of the sexual organs with the pubis, and is a first proof of the constancy 
of the general relation between the vices of conformation of the soft parts and 
the state of development of the osseous system. ^ 

The treatment of exstrophy of the bladder is divided into the palliative and 
the surgical. The former consists in the employment of all devices by which 
plaques or bowls of metal, or other substance, are made to replace the absent 
anterior wall of the bladder; or else in the introduction into the ureters of 
"sounds," or rather catheters of silver or gum communicating with a reservoir 
of boiled leather, after the manner of Piplet in 1792. But our author, deterred 
by the ill success of methods of palliation involving the ureters directly, is of 
opinion " that palliative treatment ought to be limited solely and simply to the 
application of a protheic apparatus." 

Under the head of surgical treatment, we find the statement that "this is 
really the object of the thesis." And accordingly the two routes to be travelled 
are set forth, "the one radical," described under the title of method of urinary 
derivation; "and the other," singularly enough, made to occupy a separate 
niche from those " simply protheic," " the simply palliative," " the autoplastic 
method." 

The greater bulk of this portion of the work is occupied with a consideration 
of the various plans of procedure; of Simon and Lloyd as essayists of a 
" radical" method ; and of Roux, Richard, Pancoast, Ayres, Holmes, Wood, 
and Le Fort, as originals in relation to the autoplastic. But no mention is 
made of the simple glissement of two lateral flaps, according to the method of 
Barker of Melbourne, which, however, has more recently been greatly im- 
proved upon by Dr. Henry J. Bigelow, whose successful case, first published 
in the Boston Medical and Surgical Journal in January, 1876, was noticed in 
this Journal in the following April. Dr. Bigelow removed the exposed mucous 
membrane of the bladder down to the ureters, so that flaps drawn from the 
sides were applied directly to the raw surface, and united upon the median 
line as well as transversely above it. 

Among the "conclusions" reached by the author are the following: "4. 
The autoplastic method should be employed. . . . 'I'he plan of Wood is to be 
preferred. When it is possible, the preputial flap of Professor Le Fort should 
be united with the abdominal and lateral flaps. 5. M. Le Fort's mode of 
making the suture is preferable to all those hitherto put in practice." 

Such prominence given to the method adopted by M. Le Fort— " Mon Pre- 
sident de Th^se" — as communicated to the author in the single " observation 
inedite," calls for a moment's attention to the operation itself, which accom- 
plished the surgeon's purpose after five attempts. It consisted, j^r.sf, in pre- 
paring and detaching the prepuce and neighbouring skin, turning the flap so 
formed up against the lower part of the exstrophied bladder, the penis having 
been passed through a buttonhole made for the purpose; second, in turning 
down a supra- vesical flap, after six weeks, and attaching by metallic sutures its 
inferior and the superior preputial margins. Thirdly, nine months afterwards 
the ventral flap was re-formed and turned down, but it involved the cicatrix of 
the former operation. With regard to the prepuce, says M. Le Fort, " instead of 

' Teratologie, vol. i. p. 384. 2 idem. 



202 Bibliographical Notices. [Jan. 

refreshing the surface I split it into two laminae, one vesical and the other exter- 
nal, between which the free abdominal flap was to be insinuated." ... " For 
suture I prepared a bit of gum catheter by perforating it and passing metallic 
threads through the holes." ... To fix the flaps " I transfixed the preputial 
vesical lamina with the wires, traversing the piece of gum catheter, then the 
abdominal flap, and finally the outer preputial lamina. Then the wires were 
run through holes in another bit of ' sonde,' placed externally." 

In fact, we have the quill suture presented to us ; but when the wires had all 
been secured, " they were kept in phice by a little tube of Galli." 

Fourthly, a narrow lateral abdominal flap was raised immediately, and made 
adherent to the left margin of the preputial flap; and fiflhly and finally, after 
a delay of four months " I repeated exactly on the right side the operation I 
had done on the left," and " I accomplished the task I had set myself." 

M, Valdevieso closes his remarks about this operation by saying that "we 
cannot be too much encouraged by the excellent result obtained in this case 
to imitate the course of M. Le Fort, But," he naively adds, " as we do not 
always meet with a prepuce suitable for such an operation, we fall back, in its 
absence, upon the method of Wood." 

We would here close our review of Dr. Yaldevieso's thesis, did we not feel 
compelled to notice the slighting reference by its author, formerly hospital 
interne in Phihidelphia, and member of the Pathological Society of that city, 
to the " Procede de Pancoast," which we reproduce : "The plan of procedure 
of Pancoast would not, of itself, be of much importance, were it not applicable 
in the many cases, as we are aware, in which the abdominal paries is thinned 
out above the exstrophied bladder." Professor Pancoast, let it be remembered, 
conceived and executed an operation appropriate in the case offered him, and 
happy in its result; and to him belongs the honour of having, in 1858, per- 
formed the first successful plastic operation for vesical exstrophy. C. J. 



Art. XXXIU.— Vital Motion as a Mode of Physical Motion. By Charles 
Bland Radcliffe, Doctor of Medicine, Fellow of the Royal College of Phy- 
sicians of London, etc. etc. 8vo, pp. vi., 252. London : Macmillan & Co., 1876. 

More than twenty-five years ago, as Dr. Radcliffe tells us, his confidence in 
the commonly held ideas concerning vital motion was disturbed by some facts 
coming under his observation. His reflections were first brought before the 
profession in an essay on the "Philosophy of Vital Motion," in 1851; after- 
wards, more systematically, in the " Gulstonian Lectures" for 18G0, published 
in 1861. In 1864 came out his "Lectures on Certain Diseases of the Nervous 
System." This book was reviewed by us in this Journal in the following year.* 
As our author remarks, while many shortcomings in these earlier works (and 
in one other book, " Dynamics of Nerve and Muscle," 1871) are avoided in the 
treatise now before us, yet the thesis, and all essential particulars of the argu- 
ment are still the same. 

'J'he historical sketch now given by him of the progress of discovery and 
opinion in regard to animal electricity, corresponds very nearly with that pre- 
facing the "Lectures" of 1864. The principal additional point is, that the 
original opinion of Galvani, as to muscular fibres being in a condition of charge, 



' American Journal of the Medical Sciences, July, 1865, p. 121. 



ISt?.] Radcliffe, Yital Motion as a Mode of Physical Motion. 203 

like that of the Leyden jar, when at rest, and of discharge in their contraction, 
is now referred to, as having in part anticipated Dr. Radcliffe's conclusions. Du 
Bois-Reymond's view differs from this, in believing that currents of electricity 
circulate, in closed circuits, around the "peripolar molecules" of which muscu- 
lar fibres consist. Sir Charles Bell, Dr. West of Alford, Duges of Montpellier, 
Matteucci, Engel of Vienna, and Stannius of Rostock, are credited with 
opinions approaching more or less nearly to those set forth in our author's 
present work. 

After the historical prologue, the main argument is taken up in two divi- 
sions : "Yital motion" being regarded first "physiologically," and then 
"pathologically." Eight chapters in the first division consider the "electro- 
physics" of vital motion; of simple muscular movement and simple nervous 
action ; of cardiac and other forms of rhythmical vital motion ; of rigor mortis ; 
the work of the blood and of nervous influence in vital motion; and objections 
to the view advocated of muscular motion. 

In the second division, four chapters are occupied with vital motion, as ex- 
hibited, respectively, in epilepsy and other convulsive disorders ; in tetanus 
and other spasmodic disorders ; in tremor ; and in neuralgia. An " epilogue" 
then gives, in a few pages, a summary of the whole work. 

Chapter I. of the physiological division enters into a very interesting exami- 
nation of the electrical condition of living protoplasm compared with that of 
inorganic bodies. Using for his purpose Thomson's new quadrant-electro- 
meter, the materials employed in a number of observations were, an infusion of 
hay containing amoebae, pus, mucus, distilled water, fresh-water sponge, myxo- 
mycetes, and sculptor's clay. The results obtained are thus described (pp. 
34, 85) :- 

"The fluids containing protoplasm are all along in precisely the same case 
as the distilled water. When the examination is made with the electrode be- 
longing to the insulated pair of quadrants only, it is seen that each of these 
substances, at the same time, is to the snme degree positive in relation to the 
zero of the earth, and that in all of them the potential is subject to precisely 
the same fluctuations. When, on the other hand, the examination is made 
with the two electrodes together (and when consequently the insulation is not 
preserved as it was in the last case), the constant result at all times is seen to 
be a settling down of all signs of potential to the zero of the earth — a result 
which could not happen if there were in the object any inherent differences of 
potential akin to those which are met with in muscle and nerve." " All that is 
necessary is to take the facts as so many reasons for believing that there is one 
and the same electrical condition in living protoplasmic substances and in life- 
less bodies generally." 

This conclusion would certainly appear to be much in the way of Dr. Rad- 
cliff'e's fundamental proposition, that all " vital motion" is to be resolved into 
physical motion, electricity being the " mode" in which physical motion is pre- 
sented to instrumental analysis. But our author's ingenuity (if he will pardon 
the term) is quite equal to this difficulty. He makes use of Sir William Thom- 
son's statement that the surface of the earth below, and the " thin, vacuum-like 
medium which forms the outskirts of the atmosphere above," are, with the mass of 
the atmosphere between them, in opposite states of charge ; the earth being ne- 
gative, and the outermost atmospheric layer positive. Investigation, moreover, 
shows "fluctuations and oscillations in atmospheric potential," which are im- 
portant in the same connection. Here our author finds the key to the electro- 
physics of simple protoplasmic vital movement. Expansion is consequent 
upon electrical charge and molecular repulsion. All bodies are not thus 
equally expanded ; aeriform substances most, then fluids, last solids. Among 
the parts of bodies not homogeneous in condition, there will be differences. 



204 Bibliographical Notices. [Jan. 

" In the case of the amoebge and amoeboid bodies, it may be in the hyaline 
portions, and not in the portions which have become more or less j^ranalar, 
both of which portions are distributed irregularly, that the apparently irregular 
expansions and shrinkings are manifested." 

We cannot avoid recalling here the well-known fact that many movements 
of amoebae are directly related to particles to which they are adapted, in a 
manner which is purposive, like other animal movements, which are said, in 
ordinary language, to occur in response to the stimidation of contact. Pro- 
fessor Leidy has made the remarkable observation that one species of amoeba 
may be seen actually to surround and include a nutritive particle, by the union 
and fusion of its pseudopodic extensions. Here, as elsewhere, in the study of 
contractility in animal tissues, muscular and others, we find a need for some 
term by which to name, if not to describe, the immediate agency by which 
contraction is instigated ; and for that agency the best word so far known is 
stimulation. 

Arriving, in his second chapter, at the consideration of the " electrophysics" 
of muscle and nerve, Dr. RadclifPe adverts to the existence of actual currents 
in these, as well as definite static conditions; they have an electricity of their 
own ; " present at one time, and absent at another, and capable of acting upon 
the galvanometer as well as upon the electrometer." As intimated already, Dr. 
Radcliffe believes that the condition of cpiiescent muscle is statical. But he 
adds now to his earlier statement of this, the assertion that it is so, as " the 
electrical condition of an electromotive element in the state of open circuit.^' 
The contents of the sheath in voluntary muscle, and of the cell membrane in 
involuntary muscular fibre, are compared to simple protoplasm; each fibre 
being analogous to an ensheathed amoeba. The existence of the sheath or cell- 
membrane makes a diff'erence from the amoeba, in the heterogeneity of the 
" sheath" and the "core" of the cell or fibre. These two elements, then, being 
in opposite states of electrical polarity, positive and negative, we have the con- 
ditions for electromotive action completed, when the oxygen of the blood, or of 
the air, is admitted, so as to set up such an action. 

" If, then," it is said (p. G.5), " the fibres and cells of the quiescent muscle and 
nerve are electromotive elements in the state of open circuit, of which the nega- 
tive polar portions are represented by the contents, and the positive by the 
coats, the inevitable inference is that the electrical indications which are of pri- 
mary importance, are those which act, not upon the galvanometer, but upon 
the electronometer — are those, not of the muscle-current and nerve-current, but 
of free positive and free negative electricity." "The operation of the charge 
from the constant electromotive action in the quiescent muscle may keep up a 
constant state of muscular elongation, and, consequent upon this, a constant 
readiness to enter into the state of contraction ; while it is easy to see that this 
elongalion and contraction must operate in a given direction, for the simple 
reason that the mobile contents of the muscular fibres and cells are so confined 
by the coats as to be only free to move in one direction, their case in this respect 
being in fact very similar to that of the mercury within the tube of the 
thermometer." 

Similar conditions, so far as electrical states and relations are concerned, are 
predicated also of nerves; but their structure does not afford a capacity for 
measurable expansion and contraction like that of muscle. This is evidently 
very different from the view suggested by the most familiar observations and 
experiments, that the motor nerves stand to the muscles in the simple relation 
of conductors of that agency which (whether by " charge" or " discharge" or 
otherwise), causes their contraction or relaxation. Dr. Radcliff'e does (una- 
voidably, perhaps) speak (as on p. 101) of " the direction in which motor im- 
pulses are transmitted to the muscles." 



1871.] Radcliffe, Vital Motion as a Mode of Physical Motion. 205 

Eminently clear, however, as the language of Dr. KadclifFe mostly is, being, 
indeed, a model of scientitic precision in statement, those who have read either 
of his former works must see that his present views have changed in the direc- 
tion of complication rather than of simplicity. Nor is this promising, as to 
the final result of his investigations, in the direction in which he has so far 
advanced. The great laws of nature are gloriously simple. Complication in 
the appearance of phenomena belongs to our ignorance. When the paths of a 
labyrinth are growing more and more involved, we may apprehend that we must 
be seeking an outlet in the wrong direction. 

It would be, however, an injustice to so tersely written a book, to attempt to 
convey its substance within the limits of a brief notice. Many important truths 
are expressed in connection with the pathological part of his subject ; truths 
which are more generally accepted now than when our author first wrote upon 
them. He is no longer in the advance, in urging, for example, that convulsion 
does not coincide with active febrile excitement, or with an over-active circu- 
lation in the brain ; and that spasm and tremor generally attend rather a 
diminution than an excess of blood-supp]y and nervous energy. But we do not 
feel convinced that these facts, nor those brought forward concerning the 
" physics" of rigor mortis, suffice to establish the conclusion derived by him, 
in regard to normal, healthy muscular contraction, as being inversely propor- 
tionate to the supply to the muscles of arterial blood. His analysis of the 
cardiac rhythm as an illustration of this, appears to us but a series of unproven 
suppositions. The whole work is an admirable example of special pleading. 
It is well worth reading, if only for the sake of showing how, in the present 
state of physiological knowledge (or ignorance) of the subject of muscular 
action, it is possible to defend, by cogent arguments, either of the most opposite 
hypotheses. Especially do we see, with some surprise, throughout the book, a 
depreciation, at least by comparative neglect, of the importance of that view of 
the physical forces, both inorganic and organic or " vital," which sees in their 
transmutation, as correlated modes of motion, the nearest approach to a solu- 
tion, yet possible, of many problems in the living body. When we know that 
the oxidation of carbon, hydrogen, and nitrogen, in or out of the body, will 
generate force, which is capable, according to its attendant conditions, of being 
transmuted into heat, electricity, mechanical motion, or vital, formative force, 
and that a quantitative measurement of some, at least, of these transmutations 
is possible, we must feel great difficulty in believing that there is not a positive 
relation between this generation of force and the active contraction of muscular 
organs, which does their work. Also, when we know that the consumption of 
material (whence force comes) accompanies, not the expansion or relaxation of 
muscular fibres, but their contraction, all of Dr. Radcliffe's elaborate argu- 
ments fail to convince us that the common opinion is entirely wrong, and that 
"the work of the blood in vital motion" consists in keeping the muscles in 
a relaxed or stretched condition; or (as expressed upon the final page of our 
author's " epilogue") that " the actual agency by which the work of the nervous 
system and of the blood in vital motion is carried out, is not a vital property of 
irritability, but electricity, or rather, electricity in conjunction with elasticity." 

If we are wrong in thus considering that the essential propositions, to expound 
and establish which this book was written, are not -proven, this error is against 
our inclination. We have much sympathy with the purpose of the inquiry, and 
admiration for the manner in which it has been conducted, and in which its 
results are set forth. Dr. Kadcliffe has already undergone more than one alte- 
ration of opinion in connection with his favorite subject. Let us hope that 



206 Bibliographical Notices. [Jan. 

such indefatigable perseverance, with so high an order of ability, may yet finally 
meet the reward of success, in solving a problem, which is at once one of the 
most difficult and one of the most important in physiological science. H. 



Art, XXXIV. — A Treatise on the Theory and Practice of Medicine. By 
John Syer Bristowe, M.D. Lond., F.R.C.P., Physician to St. Thomas's 
Hospital, etc. Edited, with notes, by James H. Hutchinson, M.D., one of 
the Attending Physicians to the Pennsylvania Hospital, etc. 8vo. pp. xxxii., 
1089. Philadelphia : Henry C. Lea, 1876. 

The professional reputation of Dr. Bristowe, and his experience as a teacher 
and examiner, led us to expect in this work a full, clear, accurate, and concise 
presentation of the present condition of the science and art of medicine ; and 
we have not been disappointed. It is a difficult task for any one man to pre- 
pare such a work, even if he has unlimited space for discussion ; but it is much 
more difficult to prepare it with the special aim of assisting " the junior mem- 
bers of the profession and students in medicine ;" to present all that is essential 
to a full and clear understanding of each subject, and at the same time to avoid 
burdening descriptions and discussions with details, which, however interesting 
and important in themselves, are less so to the novice in medical study than to 
the scientific investigator and physician. But duly to divide the essential 
from the non-essential and the adventitious, demands a thorough and judicial 
knowledge of the subject as a whole and in its several parts, a combination 
of literary, scientific, and practical experience and skill which are rarely asso- 
ciated in the same person. We greatly err if these conditions are not well ful- 
filled by the author of the work before us. He seems to us to have seized with 
remarkable discrimination upon the points which are essential to the several 
diseases he describes, and devoted himself to bringing them clearly into relief, 
so that of any picture he presents of a disease the strongest impression left 
upon the mind is its distinctness. A similar remark is quite as true of the por- 
tions of the work devoted to treatment, in which no long array of various 
medicines with minute directions for their combination and application are 
furnished to the reader, who is assumed to have derived this knowledge from 
more appropriate sources, or to be competent to draw it from his own experi- 
ence. In both of these respects this work reminds us of the admirable treatise 
of Niemeyer, although in both the English work is much fuller of detail than 
the German. 

The first part of the work treats of general pathology, including etiology, 
morbid growth, degeneration, mechanical derangement, and the special pro- 
cesses, terminations, and modes of treatment of disease, and is remarkable for 
the large amount of condensed material it contains. Part second, which in- 
cludes nearly nine-tenths of the whole, comprises almost all the diseases which 
belong to medicine as distinguished from surgery. To attain this degree of 
comprehensiveness within a limited space, made it necessary for the author to 
state his conclusions rather than the grounds for them, and to discard almost all 
discussion of controverted points. Such a method, which would hardly be allow- 
able in a writer who had still his position to establish, may very well be 
accepted in the present case, as the judgment of one who speaks with authority. 
Nevertheless, we miss certain statements which seems to be called for by the 



ISTT.] Bristo WE, Theory and Practice of Medicine. 20Y 

present state of medical science and opinion, as, for example, that which 
regards pulmonary phthisis as being most commonly a result of inflammatory 
consolidation. So far as this book informs us, we should be ignorant of any form 
of pulmonary phthisis in which fatally destructive processes occur independ- 
ently of tubercles. As an example of the opposite kind, we may cite the sub- 
ject of malaria, which is discussed in little more than a couple of pages, and 
yet without omitting any essential statement. We note the emphatic contra- 
diction given to the idea that epidemic cholera can originate in any association 
whatever of natural causes except those which have always existed at its origi- 
nal source in India, and that all other alleged causes merely act as favouring 
conditions for its development. In the American edition, the editor has very 
properly corrected the statement that "The essential cause of yellow fever is a 
specific contagiura of extreme virulence, which is given off by the breath," etc., 
by declaring the well-established truth that no case is on record in which a 
person, having the disease in a previously healthy quarter, has become the 
starting-point of a local epidemic. A similar error is committed in regard to 
" Cerebo-spinal fever," of which it is said that " there can be little doubt 
that it is contagious, it giving clear indication of its spread from the sick to 
the healthy." On the contrary, the indications are so obscure that no writer 
concerning this disease, who has personally observed it, alleges that it is in its 
nature contagious. Nearly all deny that it is so ; and, for our own part, hav- 
ing studied it in hospitals and in private practice, we feel bound to declare that 
it has never exhibited to us a contagious character. 

The absence of a long enumeration of remedies for diseases has already been 
noted as characteristic of this work, and it at once inspires respect for the 
author's judgment to observe that in the treatment of pneumonia and of ty- 
phoid fever, but little mention is made of veratrum, digitalis, aconite, and 
other arterial sedatives, the farrago of pseudo-science which has been dragged 
into the treatment of these and other febrile affections of late years. As the 
author remarks, "a direct cure, at all events a direct cure by means of drugs, 
is in the great majority of cases totally impossible." Not that he ignores 
either the old or the new, if only it has just claims to notice. Thus he refers 
to the cold-water treatment of febrile affections, indicating its effects without 
approving its use. Like some other agents, it has several times been in vogue, 
only to be discarded when the accidents it occasioned or the trouble it gave 
dissuaded from its use. 

The author states that he has only occasionally devoted a special paragraph 
to the differential diagnosis of diseases, and while admitting that he has been 
driven to this course by the exigencies of space, he does not on the whole re- 
gret it, " for the distinguishing of one disease from another disease should de- 
pend, not on the simple recognition of a few leading characters, . . . but 
on a bona fide and thorough acquaintance with the collective phenomena of 
disease." Such a reason appears to us inadequate, however true in fact, since 
the characteristic distinctive phenomena of every disease are easily summa- 
rized, and, when placed side by side with those of diseases with which it is 
liable to be confounded, present it to the mind's eye as a separate entity, which 
is then more readily preserved in the memory, along with its special nature, 
tendencies, and methods of cure. Moreover, a clear diagnosis lies at the very 
foundation of scientific accuracy in clinical medicine. And, finally, as a mere 
matter of convenience and saving of labour and time, its value is inestimable. 

On the whole we cannot but recommend Dr. Bristowe's work as a very full 
and reliable treatise on the theory and practice of medicine, admirably adapted 



208 Bibliographical Notices. [Jan. 

to the wants of the student and practitioner, by its equally precise and com- 
plete descriptions of diseases, and by its judicious views of their treatment. 

The additions of the American editor are always appropriate and instruc- 
tive, and supply deficieuces in the original text. We quite agree with the 
judgment expressed in his Preface, when he says that " he knows of no other 
work in which the author has been equally successful in bringing- within the 
compass of a single volume the description of so large a number of diseases, 



and in doing this in a manner as advantageous to the student. 



A. S. 



Art. XXXV. — The proper status of the Insane and Feeble Minded. A paper 
read before the Medico-Legal Society of New York, February 25, 1875. By 
John Ordronaux, LL.D., State Commissioner in Lunacy. 8vo. pp. 48. New 
York. 

In this very able paper, the subject is considered chiefly from the legal stand- 
point. The author states at the outset that our whole procedure in cases of 
lunacy is tinged with palpable contradictions, and declares that "it never has 
been, and never can be explained on rational principles why, if the State be the 
guardian in equity of all lunatics, and it has the power of issuing commissions 
under civil proceedings which shall give it the custody of such persons and the 
right to detain them in asylums ; it cannot rationally be explained why it has 
parted with that same power, when a person accused of crime asks for its pro- 
tection against the technical jurisdiction of a common law court." This is the 
key-note of his examination of the doctrine and practice of the criminal law of 
insanity; and the remedy he would adopt for the defects of the present system 
is to extend equity jurisdiction over lunatics in all cases, criminal as well as 
civil. Equity, he says, is only natural justice. "Hence every honest appeal 
in lunacy, by whomsoever made, should be listened to as a petition in equity; 
and in criminal trials, in particular, where every presumption favours innocence, 
and every doubt enures to the benefit of the defendant, the plea of lunacy should 
be heard and settled before proceeding to try a party whom the State has 
solemnly declared to be incapable at law of committing a crime." 

In support of his reform he shows that our administration of the criminal law 
in cases of insanity is in conflict with well-settled principles of law, as well as the 
facts of science, and is made the means of great injustice. Under the change he 
proposes, he contends that no practical inconvenience or harm would arise, and 
the rights of all would be amply secured. His points, if we may be allowed to 
judge, are well taken and ably sustained, albeit with a degree of subtilty in the 
reasoning sometimes, which reminds us rather of the ingenious advocate, than 
the scientific inquirer. As they are chiefly of a legal character, they would be 
imperfectly understood by the medical reader, and therefore we shall advert to 
one or two of them only. 

In addition to the objections which lie against a jury trial in ordinary cases, 
as a means of eliciting the truth and doing justice, its processes are marked by 
a mischievous absurdity when the issue depends on a question of science or any 
very special knowledge. The jury is supposed to be incompetent to understand 
the full significance of the facts that appear in evidence, and so the law allows 
experts to be called in order to enlighten them in regard to the matter in hand. 
This arrangement, wise as it is, undoubtedly, may fail to accomplish its proper 



18t7.] Proper Status of the Insane and Feeble Minded. 209 

purpose, because, whether the experts agree or disagree, the jury may disregard 
them altogether, and render a verdict according to their own foregone conclu- 
sions. If honestly disposed to be guided by the evidence of experts, then this 
jury, who are supposed to be incompetent to decide upon the facts, are obliged, 
in case the experts disagree, to sit in judgment on their conflicting opinions. 
And yet all this is approved by lawyers who are shocked by the idea of juries 
presuming to judge of the law as well as the facts of the case; as if juries 
were not fully as competent to decide upon the meaning and purpose of the 
law, as they are on the bearing and weight of scientific testimony. If they 
are competent for the latter duty, why call experts at all, the Doctor pertinently 
asks. He prefers that the question of insanity, when pleaded in defence of crime, 
should be tried by a commission of experts, and he would also embrace within 
the scope of this provision, cases in which the presence of insanity at the time 
of trial is alleged. Many years ago the Legislature of New York enacted that 
" no act done by a person in a state of insanity can be punished as an offence ; 
and no insane person can be tried, sentenced to any punishment, or punished 
for any crime or offence while he continues in that state." For reasons not 
very obvious this provision has been seldom resorted to, and men are tried in 
that State, every week in the year, where the defence is solely insanity, past or 
present. It is not improbable that lawyers have been governed by the idea that 
proof of insanity existing at the moment of trial might lead to indefinite con- 
finement, while proof of its existence at some previous period, when the criminal 
act was committed, is not incompatible with subsequent recovery ; a fact which, 
in one way or another, might procure the discharge of the prisoner. In fact, 
whatever may be his mental condition when arraigned, the plea is not insanity, 
generally, but insanity at a certain previous period. This distinction. Dr. 
Ordronaux does not always bear in mind. However absurd it may he to re- 
quire a person legally incompetent, perhaps, to make a will or a contract, to 
undertake so important an act as that of pleading to an indictment of the 
gravest character, the incompetence and the absurdity disappear the moment 
he is restored. 

Whether, in all cases, the special issue should be tried in connection with 
the general issue, or relegated to a commission of experts, is a question where 
much may be said on both sides. Bad as the former course is, the other is not 
free from serious objections. The radical defect of the jury trial is that it 
is without any competent authority to decide between conflicting witnesses ; 
but is trial by commission any better in this respect ? Who is to decide when 
commissioners disagree? If it is to be the majority, we need only remind the 
reader that the truth is not always on the side of the majority, whether of 
jurors or commissioners. Of course, a commission would have a wider 
scope of inquiry, and thereby, other things being equal, be more likely to 
reach a true conclusion. Whether it would always be the means of securing a 
higher degree of skill and true discernment, there is much reason to doubt. 
Are judges and governors so well informed as to the proper qualifications of 
experts, so free from petty prejudices and partialities, that they would always 
select for the duty only men of acknowledged eminence and worth ? Considering 
the heterogeneous crowd that now fill the ranks of medical practitioners— homoeo- 
paths, half-educated regulars, eclectics, female doctors, etc., not one of whom, 
probably, is without some friend or patron of high degree, we cannot shut out 
some grave apprehensions on this score. Indeed there are men whose profes- 
sional standing and social position would be, in the eyes of the world at large, 
an ample warrant for their appointment, who are totally unfitted for the duty 
No. CXLY.-~Jan. 1877. U 



210 Bibliographical Notices. [Jan. 

by their peculiar views or lack of special knowledge. We think Dr. Ordronaux 
can see within the line of his mental vision more than one of this description. 
Would he subject a friendless prisoner to a risk which he would deplore in the 
case of a friend of his own ? Would he wish to consign any one to the 
official inquisition of a man, however distinguished in his profession, who be- 
lieves that no form of insanity short of raving mania, and hardly that, should 
exempt the patient from condign punishment for any criminal act he may com- 
mit ? It is a vulgar notion that the disagreement of experts proceeds from 
ignorance or dishonesty, and it is not confined to the vulgar, for it is much en- 
tertained by those who ought to know better. How people of any mental cul- 
ture can expect from experts unanimity of opinion on all occasions, passes com- 
prehension, for they cannot help seeing, every day, scientific men of the highest 
eminence expressing conflicting views in books, conversation, and the discus- 
sions of societies. If geologists, chemists, physiologists, engineers, mechanics, 
may differ from one another, on such occasions, each in their respective fields 
of inquiry, why may not doctors differ on the witness-stand ? Surely Dr. Ordro- 
naux cannot suppose that three or four men investigating a case, in the charac- 
ter of commissioners, would be any more likely to agree in their conclusions. 

So far as the method of proceeding by a commission would give better opportu- 
nities for examining the prisoner, it certainly would have an advantage over the 
usual method ; and if it were made peremptory, it would be an act of justice 
and humanity towards such as are unable to avail themselves of the aid of 
experts in any other way. Nor can it be denied that when resorted to in 
obscure cases, as supplementary to a jury trial, it might be the means of pre- 
venting the harm of an unjust verdict. Beyond these particulars, we are not 
sure that the trial by commission has any advantage over a trial by jury. By 
means bf the latter, on the other hand, we obtain every possible construction 
of the facts in evidence, their significance is regarded from every point of 
view, the latest advances in knowledge bearing on the case, are brought to 
light, and the defendant feels that everything has been done for him which the 
science and skill of the times could furnish. 'J'rue, all this may be regarded as 
of little or no account, by the jury, and a verdict given in the face of it all. 
But this defect of the trial by jury we have it in our power to remedy in some 
measure, by placing in the panel men of a higher grade of culture and charac- 
ter than that we too often witness. We are not prepared to indicate exactly 
the legislation necessary to secure this result, but it would seem to require no 
great ingenuity to devise it. Still we would not deny that a large class of cases 
— those especially in which the disease is supposed to be present at the time of 
trial — might well be referred to a commission, to the great saving of time and 
expense, provided that its verdict, if unfavourable to the defendant, should be 
no bar to his pleading the special as well as the general issue, in the subse- 
quent trial. 

In treating specially of the criminal responsibility of the insane. Dr. Ordronaux 
fully embraces the views of those who are best acquainted with the nature of 
insanity, and with the ways, manners and habits of the insane. Nothing can be 
stronger than his protest against the traditional doctrines of the common law 
on this subject. "But for the traditional difficulty which has always beset com- 
mon law courts of determining how the violated dignity and sovereignty of the 
State can be adequately vindicated in questions of alleged crime, without re- 
sorting to penalties in extremis, we should long since have been delivered from 
the dread of the plea of insanity as an answer to indictments. In all other 
directions, save this, our common law jurisprudence has been willing to walk 
in the vanguard of social eniiohtenment, and to follow the lead of such emi- 



A 



ISII.^ Proper Status of the Insane and Feeble Minded. 211 

nent jurists as Lord Mansfield, Sir William Scott, ajjd Sir John NichoU. But 
here we are creeping in the same swaddling clothes which Lord Coke, as our 
legal wet nurse, put around us in Beverly's case." A statement, this, exactly 
true in fact, and most fitly expressed. 

Of course, Dr. Ordronauxis dissatisfied with the rules of law usually laid down 
by the courts in determining whether the alleged insanity of the prisoner is such 
as to exempt him from punishment, and substitutes some of his own, viz. : — 

" First. Whether the defendant, at the time of the alleged crime, knew the 
nature and consequences of the act he was committing? 

" Second. Whether, if he did so know them, he had a felonious intent in 
committing the act? 

" Third. Whether, knowing the nature and consequences of the act, he had 
the power to choose between doing or not doing it?" 

Another requirement is that the mental impairment alleged must be the 
result of disease, not of intoxication or anger. 

These tests, we are obliged to say, like those which he condemns, are not 
founded in an exact knowledge of the movements of the insane mind. All 
these questions might be answered affirmatively without implying responsibility. 
Many of the inmates of our hospitals might say, after committing an assault 
by word or blow, on a fellow-patient, "I knew that I should hurt or annoy 
him, and as a consequence, be shut up in my room, or have restraint put on 
my limbs. He twitched a newspaper from me, or called me vile names, and I 
meant to punish him for it. I would have shot him dead if I had had a pistol. 
I could have refrained from doing as I did, but I didn't choose to. It served 
him right, and I am glad I did it." Here are all the elements of crime as 
defined by lawyers, and yet we know that insanity — the mental condition which 
made him unfit to remain a member of society— was at the bottom of it all. 
Have we not heard a patient say, when asked if he were irresistibly impelled 
to do the mischief which seemed to be his principal occupation, " By no means. 
I might refrain if I pleased, but it gives me an indescribable pleasure to do as 
I do." And yet that man, when not insane, was a good citizen, neighbour, and 
husband, respected and trusted by all around him. The fault of Dr. Ordronaux's 
tests is precisely that which vitiates those of the common law. He endeavours 
by their means to discover what is beyond the reach of mortals, viz., how far and 
in what manner, precisely, insanity impairs the power and the disposition to 
pursue the right and avoid the wrong. We regret that he did not give the 
sanction of his experience and his office to the rule recently laid down by the 
Supreme Judicial Court of New Hampshire, whereby the jury are instructed 
that their duty is to ascertain whether or not the defendant is insane, and if 
they find him so, whether the act for which he is on trial was the offspring of 
such insanity; in other words, whether he would have committed the act had 
he not been insane. This rule recognizes the limitations of our own discern- 
ment, and confines the jury to their only rightful province, the determination 
of facts. 

We are glad this lecture has been published, and we wish it would be read 
by every lawyer in the land, for it is not often they see this subject so ably and 
intelligently presented from the legal point of view. I. R. 



212 Bibliographical Notices. [Jan. 



Art. XXXYl.—Cf/clopcedia of the Practice of Medicine.— FAM^di by Dr. H. 
Tox Zikmssp:n, Professor of Clinical Medicine in Munich, Bavaria. Yol. XI. 
Diseases of the Peripheral Cerebro-spinal Nerves. By Prof. Wilhelm Hein- 
RTCH Erb, of Heidelberg, Baden. Translated by Mr. Henry Power, of Lon- 
don, England. 8vo. pp. xiii., 623. 

Yol. YI. Diseases of the Circulatory System ; together with the Chapters on 
Whooping-cough, Diseases of the Lips and Cavity of the Mouth, and 
Diseases of the Soft Palate. By Prof. Rosenstein, of Leyden ; Prof. 
SciiROETTER, of Yieuna ; Prof. Lebkrt, ofYevay ; Prof. Quincke, of Berne; 
Dr. Bauer, of Munich ; Dr. Steffen, of Stettin ; Prof. Yogel, of Dorpat; 
and Prof. Wagner, of Leipsic. Translated by George W. Balfour, M.D., 
of Edinburgh; Edward D. Geoghegan, M.D., of London; Thomas Dwight, 
M.D., of Boston; J. Haven Emerson, M.D., and George C. Wiieelock, M.D., 
of New York ; and J. Solis Cohen, M.D., of Philadelphia. Albert H. Buck, 
M.D., New York, Editor of American Edition. New York : William Wood 
& Company, 1876. 

The student will find in the eleventh volume of Ziemssen's Cyclopaedia, in 
addition to the various forms of neuralgia, several diseases of the peripheral 
nerves treated of in detail, which are, in consequence of the necessity for econo- 
mizing space, passed over with little or no notice in the ordinary works on the 
Practice of Medicine. They are, however, very numerous, including a great 
variety of local spasms, paralyses and contractions, and are often the source of 
much distress to the sufferer and of perplexity to his physician. In spite of 
the careful study of which they have of recent years been the subject, but little 
is definitely known of their pathology. Indeed, although the symptoms point 
unmistakably in many cases to the existence of a lesion, it has as yet escaped 
discovery by all the methods of investigation at our command. It has hence 
been common to speak of these affections as " Functional Neuroses." 

Dr. Erb, judging from the short bibliographical sketch at the beginning of 
the volume, seems an eminently fit persons to be intrusted with the task Dr. 
Ziemssen has confided to him. After graduating at Munich he served for six 
months as Prof. Buhl's assistant; then going to Heidelberg he held a similar 
relation to Friedreich. Not satisfied with the experience gained in this way 
lie spent six months in Berlin in order to further perfect himself in scientific 
matters. Accidental circumstances induced him upon his return to Heidelberg 
to make a thorough study of electro-therapy, and in this way he was naturally 
led to give particular attention to diseases of the nervous system. During the 
last two years these two specialties have formed, we are told, the chief subject 
of his studies, and of his lectures since his appointment to lecture on electro- 
therapy at the University. An examination of the volume shows that the author 
possesses a thorough familiarity with the literature of the subjects upon which he 
writes. We notice with pleasure that his reading has embraced the works of 
American as well as of European authors; the papers of Dr. Weir Mitchell 
being frequently referred to in such terms as to show his high opinion of their 
value. 

We think it will generally be admitted that the rank and file of our profes- 
sion have very confused notions on the subject of electro-therapy, knowing in 
very few instances what form of electricity to employ, or how and when to use 
it. We do not find, however, that Dr. Erb is able to lay down very definite 
rules for our guidance. 



I 



187V.] Cyclopaedia of the Practice of Medicine. 213 

" The special iadications for the employment of this remedy (electricity) 
canuot, however," he says, "as yet be given with precision, since most of the 
facts have been discovered empirically, and still require much corroboration. 
As a matter of course," he goes on to say, " electricity will not cure all forms 
of neuralgia; it cannot even be accounted a sure palliative in all neuralgias, 
but is surpassed in this by the narcotics. This is particularly true of neuralgias 
which are due to gross anatomical changes, and of those caused by anoemia 
and the different forms of poisoning so long as these causes continue to act." 
Electricity, especially the galvanic current, will, however, often be found to yield 
good results in the so-called idiopathic neuralgias, in most of those which are 
due to a rheumatic or neuritic process, and which have become habitual ; and, 
finally, in a certain proportion of the excentric neuralgiae. 

The author is evidently of the opinion that the frequency and importance of 
the " points douleureux" in neuralgia have been very much exaggerated, espe- 
cially by the distinguished physician by whom they were first accurately de- 
scribed ; in this view agreeing with Romberg, Trousseau, and Anstie. Eulen- 
berg, indeed, was able to find them in only one-half the cases that came under 
his care. 

In regard to a point of much interest to physiologists we find the author 
expressing himself as follows : — 

" This is not, indeed, the place to enter fully into the difficult question of 
the existence of trophic nerves, yet there is no reason why we should not state 
that our opinion is entirely in favour of their existence ; and that a whole series 
of the above-mentioned trophic disturbances are only explicable on the suppo- 
sition that the nerves exert a direct influence upon the nutrition of the tissue ; 
as, for example, the changes in the colour and growth of the hair, the hyper- 
plasia of the epithelium, the deposit of pigment, the hypertrophy and in part 
the atrophy of the tissues, and perhaps also a part of the inflammatory disturb- 
ances in the skin, erysipelas, pemphigus, herpes, etc." 

It is not always an easy matter to determine the seat of neuralgia from the 
character and situation of the pain, and the author, while giving Benedict's 
rules for the diff*erentiation of peripheral from central neuralgia, adds that "it 
is probable enough they do not hold in all cases." 

"In true peripheral neuralgia," Benedict says, " the pain is of a more con- 
tinuous character (during the paroxysms), follows the course of certain nerves, 
and is never seated in the bones; on the other hand, in central (excentric) 
neuralgia the pain is of a wandering character, does not follow the course of 
any definite nerve, is particularly liable to affect the bones, and has a well- 
marked, sudden, lancinating character." Lastly, he adds, " a third group 
may be distinguished in which the pain presents the peripheral (continuous 
fixed) character, but is localized in the bones, and thus indicates that the seat 
of the affection is in the nerve roots, in the cavity of the skull, or in that of 
the spinal cord." 

In this connection a case, showing the difficulties occasionally attending the 
diagnosis of the seat of neuralgia, which recently came under the writer's 
observation, may be briefly referred to here. A negro lad, giving a distinct 
history of exposure to malaria and suffering from violent facial neuralgia, was 
admitted last August into the medical wards of the Pennsylvania Hospital. 
The pain yielded to full doses of sulphate of quinia, and never afterwards re- 
appeared. Under these circumstances, the diagnosis of malarial neuralgia 
which was made upon his admission seemed to be fully confirmed. He was 
shortly afterwards discharged; the presence of a slight amount of disease of 
the apex of the right lung having been, however, fully recognized. With this 
exception there was no evidence of disease. He was readmitted last November 



214 Bibliographical Notices. [Jan. 

with general tuberculosis which ended fatally in the course of a few days. At 
the autopsy, his brain, upon being carefully examined, was found to contain 
four caseous nodules varying in size from a large pea to a filbert, the smallest 
nodule being seated on the right side of the pons Varolii — the side upon which 
the neuralgia was seated— and, therefore, near the origin of the nerve involved. 
The volume is, from the fact already noticed that it contains matter not gen- 
erally included in text-books, one of the most valuable of the series. As in the 
other volumes, each chapter is preceded by a full bibliography. 

The authors of the papers in Yol. YI. are so numerous that it would be im- 
possible, within the limits assigned us, to present our readers with sketches of 
their lives. Indeed, this kind of introduction, in most instances, is unneces- 
sary, as they are already sufficiently well known to the reading portion of the 
profession. The gentlemen whom Dr. Buck has called to his assistance in 
translating the volume have done their work so well that there is very little to 
remind us that it was originally written in German. Dr. Rosenstein, who is 
the writer of the general introduction to Diseases of the Heart, and of the 
chapter on Diseases of the Endocardium, applies the term " diphtheritic" to 
the form of endocarditis which it is more usual to distinguish as " ulcerative," 
believing that the malignant nature which characterizes this affection is not to 
be attributed simply to the ulcerative process, but to the peculiar fundamental 
disease which induces the ulceration. Besides which, Virchow has called 
attention to the similarity of the process to that which takes place in diph- 
theria. We find him recommending in the treatment of this disease, for the 
purpose of lowering the excited activity of the heart, a remedy which, if it 
has been used at all in this country with this object, has certainly not obtained 
much popularity. This is the application of cold to the prtecordial region in 
the shape of poultices or ice-bags. This recommendation he repeats when 
speaking of the treatment of the more ordinary form of endocarditis. The 
remedy is also referred to approvingly by some of the other contributors to the 
volume. Among these we may specially mention Dr. Bauer, who in his arti 
cle on '"Pericarditis," thus alludes to it : " The application of an ice-bag over 
the heart at the same time (as the administration of digitalis) has been found 
very advantageous, whether in quieting the tumultuous action of the heart, 
together with the sensation of palpitation, or allaying the pain which accompa- 
nies the disease." The employment of cold, he says, has been proved by 
others, especially by Friedreich, to be useful, " so that nowadays the moist 
and warm applications and poultices of former times for the acute stage of the 
disease are no longer used." Again, Prof. Schroetter speaks most highly of 
the persistent and faithful use of cold in the treatment of hypertrophy of the 
heart, believing that this simple remedy is fitted most wonderfully to quiet its 
over-activity. 

In consequence of the great size of Yolumes YII. and YIIL, the editor has 
thought it best to incorporate the article on Whooping-cough, as well as the 
articles on Diseases of the Lips, Cavity of the Mouth, and Soft Palate, into this 
volume. It might reasonably be objected to this arrangement that it has given 
most inconvenient proportions to this volume. These articles, so far as we 
have been able to examine them, seem well written and instructive ; but we 
shall only refer to Dr. Steffen's observations in regard to the use of quinia in 
whooping-cough. He has found it to diminish very decidedly the duration and 
severity of the disease, if given in full ante-periodic doses, as much as nine 
grains having been taken twice daily for eleven days by a child of three years 



1 



1877.] Taylor, What is the best Treatment in Contracted Pelves? 215 

of age in one of the cases which he reports. Whether this action is to be 
based upon the still doubtful theory of fungus spores, he, however, leaves un- 
decided. 

In conclusion, it only remains for us to say that these volumes fully sustain 
the high character of the series. J. H. H. 



Art. XXXYII. — What is the best Treatment in Contracted Pelves? By 
Isaac E. Taylor, M.T)., President ; and Emeritus Professor of Obstetrics and 
Diseases of Women and Children, in Bellevue Hospital Medical College, etc. 
etc. etc. Reprinted from the Transactions of the Neio York Academy of 
Medicine for September, 1875. 

Part II. Is Craniotomy, Cephalotripsy, or Cranioclasm preferable to the 
Ccesarean Section in Pelves varying from one and a half to two and a half 
inches? Read March 2d, 1876. 8vo. pp. 64. 

Part 1st is confined to cases in which the pelvis ranges from two and a half 
to three and three-quarters inches in the antero-posterior diameter. It refers 
to two varieties of deformity, viz , the generally contracted pelvis, when the 
diameter ranges from three and a quarter to three and three-quarters inches ; 
and the simple flat pelvis, varying from two and three-quarters to three and 
three-quarters. 

In the latter, after failure of forceps, version should be resorted to. In this 
variety the long straight forceps are preferred by the author to the long curved 
ones. In the former, the latter form of instrument is recommended. 

Under Part II. the author draws the following conclusions : — 

" 1. That a mutilated foetus can be delivered with safety to the mother 
through a space of one and three-fourths inches antero-posterior, and a two 
and a half or three inches transverse, by craniotomy, cephalotripsy, or cranio- 
clasm, provided the vault has been destroyed, and the face made to present 
edgewise, or delivering the head sidewise. 

"2. That after cephalotripsy or cranioclasm, if necessary, version early per- 
formed, with propulsion from above the pubes afterward, and before the uterine 
forces are exhausted, is preferable to the first proposition, and I believe more 
available. 

"3. That the cephalotribe or cranioclast cannot be considered sufficiently 
available as tractors after cephalotripsy, to deliver the patient in extreme con- 
traction, and that other instruments as tractors are necessary to aid the 
delivery. 

" 4. That the Csesarean section should not be performed when the contraction 
or deformity is as stated above, unless some other complications or circum- 
stances exist or present." 

We are not at all prepared to endorse the views of Dr. Taylor, which are 
also those in many respects of Drs. Barnes, Hicks, and others of England, 
where the Csesarean operation has been frightfully unsuccessful, because of its 
having in most instances been one employed as a last resort, instead of being 
one of election, and performed at the most favourable time for the woman's 
recovery. We believe that the views expressed by the late Dr. John S. 
Parry of this city, in his paper entitled, "The comparative merits of crani- 
otomy and the Csesarean section in pelves with a conjugate diameter of two 
and a half inches or less," more closely represent the relative advantages of 
the two forms of delivery, as applied to the general profession. Take the 
average skill of the obstetrical operators of the United States, and let it be 



216 Bibliographical Notices. [Jan. 

tested under the most favourable circumstances in pelves of minimum diameter, 
by an equal number of operations of both varieties, and we shall find the mor- 
tality much less by the Caesarean operation than is generally credited to it, and 
quite as great by the other. 

On page 34, Dr. Taylor professes to give the results of the Caesarean opera- 
tion in England, Germany, France, Belgium, Italy, and America. He gives 
England 480 operations, and 236 recoveries, or nearly one-half saved. If this 
was the case, we should find comparatively little of the opposition that pre- 
vails against this operation in Great Britain, Where Dr. Taylor procured 
his information we cannot imagine, for it was not until 1869 that a hundred 
operations had been reached in Great Britain and Ireland, as the result of 
which, 84 women perished. Had he fully consulted the American Journal of 
Obdelrics, he would have found for the United States, instead of 12 cases and 
4 recoveries, 59 cases with 30 recoveries. We have the most reliable statistics 
for our own country that have been collected by any recorder, every case 
being obtained in a way to put the truth of the statements beyond question, 
many accounts having been rejected because locality, time, and circumstances 
could not be satisfactorily given. We have also declined all cases, where 
gastrotomy was performed, after rupture of the uterus, as this operation being 
always promptly resorted to, has been less fatal than gastro-hysterotomy, and 
besides has been more frequently done. Thus far, we have the records of 70 
operations, the same number that Dr. Parry collected of craniotomy cases ; 
and do not require to go to England to learn the comparative merits of crani- 
otomy and Ca3sarean section. It is true that when early resorted to by men of 
skill, like Drs. Taylor, Hicks, and Barnes, cranioclasm in extremely contracted 
pelves very often results favourably; but what would happen at the hands of 
average men? is the question we have to answer; and would they run any 
greater risk in attempting to save two lives by an early resort to the knife? 
We believe that the Caesarean operation will never assume the elective position 
it should in America, until operators learn fully, how successful an early resort 
to the knife has been here ; and thus cease to be influenced by that fear of it 
which English want of success has disseminated in Great Britain, and has 
materially contributed to strengthen and continue. Boldness and perseverance 
in a few men saved ovariotomy from being held up to the world as an unjusti- 
fiable operation. The same care and skill in gastro-hysterotomy would change 
the views of the profession as to the danger to be apprehended. R. P. H. 



Art. XXXYIII. — Catalogn.e of the Models of Diseases of the Skin in the 
Museum (f Guy's Hospital. By C. Hilton Faggr, M.D., Assistant-Physi- 
cian to and Lecturer on Pathology at the Hospital ; formerly Demonstrator 
of Cutaneous Diseases. 8vo. pp. xxxii., 269. London: J. & A. Churchill, 

1876. 

It is unquestionably a sign that our profession is advancing in the right direc- 
tion when a volume such as the one before us makes its appearance. It 
belongs to a class of which we see far too few examples in connection with 
the museums found in every centre of medical education, and indicates a laud- 
able desire to place the resources of such an institution in their most favour- 
able light. In the present instance the work could not have been entrusted 
to abler hands, for Dr. Fagge is everywhere recognized as an accomplished 



1877.] Fagge, Catalogue of Models of Diseases of the Skin. 217 

dermatologist. We find the models arranged according- to an "analytical 
index," or classification, proposed by the author, which divides cutaneous dis- 
eases into five groups: I. Inflammatory (or simply congestive) diseases. 11. 
Non-inflammatory diseases, not having destructive tendencies. 111. Non-in- 
flammatory diseases, aS'ecting the tissues of the skin profoundly, and generally 
destructive in their tendencies. IV. Affections of the appendages of the skin. 
Y. Parasitic diseases* Of the merits or demerits of this classification the 
present occasion does not permit us to. speak at length, but briefly stated, we 
think too little prominence is given to the anatomical structures involved and 
to the pathological process. Thus, for example, we find in the first group, 
eczema divided into acute and chronic, and the two stages of this disease sepa- 
rated, acute eczema being placed in division "A. Protecting against recur- 
rence, or at least non-relapsing (exanthemata)," while chronic eczema is placed 
in division " B. Not protecting against recurrence, and mostly relapsing." 
We cannot see that anything is to be gained by separating the stages of dis- 
eases, even in the case of an affection so multiform as eczema. 

Concerning the nomenclature employed we are much more in accord with the 
author. In looking over the names which have been adopted by Dr. Fagge to 
represent the diseases illustrated by the models, we find them to be most judi- 
ciously selected from the many synonyms with which almost every disease has 
been burdened. With few exceptions they are those used at the present day 
by teachers of dermatology in all parts of the world. 

Of the excellence of the models themselves, the name of the artist, Mr. Joseph 
Towne, who for a period of forty years has occupied the position of artist and 
modeller to the hospital, is a sufficient guarantee of superior work. From a 
personal inspection of the museum some lew years ago, we are, moreover, pre- 
pared to speak in unqualified terms of praise of these works of art. The collec- 
tion is a most valuable and extensive one (containing five hundred and thirty- 
seven models), and embraces numerous examples of almost every disease wiiich 
permits of representation. Some idea of its wealth may be obtained by glancing 
at the number of pieces with which the commoner affections are illustrated. 
Thus, of the syphilodermata there are seventy-three models ; of eczema (includ- 
ing lichen), forty-four; of psoriasis, thirty-four; of ichthyosis, fourteen; of pem- 
phigus, eleven; of keloid, sixteen. Among the rarer affections we find twenty- 
five examples of leprosy; twenty-one of those curious and complex diseases 
known as scleroderma and morphoea; seven of cornu cutaneum; thirteen of 
xanthoma; and nine of equinia. The museum stands unrivalled in the collec- 
tion of these rarer diseases. 

With each model Dr. Fagge has given a brief description of the lesions, to- 
gether with such remarks as the case appeared to call for. In many instances, 
especially with the more obscure diseases, the full histories with apposite re- 
marks are presented. The notes of the author, to be found upon almost every 
page, add greatly to the value of the volume, and are well entitled to more than 
passing notice. They show accurate observation, and a thorough knowledge of 
dermatology. The work everywhere bears distinct marks of careful preparation, 
and cannot but be highly esteemed, not only by the students of the hospital, 
but also by the profession at large. It, moreover, makes known a store-house 
of most valuable material for purposes of study, and well illustrates the solid 
work that has been done for dermatology in this renowned seat of medical 
teaching. L. A. D. 



218 Bibliographical Notices. [Jan. 



Art. XXXIX. — The Anatomy of tlxe Head, with six lithographic plates, repre- 
senting frozen sections of the Head. B}' Thomas Dwight, M.D., Professor 
of Anatomy at the Medical School of Maine, etc. etc. 12rno. Boston, H. 
0. Houghton & Co., 1876. 

Any good work on the regional anatomy either of a ymrt of the body or the 
whole of it, is a welcome addition to medical literature. « Especially so is it 
when it comes to us in English dress, and consequently can be studied by that 
very large class of medical students to whom the valuable French and German 
works are sealed books. Recognizing, as every teacher does, the very great 
value of the anatomy of relations, and having had the opportunity of preparing 
sections of the frozen head. Professor Dwight has presented to students and 
practitioners the work under review. Its fifteen chapters are devoted to the 
consideration of the bony framework of the head and face, its covering soft 
parts, and contained important organs, and through all and above all else the 
relations of the various structures to each other — " histology holding no place," 
and "many of the smaller details" being "disregarded." 

Though, of course, in a bibliographical notice no special review of the work 
can be made, it may not be out of place to call attention to a few things that 
have been specially noted in reading the book. Both by words and reference 
to a drawing, the student's attention is directed to the thinness of the plate 
separating the mastoid cells from the cranial cavity, and to " how little there 
is wanting to form a canal directly through the temporal bone." 

The old idea of the arachnoid, " that it is a serous membrane forming a closed 
sac," is declared " utterly false." 

The muscular parts of the occipito-frontalis are stated to "have no kind of 
relation to one another, except that of being inserted into the two ends of the 
fascia ;" and further on the different nerve supply to the two parts is pointed out. 
Attention might have been called to the fact that the occipito-frontalis is 
among the few muscles lying outside of the deep fascia. 

Extended reference is made to the erectile character of a part, at least, of 
the nasal mucous membrane and to Professor H. J. Bigelow's investigations. 

The buccal nerve is placed among the sensory branches of the fifth. 

The hyoid insertion of the genio-hyoglossus, "as a rule," is denied. 

The fact of the existence of Fleischmann's bursa is accepted. 

The internal lateral ligament of the lower jaw is declared to be double, the 
short portion being inserted into the inside of the neck of the bone. 

The digastric is believed to be the most important muscle concerned in open- 
ing the mouth, atmospheric pressure being the chief agent in keeping the 
mouth closed. 

The extirpation of the entire parotid gland is pronounced " an impossibility." 
We had thought this old questio vexata had been definitely and forever settled, 
and that both anatomists and surgeons had become convinced that the entire 
gland, when diseased, can be and has been removed. 

Our author agrees with Tillaux in the statement that the external carotid 
artery "does not enter the gland from below, but on the inner side, at a point 
which is variable." 

The transverse facial artery is not mentioned. " The question of the rela- 
tion of the chorda tympani to taste" is declared " far from settled." 

More space has been devoted to the consideration of variations in size of the 
jugular fossa than would probably have been given by any one else than our 



1871.] Frey, Compendium of Histology. 219 

author, who very naturally feels a considerable interest in a subject which he 
has so ably treated elsewhere. (See Amer. Journ. Med. Sci., October, 1873.) 

The statement that "there is no distinct fascia about the face, except the 
masseteric, and that under the chin," is subsequently corrected by the remark 
that the " buccinator is covered externally by a fairly defined fascia." 

Six lithographic plates, representing the sections of the head, to which we 
have already referred, are appended to the work, and add no little to its value- 
We hope that when a new edition is brought out these plates will be declared 
to represent sections of the frozen head, rather than frozen sections of the head ; 
and still more, that the author, out of regard to his readers' feelings, will use 
the expression in front instead of on front, for which he seems to have such a 
partiality. P. S. 0. 



Art. XL. — M4moires sur la Galvano-canstique Thermique par le Docteur 
A. Amussat fils. 8vo. pp. 125. Paris : Germer Bailli^re, 1876. 

The literature of galvano-cautery is meagre. With the exception of contri- 
butions scattered through the periodicals, the Theses of Duplomb and Blanchet, 
a very valuable essay by Broca, and an excellent article in the Nouveau Dic- 
tionnaire de M4d. et de Chiriirgie, there are but half a dozen works upon tlie sub- 
ject. These are by Middeldorpf, v. Bruns, Boeckel, Voltolini and Byrne ; to 
which is to be added the one under consideration. Of them all, but one, that 
of Byrne, is in English, and this one simply considers the subject from a gyne- 
cological point of view, while Yoltolini's work is confined to the use of the 
cautery in laryngology. The others are more general in their scope. 

Amussat's monograph of 125 pages, printed upon exceptionally fine paper, 
and illustrated by forty-four wood cuts, immediately attracts attention. It con- 
tains a brief historical review of the galvano-cautery, followed by the histories 
of forty-two cases treated by the author. These embrace abscesses, cysts, 
erectile tumours, lymphatic engorgements, phymosis, anal and vulvo-vaginal 
fistulas, uterine polypi, rectal and urethral strictures, tracheotomy, tubercular 
testes, pedicellated tumours of the skin, and diseases of the cervix uteri. The 
figures with which the book is bountifully supplied, illustrate morbid growths 
removed by the author, and also several instruments devised by him to meet 
special emergencies. The work is exceedingly interesting, but will prove use- 
ful and suggestive to surgeons already practically familiar with galvano-cautery, 
rather than to those who seek preliminary information upon the subject. These 
latter should first read Middeldorpf, v. Bruns or Boeckel, the first two in German, 
the last in French. 

Now that appliances for galvanic and other forms of actual cautery are so 
cheap, simple, and convenient, and their uses so manifold, a systematic work on 
the subject in the English language is greatly needed. H. G. P. 



Art. XLI. — Compendium of Histology. Tioenty-four Lectures. By Hein- 
RiCH Frey, Professor. Translated by George R. Cutter, M.D., Assistant 
Surgeon N. Y. Eye and Ear Infirmary. Illustrated by 208 engravings on 
wood. 8vo. pp. viii., 274. New York: G. P. Putnam's Sons, 1876. 

Frey's larger and fuller work on Histology is so well known that nothing is 
needed in way of critical analysis of the present book. In his preface he states 



220 Bibliographical Notices. [Jan. 

briefly that "a short compend of the most essential facts [of Histology] is de- 
sirable for students and practising physicians," because, " the hand-books have 
necessarily become constantly more voluminous in consequence of the immense 
wealth of materials." This want is felt no less in this country than in Germany. 
Many a hard-worked doctor, who would be too weary to pore over the exhaustive 
treatise of Strieker, will delight to turn to this excellent resume of our knowl- 
edge, and find the gist of what he wants to know. We therefore welcome the 
book as a most valuable and timely addition to our medical literature. The 
author is one fully competent to deal with the subject. Instead of dogmatizing 
on doubtful points, he frankly states our want of knowledge on many subjects, 
yet he does not fear to express his opinion on mooted questions, as, for example, 
in discussing the similarity of striated and non-striated muscle or the cell wall 
of the blood corpuscles. This he believes to be merely a denser outer layer, 
and on p. 22, he quotes a remarkable experiment in proof, that when they are 
heated to 52° C. they begin amoeboid movements in which not infrequently 
portions are detached. 

Dr. Cutter has, in general, done his work well, yet we are very frequently 
reminded that we are reading a German book " done into English." We should 
scarcely speak of dead cells as " cell corpses," nor when a reagent shows the 
nucleus of a cell, would we say " many reagents let it show out from the now 
discoloured cell" (p. 23). " Wandering lymphoid cells are not luanttng'' [found], 
is an expression used more than once. So, also (p. 107), " when the former 
has reached a certain size, induction lymphatic vessels, vasa afferentia pene- 
trate, /o?' the most part, manifoldly, into its convex surface," and (p. 185), 
" The bloodvessels circumvohtte the convoluted seminiferous canals," and (p. 16) 
" minimal thin layer" are rather German than English in expression. The 
constant use of protoplasma for protoplasm, and, of ovarium for ovary, etc., 
is needless in an English book. But when he uses " overlays'' for " overlies" 
(p. 8), and " cilice'' for " cilia" (5 times on pp. 34 and 35), we must protest em- 
phatically. 

The jilates are, as a rule, delightful to look upon. They are, of course, re- 
productions from the larger work, and are as clear to the eye as they are exact 
and comprehensible. A few errors we have observed in the explanatory text. 
Thus, in Fig. 39, the star is omitted from "/*;" in Fig. 99, '' df and in Fig. 
165, " hi" are omitted. In Fig. 197, " B" is printed for " R ;" and in Fig. 194, 
the semicolon should follow, and not precede " d." 

No doctor who wishes to keep up with the times, and who has neither 
Strieker's Manual nor Frey's larger book, can afford to be without this excel- 
lent work. W. W. K. 



Art. XLII. — A Manual of Midwifery. By Alfred Meadows, M.D. Lond., 
F.R.C.P., Fellow of King's College, London, Physician Accoucheur to St. 
Mary's Hospital, and Lecturer on Midwifery and the Diseases of Women and 
Children at St. Mary's Hospital Medical School, etc. Second American, 
from the third London edition, revised and enlarged, with one hundred and 
forty-five illustrations. 8vo. pp. 490. Philadelphia : Lindsay & Blakiston, 
1876. 

Having very freely noticed the first American edition of this work in the 
October number of this Journal for 1872, we have but little to add now, as the 
increase in the volume amounts to less than twenty pages, and the additions are 



18TT.] Hutchinson, Illustrations of Clinical Surgery. 221 

not very material, except in the list of illustrations, which is increased by up- 
wards of sixty wood-cuts. Although there is much in this work to commend 
it to the American practitioner, we wish that in the present edition certain 
historical errors noticed in our former review had either been corrected or ex- 
plained ; we refer to the earliest record of the Csesarean operation; and the 
statement with regard to the results of the cases that have been reported in this 
country. The writer has endeavoured not only through leading journals but, by 
a full written record, to acquaint the obstetricians of Great Britain with the 
results to mothers and children of this operation in the United States, down to 
the year 1873, and yet, in the present year, Dr. Meadows does not appear to 
have found out anything about it, but the very imperfect and erroneous table 
made years ago, and slightly added to since, by Dr. Fleetwood Churchill. 

Dr. Meadows says, on page 272, " Now according to the statistics, it appears 
that in British and American practice rather more than two-thirds of the mothers 
die, and about one-half of the children." Why he should have coupled us with 
his own country in this statement, it is difficult to understand, as we are by no 
means upon the same footing. Of the first hundred British operations, down to 
1869, eighty-four were fatal to the mother, and forty-three to the child. 'I'hat 
is, a saving of sixteen women out of a hundred. In the American table, the 27th 
operation recorded, saved the life of the sixteenth case. About fifty per cent, 
of American cases have been saved up to the present time. Take all the 
promptly performed operations, z. e., within twenty-four hours from the com- 
mencement of labour, and we have a saving of sixty-six per cent, of the mothers 
and eighty per cent, of the children, as the result of the operation when prnperli/ 
performed in this country; for there is no greater obstacle to success than the 
ruinous delay so often practised before the operation is determined upon. 

The chapter (v.) by Dr. Meadows upon the Csesarean operation, is an excel- 
lent condensation of the subject, taking up the character of cases to be operated 
upon, the importance of early interference, and the manner of performing the 
operation. We are glad to see in this article, that he has become a convert to 
the importance of using uterine sutures, and especially recommends the silver 
wire cut close. In the case which terminated so successfully under the care of 
Dr. H. 0. D'Aquin, of New Orleans, in 1867, after ten days of labour, where 
there was complete atony of the uterus ; and in some other instances in this 
country, sutures saved the lives of the women. 

Part III., Chapter III., upon the " management of natural labour," embrac- 
ing sixteen pages, is an admirable article, and one well worthy to be read and 
acted upon by obstetrical practitioners. It especially commends itself to those 
who have but recently entered the ranks of the profession, and will greatly aid 
them in properly conducting their cases. 

As a whole, we have only to repeat the recommendation of the volume, as in 
our previous notice. K. P. H. 



Art. XLTII. — Illustraftons of Clwical Surgery. By Jonathan Hutchin- 
son, F.R.C.S. Fasiculus lY. Folio, pp. 64-87. Philadelphia : Lindsay «&; 
Blakiston, 1876. 

Admirable as the preceding parts of this work have been, the present is, 
perhaps, of greater value than any of the earlier fasciculi. This is partly due 
to the excellent character of the letter-press, which, though described on the 
title-page merely as explanatory, is, in reality, the cream of the Astley Cooper 



222 Bibliographical Notices. [Jan. 

prize essay for 1864, containing' as a basis a table of fortj'-six fatal cases of 
head injuries observed during three years by Mr. Hutchinson and his colleagues 
at the London Hospital. Two other numbers, illustrative of the same class of 
cases are promised by Mr. Hutchinson, which if of equal interest with the 
present will constitute an important portion of his work. We feel some regret 
that they have not come to hand with the one now before us, that they might 
have been noticed together and in some detail. In this part are contained 
illustrations of inflammation of the arachnoid, after compound fracture; in- 
flammation of pia mater at the base of the brain, after fissure-fracture of the 
petrous bone; passive congestion, and diffuse ecchymosis of pia mater, and 
contusion of the surface of the brain. The subject is one to which Mr. Hut- 
chinson has given much attention, and with which he is fully qualified to cope. 
No surgeon whose financial ability extends to illustrated books can afford to 
be without this most valuable and beautiful work. S. A. 



Art. XLIV. — The Theory and Practice of Medicine. By Frederick T. Ro- 
berts, M.D., B.Sc, M.R.C.P., Assistant Physician and Assistant Teacher of 
Clinical Medicine at University College Hospital, etc. etc. Second American 
from the last London edition. Revised and enlarged. 8vo. pp. 920. Phila- 
delphia : Lindsay & Blakiston, 1876. 

The second edition of Dr. Roberts's work on The Theory and Practice of 
Medicine, bears abundant testimony to the industry of its author, for not 
only has a great part of it been rewritten, and much new matter added, but 
there are also few pages in it which do not show the marks of careful revision. 
These changes all seem to us judicious, and while they have unquestionably 
added much to its value as a text-book, have also rendered it less open to the 
charge of incompleteness we made against the first edition in the notice of it, 
which appeared in the number of this Journal for April 1874. Among the 
more important of the additions is a chapter "On the Diagnosis of Acute 
Specific Diseases," in which the distinguishing characteristics of these affec- 
tions are arranged side by side in tabular form — a plan which will facilitate 
very greatly the study of diff'erential diagnosis. 

We observe that the author has removed the so-called epidemic cerebro-spinal 
meningitis from the list of purely local diseases and placed it where we think it 
properly belongs, among the fevers. Notwithstanding the large increase of 
matter, the publishers have been able, by a slight increase in the size of the 
page, and by a judicious arrangement of type, to issue the work in a less bulky, 
and, therefore, a more convenient, form than before. J. H. H. 



Art. XLV. — Chemistry : General, Medical, and Pharmaceutical ; including 
the Chemistry of the U. S. Pharmacopoeia. By John Attfield, Ph.D., 
F.C.S., etc. Seventh edition, revised from the sixth (English) edition, by 
the Author. 12mo. pp. 668. Philadelphia: H. C. Lea, 1876. 

This work is now so well and favourably known, that it is only necessary to 
announce the appearance of a new edition, and to note the principal changes 



i 



181 Y.] Beard, Hay-Fever, or Summer Catarrh. 223 

or additions that have been required either by alterations in the Pharmacopoeias 
or the improvements in chemical science. To render the work more useful to 
the commencing chemical student, and to facilitate practical manipulations, 
many well chosen wood-cut illustrations (87) have been introduced. Much of 
the instruction in the principles of Chemical Philosophy has been revised, and 
dispersed under different heads appropriate observations on the same subject 
have been inserted, rendering these principles clearer and more impressive. 
Additional instruction and improved processes of analytical value have been 
introduced throughout, which have increased to a considerable extent the 
number of pages, although others have been omitted when this could be done 
without disadvantage to the student. Of these, Siebold's method for the de- 
tection of chlorides in the presence of bromides, and the improved processes 
in relation to the examination for cinchona alkaloids may be taken as examples. 
Finally, the index has been much enlarged, not only increasing the facilities for 
reference to new matter introduced, but in some degree to the original text. 
The style and appearance of this correspond, except in increased size, to the 
former American editions. R. B. 



Art. XLYI. — Observations on Diseases of the Rectum. By T. B. Curling, 
F.R.S., Consulting Surgeon to the London Hospital. 4th edition. 8vo. 
pp. xvi., 244. Philadelphia: Lindsay & Blakiston, 1876. 

It is now twenty-five years since the first edition of this work was issued. 
It has grown considerably in size and completeness, keeping pace with the 
enlarged experience of the author. It speaks well for the value of the treatise 
and for the intelligence of the medical profession, that a work on so special a 
subject should have reached a fourth edition. Any extended criticism of a work 
so stamped with approval is superfluous, and we would only suggest that Mr. 
Curling would do well in any future edition to elaborate the subject of recto- 
vaginal fistula which is here dismissed in a single brief page. His experience 
in a disease so annoying to the patient and so difficult of cure would be hailed 
with pleasure by the profession. W. W. K. 



Art. XLYn. — Hay-Fever, or Summer Catarrh ; its nature and treatment. 
By George M. Beard, A.M., M.D., Fellow of the New York Academy of 
Medicine, etc. etc. 12mo. pp. 266. New York : Harper & Brothers, 1876. 

This little book, extensively heralded, and anxiously looked for by many, 
will possess much interest for the large army of martyrs to the complaint of 
which it treats. It contains the record of some facts which may prove of 
value to those physicians, whose opportunities for observing this affection have 
been limited. For one, however, who, like the writer of this notice, has had 
a life-long and personal intimacy with the malady, it does not supply much 
that is new. 

Dr. Beard claims to have established the following conclusions by his re- 
searches. First, that all the forms of summer catarrh are identical in nature. 
This is thought to be determined by the discovery of an intermediate form, 
which, confined to the month of July, supplies the missing link required to 
unite the rose-cold of June with the hay-fever of August. This middle variety 



224 Bibliographical Notices, [Jan. 

we have not ourselves observed, though the same conclusion had been arrived 
at from the knowledge of the June and August forms existing in different 
members of the same family, identical in symptoms, and modified by the same 
measures. Dr. Beard thinks that he has demonstrated, second, that the nerv- 
ous system is principally at fault. We cannot agree with the author in think- 
ing that the intelligent medical man will be surprised at his conclusion, merely 
because the sufferers from this affection are ofttimes vigorous and full-blooded, 
for, surprise at such a combination would argue great ignorance, but we sup- 
pose the lay reader, for whom the book is largely intended, may, indeed, be 
amazed, as he is likely to be at this, or many another revelation derived from 
a science with which he is unacquainted. The same remark applies equally to 
the easily appreciated third conclusion arrived at by Dr. Beard, namely, that 
the excitants of dust, pollen, heat, etc., while not the primary causes, may co- 
equally operate with peculiarities of nervous organization to produce this 
disorder. We remember a similar conclusion being reached many years since 
in a graduation thesis, deservedly consigned to that limbo of oblivion to which 
such efforts commonly go. A really valuable conclusion of Dr. Beard's is that 
in which he demonstrates the hereditary character of the malady. 

The division into catarrhal and non-catarrhal regions made by Dr. Wyman, 
is deemed somewhat too arbitrary by Dr. Beard ; he, however, agrees with that 
gentleman in regarding the White Mountains as a sure remedy, or at least as 
a certain alleviation, in all cases. Although the locality mentioned is admitted 
not to be the only one beneficial to sufferers from periodical catarrh, and the 
relief obtained by many at sea or upon the seashore is spoken of, special 
mention is made of few other resorts. This is perhaps little to be wondered 
at in a book dedicated to the United States Hay-Fever Association, which has 
its headquarters in the White Mountains. For the members of this Association 
the book has been principally written, and they will doubtless enjoy reading the 
vivid accounts of each other's suiferiugs portrayed upon its pages. The medical 
profession will find that a good many of these narrations resemble rather old 
wives' tales than scientific records ; for they well illustrate that part of human 
nature which causes us to wax eloquent when our own sufferings are in question. 

Dr. Beard gives some valuable practical suggestions concerning the allevia- 
tion to be obtained from the use of drugs, but even here the dead fly in the 
ointment is apparent, for the warnings given as to the inconveniences and 
dangers attendant upon the use of some among them, such as quinia and 
arsenic, cannot but be regarded as unprofitable knowledge for the laity. 

A word about the society to which the book is dedicated, whose articles of 
association occupy a note in its pages. One of these articles, No. Y., states 
that " it shall be the duty of each member .... to report . . . . 
any remedy which may come to his or her knowledge during their natural life, 
and afterward, if permitted !" This article is evidently highly esteemed by the 
members of the Association, for it is the only one to which a note of admira- 
tion is appended, but whether it is the construction of the sentence, or the 
high transcendentalism of the sentiment which is the object of their admira- 
tion, we are not told. We do not profess to be thoroughly informed of the con- 
tributions to our knowledge derived from the spirit world, since Saul invoked 
the aid of Endor's witch, but we do not at present recall any valuable agents 
added to the materia medica by such means, so that we may be excused for 
entertaining but small hopes of benefit from that direction. We think that Dr. 
Wyman's book will continue to be the one to which the profession will go for 
information about this disease, though Dr. Beard's brochure will unquestion- 
ably find many purchasers, S. A. 



1877.] Report of Surgeon-General, United States Army. 225 



Art. XLYIII. — Annual Report of the Surg eon- General, United States Army, 

1876. 

From this interesting' document we glean the following- particulars: — 

The monthly reports of sick and wounded represent an average mean strength 
of 21,681 white, and 2002 coloured, troops. 

Among the loliite troops, the total number of cases on the sick list was 
37,561, being at the rate of 1732 per 1000 of mean strength. Of this number, 
32,495, or 1499 per 1000 of mean, were taken on sick report for disease, and 
5066, or 233 per thousand of strength, for wounds, accidents, and injuries of 
all kinds. 

The total number of deaths from all causes was 518, or 24 per 1000 of mean 
strength. Of these, 180, or 8 per 1000, died of disease, and 338, or 16 per 
1000, of wounds, accidents, and injuries. 

The total number of white soldiers discharged on surgeon's certificate for 
disability was 561, or 26 per thousand, and precisely the same of coloured 
soldiers. 

Among the coloured troops, the total number of cases of all kinds was 34G2, 
being at the rate of 1729 per thousand of mean strength. Of these, 2941, or 
1469 per 1000, were cases of disease, and 521, or 260 per thousand, were wounds, 
accidents, or injuries. 

The total number of deaths from all causes was 26, or 13 per 1000 of mean 
strength. Of these, 16, or 8 per thousand, died of disease, and 10, or 5 per 
1000, of wounds, accidents, or injuries. 

" It will be seen from the foregoing that the health of the army during the 
year has been good, and the mortality from disease unusually small. On the 
other hand, the number of deaths from wounds has been exceptionally large. 
'J'he figures given above include two hundred and sixty-seven (267) officers and 
men killed in battle or skirmishes with hostile Indians, who are not embraced 
in the number of cases of wounds, accidents, and injuries taken on sick report. 
Of this number, fifteen (15) commissioned officers, including one (1) medical 
officer (Assistant-Surgeon George E. Lord, U. S. Army), one (1) Acting 
Assisting-Surgeon (James M. De Wolf), and two hundred and thirty-two (232) 
enlisted men, fell in the action on the Little Big Horn River on June 25th." 

Strong testimony is borne as to the policy of promptly removing any garrison 
threatened with yellow fever to a healthy locality. 

" On the 1st Oct. 1875, a case of yellow fever, which proved fatal next day, 
was recognized in the hospital of Company E, 3d Infantry, at Coushatta, 
Louisiana. 'J'he greater part of the company was promptly moved, October 
2d, and went into camp at Springville, two miles distant. The portion of the 
command thus moved entirely escaped; but thirteen (13) additional cases, and 
eight (8) deaths, occurred in the detachment left at Coushatta with the hospital 
and company property. Three of the laundresses also iiad the fever, and one 
of them died. 'I'he last case occurred November 20th, and the last death No- 
vember 23d. Assistant-Surgeon R. Barnett, U. S. A., who was in charge of 
the hospital during this epidemic, reports that he was unable to ascertain the 
mode of its introduction. It is well known, however, that yellow fever had 
been prevailing as an epidemic at New Orleans, and the situation of this post 
on the Red River would suggest the probability of the importation of the dis- 
ease from that place." 

The work performed in the Record and Pension Division is stated to be 
behindhand, owing to the inadequate clerical force provided. By legislation 
at the last session of Congress, that force, instead of being increased, has been 
still further reduced by the discharge of 26 clerks. 
No. CXLY— Jan. 1877. 15 



226 Bibliographical Notices. [Jan. 

The continuation of the suro-ical portion of the Medical and Surgical History 
of the War, and the compilation of descriptive catalogues of the surgical and 
anatomical materials of the Array Medical Museum, have been prosecuted with 
a reduced clerical force. The amount of labour accomplished with this re- 
stricted means is remarkable. 

" To the material collected at the close of the fiscal year ending June 30, 
1875, for a report of surgical cases treated in the army during the period 
1871-75, one thousand six hundred and seven (1607) cases have been added, 
making a total now collected of four thousand and ninety-three (4093) surgical 
cases, comprising one thousand seven hundred and twenty-seven (1727) injuries 
of the head and neck, three hundred and sixty-six (366) injuries of the trunk, 
one thousand one hundred and eleven (1111) injuries of the extremities, including 
two hundred and eighty-six (286) amputations and twenty-four (24) excisions, 
and eight hundred and eighty-nine (889) miscellaneous injuries, a mass of 
valuable surgical information, well worthy of publication." 

The important government medical library is steadily being enlarged. 

"About 2000 volumes, exclusive of pamphlets, have been added to the library 
during the past year. The subject catalogue, to which reference was made in 
my last annual report, is now nearly completed, and during the year there 
were printed and distributed a few copies of a specimen fasciculus of this 
catalogue, which were issued in order to obtain the opinions of those competent 
to judge as to whether it is desirable that such a work shall be printed and 
distributed, and also for criticism and suggestions as to the form of catalogue 
which would be most acceptable and useful. The responses, in the form of 
editorials, critical notices, resolutions of medical societies, letters, etc., have 
been so numerous, so favourable to the general plan adopted, and so unanimous 
in the expression of opinion that the entire work ought to be printed as soon 
as possible, as being of great value to medical writers and teachers not only of 
this country but throughout the world, that I am fully warranted in strongly 
recommending that Congress authorize the printing of the work by the govern- 
ment printer. The M88. is in such a state of forwardness that copy can be 
furnished to the printer within a month after such authority is granted, and 
can be furnished thereafter as rapidly as the proofs can be properly read." 

In hoping that Congress will at once provide the funds for the publication 
of the subject catalogue of the library, we are sure we express the sentiment 
of our entire profession. Such a work will be invaluable to students, and con- 
tribute immensely to the advancement of our science. Its utility will not be 
confined to the profession — the public will reap the benefit of it. 



Art. XLIX. — A Century of American Medicme. 1776-1876. By Edward 
H. Clarke. M.D., late Professor of Mateiia Medica in Harvard University, 
etc.; Henry J. Bigelow, M.D., Prof, of Surgery in Harvard University, etc.; 
Samuel D. Gross, M.D., LL D., D.O.L. Oxon., Prof, of Surgery in Jefferson 
Med. College, Phila., etc.; T. Gaillard Thomas, M.D., Prof, of Obstetrics, 
etc., in Col. of Physicians and Sui-geons, New York, etc. ; and J. S. Billings, 
MD., Librarian to the National Medical Library, Washington, D. 0. Royal 
12mo., pp. 366. Philadelphia : Henry C. Lea, 1876. 

The essays comprising this volume originally appeared in the pages of this 
Journal during the past year, and therefore do not require an introduction to 
our readers. It is believed that they truthfully reflect the progress of medicine 
in our country during the past century, and that they are in every respect 
worthy of the reputation of their authors. The general commendation which 
they have elicited has induced Mr. Lea to reprint them in handsome form us a 
worthy memento of the first century of American Medicine. 



1877.] Public Libraries in the Ilnited States of America. 227 



Art. L. — The Medical Men of the Revolution, with a Brief History of the 
Medical Department of the Continental Army, etc. By J. M. Toner, M.D. 
8vo., pp. 140. Philadelphia, 1876. 

This little volume consists of an address delivered before the Alumni of Jeffer- 
son Medical College, March 11, 1876. It seems to be in some degree an expansion 
of an essay by the same writer, entitled " Contributions to the Annals of Medical 
Progress and Medical Education in the U. S., before and during the War of 
Independence."^ As here presented, the foot-notes rather exceed in bulk the 
text of the address. They, however, greatly add to the value of the work, being 
largely made up of extracts from original journals and letters of the time, 
together with short biographical sketches. At the end we find an alphabetical 
list of some twelve hundred names of medical men engaged in the revolution, 
with their States and their positions. 

Among Pennsylvania physicians who held prominent positions on the Conti- 
nental medical staff were Adam Kuhn, Wm. Shippen, Jr., and Benj. Rush. The 
latter was one of the very few who left any written records of their professional 
experience in camp, field, or hospital. 

Those of us who are accustomed to regard the olden times as more pure and 
honest than the present, can hardly retain the illusion after the perusal of'records 
such as are found in Dr. Toner's books, in .the Life of Dr. Warren, ^ and in the 
Historical Notes of the U. S. Med. Dept., 1775 to 1873.^ Misunderstandings, 
jealousies, cupidity, and treachery, prevailed then as in later years. Nor was 
the treatment of the sick soldier better than now. The mortality in military 
hospitals was at times frightful. Fevers, diarrhoeas, and other filth-engendered 
maladies, often prevailed to an extent almost incredible to the modern surgeon. 
Sanitary science was little known and less practised. Certainly, as far as the 
preservation of the soldier's health is concerned, and his restoration when sick 
or wounded, the present time need not fear comparison with the old. 

But while we remember that the medical men of "'76" were of like passions 
with ourselves, and in many points less fully equipped for their work, we have no 
desire to undervalue their important and generally self-denying services. Inas- 
much as history usually preserves the names of those who destroy life, to the 
exclusion of those who save it, we are glad Dr. Toner has sought out and 
gathered together the memoranda which form this little volume. B. L. R. 



Art. LI. — Public Libraries in the United States of America ; their History, 
Condifio7i, and Management. Special Report, Department of the Interior, 
Bureau of Education. Part I. 8vo. pp. 1187. Washington: Government 
Printing Office, 1876. 

This report constituted a part of the Educational exhibit made by Govern- 
ment at the recent Centennial Exhibition. We believe the work will be a 
surprise, and a cause of pride and pleasure to all American readers. Mr. S. 
R. Warren and Major S. N. Clark are the editors or compilers, and are 
assisted by a score of contributors from among the most learned and accom- 
plished librarians and bibliographers in the country. In the statistical portion 
of the volume we find a list of 3647 public libraries, with the chief facts capa- 
ble of tabular statement set down against each. The aim was to include all 

» Am. Jouru. Med. Sciences, April, 1875. 2 i^id. 1874. 3 i^id. 



228 Bibliographical Notices. [Jan. 

public libraries (except those of common or district schools) which possessed 
three hundred volumes or more. The arrangement is alphabetical, according 
to States and towns. 'IMius, the enumeration begins with Alabama, and the 
town of Auburn. No. 31 is the library in Tuskegee, of the same State ; and 
the next is in Alaska, at Sitka. Thus any library of known location can be at 
once found. Similarly arranged, we find a catalogue of librarians, for whose 
names the former table did not afford space. Another curious table exhibits, 
in chronological order, the catalogues printed in the United States. The first 
on the list is that of Harvard College, in 1723. The second and third are of 
the Philadelphia Library, in 1732 and 1741, printed by Benjamin Franklin. 
The entire number exceeds one thousand. Many other tables present, so far as 
it could be obtained, nearly all conceivable information concerning American 
libraries. 

The larger portion of this immense volume is made up of essays upon libra- 
ries, general and especial ; catalogues and indexes, and the art of making 
them ; books, and the way to use them ; historical societies ; art-museums — in 
short, upon every subject relating to libraries and their uses. These essays 
are a perfect treasure-house of instruction and entertainment. No person con- 
cerned in establishing or managing a public library can fail to be helped and 
guided by such papers as "How to make Town Libraries Successful," by F. 
B. Perkins; "Free Libraries," by J. P. Quincy ; "Public Libraries and the 
"Young," by Wm. I. Fletcher; " 'J'he Organization and Management of Public 
Libraries," by A¥m. F. Poole; "College Library Administration," by Otis H. 
Roljinson ; and many others. As mere pieces of literary workmanship, many 
of them are admirable. Some of the papers combine wit and wisdom in a 
most happy union — as, for instance, those on "Titles," "Indexes," and " Pro- 
fessorship of Books and Reading." 

Dr. Billings, U. S. A., contributes a sketch of the " Medical Libraries in the 
United States." 'J'his paper contains some valuable suggestions as to the for- 
mation of such libraries, and their proper cataloguing. Prof. Theo. Gill, M.D., 
in an article on the "Scientific Libraries of the United States," presents a 
directory to the annual volumes published abroad, which chronicle the dis- 
coveries and advances in each branch of science, and which, he justly states, 
should be found in every library resorted to by the scientific investigator. 

Altogether, this volume is one of extraordinary value and interest. 

B. L. P. 



Art, lit. — Transactions of the College of Physicians of Philadelphia. 
Third series. Yol. II. 8vo. pp. Ixviii., 186. Philadelphia, 187G. 

This volume contains the papers read before the College from October, 
1875, to July, 1876, to which are prefixed lists of the Officers, Fellows, and Asso- 
ciates of the College, and Biographical Memoirs of two of its Fellows, Drs. 
George W. Norris and John S. Parry, Both these memoirs are exceedingly 
■well drawn up, and delineate briefly, appreciatively, and truthfully the high 
character and valuable labours of the above-named eminent Fellows, whose 
loss, the College, the profession, and the public, have had to deplore during 
the past year. 

Thirteen papers, with abstracts of the discussions which their reading 
elicited, are embraced in this volume, all of which will repay careful perusal. 
The volume is issued in the same style as its predecessors, and like it, is 
creditable to the College, both as to the value of its contents, and its elegant 
typographical appearance. 



1877.] 229 



aUARTETlLY SUMMARY 



IMPROVEMENTS AND DISCOVERIES 



MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. Rpjiex Movements of the Cranial Dura Mater. — M. Bochefontaine 
recently presented a note to the Academie des Sciences on some particulars of 
the "reflex" movements which are produced by mechanical stimulation of the 
cranial dura mater. His observations are of great interest, both physiological 
and pathological. That the membrane is sensitive is shown by the fact that, 
when certain portions are irritated, cries of pain and general movements are 
produced. But the mechanical stimulation of certain parts produces, under 
certain conditions, movements limited to one or several parts of the body. The 
facts were observed in dogs, which were experimented on in order to study the 
excitability of the gray cortex of the brain. Some were etherized, others 
chloralized by intravenous injection, and others were slightly stupefied by 
curare. One part of the skull had been removed to expose the cranial dura 
mater. Under these circumstances, by scratching gently with the point of a 
dissecting forceps the parts of the dura mater situated at the level of the middle 
of one side of the cerebral hemisphere, the eyelids closed on that side, and some- 
times the upper lip was raised, the nose was drawn to that side, and the ear was 
moved. A stronger irritation occasioned a simultaneous movement of the limbs 
on the opposite side, and of the tail, which deviated from the side of the irrita- 
tion. A still stronger irritation, rapidly and several times repeated, determined 
movements of both sides of the face, of the neck, and of all four limbs. The 
movements of the limbs on the same side were more energetic than those of the 
opposite side. The irritation of several points of the dura mater situated an- 
teriorly in the frontal region also caused isolated movements of the eyelids, or 
of some of the muscles of the face. These movements were not observed when 
the points were irritated outside or behind the middle portion which was first 
excited. In the latter case the irritation was followed only by movements of 
the trunk. 

M. Bochefontaine next endeavoured to ascertain whether these phenomena, 
observed when the dura mater was intact, were equally to be observed when it 
was divided so as to expose the convolutions. He divided the anterior portion 
of the dura mater into four segments. When the anterior segment was indented 
with the teeth of the dissection forceps, whether strongly or gently, there oc- 
curred corresponding movements of the limbs, or limited to the orbicularis of 
the eyelid, just as in the experiments in which the dura mater had been merely 
scratched with the point of the forceps. I'he compression of the outer and 
posterior segments caused no movements limited to the face, and only those of 
the members and of the different parts of the body. On pinching the inner 
segment, seven or eight millimetres from the falx cerebri, no movement was 



230 Progress of the Medical Sciences. [Jan. 

produced. Hence the conclusion is drawn tliat the transmission of the stimu- 
lation or irritation of one side of the dura mater is not by any sensory nerve- 
fibres coming from the opposite side. The results are manifestly not due to 
any accidental stimulation of the subjacent gray cortex, since this is inexcitable 
by mechanical agencies. But in order to avoid all chance of error from this 
cause, M. Bochelbntaine repeated his experiments after having removed the 
gray cortex and the subjacent white substance from the whole of the extent of 
the sigmoid convolution. 'J'he phenomena observed were exactly the same as 
those noted before the removal of the cerebral substance. It is thus clear that 
mechanical stimulation of the cranial dura mater on one side will cause con- 
traction in one or more of the facial muscles confined to the corresponding side. 
To obtain this result, the irritation of the dura mater must be slight, or the 
animal must be placed under a certain degree of ansesthesia. A stronger me- 
chanical stimulation causes, at the same time as the contraction of the face, 
movements in the limbs of the corresponding side ; and. if the stimulation be 
still more intense, movements occur in all four limbs, those of the same side 
being moved more strongly than those of the opposite side. 

What path is taken by the irritation in ])assing from the cranial dura mater 
to the muscles ? is a question which at once presents itself. When the move- 
ment is confined to the orbicularis of the eyelids, the course is a simple one. It 
can reach the nerves directly as they traverse the substance of the membrane. 
A similar explanation accounts for the movements of the face on the corre- 
sponding side. It is more difficult to understand the mechanism by which the 
movements are produced in the corresponding half of the body. Were the 
stimulation direct, it would seem that the movements should occur in the oppo- 
site limbs. As it is not so, the conclusion is that the stimulation is transmitted 
directly to the corresponding side of the spinal cord. When all four limbs are 
moved the irritation is transmitted, both directly and by decussation, to both 
sides of the cord. But the direct transmission is more intense than that which 
passes by the decussation of the pyramids. 

These observations are undoubtedly of great interest and importance. They 
need, as they will no doubt receive, repetition and corroboration at other hands. 
They have direct bearing on the phenomena obtained on irritating, by electricity, 
the surface of the brain ; they are of great significance with regard to the origin 
of the symptoms which attend inflammation of the dura mater, and their cha- 
racter has an important bearing, in more than one respect, on the remarkable 
opinions of Dr. I3rown-Sequard now being laid before the profession. — Lancet. 
Oct. 7, 1876. 

2. Nervous Apparatus of the Lnng. — Dr. Wm. Stirling described at the 
last meeting of the British Association for the Advancement of Science the 
nervous apparatus of the lung. He pointed out that numerous nerve-cells are 
found in various organs of the body, and that the lung is no exception in this 
respect, 'i'here were numerous nerves entering the lung and accompanying 
the bronchi and bloodvessels; these nerves were derived from the pneumogastric 
and sympathetic nerves, which nerves accompany the bloodvessels. In the 
course of these nerves numerous small masses of nervous matter, constituting 
ganglia, quite visible to the naked eye, were intercalated. These ganglia were 
most numerous around the bronchi at the base of the lung, and could easily be 
isolated by means of a dissecting microscope. The probable destiny of each 
of the two sorts of nerve-fibres — white and gray — found in the ganglia was 
indicated; the former supplying the bronchial mucous membrane and the 
bronchial muscles, while the latter probably presided over the muscular fibres 
of the bloodvessels, and so, controlling their calibre, regulated the amount of 
blood passing through them. — Bnt. Med. Jouni., Sept. 23, 1876. 

3. Effect of Esmarch's Apparatus on the Circulation. — Dr. Gamgee read 
before the British Association, a paper on the changes of circulation which are 
observed when blood is expelled from the limbs by Esraarch's method. He 
stated that experiments carefully conducted on Esmarch's method with healthy 
students has produced the following results. When the blood was expelled 



18t7.] Anatomy and Physiology. 231 

from one leg, the heart beat more rapidly, only for a short time, and the same 
result followed the application of the bandage to the second leg. When the 
heart began to beat at its usual rate, the tourniquets were loosened ; and in an 
instant the limbs, previously blanched, became suffused with a blush, while 
sensibility therein became more and more blunted, and the heart bounded off 
at an exceedingly rapid rate, to return, however, to its normal beat almost 
immediately. In applying the bandage, the blood in the veins was first expelled, 
then that in the arteries, and next there was an expulsion also of the lymph. 
He was of opinion that compressing the limb would send more blood into the 
veins than into the arteries, and, as the lymph would go to swell the venous 
pressure, the venous blood jilus the lymph would be greater in amount than 
the blood sent into the arteries. But the valves in the veins would prevent 
the increase of pressure in all parts of the system. It had been suggested that 
the increase of heart-beat when the bandage was applied was intimately con- 
nected with the diminution of the normal difference between arterial and venous 
pressure; that, if the right side of the heart be subjected to greater pressure, 
that would cause an increase of the cardiac contractions. These certainly 
were facts making it likely that an increase of pressure on the right of the 
heart tended to quicken the heart-beats, and the quick beats on the removal 
of the bandage were, no doubt, the result of the removal of the arterial pres- 
sure. — Brit. Med. Journ., Sept. 23, 1876. 

4. Intestinal Secretion and 3fi)vement. — Dr. McKexdrick submitted to the 
British Association the report of the Committee on Intestinal tSecretion and 
Movement. The conclusions at which the committee arrived were as follows: 
1. Application of various soda and potash salts to the intestinal mucous mem- 
brane produces a more or less profuse secretion ; that caused by sulphate of 
magnesia, acetate of potash, sulphate of soda, and tartrate of potash and soda 
being more abundant. 2. The presence in the intestines or in the blood of 
atropia, morphia, chloral, etc., does not prevent the abstraction of sulphate of 
magnesia. 3. The splanchnic nerves are as usually admitted the vaso-motor 
nerves of the intestines, but either have no centrifugal fibres to their muscular 
coats, or affected them only indirectly by diminishing their supply of blood. 

4. The secretory nerves of the intestines have the small ganglia of the solar 
and superior mesenteric plexuses for their centres, and this secretion is unaf- 
fected by the splanchnics, the vagi, or the dorso-lumbar parts of the cord. 

5. Destruction of the lumbar part of the cord after extirpation of the solar 
plexus produces hemorrhage or hypersemia of the intestinal mucous membrane, 
which is absent after division of the splanchnics, destruction of the semilunar 
ganglia and solar plexus, or division of the mesenteric nerves themselves. 

6. The splanchnics are the afferent nerves for peristalsis of the intestine, the 
efferent stimulus probably reaching the intraparietal ganglia through the 
lumbar cord and abdominal sympathetic, the former effect being inhibitory, 
and the latter stimulating to these ganglia. These results, the President 
stated, had been drawn from numerous experiments. He considered that 
investigations of this kind promised to be of very great value with reference 
to practical medicine ; for example, with regard to the knowledge of purgative 
medicines. — Brit. Med. Journ., Sept. 23, 1876. 

5. Clinicid Confirmation of Dr. Ferrier's Researches. — At the October 
meeting of the Manchester Medical Society, Dr. Dreschfeld brought forward 
a case of unusual interest, affording remarkable clinical confirmation of the 
accuracy and practical value of Dr. Ferrier's researches as to the effect of elec- 
trical stimulation of the various cerebral convolutions. On September 8, 
1874, a man aged twenty-eight, with a syphilitic history, presented himself at 
the out-patient room of the Royal Infirmary to be treated for epilepsy. The 
case was one of a series which Dr. Dreschfeld reported in the Practitioyier for 
May, 1875, in a paper entitled " On some Cases of Syphilitic Nervous Disease." 
Potassic iodide was administered, and the convulsions ceased. The patient 
returned to the hospital at intervals on account of a recurrence of the fits, and 
on each occasion was benefited by the same treatment. When there were no 



232 Progress of the Medical Sciences. [Jan. 

Ioniser any actual fits, the man continued to suffer from occasional and sudden 
attacks of numbness in the left hand, similar in character to the aura which 
preceded his epileptic seizures. This numbness was accompanied with clench- 
ing of the fist, flexion of the wrist, pronation of the forearm, and retraction 
of the angle of the mouth on the same side. Now, these were precisely the 
movements repeatedly obtained by Dr. Ferrier when he applied an electrical 
stimulus to the ascending parietal convolution and anuular gyrus in the brain 
of the monkey {Pi oceedivgs of the Royal Society, vol xxiii. page 410). Dr. 
Dreschfeid, therefore, diagnosed syphilitic disease in that region, of a chronic 
inflammatory nature. Two years afterwards the patient died of phthisis, under 
Dr. Dreschfeld's care, and on October 2, 18TG, Dr. James Ross made a post- 
mortem examination. He found the dura mater firmly adherent to the subja- 
cent tissues at a distinctly localized spot over the region indicated, with soft- 
ening of the superficial layers of the convolution. 'J'he rest of the brain was 
healthy. Dr. Dreschfeid pointed out in his remarks that the case was also a 
fre^sh confirmation of the truth of Dr. Hughlings Jackson's view, that epilepsy 
is due to an explosion of nerve-force in the cortical portion of the brain. — 
Mtdical Times and Gazette, October 28, 1876. 



MATERIA MEDTCA, GENERAL THERAPEUTICS, 
AND PHARMACY. 

6. Salicylic Acid. — Mr. J. A. Erskine Stuart has published [Edivhn.rgh 
Med. JounicU, November, 1876) some experiments which he has made with 
this article, and gives the following as his conclusions: '"IMiat it is an anti- 
septic, deodorizer, and astringent, possessing these three properties in a marked 
manner. 'J'hat it produces a specific action on the mucous membrane of the 
mouth, nose, and throat, is undoubted, as the catarrhal symptoms are produced 
in these regions whether it is taken by the mouth or rectum. That, from its 
rapid absorption by the blood, it is cpiickly carried through all parts of the 
economy, and its action is thus quickly manifested. The antiseptic properties 
being so marked, and its character being non-poisonous, it is sure to prove 
efficient in zymotic disease, in the same way that sulpho-carbolate of soda has 
been used. 

'■ Salicylic acid, although proved by Godefl'roy to be three times as strong an 
antiseptic as carbolic acid, is so difficult to dissolve, that its spray is not effica- 
cious. Its use as an external antiseptic is thus much prevented, as, from its 
non-irritating, and non-poisonous cpialities, it is otherwise eminently suited for 
use externally. As it is not likely to rise into much fame as an external anti- 
septic, I shall conclude with a few remarks as to how its action may be ex- 
plained in three diseases in which it has been used with success, viz., rheumatic 
fever, typhoid fever, and diphtheria. 

" No explanation of the changes which salicylic acid undergoes in the economy 
has yet been attempted, as far as I have observed in the journals. Is it not 
probable, as I mentioned previously, that salicylic acid, from the heat to which 
it is exposed in the alimentary canal, splits into carbolic and carbonic acids ; 
that the carbonic acid, escaping as it passes down, causes the sensation of 
choking; and that the carbolic acid, coming in contact with gastric juice, 
forms an innocuous compound with some of its salts, and thus carries out its 
actions ? This is the chemical explanation of its action, at least. By using 
the prescription before mentioned, combining the potash and salicylic acid, we 
get rid of the carbonic acid gas, and thus prevent much of the burning in the 
throat. 

''Rheumatic Fever. — No doubt is expressed among practitioners as to the 
beneficial action of this drug in rheumatic fever. It has been tested largely 
in both hos[)itals and private practice, and found not only to shorten the dis- 
ease, but also to lower temperature and relieve pain. Cases treated with con- 



1877.] Materia Medica, General Therapeutics, etc. 233 

tinnous small doses are soon better. Its action in this disease is antipyretic. 
Possessing many of the properties of quinine, in the form of salicine, the 
temperature is lowered much in the same way as a large dose of quinine 
would do. 

"■Typhoid Fever. — In this disease, salicylic acid has been little used in this 
country, but from German sources we have reliable information regarding its 
application. Dr. Reiss, of Berlin, used as large a dose as four scruples. He 
found that often after the first dose, and usually after the second, the tempera- 
ture fell below the normal, and remained so for twenty-four hours. In these 
cases, only one daily dose of the under-mentioned formula was given, and it 
was found that eight or ten doses were sufficient. The formula for a dose was 
as follows : — 

"R. Acid, salicyl. ; Sodge carb. aa 31v; Tinct. aurant. 3 j ; Aqua) 5iss. M. 

" 'i'he result was that, generally after the fourteenth day of the fever, there 
was no abnormal rise of temperature. Dr. Reiss found that this result hap- 
pened in the most of 260 cases which he treated. 

"The action in typhoid fever may be explained thus: It acts in such 
enormous doses as an excellent astringent on the bowels, and also as an anti- 
septic on the system generally, as well as on the bowels. 

" Diphtheria. — Wagner used it as a remedial agent in diphtheria, and also 
in an epidemic of it, with success. Frontheim also used it as a prophylactic 
in this disease, and it seems to me that it will be yet much used as a prophy- 
lactic in all febrile disease. My theory of its action in diphtheria is this, that 
it acts on the body generally as an antipyretic, and that, by setting up its 
specific catarrhal action on the raucous membranes of the throat, it helps to 
arrest the disease. 

" In the Ediiiburgh Medical Journal, 1837, Dr. Blom ascribes the beneficial 
action of salicine to the fact that it acts as a tonic to the mucous membranes, 
and improves the character of the secretions. If this is the case, it may 
account in some manner for the action of salicylic acid in typhoid fever and 
diphtheria. Salicine is not so burning a substance to swallow as the salicylic 
acid, and it does not set up the characteristic catarrh which I mentioned." 

7. Action of Alteratives. — Dr. T. Lauder Brunton, in an interesting article 
on this subject [Piactitioner, September, 1876), sums up the chief points in 
his article as follows : — 

All medicines may be called alterative, but the name is specially applied to 
those which imperceptibly modify nutrition. 

Nutrition is carried on in the intestine, and probably in the body, by means 
of ferments. 

Alteratives probably modify nutrition by modifying the action of these fer- 
ments. 

Nitrohydrochloric acid probably acts in headache, and also in the depression 
of spirits associated with oxaluria, by modifying the action of ferments in the 
intestine or liver. 

Lithates are probably formed in the liver, and also in the muscles. The 
question arises — is nitrohydrochloric acid useful in stopping the lithates from 
disorder of the liver and digestion only ; or is it also useful when the lithates 
arise from other causes? 

Colchicum is probably useful in gout, by diminishing the production of uric 
acid. 

Iodide of potassium acts on the lymphatics. 

Mercury acts on the albuminous solids. 

Is the action of iodides increased by giving salt? 

8. Action of Gelseminum Sempervirens. — Dr. Sidney Ringer and Mr. Wm. 
MuRRELL have published [Lancet, Oct. 21, 1876) the results of a series of ex- 
periments made by them to ascertain the influence of gelseminum on the circu- 
lation. These experiments they say show: — 

"1. 'J'hat gelseminum produces but little, if any, efiect on the pulse. 
" 2. That it does not aflect the blood pressure. 



234 Progress op the Medical Sciences. [Jan. 

'* 3. That in man it probably acts on the respiratory centre less energetically 
than in the lower animals. 

''4. That in man it acts on the muscles of the eye, and produces other symp- 
toms before it influences the respiratory centre. 

" .5. That in man it, in all probability, affects the spinal cord before the respi- 
ratory centre. 

" 6. That it exerts no influence on the mind, and none on the cutaneous sen- 
sibility. 

" 7. That it does not affect the temperature." 

0. Adion of Alcohol on the Brain. — Mr. T. C. Kingzett read before the 
British Association a paper on this subject. He said the question of what 
became of alcohol taken into the system had been extensively studied. Thudi- 
chum was the first to determine quantitatively the amount of alcohol elimi- 
nated by the kidneys from a given quantity administered, and the result he 
obtained was sufficient to disprove the elimination theory then widely prevail- 
ing. Dupre and many others continued these researches, from which, according 
to Dupre. they might fairly draw three conclusions: first, that the amount 
of alcohol eliminated per day did not increase with the continuance of the 
alcoholic diet ; therefore, all the alcohol consumed daily must of necessity be 
disposed of daily, and, as it was certainly not eliminated within that time, it 
must be destroyed in the system ; second, that the elimination of alcohol follow- 
ing the taking of a dose was completed twenty-four hours after the dose was 
taken ; and, third, that the amount eliminated in both breath and urine was a 
minute fraction only of the amount of alcohol taken. In 1839, Dr. Percy 
published a research on the presence of alcohol in the ventricles of the brain, 
and concluded " that a kind of affinity existed between the alcohol and the 
cerebral matter." He further stated that he was able to procure a much larger 
proportion of alcohol from the brain than from a greater quantity of blood than 
could possibly be present within the cranium of the animal upon which he 
operated. Dr. Maicet, in a paper read before tlie British Association in 1859, 
detailed physiological experiments which he considered to substantiate the 
conclusions of Dr. Percy, inasmuch as they demonstrated that the alcohol acted 
by means of absorption on the nervous centres. Lallemand, Perrin, and Duroy 
had, moreover, succeeded previously in extracting alcohol from brain-matter 
in cases of alcoholic poisoning. But all these researches did not show the true 
action, if any, of alcohol on cerebral matter, and no method of investigation 
was possible until the chemical constitution of the brain was known. Thudi- 
chum's recent researches in this direction, together with some more recent 
investigations by Thudichum and the author, had placed within reach new 
methods of inquiry. In his research, he (Mr. Kingzett) had maintained the 
brains of oxen at the temperature of the blood, in water, or in water containing 
known amounts of alcohol. The extracts thus obtained had been studied in 
various ways, and submitted to quantitative analysis, while the influences exerted 
by the various fluids on the brain had been also studied. These influences 
extended in certain cases to hardening and to an alteration in the specific 
gravity of the brain-matter. Water itself had a strong action on brain-matter 
(after death], for it was capable of dissolving certain principles from the brain. 
These principles included cerebrine, myeline, and apparently a newphosphorized 
principle insoluble in strong alcohol, together with that class of substances 
generally termed extractive. At the same time, the brain swelled and attained 
a smaller specific gravity, thus, in one case, from 1036 it became 1007. Water, 
however, dissolved no kephaline from the brain. Alcohol seemed to have no 
more chemical eff'ect on the brain than water itself, so long as its proportion 
to the total volume of fluid did not exceed a given extent. The limit would 
appear to exist somewhere near a fluid containing 35 per cent, of alcohol. But, 
if the percentage of alcohol exceeded this amount, then not only a larger 
quantity of matter was dissolved from the brain, but that matter included 
kephaline. Such alcoholic solutions also decreased to about the same extent 
us water the specific gravity of brain substance, but not from the same cause; 
that was to say, not merely by the loss of substance and swelling, but by the 



IStT.] Materia Medica, General Therapeutics, etc. 235 

fixation of water. Many difficulties surrounded the attempt to follow these 
ideas into life, and to comprehend in what way these modes of action of water 
and alcohol on the brain might be influenced by the other matters present in 
blood. From Thudichum's researches it followed that the brain must be 
subject to every influence affecting the blood, and it was probable that what 
was written above regarding the action of water on the brain was likewise true 
of an extraordinary watery scrum in life. But, if the serum were rich in salts, 
those salts, by a power of combination which they had for the cerebral princi- 
ples, would preserve the integrity of the latter. On the other hand, it was 
difficult to see how any of the matters known to exist in the blood could pre- 
vent alcohol, if present in sufficient amount, from either hardening the brain 
(as it did after death) or dissolving traces of the principles to be henceforth 
carried away in the circulation ; that was to say, should physiological research 
confirm the stated fact that the brain in life absorbed alcohol and retained it, 
it would almost follow of necessity that the alcohol would act as he had indi- 
cated, and produce disease, perhaps delirium tremens. — Brit. Med. Joiirn., 
Sept, 23, 1876. 

10. Adz'on of Stryclinia a'pplied directly to the Integuments of the Nostrils in 
Man. — Dr. Moller states that strychnia applied with a brush to the nostrils, 
causes an exceptional acuteness of the olfactory sense, and will restore the 
sense of smell to those affected with anosmia. He ascribes this phenomenon to 
the direct irritation produced by the applicati'ou to the nervous terminations. 
Revue des Sciences M^dtccdes, Oct., 1876, from UgesTc.fov Lager, R. 3, Bd. 19. 

11. Bromide of Potassium as a Caustic. — In a paper read at the recent 
meeting of the French Association for the Advancement of Science, M. Pry- 
EAND, of Libourne, claims for bromide of potassium certain properties hitherto 
but slightly recognized — properties which will extend the already wide range 
of the therapeutical uses of this salt. He found that subcutaneous injection in 
rabbits of concentrated solutions of the salt led to sloughing of the skin, and 
from this he was led to try the value of what he considered to be the escharotic 
properties of bromide of potassium upon malignant and other growths, either 
by means of injections into the tumour or by the application of the powdered 
salt to a raw surface. The action of the salt is completely resisted by the 
tegument. His first clinical experiment on the subject took place in April, 
1874, when, by means of daily applications of powdered bromide, he effected 
the removal within twenty-eight days of an epitheliomatous growth on the face. 
He has since had equally good results from this treatment of atonic ulcers of 
the legs, rapid cicatrization following the separation of sloughs produced by 
the application. In such cases he uses either the powder or an ointment of 
one part in five, or a mixture (one in ten) of glycerine and the bromide. In 
many skin aff"ections, as chronic eczema, pityriasis, and acne, in pha'gedsena, 
ulcerative stomatitis, and many other local inflammatory disorders, he has found 
it of use. As a local haemostatic, a solution of one in fifty has served for epis- 
taxis, and as a general haemostatic its success in many cases of haemoptysis and 
metrorrhagia was very marked, where ergot, perchloride of iron, and rhatany 
had failed. — Laricet, Sept. 30, 1876. 

12. Action of Pilocarpin on the Submaxillary Gland of the Dog. — Mr. J. 
N. Langley gives [Journ. Anat. and Phys., October, 1876) the following 
results of experiments made by him in the Physiological Laboratory, Cam- 
bridge. 

In small doses, i. e. up to 30 mgr., pilocarpin exerts an action on the gland 
very similar to that produced by stimulation of the chorda tympani. 

It causes a rapid secretion, and a considerable increase of blood-flow; both 
secretion and blood-flow gradually declining. 

Its effects are little if at all altered by section of the chorda tympani or of 
the sympathetic nerve. 

Stimulation of the chorda tympani increases the pilocarpin effects, i.e. the 
nerve is functionally unaltered. 



236 Progress op the Medical Sciences. [Jan 

Stimulation of the sympathetic diminishes its effects, so that this nerve too 
is fnnetionally unaltered. 

The secretion is sto])ped by injecting- atropin (a fact for some time known), 
but a quantity of atropin sufficient to paralyze the chorda tympani does not 
prevent a relatively large quantity of pilocarpin I'rom producing its ordinary 
results. In fact, the secretion or absence of secretion is dependent on the 
reliitive quantity of the two poisons present, just as in the stand-still or beat 
of the heart. 

In larger doses. Instead of causing a stronger saliva-flow, it causes none 
at all,' and further prevents the chorda tympnni from producing any secretion. 

It considerably diminishes the blood-flow through the gland, as well as the 
effect of the chorda tympani on the blood-flow. 

It does not, however, stop the sympathetic secretion. The action indeed is 
not very dissimilar to that of atropin; this agrees with its action on the vagus 
and inhibitory apparatus of the heart, where in large doses it prevents any 
inhibition of the heart from stimulation of the vagus or of the junction of the 
sinus venosus, just as atropin does. 

• 

13. Second Series of Experiments on the Biliary Secretion of the Dog. — 
Prof. RuTHKKFORD and M. Vignat. in their first series of experiments (see No. 
of this Journal for January, 1876, pp. 258-9) gave an account of the action of 
several articles on the biliary secretion of the dog. In this second series 
{Journ. Anat. and Phys., October, 1876) they give the results of their experi- 
ments with several other cholagogues. We give the results below of their 
experiments : — 

i. With Eluonymin. Five grains of this, when mixed with a small quantity 
of boiling water and placed in the duodenum, powerfully stimulated the liver. 
2. Coincident with the marked action of the liver there was only a slight 
increase of intestinal secretion. Seeing that Mr. Clothier found " euonymin" 
to be an active purgative in the human subject, these experiments suggest 
that the purgative effect may be chiefly due to increased secretion ofbile. At 
any rate these experiments clearly show that this substance is worthy of re- 
ceiving far greater attention in practical medicine than it has done hitherto. 

2. Sanguinarin. 1. In one experiment three grains, in another experiment 
one grain of "'sanguinarin" when mixed with a small quantity of bile and 
water and placed in the duodenum powerfully stimuhited the liver. 2. It 
rendered the bile more watery, nevertheless it caused the liver to secrete more 
biliary matter in a given time, 3. The secretion of the intestinal glands was 
slifihtly increased by these doses. These results show that the statements of 
Tully and Mothershead ought not to be treated with indilference and neglect, 
as they at present appear to be. in practical medicine. 

3. Iridin. 1. Five grains of iridin when mixed with a little bile and water 
and placed in the duodenum very powerfully stimulated the liver. It is not so 
powerful as large doses (four grains) of " podophyllin," but it is more powerful 
than "euonymin," as is shown by the amount of bile secreted per kilogramme 
of dog; the fractions for the two " euonymin" experiments being 0.4789 cc. 
and 0.4678 cc, whereas in the "iridin" experiments they are 0.537 cc. and 
0.638 cc. The high fraction in the second iridin experiment probably resulted 
from a much smaller dog getting the same dose as in the first experiment, the 
smaller liver being thereby stimulated to do a proportionally greater amount 
of work. 2. Iridin is also a decided stimulant of the intestinal glands. Judg- 
ing from these experiments its irritant effects on the intestinal mucous mem- 
brane are decidedly less than those of "podophyllin," while the purgative 
effects are greater than in the case of " euonymin." 'I'he statement of the 
writer in the Lancet that in man " it is gentler in its action than podophyllin" 
is fully supported by these experiments, and there seems every reason why this 
substance should be removed from its present obscurity and placed in a promi- 
nent position in practical medicine. 

' The transient secretion ensuing immediately after injection is not here re- 
garded as a proper effect of a strong dose, since the larger the dose the slighter 
and more transient it becomes. 



ISTT.] Materia Medica, General Therapeutics, etc. 237 

4. Leptandria. 1. Leptandria when mixed with bile and placed in the duo- 
denum undoubtedly stimulates the liver, but its power is very feeble as shown 
by the small secretion of bile per kilogramme of dog notwithstanding the 
large doses given. It excites the liver to secrete bile, having the ordinary 
composition. Unless the biliary solvent be present, "leptandria" produces 
scarcely any appreciable effect. In this respect it resembles many other 
resinous substances, e. ^. " podophyllin." 2. It is a feeble stimulant of the 
intestinal glands. 

5. Ipecacuan, 1. Sixty grains of powdered ipecacuan mixed with a small 
quantity of bile and placed in the duodenum powerfully stimulated the liver. 
Even three grains had an effect on a dog weighing 6.8 kilogrammes very nearly 
as great as the effect of sixty grains on a dog weighing 27.2 kilogrammes ; the 
amount of bile secreted per kilogramme of dog being nearly the same in both 
cases. 2. 'J'he bile secreted under its influence was of normal composition aa 
regards the biliary matter proper. 3. No purgative effect was produced, but 
there was an increased secretion of mucus in the small intestine. 'I'he compo- 
sition of the bile did not afford any evidence of an increased secretion of 
mucus having taken place from the glands of the biie-ducts. 

The increased biliary flow that followed ipecacuan could not in these experi- 
ments be ascribed to any relaxation of "spasm of the bile-ducts," for that no 
such thing existed was clearly shown by the free flow of the bile before the 
substance was given. Nor could it be owing to contraction of the gall-bladder, 
for the cystic duct was clamped. Nor can it be ascribed to contraction of the 
bile-ducts, for the increased flow was far too prolonged to be attributable to 
any such cause. It is, therefore, certain that this substance, like the others, 
has the power of stimulating the secreting apparatus of the liver. This being 
now proved as regards the dog, it can scarcely be doubted that the modus 
operandi is the same in man. The results of these experiments will, there- 
fore, lead to new speculations regarding the pathology of dysentery; for everi/ 
step towards greater accuracy of hiovdedge regardivg the modus operandi of 
any therapeutic agerd is certainly calculated to advance our knowledge of the 
true nature of the pathological condition that is relieved or cured by it. 

6. Colocynth. 1. 'JMiis is a hepatic stimulant of considerable power. It 
renders the bile more watery, but nevertheless increases the secretion of biliary 
matter. 2. It is also a powerful stimulant of the intestinal glands. 

7. Jalap. 1. This is a hepatic stimulant of considerable power. It renders 
the bile more watery, but at the same time increases the secretion of biliary 
matter. 2. Its effect on the liver is, however, far less notable than its effects 
on the intestinal glands. Its hydragogue cathartic effects on these were fully 
manifested in these experiments. 

14. Anoesthesia hy Intravenous Injection of Chloral. — The method of pro- 
ducing anaesthesia by the injection of solution of chloral hydrate into the veins, 
first practised by M. Ore, of Bordeaux, still finds advocates, and has been em- 
ployed quite recently with success. 'I'he dangers of the practice far outvi^eigh, 
in our opinion, its supposed advantages and this is the conclusion at which 
most experimenters have arrived. Drs. Tizzoxi and Fogliata have undertaken 
a series of experiments vvith the view of elucidating the following questions: 
].. Is chloral when injected into the blood a true an[esthetic ? 2, Is the method 
free from great dangers? 3. What are these dangers? i^nd 4. Upon what 
tissue elements does chloral act? From numerous experiments, they arrived 
at the following conclusions : 1. That alrhough chloral, when injected into the 
veins, is a powerful hypnotic, it is not a true anaesthetic ; the cutaneous sensi- 
bility ceases only when a very large dose is given, and the cornea almost never 
becomes entirely insensible. 2. That the process is very dangerous ; for the 
exact dose cannot be regulated, the action is highly variable in different indi- 
viduals, there is no means of moderating the action if excessive, and that it may 
lead to phlebitis. Add to this, that a large quantity of fluid is injected sud- 
denly into the circulation, and may lead to ill effects, or air may be introduced. 
In an excessive dose, chloral produced death by its direct action on the heart, 
the action of which ceased in diastole. 3. 'J'heir experiments led them to be- 



238 Progress of the Medical Sciences. [Jan. 

lieve that the poison acts directly on the muscular fibres of the heart; that 
when locally applied it causes contraction of these fibres, and thus produces a 
tetanic systole of the ventricles, but when injected into the blood or beneath 
the skin, or given by the mouth, it excites the "diastolic extensibility" of the 
muscular fibres, and thus produces a forced diastole. They add that subcuta- 
neous injection of chloral is not more desirable, as it causes local muscular 
spasm, and hence absorption is slow and irregular, and that it is liable to cause 
gangrenous abscesses. As an antidote in poisoning by chloral they recommend 
the cold douche to the head and spine; and consider injections of strychnine, 
quinine, atropine, and curare injurious. These results will, we trust, deter 
Kn<zlish surgeons, at least, from a method of procuring ansesthesia, which is at 
once so gratuitously dangerous, and so doubtful in its eff'ects. — Lancet, Nov. 
11,1876. 

15. Si/mpfoms resulting from Ancesthesia hy Ether in Young Subjects. — 
Dr. Leon Trtpier read a paper on this subject before the French Association 
for the Advancement of Science. He related three cases in which the admin- 
istration of ether for surgical operations was attended by an arrest of respira- 
tion, and though, after long efforts at restoration recoveries took place, the 
patients were placed in a most alarming condition. He also instituted experi- 
ments on young cats with ether, and found, as in young human subjects, an 
arrest of respiration often occurred. Older animals were less liable to this 
accident. He, therefore, considers anaesthesia by ether in young subjects as 
dangerous, and that chloroform for them should be always preferred. — Gaz. 
Htbdom., Sept. 15, 1876. 

16. On the Employment of Iron in the Treatment of Chlorosis. — Dr. Du- 
jardin-Beaumetz entertains some doubts as to the utility of ferruginous prepa- 
rations in the treatment of chlorosis, and he gives reasons for his scepticism. 
Before admitting, he says, that in the work of organic reconstruction iron is 
superior to other medicines, we ought to see the quantity of iron which disap- 
pears from the economy as a consequence of anaemia. Take for example a 
young girl of the weight of 60 kilogrammes (a kilogramme is rather more than 
2 lbs.). According to the researches of Boussingault the proportion of iron 
would be, in relation to the weight of the whole body, represented as .00011, 
which would give, in the case of the girl, 5.454 of iron. But the iron is dis- 
tributed in various parts, and the blood contains only .5063 of iron in 1000 
parts so that the quantity of iron contained in the girl's blood would be about 
2 to 2|- grammes (a gramme is about 15 grains). But this quantity does not 
belong exclusively to the globules, a certain part being distributed to the albu- 
men and the fibrine, and thus the quantity reserved for the globules is dimin- 
ished. These last alone undergo a more or less marked diminution in chlorosis, 
but the deficiency never reaches more than from a quarter to a third of the 
total amount of the globules, so that in admitting the numbers in the given case 
it is found that the diminution of iron in this disease is very small and is repre- 
sented by figures varying between 10 and 50 centigrammes at the utmost. This 
small loss of iron is restored every day by the food. The arguments thus ad- 
duced show that the ferruginous preparations may act in chlorosis, not by re- 
placing the iron which has disappeared, but in stimulating the digestive func- 
tions and promoting nutrition and assimilation. Dr. Dujardin-Beaumetz does 
not deny the beneficial effects of iron in chlorosis, but he thinks that the results 
have been much exaggerated, and that, in a great number of cases, hygienic 
measures have been superior to the iron treatment. He adduces his own ex- 
perience in proof of this view, and he states that in the case of several young 
women in a school which he attended, and who were suffering from chloro- 
ansemia, the symptoms were nob at all relieved or improved by iron, but were 
cured by the introduction of hydrotherapeia and gymnastics in the institution 
where the patients were being educated.— i?r/l and Fur. Med.-Chir. Rev., Oct. 
1876, from Ball. Gen. de Tlierap., May 15, 1876. 



1877.] Medical Pathology and Therapeutics. 239 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

17. Hemorrhagic Diatliens. — Sir Wm. Jenner read before the Clinical Society 
of London (Nov, 10th), an elaborate report of a case of hsemophilia, which had 
just terminated fatally under his care in University College Hospital, and made 
as the result of his extensive experience some interesting remarks on the patho- 
logy of that affection. 

The case was a lad, aged thirteen, who was admitted on November 4, on 
account of hemorrhage from the bowel. He was known to be suffering from 
the hemorrhagic diathesis, having been several times in the hospital on account 
of severe hemorrhage from slight causes. He had also often suffered from 
spontaneous bleedings from the nose and mouth, and also from frequent swell- 
ings of the joints ; of late, the left knee had been permanently affected. A 
brother of the boy also suffered from the same condition, but no other member 
of the family. On admission, the boy was pale and prostrate, with numerous 
subcutaneous ecchymoses and considerable swelling of the right thigh. 'J'he 
hemorrhage from the bowel, generally of dark blood, continued, in spite of an 
ergotin injection, and turpentine and acetate of lead by the mouth, employed 
before the boy was seen by Sir William Jenner. who ordered an injection of 
perchloride of iron into the rectum, and gallic acid to be given internally. The 
injection returned in ten minutes, but there was no more hemorrhage, although 
small stools were passed. The boy, however, became paler, weaker, and more 
restless, and died twenty-four hours after admission. At the post-mortem 
examination, blood was found in moderate quantity in each side of the heart, 
and the clots were firm. The lungs presented no consolidation, but many 
peculiar pale patches, sharply defined, a little raised, with some adjacent hyper- 
semia, containing air, fluid, and a little more solid than the adjacent parts. The 
lower part of the rectum contained a very firm clot, and all the blood had 
evidently come from the lower six inches, where the mucous membrane was 
undermined by extravasations which had broken through it. The liver and 
spleen were healthy. The left kidney was absent ; its supra-renal body was 
disk-shaped. The right kidney was hypertrophied, weighed seven ounces, and 
presented traces of foetal lobulation. The aorta was rather small but healthy, 
and the arteries and veins were also healthy in appearance. The enlargement 
of the right thigh was due to an enormous extravasation of blood beneath the 
fascia. The clot was two inches thick, and very firm. The left knee-joint was 
found to be full of purple blood and stringy synovia. The synovial membrane 
was stained an ochre-brown. The cartilages presented evidence of chronic 
inflammation. Sir William Jenner remarked that the case resembled, in its 
general features, several other cases which had come under his notice ; resembled 
them, too, in the seats of the hemorrhage, in the character of the blood lost, 
and in the joint affections. The joint affections were of three kinds, and the 
boy suffered from the two forms which were most characteristic of the disease 
— spontaneous swelling, tenderness, and general puffiness of the joint, such as 
occurred in rheumatism ; and swelling, the result of successive secretion, with 
hemorrhage, the result of a slight injury. In a rarer form sometimes seen in the 
disease, there was much simple effusion. The firmness of the clots in the heart 
and rectum illustrates the important fact that the blood in a case of hasmophilia, 
after death and during life, did not lose its power of coagulating firmly. The 
case lent no support to the view that the walls of the arteries were in these 
cases of abnormal thinness. In most of the cases Sir William Jenner had seen, 
the bleeding was venous, not arterial. The source of the blood, the lower part 
of the rectum, was a point of great practical importance, and so also was the 
firmness of the clot which was found — a firmness probably due to the effect of 
the perchloride of iron, the best local styptic in these cases. It was very 
doubtful whether death in this case resulted from the hemorrhage from the 
bowel; the extravasation into the thigh probably assisted, and the peculiar 
state of the lungs and bronchial tubes might have been the immediate cause of 
death. 



240 Progress of the Medical Sciences. [Jan. 

The points in the pathology of this disease, which have been impressed upon 
him by the cases he has seen, are: 1st. 'J'hat the tissues are all soft, so that 
they bruise easily. 2d. That the blood is rather slovj in coagulating', but its 
coagulum, when formed, is as firm as in health. 3d. That blood is formed 
rapidly; that there is a tendency to plethora of the smaller vessels, and he had 
frequently observed that when the patient v*^as looking his best is the moment 
wdien injuries have the worst effect, and spontaneous hemorrhages are the most 
likely to occur. With regard to the etiology, it was not always possible to trace 
back the disposition to the ancestors. He had seen cases in families, where the 
ancestry could be traced for generations, where no history of hemophilia in rela- 
tions could be got; but when once developed it has often affected more than 
one member of the family. Sir William Jenner has known it transmitted by a 
daughter, who was not herself the subject of the disease. In this boy's parents, 
and in their relatives, no hemorrhagic tendency existed ; there was instead only 
some disposition to phthisis. The present was, he believed, the only case in 
which the cause of the swelling of the joints was found to lie in effusion of blood 
with excess of synovia. Dr. Legg, in his treatise, was unable to find any such 
cause for the joint affection in any well-recorded case. In the present case there 
was, in addition to these changes, evidence of long-standing inflammation of the 
knee-joint. He had pursued for some years the following treatment of the dis- 
ease, founded upon the pathological basis he had laid down: Every month, or 
oftener, some mercurial, followed by sulphate of soda, in order to control the 
tendency to plethora. The latter should also be given once every week, and 
both should be repeated at other times whenever the patient appeared to be 
fuller of blood than normal. The diet should be rather dry, with a considerable 
proportion of white fibrinous meat, and plenty of open air exercise should be 
taken, with the greatest care to avoid mechanical injuries. 

Air. Christopher Hrath said he remembered the boy as a patient under his 
care. The rest in the hospital did him good. It was, however, rather curious 
that two instances of such a rare form of malady should be in the hospital at 
the same time, for at the present moment under his care there was also a patient 
all the mule members of whose family were bleeders. He had carefully traced 
the family history in this case, and it was reported in the British MeiUcal 
Journal for January 11, 18G8. 'I'he female members of the family did not 
suffer, but they transmitted the affection to their male offspring. In the case 
of the boy under his care there was also some local infiltration of blood, but it 
seemed to be more superficial than in Sir W^. Jenner's case. The tendency to 
bleed in his patient could only be overcome by continuous irrigation with cold 
water. Internally he gave iron and hydrochloric acid. As a result of this 
tendency to bleed, all the males of the family had died out; only the females 
were left alive. 

Mr. Howard Marsh had seen four or five sueh cases among children. In all, 
or almost all, of these the joint affection was present, but there had been no 
means of determining its nature. Jn one instance the elbow-joint had been 
destroyed, probably as the result of effusion. As a rule the joints resembled 
rheumatic joints. 

'i'he President did not think that iron given internally did much good in these 
cases. When relief had been afforded to the system by bleeding, almost any- 
thing would stop it. Locally matters were quite different; there he thought 
that iron was of the greatest value. If the bleeding came from the bowel, it 
was generally from the lower part of the rectum, to which the iron solution 
could be readily applied. 

Dr. Greenhow knew of one family which had completely died out from this 
aff'ection, yet there was no family history of bleeding. Two died under his 
cognizance; one from bleeding at the nose in whooping-cough, the other from 
bleeding after the removal of a tooth. 

Sir W. Jenner said he had seen bleeding from the socket of a tooth promptly 
relieved by crystals of perchloride of iron. 

After some remarks by Mr. Mahomed on the condition of the vessels. 

Dr. Greenfield said be had seen plastic exudation in the bronchi in two cases 
where death had followed hemorrhage. 



1877.] Medical Pathology and Therapeutics. 241 

Sir William Jenner, in reply to Dr. A. P. Stewart, said that there had only 
been one subcutaneous injection of ergotine (four grains). He also observed 
that Professor Rheinkens, of Brussels, whom he had seen, and who had recom- 
mended regular bleeding to keep off the malady, had had five cases ; all of 
these patients were now dead. — Lancet, Nov. 18, 1876. 

18. Phosphorus in LeucoryUioemia. — The startling results announced by 
Dr. Broadbent, and afterwards by Dr. Wilson Fox, as having resulted from the 
administration of phosphorus in well-marked cases of splenic leucocythaemia 
has induced other practitioners to try that treatment. At a meeting of the 
Clinical Society of London, Sir William Jenner read brief notes of three 
cases of leucocythsemia treated by phosphorous. The cases had occurred in 
private practice. The first was that of a barrister seventy-one years of age, 
first seen by Sir William Jenner on July 31, 187.^. The spleen reached two 
fingers'-breadth below the umbilicus, where its notch could be felt. The tem- 
perature was 100°, and the white corpuscles were extremely numerous. On 
November 2, the spleen reached four fingers'-breadth below the umbilicus ; the 
white corpuscles were as numerous as before. He had been taking, in the 
interval, three grains of phosphorus pill three times a day. and for one week 
twice a day. He had lost llesh. Temperature 100"°. Death took place in 
December. The second case was that of a lady thirty-eight years of age, who 
presented all the usual symptoms of splenic leukaemia. There was a large ex- 
cess of white corpuscles. She also took three grains of phosphorus pill three 
times daily. The temperature ranged from 97.5° to 101°. Slie gradually got 
weaker, and died on July 26. 'i'he third case was that of a married lady, aged 
twenty-seven, who consulted Sir W. Jenner early in June. This was another 
marked case of splenic leucocythsemia. The morning temperature was natural; 
evening, 100°. The same treatment was pursued as in the other cases, except that 
in July, at Dr. Broadbent's suggestion, capsules containing phosphorus were 
substituted for the pills. There was then not much improvement. The tempera- 
ture was 100°; night-sweats less profuse; but the epistaxis was more abun- 
dant, and the white corpuscles had not diminished in size. On November 8, 
Sir W. Jenner again saw her. She had now been taking phosphorus (j\j gr.) 
in capsules since July 15. The spleen had continued to enlarge ; epistaxis 
occurred at rare intervals, but she complained of extreme giddiness on move- 
ment. The white corpuscles were at least as numerous as the red. Sir W. 
Jenner explained that he had furnished these outlines of cases occurring in his 
practice as embodying his experience of the phosphorus treatment. — Lancet, 
Dec. 2, 1876. 

19. The Blood in Ancemia. — Considerable attention has been paid of late 
to the microscopic examination of bood in various diseases. The accurate 
method of counting the number of blood-corpuscles after dilution with a defi- 
nite quantity of serum, etc., will doubtless prove very valuable ; but M Hnyem 
has pointed out (Soci^te de Biologic, November 4) that in aneemia this is only 
half the inquiry. In anaemia we have to do with the altered ratio between the 
number of the corpuscles and what may be called the" colour-richness" of the 
blood — in other words, the quantity of haemoglobin. To estimate the latter, 
M. Hayem has used a microscopic cell of known dimensions, alongside which 
he places a wafer, the tint of which is equal to that of the blood richest in cor- 
puscles and colour. A scale is obtained, in which a given number of corpuscles 
corresponds to a given colour. Having given the number of corpuscles and 
the "colour-richness," it is easy to determine the value of each corpuscle. In 
the normal state this value is found pretty constant. M. Hayem does not find 
any marked difference in the colour-richness of the blood of the two sexes ; but 
he finds a very marked difference between the adult and the new-born child in 
this respect. In the latter the real value of the corpuscles is greater than in 
adults. This explains why there is a smaller number of corpuscles. In chronic 
anaemias the real value of the blood is very inferior to that which is observed 
in the normal state. But in extreme anaemia the corpuscles undergo a notable 
hypertrophy, and in general gain in volume what they lose in number. Thus 

No. CXLY.— Jan. 187t. 16 



242 Progress of the Medical Sciences. [Jan. 

the real value of the corpuscle tends to approach the normal state, or even go 
beyond it. M. Gubler stated that araoniijst all the cachexias he had only 
observed the hypertrophy of the corpuscles, with diminution in their number, 
in Addison's disease. To this M. Hayem replied that the above held good of 
all anaemias, whatever their origin, if only the anseraia were severe. It is greatly 
to be desired that the details of method may be explained, and these results 
tested by other observers. — Med. Times and Gaz., Dec. 2, from Gazette des 
Hopitaux, Nov. 4, 1876. 

20. Treatment of Acute Rheumatism by Salicin. — Dr. T. Maclagan some 
time since {Lancet, March 4th and 11th, 1876) called attention to the beneficial 
action of salicin in acute rheumatism, and gave the result of his experience, 
as follows : " 1. We have in salicin a valuable remedy in the treatment of acute 
rheumatism. 2. The more acute the case, the more marked the benefit pro- 
duced. 3. In acute cases, its beneficial action is generally apparent within 
twenty-four, always within forty-eight, hours of its administration in sufficient 
dose. 4. Given thus at the commencement of the attack, it seems to arrest 
the course of the malady as efiectually as quinine cures an ague, or ipecacuanha 
a dysentery, 5. The relief of pain is always one of the earliest effects produced. 
6. In acute cases, relief of pain and a fall of temperature generally occur 
simultaneously. 7. In subacute cases, the pain is sometimes decidedly relieved 
before the temperature begins to fall; this is especially the case when, as is 
frequently observed in those of nervous temperament, the pain is proportionally 
greater than the abnormal rise of temperature. 8. In chronic rheumatism, 
salicin sometimes does good where other remedies fail; but it also sometimes 
fails where others do good." 

In the number of the same journal for Oct. 28th, he states that further ex- 
perience has confirmed the accuracy of the conclusions. In not one case has 
he found salicin fail to produce a speedy cure of the disease. He recommends, 
now, however, it to be given in larger doses. Fifteen grains every three or 
four hours he considers a medium dose for an acute case, but it is well to give 
20 or 30 grains every two hours, as the best way to gain the full and speedy 
benefit of the remedy is to saturate the system as quickly as possible. In very 
acute cases, he gives the above dose every hour until the pain is relieved. 
" With relief of pain, sleep returns, and the hourly dose cannot be adhered to. 
But it is well to give twenty grains, at least, every two hours during the day, 
till the temperature is down to the normal. For a week afterwards the same 
dose should be given four times a day. 

•' Salicin is an excellent bitter tonic — in my experience as good as quinine, and 
not apt to disagree as the latter is. I have always found cases of acute rheu- 
matism treated by it convalesce very rapidly ; treated in the old way, conva- 
lescence from that disease is a slow and tedious process." 

The following are his conclusions with regard to the action of salicin on the 
cardiac complications of acute rheumatism : — 

" 1. That, given sufficiently early and in sufficient dose, salicin prevents these 
complications. 

'•2. That its free administration is the best means of staying their progress 
after they have occurred. 

" 3. That such general treatment does not exclude the usual local measures 
— leeching, poulticing, etc. 

"4. That the beneficial action of the salicin on the heart ceases when the 
temperature falls to the normal. 

''5. That salicin is powerless to remove the effusion which remains after the 
fever has ceased. (To touch the gums with mercury, slightly but quickly, I 
regard as the most hopeful means of attaining this end.) 

"It is right that I should add that my experience of salicylic acid leads me 
to regard it as having much the same action as salicin, as an antipyretic and 
antirheumatic. All that I have said of the alkaloid I believe to be equally 
applicable to the acid. 

" The advantage of the former is that it is an excellent bitter tonic, and 



1877.] Medical Pathology and Therapeutics. 243 

never causes troublesome symptoms ; except in some rare cases such tinnitus 
aurium as results from a two- or three-grain dose of quinine. 

" The disadvantage of the latter is, that it geuerally causes irritation of the 
throat, and frequently induces sickness ; in one case I found it give rise to 
troublesome irritation of the bowels." 

21. Gold-Bath Treatment of Enteric Fever. — Dr. John McCombte, in an 
article on this subject ( The Practitioner, November, 1876), gives the following 
as his conclusions: " Whilst we are unable to give our assent to the opinion 
that cold water is omnipotent in the treatment of enteric fever, we consider it 
a valuable addition to the therapeutics of this disease. From the simplicity of 
its administration, from the absence of danger in its use in the majority of 
instances, and from the beneficial effect derived from the reduction of the tem- 
perature and the production of sleep, we think that it is far from having attained 
that position amongst the therapeutics of this disease which it deserves ; but 
we do not hesitate to affirm that there are other agents of great, and in some 
cases and under certain conditions of greater value, and that the treatment of 
enteric fever has not yet resolved itself, as certain German authorities would 
have us believe, into the use of the thermometer and the cold bath." 

22. The Relation of Algous Vegetation to Malaria. — The microscopical 
investigation by Dr. Lanzi, of Rome, of the fauna and flora of the marshes in 
the Roman Campagna, and of those of the Pontine Marshes, has led to the 
discovery of a peculiar alteration which the algae undergo in these localities. 
Dark granules are found embedded in the endochrome or the chlorophyll of the 
algce cells; and as the algae die these granules become more and more abundant, 
until they completely fill the cells, and the alg?e no longer appear green under 
the microscope, but black, while at the same time they pass over into a state of 
putrefaction. This process, which Signor Lanzi has carefully watched in his 
aquaria, occurs every year on a large scale in the Roman Campagna. The 
swamps which form during the winter are covered in the spring with a very 
abundant growth of alga\ In the summer, when the water dries, large surfaces 
of country are covered with a continuous layer of decaying algce. In the 
autumn they die and decay also on the surface of any water that still remains, 
and everywlaere the microscope reveals in their debris the existence of the 
above-mentioned dark-coloured granules. According to Lanzi's view, these 
granules possess the properties of a ferment. They are found abundantly dis- 
seminated in the dust of the Roman Campagna, or can be freely developed out 
of it by cultivation. Lanzi considers that they are identical with the pigmented 
spherobacteria of Cohn and the Bacteridium hrunneum of Schroeter. Now, 
the pigment-granules which are found in the liver and spleen of persons suffering 
from malarial cachexia are identical in their properties with those which 
develop out of decaying algae ; and Lanzi strongly maintains the identity of 
the so-called " malaria melanine" of pathologists with the vegetable granules. 
He has succeeded, indeed, in growing zoogloea-like vegetation from the pigment 
of malarial livers. The great carrier of these granules appears to be the wind, 
which diseminates them with the dust throughout the atmosphere of the Cam- 
pagna district. 

Signor Terrigi, who assisted Dr. Lanzi in his microscopical observations, 
made use of special apparatus to determine the vertical elevation above the 
surface of the ground which the granules can reach, and he found it to be about 
fifty centimetres — a height at which the wind could easily take them up. The 
remedial measures which Signor Lanzi suggests to subdue the malaria of the 
Roman Campagna consist in drawing off' the water from the larger swamps, in 
draining wet land, in planting trees, and in adopting a system of scientific agri- 
culture. 

The Encalyptus globulus appears not likely to answer the expectations which 
were at first formed of it, for it can only live in specially sheltered situations, 
and is not hardy enough to grow indifferently in any part of the Campagna. — 
Med. Times and Gaz., Dec. 2, 1876. 



244 Progress or the Medical Sciences. [Jan. 

23. Nitrite of Amyl in Ague, etc. — Surcjeon W. E. Saunders extols 
[Indian Medical Gazette, Nov. 1876) the efficacy of nitrite of arayl in ague, 
etc., in which its effects seem to have been most remarkable. He uses the 
" nitrite of amyl mixed with an equal part of oil of coriander, to render it less 
volatile, and at the same time to cover what is, to my sense of smell, a most 
disagreeable odour. I find it acts better in this way, owing, no doubt, to a 
more gradual and complete action, much less being lost during inhalation. 

'• It certainly is the most powerful diaphoretic I have ever seen ; and I now 
use it in all cases of fever to produce diaphoresis, which it does, as a rule, in a 
few minutes." 

He adds, " I do not mean to say that quinine should not be used in these 
cases, for there is ample proof that it tends to check the return of the attacks, 
and removes to some extent the septic condition of the blood induced by the 
malarial poison whatever its nature be; and this more especially if small doses 
of opium be combined with it. 

" In no case did the amyl fail to remove the attack in about one-third the 
usual time, and in most cases the fever did not again return. The method of 
administration I adopt is this : Four drops of the mixture, or two of amyl, are 
poured on a small piece of lint, which is given into the hands of the patient, 
and he is told to inhale it freely. He soon becomes flushed, and his pulse and 
respiration are much accelerated ; and when he feels warm all over the inhala- 
tion is discontinued, as the symptoms continue to increase for a short time 
afterwards. A profuse perspiration now sets in, which speedily ends the attack ; 
in some cases, however, the cold stage merely passed off without any hot or 
sweating stage." 

24. Chloral in Infantile Convtdsions. — Lovvrnstamm [Medicim'sh-Chirur- 
gisches Centralblatt, No. 35, 1876) speaks of numerous instances in which he 
has tested the efficacy of this drug in convulsions ; and he gives one case in 
detail. The patient was the third child of a highly nervous woman, who had 
lost her first and second children from this affection at about the same age as 
that at which this one was attacked. At the thirteenth day, twitchings of the 
eyelids and of the angles of the mouth were first observed ; these rapidly 
developed into more general convulsions, which were repeated, later, every ten 
minutes. The infant was first seen on the sixteenth day of life. He showed 
then strong twitchings of the face, trismus, clonic spasms of the limbs, spastic 
contractions of the thumbs, and contracted pupils ; the fit terminated, at the 
end of five minutes, in profuse perspiration. Two grains of chloral-hydrate 
were given every hour. The convulsions diminished in frequency and intensity, 
and, on the following day, he was free from them. As the case was considered 
to depend upon dyspepsia, an antacid in the form of magnesia usta was then 
given, and no recurrence took place. — London liedical Record, November 15, 
1876. 

25. Fust Dentition in its Causal Relation to Disease. — Dr. Lederer points 
out in this paper [Allgeineine Wiener Mtdicinische Zeitung, May 2 and 9) 
the slender grounds upon which many disorders of childhood are attributed to 
dentition. Jle remarks that the most powerful factor in the retardation of the 
teeth is rickets, and that it is precisely in rickety children that these disorders 
— bronchial and intestinal catarrh, laryngismus stridulus, convulsions, etc. — 
are most frequent. During his five years' connection with the Vienna 
Ohildren's Hospital, he noted ninety-six cases of laryngismus, and of these, 
ninety-two were in rickety subjects. He further quotes Luzinsky as having 
observed 504 cases of pulmonary and intestinal affections in rachititic children 
who showed no sign of teeth. Dentition, moreover, gives no causal indication 
for treatment ; the conditions are far more effectually dealt with according to 
general rules. The theory is therefore, useless ; but it is even worse than use- 
less, because it frequently leads mothers to defer applying for medical assistance 
until the case is too far gone, and it engenders in others a carelessness which 
is most prejudicial to the patient's welfare. Dr. Lederer, therefore, without 
denying Its occasional importance, believes that it is rarely anything more than 



187*7.] Medical Pathology and Therapeutics. 245 

an exciting cause, which, without special predisposing influence, would be 
powerless. — London Med. Record, Nov. 15, 1876. 

26. On the Use of Sulphate of Iron in Diphtheria. — In an article in the 
Gazzetta Medica delle Calabrie for Januisry (abstract in Annali Universali di 
Medicina, August), Dr. Fera asserts that he has treated eighty cases of diph- 
theria successfully, without one death, by the local a]>plication of powdered 
sulphate of iron. He describes the mode of treatment in the following' terms. 

A brush is made of horsehair, which is cut at a distance of 3 or 4 millimetres 
(about .12 or .16 inch) from the handle. The brush is then dipped in very 
finely powdered sulphate of iron, and can be easily tipplied to the diphtheritic 
patches on the tonsils, pharynx, and velum pendulum palati. or elsewhere. 
Sometimes the brush is applied energetically to the diphtheritic area, until it 
bleeds freely ; the pearly colour of the diphtheritic exudation at once disap- 
pears, and the surface becomes red, or some portions of the area mny be 
covered with mucus, which is detached by the next application. The appli- 
cation is made twice daily. After the first or second, the febrile temperature 
is gradually lowered ; the enlargement of the cervical glands is reduced and 
entirely disappears ; and in three or four days the patients are well. — Loiidon 
Med. Record, November 15, 1876. 

27. Carbolic Spray in Bronchial Catarrh. — Dr. Moritz communicated to 
the St. Petersburg Medical Society the results of his trials of carbolic acid 
spray in various forms of bronchial catarrh, relating several examples of its 
utility. Since he had much to do with this spray he found that bronchial 
catarrh, to which he was formerly much subject, either ceased to appear or was 
soon cut short. In as small a room as possible he causes half a pound of a 2 
per cent, solution of the acid to be sprayed per diem, the night being the time 
especially to be preferred. — Med. Times and Gazette, Dec. 2, from St. Peters- 
burg Med. Woch., Nov. 11, 1876. 

28. Phthisis toith Rapid Contraction of a Cavity. — Dr. Theodore Williams 
read to the Clinical Society of London (Nov. 10), the sequel of a case of phthisis 
with rapid contraction of a cavity, which he had communicated to the Society 
in 1871. At that time some eminent fellows of the Society had expressed doubts 
as to the existence of a cavity, in spite of the physical signs narrated, but the 
death of the patient, in January, 1875, and post-mortem examination, cleared 
up all doubts. The patient, a widow, aged filty-three, was admitted into the 
Brorapton Hospital, in April, 1871, with a history of pleurisy of twelve years' 
standing, and phthisis of one year's duration. Dulness was detected over the 
whole left side, cavernous sounds from the first to the third rib, and ronchi and 
rales below, and also in the right lung. Subsequent examinations showed a 
gradual diminution of cavernous sounds, and in July, 1871— z.e., three months 
after admission — they had entirely disappeared. No marked displacement of 
adjacent organs was then to be found ; but a few months later the heart and 
stomach were drawn up, the right lung drawn across the median line, and some 
shrinking of the side was visible. In 1872, she survived a severe attack of 
capillary bronchitis, but died of congestion of the right lung in 1875, the physi- 
cal signs before death indicating great shrinking of the left lung. The autopsy 
showed an old puckered cavity, about the size of a date stone, near the apex of 
the left lung, underlying the portion of chest-wall where the cavernous sounds 
had formerly been audible. The bronchus leading to the cavity was blocked 
and obliterated, and the greater part of the lung was in a state of fibrosis. The 
right lung was drawn across the median line, and was partly emphysematous 
and greatly congested. The heart was drawn up, and the left chest measured 
an inch and a half le.ss than the right in circumference. Dr. Williams remarked 
that in this case each step of the contractile process had been noted by physi- 
cal signs, and the post-mortem examination thoroughly confirmed the diagnosis. 
The fibrosis process may have had its origin in the old attack of pleurisy, and 
was the means of limiting the cavities, and arresting the disease. The cavity 
sounds were quite distinct, and he could not understand the existence of a 



246 Progress of the Medical Sciences. [Jan. 

cavern having been doubted. Cavities were overlooked during life, even by 
accomplished auscultators ; but this arose either (1) from the bronchus leading 
into them being blocked; (2) from their being small and deep-seated; or, (3) 
from development of emphysema in the neighbourhood. On the other hand, 
consolidations should not be mistaken for cavities — the difference in the expi- 
ration note, the succussion sound, the gurgle, and examination of the sputum, 
being easy means of distinction. Dr. Williams remarked, in conclusion, that 
far more cavities were overlooked than were erroneously diagnosed. — Lancet, 
Nov. 18, 1876. 

29. Thoracic Tumour simulating Aortic Aneurism. — Dr. Finny [DuUin 
Journal of Med. Science, Nov. 1876), in presenting to the Pathological Society 
of Dublin the specimens from a case of thoracic tumour, said : The diagnosis 
of intra-thoracic aneurism is, at all times, a matter of great interest, and at no 
time a matter of ease. The present case illustrates this, and also presents a 
new difiQculty in the diagnosis on which sufficient stress has not been heretofore 
laid. These specimens were taken from the body of a Frenchwoman, aged 
twenty-two years, who was admitted into the City of Dublin Hospital on the 
6th of December last. Six weeks before her admission she had been delivered 
of a child in Sir Patrick Dun's Hospital, after a labour more than usually diffi- 
cult. It was followed by pain in the right side of the chest; and for these 
pains she sought admission into the hospital. It was then found that she had 
pleurisy without eff'usion on the right side. Her chest was carefully exam- 
ined; no percussion dulness was observed anywhere abnormally, but a loud 
systolic bruit was heard in the neighbourhood of the pericardium, towards the 
base of the heart, which was unaffected by change of posture. Her pulse was 
small and feeble, and alike in both radials. 

On the 18th of December there was noticed a visible pulsation close to the 
left side of the sternum, in the second intercostal space. Dulness was noticed 
over the same region, while the beat of the heart was in its normal position. 
The left radial was noted as markedly smaller than the right, and the left pupil 
was observed to be larger than the right. Ten days later, in addition to those 
symptoms, she had profuse perspiration, which was confined to the left side of 
the face and forehead. On the 1st of January, Avhen she came under my care, 
Dr. Benson suggested the possibility of the existence of thoracic aneurism, at 
the same time suspending his opinion for further observations, as the age of 
the patient, the absence of any history of syphilis, or of direct violence to the 
chest, or of the habit of intemperance, discountenanced such a view. 

She was, on January 1, seemingly in very good health, plump and well-look- 
ing, and complained of nothing but pains occasionally in the right side of the 
chest. She had no cough or fever, and with the exception of the thoracic 
pulsation and murmur she seemed quite well. During the next three weeks 
she was carefully watched and examined every day by myself and some of ray 
colleagues, and was also seen by several other medical men, on whose judg- 
ment and opinions 1 lay great stress. After many consultations and much hesi- 
tancy we were unanimous in coming to the conclusion that it was a case of 
thoracic aneurism, and our idea was that it was a case of false aneurism of the 
left side of the ascending portion of the arch, which had bulged forward, and 
was causing pulsation in the second intercostal space. The shape and position 
of the primary and secondary sacs was further supposed to be such that the 
blood was diverted from passing into the left subclavian artery ; and thus the 
small pulsation on that side was accounted for. The points on which this 
diagnosis was based are those usually relied on as signs of thoracic aneurism — 
viz., the state of the patient's general health, the existence of an intra-thoracic 
tumour, and the evidences of pressure. The plump, healthy look of the 
patient, and the absence of all constitutional disturbances, such as cough, 
night sweats, or hectic, excluded the idea of cancer, or tubercle, or of enlarged 
glands which might be associated with those diseases. The tumour was small 
but very distinct at the second intercostal space. The pulsation was diastolic 
or single, and was rendered visible by placing pieces of paper or the stetho- 
scope over it ; at the end of the pulsation the impulse seemed very distinctly 



1871.] Medical Pathology and Therapeutics. 24t 

vibratile. It gave one the sensation of a large sac filled with a great deal of 
fluid, and very close to the surface of the skin. 

The dulness on percussion — and this was the only point to render the diag- 
nosis doubtful — extended over a larger area than the impulse corresponded to. 
It extended from the middle of the sternum, at the level of the third rib, to the 
left sterno-clavicular articulation, and for two inches from the end of the clavi- 
cle, and then in a straight line to the third rib. Outside these limits the chest 
was perfectly normal on percussion. The murmur was heard over the superior 
part of the pericardial region, aud was intensified at the lower edge of the 
clavicle. Its character was loud and ringing, and it gave the idea of being 
caused by some large cavity. It was not heard in the carotids, or down the 
spine. The evidence of pressure consisted in the absence of vesicular or other 
breathing in the space where dulness existed, while over the whole of the left 
lung the respiratory murmur was more feeble than natural, and was also much 
less than in the right lung, where the respiratory murmur was puerile in cha- 
racter. Just outside the region of dulness on the left side, the inspirations 
and expirations were prolonged, and a sound could be heard as of air whistling 
through some obstruction. The idea of pressure on the bronchial tubes was 
further confirmed by finding the whole of the left side comparatively less filled 
with air than the right side, Measurements of the chest were taken on the 1st 
of February, and the diagnosis was still further confirmed by finding that the 
left side was two inches smaller than the right at the xiphoid, and two and a 
half inches above the mammge. The unilateral nature of the foregoing signs, 
and the absence of all fever or other constitutional disturbances following a 
tedious delivery, presented a group of signs and symptoms which, on the one 
hand, excluded the possibility of phthisis, or a cancerous tumour, and pointed 
on the other to the diagnosis of a rapidly growing false aneurism of the aorta. 
This opinion was strengthened in the further progress of the case by the very 
variation of the signs and symptoms, such as is known to occur in aneurismal 
tumours. For example, the pulsation which, on the 18th of January, was very 
distinctly felt and seen, was, on the 26th, much less evident, while the left ra- 
dial pulsation had become much more full and distinct. On the 1st of Feb- 
ruary she had a great deal of cough, and evidences of inflammatory softening 
of the left lung set in. These signs were believed to be due in part to the im- 
perfect expansion of the lungs, produced by pressure on the bronchial tube, 
and in part to pulmonary phthisis, which, Dr. Stokes states, is one of the 
commonest complications of aneurism. On the 12th of February the softening 
and breaking down of the lung was more evident, as over the whole of it 
muco-crepitant rales could be heard. On the 18th of February spasmodic 
laryngeal cough set in, and continued incessantly for thirty hours, day and 
night. This cough was of a shrilly barking character, and the " stridor from 
below" (Stokes) could be heard at the fourchette of the sternum ; but neither 
at that time, nor at any other, was there aphonia. Ten days later, long after 
the laryngeal symptoms had passed away, dysphagia set in, and the patient 
complained of obstruction in the throat, so as hardly to swallow fluids. In its 
turn this symptom passed away, and half an hour before her death she was able 
to drink freely a large quantity of claret and water. She sank with the usual 
symptoms of asthenia and exhaustion, and died on the 6th of March. The 
autopsy was made eighteen hours afterwards and was conducted by myself. 
On opening the abdomen we found a good example of cystic disease of the 
kidneys, both kidneys being well mottled with these cysts. Some of them are 
so large as to admit the first joint of the finger. It is probable that this cvstic 
disease might originally have been congenital, and that after having been for 
some time in abeyance, afterwards became developed. I may mention that this 
cystic disease has not been known to be developed in adults at an earlier age 
than thirty years, and that Yirchow and Foster, and others, believe the origin 
of it to be a congenital change due to obstruction of the uriniferous tubules 
and subsequent dilatation of them into pouches. 

On opening the thorax, which by measurement after death confirmed the 
measurement taken before death, instead of an aneurism, which we expected to 
see, we found that there was dry adherent pleuritis on the right side, and a 



248 Progress of the Medical Sciences. [Jan. 

large mass of what turned out to be thickened pleura, with a vast quantity of 
lymphatic glands occupying the space where dulness existed, and lying upon 
and between the vessels in this region. 'I'he left innominate vein shows the 
position of the parts. These glands are in great numbers and enlarged, and 
lie between the pleura and the pericardium, engaging the course of the left 
phrenic nerve. Higher up we found a very large gland, the size of a large nut, 
immediately above the pulmonary artery, and engaging the branches of the 
pneumogastric nerve, the recurrent laryngeal branches of the pneumogastric 
nerve being pushed up by it, while the pulmonary and the cardiac branches 
are also engaged. This other mass of glands, making a large bunch, lay on 
the thin edge of the lung, which was pressed to the outside. On opening the 
lung we found in the apex a distinct chamber lined with a pyogenic membrane, 
large enough to receive a small orange or large walnut, while the rest of the 
lung was in various stages of softening. 

Examination of the heart showed the right auricle and the right ventricle 
perfectly healthy. The pulmonary artery was in a state of dilatation ; the pul- 
monary valves were thickened with fibrinous deposits, but competent to pre- 
vent reguraitation, and on looking closely there was found a very small fourth 
valve, which fitted in between the anterior and left valves, which is perhaps 
the commonest deformity found in connection with the right side of the heart. 

Further than this there was no evidence of organic disease of the valves ex- 
cept a slight stenosis of the aortic oritice. Turning to the aorta, it presents 
the usual appearance for the first two inches and a half; and on the junction 
of the transverse and descending portions we find that it is constricted or 
pressed upon seemingly by an enhirged gland, but is free from any atheroma- 
tous disease. Immediately beyond the orifice of the subclavian artery, just at 
the junction of the duct of T3otalli (which is filamentous) it is constricted so as 
hardly to admit my little finger. By way of contrast I have brought portions 
of the thoracic aorta, taken, one from a small old man, and the other from a 
small woman, in order to show the difference between the ordinary size of these 
vessels and what we found in this patient. 

1 believe the cause of the pulsation to have been the dilated condition of the 
pulmonary artery conveyed through the glands; the pressure of the enlarged 
bronchial glands on its branches and on the aorta gave rise to the thrill and 
vibration, while the murmur, I believe, was produced by the roughness of the 
semilunar valve, and to have been intensified by the delay the blood found in 
passing through the pulmonary and aortic arteries. The loud ringing charac- 
ter of the murmur was due to the neighbouring cavity in the lung. The larynx, 
which 1 here exhibit, is perfectly healthy, and free from any disease, and thus 
the laryngeal cough, dyspnoea, and stridor, can only be accounted for by the 
pressure of the enlarged glands on the recurrent laryngeal nerve. 

30. Symptomatic Hepatic Fever from Occlusion of Hepatic Duct. — The 
following remarks on this subject are abstracted from a course of lectures 
which M. Charcot has recently delivered at the Faculte de M6decine of Paris, 
on diseases of the liver, and which are characterized by the same power of 
observation and analysis so distinctive of the teaching of this eminent 
physician. 

As a consequence of obstruction of the common duct, the biliary ducts in 
the substance of the liver become greatly dilated, and after a while suffer 
changes, of greater or less severity, in their walls and contents. The inter- 
lobular canals partake comparatively very little in the dilatation. 

The change usually discoverable within the principal biliary passages consists 
in the disappearance of their cylindrical epithelium, a circumstance not found iu 
the interlobular canals. Mostly the dilated ducts contain a viscous bile, mixed 
with raucous flakes and debris of columnar epithelium, and, sooner or later, 
biliary sand. But it happens occasionally that, while the small biliary ducts 
in the hepatic substance are charged with bile, the large biliary canals are 
filled with a mucous liquid, destitute of the least trace of pigment or of biliary 
acids. As a rarer condition, the ducts contain a muco-purulent fluid, and in 
such case the lesion may be described as one of suppurative angiocolitis. 



18t7.] Medical Pathology and Therapeutics. 249 

The inflammatory lesions, however, are not confined to the ducts, but com- 
monly extend, as a hyperplasia, to the capsule of Glisson. Now and then, 
they give rise to the local formation of pus in the same structure, with the 
consequent formation either of a large abscess or of numerous disseminated 
lenticular abscesses. 

Another result of the obstruction of the common duct, arising from pressure 
of indurated tissue or of the distended biliary ducts, is arrest of the intra- 
hepatic circulation and stasis in the vena porta, with consequent ascites, 
hypertrophy of the spleen, and gastric and intestinal hemorrhage. In some 
cases of gastro-intestinal hemorrhage the bleeding proceeds from ulcers of the 
raucous membrane of the stomach. In other instances of hemorrhage, such as 
that from the nose, or from leech-bites, the bleeding appears referable to alter- 
ations of the blood or of the bloodvessels; and this alteration has been 
attributed to the solvent action of the biliary acids retained in the blood. M. 
Charcot, however, quotes some experiments of Yulpian to show that this 
explanation is inadmissible, inasmuch as the quantity of such acids when 
retained cannot be sufficient to produce the effects referred to. The same 
objection holds good to the attributing to this same cause the weakened action 
of heart with its results, the formation of clots in the auricle and hj;emoptic 
infarctus in the lungs, and the occasional nervous accidents terminating life in 
the form of convulsions and coma. 

But there is another symptomatic condition, known as "symptomatic" inter- 
mittent fever, which occurs at times, without any trace of actual hepatic colic, 
upon calculous obliteration of the common duct, and upon intra-hepatic biliary 
lithiasis, and, in fact, as a consequence of occlusion of the biliary duct from 
any cause, as, for instance, fibrous contraction, or pressure upon it of cancer 
in the head of the pancreas. 

The anatomical condition most favourable to the outbreak of this fever 
appears to be the presence of muco-pus mixed with stagnant bile in the biliary 
passages. It is, nevertheless, true that suppurative angiocolitis may exist 
without the occurrence of this intermittent fever; and, on the other hand, that 
this fever may arise when, rightly speaking, no suppuration is found in the 
biliary ducts. And it is equally possible that secondary hepatic abscesses may 
be wanting when this fever is present. To account for such ambiguous phe- 
nomena, M. Charcot concludes that there must be present, in the dilated and 
inflamed ducts, a septic principle, or " pyretogenic" poison, the product of 
changes occurring within the biliary liquid itself. 

But whatever be the exciting agent, an analysis of twenty cases shows that 
neither jaundice nor hepatic colic, although not infrequent, are its ordinary 
concomitants. The following are its phenomena: 1. The onset is sudden, com- 
mencing with a rigor, followed by heat and sweating, just as in an ordinary 
case of intermittent fever. Of the three stages the sweating is most prone to 
fail. 2. The non-febrile periods are very frequently clearly marked, and the 
accessions regular in their occurrence, simulating the quotidian, the tertian, or 
the quartan type. But to this rule many exceptions obtain. 3. M. Regnard 
has laid it down, though only from a single case observed, that it is a character- 
istic sign of this hepatic fever, distinguishing it from true fever, that the spe- 
cific gravity of the urine is reduced, and that leucine and tyrosine are present. 
M. Charcot, however, considers that the reduction in the proportion of urea is 
no special feature of the fever, but a result of merely damaged hepatic function. 
4. As happens with symptomatic fevers generally, the accessions of hepatic 
fever take place in the evening, instead of the morning, as is the rule in idio- 
pathic fever. 5. Hepatic fever is for the most part chronic. For instance, it 
may endure two or three months, with intervals, in which no accessions occur, 
of eight, ten, or fifteen days. 6. A favourable issue is possible — M. Henoch 
has reported one instance. 

This hepatic intermittent fever is separable from a form of fever coming on 
at times in the course of hepatic colic. Both alike are probably due to a 
similar pathogenetic cause — a septic matter derived from altered bile. The 
hepatalgic fever may be presumed to be set up from the passage of the gall- 
stone, which may either lacerate the raucous membrane of the biliary duct, or 



250 Progress of the Medical Sciences. [Jau. 

otherwise so increase the pressure in its interior as to facilitate absorption of 
the septic material. Or, again, the passage of the calculus may set up acute 
inflammation, the products of which may mingle with the bile and bring about, 
after the manner of a ferment, a very rapid alteration of its constitution. In 
support of this hypothesis it may be urged that the hepatalgic rigors scarcely 
ever happen except in case of patients a long time exposed to inflammatory 
lesion of the biliary duct; a condition of things favourable to the formation of 
a morbid material. Further, the rigor is sometimes the prelude to a series of 
febrile paroxysms, of greater or less regularity, but not without the recurrence 
of hepatic colic; and this phenomenon supports the second clause of the 
hypothesis. Of the intermissions of hepatic fever no explanation is at hand. 

In the same lecture, M. Charcot proceeds to point out the intimate analogy 
between the phenomena of hepatic fever and those of "urethral" or "uro- 
septic" fever, as seen in persons suffering with retention of urine consequent 
upon bladder and prostatic disease, and he takes occasion to describe the 
morbid renal condition known as " surgical kidney." — Brit, and For. MecL-Ckir. 
Rev., Oct. 1876, from Le Progrds Medical, Aug. 1876. 

31. Primary Cancer of the Spleen. — Of this pathological rarity there are 
few unequivocal cases on record, but among them may, perhaps, be classed, 
one that was brought before the Societe Anatomique in its April session, 
and recorded in Le Progrhs Mediccd for the 2d instant. The subject of the 
disease was a male, fifty-one years of age, admitted into La Charite, under 
the care of M. Woillez, with a history and some of the symptoms of cancer of 
the stomach. After death, however, the stomach and the whole intestinal 
tract were found to be healthy ; but the spleen and lumbar glands were exten- 
sively diseased. The former organ measured eight inches in each direction, 
was of firm consistency, and smooth surface; but on section it was found to be 
pervaded with firm yellowish-white nodules of cancer, which together far ex- 
ceeded the amount of parenchyma remaining. Some of the nodules were 
breaking down in the centre. The lumbar glands were also infiltrated, and 
formed a lobulated mass around the abdominal aorta. The liver contained a 
few miliary nodules, and was adherent to the diaphragm, whilst a solitary can- 
cerous nodule was present on the corresponding pleural layer. Other second- 
ary growths were found in the sternum, ribs, and vertebrse. The authors of 
the communication — MM. Affre and Moutard-Martin — while acknowledging 
the rarity of primary splenic cancer, point out that the disease was more ad- 
vanced in the spleen than in the lumbar glands — the only other place in which 
it could be considered to have arisen ; and they particularly insist upon the 
absolute freedom of the stomach and rectum from the disease. No mention is 
made, however, of the microscopical characters of the growth ; an omission of 
considerable importance, since it is highly probable that it was of the nature of 
lymphadenoma, in which case the extensive implication of the spleen, as con- 
trasted with the liver, and its association with the tumours, would not be so 
rare an event as the authors would have us believe. — Lancet, September 23, 
1876. 

32. Peritonitis in Children. — Dr. Kersch, of Prague, in commenting (Betz's 
Memorahilien, vol. xxi. Heft 2) upon the difficulty of determining the presence 
of peritonitis in children, concludes that the character of the breathing fur- 
nishes an almost pathognomonic symptom. Every deep inspiration produces 
pain in the hypochondria, and the breathing is therefore shallow and frequent, 
and is of the thoracic type. There is no impediment to expiration, and con- 
sequently the child can still cry vigorously. The characteristic breathing, 
then, consists of a long expiration followed by a series of extremely short 
inspirations, and, as a rule, each expiration is accompanied by a cry of the 
same duration. If this symptom be associated with a drawing up of the limbs, 
the diagnosis may be considered certain. The prognosis is more favourable 
than in adults, at least as regards life ; but when it occurs in girls between 
the ages of five and eight, the author believes that it is an important factor 
in the production of subsequent sterility ; indeed, all the cases that he has 



1877.] Surgery. 251 

known have had this result. Ten cases which were attacked between the ages 
of five and fourteen years, have been watched by the author. All have now 
been married some years, and all are childless, in the treatment of peritonitis 
in childhood, if the ordinary measures fail to reduce the quantity of fluid. Dr. 
Kersch employs puncture; if the fluid do not escape readily, he keeps the 
wound open for some days, or, should this heal prematurely, he makes a second 
puncture through the scar of the first one. 

Two cases are appended. One of these, a girl, aged five and a half years, 
had been much neglected, and when seen was in a condition bordering on col- 
lapse. 'I'he ordinary means were tried for a short time, but without effect. 
Puncture was then resorted to, and was performed in all three times. At the 
end of two montts the child was quite strong and healthy. The other patient, 
a girl, at fourteen, recovered without puncture. She was treated with large 
doses of quinine, morphia in weak solution, and cold compresses to the abdo- 
men. She is now twenty-four years old, and has been married six years, but 
has no children. The author believes the barrenness to be due to the contrac- 
tion of a layer of lymph which has been deposited upon the ovaries, and the 
consequent interference with the nutrition of these organs. — London Med. 
Record, Oct. 16, 1876. 



SUEGICAL PATHOLOGY AND THERAPEUTICS. AND 
OPERATIVE SURGERY. 

33. The Open Tre^lment of Wonvds. — Dr. Burow, of Konigsberg, reports 
{Archivf. Klin. CInrurg., xx. 1, 1876) the results of 123 operations performed 
by his father and himself during a period of nineteen years, and treated by the 
open method. The following are the figures given. 'J'here were 123 cases, 
with nine deaths, i. e., 7^ per cent., comprising thirty-three amputations of the 
thigh with six deaths, or 18 per cent.; twenty-four amputations of the leg with 
three deaths, or 12 per cent. ; and twenty-five amputations of the arm. twenty- 
nine of the forearm, nine of the foot, and two ot the hand without any fatal 
case These figures furnish a most interesting comparison with those com- 
piled by Paul, Malgaigne, Ashhurst, and others, more especially Kronlein, 
Volkmanu, and Thiersch. Dr. B. supports with sound arguments the charac- 
ter of his statistics, while acknowledging that the figures are small. He give?, 
in brief, the following as the essentials of the system he follows. In a case of 
amputation of the breast, he carefully checks the bleeding by the use of silk 
ligatures, which he cuts ofl^ short, 'i'he wound is then left absolutely open, 
being protected from dust and flies by a simple oiled cloth. No sutures or 
plasters are used. When the first oiled cloth is loosened by suppuration, a 
second is applied dressed with a simple ointment. AVhen granulations spring 
up luxuriantly, the cloth is wet with a solution of acetate of alumina. This is 
the whole treatment. After amputations of limbs, he first ligales the larger 
vessels before loosening the Esmarch's tube, completing the ligations after re- 
moving it. The wound is then left open for half an hour, with the double ob- 
ject of guarding against secondary hemorrhage and of allowing the surface of 
the wound to ooze with a serous fluid. Then he puts in three sutures, secur- 
ing them with a loop and not a knot, so as to allow for swelling of the tissues. 
Two or three strips of plaster are placed between the sutures, and the lower 
angle of the wound is left wide open for the free escape of discharges. Then 
by position of the limb and careful watching, it is made sure that the secretions 
can escape freely. He does a flap operation, insists on the greatest cleanliness 
on all hands, and never uses sponges a second time. — Medical Record, Dec. 
16, 1876. 

34. SidpMte of Soda as a Dressing. — Dr. Minnich, of the Venice Hospital, 
prefers the employment of the sulphite of soda to carbolic or salicylic acid, not 



252 Progress of the Medical Sciences. [Jan. 

only as a drcssinof for wounds, but also in erysipelas. It is much less inconve- 
nient to use, and much cheaper. He applies it in the same way as Prof. Lister 
does the carbolic acid, and the solution employed consists of one part of the 
sulphite and one of glycerine to nine parts of water. Its beneficial effects have 
been proved in a p-reat number of cases. — Med. Times and Gaz., Sept. 23, from 
Gaz. des Hop., Sept. 7. 

35. Neiu Method of Wouiul-drainage. — Mr. Chtene describes [Ed. Med. 
JoHin., September, 1876) a new system of drainage of wounds which consists 
in the substitution of hanks of catput prepared in carbolic acid solution for 
the India-rubber drainage-tubes. The number of threads in each skein must 
depend on the size and importance of the wound. " In a largre wound," he 
says, "as far as I am at present able to judge, eight or sixteen threads should 
be sufficient in each skein ; the number of the skeins depending on the shape 
and size of the wound. In cases in which very profuse discharge is expected, 
either in a specially large wound or after a tedious operation, in which the 
wounded surface is necessarily exposed for a considerable time to the irritation 
of the carbolic spray, it will be better to increase the number of separate 
skeins, stitching them to different parts of the wounded surfaces in order to 
keep them in position, than to depend on one or two thick skeins. I am led to 
form this opinion from the result in the case of excision of the knee. If it is 
ever necessary to use a skein of more than sixteen threads, one thread of cat- 
gut prepared in chromic acid should be added to act as a drain, if required, 
during the absorption and molecular disintegration of the drain. Chromic-acid 
gut should also be used to stitch the drain in position when such a procedure 
is necessary. 

"As regards the thickness of gut, I have used three thicknesses. The finer 
the gut the more numerous and the smaller will be the capillary tubes between 
the threads. The fineness of the gut will not interfere with the capillary action 
through the threads. For these reason-^. I am of opinion that the finest gut 
should be used ; by its use, the better will be the drain for any given thickness 
of skein. 

"It may be a question how much of the action is due to capillarity through 
and between the threads, and how much to the drain acting as a lead to the 
discharges. Capillarity has, I believe, the chief place. 

"I have hitherto used the gut prepared in the usual way by soaking in car- 
bolic oil. Simple soaking of the drain in carbolic lotion for a quarter of an 
hour before using will be sufficient in cases in which prepared gut is not at 
hand. 

"As long as the drain is acting, there will be a current of fluid along and 
around the threads (as well as in them), separating them from the living tissue, 
by means of which the process of absorption mainly takes place. When the 
flow ceases, then absorption of the column of fluid will first take place, the 
living walls of the canal will then reach the threads, and absorption will then 
commence. If this is a true explanation of what happens, then it is evident 
that it will not be necessary to use catgut specially prepared (as Mr. Lister, 
for instance, has shown by chromic acid) in order to delay absorption. 

" Further experiment may show that, in many wounds, all that will be neces- 
sary will be to bring the catgut ligatures out at the corners of the wound instead 
of cutting them short. This was my first idea; but I have been so satisfied 
with the skein, that I have not yet made trial of it. 

"I make no allusion in this paper to the use of catgut in draining suppurat- 
ing wounds, or in wounds not treated autiseptically. 

"I beg to recommend, as worthy of the notice of the profession, the prin- 
ciple of drainage by utilizing capillary forces through the skeins of an absorb- 
able material like catgut, if, by its use, the evils of the drainage-tube, already 
referred to, are got rid of 

" We may now anticipate a time when, with catgut stitches instead of silk, 
horsehair, or silver wire, catgut drains instead of India-rubber tubing, and 
chromic-acid gut fixing together the buttons instead of silver wire, it will not 
be necessary to uncover our wounds from first to last during healing, when the 



187t.] Surgery. 253 

deep dressin*? need never be shifted, and when the outer dressing will only re- 
quire to be removed when soaked with discharge. The amount of discharge, 
in its turn, will be reduced to a minimum by the use of an absorbable animal 
material like catpfut instead of non-absorbable foreign bodies like silk, silver 
wire, and India-rubber." 

36. Scalds hy Steam. — Inspector-General Smart gives {Brit. Med. Journ., 
Sept. 23, and Lancet of same date) a very interesting account of the cases of 
scald which recently occurred on board the Thunderer by an explosion of the 
steam boiler. Out of thirty-four vigorous men who were in the stokeholes, only 
two remain alive, and, in addition to these, eleven have since perished who 
were not so near to the exploded boiler. In all about eighty persons were in- 
volved, of whom forty-five have perished by an explosion of steam and hot 
water that burst the boiler with the force of a thirty-five ton gun, scattering 
huge masses of iron, tons of boiling water and volumes of steam, together 
with dense fumes from the extinguished fires. After an hour the living, fifty- 
eight in number, followed by nineteen corpses, reached Haslar Hospital. Of 
the latter fifteen had been brought up dead from the stokehole, and four had 
expired in the passage to the shore. Of the living, the majority were very 
severely scalded, but only one had received mutilation — of an ankle-joint, dying 
in four hours. Within thirty hours eleven others had succumbed to primary 
shock. Some of them were serai-comatose and little sensible to pain, others, 
after attempts to rally, became delirious, rolling heavily from side to side, and 
suffering from strangury, and stripping the dressings from their flayed limbs ; 
breathing heavily, and vomiting. Those who survived the shock felt relief from 
scorching agony in thirty-six to forty-eight hours, gaining fitful sleep, passed 
excretions, and some asking for animal food. Possibly steam-scalding of fauces 
and of primary air-tubes, in those who died of the so-called shock within thirty 
hours, was the lesion of most fatal import. The stage of reaction for suppu- 
rative effort was attended by internal congestions and inflammatory action in the 
brain and along the gastro-enteric track, with their characteristic symptoms. 
Under such conditions six perished on the fifth, sixth, eighth, and ninth days 
from injury. On the tenth day there remained alive forty-four, of whom twelve 
have died, twenty-seven have l3een discharged, and five remain under treatment 
(September r2th). 

One of these last cases, J. D , was severely scalded by steam over the 

head, face, and neck, in the air-passages, and over the arms and hands. He 
had been exposed to the first rush of steam up through the casing of the funnel, 
and 350 square inches of his surface had been denuded of its cuticle or covered 
with large vesications. On the sixth day all his unscalded surface was of a 
lurid red colour. He then became delirious, and had frequent fits of moaning, 
which lasted till the eleventh day, when he again answered coherently ; but 
from the fifteenth to the twentieth he was again delirous, yet after that he re- 
collected for the first time that he had been on board the Thunderer. In the 
mean time he had severe ophthalmia that had ulcerated both cornese, the left 
irrecoverably. On the twenty-second day he complained of dysphagia, when 
the fauces were found sloughy and aphthous, and at the end of the fourth week 
gastro-enteritis afflicted him till the thirty-second day. On the fortieth day the 
kidneys were excreting bile pigment, sp. gr. 1046, which state gave way to de- 
posits of urates, phosphates, and, later, oxalates. He is now convalescent with, 
however, left staphyloma and a few cicatricial contractions. 

In another case that is recovering, the patient was scalded by steam to the 
extent of 400 square inches. He has had no signs of meningitis, but from the 
suppurative stage he has had attacks of gastric irritation, and that also of the 
kidneys, to the extent of excretion of albumen with broken blood-disks. 

Such have been the two worst of the cases that have barely evaded the 
dangers which others have, only less in degree, gone through. In all, the 
results of nervous shock are well-marked in lowered courage and in dread of 
the past, from which time alone can restore them. 

Sloughing of the deeper integuments has been rare compared with that in 
gunpowder burns, wherein delirium is of earlier access. On the other hand, 



254 Progress oe the Medical Sciences. [Jan. 

early deaths from shock have been more frequent than in those burns, which 
may be attributed to the greater surface involved causing nervous depression, 
from which the reparative powers could not rally. 

A scientific observer who had been witness of the results in two great maga- 
zine explosions remarked to me that 80 square inches of inflamed surface 
induced fever with danger to life. To test this assertion. I set a painstaking 
officer, Dr. Burke, to make approximate measurements of the scalded surfaces 
in twelve cases remaining in the seventh week. He found it. in square inches, 
to have been 198, '213, 232, 265, 283, 345, 355, 363, 377, 398, 477, and 766, 
giving an average of 356 square inches excoriated or vesicated. Of these the 
men now under treatment gave 198, 355, 363, 398, 477. All these had two 
points in common— the severity of the scald on the face and head, and sloughs, 
leaving indolent ulcers on the arms, in which the new cuticle was very thin. 
The lowest, 198 square inches, was in the oldest man injured, aged fifty-three, 
who had a heavy struggle tlirough the febrile reaction. The figures 355 

belonged to the extremely dangerous case of J. D , already detailed. The 

highest, 766 square inches, is altogether exceptional, as he could not have sur- 
vived had the whole of that surface suppurated, much of it drying under the 
vesications. In him the scald was over nearly one third of his surface. He is 
one of the two remaining who were in the stokehole, and he escaped into a 
coal-bunker, from which he was drawn insensible. 

The questions of viability as dependent on the extent of surface involved, 
which determines the degree of shock, and again on the depth of tissue injured 
as taxing the reparative powers, are worthy of more precise observation. 
Perhaps in those who did not survive primary shock, the scald of the respi- 
ratory track, as well as that of the skin, precluded rallying ; while in those 
who fell later, the depth, more than superficial extent, proved fatal, which may 
explain also a higher mortality from the sequences in gunpowder explosions 
than in severe scalds not directly fatal. I would view 350 square inches, the 
mean of these measurements of scalds, and 250 square inches of surface burnt 
by gunpowder, as equally fatal injuries. 

As to the treatment. Until decided signs of rallying, it was by stimulants, 
with sago and beef-tea, anodynes of opium and chloral hydrate, chloroform to 
allay irritation of the stomach, and the use of the catheter. After rallying, 
beef-tea ond animal food, where appropriate, were given night and day. Lime- 
water with milk was given to allay irritability of the stomach. On and after the 
third day, laxatives were given when required to relieve constipation, which 
was a most suspicious sign throughout, as animal food was then well borne, and 
the healing process went on rapidly. In treating internal complications, general 
therapeutics were observed. In those of the air passages there were favour- 
able results in the congestive stage, and pneumonia developed only in two cases 
both fatal. The meningitic symptoms were beyond special treatment and yet 
two such recovered, and several also in which delirium had been present. 
Gastro-enteritic symptoms ran high, but subsided more readily than the menin- 
gitic with the establishment of suppuration, but there were instances of recur- 
rence at a later stage, in which one died with coffee-ground vomit. The renal 
disturbance was generally checked by alkalies and nitric ether. Great nervous 
prostration caused anxiety as leading to syncope, which was the mode of death 
in more than one instance in the suppurative stage. 

The local treatment was by oil and lime-water on cotton-wadding on every 
part to the fourth and fifth days, and later, in the majority, on the limbs. This 
being found inconvenient on the face, head, and neck, it was changed for a 
wash over with carbolic oil (1 to 10), then dusting on it from a common flour- 
dredger a powder, consisting of one of oxide of zinc, one of magnesia, and two 
of powdered starch, sifted on wherever moisture appeared, care being taken to 
keep free the facial orifices. It formed a mask to the features, excluding the 
atmosphere. Under its protection the process of " scabbing" went on favour- 
ably, and, the crusts detaching, the scalds were found healed, except sometimes 
on the pinna of the ear, where abscesses gave trouble. In one case only is 
there any permanent deformity by cicatrices on the face, so that I think it 
applicable also in confluent smallpox. It was used on some sores on the limbs 



i 



ISTT.] Surgery. 255 

the forearms and hands with success. Although only a mode of excluding 
atmospheric air, yet its claim is for simplicity and readiness of application. 
The treatment by oil and lime-water was in general disused before the tenth 
day; and when the above was not employed, it was substituted by a liniment of 
carbolic acid and olive oil (1 to 20) on lint under oil-silk, retained by bands of 
Lister's gauze, which although locally successful was not found free from a 
suspicion of irritating the kidneys. 

To maintain the highest possible degree of atmospheric purity, almost every 
known deodorant was used ; but preference was given to the process of Dr. 
Goolden, of disengaging chlorine, insensibly, from a mixture of nitrate of lead 
and common salt in solution, sprinkled on the floors from watering-pots, and on 
sheets hung round the offensive beds. 

37. Ranula treated by Injectio7i of Chloride of Zhic. — Prof. Panas has re- 
peatedly met with marked success from this metliod of treatment, employing 
from three or four to seven or eight drops of a solution of from ^ne-tenth to 
one-iifth in strength. One very remarkable case recently occurred, in which 
excision, suture, drainage, etc., had in vain been tried, the liquid always reac- 
curaulating ; so that at last punctures were only made from time to time in 
order to ward off" dangerous paroxysms of suff'ocation. Eight or ten drops of 
the solution (one-tenth) were injected without drawing off the contents of the 
cyst, and this after a while was repeated with a solution of one-fifth. The cure 
was very rapid, for in less than five weeks after the commencement of the treat- 
ment it was complete. The method is applicable to all kinds of mucous or 
serous cysts, for which Dr. Panas has made it a general means of treatment 
since his first case occurred, now two years ago. 'I'his was a case of subhyoi- 
dean cyst which had resisted cauterization and iodine injections, but yielded to 
a single injection of the chloride made without removing the contents of the 
cyst. — Med. Times and Gciz., Sept. 23, from Rev. Med., Aug. 21. 

38. Gostrotomy for Stricture of (Esophagus. — The medical journals of 
Paris [U Union, Medicate, Oct. 26 ; Gazette Hebdom., 27th Oct., and Le Mouve- 
ment M6dicale, 28th Oct.), contain reports of a most interesting case of gas- 
trotomy recently performed by M. Verneuil, and an account of which was 
communicated by him to the Academic de Medicine (Oct. 24), From these 
we compile the following particulars. Gastrotomy, tirst performed by M. Sedillot 
in 1849, has now been practised 16 times without success, but in all these cases 
the patients were already weakened by anaemia or cachexia. M. Y.'s patient 
was in excellent general health, and consequently a favourable subject for the 
operation. 

The patient was a lad seventeen years of age, who, on the 5th of February, 
swallowed by accident a solution of caustic potash. He immediately experi- 
enced a sensation of intense burning in the throat followed by fever and exfolia- 
tion of the mucous membrane of the pharynx and oesophagus. These symptoms 
abated, but after fifteen days he had great difficulty in swallowing. The dys- 
phagia increased, and on the 31st of March the patient was admitted into La 
Pitie Hospital under the care of M. Dumontpellier. Attempts at catheterism 
were repeatedly made without success, and on the 24th of May he v/as trans- 
ferred to the service of M. Verneuil. At this time he was much emaciated, his 
face pale and worn, temperature and pulse below normal. He was unable to 
swallow anything, all food being returned as soon as taken ; death from starva- 
tion seemed imminent. Catheterism showed the existence of a very tight 
stricture, about seven inches from the upper extremity of the gullet, so low as 
to preclude the idea of oesophagotomy. After some hesitation and repeated 
failures to introduce instruments through the oesophagus while the patient was 
under the influence of chloral, M. V., after consultation with M. Leon Labbe, 
decided to perform gastrotomy. Chloroform was administered, and full anti- 
septic precautions were taken during the operation, which was performed as 
follows : An incision was made in the abdominal wall parallel to the margin of 
the ribs on the left side, about two inches long. The skin, subcutaneous tissue, 
and the great oblique muscle were then divided, and the peritoneum exposed, 



256 Progress of the Medical Sciences. [Jan. 

which was raised by forceps and opened with scissors. The stomach, which was 
recognized by its white colour, was drawn into the wound with forceps and two 
long- acupuncture needles were passed perpendicular to the lips of the incision, 
so as to maintain the parietes of the stomach in contact with the edges of the 
incision. The margins of the incision into the peritoneum were seized with 
several hemostatic forceps. The portion of stomach exposed was then carefully 
stitched to the lips of the wound, in the abdominal walls and peritoneum by 
fourteen metallic sutures. The two acupuncture needles were then withdrawn 
and the stomach laid open. The parietes of this viscus, which since the 
application of the sutures had become intensely congested and of a violet red, 
was thickened and resembled nothing seen in the cadaver. A large sound of 
red caoutchouc was next passed into the stomach to the extent of about three 
inches, and secured by a silver wire, which traversed it and the walls of the 
organ. There was considerable hemorrhage from the incision in the stomach 
which was suppressed by the haemostatic forceps. Afterwards the whole abdo- 
men was covered with collodion and the patient removed to bed. He made a 
good recovery, and v^^as almost at once able to receive into his stomach liquid 
food. 

The progress of the case was attended by few vicissitudes. The patient was 
able to get up on August 20th, and by September 10th he could assist the 
nurses in the wards, having gradually recovered all the strength and energy 
which he had before the accident. The first sound was exchanged for one of 
an enormous size, which always remains within the fistular aperture. This 
fistula is rounded, and bordered throughout its circumference by a small pro- 
jection, formed of the red and smooth gastric mucous membrane. 'IMie patient 
injects through the sound thickened soups, hashes, potages, and drinks, having 
no other sensations at the time than those of heat and cold, and not finding one 
thing better than another, although after making the injections he often finds 
his mouth filled with saliva. He can, however, swallow none of this, and is 
obliged to expel it by the mouth. This privation of saliva and his peculiar 
mode of alimentation do not, however, seem to inconvenience the patient, if 
we may judge by his good state of health, and especially by his increase in 
weight. A month after the operation, this, which had fallen to thirty-three 
kilogrammes, rose to thirty-four (75 lbs.), and at the present time it has reached 
fortj'-two (92 lbs.). Last 'I'uesday he was to be present at the Academy, and 
take one of his meals in their presence. For these he has a very good appe- 
tite, and it is a curious circumstance that while they are being introduced into 
the stomach he executes masticatory movements. 

39. Treatment of Spasinodic Stricture of the (Esophagus. — Dr. Morell 
Mackenzie, in an interesting lecture on spasmodic stricture of the oesophagus 
{Medical Times and Gazette, Oct. 21, 1876), makes the following remarks on 
the treatment: — 

Whenever the cause, whether of constitutional or local origin, can be dis- 
covered, it should be removed. All reflex sources of irritation — especially 
those connected with the gastro-intestinal and uterine systems — should be most 
carefully sought out, and, if possible, got rid of. The nervous system must be 
braced up by moral, as well as by hygienic and medicinal agencies. It must 
not be forgotten that the hysterical disposition prevails in by far the largest 
number of cases. The mind should, if possible, be kept employed by regular 
and interesting occupation, or by change of scene and travel. Certain nervine 
tonics are specially valuable, such as the valerianate of zinc. I generally give 
it in combination with assafoetida, but it acts very well alone. 

The dietary in these cases is of the greatest importance. If the spasm is 
very severe, thickened liquids should l3e given, and it is well to bear in mind 
that warm drinks are much less apt to bring on spasm than cold ones, and in 
nine cases out of ten if the drink is sweetened it is better borne. Many pa- 
tients discover these circumstances without medical advice. Gradually the 



1817.] Surgery. 257 

food may be thickened, and panada' may be allowed. If the case progresses 
favourably, the patient will be able to return by degrees to ordinary diet. 
Stimulants should not, as a rule, be allowed, and all piquant food should be 
prohibited. It is the greatest mistake to force these patients to take solid 
food. They may sometimes be tricked out of their malady when it is slight 
and recent, but rough measures always fail. 

As regards local treatment, much can be done with the continuous current. 
The electrode should be introduced into the oesophagus at least once a day, 
and kept in position as long as the patient can bear it. I generally use a ten 
or twelve-celled battery. The application should be made soon after a meal, so 
that a considerable time may elapse between the treatment and the next time of 
deglutition. The muscles should also be galvanized externally. This treatment 
generally requires to be continued for some weeks or months. Sometimes 
great benefit, and indeed a complete cure, may be obtained by passing bougies. 
it is best to use an instrument with a metallic or ivory knob, and, if possible, 
to keep the extremity of tlie instrument opposite the seat of spasm. This 
treatment affords relief in the same way that passing a sound sometimes re- 
lieves irritability of the neck of the bladder. 1 have never obtained any satis- 
factory results from the application of stimulating or astringent solutions to 
the oesophageal mucous membrane. It has already been pointed out how 
easily those cases dependent on flatulent dyspepsia can be cured. It must not, 
however, be forgotten that in a large number of instances the dysphagia is a 
mere fancy, there being, in fact, no spasm. By passing a bougie and assuring 
the patient that there is no obstruction, such persons may sometimes become 
aware of the groundlessness of their sensations, but they are often more diffi- 
cult to cure than true spasm. 

40. Supra-pubic Cystolomy performed hy Incising the A^iterior Pariefes of 
the Bladder on the Calculus. — M. A. Amussat records {Le Courier Medical) 
an interesting case of this. The subject of it was a boy four and a half years of 
age, whom he was requested to examine by Dr. Costilhes, under the belief that 
the patient was suffering from calculus. On the 3d April, 1874, the patient 
was chloroformed, and a careful examination made, but without detecting any 
calculus. Subsequently the patient was examined by another surgeon, with 
the same negative result. The symptoms of calculus continuing, at the request 
of Dr. 0. a second examination was made on the 2d February, 1876, by M. Amus- 
sat, when the existence of a large calculus was ascertained. On the 20th of the 
same month, the patient was thoroughly chloroformed ; the bladder sufficiently 
distended with tepid water, when M. A. made an incision over the linea alba 
and above the pubes, about five centimetres long; he then made a small open- 
ing near the pubis, which he afterwards extended to four centimetres by the 
use of the hernia bistoury of Dr. Palamidesi. An examination then of the 
anterior parietes of the bladder by the touch, and an exploration by the rectum 
of the bas-fond of the bladder failed to detect the stone. M. A. then intro- 
duced a child's lithoclast, and by opening it to its greatest extent he was 
enabled to grasp the stone about a centimetre below the umbilicus. During 
these manoeuvres the abdominal muscles contracted violently, expelling the 
contents of the bladder and some fecal matter from the rectum. Not wishing 
to open the abdomen over the calculus, M. A., by careful manipulation, but 
with difficulty, succeeded in dislodging the stone and drawing it down opposite 
to the anterior parietes of the bladder and beneath the incision. He then con- 
fided the lithoclast to an assistant to hold it in position while Dr. Costilhes, 
pressing on the abdomen with his hand above the calculus, kept it steady. M. 
A. then placed his forefinger on the anterior of the organ in contact with the 
lower portion of the stone, and with his nail as a guide he made an incision 

' Panada is generally made of chicken or some white meat, but mutton and 
beef may be employed. The essence of the meat should first be extracted, and 
the residue reduced to the finest pulp. The whole should then be mixed toge- 
ther, and passed through a fine sieve. It should then be heated, and in the case 
of invalids should be served with fresh gravy. 

No. CXLY.— Jan. 1877. 17 



258 



Progress of the Medical Sciences. 



[Jan. 



into the bladder, without implicating' the peritoneum, of more than two centi- 
metres in extent, which allowed him to touch directly the calculus with his 
fing-er. Taking, then, the lithoclast in his right hand, his finger continuing to 
be applied to the calculus, he drew down the latter, and thus penetrated into 
the bladder. The instrument was then withdrawn, and an attempt made to 
seize the lower end of the calculus, but owing to the violent contractions of 
the bladder did not succeed in extracting it until after persevering efforts, and 
after seizing the end of the stone with small forceps, and with the aid of the 
bent forefinger. 

The operation finished, it became important to secure a passage for the 
urine through an elastic catheter introduced through the v/ound. But M. A. 
had been compelled, in order to extract the calculus, to withdraw his left fore- 
finger, and to seek anew for the opening in the bladder would incur the risk of 
injuring the parts, and might result in effusion of urine and abscess. After 
reflection, M. A. adopted the following plan : He introduced through the 
urethra a small metallic sound, much curved, and passed its beak out through 
the abdominal opening; he then slid a gum catheter opened at both ends over 
the sound as far as the bladder, and the metallic sound was then withdrawn. 
The edges of the wound were united by four twisted sutures ; the catheter was 
fixed by a thread to the nearest pin, and its free extremity inserted into a glass 
bottle, and the patient put to bed. 

This long and difficult operation, in which 100 grammes of chloroform was 
given, was followed for two days by prostration and loss of appetite, but the 
traumatic fever was not very high. 

On the 25th February (fifth day) the pulse was 120, the appetite returned, 
and a substantial diet allowed. The sound having been removed on the even- 
ing of the fourth day, the urine flowed freely from the wound. The progress 
of cure, with the exception of some redness about the sutures and ulceration 
around the needles, progressed favourably. On the Dth March the urine began 
to flow from the urethra. On the 24th March the wound had completely cica- 
trized, and the urine flowed entirely by the urethra. By the 14th of A.pril the 
patient was perfectly cured. 

Fisr. 2. 





The accompanying figures (for the opportunity of laying which before our 
readers we are indebted to the courtesy of M. Amussat) represent the size, 
form, and external appearance of the calculus, and the appearance also of a 
section. The calculus was very hard, weighed 4.5 grammes, was 2^ centimetres 
thick, and was composed of urate of ammonia. 

M. A. thinks that the calculus was developed in the urachus, and had be- 
come fixed there, and he refers to a case operated on by Franco [TraitS tres 
AmpU de.s Hernia, 1561, p. 139), which he thinks was of the same character. 

M. Amussat also relates two other cases of urinary calculi in old men, in 



IStY.n Surgery. 259 

which he performed the supra-pnbic operation, incisin*,^ the bhidder on the cal- 
culus, and finally refers to some cases of supra-pubic cystotomy, in which his 
father had operated in a similar manner. 

41. Effects of the entry of Air into the Veins. — M. Couty, of Yal de Grace, 
discusses in succession the various theories that have been proposed — cerebral, 
cardiac, and pulmonary — to account for the phenomena observed, and shows 
that none of them are quite satisfactory. He has made numerous experiments 
on dogs under various conditions — healthy, curarized, uninjured, and with the 
chest laid open, so that the movements of the heart might be examined and 
tracings taken. The results at which he has arrived are that air in the veins 
proves fatal through the circulatory system ; it first diminishes an*! then sup- 
presses the aortic wave and the arterial tension. Death is preceded by four 
periods, the rapidity of succession of which varies. First period: The arterial 
tension diminishes some centimetres, but this diminution is compatible with the 
exercise of the greater functions. Second period : The tension falls from four 
to eight centimetres, and disturbances arise from cerebral anaemia, acceleration 
of the respiratory movements, then further fall, loss of consciousness, etc. 
Third period : The arterial tension sinks almost to zero ; symptoms of medullo- 
bulbar anaemia appear, with contractions of the striated muscles, involuntary 
evacuations, and diminution in the frequency of the respiration. Fourth period : 
Complete arrest of the circulation ; the nerve centres die, the respiration 
ceases, and the right and left heart, the contractions of which are accelerated 
and energetic for the first three periods, are soon after arrested. But the 
arrest of the circulation may be very incomplete, and the disturbance from the 
entrace of air transitory, and then the general disturbances may be slight, or 
not perceptible, or they may only extend to the second or third period. But 
how does air in the veins arrest the circulation? M. Couty replies, by dis- 
tending the right cavities of the heart. In them it accumulates and gradually 
produces asystolia, rendering the contraction of the right heart incomplete. 
and occasioning insufficiency of the tricuspid valve. The dilatation of the right 
side is so great as to double or treble the size of the cavity. The venous 
pulse is very strongly marked, even as far as to the crural vein, and air is pro- 
jected throughout the venous system, appearing in the sinuses of the dura 
mater. Lastly, the heart contracts on an elastic fluid, and compresses instead 
of propelling it, M. Couty's view, therefore, is, shortly, distension, consequent 
on which is asystolia, and, finally, diminution or suppression of the pulmonary 
wave. — Lancet, Sept. 30, 1876. 

42. A Form of Chronic Inflammation of Bones [Osteitis Deformans). — 
Sir Jamks Paget communicated to the Royal Medical and Chirurgical Society 
(Nov. 14), a paper on this subject. He first gives a detailed account of a case 
which had been for many years under his observation, briefly noticed two other 
cases he had seen and referred to one recorded by Dr. Wilks in the Path. Trans., 
vol. XX. and of another under the care of Mr. Bryant in Guy's Hospital. 

Sir James Paget stated he had been unable to find recorded cases precisely 
similar to these, and he considered the following to be the chief characters of 
the affection : It begins in middle age or later, is very slow in progress, may 
continue for many years without influence on general health, and give no other 
troubles than those which are due to the changes of shape, size, and the direc- 
tion of the diseased bones. Even when the skull is largely thickened, and all 
its bones exceedingly altered in structure, the mind remains unaffected. The 
disease affects most frequently the long bones of the lower extremities and the 
skull, and is usually symmetrical. The bones enlarge and soften, and those 
bearing weight yield and become unnaturally curved and misshapen, suggesting 
the proposed name, " osteitis deformans." The spine, whether by yielding to 
the weight of the overgrown skull, or by changes in its own structure, may sink 
and seem to shorten, with greatly increased dorsal and lumbar curves ; the 
pelvis may become wide, the necks of the femora may become nearly horizontal, 
but the limbs, however misshapen, remain strong and fit to support the trunk. 
In its earlier periods, and sometimes through all its course, the disease is 



260 Progress of the Medical Sciences. [Jan. 

attended with pains in the affected bones, — pains widely various in severity, and 
variously described as rheumatic, gouty, or neuralgic, not especially nocturnal 
or periodical. It is not attended with fever. No characteristic conditions of 
urine or of feces have been found in it. It is not associated with any constitu- 
tional disease, unless it be cancer, of which three out of the five cases recorded 
in the paper were the subjects. The bones examined after death show the con- 
sequences of an inflammation affecting, in the skull, the whole thickness, in the 
long bones chiefly the compact structure of their walls, and not only the walls 
of their shafts, but, in a very characteristic manner, those of their articular 
surfaces. The changes of structure produced in the earliest periods of the 
disease have not yet been observed, but it may be believed that they are 
inflammatory, for the softening is associated with enlargement, with excessive 
production of imperfectly developed structure, and with increased blood-supply. 
Whether inflammation in any degree continues to the last, or whether, after 
many years of progress, any reparative changes ensue, after the manner of a 
so-called consecutive hardening, is uncertain. The microscopic characters bear 
out this view of the nature of the process, and Mr. Butlin, in his report, dis- 
cussing whether it might be of the nature of new growth, hypertrophy, or 
chronic inflammation, decides in favour of the latter. The paper goes on to 
point out the diagnosis from various forms of hyperostosis and osteo-porosis, 
some of which are dependent upon simple inflammation of bone, others upon 
strumous, gouty, syphilitic, and other specific inflammatory processes. In 
such cases it is rare to get the whole length of the bone affected, but the dis- 
tinction between them and " osteitis deformans" is most evident in the clinical 
history, and the absolute retention of good general health in the latter. The 
only parallel in this latter respect is with chronic rheumatic arthritis, which, 
however, is perfectly distinct, and is never associated with osteitis deformans. 
Eachitis and osteo-malacia have scarcely a feature in common with osteitis 
deformans. In rachitis the bones are too short, too small, and have different 
curves to the elongated and thickened bones of this disease ; and in osteo- 
malacia they are thin and bent in an angular manner. In conclusion, the paper 
indicated the variety of diseases which have given rise to different examples of 
the great porous skulls found in museums, mostly without any life history. 
Some of them are examples doubtless of — (1) osteitis deformans ; others (2) of 
osteo-malacia, as in cases described by Durham and Solly, which are distin- 
guished by their softness and lightness in proportion to their size ; (3) of 
rachitic, where the skull is very light and friable, with a fine felt-like surface ; 
similar skulls from young lions and tigers are to be found in the Museum of the 
Royal College of Surgeons; (4) from disease is early life, in which both cranial 
and facial bones become largely thickened, porous, or reticulated, and the 
cranial cavity diminished; to this group belongs the " leontiasis ossea" of 
Virchow ; lastly (5) enormous, bossed, and nadular outgrowths from the skull, 
as in the specimen described by Dr. Murchison and Messrs. Hulke and De 
Morgan in the Pathological Society's 'i'ransactions, vol. xvii. — Lancet, Nov. 
18, 1876. 

43. Trephining. — M. Sedillot, at a late meeting of the Academy of Sciences 
in Paris, communicated a paper on preventive trephining in fractures with 
displacement of splinters of the internal or vitreous table of the cranium. The 
author, in his former communications ( Comptes RenduH of Oct. 12 and Nov. 16, 
1874, tome Ixxix.) on the fractures of the internal or vitreous table of the 
cranium with displacement of splinters, had demonstrated that trephining is 
the only method of preventing inevitable and nearly always mortal complica- 
tions. The present paper contained one hundred and six confirmatory cases, 
partly derived from the publications of MM. Ohauvel, Gross, Cochu, T. and J. 
Boeckel, and Schalck, and several from M. Sedillot's own experience. Out of 
the one hundred and six wounded, seventy-seven were trephined ; twenty-nine 
were not operated on ; nine trephinings were preventive — that is to say, they 
were performed before the appearance of primitive or consecutive accidents. 
After the first day sixty-eight curative operations were done with the object 
of remedying grave complications, such as paralysis, loss of conscioufSness, 



187Y.] Surgery. 261 

convulsions, coma. Among'st these twenty-one operations were performed in 
the first five days of the wound, and forty-seven were delayed until after that 
time. Out of a hundred wounded patients the external table of the cranium 
was found unfractured in twenty-one cases ; and as the majority of the patients 
at first showed few symptoms, their wounds were frequently thought to be 
but slight. Out of the twenty-nine wounded suffering from vitreous fractures 
with splinters not trephined, there were one cure and twenty-eight deaths ; out 
of the seventy-seven tre])hined, twenty-nine cures, eighteen deaths. Nine pre- 
ventive trephinings gave six cures and three deaths; sixty-eight curative 
trephinings gave twenty-four cures, forty-four deaths ; twenty-one early trephin- 
ings, eight cures, thir.teen deaths ; forty-seven retarded operations, fifteen cures, 
thirty-two deaths. These results, according to the operator, were the confirma- 
tion of the facts and precepts laid down in his preceding communications, 
'j'he mortality was in proportion to the delay in the application of the trephine ; 
two-thirds of the patients were saved by preventive trephining; more than a 
third by early trephining ; less than a thii d by retarded trephining, and only 
one in twenty-nine in the cases where recourse was not had to trephining. M. 
Sedillot reminded his audience that he had proposed, in cases of doubt or 
hesitation as to the existence of a vitreous fracture, to have recourse to explo- 
rative trephining which Dr. Gross, of the Faculty of Medicine of Nancy, had 
performed under very bad conditions of general health. This operation was 
performed for the first time, and will certainly be again attempted. The patient, 
it is true, died, but death must not be attributed to the laying bare of the 
diploe. The suppurated state of the dura mater showed that it had received 
an indirect contusion, and the uncovering of the diploe does not usually bring 
on accidents, as we see in superficial excisions of the cranium by sabre-wounds. 
Surgical removal of a body fragment of the fractured external table does not 
cause contusion of the diploe, divided and laid bare, in all the applications of 
the trephine. Therefore it is allowable to renew this attempt. M. .Sedillot 
also analyzed ten cases of trephining to demonstrate the fact that complication 
of vitreous fractures, the time elapsed after the wound, the circumstances under 
which the wounded are placed, and their degree of vitality, have a great influ- 
ence on the condition of the patients who succumb c|uickly to, or resist in a 
surprising manner, nearly identical lesions. — Londo7i Med. Record, Nov. 15, 
1875. 

44. Fracture of the Cranium with Depression ; symptoms of compression ; 
cure luithout trepanuing. — M. Berger communicated to the Surgical Society 
of Paris, Oct. 11, 1876, an interesting case of this. 'J'he subject of it was a 
child aged thirteen years, who was struck on the right parietal region by a 
heavy bolt, which had fallen from a great height, causing a contused wound of 
the scalp and a rather extensive depression. The patient fell senseless ; reviv- 
ing afterwards he was sent to the hospital, where he had successively two 
attacks of violent general convulsions, terminating in coma with contraction 
of the upper limbs and squinting. These symptoms disappearing spontane- 
ously, M. B. concluded not to resort to trepanning. By the end of the second 
day all the cerebral symptoms disappeared and did not recur. The wound and 
the extensive denudation which at first existed were covered with granulations, 
and the patient recovered. 

M. Berger called attention to the less grave prognosis in traumatic lesions of 
the cranium in young subjects. He attributed the convulsions in the above 
case to the irritation of the surface of the parietal convolutions by the frag- 
ments of the depressed bone. 

In reference to surgical interference where there is an absence of cerebral 
symptoms menancing life, M. B. thinks that expectation is indicated by recent 
statistics, especially those of Dr. Bluhm of 925 cases of trepanning. This ope- 
ration resulted the more favourably the longer time had elapsed after the 
injury. Thus primary trepanning in fractures of the cranium with depres- 
sion resulted in a mortality of 57,14 per cent. ; secondary trepanning in a mor- 
tality of 40 per cent., and later trepanning in 16.67 per cent. only. It is, there- 
fore, he says, advantageous to postpone as long as possible surgical interference, 



262 Progress of the Medical Sciences. [Jan. 

and to wait until the most positive indications present themselves before ele- 
vating the fragments. — Gazelte Hehclom., Oct. 20, 1876. 

45. Injuries to the Shoulder. — Dr. M. SciiUller. of Griefswald, in a con- 
tribution to the Btrliucr KliviscJie Wdcheiisrrift, No. 37, 1876. on a simple 
guide to tlie differential diagnosis between fracture of the neck of the hu- 
merus and subcoracoid dislocation, alludes in the first place to the difficulty 
occasionally experienced by surgeons in distinguishing the one injury from 
the other, especially in fracture near the upper end of the humerus, in 
which the lower fragment, the shaft of the bone, is displaced inwards and 
into the axilla, whilst the upper fragment, the head of the bone, remains 
in the glenoid cavity. In this form of injury, which usually consists in frac- 
ture of the surgical neck of the humerus, the long axis of the arm runs ob- 
liquely inwards towards the coracoid pi-ocess. the elbow stands away from 
the side of the trunk, and the deltoid muscle is flattened or even concave on 
its outer surface — all signs of forward dislocation of the head of the bone. 
In many instances a fracture may be readily diagnosed, partly through crepita- 
tion, partly from a determination of the characteristic form of the end of the 
lower fragment, and of the presence of the upper fragment just below the 
acromion. Occasionally, however, a precise diagnosis of this injury may be 
rendered impossible through much effusion of blood, absence of crepitation, 
and the small dimensions of the upper fragment. Attempts at reduction per- 
formed again and again are in such a case always followed by an immediate 
return of the abnormal condition of the shoulder. Sometimes it happens that 
in one of these attempts at reduction the surgeon is able to make out crepitus, 
and then assumes that he has himself produced the fracture through the appli- 
cation of too much force, 'i'he author holds that under ordinary conditions it 
is impossible to produce fracture of the neck of the humerus in an attempt to 
reduce a dislocation at the shoulder. It often happens, however, that in a 
case of old fracture of the neck of the humerus, mistaken for and treated as a 
case of subcoracoid dislocation, the fragments are again separated in an at- 
tempt at reduction. The author does not altogether disapprove of the admin- 
istiation of chloroform in cases of doubt, but holds that apart from the fact 
that there may be cases in which the doubt cannot thus be cleared up, it would 
be more desirable to have some means of making the diagnosis surely and 
safely without anaesthesia. 'J'he method suggested as very simple and ready in 
its application is that of measuring the injured extremity, and especially the 
distance between the acromion and the point of the epicondyle. In every case 
of fracture of the neck of the humerus this distance is shorter on the injured 
than on the sound side, and this shortening is greatest in those cases which 
most resemble subcoracoid dislocation of the head of the bone. In this hitter 
injury the distance between the above-mentioned anatomical points is increased. 
The author does not agree with Malgaigne, who held that this increase in the 
length of the arm is not constantly met with in cases of dislocation. There is 
no difference of opinion, however, as to shortening of the arm in every case of 
fracture of the neck of the humerus with displacement of the shaft inwards. 
Sliortening. which in this injury is usually considerable, is, as was acknowl- 
edged by Malgaigne, never met with in cases of dislocation. The author, when 
measuring the distance between the acromion and the external epicondyle, 
takes care that the arm is abducted, and the forearm flexed at a right angle. 
The round extremity, when measured, is placed in a similar position. 'I'he tape 
is then carried to the external condyle from the same point of the acromion oa 
each side, and from either its anterior or its posterior angle. — London Medical 
Record, Nov. 1.5, 1876. 

46. Excision of the Elbow joint. — Surgeon-Major J. H. Porter, Assistant 
Professor of Military Surgery, Army Medical School, Netley, makes {Dublin 
Journ. Med. Sci., Oct. 1876) some interesting remarks on this operation, and 
relates two cases in which he has performed it, in one for gelatinous disease of 
the joint with caries of all the bones, in the other for pulpy disease of the joint 



ISn.] Surgery. 263 

and extensive caries of the humerus and ulna. In both cases about two inches 
of hone were removed. 

He states that "in investigating the experience of others, I was much im- 
pressed with the importance of the observations made by Mr. R. Hodges, of 
America, and Mr. C. T. Maunder, of London, respecting the method of opera- 
tion to secure extension of the forearm. The former remarks that, in excision 
of the elbow, no transverse cut across the triceps should be made, and the latter 
[vide British 3Iediral Journal of July, 1871) that it is essential to securing 
extension of the forearm, which power is not unfrequently lost, and for which 
he says the operation is responsible to preserve those tendinous fibres of the 
triceps muscle which are sent from beyond the attachment to the olecranon to 
blend with the fascia of the forearm, and especially with that portion of the 
fascia overlaying the anconeus muscle. Mr. Maunder commences the operation 
by a longitudinal incision at the back of the limb, in length three or four fingers' 
breadth both above and below, and crossing the point of the olecranon. He 
next sinks the knife deep into the triceps muscle, and divides it also lougitudi- 
rally into two portions, the inner one of which is tlie more firmly attached to 
the ulna, while the outer portion is continuous with the anconeus muscle, and 
sends some tendinous fibres to blend with the fascia of the forearm. It is these 
latter that are to be scrupulously preserved." 

To these suggestions of Drs. Hodges and IVfaunder, Surgeon Porter paid 
strict attention in his two cases, and " with the happy result of obtaining most 
perfect power of extension." "It is scarcely necessary," he adds, " to observe 
that with anchylosis in the straight position, there may also be power of exten- 
sion ; but as that result is not the only one desirable, it is necessary to try and 
induce the power of flexion so as to produce a generally useful limb, such as 
one possessing the natural motions of the shoulder, wrist, forearm, hand, and 
fingers. To obtain these results but little has been said by authorities, except 
as regards the movements of the elbow, and on these points opinions differ as 
to the period at which motion should commence. This, of course, might be 
influenced by the condition of the patient and the state of the wound. 

" In the two following cases the limbs were first simply laid in an extended 
position on a firm pillow, and the wound dressed with lint saturated with car- 
bolized oil, and cold applications to the outside. In both cases slight move- 
ment of the fingers was commenced the day after operation ; about the fifth day 
supination and pronation of the forearm, and as soon as the inflammation con- 
sequent on the operation had subsided, flexion of the elbow, with slight exten- 
sion, to prevent the ends of the bones coming into contact. 

''When the patients were strong enough to sit up and go about, exercises 
were enforced with a weight suspended to a cord passed over a pulley, which 
brought into action all the muscles and joints of the affected limb. 

"'I'he electric induction current was also used with decided advantage." 

In the first case five months after the operation the patient could " i)erform 
the following motions — scrub and sweep the floor, lift a considerable weight, 
place his hand behind his back so as to button his trousers, supinate or pronate 
the hand, extend the forearm, brush his hair and feed himself with a fork. The 
motions of the shoulder-joint were perfect, as well as that of the wrist, hand, 
and fingers. The sensation in the limb was similar to that in the sound one, 
and he possessed in every respect a useful arm, which would enable him to earn 
a livelihood." 

47. Sitbcutaiieons Division of the Neck of the Femur for Anchylosis of the 
Hip-joint. — Mr. Wm. Adams, in a paper read before the Royal Med. and Chirurg. 
Society, Oct. 10, 1876, stated that during the six and a half years which have 
elapsed since his first performance of this operation, he has collected from 
published and unpublished sources the details of twenty-two cases in which the 
operation has been performed, including five operated upon by himself. In the 
table accompanying the paper it is shown that the operation was successful in 
twenty out of twenty-two cases, death from pyaimia resulting in one case, and 
death accelerated by chronic suppuration following the operation in another 
case, that of a girl, aged eighteen years, who succumbed with symptoms of 



264 Progress of the Medical Sciences. [Jan. 

kidney disease and tubercular deposit in the lungs. Such a result bears good 
testimony to the general safety of the operation the dangers of which may be 
greatly diminished by the judgment of the surgeon in selecting his cases, and 
the skill shown in the performance of the operation. In cases where there is a 
doubt as to the possibility of the neck of the femur being divided subcuta- 
neously in consequence of alterations whicii may have taken place at the 
articulation, it should not be attempted, but some other operation below the 
joint, such as that first proposed and successfully performed by Mr. Gant, 
should be adopted. In two cases of anchylosis of the hip-joint, with malposi- 
tion of the limb, Mr. Gant divided the shalt of the femur subcutaneously, just 
below the small trochanter, using instruments similar to those employed by 
Mr. Adams. This operation may be performed without difficulty or risk of 
hcemorrhage. IMr. Adams has twice divided with the subcutaneous saw the 
shaft of the femur for great deformity resulting from badly united fractures, 
and once the shaft of the humerus for straight anchylosis. No suppuration 
whatever occurred. Mr. Maunder has also operated in simihir cases by dividing 
the shaft of the femur below the small trochanter, using the chisel and mallet 
instead of the saw — an operation resembling those performed by Langenbeck, 
Mayer, Fancoast, Brainard, C. S. Little, and others. The general result of 
the operation in the twenty-two recorded cases has been to correct the deformity 
and to obtain bony anchylosis, with the leg in a straight position. In several 
cases useful motion has been obtained, especially by Mr. Jessop of Leeds, Mr. 
Lund of Manchester, and Dr. Sands of New York. The paper concluded with 
the interesting fact that Sir C. Bell in 1828, had proposed division with a small 
saw of the neck of the femur in the early stages of hip disease with a view to 
allow the head of the bone to remain at rest in the acetabulum, and the hope 
that a freely movable false joint would result at the seat of the operation. Bell 
pointed out that such an operation would be attended by small risk, and, 
although he never carried out his suggestion, it was interesting to note that it 
was brought forward three years before Stromeyer's operation of subcutaneous 
tenotomy. Mr. Holmes remarked that he had only performed the operation in 
a single case, which proved fatal, and in which, owing to the condition of the 
parts, the division of the neck of the femur was not subcutaneous. In many 
cases where anchylosis follows upon strumous disease it is impossible to make 
a subcutaneous section owing to the shortening of the neck of the thigh-bone, 
and the large amount of osseous deposits, fibrous thickening, and adhesions in 
the vicinity; and he expressed his regret that Mr. Adams had not stated the 
grounds upon which a selection of fit cases was based, 'i'he field of operation 
would be much narrowed if it were only resorted to where the joint was free 
from the parts around, as by such restriction the great majority of examples of 
anchylosis with great deformity would be excluded. 

Mr. Maunder said that probably no example in modern operative surgery 
could be found associated with such great success and apparently with so little 
risk to life, as subcutaneous osteotomy. Mr. Adams had formerly pointed out 
the pathological conditions to which section of the neck of the bone was appli- 
cable, but not those to which it was inapplicable. It was in consequence of 
failure of section of the neck of the thigh-bone associated with tenotomy and 
forcible attempts at extension, in a case of fibrous anchylosis following stru- 
mous hip-joint disease operated upon by himself, and failure a week subsequently 
in another instance by Mr. W. Adams, which led him (Mr. Maunder) to resort 
to division of tlie femur below the lesser trochanter with a view to remedy the 
deformity. This he had accomplished several times vv-ith chisel and mallet. In 
two instances slight suppuration occurred for reasons explained in his paper 
on the sul)ject at the Clinical Society. In the remaining five cases (one of 
division to remedy deformity from faulty union after fracture) primary union 
occurred without the least suppuration. Mr. Maunder urged the necessity of 
the operator avoiding penetration of cicatricial tissue, owing to the readiness 
with which this new-formed material ulcerates. This he believed to have 
occurred in three cases known to him. He expressed surprise that, such 
decided success having attended the use of the chisel, Mr. Adams should speak 
of it as less subcutaneous than when the saw was used. Mr. Adams had himself 



ISn.] Surgery. 265 

performed the operation five times, and in one of these cases with an unfavour- 
able result. It was even a question yet to be determined whether the chisel 
would not replace the saw. 

Mr. Adams, in reply, admitted that the selection of proper cases was most 
important, and to this subject he had paid much attention in his pamphlet on 
subcutaneous osteotomy. The classes of cases in which the operation could be 
performed were — 1st, the rheumatic, where anchylosis had followed acute rheu- 
matism, as in the first case upon which he had operated ; 2d, the pysemic. where 
anchylosis ensued upon pycemic abscess ; and, 3d, those only of a doubtfully 
strumous nature, in which the disease had been arrested in the first staoe. In 
other cases, where the head of the femur was extensively destroyed, and change 
had taken place in the neck, Mr. Gant's operation mjoht be performed. But, 
wherever practicable, the neck should be divided, as there was more chance of 
producing a false joint there than there was in the shaft. Since his paper was 
written Mr. Maunder had improved his operation by using one chisel instead of 
three, and there was no doubt that this great success was partly due to Mr. 
Maunder's skill as an operator. He thought the operation applicable to cases 
of fibrous anchylosis which resisted other modes of treatment; as evidence 
of the operation being one well established in surgery, he pointed to the fact that 
the twenty-two cases related in his paper occurred in the practice of no fewer 
than twelve different surgeons. — Lancet, Oct. 14, 1876. 

48. Separation of the Spine of the Tibia. — There is a fracture of the tibia, 
seldom or never described in surgical text-books, which is not without interest, 
and very possibly is more common than is generally supposed. A case pre- 
sented itself to Professor Dittrl, of Vienna, not long ago: An energetic land- 
lord was ejecting one of his customers, whose-legs " crossed themselves back- 
wards," when some one who was helping the host gave the unfortunate man a 
kick either in the calf or the ham. producing altogether a complicated and not 
very intelligible accident. Blood was effused into the joint; amputation fol- 
lowed puncture; and at an autopsy it was found that the anterior crucial liga- 
ment had detached itself from its lower origin, tearing with it an oval piece of 
the upper surface of the tibia. This case led Dittel to perform a number of 
experiments on the cadaver [Cent ralhlatt far Chincrgie, No. 29), in the way 
of forcible flexion, extension and rotation of the knee; but he seems to have 
failed in any case to obtain the exact result which occurred in this and the two 
following cases. In extreme extension the tibia gave way, either as the result 
of impaction of the condyles of the femur into it or by separation of the 
epiphysis ; and if rupture inside the joint occurred at all, the posterior ligament 
carried away its lower attachment. In over- flexion, on the other hand, it was 
the anterior ligament which gave way, but it invariably remained attached to 
the tibia, and carried away part of its insertion into the femur. A number of 
other experiments of the same sort were performed, with various results. In 
No. 38 of the Centralhlatt filr Chirurgie is the record of a case described by 
Foncet in the Bulletin de la Societe de Chirurgie, 1875, in which death occurred 
from fracture, produced by falling down three stories. Afterwards, when ope- 
rations were being practised on the dead subject, it was that the left knee-joint 
was filled with blood, of which no trace was visible externally, while the whole 
spine of the tibia had been torn off by the separation of the lower attachment 
of the anterior crucial ligament. A case almost identical occurred in the 
wards of University College Hospital in April, 1873, and we believe the spe- 
cimen is now in the museum there. It differed, however, in the fact that 
the patient was a boy of eleven years, instead of being, as in the other two 
cases, of adult age. A cart-wheel passed over some part of his leg, producing 
such extensive destruction of soft parts that, in spite of attempts to save it, 
it was found necessary to amputate a fortnight after his admission. No special 
complaint of the knee was made, nor was there anything externally to point to 
an injury; but after the removal of the limb a condition precisely similar to 
that described by Poncet was discovered, but in this case the blood had been 
absorbed, and its previous existence was shown only by the yellow staining of 
the cartilage. One point may be added, which, if the close proximity of the 



266 Progress of the Medical Sciences. [Jan. 

attachments of the external semilunar cartiLage and the anterior crucial lig:a- 
ment be borne in mind, must almost certainly have occurred in the other two 
cases, viz., that the external semilunar cartilajire went up with the anterior 
crucial ligament and the separated spine of the tibia, and thus remained adhe- 
rent to the femur, while the internal, of course, kept its place on the surface 
of the tibia. — Med. Times and Gaz., Sept. 30, 1876. 

49. Suture of the Seiatic Nerve. — In the preceding number of this Journal 
(p. 586), there was noticed a case of this, and it is stated {Lancet, Oct. 21st) 
that the same operation has since been performed by Langrnbeok, and the 
details are given in a letter from Dr. Du Pre to the Journal de Medecine of 
Brussels. The sciatic nerve had been divided two years before by a fall upon 
a knife. The limb was wasted, and the outer part of the foot and leg was 
ana3Sthetic. A longitudinal incision was made over the cicatrix, and the two 
ends of the divided nerve were found two inches apart and surrounded by a 
considerable quantity of cicatricial tissue. Each extremity was considerably 
enlarged, the upper more than the lower. A small portion of the lower 
extremity was removed and examined for nerve-fibres, to ascertain whether its 
degeneration was so great as to preclude hope of recovery. Finding that it 
contained nerve-fibres, the extremity of the central portion was removed, and, 
the knee being bent, the extremities were brought together and united by two 
ligatures of catgut, the wound closed, and the knee kept in tlie same position. 
The interference with the nerve was followed by no bad symptom, and two 
months afterwards, although there was no return of motor power, it was thought 
that sensation had improved, for the patient could indicate the place touched, 
where before there had been no sensitiveness. 



OPHTHALMOLGY. 

50. Modified Operation for Cataract. — M. Galezowskt, at the recent meet- 
ing of the French Association for the Advancement of Science, described 
an operation for cataract, which he had devised. At the present time, he 
said, "every surgeon endeavours to modify Graefe's operation, which is at 
present almost abandoned." He described the modications he had adopted ; 
he does not make the sclerotic puncture and counter puncture, but restricts 
the incision to the limits of the cornea; he abandons the linear method, and 
substitutes for it an incision at the lower portion of the cornea, making a small 
flap. He also excises the lower portion of the iris, though the deformity of 
the pupil is then more observable, but this he thinks will be but a slight in- 
convenience to those who desire one thing, the restoration of sight. M. G. 
attributes to this inferior excision, the great success he has obtained, which is 
at present 100 per cent. Of 67 operations performed in the city, he has not 
failed in a single instance. By his method after the first steps of the opera- 
tion the eye is free in its motions especially after the removal of the lens, and 
to this M. G. attributes the rarity of the loss of the vitreous. Another 
modification, which he considers not less important, consists in the abandonment 
of the use of the cystitome for the division of the capsule, and effecting this 
with Graefe's knife. As soon as the puncture is made the point of the knife 
is directed to the lens and the capsule may be divided easily ; after the counter 
puncture is effected the flap is made. Latterly, instead of excising the iris he 
has made a simple incision of the sphincter pnpillas with very satisfactory 
results, but he has not determined to adopt this definitely. The statistics 
given to show the value of his method were as follows: Of 385 operations, 67 
were performed in private practice, of which last all were successful. Of 322 
operated on at his clinic, 288 were successful— i?ez;tte Scitntifique, August 26, 
1876. 



ISn.] Ophthalmology. 26t 

51. Causes and Origin of Near-Sight. — Professor Arlt, of Vienna, has 
published a small work on this subject, which has not yet reached us, but we 
give the following resume of the distinguished Professor's conclusions, com- 
municated to the Boston Med. and Surg. Jo^irnal (0(^. 19), in a letter from 
Dr. Ilasket Derbj'. 

"According to Prof. A., the ordinary immediate cause of near-sight is the 
lengthening of the eyeball in the direction of its sagittal axis. Increased 
curvature of the cornea, as well as abnormal curvature, position, or density of 
the lens are of exceptional occurrence. 

" In connection with this departure of the eyeball from its normal shape, we 
find the sclera driven back and attenuated, especially about the posterior pole, 
the choroid and retina expanded, the vitreous increased in volume by means of 
serous exudation, rendered even somewhat fluid at its posterior portion, the 
longitudinal fibres of the ciliary muscle hypertrophied, and the circular but 
slightly developed, while the ciliary processes, the iris, and the lens occupy a 
deeper plane relatively to the basis of the cornea. 

" It has never yet been demonstrated that this increased length of the eye is 
congenital. The myopia of new-born children is due to the great curvature of 
the lens that then exists. The existence of the so-called conns in new-born 
children has no connection whatever with an increased length of the eyeball in 
the sagittal direction. Myopia may originate in childhood. 

"Thus myopia itself is never congenital, though a disposition to it may be. 
Nothing goes to show that there is an abnormal innate tendency in the eye to 
increase in length ; indeed, the anatomical changes found in a myopic eye that 
has normal acuteness of vision go to controvert such a theory. 

" That myopia may be acqmred by individuals who have no hereditary pro- 
clivities in this direction we have distinct evidence. 

" 'i'he principal among the disposing causes is a certain want of tone in and 
yielding disposition of the sclerotic coat. 

"Another factor may be found in the use of muscular power, partly as re- 
gards the accommodation, partly as regards the convergence of the visual axes. 

"The remote (that is, the predisposing or exciting) causes of acquired near- 
sight include everything that tends to cause the muscular power of the eye to 
be expended in one direction, be it excessive use on near objects, be it neglect 
of use on distant objects. 

" If hereditary or diseased tendency exist in a given case, the ordinary em- 
ployment of the eyes will tend to further the giving way of the sclera. If 
circumstances are simply favourable (youth and normal development of the 
organ), myopia can only ensue when the eyes are unduly tried and insufiiciently 
rested. 

" The change in shape of the eye is brought about by a gradual pushing out 
of its posterior wall. Neither muscular action (on the part of the ciliary muscle 
or oblique muscles) brings this about, nor is it caused by forcible expansion 
of the scleral layers, or of the optic nerve sheath ; it is due solely to the re- 
peated temporary increase of pressure in the posterior segment of the eye, 

"This repeated temporary increase of pressure in the posterior portion of 
the eye is chiefly due to congestion of the uveal tract, and secondarily to exuda- 
tion of serum in the posterior part of the vitreous. 

" The congestion is caused by the impeded flow of blood from the vasee vorti- 
cosse. It is hardly likely that the simple exercise of the accommodation 
brings this about, but it is almost indubitable that, when the' convergence of 
the visual axes increases, the rectus externus and the obliqnus inferior muscles 
severally exert a pressure on the vense vorticosse that impedes their circulation. 

" 'J'hese are substantially the views Professor Arlt has just put forth. The 
pamphlet is illustrated by plates showing the different conformation of the 
ciliary muscle in the myopic, the emmetropic, and the hypermetropic eye. 

" With reference to the prophylactic measures to be adopted in the case of a 
student who exhibits acquired and increasing myopia, I was glad to find that 
Arlt advised entire disuse of the eye on near objects for a lengthened period, 
a course of atropine treatment, and, if possible, a sea-voyage or a prolonged 
journey, during which the eyes should be exercised on distant objects." 



268 Progress of the Medical Sciences. [Jan. 



MIDWIFERY AND GYNECOLOGY. 

52, The Mechanism of Spontaneous Version. — In the Annales de Gynico- 
logie for June, 1876, Dr. Geneuil relates the following' case: A woman, aged 
twenty-eight, who had previously had three children, and had a full-sized pelvis, 
was pregnant for the fourth time. At full term slight labour- pains commenced 
about midnight. By noon on the next day the pains had assumed an expulsive 
character, and the membranes ruptured in the presence of a midwife who was 
attending, and who then detected an abnormal presentation. Dr. Geneuil. on 
being summoned, found the left arm, swollen and blue, hanging from the vulva, 
the foetal head being in the right iliac fossa. 'I'he os was tightly closed round 
the shoulder, and the hand couhl not be introduced into the uterus. Dr. Geneuil 
therefore decided that it would be impossible to attempt version, and resolved 
to perform embryotomy. At the end of half an hour, having- made his prepa- 
rations, he laid his hand upon the uterus, and was astonished to find that on 
the left side there was strong contraction, while upon the right there was none. 
Thinking, therefore, that since the pelvis was large, spontaneous version might 
be accomplished, he left the case to nature. By 4 P. M. the shoulder beg-an 
gradually to recede, and by 4.30 P. M. the breech was presenting-. 'I'he con- 
tractions then became uniform on the two sides of the uterus, soon increased 
in vigour, and at ten minutes past five a dead female child, rather above the 
average size, was expelled. The author believes that his observation in this 
case explains the mechanism by which spontaneous version is accomplished, 
and that the powerful contractions on the left side of the uterus forced the 
breech down, while its comparative laxity on the right side allowed the head, 
lying in the right iliac fossa, to recede. — Obstetrical Journal of Great Britain, 
6ct"ri876. 

53, Enemata of Chloral in Natural Labour. — M. Polaillon stated at a 
meeting of the Surgical Society of Paris (Oct. 4th, 1876), that injections of 
chloral per rectum had been recommended for the relief of the pain in normal 
labour. He had used it in 17 cases, injecting from 2 to 7 grammes of the 
hydrate of chloral. In most of the cases the labour was retarded or arrested, 
and it was necessary to extract the head, arrested at the vulva, with the forceps. 
The patients' sufferings were not alleviated. In other cases the chloral had 
not modified the labour; finally, in the smaller number, the labour progressed 
favourably. Hence, he concludes it is useless or even hurtful to give chloral 
to women iu labour, at least, when attended with painful contractions and con- 
striction of the neck of the uterus. — Gazette Hebdom., Oct. 13, 1878. 

54, Extra-Uterine Foetation ; Removal by Abdominal Section of a Living 
Foetus; Recovery of Mother and Child. — Mr, Thomas R. Jessop records 
{Lancet, Nov. 4) a very interesting case of this. The subject of it was aged 
26, in her second pregnancy. When admitted into the Leeds General Infirm- 
ary, August 13, 1875, she was emaciated and pain-worn, vomiting after every- 
thing swallowed, constipated, feverish, with a dry tongue, great thirst and a 
rapid, feeble pulse. It was abundantly evident that the patient was fast 
sinking. On consultation, it was decided that the diagnosis of extra-uterine 
gestation seemed complete and gastrotomy was decided on. Accordingly, on 
the 14th of August Mr. J. performed it. The patient having been placed under 
the influence of ether and the bladder emptied of urine, an incision six inches 
long was made through the linea alba, with the umbilicus at its centre. The 
abdominal wall was unusually thin, but more vascular than common, and the 
peritoneal lining, though natural on its free surface, appeared thick and velvety 
on section. Immediately upon the completion of the incision, the breech and 
back of the child, thickly coated with vernix caseosa, came directly into view. 
At the upper part of the wound the omentum was seen lying like a cap upon 
the child's shoulders; and inferiorly the funis, of natural appearance, passed 



ISIT.] Midwifery and Gynaecology. 269 

transversely across the wound, and was traced round the external aspect of the 
left thigh of the foetus to its attachment at the umbilicus. 

The child was in a kneeling position, its breech presenting towards the 
mother's navel, its head folded upon its chest, buried beneath the omentum 
and transverse colon, the soles of its feet pointing towards the pubes, and its 
knees resting upon the posterior brim of the pelvis. Its removal was readily 
eflfected. The funis was tied and separated in the usual manner, and the child 
was handed over to the custody of two gentlemen previously appointed to 
look after its well-being. It was now seen that the gestation had been of 
the "abdominal" variety; no trace of cyst or of membrane could be found. 
The child had lodged in the midst of the bowels, free in the cavity of the 
abdomen. 

A few bands of unorganized lymph of a very friable nature, lying upon, but 
not adherent to, intestines, were readily removed by sponging, and about one 
ounce of clear serum was found in the peritoneal cavity. On tracing the 
umbilical cord, the placenta, having a larger superficial area than natural, was 
seen covering the inlet of the pelvis, like the lid of a pot, and extending some 
distance posteriorly above the brim, where it apparently had an attachment to 
the large bowel and posterior abdominal wall. Near its centre was a round 
prominence, which seemed to correspond with the swollen fundus of the uterus 
beneath. Great and especial care was taken not to cause the smallest disturb- 
ance to its connections. The placenta was indeed left untouched. The umbili- 
cal cord was now brought out of the wound and shortened, so as to have its 
cut end protruding about two inches beyond the surface of the abdomen, where 
it was secured at the inferior extremity of the wound by means of a clamp, 
which has been invented by the ingenious chaplain to our Infirmary, Mr. Gough, 
for the treatment of the pedicle in ovariotomy. The wound was now closed by 
means of six silver-wire sutures passed through the entire thickness of the 
abdominal wall, and including the peritoneum, together with as many interme- 
diate superficial sutures of silk. It was then observed that the prominence 
above the pubes, before alluded to, was due to the placenta covering the 
enlarged uterus. Strips of plaster, pads of lint, and a roller completed the 
dressings. 

The child, a female, was well developed, considering that in all probability 
it had not reached the eighth month of foetal life. 

On the 17th, the clamp was removed and the funis, in a gangrenous state, 
could be traced deeply through the wound. To prevent it from dropping into 
the abdomen it was secured outside by means of jute and adhesive plaster. 
From time to time she complained, when not under the influence of morphia, 
of very great pain at the bottom of the body and in the thighs. There was 
not at any time a discharge from the vagina, although she made complaint of 
pain and forcing as if due to uterine contraction. On the 18th of August her 
breast became distended with milk, and by the 22d it had disappeared again. 
Besides the nutrient enemas she now began to take a few spoonfuls of milk and 
gruel by the mouth. On 19th August, five days after the operation, the 
dressings were found soaked by a bloody discharge. This continued daily for 
some time in quantities varying from one or two, to as much as eight or ten 
ounces. On the 22d, it was observed to be offensive, and of a thick, dark 
grumous character; and a few days later the stench arising from it was most 
intense. On 24th August she had a severe rigor, lasting ten minutes, and this 
was followed by vomiting. 

On August 29th the vomiting had ceased, and her general condition had so 
improved that her request to have tea and a biscuit was complied with. From 
this time her diet was improved daily, fish, eggs, chicken, etc., being cautiously 
added at intervals. 

On September 4th the funis was cast off as a long, slender slough, its dis- 
charge being followed by a copious flow (six or eight ounces), of fluid. 

The wound had now healed in its entire length, with the exception of the 
round hole at its lower extremity, which had previously been occupied by the 
umbilical cord. At this time three weeks had elapsed since the operation. 
During the next fortnight the discharge was most profuse. Two, three, and 



2Y0 Progress of the Medical Sciences. [Jan. 

even four times in the twenty-four hours she was seized with agonizing abdo- 
niiual pains, which, after lasting from a few minutes to two or three hours, 
were at once relieved by an outpouring of a quantity of putrescent fluid. On 
the 10th of September 1 stood by her in one of her most severe attacks, and I 
was almost alarmed, upon hearing her exclaim, ''There, I shall get relief," to 
see not less than half a pint of a coffee-coloured fluid, of the consistency of 
treacle and unbearably offensive, rapidly forced out of the wound. 

On September 14tli she complained of pain in the right leg and foot, and 
upon examination these were found to be slightly oedematous. Tliere was also 
some tenderness along the course of the femoral vein in Scarpa's triangle. On 
the 15th a slough three inches long came away. On the 16th the discharge 
became purulent and decidedly less in quantity. It was observed that the 
supra-pubic prominence had now disappeared. By the 18th the oedema in the 
leg had gone, and on the 19tli the patient sat up in bed to dinner. Her pro- 
gress now became steady and equable. On the 27th of September she sat for 
an hour in a chair, and on the 9th of October she was able to be transferred to 
the General Ward. The discharge had now become small in quantity, thin 
and serous in character. On the 29th of October the wound is reported as 
quite healed, and three weeks later she returned to her home. From that time 
to the present, she has kept in good health. Menstruation commenced about 
a month after she left the Infirmary, and has recurred at regular periods ever 
since. 

The child was as healthy, vigorous, and large as an average child born in the 
natural way, and it continued to thrive well till July, 1876, when, after a week's 
illness, it died of croup and inflammation of the lungs, at the age of eleven 
months. '"^ 

55. The Originator of the Double-curved M/dtDifery Forrepfi. — Dr. Mc- 
Clintock has lately inquired into the history of the double-curved forceps, 
with the purpose of ascertaining to whom the credit of inventing the second, 
or pelvic, curve belongs. His learned investigations show that the first person 
who devised and made use of this form of forceps was Dr. Benjamin Pugh, of 
Chelmsford, Essex, who had the instrument made about the year 1736. But 
both Levret and Smellie also had a similar instrument in about the same time 
— Levret in 1747, and Smellie in 1751. It is possible that the idea of a pelvic 
curve occurred to each of those eminent men independently, for there is no 
evidence to show that they were acquainted with the previous discovery of the 
instrument. — Brit, and For. Med.-Chir. Rev., Oct., 1876, from Proceedings of 
Dublin Obstet. Soc, April 8, 1876. 

56. On the Action of Midwifery Forceps as a Lever. — Dr. A. L. Galabin, 
Assistant Obstetric Physician to Guy's Hospital, in an interesting paper [Obste- 
tricalJournal of Great Bntain, Nov. 1876) discusses this question which was 
raised by Dr. Matthews Duncan in the issue of the same journal for March, 
1876 (see Monthly Abstract of Medical Science for April, 1876, p. 180). 

From the mechanical study of the question Dr Galabin deduces the follow- 
ing conclusions : 1. The oscillatory movement is superfluous in all cases where 
extraction can be effected by forceps with moderate force, and it is useless when 
the head is movable, friction taking little part in its retardation. 2. When the 
head is impacted, a very slight oscillation, in which the head is made to take 
part, may assist in starting it by converting the greater statical into the lesser 
dynamical friction. 3. When the head is impacted and great force is required 
for its extraction, a mechanical advantage may be gained from leverage by 
having recourse to an oscillatory movement. The oscillations should be of very 
small amplitude, and should only be continued if it is found that each of them 
causes a corresponding advance of the head. Each oscillation should be 
accompanied by firm compression of the head, to prevent the forceps slipping 
and the lever becoming decomposed, and also by the utmost tractile force 
which is considered permissible, to assist in fixing the fulcrum. 



1877.] Midwifery and Gynaecology. 271 

57. Local Treatment of Puerperal Fever. — Dr. Fritsch, of Halle, strongly 
recommends the injectioa of large quantities of a carbolic acid solution (2 or 
3 per cent.), so as to thoroughly wash out the uterus and vagina, and to com- 
pletely distend the latter. To this end he throws in two, and sometimes three 
litres, i. e., from four to six pints, the temperature of the water being at 25^ 
R. (89*^ Fahr.). The uterus, after a thorough cleansing out, need not be 
injected oftener than three times in the twenty-four hours ; and after three or 
four days this need not be continued, but the cleansing and distension of the 
vagina must be repeated much more frequently and persisted in for a much 
longer time. Under this treatment not only are the local lesions soon ameli- 
orated, but the febrile action, as indicated by the temperature-curves, abates. 
Prof. Schroder, on the reading of the paper, mentioned that Dr. Hildebrandt 
employed for injecting the vagina a glass tube, about as thick as a finger, each 
patient being provided with her own, which is broken on her recovery. — 3Ied. 
Times and Gaz., Nov. 18, from Allg. Wieii. Med. Zeituiig, Oct. 24, 1876. 

58. Pathology of Membranous Dysmenorrhoea. — This subject has long been 
involved in difficulty, partly owing to the designations applied to it, and partly 
to the rarity with which accurate microscopic examination of the substances 
expelled have been made by competent observers. Dr. Beigel, whose compe- 
tency in every respect no one can gainsay, regards the affection as an exfoli- 
ative endometritis. It is essentially characterized (a) by the expulsion of a 
membrane at the time of menstruation, and (5) by the expulsion of this mem- 
brane at indeterminate intervals or recurring every month. 

Hence this exfoliative endometritis may exist, and does exist without dys- 
menorrhoea; physiology, etiology, and pathological anatomy demonstrate its 
nature. The name membranons dysmenorrhoea then is bad. At the same time 
the membrane expelled is not the consequence of a very early abortion ; an 
erroneous idea which the name decidua menstrualis might justify. On the con- 
trary, this affection is a cause of sterility or abortion. Moreover, it not rarely 
occurs in virgins, and its monthly expulsion has been observed in many cases. 

Beigel's opinion is based on etiology and pathological anatomy. The affec- 
tion is not specific; it comes on after primitive or secondary endometritis; it 
is often connected with diseases of very varied nature ; general diseases, such 
as cholera and phthisis; uterine diseases, such as flexiiius, and especially retro- 
version; chronic metritis, tumours, particularly fibroids and polypi, and 
mechanical irritation. The formation of a membrane is the principal ana- 
tomico-pathological characteristic of the disorder. Its expulsion is but a con- 
sequence, an accident, which attends menstruation and metrorrhagias, and 
uterine contractions, which coincide with them. As the causes are various, so 
the microscopical characters of the expelled membranes are different. They 
all, however, present a common character; they are separated from the sub- 
jacent mucous membrane by a fibrinous layer containing free round cells. 
They are constituted sometimes by hyperplasia of the normal elements of the 
mucous membrane, sometimes by degeneration, by destruction of its pai-ts, 
glands and epithelium ; sometimes by the production of embryonal elements, 
and lastly, sometimes they contain round cells, flattened epithelium, and embry- 
onal elements at the same time. — Brit, aiid Fur. Mtd.-Chir. Keu., Oct. 1876, 
from Arck.f. Gynek., Bd. ix. heft. 1, 1876. 

59. CcBsarean Section for Cicatricial Obliteration of Vagina. — Dr. Galabin 
showed to the Obstetrical Society of London (Nov. 1st) the uterus and ad- 
joining parts from a case in which he had performed Caesarean section on ac- 
count of cicatricial obliteration of the vagina. The patient, aged forty, had 
been married five years before, and two years after was confined for the first 
time. Although there was no contraction of the pelvis, she was two days in 
labour, and, as she stated, the child had eventually to be destroyed. Two 
weeks after delivery incontinence of urine commenced. She was afterwards 
for five months in Guy's Hospital, having a vesico-vaginal fistula just behind 
the pubes, which admitted the finger. She was seen by several surgeons, but 
it was considered hopeless to attempt any operation for her relief. When she 



272 Progress of the Medical Sciences. [Jan. 

left the hospital the entrance of the vagina had contracted up to a minute 
aperture. The menses never returned, but after about. a year she began to have 
periodic pains every month. Although marital intercourse appeared to be im- 
possible unless the rectum were used, she again became pregnant. Labour 
pains come on on October 2, 1876, but never became vigorous. Foetal move- 
ments ceased on the 4th. She was seen on the 5th by an extern attendant, 
who unfortunately mistook the case, having probably examined the rectum 
instead of the vagina. When she came under observation on the 7th, the 
sixth day of labour, the pulse had risen to 150. Since her condition was too 
desperate to allow the attempt at dilatation after incisions, Csesarean section 
was resolved on. The orifice of the vagina only admitted a No. 6 catheter, 
being embedded in very dense tissue. On opening the uterus, the head of the 
foetus was found to lie upwards, and no part of it had descended into the 
cervix, although it was dilated enough to admit two fingers. Some fetid gas 
escaped, and the surface of the uterus was covered with greenish slough. A 
trocar and canula was passed from outside through the constriction, and the 
uterine wound closed with thick carbolized gut. Not the slightest contraction 
of the uterus could be procured, and hemorrhage took place from the placental 
site. Notwithstanding subcutaneous injections of ergot, and the use of mani- 
pulations, ice, and eventually perchloride of iron, the patient expired before 
the abdominal wound was closed. 

Dr. Meadows thought there could be no doubt as to the propriety of the 
treatment adopted by Dr. Galabin, but he took exception to one point in the 
operation — viz., the employment of catgut sutures in the uterus ; they had 
most signally failed in his own and Dr. Routh's experience. The interrupted 
current would probably have been most useful in restraining hemorrhage and 
securing firm contraction of the uterus. 

Dr. Rogers had seen two cases of Csesarean section recover where no sutures 
had been employed for the uterine wound, the peritoneal cavity not being 
closed until firm contraction of the uterus had taken place. He had also seen 
two successful cases where silver wire sutures had been employed. — Obstetrical 
Journal of Great Britain and Ireland, Dec. 1876. 

60. Subperitoneal Fibroid Tumour of the Uterus removed through an Incision 
in the Posterior Wall of the Vagina. — Dr. R. Stansbury Sutton records [Chi- 
cago Med. Journ. and Examiner, Dec. 1876) a case of this, the first case in 
which a uterine fibroid tumour has been removed in that way. He alludes to 
the four cases in which ovarian tumours have been removed by this method — 
that of Prof. T. Q. Thomas, Dr. R. Davis, Dr. S. T. Gilmore, and Robert 
Battey, all successful. 

Dr. Sutton's patient was a coloured woman 50 years of age, with a large 
solid tumour, ovoidal in shape, filling the right half of the pelvic cavity, and 
pushing the uterus firmly to the left lateral wall. The operation was performed 
June 25, at 11.30 A. M., as follows : 'J'he patient being placed on her left side, 
the bladder emptied with a catheter, and ether administered. "The posterior 
wall of the vagina was seized, about midway between the rectum and cervix 
uteri, with a tenaculum, and cut through with one stroke of the scissors; with 
a probe-pointed bistoury and the aid of a tenaculum, this incision was extended 
as far as possible towards the rectum and towards the cervix. All bleeding 
being arrested by sponging with cold water, the peritoneum was picked up with 
Sims' small tenaculum and cut through with the scissors. This incision was 
now made of the same length as the former, with the probe-pointed bistoury. 
The finger was now readily brought in contact with the tumour. An effort made 
to enucleate the growth in its position failed. The hand, first dipped in car- 
bolized water, was carried into the cavity of the pelvis, the tumour grasped 
and all its adhesions forcibly broken up. It was found to be attached by a 
fleshy pedicle to the posterior wall of the uterus. When the hand was with- 
drawn, the small intestines followed into the vagina. These were carefully 
pushed back with the hand, which was again carried up to the growth. A pair 
of strong vulsellum forceps were carried closed along the front of the wrist and 
palm of the hand and carefully expanded over the tumour, which was now 



ISTT.] Midwifery and Gynaecology. 273 

seized and drawn into the vagina, the index finger of the left hand working 
back over the growth as much as possible the lips of the vaginal wound. The 
speculum was again introduced, and the exposed capsule incised as far as it 
could be reached and with the aid of a pair of dressing forceps, a tenaculum 
handle, and the finger nail, it was stripped back beyond the equator of the 
growth on all sides. The tumour now occupied the vagina, and, a second pair 
of forceps being fastened upon its stripped surface, the first pair were carefully 
removed. A pair of guarded hooks were also fastened into it and by these 
with Dr. Pollock's assistance, we pulled the tumour through the external outlet 
of the pelvis. Dr. Guthrie supporting the perineum with one hand and strip- 
ping back the capsule with the thumb nail of the other, as the tumour came 
out. Two vessels in the pedicle required ligation. The pedicle with some 
folds of small intestine in the vagina were now pushed back into the abdominal 
cavity. No stitches were applied in the vaginal wound, 'J'he patient had been 
forty minutes under the anaesthetic, of which eight fluidounces had been con- 
sumed. 

" The patient was now put to bed, pulse 120. Ordered one-eighth grain mor- 
phise sulph. every three hours, oftener it required. 

" 4 P. M. Catheter used — to be used every six hours." 

The patient died June 29 at 9 A.M. 

Dr. S. says " a careful investigation revealed a wound of the small intestine, 
which had been made with a prong of the vulsellura during the operation. 
'I'his wound was only discovered by making pressure along the intestines and 
finding that gas escaped at what was a mere pin hole, leading down from which 
was the line of a little rent which was so completely glued as to require some 
effort to separate the edges. At what stage in the operation this occurred I 
do not know. The danger was appreciated and careful attention given to avoid 
it. Doubtless the escape of gas was one cause of the peritonitis which carried 
her ofi"." 

61. Treatment of Inverted Uterus hy Elastic Ligature. — Dr. Arles com- 
municated to the French Association for the Advancement of Science at its 
recent meeting a memoir on the treatment of inverted uterus by the elastic 
ligature. He reported the case of a woman who had been pregnant seven times 
and aborted thrice. She had inversion of the uterus which Dr. A. tried fruit- 
lessly to reduce by all the means ordinarily resorted to. He then determined 
to draw down the inverted uterus and to surround it with a caoutchouc tube 
drawn moderately tight. The result was satisfactory ; the tumour was detached 
in about fifteen days. 

Dr. A. maintains that the elastic ligature is superior to other means hitherto 
employed : to excision ; to the simple or metallic ligature ; to the ecraseur or 
togalvano-cautery, etc. etc. Dr. A. has never met with hemorrhage or peri- 
tonitis from its use. — Revue Scientifique, Sept. 2, 1876. 

62. Removal of Inverted Uterus by the Elastic Ligature. — Professor Courty 
relates [Aimales de Gyndcologie, September, 1876) two cases of removal of 
the inverted uterus by the elastic ligature. In the first case, the uterus was 
removed by Dr. Courty after he had failed to reduce it. A caoutchouc tube 
was fastened round the neck of the uterus, and its ends fixed by a waxed 
thread very tightly drawn. This was tightened from time to time. At the end 
of thirteen days the tumour was completely detached. At the end of two 
months the patient was discharged, cured. The second case was done by Dr. 
Arl^s, who applied the ligature in the same manner, and the uterus separated 
on the twelfth day, without any complication, leaving the operator astounded 
at the simplicity, harmlessness, and efficaciousness of the operation. In order 
to mark out more clearly the line of section. Dr. Courty proposes to burn a 
furrow round the uterine neck with the galvano-cautery, in which the ligature 
will be more readily embedded. — London Medical Record, November 15 
1876. 

No. CXLY.— Jan. 1877. 18 



274 Progress of the Medical Sciences. [Jan. 

63. Dermoid Ovarian Ci/sts. — Dr. Tiios. Griffiths, of Swansea, exhibited to 
the Pathological Society of London (Nov. 21), two specimens of dermoid- 
ovarian cyst, removed successfully by abdominal section performed with anti- 
septic precautions and the use of catgut ligature. One was from a fairly 
nourished girl twelve years of age, in whom a tumour in the abdomen was first 
noticed when four years old. She suffered from pain in the abdomen at irregu- 
lar intervals, and was first seen by Dr. Griffiths on October 14th of the present 
year. He found a movable tumour, the size of a large cricket-ball, seated mid- 
way between umbilicus and pubes. It could be pushed into either flank, into 
the pelvis, or epigastrium ; when in the latter situation a cord-like structure 
could be felt continuous with it below. It was lobulated in form and elastic, 
and from its long duration and slow growth w-as thought to be of dermoid 
nature. On October 25th the abdomen was laid open, and the tumour found 
to be attached by a long pedicle to the left ovary. The pedicle was secured 
by catgut ligature, and returned into the peritoneal cavity. The case did well, 
the dressings were only disturbed three times at intervals of five days, and on 
November 9th the patient was convalescent. The contents of the cyst were 
chiefly hair, oily fluid, and foetal remains. The second case was that of a 
married woman, twenty-one years of age, who presented a tumour in the abdo- 
men which had been first noticed four years previously. 'J'herewas pain in the 
left iliac region, and the tumour was globular in shape, movable, and reached 
from the pubes to midway between umbilicus and ensiform cartilage. It was 
removed on November 8th. and found to contain six pints of creamy fluid and 
matted hairs ; it weighed 1 lb. 3 oz. after removal. It also had a long pedicle, 
connecting it with the left ovary. The patient did well, and was convalescent 
on November 20th. Dr. Griftiths had had in all four cases, all treated in the 
same way. He asked for information as to the advantages of catgut over the 
clamp in securing the pedicle, and whether the ovary should be removed with 
the growth when the former was not intimately connected with the tumour. 
Mr. Spencer Wells did not think it necessary to remove the ovary where, as in 
these cases, there was a long pedicle between the cyst and the organ ; but 
where any portion of the Fallopian tube is removed with a growth it would not 
be wise to leave the ovary behind, because of the possible consequences of 
maturation of Graafian follicles v/ithout means of escape for their contents. He 
recalled a case, thought to be a movable kidney, in which a tumour, afterwards 
ascertained to be a dermoid cyst of the right ovary, could be pushed into the 
right hypochondrium. He remarked that he had performed ovariotomy three 
hundred times before he met with a case of dermoid cyst, and tlien he had two 
examples almost at the same time ; and now, out of eight hundred operations, 
he had had twenty examples of dermoid cyst, eight of which had occurred in 
the last hundred cases. Drs. Battey and Peaslee, of the United States, had 
recently stated that dermoid cysts should never be removed, on account of the 
fatality attending the operation ; but out of his twenty cases Mr. Wells had 
lost only t-wo.— Lancet, Nov. 25, 1876. 



ISn.] 275 



AMERICAN INTELLIGENCE, 



ORIGINAL COMMUNICATIONS. 

Sub-peritoneal Fibroid Tumour removed by Abdominal Section. By 
C. B. King, M.D., of Allegheny, Penna. 

Catharine , set. 36 years, a native of Switzerland, was admitted to 

the Western Pennsylvania Hospital May 13, 1876. She has always en- 
joyed good health until the present trouble began. First menstruated at 
eighteen years of age, and has been regular ever since. Was married at 
twenty-five, and is the mother of two children, the oldest ten years of age, 
and the youngest four years. Has never miscarried. Immediately after 
the last confinement, four years ago, she noticed a lump in her left side, 
but paid no attention to it, as it gave her no pain or inconvenience. On 
July 26, 1874, during a severe storm, the locality in which she lived 
(Butcher's Run) was flooded, and she was much frightened, as she was 
compelled to stand up to her waist in the water for some time. She is 
not aware of receiving any injury at the time, but shortly afterwards her 
abdomen began to enlarge, and slowly increased to such an extent as to 
seriously interfere with respiration and locomotion. On the tenth of last 
April she was visited by Drs. McCann, Smith, and myself, when we drew 
off about fourteen quarts of fluid, which relieved her very much. The fluid 
was albuminous, did not coagulate on exposure to air, and contained no 
ovarian cells. When admitted to the hospital, the abdomen was con- 
siderably distended with fluid. The uterus could be plainly felt above the 
pubes very much enlarged. In the left side was a tumour about the size 
of a child's head. It was hard, and could be easily moved about in the 
abdominal cavity, but appeared to move independently of the uterus. 
The uterine sound entered 6^ inches, but the uterus remained fixed ; evi- 
dently bound down by adhesions. There was considerable oedema of the 
lower extremities. The urine was normal but scanty, and passed with 
some difficulty. As she had been compelled to remain in bed for the last 
five months with insufficient food, she was very aneemic. Her appetite 
was poor, menstrual flow regular and of normal quantity, except upon 
two occasions when she lost large quantities of blood. She was put upon 
iron, quinia, and strychina. 

3Iay 21. Pulse 89 ; temp. 98|°. Stomach rejects food, owing to 
enormous distention of abdomen. She was again tapped, and fourteen 
quarts of fluid withdrawn, which gave relief and enabled her to retain 
nourishment. 

June 13. Pulse 90 ; temp. 99^°. Tongue clean ; suffers no pain, but 
much inconvenience in breathing, from enormous distention of abdomen. 
Abdominal veins very much enlarged. The abdominal swelling is symme- 
trical, and measures as follows : — 



276 American Intelligence. [Jan. 

Inches. 
Girth of body at eosiform cartilage ...... 39^ 

jNIidway between umbilicus aud ensiform cartilage . . . 40^ 
At the umbilicus ......... 43 

Midway between umbilicus and pubes 4lf 

At the pubes 36 

From umbilicus to each anterior spinous process . . .12 

From symphysis pubis to umbilicus 20|- 

From umbilicus to ensiform cartilage ...... 9j 

The patient being etherized, an incision was made in the median line, 
beginning about two inches below the umbilicus, and extending five inches 
In the median line. There being very little bleeding, I cut rapidly down 
on the peritoneum, which I incised, and drew off seventeen quarts of 
straw-coloured fluid. On opening the abdominal cavity, the ovaries were 
found to be tiormal. A large quantity of serum was sponged out which 
was highly coloured with blood from tearing up of recent adhesions be- 
tween the uterus and abdominal wall. On the left side, just above the 
uterus, was found a fibroid tumour with a short and narrow pedicde 
attached to the fundus of the uterus. The pedicle was ^ inch long by | 
inch broad. Over the tumour were thickly spread enlarged veins, and 
these, collected into a plexus, were traced to the concavity of the liver, 
and were probably mesenteric in origin. The largest was ^ inch in thick- 
ness The tumour was slightly oval in shape, and about as large as a 
good-sized child's head at birth. The uterus was enlarged to the size of 
a double fist, and at one point behind, and to the right of the fundus, a 
protrusion could be felt, but no distinct fibroid could be defined. 

There was no attachment Ijetween the uterus and abdominal viscera, 
but the uterus was bound to the ajiterior wall of the abdomen by adhesions 
which api)eared to be recent, and bled freely when torn up. The tumour 
was separated from the uterus by the wire-rope ecraseur ; no bleeding 
-from the stump The plexus of veins, which were about the thickness of 
two fingers, only slightly held together by connective tissue and looked 
like a bundle of earth-worms, were then gently drawn out, and Atlee's 
clamp applied five inches from the tumour. One large vein, which came 
from the opposite side of the intestine, was separated from the clamp and 
brought out near it to avoid constricting the bowel as the plexus shrivelled 
up. The peritoneum was noticed to be of a deep red colour around the 
attachment of the uterus to the abdominal wall. There was considerable 
delay in securing a complete removal of serum and blood from the abdo- 
men. The wound was closed with silver wire, the clamp being fixed at 
upper part of incision. The cut end of pedicle, which was not included 
very tightly in the clamp for fear of cutting thi'ough the attenuated vessels, 
was touched with persulphate of iron, and the usual dressings after re- 
moval of ovarian tumour were applied. The oi)eration lasted one hour. 
The patient was ordered two drachms of solution of morphia, and beef-tea, 
as soon as her stomach would bear it, and to be catheterized every three 
hours. 

I visited her in the evening, six hours after operation, and found her 
resting comfortably ; no i)ain ; pulse 90 ; temp. 99|°. 

14^/?,, 9 A. M. Pulse 102 ; temp. 99^° ; takes beef-tea well ; slept four 
hours during night ; suffers no pain. 

15//?, 9 A. M. Pulse 100 ; temp. 99^° ; had severe pain yesterday after- 
noon, which lasted about five minutes, and was relieved by the passage of 
gas ; is cheerful, and slept some during the night. 



isn.] 



Original Communications. 



277 



\m, 9 A. M. Pulse 84 ; temp. 98 J^ ; slept from 9 P. M. to 3 A. M. ; 
dressings were changed, as the cotton was soiled by oozing of serum 
through the incision ; wound looks well ; no pain ; takes beef-tea freely. 

I'Jth, 9 A. M. Pulse 79 ; temp. 100° ; slept well all night ; no pain or 
tenderness over abdomen ; says she is hungry, and wants solid food ; 
wound looks well, and has united throughout whole extent. 

20th. Pulse 72 ; temp. 98^° ; rests well at night, and is free from pain ; 
all stitches, but one, removed. 

22c?. Pulse 72 ; temp. 98° ; last stitch removed ; clamp and ligature 
came away ; pedicle dressed with powdered oxide of zinc. 

24^/?. Pulse 70 ; temp. 98° ; bowels moved by olive oil ; sits up in bed, 
and ordered solid food ; prescribed five grs. citrate of quinia and iron, 
three times a day. 

July 7. Has been walking about the ward since 2d inst ; sound enters 
uterus five inches ; discharged cured. 

Aug. 2. Patient walked two miles to my office to-day, and says she is 
as strong as ever. There is no return of ascites. 

Case in which an India-rubber^ Nursing-tube ivas Swallowed by an 
Infant. By James Bordley, M.D., of Centreviile, Md. 

The following case appears to me as one of sufficient novelty to warrant 
its being recorded. 

The accompanying wood-cut fairly represents the size, etc., of a rubber- 
nursing tube swallowed by an infant 18 months old, and passed per 
rectum, after remaining in the bowels for a period 
of ninety days, producing no symptoms worthy of ^,-'-""" -,^ 

note until four days prior to its ex))ulsion (No- 
vember 16th, 1875), at which time complete and 
obstinate obstruction of the bowels came on, with 
all the acute phenomena so characteristic of such 
trouble. 

Although the child was watched with all that 
jealous care so characteristic of a fond mother and 
two grandmothers, no suspicion of the accident 
was entertained, and until the tube was evacuated 
it was never remotely thought of. But afterward 
the circumstances connected with its disappear- 
ance were recalled, and the date of its entry into 
the child's stomach could be fixed. One point at 
least of interest is the fact of the long retention 
of the tube without producing any ill effect ; no 
symptoms of obstruction manifesting themselves 
until four days prior to its discharge. 

After considering the question from every point, the only theory offering 
a satisfactory solution appears to me to be, that tlie tube, being too large 
at either extremity to enter the ileo-csecal valve, was retained about that 
point until the action of the fluids destroyed the rounded point or mouth, 
thereby rendering it more compressible, when it was so changed in form 
that it passed the constricted point, for it was there that the obstruction 
existed. 

The following description will serve as an explanation of the drawing : 
As may be readily seen from the cut, the tube as expelled differed consid- 
erably in form, size, etc., from its original. Its density and flexibility 




21S 



American Intelligence, 



[Jan. 



were also grreatly altered. From a soft, smooth, and elastic tube it be- 
came a bard, rough, and nearly inelastic mass. 

The parts marked out by the dotted lines represent the portion destroyed 
by the digestive fluids, and the dark spots upon it represent the general 
appearance of its surface, studded, as it were, witb small but hard and 
rough tubercles. 

The length of the tube was 2 inches ; largest circumference 2| inches. 

Description of au Improved Barneses Dilator. By T. P. Seeley, 
M.I)., of Chicago, Illinois. 

I have recently devised an improvement of Barnes's dilator, which 
all who have seen think well of, and which in actual 
practice has proved its usefulness. 

A A represents a section of the dilator, which I have 
had made of two sizes, the larger of which is about two 
inches in width by three in length when not filled, the 
acuminate end being adapted for introduction into the 
cavity. 

B is a tube passing longitudinally through the centre 
of the dilator, and attached to the distal extremity. Its 
object is to allow the entrance of a sound or director, by 
means of whicli the instrument is to be introduced into 
the uterus or rectum. It also serves to prevent the 
longitudinal extension, and thus increases the force of 
the lateral expansion of the dilator. 

D represents a metallic socket at the end of the tube, 
to prevent perforation by the director. 

C is a smaller tube connected with the dilator proper, 
by which it is to be distended with air or water after its 
introduction. 

None who have used the Barnes's dilator will fail to 
appreciate the advantage of an improvement which renders quite easy its 
introduction and retention as long as may be required. 

The improved dilators may be obtained of E. H. Sargent, of this city. 

Supptemental Beport of a Case of Ovariotomy. By James P. Orr, 
M.D., of Andersonville, Indiana. 

In the report of a case of successful ovariotomy (American Journal of 
the 3Iedical Sciences, July, 1876, page 291), I conclude by stating, that 
after four successive hemorrhages, from a small abdominal o]ieniiig, at as 
many consecutive menstrual periods, the patient reported herself entirely 
cured. Nine months after the operation I was consulted about a sore spot at 
the lower end of the original incision, and at the point at which I had made 
the second incision for the purpose of cleansing the abdominal cavity on 
the supervention of septicsemic symj>toms. On making an incision at 
this ))oint through the integument, and a thin layer of other tissues, I 
discovered the Chinese silk ligature with which I had tied the pedicle of 
the tumour, then ten months previous. I removed this silk; found it 
almost as perfect as when it had been applied ; and now, two months and 
nine days since the last operation, I find, by personal observation, the 
entire incision completely healed, and the patient increased 35 pounds in 
weight since the original operation. 




1877.] Original Communications. 279 

Circulation of the Blood Subjectively Seen. By C. A. White, M.D., 
of Washington, D. C. 

Sitting with the eyes completely closed, but usually better if facing the 
light, and looking intently as if to catch a glimpse of some object in the 
dark, one may perceive an appearance similar to that of the circulation of 
blood in the web of a frog's foot as seen under a magnifying power of, 
say, 100 diameters. The apparent caj)illary streams thus perceived in tlie 
eye are very numerous, but they are less definite and continuous than are 
those which we see in the frog's foot. The course of each also is irregular, 
and they seem to have no common direction, and are often much con- 
fused. 

This phenomenon may be more distinctly observed if there be headache 
or other cerebral excitement, and I am disposed to regard it as subjective 
vision of the circulation of the blood in the choroid. I use the word sub- 
jective, not to imply that it is an " optical illusion," but to distinguish 
the phenomenon from ordinary objective vision, regarding it as the result 
of mechanical impingement of the blood-corpuscles against the proximal 
ends of the rods that compose the bacillary layer of the retina, as they 
rush against them in the capillaries of the membrane of Rnysch. The 
peculiar reticulated distribution of the al)undant cnpillaries in that mem- 
brane accords well with the appearance as of capillary streams to be ob- 
served in the eye, as just explained. 

That the appearance of light, and even of an object, may be produced 
by mechanical pressure upon the retina, is shown by the well-known 
" phosphene" perceived when the finger is pressed against the side of the 
eye. It is true that the apparent size of the corpuscles, assumed to be 
subjectively seen by this observation, is many times greater than their 
actual size; but then the retinal image of every object seen by ordinary 
vision is exceedingly small as compared with our conception of the size of 
the object. In the case of mechanical pressure against the retina also, 
the size of the phosphene perceived is always much larger than the part 
of the retina affected, and it is about the same size whether the finger-end 
or the head of a pin be used in producing it. 

Autopsy of the Body of J. W. Wllkie, M.D., late Superintendent of 
the Auburn Amjlum for Insane Convicts, as reported to his successor, 
C. T. McDonald, AID. By D. Dimon. iM.D. 

The congenital abnormal condition of the right ventricle of the heart 
and aorta may give this report sufficient importance for publication. 

The lungs were strongly adherent to the dorsal vertebra, the adhesions 
extending some distance from the vertebra along the ribs. The anterior 
surfaces of the vertebra were in numerous places rough, being denuded of 
the periosteum. The aorta from its base to beyond the arch was not less 
than three times its usual calibre, and its walls throughout of propor- 
tional thickness. The walls of the right ventricle were uniformly less 
than two lines in thickness, the heart, in other respects, natural. The 
muscular fibres were easily separated, but this defective tenacity was that 
of the tissues generally. The reversed condition of the right ventricle of 
the heart and the aorta could not be the effect of disease, but of a con- 
genital displacement of the vessel formation of the right ventricle into the 
aorta. 

The pulsations of the radial artery in a peculiar manner indicated the 
lack of the contractile force of the ri<2:ht ventricle when the doctor was in 



280 American Intelligence. [Jan. 

his usual health, and was not changed during his sickness. It had a full 
pulsation, followed by one or two slight short ones; as if the unequal 
pulsations were made by the left ventricle drawing on the pulmonary ca- 
pillaries now full, now not so full, instead of being uniformly filled by the 
equal action of the ventricles on the aortic and pulmonary columns of 
blood. 

For more than six months previous to his dissolution he had suffered 
excruciating pains along the dorsal vertebra, from which he only found 
relief by a repetition of blisters. From first to last he experienced no 
disturbance of the functions of the heart and lungs. At intervals of ease 
he attended to his usual duties about the asylum, and in going up and 
down flights of stairs he noticed no increased frequency of respiration or 
of the pulsations of the heart. This he observed himself was evidence 
that there could be no serious organic change in that organ. Tiie only 
effect of its abnormal constitution was to diminish the force as indicated 
by the unequal contractions on the whole circulation to the extent of the 
defect in the right ventricle supported by the pericardium, somewhat con- 
tracted over the right side of the heart. This diminution of pressure on 
the circulation was not sufficient to cause any perceptible inconvenience 
from ordinary physical efforts, and the doctor's vocation and inclination 
did not induce him to exceed the bounds of moderation in muscular ac- 
tivity. 

Some of the. medical gentlemen assembled at the autopsy were erro- 
neously impressed with the opinion that the condition of the heart and 
aorta, as above described, was caused by rheumatism. The doctor did not 
fall a victim to that disease. Periosteal rheumatism caiises calcareous de- 
posits, exostosis, and anchylosis, and is not an ulcerative inflammation, a 
very severe and dangerous malady when it attacks the vertebral perios- 
teum. Nor does rheumatism cause atrophy, or, more especially, the oppo- 
site states of atrophy and hypertrophy, A diseased action could not 
unite such opposite results. 

The above (;ase strikingly illustrates the fact of a force of motion, gene- 
rated in the capillary circulation reciprocal with the heart's action. How 
this force of motion is generated is not the object of the present communi- 
cation. 



DOMESTIC SUMMARY. 

Ampnfation at the Hip-joint. — Two very interesting cases of this operation, 
both successful, are reported [Ne^v York Med. Journal, Dec. 187G) by Dr. 
Erskine Mason. The first of these was a healthy lad, aged eighteen, who had 
paralysis of the right lower extremity following scarlet fever. This became 
complicated subsequently by a faulty mode of walking, etc., with extreme 
talipes equino-valgus. For the past five years he has been enabled to place 
the limb with his hands in various abnormal positions, and desired his limb 
removed as it was an incumbrance. On examination after admittance into 
Roosevelt Hospital, it was observed that as the patient lies upon his back, the 
right thigh lies " upon its outer surface, and at right angles to the pelvis. In 
this position the head of the femur can be felt to be near the ramus of the pubis. 
The leg is at right angles to the thigh, and cannot be extended, owing to a sub- 
luxation of the tibia outward, 'i'here is a paralysis of the extensor muscles of 
the leg and thijjh, though some of the flexors and gluteal muscles are called 
into action, 'i'his limb is greatly atrophied. 



IStt.] Domestic Summary. 281 

. . . " By circumduction of the thigh, the head of the femur can be made 
to change its position to a considerable extent. While at rest it seems to be 
just outside the ramus of the pubis, where it appears a new socket had been 
formed. No pain was elicited while examining the joint. The lirab could be 
placed in almost every conceivable position." 

Dr. Mason considered that any amputation short of exarticulation at the hip- 
joint would have been of little or no use to the patient, accordingly it was per- 
formed April 20 by Dr. M. " Esmarch's bandage was tightly applied to the 
limb as high up as the point of my incision (and allowed to remain on the limb 
during the operation), while an abdominal compressor was applied to the ab- 
dominal aorta, just above the umbilicus, by Dr. Peters, who most thoroughly 
supervised this part of the operation. 1'he operation adopted was what is 
usually known as the circular method. The skin being divided with the large 
knife, it was drawn up by Dr. Markoe, and with a large scalpel I divided the 
various muscles to the ligaments, the soft parts being at the same time well 
retracted. As soon as the capsule was opened. Dr. Sands readily threw the 
bone from its socket. The anterior vessels were first ligated ; the abdominal 
compressor was then removed, while the posterior vessels were controlled with 
pressure by sponges. The very small amount of blood lost was a surprise to 
all present. 'J'hirteen vessels in all were ligated. It was estimated that not 
more than eight ounces of blood were lost during the whole operation, and half 
of this escaped from the limb through the femoral vein when this was severed. 
The fibrous capsule was then cut off close to the acetabulum, the inner half 
of the wound brought together with sutures, and the stump supported with 
straps. . , . The pulse at one time during the ligation of the vessels sank 
quite suddenly; a drachm and a half of brandy was at once given hypodermi- 
cally, and two ounces per rectum, which quickly restored it. The head of the 
femur presented a spot of erosion, about the size of the little-finger nail, just 
below the insertion of the ligamentum teres, another upon the anterior surface 
of the head near the neck, while the posterior surface was flattened and slightly 
roughened, a fact which, under the circumstances, rendered the operation still 
more justifiable. The bone was found not to have been displaced from its 
normal socket, as previously supposed, but surrounded by a large and relaxed 
capsular ligament, which, with a long ligamentum teres, permitted the great 
freedom of motion. The right side of the pelvis was found atrophied and 
tilted downward, or retracted, presenting, indeed, that form of pelvis known in 
obstetrics as a high degree of the oblique oval pelvis. The acetabulum being 
very capacious, and approaching nearer the median line than usual, caused our 
error in diagnosis. It was this condition, with the elongated ligaments, which 
allowed us to throw the head of the bone very close if not quite into the 
perineum." 

'J'he patient left the hospital " in sound health and with a beautiful stump 
July 18." 

The second case was a delicate-looking woman, aged thirty-five. " On admis- 
sion there was found a tumour situated on the antero-lateral aspect of left 
thigh, two and a quarter inches below the antero-superior spinous process of 
the ileum, and extending from the median line backward to the great trochanter. 

"The tumour was hard and immovable, and apparently connected with the 
bone ; its margins not well defined ; skin not adherent. There was no enlarge- 
ment of inguinal or lumbar glands, and no growth detected in the pelvis. Eota- 
tion of the thigh caused considerable pain, and she was no longer able to stoop 
over far enough to tie her shoe, on account of the pain the attempt produced." 

Upon consultation, it was deemed advisable to attempt the removal of the 
tumour, which Dr. Mason did March 28. "A straight incision was made, com- 
mencing three-quarters of an inch to the outer side of, and two inches below, 
the antero-superior spinous process of the ileum, and extending downward for 
the distance of five inches. From the middle of this incision another was made 
outward to the extent of three and a quarter inches. The tissues were then 
carefully divided till the surface of the tumour was reached, which presented 
a white, glistening appearance. The tumour was now seen to be situated 
directly below the capsule of the joint, and was evidently firmly attached to 



282 American Intelligence. [Jan. 

the bone. Around the margin of the growth there were several spicule of 
bony growth. After the tumour had been disconnected from the soft parts, an 
attempt was made to detach it from the bone, but on so doing the sac ruptured, 
discharging a bluish-white material of the consistency of, and resembling very 
much, boiled si arch ; what remained of the tumour was then removed, and the 
bone which formed the posterior wall of this growth, together with the sur- 
rounding spicuhe, was cut away with the chisel; indeed, the whole surface of 
the exposed bone was thoroughly scraped. Just as we were about to close the 
wound, it was noticed that in a depression of the bone there was exuding some 
of the same kind of starch-like material as was contained within the growth that 
had been removed. In the attempt to scoop out this material, the necessary 
turning of the instrument caused it to drop into the medullary cavity, so soft 
was the bone-tissue at this point. From this opening- there exuded a soft, pul- 
sating mass. It was the opinion at this time that amputation at the hip-joint 
was indicated, but, the consent of the patient not having- been previously 
obtained, the wound was closed." 

The upper portion of femur subsequently increased in size, patient suffered 
constantly with pain, and with the patient's consent amputation at the hip-joint 
was decided on and was performed by Dr. M. June 17. Patient under ether; 
Esmarch's bandage applied, together with abdominal compressor to aorta. "A 
circular incision was made with the amputating-knife through integument, the 
skin retracted, and the tissues divided down to the bone, then dissecting them 
up along the femur to the joint; after disarticulation, the femoral artery was 
ligated, after which the abdominal compressor was removed, and other bleed- 
ing points secured, fifteen ligatures being used in all; hemorrhage amounted to 
only tioo ounces ; flaps brought together and held by five sutures, and drainage- 
tube inserted ; patient showed but slight amount of shock during operation, 
her pulse being good throughout. G P. M. Patient recovered from ether, and 
removed to her ward ; there appears to be very little pain and no shock ; given 
opii gr. j, and repeated in three hours; pulse 120; temperature 98j°." The 
patient suffered a good deal subsequently from vomiting, but ultimately recov- 
ered by the 14th of September. Dr. Delafield, who examined the growth, 
reports it as a mixed tumour — sarcoma and chondroma. 

Dr. M. offers some interesting observations in regard to this operation, from 
which w^e extract the following : — 

"In this operation a great aim of the surgeon has always been to have the 
patient lose as little blood as possible, and the fact that blood has been so freely 
lost no doubt may have been a cause of death in some of the earlier cases. 
For this reason the tying the femoral just below Poupart's ligament, as a 
preliminary step, was in some instances resorted to. Now the fear of danger 
from this cause has been removed. With the assistance of the abdominal 
tourniquet, controlling the circulation through the abdominal aorta, and the 
use of Esmarch's elastic bandage, less blood need be lost than we see daily 
shed in some comparatively trivial operations. 

"As far as we have been able to ascertain, these are the first two cases of 
amputation at the hip-joint where Esmarch's bandage was applied, and it 
accomplished the end lor which it was used to a most eminent degree." 

The tourniquet which Dr. M. used was May's modification of Signoroni's, 
and completely controlled the aorta. He found it to be not easily adjusted and 
should he operate again would give preference to Lister's. 

" The use of this compressor," he observes, " is not without its dangers, as 
has been shown in some cases where it was used in the treatment of aneurism, 
and as we were only too forcibly reminded in our second case, from which, as a 
result, we had a very serious case of peritonitis, which threatened to rob us of 
our patient. 

" We are aware that the aorta has in several cases been compressed for hours 
(Murray's case, five hours) by a tourniquet, and we have used it ourselves in a 
case of aneurism, and without any serious symptoms being manifested; and 
while in our first case not a symptom, even of soreness, was present, our experi- 
ence in the second case was such that we feel it a duty to sound an alarm, and 
one which we believe should not go unheeded. 



18t7.] Domestic Summary. 283 

"'I'he time that this instrument was in use, in our cases, we regret was not 
accurately noted, but compression was only kept up till the vessels in the 
anterior portion of the wound were tied. The time of the operation, in the 
first case, till the bone was disarticulated, I am told by three separate observers 
who timed me, was twenty-nine seconds, so the period of compression of the 
aorta may thus be proximately arrived at. 

" With the second case the compressor was around the bodylong'er: here 
considerable difficulty was experienced in arranging- the instrument, and, while 
drawing" the patient down a little further to the edge of the table, the instru- 
ment slipped, which again required its adjustment; and when I had nearly 
made my incision througli the integument, the femoral was observed to pulsate, 
and the compressor had to be altered again." Dr. M.'s experience has con- 
vinced him "that compression by the tourniquet, in this operation, should not 
be prolonged beyond the time necessary to secure the anterior vessels, the pos- 
terior ones being comparatively small and readily controlled by pressure from 
sponges till severally secured." 

Dr. Mason speaks favourably of the circular operation, from the ease of its 
performance and the beauty of the resultant stump. Another great feature in 
its favour is, he says, "the ease with which it is dressed and irrigated without dis- 
turbing the patient to such a degree as would be necessary in the flap-operation. 
Again, the vessels, not being so obliquely cut, are perhaps the more readily 
taken up; and by this method, also, there probably remains a smaller suppura- 
ting surface ; and. finally, if during the operation it be discovered that the bone 
may with impunity be severed just below or at the tronchanters, it can readily 
be accomplished without any detriment to the patient; such would not be the 
case with the method by flaps. Hence this mode of operating, I think, strongly 
commends itself in cases of gunshot, railroad, or kindred injuries. While thus 
speaking so favourably of this operation I do not wish to be understood as 
saying that it should be resorted to in every case, under all circumstances, for 
I believe a surgeon should never be exclusively wedded to one method of ope- 
rating. My experience, however, has been such as strongly predisposes me in 
its favour." 

Lister's Antiseptic Method in Ovariotomy. — Dr. J. Marion Sims reports 
{Medical Record, Dec. 9, 187G) the following case in which* he performed ovari- 
otomy under the carbolic spray. . 

The patient, forty-seven years of age, noticed a tumour the size of an orange 
in the right iliac region last April. She consulted her family physician, who 
pronounced it an ovarian tumour. In June she consulted Dr. Thomas, who 
wisely told her the time had not arrived for an operation. On the 20th July she 
went to Philadelphia to see Dr. Atlee, who gave her the same good advice. I 
saw her on the 20th September. I have never seen any one so anxious for an 
operation. I dissuaded her from it, advising her to return home, and wait at 
least till next spring. I told her the tumour did not weigh more than ten 
pounds, and that an operation was not justifiable till she vomited her food, and 
began to emaciate. I saw her a month later. She declared she had not the 
strength to make the journey home, and that she threw up every time she took 
food. I still refused to operate. She wrote to Dr. Atlee, and he replied on 
the 6th November : " I can scarcely think a tumour so small can affect your 
general health so seriously. But if your emaciation and debility are the result 
of the presence of the tumour, then by all means it should be removed." I 
believe her vomiting and consequent emaciation were mainly the result of 
mental and moral causes. Whatever the cause, her declining stregth and a 
recent fugitive attack of peritonitis warned me not to procrastinate the opera- 
tion any longer. 

The operation was done on Thursday, the 23d November last. I am parti- 
cular in fixing the date, because I believe it inaugurates a new departure in 
ovariotomy. 

Dr. Sass directed the spray, which covered the seat of operation with a deli- 
cate carbolic mist. The hands, sponges, and instruments were all dipped in 
carbolic water. The operation and dressing lasted forty minutes, the spray 



284 American Intelligence. [Jan. 

being kept up nil the time. It could have been continued two hours, if neces- 
sary. There were no adhesions. The peritoneal cavity contained six or eight 
ounces of a reddish serum. The peritoneal membrane was everywhere deeply 
congested. This fact explains the presence of reddish serum, and the previous 
attack of peritonitis. 

The pedicle was very short, and at least three inches broad. It was tied in 
three sections with strong twine, and drawn out and fixed in the lower angle of 
the wound, clamp-fashion. 

The external incision was closed by sutures, and a carbolized dressing ap- 
plied. 

The pulse never rose above 90, nor the temperature over 101. 
Convalescence was fully assured in forty-eight hours, and the patient is now 
quite well. The tumour was polycystic, on right side, and weighed fifteen 
pounds. 

I hasten to lay this case before the profession merely to urge the adoption of 
Lister's antiseptic method in ovariotomy, which, I am sure, will prove as valu- 
able in this operation as it has in general surgery. 

Dr. Sass's apparatus answered its purpose admirably, and I think he has 
rendered us a great service in bringing it before the profession at this time. 

Dr. Griffiths, of Swansea, exhibited (Nov. 21st) to the Pathological Society 
of London [British Medical Journal, Nov. 2.5, 187()). two dermoid ovarian 
tumours removed respectively from females aged twelve and twenty-one. They 
were both removed under the carbolic spray. In both cases the pedicle was 
ligatured with the carbolized catgut, and then returned into the pelvis, and both 
cases recovered without any untoward accident. See Quarterly Summary in 
this number of the Journal, page 274. 

Cold Bathing in the Treatment of Summer Diarrhoeal Affections of Infants. 
— In the last number of this journal attention was called to an article on this 
subject by Dr. Yocke, of Berlin. In 187.5. Dr. Cornelius G. Comegys. Lec- 
turer on Clinical Medicine at the Cincinnati Flospitnl, called attention to the 
same method of treatment of bowel affections of children in the summer season, 
where fever is present. In the Medical Record for July 29, 1876', Dr. Comegys 
says, "It has been so successful with me. that I am confident, if applied more 
generally, it would* lessen very greatly the rates of mortality in the summer 
season. I allude to that form of disease which is denominated entero-colitis. 

" Before we are called to these cases, tentative measures for the relief of the 
diarrhoea have already been applied by the friends, so that the inflammatory 
stage is generally fully developed when we first see the patient. The skin is 
hot (temperature 102^° to 105°), the pulse rapid (180 to 150), respiration 80 
to 50, with frequent purging of semi-flui<l, greenish, watery, fecal, and half 
digested matters; the mouth and tongue are dry; the thirst intense, but the 
water taken to slake it is quickly thrown off; the eyes are staring; pupils con- 
tracted; insomnia and rolling of the head, with utterance of distressing cries, 
due to headache from hyperajmia of cerebral vessels and unappeased thirst. 
Such is a general statement of symptoms. 

" I at once proceed to give the little sufferer a bath in hydrant water, which 
with us, in summer, is about 75^. I have found it necessary to give this my 
personal attention at first, because the mother or friends will not carry out 
instructions, on account of the cries and resistance of the child; it seems to 
them a great cruelty. 

" 'J'he contact of a hot skin with cold water is certainly painful for the moment, 
hence I immerse the body from legs upward gradually, sponging the skin in 
advance, so as to obtain tolerance. 

" When the body and extremities are fully under, holding the head in the palm 
of my left hand, I pour over its surface cooler water, such as cistern water, 
which is here about 6.5'^. This is kept up for ten or even fifteen minutes. 
Meanwhile the child ceases to cry or struggle, and is evidently greatly com- 
forted; more especially when cool water is freely given to drink, the greedy 
swallowing of which shows how much of its distress is due to thirst. 

"After the bath the patient should be wrapped unwiped, in a light woollen 



1877.] Domestic Summary. 285 

shawl, and laid upon its bed, with a slight additional coverinfr. The pulse has 
lost frequency, but is quite feeble ; the breathing is slower and the skin quite 
cool, even bluish in hue. The sedation may seem at first too great ; but re- 
action soon begins, a healthy warmth and perspiration are established, and the 
child falls into a peaceful sleep. The scene has so changed that one will find 
no difficulty thenceforth in getting a bath given three or four times in twenty- 
four hours, if the alarming train of symptoms make show of revival; and they 
will revive to such an extent as to require exhibitions of the bath from time to 
time for two or three days perhaps ; for the diseased state of the mucous mem- 
brane within has not been as suddenly relieved as the abnormal heat of the 
body. 

" In the mean time internal remedies should be freely employed. Quinia, 
whiskey, beef-tea, milk and lime-water are the chief agents. One grain of qui- 
nia and a drachm of whiskey every three hours, for a child eight to sixteen 
months old, looks rather formidable, but they will be found admirable while 
the disposition to fever lasts. 

"Subsequently bismuth and pepsin are of great value to restrain diarrhoea 
and to assist digestion, so greatly at fault owing to the blow which the mucous 
membrane has suffered." 

Successful Treatment of Vascular Tainours by Ivjection loiili the Fluid 
Extract of Ergot. — Dr. Wm. A. Hammond relates {Archives of Clin. Surg., 
October, 1876) three cases of this. He injected from half a drachm to two 
drachms at a time at intervals of ten days. In none of these cases was there at 
anytime the least evidence of inflammatory action from the injections; he 
therefore attributes the successful results entirely to the action of the ergot on 
the organic fibres of the vessels. 

Ergot in the Treatment of Purpura — Dr. L. Duncan Bulkley, of New 
York, in an interesting paper [The Practitioner, Nov. 1876) states that — 

I. The treatment of purpura, as advised in the books, is ineffective and 
tedious in lighter cases, and insufficient to save life in many of the severe or 
hemorrhagic cases. 

II. Ergot possesses a very decided power in contracting the involuntary 
muscular fibres, causes divided arteries to contract, acts upon the smaller 
arteries and capillaries, and has been proved a valuable arrester of hemorrhage 
in many affections. 

III. In purpura the action of ergot is very manifest, causing, when given in 
sufficient doses, an almost, if not quite, immediate cessation of the cutaneous 
and other hemorrhages. 

IV. The most effective method of administration of ergot is by hypodermic 
injection, and this means renders it peculiarly valuable in purpura hemorrhagica 
where there is hgematemesis, so that its administration by the mouth would be 
impossible, or in cases where the stomach would not tolerate it. 

V. Willie ergotin, a purified watery extract, has been advised by many, and 
has been found to net efficiently in many cases, its action is liable to be uncer- 
tain by reason of age or faulty preparation, and after dilution with water it 
soon becomes inert. 

VI. Fluid extract of ergot may be administered hypodermically, undiluted, 
and without local accident, as abscess or inflammation, if care be exercised ; 
and its effect is very prompt and certain. 

VII. Ergot may be thrown under the skin in any part of the body; the 
gluteal and shoulder regions answer well, but the places to be preferred are 
about the pectoral muscles or at the sides of the chest, about half way down. 

VIII. Severe cases of purpura require the frequent repetition, even of very 
large doses, whether by the mouth or by hypodermic injections ; both methods 
may be combined. 

IX. Glenerally one or two grains of ergotin or from ten to fifteen minims of 
the fluid extract, hypodermically, once or twice a day are sufficient, but the 
former may safely be increased to five grains, and the latter to twenty or 
thirty minims, and repeated as often as every hour and a half. 



286 American Intelligence. [Jan. 

X. Larger doses relatively are required when given by the mouth, and their 
action, thus given, is more slow. 

XI. No fear need be entertained of any untoward effects; an ounce of fluid 
extract by the mouth, and seven grains of ergotin, hypodermically, have failed 
to give rise to any unpleasant symptoms ; and from half a drachm to a drachm 
and a half of the tincture or fluid extract have been continued for several 
months without producing ergotism. 

XII. Other preparations of ergot may be employed internally — as the powder, 
solid extract, wine, or infusion — the dose being proportioned to the effect 

■ required and produced. 

Experimental Studi/ of the Procefis of Repair. — Dr. I. N. Danforth, Lecturer 
on Pathology in Rush Medical College, has published an account {Chicago Med. 
Jouni. and Examiner, Dec. 1876) of some interesting microscopic investiga- 
tions made at brief intervals, of the same wound in a living tissue, from the 
time of its infiltration to its complete repair. 

On the evening of February 23, 1876, a healthy, active, medium-sized frog 
was brought under the influence of curare, by the subcutaneous injection of 
about ^-fiVo of a grain. The animal was then placed upon a frog plate, the 
tongue gently drawn out and its edges pinned to a piece of perforated cork, 
which was fitted to the opening in the frog plate; the perforation in the cork 
being covered by a slip of glass, upon which, of course, the tongue rested. 
Especial care was taken not to put the tissue of the tongue so much upon the 
stretch as to materially interfere with the free circulation of the blood, or the 
action of the bloodvessels. 

" A minute wound was now made through the tongue by means of a pair of 
sharp pointed scissors, lengthwise of the organ, or in the direction of the 
muscular fibres ; care being taken to select an islet of tissue which was least 
vascular, and in which the few vessels were quite small. I'he frog was now 
placed upon the stage of the microscope, the changes of the next half hour 
closely watched, and a faithful camera drawing made by Dr. Piper; the first 
drawing being executed at 9 o'clock on the evening of February 23, or about 
one hour after the wound was made. The appearances at this time were as 
follows: the wound was rather more than one-sixteenth of an inch in length ; 
its form was nearly oval, the edges having been drawn apart by the contraction 
of the muscular fibres. The bottom or floor of the wound was covered by a 
pretty firm blood clot ; the blood having slowly oozed from the cut ends of the 
minute bloodvessels which occupied the track of the wound. In watching the 
escape of this blood from the vessels, 1 noticed this singular phenomenon, 
namely : that the escaped blood globules, or more properly the current of extra 
vascular blood, moved in compact and orderly columns across the floor of the 
wound; that is, after the vessels were cut and hemorrhage had ensued, the 
escaped blood did not flow in all directions in a helter skelter disorderly manner, 
but formed itself into different columns, representing the different vessels from 
which it flowed, and these several columns advanced in regular order, with but 
little variation in tlieir course, until two streams chanced to encounter each 
other, when the larger and stronger stream would generally bear away the 
smaller and weaker one. 

" In another hour all oozing of blood had ceased, coagula had formed in the 
wounded vessels up to the next collateral branch, and the condition of the 
wound and its immediate surroundings was that of apparent ' masterly inactivity.' 

"Twelve hours after the injury the circulation was active in all parts of the 
tongue, except around the cut. In the immediate vicinity of the wound, the 
vessels are distended and gorged with blood, and stasis has occurred in the 
greater part of them. In some, however, the circulation is still wonderfully 
active and vigorous. The walls of the wound are mostly smooth and sharply 
defined, but from the (apparently) upper and lower border, a little bud, irregu- 
larly knotted, pale and terminating in a club-shaped extremity has commenced 
shooting out; the two buds (which are two masses of round cells) are almost 
opposite, and seem to be growing toward each other. ' 1 have an impression,' 
says the record which I made at the time, 'that they are incipient bloodvessels, 



181t.] Domestic Summary. 281 

and that T am about to witness the growth of new vessels.' The floor of the 
wound presents, 1st, a few minute coajrula ; 2d, blood globules, both white and 
red ; and 3d, a few pale, very minute fibres of fibrine." 

Thirty-six hours after injury. The little growing buds have undergone no 
further development, on the contrary they have grown smaller. " The minute 
fibres on the floor of the wound have increased, and are interwoven in all 
directions, and in their interstices are many blood globules of both varieties. 
The surrounding vessels are enlarged, and somewhat tortuous ; in vessels which 
show any movement of blood at all, the circulation is very active. Small 
coagula are seen at intervals along the border of the wound. The tissues sur- 
rounding the injury are becoming slightly cloudy, unlike the sharpness and 
clearness of the more remote structures. On examining the tissues involved 
with No. 5 Hartnack, I can easily see that the cloudiness is due mainly to the 
migration of leucocytes, which are rapidly insinuating themselves into the 
areolar and muscular interstices." 

Sixty hours after injury. " The wound is considerably smaller ; the cloudy 
appearance of the surrounding tissues has increased ; the border of the wound 
is now quite thickly fringed with little buds or protrusions, which, upon being 
examined with a quarter inch, are seen to be composed almost exclusively of 
cells. In some of these growing buds, a minute bloodvessel, with its tiny blood 
stream, can be made out. These vessels are always in the form of loops, a 
single minute current flowing into the cell bud through one branch of the loop, 
and immediately returning through the other. Here, then, we have a granula- 
tion growing up under our eyes, under conditions which admit of its being quite 
freely observed in a leisurely and satisfactory manner. 

"The circulation in the vicinity of the wound is very active ; the blood- 
vessels are dilated and tortuous; stasis is no longer present except in a \ew 
quite small vessels. The veins in the periphery of the microscopic field are 
enormously distended, and the blood stream is both very dark and very slow. 
In some of the vessels in sight, the jerky, interrupted movement of blood, so 
often described by authors as occurring in inflammation, can be very distinctly 
seen. Many blood globules are seen on the floor of the wound, but the network 
of fibres spoken of in yesterday's record has nearly disappeared." 

Eighty-four hours after injury. " 'J'he area of the wound is no smaller than 
it was yesterday ; in fact it seems a little larger. New vessels are multiplying 
around the wound, and new buds are pushing their way into the open space. 
The floor of the wound is now occupied by a thickly woven reticulated net- 
work of minute fibres of coagulated fibrine, which have formed since the last 
observation. The interstices are filled by blood globules, both red and white. 
The circulation is very active, and the frog seems in good health." 

One hundred and eight hours after injury. "The size of the wound has very 
greatly diminished. New vessels are still forming, new granulations are spring- 
ing up, and Ihe size of the wound is rapidly diminishing." 

One hundred and thirty-two hours after injury. Several new bloodvessels 
have appeared "and the pre-existing ones, especially the veins, are enormously 
dilated. The wound diminishes with great rapidity. The walls or ' banks' of 
the wound now present a very curious and interesting appearance. At short 
intervals, little semicircular rills of blood are seen running along the shelving 
and somewhat precipitous 'banks.' Each little semicircle, or loop, is coveretl 
in by a dense layer of small round cells ; the deeper layers of cells assume a 
spindle form ; thus new fibres are formed, and the wound is repaired." 

One hundred and fifty-six hours after. "The cut is reduced to a minute 
oval slit, and the floor is quite covered with minute newly formed fibres, inter- 
woven in all directions. Meantime, new granulations are continually forming 
along the side-walls or banks of the injured part, and thus the solution of tissue- 
continuity is being repaired." 

One hundred and eighty hours after injury. The record states the wound is 
practically closed, and its original area is nicely mapped out by the presence of 
new cicatricial tissue. 

Fourteen days after the infliction of the wound " the frog was again curarized, 
the cicatrix examined, and a careful drawing made. It was easy to trace the 



288 American Intelligence. [Jan, 1877.] 

exact extent of the injury by the lighter colour of the new tissue. I'he cicatrix 
was entirely made up of new connective tissue; no regeneration of muscular 
tissue could be discovered. The new connective tissue appeared to be entirely 
the product of spindle-shaped cells, interwoven in all directions." 

Among other points Dr. D. calls attention to the frequent changes in the 
condition of the blood-clot in the wounded part, and to the frequency of the 
escape of fresh masses of blood. At first free hemorrhage occurred, and the 
cavity of the wound was speedily filled with a coagulum. In a short time, the 
red globules had nearly disappeared, an intricate network of fine fibrinous fibres 
had formed, and in the interstices of this network, multitudes of mobile cells 
[i. e., leucocytes) had accumulated. A few hours later, this clot had nearly 
disappeared, the fibres were wanting-, except at the periphery of the wound, 
but a great number of leuco(;ytes still remained and continued their wander- 
ings over the floor of the wound. Several times while the tongue was under 
examination, the tenuous walls of the newly formed vessels would yield to the 
pressure of the blood stream. Hemorrhage would occur, a fresh clot would 
form, only to disappear after an interval of a few hours. Meantime new fibres 
were forming between the periphery of the clot (or successive clots), and the 
inner border of the wound, so that the area of the wound was constantly grow- 
ing smaller. 

The experimenter states that Dr. Piper, by a process invented by himself, 
has represented all these changes on magic lantern slides, " coloured so as to 
quite perfectly imitate nature in many instances, and enable us in all cases to 
differentiate the various tissues and structures by conventional colourings." 

0?! the Effect of the Bipedal Position in Man. — Dr. Harrison Allen made 
some remarks before the Academy of Natural Sciences of Philadelphia upon 
the physical characteristics of man, which result from the assumption of the 
bipedal position. He contrasted the position of a quadruped standing upon 
his hind legs, with that of a man in the erect attitude, such as that seen in the 
soldier standing at attention. 'I'he most conspicuous of these characteristics 
were seen in the absence of flexion at the knee-joint, the downward directed 
nostril, and the sigmoid curve of the supra-sacral vertebral column. The flat- 
tening of the sternum was a sequence upon the presence of the clavicle, and 
was, of course, not depi-ndent upon the erect position. Yet, since a fixed cla- 
vicle (at least its mammalian expression) cannot act to advantage in any other 
than this position, the flattening can be assigned a secondary place in the 
group of characters. 

Dependent upon the erect position — plus the flattening of the sternum — is 
the deflection of the heart to the left side. Dr. A. spoke at length upon the 
reasons of this deflection, and claimed for it a result of modification of the 
foetal proportions of the heart. The typical mammalian act is the foetal heart; 
the heart of the adult being a specialized I'orm. 'J'he mechanism of the deflec- 
tion is complicated. Entering into its consideration are (1) the fact that the 
right side of the heart is fixed by the cava3 at its right border, thus tending to 
tilt the i-ight ventricle toward the left. (2) The greater weight of the posterior 
aspect of the heart, which throws the posterior wall downward and the anterior 
wall upward. (3) The fixation of the left side of the heart, by the pulmonary 
veins, directly in the median line, while the flattened sternum compels the apex 
to lie either to one or the other side of the median line. Dr. A., in conclusion, 
divided the characteristics of man into two groups. The first and most im- 
portant being those the result of evolving from a quadrupedal type a bipedal 
specialized form ; the second, being those belonging to the disposition of spe- 
cial organs, such as the teeth. Within this category may be placed the rudi- 
ments of structure, which are better developed in quadrupeds, and which often 
constitute the "varieties" of human anatomy. — Froccednigs Acad. Nat. Sci., 
December 7, 1875. 



THE 

AMERICAN JOURNAL 

OF THE MEDICAL SCIENCES 

FOR APRIL isn. 



CONTRIBUTORS TO THIS VOLUME. 

SAMUEL ASH HURST, M D., Surgeon to Episcopal Hospital, Philadelphia. 

AVALTEll F. ATLEE, M.D., of Philadelphia. 

ROBERTS BAllTflOLOW, M.D , Prof, of Practice of 3Iedicine in 3Ied. Coll. of Ohio. 

JAMES BORDLEY, M.D., of Cenfreville, Maryland. 

D. WARREN BRICKELL, M.D., Prof of Ohstet. Charily IIosp Med. Coll., N. 0. 

ROBERT BRIDGES, M.D , Prof of Chemistry. Philadelphia College of Pharmacy, 

JOHN H. BRINTON, M.D., Surgeon to the Philadelphia Hospital. 

FERDINAND BROTHER. M.D., of Bunker Hill. Illinois. 

LENNOX BROWNE, F.R.C.S. Ed., Surg, to Central Lond. Throat and Ear Hospital, 

London, England. 
CHARLES S BULL, M.D., Ophlhahnic Surgeon to Charity Hospital, New York. 
SWAN M. BURNETT, M.D., of Washington, D C. 

EDWARD H. CLARKE, ALD., late Professor of Materia Medica in Harvard Univerdty. 
STACY B. COLLINS, M.D., Assistant Surgeon to Orthopaedic Hospital, Philadelphia. 
W. J. CONKLING, M.D., of Daytzn, Prof of Phys in Starling Med. Coll., Columbus, O. 
P. S. CONNER, M.D., Prof of Anato?n'/ and Clinical Surgery in Med. Coll of Ohio. 
H. CULBERTSON, M.D., Prof, of Ophthalmology in Columbus Medical College, Ohio. 
LOUIS A. DUIIRINCt. M.D., Prof of Skin Diseases in Hosp. of Univ. of Pennsylvania. 
JOHNSON ELIOT, M.D., Prof of Clin. Surg in Georgetown Univ., Dist. of Columbia. 
R. J. FARQUH ARSON, M.D., of Davenport, Iowa. 

REGINALD H. FITZ, M.D , Assist. Prof of Path. Anat. in Harvard University. 
G. E. FROTHINGHAM, M.D., Prof, of Ophthalmology in University of Michigan. 

B. F. GIB15S, M D., Surgeon U S Navy. 

Y. P. GIBNEY, M D., Assistant Surgeon to Hospital for Ruptured and Crippled, N. Y. 

L. BREWER HALL, M.D., of Phdadelphia. 

GEOROE C. HARLAN, M.D., Surgeon to Wills [Ophthalmic] Hospital, Philadelphia. 

R015EKT P. HARRIS, M.D., of Philadelphia 

HENRY HARTSHORNE, 'M.]).,late Professor of Hygiene in University of Pennsylvania. 

EDGAR HOLDEN, M.D., of Newark, New Jersey^ 

J. R n\] MVmiEY, U.\).,' of Snickersville, Virginia. 

DAVID HUNT. M.D , of Boston, 3Iass. 

JAMES H. HUTCHINSON, M.D., Physician to Pennsylvania Ilosjntal. 

CHRISTOPHER JOHNSTON, M.D., of Baltimore, Md. 

JOHN M. KEATING, M.D., Physician to the Philadelphia Hospital. 

WILLIAM W. KEEN, M D., Surgeon to St. Mary's Hospital, Philadelphia. 

C. B. KING, M.D., of Allegheny, Pennsylvania. 
H. G. LANDIS, M.D.. of Niles, Ohio. 

J. R MacGREGOR, M.D , 0/ New York. 

ERSKINE MASON, M.D., Surgeon to Bellevue and Roosevelt Hospitals, New York. 

S. WEIR MITCHELL, M.D., Physician to Infirmary for Nervous Diseases. Phila. 

THOMAS G. MORTON, M D., Surgeon to the Pennsylvania Hospital, Phila. 

WILLIAM F. NORRIS, M.D., Prof of Ophthalmology in University of Pennsylvania. 

JAMES P. ORR, M.D., of Andersonville, Bidiana. 

WILLIAM PEPPER, M.D., Prof, of Clinical Medicine in University of Pennsylvania. 

H. G. PIFFARD, M.D., of New York. 

B LINCOLN K^Y,U.\)., of Philadelphia. 

ISAAC RAY, M.D., of Philadelphia. 

IRA B. READ, M D.. of New York. 

J. C. REEVE, M.D., of Dayton, Ohio. 

JOS. G. RICHARDSON, M.D., MicroscopisI to Pennsylvania Hospital, Philadelphia. 

BEVERLEY ROBINSON, U.\)., Pky.^ician to Charity Hospital, New York. 

W. B. RODMAN, M.D., of Frankfort, Kg. 

I> B. ST. JOHN ROOSA, M.D., Prof Ophthul. and Olol. in Univ. City of New York. 

W. S. W. RUSCHENBEHGER, M.D., U. S. Navy. 

T. P. SEELEY, M.D., of Chicago, Illinois. 

E. 0. SHAKESPEARE, M.D., of Philadelphia. 

D B. SIMMONS. M.D , Surgeon to Ken Hospital, Yokohama, Japan. 

WHARTON SINKLER, M.D., Physician to Infirmary for Nervous Diseases, Phila. 

THOS. C. STELLWAGEN, M.D., D.D.S., Prof of Op. Surg. Philaia. Dental Coll. 

ALFRED STILLE, M.D., Prof, of Practice of Medicine in University of Pennsylvania. 

GEORGE STRAWBRIDGE, M.D, of Philadelphia. 

GEORGE B. TOWNSHEND, M.D., of Boston {Highlands), 3Iassachusetts. 

OLIVER F. WADSWORTH, M.D., Ophthalmic Surgeon to Boston City Hospital 

B. A. WATSON, M.D , Surgeon to Jersey City Charity Hospital, Jersey City, N. J. 

W. H. \NE\i^, M.D, of Philadelphia. 

ROBERT F. WEIR, M.D., Surgeon to New York and Roosevelt Hospitals, New York. 

J.\MES C. WHITE, M.D., Professor of Dermatologg in Harvard University, Boston. 

W. R. WHITEHEAD, M D , o/ Denver, Colorado.' 

HORATIO C. WOOD, Jr , M D , Prof of Mat. Med. and Therap. in Univ. of Penna. 

FRANK WOODBURY, M.D., of Philadelphia. 



\ 



TO READERS AND CORRESPONDENTS. 

All communications intended for insertion in the Original Department of this 
Journal are only received for consideration with the distinct understanding that 
they are sent for publication to this Journal alone, and that abstracts of them 
shall only appear elsewhere subsequently, and with due credit. Gentlemen 
favouring us with their communications are considered to be bound in honour 
to a strict observance of this understanding. 

Contributors who wish their articles to appear in the next number are re- 
quested to forward them before the 1st of May. 

Compensation is allowed for original articles and reviews, except when illus- 
trations or extra copies are desired. A limited number of extra copies (not 
exceeding yi/^j/) will be furnished to authors, provided the request for them 
bemade at thetimethe communication is sent to the Editors. 

The following works have been received : — 

Vorlesungen iiber Allgemeine und Experimentelle Patholojrie von Dr S. Stpicker, 
o Prof, der Allgemeinen und Experiinentellen Pathologie in Wien. 1 Abtlieilung, 
Wien, Wilhelm BraumuUer, 1877. 

Contribution a I'Etude de I'Encephalocele Acquise. These pour le Doctornt rn 
Medecine presentee et soutenue par Lewis A. Lkbeau, Docteur en Med. des Facultes 
de Baltimore et de Paris. Paris: Adrien Delahaye, 1875. 

Medico-Chirurgical Transactions. Published by the Royal Medical and Chirurgi- 
cal Society of London. Volume the fifty-ninth. London : Longmans, Green, Rejider, 
and Dyer, 1876. 

A Text Book of Physiology. By M. Foster, M.A., M.D., F.R.S., Prcelector of 
Physiology and Fellow of Trinity College, Cam. London: MacMillan & Co , 1877. 

The Germ Theory applied to the Explanation of the Phenomena of Disease. 
Specific Fevers. By T. Maclagan, M.D. London: Macmillan & Co., 1876. 

How to Use a Galvanic Battery in Medicine and Surgery. By Herbert Tibbits, 
M.D., Hon. Med. Supt. of National Hosp. for Paralyzed and Epileptic. London: J. 
& A. Churchill, 1877. 

Annual Reports on Diseases of the Chest, under the Direction of Horace Dobell, 
M.D., Vol. 11. London: Smith, Elder & Co., 1876. 

On "Athetosis" and Post-Hemiplegic Disorders of Movement. On the Develop- 
ment of Spindle-Cells in " Nested Sai-comas." The State of the Arteries in Bright's 
Disease. By William R. Gower, M.D., Assist. Phys. to Univ. College Hospital. 
London, 1876. 

On the Importance of the Uterine Ebb as a Factor in Pelvic Surgery. By Horatio 
R. Storer, M.D., of Boston, U S. Edinburgh, 1877. 

A Directory for the Dissection of the Human Body. By John Clelanu. M D , 
F.R.S., Prof, of Anatomy and Phys. in Queen's College, Galway. Philadelphia; 
Henry C. Lea, 1877. 

The Practitioner's Hnud-Book of Treatment; or, the Principles of Therapeutics. 
By J. Milner Fothergill, M.D., M.R.C P. Lond., Assist. Phys. to City of London 
Hosp. for Diseases of Chest, etc. Philadelphia: Henry C. Lea, 1877. 

Illustrations of Clinical Surgery. By Jonathan Hutch[nson, F.R.C.S. Fasci- 
culus V. Philadelphia: Lindsay & Blakiston, 1876. 

The Microscopist: A Manual of Microscopy and Compendium of the Microscopic 
Sciences. Third ed., rewritten and greatly enlarged. By J. H. Wythes, A.M , M.D., 
Prof, of Microscopy and Biology in Med. Coll. of Pacific, San Francisco. Philadel- 
phia : Lindsay & Blakiston, 1877. 

A Practical Treatise on the Diseases of Children. By .T, Forsyth Meigs, ALD , 
Physician to Pennsylvania Hospital, etc., and William Pepper, A.M , M.D., Prof, 
of Clinical Med. in University of Penna., etc. Sixth edition, revised and enlarged. 
Philadelphia: Lindsay & Blakiston, 1877. 



296 TO READERS AND CORRESPONDENTS. 

An Atlas of Pathological Anatomy after Plane Sections of Frozen Bodies. By 
WiLHELM Braune, Prof. of Anatomy in Univ. of Leipzig, Translated by Edwakd 
Bellamy, F.R.C.S., Sen. Assist. Surg, to Charing Cross Hospital, etc. Philadel- 
phia: Lindsay & Blakiston, 1877. 

A Practical Treatise on Diseases of the Skin. By Louis A. Duhring, M.D., 
Prof, of Diseases of Skin in Hosp. of Univ. of Penna. Philadelphia: J. B. Lippin- 
cott & Co., 1877. 

A Series of American Clinical Lectures. Edited by E. C. Seguin, M.D. Vol. II. 
Jan. -Dec. 1876. New York: G. P. Putnam's Sons, 1877. 

The Electric Bath. Its Medical Uses, Effects, and Appliances. t5y George M. 
ScHWEiG, M.D.. Phys. to New York Lying-in Asylum, etc. New York: G. P. Put- 
nam's Sons, 1877. 

Transactions of the New York Pathological Society. Vol. I. John C. Peters, 
M.D., editor. New York: William Wood & Co., 1870. 

Civil Malpractice: A Treatise on Surgical Jurisprudence. With Chapters on 
Skill in Diagnosis and Treatment, Prognosis in Fracture, and on Negligence. By 
MiLO McClelland, M.D. New York: Ilurd and Houghton, 1877. 

The Medical Register for New England. Francis H. Brown, M.D. Boston : 
H. 0. Houghton & Co., 1877. 

The Tonic Treatment of Syphilis. By E. L. Keyes, M.D., Adjunct Prof, of Sur- 
gery and Prof, of Dermatology in Bellevue Hosp. Med. Coll., etc. New York: D. 
Appleton & Co., 1877. 

Removal of a Toy Locomotive from Sub-Glottic Cavity by Tracheotomy and Thy- 
rotomy By Samuel Johnston, M.D , Baltimore. New York, 1876. 

Disinfection in Yellow Fever, as Practised at New Orleans, in the years 1870 to 
1876 inclusive. By C. B. White, M.D. New Orleans, 1876. 

Lessons to be learned from the Cholera Facts of the past year, and from a recent 
Cholera Literature. By Ely McClellan, M.D., Surgeon U. S. A. Louisville, 1876. 

Full-Term Extra-Uterine Gestation of the Tubo-Ovarian Form; with Special Ex- 
amination of the Sac, Uterus, and Appendages. By A. Sibley Campbell, M.D., 
Augusta, Ga. New York, 1876. 

Note on the Administration of Phosphorus. By Edward R. Squibb, M.D., of 
Brooklyn. Philadelphia, 1876. 

The Therapeutics of Epilepsy. By Allan McLane Hamilton, M.D. 

A Case of Ectropion, treated by Transplantation of a large Flap without Pedicle. 
By 0. F. Wadsworth, M.D. Cambridge, 1877. 

The Function of the Uvula and the Prominence formed by the Azygos Uvulse 
Muscle. By Thos. F. Rumford, M.D., St. Louis, Mo. 

Cases called Hysterical. By Frank Woodbury, M.D. Philadelphia, 1877, 

Address in Obstetrics. By R. Davis, A.B., M.D., of Wilkesbarre. Philadelphia, 
1876. 

A Modification of the Ophthalmoscope. By 0. F. Wadsworth, M.D. 

A Case of Ovariotomy. By David Prince, M.D., Jacksonville, HI, 

Notes on the Burning of Theatres and Public Halls, etc. By J, M, Toner, M.D., 
Washington. 

Explorations of the Aboriginal Remains of Tennessee. By Joseph Jones, M.D., 
Prof, of Chemistry in Med. Dept of Univ. of La. Washington City. Published by 
the Smithsonian Institution, October, 1876. 

Address on Obstetrics and Diseases of Women and Children, delivered before the 
American Medical Association, June, 1876. By Samuel C. Busey, M.D., of Wash- 
ington, D. C. Philadelphia, 1876. 

Liebig's Extract of Malt and its Chemical Composition, Manufacture, and Thera- 
peutical Use. By F. H. Davis, M.D., of III. Philadelphia, 1876 

A Case of Fibroid Tumour of the Uterus, causing Eclampsia. By B. B. Browne, 
M.D., Baltimore, Md. New York, 1877. 

Report on the Influence of Climate on Pulmonary Diseases in Minnesota. By 
Franklin Staples, M.D., of Minn. Philadelphia, 1876. 

Considerations in Relation to Diseases of the Joints. By David Prince, M.D. 

Two Cases of CEsophagotomy. By Le Roy McLean, M.D., Surgeon to Troy 
Hospital. West Troy, 1877. 

New York Academy of Medicine, 1877. An Address on the Medical Libraries of 
New York. By Samuel J. Purple, M.D., President. New York, 1877. 

The United States Pharmacopoeia and the American Medical Association. 



TO READERS AND CORRESPONDENTS. 297 

Propositions and Resolutions of the Associ.ation of Medical Superintendents of 
American Institutions for the Insane. Philadelphia, 1876. 

The Use of Uterine Supporters. By Clifton E. Wing, M.D., of Boston. 

Pneumatic Pressure and the Genu-Pectoral Posture in the Reduction of Uterine 
Luxations. By A, Sibley Campbell, M.D., of Augusta, Ga. New York, 1877. 

On the Relations of Health Boards and other Sanitary Organizations with Civic 
Authorities. By Ely McClellan, Surgeon U. S. A. Augusta, Ga., 1877. 

Report of the Fifth International Ophthalmological Congress, held in New York, 
September, 1876. New York: D. Appleton & Co., 1877. 

Transactions of Medical Society of State of West Virginia. Wheeling, 1877. 

Transactions of the Wisconsin State Medical Society, 1876. Milwaukee, 1876. 

Minutes of Proceedings of Delaware State Medical Society, 1876. Wilmington. 

Extracts from Records of Boston Society for Medical Improvement. Vol. VI. 1876. 

Transactions of the Michigan State Medical Society, 1876. Lansing, 1876. 

Transactions of the Medical Society of the District of Columbia. December, 1876. 

Transactions of Kansas Medical Society. 1876. Topeka, 1876. 

The Proceedings of the Medical Society of the County of Kings, Brooklyn, N. Y. 
January, February, March, 1877. 

Proceedings of Academy of Natural Sciences of Philadelphia, June to Dec , 1876. 

Transactions of the American Pharmaceutical Association. (Philadelphia, Sep- 
tember, 1876. Philadelphia, 1876.) 

Proceedings of the Conference of Charities, held in connection with the General 
Meeting of the American Social Science Association, at Saratoga, September, 1876. 

Report of State Board of Health of State of Michigan, 1876 Lansing, 1876. 

Report of the Board of Health of the State of Georgia, 1876. Atlanta, 1877. 

Report of the State Board of Health of the State of Colorado, 1876. Denver. 1877. 

Report of the Births, Marriages, and Deaths in Massachusetts, 1875. Prepared 
under direction of the Secretary of the Commonwealth. With editorial remarks by 
F. W. Draper, M.D., Lecturer on Hysiene in Harvard University. Boston, 1877. 

Report upon the Registration of Births, Marriages, and Deaths in the State of 
Rhode Island, for the year 1875. Prepared under the direction of the Secretary of 
State, by Edward T. Caswell, M.D. Providence, 1877. 

Nova Scotia Hospital for the Insane. Report for 1876. Halifax, 1877. 

Report of the Western Lunatic Asylum of Virginia, 1875-76, Richmond. 1876. 

Report of the State Lunatic Hospital at Northampton, 1876. Boston, 1877. 

Report of the Central Lunatic Asylum (for coloured insane), Virginia, for 1875 
and 1876, Richmond, 1876. 

Report of the New Jersey State Lunatic Asylum at Trenton, 1876, 

Report of State Hospital for Insane, Danville, Pa,, 1875-76. Danville, 1876, 

Report of State Asylum for Insane Criminals, Auburn, N, Y., 1876, Auburn, 1877. 

Report of the Pennsylvania Hospital for the Insane for 1876, Philadelphia, 1877. 

Report of the Butler Hospital for the Insane. Providence, 1877. 

Report of the Mississippi State Lunatic Asylum. Jackson, 1877. 

Report of the Massachusetts Charitable Eye and Ear Infii-mary, 1876. Boston. 

Report of the Children's Hospital of the District of Columbia, Washington, 1877. 

Report of St. Michael's Hospital, Newark, N, J,, 1876. 

Report of the New York Ear Dispensary, New Y'ork, 1876. 

Report of the Inspectors of the State Penitentiary for the Western District of 
Pennsylvania, 1876. Pittsburg, 1877. 

The foUowing Journals have been received in exchang'e: — 

Deutsches Archiv fiJr Klinische Medicin. Bd. XVIII , Heft 6, Bd, XIX., Heft 1. 

Archiv der Heilkunde, Bd. XVIIL, Heft 1 u. 2, 

Archiv fiir Anatomic, Physiologic und Wissenschaftliche Medicin, 1876. Nos. 4, 5. 

Centralblatt fur die Medicinische Wissenschaften, Nos. 50 to 53, 1876, and Nos. 
1 to 8, 1877. 

Allgemeine Wiener Medizinische Zeitung. Nos. 49 to 52, 1876, and 1 to 9, 1877. 

Deutsche Medicinische Wochenschrift. Nos. 49 to 52, 1876, and Nos. 1 to 8, 1877. 

Upsala Liikareforenings Forhandlingar. Bd. XII., No. 2. 

Bibliothek for Lseger. Bd. VII., Heft 1. 

Annali Universali di Medicina e Chirurgia. Dicembre, 1876. Gennaio, 1877. 

Giornale Italiano delle Malattie Venneree e della Pelle. Dicembre, 1876. Febbrajo, 
1877. 

Commentario Clinico di Pisa. Gennaio, 1877. 



29S TO READERS AND CORRESPONDENTS. 

L'Imparziale. Nos. 24, 187G, and Nos. 1, 2, 3, 4, 1877. 
Lo Sperimentale. 1877. Fascic. 1, 2. 
Correio Medico de Li^boa. 6 Anno, Nos. 2, 3, 4, 5, 6. 
Archives Centrales de Medecine. Jan., Fev., Mars, 1877. 
Annales de Dermatologie et de Sypbiligraphie. 'I'onie VIII., No. 1, 2. 
Annales des Maladies de I'Oreille et du Larynx. Decembre, 1877. 
Revue des Sciences Melicales en Fnince et de I'Etranger. Janvier, 1877, 
Revue Mensuelle de Medicine et de Chirurgie. Janvier, Fev., Mnrs, 1877. 
Gazette Hebdomadaire de Medecine et de Chirurgie. Nos. 49 to 52, 1876, and 
Nos. 1 to 9, 1877. 

L'Union M^dicale. Nos. 143 to 153,1876, and Nos. 1 to 26, 1877. 

Le Progr^s Medical. Nos. 50 to 53, 1876, and Nos. 1 to 9, 1877. 

Le Mouveraent Medical. Nos. 50 to 53, 1876, and Nos. 1 to 9, 1877. 

L'Annee Medicale, Nos. 1, 2, 3, 1877. 

Revue Scientifique de la France et de I'Etranger, Nos. 24 to 36, 1876. 

The Retrospect of Medicine. July-Dec. 187(>. 

The British and Foreign Medico-Chirurgical Review. Jan. 1877. 

The Lancet. Jnnunry, February, March, 1877. 

The Medical Times and Gazette. January, February, March, 1877. 

The British Medical Journal. January, Februsjry, March, 1877. 

The Medical Examiner. Februnry, March, 1877. 

The London Medical Record. January, February, March, 1877. 

The Sanitary Record. January, February. March. 1877. 

The Practitioner. January, Februnry, Mnrch, 1877. 

The Obstetrical Journal of Great Britain and Ireland. Jan., Feb., March, 1877. 

The Royal London Ophthalmic Hospital Reports. December, 1876. 

The Journal of Anatomy and Physiology. January, 1877. 

Edinburgh Medical Journal. February, 1877. 

The Glasgow Medical Journal. October, 1876. 

The Dublin Journal of Medical Science. January, February, 1877. 

The Doctor. Jnnuary, February, March, 1877. 

The Indian Medical Gazette. December, 1876, January, 1877. 

Canada Medical and Surgical Journal. January, February, March, 1877. 

The Canada Medical Record. December, 1876, January, February, 1877. 

The Canadian Journal of Medical Science. January, March, 1877. 

The Canada Lancet. January, February, March, 1877. 

L'Union Medicale du Canada. January, February, Mars, 1877. 

The usual American exchanges have been received : their individual acknowledg- 
ment we are compelled to omit for want of space. 



Communications intended for publication, and books for review, should be sent 
free of expense, directed to Tsa.ac Hays, M.D., Editor of the American Journal of the 
Medical Sciences, care of Mr. Henry C. Lea, Philadelphia. Parcels directed as 
above, and (carriage paid) under cover, to Mr. Charles J. Skeet, Bookseller, No. 10 
King William Street, Charing Cross, London, will reach us safely and without delay. 

All remittances of money and letters on the business of the Journal should be ad- 
dressed exclusively to the publisher, Mr. H. C Lea, No. 706 Sansom Street. 

The advertisement sheet belongs to the business department of the Journal, and 
all communications for it must be made to the publisher. 



CORRIGENDUM. 
Page 446, 14tli line, /or :^}^jji\\ of a grain read j-^oth of a grain. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. CXLYI. NEW SERIES. 

APRIL, 1877. 



ORIGINAL COMMUNICATIONS. 

MEMOIRS AND CASES. 

ART. PAGE 

I. The Relations of Pain to Weather, beitiof a Study of the Natural History 
of a case of Traumatic Neuralgia. By S. Weir Mitchell, M.D., of Phila- 
delphia; Member of the National Academy of ^Sciences. (With eleven 
wood-cuts.) ............ 305 

II. Addison's Disease, and its Relations with Annematosis fEssential 
Anaemia). By William Pepper, A.M.. M.D., Professor of Clinical Me- 
dicine in the University of Pennsylvania. ...... 329 

III. 'I'he Proper Treatment of Pelvic Effusions. By D.Warren Brickell, 
M.D., Prof, of Obstetrics, etc., Charity Hospital Medical College, New 
Orleans. ........ ..... 3.o8 

IV. On the Causes of Dyspnoea in Cases of Suffocative Bronchocele, 
and on the Surgical Treatment most advisable. By Lennox Browne, 
F.R. C.S.Ed., Senior Surgeon to the Central London Throat and Ear 
Hospital; Surgeon and Aural Surgeon to the Royal Society of Musi- 
cians ; to Her Majesty's Italian Opera, etc., London, England. . . 370 

V. Simultaneous Ligation of the Carotid and Subclavian Arteries for 
Aneurism of the Arteria Innominata. By Johnson Eliot, A.M., M.D., 
Prof, of Clinical Surgery in Med. Dept. of Georgetown University; one 
of the Attending Surgeons in Providence Hospital; Member of the 
Advisory and Consulting Boards of Physicians and Surgeons to St. Ann's 
Infant Asylum, ........... 374 

VI. Axillary Aneurism ; Ligature of the right Subclavian Artery ; Death 
from Hemorrhage on the sixty-second day. By R. J. Farquharson, 
M.D., of Davenport, Iowa 380 

VII. Case of Amputation at the Bip Joint. Successful Result. By Geo. 

D. Townshend, M.D., of Boston (Highlands), Mass 385 

VIII. New Investigations in Respiratory Pathology. By Edgar Holden, 
M.D., of Newark, New Jersey. (With a wood-cut.) .... 389 

IX. Perinephritis in Children. Three Cases. By V. P. Gibney, A.M., 
M.D., Assistant Surgeon to the Hospital for the Ruptured and Crippled, 
New York 395 



300 CONTENTS. 

ART. PAGE 

X. A Contribution to the Etiolosry of Optic Nerve Atrophy. By Charles 
S. Bull, M.D., Surgeon to the New York Eye Infirmary; Ophthalmic 
Surgeon to Ch:irity Hospital, New York. ...... 40.3 

XI. Obstinate Blepharospasm cured by Inhalation of Nitrite of Amyl. 
By George C. Harlan, M.L)., Surgeon to Wills [Ophthalmic] Hospital, 
Philadelphia 411 

XII. Woorara in Rabies ; Report of two Cases of, with Remarks. By B. 
A. Watson. M.D., Surgeon to Jersey City Charity and St. Francis Hos- 
pitals, Jersey City, N. J 41.3 

XIII. Beach Haven, New Jersey. A Remedy for Hay Fever or Autum- 
nal Catarrh. By Samuel Ashhurst, M.D., Surgeon to the Episcopal 
Hospital, Philadelphia 420 

XI Y. An Epidemic of Typhoid Fever produced by Sewer Poisoning. By 
D. B. Simmons, M.D., Surgeon to Ken Hospital Yokohama, Japan. . 422 

XY. A brief Description of the System of Forced Ventilation which has 
been lately introduced into the Pennsylvania Hospital, with some Sur- 
gical Statistics and Remarks on Hospital Construction. By Thomas G. 
Morton, M.D., one of the Attending Surgeons. (With a wood-cut.) . 424 

XYI. Remarks on Hypertrophy of Turbinated Corpora Cavernosa. By 
Beverley Robinson, M.D., Surgeon to the Manhattan Eye and Ear Hos- 
pital (Depart, of. the Throat); one of the Physicians to Charity Hospi- 
tal, New York. (With a wood-cut.) 431 

XYII. On the Treatment of certain Forms of Phthisis Pulmonalis by 
Rest, and the Internal Administration of Atropia. By Roberts Bartho- 
low, M.A., M.D., Professor of the Theory and Practice of Medicine, 
and of Clinical Medicine, in the Medical College of Ohio. . . . 436 

XYIII. So-called "Second Sight" of Old People. By Swan M. Burnet, 
M.D., of Washington, D. C 446 

XIX. Two New Instruments for Secondary Cataract Operation. By Geo. 
Strawbridge, M.D., of Philadelphia. (With two wood-cuts.) . . 449 

REVIEWS. 

XX. A Practical Treatise on Diseases of the Skin. By Louis A. Duhr- 
ing, M.D., Professor of Diseases of the Skin in the Hospital of the Uni- 
versity of Pennsylvania ; Physician to the Dispensary for Skin Diseases, 
Philadelphia; Author of "Atlas of Skin Diseases," etc. 8vo. pp. 618. 
Philadelphia: J. B. Lippincott & Co., 1877. 451 

XXI. Atlas d'Ophthalmoscopie Medicale et de C6r6broscopie montrant 
chez I'Homme et chez les Animau.x les Lesions du Nerf Optique, de la 
Retine et de la Choroide produites par les Maladies du Cerveau, par les 
Maladies de la Moelle Epiniere et par les Maladies Constitutionelles et 
Humorales. Par E. Bouchut, Medecin de I'Hopital des Enfants malades; 
Professeur Agreire de la Faculte de Medecine. Quatorze planches en 
chromolithographie, comprenant 137 figures, et 19 figures intercalees 
dans le texte. 4to pp. 148. Paris: Bailliere et Fils, 1876. 

Atlas of Medical Ophthalmoscopy and (Jerebro^copy. showing the Lesions 
of the Optic Nerve, of the Retina, and of the Choroid, produced by the 
Diseases of the Brain, and of the Spinal (Jord, and by Constitutional 
and Humoral Diseases. By E. Bouchut. ...... 456 

XX IT. On the Relation between Diabetes and Food, and its Application 
to the Treatment of the Disease. By Arthur Scott Donkin, M.D. Edin., 
M.D. Durham ; formerly Physician to the Sunderland Infirmary and 
Dispensary, etc. 16mo. pp. 186. New York: G. P. Putnam's Sons, 
1875 460 

XXIII. Naval Medical Schools of France and England. Reported to 
the Bureau of Medicine and Surgery. By R C. Dean, Medical Inspec- 
tor U. S. Navy. 8vo. pp. 94, and 9 plates. Washington: Government 
Printing Office, 1876 . . .463 



CONTENTS. 301 



ANALYTICAL AND BIBLIOGKAPHICAL NOTICES. 

ART. PAGE 

XXIV. St. Thomas's Hospital Reports. New Series. YoLYI. Edited 
by Dr. Bristowe, Dr. Joh*n Harley. and Mr. WagstafFe. 8vo. pp. xiv., 
355. London : J. & A. Churchill, 1875 469 

XXY. Handbuch der g^esammten Augenheilknnde. Redigirt von Prof. 
Grafe in Halle, und Prof. SUmisch in Bonn. Band Yll. Erste Halfte, 
Capital Xlll. Leipzig, 1876. 

Bezieungen der AUgernein-Leiden und Organ-Erkrankungen zur Yerander- 
ungen und Krankheiten des Sehorgans. Von Prof. Forster, in Breslau. 

The Relations of General Diseases and Diseases of other Organs to the 
Alterations and