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VOL. VI, No. I. AUGUST, 1881.
Archives of Medicine
®xiQinnl ^xtxcUs.
CROUPOUS PNEUMONIA, AN ACUTE INFEC-
TIOUS DISEASE.*
By EDWARD SANDERS, M.D.,
LATE HOUSE PHYSICIAN, BELLEVUE HOSPITAL, NEW YORK CITY; ATTENDING PHYSICIAN,
DEPARTMENT OF INTERNAL DISEASES, TO MOUNT SINAI HOSPITAL DISPENSARY.
HAVING now seen in what manner acute croupous
pneumonia differs from a purely local phlegmasia
or disease, let us now see how it resembles the acute infec-
tious maladies. We have pulled down our old tottering
ruin, let us now proceed to build up our new edifice. The
term, acute infectious disease, in its modern acceptation,
and as we now must understand it, embraces a group of af-
fections dependent upon the introduction into the blood or
infection of the system by certain peculiar specific poisons
or germs, whether the result of zymotic action, or consist-
ing of low organisms, capable of reproducing themselves to
an endless degree, infection being followed by a definite
series or group of symptoms peculiar to each member of
the class. Upon the fact that we are using the term in its
modern acceptation I would lay particular stress. The term
infection does not necessarily imply contagion, acute infec-
tious diseases being both contagious and non-contagious.
* Read before the New York Academy of Medicine, March 17, i88i.
(Continued from Vol. v, No. 3, p. 252.)
I
2 EDWARD SANDERS.
Under certain conditions, diseases which ordinarily show-
no contagious properties may become distinctly con-
tagious ; while those which have this property only to
a mild degree may manifest a peculiar virulence. These
conditions are usually found to consist in overcrowding,
filth, and the many other unhygienic states. Facts can be
advanced showing that, under certain circumstances, at
certain times, and in certain places, acute croupous pneu-
monia possesses this contagious character.
We know that among animals a contagious disease pre-
vails — in fact, it existed in our own State in an epizootic
form last summer, — known as pleuro-pneumonia, the lesions
of which are found to correspond with those of croupous
pneumonia in man. Morgagni (" The Seats and Causes of
Disease." Trans, by Benj. Alexander, M. D. Lond., 1759,
vol. i, epist. xxi, art. 26, p. 604) refers to several peculiarly
fatal epidemics, which, by others, were looked upon as con-
tagious, but himself disagrees from this. Dr. C. J. B. Wil-
liams (" Cyclop, of Pract. Med.," edited by Forbes, Tweedie,
and Connolly, vol. iii, Phila., 1845) lor^g 3,go wrote that ** the
epidemic occurrence of the disease is clearly proved, and
such has been its extent, that a contagious nature has been
ascribed to it." Under the title, " Epidemic of Pleuro-
pneumonia in some Ships of the Mediterranean Fleet," Dr.
Brayton, R. N., described before the Epidemiological So-
ciety of London a series of cases occurring under his notice,
which he considered as contagious, and as resembling the
pleuro-pneumonia of animals. Thus, he says {Med, Times
and Gaz.y January 23, 1864) : " Besides several features of
resemblance in the symptoms of the pleuro-pneumony in
the St. Jean d' Acre and Cressy to the lung disease in cattle,
it is to be noted that there are good grounds for suspecting
that the affection was communicated by the sick landed
from the vessels to other patients in Malta Hospital." That
CRO UFO US PNE UMONIA. 3
overcrowding, bad ventilation, etc., were the great etio-
logical factors in this outbreak, the following quotation
strikingly proves: "As to the chief cause of this enormous
disproportion in the sickness and mortality, etc., in two
ships of the same fleet and similarly exposed, it was clearly
shown that this lay in the excessive overcrowding of the
men at night in the St. Jean d'Acre on the lower deck,
while in the Marlborough the men were more distributed on
the different decks, and greater attention was paid to ven-
tilation of the between-decks. Only fourteen inches space
was allowed to each hammock in the former ship ; and so
thoroughly was fresh, cool air excluded from the men while
asleep, that the air above the hammocks was found to be
from eight to ten degrees hotter than the air below the
hammocks, and so offensively impure as to cause nausea to
any one going down from the open air." Dr. Ira Russell
(" U. S. Sanitary Commission Memoirs," medical volume,
1867, pp. 319-334) records an epidemic of pneumonia, oc-
curring among six colored regiments and a number of refu-
gees, in 1864, at Benton Barracks, Mo., 784 cases with 156
deaths, from January 1st to May 1st, of which he says (p.
322) : " The effect of an epidemic influence is shown by the
fact that physicians and nurses who had not been greatly
exposed to the vicissitudes of the weather, and the other
causes mentioned, have suffered from it. Besides, the sur-
geons on duty with the regiments in the barracks report
that men occupying the same bunks with those affected
were very much more liable to be attacked than those more
remote. Some of the most intelligent surgeons were led to
believe that the disease was actually contagious." In the
Lancet for September 18, 1875, p. 416, Dr. A. Wynter
Blyth reports a number of cases of pneumonia as of a con-
tagious form. He says : " When I came into North of
Devon, Dr. Christian Budd, of North Tawton, called my
4 EDWARD SANDERS.
attention to a form of pneumonia which he asserted was in-
fectious (contagious), an opinion which he formed no less
than twenty years ago, — and he related many striking in-
stances in support of his assertion." The following are sev-
eral of the cases mentioned by Dr. Blyth : A farmer affected
with acute pneumonia was nursed during his illness by his
niece. This niece became affected with the same disease,
and carried it to her husband. A man became ill of pneu-
monia in April, and died after ten days* sickness. His wife
caught the disease, her first symptoms appearing three days
after his death. About the same date a farmer's daughter,
living a mile from the house of the former patient, became
ill of it, and five other cases followed, all in the same parish,
consisting of a small village and a few scattered houses
(population, 470). A farmer in another parish became ill
April 1 6th, and died on the i8th. The servant-woman went
home ill of the same disease about a week afterward, and
gave it to her married sister with whom she was staying.
Drs. Grimshaw and Moore, as the result of their experience
in an epidemic in Dublin during 1874 {Dublin Med. Jour.^
vol. i, 1874, p. 399, et seq.) of what they term " pythogenic
pneumonia," conclude that "the bibliography of pneumonia
indicates the existence of a form of the disease which arises
under miasmatic influences, and is contagious." Dr. W. B.
Rodman {Amer. Jour, of Med. Sci.^ January, 1876, p. ^6. et
seq) reports a similar endemic of pythogenic pneumonia,
which occurred in the Kentucky State Prison, 75 cases in
all, which he considers as belonging to the class of mias-
matic-contagious diseases of Liebermeister, and which he
thinks was contagious ; while Dr. Samuel E. James records
a second endemic in the same prison, the result of over-
crowding {Amer. Jour, of Med. Sci., vol. 74, n. s. 1877, P-
54, et seq). The following extract, taken from the N. V.
Tribune^ January 21, 1880, refers to the same prison, and re-
lates a condition of affairs which has prevailed in it for years.
CRO UFO US PNE UMONIA . 5
Cincinnati, January 20. — A dispatch from Frankfort, Ken-
tucky, gives the report of the Prison Sanitary Committee, made
yesterday to the Kentucky Legislature, on the condition of the
Penitentiary. It describes a deplorable state of affairs. The
committee says that there are eight convicts confined there who
cannot live longer than a few months. There are at least fifty
others, some of whom are confined to their beds, who, in all prob-
ability, cannot live longer than the latter part of next spring, and
about 200 others who are in a state of debility and weakness prac-
tically unfitting them for duty or work. The rest of the convicts
do not present a healthy appearance, and seem affected by the in-
jurious influences which have prostrated the others. The causes
of this state of affairs are found by the committee to be numer-
ous. The penitentiary grounds are badly drained, and the sewer-
age is so defective that in damp weather water stands in portions
of the inclosure, from which arises a malaria rendering the air
impure. The yards, cells, and workshops are overcrowded, and
the accumulation of filth and general lack of cleanliness within
the prison contribute to the generation of disease. There is a
general lack of ventilation in the houses and cells. The commit-
tee expresses the opinion that one of the direct causes of the un-
healthiness of the convicts is due to their not being supplied with
a sufficient variety of wholesome food.
The following are some additional examples which I ex-
tract from a report by Dr. H. J. Hardwicke, of Sheffield,
{Gaz, M^d. de Paris, 1876, ii, p. 515): A minister suffering
from acute pneumonia was nursed by one of his relatives
during his illness, who was attacked by the same disease,
and in turn communicated it to another relative.
An old man, upon the point of death from this same
malady, sent for several of his kindred in order to see them
for the last time. Each of them was in turn attacked by
the disease. The latest epidemic of pneumonia reported
as contagious is by Dr. Adolf Kiihn {Deutsches Archiv fiir
Klin. Med., Bd. xxi, 1878, s. 348, et seq.). It was, he thinks,
distinctly contagious ; the attendants during its prevalence
in the prison were affected, as also the chronically sick ;
and the disease was conveyed by visitors to other persons
O EDWARD SANDERS.
who did not come near the prison or its inmates. In the
Berl. Klin. Wochschr., No. 37, Sept. 15, 1879, P- 55^ ^i seq,y
he further writes : " It is positive that the epidemic form
of pneumonia occurring at certain times and places bears the
distinct characteristics of a specific infectious disease." Bar-
ella (" Note sur la Pneumonic miasmatique ou zymotique,"
Bulletin de V Acad, de Mdd. de Belgique, No. 2, 1877) studies,
under the name miasmatic or zymotic pneumonia, a disease
occurring, more especially during the summer, in an epi-
demic form under conditions of bad hygiene, crowding, in-
sufficient ventilation, deleterious miasms, and contagion.
The characteristics of acute infectious diseases are :
1st. The varying frequency of their occurrence as re-
gards time and number affected, some years being marked
by their absence or the small numbers attacked ; while at
others raging as an epidemic, that is attacking numerous in-
dividuals simultaneously or successively.
One of the most remarkable facts in the history of the
acute infectious diseases, is their varying frequency, some-
times appearing as sporadic cases only, at others prevailing
through a wide circle of territory. Usually we meet with
cases of most members of this class at all times, here and
there ; but, suddenly and frequently, without any assignable
cause, cases multiply, an epidemic is prevailing. So it is
with measles and scarlatina, with diphtheria and typhoid
or typhus fever, with whooping-cough and parotitis, and so
on down the list. It is a noticeable and well-known fact
that during certain years cases of pneumonia are rare,
occurring only as single cases, here and there, sporadic ;
whereas at other times patient after patient is met with,
until, not infrequently, we find ourselves dealing with a
veritable epidemic.
Such epidemics of pneumonia have been described even
since the sixteenth century (Haeser, Geschichte der Median^
CROUPOUS PNEUMONIA. 7
Bd. ii, s. 344, 1865). Among the epidemics recorded by
earlier writers, I have already referred to several by Mor-
gagni. Among modern epidemics we have those already
mentioned as contagious. Many simple epidemics have
been reported by modern writers, but it will suffice here to
merely mention a few. Diehl (Virchows jfahresb,, 1868,
Bd. ii, p. 95) has twice observed an epidemic in the prison
of Christiana, the first in 1847, ^^^ second in 1866-67.
Couldrey {The Lancet, vol. ii, 1878, p. 701,) reports a local
epidemic of pneumonia prevailing during the month of
May at Scunthorpe, occurring in two small streets, the sani-
tary surroundings of which were bad. " There were ten
cases. Febrile symptoms preceded the pneumonia three
and sometimes four days. Diarrhoea was present in two
cases, abdominal tenderness in every case. A well-marked
crisis happened on the eighth or ninth day, the tempera-
ture falling below normal. One case proved fatal. Fine
crepitation was first detected on the evening of the third
day, slight dulness on percussion on the morning of the
fourth day, and then followed the usual signs of pneumo-
nia. There was also obstinate diarrhoea, prune-juice-col-
ored expectoration, and great prostration. Death took
place on the eighth day."
Dr. Henry H. Smith {Phila- Med. Times, vol. ix, 1879),
in a discussion before the Phila. County Med. Soc, re-
marked that owing to some unexplained cause deaths from
pneumonia had multiplied to an extraordinary degree, one-
eighth of the whole number of deaths in Philadelphia be-
ing from this complaint. The large mortality may, he
thinks, be due to the fact " that there is an epidemic."
Cullen (" First Lines of the Pract. of Physic," N. Y., 1793,
vol. i, p. 188) states "that the pneumonic inflammation has
been sometimes so much an epidemic, as to occasion a
suspicion of its depending upon a specific contagion, but
8 EDWARD SANDERS.
I have not met with any evidence in proof of this."
Lebert has convinced himself of its epidemic occurrence
in Switzerland ; Griesinger afilirms that in malarious dis-
tricts it has a tendency to ^assume an epidemic character ;
and Prof. Flint, Sr., states that it has been known at certain
times and in certain situations in the Southern States to
prevail to an extent entitling it to be called an epidemic.
Hirsch was able to collect the records of 163 epidemics,
prevailing in various parts of the world.
Pneumonia, like several of the members of the infectious
class, prevails at times with other diseases of the same
group, as with measles ; while there is marked and remarka-
ble coincidence between typhoid and pneumonia years.
Sometimes, again, pneumonia occurs in an individual con-
jointly with an infectious disease, as typhoid fever, measles,
scarlatina, etc. Here we must remember that it is not at
all uncommon to meet with patients suffering at the same
time from scarlatina and diphtheria, or measles and whoop-
ing-cough, etc., and that there is no rule governing the in-
fectious diseases which indicates the impossibility of two
of them occurring conjointly in the same person. How-
ever, it must be stated that coexistence of acute croupous
pneumonia in the same individual with some one of the in-
fectious diseases is comparatively rare.
The laws governing epidemics have yet to be accurately
determined ; those known being principally related to over-
crowding, imperfect ventilation, filth, neglect, and certain
atmospheric and telluric influences. Epidemics of pneu-
monia have usually existed just where such influences pre-
vail, as in cloisters, prisons, barracks, etc. Those referred
to by Morgagni occurred among nuns ; those of Rodman,
Kuhn, Diehl, and others, in over-filled prisons ; that of Rus-
sell, in barracks, ochlesis exerting in this instance a marked
influence ; that of Brayton, on board over-crowded ships-of-
CRO UPO US PNE UMONIA . 9
war ; and that of Couldrey, in two streets in a bad sanitary-
condition. We sometimes meet with instances of so-called
** abortive pneumonia," that is, where all the symptoms of
an acute pneumonia terminate in restoration to health in
from 32 to 74 hours. Juergensen, Flint, Wunderlich, Bern-
heim, Leube, and others, have seen such cases. Prof. Leube
describes {Allegemeine Medic. Central-Zeitung, 1Z77, No.
34) two cases of so-called transitory pneumonia, which he
considers merely abortive forms " of this infection in indi-
viduals who have a resisting power against the special poi-
son " (Dobell, '' Annual Reports on Diseases of the Chest,"
vol. iii, 1877, p. 399). Now, in epidemics of such diseases as
typhoid and typhus fevers, as is well known, we are con-
stantly meeting with abortive cases. The same is true of
other members of the class. Epidemics of the acute infec-
tious diseases are often characterized by distinct varieties,
or variations in their clinical aspect, especially as regards
mild and malignant forms. The same is true of pneu-
monia, — witness some of the modifying names employed, as,
for instance, the typhoid, bilious, malignant, asthenic, con-
tagious, etc., forms.
2d. A second characteristic of acute infectious maladies
is inability to produce them experimentally, except artifi-
cial propagation, by the employment of the specific poison
of the special disease, be considered such. We have already
seen in an earlier part of this paper, that failure has uni-
formly followed attempts at artificial production of the dis-
ease under consideration.
3d. A stage of incubation. The incubative stage of
many of the infectious diseases is, as yet, entirely unknown ;
I can only state that in the epidemics of contagious pneu-
monia recorded, an uncertain interval elapsed between the
time of supposed exposure and the appearance of the first
symptom of the malady : in one instance, three days after
10 EDWARD SANDERS.
the death of the infecting patient ; in another, in about a
week; and in several others, at indefinitely mentioned
periods. Ritter {Deutsches Archiv fur Klin. Med^ Bd. xxv,
1879, s- 52, et seq) found this stage in one series of cases, five
in number, lasting from nine to thirteen days; while in
another group of two cases, the period of incubation was
about from 21 to 24 days. According to Traube, the con-
tagious form of the disease has a stage of incubation of
three days. Of course such a question can only be decided
from the study of a large number of appropriate cases, such
as at present I find impossible to obtain.
4th. An initiatory or premonitory stage. That in many
cases of pneumonia there is a prodromal stage, lasting for
from a few days to several weeks, as a series of vague, in-
definite symptoms, we have already seen.
5th. Uniform or classical course, undeviating sequence
of symptoms, except such as are modified by or due to the
special epidemic influence prevailing. There is no other
disease, so far as I am aware, which has so definite and clas-
sical a course as acute lobar pneumonia. Usually begin-
ning abruptly with a chill, followed for a determinate
period by definite, well-marked, and almost unvarying
symptoms, it terminates, if in recovery, by a sudden and
almost plunging crisis, a sudden disappearance of all con-
stitutional manifestations. Local symptoms still prevail,
but so do they in typhoid fever, diphtheria, etc., during
convalescence ; the restoration to a normal state of the
affected tissues being itself only gradual, is necessarily at-
tended by a gradual disappearance of symptoms referrible
thereto.
As is well known, during different years variations in the
intensity or predominance of certain phenomena have been
noted in infectious troubles, as also in the type of the dis-
ease. Such is also true of pneumonia. For instance, the
CRO UFO US PNE UMONIA. 1 1
occurrence of herpes labialis during certain seasons, and its
absence at others ; the presence of marked gastric symp-
toms, or the appearance of icterus, giving rise to what has
been known as the icteric or bilious form ; the prevalence of
the so-called asthenic or malignant variety, marked by
symptoms of great prostration, stupor, or delirium ; or the
occurrence of diarrhoea, as has been noticed in certain epi-
demics.
6th. Another characteristic of infectious complaints is
absence of direct relation between constitutional symptoms
and visceral lesions. I have already dwelt upon this point,
and will only here quote the following from Juergensen
(Ziemssen's *' Cyclop, of the Pract. of Med.," vol. v, p. 146) :
" Small consolidations with high fever and severe constitu-
tional symptoms, and solid infiltrations with a compara-
tively slight fever and general disturbance, this is the rule
and not the exception."
The fact that extension of the disease is attended by in-
crease of symptoms is not contrary to the laws governing
infectious diseases ; for, do we not note the same in exten-
sion of the diphtheritic and erysipelatous processes ?
7th. Occurrence of certain complications in certain epi-
demics. At times pneumonia is marked by entire absence
of complications, while at others a large percentage of the
patients suffer from them. Thus, during my first winter in
Bellevue Hospital, most of the cases were simple and ran a
mild course ; whereas, in my second winter, among 24 cases
coming under my notice, 9 were attended by complications
directly dependent upon the pneumonia: three with pleurisy,
one of which was acute and diffused, two subacute with se-
rous effusion ; two with pericarditis ; one with acute peritoni-
tis; one with general bronchitis, this case being also attended
by abortion ; one with acute empyema, endo- and pericar-
ditis, and verticular meningitis ; and a ninth with gastro-
12 EDWARD SANDERS.
duodenitis, icterus, cholaemia, and acute parenchymatous
nephritis. The prevalence of complications is thus referred
to by Wilson Fox (loc. cit., p. 6^^) : *' The frequent associa-
tion of albuminuria with pneumonia can scarcely be re-
garded as a mere accidental complication, and it is by no
means improbable that the kidneys are, under these circum-
stances, implicated by the same cause as the lung. Other
glands also occasionally suffer, as the parotid gland ; gastro-
dudodenal catarrh and some degree of affection of the
liver are also complications. In addition to these, the serous
membranes tend also to become implicated as part of the
primary disease, and when these relations of pneumonia are
regarded as a whole, it appears that those organs are most
likely to suffer which are most commonly affected by recog-
nizable conditions of blood-poisoning." If we examine the
statistics quoted by Juergensen, we will note that different
places are marked by different rates of occurrence of certain
complications. Thus, pleurisy with effusion complicated
5.2 per cent, of the Vienna cases, 4 per cent, of the Stock-
holm cases, and 15.3 percent, of the Basle cases; pericar-
ditis, 0.5 per cent, in Vienna, 0.9 per cent, in Stockholm,
3.09 per cent, in Basle ; endocarditis, 0.2 per cent, in Vienna
and Stockholm, 0.9 per cent, in Basle; meningitis, o. I per
cent, in Vienna and Stockholm, 1.3 per cent, in Basle.
Parotitis has, in a few patients, been observed by B^hier and
Fox, such cases being particularly fatal, in these respects
resembling typhoid fever in which a similar condition has
been known to occur. Speaking generally, it may be said
that each member of the infectious group of diseases has a
special class of complications, that of pneumonia being its
tendency to involve the serous membranes, as will be ob-
served from the foregoing.
8th. Self-limitation. Thus, typhus fever runs its course
in about 14 days, typhoid in about 28 days, pertussis in
CRO UFO US PNE UMONIA . 1 3
some 6 weeks, measles in 7 days, and so on through the list.
To no other disease, I will venture to assert, can the term
self-limited be applied with greater justice than to pneu-
monia. Of course, as in some acute infectious diseases, we
find in a small percentage of cases variations from this rule,
but such cases are comparatively rare. Of 867 cases, ter-
minating by crisis, reported by various authors, 6'j'j ended
by the eighth day, and all by the eighteenth.
9th. A rate of mortality varying with each epidemic.
Statistics show that the rate of mortality in pneumonia
varies from 2 per cent, to 33 per cent. (Andral), the death-
rate differing greatly in different years, even under the same
methods of treatment. Thus Huss' statistics show rates
ranging from 9.1 per cent, to 14. i per cent, under antiphlo-
gistic measures, and from 6.1 per cent, to 13.4 per cent, after
the abandonment of this plan. Brandes* mortality was, one
year, 5.4 per cent., and the following year, 31 per cent. Of
my 24 cases 12 died. Fourteen were complicated ; of these
II succumbed. Of the simple cases only one died, this
being the old woman 72 years of age, who, while suffering
from great mental depression, made an attempt at suicide
by drowning. The cases of the previous year had been
marked by their great mildness, but few terminating fatally.
loth. Localization of morbid changes to some organ or
sets of organs. Typhoid fever seizes upon the solitary and
agminated glands of the small intestines, diphtheria in-
volves the pharynx, mumps the salivary glands, and so of
other members of the class ; the specific poison of each
disease seeming to have a selective power toward certain
organs or sets of organs. The consolidation of the lung
tissue, therefore, in pneumonia, may be considered the es-
sential morbid lesion, in the same sense that ulceration of
the solitary glands and Peyer's patches is the essential
lesion of typhoid fever. In blood diseases it is a well-
14 EDWARD SANDERS,
recognized fact that the blood poisons produce their most
marked effects on glandular organs ; it is in these that the
local manifestations of the constitutional disease show
themselves. The lungs are closely allied to these glandular
organs : first, by their anatomical structure ; second, by
their important functions as purifying agents of the blood ;
and third, by their great and almost ceaseless activity. In
this resemblance, therefore, we may perhaps find a partial
explanation for their involvement by the causative poison
of pneumonia. The fact that the disease may primarily at-
tack a single lobe, finally extending to the other parts of
the lung, is not contrary to this theory; for, do we not see
the same thing modifying the lesions in typhoid fever,
mumps, diphtheria, etc. In typhoid fever the ulcerative
process may involve only a few of the lymphatic glands of
the small intestine, or may be very much more extensive,
as in a case I have seen, where the ulcerations not only ex-
tended throughout the greater part of the small intestine,
ccecum, and lower part of the ascending colon, but even
into the vermiform appendix, two small ulcers being found
in this situation. Parotitis usually is at first single, but
tends to become double. The diphtheritic process may at
first localize itself in the pharynx, and from there may ad-
vance into the nasal passages or the larynx, while the
exanthem of the eruptive diseases may be very scanty or
very abundant.
nth. Uselessness of remedies against the disease itself,
treatment being almost entirely symptomatic. In acute in-
fectious diseases we do not treat the disease itself, but
rather such of its symptoms as may demand attention.
The same holds true of pneumonia ; fever is combatted by
antipyretics ; pain, cough, sleeplessness, etc., by sedatives ;
exhaustion or heart failure, by stimulants. The old method
had for its object the cutting short of the disease ; our
CROUPO US PNE UMONIA . 1 5
modern method ignores the lung disease itself, but turns
its attention to the avoidance and preventing of inter-
current dangers. " If," says C. Handfield Jones {Med,
Times and Gaz., vol. ii, 1873, p. 118), " then, pneumonia, as
we see it now-a-days, is a fever and not an inflammation, it
is clear that the object of treatment must rationally be, not
to arrest it, but to conduct it to a safe termination. This
view is very generally acted on, and is strongly supported
by Dr. Bennett's experience, who makes it his aim to con-
serve the patient's strength."
1 2th. The great characteristic of acute infectious dis-
eases is their specificness ; " under all circumstances, a given
kind of disease is solely due to a given kind of morbid
agent or cause " (Liebermeister, Ziemssen's ** Cycloped. of
the Pract. of Med.," vol. i, p. 14). No matter what other
conditions may be present, the producing element for each
member of the class is always a special, infectious prin-
ciple, a specific poison acting on and through the blood.
The theory that pneumonia is due to a specific blood
poison is not a new one. As long ago as the time of Morgagni,
physicians entertained the suspicion that the disease might
depend upon a blood poison. Among others of the earlier
writers, we have Carolus Strackius (" Nova Theoria," Mor-
gunt, 1786), who declares himself positively in favor of a mi-
asmatic cause for the malady. CuUen, while advancing no
arguments against the belief of the causation of the disease
by a specific poison, is only able to state that he has met
with no evidence in proof of this {loc. cit., p. 188). J. Frank,
Skoda, Robert Latour, Marrotte, were believers, to a cer-
tain extent, in the miasmatic origin of the disease. Laennec
(" A Treat, on the Dis. of the Chest and on Mediate Aus-
cultation," 3d ed., trans, by John Forbes, N. Y., 1830, p.
225) remarks: *' It is possible that the epidemic peri-
pneumony, is often owing to an analogous cause, that is to
1 6 EDWARD SANDERS.
say, to deleterious miasms, which have entered the system
by means of the cutaneous or pulmonary absorbents, since
nothing is more common than to meet with cases of this
disease, to which we can assign no occasional cause. How
many persons are seized with it, in their very chambers,
and in spite of the utmost care taken of their health." Hux-
ham and Fr. Hoffmann considered the disease a fever, of
which the pulmonary changes constituted merely the prin-
cipal localization. Pons, according to Leichtenstern, af-
firmed that "pneumonia is a general disease, complicated
by pulmonary inflammation," while, according to the same
writer. Trousseau maintained that in this disease* "the
blood contains another morbid element, of the nature of
which we are ignorant, but whose existence is revealed to
us by constant morbid manifestations," viz., pneumonic in-
flammation. In i860 Dr. Parkes {Med. Times and Gaz.^
vol. i, p. 186) wrote that " it (pneumonia) is a blood disease
of some sort, consisting, in part, in an augmentation of the
fibrin in the blood, as in acute rheumatism." We know
now that the excess of fibrin in the blood, here referred to,
is a consequence, and not a cause of the disease (Virchow).
Dr. Dupr^, in an article on catarrhal fever, written many
years ago, speaks of this infectious theory of pneumonia
(Hallopeau). In 1866 Prof. Wm. H. Draper, in a discussion
before the N. Y. Academy of Medicine, affirmed that " if it be
true that the lesion is a sequence, in point of time, of the
pyrexia, then it is altogether probable that it is a secondary
phenomenon, and a necessary and conservative process, by
which a blood poison is eliminated from the circulation.
It is true that chemistry has not yet discovered any specific
poison in the blood of persons suffering from pneumonia ;
but we are not without strong presumptive evidence in favor
of this theory. These considerations certainly lend support
to the theory that pneumonia is something more than a
CROUPO US PNE UMONIA . I /
local disease, and is rather an essential fever, having a char-
acteristic lesion, like small-pox or scarlet fever (Bull, of the
N. Y. Acad, of Med., vol. ii, 1866, p. 519). In an article,
entitled "Note sur la Fi^vre Herpetique," Parrot, in 1871
{Gaz. Hebdoin., 14 juillet, p. 374, et 28 juillet, p. 412, 1871),
makes the following remarks (p. 416) : " In a word, does the
anatomical lesion govern the disease ; or, conversely, is the
principal r61e played by the fever ? Seeing the impossi-
bility, at present, of answering these difficult questions, it
has appeared to me appropriate to point out the analogy
existing between * herpetic fever' and acute pneumonia, as
shown by our observations." Juergensen is the great
modern exponent of the infectious theory of pneumonia.
Among others who have announced their adherence to this
theory, I will mention Prof. Austin Flint, Sr. (Tr. of the
Med. Soc. of the State of N. Y., 1877); Dr. Moellmann
{Berliner Klin. Wochenschr., No. 12, 1879); ^'^' Henry H.
Smith (Phila. Med. Times, vol. ii, 1879); I^^- James An-
drews (Med. News and Lib., Sept., 1877); Bernheim (Gaz.
des Hosp., 1877, p. 228) ; Marrotte (Arch, g^n de Med., 1873) ;
O. Leichtenstern (Volkmanns Sam. Klin. Vort.,'No. 82);
and Cohnheim (Vorlesungen iiber allegemeine Pathologic, Bd.
i, 250, Berlin, 1877). Friedreich (Volkmanns Sam. Klin.
Vort., No. 75) goes so far as to admit the occurrence of a
type of pneumonia which is infectious, but does not speak
in the same way of acute pneumonia in general ; while O.
Sturges (" On Pneumonia: its Natural History," etc., Lond.,
1876) considers the disease neither a local inflammatory nor
general one, but rather one lying midway between the two.
Cohnheim classes the disease among the miasmatic-con-
tagious, and maintains that, without being directly trans-
missible, it is never in any locality developed without having
been previously imported (Hallopeau).
Some of the names used formerly to designate the dis-
1 8 EDWARD SANDERS.
ease would seem to imply a specific cause. Thus, we have
the term, febris pneumonica (Hoffmann). But here we
must remember the carelessness and inappropriateness with
which such designations were often formerly employed ;
and the fact that inflammation of the lungs, peripneumonia,
etc., were used as terms synonymous of the same. The like
is true of the French " fievre pneumonique," and the " lung
fever" of our laity. Dr. Flint proposes for the disease the
name " pneumonic fever."
The question now arises, pneumonia being an acute in-
fectious malady, how does its specific poison gain entrance
into the system, how is it taken into the body ? We
know that the poison of typhoid fever is taken into the
stomach in drinking-water, contaminated milk, and the
like, and it is presumed that it enters the system by ab-
sorption through the solitary and agminated lymphatic
glands of the intestines, on which it produces its most
marked visible effects. May it not be that the germ or
poison of pneumonic fever enters the body through the
lungs by inhalation, and then follows a course analogous to
that of the typhoid germ ? In support of this doctrine we
have the following: According to Dr. Parkes, the poison of
the contagious pleuro-pneumonia of animals is contained in
the exudation, probably the epithelium and pus, which,
taken into the lungs of a healthy animal, will reproduce it-
self and give rise to the disease. " Considering," he says,
" that the pleuro-pneumonia of cattle is probably propa-
gated through the pus and epithelium cells of the sputa
passing into the air-cells of other cattle ; that even in man
there is some evidence of a pneumonia or phthisical disease
being contagious" ("A Manual of Practical Hygiene," p.
74, 1864). Barella {Gaz. Hebdom. de MM. et de Chirurg., 2
mars, 1877, p. 136) advances the following: "The typho-
genic miasm may enter the economy by two avenues : the
CROUPOUS PNEUMONIA. 1 9
digestive mucous membrane, and the respiratory mucous
membrane ; if it seizes primarily upon the digestive pas-
sages, it produces typhoid fever ; if it acts preferably upon
the respiratory mucous membrane, it gives rise to typhoid,
miasmatic, or zymotic pneumonia. The frequency of pneu-
monia during certain epidemics of typhoid fever has been
noticed, and all practitioners are aware that at the begin-
ning it is sometimes very difficult to differentiate the one
from the other." Klebs {Archiv fur Experiment. Path, u,
Pharm., Bd. iv, 1875) affirms that he has been able to de-
termine the nature of the infectious agent. He describes a
" monas pulmonale," inoculation of which in animals was,
he claims, followed by the development of the malady in
question, also stating that O. Weber had already shown,
experimentally, that the fluid obtained from pneumonic
lungs possessed pyretogenic characters to a high degree ;
and Kuntze, following this hypothesis to its extremest
consequences, advises and puts into practice, with the
object of destroying the infecting germ, the treatment
of pneumonia by subcutaneous injections of carbolic acid.
Moore and Grimshaw relate that in a certain high-school,
following the placing of a ventilator by the sewer authori-
ties, the institution became infected by sewer-gas. Shortly
thereafter, cases of pneumonia began to develop, and, as a
consequence, the school had to be closed. The ventilator
was removed, and the cases of pneumonia ceased to occur.
For many years previous to this outbreak, there had been
no sickness in the institution. The inference is here cer-
tainly very strong that the sewer-gas and pneumonia stood
in the relation to each other of cause and effect. If such
be the case, the avenue by which the poison gained access
to the system is obvious, viz., by inhalation.
Finally, quoting from Wilson Fox {loc. cit., p. tjf)-.
*' Whether the blood poison is eliminated by the exudation
20 EDWARD SANDERS.
process must remain a matter of hypothesis, though by the
sudden cessation of the pyrexia when this stage has
advanced to a certain degree would appear to lend some
support to this view, and particularly when we remember
the analogy, and even the various phases of transition which
exist between exudative and secretory process." How-
ever, it remains for future research to decide this ques-
tion.
To sum up, acute lobar pneumonia is an acute infectious
disease, dependent upon the introduction into the system
of a specific poison, the visible expression of whose activity
is a croupous inflammation of the lungs, and may be classed
among the miasmatic-contagious group, belonging thus to
the same class of maladies as typhoid fever. In all prob-
ability, the poison is taken into the organism by absorption
through the lungs, that is, by inhalation.
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CRO UFO US PNE UMONIA . 2 1
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18. Freidreich, N. Der Acute Milztumor und seine Beziehungen zu den
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Southern Med. Rec, Atlanta, ix, p. 206.
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V Union Mdd., Jan., 1875, p. 88.
Note et observation au sujet de 1' herpes. V Union Mid,, tome
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32. de Latour, Robert. Du diagnostique etiologique de la pneumonie au
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22 EDWARD SANDERS.
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Allegemeine Medic. Central- Zeitungy 1877, No. 34.
37. Leuck, A. W. Pneumonia and its treatment. Phila. Med. 6^ Surg.
Rep., Jan. 20, 1877.
38. Marrotte. De la fievre synoque peripneumonique. Arch. Gin de
Mdd.y 1873.
39. Moellmann. Zur ^tiologie der Crouposen Pneumonic. Berliner Klin'.
Wochschr., No. 12, 1879.
40. Muller, Adolf. Endemische Pneumonic. Arch, filr Klin. Med., bd.
XX, 1878, s. 127.
41. Parkes, E. A. Case of acute asthenic pneumonia left without treat-
ment. Med. Times 6^ Gaz., vol. i, i860, p. 184.
"A Manual of Hygiene," Lond., 1864, p. 74.
42. Parrot. Note sur la fievre hcrpetique. Gaz. Hebdom. de MM. et de
Chirurg., 1871, p. 374, et p. 412.
43. Rittcr, J. Beitragc zur Frage des Pneumotyphus. Deutsches Archiv fiif
Klin. Med.y bd. xxv, 1879, s. 52.
44. Rodman, W. B. Endemic of pythogenic or miasmatic-infectious pneu-
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1867, pp. 319-334. Pneumonia as it appeared among the colored troops at
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Norsk. Mag. f. Laegevidensk, 1871.
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ADDENDA.
53. Banti, G. De la pneumonic infectieuse (rnemoire lu a la Soc. Med."
Phys. de Florence, le 16 mars, 1879, traduit par E. Vaisson). Arch. GSn. de
Mdd., 1880, cxlvi, 36-55.
54. Blackwell, E. T. Adynamic pneumonia ; Phila. Med. Times, 1880,
X, 549-551.
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ticemiquc. L Union Mid., 1875, No. 77-106.
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1879.
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Lungebetandelser i Akershus Strafanstalt i 1867. Norsk. Mag. f.
Laegevidensk, xxii.
CRO UFO US PNE UMONIA . 23
58. Fernet. De la pneumonic aigi^e et de la nevrite du pneumogastrique ;
pathogenie de la pneumonie. Bull. Soc. Clin, de Paris (1878) ; 1879, ii, 56-70.
(Discussion) 89-92.
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edition, Phila. 1881.
60. Grisolle. Traite pratique de la pneumonie aux differens age. Paris,
1841.
61. Learning. Endemic pleuro-pneumonia, as seen in New York during
the past ten or twelve years. Med. Gaz., 1880, vii, 57-63.
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Med. Jour., 1880, ii, 6.
EXPERIMENTAL AND MICROSCOPICAL STUDIES
ON THE ORIGIN OF THE BLOOD
GLOBULES.
By a. W. JOHNSTONE, M.D.,
DANVILLE, KY.
THE objects of this paper are to give the result of a
repetition of Onimus' experiments on the " origin
of the white blood corpuscles," and to place on record an
account of an undescribed method of development that is
constantly going on in the adenoid tissues. As given by-
Flint, these experiments of Onimus are as follows :
The serum from quickly-drawn blisters, after having been
freed by filtration, etc., etc., from all its organized elements,
is placed in bags of gold-beater's skin. These sacks are then
placed in the subcutaneous tissues of rabbits, and after a
sojourn of two or three days their serum is found to contain
a variable number of leucocytes.
His conclusions are that the corpuscles have sprung up
de novo from the blastema, and by analogy he argues that
there is a spontaneous generation going on in serum where-
ever it is found.
I have repeated these investigations, and in two directions
have pushed them further than their author ; that is, instead
of the blastema, in the course of the experiments I used
four different liquids, and in all cases, besides the fluids, I
examined the gold-beater's-skin after its removal.
24
STUDIES ON THE ORIGIN OF THE BLOOD GLOBULES. 2$
In addition to the serum I used a weak solution of
chloride of sodium in water, a mixture of this with the white
of an egg, and lastly the clear part of the egg alone. The
animals used were cats; the length of experiments from 17 to
50 hours ; the thickness of the enclosing membranes was in
most instances one, but in two cases two, layers of the gold-
beater's skin. In all cases I examined both membrane and
blastema before the introduction to the cat, and thus made
sure that no organisms were present. My results were that
in every case, except where I used a varnished membrane, I
found leucocytes in the blastema, and wherever they were
found in the liquid the walls of the enclosing bag were sure
to be crowded with the same organisms.
The only things that seemed to influence the number of
the corpuscles were the condition of the containing mem-
brane and the length of time the sack remained under the
skin. If these conditions were the same there were just as
many corpuscles in the solution of chloride of sodium, or
the egg mixtures, as there were in the serum. In the cases
where the skin was doubled after a longer time than was
ordinarily employed, a few corpuscles made their appear-
ance in the blastema, a few were found in the inner layer of
the bag, whilst the outer one contained a great many.
From these facts we are forced to the conclusion that the
corpuscles migrated through the walls of the bags, just as
they do to the interior of the cat-gut ligatures that are left
in similar conditions.
This, however, is only a negative kind of proof, and for
something positive I will ask the reader's attention to my
recent study of the so-called adenoid tissue.
It is not necessary here for me to give the histology of
the organs that contain this tissue, and to repeat that in the
lymph glands it is arranged into lymph follicles, lymph
cords, and interfollicular strings ; in the alimentary canal
26 A. JV. JOHNSTONE.
into follicles such as are contained by the tonsil, base of the
tongue, pharynx, sesophagus, solitary glands, Peyer's
patches, etc., etc. ; in the spleen into the ensheathing coats
of the arteries, and the so-called Malpighian corpuscles, etc.,
etc. But for our purpose, all that we need to know is that
wherever this tissue may be there is a stream of fluid com-
ing into it on one side, which, after working its way through
the sponge-like mass, passes out on the other and eventually
empties into the blood.
The two questions to which we will now address our-
selves are : Whence comes and what is the function of the
adenoid tissue ?
All histologists agree that in the animal kingdom we
find but four varieties of connective tissue and that they
are the myxomatous, the fibrous, the cartilaginous, and the
osseous. The myxomatous connective tissue is met with
almost exclusively in the earliest stages of development of
the embryonal connective tissue, and in transient foetal or-
gans, such as the umbilical cord and placenta. This tissue
appears in two varieties : first, in the shape of a protoplasmic
reticulum of greatly varying size, with nuclei at its points of
intersection, the meshes of which hold the jelly-like mucoid
basis substance (umbilical cord). In the centres of the
meshes globular and apparently isolated bodies are seen.
The other form consists of a delicate fibrous reticulum, hav-
ing oblong nuclei at the points of intersection, the meshes
being filled with single protoplasmic bodies (so-called de-
cidua cells of the placenta), or with a mucoid basis sub-
stance with scanty bodies (derma and mucosa of the em-
bryo in the earliest stages).
Recent researches have proved that this mucoid basis
substance is not a structureless mass, but that it is pierced
by a living reticulum, which is continuous with a smaller
net-work which pervades all protoplasmic formations. As
STUDIES ON THE ORIGIN OF THE BLOOD GLOBULES. 2/
the fibrous reticulum of myxomatous tissue is a protoplas-
mic formation, its fibres, too, contain a fine reticulum of liv-
ing matter, which is also continuous with the. fine reticulum
of its neighbors. So the basis substance, in either its mu-
coid or fibrous variety, differs from protoplasm only by a
chemically altered substance within the meshes. This sub-
stance in the protoplasm is a liquid, in the basis substance a
semi-solid, though not strictly glue-yielding mass.
As has been known for a long time, comparatively low
powers, when brought to bear on the adenoid tissue, demon-
strate the presence of a delicate fibrous reticulum, which
at the points of intersection is generally slightly thickened
and flattened so as to present a plate-like appearance.
These intersections are sometimes provided with nuclei,
and the meshes of the net-work are always filled with
lymph corpuscles. Although these corpuscles are so closely
packed that they often flatten each other, still each one is
generally separated from its neighbors by a narrow, light
substance which is probably liquid.
Unless the lymph corpuscles be torn apart by mechanical
injuries, such as cutting, washing, etc., etc., they are all con-
nected with each other by extremely delicate, grayish spokes,
which traverse the intermediate substance in all directions.
A like connection always exists between the lymph corpus-
cles and the fibrous reticulum nearest to them. Most au-
thors claim that this fibrous reticulum of the adenoid tis-
sue is structureless, and exhibits nuclei only at its points of
intersection.
This assertion must be based on Canada balsam speci-
mens, for it makes all minute details fade away. My own
specimens, cut from fresh lymph glands, or such as had been
preserved in a dilute solution of chromic acid, show a well-
marked net-work in the fibrous reticulum both in the un-
stained and in the carmine specimens.
28 A. W. JOHNSTONE.
While we are on this subject of the preparation of
specimens, let me say, once for all, that if we hope to see
the minute structure of this tissue our sections must be cut
from fresh or from chromic acid preparations, for alcohol or
water destroys the details. If stained at all, it should be
done with carmine, or what is better, the ^per-cent. of
chloride of gold. This last named agent has a peculiar
faculty for taking hold of the living matter of the most
minute organisms and making it stand out in a very satis-
factory manner. Lastly, I would state that glycerine seems
to be the only mounting substance now known that will
preserve tissues absolutely unchanged.
Reasoning by analogy it seems that we are forced to con-
clude that adenoid tissue is myxomatous, and, therefore, a
remnant of foetal tissue. We know that the myxomatous
tissue is abundant in the embryo, and relatively scarce in
the fully developed foetus. In the adult the vitreous body
was considered the only remnant of embryonal myxomatous
tissue. To this, however, we should add the adenoid, and
thus answer our first question.
To get a better idea of this tissue, let us turn to its most
minute anatomy, and for the present we will confine our
attention to its framework. As I have already said, in the
framework, which looks perfectly homogeneous under a
500, with a 1,200 (immersion) we can readily recognize a
delicate reticulum piercing nearly all its fibres and plates.
In some places, even without the use of a staining reagent,
this net-work is just as plain as in the corpuscles themselves,
the only difference being that its meshes are a little wider
than those in the globule. But the point to which I wish
to draw particular attention is, that the granules, at its
points of intersection, vary very much in size. Sometimes
where they are seen along the edges of broad fibres, or in
the centres of very fine ones, they give it a beaded appear-
STUDIES ON THE ORIGIN OF THE BLOOD GLOBULES. 29
ance. At others they are so small that they are just barely
appreciable. This inequality in size is most probably due
Lymph ganglion of cat magnified 1200 diameters.
aaa. Myxomatous reticulum exhibiting in its interior a delicate reticulum of living
matter.
bbb. Granules of living matter arising from the growth of the intersections of the con-
tained reticulum.
ccc. Granules grown into vacuolized corpuscles, and intermediate stages of develop-
ment.
ddd. Full-grown nucleated lymph corpuscles.
eee. Mesh of the myxomatous net-work tilled with lymph corpuscles of all stages of
development.
///. Fine spoke-like threads connecting the corpuscles with the reticulum lying within
the myxomatous framework.
to a growth that is constantly going on in these granules,
and our finding different ones at different stages of it.
30 A. W. JOHNSTONE.
This process does not stop where the lump of living mat-
ter can be called a granule, but it keeps on until it has con-
verted it into what is known as a corpuscle. This is accom-
plished by the smaller granule increasing until it has
become so large that the fibre can no longer contain it
without showing a slight bulging at the point where the
granule lies. This is what gives the beaded appearance
just referred to. But as the bead still grows it protrudes
more and more from the free surface of the fibre, until it
has the appearance of a small homogeneous yellowish cor-
puscle sticking to the side of the fibre. The corpuscle is
not separated from the fibre in this immature state, but re-
tains a connection in the shape of very delicate grayish
spoke-like threads, that can be traced directly to the gran-
ules within the fibre. This connection is constant in all the
different-sized corpuscles, except the very largest, and in all
probability is the route through which the corpuscle draws
its nourishment. We can see no differences in these grow-
ing corpuscles until they are about three-quarters the size of
a red blood globule. Then, however, they seem to be di-
vided into two classes. Whether there are two sets of fibres
that produce the different corpuscles, or how else it is done,
is more than I can say ; but I am sure that at the stage I
have indicated, one set become more highly refracting than
the other, and take more and more of the characteristics of
a red blood globule, which they eventually become. The
others, however, follow the course that C. Heitzman has
described (Sitzungsber. der Kais Akademie der Wissen-
schaften, 1873) as the course that the elementary homo-
geneous granule takes in its development into a higher
grade of protoplasm. After they reach the size I have al-
ready spoken of, a cavity containing a small amount of
liquid forms, then similar excavations show themselves, un-
til only a framework of the living matter is left between the
STUDIES ON THE ORIG/N OF THE BLOOD GLOBULES. 3 I
vacuoles. There are communications established between
these cavities, and the framework is transformed into a net-
work with thickened points of intersection, which are the
granules.
With this view of the development of protoplasm we are
better able to understand the meaning of the vacuolized
corpuscles that we so often meet with. But the different
sizes of the corpuscles, the different numbers of their gran-
ules, and the varying conditions of their nuclei and reticula,
speak for themselves. They are the different stages through
which an original granule of the fine reticulum contained by
the fibrous net-work is developed into a full-grown lymph
corpuscle.
This is further substantiated by the fact that the con-
nection, already described, between the granule that has just
passed to the outside of the fibre and the reticulum within
it, is kept up through all sizes and shapes of corpuscles, un-
til the full-grown condition is reached. Then, however,
this attachment is severed, and the globule passes away with
the lymph stream in which it has been bathed so long.
This is true of both sets of corpuscles, and can be shown as
well in the young red, as in the white. Thus we add a new
proof to the old idea that a red globule is nothing but a
mass of protoplasm containing haemoglobine within its
meshes ; but for the elaboration of this subject I refer my
reader to the researches of L. Elsberg.
The organs that I have used in these investigations are
the lymphatic ganglia of man, horse, and cat, the spleen of
man and cat, as well as the tonsil and thymus gland of
children. The characteristics of the adenoid tissue were
found to be the same in all, the principal differences being
in the proportion of red to white globules. In the tonsil
and lymphatic ganglia, the red are very scanty, though they
can be found in most fields ; but in the spleen they are far
32 A. W. JOHNSTONE.
more frequent. In this organ, like the rest, the corpuscles
are formed by the development of the granules of the net-
work within the frame, and not by budding of the endo-
thelial plates, as claimed by some. We are now ready to
give the reason for the lymph of the efferent vessels con-
taining so many more corpuscles than that of the afferent,
as well as to say where the few red globules that are found
in the lymph of the thoracic duct come from. The lymph
stream, as it passes through each successive ganglion,
carries along an increased number of the fully grown ele-
ments that have become detached from the parent fibre,
and eventually empties them into this duct, through which
they reach the blood.
In answering these questions, we are also giving the
function of the adenoid tissue, which is to produce the
corpuscular elements of the blood.
It has been known for a long time, that as age advances
the adenoid tissue becomes more and more scarce, and that
the mucous layers and other organs that were once so rich
in it, at extreme old age present scarcely a trace. In reality,
the thymus gland may be taken as the type of the whole
class. For while their degeneration is by no means so rapid,
still they all show a tendency to follow its example. This
is most strikingly shown in the history of Peyer's patches, as
has been brought out by the study of typhoid fever.
From this we would conclude that a young animal is the
best subject for the study of the adenoid tissue. This I
can testify is the case, for as age advances the granules of
the reticulum within the fibres become more scanty, and the
reticulum itself is by no means so rich as in the early days
of life. Thus we see that we live at the expense of our
cytogenic tissue. Should it ever be conclusively proved
that the white blood corpuscles share in the formation or
repair of the structures of the body, we would then have
STUDIES ON THE ORIGIN OF THE BLOOD GLOBULES. 33
the complete chain of. their history ; for we are now sure
that they represent only one stage of a development that
is going on as long as life lasts, and I am not inclined to be-
lieve that this stage is the highest of the series. The con-
clusions that I have drawn from these studies are :
1st. We must have more and better proof before we can
believe that a lymph corpuscle ever arises from a blastema.
2d. That both red and white blood corpuscles are devel-
oped from the granules of the reticulum of living matter
within the fibres of all adenoid tissues.
3d. That in different organs there is a difference in the pro-
portion of red to white globules that are produced.
4th. That the adenoid tissue is myxomatous, and, prop-
erly speaking, a remnant of fcetal life.
5th. That this tissue is stored-up material, from which
the blood corpuscles are made throughout life.
6th. That it is highly probable that the exhaustion of this
material plays an important part in senile atrophy, and the
other torpid conditions of the aged.
Before closing this paper, I wish to acknowledge the
kind assistance rendered me in its preparation by Dr. C.
Heitzman of New York, in whose laboratory much of the
microscopical work was done.
THERAPEUTIC CONTRIBUTIONS.
III.
ON THE USE OF A FEEBLY ALKALINE WATER AS A VEHICLE
FOR THE ADMINISTRATION OF THE IODIDE AND
BROMIDE OF POTASSIUM, ETC.
By E. C. SEGUIN, M. D.
ONE hears a great deal in remarks and debates at
medical societies and in private consultations of the
gastric derangement produced by remedies which are of
constant use and of unsurpassed efficacy, viz. , the iodide
of potassium and the various bromides (more especially the
bromides of potassium and sodium). This evil result, or
the dread of it, is not infrequently interposed against the
free use of these salts in large doses for the relief of serious
symptoms.
For example, a patient lies comatose from cerebral syph-
ilis, and when the advice is given to administer 3 or 4 grs.
potassium iodide every two or four hours, the attending
physician very often expresses his fears that great gastric
derangement will result, interfering with the digestion of
food. I have known the recovery of such a case placed in
the greatest jeopardy by such a dread of the local effect of
this remedy.
Again, a patient is allowed to have recurring attacks of
epilepsy while using small doses of potassium bromide,
whereas by giving larger doses the paroxysms might be in-
34
THERAPEUTIC CONTRIBUTIONS. 35
definitely suspended. The larger doses are not given partly
from a fear of bromism in general, but also, I am convinced
from numerous consultations, because it is believed that the
bromides cause gastric catarrh.
1 am perfectly ready to admit that the salts in question
may and do cause gastro-intestinal disorder, but I have
very rarely observed this in my practice during the last
three years. Having, as I believe, found the means of ad-
ministering the iodide of potassium and the various alkaline
bromides in a harmless way (as regards the digestive organs),
I fancy it may be of some utility to ^w^ a detailed account
of my plan of administration.
This plan includes the almost equally important condi-
tions:
1. The use of a simple aqueous solution of the salt.
2. Its ingestion upon an empty stom^h (fifteen or thirty
minutes before food).
3. Its very free dilution with an alkaline solution.
I. The importance of employing absolutely simple solu-
tions of certain remedies, especially of the bromic and iodic
salts, is being more and more realized by physicians, and the
nauseous and, as I believe, indigestible mixtures which were
imposed upon the profession by high authorities some twenty
years ago, are passing out of use. Certainly, in the case of
drugs whose remedial effects are as special and relatively sim-
ple as are those of the bromides and iodides, it would seem, a
priori^ that giving them in the shape of an aqueous solution
were best. Their efficacy can hardly be increased by the ad-
dition of other drugs, and their taste certainly cannot be cov-
ered up or neutralized by infusions, syrups, etc. It has been
my practice for several years to employ a solution of iodide
of potassium made by dissolving equal parts by weight of
the salt and of water. Experimenting upon a considerable
bulk, it has been found that there is a loss by volume of
3^ . E. C. SEGUIN.
one-fifth in mixing the salt and water. In other words, a
drop of this solution contains about |- of a grain, or .05. A
patient who takes a dose of one hundred drops of this solu-
tion does not in reality receive (as is often erroneously
stated) one hundred grains, or 6. of the salt, but only about
eighty grains or 5. This difference is of considerable im-
portance in the treatment of cases requiring the maximum
doses of iodide. Of this solution I direct that so many
drops be given in the dilution to be presently described,
about half an hour before meals, or before food.
The bromides I have for some years prescribed upon one
general or typical formula, varying the ingredients to suit
different cases, but keeping the standard dose the same.
This will be at once recognized as of great utility in treat-
ing a large number of cases of epilepsy in private and in
hospital practice. It is needless to defend the use of a
standard formula from the charge of routine practice, be-
cause reflection will show that with such a type-formula,
the doses for each case can be varied infinitely by subdi-
vision and arrangement of quantities of the solution. This
general formula is :
Potassii bromidi, | iss or 45.
Aquae, § vij or 200 cc.
A teaspoonful contains gr. xv, or i. of the salt.
Another formula, which I often employ, is :
Ammonii bromidi, J ss or 15.
Potassii bromidi, | i or 30.
Aquae, | vij or 200 cc.
Of this solution also a teaspoonful contains gr. xv, or i. of the
salts.
All of my anti-epileptic solutions are constructed upon
this type: one teaspoonful containing gr. xv, or i. of the
THERAPEUTIC CONTRIBUTIONS. 3/
salts. Perhaps the formulas require some explanations.
They are not intended as examples of mathematical ac-
curacy in dosage, such as would avoid an error of one grain.
They are constructed for practical use in families, and cal-
culated upon the average capacities of teaspoons. These
utensils no doubt vary in capacity, but from my own ex-
periments, and from the testimony of others, medical and
non-medical witnesses, I have been led to assume that only
about seven teaspoonfuls could be obtained from the ounce
of solution. Each of my standard bromide formulas con-
tains, practically, 49 doses, which, divided into the total
quantity of salts, yields a quotient of very nearly 15 grains,
or I. The translations into the metric system also need a
word of explanation. They are corresponding and logically
equivalent translations, and not at all literal translations,
such as abound in medical books and periodicals — transla-
tions absurdly exact, and only serving the purpose of dis-
gusting physicians with the use of the metric system in
prescriptions. In rendering Ji by 30., 3 ss by 15., and
I vij of liquid by 200 cc, the errors are, I believe, about
compensatory in each estimation, and after making allow-
ance for a small increase of bulk by the addition of 45. of
salts, reckoning the teaspoonful at a little over 4., we obtain
the same number of doses as in our English formula, viz.,
49 or 50 doses.^
Of these various bromide solutions, I direct one or more
teaspoonfuls, properly diluted, to be taken upon an empty
stomach.
II. The idea of giving the iodides and bromides on an
empty stomach is in no wise new, but is in opposition to
what I think is the general practice. Influenced by the (de-
* It is somewhat surprising, and to me a matter of gratification, fhat the
formulas which I devised in 1874-5 according to the English system, xvhen I
had no thought of employing the metric system, should have happened to em-
brace correct metric proportions.
38 E. C. SEGUIN.
lusive) notion that iodides and bromides produce gastric
irritation, most practitioners give them after eating, when
they probably undergo more rapid decomposition, and in-
terfere with the process of digestion.
Deposited into an empty stomach, which in normal con-
ditions presents a neutral or alkaline reaction, more especially
if guarded by an alkaline liquid, it is a practical reality that
these salts are very efficacious, and that they cause no gas-
tric irritation. Theoretically it is almost demonstrable
that they are absorbed quickly, fully, and with little if any
change. The contact of the solution may act as a solid
body or a portion of aliment, and cause an outpouring of
acid gastric juice ; this is, however, not proven, and if such
an event does occur, the acidity thus produced will be an-
tagonized by the alkaline salts of the solution.
III. While serving as resident physician in the New York
Hospital in 1865-7, 1 noted the addition of potassium bicar-
bonate to prescriptions for potassium iodide by some of the
visiting stafif. I did this myself in practice afterward, but
found objections to the device in that it caused the inser-
tion of one more ingredient in a formula which might al-
ready be complex enough, and in that often too much alka-
line salt was given. Some five years ago I began directing
patients to measure out their dose of bromides or of iodide
into a glass, and add a liberal quantity of Vichy water, from
one-half to a whole glassful. Gradually I adopted this as a
vehicle in all cases, and can now testify to the excellent re-
sults of this practice from a three years' large experience.
When the patient resides in a city or large town, I direct
him to procure the artificial Vichy water in syphons, which is
now so widely manufactured. Some of these imitation
waters are very honestly made nearly like the known
composition of the waters of Vichy, and others, the majority,
I suppose, are carelessly compounded. At any rate, the
THERAPEUTIC CONTRIBUTIONS. 39
syphons contain a solution of bicarbonates of sodium and
potassium highly charged with carbonic acid gas, and this is
sufficient for our purpose. For patients living where the
syphons cannot be procured, or for patients who travel
much, I direct the purchase of the effervescent Vichy salts,
either of American or foreign manufacture. A teaspoonful
of the salts in a glassful of cold water makes a sparkling
glass of Vichy water, in which the medicine can be mixed.
In the case of patients who cannot afford to buy these
preparations, I recommend that a good-sized pinch of bicar-
bonate of sodium be added to a glass of water. The advan-
tages which I claim for this method of giving bromides and
iodides in weak alkaline waters surcharged with carbonic
acid are two-fold :
First, the supposed irritating effects of the salts upon the
gastric mucous membrane is reduced to a minimum if not ab-
solutely neutralized. This statement is theoretical, but,
practically, I am able to state that I almost never observe
gastric or gastro-intestinal disorder while giving full or even
very large doses of the salts to patients of various ages. I
am thus enabled to administer from sixty to one hun-
dred and more (5. to 10.) grains of the bromides in the day ;
and even when bromism occurs, the gastric symptoms are
almost nil. The iodide of potassium I have thus given in
doses varying from small doses to | i or 32. in the day,
without indigestion. Occasionally for severe cerebral
symptoms, I have caused children to have a dose of 5.
three times a day, with only good results.
Second, the taste of the bromides and iodides is consid-
erably masked by the sparkle and sub-acid taste of the ef-
fervescent drink. Many patients have thanked me warmly
for having substituted a simple solution of bromides (or
of iodide of potassium) given in Vichy water for the classical
mixtures which they had formerly taken.
40 E. C, SEGUIN.
I should add that the salicylate of sodium is well taken
in this way: a powder of the size required, i. to 3., is dis-
solved in a glassful of Vichy water. This covers the
disagreeable sweetish taste of the salt, and, I believe, favors
its complete absorption.
In some simple cases of epilepsy I give only one dose of
bromide of potassium in the day, at bedtime or on rising.
In such cases I prescribe the medicine as a powder of from
2. to 4. or more, to be taken in a glass of Vichy water.
In some neurasthenic cases, and some cases of oxaluria
with insomnia attended by restlessness, I have obtained
excellent results from the use of a powder containing
(usually) 2. each of salicylate of sodium and bromide of
potassium taken in a glassful of Vichy water.
THE TENDON REFLEX IN GENERAL PARAL-
YSIS OF THE INSANE*
By J. C. SHAW, M.D.,
MEDICAL SUPERINTENDENT, KINGS COUNTY LUNATIC ASYLUM, FLATBUSH, N. Y.
AT a meeting of this Society held in June, 1879, ^ P^^-
sented a short communication on the tendon re-
flex in the insane.^
Since that time I have made a more special study of this
reflex as it is found in general paralysis of the insane, and it
is my object now to present the results of my observations.
In 1879 I ^^^ only examined it in ten (10) cases of gen-
eral paralysis. I then stated, and which was in accord with
views previously expressed by Prof. Westphal, that when-
ever the tendon reflex was absent we were justified in de-
ciding that sclerosis of the posterior columns existed, and I
presented sections from the spinal cord, in one case, in con-
firmation of this. I also ventured the statement that a light
cortical sclerosis would also abolish this reflex. My studies
up to this time have confirmed those ideas.
Up to that time I had only seen the reflex, normal or ab-
sent, in these cases, but my subsequent studies, made upon
a much larger number of cases, have brought under my ob-
servation the reflex in its normal condition, the reflex
absent, present to a slight degree, and exaggerated ; and it
* Read before the American Neurological Association, at its seventh annual
meeting in New York, June, i88i.
* Archives of Medicine, vol. ii, p. 46.
41
42 y. c. SUA IV.
is under these four or rather three modifications that we
shall study it. I have studied the reflex in seventy-one (71)
cases in men and eleven (11) cases in women, and have ex-
amined the spinal cords in eighteen (18) cases.
In the seventy-one cases of men we found it as follows :
Normal . . . . . . in 28 cases
Slight in 8 ''
Absent in 13 *'
Exaggerated in 22 "
In the eleven women it was as follows:
Normal in 7 cases
Absent . . . . . . in i case
Exaggerated in 3 cases
Of the eighteen cases in which autopsies have been made
and the spinal cords examined, I shall give histories in the
briefest manner possible, and shall make no attempt what-
ever to give a description of the histologic changes in these
cords at this present time, but speak of the lesions as they
occupy regions of the cord, as my object is simply to con-
nect, if possible, the alterations in this reflex with certain
definite localized lesions ; the absence of this reflex having
been considered as a symptom almost pathognomonic of lo-
comotor ataxia, and its exaggeration as a distinctive symp-
tom of spastic spinal paralysis and lateral amyotrophic
sclerosis.
All these spinal cords have been examined after harden-
ing and mounting according to Lockart Clarke's method.
Case t. — P. E,, age 27, admitted August, 1875, attack having
begun six months previously ; he is excited, and has delusions of
wealth and greatness ; when I first saw him the disease was far
advanced ; he was feeble, ataxic in speech and gait, had marked
tremor of facial muscles, left pupil slightly contracted, and delu-
sions of wealth ; he gradually became exhausted, and died.
Post-mortem showed decided lesions of the meninges and
brain, also spinal cord, the part which alone will concern us for
the present, and examination of which showed sclerosis of the
posterior columns.
THE TENDON REFLEX IN GENERAL PARAL YSIS. 43
Case 2. — H. D., admitted July 15, 1879, age 54. On admission,
well-marked delirium of extravagance ; says he owns all the world
except Canada and San Francisco, which belong to his brother.
Feb. 18, 1879, delirium of extravagance still continued, marked
ataxia of lower extremities, difficulty in speaking, tremor, lancin-
ating pains in legs ; has hyj)ochondriacal ideas. Dec. 6, 1879,
has an epileptiform attack confined to left side ; conjugate devia-
tion of eyes to left side ; tendon reflex entirely absent. April 12,
1880, has another epileptiform attack, confined to right side.
Oct 23, 1880, to-day has epileptiform attack confined to right
side; conjugate deviation of eyes to right side. Oct. 31, 1880,
patient dies.
Examination of the spinal cord shows sclerosis of the posterior
columns.
Case 3. — G. F. S., age 41, admitted June 21, 1877. Is quite
blind on admission ; says he is blind, but could see if he wore
blue glasses ; he is the greatest musician in the world, etc.
When seen by me he was in a state of advanced general paresis,
and quite demented, filthy in habits ; has never had an epilepti-
form attack (?) ; tendon reflex absent. Patient died August 10,
1879.
Examination of the spinal cord shows sclerosis of the posterior
columns.
Case 4. — R. O. B., age 32, admitted March 7, 1879. Pupils
normal ; has well-marked ataxia of gait ; is demented ; no delu-
sions of extravagance ; tendon reflex absent. Aug. 17, 1879, in the
morning had epileptiform convulsions, both sides of body con-
vulsed, lasting all day, with intermissions ; he died the next day.
Examination of spinal cord shows sclerosis of the posterior
columns.
Case 5. — I. L., age 55, admitted June 21, 1879. Delirium of
extravagance, well-marked ataxia of lower extremities, right pupil
contracted, general tremor, advanced stage of paresis ; in very
feeble condition ; no epileptiform attacks at any time ; tendon
reflex absent. Died July 23, 1879.
Examination of the spinal cord shows sclerosis of the posterior
columns.
Case 6. — H. P., age 34, admitted Feb. 4, 1878. Intemperate ;
duration of attack said to be one year ; has been suicidal and
homicidal ; delirium of extravagance ; when seen by me is in an
extreme state of dementia ; tendon reflex normal ; has occa-
sional epileptiform attacks. Died March 17, 1879.
44 7' ^' SHAW.
Spinal cord found normal.
Case 7. — C. Van S., age 32, admitted April i, 1879. Intem-
perate, pupils normal, in advanced stage of dementia paralytica,
marked general tremor, tendon reflex normal. Died Sept. 20,
1879.
Examination of spinal cord shows no lesion.
Case 8. — T. G. C, age 2>2>, admitted July 18, 1879. Intemper-
ate, pupils normal, duration of attack said to be two years. Sis-
ter very nervous, and father intemperate. Delirium of extrava-
gance, which passed off almost entirely after he had been in asylum
a short time ; all that remains of it is that he says he paid a
woman fifteen weeks' board in advance ; tremor of facial mus-
cles and tongue ; tendon reflex normal ; slight difficulty of speech.
Died of pneumonia Sept. 2, 1880.
Spinal cord shows no lesion.
Case 9. — F. M., age 32, admitted Oct. 26, 1879, Delirium of
extravagance, tendon reflex normal, marked tremor, decided de-
mentia, duration of attack said to be eight months. Epileptiform
attacks. Died in one, March 18, 1880,
Spinal cord shows no lesion.
Case 10. — J. D., age 49, admitted April 10, 1878. Intemper-
ate ; this patient was seen by me at least eight months before his
admittance to the asylum ; has had injury to head a few years
before from fall out of a wagon ; marked delirium of extrava-
gance ; marked difficulty in speech. No epileptiform attacks, but
frequent hemi-paretic attacks, which would almost completely
pass off. Tendon reflex exaggerated ; marked tremor. Sept. 16,
1879, had a paretic attack of left side ; he became gradually
weaker, and had to keep his bed ; there followed difficulty of
swallowing and respiration^ light coma passing into stertor, and he
died Sept. 20, 1879.
Examination of the spinal cord shows symmetrical degenera-
tion of the lateral columns.
Case ii. — U. Van V., age 60, admitted March 15, 1879. Light
delirium of extravagance, marked general tremor, frequent hemi-
paretic attacks of one side and then the other, decided difficulty
of speech. Died Oct. 31, 1879.
Spinal cord shows symmetrical degeneration of the lateral
columns.
Case 12. — G. C, age 34, admitted Nov. 26, 1879. This patient
was seen by me many months before his admission to the asylum ;
he is depressed and melancholic ; no delirium of extravagance ;
THE TENDON REFLEX IN GENERAL PARAL YSIS. 45
marked hesitancy in speaking ; subsequently delirium of extrava-
gance ; has hemi-paretic attacks ; tendon reflex exaggerated ;
never epileptiform attacks ; toward end of disease rigidity of
muscles ; contracture. Died Feb. 14. 1881.
Spinal cord shows symmetrical degeneration of the lateral
columns, with dilatation of central canal in cervical region.
Case 13. — O. W. P., age 44, admitted Jan. 30, 1880. Intem-
perate, left pupil contracted, marked tremor, unsteady gait, very
marked hesitancy in speaking. On admission, reflex is found
normal ; in April, 1880, reflex found exaggerated, and before
death there appears some contracture. March 28, 1881, hemi-
paretic attack of left side quite complete. Died April 17, 1881.
Examination of the spinal cord shows symmetrical degener-
ation of the lateral columns.
Case 14.— L. M., age 45,
admitted Feb. 26, 1880.
Advanced stage of demen-
tia paralytica, marked hesi-
tancy in speaking, marked
tremor of tongue and facial
muscles, a good deal of un-
steadiness of gait, tendon
reflexes exaggerated, extrav- fig. i.
aeant ideas from time to Diffused central sclerosis. Patellar reflex
... exaggerated. Case 14.
time, hemi-paretic attacks,
never had epileptiform attacks. Died Jan. 30, 1881.
Examination of spinal cord shows a diffuse sclerosis, shown in
fig. I.
Case 15. — D. McC, age 46, admitted April 26, 1880. Left
pupil contracted, marked tremor of tongue and facial muscles,
decided hesitancy in speaking, marked defect of memory, ad-
vanced stage of general paresis, slight delirium of wealth and ex-
travagance, tendon reflex exaggerated, and at last some rigidity
and contractures. Died Jan. 11, 1881.
Examination of the spinal cord shows symmetrical descending
degeneration of lateral columns.
Case 16. — F. D., age 43, admitted May 31, 1880. Intemperate,
excessive tremor of tongue, no pupillary changes, marked demen-
tia on admission, hemi-paretic attacks, but no epileptiform attacks,
tendon reflex exaggerated. Died February 11, 1881.
Examination of the spinal cord shows descending symmetrical
degeneration of the lateral columns.
46
y. C. SHAW.
The condition which is found in these cords is illustrated rough-
ly in fig. 2. The sclerosis is not strictly confined to the lateral
columns, but is much greater there than anywhere else in the other
regions of the cord.
Case 17. — P. B., age
60, admitted October 16,
1880. Speech thick, partly
aphasic ; marked tremor ;
rigidity of muscles ; quite
demented ; tendon reflex
exaggerated ; marked tro-
phic changes before death.
Died November 13, 1880.
An examination of the
spinal cord in tliis case
showed a well-defined
symmetrical degeneration
of lateral columns.
FIG. 2.
Symmetrical sclerosis of the postero-lateral
columns and slight sclerosis of the deeper
part of the posterior columns. Patellar re-
flex exaggerated. Cases 11-17.
Case 18.— W. H. C, admitted September 14, 1878. Marked de-
lirium of extravagance ; hy-
pochondriacal ideas in ad-
vanced stage of the disease
when seen by me ; tendon re-
flex slight, and subsequently
is entirely absent, contrac-
ture very marked for several
months before death, which
took place June 2, 1880.
FIG. 3. Examination of the cord
Cortical sclerosis of the spinal cord with shows a very deep cortical
dironic^ meningitis. Patellar reflex lost. ^^^^^^^^^ ..i^,, extensive
chronic spinal meningitis.
It will be seen from these cases with post-mortem exami-
nation, that whenever the tendon reflex is abolished,
we are quite safe in predicting that sclerosis of the poste-
rior columns exists, and when the reflex is found to be very
slight, that the posterior columns are the seat of disease in
all probability, and that later, when the disease is more ad-
vanced, it will be entirely abolished.
In those cases in which the reflex is found to be normal,
THE TENDON- REFLEX IN GENERAL PARALYSIS. 4/
post-mortem examination shows no lesion of the spinal
cord.
In the cases in which the reflex is found exaggerated, we
find symmetrical secondary degeneration of the lateral col-
umns, or we find a diffuse myelitis which involves more or
less of the white matter, and the lateral columns are always
involved.
We may have cases in which the tendon reflex is slight
and ultimately becomes entirely abolished, and having for
its pathological basis a marked cortical sclerosis.
Moreover, we may even have the tendon reflex entirely
abolished, and there be present marked contracture not de-
pending in any manner upon a lateral sclerosis, but depend-
ing upon cortical sclerosis due to marked chronic spinal
meningitis.
We have watched cases in which the reflex has become
slighter and slighter, and at last disappeared.
In some of the cases in which the reflex was found ex-
aggerated, and the cord subsequently examined microscop-
ically, it was found that there was a sclerosis of light
character almost everywhere, but most marked in the
lateral columns, and the posterior columns near the pos-
terior commissure also had a h'ght sclerosis. I have from
this been led to conclude that to abolish the reflex, the
sclerosis of the posterior columns must be quite extensive,
or there must be a marked cortical sclerosis, and the reflex
thus find its point of obstruction in the posterior roots.
The exaggerated reflex is closely connected with two
prominent symptoms in this disease. Those cases in which
there are marked difficulties in speech, hesitancy, stuttering
up to complete inability to speak (not aphasia proper), are
the cases in which is always found, sooner or later, ex-
aggerated tendon reflex.
And it is in those patients who have the marked difficul
48 y. c. SHAW,
ties in speech and the exaggerated tendon reflex that we
find almost invariably hemi-paretic attacks, and compara-
tively rarely epileptiform attacks. There is, therefore, a di-
rect connection between these difficulties in speech, the
hemi-paretic attacks, and the exaggerated tendon reflex,
and this is susceptible of pathological demonstration, and
will be the subject of a communication from me at a future
time.
A CASE OF ASYNCHRONOUS CONTRACTION OF THE
CARDIAC VENTRICLES, WITH REMARKS
UPON REDUPLICATION OF HEART
SOUNDS.
By FREDERICK P. HENRY, M.D.,
PHYSICIAN TO THE EPISCOPAL HOSPITAL, PHILADELPHIA.
THE publication of isolated cases of disease is alone
justified by one of two reasons : first, as affording
undeniable facts in support of some physiological or patho-
logical doctrine ; and, secondly, on account of their extreme
rarity. I can, I trust, successfully advance both of these
reasons for the publication of the following case. As to its
rarity, I need only remark that in a rather extended search
among text-books and periodicals, I have found but one
other similar case recorded. It is contained in Virchow's
Archiv for 1868, and bears the following title: " Ungleich-
zeitige Contraction beider Ventriklen." Mitgetheilt von
Prof. E. Leyden in Konigsberg.
My case was a multipara, set. 34, who was a patient in the
Episcopal Hospital when I took charge of the medical wards on
April I, 1879. She had had eight attacks of articular rheumatism,
the first when twelve years of age, and the last, three years previ-
ous to admission, at which time the heart trouble began. There
was no oedema j respiration, in the recumbent position, was tran-
quil, and the urine was free from albumen. On examining the
heart, I detected a distinct mitral regurgitant murmur, and also
what at first appeared to be a very irregular action of the cardiac
49
50
FREDERICK p. HENRY.
muscle. As the pulse was only 48 per minute and perfectly regu-
lar, I was led to study the action of the heart more minutely, and
very soon discovered that the apparent irregularity was due to a
separate action of the ventricles. The pulse was, as has been said,
48 per minute, and over the heart's apex could be counted 96
distinct pulsations, succeeding each other at regular intervals and
each apparently composed of a complete cardiac revolution. The
cardiac sounds were four in number, the first accompanied by a
murmur loudest at the apex, and their rhythm was irregular, the
first two and last two succeeding each other more rapidly than did
the second and third ; that is to say, there was a distinct pause
between the separate action of the ventricles, but decidedly
No. I. — Tracing of apex beat of heart.
No. 2. — Pulse tracing of right brachial artery.
shorter than the regular pause occurring at the close of the com-
plete revolution. The intensity of these sounds also varied in
degree ; the first and third, however, namely, those due respec-
tively to the closure of the mitral valve and the contraction of the
left ventricle, and to the closure of the tricuspid valve and the
contraction of the right ventricle, being nearly equal in intensity.
The accompanying sphygmographic tracings, kindly made by
my colleague, Dr. Louis Starr, explain the condition far better
than can any mere verbal description.
The patient left the hospital shortly after I saw her for the first
time, but returned a few weeks later with all her symptoms
RED UP Lie A TION OF HE A RT SO UNDS. 5 1
changed for the worse. She began to get worse about two weeks
after leaving the hospital. On admission for the second time, on
May 19th, she complained of severe praecordial distress, which had
then lasted for five days. She also suffered from marked dyspnoea.
There was also a considerable degree of oedema of the lower ex-
tremities, together with ascites, the abdomen around the line of
the umbilicus measuring 33 inches. It was now observed that the
asynchronous action of the cardiac ventricles was not a constant
symptom, but came and went without any apparent cause. I ex-
tract the following from notes taken at the time by the then resi-
dent physician. Dr. H. H. Bickford :
May 28th. Pulse 44, with double apex beat of heart.
June 6th. Heart and pulse are synchronous.
June 7th. Double cardiac beat to one beat of pulse.
June 14th. (Edema in feet and legs all subsided.
Measures 30 inches around abdomen. Double apex beat.
June 17th. Pulse 48. No praecordial pain. Pulse and apex
beat synchronous. Appetite good. Bowels moved once daily.
June 19th. Discharged at her own request.
There are three principal means by which reduplication
of cardiac sounds may be produced. The first, most com-
mon, and best understood, is the asynchronous closure of
the aortic and pulmonary valves, and is not a very rare
phenomenon. It occurs both physiologically, as has been
shown by Potain, and in disease when, from any cause, the
normal ratio of aortic and pulmonary tension is destroyed.
This asynchronous closure of the semilunar valves gives rise
to the bruit de rappel of Bouillaud, and inasmuch as it is
composed of a long sound, followed by two short ones, it
has been called a dactylic sound, and may be represented
by the usual symbol for the dactyl, — kj \j.
The second principal cause of reduplication of cardiac
sounds is due to an abnormal action of the left ventricle,
giving rise to the bruit de galops also first recognized and
named by Bouillaud, but afterward more minutely studied
and described by Potain. From its resemblance to the foot
of Greek and Latin metre known as the anapest, it has been
52 FREDERICK p. HENRY.
spoken of as an anapestic sound, and may be represented
with considerable accuracy by the usual symbol for the
anapest, ^ u — .
The extra heart sound which gives rise to the bruit de
galop is presystolic, and it has been demonstrated as a move-
ment by Potain, by means of the cardiograph, and the same
observer has shown that this movement is the distension of
the ventricle, accomplished and completed by the contrac-
tion of the auricle/ Potain shows in confirmation of this
view that this presystolic movement coincides with the
jugular venous pulse constantly encountered in these cases.
Potain's explanation of the mode of causation of the bruit
de galop vcidcy ht summed up as follows: The exaggerated
arterial tension that exists in cases of interstitial nephritis
causes diminished venous tension. Owing to this the ven-
tricles are more incompletely filled during the first period
of the diastole, the presystolic period, than usual. That is
to say, there is more work than usual thrown upon the
auricle. This causes a sudden distension of the ventricle,
and also the exaggeration of the jugular pulsation con-
stantly encountered in these cases.
Sibson, who has encountered this anomaly, regards it as
due to an asynchronous closure of the auriculo-ventricular
valves, but Potain, without denying the occurrence of
asynchronous closure of these valves in other conditions,
contends that the special abnormality known as the bruit de
galop, is otherwise produced, for the three following rea-
sons :
1. The abnormal sound has not the timbre of valvular
closure.
2. It does not predominate, as it should in that case, in
the region of the right cavities.
3. Potain declares that he has heard, in the same cardiac
^ Union Midicale, 1876, 3eme serie, t. 21, p. 324.
REDUPLICATION OF HEART SOUNDS. 53
revolution, the asynchronous closure of the auriculo-ven-
tricular valves, and also the bruit de galop. ,
Of the three reasons above given, the second is, to my
mind, the most convincing, but it seems to me strange that
so acute an observer should have omitted to refer to the
double impulse, which when felt or demonstrated with the
sphygmograph, is almost pathognomonic of these cases.
On reading the interesting papers of Potain, the impres-
sion is derived that the bruit de galop is alone encountered
in cases of interstitial nephritis, but that this is a mistake,
is proved by the following history of a case recently under
my care at the Episcopal Hospital.
Louis P., aet. 30, a tailor, of intemperate habits, was admitted
April 20th. His feet, legs, thighs, and scrotum were highly oedem-
atous, and there was a slight degree of ascites. The face also
was the seat of slight oedema. The heart was enlarged, the apex
beating in the fifth space, one inch to the left of the nipple line,
and, on auscultation, the bruit de galop was heard in perfection.
The urine was loaded with albumen. The man died on April
24th, and I had the opportunity of making an autopsy.
The kidneys were flabby and weighed respectively 6}^ and 7^^
ounces. Their capsules were readily detached, leaving a perfectly
smooth surface, mottled with large patches, varying from a pale-
pink to a yellowish-white. Under the microscope they were found
to present a perfect picture of extreme chronic parenchymatous
nephritis. There was no healthy epithelium to be seen. The
tubes were blocked with granular debris, and where the section
was thinnest, the picture presented by the outlines of the tubules
denuded of epithelium, closely resembled that of a brushed-out
section of lymphatic gland. Finally, there was no increase what-
ever of the interstitial connective tissue.
The heart was of flabby consistence and weighed fourteen
ounces, the enlargement being mainly confined to the left ven-
tricle, which was decidedly dilated. Examination with the micro-
scope showed the fibres to be in an advanced stage of granular
degeneration. In only a few of them could faint traces of stria-
tion be detected. The valves were all competent and healthy.^
^ From notes taken by the resident, Dr. R. P. Robins.
54 FREDERICK P. HENR Y.
Of two Other cases under my care, in which the bruit de
galop existed in typical form, in one there is no doubt as
to the kidney disease being acute parenchymatous nephritis.
This was evident from the short clinical history, the ex-
treme anasarca present, the occurrence of convulsions, the
high degree of albuminuria, and the presence in the urine
of great quantities of epithelial and highly granular casts.
This patient is at present, June 3d, an inmate of the Epis-
copal Hospital.
In the other case alluded to, the enormous oedema of
lower limbs and scrotum, and the large amount of albumen
in the urine were sufficient to exclude the diagnosis of in-
terstitial nephritis.
Although I accept Potain's explanation of the mechan-
ism of the production of the bruit de galop, I am compelled,
from the study of the cases above referred to, to reject his
statement of its association solely with interstitial nephritis.^
The bruit de galop may exist whenever there is excessive arte-
rial tension with diminished venous tension, which condition
is most frequently present in diseases of the kidney. It is
my opinion that this sound is often overlooked, and that the
heart's action is described as " irregular," when it is not so
in the strict sense of the term. Attention should always
be paid to the relative action of the heart and pulse. If
the heart's action is apparently irregular, while there is no
corresponding irregularity of the pulse, the case should be
carefully investigated, and if this be done, the least expert
in the diagnosis of cardiac disease may occasionally detect
one or other of the interesting anomalies described in this
paper.
A few words as to the diagnostic significance of the bruit
de galop.
^ " On trouve au coeur, chez les malades atteints de nephrite interstitielle, un
bruit special qui est le bruit designe par M. le professeur Bouillaud sous le nom
de bruit de galop." — Union Me'dicale, 1876.
RED UP Lie A TION OF HEAR T SO UNDS. 5 5
Potain considers this abnormal sound to be so high in the
scale of diagnostic importance that occasionally it may call
attention to the existence of an interstitial nephritis that
might otherwise continue unsuspected. This is certainly
according it a high rank. I can readily conceive of the fol-
lowing series of circumstances in the examination of a pa-
tient ; in fact it has been my own experience, and it is per-
haps to something similar that Potain alludes. For example,
in proceeding systematically with the examination of a pa-
tient, the lungs and heart are usually the first organs to
which attention is directed. In so doing, the bruit de galop
may be detected, and later, on testing the urine, albumen,
or casts will be found. It is hardly fair to say in such a
case that the bruit de galop has been of great diagnostic im-
portance. It would be, if the albumen and casts were ab-
sent, and yet a latent disease of the kidney could be cer-
tainly determined from the existence of this sound alone.
For my part, I regard it as of about as much diagnostic
value as the retinitis nephritica, of which oculists were wont
to talk so much in the first flush of their discovery, and of
which so little is said to-day. I have yet to see the first
case of Bright's disease that can be diagnosticated solely by
the ophthalmoscope.
I have entered so fully into the preceding details in
order that experts in heart disease may not hastily con-
clude that the case I report is one of the bruit de galop. A
comparison of the sphygmographic tracings with those in
Potain's papers will show the wide difference between
them. In my case also there was no kidney disease that
could be detected by the most careful application of the
ordinary tests.
I would suggest that the sound produced by the asyn-
chronous contraction of the ventricles be spoken of as a
double iambic sound, and that it be represented by the
56 FREDERICK p. HENRY.
symbol for the double iambus, — \u — u> and in so doing,
I refer to the sounds independently of any murmur that
may be associated with them. In the only two cases with
which I am acquainted, Prof. Leyden's and my own, there
was valvular disease, of rheumatic origin, giving rise to one
or more murmurs. In Leyden's case the valvular disease
was more than usually complicated. " There is," says he,
" certainly a stenosis of the aortic ostium and a tricuspid
insufficiency, probably also a stenosis of the ostium tricus-
pidale."
There is one form of valvular disease which, I think,
entirely prevents the formation of the briiit de galop,
namely, mitral obstruction. The first sound of the bruit
de galop is due to a diastolic pulsation of the ventricle,
caused by an abnormally energetic contraction of the auri-
cle in the presystolic period, and in order that the auric-
ular contraction may have full effect, the mitral orifice
must be unobstructed. 1 do not say this unadvisedly, for
in a case of mitral obstruction that was under my care
about two years ago, the left auricle had become so hyper-
trophied that its pulsation could be distinctly felt, and
aneurism was at first suspected. This was readily excluded,
and mitral obstruction immediately diagnosticated. Not-
withstanding this abnormally powerful action of the left
auricle, there was never detected the slightest diastolic
pulsation of the left ventricle.
It had been my purpose to refer to some interesting
points concerning the action of the healthy heart, suggested
by this case of asynchronous ventricular action, but this
article has already grown beyond its intended limits.
EDITORIAL DEPARTMENT.
HIGHER MEDICAL EDUCATION IN NEW YORK.
III.
THE SYSTEM OF CLINICAL TEACHING IN COLLEGES.
I include clinical teaching in medical schools under the general
head of higher medical education for two reasons :
First, for the general reason that clinical study logically follows
the elementary medical studies, and is continued, after graduation,
ad infinitum.
Second, because I am quite sure that a number of clinics in
every college are attended by practitioners for the purpose of
learning things that are new, or things which have practical
importance.
It is my purpose to show (i) that the vast material at the dis-
posal of clinical instructors in New York is not utilized in such a
way as to afford the advanced medical student systematic instruc-
tion in the different departments of medicine, and (2) that, so far
as I know, no attempt is made to coordinate the clinical and
didactic lectures during the course of study.
A college clinic is usually organized as follows : a clinical pro-
fessor or lecturer has charge of the clinic, assisted by two or more
younger physicians. The attendance of patients varies according
to the punctuality of the physicians and the care and considerate
treatment they bestow upon patients, — usually there is an abun-
dance of " material," as we call it. As a rule, no case-books are
57
58 E. C. SEGUIN.
kept, and the large majority of patients are seen only by the clini-
cal assistants, A few minutes before the time appointed for the
lecture the professor asks his assistants for "interesting" cases, or
sometimes selects them himself. In the lecture-room a series of
three, four, or five such cases is shown to the class without
classification. In a medical clinic, for example, cases of rheuma-
tism, paralysis, phthisis, etc., may be considered in one hour's
time. Occasionally, for some lectures requiring subjects to sub-
mit themselves to painful or annoying demonstrations before the
class, patients are sought beforehand. Inevitably, during a ses-
sion, the student sees a most tiresome repetition of cases under
such an unsystematic plan ; cases of dyspepsia or rheumatism may
be paraded ad nauseam before the class.
There are other serious defects in our college clinics. Nearly
always the professor lectures upon an unstudied case, and is
obliged to pass over a number of important data necessary for
accurate differential diagnosis. For example, a case of headache
is talked about before the class without the necessary examinations
of the urine, of the state of optic refraction, etc., — elements which
are often indispensable to a correct judgment. In many cases
there are delicate questions to be asked about sexual symptoms,
syphilis, etc., which many patients will never answer truthfully in
public. Often, too, dealing with almost unknown cases, the
teacher spends a quarter of an hour or more in extracting a
tangled history of symptoms from a patient, and then realizes that
the case is unimportant, or at any rate pointless for clinical pur-
poses.
Very often the clinical remarks made are mere remarks, a
desultory talk about the cases, others like it, their treatment, etc.,
showing on the professor's part a total want of appreciation of the
functions of a college clinic.
Another evil of our present plan is that cases are seldom shown
a second and third time after a first study in public. This is often
unavoidable, as clinic patients are provokingly uncertain in their
attendance. Still, by care and by the aid of clinical assistants or
of medical students, the cases can be hunted up and induced to
HIGHER MEDICAL EDUCA TION IN NEW YORK. 59
come again to enable the class to observe the progress of a disease
or the action of remedies.
It has long seem.ed to me that however inferior college clinics
must be to hospital clinics held over bed-ridden patients, much
more instruction might be extracted from them than is now done.
This improved teaching might be attained by applying the
following propositions to clinical work :
I. Recognizing that the principal function of an " out-door "
clinic, or college clinic, is to afford students an opportunity of
studying methods of examination and the diagnosis of diseases.
Considerations of pathology and of therapeutics, except, per-
haps, in surgical and special clinics, should be relegated to the
background, and made prominent only in cases of simplicity, or
cases which are likely to return to the clinic.
Under the head of methods of examination, I would include
teaching the art of questioning a patient so as to obtain the data
for a history of his case and for a diagnosis. This embraces a
peculiar kind of logic, a train of silent reasoning which the expert
examiner is carrying on all the time while talking with the patient,
and which enables him, by the aid of past experience, to follow
up useful clues and take up at the proper moment hints which
the patient may, perhaps unconsciously, have dropped in his re-
plies. In many cases a conversation of ten minutes enables the
professor to seize the capital symptoms and the etiological factors
of a case, and to write them upon the blackboard for further use
in discussion. This logic of examination varies in each depart-
ment of medicine, being in some cases superior to the physical
examination, while in others it is subordinate.
It is also desirable that the clinical teacher should briefly
describe all the instruments which he uses in examining organs
and testing functions, and give repeated demonstrations of their
use.
A most important, perhaps the most important, subject of study
at such a clinic is what I may call analytical semeiology. By this
I mean the accurate definition and close analysis of symptoms.
How often do we hear physicians of experience speak of symp-
6o E. C. SEGUIN.
toms in such a way as to show that they do not really understand
those signs, those characters through which a disease is classified ;
for example, what confusion about the terms numbness, ataxia,
hallucination, etc. Besides an accurate definition of a symptom,
and its demonstration when possible, the teacher should explain
to the student the anatomical basis of the symptom, and the
physiological function of which the symptom is (often) the per-
verted expression. This opens a wide and legitimate field for
giving students repeated lessons in those portions of anatomy and
physiology which the practical physician must know at his fin-
gers' ends. Such a study of the anatomical and physiological
basis of symptoms also opens the way in several departments of
medicine (diseases of the thoracic organs, of the nervous sys-
tem, etc.) to accurate regional diagnosis, or diagnosis of locali-
zation of disease.
Next in order of exposition comes the mode of grouping, or
association of symptoms. This should be taught both positively
and negatively, and in so doing there will be ample opportunity
to show how delusive and misleading is the so-called " pathog-
nomonic symptom." By the positive mode of studying the
association of symptoms, I mean showing how symptoms and so-
called physical signs obey certain tendencies of association and
form a " symptom-group," which though not the disease itself,
yet often serve for its classification and demonstration. By the
negative study of symptoms in their relations with other symp-
toms, I mean showing how one symptom may be a part of sev-
eral disease symptom-groups, and may even be caused by funda-
mentally different pathological conditions.
An improvement which I would suggest in college clinical
teaching, and it seems to me of considerable importance, is the
much greater use of the blackboard. Now, in most clinics, the
blackboard is only used for normal and pathological sketches or
diagrams. What I think should be generally done is, with the
aid of several blackboards, to write down (i) a summary of the
history of the case, (2) a summary of the chief symptoms as
observed in the patient, (3) the necessary anatomical diagrams or
HIGHER MEDICAL EDUCA TION IN NE W YORK. 6 1
sketches, and sometimes (4) an important law or definition.
With these data before them in writing, a class of students can
intelligently follow the remarks which the professor makes, can
carry out in concert with him the logical processes of assimila-
tion and differentiation by which the diagnosis is reached.
Without such objective reproduction of a case upon the black-
board, I firmly believe that, for all but a very few unusually
well-trained minds in the audience, the clinical teaching is foggy
and unprofitable. The class may " see " an endless series of
cases in a session, but would not the " understanding " of fewer
selected cases do much more toward their training for practical
life ? It may be said that all this writing on the blackboard is an
useless drudgery, that the student should remember the points
of a case. This is all very well for the simplest cases, presenting
only a few physical characters for study, but when we come to
deal with serious medical and surgical cases, in which enter a
great number of considerations, where a diagnosis is only to be
reached by induction from many data and by close inferential
reasoning, or if we are studying cases on the borderland of new
knowledge, I say that trusting to the memory of a mixed class of
students is altogether vain, — it is overrating their mental powers,
and by paying them this empty compliment we deprive them of
what they come to us to obtain, viz. : training. Not only is it
true that students seldom show ability to retain the data of a
complicated case, but it is also true of medical men. How often
do we see in the course of discussion at medical societies, mem-
bers of fair standing ask questions and make remarks which con-
clusively prove that they have not understood the case presented
or the paper read a few moments before they rose to speak.
Perhaps I am not exaggerating if I say that the ability to com-
prehend and retain the elements of an oral medical communica-
tion is an evidence of unusual mental power and of careful train-
ing. How can we presume these attributes to exist in our pupils ?
No ; I maintain that the young men who attend our clinics
should have every thing presented in the most objective and
tangible manner possible, should be made to participate in our
62 E. C. SEGUIN.
diagnostic reasoning, and should be given every opportunity for
note-taking.
The practice of taking notes at clinics is, it seems to me, very
important, and it is not open to the same objection as note-taking
at didactic lectures. In a clinic conducted on the plan which I
suggest, there is much beneficial repetition, time is consumed by
writing on the blackboard, so that the student is not hurried in
noting. The record of a number of cases thus analytically
studied must prove invaluable to the intelligent and earnest stu-
dent. At any time he can turn to such a case-book, and by its
guidance conduct a course of reading — reading about the symp-
toms themselves, reading on the anatomical and physiological
points noted down, reading on the pathology and pathological
anatomy of the cases, etc.
I would ask every candid reader to compare the possible results
of such clinical work with that following the exhibition of cases,
with " remarks," as practised now at college clinics.
II. The college clinics should be made to supplement the great
didactic chairs of the school. In other words, clinical and didac-
tic teaching should be carefully correlated.
At the present time clinical teaching in our medical schools
may, with perhaps some exceptions, be characterized as hap-
hazard. Whatever turns up in the way of " interesting cases,"
is shown to the class of students. No attempt is made to follow a
system in the presentation of cases, or to illustrate in the clinics
the subjects which are, at the time, being taught didactically.
Yet with foresight and a little trouble all this might be remedied.
At the beginning of the session a conference of the didactic and
clinical teachers in a school should be held, and a programme
of didactic lectures upon medicine, surgery, and a few special
subjects, constructed. If any changes become necessary in the
order of lectures, the assignment of subjects from week to week,
a memorandum should be sent to the clinical teachers interested.
With such a cooperation as to plan, by some exertion, perhaps
occasionally at a small expense, the clinical teachers could pro-
vide cases in illustration of the didactic lectures at the proper
HIGHER MEDICAL EDUCATION IN NEW YORK. 63
time, /. e.y immediately after these have been delivered. Let us, by-
way of illustration, suppose that in the second week of January the
professor of medicine has lectured upon organic diseases of the
heart. During the third week of the same month, the professor
of clinical medicine in the college could, by making an effort at
collecting patients beforehand (even if necessary sending carriages
for some of them), exhibit to the class a number of cases typical
of the chief organic cardiac diseases — of all those which allowed
the patients to leave their homes.
But, further, the clinical teaching outside of the college might
thus be coordinated, to the immense benefit of the class. The
professors of clinical medicine, physicians in the various hospitals
of the city, should likewise be notified of the subject under study
that second week in January, and they could select and arrange
the material for hospital clinics upon organic cardiac diseases,
thus enabling the students to see the bed-ridden, extreme cases of
this class. If the services of outside clinical teachers could thus
be coordinated and utilized, a medical school should have
many attached to it, certainly at least one in each hospital. The
title of professor of clinical medicine or surgery is one which most
prominent hospital physicians would be pleased to have from a
well-ordered medical school, and the conferring of the title, with
perhaps a nominal honorarium, would be a small price for the
school to pay^for their services.
The clinical teaching of specialties would have to be indepen-
dently arranged, yet even here the course could be systematized.
The clinical professors of diseases of the eye and ear, of derma-
tology, or gynecology, of diseases of the throat, of diseases of
children, etc., must in such a scheme be a law unto themselves.
Yet even they should be kept informed of the weekly progress of
teaching in the great didactic chairs, and often they would be able
to illustrate the didactic lectures. For example, when the profes-
sor of medicine was lecturing on tuberculosis, could not the spe-
cial clinics for diseases of the throat and for diseases of children
place before the eyes of the students instructive examples of lo-
cal and general tuberculosis ? Otherwise, each special clinical
64 E. C. SEGUIN.
professor could plan his own course, classifying the cases which
come within his specialty, and offering them to the class in a
certain order, either one of his own devising, or one already known
to the students as laid down in a text-book. In this way, it
seems to me, that the student would learn more though he might
" see " fewer cases.
I have followed such a plan, in the absence of any understand-
ing between the didactic and clinical chairs in the medical school
with which I am connected, for several years — in fact, since I be-
gan the clinical teaching of nervous diseases. I know the advan-
tages of such a plan, and I also think I realize its drawbacks. Its
advantages have been set forth in the preceding remarks. The ob-
jections to the plan of systematic clinical teaching in specialties
are numerous but not serious. There is considerable difficulty in
procuring cases, in engaging their attendance at a given clinic.
One is sometimes disappointed, and that, too, after a solemn prom-
ise. Of course, if the patients who were expected to illustrate a
certain lecture fail to put in an appearance, this lecture must be
postponed, and cases out of order, rare or not, must be presented;
or the opportunity may be taken to give a half didactic lecture
on methods of examination, on previous cases, etc. Such breaks
in the plan do not, in my experience, occur often enough to be
serious. A second objection is that the lecture thus planned, and
with its analytical study of cases, is less " interesting " or brilliant.
I am ready to grant this, because I fully understand how the word
" interesting " is employed by some students ; it is synonymous
with curious, showy, or exciting. The method which I have sug-
gested, obliges the lecturer to adopt a conversational tone, to
repeat statements, to be exact in the use of words, to pause to
give demonstrations ; all of which is opposed to oratorical display.
It may also be urged that according to this plan the teacher has
reached a diagnosis in the cases exhibited before they are pre-
sented to the class, and that the class is deprived of the privilege
of seeing him make a diagnosis. This would be a valid objec-
tion if the clinic were for the purpose of " showing off " the pro-
fessor's diagnostic skill, but for those who believe, as I do, that a
HIGHER MEDICAL EDUCATION IN NEW YORK. 65
clinic is for the purpose of helping to train medical students, the
making of a brilliant off-hand diagnosis by the teacher is vastly
less important than a scientific analysis of a case, however " slow "
it may appear to some members of the class.
III. College clinics might, it seems to me, also be used for the
purpose of the personal training of individual students. This is,
I believe, done to a certain extent, but it ought to be done much
more. Earnest students can be invited to come to the clinic be-
fore and after the lecture, for the purpose of examining patients
for themselves, under the guidance of one of the clinical assistants.
In my experience assistants are always willing to take on this ex-
tra duty. The greatest difficulty in the way of any considerable
extension of this personal instruction lies in a deplorably preva-
lent inertness of medical students. They are willing to crowd
about an assistant who is examining a case, and " pick up "
some knowledge easily, but very few are willing, in my experience,
to do the only thing which can make such -attendance profita-
ble, viz., sit down with a patient, take his history in writing, mark
the important symptoms, attempt a diagnosis, and submit the pa-
per to the professor, or to one of the assistants, for correction and
suggestion. The case thus worked up and corrected should be
written at length, with diagnosis if necessary, and presented at the
next clinic to the teacher. It is a matter of regret that so few, so
very few, students seem to understand that three or four cases
studied in this manner each week, would be worth more to them
than the " seeing " of any number of cases in the usual way.
E. C. SEGUIN.
NEW BOOKS AND INSTRUMENTS.
Antagonism between Medicines and between Rem-
edies and Diseases. Cartwright lectures for year 1880. By
Roberts Bartholow, M.D., Professor of Materia Medica and
General Therapeutics in the Jefferson Medical College of Phila-
delphia, etc., etc. D. Appleton & Co. 1881. pp. 122.
The Cartwright lectures have been inaugurated most auspi-
ciously by Dr. Bartholow, He has compressed into a narrow
space a brilliant summary of the facts at present known in re-
gard to one of the most fascinating questions of modern medicine.
The demonstration of a precise antagonism between the action of
drugs, has a double bearing on the theory of therapeutics. On
the one hand, new practical resources are placed at our disposi-
tion, not merely to meet the accidents of poisoning, but, as we
may hope, to combat symptoms similar to such accidents, when
they have arisen spontaneously in the course of disease. But a
further and more purely philosophical interest attaches to the
study of the toxic symptoms, for the reason that their exact (re-
mote) cause is known, and known to be an agent within our
grasp.
The very existence of such a definite train of symptoms proves
that we are able by external agencies to modify, in a given direc-
tion, the processes of a living organism. This fact is in formal
opposition to the fundamental doctrine of medical Nihilism,
which says : " It is absurd to attempt to modify anatomical con-
ditions by means of drugs." In view of the palpable contradic-
tions to this doctrine which the facts of toxicology affords, one of
two conclusions must be admitted. Either the symptoms induced
by poisons are independent of anatomical conditions ; or else
by the administration of a drug, we are able to change the ana-
tomical conditions of health to those characteristic of an artificial
66
NEW BOOKS AND INSTRUMENTS. 67
disease. It is true that the conditions thus voluntarily induced
are only similar to those of natural disease, and by no means iden-
tical with them. "We can," observes one of the most eminent
authorities on artificial pathology, "imitate symptoms but not
diseases. We can render an animal diabetic or epileptic, but we
cannot create diabetes or epilepsy.'" Nevertheless, this imitation
is already of the greatest importance. And when, in studying the
effects of one poison we find that they can be combatted by the
appropriate use of another, and that this second poison can be
shown to be capable of initiating a train of symptoms exactly the
opposite in appearance to those which have been caused by the
first, a horizon certainly opens before us of a rational therapeu-
tics, destined to encroach more and more on the therapeutics of
pure empiricism.
The hope of such a future is distinctly communicated
by Dr. Bartholow, even in the title of his lectures. Consid-
eration of the "antagonism between medicines" is immediately
followed by discussions on an analogous antagonism " be-
tween remedies and diseases," and to this latter subject are
devoted two out of the six lectures of the course.
It is on the "scientific application of the principle of antagonism
to medical practice " that the author seems to rely, to reverse the
severe judgment pronounced on materia medica by Bichat, in
1818. " It is a collection of incoherent opinions, — is, perhaps, of
all the physiological sciences, that which most exhibits the contra-
dictions of the human mind. In fact, it is not a science for a
trained intellect ; it is a shapeless mass of inexact ideas, of obser-
vations often puerile, of imaginary remedies strangely conceived
and fantastically arranged. It is said that the practice of medi-
cine is repulsive. I go further than this : it is, in respect to its
principles taken from our materia medicas, impracticable for a
sensible man." (Quoted, p. 13.)
Piquant indeed is the contrast between the uncertainty thus
pungently described, and the exquisite precisions which, accord-
ing to our author, may even now be predicted of so many thera-
peutical manoeuvres. We would not deny Prof. Bartholow's
energetic optimism. Optimism, even when exaggerated, often
serves, like the flag of the color sergeant, to lead a substantial ad-
vance. But in estimating the resources at our disposal for the
removal of disease, we think it is of great practical importance to
bear in mind the (often unknown) teriium quid, which distinguishes
* Vulpian. Le9ons sur les maladies de la moelle epiniere.
68 ARCHIVES OF MEDICINE.
morbid processes of spontaneous, /, e., internal origin, from those
which have originated in external influences, whether traumatic or
toxic. The problem for somatic diseases is the same as for in-
sanity : health failure at any one point of the organism very often,
if not always, implies deviation of the entire organism from the
norm. Hence, we are inclined to believe at least one cause of
the frequent failure to allay spontaneous symptoms by remedies
which have been successfully antagonistic to the same symptoms
when artificially induced.
Did we follow Dr. Bartholow literally, we might infer that the
different success in the two cases really depended on an absence of
anatomical lesion as a basis for toxic symptoms. We are told to
select our therapeutical agents on the basis of " physiological an-
tagonism." And this "means simply a balance of opposed actions
on the same tissue. It does not induce a change of structure.
The opposing agents counterbalancing each other, the functional
disturbance subsides, and the normal equilibrium is restored."
(p.")
But physiological actions are inconceivable except as the con-
comitant of molecular changes in the elements in function. The
difference between each molecular change and gross palpable
lesions of structure, is one of degree not of kind. An agent that
causes arterial tension by relaxing the peripheric arterioles, de-
termines a rearrangement of the molecules in their muscular coat.
An antagonistic drug which should raise the tension by really
acting on the same arterioles, must necessarily reverse the molec-
ular arrangement effected by the first. The objective of the
second drug is not the " opposing action of the first," but the
tissue which has been modified by that.
But there are further objections to Dr. Bartholow's formula.
We think it can be shown, even from his own summary of facts,
that *' opposed actions on the same tissue " never take place ex-
cept in one direction. When a tissue or organ is paralyzed by
any poison, it fails to respond to other poisons which ordinarily
have a tendency to stimulate it. This failure is observed whether
the paralyzing agent be administered first, or when the stimulating
agent is in full operation. In the latter case, the stimulating poi-
son is effectually antagonized. It is on this account that, as Dr.
Bartholow himself remarks, the list of antagonisms effected by
atropine is so large : it paralyzes so many " end-organs." Para-
lyzing the ciliary branches of the third nerve to the pupillary
sphincter and to the ciliary muscle, atropine antagonizes all
NEW BOOKS AND INSTRUMENTS. 69
drugs which cause myosis, either by stimulating the third nerve,
or by antagonizing the ciliary muscle or circular fibres of the
iris.* Thus, it antagonizes pilocarpine, eserine, muscarine, and
the initial action of morphine. In the later stages of morphine
poisoning, where vaso-motor paralysis of the iridian blood-vessels
increases the myosis by turgescence of the iris, the counteracting
effect is aided by its influence on the circulation. Now, in all
the above cases, the antagonism of atropine to the myotic drugs is
not reversed. When the pupil has been dilated by atropine, it is
admittedly difficult to counteract it by any antagonist. In the
most famous and thoroughly discussed antagonism, that between
morphine and atropine. Dr. Bartholow declares that the pupil
offers no sure guide, and that the action of atropine preponder-
ates. Muscarine will not contract the pupil dilated by atropine.
(See p. 63 of Lectures.)
According to Bartholow the " atropinized pupil resists the act-
tion of eserine " (p. 54). If, however, as Galezowski declares, ese-
rine discs will contract a pupil so dilated, it would be by directly
tetanizing the circular fibres of the iris ; thus there would be no
" opposed action " on the third nerve.
Quite similar observations hold true of the heart. Here again
the " antagonism " of atropine is extensive and conspicuous, be-
cause it paralyzes the terminal fibres of the vagus in the cardio-
inhibitory ganglion. Thus it antagonizes, in Dr. Bartholow's
sense, by " opposed action on the same tissue," all the drugs
which slacken the pulse by stimulating either the central or
peripheral portion of the inhibitory apparatus. Thus, it is antag-
onistic to digitalis, to morphine in its early stages, to musca-
rine. But the experiment is classical in toxic experimentation,
wherein the heart, arrested by muscarine, may be set to beating by
atropine, while the atropinized heart altogether refuses to respond
to muscarine. When morphine succeeds in reducing the pulse
accelerated by atropine (and this is admittedly difficult), it does
so by diminishing the excitability of the excito-motor ganglia.
Here again, therefore, there is not " an opposed action on the same
tissue," but a similar, i. e.y paralyzing action on a very different
tissue.
^ Dr. Bartholow admits, in several places, that atropine " stimulates the ra-
diating fibres of the iris ; " but of this we know of no proof. The experiments
upon the excised eye, we believe first performed by Brown-Sequard, only demon-
strate that atropine acts on nerve terminations, and that the central communi-
cation of the third nerve is not essential. This is precisely analogous to its ac-
tion on the terminal branches of the vagus, after section of the trunk.
70 ARCHIVES OF MEDICINE.
Similarly, atropine will arrest the salivation caused by physo-
stigma or pilocarpine, for it paralyzes the chorda tympani.
When this paralysis has once been effected, salivation is no longer
possible. Chloral will moderate the convulsions caused by strych-
nine ; there is no proof that strychnine will avert the respiratory
paralysis threatened by toxic doses of chloral.
Dr. Bartholow admits this last fact with great surprise. We
consider it rather as an illustration of a general law that we have
already indicated, and which may be thus formulated :
" The response of an organ to a physiological or toxic stimulus
may be prevented by paralyzing the organ. But paralysis of an
organ cannot be antagonized by stimuli addressed to the organ,
since the paralysis implies that susceptibility to impressions has
been lost. Cure of paralysis can only be obtained by elimination
of the paralyzing effect. During the process of elimination, the
effects of the paralysis may often be combatted by stimulation of
other organs remaining able to respond. This constitutes a net
antagonism to the effects of the poison, often effectual, but
always indirect."
It is this form of antagonism which is to be inferred from the
" physiological basis " described by Dr. Bartholow. Part of this
basis is afforded by the mechanisms which exist throughout the
body for systemic alternation of functions, with consequent " re-
straint of activities within proper limits."
" If there were not some antagonism to the spasm centre, every
trifling peripheral irritation would produce most extravagant re-
flex effects. * * * The movements of .the vessels are regu-
lated by a vaso-motor centre in the medulla. By the opposed action
of the dilator and constrictor forces, the vascular tonus is main-
tained at the normal. A similar mechanism controls the cardiac
movements ; there is a motor apparatus for carrying on the
action of the heart, and a regulator apparatus for restraining the
movements within proper limits. * * * If the arterioles suddenly
dilate, the blood-pressure as quickly falls, but danger to the circu-
lation is prevented by an increased action of the heart. * * *
Here opposing forces maintain their equilibrium " (p. 21).
The presumption is that artificial antagonism to a given process
in an organ will be best effected by acting upon the apparatus
which provides for physiological antagonism to the same process.
If we apply this principle to some of Dr. Bartholow's favorite
illustrations of antagonism, we shall discover quite a different in-
terpretation of them from that given in these lectures. For in-
\
NEW BOOKS AND INSTRUMENTS. /I.
stance, atropine is said to " stimulate respiration," because ac-
celerated respiration is a phenomenon induced by atropine.
Hence atropine is considered a valuable antagonist to any poison
threatening death by "respiratory paralysis."
Now, it must be observed, in the first place, that each of these
opposed terms is not simple, but extremely complex. The accel-
eration of the respiration may depend upon several circumstances,
and so also its slackening ; and special inquiry is necessary before
we can be assured in any given case, that these are exactly op-
posed to each other. Analogy, at least, would suggest that atro-
pine paralyzes the inhibiting respiratory centres,* and that the
respiratory movements are thus accelerated in the same way as
the cardiac, when their inhibitory apparatus is paralyzed. In an-
tagonizing morphine, the same succession of events presents itself
for the respiration as for the heart at the beginning of morphine
poisoning. The respiration may be slowed, because the increased
intracranial pressure has stimulated the inhibitory centre of in-
spiration, as it has the roots of the vagus and of the motor oculi
nerve. Then the. paralyzing effect of atropine would be benefi-
cially antagonistic. Later on, when the susceptibility of the in-
spiratory centre itself is becoming benumbed, it might be (ac-
cording to our theory) indirectly aroused by more rapid capillary
circulation both throughout the tissues and in the medulla itself.
By accelerating the circulation, therefore, atropine brings to bear
upon the inspiratory centre the normal blood-stimulus to which
it is physiologically adapted to respond. The antagonism to the
effect of the morphine would therefore be indirect.
We would note, in passing, that the common assertion (which
Dr. Bartholow endorses), that morphine induces carbonic acid
narcosis, seems to us very inaccurate. The characteristic reaction
of the inspiratory centre to an excess of carbonic acid in the
blood is convulsion, which morphine does not cause in adults.
We think it could be shown that the slackening of the respiratory
movements coincides with, and follows, diminution of molecular
respiration in the tissues. The phenomena are those of apnoea,
not of asphyxia ; there is not an excess of carbonic acid irritat-
ing the inspiratory centre, but a deficiency, and leaving it in ab-
normally long intervals of repose. Hence might be suspected an-
other mode of action of atropine, viz., accelerating the circulation
and tissue-change. But i,nto speculations like these. Dr. Bartholow
* Described by Rosenthal, Bemerk. ub. d. Thatigkeit d. automatischen
Nervencentren, etc. Erlangen, 1875.
72 ARCHIVES OF MEDICINE.
(even was the genius for limitations required, not only for power'
but for scientific summaries) does not enter. His summary, how-
ever, contains many illustrations of the doctrine we maintain,
namely, that effective antagonism is always either paralytic or in-
direct. Thus, having no direct control over the cardiac tetanus
of angina pectoris, we can yet relieve the attack by paralyzing the
contracted arteries through inhalations of amyl nitrite. Failing
to arrest uterine hemorrhage by astringents directly applied to the
bleeding surface, we may effect our purpose with nux vomica,
which " stimulates the cardiac and respiratory centres."
And so on. The more examples we multiply the less should we
be ready to accept Dr. Bartholow's doctrine of mutual antagonism
by means of " opposed actions in the same tissues ; " the more in-
clined to believe that the antagonistic influence is necessarily ex-
erted upon different organs, or upon tissues in the same appa-
ratus.
We have selected for comment the topic that happened to at-
tract our attention. We leave to others the agreeable task of
seeking food for other reflections from these most suggestive lec-
tures, [m. p. j.]
Medical Electricity : A Practical Treatise on the Ap-
plications of Electricity to Medicine and Surgery. By
Roberts Bartholow, A.M., M.D., LL.D., Professor of Materia
Medica and General Therapeutics in the Jefferson Medical Col-
lege, etc. With 96 illustrations. Philadelphia : Henry C. Lea's
Son & Co., 1881, pp. 262.
The announcement of a new work on medical electricity gives
rise at once to the queries : Why has another been added to the
numerous ones already published ? What faults and deficiencies
in the latter does the former correct and supply ? for certainly a
sufficient number of defective works on this subject are already
before the public. In the preface to the above-named work the
author gives an answer to these questions from his standpoint,
namely : " That there are excellent works on medical electricity,
is undeniable ; but some of them are too voluminous, others too
scientific, and not a few wanting both in fullness and in accuracy.
I have attempted, in the preparation of this work, to avoid these
errors ; to prepare one so simple in statement that a student with-
out previous acquaintance with the subject may readily master the
essentials, so complete as to embrace the whole subject of medical
* According to a remark quoted by Lewes from, we think, Goethe.
NEW BOOKS AND INSTRUMENTS. 73
electricity, and so condensed as to be contained in a moderate
compass. I have assumed an entire unacquaintance with the
elements of the subject as the point of departure, for I am ad-
dressing those who have failed to acquire this preliminary knowl-
edge, or having acquired it, find that after the lapse of years it has
become misty and confused." That the author has been quite
successful in the accomplishment of his object few would deny.
His pleasing style and clearness of expression cannot fail to make
a readable book, even when applied to a dry subject. Yet lucid
statements and attractiveness of style may fail to thoroughly in-
struct the reader. A few pages devoted to the enunciation of the
simple laws which govern electrical phenomena, with a few illus-
trations of their application, will do more to instruct than whole
chapters which describe such phenomena in the most simple
language, but fail to go to the root of the matter and refer them
to fundamental principles. While this applies to the work in
question to a much less degree than to the majority of works on
medical electricity, still it is not wholly inapplicable.
Our author states that : " In the account of electrical phenom-
ena I have adhered to the modes of expression with which the
medical electrical text-books have made us familiar. The time
has not yet come, it seems to me, to adopt the terms and explana-
tions now employed by practical electricians ; it is a transition
period in which both the old and the new should have a measure
of recognition." It is disappointing to find, with this acknowl-
edgment of the existence of new terms and explanations, an ad-
herence in this new book to old modes of expression. If, as stated,
the book is intended for the instruction of those who have not
acquired such knowledge, and those who have forgotten that
which they once knew about it, would it not be better to start them
on a reformed basis than on one that is obsolete or retiring ? Or,
if both are to be recognized, let the modern one be put in the
foreground as a working basis, thus saving the student from the
difficult period of transition by making him familiar in thought
with that which he must use sooner or later, while the older forms
of expression may be easily explained and their defects pointed
out.
Part I (pp. 80) is devoted to electro-physics. The chapter on
*' forms of galvanic combinations " gives a more complete account
of the chemical reactions taking place in the different cells de-
scribed than is usually found in works on medical electricity. It
is surprising to find in Part II, on electro-physiology, in referring
74 ARCHIVES OF MEDICINE.
to animal electricity of nerves and muscles, and the experiments
of Du Bois Reymond and others, that no mention is made of the
more recent experiments and views of Hermann ; although it is
expressly stated that in consequence of the uncertainty of our
knowledge on this subject only the slightest sketch would be
given ; yet to have mentioned Du Bois Reymond's most powerful
opponent in this great physiological war would have required but
a few words, while it would have furnished the reader with a hint
to further research.
In Part III, on electro-diagnosis, one of the most important
subjects in electro-pathology is considered ; namely, the " degen-
eration reaction," a subject which has been very slow in finding
its way into text-books in English on medical electricity. This is
one of the best features of the work. It is quite remarkable,
however, that our author should have included, without any quali-
fication, progressive muscular atrophy, with glosso-labio-laryngeal
paralysis and infantile paralysis, as examples of diseases in which
the degeneration reaction is to be found, when it is well known that
it is the exception, and not the rule, to find qualitative changes in
the first-named disease ; and that reaction to faradism is usually
preserved, though possibly diminished, in the muscles as long as
there is a trace of muscular tissue left, this very point being of
considerable diagnostic value. It may be that the true degenera-
tion reaction always exists in certain fibres undergoing atrophy,
but as the muscle is not affected en viasse^ it would not be easily
recognizable, being masked by the reaction in the unaltered fibres
until a very late stage. So that, practically, from a diagnostic
point of view, this disease does not conform to those with which
it is associated by our author.
In Part IV, on electro-therapeutics, we find a conservative view
maintained as compared with the majority of text-books ; though
not infrequently it seems as if exceptionally favorable cases had
been selected, which are, no doubt, encouraging to the student,
until he finds that failures, or imperfect results, are more frequent
than the successes he had expected. A point not sufficiently ap-
preciated is maintained by the author, namely, the necessity for
frequent application of electricity, particularly in the treatment of
painful affections ; for example, in cervico-brachial neuralgia he
recommends ^^ stances of five to ten minutes* duration, three times
a day." It is questionable whether sufficient stress is laid upon
the polar method in the treatment of painful affections. It is
stated that " it is good practice to apply the anode to the painful
NEW BOOKS AND INSTRUMENTS. 75
point ; " this, however, is rather luke-warm compared with the
views of some acknowledged authorities.
Part V treats of electricity in surgery, presenting a good chapter
on electrolysis. In the succeeding chapter on electric heating and
lighting is an explanation of the " secondary cell " of Plante used
in Trouve's polyscope ; as justly observed "the principle involved
is of great importance, and as it is likely to enter largely into the
construction of medical electrical apparatus, the reader ought to
have a clear comprehension of it and of the apparatus." After
describing various forms of cautery batteries and their uses, also
Adams's electric laryngoscope, the book is concluded by Part VI,
in which thermo-electricity is considered, and reference made to
Lombard's thermo-electric pile as an instrument for determining
variations in body temperature. [w. r. b.]
Supplement to Ziemssen's Cyclopaedia of the Prac-
tice of Medicine. Edited by George L. Peabody, M.D.,
Instructor in Pathology and Practice of Medicine, College of Phy-
sicians and Surgeons, New York ; Pathological and Medical Reg-
istrar to the New York Hospital. New York : Wm. Wood & Co.,
1881, pp. 844.
The object of this volume, according to its editor, is to give a
concise account of the progress made in the various departments
of medicine during the time that has elapsed since the several vol-
umes of the cyclopaedia were published. Only those subjects are
treated which appeared in the American edition, and some of these
are omitted ; nothing of importance having appeared relating to
them. The space assigned for the review of this volume will
not allow a list of its twenty-eight contributors, or the titles to the
sixty-one subjects treated, to be given ; preventing entirely a re-
view of the articles separately. Suffice it to say that eleven of the
contributors are from New York, ten from Boston, three from
Chicago, one from Philadelphia, one from Cincinnati, one from
Ithaca, and one from the U. S. Army.
The work is, in the main, a bibliography, supplementary to that
of the cyclopaedia, and a review of the same. Some of the con-
tributors, however, have treated the subject from their own stand-
point, impressing the stamp of their own individuality upon their
article, which, for the average reader, makes a more satisfactory
production for perusal. Such a work must, of necessity, be more
or less imperfect and unsatisfactory. The limitation of space, nec-
essary to prevent the work from becoming too voluminous, often
76 ARCHIVES OF MEDICINE.
cripples the reviewer and renders his summary incomplete in the
number of articles referred to, or imperfect in his treatment of
them. One of the most original and most valuable articles is that
of Geo. Sternberg, M.D., U. S. Army, on Yellow Fever, as it sums
up our knowledge concerning this disease after the experience de-
rived from our recent epidemics, and the efforts, both individual
and national, to elucidate this important subject. Coming from
the pen of one who has devoted himself especially to this topic
during the eventful period named, his article well deserves study.
However unsatisfactory it may be to find that so many doubtful
points are still left in doubt, we must feel gratified at seeing evi-
dence of a conservative spirit in the conclusions given. It is sur-
prising to find in reviewing this book how important a place the
germ, or parasitical, theory of disease has occupied in the thought
and work of medical men during the last few years ; not limited,
as formerly, to the realm of pure speculation, but largely devoted
to reasoning based upon critically experimental data. Here, also,
conservatism holds the balance of power.
One of the most valuable features of this work for the thorough
student is its bibliography. It is to be regretted, however, that
there is so much inequality in this particular. In the article on
Syphilis, by Prof. James Nevins Hyde, of Chicago, the editor
has left out altogether " a very voluminous and carefully selected
bibliography, containing nearly five hundred references," on ac-
count of limited space. A carefully selected bibliography is of
more importance, however, than a voluminous one. Indeed, un-
less the worthless abstracts and reviews, and the unimportant ^
articles are excluded, a bibliography becomes a hindrance instead
of a help to the student. On the whole, the work represents a
large amount of bibliographical research, and no one who has not
attempted such a task is likely to appreciate the consumption of
time and the judgment required to collect and summarize such a
mass of data as appears in this volume.
To the thinking reader it presents a vast array of facts and theo-
ries which proper study may utilize, while to the routine prac-
titioner or the superficial student, it presents, in many of its chap-
ters, a quagmire of irreconcilable views ; in others, a field barren
of that fruit which he seeks, namely: the strictly practical. In this
respect, many of the contributors have been true to the original
work which they have supplemented. To those who possess the
cyclopaedia this volume forms an indispensable addition, and
even those who do not possess the former will find it a valuable
acquisition by itself. [w. r. b.]
NEW BOOKS AND INSTRUMENTS. 77
The Metric System in Medicine. By Oscar Oldberg,
Phar. D. Presley Blakiston, Phila., pp 182.
As a book of reference the little work before us will be found
extremely useful and accurate, but if intended to radically further
the cause of the metric system among Americans it will share the
fate of its predecessors for reasons which will be given later on.
Part first commences with some historical remarks. Among
these we look in vain for a mention of the labors of the late
Doctor Edouard Seguin, who by teaching and example has done
perhaps more than any one American to popularize the metric
system.
After a brief description of metric terms come 24 pp. of tables
of equivalents of linear, square, and cubic measures and of weights,
very accurate and of great usefulness for reference.
Next follows, occupying 77 pp., a metric prescription formulary,
which contains three hundred and thirty-four formulae, selected,
the author states, " from the pharmacopoeias and formularies of
the great hospitals of New York, Philadelphia, Boston, London,
etc., or are contributed from the practice of the medical officers
of the Marine Hospital service, who have been using the metric
system exclusively since April 27, 1878. Quite a number of the
prescriptions are transcribed from the hospital formulary com-
piled by Chas. Rice, Ph. D., of New York."
Culled from so many sources it will be hard to trace the out-
rageous Latin they contain to its proper source. After a pretty
careful perusal of the formulae not one unabbreviated word was
found in the genitive case. The following is a prescription ap-
pearing on page 119.
Sulphur, praecip., 15 gm.
Pyroleum cardinum, 15 gm.
Creta praeparata, 10 gm.
Sapo mollis virid., 30 gm.
Butyrum petroleum, 30 gm.
As the book is intended " especially for students " (preface)
good Latin, if Latin there must be, should be placed before
them.
As the formulae are introduced simply to illustrate the way of
writing metric prescriptions it would seem as if three would do as
well as three hundred. .
Next come dose tables occupying 53 pp., very full and presum-
ably accurate, although we see among them the dose of fluid ex-
78 ARCHIVES OF MEDICINE.
tract of conium to be only .i — .4 (2 — 5 minims), and that ot
iodide of potassium to be .1 — i. (2 — 15 grains).
Now to return to the first part of the work. The title of the
book tells us the work is " an account of the metric system of
weights and measures Americanized and simplified," etc. To
simplify the metric system is impossible, it being already the most
rational and simple. To Americanize the system the author says
(p. 20) " we will hereafter drop the term cubic-centimeter, and
adopt in its place the term fluigram the word fiui-
gram is, besides, more convenient, euphonious, and American than
the word cubic-centimeter." Again, p., 23, *' Tenths, hundredths,
and thousandths of both the gram and fluigram may be conven-
iently called * dimes,' * cents,' and * mills ' when referred to in
speaking." Now, we claim that to Americanize the metric system
in any way, except to spread it broadcast over the country in its
original form, is to destroy its most commendable feature, /. e.^
that of international uniformity. If we adopt the metric system,
let us adopt it entire, French being much more universally un-
derstood among scientists than English. Such slight deviations
from the original as cubic-centimeter for centimetre cube and
gram for gramme, being unimportant.
The abbreviation gm. for gram we think injudicious, as it is
often mistaken for our old gr. We think the decimal point or line,
as advocated by the late Dr. Seguin and used by him in his Pre-
scription and Clinic Record, quite sufficient, more simple, and less
liable to permit mistakes.
For example, Prescription No. 216, p. too, reads :
Ferr. reductum, 7 gm.
Quinin. sulph., 8 gm.
Strychnin, nitr., 0.15 gm.
This, it seems to us, is less simple and not so safe in the drug-
gist's hands as :
Nitrate of strychnine,
0.15
15
Reduced iron,
7.00 or 7
00
Sulphate of quinine,
8.00 8
00
neither of which could be well taken for any thing but a metric
prescription.
" To drop the old system of weights and measures entirely, and
start out anew with the metric system, after learning the doses of
medicines over again in metric terms, I conceive to be more con-
NE W BOOKS A ND INS TR UMEN TS, 79
venient than safe," p. 17. We think it would be more safe than
convenient, if by convenient he means easy.
To popularize the metric system we must begin with the stu-
dent. To whom shall we look for help ? Most assuredly to our
writers of students' text-books, to our medical journals, and to our
didactic and clinical lecturers. What are our authors doing to
further the cause of the metric system ? Take the three most
popular works in America on materia medica and therapeutics :
Wood's, Bartholow's, and Stille and Maisch's. In all the doses in
the text are given in grains and minims ; in one only is a poso-
logical table in both systems ; in another there is a table of
equivalents hidden in an appendix at the end of the book ; while
in one not a metric word or figure occurs in the whole book.
Few medical journals in our country uses the metric system
exclusively, and the number of our lecturers so using it could be
counted on the fingers of one hand. [r. w. a.]
Anatomical Plates. By Prof. J. N. Masse, Paris. Ar-
ranged as a companion volume for " The Essentials of Anatomy."
Edited by Ambrose L. Ranney, A.M., M.D. G. P. Putnam's
Sons, New York, 1881.
For many years Masse's Anatomical Plates have been known to
English readers through its translation by the late Prof. Granville
Sharp Pattison. This translation is assumed by the editor of
this volume ; and, having made such alterations and additions as
were required to bring the plates and text up to date, he offers it
to the profession as a companion to his " Essentials of Anatomy."
The book illustrates osteology, arthrology, aponeurology,
splanchnology, myology, angeiology, and neurology. To these il-
lustrations have been added diagrammatic cuts of many nerves,
with special reference to their communications and distribution.
As illustrations of anatomical fact the plates are accurate and
well executed, and their arrangement relative to the text renders
reference as easy as possible.
For the purposes, however, for which this work was prepared,
we prefer the use of color and greater size, thereby to secure a
more immediate perception of an organ and its relations. For
the " country physician and surgeon," for whom this and so
many other reference books are kindly made by the " brothers in
town," there is the greater necessity that reference should be
ready and easy. A paged index would help in this respect, and
when the plate desired is found it should represent as many of
8o ARCHIVES OF MEDICINE.
the sought-for relations of an object as are possible in a picture.
Suppose, for example, a " country surgeon " should be called on
to ligate the femoral artery, and, in the matter of anatomy,
should consult this book, he would find in one plate the artery in
relation with muscles ; in another plate, the artery in relation
with the nerves ; while its relations with the veins, and the not-a-
little important sartorius muscle, are not shown at all. These
matters may have been left to the text-books. We are tempted
to select an example of the insufficiency of the plates for the
physician ; because, it may be, the editor assures us in the pref-
ace, that when the physician "wishes to refer to the position of
any particular viscus, and to study its relations, or when symp-
toms depending on nervous connection arise in disease which he
cannot explain, referring to this atlas, all his difficulties are re-
moved." This quotation may mean and promise more than the
writer of it intended. In truth, we are constrained to remark
the same of the whole preface.
We would note a minor defect in the putting-together of the
book. Some half dozen of the plates are inverted, so that it be-
comes necessary to turn the book around during reference.
The book is of moderate size, and its cost is brought within
the means of every one in need of it, and, as a remembrancer, it
may meet most of the reasonable demands made of it.
[j. V. D.]
ORIGINAL OBSERVATIONS.
TUMOR OF THE MOTOR ZONE OF THE CEREBRAL CORTEX.
By CHARLES K. MILLS, M.D.,
NEUROLOGIST TO THE PHILADELPHIA HOSPITAL.
In August, 1880, I saw, with Dr. F. Dercum, of Philadelphia,
the following interesting case :
Mrs. W., aged about 30, in the autumn of 1879 began to suffer
with headaches. In March, 1880, she had an attack, beginning
with numb sensations in the fingers of the left hand. These were
followed by twitching movements of the fingers. The spasm ex-
tended to the left arm, and before the attack passed off a general
convulsion occurred, the movements being most violent on the left
side. After this seizure she found that the left upper extremity-
was decidedly weaker than the right. In May, 1880, she had an-
other spasm, which involved only the left upper extremity. Subse-
quently, up to the time that she was first seen by me, she had
about half a dozen more spasmodic attacks, which began with
twitching movements of the fingers of the left hand. The convul-
sion was always most severe upon the left side, and was usually
limited to it. Its greatest violence was spent upon the arm. After
each attack the left half of the body became more and more
paretic. The left upper extremity showed the greatest amount of
paralysis. She suffered more or less pain in the head all the time,
and at frequent intervals had paroxysms of agonizing pain, accom-
panied by vomiting.
In September, 1878, Dr. Wilson Buckby had attended this pa-
tient for typhoid fever. I learned from Dr. Buckby that on the
fourteenth day of her sickness she had had a severe convulsion,
on the subsidence of which she was left with partial paralysis of the
81
82
ARCHIVES OF MEDICINE.
limbs and face of the left side. In four days this paresis disap-
peared, and the fever ran its regular course to recovery. She had
no other attacks of spasm until March, 1880.
In August, 1880, her condition was as follows : Her mind seemed
clear, but acted slowly. She answered correctly, but not quickly.
It was difficult for her to fix her attention. She would frequently
burst into tears, apparently because of her excruciating headache.
The pain was worse in the right fronto-parietal region. Percussion
above and around the right ear caused greater pain than at any
other place on the head. Sight was very imperfect, and ophthal-
moscopic examination showed double optic neuritis. Hearing
was defective in the right ear. Sensibility was impaired, but not
abolished, on the left side. Both the upper and lower portions of
the left side of the face were partially paralyzed. Paralysis of the
left arm was nearly complete ; the limb was a little wasted, but
showed no contractures. The same condition, but less marked,
was shown by the left lower extremity. The left patellar reflex
was diminished. No aphasia was present. The bowels and blad-
der were partially paralyzed. The urine contained neither
albumen nor sugar.
The patient died August 27, 1880.
A post-mortem examination was held 37 hours after death, Drs.
Dercum, Buckby, Collins, and myself being present. Beneath and
adherent to the pia mater of the convexity of the right hemisphere
was found a tumor about i \ inches in diameter. It was nodulated.
On section, it was bloody, and had a mottled appearance. It
involved the middle portion of the ascending parietal convolu-
tion and the upper part of the inferior parietal lobule, pushing
ORIGINAL OBSERVATIONS. 83
aside the interparietal fissure. The anterior extremity of the pupil
was about \ of an inch back of the centre of the fissure of Ro-
lando. On the inner side of the tumor the white matter of the
brain was broken down. The only other lesion discovered was a
slight adhesion of the dura to the pia mater over the upper ex-
tremity of the ascending convolution of the left side.
The tumor was examined, microscopically, by Dr. L. B. Hall, of
Philadelphia, who reported as follows : " On section of the
hardened tumor left with me, I found it to be of the same brown
color throughout. The microscope showed this color to be due to
numerous very minute points of hemorrhage scattered through-
out the entire mass. The cell element consisted of large, rounded,
multinuclear cells, filling a stroma of very fine fibres, with rela-
tively large interspaces. Retrograde changes appeared in places
where the whole was little more than a diffluent mass of debris.
The appearances of the specimens best agree with carcinoma
cerebri."
Remarks, — A considerable number of cases similar to the one
here reported are now on record. The case is one which illus-
trates the possibility of making an accurate local diagnosis of
tumors involving the motor zone of the brain and immediately
adjacent parts. Before the death of the patient I expressed to
Drs. Dercum and Buckby the opinion that the case was one of
tumor of the cerebral cortex, involving the middle portion of the
ascending parietal convolution and the adjoining parieto-temporal
region. I further stated my belief that the growth of the tumor
had probably begun in the ascending convolution. The distinc-
tive general symptoms of brain tumor were present, namely :
agonizing headache, vomiting, vertigo, psychical disturbances, and
optic neuritis. Certain symptoms, to my mind, pointed conclu-
sively to a tumor of the motor zone, and one primarily impli-
cating the brachial centres. These were (i) the occurrence of
spasms, beginning invariably in the fingers of the left hand, some-
times limited to the left upper extremity, and always either limited
to, or most violent upon, the left side of the body ; and (2) the
occurrence of paresis, and eventually of marked paralysis, of the
left arm, leg, and left side of the face, the paralysis of the left
arm being the most complete. The involvement of the parieto-
temporal region was indicated by the impairment of sensibility
and of the special senses. The localized headache and the pain
elicited by percussion above the ear, confirmed the localization
indicated by the other symptoms.
84 ARCHIVES OF MEDICINE.
REPORT OF TWO CASES OF INTRA-CRANIAL DISEASE.
By WM. S. CHEESMAN, M.D.,
FORMERLY HOUSE PHYSICIAN TO BELLEVUE HOSPITAL.
The following cases have seemed to me worthy of record in the
interests of cerebral localization :
Case i. — Bridget R., aet. 42. No history of injury or syphilis.
Three years before her admission to the hospital she began to
have slight spasms of the right side of the face, at irregular inter-
vals, and infrequently, not oftener than once a month. Two
months before admission, these convulsions became very frequent,
occurring every few minutes, and about one month later the
right upper and lower extremities began to participate in them.
During the convulsion consciousness was not lost, and the intervals
were free from symptoms. She had no pain at any time. Sight,
hearing, and ocular movements unimpaired.
Two days before her admission, the patient became unconscious
during one of these attacks, and, on recovering consciousness, was
found to be hemiplegic on the right side. She had right unilateral
convulsions every few minutes, and touching the right side caused
her to cry out.
When admitted she answered questions rationally, though her
speech was thick. Her replies were often interrupted by a right
unilateral convulsion, during which she would lose consciousness.
Right hemiplegia, with conjugate deviation of the eyes to the left,
existed in the intervals. Pupils normal and sensation unaffected.
Albuminuria and hyaline casts. No cardiac lesion. Tempera-
ture 100° F.
On the third day after admission the patient died. Her symp-
toms were considered to depend upon a cerebral tumor located in
the cortex of the left hemisphere.
Autopsy. — On viewing the brain after its removal, a bulging was
noticed on the left hemisphere. On longitudinal section of the
left hemisphere, the medullary substance was found reddened, and
the line of the cortex very indistinct. To the touch the brain was
almost diffluent. A portion of the hemisphere, three inches long,
and one and a quarter inches deep, was thus affected. The ascend-
ing frontal and ascending parietal convolutions and a part of the
ftiird frontal convolution were implicated, the disease extending
inward to the lateral ventricle. The contrast between the healthy
brain tissue of the posterior lobe and th# soft, mottled portion
affected by disease was very marked.
\
ORIGINAL OBSERVATIONS.
85
Macroscopic appearances at the time of the autopsy seemed to
indicate that the lesion was an acute cerebral softening, but the
microscope showed it to be a glioma.
FIG. I.
External extension of glioma in Case i.
Case 2. — Mary Ann W.
The patient was brought to the hospital comatose. No history
could be obtained. No signs of injury to the head. Pupils nor-
mal. Temperature, ioi^°. No albuminuria or casts. No car-
diac lesion.
In the evening, after admission, the patient had a right unilateral
convulsion, limited to the face, neck, and upper extremity. These
convulsions continued through the night at frequent intervals.
The patient died next morning with pulmonary oedema.
In view of the symptoms it seemed probable that she had
suffered from some lesion of the cortex of the left hemisphere,
affecting the motor centres of the face and upper extremity ;
though, in the absence of history, the nature of this lesion could
only be conjectured.
86
ARCHIVES OF MEDICINE.
Autopsy. — No fracture of the skull could be discovered, and no
signs of injury. But, on removing the calvarium, a clot was found
covering a portion of the surface of each hemisphere. The
brain substance beneath was softened, but the rest of the organ
healthy.
The areas affected were :
On the right hemisphere, the upper extremity of the ascending
frontal convolution ; on the left hemisphere, the upper extremity
of the ascending frontal and the posterior extremity of the first
frontal convolution.
Convexity of the brain after Ecker. Areas of clots and injured cortex.
The softening was less marked on the right than on the left
side.
The clot on the right side had caused no symptoms.
V
I
ORIGINAL OBSERVATIONS. 8/
A SOMEWHAT REMARKABLE CASE OF GLAUCOMA— APHASIA
—DEATH FROM PROBABLE APOPLEXY.*
By DAVID WEBSTER, M.D.. New York.
Mr. N, B. first consulted Dr. Agnew in the spring of 1863, for
a gradual impairment of vision in his left eye. The eye was found
to be affected with chronic glaucoma, and an operation was ad-
vised. When the patient came for advice a second time, in the
spring of the following year, the eye had lost all perception of
light and was very painful. In short, the* disease was glaucoma
absolutum. The patient was then ready to assent to any thing for
the relief of his pain, and Dr. Agnew performed an iridectomy
upward with the result of quieting the eye. He had no more
pain or inflammatory symptoms in this eye to the day of his death.
March 15, 1866. — Mr. B., now aet. 44, and married, is apprehen-
sive of loss of sight of right eye. Reads J. No. i, but sometimes
sees better than at other times. Has a small crescent of choroidal
atrophy at temporal border of optic disc.
Nov. 28, 187 1. — Patient complains that a haze came over right
eye while he was reading the newspaper last evening, and contin-
ued for about five minutes. Vision = |-g- -j-. Ophthalmoscopic
examination shows some excavation of the optic papilla, and pul-
sation of the retinal veins. Tension -\- ?
May 27, 1873. — Patient has had several periods of slight ob-
scuration of vision of late. Vision = |f ; no limitation of visual
field. Tension -\- ? Ophthalmoscopic examination shows pre-
cisely the same appearances as noted under last date.
March 18, 1874. — The patient being very anxious about his
eye, was sent to Dr. H. D. Noyes in consultation. Dr. Noyes
carefully examined Mr. B., and wrote as follows : " Mr. B., I
find, has R. V. = ff, with no impairment of field. Tension -\- i,
or perhaps more. With -\- \ \ see molecular opacities in the
lens, but none in the cornea or vitreous. The nerve exhibits a
shallow central excavation, veins ampulliform and pulsating, ar-
teries very small and emptied on slight pressure. The vessels fol-
low the line of the pit in a way which makes me think that this
is not due to original excavation, but to the pressure. I
should favor an iridectomy with little delay, because of the
existing effect on the arteries and of the changes in the lens. I
do not think the risk will be important. As to the fellow eye, I
see no reason to enucleate, because it is not troublesome, while if
* From the practice of Prof. C. R. Agnew, M.D.
88 ARCHIVES OF MEDICINE,
it were I should rather do an opposing iridectomy, believing that
would be sufficient. Unless a glaucomatous eye is painful I would
not remove it to protect the other, and as such is not here the
case, I would try to save the organ."
It was decided, however, to defer the operation until there
should be more marked impairment of the vision, or limitation of
the visual field, especially as there was a peculiar hebetude in the
behavior of the patient that suggested the propriety of more than
usual caution on the part of the surgeon.
June I, 1874. — Some arching forward of iris from commencing
proliferation of vitreous ; venous pulsation more marked, and
slight pulsation of one branch of the central retinal artery. Vision
= -f-g-; visual field remains normal.
Sept. I, 1874. — Called to see Mr. B. in consultation with his
family physician. He was, some days ago, attacked with vomit-
ing and severe headache, referred to the left fronto-parietal region.
At the same time he became the subject of aphasia and agraphia,
being unable to express himself either orally or in writing. To
every question he would reply, " You see," or " You know."
Pulse 60, temperature normal. His family physician has learned
that he had syphilis some twenty years ago. Put upon iodide
of potassium in increasing doses.
Oct. 10, 1874. — Patient has sufficiently recovered to come to
the office. He seems to be slowly recovering from his aphasia.
The question was asked : " Have you any pain in the head at
all ? " He replied, " Yes, across here," puting his hand on the
top of his head. " I feel a kind of a treatment across there — I
can excel, I can try a good deal of people. I can tell a good many,
that is, people of the past, in the time. My treatment here I
could pass. Am well."
Question. — " Can you write ? "
Answer. — ''Yes, pretty well."
"Write." Patient writes :
J " N. B. hot aurred baths with gunds every week — Unicas St."
Dr. E. C. Seguin, who saw Mr. B. on October 15th, writes as
follows :
"Your patient, Mr. B. has a peculiar form of aphasia, or,
more properly speaking, he is in a very peculiar stage of recov-
ery from aphasia. He is reconstructing his language and the at-
tempt is strangely incoherent. There being no cardiac murmur,
I incline to the opinion that he has had thrombosis of a small
branch of the left Sylvian artery, supplying Broca's region. He
ORIGINAL OBSERVATIONS. 89
admits having had venereal disease, but is in no state to answer
questions as to the particulars of the attack : the thrombosis may-
have been the result of syphilitic arteritis."
Mr. B. died about six months after his attack, having never
completely recovered from the aphasia. There was no post-mor-
tem examination in his case, but the certificate of death records,
" softening of the brain."
The case is an interesting one in many respects. The fate of
the left eye shows how dangerous it is to defer an operation in
chronic glaucoma, where the sight is rapidly failing. Such cases
are almost certain to terminate in a painful inflammatory abso-
lute glaucoma, and when this condition is reached an iridectomy
does not always relieve the pain, as it happily did in this case, but
very frequently such eyes have to be enucleated.
The history of the right eye shows that the prodromata of glau-
coma may exist for years without marked impairment of vision or
limitation of the visual field. The event shows that it was just as
well that the operation was not performed upon this eye, as the
vision remained very nearly perfect, except during short periods
of obscuration, as long as he lived.
If there was any causative relation between the disease of the
eyes and the " softening of the brain," it is difficult to explain it.
Syphilis was probably the cause of the intracranial lesion, and it
may, indeed, have been the primary cause of the glaucoma, but of
that we are by no means certain.
HISTORY OF ATTEMPTS MADE TO CURE THREE CASES OF
CHRONIC TRIGEMINAL NEURALGIA.
By E. C. SEGUIN, M. D.
It must have appeared to many physicians besides myself that
the custom of reporting only successful cases, and of slighting, or
altogether omitting, an account of our unsuccessful attempts at
cure, was a bad one, and this for several reasons. One of these
is that the perusal of such one-sided reports is quite sure to in-
spire some of our confreres with undue confidence in the power
of drugs over disease, and to shape their prognosis accordingly.
Among the diseases which most tax our patience and thera-
peutic skill, there are few more redoubtable than chronic trigem-
inal neuralgia, or tic douloureux. Excellent as is the reputa-
tion of this affection for incurability, yet the published records of
90 ARCHIVES OF MEDICINE.
this committee embrace several instances of its cure by drugs in
patients who had suffered fourteen years or less {vide New York
Medical Journal^ Dec. 1878, p. 621).
I propose this evening, for the purpose of enabling you to profit
by my unsatisfactory experience, to relate briefly the history of
three cases of the disease in question, which have not been
cured.
Case i. — Mr. F. O., aged 45, oyster dealer. History taken when
first seen, Dec. 12, 1878. General health has always been excel-
lent. In 1856 had a single malarial chill, followed by two slight
attacks of right supra-orbital neuralgia.
Present tic douloureux began in 1857, by a few "sticking"
pains near the right infra-orbital foramen : a single pain like the
pricking of a needle several times a day. This pain steadily in-
creased in severity and frequency. Came north from Georgia in
1858, and for one year was free from pain. After that time it re-
turned. Two or three times a year afterward he had spontaneous
relief for some weeks. In the last two or three years constant
suffering. Patient has tried a good many medicines without
relief.
Now has a paroxysm of pain every two or three minutes day
and night. Eating, drinking, talking, attempts to wash or wipe
the skin of the face on right side excite paroxysms of pain.
About three years after commencement of trouble (1857) the
pain extended to the whole of the upper maxilla, later to the
lower jaw, and recently the whole of the right trigeminus, lingual
branch included, has been the seat of pain. There is no regu-
larity or periodicity in time of appearance of the pain, or in its
degree of intensity. The patient never has common headache or
dizziness. In i857-'58 one tooth was pulled from the right upper
jaw, and another in 1867 ; pain aggravated each time.
Denies injury to face and syphilis.
Examination. — Patient is a large and powerful man, of healthy
aspect, with a facies indicative of suffering. Every few minutes
he has an epileptiform (/. ^., sudden) onset of pain in right side of
face and head to vertex ; pain sharp and cutting ; paroxysm lasts
a few seconds, and during it the face flushes. The cutaneous
sensibility of the affected region is normal to simple touch and to
aesthesiometer test. Hearing of right ear O, drum thick and
whitish. Hearing of left ear 12-15 inches (watch). The corneae
are normal ; right pupil is a trifle smaller than the left in intervals
between pains. The teeth on right upper and lower jaws are
ORIGINAL OBSERVATIONS. 9 1
covered with an extraordinary layer of " tartar," and some are
loosened. Patient has not dared cleanse teeth on that side for
years. There are no tender points upon the face or in the mouth.
Teeth on the left side are fairly clean.
Was ordered solutions of Duquesnel's crystallized aconitia, in
doses of -gV grain, and this was given in increasing doses, with no
relief. On Dec. i8th, following note recurs : Aconitia must be
deemed a failure. Has taken -j^ grain in 24 hours. Constant
great effects on sensory nerves, coldness and tingling. Has pains
almost every two minutes. Fowler's solution ordered in increas-
ing doses after meals. Dec. 30th. Has increased arsenic to 16
drops after each meal ; nausea ; no relief to pain.
Ext. gelsemii fluid, ordered Dec. 30th, gtt. v before each meal,
and at bedtime. Jan. 14 (1879), full effects of gelsemium ob-
tained from doses of gtt. xiv and xv, four times a day. No relief
to pain.
Sol. phosphori Thompson ( 3 i=i:V grain P.), tried in doses of
3 i an hour before each meal for several days ; no effect.
Injections of chloroform in cheek used on Jan. 20th, 21st, and
2 2d. Injections made through mucous membrane, toward right
infra-orbital nerve. Five minims on 20th, ten on 21st, with no
relief ; slight swelling and burning pain. Attempt to inject m. xv
on 22d resulted in asphyxia, and apparent death, previously re-
ported to the committee.
Mixed treatment, iodide of mercury, and saturated solutions of
iodide of potassium ordered on Jan. 23d. On Feb. nth slight
effect on gums is noted ; takes about 40 gtt. of sol. sat. K I. three
times a day ; no relief.
Galvanism, stabile, strong current (25 cell) ; kathode on tender
points from 7 to 15 minutes. Patient thinks pain is aggravated
by the current.
Ammonio-sulphate of copper ordered, .08 with ext. cannabis
ind. 03. before each meal since Feb. nth ; stopped on 15th ; no
relief.
Operation, — Resection of right infra-orbital nerve performed,
Feb'y . . Nerve removed outside and inside orbit. Healed by
primary union.
March 9th. Face perfectly healed ; only part that is absolutely
anaesthetic to faradic current by brush in a spot about 2 cent,
square under right eye. Has partial sensibility to brush, and
pricking in rest of cheek, in ala nasi, and upper lip, and inner
aspect of cheek and mouth. To-day less pain, but he suffered
92 ARCHIVES OF MEDICINE.
very much on 6th, 7th, and yesterday. A paroxysm seen in office
seems less severe than those before operation. Ordered quinia
sulph. .25 ; morphia sulph., .02 three times a day.
March 14th. Much better. Few attacks in supra-maxillary
region. Talking and chewing can be done without agony. Has
had several severe attacks of pain in infra-maxillary region, and
in outer part of orbit ; not in supra-orbital district. Has had good
nights. Continue quinia and morphia.
March 19th. Is fifty per cent, better than before operation
(patient's own estimate).
March 28th. No " neuralgic" pain in right upper jaw and lip,
but the lower jaw and lip are seat of severe neuralgic pains, not
as severe as formerly. Ordered pil. quiniae et morphige et bella-
donnae twice a day. Ordered fluid extract of aconite, gtt. i /. /. d.
March 31st. No neuralgic pain in upper jaw; severe in lower
jaw. Continue aconite.
April 14th. Considers his condition improved at least 50 per
cent. Takes iv or v gtt. aconite, with slight physiological effects.
Sleeps soundly. No severe paroxysms in two weeks.
During May more pain ; severe paroxysms in anaesthetic dis-
trict. Fowler's solution, aconite, morphia again tried in vain.
Was not seen again until Dec. 17, 1880. Was free from ex-
treme suffering for several months. In last few months almost
constant severe pain.
I have since tried aconitia and gelsemium to physiological
effects, without relief.
Dr. Weir is planning to remove Merkel's ganglion.
Case 2. — Mr. H. S., janitor, aged 29 years. History of case
taken October 2, 1878 i^ide a partial report on the case in New
York Medical Record^ Jan. 4, 1879).
Previous to the development of the present affection, he had
been subject to occasional dull headaches. Ten years ago (1868)
he suddenly experienced a very severe sharp pain all through his
head, " as if devils were at work there," lasting half an hour.
There was no dizziness or faintness, or nausea, or impairment of
sight, or paralysis. For a period of six months he remained free
from pain, and, indeed, was perfectly well. After that time,
nearly ten years ago, a " dull, stupid pain " began over the right
eye, extending from the supra-orbital notch inward to the nose,
and down the side of the nose to the ala nasi. This pain was
paroxysmal, and worse in the daytime. Later the pain extended
to the eyeball, and was exceedingly severe, the paroxysms re-
ORIGINAL OBSER VA TIONS. 93
curring from ten to twelve times a day. In the course of two or
three years the pain made its appearance in the right temple —
worse at night.
In the last few years most of the pain has been on the top of
the head, above the temple, and in front of the ear to the bregma.
There has lately been only an occasional pain in the side of the
nose, and not much pain in the temple proper. During the past
summer, and since, there has been some occipital pain on both
sides — more on the right. In the last year there has also been
pain in both the upper and lower jaws, in the upper lip near the
median line ; none in the tongue (on right side). In the last four
years vision has been dim, and glasses have not remedied the de-
fect. Five years ago had temporary diplopia, but this was while
taking some unknown medicine. At various times during this
long illness has had " dizzy spells," with varying frequency ; few
in the last months. Has had no other symptoms of a neuralgic
nature. Memory is impaired and virility quite lost. Had severe
dyspepsia and vomiting three years ago, and has been costive dur-
ing the whole period of the disease.
Examination. — The various painful regions are hyperalgesic,
but not numb, and the tactile sensibility is perfectly preserved on
both sides. There is no facial paralysis ; the right pupil is posi-
tively small, the left normal. After dilatation by atropine the
ophthalmoscope reveals no lesion in the fundus. Hearing, smell,
and taste are normal. Cornea clear. The urine (frequently ex-
amined by other physicians and found normal) is now free from
albumen. Marked anaemia is exhibited by the skin and mucous
membranes ; has always been pale. Denies syphilis.
The pains, which occur frequently in my office, are the most
terrible which I have ever witnessed ; the patient fairly writhing
in his chair, or even falling to the fk)or (not unconscious) in his
agony. During the attack the right eye is much injected, and
tears flow freely from it, while the left eye remains dry.
The patient states that no medicine has ever relieved him, and
that he has tried a great many.
The treatment in this case, though prolonged until now, Feb.,
1881, has been relatively simple.
Duquesnel's aconitia in doses of yj-g- grain. Solutions by Neer-
gard at first, later in the shape of Schieffelin's granules, given
from two to four times a day. Full physiological effects were easily
obtained, and were kept up for many months. Numbness and a
remarkable cold chilly condition were the signs. At times the
94 ARCHIVES OF MEDICINE.
subjective cold was so great that he would come to my office
shivering in an overcoat.
In this case as in Case 3, increased susceptibility to the action
of the drug was observed as time went by. In the last few
months, one dose of y^ grain produces effects which last from
six to nine hours.
Besides aconitia, iron and Fowler's solution in moderate doses
have been administered frequently. Has had several attacks of
subacute rheumatism rapidly cured by sodium salicylate.
On the whole the result obtained is very gratifying — it is a rel-
ative cure.
Patient a few weeks after beginning of treatment ex-
perienced no excruciating paroxysms, and gradually resumed his
occupation as janitor. In last few months seldom loses half a
day. Has kept a record of attacks, classifying them into severe
and mild : has had very few severe ones in each month, and has
registered many days without any pain.
There has occurred a curious shifting of pain. It was formerly
more intense in fronto-temporal region, it is now developed
mostly near the parietal eminence.
The patient's general condition has greatly improved ; he still
has a peculiarly white skin, but his lips, etc., are fairly well
colored.
The change in moral is most remarkable ; is now cheerful and
enjoys both his work and his family pleasures ; whereas about a
year ago he looked upon life as a burden.
Case 3. — Mr. W. L. P., clerk, age 54 years, seen September 22,
1880.
Had always enjoyed good health.
In 1876 there appeared a pain in front of the right temporo-
maxillary articulation ; a deep pain. At first the pain was occa-
sional, excited by washing face. Pain has steadily increased in
frequency and severity, until now paroxysms occur almost every
moment. The pain is rather worse in afternoon and night, not typ-
ically nocturnal. In about a year after beginning the pain ex-
tended to infra-maxillary and infra-orbital nerves (never appear-
ing at mental foramen). It extends into the gums in right upper
and lower jaws, and " strikes " in the lower jaw at a point a little
posterior to the angle of the mouth. No pain above zygoma and
orbit. Saliva flows in the paroxysms. All movements of jaws
cause more pain. Weather is without influence.
No malarial fever since his i6th year. Never had syphilis.
\
ORIGINAL OBSERVATIONS. 95
Used much tobacco until recently. Temperate. Has had seven
teeth pulled from the right upper jaw without relief.
Examination. — No tender point except at the mental foramen,
where there is no pain. No evident anaesthesia. Some atrophy
of fatty tissues of face on the -right side. Opening mouth causes
a paroxysm. Hair on face kept stubby and is worn on cheek by
constant friction of hand and fingers during paroxysms. Attacks
last from one to one and a half minutes. General health good.
The treatment was begun Sept. 22d, by giving Duquesnel's
crystallized aconitia, in the shape of tablets made by Caswell &
Hazard, ^^ grain every two hours.
25th. — No strong aconitia effect. Sleeps without chloral. Or-
dered -g-J-Q grain every hour. To-morrow y^^ grain every two or
three hours,
27th. — Great relief ; did not feel aconitia much, yot every two
hours till 5 P.M., when he was quite numb, and sight was dim.
29th. — Marked improvement ; pain only in zygomatic region.
From the 29th to Oct. i, included, sol. phosphori Thompson was
used, 3 i three times a day. Pain made worse. Again given y^
gr. aconitia.
Oct. 4th. — Severe pain ; no aconitia for one day. Takes sol.
Fowler., gtt. viii after each meal, increasing. Ordered continue
Fowler, and take ext. gelsemii fld. gtt. v every 2 hours. Continue
and increase the Fowler's solution.
loth. — Ext. gelsemii fld. is also being used, but no aconitia.
Takes gtt. viii of gelsemium every three hours with moderate
effect ; double vision at times ; lids heavy. Very little severe
pain ; has lost habit of rubbing cheek in paroxysms ; good
nights.
20th. — Has reached a maximum dose of gtt. xvi Fowler after each
meal. Gelsemium as above. The gelsemium is stopped ; Fowler's
continued, and aconitia, y^ gr., every two hours ordered.
23d. — Very little pain in last forty-eight hours ; feels the aconi-
tia ; attacks slight; pain nearly localized near right temporo-max-
illary articulation ; can eat and talk with little pain.
Iodide of potassium, saturated solution in doses of gtt. xx be-
fore each meal in much water, increased by 5 drops daily, was
begun on 28th. Fowler's abandoned. Aconitia y^ gr./. r. n.
Nov. 3d. — Coryza and hoarseness, neuralgia slight. Takes
gtt. xl. /. /. d. Stop. Cautery on focus of pain in front of ear
tried on 5 th. Pain aggravated.
Ammonio-sulphate of copper was tried during November, De-
g6 A J? CI// FES OF MED/C/NE.
cember, and January (1881), given in pills, dose increased from
.05 /. /. d. after meals, to .20 after each meal and at bedtime.
Aconitia -j^o" was used/, r. n, by patient all the time.
Pain very variable ; a few days almost without pain ; other
days much pain, often under influence of storm or rain. At one
time copper before meals produced griping and watery stools ; no
ill effect when administered after food. .
Dec. nth. — The note is made that patient has become much
more sensitive to aconitia ; is affected in ten minutes by one tab-
let, whereas formerly it required an hour or more to obtain any
prickling.
The whole of January, 1881, was very comfortable.
I St. — No severe paroxysms. Was in Canada part of the time.
Now can use only one or two tablets of aconitia a day — formerly
could take one (y^ gr.) every two or three hours.
Feb. 19th. — In last month gelsemium and aconitia. Much more
pain in last fortnight, though not as much as before treatment.
Pain is severe in spite of full effects of gelsemium, gtt. v every two
hours.
A fair summing up of these att!empts at relief of incurable con-
ditions is, it seems to me, that aconitia is the chief agent to be re-
lied on for the alleviation of the pain of chronic trigeminal neur-
raliga, and for its cure. Of course, malarious and syphilitic neur-
algias are excluded from this statement ; in them we have
special indications.
Gelsemium and arsenic have both seemed to exert a secondary
beneficial influence.
Galvanism, the actual cautery, injections of chloroform, were
useless. Morphia and chloral afforded mere temporary relief.
VOL. VI, No. 2. OCTOBER, .881,
Archives of Medicine.
©rtgitxal ^xticXts.
THE INFLUENCE OF BAROMETRIC CHANGES
UPON THE BODY IN HEALTH
AND DISEASE.
By ANDREW H. SMITH, M.D.,
NEW YORK.
THE effect upon the body, in health and disease, of va-
riations in barometric pressure, is a subject which has
not received the attention from the profession which its im-
portance entitles it to. Beyond some studies of the effect
of altitude upon phthisis and the influence of barometric
changes in determining pulmonary hemorrhage and attacks
of spasmodic asthma, but little discussion seems to have
been excited. Even the introduction of compressed and
rarefied air as therapeutic agents appears to have done very
little to stimulate inquiry as to the part played by the con-
stant natural changes in the density of the atmosphere in
preserving health or inducing disease. Yet these changes
cannot be without their influence, and there is opened here
a wide field, not only for speculation, but for scientific
observation, which may bring important accessions to our
knowledge of the etiology of those affections which ap-
pear in the form of attacks recurring at irregular intervals.
The introduction, within a comparatively few years, of
the use of compressed air in submarine engineering opera-
97
9^ ANDREW H. SMITH.
tions, has given an opportunity for studying, on a large
scale, the effect of a prolonged sojourn in a greatly con-
densed atmosphere, and of the subsequent removal of
the pressure. The facts observed are very suggestive, and
point unmistakably to a disturbance of the normal dis-
tribution of the blood with each change in the pressure
of the atmosphere.
As the result of exposure for several hours to a pres-
sure of two or three atmospheres, there may be devel-
oped a group of morbid phenomena to which the writer,
in an essay published some years ago,^ attached the name
of the Caisson Disease. The definition of this disease is
as follows :
A disease, sometimes fatal, depending upon increased at-
mospheric pressure, but always developed after the pressure is
removed. It is characterized by extreme pain in one or more
of the extremities, and sometimes hi the trunk, which may or
may not be associated with epigastric pain and vomiting. In
some cases the pain is accompanied by paralysis more or less
complete, which may be general or local, but is most frequently
confined to the lower half of the body. Cerebral symptoms,
such as headache, vertigo, and coma, are sometimes present.
The above symptoms are connected, at least in the fatal cases,
with congestion of the brain and spinal cord, often resulting
in serous or sanguineous effusion, and with congestion of most
of the abdominal viscera.
That such decided results, including even death, may be
brought about by extreme changes of atmospheric pressure,
certainly leaves room for the surmise, that slighter changes,
occurring from natural causes, may produce, at least, propor-
tionate effects. I think that the essay already referred to,
contained the first suggestion, that this might be the expla-
nation of the neuralgic pains which many persons complain
^ Essay on the effects of high atmospheric pressure, including the caisson
disease. Published by the East River Bridge Company, 1873.
THE INFLUENCE OF BAROMETRIC CHANGES. 99
of at the approach of a storm, and which are generally as-
cribed to the moisture in the atmosphere.
A study of the mechanism, by which the congestions ob-
served in the caisson disease are produced, will serve to il-
lustrate the action upon the system of the comparatively
trivial changes of the barometer, just as the effect of drugs,
taken in excessive or poisonous quantities, may throw light
upon their action in medicinal doses.
It is obvious, that, if the blood were exposed to an equal
pressure in all parts of the body, there would be no change in
its distribution. It is equally clear, that the blood, if free to
move, will pass from a place where the pressure is greater
to one where it is less. The body is made up of structures
of different densities, which present a varying resistance to
compression. But, permeating these structures in every
direction, are vessels in perfect communication throughout
the entire system, and filled with a mobile fluid which is
free to change its locality in obedience to any force which
is brought to act upon it. Now, when the surface of the
body is subjected to an even pressure on all sides, the ten-
dency is to a distribution of this pressure toward the centre.
If the body were composed entirely of solids, this could be
effected only by the compression of those solids, and a point
: would Very soon be reached, where the resistance would
^B balance the compressing force, and the parts lying more
^H toward the centre would remain unaffected. But the pres-
^H ence of a fluid in the structures, with free channels in which
^H to move, changes all this. While the solid tissue resists
^H compression, the fluid blood retreats from the surface to the
^K centre, and accumulates there, until an equilibrium of pres-
^H^bure is produced.
I^^^B Hence, we deduce the law, that under high atmospheric
^^^^^ressure, the centres will be congested at the expense of the
periphery.
100 ANDREW H. SMITH.
But, aside from location, vessels coursing through dense
and resisting organs, will be less exposed to external pres-
sure than those passing through soft and yielding structures.
Hence, a second law, that firm and compact structures will
be congested at the expense of those more compressible.
But there are structures, very soft and yielding in them-
selves, yet enveloped in a rigid casing of bone which entirely
shuts off the influence of external pressure. Hence, the
establishment of the equilibrium in them is wholly depend-
ent upon an afflux of blood. This gives us the third law,
that structures within closed bony cavities are congested at
the expense of all others.
In accordance with these laws, we shall find, that, while in
the caisson, the condition of the different parts in regard to
the supply of blood will be as follows :
The skin and the superficial structures will be anaemic'
The central portion of the limbs and the interior organs of
the body will be congested. The solid viscera of the abdo-
men will be especially engorged, on account of both situa-
tion and structure. The brain and spinal cord and the in-
terior of the shaft of the long bones, will be congested to a
high degree from the operation of the third law.
These changes are not perfected until a considerable time
has been passed in the compressed air. The circulation, up
to this point, goes on everywhere with vigor, the change
being in the relative calibre of the vessels, not in their ten-
sion. The counter-pressure becomes uniform throughout
the whole vascular system, but this counter-pressure super-
sedes the natural muscular resistance or tone of the vessels,
which have become passive tubes. The blood is distributed,
not in accordance with the physiological demands of the
different parts, but in obedience to overpowering physical
force.
^ This is shown by the pallor which is very characteristic.
THE INFLUENCE OF BAROMETRIC CHANGES. 10 1
This is the condition of the circulation at the moment
that the process of locking out begins. Yet the changes
which have taken place up to this point are not the cause of
the morbid phenomena which constitute the caisson dis-
ease, else the attack would take place while in the com-
pressed air, instead of after leaving it. It is evident that
the removal of the pressure, ■dLX\di not the pressure itself, is the
immediate cause of the seizure.
This removal is effected in the few minutes which are
occupied in locking out.^ But it is not to be supposed that
the vessels will instantly assume their normal condition.
They are in a state of relaxation, not only in the congested,
but also in the anaemic parts ; in the former, because of
over-distension ; in the latter, because the muscular coat
cannot at once recover from its inaction. The aggregate
capacity of the vascular system will, therefore, be in excess,
compared to the volume of blood to be conveyed ; or, in
other words, there will be a lowering of vascular tension.
Hence, the circulation will be languid, and the congested
parts will not readily empty themselves of the excess of
blood which they contain. Especially will this be the case
in the brain and spinal cord, where the conditions are most
favorable for the production of congestion. The capillaries
being clogged with effete blood, the nutrition of the part
must suffer, and disturbance of function will result.
It is to this, I think, that the delirium and the transient
loss of consciousness, which occasionally occur, are to be
attributed. When the spinal cord is the seat of this condi-
tion, pain in the parts deriving their nerves from that sec-
tion of the cord may result, or paralysis, more or less com-
plete, may follow.
This appears to me to account for the phenomena in
those cases, in which the local symptom is paralysis, or pain
^ I. e., passing from the caisson into the open air, through the air-lock.
102 ANDREW H. SMITH.
of a transient or shifting character. These cases may, I
think, be considered as entirely spinal in their origin. But,
in many cases, there are evident local changes, such as tume-
faction, rise of temperature, etc., which indicate local irrita-
tion, and which are probably due to obstruction of the
vessels of the part as a sequel to the local congestion. This
explanation is applicable also to those cases, in which the
pain is fixed in one locality, which may be very much cir-
cumscribed, and where it persists for days without intermis-
sion, feeling, as the patient expresses it, " as if it were in the
bone," where it very likely is. Such a pain presents a
marked contrast to those shifting pains which have been
described, and, if considered of spinal origin, would indicate
a serious lesion confined to a minute portion of the cord.
That such a circumscribed lesion might occur as a very rare
exception, must be admitted ; but that it should be present
in a considerable proportion of cases, is, in the last degree,
improbable.
The testimony of all observers is, that the liability to
attack is directly as the duration of the stay in the caisson.
This admits of an easy explanation on the theory which I
have advanced. The more thoroughly the system has
become adapted to the change in the circulation, the less
readily it will resume its normal condition, when the pres-
sure is removed. The congested vessels, especially, will lose
their contractility in proportion to the time their muscular
fibres have been upon the stretch.
Now it is evident that the changes in the circulation
which take place in the caisson must occur, to some extent,
whenever there is a rise of the barometer, and, conversely,
that a fall of the mercury must result in changes similar
in kind, however slight in degree, to those attending a
change from the caisson into the open air. But it
may be argued, that the phenomena of the caisson disease
THE INFLUENCE OF BAROMETRIC CHANGES. IO3
require a change of pressure so enormously disproportioned
to any changes occurring from natural causes, that it would,
be absurd to reason from one to the other. But the fact is,
that observation of the effects of high pressure reveals a
difference in the susceptibility of different persons to its
influence which would not, a priori^ have been expected,
and which becomes a prime factor in calculating the effect
of minor degrees of condensation of the atmosphere.
Of the men employed under my observation in the cais-
sons of the East River Bridge, a large proportion bore the
excessive pressure (reaching at last to 36 lbs. additional
to the square inch) without the slightest ill effect ; while,
on the other hand, some quite severe cases resulted from a
very short exposure to the slight pressure employed in the
early part of the work. For instance, a student of engi-
neering visited the Brooklyn caisson, where the pressure did
not exceed 15 lbs., and, after a very brief stay, was seized,
on coming into the open air, with temporary paralysis.
That a short exposure to a pressure of 15 lbs. should par-
alyze one man, while another was able to bear, day after
day, without inconvenience, a pressure of 36, or even, as at
St. Louis, of 50 lbs., is to be accounted for only by assum-
ing a vast difference in susceptibility, the limits of which
difference in either direction can only be surmised. Back
of this there is probably a difference in the efficiency of the
vaso-motor system, or, perhaps, in the structure of the ves-
sels themselves, so that, in one case, the vessels resume, at
once, their normal condition, when the pressure is re-
moved, while in the other, the abnormal distribution of the
blood persists in certain localities.
Whatever the predisposing condition may be in this lat-
ter class of cases, we have only to assume its existence in
an exaggerated degree, to bring the subject within the
range of the influence of ordinary barometric changes. If
104 ' ANDREW H. SMITH.
one man can bear a change of 90 inches without feeling it,
while another is paralyzed by a change of 30 inches, it is
not incredible, that a third may have aching limbs as the
result of a fall of 2 inches.
In point of fact we know, that there are many persons
who can foretell, by their sensations, the approach of a
storm, and who are in the habit of saying, " We shall have
rain to-morrow ; I feel the dampness in my bones." Now
the proof, that the moisture in the atmosphere is not the
cause of their suffering is found in the fact, that a
sudden shower may saturate the earth and fill the air with
dampness, without causing them to complain, nor do they
feel any ill effect from exposure to the falling dew. But,
whenever the glass goes down, though the air may not be
sensibly damp, they experience more or less discomfort.
In such persons the action, as before suggested, is probably
similar to that observed in a greatly intensified degree in
the caisson disease. The change from a higher to a lower
degree of atmospheric pressure disturbs the circulation in
a way to affect certain nerve cells or nerve fibres ; the in-
dividual having a strong natural or acquired predispo-
sition, a " neuralgic habit," which needs but the slightest
cause to develop a greatly disproportioned effect.
This predisposition, or habit, may consist simply in the
existence along a nerve, or at its origin, of a point, at which
the capillaries are, for some reason, more than usually dis-
tensible. Such a condition of the cutaneous capillaries is
seen sometimes in children who have a mother's mark that
has so faded as to be imperceptible, except when the child
cries, when it becomes plainly visible. Some cicatrices, also,
present the same conditions, a key, perhaps, to the neural-
gias following gunshot wounds, which are especially prone
to be affected by changes of weather.
A curious fact, however, in regard to the terrific pains of
THE INFLUENCE OF BAROMETRIC CHANGES. 10$
the caisson disease is, that they are often not felt, until sev-
eral hours after coming into the open air. In these cases, it
is probable, that the area of capillary obstruction does not,
at first, include a centre of pain, but that it widens, as all
capillary disturbance is disposed to do, until such a centre
is reached.
This delay in the development of neuralgia from lessen-
ing of pressure, would tend to obscure the study of cases in
connection with barometric changes,' the pain, perhaps,
coinciding in point of time with a rise, though caused in re-
ality by a fall, of the barometer.
No one can have failed to remark the difference which we
feel in our mental and bodily efficiency in different states of
the weather. On clear, bright days the brain is active, the
muscles vigorous, and the internal organs appear to work
smoothly. On damp and foggy days, on the contrary, mental
effort is irksome, the limbs drag, the appetite is less, the di-
gestion slower, and the whole tone of the system is lowered.
This difference may be explained, at least in part, on the
principle under discussion. When the air is clear, the bar-
ometer is usually high, and the greater pressure upon the
surface drives the blood to the interior of the body, and es-
pecially to the organs in closed cavities — such as the brain,
and to solid and dense organs — such as the liver and kid-
neys, thus stimulating their functions. At the same time,
the pressure assists the muscular tone of the vessels in di-
minishing the total vascular area, and thus insuring celerity
of the blood current everywhere. But when the pressure
falls, as it does in damp weather, the peripheral vessels, de-
prived of a part of their support, yield to distention, and
there is a transfer of blood to them from the more central
organs, and, at the same time, a general slowing of the cir-
culation, all resulting in lessened vital energy.
^ For a very interesting study of this kind, see a case reported by Dr. Weir
Mitchell, Am. Jour, of Med. Sci., Jan., 1877.
1 06 A NDRE W H. SMITH.
How much these changes have to do with initiating dis-
ease, is a question which opens a wide field for conjecture.
That increased pressure on the surface might be sufficient
to determine the rupture of a miliary aneurism in the brain,
is easily conceivable. That diminished pressure might con-
cur with other causes in bringing about internal congestions
and inflammations, is at least probable ; and that the low-
ered vital tone from a sudden fall of the barometer may
render the system an easier prey to other causes of disease,
is a justifiable inference.
There are many forms of disease that recur at irregular
periods in persons susceptible to them, the subject being, in
the intervals, apparently in perfect health. There are, evi-
dently, in these cases a predisposing cause, which is per-
manent, and an exciting cause, which is transient. The
former is inherent in the individual ; the latter is some
influence operating from without. Neither is capable
alone of producing an attack, their joint action being
required.
The predisposing cause, for the most part, eludes our
observation. The exciting cause is often sufficiently
apparent and may be error in diet, exposure to cold,
over-fatigue, mental excitement, etc. But sometimes the
strictest inquiry fails to elicit the cause, although some
must have existed. That some, at least, of these cases
are attributable to such disturbances of the circulation
as have been mentioned as depending upon change
of atmospheric pressure, appears to me to be more than
likely.
At this time, when the state of the barometer at any
given hour is a matter of permanent record, accessible to
all, it would not be difficult, especially in hospitals, to
compare notes of cases with barometric tables, and re-
sults of great scientific value might be obtained.
A STUDY OF THE PHYSIOLOGICAL AND TOXIC
EFFECTS OF GLYCERINE IN
LOWER ANIMALS.
By R. W. AMIDON, M. D.,
ASSISTANT PHYSICIAN TO THE MANHATTAN EYE AND EAR HOSPITAL, NERVOUS DEPARTMENT.
WHILE studying the effects of arnicine in the frog
during the last summer, at the Physiological La-
boratory of Dr. Ott, at Easton, Pa., it was noticed that no
preparation of the drug had much effect except a solution
in glycerine. This solution produced such striking and
constant symptoms that a suspicion was aroused that they
were due to the glycerine and not to the arnicine, and a
few experiments confirmed this view. The fact that gly-
cerine so often enters into solutions of drugs physiologi-
cally studied, and that it might in this way mislead the
experimenter, led to a detailed study of its effects on
frogs and rabbits, the results of which are given herewith.
Many of the experiments were conducted by Dr. Ott him-
self.
The general effect in frogs is as follows : If from three
to ten drops of glycerine are given hypodermically, pure or
diluted, to a frog, the first effect is, of course, the ordinary
contortion elicited by the local action of the drug on the
sensory nerves.
In from five to fifteen minutes, however, it will be noticed
that the frog, if induced to jump, will sprawl a good deal,
107
I08 R. W. A MID ON.
and seems to have rather hard work to retract his hind legs.
This, it will be seen, is due not to a paresis of the legs, but
to a stiff condition of the same From this time forward
very frequent fibrillary contractions will be noticed in all
the voluntary muscles. Soon, if the animal be carefully ex-
amined, it will be noted that the lightest pressure of a
muscle will throw it into a momentary tetanic spasm, while
irritation of a purely sensory part, as the toe, will cause
attempts at ordinary reflex action. Generally in the course
of one half an hour, or sooner if the dose be large, the frog
will be thrown into a general tetanus, the fore legs adducted
and crossed over the chest, the hind legs rigidly extended.
Now the muscular hyper-excitability will be very marked.
Light pressure will throw the irritated muscle into a violent
tetanic spasm, so that the limbs may be made to assume
temporarily any attitude desired, the original attitude be-
ing assumed after the irritation is stopped.
Painful impressions on a sensory part will cause an evi-
dent endeavor on the part of the animal to shrink and draw
himself away, a thing which is of course impossible on ac-
count of his extreme rigidity. There are indubitable signs
of pain, however. The tet^anic state invades all voluntary
muscles, respiration ceases, while the circulation continues
for some time, the heart finally stopping in an apparent
diastole; the auricle fluttering for along time after ven-
tricular contractions cease. The tetanic condition does not
relax with death, but passes uninterruptedly into an extreme
rigor mortis.
Given in larger doses by a vein or under the skin of a
rabbit, a somewhat similar but not identical train of symp-
toms follows.
Two or three hours after the administration of from six-
teen to thirty cubic centimetres under the skin, and sooner
after a larger dose, a rabbit begins to appear weak, his legs
PHYSIOLOGICAL AND TOXIC EFFECTS OF GLYCERINE. IO9
slide out from under him, and he sinks down apparently
from sheer exhaustion.
The heart becomes weak and irregular, the respiration
superficial, the head becomes tremulous and droops, fibril-
lary twitchings are seen in the head and all four extremities,
and finally a general clonic spasm runs through the animal,
respiration ceases, while the heart continues to beat feebly
for some minutes longer.
One to five cubic centimetres introduced into a vein
cause a rather sudden stoppage of both respiration and cir-
culation, preceded by a general shudder. The exalted mus-
cular excitability seen in the frog is not as marked in the
rabbit, and the tetanic condition is not seen. Haematuria
follows both modes of administration of the drug provided
the animal does not die suddenly.
Experiments with the mercurial kymograph of Ludwig
showed that, in the rabbit, the intravenous injection of one
to two cubic centimetres of glycerine caused immediately a
rise, followed by a fall of blood pressure, accompanied by
diminished force, increased frequency, and irregularity of
the cardiac contractions.
If the dose given were small, the circulation would seem
FIG. I.
Curve showing immediate rise in blood pressure.
no
R. W, AMIDON.
FIG. 2.
Curves showing changes in blood pressure.
PULSE. PRESSURE.
a. Immediately before first experiment .... 210 104 mm.
b. One minute after injection of glycerine . . . 264 92 "
c. Two minutes after injection ...... 222 90 "
Curves shovi'ing changes in blood pressure.
PULSE
Before second experiment
a. One minute after glycerine injection .... 282
b. TyNo minutes after ....... 204
c. Four minutes after a second injection given at the seven-
teenth minute .... ... 246
PRESSURE.
104 mm.
94 "
96 "
84 "
to recover a perfect equilibrium in a short time (quarter of
an hour to one hour), while if a large dose (two cubic
PHYSIOLOGICAL AND TOXIC EFFECTS OF GL YCERINE. 1 1 1
centimetres) were given, the blood pressure would rapidly
fall, the pulse become rapid, feeble, and finally extinguished,
and the animal would die, seemingly of cardiac paralysis.
To demonstrate that the effect of the glycerine was pe-
ripheral and not central, an experiment was performed, the
results of which are given below, and which show similar
but modified results to former ones. The medulla ob-
longata and the cardiac nerves on both sides of the neck of
a large rabbit were exposed, and when the connection with
the kymograph was established as usual, both the medulla
and the cervical cardiac nerves were cut.
TIME.
PULSE.
PRESSURE.
SECONDS.
RATE PER MINUTE.
MM. OF MERCURY.
I St
240
32
15 th
220
injected 1.3 glycerine.
32.
39th
240
32
40th
indistinguishable
34
4TSt
32
42d
30
43CI
"
26
46th
20
47th
19
48th
18
50th
16
62d
14
To ascertain whether glycerine stops the heart by irritat-
ing the peripheral pneumogastric, or by direct action on the
heart substance itself, the peripheral pneumogastric was
paralyzed by the administration of atropia, and then glycer-
ine was given, with about the same results as before, thus
showing that very likely the circulatory changes are due to
direct action of the glycerine on the heart. If now in this
atropinized and glycerine-poisoned animal the sciatic nerve
be severely excited by a strong faradic current, a sudden
112
R. W. AM WON.
and large rise of blood pressure will ensue, showing both
that the centripetal paths are open, that the vaso-motor
centre is intact, and that its centrifugal fibres conduct im-
pressions.
The accompanying curves show the effect of glycerine on
the respiratory function of the rabbit. An experiment
where the vagi were previously cut showed no peculiarity
over the other except that the effects of the drug were for
some reason delayed. The respiration is at first made
slow and more shallow, and later, before death, is distin-
guished by deep respiratory movements and a long respira-
tory pause. The gradual failure of respiration is synchro-
nous with the failure of the heart, and is undoubtedly due
•to the same cause.
FIG. 4.
Respiratory curves in rabbit poisoned by glycerine, a, before injection ;
one minute after ; c, four minutes after, just before death.
The general symptoms in the frog have been narrated.
It remained to ascertain on what part of the nervo-muscular
apparatus the drug exerts its power. The following is a
r^sum^j in as few words as possible, of the experiments per-
formed to arrive at a decision on that point : A frog already
tetanized with glycerine will remain so if his whole central
nervous system, brain, medulla, and cord, be destroyed. A
frog whose brain has been cut off before the administration
PHYSIOLOGICAL AND TOXIC EFFECTS OF GLYCERINE. II3
of the drug will become tetanic. If the medulla be cut off
the same result will follow, only more slowly, because of
the sluggish circulation. Again, section of the nerves lead-
FIG. 5.
Respiratory curves in rabbit with vagi cut, and poisoned with glycerine, a,
after section before glycerine ; b, ten minutes after ; c, twenty minutes after,
just before death.
FIG. 6.
Traces of muscular contraction taken with Marey's myograph, a,
kA normal muscle ; b, the curve of a muscle poisoned by glycerine ;
tuning-fork vibrating at the rate of 60 vibrations per second.
the curve
c, trace of
114 >^. fV. AMIDON.
ing to the limbs has no effect on the spasm. By cutting
off the blood supply to any part, either by ligating the ab-
domen, leaving the cord intact, or by ligating all of a limb,
except the nerve, it is found that no tetanus ensues in the
protected part. This narrows down the field to either the
motor-nerve termini or the muscular substance itself. Gly-
cerine given after or with curare produced the tetanic symp-
toms, thus showing that, without doubt, glycerine attacks
the muscular fibre itself.
There are appended myographic tracings of the muscles
from healthy frogs and of muscles from frogs poisoned by
glycerine, the curves of which exhibit the most marked dif-
ferences.
In the case of the healthy muscle it will be noticed that
the contraction is of very brief duration, occupying only
from one thirtieth to one twenty-fourth of a second, while
in the tetanized muscle the contraction lasts from one half
to three quarters of a second.
If the brain of a frog be removed, it will be found by the
sulphuric acid test that glycerine diminishes the reflex irri-
tability. If, then, the medulla be cut off, reflex action be-
comes exaggerated, showing that the former depression of
reflex irritability is due to an excitation of the centres of
Setschenow in the medulla oblongata.
It is thus seen that glycerine, particularly in the frog, has
physiological effects which should lead to its abandonment
as a solvent or diluent of other drugs in physiological ex-
periments.
[
LACERATION OF THE CERVIX UTERI.
By H. J. GARRIGUES, M.D.,
NEW YORK.
DR. EMMET has called special attention to a cicatri-
cial plug often formed in the angles of a lacerated
cervix, and to the importance of its removal.' A short time
ago the doctor brought me two bodies which he had re-
moved from such a case, digging them out like bullets em-
bedded in flesh, and requested me to examine them, as no
description of this tissue had been published hitherto.
These bodies were of irregular, roundish shape. The
largest measured 1 1 by 9 millimetres, the smallest 9 by 7
millimetres. They were of slightly yellow-red color, trans-
lucent (they had been put in a mixtnre of glycerine, alco-
hol, and water), and composed of a dense elastic tissue.
The larger of them was hardened in a solution of chro-
mic acid, and cut perpendicularly to the surface. The sec-
tions, stained with carmine showed an epithelial layer, a mu-
cous membrane, and a cicatricial tissue.
The epithelium is very thick and composed of two zones.
The upper zone, corresponding with the stratum corneum of
the epidermis, is composed of large flat cells, each with a
nucleus, with the exception of a few of the most superficial
which have become quite flat and horny, but, as a rule, even
" Emmet, Principles arid Practice of Gynecology, 2d edition, 1880, p. 473.
115
Il6 H. y. GARRIGUES.
the superficial cells are rather thick and provided with a
central nucleus. Seen in front view they are rhomboid or
multangular, with fine indentations in the edge. Seen in
side view they appear spindle-shaped, being thick in the
middle and tapering toward both ends. They are arranged
in such a way as to cover one another with one half of their
length. I can count as much as twenty such rows of cells
one below the other.
The lower zone, corresponding with the rete Malpighii of
the epidermis, is only one fourth as thick as the horny zone,
and composed of much smaller cuboidal cells, gradually
changing shape so as to become like those in the upper
zone. In the very deepest layer the cells are even a little
columnar, /. ^., longer than wide.
In this epithelium are seen deep, narrow bays taken up
by prolongation from the underlying layer. They extend
sometimes into the horny layer, but are always covered all
over with a layer of the mucous stratum.
Under the epithelium is seen a mucous, or dermal layer
with papillae. The chief direction of the fibres of the con-
nective tissue is parallel to the surface. The upper part con-
tains some small round cells, which especially are found in
large number in the papillae. In the deeper parts the cells
become more scarce.
This dermal layer changes imperceptibly into a cicatri-
cial tissue composed of dense connective tissue, with bundles
going in all directions. In this tissue are found quite a
number of arteries and veins, but neither nerves nor muscle
fibres.
This examination, then, proves that there really exists a
" cicatricial plug," but that it is covered by the mucous
membrane and epithelium of the portio vaginalis, which has
grown over it from the torn edges.
I had hoped to find nerves embedded in this tissue, which
LACERATION OF THE CERVIX UTERI. HJ
would have explained the singular nervous disturbances so
commonly observed in patients suffering from laceration of
the cervix. I have myself observed a very marked instance
of this kind. The patient was a highly cultivated French
lady, with an extremely developed nervous system. After
having spent most of her life in easy circumstances, she lost
her fortune and became a widow, obliged to make a living
as a teacher. She would certainly not have gone through
all the troubles and expenses of an operation if she could
have avoided it, but she suffered so much pelvic pain that
she could scarcely walk. She had constantly the harassing
feeling that her nails were being torn from her fingers, and
she saw herself surrounded by wild beasts with open
mouths. From the very moment of the operation these
latter sensations and delusions stopped, and after some
months she was perfectly able to attend to her business,
which entails a good deal of walking on her. It is now
almost a year since I operated upon her, and she continues
well.
But since the plug, as stated, did not contain any nerve
twigs, the cicatrix must influence the nerves in a more in-
direct way, probably by the pressure on the underlying
nerve-ends produced by the contracting cicatricial tissue.
I will seize this opportunity to add a few words about the
obstetric indication for hystero-tracheloraphy, or Emmet's
operation for lacerated cervix. The indications so far
pointed out are all gynecological, such as leucorrhcea, neu-
ralgia, anaemia, and the danger of carcinomatous degenera-
tion. In watching recently a case of tedious labor, it struck
me that the obstetric side of the question had been over-
looked. It was a tripara. At my very first examination I
found a thick, double-lacerated cervix. The pains were
good, but this dense inflamed tissue opposed a great resist-
ance to dilatation. In spite of a constant use of the hot
Il8 H, J. GARRIGUES.
douche, chloral, and Barnes' dilators, it took twelve hours
to get this hard, unyielding cedematous neck sufficiently-
opened to let the head pass, and even then it was only with
the forceps that I could deliver the lady from the fearful
suffering due to the pressure against an inflamed cervix.
The child was yet entirely in the uterus, the anterior lip
formed a finger-thick cushion, which prevented the head
from passing the pubic arch, while the whole uterus was so
far down that during tractions and after delivery the anterior
lip was visible in the vulva.
Such cases ought to be operated on before another preg-
nancy supervenes. Cicatricial tissue is cut away, a new
vitality is imparted, during the healing process hyperplasia
is subdued, and the restoration of the normal relations of
the parts allows a free circulation to go on. Thus the cer-
vix becomes fit to play its part in the next confinement, so
as not to disturb an otherwise natural labor.
A few years ago I treated a young lady who had a double
laceration dating from her early confinement. Before she
came under my treatment she had been treated for months
and then sent to Europe on account of her constant ailing.
After having replaced a retroflected uterus, and kept it in
position by aid of a Peaslee's flexible pessary, and treated
her leucorrhoea in vain during four months with hot water
injections and astringent applications, I performed hystero-
tracheloraphy with perfect success.
The leucorrhoea stopped, the backache of which she had
suffered for years was gone. I advised her to renew her
marital relations, which had been entirely interrupted for
years on account of her health. She conceived immedi-
ately, bore a child without the least trouble, nursed it her-
self, and was, in fact, restored to health and enjoyment of
life.
These two cases, I think, illustrate the obstetric side of
LACERATION OF THE CERVIX UTERI. II9
the question ; and show, on one hand, how a lacerated cervix
may be a serious impediment to labor, and, on the other,
how a cervix which has been restored by Emmet's opera-
tion, performs its function naturally during labor, and even
may come through this ordeal without sustaining new
injury.
THE PROPHYLAXIS OF INSANITY.*
By MARY PUTNAM JACOBI, M. D.
A TERRIFIED popular imagination still pictures in-
sanity as some mysterious and monstrous incubus,
coming from distant regions of darkness to crush out human
reason. In reality, however, insanity means a complex
multitude of morbid states, varying indefinitely in form
and intensity, but all cornposed of elements which preexist
in health. This fact affords a basis for prophylaxis, for it
indicates the possibility of detecting these elements and,
to a certain extent, of anticipating their morbid combina-
tions.
There are as many degrees in the soundness of men's
minds as in the soundness of their digestions. Study of
the organism of the family, sometimes in several genera-
tions, often serves to detect flaws in the individual organi-
zation otherwise too minute for notice. It is to the family
organism that especially applies the doctrin'e of the blend-
ing of apparently opposite elements, — as genius and in-
sanity, both springing from an unstable equilibrium of the
nervous system. These elements sometimes, though rarely,
blend in the same person. But far more frequently it is in-
heritance from the undeveloped side of an organization of
genius which results in an organization of imbecility.
* A portion of a paper read before the American Social Science Association,
at Saratoga, Wednesday, September 7, 1881.
THE PROPHYLAXIS OF INSANITY, 121
The original organization gives the physical substratum ;
upon this the succession of psychic processes, which begin
with the dawn of consciousness, builds up the mental indi-
viduality. Ideas, feelings, volitions, enter liberally into the
structure of the mind, — are the constituent elements of
which this has been built up. Permit me to quote the
description given by the celebrated Griesinger :
" Self-consciousness, — the Ego, — " he says, '' is an ab-
straction in which are contained, closely welded together^
residue of all the sensibilities, thoughts, and volitions which
the individual has ever experienced.
u * * * These are gradually aggregated into complex
masses of conceptions, varying in density and resistance^
according to the internal cohesion of their elements.
* * * The character of the individual varies with their
relative predominance ; their constant struggle with one
another constitutes the internal conflict which is essential to
normal mental existence.
" * * * The development of insane delusions follows
the same laws as that of healthy ideas. New sensibilities,
volitions, and conceptions present themselves to the pre-
existing conception-masses, are at first repelled by these,,
gradually penetrate them, and if the cohesiveness of the
latter be weak or weakened, assimilate to them until the
Ego is transformed or completely falsified. In this process
the previous composition of the Ego is seen to be of immense
importance. A weak (loosely knit) nature will, much earlier
than a strong one, be overborne by anomalous concep-
tions." '
Thus, at any given moment, the mental organism con-
sists not only of its physical substratum, but of that and
of the long series of psychic processes which have been
built up on it. It is a fundamental law of all organized
^ "Pathologic und Therapie der Psychischen Krankheiten," 1867.
122 MARY PUTNAM JACOBI.
tissues, and most conspicuously illustrated in the brain, that
function not only depends upon structure, but ends by
modifying it. Hence, morbid modifications of psychic pro-
cesses may be initiated either in them or in the physical
substratum. This is equivalent to the previous assertion
that insanity may be determined either by a psychic or a
somatic cause, but generally requires the concurrence of
both.
In the existing professional and popular reaction against
the old puerilities of the exclusively moral theory of insan-
ity, these facts are often overlooked or misunderstood.
The question of prophylaxis has become narrowed down to
the question of prophylaxis in marriage. This is not
only much too narrow, and the social difficulties in the way
very great, but the rules for practice have been by no
means worked out, and many of those which have been
suggested are erroneous or superficial.
. The fact that the previous constitution of the mental
conception-masses modifies the process of their falsifica-
tion under the influence of mental disease, should sug-
gest an effort to so build up this constitution that it
may be fitted to resist strain. For the formation of the
conception-masses is far from being a spontaneous or self-
directed process. No ideas can enter the forming mind ex-
cept from without, from communication with its fellows,
or from the transformation of sense impressions. It is
therefore largely in our power to determine the nature of
the ideas of any child who is thoroughly guarded from his
cradle. Again, the will develops in the mould it makes for
itself by successive volitions; these may to a considerable
extent be commanded or contrived. It follows that, hand
in hand with prophylactic treatment of the physical sub-
stratum of the inherited nervous organization, should go
strenuous educational prophylaxis of the psychic processes.
THE PROPHYLAXIS OF INSANITY. 1 23
But there is needed a far-sighted, comprehensive, minute
education, which should begin with the dawn of con-
sciousness, and extend, if possible, through life. It should
have a detailed objective or reason for each step in the
elementary lesions of the disease which menaces the per-
son, or in the elementary defects of his menaced constitu-
tion.
To assert that moral prophylaxis is useless because in-
sanity is merely a symptom of physical disease, is to con-
tradict the facts of the double nature and double origin of
the psychoses which are admitted by the best authorities.
Educational prophylaxis could only be expected to contrib-
ute one factor toward the solution of the problem ; but it
is one, and all the more worth considering, because at pres-
ent it is so generally neglected.
A more plausible objection is that the moral substratum
of minds predisposed to insanity is peculiarly perverted, so
that they are insusceptible of education. That it is pre-
cisely this insusceptibility which especially manifests their
predisposition.
Finally, it may be alleged that the traits of character
which exist in a person before an attack of insanity, can
offer no guide for treatment, because in the attack these
are all reversed.
This last objection is met by the answer that the
prophylaxis of mental, as of somatic diseases, is to be di-
rected, not to the symptoms of the malady, but to the con-
stitutional defects which facilitate its invasion, and to the
circumstances of the surrounding medium which become
the occasioning cause. Thus, it is known that under a
great weight of responsibility a cheerful-tempered, but
feeble-willed person may break down into melancholia.
The prophylactic training should therefore be directed, not
toward making such a person cheerful, but toward inuring
124 MARY PUTNAM JACOB I.
him, by gradual practice, to bear responsibility. And so
for other analogous cases.
The ideal prophylaxis implies that in neuropathic families
the entire life of each child, its physical and moral training,,
and every detail of its social surroundings, should be
planned with a view to avert mental disease. According
to the degree of predisposition, this is liable to occur spon-
taneously at ordinary physiological crises, as puberty, men-
struation, pregnancy, parturition, lactation, the climacteric ;
or only under the influence of external causes. In the lat-
ter case, the far-sighted disposition of the social medium of
a predisposed person* may often avert an attack of insanity
by averting the cause.
It is evident that the far-sighted and self-controlled guar-
dianship required should be entrusted to a person not shar-
ing the family constitution ; to the parent who may be ex-
empt, or, if both are affected, to a person who is not a
relative at all. For the present purpose only a word is
needed in regard to the main details of physical pro-
phylaxis.
They are : abundance of nitrogenous food ; daily cold
bathing ; pure air ; daily exercise in it, especially by means
of cultivation of the ground, the cardinal employment for
the body and mind of neurotics.
A fifth point of great importance is rest ; equally so for
an immediately threatened attack, and in the life-long man-
agement of susceptible persons. For them over-exhaustion
and fatigue are always to be dreaded, and to these they are
particularly prone, from the extremely deficient power of
resistance of their nervous system. It is worth noticing that
it is neuropathic families more than any others who are lia-
ble to neglect the foregoing precautions.
For effective moral prophylaxis, it is desirable that a cer-
tain amount of information be popularly diffused, to facili-
THE PROPHYLAXIS OF INSANITY. 1 25
tate the awakening of domestic solicitude, the recognition
of incipient insanity, and of the slighter but significant
marks of the insane temperament. This may prove as use-
ful as it has already done in regard to scrofula, rhachitis,
tuberculosis, and other constitutional diseases.
KrafTt-Ebing ranks severe and congenital hysteria with
the psychic degenerations, and shows it to be the forerunner
of much real insanity.' Knowledge of this fact might do
much to check the capricious and vacillating treatment to
which youthful hysterical patients are generally subjected.
On the other hand, in the permanent prophylaxis for adult
life, which must so largely be committed to the patient, it
is extremely useful to be aware of the relative benignity of
the very forms of insanity which usually excite the most
alarm. Acute melancholia, mania, and primary dementia
are classed with the functional disorders or psycho-neuroses,
tending, under favorable circumstances, to spontaneous re-
covery. This knowledge might help to avert at least those
distressing suicides which are committed, not from insane
impulses, but under the dread of impending insanity. They
are far from proving that this has already set in, for it is
really not irrational to choose death in preference to perma-
nent dementia.
The following traits are signalized as characteristic of the
neuropathic constitution — constitution which affords the
main physical and moral basis for the development of
insanity.
In neuropathic families the children early manifest a re-
markable nervous excitability, with tendency to severe
neurotic disorders at physiological crises, as convulsions
during dentition, neuralgias at menstruation. The estab-
lishment of menstruation is often premature, often pre-
ceded and followed by profound chloro-anaemia. The
^This statement is not made in regard to acquired hysteria, symptomatic of
uterine or other diseases.
126 MARY PUTNAM JACOB J.
cerebral functions are easily disturbed, slight physical disor-
ders being attended by somnolence, delirium, hallucinations.
The nervous system seems to be everywhere hyperaesthetic.
Reaction to either pleasing or displeasing impressions is
excessive ; there are abundant reflex neuralgias, vaso-
motor irritations. Pallor, blushing, palpitations, praecordial
anxiety, are caused by trifling moral excitement, or by
agents lowering the tone of the vaso-motor nerves, as heat
or alcohol.
The sexual instincts are precocious and often perverted.
The establishment of puberty is often the sign for the de-
velopment of spinal irritation, hysteria, or epilepsy.
The psychic characteristics correspond. The disposition
is strikingly irritable and touchy ; psychic pain arises for
trifling cause; at the least occasion the most vivid emo-
tions are excited. The subjects of this temperament
alternate rapidly from one extreme to the other ; their
sympathies and antipathies are alike intense ; their entire
life is passed between periods of exaltation and depres-
sion, leaving scarcely any room for healthy indifference.
On the other hand, there is a remarkable inexcitability
of ethical feeling. Vanity, egotism, and a jealous sus-
piciousness are common, and the temper is often violent.
The mind is often obviously feeble, with few and mono-
tonous ideas, and sluggish association of them. At other
times ideas are readily excited, the imagination is active,
even to the production of hallucinations ; but mental ac-
tivity is ineffective because of the rapidity with which it
leads to exhaustion. There is no time to complete any
thing before the energies flag. The will is equally de-
ceptive in its apparent exuberance and real futility. Its
capricious energy and innate weakness is a fit counterpart
for the one-sided talent or even whimsical genius which
often marks the intelligence.*
^ Abridged from Krafft-Ebing.
THE PROPHYLAXIS OF INSANITY. 12/
This disposition constitutes the moral substratum which^
together with the physical constitution, affords the consti-
tutional basis for psychic disease. In it two elements are
conspicuous : a profound and often unconscious egotism,
resulting from the predominance of the instincts over the
faculties for external relations ; and a constant ineffective-
ness in the maintenance of these relations, — in other words,
abnormal weakness of the will. These elements reappear
in insane diseases. Egotism is the nucleus of the exactions
of hysteria, and determines the form of all delusions, which,,
whether primary, or engendered from emotional insanity^
invariably centre on the depression or exaltation of self.
The suspiciousness and violent temper so frequent in the
neuropathic, develops easily into the technical delirium of
persecution or of quarrelsomeness. The psychic hyper-
aesthesia common to several psychoses, but typical of
melancholia, depends, on the one hand, on the same
primitive egotism ; on the other hand, on the weakness
of the will, on account of which the normal channel
from feeling to action is blocked. Pent-up feeling is
always hyperaesthetic ; psychic pain is the correlative of
external ineffectiveness, even when not directly caused
by it.
Diminished interest in external relations results in psychic
anaesthesia, especially in regard to moral appreciations.
This anaesthesia is again the direct correlative of the excess
of instinctive and personal interests, and of the weakness of
the will which fails to enlarge the scope of the personality^
as it is naturally destined to do.
When the wuU is feeble, sluggish, inert, the tendency of
the mind to sink under pressure, and especially under the
weight of responsibility, is very great. " The fact of human
freedom," says Griesinger, " is the fact of the conflict in
consciousness of opposing ideas, and of the termination of
128 MAJ^V PUTNAM JACO'BI.
the strife by the conception-mass representing the Ego,
which assimilates part of the ideas, and represses the rest."
Feeble natures cannot bear this conflict without excessive
pain, to which, at last, they not unfrequently succumb. In
melancholia, the consciousness of diminished will power is a
prominent and most painful symptom of the morbid state.
The feebleness of the will may be manifested, not by
sluggishness, but by infinite caprice and incessant vacilla-
tions. This may reflect a torrent of incoherent ideas ; or it
may represent so rapid a transformation of an idea into an
impulse, that the latter alone seems to exist. Here the
channel from the internal to the external world is not ob-
structed ; its resistance, on the contrary, is abnormally di-
minished ; yet the volition is still ineffective. Effective
volitions demand distinct and correct ideas of the external
medium upon which they are to be expended. But one of
the most essential elements of insanity, and of the constitu-
tion predisposing to it, is the diminution in the number,
force, variety, and accuracy of the ideas held concerning
the external world, and on the relations of the individual
to it. This monotony of. ideas is sometimes, before the at-
tack, concealed behind desultory verbiage. Sometimes,
during the immediate prodromata of an attack, it is tem-
porarily replaced, even in feeble-minded people, by an un-
wonted vivacity and power. Completed delirium, however,
is always monotonous. Correlated to the egotistic instinct,
it always centres on the personality of the individual, which
is outrageously oppressed or illimitably exalted. The ideas
are few ; their asssociations sluggish ; memory and atten-
tion are weakened even to extinction.
A deficient power of attention is generally a marked
characteristic of the neuropathic state; it lies at the basis
•of the irritable impatience which is so frequent in it. This
leads to the formation of loosely knit conception-masses,
THE PROPHYLAXIS OF INSANITY. 1 29
ready to assimilate anomalous notions. The mind is natu-
rally credulous ; unapt for criticism. It offers less resistance
than another to the invasion of false ideas.
Thus the three great elements in the moral substratum of
a person predisposed to insanity, are : the egotistical pre-
dominance of the instincts over the faculties of reflection
and external relation ; the ineffectiveness of the will, even
when this is impulsive or violent ; the inaptitude for ideas,
resulting in their poverty and imperfect combination. The
whole nature is shrunken upon itself; there is not enough
vital turgescence to expand it to its normal circumference
and to the points of contact of this with the external
world.
The cardinal point in the management of such natures is,
therefore, the expansion of their shrunken individuality.
This is to be effected by means of a strenuous educational
system, directed at once toward the repression of the ego-
tistic instincts, the enrichment and systematization of the
ideas, and, through multiplication of acts and external re-
lations, the energizing of the feeble will.
The scope of the method will be made clearer by some
examples. Thus : grief is an efficient moral cause of insan-
ity. That it does not more often render people insane, is
indeed a remarkable proof of the resources of the healthy
human organism. However various the occasions for grief,
yet in so far as these all imply personal loss, the principle of
their influence is always the same.
The mind 'becomes so concentrated on the thought of
this loss, that the latter acquires the ascendancy of a fixed
idea. Apart from physical disease, the inability of diversion
is great, in proportion to the habitual poverty and monot-
ony of ideas ; to the fewness of relations with the external
world ; to the preponderance of habitual interest in matters
relating to self: to the inertness of the will, unable by
I30 MARY PUTNAM JACOB I.
vigorous action to expend externally irritations of psychic
pain.
Similarly, when disappointment or humiliations, great or
small, real or fancied, are the cause, or injuries, or the sus-
picion of injuries, the power of the predisposition and of
the occasioning cause being constantly in inverse relation
to each other, we reach a grade of exaggerated hysteria or
hypochondria where the egotistic instincts become able of
themselves to generate melancholy, irritability, and delu-
sions.
In another class of causations, shock plays a prominent
part. Inability to resist shock is partly proportioned to
poverty of ideas, which permit overwhelming surprises;
partly to habitually unrestrained emotionality; partly to
the passivity which prevents quick reaction. Analogous is
the effect of strain, of excessive anxiety, of long-standing
care and responsibilities. Healthy and justly proportioned
indifference is essential to healthy equilibrium ; an excess
of sensibility over reflection or will power, predisposes to in-
sanity under sufficient irritation. All experience shows
that an excess of egotistic sensibility is far more dangerous
than an excess of sympathy, the latter being indeed ex-
tremely rare in the neuropathic constitution. It may be-
come a cause in non-constitutional insanity. Another line
of causation is that in the direction of ideas, where the
invasion of false ideas is facilitated by habits of credulity,
superficial reasoning, loosely knit conception-masses. An
unreflecting enthusiasm easily embraces exciting doctrines,
as in the various religious or political manias, or is carried
away by suggestions which covertly appeal to the egotistic
instincts, flattering or alarming them, or submits to incon-
gruous beliefs, as in the so-called partial insanity or mono-
mania.
Perhaps none of the details of an educational prophylaxis
THE PROPHYLAXIS OF INSANITY. 13 1
are foreign to the principles theoretically advocated for or-
dinary education. But in this they are applied, if at all, in
a manner so lukewarm and vague as would render them
useless for so grave a problem as the prophylaxis of insanity.
To consider these principles in the order already enume-
rated: the repression of egotistic instincts demands effort in
two directions. Negatively, these are to be atrophied by a
studied atmosphere of indifference to caprice, violent tem-
pers, ridiculous pretensions, exorbitant exactions; none of
which are allowed to be gratified. In this permanent atmos-
phere, created by the mind controlling and guarding the
child, he may learn to appreciate his insignificance relatively
to the external world. Toward this and its interests he is
secretly apathetic, except so far as they may be made sub-
servient to his own vanity. The principle of justice, based
on the simple fact of primitive equalities, must be pro-
foundly in-wrought, by practical exercises, into the con-
sciousness of the neurotic. He is naturally inclined to
submit every thing to the test of his sympathies and an-
tipathies ; and the cultivated habit of reference to simple
justice instead, will save him from innumerable entangle-
ments, perplexities, and agitations, most dangerous to his
mental equilibrium.
The multiplicity of human interests, the vastness and im-
portance of the interests of the world, as compared with his
own, may be impressed upon the child's imagination in
many ways, if ingenuity be not lacking. The incidents,
utilized or contrived, necessarily vary with the age of the
child, but the same complex end is always to be held in
view : restoration of the normal proportion between egotis-
tic instincts and faculties of relation, and excitation of
healthful ideas through healthful practical experiences and
association with the fortunes of his fello\vs. Sometimes,
together with mental vivacity, sometimes with mental in-
132 MARY PUTNAM JACOB I.
ertness, the mind of the neuropathic individual is apt to be
really indifferent to intellectual relations, to knowledge for
its own sake, to disinterested curiosity, the happiest appan-
age of a sound intelligence. Interested motives must be
skilfully supplied, sufficiently to provide for the acquisition
of knowledge essential to the enrichment of ideas, yet with
caution, lest vanity and amour propre be unduly stimu-
lated.
The acquisition of knowledge, the training in morals, the
formation of habits of thought, must all be centred upon
practical activities. It is the proper development of these
which is to be relied upon to energize the feeble will ; to
accustoro it to effectiveness by training to productive in-
dustry ; to broaden and deepen the channels from internal
concepts to impulses ; to provide thus for the overflow of
dangerous irritations ; to check the flightiness, frequent
forerunner of insane impulse ; to widen the range of inter-
ests and of correlative ideas, and hence of resource against
shock, vexation, and misfortune ; to moderate inordinate
vanity by submitting its pretensions to practical tests ; to
regulate moods by habits of daily labor ; and to enlarge the
entire personality, for the future as well as the present, by
insuring, from internal pressure, the creation of a perma-
nent career. This latter element of prophylaxis might well
save from insanity many of the " lazy and languishing
young ladies ** whom Mortimer Granville complains of as
filling private insane asylums.
It is not enough to attempt to widen the range of ideas.
In some directions, and unguarded, this proves simply dis-
astrous to persons of innately feeble intelligence. They
must be trained in the formation of practical concepts ; as-
sociated as much as possible with practical facts, with sense
impressions, and with experiences in action. Clearness, defi-
niteness of ideas, their frequent association with images, af-
THE PROPHYLAXIS OF INSANITY. 133
ford no inconsiderable safeguard against morbid mental con-
fusion. Similarly the careful training of the senses in vari-
ous techniques contributes much toward the steady outward
direction of nervous energies, which is needed to counteract
the tendencies to internal concentration.
In this connection gymnastic training has a mental as
well as a physical influence. It would be difficult to prove
that such training of the periphery of the nervous system
could counteract the development of hallucinations, which
are caused by central irritation of the sensory centres. But
it certainly lies in the line of such counteraction.
If it be important to fill the mind with concrete ideas, it
is at least as important that these be correct, and not liable
to be uprooted in later life. This liability constitutes a
real danger in the notions of popular theology, which are
so loosely allowed to be acquired even by guardians who
do not believe in them. To persons predisposed to in-
sanity, the uprooting of fundamental ideas can by no means
be performed with impunity. It is important to train such
persons early in a sound and simple philosophy, which shall
provide a firm basis for thought and life without inviting to
speculative thinking.
Finally, since the object to be gained is firmness and
strength for the mind in dealing with its own concepts,
practical exercises in the elementary intellectual acts are
extremely important. These are but feebly carried out in
ordinary schools, because the object in view is not distinctly
perceived or firmly grasped. The first signs of failing men-
tal power are, loss of memory, of power of association of
ideas, of summoning contrasting ideas into consciousness,
of reproducing or comparing or criticising them. It is in-
dicated, therefore, to train the mind in advance to profound
habituation with these various processes. Such training
will avail nothing when physical lesions have begun to de-
134 MARY PUTNAM JACOB/.
stroy the intellectual mechanisms. But it may avail much
in the cases where the integrity of these first becomes im-
paired from obstruction of function and psychic disability.
One other detail deserves notice, for it rarely receives
attention. In minds predisposed to insanity there is often,
perhaps always, a marked deficiency of elasticity. An im-
pression sinks and remains ; the mind cannot disengage
itself nor recover its tone ; it cannot pass quickly enough
into the contrasting mood : a capacity to do this is the
natural provision against strain : it probably corresponds to
a law of rhythmic action in the physical mechanisms of
thought. This capacity should, therefore, be carefully cul-
tivated by encouraging alternations of attention at the first
sign of fatigue. The contrary practice of forcing an imma-
ture mind to continued attention while under the influence
of fatigue, instead of teaching it how to quickly change, is
the habit of common-place education. Injurious to all, it is
especially so to persons predisposed to depressing forms of
insanity. It exhausts still further the elasticity in which
they are naturally deficient.
The management of the perverted instincts of neuropathic
constitutions may, when these are advanced in deteriora-
tion, prove a hopeless task. At a less severe degree, how-
ever, many bad propensities may be held in check by a
skilful combination of the methods of punishment, — emu-
lation and distracted attention.
One difficulty in guiding these cases generally lies in the
fact that their pathological nature is not early recognized.
Children are incessantly moralized, whose minds do not
contain any conceptions of morals, and only an imperfect
mechanism for ethical functions. According to the degree of
imperfection, such persons must be dealt with as animals,
who can certainly be trained into habitual lines of conduct,
even though destitute of the corresponding abstract ideas.
THE PROPHYLAXIS OF INSANITY. 1 35
One morbid appetite calls for special mention, that,
namely, for alcoholic liquors. This, like the others, is often
manifested early in life, and, as known, is not only a symp-
tom of a neuropathic constitution, but, when indulged, a
potent occasional cause of insanity. The management of
this appetite is a most difficult problem. It has been
plausibly suggested that the permanent and moderate ad-
ministration of alcohol in the form of beer, might, with
other treatment, help to avert the development of the irre-
sistible craving.
Such are the abstract principles of a system of treatment
which, if seriously carried out, properly associated with
physical treatment, and so arranged that every other con-
sideration should be subordinated to the attainment of its
ends, should prove of real value in helping to avert many
cases of insanity.
THE INFLAMMATORY ORIGIN OF TUMORS*
By H. F. FORMAD, B.M., M.D.,
LECTURER ON EXPERIMENTAL PATHOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, ETC.
THE study of the cause of tumors has been one of the
deepest interest to physicians since the earliest days
in medicine ; chiefly because an unfathomable mystery sur-
rounds their origin. For several years I have been attracted
to the study of tumors, and after careful consideration of
clinical facts, and close histological studies, I have come to
the conclusion, that " mystery " or " obscurity " should not
be associated with their etiology. In this paper I shall en-
deavor to prove my proposition, viz.: that nearly a/l tumors
are direct products of inflammation.
The idea of regarding tumors as inflammatory products
is not new. John Burns ^ described medullary cancer as a
sponge-like inflammation. The French school in the early
part of this century, particularly Broussais'^ (1826), regarded
all tumors as products of chronic inflammation. More than
this, even Galen ^ in the second century, 1700 years ago,
says that " nasal polyps are due either to inflammation or
develop from a node (Phyma) or from germinal matter
(Blastema)." Virchow says that many tumors are un-
doubtedly the products of inflammation, and that it is dif-
* Read before the Pathological Society of Philadelphia, April 28, i88i.
* Dissertation on Inflammation, Glasgow, 1800.
"^ Broussais, Histoire des Phlegmasies Chroniques, Paris, 1826.
^ De tumoribus praeter naturam. Cap. 17, quoted after Virchow, Die Kr.
Geschwulste, i, p. 35.
136
THE INFLAMMATORY ORIGIN OF TUMORS. 13/
ficult to draw a line separating them from those tumors
whose origin cannot be ascribed to inflammation.
In the etiology of tumors there are, after Virchow/ to be
considered three causal conditions : first, local causes upon
which depend the development of a tumor in a particular
place ; second, a general predisposition ; third, a general
cause, which, for the sake of convenience, is made to relate
to the fluids of the body and is called dyscrasia or cachexia.
'' Cachexia," Virchow says, ** is not always present. It
never has been observed in the beginning of the formation
of the tumor, but always as subsequent to it, and the con-
dition can be brought about by other than cancerous juices.
Cachexia will manifest itself only in such persons in whom
the stomach, liver, or lymphatic apparatus becomes pri-
marily or secondarily affected by cancer or any thing else.
There is a physiological predisposition in certain tissues to
be more readily attacked and sooner affected by disease
than others. Highly organized tissues are very little pre-
disposed to excessive abnormal formative activity. The
latter occurs more in the connective tissue and its de-
rivatives and the lymphoid and epithelial tissue ; in the
epithelial tissues, the new-formation takes its departure usu-
ally only from the younger undeveloped cells {i. e. from the
lower stratum of the rete mucosiim). This predisposition in
tissues may be acquired; it does not need to be inherited.
" We also know that on mucous surfaces tumors occur for
the most part in such places where there previously was a
simple inflammatory disturbance; e.g.^ where the simple in-
.flammatory hyperplasia of chronic catarrh precedes the
growth of polyps, and polyps may develop into cancer. In
cancer of the stomach there is always seen a gradual transi-
tion of the catarrhal products to carcinomatous structure.
Exostoses, warts, elephantiasis, are all preceded by inflam-
^ Die Krankhafte Geschwulste, i.
■
138 //. F. FORM AD.
mation. We next come to certain regions of the body
which, from their situation and the character of their func-
tion, are exposed to irritation and injuries. This renders
them especially predisposed to take on a diseased nature :
£. g.y the stomach, sexual organs, bones, skin, and the differ-
ent orifices. If we make an estimate of all malignant
growths we find that most occur at orifices and at the ori-
fices which are exposed to the greatest injury, conse-
quently those of the digestive and sexual apparatus are
most affected."
Virchow properly remarks: ''If there would exist pri-
marily a specific dyscrasia we would not have a single pri-
mary tumor focus from which metastasis proceeds, but we
would have tumor eruption in all possible places without
any definite plan."
All these facts together lead Virchow to the conclusion
that even in malignant growths the primary growth does
not come from a dyscrasia, and that every tumor is local
and frequently of inflammatory origin.
These are the doctrines for which Virchow alone receives
credit : but if we look through the older literature and
even through the native literature of America we shall find
-a book written twenty years before Virchow's time, in which
those fundamental ideas concerning tumors are set forth in
ail their essential points. I have reference to Prof. S. D.
Gross' work: The Elements of Pathological Anatomy^ pub-
lished in 1839. I shall quote only a few sentences. "■ Tu-
bercle," Prof. Gross says, " is always the result of inflamma-
tion, and that this is the case likewise with scirrhus, seems
sufficiently evident from what has been stated in regard to
its exciting causes. Very frequently, it is true, the disease
arises imperceptibly without local injury or obvious consti-
tutional derangement. But this certainly does not prove
that inflammation is not concerned in its production. How
THE INFLAMMATORY ORIGIN OF TUMORS. 1 39
often do we find traces of inflammation after death, with-
out having had the slightest indication of it during life.
The fact, then, that inflammation is not manifested always
by the usual phenomena, does not invalidate the idea of its
presence." In another place he says : " Predisposition must
also be accounted for and, in some instances, it seems to be
connected with a hereditary taint, being transmitted from
parents to their offspring." Hence he believed in the local
inflammatory origin of tumors and conditions which pre-
dispose to them.
Dr. Woodward, U. S. Army, in his excellent paper on the
structure of cancerous tumors,^ agrees also with Virchow,
saying : " The origin of the first growth was always to be
looked for in local influences. Former injuries of one kind
or another could be affirmed in a large number of cases to
have preceded the development of the disease, and though
frequently the patients had lost all recollection of the origi-
nal harm, yet it was in this direction we ought to look,
rather than seek to explain away the real difficulty by in-
voking the aid of an imaginary cachexia."
Although Dr. Woodward at another page says : *' The
time has not come yet for any one to tell why cancer origi-
nates," he must be classed with the authors of the inflam-
matory theory of tumor formation, as he expresses the view
that cancer cylinders are largely formed from migrated
white blood corpuscles ; the latter when infiltrating tissues
being always of inflammatory origin.
Samuel, of Konigsberg,'^ although agreeing with Virchow
in all the essential points, maintains more strongly than any-
body else the view that inflammation is the main cause of
tumors. He says: "The idea of excluding or even limiting
the causative relation of chronic inflammation to neoplasms,
leads far astray from the right path."
* Toner Lectures, Washington, 1873. ^ Handbuch d. allg. Path., 1879.
I40 H. F. FORM AD.
The main reason for this view of Samuel is obvious. Like
Virchow he cannot conceive of the difference between per-
manent inflammatory products and tumors, and he classes
the products of specific inflammation,^.^., gumma, tubercle,
lupus, etc., with the tumors.
Before giving my own views, I like to mention briefly the
other theories on the etiology of tumors.'
Cohnheim, of Leipzig,'' holds rather an exclusive view.
Regarding tumors as typical new-formations of embryonal
origin, he classes them as malformations, forming a subdivi-
sion of " monstra per excessum." True tumors, according
to him, cannot originate by virtue of any kind of interfer-
ence ; only one causal factor exists, viz., an ''''anomalous
embryonic arrangemeitt.''
Similar views had been so far expressed by other pathol-
ogists in regard to the origin of the dermoid tumors alone.
These have been proven by Liicke and others to be due to
anomalous invaginations of the outer layer of the blasto-
derm during the formation of the structure of the eye,
mouth, neck, the ovaries, the testicles, etc.
Cohnheim applies to all neoplasms a similar mode of ori-
gin. He explains the anomalous embryonic arrangement
which forms the starting-point and becomes the cause of
tumors, by the following hypothesis : " In an early stage
of embryonal development there may be undoubtedly pro-
duced more cells than are necessary for the construction of
a certain part ; so that a certain number of cells remain
superfluous. Their number may be very small, but they
possess great proliferating power on account of their em-
bryonal nature. This must occur before the complete dif-
ferentiation of the blastodermic layer and the formation of
^ For the details of these views, and a complete record of experiments made
in connection with tumors, see my paper, "The Etiology of Tumors," i88i,
which can be obtained from the Secretary of the Pathological Society of Phila-
delphia, or by writing to my direction.
^ Allgemeine Pathologic, 1877.
THE INFLAMMATORY ORIGIN OF TUMORS. I4I
organs." This appears to him the easiest explanation, why,
from such a misplacement, there occurs, not the under-
growth of a certain part of the body, e.g.^ giant leg, but
simply a histoid tumor ; i. e.y it results in an excessive under-
growth of only one tissue of the part. The superfluous cell
material may be distributed uniformly, or it may remain
together in one place. In the first case there will result a
superfluous part of the system, like supernumerary fingers ;
in the second case, a tumor.
Germs may fail to develop on account of the lack of
necessary stimulus, or because of the resistance of sur-
rounding structures.
Epstein' is a decided believer in Cohnheim's embryonal
hypothesis. Having discovered epithelial pearls in the mu-
cous membrane of the gums, the tongue, and the genitals
of new-born infants, he thinks to have found a proof for
Cohnheim's view, regarding these pearls as the famous
supernumerary embryonic collections of cells. These hav-
ing no physiological purpose may either disappear, or
under certain conditions of nutrition form the starting-
point for tumors.
Prof. Maas, of Freiburg,'' declares himself strongly in favor
of Cohnheim's theory on the etiology of tumors. He rejects
positively all other theories, admits, however, traumatic in-
fluences in a greater extent than Cohnheim does. He
even thinks that an injury frequently induces the develop-
ment of tumors, but only in such parts where supernumer-
ary embryonic cells exist. He says that only in such places
containing those supernumerary cells an injury will react,
starting a tumor by a " tumor-producing proliferation of
cells"; while an injury inflicted upon a part where the
cells are normal, will never produce that eff"ect. By this
^ Epstein, Ueber Epithelialperlen, etc., Zeitsch. fiir Heilkunde, i, 1880.
' Maas, Zur Etiologie der GeschwUlsten, Berliner Klin. Wochenschr.^ No.
47, 1880.
142 H. F. FORM AD.
hypothesis he tries to explain why thousands of injuries are
not followed by the formation of tumors, while in a few
instances tumors develop promptly in consequence of a
trauma, and this only because in these few instances
there must have been present abnormal embryonic cells
which gave rise to the development of the tumor.
Hence he thinks that even a traumatic theory of the
development of tumors can be established only by Cohn-
heim's hypothesis.
He quotes several cases where naevi and other congenital
formations developed into cancers in consequence of an in-
jury ; the latter, however, not being necessary in the pres-
ence of the numerous cases of congenital growths on rec-
ord, and the large quantity of cases of tumors in which
a traumatic history cannot be traced.
Cohnheim's hypothesis on the etiology of tumors seems of late
to gain some more ground in Germany. While my paper was in
press, the just-issued (August 8, 1881) part of vol. 85 of Vir chow's
Archiv reached my hands, which contains an article (Exper. Un-
tersuch ueber die ^tiologie der Geschwiilsten) by Dr. Leopold,
who violently supports, and thinks to have proven by experiments,,
the view of Cohnheim. I can give here only the mere outlines of
the contents of the paper.
The author had made a series of transplantation experiments in
Pathological Institute of Leipzig, under the direct supervision of
Cohnheim. Essentially these experiments went only to confirm
the experiments of Zahn,^ e. g., that only embryonal (foetal) tissues
transplanted into the anterior chamber of the eye or into the peri-
toneal cavity will grow; while adult tissues do not grow but be-
come absorbed sooner or later. Successful results Leopold ob-
tained only with embryonal cartilage, transplanting small frag-
ments into the anterior chamber of eye, where they continued to
grow and in about six months reached a bulk three hundred times
larger than the original pieces inserted. Larger pieces of tissues
and organs, i. e., a whole foetal head or a thigh inserted into the
peritoneal cavity, did, however, not grow even after the lapse of
* Zahn, Sur le sort des tissus implantes, etc., Congres Med. International^
1877, Geneve, 1878.
THE INFLAMMATORY ORIGIN OF TUMORS. 1 43
months, but were peculiarly preserv^ without decomposing, be-
coming enveloped into a connective-tissue capsule. The fragments
of cartilage referred to above had not only considerably increased
in size but showed advancing development, viz. : the formation of
marrow-cavities and of bone lamella.
From this the author concludes, that he has produced ex-
perimentally a tumor, an artificial enchondroma (?). He thinks
that he will also be able " to produce artificially in the same man-
ner epithelioma, myoma, adenoma, and dermoids."
I think, however, that he must succeed better with them than
with his " artificial enchondroma," which is nothing else than a
simple graft of cartilage transforming into bone.
I must confess that Cohnheim's embryonal hypothesis is very
seducing, but still it can hold good only for the congenital tu-
mors, viz. : Rhabdo-myoma, sim.ple angioma, and lymphangioma,
dermoids, and perhaps the heterotopic adenomata. For all the
rest of the tumors Cohnheim's theory is untenable, as will be
shown later.
Rindfleisch,^ in his famous text-book on pathological
anatomy, expressed himself decidedly in favor of a spon-
taneous origin of ttcmors. His classical phrase : ** Tumors
arise spontaneously, but they do not heal spontaneously ;
while inflammations do not arise spontaneously, but they
heal spontaneously " — expresses really very perfectly the
notion of the practical physician. The persistence, the
" organ-like character of tumors," he explains by the fact
that tumors follow more the rules of physiological growths.
Inflammatory formations on the other hand are produced
essentially by a conflux of mobile cells at the spot of
irritation, hence their rapid appearance and almost trace-
less disappearance.
Rindfleisch considers the evolution and involution of
tissues and organs to be an important factor in the eti-
ology of tumors. Thus, he explains the development of
tumors of the connective-tissue group by a localized, ex-
cessive proliferation of connective-tissue elements during
^ Rindfleisch, Lehrbuch der pathol. Gewebelehre, 1875.
144 H. F. FORM AD.
evolution (in young persons), and the occurrence of epi-
thelial new growths during involution (in older persons),
by a local proliferation of the superabundant epithelial
elements. He admits, though, that local irritation plays an
important role.
In connection with the idiopathic or spontaneous theory
due notice must be given to the views of Mr. Payne,^ who
applies Spencer's dynamical laws to the causation, or rather
to the growth of tumors.
Herbert Spencer says: "Growth is unlimited or has a
definite limit according as the surplus of nutrition over ex-
penditure does or does not progressively decrease. Tumors,
having no function, have no expenditure, and hence all the
force is used up in growths, and the larger the tumor the
more force is liberated and the larger it grows. They are
Hke plants in being almost wholly accumulators ; they have
no expenditure of force, hence their unrestrained increase
in size."
Mr. Payne properly remarks : " New growths are more
frequent in passive tissues than in actively fluctuating tis-
sues. Fatty tissues, bone tissues, and all varieties of growths
which originate from connective tissues, are instances of the
connection of mechanical passivity with excessive growth."
On the other hand, he explains the extraordinary rarity of
tumors composed of striated muscular tissues by the strong
activity of the latter, the nutritive supply being balanced by
the expenditure of force.
A nervous theory of the etiology of tumors is also more
or less ably advocated.
Dr. Snow,'' of London, in his paper on the etiology of
cancer, based upon two years' statistics from the cancer hos-
pital, comes to the conclusion that nervous depression,
especially mental trouble, is the most prominent cause of
^ Payne, Origin and Relation of New Growths, Brit. Med. Journal, 1874.
' Snow, London Lancet^ December, i38o.
THE INFLAMMATORY ORIGIN OF TUMORS. 145
cancers. After careful inquiry into the history of a large
number of cases, he comes to the following conclusions :
1. ** Hereditary tendency, as a predisposing cause of
cancer (at all events of mammary and uterine), is almost
valueless, if not entirely so, and in practical diagnosis should
altogether be ignored as misleading.
2. " Mechanical injuries directly produce cancer in a cer-
tain percentage of cases, but this percentage is small.
3. "As direct and immediate causes of cancer (espe-
cially in my own experience of uterine cancer) mental
trouble, hard work, are very potent agents, and exert more
influence than any other antecedent within our present
knowledge."
The immediate cause of tumors has been repeatedly
traced, beyond doubt, directly to inflammatory processes.
Hence an inflammatory theory of the etiology of tumors is
not a hypothesis.
The dyscrasic, embryonal, spontaneous, and nervous theo-
ries, as ingenious as they are, can hardly, at present, be re-
garded as theories, but must be called hypotheses ; for so
far not a single tumor can be proven to have really de-
veloped from the causes promulgated. I gave those hy-
potheses due consideration, but I did not attempt to criti-
cise them for want of time and space ; and, again, there is
nothmg to be disproven, where nothing is proved.
I will now enter into some details of the inflammatory
view, the one I have adopted.
It is properly held by some that no line of distinction can
be drawn between true tumors and chronic inflammatory
products. I shall bring forward some facts now generally
acknowledged, and also some investigations of my own,
which will yet considerably strengthen this view.
Practically we do not know what inflammation really is ;
146 H. F. FORM AD.
we know only some of its causes, symptoms, and some of
the terminations. But the inflammatory process itself and
some of its terminations have been pretty well studied and
are well known through the labors of Virchow, Cohnheim,
Strieker, Ziegler, Ranvier, and Samuel abroad, and W. F.
Norris, Woodward, and E. O. Shakespeare in this country.
From these observations we also learn that many and some-
times all the signs of inflammation may be wanting in that
process, and really the symptoms are altogether absent in
many of the so-called chronic inflammations.
Many of the products of inflammation are not only diffi-
cult to distinguish from tumors, but are really recognized as
true tumors.
The criterion of true tumors is regarded to be their tendency
for permanency in contradistinction to inflammatory products
which tend to disappear ; but it can be shown that, while true
tumors occasionally do disappear, inflammatory products, very
frequently, never disappear.
There are many cases of sudden and gradual disappear-
ance of tumors on record. I shall mention only a few.
Dr. Th. Dwight' reports a case of an unmistakable tumor
of the rectum, which had disappeared spontaneously. In
the discussion of the paper the argument was brought for-
ward, that of all tumors, only lymphoma is known to dis-
appear, and as this tumor was single, it probably was not
lymphoma, the latter tumor always occurring multiple ; the
probability being more in favor of its having been medul-
lary sarcoma (commonly mistaken for encephaloid).
Prof. Louis A. Duhring'' has met in his practice a peculiar
tumor, which he has called inflammatory fungoid neoplasm.
This appeared suddenly as round or oval, circumscribed,
* Dr. Th. Dwight, The Disappearance of Tumors, Boston Med. and Surg.
Journal. 1880, p. 562.
''Duhring. See supplement to a case of Inflammatory Fungoid Neoplasm, by
Louis A. Duhring, Philadelphia, 1880, pp. 12, 16, 18.
THE INFLAMMATORY ORIGIN OF TUMORS. 1 47
nodular or fungoid growth of a dark-red color and of the
size of a pea to that of an egg. Having attained a definite
size, as a rule, these growths would soften, diminish in vol-
ume, and undergo, sooner or later, spontaneous involution
without pigmentation and without scar. Although resem-
bling sarcoma, as Dr. Heitzmann of New York pointed out.
Dr. Duhring considers that this disease is unquestionably
an inflammatory new-formation, allied to sarcoma, but dif-
fering from it as described by authorities. The great peculi-
arity of these growths was their rapid rise and fall, rising
in a night and disappearing within a week.
H. Fisher^ records a case of a man from whom, a large
tumor of the neck had been extirpated ; two days after the
operation a swelling of a gland as large as a fist disap-
peared during a night; at the same time high fever set in
and the patient died. Three days later, at \}i\e post-mortem^
no cause of death could be found. In the axilla was found
a small swollen gland. Fisher believed that a very acute
fatty degeneration and re-absorption of the tumor elements
took place. In a second case a tumor of a lymphatic gland
as large as a fist diminished to the size of a small apple
during the progress of an acute meningitis and tubercular
pericarditis. In a third case during ilio-typhus in a girl six-
teen years old, a lymphatic tumor of the neck, $ cm. long
and 3 cm. wide, diminished to the size of a bean. In a
fourth case a goitre disappeared during the progress of scar-
latina. The author adds a few cases of tumors in which,
after trifling interference, noticeable diminution of size oc-
curred, n
Berns, of Amsterdam, also records similar instances of
the disappearance of tumors.
Liicke'* also observed tumors diminish and even perma-
nently atrophy under the influence of exhausting diseases.
^ Deutsche Zeitsch. f. Chirurgie, xii, Heft i und 2, 1879.
"Lucke, /. c.y p. 1 6.
148 ^ H. F. FORM AD.
Virchow* says that warts, condylomata, and even fibroma
have frequently teen observed to heal and to disappear,
undergoing a slow atrophy and resorption.
Simon* records the case of a recurrent fibroid which dis-
appeared completely when treated by cold (?).
Prof. Wm. Goodell^ says that fibroid tumors when affect-
ing the womb at a period near the menopause, frequently
undergo retrograde change. " The climacteric once
reached, these growths generally grow smaller and may
even disappear."
Even Rindfleisch, in his text-book, records that pedicu-
lated tumors have fallen of their own accord, and that en-
tire cancerous nodes have been observed to cast off spon-
taneously.
Drs. Ripley" and Robinson, of New York, each recorded
a case of complete disappearance of epithelioma. Dr.
Robinson's case was one of epithelioma of larynx, which
had perfectly healed. Dr. Ripley's case is particularly in-
teresting, as it formed the subject for discussion in the
Pathological Society of New York. The case was epithe-
lioma of lip of several years' duration, and was not removed
on account of the bad health of the patient. Subsequently
the new growth spread by extension to both submaxillary
glands. While the secondary deposits below the chin con-
tinued to grow, producing tissue destruction, the original
growth on the lip healed and was fully replaced by perfect,
healthy scar-tissue. In the discussion the following points
of interest were brought forward by Dr. Satterthwaite and
others : Cancers occasionally heal spontaneously, or a cure
is accomplished through an acute inflammatory process in-
^ Virchow, Geschwiilste (/. c, p. 359).
' Simon, Discussion on Cancer, Brit. Med. Jour., 1874.
^ Goodell, Clinical Observations on the Radical Treatment of Fibroid Tu-
mors of the Womb. Transactions Med. Society, State of Penna., 1880.
* Ripley, Epithelioma of Lip — Spontaneous Healing of the Original Lesion,
N. Y. Medical Record, July 16, 1881. This is only one of the several cases
which I have seen recorded since the reading of this paper.
THE INFLAMMATORY ORIGIN OF TUMORS. 149
duced by means of local applications ; the healing being a
process of cicatrization. The connective tissue proliferates,
" squeezing all the cellular elements (of the cancer) to
death," and forms dense scar-tissue. ^
I would like to remark here, that the healing process of
an ordinary granulating ulcer is precisely the same as in
cancer, wherever healing of the latter occurs. Here, like
there, healing is accomplished by the additional formation
of connective tissue, i. e., cicatrization. Poultices, pressure,
etc., act beneficially in the healing of ulcers, only because
they promote the transformation of granulations into scar-
tissue, and induce a fatty degeneration of superfluous cell
masses ; they assist the connective tissue in " squeezing to
death" the exuberant granulations, from which to sarcoma
there is only one step. Liicke^ says that sarcomata in very
young individuals occasionally grow as rapidly as acute ab-
scesses, and are frequently mistaken for the latter.
I mention this in order to point out the close analogy
that exists in the termination of tumors and that of inflam-
matory products.
We have seen that tumors occasionally heal a^id disappear.
On the other hand, it is well known that many inflamma-
tory products^ particularly chronic ones, never do disappear^
and that the symptoms and cause of them, are frequently less
obvious than in the case of tumors. The connective tissue
which, in proliferating, constitutes the main bulk of ele-
phantiasis and of the cirrhosis of organs and a good many
other pathological tissues outside of tumors, never dis-
appears.
Virchow properly considers elephantiasis Arabum and
soft fibroma morphologically and etiologically identical,
and in the same sense he does not admit any difference
between the connective tissue of an advanced cirrhosis of
^ Liicke, Die allg. chir. Diagnostik d. Geschwtilsten, Volkmann's Klin. Vor-
trage, 97, 1875.
150 H. F. FORM AD.
organs and that of a diffused fibroma. In fact, we are only
in the habit of calling a proliferation of connective tissue
in the mamma an intercanalicular fibroma, because the
connective tissue affects an external part, while a similar
affection of the liver or kidney we term an inflammatory
one — a cirrhosis. Why should we make such a distinction ?
I fully believe in an acquired predisposition to tumors.
Acquired through external influences, i. e., through any
thing that may excite an inflammation or a long-continued
irritation, and consequent disturbance in the tissues, e. g.,
injuries, long standing, pressure or irritation, colds, etc.
Injuries are properly regarded as exciting causes of tumors,
but this may only be so in a certain class of cases, perhaps
in hereditary tumors. From my inquiries I am inclined to
believe that the inflammatory process creates conditions in
the tissues which directly, and more than any other cause^
predispose to tumor formation, and hence I would regard
inflammation a predisposing rather than an exciting cause.
Good and exhaustive statistics should be made in this di-
rection.
Any inflammatory process, due either to external or in-
ternal injury or irritation, etc., may produce a new forma-
tion of tissue — a tumor. This may depend particularly
upon an imperfect process of healing, as I shall show later.
We even do not need here to take into consideration
gummata, tubercle, lupus, etc., the well-established products
of inflammation, which so frequently occur as well-defined
tumors. I think we can come to a satisfactory conclusion
on the inflammatory origin of the true neoplasm even with-
out them.
My own experience is limited, but in the cases of tumors
in which I had the opportunity to get the history myself,
or where I insisted upon an exhausted anamnesis in cases
of others, it was possible in nearly one half of the cases to
THE INFLAMMATORY ORIGIN OF TUMORS. 151
trace out a local inflammatory process preceding the tumors
at some time or other. Sometimes it dated years back.
Careful inquiries nearly always revealed some cause, viz.,
an injury, long-standing irritation, mechanical or toxic, or
an impaired or excessive use of the part, pressure, or a long-
standing catarrh, or something of that nature.
Tissues which are most liable to be the seat of inflamma-
tion, are also the most common seat of tumors. Again, those
tissues which do not participate in active inflammatory
processes (ganglionic and striated muscular tissue) seldom
or never give rise to tumors.
The extensive and careful statistics of Dr. d'Espine, of
Geneva, show that the os uteri and the stomach are the
most frequent seats of primary cancer, and they are also
distinguished for their remarkable liability to catarrhs.
Virchow has repeatedly pointed out in a catarrhally inflamed
gastric mucous membrane the gradual transition to car-
cinoma.
Dr. J. H. Musser directed my attention to the fact that
primary cancer of the gall-bladder is nearly always preceded
by gall-stones. He demonstrated a beautiful specimen of
recently developed cancer of the gall-bladder to the Patho-
logical Society of Philadelphia, in which the clinical history
revealed gall-stone for years. In looking up the literature,
Dr. Musser found numerous cases of primary cancer of
gall-bladder, and every one was preceded and accompanied
by gall-stones. Unquestionably in all these cases the stones
excited a catarrhal inflammation and this produced the can-
cer. A gradual transition from catarrhal inflammation
of the mucous surface of the gall-bladder and duct to
cancerous formation, was distinctly demonstrated in the
microscopic preparations from Dr. Musser's case.
I have on several occasions contributed ' to prove, that
^ See Transactions of Path. Society of Philadelphia.
152 H. F. FORM AD.
most of the so-called indolent ulcers are epitheliomata ;
nearly all those everlasting ulcers are surface cancers. But
at one time they were little sores and were produced by an
injury. There are a number of these indolent ulcers in Phila-
delphia hospitals ; they are all due to inflammation, which is
directly traceable. I examined many of them microscopi-
cally, and nearly every one proved to be an epithelioma.
Dr. S. W. Gross ^ is of the opinion that cancer of breast
may result from ordinary eczema or psoriasis of the nipple,
just as epithelioma of the tongue may follow ichthyosis or
hyperplasia of the epithelium of that organ. Dr. Gross
finds from his own statistics, that non-carcinomatous tumors,
too, have been traced to a trauma in one example out of
every eight and a half cases.
Dr. A. G. Gerster,^ presented recently to the Pathological
Society in New York three specimens, which illustrated
beautifully the traumatic origin of cancer. The first case
was a cancer of the sole of foot, which had killed the pa-
tient by metastasis of the growth to the brain and nearly
all other inner organs. The doctor had observed the case
for years, and had traced with absolute positiveness the
primary tumor of the foot to a simple erosion of the skin
from stepping on a nail. The second case was cancer of the
outer malleolus, also directly formed at the seat of injury.
The third case was a cancer of the lower extremity, de-
veloped directly in a scar, the result of a burn dating thirty
years back. The tumor did, however, not develop until a
year prior to the amputation, when he had struck himself
accidently upon the same spot.
I have seen, myself, several similar cases of tumors posi-
tively of traumatic origin in the University Hospital clinic
and elsewhere. As some of them are and others will be
* Gross, Tumors of the Mammary Gland, 1880.
^Gerster, Specimen illustrating the Traumatic Origin of Cancer. N. Y.
Medical Record, July 16, 1781.
THE INFLAMMATORY ORIGIN OF TUMORS. I5S
recorded in the proceedings of our Pathological Society, I
will refrain from mentioning them here individually.
Winkel/ who investigated exhaustively the etiology of
myomata of the uterus, came to the conclusion that these
tumors are caused either by direct excitants, viz.: coition, in-
jury, abortion, rough removal of placenta, cellulitis ; or in-
directly : through repeated lifting, shock, sudden hyperae-
mia, etc. " These," he says, " inevitably first produce
disturbance of circulation, stasis and wandering out of
white blood corpuscles, etc." What do we need more ; is
it here not plain that the inflammatory process was the
causative factor of the new growth? The author, however,^
unnecessarily adds : " This extravasats or transudats gives
the impulse for the new-formation like an ovulum, etc."
Epithelioma of lips, one of the most common tumors,
gives also a clinical proof of the inflammatory theory; here
the irritation by tobacco-juice, as well as the pressure of the
pipe, must be the cause, as the new growth occurs pre-
eminently in men who are inveterate smokers.'^ I exam-
ined the teeth in three cases of epithelioma of the tongue '^^^
in every case they were bad, many being broken, and had
been in that condition for years ; probably the irritation and
injury to the tongue were the cause of the new-formation.
Similar observances have been made by others.
Epithelioma of penis has repeatedly been traced to a
congenital or acquired phimosis, a condition which naturally
gives rise to constant irritation and usually calling forth an
inflammation.
The workmen in coal-tar and paraffine manufactories
sufl'er very frequently from acute and chronic inflamma-
tions of the skin. Volkmann^ has already described several
*Winkel, Volkmann's Samml. Klin. Vortrdge, No. 98.
"I once saw an epithelioma of the lip in an Irish woman ; upon inquiries I
learned, however, that she had indulged in smoking a short pipe for many years..
^ Volkmann' s Sammlung Klin. Vortrdge.
154 H. F. FORM AD.
cases in which true epithelial cancer was developed from
those chronic inflammations, and Tellman* now adds
another of the same nature, ending fatally after numerous
operations. This form of cancer has a parallel in the
chimney-sweeper's cancer.
Most of the myelinic neuromata occur only in amputated
stumps, developing at the cut ends of nerves, and hence are
direct inflammatory products. (Perls.)
Frequently warts, naevi, and keloids,'* through interference
which sets up an inflammation, increase and multiply, and
even are converted with malignant tumors.
Liicke and Virchow found that whenever an autopsy re-
vealed cancer or any tumor of stomach or oesophagus, the
clinical history nearly always revealed '' drunkard^ We
have seen before that from long-continued catarrh to carci-
noma there is only one step.
Lipomata very frequently occur in portions of the body
which were subject to excessive pressure or irritation. Prob-
ably, however, we must first have the development of con-
nective tissue, — a fibroma, — before we have a lipoma.
Extremely frequent is the occurrence of sarcoma in
young persons in consequence of direct injury, or develop-
ing in any imperfectly healed scars. Hundreds of cases of
chondroma and osteoma, too, have been traced by a distinct
and clear history and evidence directly to blows, fractures,
cuts, and other injuries.
Any one can convince himself of the above-mentioned
facts by just looking carefully over the literature, and by
taking careful histories of his own cases. Hundreds of
tumor cases of positively traumatic origin are also recorded
in the classical works on tumors of Virchow, Weber, Miiller,
^ Tellman, Deutsche Zeitschr. fiir Chir., vol. xii.
^ Concerning keloids I would like to remark that, as is well known, most of
them consist morphologically of cicatricial tissue. Surgeons who remove them
find that they always return. They do not return, but the scar-tissue returns —
as in loss of substance true skin is never reproduced, but only a scar.
THE INFLAMMATORY ORIGIN OF TUMORS. 155
and Broca. All the present younger working pathologists
in Europe are in favor of an inflammatory origin of tumors,
though none of them expresses himself definitely ; still they
return gradually to the view which the fathers of pathology
held originally.
Inflammation is the only factor which has been traced to
be the positive cause of tumors in a number of cases. This
is proven by high authority and statistics. But as these
authenticated cases of inflammatory origin are in moderate
number, and as those with no cause, by reason of careless
note-taking, are in enormous majority, the inference is
drawn that inflammation has little or no significance in the
pathogenesis of tumor.
I beg leave to argue as follows : In a certain number of
cases it is positively known that inflammation preceded and
was the cause of the new growth. In regard to the remain-
ing cases of tumors we know nothing, no positive cause
could be traced. Hence I think it logical, for the present,
to consider inflammation as the cause of tumors in general.^
All other alleged causes are only speculations ; and nothing
reasonable can be brought forward against the inflammatory
theory. Speculations are valueless, I think, in the presence
of positive facts, even if these be few in number. In sci-
ence any amount of negative results are always disregarded
in the presence of even a few positive facts. Until contrary
proof be given we are at present, by a mass of evidence, forced
to the conchision, that turners represent merely one of the ter-
minations of inflammation.
The question now arises in what way does inflammation
produce a tumor, and why and when does a tumor develop
after an injury? Why is not every injury followed by a tu-
mor if inflammation is the cause? Prof. Maas' ingenious
* I would exclude here only the purely congenital new-formation, e. g., sim-
ple angioma, and lymphangioma, rhabdo-myoma, the dermoid cysts, and a
few of the nsevi. These are simple congenital anomalies of the organism.
' Maas, Berliner Klin. Wochenschrift, No. 47, 1880.
156 H. F. FORMA D.
answer was, that it depends upon the presence or absence
of Cohnheim's supernumerary embryonic cells at the seat
of the injury. If those misplaced or aberrant cells happen
to be present in a part, a trauma will induce inflammation
followed by a tumor; if no extra cells are present, a simple
inflammation will follow, and nothing more. But this is
only a hypothesis, it cannot be demonstrated. Embryonal
(foetal) cells could not continue to exist unchanged in the
adult individual ; nor do they need to be pre-existing in
order to form a tumor. They can be and are always cre-
ated by any inflammatory process.
I will try to answer the above question by facts, which
microscopic examination reveals, and which will show that
the study of histogenesis must go hand in hand with that of
the etiology, and possibly might disclose the mysteries of
the cause of tumor.
It is true that not always direct observation of active pa-
thological processes can be made. In the case of tumors
only inferences of previous cell activity can be drawn from
the microscopic picture; but the pathological process can
frequently be traced out under the microscope, from the
various transitional stages of the elements of the new form-
ing or formed tissue.
It is in accordance with the modern views to say that
every tumor has its strict physiological prototype. Even
for the cancer, only the peculiar atypical arrangement of
the cells remained a criterion, while the cells themselves
are supposed to be strictly identical with those found nor-
mally.
It appears to me, and the more I study the histology of
tumors the more I become convinced, that any variety of
cells composing a tumor are not identical with those found
normally, but resemble those met with in chronic inflamma-
tory products. In tumors, the shape and the peculiar varia-
THE INFLAMMATORY ORIGIN OF TUMORS. 157
tion in size of the cells and nuclei, the character of the
intracellular network, and of the amoeboid motion of certain
cells, the intercellular substance, the occasional arrangement
into nodes, the relation to reticulum and blood-vessels, and
the peculiarity of the latter are all precisely like what is
found in chronic inflammatory products and not like in
normal tissues.
There is a great difference between the tissue elements of
fibroma and those of normal connective tissue, for example.
I shall give briefly the details of my investigation of the
structure of fibroma which, when completed, will be pub-
lished and illustrated elsewhere.
Concerning the structure of normal connective tissue, the
following seems to be generally established and in good
prepa^-ations quite demonstrable.
The ultimate connective-tissue fibrils (the fibrillar variety)
are in varying number united together to form bundles;
these again occasionally unite to form larger bundles ; these
bundles arrange themselves at different localities in various
manner, i. ^., parallel as in tendons, or as a lattice work in
membranes, or decussate at different angles and in all pos-
sible directions in all other localities, leaving between small
spaces, these spaces being dependent for their shape and
size upon the arrangement of the bundles. They commu-
nicate with one another, and thus form a system of channels
throughout the whole connective-tissue system of the body.
These channels contain a small amount of fluid containing
mucin, and they are the receptaculi of the sometimes enor-
mous quantities of serum in oedema. These same spaces
or channels may also get filled with air, producing emphy-
sema in skin and other parts of the body.'
* The subcutaneous tissue of the whole body can be filled with air, so as to
produce enormous emphysematous disfiguration, by forcing air through blow-
tubes at a few points or possibly even from only one point of the body below
the skin. I have seen children purposely prepared in this way for beggars' pur-
pose.
158 H. F. FORM AD.
Von Recklinghausen has shown that the spaces in the
connective tissue communicate with the lymphatics, and he
calls the spaces juice-channels ; they act as '' vasa serosa '^
(Orth), conducting the serum from blood-vessels to the lym-
phatics, and '* feeding" (Tyson) the tissues.
By the nitrate of silver method, of von Recklinghausen,
which is now the common property of all the laborato-
ries of the world, it can be easily demonstrated that each
of the connective-tissue bundles spoken of is surrounded
by a distinct membrane composed of large fiat cells.
These flat, so-called endothelial cells are very thin, nucle-
ated, and are closely united at their periphery with one
another, so as to form continuous membranes or sheaths,
which envelop each or several fibrillar bundles, and thus at
the same time form a lining for the spaces between them.
Without nitrate of silver the endothelial cells cannot be
seen ; all that is seen are the nuclei of the cells : round
or oval in shape if viewed from above, or spindle-shaped
if the whole cell is seen in profile. I will not enter into
further details here ; this suffices to make myself now in-
telligible concerning some points in the histology of con-
nective-tissue tumors, particularly fibroma.
I investigated by the nitrate of silver method three
specimens of fibroma : 1st, a small, hard fibroma from
the finger of a girl, aet. 20, developed from the tendon ;
2d, one of the size of two fists, from the broad ligament of a
woman, aet. 35 ; and 3d, an intra-uterine fibroma of the
size of one fist, from a woman, aet. 40.
I might say at the outset that in the preparation of
the first and third specimens I failed altogether to dis-
cover any perfect endothelial sheaths surrounding the
bundles of fibres, which were so beautifully seen in a prep-
aration of tendon, made for comparison simultaneous
with the fibroma specimens. In specimen 2d only a few
THE INFLAMMATORY ORIGIN OF TUMORS. 1 59
perfect endothelial sheaths were visible. The microscopic
picture of one of the silver preparations (from specimen No.
i) was this : The fibrils were on the average much thicker
than in normal connective tissue ; some running straight^
others rather wavy and not quite parallel with one another^
frequently decussating. Only few perfect fasciculi or bun-
dles of fibres were seen, but most of them had not a trace
of endothelial ensheathment. Some had a partial endothe-
lial sheath in some places, and here the bundles appeared
constricted. In several places were seen irregular proto-
plasmic masses apparently in connection with the fasciculi
and proved to be partially detached endothelial cells. Be-
tween the bundles were seen several groups of young in-
different cells, resembling white blood corpuscles. Other
cells were double the size of the latter, some spindle-
shaped and with prominent nuclei. The latter were seen
occasionally in a state of division, or were already divided*
They resembled remarkably the germinating endothelial
cells from serous surfaces, as described by E. Klein, of
London, represented by him in his Atlas of Histology,
plate vi.
I interpret the microscopic picture as a whole thus : The
endothelial cells composing the sheaths of bundles of con-
nective tissues have become isolated, and hence the sheaths
are destroyed. The boundaries being removed, the liber-
ated connective-tissue elements grow with great vigor. The
growth is perhaps promoted yet more by the presence of
the serum of the juicc-channels, with which the cellular and
fibrillar elements now come in direct contact, the sheaths
being destroyed. The cells and fibres here, like in elephan-
tiasis, *' feed " (as Prof. Tyson would say) upon that serum
in which they are soaking. The endothelium is proliferat-
ing (germinating, Klein) and probably gives rise to those
groups of indifferent cells, which evidently form the main
l6o H. F. FORM AD.
source of the new growth. Foerster^ has pointed out
that in the development of fibroma the fibres arrange them-
selves more or less concentrically around and develop from
these islands of cells, thus giving rise to the lobulated ap-
pearance of this new growth. It is also very probable that
emigrated white blood corpuscles assist in forming those
collections of cells.
What interests us at present, however, is the absence of
the endothelial sheaths in the connective-tissue bundle in
the fibroma, and that this feature fibroma has in common
with all connective-tissue formations which owe their ori-
gin to inflammation, as will be shown directly.
I can afifirm the absence of endothelial sheaths in the
new-formed fibrillar connective tissue as met with in cir-
rhosis of organs, which invariably accompanies the prolifera-
tion of the alveolar connective tissue in such situations. It
would be very desirable that other histologists would under-
take research in this direction.
Cornil and Ranvier'' describe the disappearance of the
endothelial ensheathments in connective tissue which is the
seat of inflammation. They describe the appearances as
follows : " The fasciculi are smaller, less distinctly fibrillar ;
they do not appear to be enveloped by a special layer which
limits them and which causes them to swell irregularly
when acted upon by acetic acid." C. and R. consider that
the " large flat cells " are replaced by embryonic tissue.
The inflammatory process is, to my knowledge, the only
factor which can disconnect or isolate endothelial or epi-
thelial cells united together to form a certain lining or cover-
ing. Let us take, as an instance, the lung. The flat cells
which form the lining of the air-vesicles, are so closely
* Foerster, Atlas der mikroskopischen und pathologischen Anatomic, Leipzig,
1855.
"Cornil and Ranvier, A Manual of Pathological Histology, translated by
Shakespeare and Simes, Philadelphia, 1880.
THE INFLAMMATORY ORIGIN OF TUMORS. l6l
united or grown together in the normal adult individual,
that no means at our command at present can isolate them.
But in catarrhal pneumonia the inflammatory process de-
molishes that lining instantly ; the cells which compose
it " return to their embryonic state " (Strieker); they be-
come completely isolated.
The abnormal increase in bulk of tissue in both the
fibroma and the inflammatory connective-tissue products,
appears to me to be due to the same cause :
1. The removal of the boundaries which keep the fibres
intact, viz., the destruction of the endothelial ensheath-
ments.
2. The proliferation of the endothelial cells of these de-
stroyed sheaths and of the connective-tissue elements them-
selves, and probably with the aid of white blood corpuscles.
If the endothelial sheaths of the connective-tissue bundles
and other normal boundaries are re-established in the in-
flamed tissue, then it will return to its normal state, or in
case of loss of substance, will heal by permanent scar-tis-
sue. The healing process was perfect.
On the other hand, the same tissue will give rise to a
fibroma if this healing process was imperfect ; i.e., the endo-
thelial ensheathments are not re-established, the connective-
tissue elements remaining freed from any restriction pro-
liferate on their own accord, grow above the physiological
limit, and thus inflammation terminates in a tumor.
Hence, from histogenetic grounds, I would suggest that
fibromata should be classed as a product or rather as one of
the terminations of inflammation.
This is also in accord with clinical experience.
Now, is an inflammatory origin less evident in other tu-
mors ? Can there be shown any positive microscopic differ-
ence, for instance, between a mass of inflammatory granula-
tion tissue and a sarcoma? There cannot. To my knowl-
1 62 H. F. FORM AD.
edge distinguished histologists have repeatedly had sad
experience in this.
If the discoveries of Classen and Woodward should prove
correct, we would, to my mind, have another additional
proof that cancer is only one of the terminations of inflam-
mations. I will quote the following :
Woodward ^ says : " My own studies of thin sections led
me to the conclusion that the migration of white blood
corpuscles played a great role in the development of cancer-
ous growths, and that at least in certain cases the cancer
cylinders were formed by the transformation of these cor-
puscles, which first accumulated in the lymphatic capillaries
and the passages leading to them."
Classen '^ is even still more positive, saying that he has
proven *' that the cells of cancer cylinders and all the ele-
ments of cancerous growths are no other than migrated
white blood corpuscles escaped from the blood-vessels."
Though in my own research I did not succeed as yet to
confirm the observations of Woodward and Classen, they
are possibly correct, and I utilize them as coming from such
high authority. Besides, they correspond so remarkably to
what I believe to have established for fibroma.
My view of the histogenesis of fibroma holds good also
for primary glandular carcinoma.
The glandelemma or basement membrane in glands
(wherever such exists), upon which the epithelial cells rest,
may be destroyed in precisely the same manner as the en-
dothelial sheaths of the fibrillar bundles. This is demon-
strable in carcinoma beginning to develop in a gland, or in
the transformation of an adenoma into cancer. Here, as in
fibroma, only an inflammatory process can accomplish this
destruction of the normal boundary. If this boundary
^Woodward, On the Structure of Cancerous Tumors. Toner Lectures,
Washington, 1873.
'^Classen, Ueber Cancroid der Cornea, etc. Virchows Archiv, Heft, i, 1870.
THE INFLAMMATORY ORIGIN OF TUMORS. 1 63
be not re-established after an injury, by perfect healing,
there is nothing to prevent the epithelial cells from travel-
ling into surrounding connective-tissue spaces and to thus
form a cancer.
It is not the want of resistance of the surrounding tis-
sue (as is generally held), but simply the getting loose of
the normal cells from their place of attachment, which con-
stitutes the formation of a malignant tumor.
It is the mobility of the cells, I think, that conditions
the malignancy of a tumor. Any tumor, even the most
benign lipoma, would be eminently malignant, if the cells
composing it could get loose and travel through the widely
open paths of the system of juice-channels.
It would appear that I have deviated from the scope of
my subject ; but I think all these points considered have a
direct bearing upon the etiology of tumors. Of course, I
consider this communication nothing more than an attempt
at the solution of the etiology of tumors. I hope it may
suggest some thoughts, and encourage others to undertake
research on this subject, which, I believe, will establish the
fact that all tumors are products of the inflammatory process,
and that they should be considered as 07ie of the terminations
of inflammation.
EDITORIAL DEPARTMENT.
TREATMENT OF STRICTURE OF THE MALE URETHRA.
One can well begin a task of this nature, and upon this sub-
ject, by quoting from Pope, who wrote : —
" What dire offence from amorous causes springs,
"What mighty contests rise from trivial things."
While it is not fair to presume that Pope had in mind each of
the peculiar physical infirmities and so-called punishments often
meted out to those who violate a law of God to gratify the
*' passions of men," yet either from practical observation, personal
experience, or prophetic vision, he set to rhyme a sentiment that
will appeal to the reason of the erring multitude and its medical
advisors.
Had he lived till the present time and viewed with indifference
and unconcern the presence of a stricture of his own urethra,
while indulging in the so-called good things of the world, he
would have, no doubt, like ordinary mortals, been forcibly re-
minded of the truth of the stanza of his contemporary John
Gay:
" So comes the reckoning when the banquet's o'er —
The dreadful reckoning and men smile no more."
It is not impossible nor entirely inconsistent to suppose that.
Pope, having had " urethral irritation " which had *' from amor-
ous causes " sprung, visited the specialists of his day and had
been edified or annoyed by their individual theories and per-
sonal animadversions, rather than relieved by their art : — a vari-
164
STRICTURE OF THE MALE URETHRA. 1 65
ety of experience that cannot be said strictly to have died with
Pope — or any one else. This fancied experience might have
caused him to have written "What mighty contests rise from
trivial things." However this may be, it is a fact that there is
scarcely any, if any surgical condition to which the male portion
of the human family is so strongly predisposed, by reason of its
indiscretions, as to stricture of the urethra. Gonorrhea and
other morbid processes which depend upon impure or intemperate
sexual intercourse are of the most common occurrence. Any
one attached to the venereal service of a dispensary or hospital
can recall without any effort the coming of the aged mendicant,
who with a feeble frame and tremulous voice presented his " run-
ning " for treatment. It is not of infrequent occurrence that the
other extreme of life presents itself for treatment ; children yet
in their 'teens, children in arms, and, one might add, babes at the
breast, who have become affected by the lascivious dalliances of
diseased nurses. The extremes suffer the least of all ; between
them, in all stations of life, honor, and power, is to be found the
material that fills the morning hours of the busy practitioner, as
well as the venereal wards of the hospital, the class at the dis-
pensary, and, worst of all, fills once happy homes with distrust,
disease, and death.
The influence of the sexual passion is exceedingly powerful and
reaches everywhere. It has caused the overthrow of empires,
destroyed cities, disrupted social order, and scandalized the holy
calling ; all yield to its influence, and a multitude revel in that with
which God endowed animal nature for the preservation of species.
A prominent surgeon and specialist of venereal diseases was once
heard to say, " Show me a man who has never had the clap and
I will show you a curiosity." He might have added — or a very
lucky man. This statement is, of course, somewhat hyperbolical,
yet it emphasizes with full force the generally accepted state of
things. A disease of such common occurrence, one which dates
its birth so near to the inception of the human passion which pre-
disposes to it, must cause much suffering, and be followed by
troublesome and dangerous sequels. The sequel that will engage
i66
y. D. BRYANT.
our attention at this time is commonly and scientifically known
as stricture ; and, while the laity do not comprehend the full force
of the word, its suggestion will often lead to a confession of judg-
ment.
It will be our purpose at this time to recall as far as practi-
cable, the various methods which have been employed for the
treatment of stricture during the last thirty or forty years, as well
as to cursorily mention their association with much earlier periods.
During this period, many of the best surgeons and most noted
specialists have devoted their earnest efforts to a solution of the
questions associated with it. One who attempts to follow out all
of the methods, with their variations, will find himself engaged in
a task not at all consistent with the time and patience of the
reader, or the space to which it can be allotted reasonably in a
medical journal. The classification of stricture — upon which the
treatment so largely depends — has changed but little during the
last half century. We meet to-day, as then, with the organic and
inorganic, the traumatic and idiopathic, the congenital and ac-
quired, the inflammatory and spasmodic forms ; yet, while the
classification has remained substantially the same, differences of
opinion have arisen and continue to arise regarding the exact re-
lation of one form to another, and their relations to the urethra.
Their pathology, which is closely interwoven with their classifica-
tion, and upon which it so markedly depends, has been a matter
of dispute, especially regarding the spasmodic and congenital
varieties. The treatment of to-day admits of nearly the same sub-
divisions as formerly, having gained, however, a more technical
nomenclature, but still bearing strongly the ear-marks of the older
masters. Some of the former methods are almost obsolete in prac-
tice, and are only mentioned in the text-books to be condemned.
The improvements in the implements for the treatment of stric-
ture have, if any thing, been in the advance of the results of the
treatment ; yet, these improvements have rendered it simpler, more
satisfactory, and, in most instances, safer for the patient. The
treatment is rationally divided into constitutional and local, the
former usually being medicinal. While the importance of each is
STRICTURE OF THE MALE URETHRA. 1 6/
well understood, the former is, at the present day, overshadowed
by the latter. This may be due in part to the unwillingness of
the patients to submit to delay. We think, however, that the de-
sire of many surgeons to utilize the latest instrumental improve-
ments has much to do with it. Still, that less emphasis is given to
the general treatment than formerly, is seen by referring to Guy's
Hospital Reports ^ April, 1840, wherein Mr. Bradsby Cooper said
substantially : " Mechanical application contributes but little tow-
ard radical cure, unless constitutional means be combined." He
still further emphasized his belief in the importance of the general
treatment, when he asserted that *' constitutional remedies alone
may cure recent strictures." He advocated the warm bath, bleed-
ing, opium, belladonna, etc., for irritable and bleeding strictures.
If Mr. Cooper had possessed the means at the command of mod-
ern surgeons, he would have relied less, no doubt, upon the
constitutional ones. The local measures had the same general
classification as at present, only being necessarily less diversified.
The various modes of dilatation were employed according to the
peculiar views of the surgeon. It was the practical failure of this
method in many cases, which naturally suggested the necessity of
additional means of relief, and led to the development of the
methods of treatment by cautery, divulsion, incision, etc., all of
which, it will be seen, tended to hasten or supplant the absorptive
and dilating influences induced by the older methods ; one of
which — dilatation — has borne the test of experience longer than
any other, having been employed by Galen to remove ''carnos-
ities."
There are many surgeons who now rely entirely upon some
form of dilatation. This is due largely to its perfect safety, as
estimated by their timidity of the prompter means of relief.
Sometimes, in a small and almost impermeable stricture, filiform
bougies are allowed to remain a definite time, provided they
cause no discomfort to the patient. This treatment, however, is
not persisted in. Sir Benjamin Brodie, who is said to have spent
one year in passing an instrument into the bladder, once advo-
cated the use of continuous dilatation under the following circum-
1 68 y. D. BRYANT.
Stances : " Old grizzly cartilaginous strictures which a bougie
will not dilate, strictures with false passages, strictures with an
irregular-shaped urethra, strictures with rigors following each
instrumental introduction." Others at his time favored this
method either alone or in conjunction with caustics. In the Lan-
cet^ March 13, 1847, is to be found the somewhat novel method
of Mr. J. Goodman, who proposed what he was pleased to call
the " hydraulic dilatation" method. This consisted in throwing
a stream of warm water through a catheter against the stricture,
which from preference should possess a spasmodic element and
be associated with acute retention. Messrs. Jordan, Shellton,
Adams, and Wakley also advocated it in the treatment of stric-
tures unassociated with these complications. This method has
been recommended somewhat recently by Gaze, of Strasbourg,
Hadden and Golding, of New York. It has attracted attention
more on account of its novelty than utility. Later, Mr. Wakley
(185 1), with his ingenious array of guides and sliding tubes, made
use of all forms of dilatation. The same can be said of Mr.
Arnott, who in 1841 recommended fluid pressure through the
agency of a varnished silk tube lined with gut, which, when
passed through the stricture, was distended by various fluids.
These methods, while showing a great fertility of resource on
the part of their projectors, did not constitute a real advance
in treatment, except in so far as they taught the very useful
lesson of care and gentleness in manipulation. The method by
rapid dilatation has been strongly advocated, though it has never
met with continuous favor, and is seldom employed at the present
time, except in lieu of mild divulsion, to which form of treatment
it is closely allied. It is much better to divulse mildly with a
suitable instrument, than to submit the patient to the rapid intro-
duction of separate instruments, each of which must come into
extensive contact with other than the diseased tissue, thereby in-
creasing the danger from chills and other recognized complica-
tions. The process of "vital dilatation," — after Dupuytren, — also
called the "pressure method," has few, if any, advocates at the
present day. It consisted in bringing continuous pressure to bear
STRICTURE OF THE MALE, URETHRA. 1 69.
against the stricture by means of the point of a catheter, or other
suitable instrument, fastened or held in position. This was em-
ployed in the so-called impassable obstructions. A December
number of the Medical Gazette, 1843, contains an article earnestly
advocating its use. It informs us the " pressure should be con-
tinued for an hour at a time, if necessary," and " that a half
dozen sittings" will enable one to " get in." Mr. Samuel Solly,.
of St. Thomas' Hospital, in an April number of the Lancet, 1856,
stated that "not one case in two hundred need be cut," that "cut-
ting in the most skilful hands is dangerous," that the " pressure
treatment," catgut bougies, and constitutional means were suffi-
cient to cure any case. Here again is taught the lesson of cau-
tion and respectful consideration for the individuality of the
human urethra. Chemical agents have been employed, until late
years, in the treatment of obstinate, irritable, and bleeding stric-
tures, at various times since the fifteenth century. Antimony,,
arsenic, subacetate of copper, quick-lime, and other similar
agents, were advocated by Lacuna, Diaz, and others ; subsequently
by Pare and Wiseman. John Hunter brought it into notice in
England during the latter part of the eighteenth century, and
recommended the use of nitrate of silver in " obstinate obstruc-
tions."
Sir Everard Home followed, and extended its use to nearly all
forms of stricture. At the beginning of the nineteenth century,
Mr. Whateley advocated the superiority of potassa fusa. A little
later, Ducamp, Lallemand, and others employed it in France.
Phillips, Wade, Morgan, and Clarke, of England, followed ; they
limited the extent of its use, and improved the methods of its ap-
plication. During the last few years but little has been said in its
favor ; its questionable action, the danger attending its general use,,
and the advent of better means of treatment, have rendered it:
objectionable in theory and almost obsolete in practice. Galvan-
ism was first used in the treatment of stricture by Crussel, subse-
quently by Willebrand, Wertheimer, Jaksch, Althaus, and others.
Somewhat later, Mallez and Tripier announced important and un-
usually successful results, which, however, were not fully confirmed
I/O y. D. BRYANT.
"by those made at Charity Hospital in 187 1 by Drs. Keyes and
Beard. Later still, 1874, Dr. Newman, of this city, reported quite
a number of cases successfully treated by himself. This method
has attracted little more than the casual notice of those not
wedded to electro-therapeutics. Much of the beneficial effect
attributed to its use, no doubt, arose from the mechanical effects
of the bougies and electric current, rather than any electrolytic
action.
The method by divulsion, or forcible rupture of the stricture
tissues, had its inception in the treatment by rapid dilatation by
means of sounds, etc. It prevented the injury done the mucous
membrane of the organ by the friction arising from the repeated
introduction of instruments, as well as avoided many of the com-
plications attending incision. Mr. James Arnott's silk tube dila-
tor, before mentioned, was arranged to act on this principle. Mr.
Luxmore endeavored, half a century ago, to supply the need, by
the use of a four-bladed expanding instrument, which could be
adapted to the continuous or rapid methods. Some years after,
Leroy d'EtioUes utilized this principle ; then followed M. Per-
reve, with his two-bladed instrument. This method grew rapidly
in favor, becoming markedly illusfrative of that traditional broom
which is asserted to always sweep clean. Even Mr. Holt, of
AVestminster Hospital, whose name is closely associated with this
method, became its earnest advocate in 1852, notwithstanding he
.asserted in the Lancet, in 1850, that he considered it "unjustifiable
to operate upon the urethra, if a catheter could be passed, in
nine hundred and ninety-nine cases in a thousand." He ad-
vocated "time and caution," and had seen no case uncured
into which an instrument could be passed. In 1852 we find
him with a modified Perreve in his hand, which he employed
•commonly in accordance with certain rules and for the following
reasons :
1. " The dilator being introduced in a small compass, passes
the stricture with greater facility and less pain to the patient."
2. " It can be increased from No. i to 12 in size, without being
removed from the bladder."
STRICTURE OF THE MALE URETHRA. 1 71
3. " This is attained by bringing but one instrument in contact
with the bladder."
4. " The dilating tubes can do no damage ; they cannot escape
from between the blades of the instrument."
5. " Dilatation can be regulated in amount to correspond to
the feelings of the patient, without withdrawing the instrument."
6. " The shape of the blade causes the dilatation to be gradual,
notwithstanding the size of the tube introduced."
In his wake followed Voillemier, Hillman, Jackson, Fayer,
Heath, and Sir Henry Thompson. In the Medical Times and
Gazette^ May, 1863, is to be found a description of an instrument
devised by Mr. Thompson for the purpose of " gradual disten-
tion," as he termed it, which was to be secured at a " single sit-
ting ; " whatever this may mean, it but resulted practically in tear-
ing the tissues asunder and producing hemorrhage, consequently
causing divulsion in the accepted sense of American surgery.
There was some excuse for the misnomer applied to the instru-
ment — "dilator," — since the custom of the profession sanctioned
it ; the term divulser, as yet, not having an accepted place in its
nomenclature. The part acted by American surgeons in this
drama has been a prominent one. They have not only operated
with rare success, but have modified and invented instruments,
adapting them to smaller strictures, easier access to the bladder,
better command over the distending influence, etc., etc.
The worth of this method has been variously estimated by the
modern surgeons of this country. By some it was employed
without much discrimination of the nature or location of the
stricture ; by others to those of traumatic origin, or having irrita-
ble or resilient characterestics. At the present time it is limited,
if used at all, to strictures of a dense cartilaginous formation,
whether due to traumatic or gonorrheal influences, together with
those having marked resilient or irritable tendencies, provided
they be located in the subpubic portion of the urethra. It is
just to add that Dr. Agnew accepted it with reluctance, and has
since abandoned it entirely. He considers it " rude and unsurgi-
cal," and cites two facts which, in his opinion, militate against its
172 y. D. BRYANT.
use. (i) " Nothing can be accomplished which cannot be obtained
by gradual dilatation. It is true the latter is a slow process, but I
can conceive of no reason connected with a mere consideration of
time which justifies a surgeon in jeopardizing the life of the
patient." (2) " The tendency to re-formatiom of the stricture is
not lessened by divulsion ; after laceration of the tissues, an
ulcer is left which can be repaired only by granulation and cica-
trization ; the new tissues will not become like the normal urethra^
but will contract and certainly demand the repeated use of bougies
for an indefinite time." Drs. Gouley, Van Buren, and Keyes,
and other recognized authorities, speak kindly of the method
when limited to the situation and variety of strictures before men-
tioned.
Incision, or cutting of strictures, is not a modern operation.
According to some authorities it was practised at the beginning of
the Christian era. There are definite accounts of its employment
in France by Allies in 1775, by Physick, of Philadelphia, in 1795,
by John and Charles Bell in 1807, and Stafford in 1827. Many
of the older surgeons employed caustics in conjunction with in-
cision. While the English and American surgeons showed due
dilligence in the advancement of this method, to the French sur-
geons belong much of the credit of having developed it, aided
by their almost innumerable and variously constructed urethro-
tomes. Among those who were closely associated with the
method in France are to be found the names of Ducamp, Amus-
sat, Civiale, Sedillot, Ricord, Mercier, Reybard, and Maisonneuve.
To describe the peculiar method of each is impracticable and
unnecessary, if not almost impossible. The subdivisions of this
method are substantially the same to-day as when accepted by
the older surgeons, viz., internal and external division ; internal
division being limited to those obstructions in front of the trian-
gular ligament, by some, and to those in the spongy portion, by
others, each of which may be incised from behind forward, or the
reverse.
Something of the early history of this method of incision has
already been given.
STRICTURE OF THE MALE URETHRA. 173
The method of external division is, as one would sup-
pose, of older date than the internal. The latter begot the
necessity of making incisions in the dark with rudimen-
tary implements, while the former served to utilize the sense of
■sight and touch, as well as the ordinary cutting instruments of its
time. To Wiseman, in 1652, is said to belong the credit of hav-
ing first performed the operation with a view of curing stricture.
A few years later Solingen repeated it. It was done by Tolet and
Colet in 1690, then by Petit and Le Dran in 1740. The cases
operated on by these gentlemen admitted of the introduction of
an instrument into the bladder. In 1783 John Hunter, without
a, guide, did what is now sometimes called perineal section, but
more correctly known as external perineal urethrotomy. He
was, however, antedated by Molins, an English surgeon, who did
a similar operation in 1662.
Perineal section was rarely done till employed and championed
by Granger in 1815. In 181 7 Alexander H. Stevens added his
name to its list of supporters. Then followed Dr. Jamieson, of
Baltimore, in 1820-23. Dr. David L. Rogers, of this city, in
1823 reported twelve cases successfully treated.
Dr. J. C. Warren, of Boston, and other New York surgeons
employed and approved the method. In 1840 Dr. Syme, of Edin-
burgh, used it, and subsequently, 1844, forcibly proclaimed him-
self in favor of cutting old, tough, and resilient strictures ;
■^' those where relief can not be obtained by the passage of in-
struments." Many of those who preceded him, employed it only
as a means of treatment in retention of urine. The claim has
been made by some that to Mr. Arnott, of Middlesex Hospital, in
1822, belongs the credit of first having used it for impassable
and uncomplicated stricture. Be this as it may, no one will gain-
say the fact that to Dr. Syme belongs the honor of developing its
worth and contending for its permanency. Associated with this
operation are to be found the names of Gouley, Van Buren, Wood,
Weir, and others of this city, and to these gentlemen belongs
much of the honor of having offered the surgeons of the present
time the means of triumphing over urethral obstructions. The
174 y. D. BRYANT.
permanency of external perineal urethrotomy is well established,
and in cautious hands it will serve to perpetuate the names of
those who have perfected it. The subcutaneous method, advo-
cated by Dick and others, has attracted but little attention, yet it
has been and now is employed occasionally by surgeons of note ;
its application being properly limited to the penile portion of the
organ. The methods most in use for the treatment of strictures
anterior to the subpubic arch are gradual dilatation and internal
incision ; the former having the greater number of advocates.
There is much to be said in favor of both methods ; much argu-
ment and not a little animosity have been exhibited during the
last few years by those who are strongly wedded to their special
forms of treatment. To Dr. Otis, of this city, undoubtedly be-
longs the credit of having instituted something like a new era in
the location, number, and size of strictures, as well as the capacity
of the urethra, and the relation which it bears to the circum-
ference of the organ. Mr. Berkeley Hill, of the University Col-
lege, England, while speaking of the views of Dr. Otis in a
communication to the Lancet, Apr., 1876, said that " Dr. Otis
during his visit here enunciated views which vary considerably
from, and, indeed, are opposite to the doctrines usually taught in
this country." Many other allusions complimentary to Dr. Otis'
independence of thought, action, and ingenuity of resource can
be found scattered through the medical journals of England, and
in not a few in this country.
The questions raised by Dr. Otis may be briefly summarized as
follows :
1. Regarding the normal calibre of the urethra.
2. The definite proportional relation of the urethral circum-
ference to the circumference of the flaccid penis containing it.
3. The existence of strictures larger than the previously ac-
cepted size of the calibre of the canal.
4. That gleet and troublesome reflex irritations depend upon
these strictures.
5. The greater frequency of stricture in the anterior portion,
of the urethra than elsewhere.
STRICTURE OF THE MALE URETHRA. 17S
6. The possibility of a radical cure by this method of treat-
ment.
7. The advantages of this method over the methods by dila-
tation as regards safety, comfort, time, and permanency of results.
That the normal calibre of the urethra had not been correctly
estimated, prior to the investigations of Dr. Otis, has been con-
clusively proven by that surgeon.
One has but to refer to the dimensions laid down by Sir Henry
Thompson, which had heretofore been accepted as practically cor-
rect, to realize the misapprehensions under which he has labored.
The importance of a better knowledge of the size of the urethra
can but have a direct bearing upon the proper treatment of
stricture. Constrictions which before this were supposed to have
been distended to the normal calibre of the canal, are now
found to require the use of a much larger-sized instrument, to-
meet the aim previously sought and supposed to have been at-
tained.
The older masters were satisfied if a No. 8 could pass, and ad-
vised it to be "employed continuously." An exponent of gradual
dilatation, at the present time, might as well stop at No. 8 as No.
16, so far as the ultimate result is concerned. If it be necessary
to distend the urethra quite or entirely to its normal calibre for
the practical cure of a stricture by dilatation, then the importance
of determining its calibre by actual measurement or practical
deductions is clearly obvious. It has been the custom of con-
scientious and well-informed surgeons of past time, as it is at the
present, to say to a patient with a strictured urethra, " I can not
assure you I will cure the stricture ; it will probably return if my
directions be not followed "; which means to pass a sound as often
as in his judgment the case may require. May not the necessity
for these candid and humiliating statements depend largely upon
the fact, that till Dr. Otis determined the actual calibre of the
urethra, the treatment had not been carried to the extent of dilat-
ing the canal to nearly its normal dimensions ? The surgeon
might as well cease at No. 6 or 8 — like our forefathers — so far as
a cure is concerned, as at No. 16 or 18, as many do now, since the
17^ y. D. BRYANT.
latter measurements are but little nearer the normal size, of the
^urethra as now determined, than the former were to its supposed
dimensions. It is certain that if dilatation is to be practised with
a view of ultimate recovery — how else can the possibility be deter-
mined — the strictured tissues must be subjected to a far greater de-
gree of dilatation than formerly. While we gladly admit the truth of
the assertions of Dr. Otis regarding the greater size of the urethra,
we are as yet unwilling to endorse his belief in the uniformity of
measurement from the bulb to the meatus. We have seen meatus
corresponding in size to the passage beyond, but it has been the
exception rather than the rule. The capacity of the canal, in
our opinion, is, as a rule, greater beyond, than at the meatus.
It has been our misfortune, — or rather the patients', — in two or
three instances, to have incised the meatus too freely, which
caused an imperfect delivery of the urine, soiled the clothes, and
tarnished the foot-wear. In each of these cases, however, the
most expansible portion of the canal, after the operation, was still
beyond the meatus. It is our opinion that the meatus externus is
narrower and less expansive than any portion of the canal be-
yond, and that this plan of construction serves an important
function in regulating the expulsive power of the bladder and
urethra, as well as the integrity of the stream. That a more or
less definite relation should exist between the circumference of
the flaccid penis and the canal it contains seems quite natural.
Its recognition is an important aid in regulating the size of dilat-
ing instruments, thereby obviating the danger of over-distention.
It likewise reduces an heretofore empiric procedure to one rest-
ing upon an almost scientific basis. That strictures do exist
larger than the formerly accepted size of the passage, is evident
when one recalls the fact that the circumference of a moderately
distended urethra was estimated at from twenty-five (25) to
thirty-five (35) millimetres, depending upon the portion measured,
which does not correspond in size with many constrictions de-
tected by the urethrotome. It is fair to presume, in that strictures
vary in calibre, that slight constrictions of the now determined cir-
cumference will not reduce it to the dimensions previously ac-
STRICTURE OF THE MALE URETHRA. IJJ
cepted as normal. The assertion that gleet and troublesome re-
flex irritations often depend on these strictures is unquestionably-
true so far as gleet is concerned ; nor is it impossible to sup-
pose that various neuralgias and spasms may be caused,
since constrictions of the passage are well known to produce
them. The assertion that an organic stricture in the anterior
portion of the urethra will cause a more or less persistent spas-
modic contraction of the deeper part, has given rise to consider-
able discussion, much of which has been intemperate in its dic-
tion.
This idea was advanced by Civiale in 1850. Mr. Hancock, in
the Lancet^ February, 1852, expressed the belief that spasmodic
contractions might occur at not only the membranous part but
" within one inch of the external meatus " ; that " these spas-
modic affections frequently accompany organic strictures," etc.
This question demands a careful and unprejudiced examination.
It is certain that there are many cases having obstructions in the
membranous part, that are associated with organic stricture in
the anterior portion. It is likewise certain that these obstruc-
tions are often' quite fickle in their characteristics ; sometimes
very rebellious, again failing to offer much, if any obstacle to
the passage of an instrument. Whether these phenomena depend
entirely upon a pure spasmodic contraction, incited by anterior
irritation, or the contraction be caused by direct instrumental
contact, or other causes, we are unwilling at present to declare.
Neither are we yet prepared to accept the dictum that strictures
of an acquired nature occur more often in the anterior portion
of the urethra than elsewhere. We are prepared, however, to
examine with care all cases which may fall beneath our tender
mercies, and hope to be able to substantiate the assertion made
by Dr. Otis regarding them.
If it be possible to cause a radical cure, we believe the cutting
process holds out the best opportunity yet known. When prop-
erly done it divides all the contracted tissues, and the space
becomes filled in by the projection of the submucous structures,
and " patched " by a new growth, which can hardly possess the
178 y. D. BRYANT.
same characteristics as the original trouble. This, together with
the absorption of the indurated tissue, is thought to reduce the
canal to its virgin state, plus a patch of new tissue.
However this may be, those who advocate the method show
conclusive proof that strictures which were cut six or eight years
previously, have not as 5^et manifested their presence by symp-
toms, or on exploration.
We feel that a certain proportion of them, at least, should be-
come radically cured, since it would be but a just reward to the
patient for the additional dangers incurred. We do not believe
this method to be as safe as that by dilatation. The fact that the
tissues are divided, that hemorrhage occurs, that inflammation
must follow in the process of repair, and that these expose the
patient to dangers from the recognized sequels of operations here
and elsewhere on the body, seem to us of necessity to settle the
question in the negative. We can recall, in our own experience,
the instance of a young man with a tough stricture of the spongy
urethra, which was cut. The hemorrhage was more or less con-
stant, and often profuse, for two weeks, requiring' the use of the
best recognized methods to stop it. The urethra became in-
flamed, and an abscess was near forming ; but the patient recov-
ered with a cordee which lasted some months. No one claims to
be able to say positively when or how much bleeding will occur,
or when it will cease. It is impossible to accurately predicate
these facts.
We have learned of cases that have been almost exsanguinated,
of cases that have died from pyaemia, and other sequels. That
these are exceedingly rare there can be no doubt, yet that they are
liable to occur, and do occur — two undisputed facts — will always
clothe the method by incision with greater danger to the patient
than from gradual dilatation.
So far as time, comfort, and permanency are concerned, the
method by incision outvies all others in expediency. The truth
rests simply here, no one method can be used to the exclusion of
all others, and whoever advocates this or that method as his exclu-
sive one will, no matter how good the method or great his reputa-
STRICTURE OF THE MALE URETHRA. 179
tion, cover both with obloquy. We believe this method should
be advanced with great caution, else the young, inexperienced
surgeon, becoming fascinated by its brilliancy, with visions of a
great reputation and a large bank account before him, may, in
his sincere efforts to reduce to the standard size the male urethra,
in his vanity, become a victim to that "vaulting ambition which
o'erleaps itself and falls on the other side."
J. D. BRYANT.
NEW BOOKS AND INSTRUMENTS.
A New Foot Dynamometer.* By W. R. Birdsall, M.D.
If an apology is necessary in presenting what at first sight may
seem too unimportant a subject for the consideration of such a
society as this, the answer may be given that any means which
renders more exact and perfect our method of physical examina-
tion is not unworthy, of consideration.
Having felt the want of a more accurate method for determin-
ing paretic conditions of the lower extremities than the usual one
by watching the gait and testing the resistance of certain groups
of muscles in the hand, I attempted to construct an instrument
corresponding in character to the dynamometer used in testing
the power of the grasp in the upper extremity. The instrument
before you is the result.
It consists of a base-board i8 x 6 inches, in which are mortised
two upright supports for an iron rod which forms an axis on which
the foot-board turns. Three grooves are cut in the base-board at
one end, and corresponding grooves in the under surface of the foot-
board, into which to slide the ordinary elliptical spring dynamometer
used for testing the grasp. An adjustable ^^z^^^ slides on the up-
per surface of the foot-board for the purpose of giving a definite
position to the foot. In order to fasten the foot firmly to the
board and furnish a point for traction, a broad toe-strap is used
when the anterior tibial group of muscles is to be tested, and a
narrow heel-strap for testing the posterior group. It is prevented
from slipping by being passed through slits in the foot-board.
The latter is also covered with rubber to prevent the foot from
slipping.
The instrument is operated in the following manner : For test-
ing the anterior tibial group of muscles : the person being seated,
* Read before the American Neurological Association, June 17, 188 1.
180
NEW BOOKS AND INSTRUMENTS. l8l
the foot is placed on the foot-board, in a position at right angles
to the leg, which should be perpendicular. The heel rests over
the spring, against the gauge which is placed in position No. i,No.
2, or No. 3, according to the length of the foot. The toe-strap is
then passed around the foot-board and the foot, and strapped as
tightly as possible. The spring is placed in one of the grooves.
The person is then told to flex the foot as strongly as possible.
This action of rotation at the ankle joint, the foot being secured
to the board, produces traction on the forward end of the foot-
board and a downward pressure at its rear end, these two parallel
but unequal forces tending to rotate the board on its axis, com-
pressing at the same time the spring which offers resistance,
whose indicator shows the amount of work accomplished. As the
spring is not stationary, it is removed each time for the con-
venience of reading.
If, when the gauge is in position No. i and the spring in groove
No. I, a certain result be obtained, the removal of the spring
nearer to the foot-board axis would give the foot a greater lever-
age, and, consequently, a greater number of degrees would be
exhibited on the indicator ; while with the spring in groove No. i
and the gauge at No. 2 or No. 3, the reverse effect would be pro-
duced. This, enables one to adjust the instrument for different
degrees of foot power.
In testing the posterior group the instrument is reversed : the
toe being placed against the gauge, and the heel-strap fastened
over the instep, on an effort being made to raise the heel (contrac-
tion of the posterior tibial group), traction is made by the heel,
and pressure by the ball of the foot, acting upon the instrument as
in the previous case.
A NEW FOOT DYNAMOMETER.
1 82 ARCHIVES OF MEDICINE.
The foot-board may also be strapped on to the posterior surface
of the leg, and an effort made to extend the leg upon the thigh
will also be indicated, though with greater chances of error than
in the other cases.
As in the dynamometer for the hand, so in this one, it is not the
absolute power which we particularly desire to determine, but the
relation between the right and the left sides, so that the position
of the foot or of the spring is not of much importance, provided
the conditions are the same for each member tested. It is to se-
cure this that the gauge was added and definite positions given to
the spring.
For the purpose of uniformity in registering cases, these two
conditions are indicated by a fraction in which the position
of the gauge represents the numerator — being above — and the
position of the spring the denominator. Thus if the gauge be
back of the first groove and the spring in the first groove, the
formula would read \\ if the spring be changed to the second
groove, the gauge remaining as before, \ would be the formula,
etc.
Precautions. — ist. Be sure that the feet are in the same posi-
tion on the board ; this is easily accomplished by means of the
gauge against which the heel or the toes rest.
2d. See that the strap is tightly adjusted so that there is no
slackness. This is the most important point of all, and consti-
tutes the greatest source of error in the use of the instrument.
The excursion made by the foot in contraction of the muscles of
the anterior tibial group is not great, and if the foot must be
raised even a short distance before it begins to exert traction, a
good deal of power is lost. I have found, however, that with
proper care this can be avoided.
3d. As flexion or extension of other muscles makes considera-
ble difference in the power of contraction, the position of the ex-
tremity and that of the instrument should be as nearly alike as
possible in both feet. The proper position is to have the foot at
right angles to the leg, the latter being perpendicular.
4th. Care must be taken that the weight of the body is not
thrown upon the instrument. This may be avoided by a sitting
posture, not allowing the subject to bend his body forward.
5th. The tests should be repeated at least five times for each
foot, and the average taken ; this applies as well to the hand
dynamometer, for the subject in his first effort may not quite un-
derstand what movement should be made, and as it is a matter of
NEW BOOKS AND INSTRUMENTS. 1 83
voluntary effort the results at all times will vary on account of
unequal exertions.
6th. See that the spring is always introduced in the same po-
sition and is firmly located in the groove.
My object has been to construct a cheap and simple instil-
ment that would not get out of order and which could be easily
and quickly adjusted.
This instrument is so simple in construction that any carpenter
and blacksmith can make one. As those who would use such an
instrument have already a hand dynamometer, an important item
in the expense is done away with.
If it is desired, the instrument can be converted into a dynamo-
graph by fastening with a clamp a Pond's sphygmograph upon
the outside of one of the uprights, and allowing a bent wire fas-
tened to the edge of the foot-board to impinge on the rubber cap
of the sphygmograph.
It is hardly necessary to dwell upon the uses of the instrument.
All that is claimed for it is that it furnishes a more exact method
for studying the distribution of paresis in the anterior and poste-
rior tibial groups of muscles than those hitherto in use.
I may state that in the majority of healthy persons, I have
observed very little difference in strength between the right and
the left sides. ^
Rheumatism : its Nature, its Pathology, and its Suc-
cessful Treatment. By T. J. Maclagan, M.D. London :
Pickering & Co., 1881, pp. 333.
The chief aim of the author of this work is to explain all the
phenomena of articular rheumatism by means of the germ theory
of disease. His procedure is logical. Before advancing his own
views he attacks the lactic acid theory, the only one that has any
claim to general acceptance. Confidence in this theory had al-
ready been shaken by the failure of the alkaline treatment, and
still more by the brilliant results of one which, in spite of Dr.
Maclagan's claim to the contrary, must yet be regarded as, in a
certain sense, empirical. I refer, it is scarcely necessary to say, to
the treatment by the salicyl compounds.
While denying that lactic acid is the cause of rheumatism. Dr.
Maclagan admits its presence in abnormal amount in that affec-
tion, but considers it and the joint inflammation to be common
effects of a rheumatic poison, which enters the system from with-
^ Tables were exhibited illustrating the manner of recording cases and the
results in certain diseases.
1 84 ARCHIVES OF MEDICINE.
out. He also admits that this excess of acid may be a secondary-
cause of the articular and muscular symptoms, its accumulation
leading to functional disturbance of the locomotor apparatus of
which it is an excretory product. Functional disturbance, he
^ys, is manifested in white fibrous tissue by pain. It is thus that
he explains Dr. Foster's remarkable case of a diabetic, in whom
the administration of lactic acid was followed by six well-marked
attacks of an affection which it was impossible to distinguish from
acute articular rheumatism. " Excess of acid may cause joint
pains, but what causes the excess of acid ? " In Dr. Foster's case
the " lactic acid was given to the patient, and its presence in ex-
cess was readily accounted for. In acute rheumatism the excess
of lactic acid is the phenomenon which, of all others, it is at once
most essential and most difficult to explain." Dr. Maclagan's ex-
planation is that the acid is the product of an unusual activity in
the retrograde metamorphosis of muscle, which, considering that
muscle is not generally regarded as being prominently affected in
articular rheumatism, is not entirely satisfactory. Rather too
much space is, in our opinion, devoted to the refutation of Rich-
ardson's experiments of injecting lactic acid into the systems of
some of the lower animals. Senator treats these same experiments
in a much more cursory manner. After stating that they had
been disproved by MoUer and Reyher, he remarks that it would
have been surprising if they had succeeded, as they were per-
formed upon animals, — cats and dogs, — almost wholly insuscepti-
ble to rheumatism, and peculiarly unsuitable for such experiments
in that they are devoid of sweat glands.
A chapter is devoted to the miasmatic theory of rheumatism,
the one adopted by the author. Other observers have noticed a
similarity between the febrile course of rheumatism and the ma-
larial fevers. Senator considers rheumatism allied to malarial
fever and influenza, but points out, at the same time, that the
maximum prevalence of the disease between October and May,
militates against the miasmatic theory.
The principal points of resemblance between rheumatism and
malarial fever, referred to by Dr. Maclagan, are rather negative
than positive. They are as follows :
1. Both are " specially apt to occur in low-lying, damp locali-
ties, in certain climates, and at certain seasons of the year.
2. " Some people are more liable to be attacked than others.
3. " They have no definite period of duration.
4. " They are not communicable from the sick to the healthy."
NEW BOOKS AND INSTRUMENTS. l8S
He traces still further analogies between their symptoms, to
which we have not space to refer.
Dr, Maclagan divides the miasmata into two classes, eruptive
and non-eruptive, classing rheumatism as an eruptive fever. The
distinction, says he, between an eruptive and a non-eruptive fever
is, *' that the latter consists simply of fever, the former of fever
plus a local lesion. The local lesion of rheumatic fever is the
joint affection." It seems to us that on similar grounds the sple-
nic tumor of intermittent fever might also be called an eruption^
for it is certainly a local lesion.
Dr. Maclagan's theory may be briefly stated as follows :
In all the contagia and miasmata, the poison, entering from with-
out, finds, in some part of the body, a nidus in which the germs
are reproduced with great rapidity. This nidus, also called by
him the second factor of the poison, he regards as essential to the
reproduction of the poison germs. It varies in amount and situa-
tion in different individuals and may, it is to be inferred, be ab-
sent in those insusceptible to the disease. When the heart is at-
tacked, it is because the second factor exists in the fibrous tissue
of the valves. All this is in strict analogy with what is known re-
garding the habits of parasitic organisms whose existence is not at.
all hypothetical, and is a logical result of the germ theory.
Dr. Maclagan quotes from the work of the late Prof. J. K.
Mitchell, on the "Cryptogamous Origin of the Malarious and Epi-
demic Fevers," but, strange to say, appears to be entirely unac-
quainted with the same author's views regarding the spinal origin
of acute articular rheumatism. Our space permits no more than
a mere reference to the interesting papers of Prof. Mitchell (con-
tained in the volume of the American Jojirnal of the Medical Sci-
ences for 183 1, p. 35, and the volume for the same journal for
1833, p. 360), and the remark that his views have been of late
years revived by the writings of Charcot and Weir Mitchell.^
The chapters on the different forms of rheumatic cardiac in-
flammation are highly interesting and, in some respects, entirely
original. He denies the existence of inflammation of the valvular
portion of the endocardium, except as secondary to inflammation of
the fibrous structure of the valves, and when endocarditis coexists
with myocarditis, he considers that the former is secondary to the
latter. In this he differs from Roberts, Bristowe, Peacock, and
others, and solely on the ground that the endocardium is a non-vas-
^See article on "Spinal Arthropathies." A??i. your. Med. Sci., April, 1875.
1 86 ARCHIVES OF MEDICINE.
•cular structure. We agree with him in this view, for as the nutrition
of a non-vascular structure must be secondary, so must its perver-
sion of nutrition, known as inflammation, be also secondary. Dr.
Maclagan is of the opinion that the diagnosis of myocarditis is
not the " impossible thing it is usually supposed to be," and con-
siders that such diagnosis may be a matter of " supreme impor-
tance " to the patient, but, except as indicating the necessity of
absolute quiescence, this hardly appears in the sequel, for there is
no difference in his treatment of cases whether they have heart
disease or not. Salicin, administered so as to saturate the system
as soon as possible, is the treatment of all alike. A muffling of
the heart's sounds he considers diagnostic of myocarditis, distin-
guished from the muffling of hypertrophy by the absence of signs
of increased force of action.
In regard to the method of administering salicin, Dr. M. finds
that one ounce is requisite to remove the acute symptoms, and
this amount should be administered within the first sixteen or
twenty-four hours, after which it should be given in gradually di-
minishing doses for a week or ten days. His emphatic recommen-
dation that the patient should keep his bed for one week is a most
significant commentary upon the success that attends this treat-
ment. The beneficial effect of salicin is most marked in early
attacks. In chronic thickening of the fibrous textures, due to
repeated attacks, exacerbations of pain may be excited by causes
other than the rheumatic poison, and over these the salicyl com-
pounds exert no effect. In such cases the alkalies are of service.
While characterizing the administration of salicylic acid in rheu-
matism by the German physicians as a " pure piece of empiri-
cism," Dr. Maclagan claims that his use of salicin in the treat-
ment of the same disease " more than a year before salicylic acid
was brought into notice by Strieker and Riess " " was
not a piece of empiricism but a logical inference." He observed
that a "low-lying, damp locality, with a cold rather than warm
■climate, are the conditions under which rheumatism is most likely
to arise." He further observed that the plants indigenous to this
kind of soil and climate belong to the order Salicaceoe. " Among
the Salicacese, therefore, I determined to search for a remedy for
rheumatism." The brilliant success attendant upon this search -is
enough to encourage others to pursue similar investigations.
Without pausing to discuss the precise meaning of the term
empirical, as applied to the use of a drug, we would make the
criticism that Strieker and Riess were probably familiar with Dr.
NEW BOOKS AND INSTRUMENTS. 1 8/
Maclagan's success with salicin in the treatment of rheumatism,
as he had employed it more than a year before they began the ad-
ministration of salicylic acid in the same affection ; and as they
were certainly aware that the two drugs belonged to the same or-
ganic series, it is more than probable that their use of salicylic
acid in the treatment of rheumatism was also *' not a piece of em-
piricism, but a logical inference " from the facts observed by Dr.
Maclagan.
Dr. M. combats the view of Senator that salicin owes its thera-
peutic virtues to its conversion into salicylic acid, both on chemi-
cal grounds and because " salicin possesses therapeutic virtues
not possessed by salicylic acid ; and that salicylic acid gives rise
to symptoms which do not follow the administration of salicin."
Further, when a patient is suffering from the toxic effects of
salicylic acid, salicin may be administered freely with benefit.
Under its use the rheumatic and salicylic symptoms both disap-
pear. These important statements are apparently confirmed by
interesting reports of cases.
Dr. M. acknowledges that the hopes entertained in regard to
the salicyl compounds as prophylactic against the endocardiac
complication, have not been realized, and attributes this failure
partly to the use of insufficient doses, but chiefly to the insidious
nature of the heart affection. The endocardial blow, its first
indication, is consecutive to thickening of the fibrous structure,
friction of the segments, and roughening, as a consequence of
such friction. Therefore, when an endocarditis is detected, it
has probably existed for at least thirty-six hours. In cases of
acute pericarditis, he recommends venesection, leeches, and blis-
ters, but very properly limits the employment of the first of these
measures to the " urgent symptoms of the first stage of a very
acute attack."
Dr. Maclagan recognizes three conditions under which head
symptoms may occur in rheumatism.
1. As a symptom of inflammation of the membranes of the
brain.
2. As a symptom of inflammation of the substance and mem-
branes of the heart.
3. In connection with very high temperature of the body.
The first is so rare that he entertains a " grave doubt" whether
it be not an accidental complication. Head symptoms in the
course of heart disease he regards as due to unusual nervous
susceptibility ; while the third variety, cerebral hyperpyrexia, he
1 88 ARCHIVES OF MEDICINE.
considers due to the irritant action of lactic acid upon the thermal
peripherse. This irritation, transmitted to the thermic centre,
may result in paralysis of the heat-inhibiting function, and conse-
quent hyperpyrexia. This conclusion he reaches after a most
interesting discussion of the relations between cerebral hyper-
pyrexia and sunstroke.
Dr. Maclagan is evidently unacquainted with the able paper on
cerebral rheumatism, by Prof. Da Costa, contained in the Am. Jour,
of the Med. Set. for April, 1875. If he had been, he might have
referred to still another condition under which head symptoms
occur. Da Costa regards albuminuria as the " most common
cause of a group of the disorder mainly characterized by stupor
and coma."
The arrangement of the last chapters of the book is faulty.
The chapter entitled " Cerebral Rheumatism" is devoted to a dis-
cussion of the first two conditions under which head symptoms
occur ; then follows a chapter upon the relation of rheumatism
and chorea, one, by the way, of great interest ; and, finally, the
chapter entitled " Rheumatic Hyperpyrexia." The order of the
last two should be reversed.
The work is an infallible witness of the author's extensive and
accurate knowledge of physiology and pathology, as well as his
practical acquaintance with the subject of which he treats. It is
a rare combination of the theoretical and the practical, and, as a
whole, receives our most emphatic approval. It should be care-
fully perused by all who wish the latest information concerning
the salicin treatment from its dicoverer, as well as by those who
desire to be acquainted with the latest views in regard to the
pathology of an affection which is, indirectly, one of the greatest
scourges of the human race. [f. p. h.]
A Practical Treatise on Impotence, Sterility, and
Allied Disorders of the Male Sexual Organs. By
Samuel W. Gross, M. D., etc. Philadelphia : Henry C. Lea's Son
& Co., 8vo, pp. 174.
The book we are called on to review is written by one so well
known to us and to the profession, on account of the valuable little
work on " Tumors of the Mammary Gland," which was issued a
short time since, as well as other meritorious productions, that the
usual task attending a review becomes a pleasure by reason of the
anticipated knowledge forthcoming. The work in question does not
comprehend all of the disorders to which the male genital organs
are liable, but is limited to " impotence, sterility, and allied disor-
NEW BOOKS AND INSTRUMENTS. 1 89
ders of the male sexual organs." It is composed of 170 pages of
well-printed matter, and contains 16 illustrations descriptive of
the instruments variously employed, together with those illustrative
of the various pathological conditions incident to the diseases
of which it treats. Chapter first is devoted to impotence, which
is defined as "an inability to copulate or perform the sexual act,
due either to a deficiency or absence of the power of erection,"
plus " all other conditions which render the intromission of the
penis impracticable." About 70 pages are allotted to this sub-
ject, wherein it is classified into the atonic, psychical, symptomatic,
and organic varieties. The atonic variety is considered to be due
to changes in the prostatic portion of the urethra, or to a modi-
fied reflex excitability of the genito-spinal centre, which is lo-
cated, according to Eckhard, from the first to the third sacral spinal
nerves. The author's arguments and conclusions are based upon
the records of 149 cases which have eome beneath his own obser-
vation. Space will not allow of a separate consideration of each
form of impotence in detail, but it is proper to say that the best
possible use is made of the cases to show that stricture of the
urethra, and other morbid urethral processes bear a very close
causative relation to it. About 50 pages are devoted to sterility
in the male, which is defined to mean infertility or absence of sem-
inal fluid. The relative frequency of sterility in the sexes is based
upon 192 cases in which the husband and wife were both exam-
ined. His conclusions show the husband to be in the fault in
one in every six cases. Napoleon the First might have been
spared many of his historical protestations could he have been
submitted to the test of latter-day science. Chapters third and
fourth, the final ones, are devoted to spermatorrhoea and prosta-
torrhoea, and, like their associates, are clearly entitled to careful
thought.
The general style is good. Dr. Gross is a gentleman who cer-
tainly has something of use and interest to submit when he writes
a book, which fact alone is very reassuring. He chooses his sub-
jects with good sense, treats them succinctly, and draws conclu-
sions which his facts sustain. He is ofttimes positive, even to dog-
matism, which, we believe results from a full faith on his part in the
justice and truth of his conclusions. We notice a strong tendency
to create new words — to extend the nomenclature of the subject —
as well as to make use of those not usually met with in text-books.
While there is no law against verbal proliferation, yet the simpler
the text the more acceptable will be the work to the profession at
190 ARCHIVES OF MEDICINE,
large. We willingly welcome this little volume as an useful addi-
tion, and commend it to the consideration of all. [j. d. b.]
The Diseases of Children. By Wm. Henry Day, M.D.
Second edition. Rewritten and much enlarged. Philadelphia :
Presley Blakiston, 1881, pp. 752.
Dr. Day's treatise cannot be said, even in the second edition, to
sum up much recent knowledge in paediatrics. Hence, from this
point of view, it is no advance upon the several excellent treatises
already extant, among which Meigs and Pepper's remains our fa-
vorite in the English language. As a systematic treatise it falls,
decidedly behind the lectures of Henoch on children's diseases,
which have just been published at Berlin. For, in about the same
number of pages, it contains conspicuously less information on the
subjects which it treats ; it touches upon fewer subjects, — several,
especially from among the diseases of the new-born, are omitted
altogether ; those discussed are handled in a way at once less com-
prehensive and less precise ; more skill is shown in avoiding knotty
problems than in their elucidation ; finally, the personal clinical
experience on which the volume is professedly based, seems to us.
remarkably meagre. The average clinical outline of ordinary dis-
eases is drawn in a manner sufficiently clear and concise to be
readily apprehended by the beginning student. But such outlines
have often been drawn before ; and Dr. Day, instead of adding to
the labors of reputable predecessors, has often rather subtracted
from the results obtained by them. This remark especially applies,
to the paragraphs on pathological anatomy, and to the grouping of
clinical variations in the type of diseases, — even to those which are
characteristic of childhood, and hence the special subject of con-
sideration in a treatise on paediatrics.
Thus we are told that in typhoid fever the " temperature runs up
to 103° or even to 105° " (p. 87). But there is no hint, much less
description, of characteristic temperature curves, or of their peculiar
modifications in childhood. We should not, indeed, suppose, from
Dr. Day's description, that this fever as seen in children differed
in any particular from the ordinary adult types. The most fero-
cious lesions are described in the intestine. " Near the ilio-caecaL
valve is shown a tendency to destruction of the mucous membrane,,
and ulceration or even sloughing or perforation of the peritoneal
coat. The glands of Peyer's patches take on the appearance of
vesicles or pustules,. and subsequently they burst and produce an
ulcer with oval or irregular outline," etc. Now it is a well-known
fact that the enteric lesions in the typhoid fever of children are
NEW BOOKS AND INSTRUMENTS. IQF
very slight. To quote Henoch again : Out of to fatal cases-
among 137 observed, Peyer's patches were only ulcerated in 3,
and in these the ulceration was slight.
Similarly, the nervous symptoms are usually remarkable for their
mildness ; but for this the reader is not prepared by Dr. Day.
The relations of scarlatina to diphtheria are not mentioned ; the
tonsillar exudation in *' scarlatina anginosa " is described as *' yel-
lowish lymph," and not further considered. Albuminuria, or
rather the acute desquamative nephritis of which it is a symptom^
is looked upon as an accident resulting from exposure to cold,.
But, in reality, quite apart from such exposure, the direct action
of the fever poison on the kidneys is of itself sufficient to excite
nephritis. The poison does not " escape " through the skin, when*
it has paralyzed the cutaneous circulation and thus caused the
eruption. It is certainly not " escaping " at the period of desqua-
mation ; hence is not liable to be pent up in the body by a chill.
There are important varieties of scarlatinous albuminuria, or
nephritis, but these are not distinguished by Dr. Day. Two use-
ful remarks are made, however, in this connection: that tuber-
culosis often originates in scarlatina; and that headache occurring
in children, perhaps at a long time after convalescence from this-
disease, should awaken suspicion of uraemia and latent nephritis.
In regard to pathology, our author rests with the opinion of
Harley, " who describes scarlatina as essentially a disease of the-
lymphatic system." He also quotes Klein's researches, but very
imperfectly : " In the kidneys there is a proliferation of epi-
thelium cells, and changes in the walls of the blood-vessels.
Later on there is a development of round cells, which constitute
a true interstitial nephritis, due to an embolic process." Now
Klein asserts that hyaline changes in the blood-vessels precede
all alteration of epithelium, being observed in cases which have-
succumbed after only a two days' illness. We cannot understand
how the lymphoid infiltration of diffuse nephritis can in any way
be attributed to embolism !
Dr. Day describes acute croupous pneumonia as an ordinary
disease of childhood, whereas, according to the experience of
authorities, it is extremely rare. Our author does not distin-
guish between a lobar induration, simulated by the aggregation of
inflamed lobules, and that caused by exudation of fibrine — " by
bleeding into the lung," as it has been expressively termed. Al-^
though we are told that in croupous pneumonia the epithelium of
the alveoli is unaltered, we are nevertheless warned that the unre-
192 ARCHIVES OF MEDICINE.
solved products of the disease may lead to phthisis. According to
Buhl, this sequel is never observed except in desquamative pneumo-
nia. The importance of lymphoid infiltration, and of lymphatic en-
gorgement in the development of phthisis from chronic pneumonia,
is overlooked by our author. Perhaps it is on this account that a
separate chapter is devoted to enlargement of the bronchial
glands, a lesion which, as a sequel to chronic pulmonary inflam-
mations, deserves only to be considered in connection with them.
Dr. Day gives one or two interesting histories, showing that sup-
puration of such glands may be mistaken for pulmonary caverns ;
but passes over lightly the caseous pneumonia, or even tuber-
culosis, which co-existed with such lesions in cases described.
It is ungracious to insist exclusively on the negative aspects of a
book. But in this one there are really few positive elements re-
quiring attention. One of the most interesting, is the record of a
case of intussusception in a child of 2 years and 9 months old,
treated by Dr. Day, and terminating in complete recovery.
[m. p. j.]
Anatomical Studies upon Brains of Criminals. A Con-
tribution to Anthropology, Medicine, Jurisprudence, and Pf^-
chology. By MoRiz Benedikt, Professor at Vienna. Tr '&-
lated from the German by E. P. Fowler, M.D., New York,
Department of Translation of the Medico-Chirurgical Society.
New York : Wm. Wood & Co., 1881, pp. 185.
The original of this translation was written in the summer of
1878. The author presents a description of the external confor-
mation of 22 brains of criminals, with an analysis of the conflu-
ence of the principal fissures in 19 cases. From these facts he
attempts to establish an abnormal type of cerebral fissures,
which he calls the confluent-fissure type. He furthermore claims
that the brains of the criminals presented belong to this type.
Reference is made in the preface to some of the noted contrib-
utors to cerebral anatomy ; no mention is made, however, of one
to whom we are indebted, perhaps more than to any one else, for
our knowledge on this subject, namely. Prof. Theo. Meynert, of
Vienna. This omission will not surprise those who are acquainted
with certain local jealousies that exist in Vienna, to which vague
reference is made by the author with an evident attempt to establish
himself as a scientific martyr. Of the numerous interesting ques-
tions discussed by our author which are open to criticism, let us con-
sider first the main point which he attempts to prove, namely : that
there is a special type of confluent fissures, which indicates inferior
NEW BOOKS AND INSTRUMENTS. IQS
development. The author states that " the most important char-
acteristic of this type consists in this. If we imagine the fissures
to be water courses, it might be said that a body floating in any
one of them could enter almost all the others." " For some
time a marked Assuring of the brain was regarded, erroneously, as
a sign of high development. It is true that if in the ascending
scale of animal life there appears a new typical fissure, it signi-
fies, as a rule, an extended development of the surrounding cer-
ebral region. But when there is no new development around the
fissure, and especially when the more marked fissure results from
a junction of typical fissures, the fissure thus emphasized indi-
cates a defect arising from the absence of annectants." We con-
tend that " marked fissuring of the brain " is still regarded, and
not erroneously, as a sign of high development. Increased
growth gives rise to more complicated convolutions, and, neces-
sarily, to more extensively meandering fissures ; a reduction in
the complexity of convolutions must, on the. other hand, lead to
the simplification of the fissures, and to a reduction in the num-
ber of the secondary and tertiary fissures in particular. In other
words, it is a deficiency of fissure formation, not an excess, as our
author states, which is a result of deficient gyrus development.
We heartily agree with the author when he says that " for many
of the descriptive details here given, such as are absent in all pre-
vious cerebral representations, we are indebted to the special at-
tention which I have bestowed upon these brain specimens."
This view is strengthened by an inspection of the original photo-
graphs of the brains examined ; " atypy " is exhibited to a greater
degree by distortions and confluent fissures due to improper
treatment of the specimen, than to ante-mortem conditions. The
author states, however, that " in endeavoring to describe any
given brain, great numbers of details are observed which are dif-
ficult to delineate. In some brains we encounter an exhibition
such as in other brains at least escapes observation. If now
we revise these other brains in this respect, then this exhibition
becomes here and there more or less plainly expressed," etc. It is
just this revision to suit a pet theory to which we object. There
is no more ample field in anatomy for a prolific imagination to
advance untrammeled than just here among the cerebral convo-
lutions, and our author has convinced us that his efforts in this
direction have not fallen short of his former productions.
The second proposition stated is, that the brains of criminals
presented belong to the confluent-fissure type, which leads him to
194 ARCHIVES OF MEDICINE.
the conclusion that "the brains of criminals ex^hibit a deviation
from the normal type ; and criminals are to be viewed as an an-
thropological variety of their species, at least among the cultured
races." When we consider the small number of brains examined,
the admission that we have as yet had no comparative race-study
of brains, and his statement that the larger proportion of brains
found in dissecting-rooms belongs to the confluent-fissure type,
we are not prepared to dispute the author's own statement that
*' it is self-evident that the observations here collected are the re-
sult of an a priori conviction," etc. He wisely adds, that the
matter should not leave the hands of the anatomist without fur-
ther proof.
We must dissent from the author's sweeping assertion' that
" there exists no qualitative difference between the brains of mam-
malia and those of primates," in the sense which he applies it to
the cerebral convolutions. The search after homologies is one
that requires extreme care. That numerous homologies can be
traced between the brains of lower mammals and those of the
primates, is undoubted ; but there is a limit beyond which this
process cannot be carried with certainty. The general facts of
evolution teach us caution in this respect. The same law must
apply here which applies to other organs. The effects of Trans-
mission, which tends to reproduce in progeny the characteristics of
progenitors, are modified by Adaptation to varying circumstances,
which produces continual variation ; these two tendencies pro-
duce constantly diverging forms ; so that when the phylogenic
relationship between two animals is remote, the chances of tra-
cing homologies become proportionately less, and when found,
present indefinite characteristics. The statement, then, that
'' architecturally there exists no fissure arrangement (idea) in the
animal brain which has not been expressed in the human," cannot
be true, for we could not include morphological variations in the
" animal " brain which arose after a divergence from the common
type had taken place. It is not a series with which we have to do,
but divergencies.
The laudable efforts to put the study of crime on a more scien-
tific basis cannot be too highly praised ; we must be on our guard,
however, against views concerning so manifold a subject, when
they are based on a small number of observations of doubtful
import, though they be supported by a priori argument. A plausi-
ble theory may lead us to the discovery and interpretation of im-
portant facts ; or it may, on the contrary, force us to distort and
NEW BOOKS AND INSTRUMENTS. I95
mask the truth. We regard the conclusions of the author as
premature ; too little is known as yet concerning the limits of the
typical topography of the cerebral convolutions to class as atypi-
cal conditions which the author claims are found in dissecting-
room subjects in the larger proportion of cases ; but if the work
leads to a more extensive and thorough comparative study of the
brain in different races, it will not have been written in vain.
The wood-cuts, which the translator considers compare favor-
ably with the beautiful photographs of the original, are coarse and
the impressions poor ; otherwise the book presents a neat appear-
ance, [w. R. B.]
ORIGINAL OBSERVATIONS.
TUMOR OF THE PONS VAROLII.
By F. T. miles, M. D.,
professor of physiology, and clinical professor of nervous diseases, university of
maryland ; member of the american neurological association.
Florence Brown, aet. 17, well developed, was brought into the
University Hospital in a stupid, apathetic condition, which made
it difficult to obtain from her her history.
She said she had been sick for more than a week before coming
to the hospital, that she had had a fall, after which she gradually
grew worse, but that she had been sick before the fall. She pre-
sented the symptoms, well-marked, of a crossed paralysis, the left
side of the face and the right arm and leg being affected. The
paralysis of the left side of the face was complete, so that she
could not close the left eye nor corrugate the brow on that side.
The right arm was completely paralyzed, the right leg partially.
She could walk feebly, dragging the right foot. No incoordination
was observed. Sensation, tested for in various ways, appeared to
be completely abolished in the left side of the face, including the
conjunctiva. Ammonia held to the left nostril, the right being
closed, caused no irritation. The tongue could be protruded,
but the sensitiveness of the two sides could not be conclusively
tested on account of the hebitude of the patient. Sensation was
very greatly impaired, if not totally lost in the right hand and
arm, and decidedly diminished in the right foot and leg. The
sensitiveness of the trunk was not tested. The hearing of the
left ear was blunted. The globe of the left eye remained fixed
and immovable. There was no strabismus. The conjunctiva
was inflamed, and the cornea so cloudy from recent inflammation
that the pupil could not be observed. Deglutition was somewhat
196
ORIGINAL OBSERVATIONS.
97
interfered with, but she ate with appetite. There was no vomit-
ing. The temperature varied within narrow limits, being some-
times above and sometimes below the normal. Pulse, frequent
and weak.
She passed her evacuations in bed, but this appeared rather the
result of her apathetic condition than of a paralysis of sphincter
or bladder. Indeed, her mental faculties were so much blunted,
and it was so difficult to rouse and fix her attention, that it was
almost impossible to thoroughly investigate the symptoms.
Fig. 2.— Transverse section of pons, showing
the location of the intra-pontine growth.
Fig. I.— Nodulated growth on anterior
surface of pons.
A diagnosis was made of a lesion in the region of the left half
of the pons, with probably a thickening of the dura mater of
Syphilitic origin. She was prescribed active antisyphilitic treat-
ment, but without effect. She sank rapidly, dying comatose,
without convulsions.
The autopsy showed the membranes healthy in appearance, the
hemispheres and cerebellum normal throughout. The pons was
remarkedly distorted, and apparently hypertrophied, as shown in
the wood-cut taken from a photograph of the specimen. Not
only was it unsymmetrical, owing to an enlargement of the left
198 ARCHIVES OF MEDICINE.
half, but its surface was uneven and nodulated, the upper and
lower margins projecting over the cerebral peduncles and
medulla. The peduncles, particularly the left, showed somewhat
of this swollen and nodulated character. The anterior pyra-
mids were much distorted, the right pushed aside, the left deeply
indented and as if compressed by the swollen margin of the
pons. The floor of the fourth ventricle was distorted on the
left of the median fissure, being widened and bulged upward.
After hardening in alcohol, a transverse section was made through
the pons a little nearer its lower than its upper margin, passing
through the middle peduncle of the cerebellum, the face of which
section is shown in fig. 2. There appeared a growth occupying
the left half of the pons, and encroaching on, or rather pushing
aside the raphe. Although it merged into the surrounding tissue,
which it had apparently pushed aside, without contrast of color,
or distinct line of demarcation, yet the circular shape of its sec-
tion was shown by faint concentric markings here and there
throughout its substance. Other sections proved the mass to be
nearly spherical in shape. Near its centre there was an appear-
ance of slight disintegration.
The symptoms in this case were for the most part typical of
unilateral lesion of the pons Varolii ; almost all of them find their
explanation in the position of the new growth. The motor (pyra-
midal) tracts and the tracts of sensation which connect the limbs
of the right side with the left hemisphere, were interrupted by
the tumor in the pons above their decussation in the medulla,
while we may suppose that the nuclei of the fifth, sixth, and por-
tio dura were involved in the growth, causing paralysis of those
nerves on the left side, and thus giving the crossed, or alternate
paralysis so often seen in pons lesion. The complete paralysis of
the facial, resulting from the implication of its nucleus, is distinc-
tive of lesion of the pons, as compared to its partial paralysis
from lesion of the hemisphere or its ganglia. With such an ex-
tensive lesion it is difficult to see how the tracts of sensation and
volition for the nerves of the right side of the face escaped, and
yet that they did so would appear from the complete absence of
anaesthesia and paralysis on that side.
Paralysis of the oculo-motor nerve, such as existed in this case,
would not be expected in a lesion of the pons, the nucleus of
that nerve being situated too high up. Nothnagel says^ that a
paralysis of the bulbo-muscular branches of this nerve proves an
* Topische Diagnostik der Gehirnkrankheiten. Berlin, 1879.
ORIGIN-AL OBSERVATIONS. 1 99
extension of the disease beyond the pons, except, perhaps, in
cases of conjugate deviation of the eyes. Likewise with regard to
the inflammation of the conjunctiva and cornea : the same author
treating of lesions of the pons VaroHi says :^ " Vasomotor lesions
of the face are not described ; the ' neuroparalytic ' inflamma-
tion of the bulb accompanying lesion of the trigeminus belongs
certainly not to the symptoms of pons lesion, according to the
cases at present recorded. In short, they are absent in almost
all intra-pontine lesions of the trigeminus." There was no appear-
ance of alteration of the nerve after its exit from the pons, nor
of the ganglion of Gasser. It is possible from the remarkable
hypertrophic and nodulated character of the surface of the pons,
that pressure may have been exerted upon the nerve trunk suf-
ficient to produce the trophic disturbances observed. The same
may be said of the trunk of the oculo-motor, the rather as we see
the swollen and nodulated condition referred to, extending upon
the surface of the left crus cerebri. We would thus have, joined
to the symptoms of simple intra-pontine lesion, those which were
the result of compression of nerve trunks. The specimen has not
yet been examined microscopically.
A CASE OF MYSOPHOBIA.
By J. C. SHAW, M.D., Brooklyn.
E. J., male, aged 15 years, brought to me by his mother on
May 26, 1879.
For the past few years has enjoyed good health. About six
weeks ago the first decided symptoms appeared, but for months
before, his mother had noticed that he was excessively particular
to wash his hands very clean, which is unusual for boys, as she
remarks. About six weeks ago he began to say to her : " He had
been touching the paint ; did she think it could come off the wall
and poison him ? " He would not take off" his own hat, but ask her
to do it for him ; also, to unbutton his coat. If he wished to come
in the front door he would not take out his night-key and come
in, but would knock on the door with his elbow. He is afraid
that if he touches any thing with his hands it will poison him ;
every time he touches any thing he is very particular to wash his
— ___ .
200 ARCHIVES OF MEDICINE.
hands very clean. He spat on the carpet a few days ago, and then
rubbed it off with his boot ; he immediately came down stairs to
his m.other, told her about it, and asked if she thought he could
have got any of the color off the carpet so as to poison him. He
would go about holding his hands and arms away from his body,
as if he were afraid of touching his clothes. When he goes to bed
at night he will wash his hands a dozen times and use as many
towels ; if prevented from doing this he appears disturbed, and
will sometimes rush over to the water-pitcher and thrust his hands
in, which appears to satisfy him. For a short time past he has fre-
quently asked his mother if he had cobwebs on his face, and
especially about his mouth. His mother thinks that of late he
has presented a vacant, idiotic expression that he never used to
have.
When the boy is talked to he speaks sensibly, but will give no
explanation of why he is afraid of being poisoned by touching
things ; says he has frontal headache at times, especially when he
goes to school ; for the past six weeks has not gone to school, and
has not had the headache, but a few days ago had a sharp pain in
left occipital region. He looks dull and apathetic ; is not given
to self-abuse. He has a decided neurotic family history : the
brother and father of his mother suffer from some nervous dis-
order, but no accurate account of it could be obtained ; but I infer
that it is a mental disorder. The marked neurotic family history
in this case inclines me to the opinion that graver mental disorder
will be developed in this boy.
Mysophobia was first described by Dr. Wm. A. Hammond in
1879,^ a few months previous to my seeing the above case.
Dr. E. C. Seguin has since reported a case.''
^ Neurological Contributions ^ vol. i, p. 40.
"^ Archives of Medicine, August, i88o.
VOL. VI, No. 3. DECEMBER, 1881
Archives of Medicine.
©vxgittal ^xtxcUs.
A CLINICAL STUDY OF LEPROSY.*
By henry DICKSON BRUNS, M.D.,
NEW ORLEANS.
THE proneness of the older authorities on diseases of
the skin to excessive subdivision, long aided in hin-
dering a proper appreciation of this subject.
Happily the increase of more exact pathological knowl-
edge has greatly simplified our ideas upon this class of dis-
eases, and in considering the pathology of leprosy I shall
endeavor to show that the so-called varieties are dependent
upon what might be termed a pathological accident.
Proceeding to the examination of the clinical grounds for
the various divisions of the disease into varieties, the older
and more minute subdivisions are passed over, only such as
are found in recent works being considered.
Most modern authorities divide the disease into the
tubercular and anaesthetic varieties ; a third variety, the
macular, is added by some.
Even those, however, who divide the disease into these
two distinct varieties, are forced to admit that they may,
nay, very often do, succeed one upon the other. Thus,
Danielssen and Boeck state that the anaesthetic complicates
* Extract from a prize thesis of that title submitted to the Faculty of Jefferson
Medical College, March, 1881, and now printed by their kind permission.
201
.
202 HENRY DICKSON BRUNS.
the tubercular variety in one in every six cases, while in
one case in every twenty the anaesthetic variety becomes
tubercular. Hansen, however, not admitting an anaesthetic
variety, holds that anaesthesia occurs, not as a mere chance
complication, but regularly late in the course of every tuber-
cular case, provided the patient survives long enough to
allow of its manifesting itself. He demonstrated the pres-
ence of anaesthesia in 135 out of 144 tubercular cases.' The
nine in which it was absent were all of recent origin.
{Archiv filr Dermat. u. Syph., 1871. Kaposi, loc, cit.) Han-
sen's opinion is supported by Bidenkap {Norsk Mag. for
Laege. v. iv. Kaposi, loc. cit.) Dr. J. H. Bemiss, writing
from the Sandwich Islands, says : " There are present here
the two forms : tubercular and anaesthetic. This division is
based upon the predominance of one or the other of the
two most important symptoms. In actual observation the
disease does not always admit of such strict classification,
but generally shows the two forms combined in greater or
less pathologic preponderance. It may start as purely
tubercular or purely anaesthetic, but does not often preserve
a single type throughout its course ; in the one case anaes-
thesia, in the other tubercles, making their appearance in
due time."
My own experience coincides exactly with that of Dr.
Bemiss. I have never examined a case of tubercular leprosy
in which more or less anaesthesia could not be demon-
strated. By reference to the analysis of cases, it will be
seen that out of fifteen tubercular cases twelve were also
anaesthetic. Of the two anaesthetic cases given in the table,
one developed tubercles within three years from the first
^ It will appear further on that anaesthesia may be due to two causes : pressure
upon the nerve trunks (the lesion in the true anaesthetic type), and pressure upon
the peripheral nerves (a phenomenon which undoubtedly occurs in all old-stand-
ing tubercular cases). To which of these causes the anaesthesia in Hansen's
cases was due does not appear. Anaesthesia should always be determined by
thrusting (as apparently was done here) a needle deeply into the true skin; other-
wise we may be deceived by thickened epidermis.
I
A CLINICAL STUDY OF LEPROSY. 203
attack ; the other now presents infiltration of the brow and
eyelids, one of the initial symptoms of tubercular leprosy.
With Drs. Kaposi and Bemiss, then, I conclude that the
varieties (as now made) are dependent on symptoms which
are by no means constant, but vary with varying causes/
But in the following description I shall classify as tubercular
in type, preferring the word used by Dr. Kaposi, all those
cases in which the symptoms are mainly due to the presence
of leprous new-formation in the corium and mucous mem-
brane, and as anaesthetic,^ those cases alone which owe their
striking features to compression of the nerve trunks by the
same neoplasm ; for thereby the study of the disease will
be much facilitated, so widely do the two groups differ in
their clinical manifestations. At the same time, I repeat
that the division is, on the whole, an arbitrary one, and that
the two types may, and as a rule do, complicate one another
in old-standing cases.
" The macular variety " is a phrase employed with vary-
ing signification by various writers. Some place under this
title those cases which manifest the maculae characteristic
of an early stage of the tubercular type, in which tubercles
are as yet absent. This, however, as I have just said, is not
a variety, but merely one stage of one type of the disease.
Indeed, I am inclined to believe it somewhat uncommon, at
least in Louisiana, to see this stage clearly defined, i. e., the
maculae existing without tubercles or infiltration. I have
never met with such a case, and Dr. J. H. Bemiss remarks :
"As to a third variety, macular, my observation does not
warrant my stating any such class. True, maculae of one
sort or another are common enough, but these cases already
present one or the other of the two forms generally recog-
^ The disease undoubtedly presents also slight variations in form in different
localities, a fact which may serve to explain, in part, the nonconformity of the
descriptions given by authors who have studied the disease in different coun-
tries.
'*/.<?., in type.
204 HENRY DICKSON BRUNS.
nized." The doctor then describes two cases in which
maculae were the most prominent symptom, but in one a
few tubercles had already made their appearance, and in the
other infiltration around the alae nasi was beginning. This
is a point which is, I think, not sufficiently dwelt upon.
Many of the descriptions would lead one unacquainted with
the disease to suppose that cases presenting numerous and
conspicuous maculae were exceedingly common.
There are other authorities who regard morphoea as a ma-
cular variety of leprosy. Thus, Erasmus Wilson speaks of
it as an impression of the gigantic footsteps of that grand,
that elephant disease, the leprosy of the middle ages. But
the infiltration, the varying degrees of anaesthesia, the loss
of hair from the affected part, although present in leprosy,
are not primary, but secondary symptoms. They may be the
result of any infiltration which seriously interferes with the
circulation through the skin, and to disturbances of function
in the trophic and sensory nerves. The infiltration, too, of
morphoea differs in character from that of leprosy. Again,
the purely local and comparatively trivial nature of morphoea
does not, I think, warrant for it the supposition of a con-
stitutional cause. True, it occurs principally in females and
debilitated individuals (Tilbury Fox), but this is a strong
argument against a specific cause. For an inherently weak
spot in the organism may not, so long as the general health
remains unimpaired, present any untoward appearance, but,
should the nutrition of the whole body sink to a low ebb, it
must of necessity suffer more gravely than any other part.
For these reasons, therefore, I do not believe in the iden-
tity of morphoea and leprosy.
The symptoms of leprosy may be divided into general
and local.
The general symptoms are common to both types, and
are by no means characteristic. I shall consider them first.
A CLINICAL STUDY OF LEPROSY. 20$
With whatever form of the disease the patient may be
afflicted, if it has endured for any considerable length of
time, he will always present a miserably emaciated appear-
ance. The fat has in great part disappeared from the body,
and the muscles are soft and atrophied. The skin usually
participates in this emaciation, and has a thin, finely-wrinkled
appearance like tissue-paper. I have specially noted this on
the hands.
In the atrophying muscles of both types, but especially
in the anaesthetic, local contractions, or twitchings of a few
muscular fibres here and there, are to be observed. If not
present at the time of inspection, they may frequently be
excited by smartly tapping the muscle with the finger. Such
contractions Dr. Hammond terms fibrillar in his work on
diseases of the nervous system.
They are common in many nervous diseases accompanied
by wasting of the muscles. In the muscles composing the
ball of the thumb, and in those around the mouth and or-
bit, they are of most frequent occurrence.
CEdema, as in many states of great depression and distur-
bance of circulation, is common, and is most marked in the
lower extremities.
Swelling of the inguinal glands is not unusual, especially
in the tubercular type. I have not observed induration of
any other glands, but it is said occasionally to occur.
Turning to the appended charts it will be seen that the
temperature of the three male patients rarely sank below
99° F., the averages being all above this degree, and that
there was a slight but constant evening elevation. The
charts of the two females, presenting almost normal curves,
are of little interest, save that one of them (Deneina
Boyens) serves to illustrate, more markedly even than any
of the male patients' charts, the sudden, high, and brief
febrile paroxysms to which lepers are subject.
206 HENRY DICKSON BRUNS.
It is said that the temperature of the surface of anaes-
thetic parts is appreciably lower than the general tempera-
ture of the body. This is what might have been supposed
a priori, but I have not had the means of verifying it.
The pulse in the three male patients just alluded to was
fast and weak, the averages, taken in the sitting posture, being
about 102, 85, and 89 beats per minute. There was a slight
falling off in the number of beats per minute, toward even-
ing. This rapid and weak pulse appears to be a characteris-
tic of the disease, for Dr. J. Kinnis states the average pulse
rate (sitting posture) at loo-iio beats per minute : weak.
The most rapid pulse which he encountered was 124, the
slowest 88 beats per minute.
Surgeon Major W. I. Van Someren gives the following
figures : Out of 426 cases the pulse was below 70 beats per
minute in 57 cases, from 70 to 80 in 100 cases, from 80
to 90 in 132 cases, from 90 to 100 in 83 cases, 100 beats
and upward per minute in 54 cases.
It has been stated that the pulse of the anaesthetic type
is habitually slow, but in the case of this type under my
charge the average morning pulse was 9o|- beats per minute,
the evening, Zj\ (Antoine Gaspard).
Albuminous urine seems to be regarded as a characteris-
tic symptom by most authors, but in none of my cases was
it present (see charts). In a number of examinations made
by Van Someren, the urine was found to be more or less al-
buminous in 40 out of 100 cases, saccharine in i, phos-
phatic in 37, alkaline in 42, acid in 2, and neutral in 52.
At various epochs the unfortunate leper has been either
an object of abhorrence and disgust on account of a suppo-
sitious salacity, or of contempt and pity as the victim of
sterility and impotence. The former idea is utterly, the lat-
ter, partially false : that is to say, leprosy does not of ne-
cessity produce sterility, although the leper may be reduced
A CLINICAL STUDY OF LEPROSY. 20/
to such a state either as the result of the depression of gen-
eral health ^ under which he labors, or by reason of the tes-
ticle becoming involved in the morbid process.
Lastly, before passing to the consideration of the local
symptoms, mention should be made of the overpowering
languor, hebetude, and drowsiness which invariably possess
the leprous patient.
In the description of the local symptoms, I shall take up
first the tubercular, and then the anaesthetic type. For pur-
poses of clinical convenience, each type maybe said to have
three stages ; this, however, is an arbitrary division : one
stage glides into another without any sharp line of demarca-
tion, maculae and tubercles coexisting, as a rule.
Tubercular type — morbid changes chiefly in corium —
may be either acute or chronic. Divisible into :
First, or prodromic stage ;
Second, or macular stage ;
Third, or tubercular stage.
Chronic form : Prodromic stage.
Some months before the appearance of any objective
symptoms, the leprous subject usually experiences those
disturbances of general health which, almost always, precede
a severe attack of illness. He suffers from lassitude, mal-
aise, loss of appetite, nausea, epigastric oppression, indiges-
tion, slight fever with evening exacerbations, or paroxysms
of chills and fever. A chronic bullous eruption, lasting days
or months, and strongly resembling that of pemphigus, is
also described as one of the premonitory symptoms. This
eruption was formerly maintained to be pathognomonic of
the anaesthetic type, but it is impossible to foretell the ap-
pearance of a certain type by means of this or any known
prodromic symptom.
In two of my cases, epistaxis was a promonitory symp-
^ Dr. Enders asserts that leprous women are generally barren.
208 HENR V DICKSON BR UN S.
torn. Dr Kinnis, also, has noted this and brief febrile at-
tacks in the earlier stages of leprosy in Ceylon. Only 5 out
of 17 of my cases are set down in the analysis as having had
any prodromic stage, and out of 117 cases (examined by
Van Someren) which had a history of antecedent *■' mala-
rial fever," 52 had no other prodromes. Doubtless all of
these figures fall far short of the truth, but those who have
had most experience will best appreciate the difficulty of
obtaining an intelligent " previous history " from the class
which frequents large hospitals.
After these prodromes have lasted for months or years
(they may have been entirely absent), the second stage is
ushered in by the appearance of the first maculae.
Second — Macular stage.
As the maculae characteristic of this stage make their ap-
pearance, the prodromic symptoms just described, in most
cases, disappear.
These maculae are claret-colored, the color vanishing on
pressure, and slightly elevated, their outlines being either
clearly or ill-defined. In size they vary from the palm of
the hand to a finger-nail, but are usually about the dimen-
sion of a silver dollar. Their favorite sites are the trunk
and the extensor surfaces of the upper and lower extremi-
ties. They are occasionally seen on the face. On touching
one of these spots, the skin is perceived to be harsh, infil-
trated, and hyperaesthetic ; rarely normal as to sensibility.
Gradually, however, the original and ruddy hue of the
macula becomes a light coffee-color, which does not disap-
pear under pressure, and hyperaesthesia gives place to an-
aesthesia.
Now the cuticle commences to desquamate lightly, and
the patches look dry, tense, and shining, or unctuous from
hypersecretion of sebaceous matter. The latter condition
is more frequently seen in negroes.
A CLINICAL STUDY OF LEPROSY. 209
Among them also the spots are said to be reddish or
copper-colored (Campet, /. c.) ; in the yellow races they may
be of lighter or darker shade than the normal skin. After
a certain time the macula disappears completely, or atrophy
of the skin takes place ; a shining, brilliant white, finely
wrinkled spot, destitute of glands and hair, remaining. Oc-
casionally tubercles crop out upon the former sites of the
maculae. The latter continue thus to appear and disap-
pear at intervals of a few weeks, or several months (half a
year) ; slight febrile symptoms preceding, as a rule, the ad-
vent of each fresh crop. ^
The later crops, however, remain as a permanent brown
discoloration of the skin which gradually spreads and deep-
ens until it involves the whole surface ; the shade being
darkest upon those portions of the person habitually ex-
posed to the air.
An erythematous blush diffused over a considerable area
and preceded, or not, by maculae, is by no means a rare
precursor of tubercular deposition.
As this blush fades away, the skin acquires the character-
istic brownish tint, and in a short time tubercles are depos-
ited. Dr. J. H. Bemiss describes such a case : a Sandwich
Island native came to him *' with the left side of the face
swollen, painful, and presenting all the characteristics of
phlegmonous erysipelas, for which he was treated." Finally
the pain and redness passed off, leaving a hypertrophied
state of the skin. Here the tubercles were subsequently
deposited, not at "the seat of the former inflammation, but
" upon the pharynx and posterior part of the tongue." At
the same time the right hand became partially anaesthetic.
Twice only have young maculae come under my observa-
tion. On both occasions they were claret-colored, and hy-
peraesthetic. Tubercles and infiltration were also present.
The macular stage may, however, precede the tubercular by
210 HENRY DICKSON BRUNS.
as much as five years (Danielssen and Boeck). In a case
mentioned by Erasmus Wilson maculae and discoloration
were the only symptoms for five or six years ; at the end
of this period tubercles appeared.
Third. — Tubercular stage.
Over the whole body, especially over the face and lower
parts of the extremities, the skin has now assumed a dark
appearance. It is hard to convey in words an exact idea
of this tint. On the trunk and upper parts of the limbs
the skin is about the color of a mulatto's, or the color of
the light brownish-yellow blotches seen upon the persons
of pregnant women, or, more exactly, of the dark patches
of leucoderma. Upon the exposed portions of the person
the shade may be the same, but usually deepens to a dusky
reddish-brown. The *' Atlas of Skin Diseases " by Dr. Til-
bury Fox contains a plate in which the color is well repre-
sented, but the shade is much darker than I have ever seen
it.
Upon the parts first attacked, as a rule, face, hands, or
feet, the skin is usually found thickened, and looking semi-
translucent, as though a gelatinous material lay immedi-
ately beneath a discolored cuticle, especially around the
alse nasi, over the malar bones, and in the lobes of the
ear.
There may be, at this early period of the stage, however,
no discoloration, a delicate pink blush, with here and there a
fine tortuous venule, overspreading the thickened skin.
The eyebrows, lashes, and beard have now fallen, or be-
come scant, the lobes of the ear still more pendulous, and
the alae nasi flat and spreading.
Large thick plates of an elastic-feeling substance are then
deposited in these localities. As tubercles begin to appear
in well-marked crops, the erythematous condition and semi-
transparent look of the skin subside, as a rule, but I have
A CLINICAL STUDY OF LEPROSY. 211
known them to coexist with tubercles for a considerable
time.
The early prodromic symptoms of lassitude, fever, noc-
turnal pains, etc., often precede the advent of a crop of
tubercles, and then pass away after the critical period, leav-
ing the patient much more comfortable.
Tubercles are most common on the face in my experi-
ence ; then on the extensor surface of the upper and lower
extremities. I have never met with them on the trunk,
although they may occur in this situation.
On the hands they cluster thickly upon the extensor side
of the phalangeal joints, interfering seriously with motion.
Sometimes they affect the toes in like manner, seeming
prone, in fact, to collect around any and all joints. Tuber-
cles may be solitary and scattered, but in their chosen locali-
ties are usually found matted together in nodular clumps
some inches in extent.
Such groups are commonly seen in the skin of the brows,
deepening the natural wrinkles into furrows, over the tri-
ceps extensor cubiti, and on the back of the hand. In
shape these growths are hemispherical, or slightly conical,
with a base broad in comparison to the height. They vary
from the size of a pea to that of a chestnut. Such small
nodules as the first mentioned have been observed clus-
* tered in groups and circles like the deposits in lupus.
On handling one of these bodies it is perceived to be
embedded in the corium and the subcutaneous connective
tissue, and usually may be made to slide freely over the
subjacent bone or muscle. Tubercles are firm, elastic, pain-
ful upon pressure; often preserving the previously described
translucent appearance when it has wholly vanished else-
where. The skin over the node is thin, smooth, shining,
with lightly desquamating cuticle.
At this period the small superficial blood-vessels once be-
212 HENRY DICKSON BRUNS.
fore alluded to are fewer, but of larger size, red and tortuous.
They radiate toward a centre, where they dip down into
the skin, and are lost to sight, recalling exactly the retinal
vessels seen with the ophthalmoscope. They are most
numerous by far upon the face, but may also be found upon
the chest and hands.
Flat or nodulated masses are identical in all these re-
spects with the tubercles.
After a varying length of time the morbid process next
attacks the mucous membranes. Tubercles exactly resem-
bling those in the skin, though usually of smaller size, are
deposited in the membranes of the nose, the mouth, the
pharynx, the larynx, the bronchial tubes, the intestines, and
the eye, in the order given.
All visible portions of these mucous surfaces become
thickened, and deeply covered with an ashen-gray epi-
thelium in the greater part of their extent. Thus the in-
terior of the nostrils is pale, or grayish, with here and there
dry, red fissures, or small tubercles. The tongue is coated
down the centre with a broad, grayish-yellow stripe, leaving
only the edges and tip of a pale, unhealthy-looking pink.
The papillae are prominent ; the surface marked with small
excoriations, occasionally studded with tubercles, causing
a curious lumpy appearance and some loss of mobility.
Similar characteristics are presented by the membrane of,
mouth, pharynx, and larynx. The hard palate, it is said,
is usually covered by a flat plate of infiltration, which is
sometimes dotted over with tubercles, single or in groups,
showing red upon the dull gray ground.
It is hardly necessary to state that the voice is greatly
altered, or may even be completely destroyed by these
changes, and that occurring in the larynx they may en-
danger life.
When the eye is attacked, the first phenomenon observed
A CLINICAL STUDY OF LEPROSY. 213
is general and intense injection of the conjunctiva, accom-
panied by lacrymation.
Some time after this a more or less extensive pannus
(pannus leprosus) may be observed encroaching upon the
edge and spreading over the surface of the cornea. The
process may then pause here, as I have seen it do, the in-
jection disappearing, and the pannus seeming to become
much thinner and more transparent, from the emptying of
the formerly distended capillaries. At this stage close in-
spection will make out, as the result of the previous inflam-
mation, some thickening, and a few minute tubercles not
larger than grains of sand, around the cornea. If, instead
of ceasing at this point, the morbid action, on the contrary,
continues, the cornea may be perforated, synechia anterior
resulting; or, deposits which have now been thrown out
upon the iris, extend across the posterior chamber to the
lens, synechia posterior (Dr. Kaposi, loc. cit.) Then the eye
may be destroyed by atrophy or softening. At times an
acute general ophthalmia sets in and hastens the total de-
struction. Great pain may accompany these changes.
And now we reach the " last scene of all that ends this
strange eventful history," — retrogression of the neoplasm,
and all its horrible consequences. Those crops of tu-
bercles, and the same is true for all forms of deposit which
first appear, are, as a rule, soon absorbed, but only to be
succeeded by larger and more stable crops, individual mem-
bers of which may persist for years.
Three forms of retrograde metamorphosis are enumer-
ated.
I cannot, however, regard as material the difference
between the second and third forms.
I. Atrophy: the tubercle undergoes atrophy or absorp-
tion from the apex toward the base. The cuticle des-
quamates the while, and the whole mass disappears in
214 HENRY DICKSON BRUNS.
days or weeks, a thin, contracted, wrinkled, light brown, or
white spot of atrophied skin remaining. Young tubercles,
it is said, are apt to be deposited around this spot.
2. Softening: the tubercle softens or breaks down at
the top, pouring out a cheesy, purulent discharge through
one or several openings. The base remains, or disappears
by atrophy and absorption.
3. Ulceration : due, according to most authorities, to ac-
cidental mechanical causes.
Mechanical or therapeutical irritation, and pus pent
under infiltrated masses, are ascribed as causes of erysipelas
or lymphangitis during this process.
The ulcers produced are worthy of further considera-
tion. They are sluggish, non-granulating, marked by great
necrosis of tissue.
Occasionally of small size, with flat edges, and pre-
senting the smooth, yellowish pink surface common to
non-granulating sores, they are usually, in my experience,
large, with high, perpendicular, hard edges.
These edges are either of a white or faint pink hue, or of
the bluish tint peculiar to young scars.
The base of the ulcer has a fleecy look, not unlike the
woolly side of a piece of patent lint. This is due to fine
fibrillae of tissue which, having to some extent resisted the
ulcerative process, project beyond the general level.
As the ulcerated surface is of a dark red color, finely
dotted and streaked with various shades of yellow, dark
blue, olive-green, etc., the impression produced is of a
yellowish-red surface marbled in very dark blue, or green.
I have frequently seen small, dark yellow masses of dead
tissue projecting from the base of an ulcer, but the fungous
growths described by some have never come under my
observation.
At times these ulcers attain enormous dimensions, cover-
A CLINICAL STUDY OF LEPROSY. 21 5
ing and encircling a foot and leg; situations in which I
have always observed the larger ones. In such a case the
discharge is thin and ichorous, and the ulcers manifest no
tendency to heal. As in all chronic inflammations, the
surrounding structures are thickened and discolored.
When the smaller ulcers heal the scars produced are thin
and pale. Strong contraction takes place in the cicatrix,
producing an appearance of radiation from a central ele-
vated point, which is heightened by the distribution of a
dark coloring matter along the lines of radiation through
the light colored-scar.
All, or almost all, of the horrible and repulsive features
which have made the name of leprosy a terror for ages, and
the miserable leper an outcast — anathema — upon the face
of the earth, are due to the ulcerative process just de-
scribed.
On the face tubercles rarely break down ; but I have seen,
as the result of such an occurrence, a patient with a small,
cup-like, running sore upon the cheek.
The nasal cartilages are early, but the bones are not, at-
tacked as in syphilis. Distortion of the organ results, for
the bones remain prominent, while the tip becomes broad,
thick, flattened, and turned up.
Around and in the eye ectropion and ulceration of the
cornea are the results of these changes. In the mouth they
may cause loss of the uvula, and produce small sores
which give rise to pain on swallowing warm food. One of
my patients complained constantly of this. Great fetor of
the breath may accompany the breaking-down of deposits
in the mouth.
It is, however, upon the hands and feet that we perceive
the saddest effects of ulceration. When this occurs around
the nails they scale off, leaving the matrix exposed and raw.
Should an ulcer form over a phalangeal joint it becomes
2l6 HENRY DICKSON BRUNS.
gangrenous, deepens rapidly, destroys and removes the
distal part of the finger or toe. Frequently softening with
discharge, or absorption of the bone and other tissues of
an intermediate phalanx, takes place, and the parts retract-
ing, the third, is drawn down upon the first phalanx. Upon
hands thus deformed, the fingers stand out at every con-
ceivable angle, it is said, producing a most curious effect.
Fortunately, little or no pain accompanies this mutilation,
and the healing process is very rapid.
Tubercular type — Acute form.
Most authors also describe an acute form of this type,
which differs, not in the nature of the morbid processes,
but in the degree of rapidity with which they run their
course. Its prodromic and eruptive stages are characterized
by considerable fever, and the tubercles instead of appear-
ing and disappearing in crops, burst forth once and for all
in great numbers. In a fortnight ravages are committed
which it would take the chronic form months to inflict.
After a certain time this form may become chronic, and in
that case the disease runs its usual course : should it, on the
other hand, continue acute, cerebral complications, pneu-
monia, pleurisy, chills with febrile exacerbations, within a
few months close the scene. Occasionally the fever may be
typhoid in character, but usually presents the common
symptoms of high temperature, rapid pulse (120-130 per
minute), thirst, insomnia, headache, delirium, constipation,
and high-colored urine. The initial attack of leprosy is
rarely made in the acute form, but chronic cases frequently
terminate in this manner.
Anesthetic type — Morbid process chiefly in sheaths
of nerve trunks.
Form, invariably chronic.
The anaesthetic type, while almost unknown in certain
latitudes, seems in others to be the prevailing form of
A CLINICAL STUDY OF LEPROSY. 21/
leprosy.' The former is the case in Louisiana, I must con-
clude, as no report of an anaesthetic case has reached me,
and only one has fallen under my observation. Indeed, it
may be asserted that, on the whole, the anaesthetic is the
rarer of the two types.
This type manifests itself in two distinct modes : it either
supervenes upon, and complicates a tubercular case, or it
exists as a distinct type from the beginning. In either case
the symptoms are much the same.
Prodromic or macular symptoms precede the disease in
some instances, in others it developes under the skin which
in no wise indicates the presence of its chief symptom, —
derangement of sensation.
This type may also, as a matter of convenience, be divided
into stages; but the remarks already made concerning a
like arrangement of the tubercular type, are applicable
here.
First. — Prodromic stage.
There is no essential difference between this and the cor-
responding stage of the tubercular type.
One phenomenon alone needs more extended considera-
tion, viz., the bullous eruption before mentioned ; a symp-
tom usually, but not always, premonitory of this type.
Occasionally preceded by a febrile movement which
ceases as they come out, at other times appearing suddenly
upon a raised and reddened surface, these bullae exactly re-
semble those of pemphigus vulgus, but not more than two
or three are present at one time. Their size varies from
that of a small pea to that of an Qgg. After lasting
hours or days the bullae break, pouring out a clear, sanious,
or " bluish-stained " ^ serum, and dry, a pigmented, or white
and glistening spot remains. At other times a shallow,
^ Pruner, quoted by Kaposi. Egypt, New Zealand, Thomson {loc. cit.), Van
Someren {loc. cit.).
' See Hyde, American Practitioner (loc. cit.).
2l8 HENRY DICKSON BRUNS.
sluggish ulcer is left. The ulcer heals slowly, covered by a
thin scab ; the resulting cicatrix being thin, devoid of hair,
or covered by a fine white down. At times the bullae do
not retain the size and form in which they first appeared.
The bleb extends, forming a vesicular ring, which be-
comes dry and flat in centre. The spread of the inflamma-
tion in this manner may choke the central bit of tissue,
causing it to become gangrenous, an unhealthy chronic ulcer
resulting. Such white and atrophied spots as are formed in
consequence of these changes preserve their normal sensi-
bility for a time, but subsequently become anaesthetic. This
eruption may appear years before any other symptoms
manifest themselves, or, on the other hand, may crop out
upon portions of skin which have lost their sensibility.
During this period it is usual for some of the other pro-
dromic symptoms, mentioned while treating of the tubercu-
lar type, to be more or less prominent.
Second. — Macular stage.
It is rare for this stage to be clearly marked. As we have
already seen, certain maculae exist during the presence of
the pemphigus-like eruption. Other maculae, consisting of
light-red spots, similar to those described under this division
of the tubercular type, or various pigmented, discolored,
well- or ill-d.efined patches are found scattered over limbs,
face, or trunk.
Third. — Stage of anaesthesia and atrophy.
Some little time after the advent of the disease, and
while the above-mentioned maculae are appearing and dis-
appearing, it is usual for hyperaesthesia to manifest itself in
certain localities. The hyperaesthesia may vary in degree
and extent. Sometimes it is only the white or otherwise
tinted spots left by the bullous eruption which display this
condition ; or any of the maculae, especially the red ones,
may be hyperaesthetic when they first appear. Again, this
I
A CLINICAL STUDY OF LEPROSY. 219
state may exist in the skin of certain localities only, or over
the whole cutaneous surface. Finally, an erythematous
blush may, after the appearance of hyperaesthesia, suffuse
the affected area. In degree, the exaltation of sensibility
may vary from a feeling of tingling or formication to that
of acute pain, local or general in extent; excited by contact
alone, or spontaneous and persistent. When the latter con-
dition is present, the patient may start frequently during
sleep, or be subject to attacks of trembling, reflex in their
nature, which shake him as would the paroxysm of an ague
fit. This state of course renders him perfectly helpless, so
that his attendants are even obliged to feed him. During
this time various nerves may be felt very much swollen and
extremely sensitive. I am ignorant how long this condition
may endure, but the ordinary symptoms of pricking and
formications may last, with intermissions, for years before
they pass into anaesthesia.
Slowly, very slowly, those spots and stains which first be-
came hyperaesthetic descend in the scale, lose first their
morbidly exalted, then their normal function, which thus
passes finally on into complete extinction — anaesthesia.
Thus early in the progress of the disease the white atro-
phied patches of skin become anaesthetic, and this condition
usually co-exists with hyperaesthesia in other localities. At
this time also portions of skin entirely normal in appear-
ance, but quite devoid of tactile sense, are frequently met
with ; and this anaesthesia, it is said, may have a shifting
character.
Following, however, the progress of the hyperaesthesia,
sensibility gradually fades from broader and broader areas,
and from deeper- and yet deeper-lying structures, so that
skin, cellular tissue, and muscle become at last little more
than " senseless things." As a rule, this process is confined
to certain regions, an extremity or a circumscribed extent
220 HENRY DICKSON BRUMS.
of surface, which may be points of distribution for given
sensory nerves. But this is by no means always the case,
for the anaesthesia may invade, without entirely occupying
the area controlled by several distinct sensory filaments;
islands of normal skin being found here and there.
Subsequently, as the disease progresses, the anaesthesia
creeps insidiously on, until the whole body may become in-
volved, and only scattered points remain normal.^
With the loss of sensibility other changes have been
keeping pace. The skin over the anaesthetic regions has
become thin, finely-wrinkled, harsh, livid, or of a light-brown
hue.
Its functions are destroyed, and temperature lowered.
The hair falls, especially upon the face. Where it re-
mains upon anaesthetic spots, it may turn white, and it is
asserted that the hair over the entire cutaneous surface may
be blanched. Great muscular wasting takes place; occa-
sionally to such an extent, that mobility is impaired or
completely lost in one or all of the members. Indeed, the
emaciation is extreme.
As the result of the atrophied skin being drawn tightly
across the prominent bones at some points, and hanging in
loose, wrinkled, flabby folds at others, the discolored or
livid countenance looks prematurely old, and wears an ex-
pression of suffering, hebetude, or idiocy. The lower lip
hangs, exposing the teeth most hideously, and allowing the
saliva to trickle from the mouth.
Additional horror is given to the aspect of the patient
when the eye becomes involved in these atrophic changes.
^ It is said that this anaesthesia may vary as to its quality, i. <?., may vary as
the stimulus to sensation is varied, and that patients who are not able to walk
with their eyes shut, or to feel a needle thrust into the skin, may appreciate the
passage of an electrical current. May not this variation in quality, however,
be more rationallyr eferred to a variation in degree ?
A degree of anaesthesia which would preclude a patient from feeling a needle
thrust into the skin, might permit of his feeling the more permeating stimulus
of an electrical current.
A CLINICAL STUDY OF LEPROSY. 221
The cornea becomes opaque, and ulcerated, the iris discol-
ored and atrophied, and at last the whole organ shrinks
into a yellowish amorphous knot.
All the mucous membranes become dry and retracted ; a
dry ulcer very frequently penetrates the septum nasi. From
these causes the voice is altered, and thirst is usually a
prominent symptom.
Such deformities as accompany nervous diseases charac-
terized by wasting, present themselves in the extremities.
Fingers and toes are distorted and stiff; the nails thin, scaly,
striated, frequently lost. The withered hand, with clubbed
fingers, prominent bones and tendons, is often permanently
distorted into a bird-like claw, the *' main-en-griffe."
After these symptoms have lasted a year or two, and
usually before they have attained such intensity as that
described in the last few lines, the epidermis of the atro-
phied skin over the extensor surface of a phalangeal
joint, begins to desquamate. Then, as the result of pres-
sure^ exerted by the bone at this point, the skin becomes
thinner, whiter, more tense and shining than before. Soon
a small crack appears, or a swelling resembling somewhat a
blister or boil ; this breaks, sets up a process of ulcera-
tion, opens the joint, and amputates the part. Or, the bone
and soft tissues on the distal side may not be amputated,
but dissolved away, as it were, by necrosis with profuse
discharge. The latter is said to be very common. An in-
termediate phalanx may be removed, as in the tubercular
type.
At other times a bluish, tender, fluctuating swelling
arises over some joint. This opens and pours out a
sanious discharge ; a deep, funnel-shaped ulcer, with dis-
colored, thick, cartilaginous edges being formed. At the
^This pressure is the exciting cause in most cases ; very slight injuries, in some
others. In still another class the ulceration is termed idiopathic, in that no
caus^ can be assigned for it.
222 HENRY DICKSON BRUNS.
bottom of this ulcer the exposed bone undergoes necro-
sis, exfoliates, and, after the lapse of months or years, is
discharged. This form of ulceration is most common on
the feet, and, as a rule, occurs symmetrically first upon
one and then upon the other extremity. It is usually
preceded and accompanied by chills and fever.
As I remarked when speaking of similar phenomena be-
longing to the tubercular form (it is still more true of this
type), these processes are devoid of pain ; although it is
said that a certain amount is felt, occasionally, in the ab-
sorbent vessels around the part. The morbid action
rarely extends beyond the wrist or ankle, and, I believe,
no instance of its having reached higher than elbow or
knee, is recorded.
Finally, when this stage has attained a climax, fingers and
toes perish by spontaneous, dry gangrene.
The duration of the chronic form of the tubercular type
is variously estimated at from eight to ten years. There is,
however, a class of cases manifesting slight but indubitable
symptoms, such as infiltration over the malar bones and
about the nose and pendant ear lobes, that enjoys almost
perfect health for a great number of years.
Toward the close the disease becomes acute and carries
off the patient, or he sinks into a lethargic state, and
death results from inanition, pulmonary consumption, in-
tractable diarrhoea, or some one of the common compli-
cations.
As noticed in another connection, the anaesthetic may
complicate the tubercular type at this period ; then, both
types persisting, the latter puts an end to life.
That life is prolonged by the supervention of the anaes-
thetic type seems to be the general impression.
I have had no experience with the acute form of the tu-
bercular type. The two most rapid cases I have ever seen
A CLINICAL STUDY OF LEPROSY. 223
occurred in the persons of two sisters, Boyens by name, pa-
tients in the Charity Hospital at New Orleans. The case of
the elder terminated fatally within three years; the younger
is still living, but the disease has made fearful progress. The
most protracted case that I know of has lasted seventeen
years, and the patient's condition, when I last saw her, was
not alarming.
The average duration of the anaesthetic type is set
down at about eighteen and one half years.
The patient is, as a rule, free from all complications dur-
ing the major part of his illness.
As the disease advances, the victim of it sinks into a con-
dition of depressed vitality. The skin is cold, the pulse
weak, the limbs paralyzed ; the nerve centres are invaded,
there is great moral and physical sluggishness, and clonic,
or, more frequently, tonic spasms occur. Death takes place
from marasmus, tetanus, colliquative diarrhoea, or nephritis.
A few words now upon some of the more important com-
plications.
So common are bronchitis, indigestion, and diarrhoea in
leprosy, that they may rather be styled accompaniments
than complications of the disease. The bronchitis of
chronic and persistent type is due to congestion, or to the
breaking down of tubercles in the mucous membranes of
the tubes. The colliquative diarrhoea may be the product
of the same causes, or result, as does the indigestion,^ from
the vitiated condition of the blood and the depression of
the general health.
Albuminuria is probably, in the majority of cases, due to
the invasion of the kidney by the morbid process.
Leprosy predisposes to other affections of the skin. Ec-
zema, elephantiasis Arabum (in countries where it is en-
demic), herpes zona, impetigo, lichen, moUuscum fibrosum,
^ Of Van Someren's patients, 25 per cent, suffered from impaired digestive
power.
224 HENRY DICKSON BRUNS.
pityriasis, and scabies are all on record as complications.
These are worthy of note, for they may, by modifying the
appearance of the disease, obscure the diagnosis. Espe-
cially is this true of scabies. Indeed, the peculiar changes
produced by the presence of the acarus in a leprous skin,
led several excellent observers to mistake the nature of this
complication, and to declare it an eruption peculiar to lep-
rosy, or, at least — a later opinion, — a form of itch found under
no other circumstances. Owing to the state of the skin,
the parasite thrives exceedingly well, and small lumps, con-
sisting of masses of thickened epidermis, and countless
numbers of the dead insects, are seen upon the hands and
other portions of the body.
This disease does not protect against the exanthemata.
Cases of variola and varicella have occurred in the per-
sons of lepers in the hospitals at Bergen. Dr. Kaposi
quotes from Lawrence {jfour. Cut. Med.^ vol. i, No. 2, 1867)
a case in which measles supervened during the progress of
tubercular leprosy. Dr. J. H. Bemiss also gives us to un-
derstand that small-pox attacks lepers, and that vaccine
matter readily " takes " on them.
Syphilis is only too often found as a co-existing plague in
Norway, Sweden, the Hawaiian Islands, and other coun-
tries.
Lepers are said to be very susceptible to the influence of
cold, and improper food,^ which renders them especially liable
to phthisis, erysipelas, and nephritis.
Lastly, hepatic disorders may arise in hot climates to-
ward the end of an attack.
^ According to Dr. Enders {loc. cit.) leprosy in women is usually kept in abey-
ance so long as menstruation is regularly performed, but the least disturbance
of this function may precipitate or aggravate, should it already exist, the dis-
ease. This, however, is z.post hoc propter hoc argument, and it appears to me
more than possible that the disturbance of menstruation is rather, as in tuber-
culosis, an early signal of the approach of a grave constitutional disease.
A CONTRIBUTION TO THE PATHOLOGICAL
ANATOMY OF LEPROSY (LEPRA ARABUM*).
By H. D. SCHMIDT, M.D.
PATHOLOGIST OF THE CHARITY HOSPITAL OF NEW ORLEANS.
THE existence of leprosy in Louisiana in the form of
an endemic disease, though not of a recent date, has
of late years attracted the attention of the medical profes-
sion of this State, and thus induced me to a closer study of
the pathological anatomy of this disease on three severe
cases which terminated fatally in the Charity Hospital dur-
ing the course of last year. The results obtained from the
macroscopical and microscopical examinations of the various
organs of these cases will form the chief subject of this pa-
per; it may, however, not appear out of place to introduce
it by a brief review of the history of the disease.
The general characters of this dreadful disease have been
known to mankind for hundreds, nay, thousands of years, it
having already existed among the ancient Jews during their
captivity in Egypt, though recent authors point to Hindos-
tan as its birthplace. From this centre it spread, in the
course of centuries, over the greater part of Asia, to the
South of Europe, slowly and steadily extending in a north-
ern and western direction to Germany, France, Great Brit-
ain, Russia, and Scandinavia, and finally to America. Dur-
* Read at the Fifth Annual Meeting of the American Dermatological Associ-
ation, held at Newport, R. I., Sept. i, i88i, by James Nevins Hyde, M.D., of
Chicago.
225
226 H, D. SCHMIDT.
ing the Middle Ages the prevalence of leprosy among the
European nations was so great, as to necessitate the estab-
lishment of numerous asylums, or lazar-houses, in every
country, for the special purpose of receiving and nursing
the persons affected with this disease. Since two centuries,
however, the disease commenced to gradually disappear
from Europe, so that at present, with the exception of Nor-
way, leprosy has ceased to prevail upon the soil of that con-
tinent, and is there only met with in a sporadic form. But
while, perhaps by the progress of civilization, it has disap-
peared from these countries, there are still many localities
left upon the globe where it permanently dwells, or lingers
in its old endemic form. Such are : Hindostan and Bengal,
as well as the islands of the Indian Ocean, China and Japan,
Persia, Syria, and Palestine, with the islands of Cyprus,
Rhodes, Mitylene, Samos, and Crete, many localities in
Australia to which it was carried by the Chinese, some parts
of Africa, the island of Madeira, the shores of the Mediter-
ranean Sea, the West India Islands, the eastern coast of
South and Central America, the Sandwich Islands, to which
it was also brought by the Chinese, and some other localities.
As may be presumed, a disease as repulsive and dreadful
in its nature as leprosy, and to the amelioration of which
the reigning authorities and philanthropists of all countries
in which it prevailed appear to have contributed their
share at all times, must have constantly kept awake the in-
terest of medical men, — even in those periods of history
when medical science had, as yet, not assumed the definite
form in which we behold it to-day ; and it is thus that the
physicians of every historical period were as well acquainted
with the clinical phenomena of this disease as we are at
present. The investigations into its cause and nature, how-
ever, received a fresh impulse, in 1848, by the appearance
of Daniellsen and Boeck's work, containing the labors of
THE PATHOLOGICAL ANATOMY OF LEPROSY 22/
these authors at the infected locaHties in Norway, to which
they had been sent by the Swedish government. About
ten years later, Virchow, in answering a call from the same
government, visited Norway for the purpose of investigat-
ing the pathology of the disease ; and it is to him that we
owe, like so many other pathological discoveries, the first
accurate account of the abnormal histological changes upon
which the various phenomena of leprosy depend. The la-
bors of Virchow proved to be another stimulus to further
inquiries and discussions concerning the aetiology, pathol-
ogy, and treatment of leprosy, and gave rise to very numer-
ous statistical and pathological observations, made since
that time, both by appointed medical commissions, or by
private physicians practising in those localities where the
disease still prevails, — and a great number of excellent trea-
tises and reports have accordingly appeared, within these
last twenty years, to enrich the literature of leprosy. Every
important point of this disease, therefore, has already been
so thoroughly discussed as to leave scarcely any thing new
to be added, unless it were to corroborate by some closer
details the comparatively limited observations already made
in the pathological anatomy of the organs affected by the
disease.
The clinical phenomena of leprosy are so generally known
from the descriptions found in text-books as to require no
special notice in this place ; though it may be proper to re.
mark that the two varieties of the disease generally de-
scribed, the tuberculated, and the fion-tuberculated, or aitcss-
thetic, are, by many authors, no more regarded as distinct
forms, but in reality depend upon the particular organs in
which the pathological changes first take place. Thus, in
the tuberculated form of leprosy, the neoplastic growth,
represented by small proliferating cells, first appears in the
cutaneous or subcutaneous tissue, giving rise to the thick-
228 H. D. SCHMIDT.
ening, and to the formation of those characteristic knots, or
tubercles of the skin, while in the anaesthetic form the cellu-
lar growth first affects the connective tissue of the nerves.
The great majority of cases of leprosy belong to the tuber-
culated form ; but, as in most of these, besides the affection
of the skin, phenomena characteristic of the anaesthetic
form of the disease are also observed, it has been asserted
by recent authors that all cases of tuberulated leprosy
would finally become anaesthetic, if the patient's life were
not previously cut short by the disease, before the neoplas-
tic elements had also made their appearance in the nervous
tissues. This view concords with the cases upon which I
made th^ post-mortem examinations, together with others that
came under my direct observation in private practice.
The original histological element of leprosy, giving rise to
the various pathological phenomena of this disease, is repre-
sented by numerous small cells, first discovered by Virchow,
proliferating throughout the connective tissue of the
affected organs. The exact origin of these elements seems
to be, as yet, not definitely settled ; for while some pathol-
ogists refer it to the cells of the cutaneous or subcutaneous
connective tissue, or to that of mucous membranes, or to
the interstitial tissue of other organs, others place it in the
walls of the blood-vessels or lymphatics. Reserving the
discussion of this point until I shall have stated the results
of my own examinations, I proceed to the description of
the condition of the organs of the cases above mentioned,
commencing with the autopsies.
Case i. — A girl, about 20 years of age, entered the hospital —
accompanied by her sister, likewise affected with leprosy — about
a year previous to her death. The mother of these women had
died from the same disease ; they were natives of Denmark.
Autopsy. — The skin of the face was thickened as usual, though pre-
senting no tubercles of any remarkable size, the ears enlarged and
elongated, especially the lobes ; the skin of the upper and lower
THE PATHOLOGICAL ANATOMY OF LEPROSY. 229
extremities was in the same condition, presenting a number of tu-
bercles, some of which were ulcerating at the time of death. The
tongue was thickened, the thickening probably extending into the
larynx, which, however, was in this case not examined. The con-
junctiva was yellowish. When the thorax was opened the lungs
collapsed to an unusual extent ; their appearance was normal,
though they were soft and flabby. The heart small but normal.
In the abdomen, the tributaries of the portal vein were found con-
gested. The stomach and intestines were highly congested
throughout. The duodenum and other portions of the small in-
testines presented an intense yellowish brown tint, that of bile,
which, together with the red tint of the congested blood-vessels,
rendered the aspect very peculiar. The greater number of the
glandular patches of Peyer, as also many of the solitary glands,
were found diseased ; they were swollen and of a brownish tint,
the affection increasing the nearer they were placed to the termi-
nation of the ileum. Some small ulcers were met with in the
ascending and transverse colon. All the mesenteric lymphatic
glands were greatly swollen and rendered blue by the congestion.
Those placed alongside the vertebral column — both in the abdo-
men and thorax — were in a similar condition. The liver was nor-
mal in size, but soft in consistence and yellowish in tint. The kid-
neys were smooth, normal in size and form, but flabby in consis-
tence ; when cut, their cortical substance presented a pale, though
not yellowish tint. The spleen was almost smaller than normal,
but of a narrow and elongated form, the color of its surface and
parenchyma normal. The suprarenal bodies normal in color, but
narrow and elongated in form ; the bladder normal. The walls
of the aorta — especially in the abdomen — and of the iliac arteries
greatly thickened, and the calibre of the vessels diminished ; the
latter condition was observed on the arterial trunks arising from
these vessels. The surface of the brain, with the exception of
some vessels of the pia mater being filled with blood, presented a
normal appearance ; but when cut, the surface of the section ap-
peared rather anaemic. The spinal marrow was not examined.
The semilunar and other ganglia of the solar plexus were found
very small and soft, atrophied.
Case 2. — A middle-aged man, native of Louisiana, French de-
scent.
Autopsy. — Lungs normal. Heart normal in size ; tricuspid and
mitral valves thickened throughout by neoplastic matter in the
230 H. D. SCHMIDT.
form of nodules ; corpora Arantii of the semilunar valves of the
aorta considerably enlarged, but the valves themselves, as also
those of the pulmonary artery, of a healthy appearance. A con-
siderable portion of the intima of the latter and of the arch of the
aorta presented a scarlet color (endo-arteritis). The wall of the
left ventricle, when cut, showed a darker color than normal. The
alimentary canal, as in the first case, was found congested through-
out, the solitary and conglomerated glands greatly swollen, many
of them exhibiting a brownish tint. The lymphatic glands of the
abdomen — the mesenteric included — were also greatly enlarged,
though not blue from congestion. The liver was normal in size
and almost of a normal color, though rather soft and in many
places exhibiting a pale yellowish tint ; the gall-bladder con-
tained a golden-colored bile. Of the kidneys the one was of
natural size, but misshaped ; when longitudinally divided about
two thirds of the cortical substance was found intensely congested,
while the remaining third exhibited a yellowish tint. The other
kidney was below the normal size, and still more misshaped by
consisting of three larger and two smaller lobes ; its vessels were
issuing from the furrow formed at the place of junction of the
lobes upon the flat side of the organ ; when divided it presented
a yellowish tint with a narrow red border directly under the cap-
sule. The spleen was greatly enlarged, nearly twice the normal
size, and misshaped, though normal in color and consistence ;
when cut the parenchyma exhibited a normal appearance.
With the exception of many of the larger vessels of the pia
mater being filled with blood, the brain presented nothing ab-
normal, nor did the larger nerve-trunks ; the spinal marrow was
not examined.
Case 3. — A man, between 30 and 40 years of age, native of
Louisiana, French descent. In this case the skin was affected to
a great extent ; there were a number of ulcers present upon the
forearms, hands, legs, and feet, from which, during life, a horri-
ble odor arose. Upon the mucous membrane of the nose the dis-
ease had very considerably advanced, destroying portions of the
nasal cartilages, and causing the nose to bend inward. Six
months before the patient's death, tracheotomy had been per-
formed to relieve him from suffocation.
Autopsy. — The mucous membrane of the epiglottis and larynx
was greatly thickened and ulcerated. The posterior and inferior
portions of the lungs were congested, the rest normal. The
THE PATHOLOGICAL ANATOMY OF LEPROSY. 23 1
heart was normal, nor did the large blood-vessels appear to *
be affected. The mucous membrane of the alimentary canal was
only slightly congested, though the mesenteric lympathic glands
were, as in the preceding cases, much swollen ; the same con-
dition prevailed upon the other abdominal and the thoracic
lymphatic glands, while those of the femoral and inguinal re-
gion had attained an enormous size, presenting a dark bluish
and brown color. The liver was rather enlarged and pre-
sented a mottled appearance of dark blue and yellowish spots, in-
dicating both congestion and fatty degeneration ; its surface was
rather rough. The kidneys were normal in size and form ; some
portions appeared congested, while others presented the yellowish
tint. The spleen was normal. The vessels of the pia mater, as
also those of the brain substance were congested, but no other
lesions upon this organ were observed at the autopsy. The ves-
sels of the spinal marrow were considerably congested ; the cord
itself, especially in the cervical region, appeared swollen. The
Gasserian ganglion was found considerably indurated, and smaller
than normal. No thickening of the connective-tissue sheaths of
the larger nerve-trunks could be discovered.
The above statement shows that these three cases re-
sembled each other in the macroscopical pathological chan-
ges observed upon the various organs, the condition of the
latter fully corresponding to that of other numerous cases
described by various authors. In proceeding, now, to the
microscopical examination, I shall commence with that or-
gan upon which the particular changes characterizing the
disease are first observed, namely, the skin.
It has already been remarked that the characteristic his-
tological element of leprosy is represented by certain small
proliferating cells of a round, oval, uni- or bipolar, or other-
wise irregular form. The origin of these cells is generally
referred to the cells properly belonging to the connective
tissues of the affected organs, such as the skin or mucous
membrane, or of the adventitia of the vessels, the sheaths of
nerves, the capsules, etc., but, as I shall show directly, the
neoplastic cells may also be derived from the glandular, epi-
232 H. D. SCHMIDT,
thelial, endothelial, and even fat-cells. While many of them
may be observed single, the greater part of them, especially
in tissues where the pathological process has been in opera-
tion for some time, are met with in the form of groups, con-
sisting of from two to a dozen, or even more, of individuals,
each group representing the progeny of the original cell.
The form of these groups, though almost always irregular,
is generally elongated, oval, pyramidal, or ellipsoidal ; even
those groups derived from the nuclei of the fat-cells finally
assume an irregular, oblong, or ellipsoidal form.
For the study of these cells in the skin, the thickened ear
is probably one of the most suitable parts for making thin
sections, especially the lobulus, as it represents two layers
of skin united by the subcutaneous tissue, the panniculus
adiposus.
In examining, then, a thin section taken from the lobulus
of the ear — which, in old lepers, is always found very con-
siderably enlarged, — the characteristic cellular element may
be studied in its various stages of development. Judging
from the results of the examinations which I made of dif-
ferent portions of the ear, or other parts of the skin, in the
three cases under discussion, it appears that the disease
commences in the pars reticularis of the corium, whence it
may proceed, in one direction, and invade the pars papil-
laris, and even extend throughout the mucous layer of the
epidermis, or, in another direction, to invade the subcuta-
neous tissue ; but it may also extend in both directions at
the same time. In the sections which I examined, espe-
cially those of the lobes of the ear, the disease had always
invaded the subcutaneous tissue, in one case even all the
fat-cells, while in many places of the section the pars papil-
laris, and in consequence also the epidermis, had remained
free, and showed a perfectly normal structure. In other
places, on the other hand, not only the papillary layer of
THE PATHOLOGICAL ANATOMY OF LEPROSY. 233
the cojium, but also the stratum mucosum of the epider-
mis had been transformed into the neoplastic tissue. The
individual cells representing the latter show an average di-
ameter of about .008 to .01 mm., and contain a round nu-
cleus of about .005 mm. in diameter, with a distinct double
contour, in the interior of which a number of small gran-
ules are observed. In some instances a narrow constric-
tion, or dividing line, is observed upon the nucleus, or the
latter is already divided, so that two of these bodies are
found enclosed within the cell. After the division of the
nucleus, that of the protoplasm of the cell takes place.
But though the boundaries of the cells, thus arisen, are in
most instances distinctly seen, the cells themselves are
not always observed detached from each other; on the
contrary, the process of division may take place again on
these new cells, and continue during their growth until a
large group, as already mentioned, is formed. A close ex-
amination of such a group will show that, though bounded
by an unbroken outline, it represents not a single cell con-
taining a number of nuclei, but that each of the latter is
surrounded by protoplasm, representing an individual cell.
The nucleus, however, is not always distinctly seen in every
cell of the group, but frequently hidden by the protoplasm.
It has been stated by some authors that these neoplastic
cells take their origin from the cells or nuclei of the blood-
or lymphatic vessels ; this, however, appears not to be the
case, for, though the number of nuclei contained in the
walls of these vessels, especially those of the adventitia,
really appears in some instances to be increased, the in-
crease forms rather the exception to the rule ; nor do the
cells proliferate to a greater extent in the close vici'nity of
these vessels than elsewhere.
The external or fibrous layer of the hair-sacs, also, ap-
pears to be rarely invaded by the proliferating cellular ele-
234 H. D. SCHMIDT,
ments ; in most instances I have observed it to present a
perfectly normal appearance, even when closely surrounded
by the proliferating cells. Different it is with the external
root-sheath, which is frequently observed to have gained in
thickness, and to be completely separated from the internal
root-sheath, which, in its turn, is detached from the cuticle
of the hair; in some places, also, the last named root-sheath
appears thickened. In some instances the hair itself has
remained attached to the papilla, while in others it is
detached and found some distance from the latter. Many
hair-sacs present — always below the neck — a considerable
dilatation, or varicosity, resembling a commencing invagi-
nation confined to the external root-sheath and the fibrous
layer of the sac. By this dilatation the empty space be-
tween the external and internal root-sheaths is considerably
increased, though the two layers involved are usually
thickened in the vicinity of the dilatation mentioned. It is
possible that this phenomenon is produced by a contrac-
tion of the. pars reticularis of the neighboring corium.
Though traces of the ducts of the sudoriferous glands
are not often met with in the sections, the coils of the
glands themselves appear to generally remain unaffected,
their secreting cells mostly presenting a normal appearance ;
in some instances only the cells of the connective tissue
surrounding the coil appeared enlarged. On the other
hand, the secreting cells of the sebaceous glands are fre-
quently involved in the general infection, and the process
of cell-proliferation commences, as in the corium, by a di-
vision of the original nuclei, continuing until each individual
gland-cell has been converted into a number of the charac-
teristic smaller cellular elements. In sections stained with
picro-carmine the particular pathological condition in which
the latter are met with is easily distinguished by the color,
for while, in some places, they appear stained with carmine,
THE PATHOLOGICAL ANATOMY OF LEPROSY. 235
they exhibit the yellow color of the picric acid in others,
indicating the retrogressive metamorphosis which they are
undergoing. Sometimes one or more nuclei, or even entire
cells, of a group exhibit the ordinary uncolored refractive
appearance of fat in the form of a smaller or larger globule ;
but frequently the whole group of cells may also be found
converted into a large single fat-globule. This singular be-
havior of the protoplasm of these cells I am unable to ex-
plain satisfactorily, though it is evident that the absorption
or non-absorption of the picric acid by the former is indica-
tive of different stages in the degenerative process of the
cells. The phenomenon is, however, not only observed on
the secreting cells of the sebaceous glands, but also on those
of the corium, and on others to be mentioned hereafter.
The acini of these glands are frequently met with filled and
dilated with fat.
In the fat-cells the pathological process commences, as
in the other tissues, by a successive division of the nucleus,
giving rise to the formation of new cells, which, in most in-
stances, remain attached to each other in the form of a
smaller or larger group. They appear to proliferate along
the membrane of the original fat-cell, absorbing it during
their growth. It is thus that, frequently, individual fat-cells
are met with, a large portion of the surface of which is rep-
resented by the proliferating cells, whilst the rest has re-
mained unaltered, and presents the ordinary refractive ap-
pearance by virtue of the portion of normal membrane
left, as well as of the fat still inclosed. In some of these
instances the cells are stained with carmine, showing that
the fatty metamorphosis has, as yet, not commenced,
though generally they have already absorbed the picric
acid, indicating that the degenerative process is going on.
The small groups of fat-cells lodged in the areolae of the
pars reticularis of the corium, almost always undergo the
236 H. D. SCHMIDT.
characteristic change just described ; they had done so, at
least, in all the sections of skin which I examined. The
same happens with the larger groups in the subcutaneous
tissue, if the patient lives long enough. In the sections
extending throughout the lobulus of the ear of Case i not
a single normal fat-cell could be discovered, whilst in the
other cases a few small groups had been left unaffected in
the subcutaneous tissue. In the neoplastic groups of cells,
originating from the nuclei of the fat-cells and destroying
the latter, the phenomenon of fat-globules making their ap-
pearance is observed in the same manner as in those of the
corium or of the sebaceous glands.
In sections made through the helix and anti-helix of the
ear the same conditions and changes above described were
likewise observed to prevail, though they extended not to
the perichondrium and cartilage, both of which presented a
normal appearance. The same remarks are applicable to
the mucous membrane and subcutaneous tissue of the
thickened epiglottis. Here the neoplastic growth presented
exactly the same characters as in the skin, invading all the
parts, including the epithelial cells of the racemose glands,
but leaving the perichondrium and cartilage, as well as the
fat-cells, untouched. Upon the anterior surface of the epi-
glottis the mucous membrane was found almost entirely
detached from its subcutaneous tissue, very probably by the
softening of the tissues.
In the tongue the pathological changes had not proceeded
to so great an extent as in those parts already mentioned.
The proliferation was chiefly confined to the perimysium of
its composing muscular bundles, and to the connective tis-
sue surrounding the vessels, though the mucous membrane
was also found slightly involved in these changes. A few
of the blood-vessels showed an increase of the nuclei of
their adventitiae.
THE PATHOLOGICAL ANATOMY OF LEPROSY. 237
As already mentioned in the first of these cases, the aorta
and other large arteries were found very considerably af-
fected by the disease, resulting not only in a thickening of
their walls, but, moreover, in a general reduction of their
normal calibre. The microscopical examination of thin
horizontal sections of the aorta showed that, as in the
other tissues, the thickening depended upon a proliferation
of the nuclei, particularly of those belonging to the mus-
cular fibre-cells. In these, however, the neoplastic growth
appeared to be mainly represented by proliferating nuclei,
generally appearing in small oblong or ellipsoidal groups
of two or three individuals, their axes lying at right angles
with that of the muscular fibres ; larger groups of these
nuclei were, however, also here and there observed. In
some places, in the media of the vessel, the proliferation
had been going to such an extent as to almost fill up the
interior of these fibres by long rows or masses of nuclei, ap-
pearing highly stained with carmine, while the protoplasm
of the fibre-cells presented the ordinary staining, and the
elastic-tissue fibres had remained perfectly colorless. -In
the adventitia of the vessel the proliferation of the nuclei
had only proceeded to a very small extent ; it therefore
presented a normal appearance in general, while in the in-
tima the pathological changes had in many places given
rise to the fatty metamorphosis, and to a complete disor-
ganization of the membrane by softening and ulceration.
The proliferating elements here appeared mostly in the
form of round cells, having undergone fatty degeneration
and resembling pus-cells ; though in some places numerous
nuclei and cells more or less stained with carmine were
observed in the different layers of this membrane. As in
the media, the extent of the morbid changes differed in
different places of the intima, the degree of thickening of
the wall of the vessel being proportionate to that of the
238 H. D. SCHMIDT.
proliferation. On the whole, the pathological process here
greatly resembles that of chronic endo-arteritis.
Before proceeding to the description of the pathological
changes observed in some of the glands, and in the nervous
tissues, some brief remarks regarding the staining and ex-
amination of the sections of the organs may here not be
out of place. In the study of the neoplastic growth of
leprosy, as in other histological investigations, much ad-
vantage is gained by staining the sections with two or
three colors for the purpose of defining different conditions
of the anatomical elements of the tissues. The picro-
carmine of Ranvier and the alum-haematoxylin I have
found the most suitable to meet the object in view, for
while the carmine is only absorbed by the normal proto-
plasm of the nuclei and cells, the picric acid, moreover,
stains the fatty substances, and the haematoxylin imparts a
deep blue to the nuclei before coloring the protoplasm of
the cells. Thus, in staining the sections with picro-carmine
only, the commencing degeneration or fatty condition of
the protoplasm is easily recognized by the yellow staining
of the picric acid, while the normal protoplasm will appear
carmine, and the fully formed fat not appear stained at all,
but manifest itself by its ordinary refractive appearance.
The nuclei of the cells, though recognizable, do not always
appear very distinct; but, if the section is subsequently put
in a weak solution of haematoxylin, and left there only suf-
ficiently long to stain the nuclei alone, these bodies will be
very easily distinguished by their blue color from the other
elements ; though, if the section is left too long a time in
the staining liquid, the protoplasm of the cells will be ren-
dered dark purple, or even blue, by the haematoxylin
hiding or driving out the carmine. Another advantage of
the subsequent staining with haematoxylin is, as I have
found, to enable one to distinguish the comparative age or
THE PATHOLOGICAL ANATOMY OF LEPROSY. 239
freshness of the protoplasm by the degree of intensity of
the staining; in other words, the more recent the histo-
logical product the more readily and intensely it will be
stained. The proliferating nuclei, therefore, will be found
more highly stained than those of the normal tissues.
In the same way fibrinous products, such as thrombi, or
emboli, in the blood-vessels, will be found highly stained
by haematoxylin, and rendered more distinct for recogni-
tion. The examinations should not be confined to sections
mounted in one and the same medium, such as Canada
balsam. This substance renders the preparations remarka-
bly clear and transparent, and, provided they are perfectly
stained, offers many advantages in their examinations, con-
sisting, especially, in obtaining a correct idea of the relation-
ship of the anatomical elements of a tissue to each other,
of which, in virtue of the transparency, a more perspective
view is obtained. For the study of the more minute details
of a tissue, however, the Canada balsam is unsuitable, as, in
proportion to the transparency gained, definition is lost.
While, therefore, some sections may be mounted and exam-
ined in Canada balsam, others should, at the same time, be
examined in glycerine, which renders the tissues sufficiently
transparent to show their minutest details. In the exami-
nations themselves great advantage will be derived from
using oblique illumination by the achromatic prism, for the
application of which, however, only very superior objectives
with high angular apertures are suitable.
In continuation of the description of the microscopical
condition of the organs examined in the cases of leprosy
under discussion, I shall now proceed to the liver. The
pathological changes observed in this organ presented the
same general characters in all three cases, the difference
observed consisting only in the degree of their extent.
The pathological process, as in the tissues already described,
240 H. D. SCHMIDT.
here also consisted in the characteristic proliferation of the
cellular elements, affecting not only the connective tissues,
but, moreover, the hepatic cells themselves, and even the
endothelium of the intra-lobular hepatic veins. In the first
case the proliferation of the connective-tissue cells was
chiefly confined to the walls of the intra-lobular veins, from
which the morbid process had extended to the endothelial
cells of these vessels, manifesting itself by the division of
their nuclei and their ultimate fatty degeneration. In con-
sequence of these changes, the walls of the vessels were
slightly thickened and their lumen decreased in size. The
portal vessels and their capsule, on the other hand, appeared
in this case not much affected, — only in the latter a slight
proliferation of cells was observed.
The greater portion of the secreting elements — the
hepatic cells — had received their full share of the infection,
and were met with in the various stages of fatty degenera-
tion. The degenerative process appeared to have mostly
extended through that portion of the lobules farthest
removed from the vessels, only in some places the degene-
ration had extended to the cells in the vicinity of the inter-
lobular vessels, while those forming the central portion of
the lobule and surrounding the intra-lobular (hepatic)
veins, were mostly found perfectly colored by the carmine.
Throughout the sections a number of cells of a brown
color, and containing a number of highly refractive, dark-
bordered granules, were observed. The brown color of
these cells was probably due to the presence of bile, and
as the granules had remained unaltered, even in cells where
the protoplasm had undergone fatty degeneration, they
very likely represented pigment. In the degenerated por-
tions of the lobules, a number of the cells were found
colored yellow by the picric acid, while others were color-
less, or contained one or two large ordinary fat-globules
THE PATHOLOGICAL ANATOMY OF LEPROSY, 24I
great numbers of the latter, however, were also found in
connection with the other cells, wherever the degenerative
process was going on, and even amidst the cells of normal
appearance, that is, those stained with carmine, many of
which contained one, two, or more fat-globules, probably
derived from the fatty degeneration of the nuclei. On
these cells, also, the beginning of the process could be
observed manifesting itself, as usual, by the division of
their protoplasm and the presence of two or more nuclei,
though in those cells already undergoing the fatty meta-
morphosis the nuclei could be no more distinguished. In
this liver, as may be judged from the above sketch, the
degenerative process had already advanced to a consider-
able extent, moreover indicated by a certain faintness and
delicacy observed in the outlines of all the minute ana-
tomical elements of the organ.
In the second case, though the same changes, as above
described, were observed in connection with the hepatic
cells, the disease manifested itself more strikingly upon the
connective tissues of the organ. Thus, the capsule of the
portal vessels (Glisson) was found affected and considerably
thickened throughout, and encroaching upon the neighbor-
ing hepatic cells. The thickening, however, did not evenly
extend throughout the whole capsule, but was much greater
in certain places, where, in thin sections, it appeared in the
form of bulgings projecting into the neighboring paren-
chyma. While the adventitia of the inter-lobular vessels
was likewise undergoing these changes, their other coats,
as also those of the ducts, appeared unaffected. But the
proliferating cells of the adventitia and capsule, instead of
being transformed into a so-called granulation or cicatricial
tissue, as takes place in the ordinary cirrhosis of the liver,
here rather manifests a tendency to an early fatty degener-
ation ; and, accordingly, as in the corium of the skin.
242 //. D. SCHMIDT.
these elements were also met with in various forms and
conditions, either singly or in groups, unchanged, or con-
taining large and distinct fat-globules. It is to this circum-
sta:nce, that the softness of the liver in leprosy, and the
want of the knotty appearance produced by the organiza-
tion and contraction of the granulation-cells, as observed in
the so-called " hobnail-liver," must be attributed. In the
capsule and walls of the intra-lobular veins the morbid pro-
cess had proceeded to a still greater extent, involving the
endothelial cells, the proliferation of which finally led to an
obliteration (thrombosis) of the lumen of these vessels.
There was hardly an open intralobular vein met with in
the sections examined of this liver. It remains to be
stated that in the instances just described the remains of
the connective tissue of the capsule or adventitia could
always be seen defined to a certain extent around the
lumen of the vessels. There were certain masses of cells
met with in these sections, however, which perfectly cor-
responded in their details with those presented by the hori-
zontal or transverse section of a small intralobular vein,
but of which the outlines bordered directly on the sur-
rounding hepatic cells without showing any definite traces
of connective-tissue fibres, though the mass appeared to be
crossed by apparently fibrous elements. I am unable to
decide satisfactorily upon the true nature of these bodies,
unless they represent small centres of proliferating hepatic
cells, the appearance of fibres being caused by the empty
capillaries stretched throughout the mass. The epithelium
of the hepatic ducts, as seen in horizontal sections, gener-
ally appeared highly colored by the carmine, indicating its
normal condition. In this case, also, numerous brownish
hepatic cells with dark-bordered granules were met with
throughout the sections. The outer capsule of the organ
was always found in a normal condition.
THE PATHOLOGICAL ANATOMY OF LEPROSY. 243
In the third case the same pathological changes observed
in the liver of the second were also met with. In addition
to these, however, the minute vessels of the organ were
found congested ; in many places, even, to such a degree as
to become completely filled with blood-corpuscles and free
haemoglobin, the presence of the latter indicating a stasis.
This condition fully explains the dark bluish appearance
which the organ presented at the macroscopical exam-
ination.
From the presence of the neoplastic element in the con-
nective tissue of the liver, it might be inferred to be like-
wise met with in the kidneys. This, however, as will be
seen directly, is not the case ; for these organs, at least in
the cases under discussion, appeared to form an exception
to the rule. The chief pathological phenomenon observed
here consisted in the formation of albuminoid cylinders in
the uriniferous tubules.
Thus, in the first case, a considerable number of these
cylinders were observed in all the different portions of the
tubules ; many of them consisted entirely of the albumi-
noid substance, while in others epithelial cells were seen
to be embedded. These cylinders possess the power of ab-
sorbing carmine, or other staining material, in a high de-
gree, and are in consequence easily distinguished by their
staining and lustrous appearance. The epithelial cells of
the tubules, in this case, had generally preserved their nor-
mal size and appearance, with the exception of a small num-
ber in which they presented the same high carmine color-
ing, or staining, as the cylinders. On a former occasion, in
connection with a discussion on the pathological changes
observed in the yellow fever kidney, in which the same phe-
nomenon is observed, I have dwelt at length upon this sub-
ject, expressing the view that these particular cells repre-
sented the initial stage of the retrogressive metamorphosis,
244 H. D. SCHMIDT.
containing the abnormal material of which the cylinders
were subsequently formed, a view which has been advanced
of late years, and is now held by a number of prominent
pathologists. The epithelial cells covering the glomeruli
also presented the intense staining and lustrous appearance
before mentioned. In some places of the sections a num-
ber of cells were likewise observed, the protoplasm of which
had remained uncolored, while their nuclei had absorbed
the carmine, though no fat-globules could be detected. In
the interior of some capsules from which the glomeruli had
fallen out, a pale carmine-colored exudate was moreover ob-
served. The larger and smaller blood-vessels throughout
the sections were generally found empty of blood-corpuscles,
though in certain places of the medullary portion of the or-
gan small portions of the capillary network, as well as some
arterioles, were met with containing small fibrinous emboli,
intensely colored blue by the haematoxylin ; in these arteri-
oles the endothelial cells were, in some places, also colored
by this agent. As already mentioned, there were no traces
of the characteristic neoplastic element observed in the con-
nective tissue of this organ, neither in the walls of the blood-
vessels, nor in the interstitial tissue ; they everywhere pre-
sented their normal appearance.
In the second case, with the exception of the emboli in
the blood-vessels, the same changes as just described were
observed ; the exudate from the epithelial cells covering the
glomeruli was rather more abundant.
As in the liver of the third case, in its kidneys, also, the
pathological condition of these organs presented itself in a
still severer form than in the preceding cases. For, though
here the albuminoid cylinders were not as numerous, the
epithelial cells of the uriniferous tubules had in many pla-
ces undergone a complete fatty degeneration, the degen-
erated individual cells being represented by fat-globules,
THE PATHOLOGICAL ANATOMY OF LEPROSY. 245
which, in many instances, presented the original form of the
entire cell. Besides, the lumen of many tubules was filled
with fat. The cells of the epithelium covering the glomer-
ular vessels presented a high staining, as in the other cases.
The blood-vessels, especially the straight arteries of the
medullary substance, were found filled with blood-corpuscles
and free haemoglobin, and extensive extravasations of this
coloring substance had taken place from the vessels into
many of the tubules, to the cells of which it had imparted
an intensely brown color. With all these changes, no pro-
liferating cells could be detected in the walls of the blood-
vessels, or in the interstitial tissue.
The pathological changes observed in the lymphatic
glands greatly resemble in their nature, those already de-
scribed as taking place in the liver. In the third case, they
were observed to have advanced farthest, for which reason
I shall place this case first in the following description.
While the outer stratum of the connective tissue of the
capsule investing the glandular tissue, namely, showed a
normal condition, the inner layer, with the trabeculae arising
from it, presented great numbers of the proliferating neo-
plastic cells in smaller or larger groups and distinguished by
the same characters as those met with in the skin or in the
capsules of the inter-lobular and intra-lobular veins of the
liver. Many of these elements had undergone fatty degen-
eration, indicated by numerous, generally large fat-globules.
In the follicular substance of these glands, also, the same
proliferating cells were met with in great numbers ; though
here the successive stages of the retrogressive metamorpho-
sis, as in the sebaceous glands of the hair-sacs and race-
mose glands of the epiglottis, could be distinguished by the
difference in the staining of the elements concerned. Ac-
cordingly, some of the groups of cells were found stained
with carmine, while others presented the yellow color of the
246 H. D. SCHMIDT.
picric acid, indicating that the retrogressive changes had
commenced, and others, finally, contained large refractive
fat-globules. The follicular columns themselves appeared
enlarged by the proliferating neoplastic elements. Whence
the latter were derived, that is, from the lymph corpuscles
of the follicular tissue, or from the cells of its reticulum, re-
mains difificult to decide; but, judging from the great num-
ber of those cells, it may be presumed that the lymph-cor-
puscles had been involved in the pathological process. In
the reticulum of the lymph-tracts the proliferating element
presented a new feature, for here it was represented by yel-
low or brown, highly refractive, mostly round, oval, or ob-
long bodies, consisting of small round nuclei, distinguished
by a double contour, and by containing a few small granules
in their interior. In many places, especially in the vicinity
of the capsule and the hilus, these bodies filled up the en-
tire lymph-tract, and, by virtue of the mass, they then pre-
sented a deep brown color. The larger ones appeared un-
attached to the reticulum, and, in consequence, not derived
from the nuclei and cells of this structure ; a number of the
smaller, however, were directly observed to represent the
nuclei of the multipolar cells, forming the reticulum of the
lymph-tracts; they were of a light yellow color, and ap-
peared highly refractive. As in the follicular tissue, here
also some of these bodies, especially those unattached to
the reticulum, may have originated from the nuclei of free
lymph-cells. As in the outer stratum of the capsule, the
cells of the connective tissue, surrounding the blood-vessels
in the hilus, had not been affected by the proliferation-pro-
cess, though the latter had extended to the walls of the
lymphatic vessels ; the blood-vessels, also, presented a nor-
mal appearance. Judging from the condition above de-
scribed, the lymph-current in these lymphatic glands must
have been entirely arrested.
THE PATHOLOGICAL ANATOMY OF LEPROSY. 247
In the lymphatic glands of the first and second case the
same pathological phenomena were observed, the difference
met with existing only in the smaller extent of the morbid
process.
In the medullary substance of the supra-renal bodies a
considerable number of cells were also observed to have
multiplied into groups and undergone the same retrogres-
sive changes as observed in the tissues already described.
In the spinal marrow of the third case the proliferation
of cells was only met with in the ependyma of the central
canal, which, in some places, was even found to be occluded.
A number of the nuclei of the posterior commissure in the
vicinity of the canal, also, were observed to have multiplied.
These changes were found to extend along the entire cen-
tral canal up to its orifice in the fourth ventricle. The nu-
clei of the neuroglia, on the other hand, had remained un-
affected. But while the connective element had thus far
preserved its normal condition, considerable portions of the
nerve fibres, particularly in the posterior, but also in the
other white columns, had undergone degeneration. The
axis-cylinders of these fibres had absorbed no color, and the
medulla of many of them appeared swollen and increased
in diameter. This condition existed throughout the whole
cervical region, and was even met with, though in a much
lesser degree, in the lumbar region.
In the medulla oblongata, also, many bundles of nerve
fibres manifested this state of retrogressive metamorphosis
by the absence of their absorbing power for the staining
material, while a number of ganglion-cells were observed
to have undergone a pigmentary degeneration, the whole
ganglionic body representing a mass of brown pigment
granules. The smaller blood-vessels, both in the medulla
oblongata and the spinal marrow, were found filled with
blood corpuscles.
248 H. D. SCHMIDT.
In some parts of the corpus striatum, a considerable
proliferation of nuclei was observed in the ependyma,
causing a number of ridge-like elevations, or folds, upon
this layer. The same proliferation was observed of the
nuclei of the neuroglia throughout the whole ganglion,
where they appeared in groups of two, four, or more.
While the nuclei of the ganglion-cells appeared perfectly
stained and normal, the protoplasm of these bodies had
refused the staining material, and appeared colorless.
No particular changes were observed in the sections made
of the cortex cerebri of the central convolutions.
The Gasserian ganglion was, as already mentioned, indu-
rated and smaller than normal, its investing connective-
tissue sheath thickened and adhering to the dura mater.
The induration and thickening was due to a prolifera-
tion of the nuclei of the connective tissue, extending,
however, into the ganglion itself. The same phenomenon
was observed on the semilunar and other ganglia of the
solar plexus.
The changes observed in the nervous tissues of this case,
though sufficiently severe, were not quite as extensive, as
they have been met with by other observers in some other
cases ; thus, the connective-tissue sheath of the larger nerve-
trunks, in which, in a number of instances, the neoplastic
element was met with by other observers, had here remained
unaffected. The lesions in the spinal marrow, also, have in
several cases been observed in a more severe form. In a
case of lepra ana^sthetica, Steudener found in the spinal
marrow a narrow cavity, filled with a viscid mucoid fluid,
and formed at the expense of the gray substance. Lang-
haus found in the spinal marrow softening and atrophy of
the commissure, the columns of Clarke, and the posterior
horns, especially in the cervical enlargement and in the
upper dorsal region. In the peripheral nerves he found
THE PATHOLOGICAL ANATOMY OF LEPROSY. 249
thickening of the peri- and endoneurium, with atrophy of
the medullary sheaths, though the axis-cylinders had been
preserved. Tschiriew observed in the central canal of the
cervical portion of the spinal marrow many lymphoid
embryonal cells of a round form, infiltrating, also, the walls
of the canal. The same elements he met with in the gela-
tinous substance of the posterior horns. In the left poste-
rior horn he noticed small hemorrhages and extravasated
colored blood corpuscles, and also a diminution and altera-
tion of the ganglion-cells.
The larger veins, also, on which, in the above-described
three cases, no particular change was observed, have been
found affected in a few other cases. Thus, in Steudener's
case, the brachial vein, at the middle of the upper arm, was
found considerably thickened and obstructed by a puriform
disintegrated thrombus. Bcettcher observed on the veins
of the forearm a thickening of the adventitia, caused by
the proliferation of the small cellular elements. The mus-
cular coat, also, had increased in thickness, causing a, dimi-
nution in the lumen of the vessels. Moxon, also, described
a case of leprosy in which small knots, filled with a pus-like
liquid, were, in numerous places, found connected with the
walls of the veins of the forearm and hands.
The neoplastic cellular element, characteristic of leprosy,
has also been observed by Bull and Hansen to occur in
the cornea and iris ; in the former the growth generally af-
fects the periphery, leaving free the centre.
Hansen, who has largely contributed to the pathology of
leprosy, described, as early as 1870, certain round, oval, or
spindle-shaped cells, containing besides the nucleus one or
more larger or smaller round granular masses of a yellow
color, which generally absorb carmine. These elements he
met with, not only in the leprous tubercles of the skin, but
also in the affected lympathic glands, the interlobular tis-
250 H. D. SCHMIDT.
sue of the liver, the spleen, and even in the choroid and
retina of the eye. To these elements, which he appears to
regard as characteristic of leprosy, he refers again in his
more recent contributions. In all the sections of the
organs which I have examined, I have not been able to
detect any cells resembling those described by Hansen,
unless they are identical with the refractive, yellow nucle-
ated masses, which, as already stated, I observed in the
lymph-tracts of the lympathic glands.
Amyloid degeneration has been stated to occur in the
liver and kidney, though no traces of this process were met
with in the cases which I examined. Boettcher observed,
in his case, upon the cut surface of the liver, numerous white
dots upon the ramifying branches of the portal vein ; those
are, very probably, identical with the bulgings I have
described above, formed by the neoplastic cells in the
capsule of the interlobular veins.
From the description rendered above it may be gathered
that the results obtained from my examinations correspond,
in the main, with the statements of other observers. It will,
however, be noticed that, while the latter have generally
described the neoplastic element as limited to the connec-
tive tissue, my observations show that the proliferation also
takes place on the cells of glands and of the endothelium of
vessels, such as I observed in the sebaceous and lymphatic
glands, the liver, suprarenal body, and the endothelium of
the intralobular veins. The whole pathological process,
therefore, can hardly be regarded as a mere hyperplasia of
the connective tissues, but its products, as it appears to me,
represent rather a neoplastic growth, resembling in its
general character the tubercle of tuberculosis, ultimately
undergoing, like the latter, a retrogressive metamorphosis.
The neoplastic cellular element of leprosy, remaining for a
long time limited to the skin, and being probably also of a
THE PATHOLOGICAL ANATOMY OF LEPROSY. 25 I
slower growth than the tubercle of tuberculosis, does not
immediately endanger the life of the patient ; and it is for
this reason that the disease may extend over a period of
twenty or even thirty years, before it leads to death.
The fatal termination of leprosy depends, undoubtedly,
mostly upon the neoplastic cells appearing in the internal
organs, especially the lymphatic glands and liver ; the
affection of the former depraving the blood, and, in conse-
quence, interfering seriously with the nutrition of the
organism, while the organic disease of the latter gives rise
to the pathological phenomena observed in the alimentary
canal, almost always present in the later stages of the
disease, and taking a share in the general exhaustion of the
patient. To the abnormal nutrition of the organism, also,
must be attributed the retrogressive changes observed in
the nerve fibres of the spinal marrow and brain, as they can
hardly be caused solely by the proliferating cells in the
walls of the central canal. The congestion of the vesssels
of the cerebro-spinal axis is probably due to a neuro-
paralysis of its blood-vessels, while the anaesthesia of the
skin and muscles may partially depend upon the presence
of the proliferating cells in the connective tissue of the
peripheral nerves.
THE STRUCTURE OF THE UPPER END OF THE
FEMUR, AND SOME SPECIMENS OF ACCI-
DENTAL DEVIATIONS OF THIS STRUCTURE.
By J. S. WIGHT, M. D.,
PROFESSOR OF SURGERY AT THE LONG ISLAND COLLEGE HOSPITAL.
[During the delivery of this lecture the original specimens of normal and
deviated structure of bone were used for illustration. In this report for these
Archives photo-lithographs of these specimens have been employed, thus
changing the phraseology, but not the meaning of the text.]
GENTLEMEN : I am here this morning to talk over
some points in regard to fracture of the neck of the
femur. The word over expresses what I mean ; for we have
been through the material before us, some of it at any rate.
And now I propose to go through the matter again, and
present you with some new material.
In the first place, let me direct your attention to the neck
of the femur and its capsule. It is sufficiently accurate to
say that the neck of the femur is bounded above by the
femoral head. The base of the neck of the femur is bounded,
in front, by the spiral ridge ; posteriorly, by the posterior
intertrochanteric ridge ; that irregular space which I show
you between these two ridges above, constitutes the supe-
rior boundary ; and, roughly, a line drawn between the
lower ends of the intertrochanteric ridges marks the inferior
boundary of the base of the femoral neck.
Please to observe that I use the word ridge instead of
line to designate the elevation of bone at the base of the
252
STRUCTURE OF THE UPPER END OF THE FEMUR. 253
femoral neck in front. It is more appropriate. So much
for the femoral neck ; and we must not violate our defini-
tion as we go on in our work.
The upper end of the cervical capsule of the femur is
attached to the circular eminence of the acetabulum. The
lower end of the cervical capsule of the femur is attached
(i) in front, to the base of the spiral ridge; (2) posteriorly,
to the middle of the femoral neck ; (3) above, by a line run-
ning from the middle of the femoral neck to the upper end
of the spiral ridge ; (4) below, by a line running from the
lower end of the spiral ridge to the middle of the femoral
neck. Sometimes more and sometimes less than one half
of the femoral neck is covered posteriorly by the cervical
capsule. Almost always the entire femoral neck is covered
in front by the cervical capsule. So much for the cervical
capsule, and we must not violate our definition. But we
shall soon see the bearing this definition will have on the
subject of fracture of the neck of the femur.
The logical sequence coming out of these facts is : (i) In
a rare instance, where there is some space between the spiral
ridge and the basal insertion of the cervical capsule, there
could be an extracapsular fracture of the neck of the femur.
In any other instance an extracapsular fracture of the neck
of the femur would be impossible. (2) In another instance,
when the outer and lower half of the femoral neck is broken,
the fracture will be intracapsular in front and ^;ir/r^capsular
behind. The same conclusion will hold good when the fem-
oral neck is driven into the cancellous tissue of the trochan-
ters. (3) In another instance, when the inner and upper end
of the femoral neck is broken, the fracture will be intracap-
sular^
^ Since writing the above paragraphs I have found three specimens in which
the capsule was adherent to the anterior surface of the femoral neck for at least
three fourths of the distance from the anterior trochanteric ridge. In one of these
there was a fracture of the outer half of the femoral neck, and therefore a veri-
table extracapsular fracture of the neck of the femur. But how can we know
that we have such a case without z. post-mortem examination ?
254
y. S. WIGHT.
In order to have a better idea of the subject under con-
sideration, it is important to keep in mind some points in
regard to the intimate structure of the upper end of the
femur. To show this structure the upper end of the femur
is cut into sections in three different directions, namely :
I. In a longitudinal direction, so that the sections will be
vertical (see fig. i). The figure is drawn from a bisection of
a normal femur, and shows the manner in which the com-
pact tissue runs up to the head of the bone on the inner
and under side of the femoral neck, becoming thinner as it
sends off plates of bone and approaches the base of the
head. On the outer side of the femur the compact tissue
also becomes thinner as it sends off plates of bone and
forms the great trochanter. The wedge-formed compact
tissue on the inner and under side of the femoral neck,
marked i, may be called th^ femoral brace.
FIG. I.
2. The sections are also made in an antero-posterior and
longitudinal direction. See figs, ii, iii, and iv. (a.) Fig.
STRUCTURE OF THE UPPER END OF THE FEMUR. 255
ii represents the upper end of the femur, having about
one fourth of the head and neck and great trochanter re-
moved from the upper side. The part marked i is above
the lesser trochanter, and the part marked 2 shows the can-
cellous tissue of the spiral ridge. The compact tissue of
the neck is thin, (b.) Fig. iii represents the upper end of
the femur, having about one half of the head and neck and
great trochanter removed from the upper side. The part
marked i is the upper end of the lesser trochanter, and the
part marked 2 shows the cancellous tissue of the spiral
ridge. The part marked 3 shows but very little compact
tissue. The compact tissue of the neck begins to be
thicker, (c.) Fig. iv represents the upper end of the
femur, having about three fourths of the head and neck
and great trochanter removed from the upper side. The
part marked i is the lesser trochanter, and the part marked
2 shows the cancellous tissue of the spiral ridge, while the
part marked 3 shows a few plates at the base of the lesser
FIG. II.
FIG. III.
FIG. IV.
256 J^. S. WIGHT.
trochanter, fused into a bony plate having considerable
firmness. In some specimens this subtrochanteric plate, or
spur, of bone is absent, the entire structure being cancellous.
The heavy compact tissue of the femoral brace will be seen
in the neck of the bone.
3. The sections are made transversely to the femoral
neck, and continued till they pass well through the trochan-
ters. See figs. V, vi, vii, viii, ix. (a.) Fig. v represents a
transverse section of the outer part of the femoral neck,
intracapsular in front and extracapsular behind. The part
marked i and 2 shows the femoral brace. The part marked
4 is the anterior compact tissue of the femoral neck, being
thinner than the femoral brace. Part of the great trochanter
is shown at 3. The cervical capsule may be seen at 5 and 5.
(b.) Fig. vi represents a section from which the piece seen
in fig. V was cut. The part marked i and 2 shows the fem-
oral brace ; figure 2 is at the extremity of the lesser tro-
chanter ; figure 4 shows the anterior compact tissue expand-
ing into the greater trochanter ; and figure 3 shows the pos-
terior and upper part of the great trochanter; while figure 5
shows the inner end of the subtrochanteric plate of compact
tissue, (c.) Fig. vii represents a section from which the
piece seen in fig. vi was cut. The part marked i represents
the femoral brace, which is seen to be continuous with the
compact tissue of the femur in front, which, at 4, expands
rapidly into cancellous tissue. At 3 is seen the compact
tissue of the greater trochanter ; and figure 5 shows the sub-
trochanteric plate of compact tissue, over which is seen the
lesser trochanter, marked 2. (d.) Fig. viii represents a
section from which the piece seen in fig. vii was cut. The
part marked i represents the femoral brace, which is seen
to be continuous with the compact tissue of the femur in
front, which slowly expands into cancellous tissue. The
lesser trochanter is marked 2, and the greater trochanter is
STRUCTURE OF THE UPPER END OF THE FEMUR. 257
FIG. V.
FIG. VI.
FIG. VII.
258
y. S. WIGHT.
marked 3. The subtrochanteric plate of compact tissue is
shown at 5. (e.) Fig. ix represents a section from which
the piece seen in fig. viii was cut. The part marked i rep-
resents the femoral brace, and the part marked 4 is the
anterior wall of the femur, while the part marked 2 is the
out-set of the lesser trochanter. At this point there is no
subtrochanteric plate.
FIG. IX.
The trochanteric pyramid is that eminence of bone found
on the external aspect of the greater trochanter. In general
the summit of the trochanteric pyramid is nearly over and
external to the posterior wall of the femoral neck. This
fact is readily seen by inspecting figs, ii, iii, iv, v, and
vi. I find this condition to be a common one. In general
the anterior surface of the upper end of the femur is, in the
main, convex, while the posterior surface is concave. The
practical importance of this condition will appear in due
time.
STRUCTURE OF THE UPPER END OF THE FEMUR. 259
The compact tissue of the anterior and posterior walls of
the femoral neck expands into cancellous tissue at the base
of the femoral head and at the trochanters. The femoral
brace is firm and heavy at its base, while it is pointed and
sharp at its junction with the femoral head. Hence it ap-
pears that the femoral neck is eminently fitted for being
driven into the cancellous tissue of the femoral head or of
the trochanters. Also it appears that a blow on the outer
aspect of the upper end of the femur will be applied some-
what directly over the compact tissue of the posterior wall
of the femoral neck, and will make the impaction greater
behind than in front, so that in general the shaft of the fe-
mur will be out-rotated, when the base of the femoral neck
is driven into the cancellous tissue of the trochanters. Also,
it appears that the top of the femoral brace can be driven
into the femoral head, when the femoral head will be rota-
ted, or tilted, somewhat downward.
Let me draw especial attention to the relations of the
compact and the cancellous tissues, as represented in figs,
vii, viii, and ix. Figure I is on the heaviest part of the
compact tissue, and from this point in opposite directions
the compact tissue gradually becomes thinner, as it gives
off the plates of cancellous tissue, not only in front but also
behind. The compact tissue is actually expanded into the
cancellous tissue, — only in some cases a few plates of can-
cellous tissue are given off in company, as already de-
scribed, constituting quite a firm plate of bone. A blow on
the femoral pyramid, as in falling on the trochanter, is ap-
plied almost directly over this plate of bone, when it exists
at the base of the lower 
