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Columbia  (Hnttier^fttp 
tntI)fCttpof3flftti8ork 

College  of  ^1)psimni  burgeons: 

Hibrarp 


Digitized  by  tine  Internet  Arcliive 
in  2014 


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PROPERTY  OF  THE 
.  WOMANS'  MEDICAL 
OF  THE 
NEW  YORK  INFIHMAn . 


JSOT  XO  BE  XAKm 


THE  O 


NEW  YORK 


MEDICAL  JOURNAL. 


VOLUME  II. 


NEW  YORK: 
MILLER  &  MATHEWS,  No.  757  BROADWAY. 
1  8  6  6. 


JOHK  MEDOLE,  PBINTEB, 

4  Thames  Street,  N.  T. 


INDEX  TO  YOL.  II. 


Pago 

Abortion  followed  by  Pii';rperal  Tetanus   74 

Abortion,  habitual,  in  Flexion  of  the  Uterus   C9 

Abscesses — Deep  Seated   36 

Academy  of  Medicine   272 

Aloetic  Preparation  in  Constipation   264 

Amaurosis,  Double   154 

Amaurosis.  Simulated   361' 

Amenorrhoea   71 

Ammonia  in  the  Blood.  Experiments  confirming  the  non-existence  of   224 

Amputated  Limb.s,  Abuses  of  Bandages  in   1 

Amputation  at  the  Hip  Joint   161 

Anaisthetic  and  Sedative  Properties  of  Bichloride  of  Carbon   394 

Aneurism  of  the  Aorta  196,  298 

Aneurism  of  the  Innominata   295 

Aneurism  of  the  Innominata  and  Carotid  Arteries   122 

Aneurism  of  the  Thoracic  Aorta   446 

A  New  Poison   149 

Animal  Food   225 

Aorta,  Aneurism  of  the  Thoracic     446 

Aorta,  Aneurism  of   298 

Aorta,  Aneurism  of   196 

Aplitha;  of  the  Mouth  and  Throat,  in  Adults   155 

Arrest  of  Development  in  the  Kidney   299 

Arteriotomy  and  other  Remedies  in  Puerperal  Convulsions   27 

Asthenopia,  Discussion  on   41 

Asthenopia  not  connected  with  Hypermetropia   11 

Astringents,  Stimulant- Astringents  and  Caustics,  in  Affections  of  the  Eye...  393 

Bandages  in  Stumps  of  Amputated  Limbs,  Abuses  of   1 

Bichloride  of  Carbon — Anesthetic  and  Sedative  Properties  of   394 

Biddle's  Materia  Medica — Notice  of   381 

Blood — Non-Existence  of  Ammonia  in   224 

Bolter.  (Dr.  A.)  Congenital  Hypertrophy  of  the  Tongue   435 

Bony  Growths  in  the  External  Ear   424 

Bony  Tumor  of  the  Finger   292 

Brain  in  a  Case  of  Meningitis.     134i 

Brain — Influence  of  Civilization  on   220 

Brain,  Weight  of — in  relation  to  the  Intelligence  in  the  Vertebrata   22lJ 

Breast — Cancer  of   13* 

Bright's  Disease,  Nature  and  Treatment  of — Simplest  Forms  18,  254 

Bullet  impacted  in  a  Metacarpal  Bone   1'39» 

Bullet  removed  from  Ramus  of  Jaw   186 

Byford's  Practice  of  Medicine  and  Surgery  applied  to  Diseases  of  Women — 

Review  of   199 

Case  of  Aneurism  of  the  Innominate  and  Carotid  Arteries   122 

Case  of  Compound  Dislocation  of  the  Tibia  forward   124 

Case  of  Tubal  Pregnancy   120 

Calculus  Salivary   195 

Calculus  Vesical   194 

Cancer  of  the  Breast   138 

Cancer — Relief  in   IT 


iv  INDEX. 

Page 

Carbonic  Acid— Physiological  Action  of   225 

Carotids— Wound  of  both   187 

Causes  endangering  Life  of  Foetus  during  Labor   390 

Cell  Pathology   224 

Cerebellum— Functions  of   223 

Chambers'  Renewal  of  Life— Review  of   374 

Chloroform  Internally  a  Remedy  for  Congestion   6 

Chloroform — its  action  and  administratioa.  Notice  of  Sansom's   384 

Childbirth— Diet  after   388 

Cholera  77,  236 

Cholera  Infantum   293 

Cholera — its  Characteristics  in  Egypt   318 

Cholera — Sugestions  regarding   126 

Cholera,  the  Epidemic,  of  1849  and  1854    215 

Chronic  Intestinal  Obstruction   192 

Civilization,  Influence  of,  on  the  Brain   220 

Circular  No.  6— Review  of   448 

Colon— Ulceration  of  the   34 

Concussion  of  the  Spine   230 

Congestion — Chloroform  internally  a  remedy  for   6 

Oonant.  (Dr.  D.  S.)— Death  of  158,  366,  439 

Consanguinity — Marriages  of   63 

Constipation  cured  by  an  external  application  of  an  Alcetic  Preparation. ...  264 

Contributions  to  Obstetric  Jurisprudence   fl 

Coolidge,  (Surg.  R.  H.)— Death  of   396 

Craniotabes   136 

Crushing  of  Leg,  with  recovery     233 

Danger  of  Subcutaneous  Injections   146 

Day,  (Dr.  W.  D.  F.) — Case  of  Aneurism  of  the  Innominate  and  Carotid  Ar- 
teries  122 

Death  of  Dr.  D.  S.  Conant   158,  366,  439 

i  r.  R.  H.  Coolidge   396 

Death  of  Prof.  C.  R.  Gilman   159 

Deep  Seated  Absces.ses   36 

Delivery— A  New  Mode  of  Effecting    386 

Delivery— The  Propriety  of  Inducing  Premature   IfcO 

Dictionary  of  Medical  Science — Notice  of  Dunglison's   143 

Die  Ohreaheilkunde  der  Gegenwart — Review  of  Kramer's    212 

Diet  suitable  after  Childbirth   388 

Dilatation  of  Os  during  Labor  by  Incisions   317 

Discussion  on  Asthenopia   :   41 

Disease  of  Hip  Joint   32 

Diseases  of  Women,  Review  of— Byford"s  Practice   199 

Diseases  of  the  Ear— Review  of  Roosa's  Translation  of  Troltsch   307 

Dislocation  of  Femur  into  Ischiatic  Notch   272 

Dislocation  of  Tibia  forward   124 

Double  Complicated  Hare-Lip   303 

Dunglison's  Dictionary  of  Medical  Science — Notice  of   J  43 

Duodenum — Inflammation  of   138 

Dyer,  (Dr.  E.) — Asthenopia  not  connected  with  Hypermetropia   11 

Ear — Bony  Growths  in  the  External   424 

Effects  of  Iodide  of  Potassium   144 

Electro-Magnetism  in  Post-Partum  Hemorrhage   75 

Epithelial  Cancer  of  left  Cheek  and  the  Lips   270 

Erysipelatous  Inflammation  of  Scrotum  and  Penis   227 

Etiology  of  General  Progressive  Paralysis   154 

External  Manipulation  for  Version   433 

Eye — Astringents  and  Caustics  in  Aflections  of  the   393 

Facilitation  of  the  First  Stage  of  Labor   313 

Femur  dislocated  into  Ischiatic  Notch   272 

Femur— Separation  of  the  Epiphyses  of   131 


INDEX.  V 

Page 

Fever.  Lectures  on — Review  of  Merrill's   206 

Fever — Treatment  of   150 

Finger — Bony  Tumor  of   292 

Flexion  of  the  Uterus,  producinj?  Habitual  Abortion   69 

Floating  Cartilage  removed  from  the  Knee  Joint   266 

Foetal  Remains  in  Tumor  of  Testis   355 

Foetus— Causes  endangering  Life  of,  during  Labor   390 

Foetus — Retention  of  Urine  in   76 

Food  as  Preventive  Medicine   65 

Food— EfTects  of  Scarcity  and  Deficient   219 

Fracture — Compound  Comminuted,  of  the  Leg   234 

Fractures,  Gun-shot — of  the  Thigh   280 

Fracture  of  the  Thigh  ,   140 

Fractures — Ununited  and  Oblique,  Instrument  for   116 

Functions  ot  the  Cerebellum   223 

Furman's  Medical  Register — Notice  of   144 

Gaillard,  (Dr.E.S.)—lnftrumenl  for  treating  Ununited  and  Oblique  Fractures  116 

Oilman,  (Dr.  C.  R.)— Death  of   15'J 

Gun  shot  Fractures  of  the  Thigh   280 

Gun-shot  Injury  of  the  Median  and  Internal  Cutaneus  Nerves  of  the  Right 

Upper  Extremity   174 

Hare-Lip — Double  Complicated  303 

Hammond.  (Dr.  W.  A.) — on  the  Treatment  of  a  certain  Form  of  Paralysis 

occurring  in  Children   168 

Hammond  on  Wakefulness — Notice  of   310 

Hemorrhage,  Post-partum — use  of  Electro-Magnetism  in   75 

Hints  about  the  Nature  and  Treatment  of  the  Simplest  Forms  of  Bright's 

Disease   18 

Hip  Joint — Amputation  at   161 

Packard  (Dr.  J.  H.) — on  Amputation  at  the  Hip  Joint   161 

Hip  Joint — Disease  of   32 

Human  Body — Variability  in  the  Construction  of   221 

Hutchison  (Dr.  J.  C.)— Case  of  Epithelial  Cancer  of  Left  Cheek  and  Lips. . .  270 
Howe,  (Dr.  H.  M.) — Prolonged  Constipation  cured  by  external  application  of 

an  Alcetic  Preparation   264 

Hydrophobia — Remedy  for   145 

Hypertrophy  of  the  Tongue— Amputation  for   435 

Hyposulphite  of  Soda  in  Scarlet  Fever   430 

Hysteria— Sclerosis  of  the  Lateral  Columns  of  the  Spinal  Cord  in  a  Case  of,  153 

Ileum  in  Purpura  Hemorrhagica   34 

Iodide  of  Potassium — Effects  of   244 

Inflammation  of  the  Duodenum   138 

Inflammation  of  CE.sophagus  in  an  Infant   373 

Influence  of  Social  Position  on  Life   62 

Inhaler  for  Sulphuric  Ether   262 

Injection  of  Quinine.  Subcutaneous — in  Malarious  Fever   151 

Innominata — Aneurism  of   295 

Innominata — Laryngeal  Symptoms  in  Aneurism  of   296 

Intestinal  Obstruction — Chronic   192 

Invertebrates — Temperature  of  some  of  the   241 

Ischiatic  Notch — Dislocation  of  Femur  into   272 

Jaw — Bullet  removed  from   186 

Kidneys— Arrest  of  Development  in   299 

King,  (Dr.  A.  F.  A.) — on  Arteriotomy  and  other  Remedies  in  the  Treatment 

of  Puerperal  Convulsions   27 

Knee  Joint — Removal  of  Floating  Cartilage  from   266 

Knee  Joint— Strumous  Disease  of   32 

Labor — Facilitation  of  First  Stage  of   313 

Labor — Dilatation  of  Os  during  Labor   317 

Labor — Management  of  Third  Stage  of.   316 

Laryngeal  Symptoms  in  Aneurism  of  the  Innominata   296 


vi  INDEX. 

Page 

Larjnx,  Tumors  from   22fi 

Lectures  on  Diseases  of  the  Stomach — Review  of  Briiiton's   141 

Lectures  on  Fever — Review  of  Merrill's   206 

Lectures  on  Inflammation — Notice  of  Packard's   379 

Lectures  on  Surgical  Pathology — Review  of  Paget's   210 

Leg — Compound  Comminuted  Fracture  of     234 

Leg— Crushing  of  Soft  Parts  and  Bones  of,  with  Ri-covery   233 

Lente  (Dr.  F.  D.) — A  New  Inhaler  for  Sulphuric  Ether   202 

Lente  (Dr.  F.  D.) — Modification  of  the  Bi-valve  Speculum  Vaginai   183 

Lesion,  New — of  the  Brain,  in  General  Paralysis   152 

Lidell  (Dr.  John  A.) — On  some  of  the  Abuses  which  Pertain  to  the  Employ- 
ment of  Bandages  in  Treating  the  Stumps  of  Amputated  Limbs   1 

Lombard  (Dr.  J.  S.) — On  the  Temperature  of  some  of  the  Invertebrates. . . .  241 

Longevity  in  England  and  Wales  79 

Malarious  Fever,  Treated  by  Subcutaneous  Injection  of  Quinine   151 

Marriages  of  Consanguinity   63 

Materia  Medica — Notice  of  Biddle's   381 

Medical  Department  of  the  Army   390 

Medical  Register  of  the  City  of  New  York — Notice  of.   144 

Medicinal  Uses  of  the  Ptelia  Trifoliata   184 

Meningitis — the  Brain  in  a  Case  of.   124 

Merrill's  Lectures  on  Fever — Review  of.   200 

Metacarpal  Bone — Bullet  Impacted  in   139 

Mitchell  (Dr.  S.  W.)— Paralysis  from  Peripheral  Irritation  321.  401 

Mortality  of  Childbed  as  Affected  by  the  Number  of  Labors   392 

Mursick  (Dr.  G.  A.) — Report  of  a  Case  of  Gun-shot  Injury  to  Nerves  of 

Right  Upper  Extremity   174 

Nature  and  Treatment  of  the  Active  Congestive  Variety  of  Bright's  Disease  254 

NiEVus  of  the  Cheek,  with  Phlebolites   232 

Nerves,  Injury  to  the  Median  and  Internal  Cutaneous,  of  the  Right  Upper 

Extremity   174 

Necrosis,  Phosphorus   300 

Nelson  (Dr.  R.) — Case  of  Tubal  Pregnancy   120 

New  Instrument  for  Ununited  and  Oblique  Fractures   116 

New  Mode  of  Effecting  Delivery   380 

New  York  Academy  of  Medicine   272 

New  York  Pathological  Society  32,  129,  186,  292,306,  439 

North  on  Epidemic  Cholera.  Notice  of   311 

North  (Dr.  N.L.) — on  the  Hyposulphite  of  Soda  in  Scarlet  Fever   430 

Notice  of  Dunglison's  Dictionary  of  Medical  Science   143 

Notice  of  Hammond  on  Wakefulness   310 

Notice  of  the  Medical  Register  of  New  York   144 

Notice  of  North  on  Epidemic  Cholera   311 

Notice  of  Packard's  Lectures  on  InHainmation   379 

Notice  of  the  Report  of  the  Citizens'  Association  on  Cholera   311 

Notice  of  Sansom's  Chloroform;  its  Action  and  Administration   384 

Notice  of  Tanner's  Practice  of  Medicine   383 

Number  of  Labors  Affecting  Mortality  of  Childbed   392 

Obstetric  Jurisprudence — Contributions  to   81 

Occlusion  of  Ureters  and  Duodenum   299 

Oesophagus,  Inflammation  of,  in  an  Infant   373 

On  some  of  the  Abuses  in  treating  the  Stumps  of  Amputated  Limbs   I 

On  Wakefulness — Notice  of  Hammond   310 

Ophthalmological  Society   41 

Ophthalmia  Sympathetic   234 

Osteo-Myelitis   195 

Ovarian  Tumor   191 

Ovariotomy  in  Italy   78 

Ozone   222 

Packard's  Lectures  on  Inflammation — Notice  of   379 

Paget's  Lectures  on  Surgical  Pathology — Review  of   210 


INDEX.  Vll 

Page 

Paralysis  from  Peripheral  Irritation     321 

Paralysis,  General — A  new  Lesion  of  the  Brain  in   152 

Paralysis,  certain  Form  of,  in  Children   168 

Paralysis— Etiology  of  General  Progressive   154 

Pathological  Society  32,  129,  186,  292,  366,  439 

Pathology,  Cell   224 

Peripheral  Irritation— Paralysis  from   321 

Peters. (Dr.  J. C.) — Hints  about  the  Nature  and  Treatment  of  the  ActiveCon- 

gestive  variety  of  Bright's  Disease   254 

Peters,  (Dr.  John  C.) — Nature  and  Treatment  of  the  Simplest  Forms  of  Bright's 

Disease   18 

Phlebolites  in  Na;vu8  of  the  Cheek   232 

Phosphorus  Necrosis   300 

Physiological  Action  of  Carbonic  Acid   225 

Plastic  Operation  for  Removal  of  Epithelial  Cancer  of  Left  Cheek  and  Lips,  270 

Poison — A  new   149 

Popliteal  Artery— Wound  of   297 

Potter,  (Dr.  O.  F.)— Medicinal  Uses  of  the  Ptelca  Trifoliata   184 

Practice  of  Medicine — Notice  of  Tanner's   383 

Precocious  Puberty   392 

Premature  Delivery — The  Propriety  of  Inducing   180 

Preventive  Medicine   05 

Principles  of  Surgery — Review  of  Syme   304 

Progre.ss  of  the  Medical  Sciences   62 

Ptelea  Trifoliata — Medicinal  Uses  of   184 

Puerperal  Convulsions — Arteriotomy  and  other  Remedies  in   27 

Puerperal  Tetanus  following  Abortion  and  Plugging  of  the  Vagina   74 

Purgatives — Habitual  use  of   146 

Purpura  Hemorrhagica — Ileum  in   34 

Quinine,  Subcutaneous  Injection  of,  in  Malarious  Fever   151 

Rectum — Tumor  of   373 

Rectum — Ulcer  of   231 

Remarks  on  the  Temperature  of  some  of  the  Invertebrates   241 

Remedy  for  Hydrophobia   145 

Renewal  of  Life — Review  of  Chambers'   374 

Repair  of  Extensive  Injuries   231 

Retention  of  the  Urine  in  the  FcEtus   76 

Review  of  Brinton  on  Diseases  of  the  Stomach   141 

Review  of  Byford's  Practice  of  Medicine  and  Surgery  in  Diseases  199 

Review  of  Caswell's  Translation  of  Semeleder's  Rhinoscopy  and  Laryngo- 
scopy  477 

Review  of  Chambers'  Renewal  of  Life   374 

Review  of  Circular  No.  6   448 

Review  of  Paget 's  Lectures  on  Surgical  Pathology   210 

Review  of  Roosa's  Translation  of  Troltsch's  Diseases  of  the  Ear   307 

Review  of  Kramer's  Die  Ohrenheilkunde  der  Gegenwart   212 

Review  of  Syme's  Principles  of  Surgery   304 

Reynold's  (Dr.  J. B.)— Case  of  Ver.sion  by  External  Manipulation   433 

Rigor  Mortis  not  Muscular  Contraction   220 

Roosa  (Dr.  B.  St.  J.)— On  Bony  Growths  in  the  Meatus  Auditorius  Externus.  424 

Roosa's  Translation  of  Troltsch's  Diseases  of  the  Ear — Review  of   307 

Rhinoscopy  and  Laryngoscopy;  their  value  in  Practical  Medicine — Review 

of  Semeleder's   477 

Salivary  Calculus   195 

Sansom's  Chloroform;  its  Action  and  Administration — Notice  of   384 

Scarlet  F ever — Hyposulphite  of  Soda  in   430 

Schonberg's  Improved  Map  of  the  United  States   385 

Schweigger,  (Dr.  C.) — On  Stimulated  Amaurosis   361 

Sclerosis  of  the  Lateral  Columns  of  the  Spinal  Cord,  in  a  Case  of  Hysteria. .  153 

Scrotum  and  Penis — Erysipilatous  Inflammation  of   227 

Semeleder's  Rhinoscopy,  and  Laryngoscopy — Review  of   477 


Vlll 


INDEX. 


Page 

Separation  of  the  Epiphyses  of  the  Femur   131 

Simulated  Amaurosis   361 

Sloughing  of  the  Small  Intestine   235 

Smith,  (Dr.  O.  H.)-On  the  Epidemic  Cholera  of  1849  and  1854   215 

Social  Position — Influence  of,  on  Life   62 

Speculum  Vaginae— Modification  of  the   163 

Spine — Concussion  of   230 

Sterility,  affected  by  Uterine  Displacements   72 

Stomach— Review  of  Brinton  on  Diseases  of   141 

Storer  (Dr.  H.  R.) — Contributions  to  Obstetric  Jurisprudence   81 

Strumous  Disease  of  Knee  Joint   32 

Subcutaneous  Injections — Danger  of   146 

Suggestions  regarding  Cholera   126 

Sulphuric  Ether — A  New  Inhaler  for   262 

Syme's  Principles  of  Surgery — Review  of   304 

Sympathetic  Ophthalmia   234 

Taenia.  Expulsion  of — and  Cure  of  Double  Amaurosis   154 

Talc,  as  a  Dressing   145 

Tanner's  Practice  of  Medicine — Notice  of   383 

Tapeworm — Prevalence  of,  in  Birmingham   210 

Temperature  of  some  of  the  Invertebrates   241 

Testicle— Tumor  of   129 

Tetanus,  Puerperal — following  Abortion   74 

Thigh— Fracture  of  the   140 

Thigh— Gun-shot  Fractures  of   280 

Third  Stage  of  Labor — Management  of   316 

Thomas,  (Dr.  T.  G.) — On  the  Propriety  of  Inducing  Premature  Delivery. . .  183 

Tibia — Compound  Dislocation  of,  forward   124 

Tongue — Congenital  Hypertrophy  of   435 

Treatment  of  a  certain  Form  of  Paralysis  occurring  in  Children.   168 

Treatment  of  Fever   150 

Tubal  Pregnancy — Case  of   120 

Tumor  of  the  Rectum   373 

Tumor  of  Testis,  containing  Foetal  Remains   355 

Tumor  of  the  Testicle   129 

Tumor — Ovarian   191 

Tumor  removed  from  Larynx   226 

Tumor  Uterine   188 

Turpentine  as  a  Dressing  for  Wounds   146 

Ulceration  of  the  Colon   34 

Ulcer  of  the  Rectum   231 

Umbilical  Hernia   235 

Urinary  Organs  in  a  Case  of  Vesical  Culculus   34 

Urine — Retention  of,  in  Foetus   76 

Uterine  Displacements — influence  of,  upon  the  Sterile  Condition   72 

Uterine  Tumors   188 

Van  Buren,  (Dr.  \V.  H.) — On  Tumor  of  Testis  containing  Foetal  Remains...  355 

Variability,  as  manifested  in  the  Construction  of  the  Human  Body   221 

Version  by  External  Manipulation   433 

Vesical  Calculus   194 

Vesical  Calculus — Urinary  Organs  in  a  Case  of   34 

Wilson,  (Dr.  J.) — Removal  of  a  Large  Floating  Cartilage  from  the  Knee 

Joint   266 

Wine   67 

Wounds  dressed  by  a  solution  of  Turpentine   146 

Wound  of  both  Carotids   187 

Wound  of  the  Popliteal  Artery   297 

Weight  of  the  Brain  in  relation  to  the  Intelligence  in  Vertebrata  221 

Yale,  (Dr.  L.  M.) — Case  of  Compound  Dislocation  of  Tibia  forward   124 


IsTEW  YORK 

MEDICAL  JOURNAL, 

A  MONTHLY  RECOKD  0!  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
OCTOBER,   186  5. 


ORIGINAL  COMMUNICATIONS. 

On  some  of  the  Abuses  which  pertain  to  the  Employment  of 
Bandages  in  treating  the  Stumjjs  of  Amputated  Limbs,  vnth 
Cases.  By  John  A.  Lidell,  M.D.,  of  New  York,  Professor 
of  Anatomy  in  National  Medical  College;  formerly  Sur- 
geon U.  S.  Vols.,  in  charge  of  Stanton  General  Hospital; 
Inspector  Medical  and  Hospital  Department,  Army  of  the 
Potomac,  &c. 

The  results  of  the  capital  operations  in  Surgery,  whether  fa- 
vorable or  otherwise,  depend  very  much  upon  the  care  and  skill 
with  which  their  after-treatment  is  conducted.  No  matter  how 
dexterously  or  how  ingeniously  any  one  of  the  great  opera- 
tions may  be  performed,  the  ultimate  safety  of  the  patient,  in 
such  case,  is  by  no  means  assured,  unless  the  after-treatment 
be  judiciously  and  sagaciously  followed  up.  When  viewed 
from  this  stand-point,  it  docs  not  appear  exactly  right  for  the 
master  in  the  surgical  art  to  simply  do  an  important  opera- 
tion, and  tlien  turn  over  its  after-care  to  a  tyro  in  the  surgical 
art.  All  the  trained  faculties,  the  careful  culture,  and  the  ripe 
experience  of  even  the  most  gifted  surgeon  can  be  advan- 
tageously employed  in  anticipating  and  warding  off  the  hidden 

Vol.  II.— No.  1.  1 


2 


ABUSES  IN  BANDAGING 


[Oct., 


damages  by  wliich  the  pathway  of  such  a  patient  is  surrounded. 
He  is  the  best  surgeon  who  not  only  operates  well,  l)ut  man- 
ages the  case  well  in  other  respects  ;  selecting  the  proper 
time  to  operate,  in  the  first  instance,  and  never  afterwards 
losing  sight  of  the  patient  till  recovery  is  established.  I  do 
not  wish  to  speak  in  a  disparaging  way  concerniDg  the  claims 
of  operative  surgery  upon  our  regard;  but,  at  the  same  time, 
it  seems  necessary  to  state,  in  this  place,  my  conviction,  tliat 
the  superior  success  which  attends  some  surgeons  in  the  man- 
agement of  difficult  cases,  is,  speaking  in  a  general  way,  to  be 
attributed  quite  as  much  to  the  skill  with  which  they  conduct 
the  after-treatment  as  to  the  skill  with  which  they  operate; 
and  every  additional  year's  experience  strengthens  me  in  this 
convictioD. 

In  order  to  manage  any  important  case  in  operative  surgery 
aright,  suitable  attention  must  be  paid  to  the  ventilation  and 
cleanliness  of  the  patient's  quarters,  to  the  alimentation  and 
medication  of  the  patient  himself,  and  to  the  care  of  the  dress- 
ings. Now,  the  employment  of  bandages  enters  very  largely 
into  the  matter  of  surgical  dressings,  and,  on  that  account,  it 
becomes  a  subject  of  importance.  Furthermore,  that  this  sub- 
ject, in  so  far  at  least  as  the  proper  application  of  bandages 
to  stumps  is  concerned,  has  not,  on  the  part  of  some,  received 
sufficient  attention,  the  following  cases  are  ofiTered  in  proof  : 

Case  I. — Disastrous  consequences  produced  by  handaging  a 
stump  too  tightly;  death  from  gangrene  on  the  ninth  day  after 
the  operation. 

April  10th,  1865,  a  Confederate  soldier,  a  prisoner  of  war, 
was  brought  in  from  the  fi'ont  to  Burke's  Railroad  Junction, 
which  was  the  depot  of  our  army  at  the  time  of  and  for  a 
while  after  General  Lee's  surrender.  He  had  suffered  ampu- 
tation of  the  left  leg  at  its  middle,  by  the  flap  method,  and 
complained  bitterly  of  pain  in  it.  On  removing  the  dressings 
from  the  stump,  the  bandages  were  found  to  be  very  tight,  the 
soft  parts  swelled  and  gangrenous,  the  swelling  alone  extend- 
ing above  the  knee. 

The  next  morning,  April  lltli,  my  attention  was  called  to 
him  by  the  surgeon  in  whose  care  he  had  been  placed  on 
arrival,  Dr.  Snell,  of  the  Confederate  army.  The  patient  was 
in  a  very  bad  condition.    The  stump  was  much  swelled  and 


1865.] 


AMPUTATED  LIMBS. 


3 


very  painful.  The  swelling  extended  not  only  as  high  as  the 
knee,  but  also  some  distance  up  the  thigh.  The  flaps  were 
sphacelated,  and  the  skin  presented  a  yellowish-brown  and 
mottled  appearance  nearly  as  high  as  the  knee,  with  several 
large  blebs,  containing  a  dirty,  yellowish  colored  serum  scat- 
tered here  and  there  on  this  surface.  This  incipient  mortifica- 
tion extended  as  high  as  the  tight  bandages  had  done,  but  no 
line  of  separation  was  yet  established.  There  was  a  strong 
odor  of  gangrene.  He  complained  much  of  pain  in  the 
affected  part,  and  had  a  good  deal  of  constitutional  disturb- 
ance in  the  shape  of  irritative  fever.  But  little  change,  either 
general  or  local,  had  taken  place  since  the  previous  day.  He 
informed  us  that  the  leg  was  amputated  on  the  7th,  at  the 
front,  where  he  was  wounded;  that  the  stump  was  bandaged 
very  tightly,  so  that  it  gave  him  much  distress  from  the  out- 
set; that  the  stump  could  not  be  dressed  till  he  reached  Burke's 
Station  on  the  10th,  only  three  days  afterwards,  when  the  con- 
dition of  things  above  described  was  discovered.  I  directed 
him  to  1)0  removed  to  the  Ninth  Corps  Hospital,  which  was 
then  located  in  the  neighborhood,  as  he  would  not  bear  trans- 
portation to  City  Point. 

April  14th.  He  is  much  worse,  and  very  low  ;  countenance 
almost  Hippocratic;  the  gangrene  has  extended  up  inner 
side  of  thigh,  almost  to  groin  ;  odor  of  gangrene  very  strong; 
tongue  dry:  had  been  treated  with  tinct.  iodine  applied 
locally,  and  opiates,  stimulants  and  nutrients  administered  in- 
ternally. 

April  1 5th.  Says  he  feels  better,  and  is  now  free  from  pain; 
but  he  is  in  reality  worse,  as  the  mortification  has  extended. 

April  16th.  He  died  at  four  o'clock  a.  m.  I  did  not  meet 
with  another  gangrenous  stump  among  2,000  wounded  brought 
to  Burke's  Station. 

Comments. — It  has  been  recommended  by  some,  within  the 
hearing  of  the  writer,  to  bandage  the  stump  tightly  in  mili- 
tary practice,  in  cases  where  amputation  is  performed  on  the 
field  of  battle,  on  the  ground  that,  by  so  doing,  the  patient 
would  be  better  enabled  to  bear  transportation  to  the  rear,  and 
he  has  seen  this  precept  followed  out  by  at  least  one  promi- 
nent army  surgeon,  but  with  what  results  it  is  not  known,  as 


4 


ABUSES  IN  BANDAGING 


[Oct., 


the  patients  passed  directly  beyond  our  view.  The  foregoing 
case,  however,  illustrates  some  of  the  hazards  attending  this 
practice. 

The  gangrene  of  this  stump  appears  to  have  been  produced 
in  the  same  way  that  gangrene  of  a  fractured  limb  is  some- 
times produced  by  the  early  application  of  a  tight  bandage — 
viz.,  by  interfering  with  the  circulation  of  the  blood  in  the 
part.  The  bandages  having  been  put  on  tightly,  prior  to  the 
advent  of  swelling,  there  is  danger  that  when  the  parts  swell 
up  through  the  agency  of  inflammatory  action,  the  constriction 
may  become  so  great  as  to  completely  arrest  the  flow  of  the 
blood  back  towards  the  heart,  thereby  putting  a  stop  to  the 
processes  of  nutrition  (vitality)  in  the  part,  and  causing  a  wet 
gangrene.  This  accident  is  not  so  likely  to  happen  in  the  case 
of  the  stump  of  an  amputated  limb  as  in  the  case  of  a  frac- 
tured limb,  because  the  quantity  of  blood  to  be  returned 
through  the  veins  is  very  much  less  in  the  former  than  in  the 
latter  instance. 

Again,  it  seems  probable  that  tight  bandaging  acts  in- 
juriously upon  a  stump,  even  if  the  constriction  is  not  so  great 
as  to  cause  mortification:  firstly,  because  of  the  stagnation  of 
the  blood  occasioned  directly  by  it;  and  secondly,  because  of 
the  deleterious  effect  of  such  stagnation  of  the  blood  upon  the 
reparative  processes  in  the  stump.  Mr.  B.  Phillips,  of  West- 
minster Hospital, Yi^iSm^i^Q  the  following  statement  in  point: 

"  A  custom  exists  in  many  portions  of  the  continent  of  ap- 
plying very  tightly  a  bandage  around  the  stump,  for  the 
purpose  of  preventing  the  retraction  of  the  muscles,  and  a 
consequent  exposure  of  the  end  of  the  bone.  This  system 
exists  at  La  Charity,  in  Paris  ;  and  it  is  a  notorious  fact  that 
the  proportion  of  unfortunate  terminations  in  cases  of  ampu- 
tations is,  in  that  hospital,  very  great."  Mr.  Carswell,  the 
pathologist,  suggested  to  Mr.  Phillips,  "the  probability  of 
these  bandages  producing  a  congestion,  which  would  tend  to 
excite  the  development  of  disease."  Vide  London  lledical 
Gazette,  vol.  xiii.,  pp.  193,  194. 

Case  II. — A  thigh  stump  uncomfortable  because  its  dressing 
was  too  loosely  applied. 

April  11,  1865.    While  walking  through  a  warehouse,  in 


1865.] 


AMPUTATED  LIMBS. 


5 


which  a  number  of  our  wounded  had  been  temporarily  pro- 
vided for  at  Burke's  Junction,  shortly  before  the  departure  of 
a  railroad  train  intended  to  convey  them  to  City  Point,  an  in- 
fantry soldier,  belonging  to  the  Sixth  Corps,  asked  me  to  look 
at  his  stump,  stating  that  it  felt  very  uncomfortable.  His  left 
tliigh  had  been  amputated  at  the  junction  of  the  lower  with 
the  middle  third,  by  the  circular  method.  He  said  that  the 
operation  was  performed  on  the  6th,  for  gun-shot  injuries  in- 
flicted that  day.  I  found  the  stump  itself  doing  remarkably 
well.  Healthy  suppuration  was  already  established,  and  there 
was  no  abnormal  swelling,  heat,  redness,  or  irritation  of  any 
kind  whatever  in  it.  The  discomfort  was  due  entirely  to  the 
manner  in  which  the  dressing  had  been  applied.  The 
bandages  (rollers)  had  been  put  on  so  loosely  as  not  to  afford 
adequate  support  to  the  parts.  Indeed,  the  dressing  which  I 
found  on  his  stump  was  so  loose  as  almost  to  fall  off,  and  ex- 
tended but  about  five  inches  upwards  towards  the  groin,  while 
his  thigh  was  unusually  long.  The  consequence  was  that  the 
end  of  tlie  stump  was  not  held  steady,  and  that  the  long  mus- 
cles of  the  thigh  were  subject  to  spasmodic  twitchings,  because 
they  were  not  properly  supported  by  exterior  pressure.  A 
roller  bandage,  applied  with  moderate  firmness  nearly  all  the 
way  from  the  stump-end  up  to  the  groin,  so  as  to  act  both  as 
an  expulsive  and  supporting  bandage,  at  once  afforded  him 
complete  relief,  for  which  he  expressed  much  gratitude. 

Comments. — In  this  case  the  bandage  certainly  did  not  per- 
form any  useful  office,  as  it  was  originally  applied.  Indeed, 
the  patient's  condition  differed  but  little  from  what  it  would 
have  been  if  no  bandage  whatever  had  been  put  on  the  stump. 
This  remark  brings  us  to  the  question  of  treating  amputations 
by  leaving  the  stump  open,  that  is,  without  any  dressing  what- 
ever. I  am  inclined  to  think  that  this  practice  is  advan- 
tageous in  many  cases  where  union  must  be  effected  by  granu- 
lation, and  where  it  is  not  necessary  to  move  the  patient.  I 
am  confident  that  I  have  seen  patients  recover  in  hospital  prac- 
tice by  leaving  their  stumps  open,  and  they  were  thigh  stumps 
at  that,  who  would  not  have  recovered  if  their  stumps  had 
been  kept  closed  up  and  bandaged  according  to  the  old 
methods.   No  accumulation  of  matter  can  occur  in  an  open 


6 


CHLOROFORM  INTERNALLY 


[Oct, 


stump,  and  in  this  way  the  danger  of  a  fatal  termination  by 
pyjemia  appears  to  be  considerably  lessened.  Betides,  the 
open  stump  may  readily  be  made  to  heal  from  the  bottom,  and 
thus  the  occurrence  of  sinuses  may  be  avoided. 

But,  if  it  be  necessary  to  transport  the  patient  to  a  distance, 
as  it  is  in  the  practice  of  surgery  with  armies  in  the  field,  then 
the  stumps  of  the  amputated  limb  must  be  fixed  up  by  the  means 
of  dressings,  in  such  a  way  that  they  will  bear  the  transporta- 
tion. It  is  clearly  inadmissible,  in  such  instances,  to  leave  the 
stumps  open,  for  the  jolting  of  the  ambulance  or  the  railway 
carriage,  as  the  case  may  be,  will  inflict  grievous  injury  upon 
the  flaps  or  other  tissues  that  have  been  left  to  cover  the 
stiunp-bone,  and  at  the  same  time  cause  a  great  deal  of  un- 
necessary sufi"ering  to  the  patient.  Besides  keeping  the  soft 
parts  quietly  in  apposition,  another  oflBce  of  the  dressings,  in 
such  cases,  is  to  hold  the  stump  steady,  and  keep  the  soft  parts 
in  comfortable  relationship  with  the  stump-bone.  For  this 
purpose  the  dressing  should  be  light,  and  the  bandage  should 
be  applied  smoothly,  evenly,  with  moderate  firmness,  and  to  a 
good  distance  upwards  towards  the  next  articulation,  in  all 
cases  wherein  amputation  has  been  performed  in  the  con- 
tinuity of  a  limb,  and  not  at  its  point  of  union  with  the  trunk, 
e.  (/.at  the  shoulder  or  hip  joint. 


Cltloroform  Internally  a  Eemedy  for  Congestion.    By  A.  P. 
Merrill,  M.D.,  of  New  York  City, 

No  pathological  condition  is  more  common  and  fatal  than 
congestion.  TVhether  it  be  active  or  passive,  sthenic  or 
asthenic,  it  is  this  abnormal  condition  in  certain  portions  of 
the  circulatory  system,  this  stasis  of  blood  in  certain  organs 
and  tissues,  which  presents  itself  to  the  physician  oftenest,  and 
which  causes  him  the  greatest  embarrassment  in  his  diagnosis 
and  treatment.  And  it  is  this  condition,  more  than  any  other, 
which  leads  to  immediate  death,  or  which  becomes  the  founda- 
tion of  inflammation,  hypertrophy  and  ulceration,  so  often  re- 
sulting in  protracted  suffering,  and  the  final  destruction  of  life. 


1865.] 


FOB  CONGESTION. 


7 


Wliether  congestion  be  considered  a  nervous  or  a  blood  dis- 
order, or  whether  originating  in  the  one  it  produces  the  other 
as  one  of  its  effects,  I  leave  to  the  medical  schoolmen  to  de- 
termine; but  that  we  have  a  remedy  for  it,  whatever  may  be  its 
cause  and  character,  is  a  matter  of  importance  to  the  profes- 
sion, and  of  vital  interest  to  mankind.  That  remedy  is 
chloroform  administered  internally. 

When  I  declare  that  I  have  found  chloroform  thus  given  to 
be  an  effective  remedy  for  the  chill  of  fever — which  it  is  capa- 
ble of  subduing  so  completely  as  to  prevent  febrile  reaction, 
and  thus  cut  short  the  disease  in  its  inception — every  physician 
will  be  able  to  appreciate  the  importance  of  the  fact,  and  a 
large  number  of  diseased  conditions  of  a  kindred  character 
will  occur  to  him  which  must  derive  benefit  from  the  same 
treatment.  Fever,  the  great  outlet  of  human  life,  and  Asiatic 
cholera,  one  of  its  most  obscure  and  fatal  forms,  which  now 
threatens  to  involve  both  Europe  and  America  in  its  epidemic 
power,  will  first  deserve  attention.  Congestion,  in  certain  of 
the  viscera,  is  an  inceptive  morbid  condition  in  these  fatal 
forms  of  disease,  and  it  is  this  and  its  sequences  which  deter- 
mine the  indications  of  treatment.  These  once  removed,  all 
the  rest  is  easy. 

The  cognate  affections  to  be  noticed  are  concussion,  hem- 
orrhage, asthma,  puerperal  and  infantile  convulsions,  narcotic 
and  strychnine  poisoning,  cyanosis,  amaurosis,  dysmenorrhosa, 
angina,  apoplexy,  asphyxia,  cerebral,  spinal  and  meningeal 
irritation,  spasm,  chorea,  delirium  tremens,  cholera  morbus, 
hiccup,  coma,  colic,  epilepsy,  hooping-cough,  insanity,  hysteria, 
tetanus,  neuralgia,  paralysis,  vertigo,  pneumonia,  rabies,  con- 
gestion of  the  stomach,  bowels  and  brain,  hypochondriasis, 
gastralgia,  dysentery,  diarrhoea,  gout,  rheumatism,  dropsy,  sea- 
sickness, and  other  affections  depending  upon  congestion,  more 
or  less,  and  generally  of  a  sthenic  character;  to  which  may 
be  added  forms  of  disease  supposed  to  be  of  an  asthenic  char- 
acter, such  as  sun-stroke  and  anaemic  congestion  caused  by  loss 
of  blood-  In  proportion  as  these  and  other  maladies  are  de- 
pendent upon  congestion,  may  we  expect  them  to  be  bene- 
fited by  chloroform  internally,  both  by  the  stomach  and  the 
rectum. 


CHLOROFORM  INTERNALLY 


[Oct., 


The  effects  produced  by  chloroform  internally,  appear  to  be 
very  different  from  those  caused  by  inhalation.  No  signs  of 
anesthesia  have  been  observed  from  its  internal  use,  and  so  far 
as  danger  arises  from  congestion  in  the  use  of  anaesthetics,  chlo- 
roform internally  may  be  considered  the  proper  remedy.  Its 
effects  upon  the  system,  when  used  internally,  are,  to  equalize 
the  circulation  of  blood,  improve  respiration,  relieve  conges- 
tion of  the  skin,  restore  and  compose  the  mental  faculties,  and 
produce  quiet  sleep.  Sometimes  the  sleep  thus  produced  is 
followed  by  considerable  nervous  restlessness;  but  this  is  only 
temporary,  and  it  causes  no  permanent  inconvenience.  Indeed, 
I  have  observed  it  only  in  children  who  have  taken  large  doses 
for  the  relief  of  convulsions. 

During  the  last  thirteen  years  I  have  used  the  remedy  effect- 
ually in  many  of  the  diseased  conditions  above  referred  to, 
especially  in  fever,  pneumonia,  convulsions,  colic,  sun-stroke, 
concussion,  vertigo,  apoplexy,  asthma  and  delirium  tremens  ; 
but,  until  lately,  I  have  not  met  with  an  opportunity  to  prove 
its  efficacy  in  pulmonary  hemorrhage.  That  opportunity  was 
afforded  by  the  following 

Case.— On  the  17th  of  August,  1865,  Anthony  Duffy,  aged 
thirty-eight,  a  laborer  in  Washington  Square,  was  seized  with 
hemorrhage  from  the  lungs  while  returning  home  from  his 
work.  He  had  been  complaining  all  day  of  a  sense  of  full- 
ness and  oppression  of  the  chest,  was  unable  to  take  his  usual 
food,  and  had  several  bleedings  from  the  nose.  Just  before  his 
attack  he  drank  nearly  a  quart  of  cold  milk,  and  eat  two  ripe 
peaches.  As  he  passed  the  door  of  my  office,  he  was  spitting 
blood,  and  he  proceeded  only  a  few  steps  further,  when  the 
gush  of  blood  was  profuse.  He  sat  down  upon  the  steps  of  a 
dwelling,  and,  becoming  insensible,  rolled  upon  the  pavement. 
I  found  him  weltering  in  blood,  which  was  still  streaming  from 
his  mouth  and  nose,  obstructing  his  breath.  Indeed,  he  was 
gasping  as  in  the  agony  of  death  from  suffocation.  His  eyes  were 
open  and  pupils  dilated,  his  face  pale  and  ghastly,  the  cai)illary 
circulation  of  the  surface  congested,  and  he  had  convulsive 
movements  of  the  limbs.  His  pulse  was  large  and  very 
slow. 

I  turned  his  face  upward,  and  poured  into  his  mouth,  from  a 


I 


1865.] 


FOR  CONGESTION. 


9 


vial,  about  two  fluidrachins  of  chloroform,  which  he  swallowed, 
and  from  that  moment  the  hemorrhage  ceased.  Partly  from  ex- 
haustion, l)ut  principally  from  accumulation  of  blood  in  the 
bronchi  and  stomach,  his  breathing  was  exceedingly  difficult, 
and  he  remained  insensible,  with  considerable  rigidity  of  the 
limbs.  In  about  ten  minutes  I  gave  him  another  drachm  of 
chloroform,  and  then  he  was  placed  upon  a  litter,  and  carried 
a  short  distance  to  his  lodgings.  On  his  arrival  there  he  ap- 
peared to  have  recovered  his  senses,  but  his  breathing  con- 
tinued very  labored,  and  he  was  unable  to  speak.  I  then  ad- 
ministered another  drachm  of  chloroform,  which  was  about 
half  an  hour  from  the  first  dose,  and  applied  sinapisms  to  his 
breast  and  between  his  shoulders.  He  swallowed  also  a  little 
whisky  and  water,  which  caused  him  to  vomit,  ejecting  from 
his  stomach  large  quantities  of  grumous  blood;  but  there  was 
no  sign  of  present  hemorrhage.  From  this  time  he  gradually 
recovered,  occasionally  expectorating  clots  of  blood. 

In  this  case  sleep  was  not  produced  by  the  chloroform,  which 
I  have  generally  considered  evidence  that  the  system  was  fully 
under  its  influence.  Probably  the  intensity  of  the  attack,  and 
the  extent  of  the  congestions,  required  a  larger  quantity  than 
was  given  to  effect  this  purpose;  but  I  did  not  then  know  of 
an  instance  in  which  more  than  half  an  ounce  had  been  given 
in  half  an  hour.  A  few  days  afterwards,  a  gentleman,  of  my 
acquaintance,  swallowed  a  table-spoonful  at  one  dose  for  gas- 
tric congestion,  with  no  other  effect  than  entire  relief,  with 
several  hours  of  quiet' sleep. 

On  the  4tli  of  September,  1865,  Mrs.  W.,  a  married  woman, 
aged  forty-live  years,  was  seized  with  paralysis  of  the  leftside, 
with  the  head  drawn  back,  and  the  whole  spine  curved  back- 
ward. She  soon  became  insensible  and  speechless.  Her  limbs 
were  cold,  pulse  130,  eyes  closed,  pupils  dilated,  and  she  was 
exceedingly  restless,  with  a  constant  movement  of  her  right 
hand  and  arm,  as  if  attempting  to  grasp  something  in  the  air. 
I  prescribed  a  cathartic  and  sinapisms,  and  gave  her  a  small 
teaypoonful — twelve  to  the  ounce — of  chloroform.  This 
quieted  the  restlessness  almost  instantly,  and  I  directed  the 
dose  to  be  repeated  as  often  as  restlessness  returned.  Follow- 
ing out  this  plan,  she  took  an  ounce  during  the  first  twenty- 


10 


CHLOROFORM  INTERNALLY  FOR  CONGESTION.  [Oct., 


four  lioiirs,  with  the  uniform  effect  of  relieving  restlessness,  and 
sometimes  inducing  sleep. 

Sept.  5. — Her  bowels  had  been  freely  purged,  she  had 
passed  a  little  urine,  and  her  limbs  of  the  paralyzed  side, 
hitherto,  in  the  language  of  her  husband,  "  as  rigid  as  iron," 
could  be  slightly  flexed.  But  her  head  was  drawn  back  as 
firmly  as  before.  The  same  treatment  was  continued,  with  the 
addition  of  a  little  broth  and  milk  punch.  At  five  p.m.  she 
had  taken  six  teaspoonfuls  of  chloroform,  or  half  an  ounce, 
and  the  fits  of  restlessness  were  more  frequent  and  troul)le- 
some,  insomuch  that  she  had,  in  spite  of  watchfulness,  fallen 
from  the  bed.  The  chloroform  was,  therefore,  discontinued, 
and  she  took  during  the  night  hyoscyamus,  valerian,  musk, 
strychnia,  aconite  and  calomel. 

Sept.  6.— She  had  passed  a  very  restless  night;  pulse  140; 
breathing  labored;  deglutition  diSicult;  head  drawn  back; 
limbs  more  rigid;  had  been  sufficiently  purged.  The  chloro- 
form was  now  resumed  as  before,  the  first  dose  relieving  rest- 
lessness and  causing  sleep.  During  the  day  and  night  she 
took  six  doses.  In  the  evening  the  left  arm  and  leg  had  lie- 
come  quite  flexible,  but  not  much  subject  to  her  will.  Head 
still  back,  and  wholly  insensible. 

Sept.  7. — The  paralysis  of  the  limbs  appeared  quite  relieved, 
but  the  head  still  drawn  back;  pulse  120,  and  more  feeble; 
breathing  quite  labored;  deglutition  more  difficult;  and  she 
had  every  appearance  of  sinking.  Chloroform  was  given  sev- 
eral times  during  the  day,  relieving  the  restlessness  as  before; 
but  at  night  swallowing  had  become  so  difficult  that  the  use 
of  internal  remedies  was  suspended,  and  sinai^isms  apjjlied  to 
the  spine  and  limbs.  She  gradually  declined,  and  died  at  seven 
o'clock  on  the  morning  of  the  8  th. 

Altliough  this  case  terminated  unfavorably,  the  great  power 
of  chloroform  over  disordered  innervation  was  strikingly  ex- 
emplified in  the  treatment,  and  I  have  no  doubt  that  the  life 
of  the  patient  was  prolonged  by  its  use.  Certainly,  it  was  the 
means  of  saving  her  much  suffering;  and  this  without  disturb- 
ing the  digestive  functions,  as  opiates  would  have  done.  The 
cerebro-spinal  symptoms,  with  entire  insensibility  and  restless- 
ness, gave  sufficient  evidence  of  the  serious  character  of  the 


1865.] 


ASTHENOPIA. 


11 


disease.  She  had  suffered  an  attack  of  hemiplegia  of  the  same 
side  four  months  previously,  and  from  which  she  had  not  fully 
recovered,  but  on  that  occasion  the  head  had  not  been  seriously 
affected. 


Asthenopia  not  connected  loith  Hyper metropia.    By  E.  Dyer,. 
M.D.,  of  Philadelphia. 

[Eoacl  before  the  American  Ophthalmological  Society,  June  14,  1865.] 

There  are  certain  cases  of  asthenopia  -wMcli  liave  inter- 
ested me  much,  and  I  beg  to  call  the  attention  of  the  So- 
ciety to  them  for  a  few  moments.  In  these  cases  there  is  no 
hypermetropia,  latent  or  apparent.  The  accommodation  is 
good.  There  is  in  a  majority  of  cases  myopia  more  or  less 
marked,  sometimes  even  as  high  as  J  or  ^.  The  symptoms 
vary  in  some  important  particulars  from  asthenopia  dependent 
on  hypermetropia.  The  patient  never  complains  of  being 
obliged  to  suspend  the  use  of  the  eyes  while  reading,  from  the 
letters  becoming  indistinct  or  the  words  running  together,  but 
it  is  either  absolute  pain  in  the  eyes  themselves,  or  a  sensation 
so  disagreeable  that  he  at  once  ceases  to  use  them.  He  always 
says  that  if  he  chose  to  continue  he  could  do  so,  as  his  vision  is 
as  clear  as  when  he  commenced  to  read.  Rest  for  an  hour 
does  not  relieve  him,  and  he  can  not  recommence  his  work  as 
the  hypcrmetrope  can.  The  pain  or  sensation  lasts  generally 
for  several  hours,  often  over  night,  and  sometimes  for  several 
days.  The  pain  is  generally  confined  to  the  eyeballs,  and  does 
not  affect  the  forehead  and  temples.  The  mind  has  a  great 
influence  on  the  length  of  time  the  eyes  can  be  used  without 
feeling  the  pain.  I  have  known  ladies  who  could  read  a  long 
letter  from  an  absent  liusband  or  others  in  whom  they  were 
particularly  interested,  when  they  could  not  read  half  a  page 
from  a  book  or  an  indifferent  correspondent.  The  amount  of 
use  that  these  patients  can  bear  is  very  inconstant.  Sometimes 
they  can  read  for  half  an  hour,  and  the  next  day  or  week  they 
can  not  bear  the  sight  of  a  book,  and  dread  any.attempt  to  use 
the  eyes.  They  generally  let  the  affection  run  on  for  some 
months  before  they  seek  medical  advice. 


12 


ASTHENOPIA. 


[Oct., 


General  fatigue  of  the  whole  body  does  not  often  affect  the 
eyes  as  it  does  in  hypermetropes,  and  tliey  can  use  them  as  well 
after  prolonged  exertion  as  when  they  are  not  tired.  Some- 
times there  are  uterine  or  heart  complications,  but  not  generally. 
Masturbation  is  often  acknowledged  by  these  patients,  but 
whetlier  oftener  than  in  other  diseases  I  can  not  say.  There  is 
generally  some  intolerance  of  light,  especially  of  gas  light, 
which  is  not  dependent  on  the  use  of  the  eyes.  They  can  bear 
the  light  if  excited,  and  can  often  go  to  the  opera  or  a  party 
without  feeling  discomfort  at  the  time,  but  the  next  day  or  two 
they  suffer  the  penalty.  At  home,  when  there  is  no  excitement, 
they  avoid  the  light.  The  pain  produced  by  indiscretions  of 
the  above  kind  is  almost  exactly  like  that  brought  on  by  using 
the  eyes.  It  is  mostly  found  in  persons  under  thirty  years  of 
age  ;  when  occurring  after  that  age  it  is  generally  a  consequent 
of  using  the  eyes  too  soon  after  confinement.  It  is  restricted 
almost  entirely  to  persons  of  the  better  class  of  society.  I 
have  never  seen  it  connected  with  strabismus  convergens,  but 
sometimes  with  strabismus  divergens.  I  have  seen  only  one 
case  complicated  with  astigmatism. 

The  ophthalmoscopic  appearances  are  not  well  marked  or 
constant.  Generally  there  is  nothing  abnormal.  Occasionally 
it  is  observed,  wlien  tlie  myopia  is  excessive,  that  the  size  of 
the  staphyloma  posticum  does  not  correspond  with  the  degree 
of  myopia,  but  this  is  often  the  case  when  no  asthenopia  exists. 
Frequently  the  optic  nerve  is  "  dirty,"  i.  e.  not  clear,  and  also 
the  choroid,  which  is  striated.  These  stria  run  towards  the 
posterior  pole  of  the  globe,  but  this  appearance  is  so  common 
that  it  can  not  be  mentioned  as  a  characteristic  of  this  kind  of 
asthenopia. 

From  the  observation  of  a  number  of  these  cases  I  was  led 
to  the  conclusion  that  some  trouble  with  the  accommodation 
was  generally  the  cause  of  the  pain  or  disagreeable  sensations. 
An  emmetropic  person,  with  an  accommodation  of  one-fifth, 
ought  to  be  able  to  read  without  fatigue  at  ten  inches,  as  he 
would  only  use  half  his  accommodation.  On  the  other  hand, 
a  person  with  myopia  one-tenth  should  read  at  that  distance 
without  using  his  accommodation  at  all.  Still,  both  complain 
of  asthenopia.    It  occurred  to  me,  although  the  most  careful 


1865.] 


ASTHENOPIA. 


13 


examination  failed  to  detect  any  insufficiency  of  the  internal 
recti,  that  still  there  might,  in  both  cases,  be  a  discrepancy 
between  the  power  of  the  ciliary  muscle  and  the  angle  of  con- 
vergence.   In  other  words,  I  concluded  that  there  was — 

1st.  Some  disturbance  of  the  relative  accommodation. 

2d.  There  seemed  to  be  a  want  of  tone  or  power  of  the 
ciliary  muscle  for  continued  action. 

3d.  Want  of  mental  energy,  the  patient  having  lost  con- 
fidence in  his  power  to  use  his  eyes. 

My  object  is  to  offer  to  your  notice  a  course  of  treatment 
which  I  have  used  during  the  past  two  years,  which  I  have 
called  gymnastic  exercise  of  the  eyes.  It  seems  to  answer  the 
three  indications  mentioned  above.  Of  course,  the  general 
health  of  the  patient  must  be  cared  for,  and  this  treatment  is 
only  added  to  the  general  course  of  tonics,  air,  exercise,  stimu- 
lants, counter-irritants,  attention  to  the  uterine  functions,  &c. 

1st.  I  change  the  relation  of  the  accommodation  to  the 
angle  of  convergence  of  the  axes  of  the  eyes  by  glasses.  To 
the  emmetrope  I  give  convex.  No.  30  or  36.  With  a  myope 
of  one-tenth  or  less,  I  simply  correct  the  myopia.  In  the  higher 
grades  of  myopia  it  suffices  to  carry  the  far  point  out  to  10  or 
15  inches.* 

I  will,  for  example,  suppose  cases  of  these  three  classes, 
using  the  same  fractions  in  each  case,  for  the  sake  of  sim- 
plicity. 

An  emmetrope,  with  an  accommodation  of  i,  holds  his  book 
naturally  at  12  inches,  at  which  distance  he  uses  one-half  of  his 
accommodation.  The  angle  of  convergence  of  the  axes  of 
vision  to  12  inches  is  not  sufficient  for  him  to  use  one-half  of 
his  accommodation,  and  he  is  furnished  with  convex,  No.  36. 
If  he  still  holds  his  book  at  12  inches,  he  uses  only  one- third  of 
his  accommodation,  and  the  relation  of  the  convergence  of  the 
axes  of  vision  to  the  accommodatron  is  altered,  and  he  finds 
great  relief.  He  will  probably  not  do  this,  ^'.  e.  hold  his  book 
at  12  inches,  but  bring  it  to  9  inches,  when  he  will,  with  this 

*  I  have  treated  several  cases  of  asthenopia  which,  from  the  general 
symptoms,  seemed  to  belong  properly  to  this  class,  but  in  which  a  slight 
amount  of  hypermetropia  existed.  I  gave  them  convex,  No.  3G,  plus  the  de- 
gree of  hypermetropia.    They  all  recovered  rapidly. 


14 


ASTHENOPIA. 


convergence,  be  able  to  use  one-half  of  Ills'  accommodation, 
which  is  exactly  the  amount  used  when  supplied  with  -\-  86. 

A  m)^ope  of  one-twelfth  (accommodation  as  in  the  previous 
case,  one-sixth),  can  not  converge  to  twelve  inches  witliout 
using  some  of  his  accommodation.  He  is  furnished  with 
—  -,'2)  carrying  his  far  point  to  (infinity).  If  he  then 
holds  his  book  at  twelve  inches,  he  uses  one-half  of  his  ac- 
commodation, which,  at  once,  changes  the  habitual  relation  of 
it  to  the  convergence  of  the  axes  of  vision. 

In  a  myope  of  one-sixth  (Ac.  =  one-sixth),  the  condition  is 
similar.  Furnished  with  —  fV,  the  myopia  is  partially  re- 
lieved, and  if  he  hold  his  book  at  12  inches  he  would  use  no 
accommodation  at  all.  But  he  Mali  not  do  this,  but  from  habit 
will  hold  his  book  nearer,  say  at  8  inches,  where  he  will  use  one- 
half  of  his  accommodation,  and  do  it  with  ease.  Cases  of  this 
third  class  are  not  as  common  as  those  of  the  first  and  second. 

Having  thus  altered  the  relative  accommodation  we  come  to 
the  practical  use  of  it  in  fulfilling  the  second  indication,  viz.: 
want  of  tone  or  power  of  the  ciliary  muscle  for  continued  ac- 
tion. 

As  before  remarked,  these  patients  rarely  seek  professional 
advice  till  they  have  sufiFered  for  several  months,  sometimes 
years,  and  the  ciliary  muscle  has  lost  its  tone.  The  act  of  ac- 
commodation is  purely  muscular.  Why  should  not  the  ciliary 
muscle  be  strengthened  by  regular  exercise  as  well  as  any  other 
muscle  ?  My  course  of  treatment  has  been  as  follows:  I  order 
the  patient  never  to  use  his  eyes  without  the  glasses  prescribed, 
and  never  to  use  them  except  as  I  direct.  Sewing,  writing, 
music  or  painting,  must  not  be  attempted  during  the  first  part 
of  the  treatment.  The  patient  must  be  warned  that  at  first 
some  inconvenience  will  be  found,  till  he  becomes  accustomed 
to  the  glasses.  He  must  select  a  book  with  good,  clear  type 
of  medium  size,  and  read,  according  to  the  case,  3  to  15  minutes 
in  the  morning.  If  no  pain  follows,  read  a  minute  longer  at 
noon,  and  increase  a  minute  at  evening  (not  after  half  an  hour 
before  sunset).  If  the  pain  following  the  first  reading  lasts 
until  the  time  of  the  second,  the  patient  must  not  mind  it.  but 
read  a  minute  less  than  he  did  in  the  morning,  and  a  minute  less 


1865.] 


ASTHENOPIA. 


15 


at  niglit,  if  it  still  continues.  In  this  way  a  point  must  be  found 
■when  he  can  read  a  certain  number  of  minutes  without  pain. 
Then  let  him  progress  a  minute  each  day,  or  faster,  if  prudent, 
though  it  is  better  to  go  too  slowly  than  too  fast.  When  the 
patient  gets  up  to  30  to  4(3  minutes  three  times  a  day,  other  use 
of  the  eyes  than  reading  may  be  carefully  substituted.  When 
GO  to  70  minutes  are  reached,  the  glasses  (except  in  the  third  class) 
may  be  gradually  dispensed  with.  The  patient  may  read  at 
noon  one-quarter  of  the  time  -without  them,  then  one-half,  and 
so  on,  leaving  them  off  gradually.  The  surgeon  must  be  guided 
by  the  nature  and  course  of  the  case.  One  minute  a  day  seems 
a  small  matter,  but  if  a  person  begins  with  reading  one  minute 
three  times  a  day  and  increases  a  minute  each  day,  at  the  end 
of  a  month  he  will  be  reading  an  hour  and  a  half  a  day. 

I  have  found  it  of  great  assistance  to  explain  the  rationale 
of  the  treatment  to  the  patient,  and,  as-I  have  before  remarked, 
these  cases  rarely  occurring  except  in  the  educated  classes,  they 
readily  understand  it,  and  are  anxious  to  assist  the  surgeon  in 
the  treatment.  For  this  purpose,  the  term  gymnastic  exercise 
of  the  eyes  is  useful.  T  tell  them  that  in  reading,  pure  muscu- 
lar action  is  required  as  much  as  in  lifting  a  weight;  that 
through  want  of  use,  general  debility,  or  some  derangement  of 
the  general  system,  they  have  lost  the  power  to  exert  the  muscle 
brought  into  action  in  reading  without  fatigue;  that  they  can 
strengthen  this  muscle  and  increase  its  power  of  endurance  by 
regular,  constant  and  systematic  exercise,  as  well  as  any  other 
muscles  in  the  body. 

I  come  now  to  the  third  indication — want  of  mental  eliergy; 
the  patient  having  lost  confidence  in  this  power  to  use  his  eyes. 
This  course  of  treatment  serves  to  distract  the  mind  of  the  pa- 
tient and  restores  his  confidence  in  his  ability  to  use  his  eyes. 
He  has  become  discouraged;  he  has  had  the  horror  of  blindness 
carefully  instilled  by  friends  and  sometimes  by  well  meaning 
physicians,  who,  not  feeling  quite  sure  of  their  ground,  err  on 
the  safe  side,  and  prescribe  entire  rest.  In  these  cases  "  the 
safe  side  "  is  the  wrong  side.  When  the  glasses  are  procured 
and  the  patient  is  assured  that  there  is  no  absolute  disease  of 
the  eye  as  revealed  by  the  ophthalmoscope,  he  commences  his 
course  of  treatment  with  hope  and  zeal.    The  mere  fact  that  he 


16 


ASTHENOPIA. 


[Oct., 


is  told  that  lie  must  use  his  eyes  gives  him,  to  a  certain  extent, 
the  power  to  do  so. 

I  have  notes  of  forty  cases  of  this  peculiar  kind  of  asthenopia 
treated  in  this  manner,  and  in  thirty-eight  the  results  were 
highly  satisfactory.  In  one  of  the  two  failures  there  was  seri- 
ous uterine  disease;  and  in  the  other,  the  patient  was  ol)liged 
to  leave  the  city  before  the  treatment  had  had  a  fair  trial. 

The  necessity  of  persevering  and  following  directions  to  the 
letter  can  not  be  too  carefully  impressed  upon  the  mind  of  the 
patient.  If  they  are  careless  and  do  not  read  regularly  or  read 
too  much,  they  will  be  sure  to  be  thrown  back,  and  have  the 
whole  ground  to  go  over  again.  As  these  cases  are  always 
long,  extending  over  months,  it  rarely  happens  that,  from  ne- 
cessity or  carelessness,  some  indiscretion  is  not  indulged  in 
which  entirely  throws  them  back,  and  they  can  not  use  the  eyes 
more  than  they  could  when  they  commenced  treatment.  How- 
ever the  improvement,  when  this  has  happened,  is  much  more 
rapid  than  at  first.  I  will  give  you  one  or  two  cases  showing 
how  this  may  occur,  and  how  careful  both  surgeon  and  patient 
must  be. 

Dec.  9, 1863,  Miss  ,  set.  27,  has  been  in  the  habit  of  sew- 
ing almost  all  day  for  nine  years.  A  year  ago  she  had  "  some 
trouble"  in  her  eyes;  since  then  she  has  not  been  able  to  use 
them  at  all. 

She  now  complains  of  pain  in  the  eyes  and  forehead  and  mod- 
erate intolerance  of  light.  Can  not  read  ten  minutes  without 
bringing  on  severe  pain.  Has  slight  leucorrhoea  and  pain  in 
the  back.  No  amblyopia;  no  hypermetropia;  no  insufiiciency 
of  internal  recti.  Ophthalmoscopic  appearances  normal,  ex- 
cept slight  congestion  of  the  optic  nerve  of  the  right  side. 

I  ordered  convex,  No.  36;  Syr.  ferri  pyrophas.,  veratrine 
(grs.  x-ii.)  ointment  for  the  forehead,  warm  clothing,  exercise 
in  the  open  air,  a  tablespoonful  of  whisky  before  meals,  and 
the -gymnastic  exercise,  commencing  with  five  minutes  three 
times  a  day. 

Feb.  21st,  1864. — Patient  read  seventy  minutes  twice  yester- 
day, and  her  eyes  felt  so  "well  that  at  the  third  reading  she 
thought  she  would  see  if  she  could  not  read  eighty  minutes. 
She  did  so,  without  pain  or  trouble  of  any  kind,  but  this  morn- 


1865.] 


ASTHENOPIA. 


17 


ing  the  same  old  sensations  came  on,  and  she  was  only  able  to 
read  three  minutes.  All  the  previous  symptoms  had  returned. 
It  was  not  at  her  menstraal  period.  She  was  ordered  to  begin 
again  and  read  only  three  minutes  at  a  time,  and  increase. 

March  30,  18G4.— Up  to  thirty-five  minutes.  Continue. 

April  20,  1864. — Reads  an  hour  three  times  daily  without 
trouble.  Continue.  To  see  me  again  if  there  was  any  more 
trouble. 

May,  1865. — Patient  has  not  returned,  but  I  have  heard  in- 
directly, from  a  friend  of  her's,  that  she  has  not  had  any  trouble 
from  her  eyes  for  a  long  time. 

In  this  case  the  indiscretion  was  very  slight,  only  increasing 
ten  minutes  at  a  single  reading  when  she  was  reading  seventy 
minutes  three  times  daily. 

In  another  case  a  patient,  with  general  derangement  of  the 
nervous  system,  myopia  one-eighth,  (had  not  used  her  eyes  for 
a  year,)  was  improving  rapidly,  and  was  reading  thirty  minutes 
at  a  time.  She  undertook  some  sewing  and  worked  all  day. 
She  was  confined  to  the  bed  for  several  days,  and  had  intense 
neuralgic  pain  in  consequence,  which  was  relieved  by  subcuta- 
neous injections  of  morphia. 

In  another  case,  Miss  B.,  jet.  20,  consulted  me  Feb.  16, 1863; 
had  not  been  able  to  read  for  two  years.  Myopia  one-eighteenth. 
Subjective  symptoms  as  before  described.  Prescribed  concave 
—  tV>  and  general  treatment  of  iron,  exercise,  &c.  It  was 
not  until  October  22  that  she  could  read  ten  minutes  with  ease. 
During  this  time  she  had  been  obliged  three  times  to  go  back 
to  two  minutes  at  each  reading,  and  increase  gradually. 

Dec.  19,  1864. — Can  use  the  eyes  without  pain.  Since  then 
have  not  seen  the  patient,  but  have  heard  from  her  relations 
that  she  has  no  more  trouble. 

I  will  mention  a  case  whose  cure  I  consider  entirely  de- 
pendent on  the  regular  use  of  the  eyes.    Mrs.  ,  aet.  4] , 

consulted  me,  and  gave  the  following  history:  Since  she  was 
married,  nineteen  years  ago,  she  has  never  been  able  to  use 
her  eyes  at  all.  Her  husband  has  been  in  the  navy,  and  of 
course  absent  nearly  all  the  time.  Whenever  she  received 
his  letters  she  read  them,  but  was  sometimes  confined  to 
her  bed  for  two  days  in  consequence,  and  always  suffered 
Vol.  II.— No.  7.  2 


18 


TREATMENT  OF  BRIGHT's  DISEASE. 


[Oct., 


intense  pain  in  tlie  eyes  and  head.  She  has  been  under  treat- 
ment many  times  without  benefit.  She  can  not  read  two 
lines  without  pain,  wliich  often  lasts  over  night.  Hhe  lias 
myo])ia  ^  to  ^.  Health  rather  below  the  standard,  lias  taken 
tonics  and  iron  for  the  last  ten  years.  Slight  maceration  of 
the  pigment  of  the  choroid.  Posterior  Ktajihyloma  smaller  than 
would  be  expected  from  the  amount  of  the  myopia.  I  gave 
her  Blancard's  pills,  a  stimulating  wash  for  the  forehead,  and 
concave  one-twelfth  for  reading.  I  told  her  to  begin  with  five 
minutes  and  follow  the  plan  explained  before.  In  eighteen 
days  she  read  nineteen  minutes  without  a  particle  of  pain,  and 
came  to  me  with  enthusiasm  and  said:  "Doctor,  I  have  read  a 
book  through;  I  have  not  read  one  for  nineteen  yeais."  Ten 
days  after  she  reported  that  she  had  on  one  occasion  read  three 
minutes  too  long,  and  was  put  back  to  ten  minutes.  Two 
months  afterwards  she  was  only  up  to  fifteen  minutes,  having 
in  the  meantime  been  twice  up  to  thirty  minutes,  but  having 
fallen  back  through  indiscretions.  Since  then  she  got  up  to 
ninety  minutes,  and  kept  there  Avitliout  trouble.  During  the 
treatment  I  changed  the  preparation  of  iron,  and  also  gave  her 
veratrine  ointment. 

In  this  case,  I  do  not  think  the  favorable  result  was  owing 
to  the  iron,  for  she  had  been  taking  it  for  ten  years,  more  or 
less,  and  had  been  taking  and  was  taking  the  ferrated  elix. 
cinch,  when  I  first  saw  her. 


Hints  ahout  the  Nature  and  Treatment  of  the  simplest  form  of 
BrigJd's  Disease.    By  John  C.  Petees,  M.D. 

For  the  basis  of  this  article  I  commence  with  the  assump- 
tion that  simple  suppression  of  perspiration  may  induce  the 
first  stage  of  Bright's  disease.  It  lias  been  well  said,  that  the 
important  influence  which  the  temperature  and  secretions  of 
the  skin  exert  upon  the  kidneys  is  a  part  of  every  man's  per- 
sonal experience;  but  nothing  illustrates  this  more  strikingly 
than  the  experiments  which  com[)letely  suspend  the  cutaneous 
excretions.    Thus  :  Dr.  Styles  had  the  fur  of  a  rabbit  removed 


1^65.] 


TREATMENT  OF  BRIGHT's  DISEASE. 


19 


and  covered  the  skin  with  a  coating  of  collodion  ;  in  an  hour  or 
two  the  urine  became  albuminous.  Again,  Carpenter  says  :  a 
partial  suppression  by  the  same  means  gives  rise  to  febrile 
symptoms  and  albuminuria. 

A  large  number  of  cases  of  Bright  disease  arise  from  simple 
exposure  to  cold  and  wet ;  and  many  more  occur  after  attacks 
of  scarlet  fever,  with  or  without  exposure  to  cold,  although 
Dr.  Clark  says  the  opinion  is  universal  that  it  is  exposure  of 
the  surface  of  the  body  to  cold  air  which  produces  the  dropsy 
and  other  symptoms  of  Bright's  disease  after  scarlatina,  and 
he  does  not  doubt  tliat  this  belief  is  well  founded  in  the  main. 
But  in  scarlet  fever,  in  addition  to  suppression  of  the  functions 
of  the  skin,  we  have  a  blood-poisoning,  while  the  kidneys  may 
be  found  not  only  remarkably  congested,  but  their  secretory 
and  tubular  surfaces  may  become  the  seat  of  a  similar 
vascular  injection  or  efflorescence  to  that  existing  in  the  vascu- 
lar rete  of  the  skin;  and  this  eruption  on  the  surfaces  of  the 
urinifcrous  tubes  and  the  associated  swelling  and  congestion  of 
these  organs  may  cither  impede,  interrupt,  or  altogether  sup- 
press the  functions  of  the  urinary  excretion,  and  thereby  occa- 
sion an  accumulation  of  excremential  and  contaminating  mate- 
rials in  the  blood.  (Copland.)  The  affection  of  the  kidneys 
may,  in  fact,  transcend  that  which  occurs  on  the  skin  in  scarlet 
fever,  and  almost  rival  that  which  can  so  often  be  observed  on 
the  throat.  In  scarlet  fever  an  acrid  and  even  corrosive  nar- 
cotico-alkaloidal  poison,  like  that  which  exists  in  the  rlius 
toxicodendron,  belladonna,  stramonium,  turpentine  or  can- 
tharides,  may  produce  its  ravages  upon  the  blood,  skin,  mucous 
membranes,  kidneys,  and  nervous  system.  But  simple  suppres- 
sion of  perspiration  may  also  induce  blood-poisoning,  for  large 
quantities  of  chloride  of  sodium,  acetic  and  formic  acids,  urea, 
carbonic  acid,  and  nitrogen  gases,  and  other  acrid  substances, 
are  naturally  excreted  from  the  healthy  skin.  This  may  be  dwelt 
upon  mucli  more  fully  in  another  article;  at  present  I  wish  to 
refer  almost  exclusively  to  the  retention  of  watery  fluid  and 
vapor  which  a  check  of  perspiration  induces.  Lavoisier  and 
Seguin  found  the  average  quantity  of  simple  watery  fluid  lost 
by  cut  me  )u^  perspiration  during  24  hours  amounted  to  nearly 
2  lbs.  avoirdupois.    Dalton  assumes  that  25.^  ounces  is  the  nor- 


20 


TREATMENT  OF  BRIGHT's  DISEASE. 


[Oct., 


mal  quantity  for  an  adult  man,  while  laborers  in  gas-works  have 
been  known  to  lose  3.^  lbs.  in  weight  by  cutaneous  and  pul- 
monary exhalations  in  one  hour;  finally,  Funke  has  produced  a 
forced  perspiration  amounting  to  the  rate  of  from  10  to  2G  lbs. 
in  24  hours.    Thus,  a  sudden  check  of  perspiration  may  cause 
an  absolute  retention  of  many  ounces  or  even  pounds  of  water 
in  the  system  ;  and  it  is  an  almost  equally  well  known  fact 
that  a  great  increase  in  the  proportion  of  water  alone  in  the 
blood  has  a  tendency  to  produce  oedema.    Dropsy  has  been 
induced  artificially  by  the  injection  of  pure  water  into  the 
blood  vessels;  for  Poiseuille  and  Goodfellow,  who  have  often 
attempted  to  force  water  through  the  capillary  network  of  an 
organ,  found  that  this  simple  fluid  injected  into  the  arteries 
did  not  return  quickly  by  the  veins,  as  it  does  in  the  case  of 
glutinous  saline  injections  ;  but,  on  the  contrary,  a  great  part 
of  it  escaped  into  the  tissues  and  produced  a  local  dropsy.  On 
adding  albumen  to  the  water,  or  employing  normal  serum,  tliis 
infiltration  did  not  occur,  showing  clearly  that  albumen  alone, 
when  in  normal  quantity,  may  hinder  to  some  extent  the 
efi'usion.    Again,  it  is  absolutely  necessary  that  the  albumen 
should  be  in  sufficient  quantity  ;  for  if  the  water  be  in  excess, 
the  fluid  will  still  filtrate  through  the  tissues.    Hence  it  is 
evident  that  a  watery  condition  of  the  blood,  or  a  great 
diminution  of  its  albumen,  is  eminently  calculated  to  facilitate 
tlie  escape  of  serum  through  the  capillary  vessels  ;  in  short, 
favor  the  occurrence  of  dropsy. 

The  simjylest  form  of  Bright's  disease.— la  this  variety 
the  kidney  is  merely  dropsical,  auasarcous  or  cedemalous  ;  its 
tissues  and  tubes  are  simply  infiltrated  by  a  greater  quantity  of 
fluid.  After  death  we  find  a  large,  flabby,  more  or  less  sodden, 
watery  kidney  ;  serum  drops  from  it  in  large  quantity  when  a 
section  is  made  of  it  ;  its  vessels  are  turged  with  a  thick  red 
blood  that  has  been  deprived  in  a  great  measure  of  its  serum. 
Goodfellow,  whose  description  has  been  quoted  above,  is  cer- 
tain that  the  oedematous  condition  of  the  kidney  precedes  the 
general  anasarca,  and  thinks  that  in  the  most  recent  and  purest 
cases  of  Bright's  disease  it  would  not  be  very  wide  of  the  truth 
to  say  that  they  are  merely  cases  of  parenchymatous  dropsy  of 
the  kidney. 


1865.] 


TREATMENT  OP  BRIGHt's  DISEASE. 


21 


This  dropsical  affection  of  the  kidney  is  analogous  to  the 
oedema  of  the  lungs,  -which  so  often  occurs  in  uremia.  Dr. 
Clark  has  seen  several  eases  in  which  the  lung,  when  struck 
with  the  finger,  trembled  like  a  jelly,  and  gave  the  sensation  of 
fluctuation  when  percussed — so  great  was  the  amount  of  water 
it  contained.  From  exposure  to  cold,  or  from  local  nervous 
debility,  or  paralysis,  this  dropsy  of  the  lungs  may  commence 
and  reach  its  height  in  ten  minutes,  and  produce  an  amount  of 
dyspnoea  that  seems  to  threaten  life  ;  it  may  continue  for  one, 
two,  or  three  hours,  and  then  abate,  if  free  action  of  the  skin  or 
kidneys  takes  place  ;  or  it  may  persist  for  days,  or  destroy  life  in 
a  much  shorter  time  ;  or  subside  and  recur  at  tlie  same  hour  the 
next  day,  or  at  a  distant  period,  always  presenting  the  same 
threatening  aspect.  I  have  seen  it  occur  and  prove  fatal  in  a 
few  hours  from  the  patient  taking  a  short  walk  on  a  raw,  cold, 
wintry  day.  Urajmia  alone  can  induce  it,  although  conjoined 
heai  t  disease  is  a  more  common  and  efficient  cause. 

.  The  effects  of  dropsy  of  the  kidney  are  comparable  to  those 
of  oedema  of  the  parenchyma  of  the  lungs  ;  there  is  the  same 
pressure  on  the  substance  of  the  organ,  and  upon  its  vessels, 
tubes  and  nerves.  A  partial  or  complete  paralysis  of  the  renal 
nerves  may  thus  bo  brought  about,  just  as  paralysis  of  the  legs 
occurs  from  dropsy  of  the  spinal  theca. 

Treatment. — The  mildest  and  the  most  active  diaphoretics 
may  be  useful  or  required  in  this  variety.  Wood  truly  says  : 
They  deplete  from  tlie  blood  vessels,  and  sometimes  very 
copiously.  It  is  not  only  the  watery  parts  of  the  blood  that  are 
carried  off  under  their  influence,  but  some  of  the  salts,  and,  to  a 
certain  extent,  the  organic  constituents  also.  They  promote 
absorption  by  their  depletory  influence,  and,  on  this  principle, 
are  sometimes  used  very  happily  in  dropsy ;  he  has  known 
severe  dropsy  to  yield  to  this  class  of  medicines,  in  which 
diuretics  had  been  employed  without  effect.  Again,  he  con- 
tinues :  It  sometimes  happens  that  the  skin  falls  into  an  inactive 
or  torpid  state,  and  ceases  to  peiform  its  functions  proi)cr]y  ; 
in  consequence  of  which  the  blood  may  become  impure,  and 
various  internal  irritations,  whether  of  a  vascular  or  nervous 
character,  may  arise.    Here  is  an  obvious  indication  for  the 


22 


TREATMENT  OF  BRIGHT's  DISEASE. 


[Oct., 


use  of  diaphoretics,  especially  those  of  a  somewhat  stimulating 
character.    Wood  admits  three  varieties  of  diaphoretics,  viz.: 

1st.  Nauseating  diajjhoretics,  like  tartar  emetic,  ipecac,  san- 
guinaria  and  lobelia. 

2d.  Refrigerant  diaphoretics,  including  citrate  of  potash, 
acetate  of  ammonia,  &c. 

3d.  Stimulaiing  diaphoretics,  such  as  prickly  ash,  Virginia 
snake  root,  &c. 

Pereira  also  describes  several  varieties,  viz. : 

1st.  Alkaline  and  saline  diaphoretics,  such  as  the  acetate 
and  carbonate  of  ammonia,  the  alkalme  citrates  and  tar- 
trates, sal  ammoniac,  nitrate  of  potash,  and  other  salts  of  the 
alkalies,  all  of  which  are  frequently  used  to  promote  perspira- 
tion. 

2d..  Nauseating  diafhoretics,  such  as  tartar  emetic  and 
ipecac,  which  are  most  useful  in  febrile,  acute  congestive,  or 
inflammatory  disorders,  and  are  preferable  to  the  opiate  dia- 
phoretics when  there  is  inflammation  or  congestion  of  the  brain, 
or  tendency  thereto;  he  thinks  the  diaphoretic  powers  of  ipecac 
to  be  considerably  less  than  is  commonly  supposed,  and  that 
Dover's  powder  owes  its  powers  of  producing  sweating  almost 
exclusively  to  the  opium  it  contains. 

3d.  Opiate  diaphoretics,  which  he  thinks  have  a  remarkable 
tendency  to  produce  sweating,  and  that  in  diabetes  and  granu- 
lar disease  of  the  kidneys,  (?)  Dover's  powders  is  the  best  sudo- 
rific we  can  use,  especially  when  conjoined  with  the  warm  bath. 
Opium  and  camphor  are  also  mentioned  as  a  serviceable  sudorific 
compound. 

■1th.  Oleaginous  and  resinous  diapihoreiics,  such  as  sassafras, 
camphor,  mezereum,  guaiacum,  copaiva,  and  the  turpentines. 

Beck  only  mentions  tartar  emetic,  acetate  of  ammonia, 
citrate  of  potash,  ipecac,  eupatoiium  perlbliatum  or  bone- 
set,  asclepias  tuberosa,  and  aristolochia  serpcntaria  as  dia- 
phoretics. Abies  selects  dulcamara,  mezereum,  viola  tricolor, 
aconite, rlius  toxicodendron,  rhododendron  chrysanthemum, Pul- 
satilla, and  phosphorus  as  the  most  reliable  sudorifics.  Other 
authors  speak  of  alterative  diap)horcfics,  such  as  sassafras, 
mezereum,  guaiac  and  sarsaparilla.  We  now  pass  to  the  con- 
sideration of  the  individual  remedies  of  this  class. 


1865.] 


TREATMENT  OF  BRIGHT's  DISEASE. 


23 


1.  Citrate  of  iwtasli. — Wood  asserts  that  when  the  skin  is 
hot  and  dry,  and  the  circulation  accelerated,  there  is  no  diapho- 
retic "which  operates  more  certainly  and  effectually;  ho  re- 
gards it  as  more  certain  than  tartar  emetic  as  a  mere  sudorific; 
says  it  allays  nausea  and  thirst  with  promptness,  lowers  the 
pulse,  heat  of  skin,  and  induces  perspiration,  as  well  as  pro- 
motes the  secretion  of  the  kidneys.  When  a  strong  sedative 
impression  on  the  circulation  is  desired,  or  \  grain  of  tartar 
emetic  may  be  added  to  each  dose,  or  a  few  drops  of  aconite; 
when  there  are  nervous  symptoms,  such  as  morbid  vigilance, 
muscular  startings,  twitchings,  etc.,  Hoffman's  anodyne  or 
sweet  spirits  of  nitre  may  be  combined  with  it.  Wood  thinks 
it  greatly  superior  to  the  spiritns  mindcreri,  both  in  diapho- 
retic power,  and  for  calming  irritability  of  the  stomach;  it  is 
one  of  the  most  effective  anti-emetic  remedies,  and  he  knows 
nothing  equal,  to  it  in  fever  with  a  disposition  to  frequent 
vomiting.  In  his  earlier  practice  he  used  the  acetate  of  ammo- 
nia a  great  deal,  but  found  it  almost  unifoi-mly  so  much  inferior 
to  the  citrate  of  potash,  and  so  much  less  acceptableto  the  patient, 
that  he  has  long  ceased  to  give  it,  except  in  exceptional  cases. 
It  should  always  be  made  from  the  juice  of  good,  fresh,  sound, 
and  very  sour  lemons;  of  which  about  4  fluid  ounces  should  be 
gradually  saturated  with  bicarbonate  of  potash,  the  salt  being 
added  slowly,  till  all  effervescence  ceases.  Dose,  a  table- 
spoonful  every  one,  two,  or  four  hours.  It  is  doubtless  as 
efficient  as  the  tartrate  of  potash.  The  addition  of  a  small 
quantity  of  syrup  of  orange  peel  renders  it  much  more  ac- 
cej)table. 

2.  Solution  of  acetate  of  ammonia,  or  spiritns  mindereri. — 
For  some  readily  accountable  reasons  this  remedy  has  been 
used  far  more  frequently  than  the  citrate  of  potash;  it  certainly 
has  cheapness  and  disagreeableness  in  its  favor;  the  former 
may  be  a  sufficient  excuse  in  hospital  practice,  and  in  countries 
far  removed  from  intercourse  with  the  tropics.  It  is  undoubt- 
edly an  efficient  remedy,  especially  the  German  preparation, 
which  is  very  much  stronger  than  the  English  or  Amei'ican 
formula,  but  is  used  in  one  or  two  drachm  doses,  instead  of  by  the 
tablespoonful,  as  witli  us.  It  is  thought  to  be  particularly 
useful  in  the  dropsies  which  occur  after  scarlet  fever  and 


24 


TREATMENT  OP  BRIGHt's  DISEASE. 


measles,  although  Todd  has  also  recommended  it  in  inflam- 
atory  dropsies.  Richter  found  it  most  valuable  for  its  diaplio- 
retic  properties;  he  thinks  it  first  renders  the  pulse  somewhat 
fuller  and  more  frequent,  and  augments  the  general  activity 
and  warmth  of  the  skin  until  sweat  breaks  out,  when  these 
symptoms  decline,  and  coolness  and  relaxation  occurs;  when 
it  does  not  act  upon  the  skin  it  augments  the  secretions  from 
the  lungs  and  kidneys.  Dierbach  pronounces  it  one  of  the 
most  powerful  and  certain  means  for  the  production  of  perspi- 
ration. It  IS  sometimes  given  alone,  but  more  frequently  com- 
bined with  10,  15,  or  20  drops  of  wine  of  antimony  to  each 
dose,  or  with  equal  quantities  of  wine  of  ipecac,  or  with  from 
one  to  three  drops  of  aconite,  or  with  spirits  of  nitre.  Drs.  Swett 
Metcalf,  Bulkley,  and  Jos.  M.  Smith  treated  25  cases  of  Bright's 
disease  by  the  hot  vapor  bath  and  spirits  mindereri  and  ipecac; 
of  these,  seven  recovered,  twelve  were  relieved,  one  was 
somewhat  improved,  and  five  died.  It  is  evidently  best 
adapted  for  mild  and  recent  attacks;  still  it  has  overcome  some 
obstinate  and  chronic  cases,  even  those  occurring  in  elderly 
persons,  when  given  in  full  doses,  say  two  ounces  daily  of  the 
German  preparation,  and  followed  up  for  several  weeks.  As 
there  are  few  remedies  which  are  so  successful  as  a  teaspoon- 
ful  or  two  of  this  solution  in  sick  headaclies,  and  as  it  speedily 
puts  an  end  to  the  phenomena  of  drunkenness  in  alcoholic  in- 
toxications, it  may  prove  useful  in  some  of  the  head  affections 
of  Bright's  disease.  When  the  hydrsemia  is  somewhat  lessened, 
Basham  gives  the  liquor  ammoniae  acetatis  in  a  combination 
which  he  thinks  both  agreeable  and  efficacious,  viz.:  in  con- 
junction with  acetic  acid  and  the  muriate  tincture  of  iron. 
He  has  reason  to  think  this  formula  more  eS"ective  than  when 
the  same  ingredients  are  given  separately.  The  spiritus  min- 
dereri must  first  be  rendered  acid,  by  the  acetic  acid,  before 
the  muriate  tincture  is  added,  otherwise  the  ammonio-chloride 
of  iron  is  precipitated,  and  is  with  difiicnlty  redissolved  in  an 
excess  of  acetic  acid.    He  prefers  the  following  prescription : 

Liq.  ammon.  acet.  3j. 

Acidi  acetici  dilut.  -   -    -   -   gutt  xx 

Tinct.  ferri  sesquichloridi     -    gutt  x 
to  be  given  in  an  ounce  of  water  three  times  a  day. 


1865.] 


TREATMENT  OP  BRIGHt's  DISEASE. 


25 


Tlie  And  Elixir  of  Holler,  or  Elixir  vitrioli  Mysichti,  has 
cured  several  cases  of  Briglit's  disease,  marked  by  swelling  of 
the  face,  hands,  limbs, and  abdomen,  very  scanty  and  albuminous 
urine,  dropsy  of  the  chest,  and  oedema  of  the  lungs,  with  ina- 
bility to  lie  down,  and  severe  suffocative  attacks.  Dose,  ten 
drops  every  hour,  in  urgent  cases,  given  iu  "wine  or  gin  and 
water;  or  twenty  to  thirty  drops  several  times  a  day. 

Vinegar. — With  a  view  to  its  refrigerant  and  diuretic 
properties,  it  has  sometimes  been  used  in  dropsy.  Dr.  Gregory, 
of  North  Carolina,  employed  it  with  great  success  in  the  quan- 
tity of  a  pint  daily.  Simpson's  recommendation  should  not 
be  forgotten.  A  Dr.  Beyer  has  treated  six  cases  with  wine 
vinegar  alone;  he  gave  tablespoonful  doses  every  one  or  two 
hours;  in  the  course  of  three  or  four  days  profuse  general  per- 
spiration would  set  in,  followed  by  three  or  four  fluid  stools 
per  day,  and  very  copius  diuresis;  recovery  took  place  in 
about  three  weeks,  and  about  one  and  a  half  or  two  quarts  of 
vinegar  were  used  in  each  case.  Cases  occurring  after  scarlet 
and  intermittent  fever  have  recovered  under  its  sole  use;  the 
appetite  usually  improved  while  using  it,  and  the  remedy  was 
generally  taken  readily  until  a  cure  was  nearly  affected,  when 
it  became  distasteful;  still  the  progress  of  the  improvement 
continued  unabated,  and  a  perfect  cure  was  accomplished  with- 
out the  aid  of  other  medicines. 

Lemon  juice. — Frank  reports  six  cases  either  permanently 
or  temporarily  cured  by  tablespoonful  doses  every  two  hours; 
all  other  drink  and  fluids  were  interdicted,  and  only  white 
meats,  bread  and  vegetables  were  allowed;  from  100  to  200 
lemons  were  consumed  in  about  two  weeks,  and  improvement 
commenced  in  a  few  days.  The  patients  generally  perspired 
freely  at  night;  the  urine  was  increased,  in  some  cases,  to  two 
and  a  half  or  three  or  even  six  quarts  per  day;  if  constipation 
was  present,  loose  stools  occurred;  if  debilitating  or  even  col- 
liquative diarrhoea  was  present,  it  diminished  as  the  action  of 
the  remedy  on  the  skin  and  kidneys  increased.  It  seemed  to 
be  especially  useful  when  dropsy  of  the  chest  and  oedema  of 
the  lungs  were  present;  when  the  face,  hands,  feet,  and  limbs 
were  bloated;  when  ascites  was  present,  and  the  patient  was 
unable  to  lie  down  from  dropsy  of  the  chest,  and  had  repeated 


26 


TREATMEXT  OF  BRIGHTS  DISEASE. 


[Oct., 


attacks  of  suffocative  oppression  from  oedema  of  the  lung's.  It 
probably  acts  in  the  same  way  as  cream  of  tartar,  citrate  of 
potash,  and  acetate  of  ammonia,  and  may  be  most  usefully  em- 
ployed as  a  common  drink,  when  other  remedies  are  used  or  re- 
quired. 

Bitartrate  of  poto.sh,  or  cream  of  tartar. — Bennet,  of  Ed- 
inburg,  has  distinguished  himself  by  his  warm  advocacy  of  this 
remedy  in  Bright's  disease;  he  regards  it  as  the  most  valuable 
of  the  whole  class  of  laxatives  and  diuretics,  and  has  frequently 
seen  it  produce  the  most  powerful  effects  when  every  other  had 
failed.  He  has  known  cream  of  tartar  to  operate  after  digitalis 
and  other  remedies  had  proved  useless;  sometimes,  also,  after 
it  had  been  given  without  effect  at  an  early  period  of  the  dis- 
ease, it  has  succeeded  remarkably  well  at  a  later  one,  which 
warrants  our  having  recourse  to  the  remedy  again  and  aaain. 
after  certain  intervals,  should  it  not  act  at  first.  He  has  rarely 
seen  other  diuretics  succeed  when  repeated  attempts  by  means 
of  the  bitartrate  had  failed.  In  full  doses  it  acts  as  a  refriger- 
ant, laxative  and  diuretic,  and,  while  other  purgatives  augment 
renal,  hemorrhoidal  and  menstrual  hemorrhages,  this  one 
moderates  and  even  arrests  them.  Combined  with  jalap  it 
forms  an  efficient  hydragogue  cathartic,  which,  in  some  forms 
of  dropsy,  and  in  simple  anasarca  particularly,  is  rapid  and 
decided  in  its  action.  Stille  recommends  twelve  grains  of 
jalap,  thoroughly  triturated  with  thirty  of  cream  of  tartar,  as 
a  certain  and  not  disagreeable  purgative.  But  the  resin  of 
jalap  in  a  pill,  with  one  quarter  or  one  half  grain  of  podophyllin, 
is  more  efficient  when  aided  by  the  free  use  of  cream  of  tartar 
water,  with  or  without  juniper  berries,  with  which  it  is  often 
associated.  One  half  ounce  each  of  cream  of  tartar  and  bruised 
juniper  berries,  in  a  pint  of  boiling  water,  is  one  of  the  most 
efficient  combinations  in  the  passive  forms  of  general  dropsy.  In 
the  form  which  so  often  occurs  as  a  sequela  of  scarlatina  it  is  of 
great  service,  either  alone  or  combined  with  tincture  of  disritalis. 

Finally,  Goodfellow  prefers  the  compound  magnesia  flraught 
of  the  Middlesex  Hospital,  viz.:  magnes.  carb..  five  or  ten 
grains,  magnes.  sulph.,  5i..  given  in  peppermint  water  several 
times  a  day;  he  says  he  never  loses  a  case  of  the  recent  acute 
form  of  Bright's  disease.  Occasionally  a  small  quantity  of 
tartar  emetic  is  added. 


1865.]       ARTERIOTOMY  IN  PUERPERAL  CONVULSIONS. 


27 


On  the  Use  of  Arteriotomy  and  other  Remedies  in  the  Treat- 
ment of  Puerperal  Convulsions.  By  A.  F.  A.  King,  M.D., 
of  "Washington,  D.  C. 

By  the  term  "  puerperal  convulsions  "  we  mean,  not  any  con- 
vulsion occurring  during  pregnancy,  but  only  those  that  are 
dependent  upon  the  puerperal  state.  It  is  evident  that  convul- 
sions may  occur  at  any  time  during  gestation  from  the  same 
causes  as  tlicy  do  in  the  unimpregnated  female,  perfectly  inde- 
pendent of,  and  without  any  connection  with,  the  parturient 
state;  for  example,  they  often  arise  from  local  irritations,  such 
as  an  ab,~ccss  or  thrombus  of  the  labia  pudenda  and  other  sex- 
ual diseases;  also  from  digestive  derangements,  blood  poisons, 
mental  emotion,  &c.  The  ensuing  remarks  will  therefore  be 
restricted  to  tliose  cases  of  eclampsia  which  are  dependent  upon 
the  puerperal  state,  and  which  alone,  properly  speaking,  deserve 
the  name  of  puerperal  convulsions. 

The  method  of  treatment  that  I  propose  to  suggest  for  this 
complaint  is  based  upon  the  following  views  in  regard  to  its 
nature  and  causes: 

1st.  That  puerperal  convulsions  are  due  to  an  abnormal  ex- 
citation of  certain  central  parts  of  the  cerebro-spinal  nervous 
system,  caused  by  an  increased  afflux  of  arterial  blood  and  a 
deficient  supply  of  venous  blood  circulating  through  those  cen- 
ters; in  other  words,  central  nervous  irritation  from  abnormal 
distribution  of  arterial  and  venous  blood. 

2d.  That  the  principal  cause  of  this  disturbance  of  the  circu- 
lation is  pressure  of  the  gravid  womb  upon  the  abdominal  aorta 
and  ascending  vena  cava,  whereby  the  arterial  blood  is  retard- 
ed in  its  downward  current  to  the  lower  parts  of  the  body; 
while  the  venous  is  retained  below  and  hindered  in  its  upward 
current  to  the  brain. 

3d.  That  this  mechanical  obstruction  to  the  circulation  is  in- 
creased by  constipation,  tight  lacing,  frequent  sexual  inter- 
course during  gestation,  and  tonicity  of  the  muscles  of  the  ab- 
domen— conditions  which  may  help  to  account  for  the  spasms 
occurring  more  frequently  in  primipara. 

I  am  fully  aware  that  this  theory  of  mechanical  obstruction 
to  the  abdominal  circulation  being  a  cause  of  puerperal  eclamp- 


28 


ARTERIOTOMY  IN  PUERPERAL  CONVULSIONS.  [Oct., 


sia  is  l)y  no  means  a  new  one;  but  those  who  have  attempted 
to  exphvin  the  rationale  of  its  operation  have  only  arrived  at 
the  facts,  that  it  causes  either  determination  of  blood  to  the 
brain,  or  that  it  so  interferes  with  the  function  of  the  kidneys 
as  to  induce  uraemic  intoxication.  No  writer  has  told  us,  how- 
ever, ,so  far  as  I  am  aware,  whether  this  hyperajmia  of  the  brain 
consists  in  an  excess  of  arterial  or  of  venous  Idood — a  distinc- 
tion which  seems  to  me  to  be  of  the  utmost  practical  import- 
ance; for  does  not  physiology  teach  us  that  the  one  (arterial 
blood)  is  a  direct  stimulant  to  the  brain,  while  the  other 
(venous)  is  a  most  potent  sedative  ? 

Now  we  know  perfectly  well  that  excessive  stimulation  of  a 
part,  if  long  continued,  soon  leads  to  irritation,  and,  if  still  fur- 
ther persisted  in,  to  inflammation  and  structural  change;  hence 
whenever  there  is  a  superabundance  of  stimulating  arterial 
blood  circulating  through  a  healthy  brain,  especially  if  the  an- 
tagonizing sedation  of  venous  blood  be  diminished,  that  healthy- 
brain  becomes  an  irritated  brain;  and  what  is  so  significant  of 
central  nervous  irritation,  whether  it  arise  from  centric  or  ec- 
centric causes,  as  irregular  muscular  contractions,  spasms,  con- 
vulsions, and  where  have  we  a  more  perfect  illustration  of  the 
truth  of  these  principles  than  in  the  phenomena  of  puerperal 
eclampsia?  As  to  the  second  proposition,  to  wit:  that  the 
principle  cause  of  this  disturbance  of  the  circulation  is  pressure 
of  the  gravid  wom1)  upon  the  blood  vessels,  there  may  be  urged 
the  objection  that  the  convulsions  do  not  at  once  cease  after  de- 
livery. But  this  difficulty  is  by  no  means  insurmountable — it 
may  be  explained  in  at  least  two  ways. 

From  what  has  already  been  said  it  is  clear  that  irritation 
of  the  brain  may  be  one  reason  why  the  spasms  continue,  or 
there  may  even  be  true  inflammation  of  that  organ.  Indeed, 
cases,  are  not  wanting  in  which  not  only  has  there  been  irrita- 
tion and  inflammation  of  the  brain,  but  examination  after  death 
has  revealed  that  actual  softening  had  taken  place.  In  such 
cases  how  can  we  expect  that  the  convulsions  should  be  cured 
by  delivery  ? 

Again,  uterine  pressure  being  removed  and  no  local  changes 
having  occurred  in  the  brain,  the  symptoms  may  yet  be  due  to 
structural  changes  in  the  blood  vessels.    For,  when  we  remem- 


1865.]       ARTBRIOTOMY  IN  PUERPERAL  CONVULSIONS. 


29 


ber  that  the  veins  of  the  lower  extremities  have  been  for  a 
considerable  time  dilated  with  the  pressure  of  accumulated 
blood,  and  when  we  consider  also  that  the  arterial  blood  vessels 
below  the  obstructed  aorti,  not  having  received  their  due  sup- 
ply of  blood,  may  have  become  somewhat  contracted,  or  at  least 
have  acquired  an  unnatural  degree  of  tonicity,  is  it  not  reason- 
able to  suppose  that  the  little  impediment  that  these  offer  to 
the  circulation,  coupled,  perhaps,  with  a  degree  of  excitement 
of  the  brain  hardly  deserving  the  name  of  irritation,  may  ac- 
count for  the  continuance  of  convulsions  after  uterine  pressure 
has  been  removed  by  delivery  ? 

That  the  disturbance  of  the  circulation  which  we  have  been 
considering  is  increased  by  constipation,  tight  lacing,  muscular 
tonicity  of  the  abdominal  wall,  and  to  frequent  sexual  inter- 
course, is  too  evident  to  admit  of  doubt,  for  it  is  plain  that 
each  of  these  contributes  more  or  less  to  augment  the  pressure 
of  the  gravid  womb  upon  the  blood  vessels.  And  now,  if  these 
views  of  the  pathology  of  the  disease  are  correct,  what  treat- 
ment shall  we  employ  ? 

First,  as  a  matter  of  course,  all  causes  should  be  removed 
or  avoided.  Hence,  delivery,  purgation,  loose  lacing,  and  sex- 
ual abstinence  become  important  remedies,  the  last  two  not  to 
be  overlooked. 

Second — Uood-Ietting. — In  conformity  with  the  views  already 
expressed,  it  would  seem,  d  priori,  that  if  there  is  a  remedy 
which  we  should  avoid  in  puerperal  convulsions  it  is  bleeding 
from  the  cephalic  vein,  for  we  must  recollect  that  by  so  doing 
we  are  taking  sedative  venous  blood  from  an  encephalon  al- 
ready over-stimulated  with  arterial  blood,  (t.  e.  we  do  so  indi- 
rectly, by  lessening  the  amount  of  blood  going  to  the  subclavian 
vein;  we  favor  the  descent  of  that  from  the  jugular.)  Venous 
blood  is  what  the  brain  wants  and  what  it  must  and  will  have. 
The  very  convulsion  that  we  seek  to  cure  is  but  an  effort  of 
nature  to  equalize  the  cerebral  circulation  by  forcing  venous 
blood  to  the  brain;  it  is  one  of  those  conservative  processes  by 
which  the  central  parts  of  the  nervous  system  strive  to  maintain 
their  own  integrity.  And  does  not  the  relaxation  that  imme- 
diately succeeds  the  convulsions  show  how  completely  the  ten- 
dency to  spasm  is  relieved  by  venous  hypersemia  of  the  brain  ? 


30 


ARTERIOTOMY  IN  PUERPERAL  CONVULSIONS,  [Oct., 


Nor  is  it  until  the  venous  congestion  of  the  head  has  once  more 
given  way  to  the  flood  ot"  arterial  blood,  that  the  spasm  again 
returns. 

Venous  blood  is  the  natural  sedative  narcotic  for  tlie  re- 
laxation of  muscular  spasm.  What  is  it,  for  example,  that  pro- 
duces the  relaxation  of  anaesthesia,  intoxication  and  asi)h_vxia? 
It  is  that  in  each  of  these  cases  there  is  an  excess  of  the  sedative 
carbon  or  carbonic  acid,  and  a  diminution  of  the  stimulant 
oxygen  circulating  through  the  nervous  tissues, — in  a  word,  less 
arterial  blood,  more  venous.  In  corroboration  of  these  views, 
I  transcribe  a  short  quotation  from  Prof.  Meigs  on  Puerperal 
Convulsion,  (Letter  4-tth,  pages  665-6.)  Speaking  of  the 
paroxysm  itself  he  says  : 

"  As  soon  as  the  diaphragm  begins  to  grow  rigid,  the  ox- 
ygenation of  blood  in  the  lungs  is  arrested  ;  the  hurried  heart 
propels  the  blackening  columns  into  tlie  lung  capillaries,  wliich 
rob  them  of  the  small  remainder  of  oxygen,  so  that,  when 
driven  over  into  the  systemic  ventricle,  and  thence  launched 
into  the  brain  and  cord,  that  deoxidized  and  highly  carbonated 
blood  ceases  to  develop  the  neurosity,  and  the  patient,  utterly 
anaesthetized,  falls  into  the  profoundest  stupor,  the  face  and 
hands  grow  darker  and  darker,  until  the  cyanosis  has  asphyx- 
iated her  brain.  This  cyanosed  hue,  which  presents  to  the 
spectator  a  scene  and  prospects  truly  frightful,  is  always  hailed 
by  me  with  joy,  for  I  discover  in  it  a  sure  sign  of  an  approach- 
ing termination  of  the  crisis." 

Again  he  says:  "  If  you  hold  a  chloroformed  sponge  to  a 
woman's  mouth  you  will  readily  induce  a  state  of  anaesthesia 
which  will  stop  the  paroxysm,  but  not  sooner  or  more  safely 
than  the  cyanotic  anesthesia  itself." 

According  to  these  views,  therefore,  it  would  seem  that  any 
remedy  which  tends  to  diminish  tlie  quantity  of  venous  blood 
in  the  brain,  as  bleeding  from  the  arm,  is  one  not  to  be  recom- 
mended. Yet  in  the  very  face  of  this  we  know  that  the  indis- 
putable test  of  practical  experience  has  proved  beyond  a  doubt 
that  venesection  is  one  of  the  best  of  remedies.  That  it  does 
relieve  them  in  many  cases  can  not  be  denied;  but  I  see  no 
reason  why  veratria  or  tartar  emetic  might  not  answer  just  as 
good  a  purpose,  with  the  advantage  of  not  incurring  those 


1865.]       ARTERIOTOMY  IN  PUERPEEAL  CONVULSIONS. 


31 


immense  losses  of  blood  which  are  unavoidable  in  venesection  ; 
for  the  only  way  that  we  can  explain  the  modus  operandi  of 
bleeding  from  the  arm  in  this  complaint  is  that  it  diminishes 
the  action  of  the  heart,  and  as  a  natural  consequence  lessens 
the  amount  of  arterial  blood  pumped  upwards  to  the  brain  ; 
at  the  same  time  the  feeble  ventricular  contractions  retard  the 
pulmonary  circulation  so  that  respiration  is  impeded,  and  con- 
sequently the  venosity  of  the  whole  bulk  of  the  blood  becomes 
increased. 

Venesection,  therefore,  relieves  puerperal  convulsions  simply 
by  lessening  the  force  of  the  heart.  "Why  should  not  veratria, 
tartar  emetic,  or  digitalis  do  the  same  ?  These,  however,  are 
not  the  remedies  that  I  desire  especially  to  recommend.  Tiie 
one  that  I  wish  to  suggest  in  particular  is  arteriotomy — opening 
the  temporal  artery.  The  gravid  womb,  let  us  recollect,  is 
pressing  upon  the  aorta  below  ;  the  arterial  blood  can  not  get 
down,  but  is  backing  up  and  flooding  the  brain  and  cord  ;  by 
bleeding  from  the  artery  we  lessen  the  whole  amount  of  arte- 
rial blood  above  the  obstruction,  deplete  the  brain  locally, 
and  indirectly  diminish  the  force  of  the  heart  quite  as  readily 
as  by  bleeding  from  the  arm  ;  moreover,  we  have  not  robbed 
the  brain  of  venous  blood.  At  the  same  time,  by  opening  a 
vein  in  the  leg  (below  the  obstruction) — which  is  the  second 
remedy  I  would  suggest— we  relieve  the  distension  of  the  lower 
veins,  obviate  congestion  of  the  kidneys,  and  invite  the  arterial 
blood  to  descend. 

In  conclusion,  therefore,  while  it  must  be  admitted  that 
bleeding  from  the  cephalic  vein  is  undoubtedly  a  useful  remedy 
in  this  disease,  it  appears  to  me  that  the  modilied  forms  of 
blood-letting  and  other  remedies,  to  which  I  have  alluded,  might 
accomplish  better  results  much  more  promptly  and  with  a  far 
less  expenditure  of  blood. 


82 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


PEOOEEDINGS  OF  SOCIETIES. 

NEW  YORK  PATHOLOGICAL  SOCIETY. 
Staled  Meeting,  April  12,  1865. 
Dr.  GuRDON  Buck,  President,  in  the  Chair, 

STRUMODS  DISEASE  OF  KNEE-JOINT  DR.  L.  VOSS, 

Dr.  Voss  presented  the  right  knee-joint  of  a  girl,  seven  or  eight 
years  of  age,  who,  for  some  time  past,  liad  been  suH'ering  from  stru- 
mous disease  of  tliat  part.  She  first  presented  herself  to  the  doctor 
with  a  large  abscess  on  the  outer  aspect  of  the  joint.  This  was 
opened.  Subsequently  sloughing  took  })lace  in  the  abscess,  and  the 
patient  ran  down  so  rapidly  that  exsection  could  not  be  performed. 
The  thigh  was  accordingly  amputated,  to  save  life. 

On  examination  of  the  joint,  after  the  removal  of  the  limb,  a  most 
interesting  condition  of  the  part  was  seen  to  exist.  The  outer  con- 
dyles of  the  joint  were  very  much  roughened  and  diseased,  while  the 
inner  condyles  were  perfectly  smooth  and  uninjured.  These  two  parts 
were  separated  from  each  other  by  a  vertical  false  membrane,  and  the 
partition  thus  formed  seemed  to  be  complete  enough  to  prevent  the 
extension  of  the  disease  further  than  the  affected  part. 

DISEASE  OF  THE  HIP-JOINT  DR.  VOSS. 

Dr.  Toss  stated  that  he  had  another  specimen  in  the  hands  of  Dr. 
Jacobi,  which  he  hoped  to  have  an  opportunity  for  showing  that  even- 
ing, and  would  do  so  as  soon  as  that  gentleman  arrived.  The  speci- 
men was  one  of  disease  of  the  hip-joint,  in  a  very  advanced  stage.  The 
child  had  been  treated  for  four  or  five  weeks  in  the  horizontal  position, 
by  extension,  wh,'ii  it  began  to  show  symptoms  of  tubercular  menin- 
gitis, by  which  it  was  carried  off. 

Dr.  Voss  remarked,  in  this  connection,  that  two  years  ago  he  had 
occasion  to  show  the  Society  an  inflamed  hip-joint  which  had  been  re- 
moved from  a  child  who  died  from  the  same  cerebral  disease.  In  that 
instance  the  joint  showed  the  existence  of  a  small  sequestrum  in  the 
substance  of  the  neck  of  the  bone.  With  respect  to  this  tubercular 
meningitis,  subsequent  to  inflammatory  affections  of  the  joint.  Dr.  Voss 
stated  that  he  could  recollect  four  or  five  similar  cases,  and  he  thought 
that  the  relation  of  the  brain  trouble  to  the  disease  of  the  joint  de- 
served careful  study. 

Dr.  Savre  remarked,  that  the  specimen  was  a  very  interesting  one, 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


33 


as  illustrating  the  beautiful  attempt  on  the  part  of  nature  to  liniit 
the  disease.  He  had  never  seen  such  a  membrane  in  that  relation  be- 
fore. He  had  often  noticed  the  frequency  with  which  the  external 
condyle  is  affected,  compared  with  the  internal,  and  it  was  due  to  this 
fact  that  the  peculiar  deformity,  the  subluxation  of  the  knee  back- 
ward and  outward,  took  place.  He  had  met  with  two  instances  of 
death  by  tubercular  meningitis  following  strumous  disease  of  the  joint, 
and  agreed  with  Dr.  Yoss  in  the  conclusion  that  the  cerebral  disease 
was  not  of  unfrequent  occurrence,  under  the  circumstances. 
*  Dr.  Buck  also  recalled  an  instance  of  death  from  meningitis  occur- 
ring in  a  child  eight  or  nine  years  of  age,  in  the  advanced  stage  of 
hip-joint  disease. 

ULCERATION  OF  THE  COLON — DR.  LEWIS  SMITH. 

Dr.  Lewis  Smith  presented  a  portion  of  the  descending  colon,  taken 
from  a  child  aged  two  years  and  four  months.  The  sickness  of  the 
patient  dated  back  to  last  summer,  when  it  had  the  summer  complaint, 
and  the  bowels  continued  relaxed  from  that  time  until  death.  The 
evacuations  were  not  very  frequent — three  or  four  in  the  course  of 
twenty-four  hours — never  bloody,  and  usually  of  a  dark  color.  There 
was  no  marked  emaciation  attending  the  symptoms,  and  the  patient, 
not  being  considered  in  any  particular  danger,  had  not  been  subjected 
to  any  treatment.  At  the  commencement  of  this  month  it  was  sud- 
denly seized  with  a  convulsion,  and  died  in  the  course  of  six  hours 
after. 

At  the  autopsy  no  permission  was  granted  to  examine  the  brain. 
The  small  intestines  were  healthy,  and  the  mesenteric  glands  were 
not  enlarged;  the  seat  of  the  abdominal  disease  was  found  to  be 
in  the  colon.  The  mucous  membrane  of  this  canal  was  thickened,  and 
there  were  numerous  minute  ulcers,  especially  in  the  descending  por- 
tion, which  extended  simply  through  the  mucous  membrane,  and  were 
surrounded  by  a  more  or  less  complete  zone  of  vascularity.  In  the 
centre  of  some  of  these  ulcers  were  occasionally  found  papilla,  which 
appeared  to  be  the  solitary  follicles. 

The  case,  aside  from  its  pathology,  was  interesting  in  reference  to 
the  production  of  the  disease.  The  child  lived  on  the  ground  floor  in 
a  wooden  tenement  house,  which  was  surrounded  on  three  sides  by 
stagnant  water,  and  the  disease  of  the  intestine  seemed  to  have  been 
induced  by  the  insalubrity  of  the  situation,  and  in  that  respect,  as  well 
as  in  its  pathology,  it  bore  a  reseml^lance  to  the  diarrhoea  which  has 
been  so  common  among  our  soldiers. 

Vol.  II.— No.  7.  3 


34 


PROCEEDINGS  OF  SOCIETIES. 


[Oct., 


ILEUM  IN  PURPURA  HEMORRHAGICA  DR.  SMITH. 

Dr.  Smith  also  presented  the  ileum  taken  from  a  child  eight  years 
old.  The  patient  was  of  healthy  parentage,  and  was  in  good  condi- 
tion until  the  25th  of  last  mouth,  when  it  Ijegan  to  vomit  blood,  and 
soon  after  to  discharge  blood  from  the  bowels.  On  the  following  day, 
spots  of  purpura  hemorrhagica  were  observed  upon  the  lower  extrem- 
ities. From  this  time  until  the  31st  of  last  month,  when  death  ensued 
from  exhaustion,  the  patient  had  from  three  to  four  bloody  passages 
a  day. 

The  thoracic  and  abdominal  viscera  were  both  examined,  and  noth- 
ing unusual  was  noticed,  except  a  bleached  appearance  of  the  organs. 
The  liver  was  very  fatty.  Dr.  Smith  had  never  seen  such  an  extreme 
fatty  degeneration  of  the  liver  before  in  a  child  so  young.  There  was 
no  lesion  of  the  intestine  noticeable,  save  a  great  vascularity  of  the 
mucous  membrane  of  the  ileum,  and  this  was  evidently  the  source  of 
the  hemorrhage. 

The  case  seemed  to  be  one  of  purpura  hemorrhagica,  without  any 
pre-existing  disease.  So  far  as  his  experience  went,  Dr.  Smith  con- 
sidered it  a  rare  case. 

rRINART  ORGANS  IN  A  CASE    OF  VESICAL  CALCULUS — DR.  GURDON  BUCK. 

Dr.  Buck  exhibited  a  specimen  of  the  urinary  organs  removed  from 
a  patient  who  died  the  day  previous,  in  the  New  York  Hospital.  The 
patient  was  admitted  March  14th,  for  stone  in  the  bladder,  and  was 
treated  by  lithotripsy.  He  was  a  deaf  mute,  a  native  and  resident  of 
Bergen,  N.  J.;  of  spare  habit,  light  complexion,  and  sixty-four  years 
of  age.  The  history  that  was  obtained  from  him  was,  that  he  had 
been  suffering  from  symptoms  of  stone  for  four  years.  The  mforma- 
tion  that  could  be  gotten,  considering  his  difficulty  in  communicating 
his  ideas,  was  necessarily  very  imperfect.  No  member  of  his  family 
accompanied  him,  and  his  wife,  who  frequently  visited  him,  was  also  a 
deaf  mute.  He  was  very  much  disturbed  by  frequent  micturition. 
On  examination,  the  stone  was  felt  without  any  diflBculty.  His  gen- 
eral condition  did  not  appear  materially  to  have  suffered,  for  he  kept 
up  his  active  habits  of  a  farmer  without  any  serious  inconvenience. 
The  urethra  was  found  of  full  dimensions,  and  there  was  no  apprecia- 
ble enlargement  of  the  prostate,  as  far  as  could  be  judged  by  the  usual 
method  of  examination.  The  instruments  entered  the  bladder  with- 
out occasioning,  in  the  examination,  any  undue  amount  of  irritation.  ' 
The  stone  was  found  to  be  about  the  size  of  an  English  walnut. 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


35 


From  the  size  of  the  stone,  from  the  favorable  condition  of  the  urethra, 
and  the  general  aspect  of  the  patient,  it  was  considered  to  be  a  case 
favorable  for  the  operation  of  lithotrity.  The  first  operation  was  per- 
formed March  16th.  The  bladder  was  first  injected  with  about  five 
ounces  of  water,  and  the  stone  was  then  readily  seized  by  a  grasp  of 
about  an  inch,  and  was  crushed.  There  was  some  delay  in  making  a 
subsequent  seizure,  and  further  attempts  were  for  the  time  accordingly 
desisted  from. 

On  the  30th,  the  operation  was  repeated.  The  effect  of  these  op- 
erations was  not  particularly  disturbing;  there  was  no  febrile  action 
developed;  but,  as  usual,  there  was  some  blood  mixed  with  the  urine 
after  the  first  twenty-four  hours,  together  with  an  increase  of  the 
viscid,  tenacious  mucous  secretion,  which,  before  the  operation,  had 
been  quite  abundant. 

The  same  quantity  of  water  was  injected  into  the  bladder  at  the 
second  operation.  The  instrument  entered  readily;  the  lithotrite 
passed  the  neck  of  the  bladder  with  entire  ease,  and  there  were  five 
seizures  promptly  made,  and  in  each  instance  the  fragments  were 
crushed.  Not  more  than  from  three  to  five  minutes  were  occupied  in 
the  operation.  On  the  27th,  a  third  operation  was  performed;  four 
seizures  were  made  with  good  effect,  and  no  more  time  occupied  than 
during  the  previous  manipulations.  On  the  31st,  a  few  days  subse- 
quently, a  fourth  operation  was  performed.  The  patient  was  rather 
of  a  desponding  tone  of  mind,  feehng  lonely,  in  not  being  able  to  com- 
municate with  those  around  him.  About  this  time  he  would  have  a 
slight  febrile  reaction  almost  every  day;  but,  aside  from  this,  he 
seemed  to  be  about  the  same,  until  the  1st  of  April,  when  it  was  no- 
ticed that  his  appetite  began  to  fail,  and  he  gradually  sank,  and  died 
on  the  4th. 

Dr.  Bock  was  disappointed  in  the  case,  in  the  small  discharge  of  the 
fragments  resulting  from  the  operations.  These  operations  were  suc- 
cessful in  the  breaking  up  of  the  stone,  and  he  was  positive  that  a  con- 
siderable number  of  the  fragments  had  been  for  some  reason  retained. 
The  explanation  for  this,  however,  was  found  in  the  extensive  disease 
of  the  urinary  organs  at  the  post-mortem  examination. 

A  careful  examination  of  the  interior  of  the  bladder  clearly  proved 
that  no  injury  whatever  was  inflicted  upon  the  mucous  membrane  of 
that  organ  by  the  instrument.  The  bladder  is  of  large  size,  and  the 
fundus  was  found  rather  thin,  tlie  mucous  menil)rane  at  the  same  time 
being  softened.  There  were  innnerous  fragments  found  in  the  cavity 
of  the  organ.    The  left  lateral  lobe  of  the  prostate  was  enlarged  in- 


36 


PROCEEDINGS  OF  SOCIETIES. 


[Oct., 


ternally ;  which  enlargement,  by  virtue  of  its  position,  prevented  the 
passage  of  urine;  while,  at  the  same  time  acting  as  a  valve,  it  did  not 
offer  any  impediment  to  the  entrance  of  an  instrument  into  the  blad- 
der. In  consequence  of  this  damming  up  of  the  urine,  the  bladder 
was  increased  in  size,  and  the  ureters  very  much  distended.  The  kid- 
neys, being  about  the  natural  size,  were  filled  with  abscesses,  some  of 
which  contained  calculi. 

Dr.  Yoss  asked  if  he  bad  been  in  the  habit  of  using  anaesthetics  in 
cases  of  lithotrity. 

Dr.  Buck  stated  that  he  preferred  that  the  patient  should  have  his 
sensibility,  in  order  that  the  action  of  the  bladder  miglit  be  controlled. 
He  stated  that  in  a  second  case  of  operation  for  hthotrity,  which 
was  performed  upon  a  lad  seventeen  years  of  age,  he  was,  on  account 
of  the  irritability  of  the  patient,  compelled  to  use  ether.  The  repeti- 
tions of  the  operation  numbered  fourteen  or  fifteen,  and  in  every  one, 
with  two  exceptions,  ether  was  employed. 

Stated  Meeting,  April  26,  1865. 

DEEP-SEATED  ABSCESSES  DR.  GURDON  BUCK. 

Dr.  Buck  cited  the  foUowiug  case  of  deep-seated  abscess,  then  in 
progress  at  the  isew  York  Hospital: 

The  patient,  aged  twenty-five,  was  admitted  a  few  days  ago  into  the 
New  York  Hospital,  with  an  inflammatory  swelling  of  the  neck,  on 
the  left  side,  occupying  the  lower  portion,  including  the  region  of  the 
sterno-cleido  mastoid  muscle,  and  extending  three  fingers  upwards 
from  the  clavicle,  and  spreading  outwards  perhaps  two  fingers'  breadth 
beyond  the  outer  margin  of  the  clavicular  region  of  the  sterno-cleido 
mastoid  muscle.  The  swelling  was  diffuse,  not  salient,  and  its  surface 
was  red,  tense,  hard,  and  resisting.  The  integuments  and  subcuta- 
neous tissues  were  thickened,  and  did  not  admit  of  any  slipping  upon 
each  other.  The  patient  suffered  a  good  deal  of  pain,  and  had  great 
difficulty  in  moving  his  head  in  any  direction,  on  account  of  the  dis- 
turl:)auce  in  the  neck  caused  by  it.  He  complained  of  trouble  at  times 
in  his  l)reathing,  at  night,  and  also  in  his  deglutition.  The  swelling 
was  of  recent  origin,  and  evidently  of  an  inflammatory  character;  it 
had  existed  a  certain  number  of  days,  long  enough  for  suppuration  to 
have  taken  place,  though  no  distinct  fluctuation  could  be  felt. 

From  the  complaint  in  his  breathing  and  swallowing,  I  was  led  to 
explore  his  throat,  particularly  the  entrance  of  the  larynx,  and  ascer- 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


37 


tained,  by  touch,  that  on  the  corresponding  side  half  of  the  edge  of 
the  epiglottis  was  thickened,  and  the  aryteuo-epiglottidean  fold  which 
constitutes  the  margin  of  the  entrance  of  the  larynx  was  also  thickened. 
This  condition  of  things  put  a  very  serious  aspect  upon  the  case,  and 
gave  ground  for  the  belief  that,  if  allowed  to  continue,  it  might  at  any 
moment  produce  sudden  suffocation.  I  regarded  it  as  exceedingly 
important  to  procure  an  outlet  for  the  matter.  Though  there  was  no 
fluctuation  to  guide  me,  yet  I  could  recognize  one  spot  where  the  sur- 
face yielded  more  than  elsewhere,  and  that  determined  me  as  to  the  point 
for  explorative  puncture.  I  carefully  considered  the  situation  of  this 
spot  in  reference  to  the  vessels;  it  was  to  the  outside  of  the  course  of 
the  external  jugular  vein,  and  sufSciently  above  the  clavicle  to  be 
above  the  course  of  the  arteries  which  occupied  that  region.  I  made 
an  incision  through  the  skin  to  the  depth  of  about  a  half  or  three- 
quarters  of  an  inch,  and  then  made  use  of  a  director,  pressed  it  through 
the  tissues,  and  presently  arrived  at  a  place  where  no  further  resist- 
ance was  met  with.  This  indicated  that  I  had  reached  the  cavity  of 
the  abscess,  and  by  a  little  forcible  stretching  of  the  opening  a  drop 
of  matter  flowed  along  the  groove.  I  then  carefully  enlarged  it,  giv- 
ing exit  to  the  contents  of  the  abscess. 

There  was  no  further  increase  of  the  symptoms  which  gave  us  soli- 
citude; the  patient  was  conscious  of  relief,  in  a  greater  facility  ia 
swallowing.  In  the  progress  of  the  di-sease,  the  matter  showed  a  dis- 
position to  approach  the  surface  at  the  median  line,  above  the  notch 
of  the  sternum,  where  the  parts  softened  and  where  evidently  the  com- 
munication was  more  direct  with  the  matter.  This  directed  me  to  make 
a  free  opening  at  that  point,  and  since  then  the  ease  has  gone  on 
steadily  and  well,  and  the  swelling  in  the  epiglottis  and  neighboring 
parts  has  disappeared. 

In  connection  with  the  foregoing  case,  he  then  related  others  which 
resembled  it. 

Some  years  ago,  a  patient  of  the  New  York  Hospital,  who  had  a 
deep  aljscess  in  the  neck,  died  instantaneously  while  in  the  water- 
closet.  On  examination,  after  death,  there  was  found  oedema  of  the 
glottis,  and  this  had  been  produced  from  the  extension  of  the 
inflammation  from  the  abscess,  which  at  the  time  was  in  a  sloughing 
condition. 

These  abscesses,  situated  deeply  and  behind  the  fascia  of  the  neck, 
are  very  serious  in  their  nature,  and  expose  the  patient  to  great  dan- 
ger.   The  same  is  true  of  deefj-seated  aliscesses  higher  up. 

lu  my  private  practice,  an  ofiSce  patient  presented  himself  with  a 


38 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


deep  abscess  under  the  angle  of  the  jaw,  and  was  beginning  to  suffer 
in  the  same  way  as  in  the  first  case  related.  Though  no  fluctuation 
was  perceptible,  I  pursued  the  same  course,  carefully  puncturing  and 
enlarging  the  abscess,  taking  care  at  the  same  time  to  keep  clear  of 
the  vessels  in  the  neighborhood. 

My  belief  is,  that  the  parts  interTcning  between  the  surface  of  these 
abscesses  and  .their  cavities  are  generally  exterior  to  the  course  of 
the  arteries.  The  facial  artery,  which  hugs  the  edge  of  the  jaw, 
passes  over  to  the  anterior  insertion  of  the  masseter  muscle,  and  is  not 
pushed  to  the  surface  with  the  swollen  parts.  I  think,  as  a  general 
rule,  this  is  the  case;  so  if  you  are  careful  not  to  go  beyond  the  cav- 
ity of  the  abscess,  in  your  i)uncture,  the  operation  is  not  attended 
with  danger. 

There  is  another  case  which  I  might  relate,  which  was  an  instructive 
one.    It  was  an  instance  of  a  deep  abscess  in  the  iliac  fossa. 

It  had  been  treated  in  the  medical  wards  of  the  New  York  Hospital, 
where  the  existence  of  the  abscess  was  recognized.    While  under 
treatment  there  the  abscess  opened  into  the  bowel,  and  a  sudden  dis- 
charge of  pus  took  place  per  rectum.    The  matter  continued  to  show 
itself  afterwards  in  the  stools.    When  transferred  to  the  surgical  side, 
his  condition  was  this:  In  the  right  iliac  region  there  was  a  swelling 
filling  up  the  iliac  fossa  as  far  as  the  brim  of  the  pelvis,  so  that  you 
could  not  insert  yovir  finger  between  the  crest  of  the  ileum  and  the  ab- 
dominal wall;  in  other  words,  it  was  impossible  to  make  a  depression 
in  the  integument  at  that  point  equal  to  that  which  it  is  even  possible 
to  make  in  the  fleshiest  subject.    This  swelling  filled  up  the  depres- 
sion seen  at  that  point,  and  could  be  traced  a  certain  distance  towards 
the  median  line,  when  it  was  gradually  lost.    It  extended  down  to 
Poupart's  ligament,  and  distended  its  outer  half.    The  integument 
overlying  the  tumor  was  neither  red  nor  adherent.    The  thigh  was 
slightly  retracted,  and  was  kept  in  that  position,  whether  the  patient 
was  standing  or  in  the  recumbent  ix)sition.    The  swelling  had  ex- 
tended upwards,  and  overlapped  nearly  one-half  of  the  crest  of  the 
ileum  posteriorly.    This  portion  of  the  swelling  was  resonant,  and,  on 
handling  it,  you  could  distinguish  that  it  contained  air.    This  was  ex- 
plained, on  the  supposition  that  there  was  a  communication  with  the 
gut,  and  that  gas  had  escaped  into  the  cavity  of  the  abscess.  The 
course  I  pursued  with  this  was,  to  carefully  make  an  opening  over  the 
posterior  portion  of  the  swelling.    I  cut  down  carefully,  and  satisfied 
myself  that  I  could  transmit  an  impulse  from  the  portion  of  the  swell- 
ing  occupying  the  fossa,  anteriorly  to  this  posterior  portion  which  was 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


39 


resonant.  The  question  was,  whether  the  gut  had  not  made  its  way 
to  the  surface;  but  the  transmission  of  the  fluctuation  from  one  por- 
tion of  the  swelHng  to  the  other  settled  the  question  that  such  was 
not  the  case.  An  opening  was  made  at  the  point  indicated,  when  a 
free  escape  of  pus  and  gas  took  place.  An  interesting  point  in  the 
progress  of  the  case  was,  that  pus  no  longer  discharged  itself  from  the 
bowels,  except  immediately  after  the  operation,  when  the  matter  ap- 
peared in  the  stools  two  or  three  times  in  succession.  The  opening  is 
now  closing,  and,  it  being  the  fourth  day,  the  patient  is  doing  well, 
and  has  no  further  passages  of  pus  per  rectum. 

This  deep-seated  abscess,  of  which  the  previous  case  is  an  illustra- 
tion, has  for  many  years  interested  my  attention,  and  perhaps  my  ob- 
servations have  directed  the  attention  of  surgeons  in  New  York  more 
particularly  to  the  subject.  I  publisiied  an  article  on  the  subject  some 
years  ago.  It  is  an  abscess  which  may  originate  in  the  iliac  fossa  or 
in  the  lumbar  region,  but  it  is  important  to  determine  that  point  in 
reference  to  the  treatment  which  should  be  employed.  I  have  met 
with  it  in  both  sexes.  In  two  cases  which  I  can  distinctly  recall,  it 
was  preceded  by  erysipelas  of  the  limb  affecting  the  absorbents. 
These  latter  were  both  males.  The  youngest  case  that  I  have  met 
with  was  in  a  female,  a  girl  of  tubercular  diathesis,  and  highly  scrofu- 
lous. In  one  case  the  abscess  was  produced  by  a  foreign  body  which 
had  made  its  way  from  the  cajcum,  and  set  up  inflammation  posteriorly 
in  the  fossa  of  that  side.  The  foreign  body  afterwards  presented 
itself  in  an  opening  in  the  groin  which  had  previously  been  made  for 
the  evacuation  of  matter,  and  proved  to  be  a  pin,  which  was  exten- 
sively incrusted.   That  patient,  a  male,  ultimately  recovered. 

In  several  of  the  cases  the  abscess  has  originated  in  the  puerperal 
state.  The  proper  treatment,  which  has  been  successful  in  my  hands, 
has  been  this:  upon  ascertaining  the  existence  of  the  abscess,  I,  with- 
out even  waiting  for  fluctuation  to  establish  itself,  make  an  outlet  for 
the  matter  below  the  outer  half  of  Poupart's  ligament,  and  parallel 
with  it,  first  through  tlie  integument,  exposing  the  fascia  of  the  thigh. 
This  fascia  being  divided,  you  pass  under  the  ligament  and  get  behind 
the  iliac  fascia.  The  incision  thus  made  is  to  be  kept  open  by  a  plug 
of  lint,  renewed  every  twenty-four  hours. 

Dr.  Draper  remarked,  that  the  last  case  referred  to  by  Dr.  Buck 
had  been  under  his  charge  at  the  hospital.  There  was  resonance 
down  to  Poupart's  ligament,  before  the  abscess  discharged  itself,  and 
Dr.  Drai)er  was  inclined  to  think,  at  the  time,  that  it  was  due  to  ad- 
hesion of  the  walls  of  the  intestine  at  that  point.    He  was  under  the 


40 


PROCEEDINGS  OF  SOCIETIES. 


[Oct., 


impression  that  the  man  had  suffered  a  great  deal  from  pain  in  the 
back,  and  for  that  reason  he  thought  that  the  diagnosis  of  disease  of 
the  spine  had  been  made,  and  that  the  abscess  had  been  referred  to 
that  condition  as  the  cause.  He  had  one  case  very  similar  to  that, 
about  two  months  ago.  A  woman,  forty  years  of  age,  complained  of 
severe  pain  in  the  middle  of  the  inner  aspect  of  the  thigh,  wliich  at 
first  was  supposed  to  be  due  to  muscular  rheumatism;  but  external 
applications  failing  to  have  any  good  effect,  a  more  careful  examina- 
tion was  made,  when  deep-seated  tenderness  in  the  groin  was  discov- 
ered. That  tenderness  increased,  and  a  decided  swelling  took  place; 
an  abscess,  eventually  formed,  pointed  below  the  inner  half  of  Fou- 
part's  ligament,  and  was  opened  by  Dr.  Sands.  There  was  marked 
retraction  of  the  thigh,  as  one  of  the  symptoms.  That  patient  entirely 
recovered. 

Dr.  Sands  inquired,  in  what  proportion  were  abscesses  which  pointed 
in  the  groin  due  to  diseased  bone  in  the  spine  ?  It  was  evident  to 
him  that  there  were  cases  where  dead  bone  was  not  the  cause,  as  was 
shown  by  the  patients  recovering. 

Dr.  Buck  remarked,  that  be  should  not  regard  the  encountering  of 
bare  bone  in  the  tract  of  the  abscess  as  necessarily  a  condition  which 
precluded  a  recovery.  I  can  recall,  said  he,  two  instances — one  in  a 
young  man  of  scrofulous  constitution,  who  had  a  well  marked  abscess  in 
the  iliac  fossa — which  I  treated  in  the  way  descriljed.  It  continued 
to  discharge  for  nearly  two  years,  during  which  time  I  made  every 
efibrt  to  close  it,  but  failed.  I  was  able  to  pass  in  a  bougie  some 
seven  or  eight  inches,  and  could  distinctly  feel  it  grate  over  a  bare 
surface  in  some  portion  of  its  tract.    The  patient  finally  recovered. 

Another  case,  which  I  might  here  refer  to,  was  one  of  hydrocele, 
occupying  the  inguinal  canal.  It  was  treated  with  free  incision,  and 
afterwards  was  succeeded  by  a  large  abscess  in  the  hollow  of  the  limb, 
which  was  also  opened,  and  remained  discharging  for  some  time.  In 
that  case,  too,  I  could  pass  a  bougie  seven  or  eight  inches  over  bare 
bone.    This  case  also  recovered. 

Dr.  Buck  finally  mentioned  the  following  case:  A  sailor  worked 
on  board  of  a  vessel  up  to  the  day  of  his  admission  into  the  hospital, 
when  he  presented  liimself  with  a  prominent  swelling  that  occupied  the 
iliac  region,  hugging  the  crest  of  the  ileum,  and  extending  close  down 
to  the  outer  portion  of  Poupart's  ligament.  It  stood  out  quite  sa- 
lient. There  was  no  tenderness,  no  redness,  no  adhesion  of  the  skin; 
neither  was  there  any  embarrassment  in  the  motions  of  the  limb  of 
that  side.   The  case  excited  a  good  deal  of  interest,  and  at  a  cousulta- 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


41 


tiou  there  was  some  diversity  of  opinion;  some  were  disposed  to  re- 
gard it  as  one  of  those  deceptive  cases  of  fluctuation;  and,  in  fact,  that 
was  the  view  entertained  by  the  gentleman  who  had  charge  of  the  case. 
In  one  of  my  examinations  I  made  tliis  discovery,  that  fluctuation 
could  be  transmitted  from  the  swelling  to  below  the  lower  half  of 
Poupart's  ligament.  That  discovery  cleared  up  the  case  to  my  mind, 
and  convinced  me  not  only  that  there  was  fluid  there,  but  that  that 
fluid  was  behind  the  iliac  fascia,  and  in  the  iliac  fossa.  The  case  was 
proceeded  with,  however,  with  the  view  of  removing  a  tumor.  An 
incision  was  made  across  the  most  prominent  portion  of  the  swelling, 
the  skin  and  fascia  were  in  turn  divided,  when  finally  the  tumor  was 
opened  into  and  discharged  a  large  quantity  of  pus.  I  then  requested 
my  colleague  to  introduce  his  finger  and  see  if  it  would  pass  behind  the 
outer  half  of  Poupart's  ligament.  That  decided  the  situation  of  the 
abscess,  and  confirmed  the  conclusion  arrived  at.  This  case  was  a  re- 
markable one,  as  showing  an  entire  absence  of  the  inflammatory 
elemeat;  and  there  was  no  disease  in  the  lumbar  region,  as  it  was  im- 
possible for  such  a  state  of  things  to  exist  and  the  man  all  the  time 
be  engaged  in  the  laborious  occupation  of  rolling  barrels  of  flour. 


AMERICAN  OPHTHALMOLOGICAL  SOCIETY. 

Second  Annual  Meeting,  Wednesday,  June  14,  1865. 

MORNING  SESSION. 

Dr.  E.  Delafield,  President. 

The  business  in  order  was  the  topic  of  discussion  selected  last  year, 
viz.:  The  morbid  conditions,  functional  and  organic,  included  under 
the  name  of  asthenopia,  their  pathology  and  treatment. 

Dr.  E.  Dyer,  of  Philadelphia,  opened  the  discussion  by  reading  a 
paper,  (see  page  II  of  this  number.) 

discussion  on  asthenopia. 

Dr.  NoYES. — I  should  like  to  make  the  inquiry  of  Dr.  Dyer,  if,  when 
he  has  brought  these  patients  up  to  what  he  considers  a  fair  amount 
of  reading  power — that  is,  for  example,  half  an  hour  at  a  time — he 
permits  them  to  dispense  with  their  glasses  ? 

Dr.  Dyer. — I  do  not  permit  them  to  dispense  with  the  use  of  the 
glasses  until  I  have  got  them  up  to  an  hour  and  half  three  times  a  day, 
which  is  fair  use  of  the  eyes;  then  I  allow  them  to  drop  them  gradually: 


42 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


for  example,  one  session  during  the  day,  generally  at  mid-day,  to  leave 
off  their  glasses  and  read  a  quarter  of  the  time,  and  see  if  they  can  do 
it;  and  then,  if  they  can,  a  little  longer  next  time,  till  they  can  en- 
tirely dispense  with  thera. 

The  President  (Dr.  Delafield). — If  the  Society  will  indulge  me, 
this  is  a  subject  of  which,  for  forty  years,  I  have  seen  so  much  tliat  I  feel 
as  if  I  must  say  something  upon  it.  Tliere  is  now  living  a  lady,  mar- 
ried in  1812,  wife  of  a  classmate  of  mine,  at  Yale  College,  who,  in 
consequence  of  this  disease,  has  never  read  or  written  during  all  this 
time.  Within  three  months  I  have  had  as  patient  a  lady,  eighty 
years  of  age,  with  tliis  same  effect.  The  common  case,  as  you  all  know, 
is  witli  young  people,  tliough  no  age  is  exempt  from  it;  no  period  of 
time  will  allow  a  case  to  get  well  spontaneously.  I  believe  I  can  say 
I  have  hardly  known  a  case  to  get  well  without  medical  treatment. 
Every  case  that  has  come  to  me  has  been  told,  sometimes  by  medical 
friends,  sometimes  by  others,  "rest  your  eyes  and  you  will  get  well." 
I  never  saw  a  case  get  well  by  resting  the  eyes.  This  difficulty  occurs 
very  largely,  as  you  all  know,  in  girls  educated  at  boarding  schools; 
very  largely  in  girls  more  or  less  hysterical,  at  all  events  more  or  less 
delicate,  from  imperfect  and  improper  physical  management,  improper 
diet,  want  of  exercise,  want  of  fresh  air.  The  symptoms  are  very 
like;  it  is  true  there  is  a  variety,  but  I  do  not  think  the  variety  is  ma- 
terial; I  find  very  much  the  same  treatment  adapted  to  all.  For  in- 
stance, as  a  general  rule,  the  sight,  so  to  speak,  is  perfect;  the  patient 
looks  at  an  object  perfectly  well.  I  have  not  found  that  a  large  pro- 
portion of  them  were  myopic — a  small  proportion  in  my  practice;  and 
I  see  very  much  of  this  particular  disease.  I  have  seen  and  treated 
many  hundreds  of  them  within  the  last  forty  years.  In  a  moderate 
proportion  of  cases,  after  the  patient  uses  the  eyes  a  certain  length  of 
time  "  the  eyesight  blurs,"  as  they  use  the  phrase;  they  do  not  see  as 
well.  This  is  an  exception  to  the  general  rule.  I  do  not  find  it  ne- 
cessary in  treating  the  case  to  remark  the  difference.  T  did  not 
intend  to  have  said  any  thing  on  this  subject,  and  therefore  h?ive  not 
arranged  my  thoughts — so  my  remarks  will  be  somewhat  desultory. 

The  principle  stated  by  Dr.  Dyer  is  mainly  the  correct  one;  I  have 
been  in  the  habit  of  applying  it  for  many  years.  Some  of  you  who 
know  what  kind  of  practice  I  have  had  in  the  city  are  aware  that  I 
see  a  great  many  women  with  diseases  pecuhar  to  their  sex.  My  at- 
tention was  first  brought  to  this  particular  mode  of  treatment  by  the 
fact  that  so  large  a  portion  of  the  women  coming  to  me  with  uterine 
diseases  had  been  told,  "you  must  keep  still."    They  have  kept  still 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


43 


for  months,  some  of  them  for  years,  and  have  got  no  better.  They 
come  to  consider  quietude  their  only  safety.  I  saw,  this  morning,  a 
patient  with  moderate  hemorrhoids;  I  can  not  get  her  to  get  off  her 
sofa;  the  consequence  is,  she  suffers  all  the  time.  Well,  there  is  a 
whole  class  of  diseases  of  the  female  constitution  aggravated  by  in- 
dulgence; that  is,  they  make  an  attempt  to  do  a  particular  thing 
which  causes  pain,  and  finding  that  the  pain  occurs,  they  feel  it  will 
be  wrong  to  pursue  it.  Now,  in  cases,  for  instance,  of  ordinary  ulcera- 
tion of  the  OS  uteri,  the  practice  general  in  our  profession  is,  to  keep 
these  i)atients  quiet ;  and  they  will  hardly  ever  get  well  if  they  are 
kept  so.  I  say  to  these  patients,  "  you  ought  to  walk  about,"  or  "  you 
must  walk  about;  go  on  from  day  to  day,  and  by  and  by  you  will 
acquire  the  power; "  and  after  a  short  time  such  patients  go  on  horse- 
back, and  take  any  amount  of  active  exercise,  notwithstanding  the 
ulceration  of  the  os  uteri.  They  get  well.  Such  cases  I  am  in  the 
habit  of  seeing  from  necessity,  and  I  treat  them  in  this  way  as  a  general 
rule.  I  remember  at  this  moment  a  lady  brought  to  me  from  Mil- 
waukee, who  had  been  four  years  on  her  couch  with  one  of  these  affec- 
tions, thinking  she  could  not  walk.  In  two  months  she  rode  on  horse- 
back, and  in  three  months  went  to  Europe,  by  adopting  this  principle 
and  attending  to  her  general  health.  Of  course,  this  principle  alone 
was  not  sufficient.  Many  years  ago,  in  the  Dublin  Hospital  Reports, 
the  application  of  alkaloids,  those  which  have  an  irritating  effect  on 
the  skin,  was  recommended,  and  it  was  taken  up,  not  by  the  profession, 
but  by  an  empiric  of  this  city,  and  his  success  in  the  treatment  of  this 
disease  by  these  alkaloids  was  very  remarkable ;  but  the  profession  did 
not  take  up  this  particular  class  of  remedies.  That  class  of  remedies, 
conjoined  with  the  principle  that  Dr.  Dyer  has  been  elucidating,  and 
attention  to  the  patient's  general  health,  I  think  I  may  say,  will  cure 
forty-nine  cases  out  of  fifty  of  this  troublesome  disease.  I  hardly  hesitate 
in  saying  to  a  patient  coming  to  me,  "  I  think  you  will  get  well  in  the 
course  of  a  few  weeks."  The  care  of  the  patient's  general  health,  how- 
ever, is  the  foundation  of  every  thing.  All  these  patients  are  nervous, 
sensitive;  as  a  general  thing  all  of  them  have  been  in  the  habit  of 
reading  and  writing.  Few  of  them  have  been  in  the  habit  of  taking  the 
amount  of  fresh  air  and  exercise  necessary.  This  want  of  exercise  and 
management  of  the  general  health  very  much  originates,  it  appears  to 
me,  from  the  fact  that  our  profession  do  not  go  suflBciently  into  detail, 
in  telling  patients,  for  instance,  every  thing  they  may  eat,  and  every 
thing  tliey  must  avoid;  every  thing  that  goes  into  their  mouths  must 
be  regulated ;  also  the  precise  amount  of  exercise,  exposure,  and  fresh 


44 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


air.  We  are  so  much  in  the  habit  of  saying,  "  you  must  carefully  avoid 
indigestible  food" — that  amounts  to  just  nothing.  If  we  go  accurately 
and  carefully  into  detail  in  giving  our  patients  directions  on  this  sub- 
ject they  will  get  the  benefit  of  them  and  derive  advantage;  and  so  in 
regard  to  the  hygienic  directions  generally.  All  this  I  consider  very 
essential  to  the  foundation  of  the  treatment;  but  the  application  of 
the  alkaloids  is  the  remedy.  In  the  first  place,  I  give  the  patient  a 
lecture  as  to  the  management  of  her  general  health,  after  catechising 
her  very  carefully  as  to  all  her  different  habits.  Then  I  at  once  rub 
upon  her  temples  and  forehead,  and  perhaps  behind  her  ears  or  the 
nape  of  the  neck,  say,  the  saturated  tincture  of  aconite,  or  a  solution  of 
veratria,  gr.  iv.,  ad  aquam,  3i. ;  and  I  say  to  the  patient,  "Now, 
when  you  go  home  see  how  much  you  can  read.  You  certainly  can 
read  fifteen  minutes  the  first  time."  And,  under  the  influence  of  this 
article,  (where  it  is  producing  a  powerful  influence,)  she  can.  As  a 
general  rule  it  is  so  after  the  application  of  one  of  these  powerful 
stimulants.  Then  the  practice  is  to  make,  every  day,  one  of  these 
efforts.  Saturated  tincture  of  aconite  is  one  stimulant.  The  next  day 
I  would  apply  a  moderately  strong  solution  of  two  grains  of  veratria 
to  the  drachm,  applied  in  the  same  manner,  the  same  way.  Then 
I  apply  something  like  Granville's  Lotion.  I  use  equal  parts  of  aqua 
ammonia  and  alcohol — say  two  ounces  of  such  a  mixture.  That  is  ap- 
plied for  thirty  seconds  to  the  forehead,  temples,  back  of  the  neck, 
behind  the  ears,  always  stopping  short  of  vesication.  Every  other  day 
some  one  of  these  things  is  done.  I  find,  as  a  general  rule,  if  the 
patient  in  the  mean  time  will  have  followed  my  directions  as  to  general 
health,  she  can,  in  the  course  of  a  fortnight  perhaps  read  half  an  hour. 
Poor  patients — infirmary  patients — can  not  be  gotten  well  in  this  way. 
I  do  not  find  that  prescribing  these  things — telling  patients  about  these 
things — answers  any  purpose.  I  have  often  received  letters  and  an- 
swered them,  prescribing  what  should  be  done,  but  relief  has  not  been 
afforded.  The  surgeon  himself  must  see  to  it.  It  is  troublesome  to  the 
patient;  she  neglects  the  applications  and  fails  to  observe  all  the  di- 
rections; and  I  know  of  no  other  way  of  producing  the  desired  effect 
than  for  the  physician  to  attend  to  it  himself  The  only  other  mode 
in  which  these  applications  in  very  obstinate  cases  are  employed,  is 
by  a  solution  of  veratria  applied  to  the  eye  itself.  It  is  very  painful. 
To  a  grain  of  veratria  put  an  ounce  of  water.  I  never  went  beyond  a 
grain.  I  used  to  employ  it  for  obstinate  cases  of  asthenopia,  but 
lately  I  have  not  found  it  necessary;  I  can  get  along  without  it.  I 
know  my  frieuds  in  this  city — and  I  have  often  talked  with  them  on  the 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


45 


subject — have  not  seemed  to  attach  as  much  importance  to  this  class 
of  remedies  as  I  do.  I  no  longer  feel  any  doubt  about  the  cure  of 
these  cases;  and,  although  these  remedies  may  not  be  infallible,  their 
effect  is  so  good  that  in  using  them  I  have  never  failed. 

I  suppose  I  might  talk  all  day,  gentlemen,  upon  this  subject,  but  I 
wont  tire  you.  These  are  the  main  ideas  which  I  wish  to  throw  out 
upon  the  subject.  The  exercise  of  the  eyes,  as  insisted  on  by  Dr. 
Dyer,  I  look  upon  as  called  for  in  these  cases — the  forced  use  of  the 
eyes,  not  stopping  simply  because  there  is  pain.  By  the  way,  I  re- 
memlier  a  curious  fact  which  occurred  a  good  many  years  ago.  A 
gentleman  who  had  this  disease  told  me  he  determined  not  to  be  con- 
quered by  it,  and  he  went  out  into  the  bright  sun,  and  let  the  sunlight 
fall  upon  the  book,  and  then  read  in  spite  of  the  distress  it  gave  him; 
he  said  it  did  him  good,  and  he  got  better.  This  very  thoroughly 
illustrates  the  principle  Dr.  Dyer  insists  upon. 

Dr.  Derby  (of  Boston). — I  have  but  a  few  hastily  prepared  remarks 
to  offer  on  the  classification  of  asthenopic  affections,  and  the  relief  of 
one  of  the  more  important. 

Understanding  by  asthenopia  the  inability  to  sustain  the  consecutive 
use  of  the  eyes  on  near  objects,  the  vastness  of  the  field  opened  for 
discussion  becomes  at  once  apparent.  And,  owing  to  the  variety  of 
structural  anomalies,  as  well  as  of  local  or  general  morbid  processes 
that  may  bring  about  a  state  of  things  coming,  to  some  extent,  under 
the  above  definition,  the  necessity  of  classification  makes  itself  at  once 
felt. 

It  was  originally  proposed  to  divide  asthenopia  into  two  gi'eat 
classes  : 

1st.  Where  the  continued  use  of  the  eyes  on  near  objects  is  physi- 
cally— 

2d.  Where  the  same  is  optically,  impossible. 

The  classical  description  of  the  first  by  Donders*  is  familiar  to  all. 
I  give  it  in  his  own  words  :  "  All  work  on  near  objects  causes  either 
pain  or  an  extremely  disagreeable  sensation  in  the  eyes,  sometimes, 
too,  redness,  blinking  with  the  eye-lids,  a  disposition  to  close  the  eyes, 
etc.,  so  that  it  becomes  necessary  to  cease  from  work.  The  symp- 
toms then  generally  diminish.  Sometimes  they  gradually  assume  a 
more  permanent  character  and  then  become  very  obstinate.  Vision 
is  of  natural  acuteness.  The  range  of  accounnodation  remains  normal, 
even  though  the  eyes  be  wearied  and  painful.    Not  infrequently 


«  ArchiT  fur  Ophthalmologio,  Bd  4,  Abth  1,  8  330. 


46 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


a  small  amount  of  myopia  is  present.  Convex  glasses  are  of  no  use. 
I  can  give  but  unsatisfactory  hypotheses  as  to  the  nature  of  this  affec- 
tion. Nor  am  I  inclined  to  believe  that  hyperajsthesia  of  the  retina 
lies  at  the  bottom  of  it." 

In  this  class  of  cases,  then,  the  eyes  can  not  be  used  on  near  objects 
on  account  of  the  pain  and  inconveuieuoe  resulting.  It  will  be  ob- 
served, however,  that  the  vision,  up  to  the  last  moment  of  the  act, 
remains  as  distinct  as  at  first.  In  the  second  class  the  symptoms  are 
so  familiar  that  it  seems  superfluous  to  recall  them.  Indistinctness  of 
vision  arising  after  a  more  or  less  continued  effort,  accompanied  by 
pains  in  tlie  forehead,  a  flow  of  tears  and  a  disposition  to  close  the 
eyes,  all  of  which  phenomena  are  relieved  by  rest. 

Into  one  or  the  other  of  these  classes  every  case  of  asthenopia  may 
be  brought;  the  first  as  little  understood  in  our  day  as  when  Uonders 
first  wrote  in  1858,  and  when  firmly  fixed  as  little  amenable  to  treat- 
ment, an  ignis  fatmiis  among  ophthalmic  affections,  ip  one  case  in- 
herited, in  another  the  result  of  imprudence,  often  absent  in  the  invalid 
and  present  along  with  the  most  vigorous  health — a  complete  enigma 
as  to  its  seat,  its  cause,  or  its  cure — more  common,  I  think,  in  this 
country  than  in  Europe,  and,  as  far  as  my  observation  reaches,  more 
commonly  met  with  in  the  East  than  in  the  West,  decrefising  in 
frequency  of  occurrence  as  we  withdraw  from  the  Atlantic  seaboard. 
The  second,  generally  congenital,  and  reducible  to  one  or  two  causes 
— ^i-emoval  of  the  boundaries  of  the  field  of  accommodation  from  the 
eye,  or  insufficient  muscular  action;  in  other  words,  hypermetropia  or 
insufficiency  of  the  internal  recti. 

I  have  carefully  collated  the  cases  of  asthenopia  occurring  in  my 
own  private  practice,  excluding  infirmary  patients  as  offering  relatively 
fewer  cases  of  the  affection,  and  less  opportunity  for  subsequent  study. 
Out  of  1,800  recorded  cases  in  general  ophthalmic  practice  I  find  369 
cases  of  asthenopia  in  general.  Of  these  241  belonged  to  the  first 
class  and  125  to  the  second,  or  asthenopia  simplex.  Nearly  all  of 
these  latter  were  dependent  on  hypermetropia. 

I  am  aware  that  two  years  after  his  views  on  the  subject  of 
asthenopia  were  broached,  the  system  of  classification  above  men- 
tioned was  given  up  by  Bonders,  who  adopted  the  second  division  as 
the  type  of  the  affection  and  insisted  on  hypermetropia  as  almost  in- 
variably the  cause.  He  says,*  "  I  readily  admit  that  many  different 
conditions  were  included  under  the  name  of  hebetudo  or  asthenopia. 


*  On  the  Anomalies  of  Accommodation  and  Beiraction  of  the  Eye.  London,  1861. 


1865.] 


J'EOCEEDINGS  OF  SOCIETIES. 


47 


When  iucouvenience  was  felt  on  continued  exertion,  this  appeared  to 
some  sufficient  to  justify  the  inference  that  asthenopia  existed.  On 
this  account  different  forms  of  irritation,  congestion  in  myopic  eyes, 
hyperesthesia  of  the  eye,  with  increasing  pain  on  exertion,  different 
affections  of  the  retina  and  of  the  choroid,  nay,  even  the  beginning  of 
trachoma,  and  foreign  bodies  in  the  sac  of  the  conjunctiva,  might  all  be 
united  under  one  denomination.  But  I  can  not  concur  in  the  adoption 
of  such  a  primitive  semeiotic  method.  It  leads  inevitably  to  confusion 
of  ideas  and  of  conditions.'' 

Undoubtedly  the  causes  here  cited  give  rise  to  symptoms  more  or 
less  resembling  those  of  true  asthenopia.  But,  abstracting  entirely 
from  such  and  all  of  them,  it  must,  I  think,  be  admitted  that  in  our 
country  and  climate  there  exists  a  widely  diffused  and  exceedingly 
prevalent  affection — generally  to  be  traced  either  to  excessive  use  of 
the  eye  in  health,  or  to  the  premature  use  of  it  during  the  convales- 
cence from  some  debilitating  disease  of  the  general  system,  where  con- 
tinued use  of  the  eyes  on  near  objects  is  impossible  without  present 
pain  and  subsequent  discomfort.  The  eye  is,  to  all  appeai'ance,  both 
externally  and  ophthalmoscopically,  absolutely  normal.  Paralysis  of 
the  accommodation  fails  to  discover  a  vestige  of  hypermetropia.  The 
interni  are  of  normal  strength.  The  general  health  may  be  satisfactory 
— often  indeed,  I  admit,  is  not.  Sometimes,  under  the  influence  of  an 
alcoholic  stimulus,  the  symptoms  temporarily  disappear,  or  under  the 
excitement  of  important  business  the  eyes  are  used  with  apparent  ease, 
and,  when  the  excitement  ceases  completely  relapse  into  their  old  con- 
dition. This  affection  may  last  weeks,  months,  or  a  lifetime,  and  in 
the  majority  of  cases  resists  any  and  every  therapeutic  agent.  That  it 
is  excessively  prevalent  among  us  I  think  none  will  deny,  and  what  to 
call  it  except  asthenopia,  or  its  synonym  hebetudo,  I  am  at  a  loss  to 
conceive.  The  terra  "morbid  sensibility  of  the  retina"  has  justly  been 
relinquished — an  inconvenient  name,  which  in  itself  begged  a  contro- 
verted question. 

A  single  word,  in  conclusion,  on  the  subject  of  hypermetropia.  This 
great  cause  of  a  leading  form  of  asthenopia  of  course  occurs  as  such  in 
every  conceivable  degree.  I  do  not  remember  to  have  found  trouble 
arising  from  a  less  degree  than  i,  while  out  of  more  than  120  cases, 
six  were  found  where  H=y,  and  three  where  H=^.  Of  course  ac- 
quired hy[)ermetropia  is  here  excluded.  Some  curious  instances  of  in- 
herited hypermetropia  came  under  my  observation.  The  two  Messrs.  R., 
one  possessing  H=ia,  the  other  also  hypermetroi)ic  in  a  high  degree, 
married  wives  each  of  whom  had  11=^^.    Of  the  issue  of  the  first 


48 


PROCEEDINGS  OP  SOCIETIES 


[Oct., 


couple,  three  daughters  consulted  me  on  account  of  asthenopia,  and 
were  found  to  have  Hin  to  Hni  .^g.  Two  children  of  the  second 
couple  have  respectively  J;,-  and  ^. 

As  is  well  known,  the  original  method  of  treating  asthenopia  arising 
from  this  cause  was  by  neutralizing  the  manifest  hypermetropia,  and 
knowing  the  amount  of  latent  that  lay  concealed,  to  keep  pace  with  its 
development  from  time  to  time  until  all  became  manifest.  And  ranch 
stress  was  laid  on  the  supposed  necessity  of  making  the  neutralizing  glass 
as  far  as  possible  part  and  parcel  of  the  eye,  only  to  be  laid  aside  when 
the  eye  "  ceases  to  see."  These  views  have  recently  been  subjected  to 
important  modifications,  and  the  assumption  that  moderate  use  of  the 
accommodation  on  distant  objects  can  not  be  indulged  in  without  in- 
jury, has  been  proved  fallacious.  Considering,  therefore,  the  incon- 
veniences arising  from  the  constant  use  of  glasses  for  all  purposes,  and 
the  state  of  dependence  on  them  to  which  the  wearer  becomes  finally 
reduced,  we  may  allow  a  patient  who  sees  distant  objects  moder- 
ately well  without  assistance,  to  content  himself,  temporarily  at  any 
rate,  with  the  use  of  glasses  for  the  near. 

Dr.  Williams  (of  Cincinnati). — The  experience  which  I  have  had 
for  a  number  of  years  with  this  class  of  cases  has  been  considerable, 
and  I  have  found  a  number  of  patients  where  I  had,  by  careful  and 
repeated  examinations,  excluded  all  idea  of  the  usual  causes  of  asthe- 
nopia, such  as  myopia,  hypermetropia,  astigmatism,  and  paralysis  of 
accommodation,  and  still  found  cases  that,  notwithstanding  the  sight 
was  perfect,  the  range  of  accommodation  normal,  and  the  eyes  oph- 
thalmoscopically  and  in  every  other  respect  perfectly  natural,  still  the 
patients  were  not  able  to  use  their  eyes  for  any  length  of  time  without 
feeling  great  inconvenience.  But  I  have  generally  found  in  these 
cases  that  before  coming  to  me  they  have  consulted  physicians  fre- 
quently, and  have  been  invariably  told  that  their  symptoms  were  those 
of  approaching  amaurosis — and  the  patients  having  a  horror  of  that, 
think  they  must  not  use  their  eyes.  Thus  they  regard  the  non-use  of 
their  eyes  as  an  absolute  necessity;  and  go  on  using  them  but  very 
little,  feeling  always  a  terrible  apprehension  that  they  will  eventually 
become  blind.  Of  course  their  eyes,  under  such  circumstances,  do  not 
get  any  better.  I  believe  that  in  all  these  cases  the  disease  is  seri- 
ously aggravated  by  the  mental  apprehensions  of  the  patients;  and  I 
make  it  a  point  in  their  treatment  to  make  a  careful  and  thorough 
examination,  so  as  to  be  able  to  satisfy  myself  whether  there  is  any 
disease  that  is  likely  to  destroy  or  seriously  impair  the  vision.  If 
there  is  not,  I  assure  the  patient,  in  the  most  confident  way  possible, 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


4:9 


that  he  need  not  have  any  apprehensions  about  being  blind.    I  usu- 
ally tell  him  he  could  not  get  blind  if  he  were  to  try.    I  endeavor 
to  get  the  confidence  of  my  patients  in  that  way,  so  as  to  relieve  them 
of  the  apprehension.    I  know,  from  my  own  individual  case,  the  effect 
of  relief  of  that  apprehension.    Years  ago,  as  a  student,  I  was  in  the 
habit  of  using  my  eyes  a  good  deal  at  night,  frequently  reading  till 
one  or  two  o'clock  in  the  morning — sometimes  in  my  bed  for  several 
hours;  and,  after  persisting  in  this  for  several  years,  although  I  had 
remarkably  strong  eyes,  they  began  to  have  symptoms  of  asthenopia — 
fatigue,  pain,  and  sometimes  an  indistinctness  of  vision,  produced,  no 
doubt,  by  the  temporary  congestion  of  the  choroid;  and  I  can  now, 
by  looking  at  a  white  surface  at  this  time,  see  the  choroidal  circula- 
tion upon  my  eyes.    When  I  was  at  the  clinic  of  Dr.  Graefe  I  was 
troubled  in  that  way,  and  was  greatly  apprehensive  that  I  might 
eventually  lose  my  eyesight,  although  it  was  still  perfect.    I  asked 
him  to  examine  my  eyes  with  the  ophthalmoscope.    He  did  so,  and 
told  me  that  there  was  no  appearance  of  disease;  that  there  was  no 
congestion  of  the  retina:  no  organic  lesions  of  the  retina  or  choroid; 
it  was  just  a  little  nervous  irritation.  (I  don't  remember  the  exact  ex- 
planation he  gave.)  He  distinctly  assured  me  I  need  not  be  apprehen- 
sive of  losing  my  eyes;  and  from  that  day  to  this  they  have  been  bet- 
ter without  my  having  done  any  thing,  except  just  to  use  my  eyes  a 
little  more  reasonably  than  I  did  before  that  time.    I  have  had  this 
experience  occur  to  me  in  tlie  treatment  of  patients  time  and  again. 
I  remember  one  lady  who  had  not  read  five  lines  of  print,  at  one  time, 
for  twenty  years.    She  had  been  told  by  all  the  physicians  she  had 
ever  consulted  that  it  was  absolutely  necessary  for  her  to  refrain  from 
using  her  eyes;  she  would  finally  become  amaurotic,  and  the  less  she 
used  the  eyes  the  longer  the  serious  catastrophe  would  be  delayed. 
As  she  was  a  little  presbyopic,  I  told  her  she  must  use  glasses.    I  had 
the  greatest  possible  difficulty  in  getting  her  to  look  for  a  second 
through  them.    I  told  her  the  doctors  who  had  treated  her  before 
had  not  understood  the  case;  I  was  satisfied  the  glasses  would  cure 
her;  and  I  fitted  her  with  a  pair  of  Is^umber  30,  convex,  which  re- 
lieved the  presbyopia,  and  she  has  been  using  her  eyes  just  as  much 
as  she  pleased  up  to  this  time,  and  with  very  little  inconvenience.  In 
the  treatment  of  those  cases  which  I  have  found  in  young  men  and 
young  ladies,  I  have  sometimes  resorted  to  convex  glasses,  according 
to  the  directions  of  Dr.  Dyer,  without  exactly  knowing  why.    I  have 
tried  this  mode  in  two  cases— one  a  young  lady,  twenty-eight  years  of 
age,  and  the  other  a  young  man,  twenty-two  or  twenty-three.    I  made 
Vol.  II.— No.  7.  4 


50 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


them  use  their  eyes  with  convex  glasses  whenever  they  began  to  read; 
and  I  insist  on  the  regular,  systematic  use  of  the  eyes  in  all  these 
cases,  always  stopping  short  of  fatigue,  if  possible;  and  by  the  use  of 
moderately  convex  glasses  I  have  found  benefit,  although  there  was 
no  hypcrvidropia,  and  no  paralysis  of  accommodation.  I  use  first,  as  a 
sort  of  anodyne,  a  solution  of  sulphate  of  morphine.  I  use  six  grains 
to  the  ounce,  a  pure  article,  which  generally  produces  but  little  if  any 
imtation.  I  use  it  three  or  four  times  a  day,  put  three  or  four  drops 
in  the  eye,  and  give  it  time  to  take  effect.  Patients  have  experienced 
very  decided  relief  from  it.  In  addition  to  that  I  give  them  iron, 
or  quinine,  or  nux  vomica,  or  something  of  the  kind.  I  give  them 
regular,  systematic  exercise,  and  use  the  local  application  of  cold  water 
in  the  form  of  the  douche  to  the  eyes  twice  a  day,  I  apply  it  with  a 
small  spout,  the  end  being  perforated;  put  it  on  the  hydrant  and  let  it 
douche  their  eyes  for  five  or  ten  minutes;  and  I  have  sometunes  had 
them  relieved  of  great  neuralgic  pain;  but  the  rule  governing  the 
application  must  be  the  strength  of  the  eyes  and  the  power  to  persist 
in  using  them.  With  these  remedies  the  physician  may  begin  with  a 
strong  assurance  that  the  patients  will  not  lose  their  eyes;  I  have 
generally  succeeded  in  relieving  them. 

Dr.  Delafield. — I  should  like  to  mention,  in  respect  to  this  forced 
use  of  the  eyes,  that  they  should  never  be  used  before  breakfast,  and 
never  when  the  patient  is  much  fatigued.  This  is  a  very  essential 
point  to  be  observed. 

Dr.  Dyeb. — My  own  experience  has  satisfied  me  of  the  necessity  of 
observing  this. 

Dr.  Williams  (of  Boston). — I  did  not  intend  to  say  any  thing  on 
this  subject,  but  perhaps  it  may  be  well  that  all  the  corroborative  ex- 
perience should  be  brought  to  bear  that  we  can  bring  with  reference 
to  this  peculiar  class  of  asthenopic  cases;  and  all  my  own  experience 
leads  me  to  believe,  with  Dr.  Dyer,  in  the  importance  of  the  system- 
atic gymnastic  exercise  of  the  eye,  as  he  terms  it,  and  in  the  import- 
ance of  makuig  a  good  impression  on  the  mind  of  the  patient.  My 
attention  was  very  early  drawn  to  these  cases;  before,  in  fact,  I  had 
any  thing  to  do  with  them  myself.  I  was  so  situated  that  I  was  con- 
stantly hearing  about  cases  of  successful  treatment  of  what  was  called 
morbid  sensibility  of  the  retina.  Patients  had  been  for  a  greater  or 
less  length  of  time  suffering  under  that  affliction,  which  is  asthenopia, 
as  Dr.  Dyer  has  described  it;  and  they  had  been  subjected  to  rather 
an  active  treatment,  and  generally  told  to  absolutely  refrain  from 
using  the  eyes  at  the  same  time.    Local  depletion  had  been  used 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


51 


pretty  extensively,  and  low  diet  insisted  on.   Many  of  these  patients 
came  to  the  charlatan  to  whom  you  have  alluded,  and  he  put  into 
their  eyes  remedies  which  had  a  perfectly  surprising  influence  both  on 
the  mind  and  body.    The  patients  were  put  to  bed  about  twenty-four 
hours,  after  putting-  strong  alkaloids  on  the  eyes,  and  the  impression 
made  was  astonishing-.    Tlie  patients  considered  the  man  a  prophet, 
and  ascribed  the  cure,  which  was  in  many  cases  effected,  as  coming 
through  these  remedies  which  he  and  no  one  else  knew  how  to  use. 
What  were  the  real  facts  of  the  case  ?    This  man,  who  had  a  great 
deal  of  tact,  took  these  hysterical  patients  and  gave  them  roast  beef 
and  stimulants,  let  them  take  drives  about  the  country  and  enjoy 
themselves  as  much  as  possible,  taking  away  all  their  old  associations. 
(Whether  he  directed  them  to  use  the  eyes  or  not  I  can  not  say.)  He 
placed  them  in  circumstances  different  from  those  in  which  they  had 
been  placed,  and  he  altered  absolutely  the  general  treatment.  His 
patients  did  extremely  well,  and  the  observations  I  had  of  some  of 
them,  who  afterwards  came  under  my  care,  was,  that  he  ascribed 
much  more  importance  to  the  general  treatment  than  to  the  local 
applications,  which  were  of  this  agonizing  character,  and  which,  I 
believe,  were  used  more  to  make  an  impression  on  the  patient  than 'on 
the  disease.    It  answered  the  purpose  in  making  an  impression  on  the 
disease,  however,  by  acting  through  the  minds  of  the  patients.  Hav- 
ing this  first  brought  very  prominently  to  my  notice,  and  observing 
the  cases  as  they  began  to  come  under  my  own  care,  I  was  satisfied 
that  his  patients  were,  many  of  them,  suffering  from  dread  that  they 
were  to  be  blind.    FeeHng  an  inconvenience  in  using  their  eyes,  and 
feeling  they  would  "strain  the  eyes,"  as  they  termed  it,  and  grow 
gradually  blind,  they  followed  readily  enough  the  advice  given  them, 
and  that  was  to  refrain  absolutely  from  using  the  eyes,  sometunes 
with  the  advice  to  shut  themselves  up  in  a  dark  room.    On  examina- 
tion with  the  ophthalmoscope,  I  did  not  often  find  the  slightest  ten- 
dency to  amaurosis;  and  I  encouraged  the  patients  to  use  their  eyes 
all  they  possibly  could.    I  told  them  there  was  no  tendency  whatever 
to  blindness,  and  they  could  use  the  eyes  to  advantage  rather  than 
leave  them  entirely  without  exercise;  that  they  needed  exercise  for 
developing  the  eyes  as  much  as  any  other  organ,  and  that  to  be  de- 
veloped they  should  be  kept  in  constant  use.    I  found  it  important  at 
the  same  time  to  give  them  tonic  general  treatment,  and  especially  to 
caution  them,  as  many  of  them  were  persons  with  delicate  organiza- 
tions and  health,  against  an  imprudent  amount  of  exercise.    I  told 
them  to  take  exercise  regularly  and  frequently,  and  to  divide  the  ex- 


52 


PROCEEDINGS  OF  SOCIETIES. 


[Oct., 


ercise,  not  taking  so  much  at  one  time  as  to  become  thoroughly  pros- 
trated; for  it  seemed  to  me  that  the  general  nervous  prostration  which 
ensued  on  excessive  exercise  prevented  the  eyes  from  getting  along 
well.  I  agree  with  the  observations  already  made  as  to  the  use  of 
the  eyes  before  eating.  It  is  also  very  desirable  that  patients  should 
not  use  them  when  suifering  with  illness,  or  at  the  menstrual  period. 
I  found  out,  before  knowing  much  about  hypcrmetropia,  that  glasses, 
in-  a  certain  number  of  cases,  answered  very  well.  I  mean  that  glasses 
were  of  more  use  than  merely  to  give  them  encouragement  in  using 
the  eyes.  I  gave  them  glasses  which  I  tested  carefully,  and  fitted  to 
the  eyes  as  well  as  1  could,  and  they  went  on  better;  but  in  a  consid- 
erable number  of  cases  these  were  only  valuable  where  hypcrmetropia 
existed,  as  we  now  recognize  it.  The  patients  were  required  to  use 
the  eyes  by  encouraging  them,  and  by  givhig  them  tonic  general  treat- 
ment, and  placing  them  in  circumstances  cheerful  and  hopeful;  so  that, 
instead  of  having  the  attention  constantly  fixed  on  the  idea  of  blind- 
ness, and  filled  with  morbid  fear  of  it,  they  were  encouraged  to  be- 
lieve tliat  they  never  would  he  blind;  they  might  use  the  eyes  some, 
and  gradually  more  and  more. 

AFTERNOON  SESSION. 

The  President,  Dr.  Delafield,  ua  the  Chair. 

Dr.  Sands. — If  this  discussion  of  the  question  of  asthenopia  is  still 
in  order  I  will  make  one  or  two  remarks,  although  I  do  not  suppose  I 
can  say  much  to  elucidate  this  difiBcult  subject.  But  my  experience 
has  included  several  cases  that  come  under  the  second  category 
mentioned  by  Dr.  Derby,  one  of  which  interested  me  very  much  on 
account  of  its  obscurity  and  the  difficulty  I  had  in  treating  it.  The 
case  was  that  of  a  young  gentleman,  about  seventeen  years  of  age, 
living  in  New  England.  He  had  been  sent  abroad  by  his  father  to 
complete  his  education,  and  to  spend  a  couple  of  years  in  Europe.  He 
was  at  that  time  in  the  enjoyment  of  perfect  health.  Having  made 
the  tour  of  the  Rhine  and  spent  two  or  three  months  in  Switzerland 
and  the  neighboring  country,  he  returned  to  Paris,  and  then  began  to 
experience  pain  in  using  his  eyes.  He  had  never  been  a  very  hard 
student,  and  was  not  over-working  his  eyes  at  the  time.  He  was 
exceedingly  surprised  at  the  occurrence  of  the  symptom  mentioned, 
and  went  to  a  well  known  oculist  in  Paris,  who,  upon  examination, 
told  him  he  was  suffering  from  hyperajsthesia  of  the  retina,  and  that 
the  affection  had  been  brought  on  by  the  previous  habit  of  masturba- 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


53 


tion,  which,  I  think,  he  had  indulged  in  up  to  that  time,  though  never 
to  any  great  extent.  The  physician  created  an  immense  amount  of 
alarm  in  the  mind  of  the  boy,  and  placed  him  under  treatment  of  a 
complicated  character,  a  great  many  remedies  being  prescribed,  both 
externally  and  internally.  He  was  enjoined  to  relinquish  the  use  of 
his  eyes,  and  under  no  circumstances  to  apply  himself  to  work  in  less 
than  a  year.  This  intelligence  was  communicated  to  his  parents  at 
home,  who  received  it  with  a  great  deal  of  disappointment,  and  sent 
for  him  to  return.  Upon  his  arrival,  I  was  consulted.  I  had  supposed 
that  perhaps  the  astheuopic  symptoms  might  depend  upon  the  exist- 
ence of  hypermetropia.  On  examination,  however,  I  detected  a  very 
slight  degree  of  myopia — I  think,  one-fortieth;  the  power  of  accommo- 
dation equaled  ^,  and  vision  under  no  circumstances  was  indistinct. 
He  did  not  have  the  blur  of  which  hyperopic  patients,  who  are  suffer- 
ing from  asthenopia,  usually  complain.  He  referred  the  pain  to  the 
ball  of  the  eye  rather  than  to  the  supra-orbital  region.  I  could  dis- 
cover no  evidence  of  disease  by  ophthalmoscopic  examination,  except  a 
small  amount  of  capillary  hypera;mia  in  the  optic  nerve.  The  sharp- 
ness of  vision  was  normal;  I  believe  it  was  a  little  above  the  normal, 
for  he  saw  No.  20  of  Dyer's  test  type  at  a  distance  greater  than 
twenty  feet.  This  young  man's  physical  health  was  good;  his  mental 
condition,  however,  was  one  of  depression,  induced,  I  think,  by  the 
advice  given  him  when  he  was  under  the  care  of  the  oculist  in  Paris. 
I  did  all  I  could  to  encourage  him,  and  assured  liim  that  he  would  re- 
cover. I  was  satisfied  that  he  had  no  disease  of  the  fundus,  and  uo 
insufBcieucy  of  the  internal  recti.  Having  read  an  account  of  some 
cases  by  Bonders  where  astheuopic  symptoms  were  ascribed  to  inor- 
dinate contraction  of  the  ciliary  muscle,  I  was  inclined  to  suspect  that 
this  might  possibly  be  the  cause  of  my  patient's  symptom.  He  suffered 
no  pain  when  looking  at  distant  objects,  but  only  when  the  ciliary 
muscle  was  brought  into  play  during  the  act  of  accommodation.  I 
provided  him  with  convex  glasses  of  twenty  inches  focal  distance.  I 
hoped  that  by  this  means  he  would  be  able  to  relax  the  greater  part 
of  his  acconmiodation,  and  in  this  way  get  rid  of  his  painful  symptoms. 
But  when  the  optic  lines  were  made  to  converge  upon  near  objects,  it 
was  about  as  painful  for  him  to  suspend  his  accommodation  with  the 
use  of  the  convex  glasses  as  it  had  previously  been  to  exert  it  without 
the  glasses.  Bonders  relates  several  cases  in  which  asthenoi)ic  symp- 
toms depended  upon  spasmodic  contraction  of  the  ciliary  muscle,  and 
in  which  complete  relief  followed  the  instillation  of  a  solution  of 
atropine  sufficiently  strong  to  wholly  paralyze  the  accommodation  and 


54 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


set  the  ciliary  mnscle  at  rest.  It  was  found  necessary,  in  one  instance, 
to  maintain  tlic  action  of  atropine  for  a  period  of  six  months  before  a 
cure  could  ))e  affected.  Meanwhile,  the  patient  was  allowed  to  read 
by  means  of  convex  glasses  of  suitable  strength  to  compensate  for  the 
temporary  loss  of  accommodation.  These  facts,  I  think,  would  lead  us 
to  look  for  an  explanation  of  asthenopic  symptoms  often  rather  in  the 
apparatus  of  accommodation,  in  the  ciliary  muscle  and  the  nerves  which 
supply  it,  than  in  any  error  of  refraction  or  any  disturbance  rclathig  to 
the  general  health.  I  have  not  yet  tried  the  effect  of  atrojjiiie  in  the 
case  I  have  related,  as  the  young  man  is  no  longer  under  my  observa- 
tion. 

Dr.  NoYEs — The  discussion  in  which  we  have  been  engaged  has 
been  to  rac  personally  very  interesting,  and  doubtless  to  those  of  us 
who  have  to  meet  cases  of  asthenopia  the  explanation  of  these 
puzzling  cases,  or  any  light  thrown  upon  their  character,  will  be  the 
information  which  wc  are  most  desirous  of  receiving.  The  discussion 
has  thus  far  related  to  only  one  class  of  asthenopia.  I  think  it  will 
Bot  be  amiss  cursorily  to  ran  over  some  of  these  diseases  which,  in  the 
general  classification  of  medical  men,  are  included  under  this  name  of 
asthenopia.  Turning  this  morning  to  the  definitions  of  astheno2)ia  as 
they  occur  in  some  of  our  recent  standard  books,  in  an  edition  of 
McKenzie,  the  last  published  in  this  country,  I  found  his  definition 
of  the  term  to  be,  "Incapability  of  sustaining  the  eye  iu  adjustment  for 
near  objects."  Lawrence,  without  exactly  defining  the  term  in  a 
formal  manner,  gives  these  words,  which  I  take  as  his  definition:  "  An 
affection  of  the  retina  from  excessive  employment,  commonly  called 
weakness  of  sig-ht."  McKenzie  grouping  the  symptoms  round  adjusts 
ment  to  near  objects,  and  Lawrence  grouping  the  symptoms  round 
simply  a  morbid  condition  of  the  retina.  Turning  then  to  the  treatise 
of  Slellwag  von  Carion,  his  definition  of  asthenopia  (and  he  has  an 
admirable  practice  of  formally  defining  the  disease  which  he  is  about 
to  discuss)  includes  : 

First,  "  The  inability  to  keep  the  dioptric  system  or  the  visual 
lines  for  a  long  period  directed  to  near  objects;  and,  secondly,  in  close 
pathological  relation  to  this  condition  hypera;sthesia  of  the  retina  and 
ciliary  nerves." 

This  definition  of  asthenopia  is  unquestionably  the  definition  which 
we  would  be  most  likely  to  adopt;  but  at  the  same  time  I  think  there 
is  a  great  tendency  to  exclude  from  the  definition  of  asthenopia  all 
those  cases  of  refractive  errors  and  muscular  disturbances  wliich  are  not 
properly  disturbances  of  the  ciliary  muscle,  and  to  include  under  the 


1865.] 


PEOCEEDINGS  OP  SOCIETIES. 


55 


term  of  asthenopia,  or  hebttudo  visiis,  cases  in  which  neuralgic  symp- 
toms predominate.  This  is  the  definition  which  the  term  is  gradually 
assuming. 

But  a  glance  at  the  literature  of  the  profession  shows  that  such  was 
formerly  not  the  understanding  of  asthenopia,  and  we  all  know  per- 
fectly well  that  there  are  now  at  least  two  or  three  well  recognized 
subdivisions  into  which  it  can  be  divided.    First,  errors  of  refraction 
prhicipaliy,  or  hypermetropia  and  astigmatism.    Second,  insufficient 
power  of  the  internal  recti  muscles:  they  can  not  perform  their 
work  of  converging  the  visual  lines  when  the  eyes  are  engaged  upon  near 
objects.    Again,  thirdly,  there  is  another  sot  of  cases  characterized  by 
excessive  irritability  of  the  retina,  and  accompanied  by  ciliary  disturb- 
ance, or  neuralgia  of  the  eye.    They  suffer  from  extreme  intolerance 
of  light;  and  ou  examination  by  the  ophthalmoscope,  as  far  as  it  can 
be  permitted,  will  discover  no  lesion,  no  organic  change;  and  that 
there  can  be  no  morljid  change  is  corroborated  by  the  fact  that  their 
visual  power  attains  the  normal  standard.    It  is  not  for  me  to  say  any 
thing  on  the  subject  of  hypermetropia,  or  astigmatism,  or  myopia; 
it  would  be  a  piece  of  supererogation.     I  only  desire  to  recall 
these  facts,  in  the  form  of  historical  reference.    Then,  as  to  the  insuf- 
ficieucy  of  the  internal  recti  muscles.    This  unquestionably  has  a 
nearer  relation  to  the  subject  of  asthenopia,  in  the  aspect  in  which  we 
are  now  disposed  to  view  it,  than  do  the  simple  errors  of  refraction ; 
because  this  muscular  part  requires  to  be  exerted  in  all  use  of  the  eye 
upon  near  objects.    The  accommodation  of  the  eye  and  this  muscular 
convergence  are  inseparably  connected.    We  are  all  aware  that  the 
correction  of  this  difiiculty  is  to  be  accomplished  in  one  of  three  ways: 
either  by  the  division  of  the  external  recti  muscles,  by  the  use  of  prisms, 
or,  what  has  been  a  very  recent  suggestion,  the  employment  of  elec- 
tricity, acting  directly  on  the  internal  recti  muscles.    Of  this  last  I 
know  nothing,  with  tiie  exception  of  what  is  contained  in  the  last  num- 
ber of  the  Archives  fur  Ophtkalmologie,  by  Dr.  Landsberg.    As  to  the 
division  of  the  external  recti  muscles,  I  have  performed  it  in  only  a 
very  few  instances,  and  that  only  in  cases  where  the  amount  of  insuf- 
ficiency was  so  very  decided  as  to  require  a  prism  of  fourteen  or  six- 
teen degrees  to  enable  the  patient  to  see  near  objects,  and  in  these 
cases  the  results  are  sufficiently  satisfactory.    As  regards  the  employ- 
ment of  prisms,  and  keeping  them  constantly  in  use,  my  experience  has 
not  been  very  large.    I  have  never  ventured  to  employ  prisms  whose 
angles  were  higher  than  an  aggregate  of  eight  degrees.    The  dissatis- 
faction which  patients  expressed  was  sufficient  to  prevent  me  from  push- 


56 


PEOCEEDINGS  OP  SOCIETIES. 


[Oct., 


iug  the  experiment  with  higlier  degrees.  With  prisms  of  four  and  six 
degrees  I  have  found  decided  benefit.  I  liave  found  tliat  ivliere  the 
deficiency  was  confined  to  but  one  internal  rectus,  the  correcting 
prism  must,  as  it  were,  be  divided,  and  one-half  be  placed  before  each 
eye. 

I  have  been  compelled,  as  I  mentioned  to  some  of  the  gentlemen 
here  in  Kew  York,  some  time  ago,  to  look  for  a  readier  method  of 
discovering  insufficiency  of  the  recti  interni  than  has  hitherto  Ijeea 
practicable.  The  means  proposed  by  Graefe,  viz.,  by  looking  at  a  ver- 
tical line  with  a  round  spot  on  its  centre,  was  the  foundation  of  the 
examination;  and  1  discovered  that  I  succeeded  better  in  taking  a 
piece  of  black  paper,  and  drawing  a  white  line  and  dot  on  it.  Across 
the  middle  of  the  line,  and  at  right  angles  to  it,  I  draw  a  dotted  scale, 
divided  into  eighths  of  an  inch,  and  numbered  each  way  from  the  cen- 
tre. The  white  dot  is  at  the  intersection  of  the  vertical  line  and  the 
horizontal  scale.  As  usual,  a  prism  of  about  10°  is  placed  with  its 
base  upwards  or  downwards,  before  one  eye,  and  a  disk  of  red  gla.ss 
before  the  other.  If  now  there  be  insufficiency  of  the  interni,  the  pa- 
tient sees  two  lines  as  well  as  two  dots;  one  of  these  lines  decidedly 
red,  and  the  other  nearly  white,  although  fringed  by  chromatic  aber- 
ration. The  difference  in  color  is  enough  to  attract  his  attention 
much  more  quickly  than  by  looking  at  a  black  line  upon  a  white  sur- 
face. The  scale,  moreover,  enables  the  patient  to  describe  the  degree 
of  sepai'ation.  I  have,  with  this  diagram,  saved  myself  the  loss  of 
much  time.  I  could  never  before  easily  get  patients  to  understand 
what  I  wanted  them  to  do. 

Dr.  Dyer  states  that  he  prescribes  weak  convex  glasses  to  asthenopic 
patients,  with  normal  refraction,  for  the  purpose  of  altering  their  rdo/- 
tive  accommodation.  In  other  words,  not  for  the  purpose  of  diminish- 
ing the  amount  of  accommodative  effort  by  the  aid  of  the  convex  glass 
— for  example,  subtracting  ^j-  from  i\ — but  to  cause  their  accom- 
modation to  act  under  a  different  angle  of  convergence.  He  calls  into 
play  the  intimate  association  subsisting  between  the  internal  recti  mus- 
cles and  the  ciliary  muscles.  The  convex  glass  brings  the  near  point 
a  little  nearer  to  the  eye,  and  requires  a  little  greater  effort  of  the  in- 
ternal recti.  In  this  way,  perhaps,  a  good  influence  is  exerted  upon 
the  ciliary  muscles.  They  may,  perhaps,  be  said  to  have  a  "  better 
purchase  "  in  their  contraction,  while  the  systematic  training  developes 
their  strength. 

I  have  seen  benefit  derived  from  wearing  weak  prisms,  in  cases 
where  I  did  not  feel  certain  that  the  internal  recti  were  at  fault,  but 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


57 


iu  whom  asthenopia  was  sufficiently  distressing.  I  have  combined  a 
prism  of  two  degrees  with  a  convex  leus  3^,  and  thus  relieved  a  very 
troublesome  degree  of  asthenopia.  With  these  contrivances,  there  oc- 
curs a  change  in  the  relative  accommodation.  Certainly  not  the  change 
produced  by  simple  convex  glasses;  but  yet  the  eyes  accommodate, 
under  conditions  unlike  those  to  which  they  have  been  accustomed.  I 
have,  in  some  cases,  doubted  whether  the  benefit  derived  from  prisms 
was  because  of  the  relief  to  the  internal  recti,  and  not  rather  because  of 
the  modification  in  the  conditions  of  accommodation.  Before  leaving  the 
subject  of  the  use  of  prisms,  I  would  remark,  that  some  patients,  using 
prisms  of  only  two  degrees  each,  have  complained  of  the  spherical 
aberration.  A  physician,  accustomed  to  use  the  microscope,  and  a 
draughtsman,  both  asserted  that  the  page  comes  up  to  them  in  a  con- 
vex surface.  After  my  attention  was  drawn  to  the  phenomenon,  I 
myself  became  conscious  of  it.  I  think  it  curious,  and  am  not  pre- 
pared to  suggest  an  explanation.  It  is  not  strictly  spherical  aberra- 
tion, but  is  a  loss  of  flatness  of  field,  a  sort  of  pseudoscopy. 

If  you  will  permit  me  to  have  a  word  to  say  in  regard  to  cases  to 
which  I  think  the  term  of  hyperajsthesia  of  the  retina  may  properly 
belong,  the  suiyect  may  be  illustrated  by  three  cases  which  I  distinctly 
remember.  Two  of  these  were  in  the  persons  of  physicians.  One  of 
them,  a  surgeon  in  the  navy,  had  been  stationed  on  the  African  coast; 
had  been  subjected  to  the  intense  light  of  the  tropics.  His  eyes  became 
extremely  sensitive  to  light,  and  he  not  only  could  not  use  them,  but 
was  rarely  free  from  ciliary  neuralgia.  He  had  subjected  himself  to 
all  sorts  of  treatment,  almost  poisoned  himself  with  strychnine,  had 
used  quinine,  adopted  all  the  local  applications  which  his  knowledge  and 
study  of  what  was  written  on  the  subject  could  suggest.  After  he 
had  been  suffering  in  this  manner  for  about  five  years,  he  came  under 
my  observation,  and,  on  examination,  I  saw  there  was  no  departure 
from  a  normal  structure,  and  no  deficiency  in  the  power  of  accommo- 
dation, or  of  any  other  function.  I  could  assure  him  that  he  was  in 
no  danger  of  becoming  blind;  that  he  would  probably,  ere  long,  be 
better;  advised  him  as  to  a  course  of  out  of  door  exercise,  and  avoid- 
ance of  the  use  of  his  eyes  and  of  bright  light,  and  gave  him  blue 
glasses.  Under  this  encouragement  and  general  management,  after 
being  on  shore  six  mouths,  away  from  the  irritating  influences  to  which 
he  had  been  subjected,  he  recovered  the  use  of  his  eyes  and  again 
went  to  sea.  .  There  is  now  living  in  the  city  a  physician  who  has  the 
same  misfortune.  He  came  to  me  for  a  certificate,  to  be  present- 
ed at  the  provost  marshal's  office.    I  made  an  ophthalmoscopic 


58 


PROCEEDINGS  OP  SOCIETIES. 


[Oct., 


examination,  with  as  little  gas-light  as  I  could  get  along  with,  and 
it  produced  agonizing  pain  for  twenty-four  or  forty-eiglit  hours. 
It  was  always  the  case  that  the  attempt  to  read,  or  to  fix  his  eyes  upoa 
distant  objects,  as  well  as  near,  provoked  extreme  pain.  There  was 
no  error  of  refraction,  impairment  of  vision,  or  muscular  disturbance; 
the  general  health  fully  up  to  the  average.  I  could  regard  this  case 
in  no  other  light  than  one  of  extreme  irritability,  whose  starting  point 
was  the  i-etina,  and  which  was  reflected  upon  the  ciliary  muscle  aud 
nerves.  One  other  case,  of  a  similar  sort,  has  presented  itself  to  my  ob- 
servation. These  are  the  several  categories  which  present  themselves 
under  the  title  asthenopia.  They  will  hereafter  he  known  by  their 
proper  designations  of  errors  of  refraction,  debility  of  the  internal 
recti,  hyperajsthesia  retinae.  The  term  asthenopia  is  at  the  present 
time,  when  used  to  designate  a  distinct  disease,  and  not  merely  a 
symptom,  being  narrowed  down  to  cases  of  ciliary  spasm,  or  neu- 
ralgia. 

Dr.  Althof. — I  have  not  much  to  say  in  addition  to  what  these 
gentlemen  have  very  ably  exposed  to  us.  I  have  only  to  remark  that 
so  far  as  the  treatment  of  cases  of  asthenopia  by  glasses  is  concerned, 
it  is  a  subject  which  is  becoming  from  day  to  day  more  important,  and 
I  have  no  doubt  that  if  we  had  the  same  facilities  in  the  city  of  New 
York  that  are  had  in  Europe  for  providing  our  patients  with  glasses, 
we  could  use  them  to  very  great  advantage  in  many  cases  of  asthe- 
nopia where  now  we  can  not.  So  far  as  this  graduated  table  which  Dr. 
Noyes  has  prepared  and  exhibited  is  concerned,  I  have  used  a  similar 
contrivance  for  a  time,  but  have  not  found  any  great  advantage  from 
it.  It  is  not  easy  to  be  used  while  examining  a  patient  for  insuffi- 
ciency of  the  internal  recti.  I  am  suffering  from  a  very  high  degree  of 
this  difficulty  in  the  right  eye;  there  is  a  divergence  of  two  aud  a  half 
lines.  I  am  utterly  unable  to  produce  tlie  double  images.  With  the 
aid  of  the  colored  glass  which  has  been  used  for  a  good  length  of  time 
— which  I  have  seen  used  as  far  back  as  1858 — I  have  always  l)een 
able  to  bring  those  persons  that  are  not  very  much  accustomed  to 
giving  correct  statements  about  their  eyes,  to  something  like  a  decent 
statement  respecting  them.  I  have  heard,  this  morning,  in  regard  to 
asthenopia,  very  little  that  I  have  not  before  read  in  the  books  of  the 
great  authors.  The  only  thing  I  have  heard  which  was  entirely 
new  to  me  has  been  contained  in  the  remarks  of  Dr.  Dyer — that  por- 
tion relating  particularly  to  the  use  of  concave  glasses.  The  sugges- 
tion of  Dr.  Dyer,  as  to  the  employment  of  a  kind  of  gymnastic  exercise 
of  the  eye,  has  for  some  time  been  known  to  the  profession,  but  the 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


59 


exactitude  with  which  he  forces  his  patients  to  do  exactly  what  he 
wants  them  to  in  observing  his  directions  about  their  eyes  is  entirely 
new  to  me.  I  have  never  been  able  to  do  it,  and  I  am  pleased  to  learn 
that  there  is  a  way  of  reaching  this  result — a  thing  which,  as  I  stated 
at  a  meeting  of  the  New  York  Ophthalmological  Society,  has  puzzled  me 
extremely.  It  is  very  difficult,  as  I  have  said,  to  find  out  whether  or 
not  people  are  really  suffering  from  insufficiency  of  the  internal  recti. 
I  myself  belong  to  this  class,  and  if  I  wore  examined  by  a  very  skillful 
oculist,  I  think  he  would  be  puzzled  to  know  whether  I  did  or  not 
— to  know  that  I  am  squinting  divergently  to  a  very  considerable  ex- 
tent ;  that  I  have  all  the  symptoms  of  asthenopia  of  the  internal  recti 
without  being  able  to  produce  the  double  images  which  ought  to  ac- 
company the  squinting.  Dr.  Dyer  has  stated  that  by  giving  persons 
concave  glasses  which  enabled  them  to  read  at  about  fifteen  inches,  he 
has  been  able  to  relieve  a  good  deal  of  suffering.  I  should  like  to 
know  what  method  Dr.  Dyer  has  adopted  to  satisfy  himself  that  in 
these  cases  there  certainly  was  no  insufficiency  of  internal  recti.  The 
treatment  of  insufficiency  of  the  internal  recti  by  concave  glasses  is  a 
thing  which  Graefe  has  exposed  in  that  first  paper  of  his,  if  I  am  not 
mistaken,  in  which  he  speaks  of  the  three  different  classes  of  asthe- 
nopia— alludes  to  the  certain  classes  of  asthenopia  to  be  ascribed  to 
insufficiency  of  the  internal  recti;  and,  particularly  lately,  a  good  many 
cases  have  come  under  my  observation  in  which  I  have  only  been  able 
to  satisfy  myself  that  this  insufficiency  of  internal  recti  existed  after 
very  long  and  careful  examination — three  or  four  of  them.  I  would 
be  very  much  obliged  to  Dr.  Dyer  if  he  would  tell  me  if  his  examina- 
tion has  satisfied  him  beyond  any  doubt  whatever  that  the  patients  in 
these  cases,  in  which  he  relieved  them  by  giving  them  convex  glasses, 
were  not  suffering  from  insufficiency  of  the  internal  recti.  As  to  the 
suggestion  of  Dr.  Sands,  to  apply  a  convex  glass  to  an  emmetropic  eye, 
it  would  be  only  substituting  one  evil  for  another,  and  I  can  not  agree 
with  him.  It  is  an  old  experience,  and  has  been  admitted  by  all  the 
authors  who  have  so  far  advanced  our  knowledge  in  the  structure  of 
accommodation  and  refraction.  They  never,  under  any  circumstances 
whatever,  ai-e  able  entirely  to  paralyze  their  accommodation.  A  man 
who  has  presbyojiia,  who,  instead  of  reading  at  eight  inches  reads  at 
twelve,  you  give  him  glasses  one  twenty-fourth  and  you  will  never  find 
that  he  reads  at  eight  inches;  he  will  read  at  nine  or  nine  and  a  half 
inches.  So  far  I  am  sure;  Dr.  Dyer  gives  his  emmetropic  eyes  a  convex 
glass;  they  all  do  wliat  he  wants  tlieui  to  do— that  is,  tliey  exercise  a 
certain  range  of  their  accommodation;  they  do  not  really  read  in  one 


60 


PROCEEDINGS  OF  SOCIETIES. 


[Oct., 


point,  but  they  do  really  use  a  certain  fraction  of  the  whole  width  of 
their  accommodation.  So  far  as  the  using  of  concave  glasses  for  myopic 
eyes  is  concerned,  I  should  like  to  have  Dr.  Dyer  answer  whether 
there  was  any  insufficiency  in  all  these  cases. 

Dr.  Dyer. — I  am  very  liappy  indeed  to  answer  this  question.  I 
have  no  particular  method  of  determining  whether  there  is  any  insuffi- 
ciency of  the  internal  recti  besides  those  commonly  used.  I  am  never  sat- 
isfied with  the  first  examination;  I  always  try  both  eyes  successively 
and  come  to  the  best  conclusion  I  can;  if  I  can  not  determine  it,  I 
take  it  for  granted  that  it  is  not  there,  although  I  am  perfectly  aware 
of  the  difficulty  which  Dr.  Noyes  and  Dr.  Althof  have  expressed — the 
difficulty  of  determining  when  the  person  is  not  particularly  educated 
or  bright.  The  point  that  I  wished  to  bring  before  the  society,  and 
the  one  that  I  wished  particularly  to  have  discussed — an  idea  which  I 
am  not  competent  to  explain,  though  I  have  been  working  on  it  in 
giving  glasses  to  these  people — is  this  :  that  there  is  a  want,  a  de- 
ficiency, of  the  relative  accommodation,  or  a  discrepancy  between  the 
power  of  the  internal  recti  and  the  ciliary  muscle;  and  if  that  is 
altered,  and  the  hypermetropic  man  has  a  convex  glass  given  him, 
of  course  the  range  is  altered.  But  it  is  the  same  with  the  myope. 
That  is  one  principle  I  have  been  working  on,  and  endeavoring  to  es- 
tablish a  more  perfect  relation  between  the  two. 

Dr.  Althof. — Mr.  President,  I  was  far  from  believing  that  Dr. 
Dyer  had  not  taken  every  pains  to  ascertain  the  real  state  of  the  eye 
muscles  in  the  cases  of  myopic  patients  to  wliom  he  gave  concave 
glasses.  As  I  stated  before,  I  am  very  glad  indeed  to  have  heard 
the  point  introduced  in  the  way  it  has  been  to  the  notice  of  the  society, 
for  I  am  very  glad  of  having  the  opportunity  of  trying  some  remedy 
for  cases  which  I  have  given  up  as  incurable  by  me.  As  to  the 
allusion  made  by  Dr  Noyes  to  the  article  by  Dr.  Landsberg  in  the  last 
number  of  the  Archives,  I  for  my  part  do  not  believe  that  any  very 
beneficial  results  can  be  hoped  for  from  the  use  of  electricity.  It  is  at 
least  nine  years  since  a  physician  of  Berlin,  one  of  our  most  experienced 
physiologists,  communicated  to  the  society  of  Berlin  his  ideas  on  the 
use  of  electricity  in  diseases  of  the  eye.  I  recollect  myself  having  seen 
in  his  house  cases  sent  by  Graefe,  and  I  have  seen  any  quantity  of 
cases  treated  by  electricity  in  Berlin;  I  have  seen  plenty  of  them  iu 
Vienna  under  the  care  of  the  now  rather  celebrated  electrician,  Dr. 

 ,  but  I  have  never  seen  any  benefit  whatever  derived  from  the 

use  of  it. 

Dr.  Jeffries. — Mr.  Chairman,  I  did  not  intend  to  say  any  thing  on 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


61 


the  question  of  asthenopia,  thinking  my  report  already  presented  would 
be  sufficient;  but,  just  before  leaving  home,  I  received  one  of  the 
English  journals  in  which  the  physiology  of  the  ciliary  muscle,  and  also 
its  anatomy,  are  discussed  in  such  a  way  as  seemed  to  me  very  ex- 
traordinary. The  whole  of  the  experiments  of  Bonders,  Helmholtz, 
Ludwig,  and  every  other  eminent  physiologist,  and  their  conclusions  with 
reference  to  the  change  of  shape  of  the  lens  as  indicated  by  the  images 
reflected  from  its  anterior  and  posterior  surfaces  and  from  the  cornea, 
are  all  set  aside.  The  article  referred  to  is  in  the  last  number  of  the 
Ophthalmic  Review,  and  was  written  by  Dr.  Henry  Lawson.  I  was 
surprised  to  find  such  a  piece  in  this  journal,  which  is  supposed  to  hold 
a  high  position  in  the  department  to  which  it  is  devoted.  The 
author  has  fallen  into  an  error  in  drawing  from  analogy  (which  never 
proves  any  thing)  after  experimenting  with  the  eye  of  the  emu.  The 
idea  is,  that  the  ciliary  muscles  bend  the  cornea,  make  it  more  convex, 
and  elongate  the  eye.  I  should  infer  from  that  part  of  the  article 
relating  to  the  anatomy  of  the  muscle,  that  the  one  who  wrote  it 
entirely  neglected  to  take  notice  what  that  muscle  is.  The  circular 
fibres  were  discerned  by  Miiller  and  by  Arlt  at  the  same  time,  without 
any  correspondence  between  each  other,  and  also  by  somebody  else. 
Arlt  did  not  assume  that  the  function  of  accommodation  rested 
with  the  ciliary  muscle,  but  with  the  four  recti  muscles.  It  was 
with  the  idea  of  sustaining  his  theory  that  he  went  to  work  very 
carefully  on  the  eye  itself.  I  saw  his  way  of  going  to  work — the 
faithfulness  with  which  he  investigated  every  thing.  He  has  given  us 
the  anatomy  of  the  muscle  very  faithfully  and  very  perfectly. 

[Dr.  Jeffries  explained,  by  the  use  of  a  figure  on  the  blackboard, 
the  anatomy  of  the  muscle,  and  proceeded  to  criticise  the  article  in 
question.] 

Dr.  Dyer. — There  is  a  short  matter,  Mr.  President,  disconnected 
from  the  subject  that  has  been  discussed,  relating  to  the  facilities 
for  accurately  determining  astigmatism.  I  find  there  is  a  practical 
difficulty  in  using  the  lines  which  Snellen  has  given  us,  and  the  difficulty 
seems  to  be  that  tlie  lines  are  too  thick  for  their  length.  I  divided  the 
square  into  a  greater  rmmbcr  of  lines,  dividing  them,  however,  in  the 
same  manner,  and  making  them  horizontal  or  perpendicular,  one  cor- 
responding to  each  of  the  test  letters — 20,  40,  50,  etc.  I  find  them 
very  useful.  I  have  determined  it  with  patients  who  were  suffering 
from  actual  astigmatism,  and  by  observations  I  have  had  with  persons 
made  astigmatic  with  cylindrical  glasses.  I  here  exhil)it  a  drawing 
intended  to  illustrate  it — one  made  with  water  colors,  wliicli,  by  the 


62  PROGRESS  OP  THE  MEDICAL  SCIENCES.  [Oct., 

way,  I  am  not  ia  the  habit  of  using.  I  iutend  to  have  this  printed 
soon. 

Before  sitting  down,  however,  Mr.  President,  I  wish  to  relate  a 
series  of  experiments  which  I  have  been  carrying  on,  unsuccessfully, 
however;  but  a  description  may  interest  some  of  the  members  of  the 
society  and  induce  them  to  pursue  this  investigation.  It  occurred  to 
me  that  if  a  lens  were  colored  alternately  blue  and  yellow,  that  with  an 
astigmatic  patient  the  effect  of  those  ought  to  be  green,  on  the  same 
principle  that  a  wheel  painted  in  alternate  sections  yellow  and  green 
ought,  on  being  revolved,  to  exhibit  green.  I  find  they  do  not,  how- 
ever; they  look  more  like  gray  than  any  thing  else.  I  tried  it  with  a 
great  many  patients,  both  those  that  were  astigmatic  by  nature  and 
those  made  so  artificially.  I  have  tried  various  shades,  various  thick- 
ness of  the  lens,  various  differences  of  distance  between  the  lines,  tried 
them  with  oil  colors,  water  colors,  and  with  crayons.  I  have  pressed 
several  artists  into  the  experiments,  but  the  result  has  been  absolutely 
and  entirely  unsatisfactory.    Theoreti('ally  I  can  not  see  how  it  is. 

The  committee  on  the  nomination  of  ofBcers  for  the  ensuing  year 
then  reported  the  following  as  their  nominations  : 

For  President,  Dr.  Edward  Delafield,  of  New  York. 

Recording  Secretary,  Dr.  Henry  D.  Noyes,  of  New  York. 

Corresponding  Secretary,  Dr.  Herman  Althof,  of  New  York. 
Which  report  was  unanimously  confirmed. 

Adjourned  to  meet  at  Boston,  Mass.,  the  2d  Tuesday  of  June,  1866. 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 

I.— HYGIENE. 

1.  On  the  I/iJiuence  of  Sccial  Position  on  Life. 

It  is  said  proverbially  that  poverty  favors  longevity,  because  the 
poor  are  not  subjected  to  the  bad  consequences  of  luxury  and  wealth. 
Dr.  Majer  shows  the  folly  of  the  i)oi>uIar  dictum.  It  has  been  proved 
by  the  researches  of  Benoiston,  De  Chateauneuf,  De  Villerme,  Casper, 
and  others,  that  the  value  of  life  is  less  among  the  impoverished  than 
the  rich.  Thus,  of  an  equal  number  of  infants  of  the  same  age 
double  the  number  will  die  of  the  poorer  than  of  the  wealthier  class. 
Where  there  is  the  greatest  misery,  there  is  the  greatest  mortality. 
According  to  Casper,  the  mean  duration  of  life  among  the  better 
classes  of  Berlin  is  fifty  years,  but  among  the  i^aupers  thirty-two  years 
only.    The  same  writer  compares  the  death-rate  of  the  princely  and 


1865.]  PROGRESS  OP  THE  MEDICAL  SCIENCES. 


63 


noble  houses  given  in  the  Almanach  de  Gotlia  with  the  indigent  of 
Berlin,  and  he  shows  that  of  1000  infants  among  the  former,  57  die 
in  the  first  five  years  ;  but  of  the  same  number  among  the  latter,  3J:5. 
Whilst  the  half  of  the  poor  only  have  attained  the  thirty-second  year 
of  life,  half  of  the  noble  have  attained  the  fifty-second.  During 
epidemics  the  poorer  classes  are  in  an  especial  manner  decimated. 
That  simple  well-being  prolongs  Hfe  is  demonstrated  by  the  low  rate 
of  mortality  among  persons  who  "  assure  "  their  lives  in  the  assurance 
offices.  A  fifth  or  sixth  part  of  negro  slaves  die  annually.  But  the 
mortality  among  the  free  negroes  who  serve  in  the  English  colored 
regiments  is  only  3  per  cent.,  that  of  slaves  being  17  per  cent.  The 
learned  professions,  followed  generally  by  persons  of  easy  means,  have 
an  incontestable  influence  upon  the  duration  of  hfe.  Thus,  the  ruean 
age  of  fifty -two  French  literary  men  was  sixty-nine  years.  Physicians, 
according  to  Dr.  Escherich,  can  not  hope  for  a  long  life.  At  all 
periods  of  age  they  succumb  in  larger  numbers  than  other  professions. 
But  the  greatest  mortality  is  during  the  early  periods.  Three-fourths 
die  before  fifty  years  of  age,  and  ten-elevenths  before  sixty.  Old  men 
are  rare  among  them. — [Annales  cVHiigiine  Puhlique  et  de  Medecine 
Legale,  Jan.,  18G5  ;  Cansfalt's  Jaliresber.,  vii.,  58,  1864.)  {Half- Yearly 
Abstract  of  the  Medical  Sciences,  etc.) 

2.  Researches  on  Marriages  of  Consanguinity  in  the  Commune  of  Batz, 

near  Croisie  (Loire  Inferieure). 

Dr.  Viennois  spent  a  month  in  Batz,  the  residents  of  which  have, 
for  centuries,  been  in  the  habit  of  contractig  marriages  of  consan- 
giiinity,  and  of  living  in  nearly  total  isolation  from  the  neighboring 
districts.  There  were  46  such  marriages  at  the  time,  in  the  place. 
He  inquired  into  the  previous  history  of  the  husband  and  of  the 
wife  ;  he  examined  them  and  their  children,  with  regard  to  their 
physical  and  intellectual  development.  He  questioned  the  old 
members  of  the  community  also,  and  with  these  various  materials  he 
drew  up  tables  which  show  that  consanguinity  has  brought  on  no 
disease,  no  degeneration,  no  arrest  of  development,  and  that  the  stock 
has  remaiped  very  handsome  and  very  pure. — (Gazette  Hebd.  de  Med. 
et  de  Chir.,  Janvier  20  and  27,  1865.}  Half -Yearly  Abstract  of  the 
Medical  Sciences,  etc. 

3.  Consanguineous  Marriages. 

WhUe  touching  on  questions  still  involved  in  obscurity,  we  may 
briefly  advert  to  the  alleged  influence  of  consanguineous  marriages  on 
the  production  of  congenital  disease  or  deformity.  Several  new  points 
are  brought  forward  in  the  "  Archives  de  la  Medecine  Navale,"  and  in 
the  "Annales  de  la  Societe  de  Medecine  de  la  Loire." 

The  former  publication  adduces  some  interesting  information  on 
the  consanguineous  unions  of  the  negro  race,  and  more  especially  in 
the  posterity  of  the  Portuguese  merchant  named  Da  Souza,  who  died 
in  1849  at  Widah,  in  the  kingdom  of  Dahomey;  all  the  navigators 
who  have  of  late  years  traded  on  the  African  coast  are  well  acquainted 
with  these  curious  particulars.  Da  Souza,  who  for  many  years  lived 
in  the  country,  had  acquired  a  large  fortune  in  the  slave  trade,  and 
left  about  a  hundred  children,  the  ofi"spring  of  four  hundred  women 
immured  within  his  harem.  By  the  order  of  the  king  of  Dahomey, 
hostile  to  the  growth  of  a  half-caste  race,  this  numerous  progeny  has 


64 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Oct., 


been  confined  in  a  peculiar  inclosnre  (Salaim)  under  the  authority  of 
one  of  Da  Souza's  sons.  These  wretched  mulattoes,  unpopular  in  the 
country,  and  strictly  watched  by  the  agents  of  the  king,  the  most  ab- 
solute tyrant  in  existence,  have  no  possible  intercoui'se  but  with  each 
other,  or,  to  speak  more  plainly,  live  in  the  most  lamentable  state  of 
promiscuity.  In  1863,  the  third  generation  of  children  was  growing 
up.  The  color  of  their  skin  is  gradually  returning  to  ebony  black, 
although  they  i^reserve  in  their  features  sliglit  indications  of  a 
European  origin.  Now,  it  has  been  ascertained  that  among  all  the 
descendants  of  Da  Souza,  who  have  formed  amongst  themselves 
unions  between  the  very  closest  relations,  not  a  single  instance  exists  of 
deaf-muteness,  blindness,  cretinism,  or  congenital  deformity;  it  is, 
however,  an  equally  remarkable  fact  that  this  herd  of  human  beings  is 
gradually  decreasing  in  numbers,  and  that  its  total  extinction  at  no 
very  distant  period  can  even  now  be  predicted. 

This  decrease  does  not  appear  to  be  referable  to  consanguinity,  and 
it  would  be  irrational  to  apply  to  the  posterity  of  Da  Souza  an  argu- 
ment not  generally  admitted  in  the  case  of  Europeans. 

Sterility,  as  well  as  iDolydactylism  and  other  analogous  deformities, 
would  seem  to  be  attributable  to  some  other  cause,  such  as,  for  in- 
stance, what  Dr.  Hervier  terms  the  constitutional  predominance  of 
the  maternal  system.  This  gentleman  recently  communicated  to  the 
Medical  Society  of  Sainte-Etienne  a  paper  in  which  this  theory  is  in- 
geniously defended.  The  author  contends  that  the  social  inferiority 
in  which,  in  all  ages  and  in  eveiy  nation,  women  have  been  kept,  is 
not  the  result  of  mere  ignorance  and  prejudice.  Every  religious 
cosmogony  and  every  legislation  have  ratified  this  universal  belief  in 
the  dependency  and  subordination  of  the  female  sex,  actuated  either 
by  an  instinct  of  self-preservation,  or  by  the  observation  of  a  circum- 
stance which  seems  to  have  escaped  the  notice  of  anthropologists 
since  their  attention  has  been  directed  to  the  study  of  the  results  of 
consanguineous  unions.  The  fact  alluded  to  is,  that  in  every  family 
in  which  the  constitutional  powers  of  the  mother  are  in  a  considerable 
degree  superior  to  those  of  the  father,  the  offspring  is  physically  or 
mentally  deficient,  or  affected  with  congenital  deformities,  much  less 
frequently  observed  under  opposite  circumstances.  The  author,  in 
illustration  of  this  somewhat  hazardous  assertion,  brings  forward 
several  instances  of  women  of  Eive-de-Gier,  who  have  given  birth  to 
several  children  by  different  fathers.  "The  first  children,"  says  he, 
frequently  born  out  of  wedlock,  and  consequently  the  offspring  of 
men  of  superior  bodily  development,  (women  uncorrupted  by  love  of 
admiration,  or  by  want,  seldom  yielding  to  any  others, )  were  generally 
graceful  and  well-favored;  the  younger  children,  on  the  contrary, 
were  the  result  of  marriage  or  of  illegitimate  unions  brought  about 
by  a  craving  for  luxurious  indulgences,  or  by  pressing  want,  and  the 
fathers  were  generally  inferior  in  i^hysical  development  to  the  motliei-s. 
Hence,  between  the  two  classes  of  children,  a  marked  difference  in 
favor  of  the  former,  the  latter  being  generally  destitute  of  the  physical 
and  moral  perfections  observable  in  the  others." 

These  are,  in  addition,  but  the  results  observed  from  the  intercourse 
of  healthy  but  inharmonious  subjects,  and  "the  consequences  must 
be  far  more  striking,"  observes  Mr  Hervier,  "  if  one  of  the  parties,  or 
both,  labor  under  some  constitutional  taint.  Under  these  circum- 
stances, the  congenital  deviations  and  deformities  referred  to  consan- 
guinity, such  as  sterility,  polydactylism,  deaf  muteness,  <fec.,  can 
scarcely  fail  to  ai^iiear." 


1865.]  PROGRESS  OP  THE  MEDICAL  SCIENCES. 


65 


At  Kive-de-Gier,  a  town  eontaing  15,000  inhabitants,  the  author  has 
met,  in  crossed  couples,  in  which  the  blemish  alluded  to  existed, 
twenty-five  instances  of  sterility,  twelve  of  deaf-muteness,  and  three  of 
polydactylism ;  whereas,  in  upwards  of  twenty  consanguineous  but 
well  assorted  marriages  the  children  have  lived,  and  may  be  consid- 
ered as  models  of  health  and  symmetry. 

Mr.  Hervier  would  not  be  understood  to  assert  that  every  case  of 
deaf-muteness,  polydactylism,  or  deformity,  hitherto  ascribed  to  con- 
sanguinity of  the  parents,  is  necessarily  referable  to  the  unfavorable 
circumstances  here  pointed  out,  but  merely  contends  that  such  an  origin 
is  admissible;  and  he  therefore  suggests  a  modification  of  the  series  of 
questions  now  submitted  to  the  parties  at  the  municipal  offices  before 
proceeding  to  the  celebration  of  marriage.  He  conceives  that  it  would 
be  desirable  to  ascertain  what  is  the  nature  of  the  deformities  which 
the  constitutional  superiority  of  the  wife  over  her  husband  is  likely  to 
induce  in  the  offsijring;  and  also,  in  what  proportion  differences  of 
age,  temperament,  &c.,  between  the  parents  are  likely  to  prove  injuri- 
ous to  the  preservation  and  proper  development  of  the  human  race, 
at  least  in  a  physical  and  physiological  point  of  view. 

The  intervention  of  authorized  scientific  corporations  in  the  matter 
does  not  appear  necessary  to  accomplish  the  object  of  the  author;  it 
will  be  sufficient  to  invite  the  attention  of  observers  to  this  curious 
point  of  social  hygiene,  and  we  have,  therefore,  deemed  the  subject 
deserving  of  a  brief  notice  in  the  present  article. — Journal  of  Practical 
Medicine  and  Surgery, 


i.  On  Preventive  Medicine,  as  illustrated  in  the  proper  use  of  Food. 

Mr.  Wilson  thinks  that  we  are  all,  especially  our  children  and 
youths,  much  under-fed.  He  recommends  three  ample  meals  of 
mingled  animal  and  vegetable  food  ;  and  will  have  ' '  no  putting  off 
of  the  stomach  with  bread  and  butter  and  slop  as  the  effigies  of  two 
of  the  three  meals  of  the  day."    Mr.  Wilson  says  : 

"  But  a  period  comes  when  milk  is  no  longer  the  diet  of  children, 
and  when  custom,  originating,  as  we  have  seen,  in  Nature's  prompt- 
ings, has  determined  the  necessity  of  three  meals  in  the  day.  The 
infant  demands  more  than  three  meals,  and  makes  no  distinction 
between  the  day  and  the  night.  The  day  of  the  infant  is  a  day  of 
twenty-four  hours  ;  the  day  of  childhood,  as  of  the  remainder  of  life, 
has  a  duration  of  twelve  to  sixteen  hours.  The  three  meals  at  present 
under  consideration  are  the  morning  meal,  the  mid-day  meal,  tho 
evening  meal.  These  meals  represent  the  wants  of  the  body  arising 
during  the  intervening  intervals.  The  morning  meal  is  intended  to 
supply  the  moderate  waste  of  the  night,  the  mid-day  meal  the  active 
waste  of  the  morning,  the  evening  meal  the  active  waste  of  the  after- 
noon. The  amount  of  the  three  periods  of  waste  is  pretty  equal ;  the 
amount  of  the  supply  should  be  equivalent  to  that  of  the  waste. 

"I  am  desirous  of  impressing  upon  my  hearers  my  opinion  and  firm 
conviction  that  food  is  not  only  a  necessity,  but  in  civilized  life  a 
three-fold  necessity,  and  that  the  three  meals  should  each  represent 
the  third  of  the  nourishment  of  the  day,  and  be  so  apportioned  as  to 
comprehend  an  equal  amount  of  variety  and  an  equal  amount  of 
nourishment.  In  the  primitive  life  of  the  laboring  class  this  law  is 
fully  appreciated,  and  is  acted  upon  to  the  full  extent  of  their  means. 
With  the  exception  of  a  somewhat  more  bulky  mid-day  meal,  the 

Vol.  II.— Xo.  7.  5 


66 


PROGRESS  OP  THE  IfEDICAL  SCIENCES, 


[Oct., 


morning  meal  and  the  evening  meal  do  not  far  diverge  from  the 
standard  of  the  mid-day  repast.  ^  x, 

"But  the  educated  classes  are  apt  to  fancy  that  they  possess  a 
knowledge  superior  to  that  of  Nature,  and  the  result  is  a  perversion 
of  the  law  of  nourishment  that  leads  to  the  development  of  debility 
and  disease.  A  careful,  well  meaning  mother,  from  purest  ignorance 
—another  expression  for  superior  knowledge,  the  "little  knowledge 
that  is  so  proverbially  dangerous— wiU  tell  you  that  she  conform.s  to 
the  law  of  Nature  in  providing  for  her  children  three  meals  in  the 
day  She  wiU  describe  those  meals  as  breakfast,  dinner,  and  tea,  and 
you  wiU  find  the  composition  of  those  meals  to  be  as  follows  :  A 
vegetable  breakfast,  namely,  bread  and  butter,  with  tea  and  a  httle 
milk  -  a  dinner  half  animal  and  half  vegetable  ;  and  a  "tea,"  vege- 
table'like  the  breakfast.  Here,  then,  we  find  education  bringing 
about  a  total  change  in  the  diet  of  man.  Born  an  animal  feeder,  he 
is  quickly  transformed  into  a  vegetable  feeder  ;  that  is,  more  than 
two-thirds  of  his  diet  is  vegetable  and  the  remaining  third  only 
animal,  the  exact  opposite  of  that  which  I  consider  should  be  the 
standard  diet  of  children,  namely,  one-third  vegetable  and  two-thirds 

^"^'•Jly  deduction  from  these  premises  is,  that  children  are  almost 
universally  under-fed,  and  that  the  majority  of  the  diseases  of 
children  arise  from  the  debilitv  of  constitution  induced  by  this  habit 
of  under-feeding.  If  I  am  right  in  this  view,  preventive  medicine 
may  do  much  in  the  prevention  of  disease  by  correcting  an  error  so 

The  d^et'of  children  of  all  ages  should  be,  a  substantial  breakfast, 
with  animal  food  in  some  shape  ;  a  substantial  dinner  of  meat,  vege- 
tables, and  cereal  pudding  ;  and  a  substantial  supper,  also  consisting, 
in  part,  of  animal  food.  The  drink  may  be  milk,  tea,  cocoa,  and, 
possibly,  beer.  I  would  call  this  the  diet  of  health  ;  a  diet  capable  of 
making  a  strong  body  and  also  a  strong  mind  ;  and  a  diet  capable  of 
preventing  disease.  Compare  it  for  an  instant  with  the  mdk-and- 
water  and  bread-and-butter  diet  of  some  establishments  ;  the  meagre 
dinner  of  meat,  and  the  miserable  grouting  of  rice  and  amylaceous 
pulp.  Piice  and  amylaceous  pulp  should  have  no  place  in  the  diet  of 
health,  but  should  be  reserved  for  the  sick  room. 

"  Born  in  prejudice  and  matured  in  prejudice,  it  is  the  struggle  of 
a  lifetime  to  throw  off  the  trammels  of  prejudice.  We  are  apt  to 
attach  a  peculiar  signification  to  the  terms  which  we  are  in  the  habit 
of  employing.  Ask  a  person  what  he  usually  takes  for  breakfast, 
and  he  will  pretty  certainly  begin  his  enumeration  with  the  word 
"  tea  "  the  mere  drink  of  the  meal ;  it  is,  in  truth,  with  him  a  mere 
break-fast,  instead  of  being,  as  it  ought  to  be,  a  substantial  morning 
meal.  The  dinner  of  labor  is  the  luncheon  of  fashion  ;  then  follows 
the  mildly  alkaUne  and  stimulating  drink  that  is  termed  "the  tea  ;'' 
and  last  of  all  comes  the  supper,  the  late  dinner  of  fashionable  life. 
We  have,  therefore,  before  us  a  succession  of  three  meals  and  an 
intermediate  drink,  but  the  drink  precedes  the  last  meal ;  and,  there- 
fore, the  orderly  matron,  who  is  more  attentive  to  her  1,  2,  3  than  she 
is  to  the  intention  of  the  daily  fare,  prescribes  for  her  children  break- 
fast, dinner,  and  tea— two  slops  and  a  meal.  But  let  her,  in  good 
English  phrase,  call  the  children's  meals  breakfast,  dinner,  and  sup- 
pei%  and  then  we  immediately  obtain  two  dinners  and  one  slop,  the 
breakfast— an  obvious  improvement.  I  have  secured  to  many  a  child 
a  reasonable  evening  meal  by  suggesting  to  the  mother  the  mere  use 


1865.]  PROGRESS  OP  THE  MEDICAL  SCIENCES.  67 


of  the  word  "supper"  as  the  name  of  the  third  meal.  No  human 
being  could  call  bread  and  butter  and  tea  by  the  hearty  name  of 
supper. 

"Assuming  that  the  amount  and  richness  of  the  supply  of  food 
should  be  determined  by  the  offices  which  it  has  to  perform,  there  is 
no  period  of  life  when  more  food  is  required  than  in  childhood  and 
youth.  The  hard-worked  laborer  in  a  long  summer's  day  scarcely 
exhausts  a  gxeater  quantity  of  nutritious  matter  than  a  growing  boy  of 
ten  or  twelve  years  of  age;  in  the  laborer  the  consumption  is  waste; 
in  the  growing  boy  it  is  bestowed  in  the  construction  of  the  body,  in 
developing  and  building  up  the  future  man.  And  it  is  no  uncommon 
thing  to  find  that  although  the  general  construction  of  the  body  has 
been  fairly  performed,  there  is  some  one  organ  of  the  economy  that 
has  fared  less  well  than  the  rest,  and  that  part  not  uncommonly  the 
skin;  hence  the  origin  of  acne,  of  the  ringworms,  tt  hoc  genus  omne. 

"If  it  be  admitted  that  food  is  the  source  of  the  elements  of  Avhich 
the  body  is  composed,  what  kind  of  body  can  be  expected  in  the  case 
of  a  deficient  supply  of  food,  whether  that  deficiency  proceed  from 
actual  want  or  from  some  perverse  theory  of  refinement  founded  on  a 
false  conception  of  the  nature  and  objects  of  food,  and  of  its  direct 
convertibility  into  the  flesh  and  blood  of  man  ?  Parents  are  too  apt 
to  take  their  own  stomachs  as  the  standard  of  diet  of  their  children  ; 
a  cup  of  tea  and  a  slice  of  toast  suffices  for  them,  so  it  must  suffice  for 
the  little  ones.  I  knew  a  lady  who  brought  up  her  children  on  mutton 
alone,  because  she  herself  could  digest  nothing  but  mutton.  Her 
children  were  a  feeble,  puny,  sheepish  race,  always  in  the  doctor's 
hands.  A  mother,  in  anticipation  of  the  full  meal  at  seven  o'clock, 
can  afi'ord  a  light  lunch;  but  she  unfortunately  concludes  that, 
because  a  light  mid-day  meal  is  good  for  her,  a  spare  dinner  is  equally 
proper  for  her  children.  She  has  heard  somewhere  that  suppers  are 
heavy  and  interfere  with  sleep;  so  the  children  must  be  content  with 
their  tea,  and  go  supperless  to  bed.  Parents  have  rights  over  their 
children,  but  not  the  right  of  feeding  them  in  such  a  manner  as  to 
make  them  the  subject  of  disease.  Such  parents  become  the  authors 
of  a  puny  and  degenerate  race,  and  are  unintentionally  traitors  to 
their  country. 

"  If  the  two  periods  of  life  already  adverted  to  be  important  in 
their  influence  on  the  future  man— namely,  the  period  of  infancy, 
ranging  from  birth  to  the  age  of  two  years,  and  the  period  of  child- 
hood, ranging  from  two  years  to  seven  years— the  next  two  periods, 
namely,  those  of  boyhood  and  youth,  are  equally  so.  While  the 
food  of  the  infant  and  the  food  of  the  child  are  abundant  and  regular, 
the  food  of  the  boy  and  the  food  of  the  youth  should  be  the  same. 
Both  are  occupied  in  the  great  business  of  growing  life  ;  on  both  are 
dependent  the  future  man,  for  his  strength  and  for  his  manhood  "— 
(Medical  Tim.ef.  cfc  Gazette,  January  27th,  1865.)  Half- Year  I, j  Al- 
stract  uf  the  Medical  Sciences,  etc. 


6.  Wine,  mighty  Wine. 

Dr.  Jules  Guyot  thus  says  or  sings  of  his  country's  wines  in  V  Union 
Mkdicale : 

_  However  far  back  we  look  into  Pagan,  Jewish,  or  Christian  civiliza- 
tion, we  find  the  vine,  and  its  fermented  juice,  wine,  in  the  highest 
repute  as  an  inspirer  of  the  human  heart. 
In  Pagan  times,  the  vine  and  wine  had  their  gods,  their  priests,  and 


68 


PROGREBS  OF  THE  MEDICAL  SCIENCES. 


[Oct., 


■worship.  Wine  inspired  the  poets,  and  in  their  mouth  celebrated 
love,  gloiy  and  genius,  the  agents  of  all  civilization. 

In  Jewish  days,  sacred  hi.story  everywhere  offers  us  the  vine  as  a 
symbol  of  fectindity  and  riches,  and  wine  as  the  source  of  force  and 
contentment  of  the  human  heart.  From  the  days  of  the  Deluge  the 
vine  and  wine  are  linked  to  man's  existence  as  forming,  in  some  sense, 
a  part  of  his  first  regeneration. 

Then  comes  the  Christian  era,  when  we  find  Jesus  showing  the  ne- 
cessity of  the  use  of  wine  in  family  repasts  and  social  meetings,  by  the 
miracle  at  the  marriage  at  Cana. 

The  pure  fermented  juice  of  the  grape — natural  wine — is,  in  fact,  the 
most  generous  in.spirer  of  the  heart  of  man;  it  opens  a  new  era  to 
man's  siurituality,  and  conducts  him  Tipwards  towards  perfection,  by 
insi:)iring  him  with  love  and  genius.  This  is  one  of  the  great  truths 
inscribed  in  the  sacred  writings,  accepted  originally  by  ingenuous 
faith,  rejected  by  pride  and  philosophic  ignorance,  but  soon  recog- 
nized by  the  true  science  of  observation. 

Read  the  history  of  ancient  and  of  modern  peoples,  and  you  may 
calculate  their  degree  of  civilization,  their  courage,  their  goodness, 
their  genius,  by  the  use  of  wine  as  an  alimentary  constituent  of  their 
ordinary  repast. 

The  surface  of  the  earth  is  large,  but  the  siiots  where  the  vine  will 
grow  are  small;  and  we  find  that  true  genius  has  arisen  at  those  spots, 
and  has  extended  thence,  and  only  into  those  parts  into  which  wine 
has  been  imported. 

Where  the  wine  enters  not,  there  exists  neither  science,  nor  arts,  nor 
manufactures.  Islamism  owes  its  imperf ectability  and  its  decay  chiefly 
to  its  proscription  of  wine. 

There  is  only  one  true  wine  proper  to  nourish  and  fortify  the  heart 
and  the  mind  of  man  fraternally  and  socially  and  Christianly;  and 
that  is  the  pure  juice  of  the  grape,  obtained  by  simple  fermentation. 
Wiaes  that  have  been  boiled,  sweetened,  and  distilled,  are  no  longer 
natural  alimentary  and  physiological  wines.  These  may  please  the 
taste  and  nourish  the  body;  but  they  have  not  the  jiower  of  uniting 
men  in  spirit,  and  of  elevating  their  hearts. 

He  who  uses  gi'ape  wine  is  of  good  and  generous  heart,  joyous  and 
promjit  in  spirit;  he  produces  much,  and  is  bountiful  to  his  brothers. 
He  who  drinks  of  other  wines  is  cold  and  heavy  in  heart  and  spirit, 
and  is  rather  disposed  to  take  than  give. 

France  has  for  centuries  cultivated  the  grape.  First  it  was  estab- 
lished in  its  hotter  provinces;  now  it  is  ciUtivated  in  eighly  depart- 
ments. To  it  France  owes  a  great  part  of  its  population  and  its 
riches,  its  force,  its  contentedness,  its  bravery,  its  genius,  and,  above 
all,  its  love  and  devotion  to  aU  humanity. 

Wines,  pure  and  natural,  associated  as  drinks  with  ordinary  food, 
are  essentially  hygienic.  Cheap  wine  is  the  wine  of  the  people. 
Drunk  in  moderation — one  bottle  to  two  or  three  people — it  gives  force 
and  courage,  and  nourishes  like  bread  and  wine.  The  wine-grower 
sells  his  best  wine,  and  drinks  the  weakest;  but  he  is  strong,  and  con- 
tented, and  happy.  If  he  drink  beer  or  cider,  he  is  strong,  but  he  is 
also  saddened.  If  he  have  only  water,  he  is  feeble  and  wretched. 
Tea  and  coffee  have  their  bodily  and  spiritual  influence;  but  wine  alone 
bears  with  it  the  traditional  inspiration  of  humanity. 

Pure  natural  wines,  even  when  taken  to  excess  at  the  festive  board, 
do  not  produce  evil  results.  A  free  and  vivacious  gayety,  an  exagger- 
ated sentiment  of  universal  love  and  benevolence,  are  the  excessive  in- 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


69 


spirations  of  good  wine.  The  illustrions  Cobclen  has  well  said,  French 
wines  are  the  true  wines  of  spiritual  gayety;  and  twenty  years  hence 
it  will  be  added,  they  are  the  true  wines  of  civilization  and  universal 
peace. 

The  vice  of  drunkenness  is  unknown  amongst  the  growers  of  the 
vine.  The  most  degraded  forms  of  drunkenness  are  observed  amongst 
those  who  partake  of  falsified  wines,  and  spirits  extracted  from  grains, 
potatoes,  beet-root,  etc. 

The  true  qualities  of  French  wines  are  their  purity  and  primitive 
simplicity;  and  they  must  be  appreciated  rather  by  their  hygienic  and 
physiological  than  by  their  sensual  qualities.  France,  almost  alone  in 
the  world,  produces  wines  hygienic,  physiological,  and,  as  an  old  Latin 
inscription  over  the  door  of  the  cellars  of  the  Chateau  de  Sauvigny 
has  it,  theological.  These  wines  offer  a  thousand  shades  of  difference, 
corresponding  to  as  many  different  qualities,  and  to  as  many  different 
effects  produced  npon  the  mind  and  body.  Every  temperament,  ev- 
ery social  position,  can  have  the  wine  best  suited  to  it.  In  the  wines 
of  Burgundy  we  have  a  generous  bouquet,  fullness,  and  warmth,  a  stim- 
ulating and  rich  taste;  they  give  force  and  activity  to  the  body,  rich- 
ness of  ideas,  and  gayety  spiritual  and  genial. 

The  wines  of  Bordeaux  possess  a  bouquet  delicious  and  unrivaled 
in  expansion,  duration,  and  softness;  a  taste  full,  velvety,  and  bal- 
samic. They  render  the  digestion  easy;  they  give  comfort  and  repose 
to  body  and  mind,  and  distui-b  not  the  brain. 

Champagne  wines  should  figure  at  all  the  festivals  of  families  and  of 
nations.  They  have  rendered  great  services  to  the  spirit  of  associa- 
tion, and  have  produced  so  many  happy  and  fertile  ideas,  that  they 
may  be  well  considered  as  powerful  elements  in  the  social  and  spiritual 
movements  of  mankind. 

The  wines  of  the  Alps,  the  Pyrenees,  of  the  Rhone,  the  Garonne, 
the  Loire,  the  Seine,  the  Moselle,  and  the  Rhine,  are  treasures  of  in- 
spiration, of  love,  bravery,  and  genius.  France  is  the  California  of 
the  esprit  and  the  heart  of  men.  Its  cellars  are  the  richest  depots  of 
the  concord,  the  happiness,  and  the  progress  of  humanity. — BrilisJi 
Medical  Journal,  Sept.  9,  lb65. 


II.— OBSTETRICS  AXD  DISE  ASES  OF  WOMEN  AND 
CHILDREN. 

6.  0)1  Habitual  Abortion  in  Flexion  of  the  Uterus, 

It  is  well  known  that  many  women  are  unable  to  carry  an  ovum  to 
the  full  term  of  utero-gestation,  and  that  they  abort  at  the  same 
period,  in  successive  pregnancies,  without  manifest  cause.  This  has 
been  explained  by  supposing  that  the  first  abortion  impresses  upon 
the  uterus  some  peculiar  weaknes-s  or  tendency  to  abort ;  so  that  the 
event  recurs,  even  although  the  original  cause  be  no  longer  in  opera- 
tion. The  author  does  not  accept  this  exijlanation,  but  belives  that 
every  abortion  must  have  some  determinate  cause,  and  that  the  pre- 
sumed "  tendency  "  to  abortion,  as  a  mere  result  of  previous  abor- 
tions, exists  only  in  imagination. 

While,  on  the  one  hand,  it  miy  very  well  happen  that  the  so- 
called  habitual  abortion,  in  any  patient,  may  depend  upon  the  con- 
tinued action  of  the  same  cause,  it  may  also  depend,  each  time,  upon 


70 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Oct., 


a  different  one.  It  lies  beyond  tlie  scojie  of  a  journal  article  to  discuss 
all  the  possible  causes  of  abortion  ;  and  the  author  confines  his  obser- 
Yations  to  three  cases,  -Nvhich  appeared  to  depend  upon  ante-flexion  of 
the  uterus.  It  is  •well  known  that  abortion  may  be  produced  not  only 
by  flexions,  but  also  by  other  malpositions  of  the  uterus.  This  has 
been  explained  by  supjaosing  that  the  uterus,  in  its  unnatural  position, 
exerts  compression  vipou  both  its  own  and  the  j^elvic  blood  vessels, 
and  thus  impedes  the  return  of  venous  blood  from  its  tissues.  In  this 
■way  is  produced  a  permanent  congestion  of  the  uterine  i)arenchyma  ; 
and  this,  at  the  period  of  menstruation,  may  lead  to  rupture  of  the 
vessels  of  the  hyperjemic  uterine  placenta,  or  of  the  decidua.  Such 
rupture  may  produce  sufficient  hemorrhage  to  detach  the  ovum  and 
produce  its  expulsion ;  or  it  may  be  only  enough  to  threaten  an 
abortion  which  treatment  will  prevent. 

The  ordinary  chronic  hyjieriemia  of  uterine  flexion,  which  affects 
the  mucous  membrane  as  well  as  the  parenchyma,  is  much  increased 
at  the  commencement  of  pregnancy.  Every  flexion  also  modifies  the 
changes  of  position  of  the  gravid  uterus,  which,  through  its  increasing 
weight,  becomes  more  or  less  ante-  or  retro-verted.  Hence  there  is 
an  addition  to  the  ordinary  impediment  to  the  return  of  venous  blood, 
and,  at  the  same  time,  an  unusually  active  flow  of  arterial  blood.  The 
increase  of  the  ante-  or  retro-version  is  what  chiefly  requires  attention ; 
since  this,  and  not  the  flexion,  is  the  exciting  cause  of  abortion. 

Anteflexion  is  the  malposition  that  most  frequently  causes  habitual 
abortion,  although  it  may  often  not  be  recognized  at  the  time,  being 
much  diminished  by  the  contraction  of  the  longitudinal  muscular 
bands,  so  that  the  uterus  may  come  to  have  its  long  axis  coinciding 
with  that  of  the  pelvic  entrance.  As  involution  takes  place,  the 
former  flexion  reappears. 

As  practical  rules,  the  author  lays  down  the  following  :  1.  If  a 
woman  suffering  from  flexion  become  i^regnant,  she  should  be  ex- 
amined in  the  second,  or,  at  latest,  in  the  third  month  of  her  preg- 
nancy, in  order  to  ascertain  what  changes  of  position  the  uterus  has 
undergone.  2.  In  any  case  in  which  abortion  has  already  commenced, 
without  assignable  cause,  an  examination  should  be  made  some  time 
afterwards,  in  order  to  ascertain  whether  there  be  any  flexion  present, 
which,  during  the  actual  period  of  abortion,  was  for  the  time  over- 
come by  muscular  action. 

In  mentioning  the  want  of  statistics  upon  the  question  of  the  con- 
nection between  flexion  and  abortion,  the  author  jjoints  out  that  the 
power  to  ijroduce  an  injurious  degree  of  congestion  must  depend  upon 
the  degree  of  the  malposition;  and  that  the  slighter  grades  may  be 
entirely  harmless. 

The  rational  treatment  consists  in  an  endeavor  to  remedy  the  flexion 
in  the  non-pregnant  state,  so  as  both  to  facilitate  conception,  and  to 
prevent  the  recurrence  of  the  dangerous  ante-  or  retro-version  when 
pregnancy  takes  i^lace.  The  absolute  cure  of  a  flexion  can  only  very 
seldom  be  effected;  but  sufficient  improvement  for  the  end  in  view 
may  generally  be  obtained.  After  such  imiDrovement,  it  is  still 
necessary  to  examine  the  position  of  the  uterus  in  early  pregnancy, 
and  to  see  if  it  can  be  modified  with  advantage. 

The  author's  treatment  consists  in  confining  the  patient  to  bed 
eight  days  before  the  time  at  which  the  second  menstrual  period 
would  occur  if  she  were  not  pregnant  ;  and  in  a  daily  endeavor  to 
rectify,  by  the  fingers,  any  malposition  that  examination  may  detect. 
If  the  tendency  be  towards  anteversion,  the  patient  must  lie  on  her 


1865.] 


PROGEESS  OP  THE  MEDICAL  SCIENCES'. 


71 


back  ;  if  towards  retroversion,  on  her  side.  She  must  remain  in  bed 
for  eight  days  after  the  menstrual  time,  continuing  the  same  daily- 
treatment,  and  then  may  rise,  and  move  about  cautiously,  avoiding 
strong  exertion.  Eight  days  before  the  third  period  she  must  return 
to  bed,  and  again  undergo  daily  manipulation  ;  but,  when  the  first 
week  of  the  fourth  month  has  passed,  if  the  uterus  (as  is  usual)  has 
then  risen  well  above  the  pelvic  brim,  all  fear  of  ante-  or  retro-version 
may  be  laid  aside,  the  patient  may  leave  her  bed,  and  return  to  her 
ordinary  mode  of  life. 

The  author  concludes  by  expressing  his  belief  that  flexions  of  the 
womb  are  not  cured  by  ordinary  pregnancy,  but  that  they  are  repi-o- 
duced  after  labor  at  full  time. — ( Monaleschrift  f.  Gehurlak,  September, 
1864  •,  imA  Sclimidt's  Jahrhucher,  No.  2,  1865.)  Half-Yearly  Abstract 
of  the  Medical  Sciences,  etc. 

7.  Amenorrhcea. 

The  history  of  ovulation  has  supplied  M.  Raciborski  with  a  new 
field  of  inquiry,  which  he  has  laboriously  cultivated,  and  in  which  he 
has  succeeded  in  discovering  new  physiological  aspects  unknown  to,  or 
at  least  not  described  by,  his  predecessors.  Amongst  other  interesting 
subjects,  lie  expatiates  on  a  form  of  amenorrhcea  due  to  mental  causes, 
such  as  excessive  dread  of  pregnancy,  oi%  on  the  contrary,  an  inordi- 
nate desire  of  bearing  children.    (Archives  de  Medicine,  May,  1805. ) 

In  the  male  mental  pre-oceupation  greatly  influences  the  in-ocreative 
function.  Montaigne,  in  his  remarks  on  the  power  of  imagination, 
relates  an  instance  of  transient  sexual  incompetency,  of  which,  in  all 
probability,  he  had  himself  been  the  subject.  Incapacity  of  this  kind 
is  of  frequent  occurrence,  and  insjsires  no  anger  to  a  sensible  wife, 
aware  that  kindness  will  prove  far  more  successful  in  restoring  power 
than  bitter  reproach  and  offensive  expressions  of  scorn.  The  physio- 
logical explanation  of  this  unsatisfactory  condition  is  simple.  In  con- 
sequence of  the  apprehension  of  failure,  the  mental  frigidity  is 
conveyed  by  the  sympathetic  system  of  nerves  from  the  brain  to  the 
organs  of  generation,  and  the  result  is  an  entire  cessation  of  their 
powers  of  expansion.  Under  the  influence  of  the  vaso-motor  nerves, 
the  blood  vessels  of  these  organs  contract,  the  temiierature  of  the  part 
is  lowered,  and  a  condition  ensues  in  which  sexual  access  becomes 
impracticable. 

M.  Raciborski,  arguing  from  analysis,  opines  that  the  excessive 
dread  of  pregnancy,  or  the  immoderate  desire  of  bearing  children,  act 
on  the  female  in  a  somewhat  similar  manner,  and  may  induce  more  or 
less  delay  in  the  appearance  of  the  catamenia,  and  even  a  protracted 
state  of  amenorrhcea. 

This  author  was  consulted  on  several  occasions  by  women  who,  after 
a  long  struggle,  had  yielded  to  their  feelings  and  forgotten  their 
virtuous  resolutions.  Alarmed  at  the  possible  consequences  of  their 
imprudence,  and  living  in  perpetual  terror  of  pregnancy,  they  im- 
patiently counted  the  days  which  must  intervene  before  the  return  of 
the  menses,  and  anxiously  watching  for  the  usual  premonitory  symp- 
toms, awaited  in  a  state  of  most  distressing  jjerplexity  the  time  at 
which  their  woi-st  fears  might  be  allayed  or  confirmed.  In  a  case  of 
this  kind,  a  lady,  usually  perfectly  regular,  was  thrown  by  a  delay  of 
one  week  into  a  state  bordering  on  insanity.  Tlie  treatment  adopted 
by  M.  Raciborski  consisted  in  arguments  calculated  to  remove  her 
fears,  to  which  he  mainly  attributed  the  alarming  ijostponement  of  the 


72 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Oct., 


catamenia,  and  in  the  exhibition  of  harmless  remedies.  He  prescribed 
gentle  anodynes,  and  the  mildest  form  of  stimulants,  sucli  as  a  few 
drops  of  liq.  ammon.  acetatis  in  lime-flower,  or  black-currant  tea,  and 
mustard  foot-baths.  After  an  interval  of  two  days,  the  menses  reap- 
peared, and  the  delighted  patient  solemnly  declared  that  the  le.sson 
•would  never  be  forgotten. 

On  the  other  hand,  M.  Eaciborski  asserts  that  too  ardent  a  wish 
for  children  may  also  act  in  a  reflex  manner  on  the  vasso-motor  nerves 
of  the  ovaries,  and  induces  amenorrhcca. 

"In  young  married  women,"  says  he,  "  it  is  not  unusual  to  observe 
at  several  successive  monthly  periods  a  delay  of  a  few  days  before  at 
last  they  become  really  pregnant.  These  delays  are,  in  a  certain  degree, 
referable  to  a  strong  desire  to  have  a  family.  When,  however,  several 
months  have  elapsed  without  any  sign  of  this  much  ivished  for  result, 
the  anxiety  on  the  subject  often  becomes  excessive;  and  constantly 
preoccupied  with  one  idea,  that  she  may  be  sterile,  the  young  wife 
feels  happy  when,  at  the  return  of  the  date  at  which  the  menses  may 
be  expected,  she  experiences  none  of  her  customary  symptoms;  she 
hopes  that  the  catamenia  may  fail,  and  that  at  last  she  is  pregnant. 
At  each  monthly  period  she  is  agitated  by  the  same  hopes,  and,  to 
avoid  a  disappointment,  submits  to  all  manner  of  precautions.  Be- 
tween this  kind  of  amenorrhcea  and  that  we  have  previously  described, 
a  considerable  difference  exists.  In  the  former,  when  the  patient 
dreads  pregnancy,  every  efibrt  is  made  by  her  to  bring  on  menstruation, 
which,  in  general,  reappears  in  the  course  of  a  few  days.  In  the 
latter,  on  the  contraiy,  all  the  precautions  taken  to  prevent  the  frus- 
tration of  cherished hopes,  the  absolute  repose  joyfully  submitted 
to,  the  complete  abstinence  from  any  cause  of  mental  or  physical  ex- 
citement, all  contribute  to  perpetuate  the  modified  condition  of  the 
ovarian  circulation,  and  to  protract  the  duration  of  the  amenorrha?a. 
The  greater  number  of  the  cases  of  what  has  been  termed  Grosesses 
nerreuses,  recorded  by  various  authors,  have  no  other  origin,  and  are 
almost  invariably  instances  of  protracted  amenorrhcea  referable  to 
this  cause." 

M.  Raciborski  relates  an  interesting  case  in  point;  but  his  remarks 
on  the  variety  of  amenorrha?a  due  io  the  apprehension  of  j^re/jnancy 
appear  to  us  original,  and  deserving  of  the  attention  of  the  practi- 
tioner.— Medical  Circular,  August  2,  1865. 


8.    On  the  irtflttence  of  Uterine  Displacements  upon  the  Sterile  Condition. 

Dr.  Marion  Sims  said  that  we  were  all  interested  in  the  subject  of 
sterility,  when  we  remember  the  fact  that  every  eighth  marriage  was 
sterile.  He  did  not  propose  then  to  give  us  a  complete  paper  on  the 
subject,  but  only  to  present  it  in.  one  of  its  relations,  viz. :  that  of  its 
dependence  upon  misplacements  of  the  uterus.  He  divided  his  sterile 
patients  into  two  clases  :  1st.  Those  who  were  married  a  sufficient 
length  of  time  and  did  not  conceive;  2d.  Those  who  had  borne  chil- 
dren, but  for  some  reason  ceased  to  do  so  long  before  the  termination 
of  the  child-bearing  period.  The  first  he  called  "natural  sterility;" 
the  second,  "acqiiired  sterility." 

To  show  the  frequency  of  uterine  displacements  in  this  relation,  he 
said  that  of  250  cases  of  "natural  sterility"  that  had  fallen  under  his- 
observation,  103  had  antcversion,  and  (Vs  retroversion;  and  of  255 
cases  of  "  acquired  sterility,"  Gl  had  anteversion,  and  111  retroversion. 


1865.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


73 


the  anteversions  predominating  in  the  first  class,  the  retroversions  in 
the  second — the  two  opposite  displacements  being  almost  in  inverse 
proportion  in  the  two  classes,  and  forming  about  two-thirds  of  the 
■whole  number,  being  'S-i'd  out  of  505  cases;  which  proved  beyond  ques- 
tion the  bearing  and  importance  of  these  displacements  in  connection 
■with  the  sterile  condition.  He  then  illustrated  by  diagrams  the  normal 
position  and  relations  of  the  uterus,  explained  the  various  causes 
and  comialications  of  anteversion,  ■whether  dependent  wpon  fibroid 
tumors,  elongation  of  the  infra-  or  supra-vaginal  cervix,  shortening 
of  the  utero-sacral  ligaments,  or  hypertrophy  of  the  fundus.  In  all 
these  cases,  he  said,  we  could  not  do  much  for  the  relief  of  the  sterile 
condition  by  merely  mechanical  means ;  that  our  efforts  should  be  di- 
rected to  seeing  that  the  os  tiucie  was  properly  open,  that  the  canal 
of  the  cervix  was  free  from  engorgement,  and  that  the  secretions, 
both  vaginal  and  cervical,  were  not  j^oisonous  to  the  spermatozoa.  He 
said  that  there  was  one  form  of  anteversion  that  was  easily  cured  by  a 
simple  and  novel  operation,  ■which  he  originated  some  eight  or  nine 
years  ago.  He  illustrated  this  by  cases  and  diagrams.  It  was  as 
follows  :  The  uterus  lies  down  on  the  anterior  wall  of  the  vagina,  and 
parallel  with  it.  The  fundus  is  most  usually  the  seat  of  a  fibroid 
growing  anteriorly.  The  anterior  wall  of  the  vagina  is  greatly  elon- 
gated, the  OS  tinciie  pointing  directly  backwards,  Under  these  circum- 
stances, he  has  shortened  the  anterior  wall  of  the  vagina  an  inch  and 
a  half,  by  denuding  a  surface  a  half  inch  wide  and  two  inches  long 
across  the  axis  of  the  vagina  in  juxtaposition  with  the  cervix  uteri,  and 
making  a  similar  transverse  scarification  parallel  ■with  the  first,  about 
an  inch  and  a  half,  more  or  less,  anteriorly  to  it,  and  then  uniting 
these  two  transverse  cut  surfaces  by  silver  sutures,  just  as  we  woiild 
unite  the  edges  of  a  transverse  vesico-vaginal  fistula  by  them.  This 
necessarily  shortens  the  elongated  anterior  wall  of  the  vagina,  draws 
the  cervix  forwards  into  its  normal  relations,  and  as  a  consequence 
elevates  the  fundus.  He  related  several  successful  ca.ses  of  this  oper- 
ation, and  had  seen  it  followed  by  conception  and  child-bearing.  He 
then  passed  to  the  consideration  of  retroversion  as  influencing  the 
sterile  condition,  pointed  out  its  varieties  and  anomalies,  and  showed 
how  it  was  to  be  diagnosed  and  how  replaced.  By  diagrams  he  illus- 
trated various  modes  of  reduction,  showed  how  conception  was  difii- 
cult,  and  sometimes  impossible,  in  some  forms  of  retroversion, 
advocated  mechanical  treatment,  pointed  out  the  dangers  of  23essaries, 
but  advocated  their  use  when  judiciously  applied  under  proper  cir- 
cumstances. He  prefers  a  malleable  ring,  either  of  block  tin  or  a 
ring  of  copper  wire  covered  with  gutta  iiercha,  and  then  bent  or 
curved  to  the  proper  diameters  of  the  vagina  of  each  jiatient.  He 
said  this  was  a  modification  of  Hodge's  pessary.  Under  some  circum- 
stances he  also  uses  Meigs'  ring  pessary,  made  of  watch  spring  covered 
with  gutta  joercha.  He  jiointed  out  the  peculiar  advantage  of  each  of 
these,  and  i)aid  a  just  tribute  to  his  countrymen,  Drs.  Hodge  and 
Meigs,  who  were  the  earliest  advocates  of  mechanical  treatment  of 
uterine  disijlacements.  He  said  that  the  great  secret  of  treating  the 
sterile  condition  when  dependent  upon  retroversion  was  to  adjust  a 
malleable  ring  which  would  hold  the  uterus  in  its  normal  position,  and 
which  was  to  l)e  worn  always  during  the  act  of  coition.  He  ex^ilained 
its  ijhilosophy,  its  efiiciency,  its  safety,  and  its  harmlessne.ss,  and  re- 
lated a  great  many  cases  in  which  its  use  had  been  followed  by  con- 
ception; one  after  a  sterile  marriage  of  six  years,  another  of  ten  years, 
another  of  fifteen  years,  and  others  at  various  periods  of  time  after 


74 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Oct., 


sterile  marriages.  He  also  showed  liow  miscarriages,  often  dependent 
upon  tliis  displacement,  are  prevented  by  the  nse  of  a  properly  fitted 
malleable  pessary.  He  then  pointed  out  the  course  to  be  adopted 
when  it  was  impossible  for  the  patient  to  wear  a  pessary,  showing  why 
it  was  so,  and  what  was  to  be  done. — Medical  Times  &  Gazette,  August 
19,  1865.. 

9.  Case  of  Puerperal  Telann.s,  following  Abortion  and  Plugging  of  the 
Vagina.    By  Joseph  Blackshaw,  Esq.,  Stockport. 

On  Saturday,  November  8th,  18G4,  I  was  called  to  see  Mrs.  H.,  aged 
48  years,  the  mother  of  a  numerous  family,  of  a  highly  nei-vous  tem- 
perament, and  whose  general  health  had  previously  suflered  from  some 
domestic  anxieties. 

She  was  in  bed,  very  faint  from  profuse  hemorrhage  from  the  uterus. 
I  made  an  examination,  and  detected  an  ovum  of  about  ten  weeks' 
growth  within  the  os  uteri.  In  consequence  of  the  amount  of  the 
hemorrhage,  I  plugged  the  vagina;  ordered  cold  applications,  stimu- 
lants, and  the  usual  astringent  remedies,  including  the  ergot  of  rye; 
and  she  rallied  in  the  course  of  the  following  day.  The  plug  remained 
in  the  vagina  twelve  or  fifteen  hours,  and,  when  removed,  was  not 
again  resorted  to,  as  the  hemorrhage  had  almost  ceased,  and  the  ovum 
was  expelled  a  few  hours  afterwards.  She  progressed  satisfactorily 
for  about  nine  days,  at  the  end  of  which  time  she  was  able  to  sit  \vp, 
and  about  to  leave  her  room.  Thinking  it  unnecessary  for  me  to  con- 
tinue my  visits  daily,  I  left  her,  with  directions  to  report  to  me  her 
progress. 

On  the  day  following,  (Tuesday,)  just  ten  days  from  my  first  vi.sit, 
I  was  unexpectedly  requested  to  see  her.  She  thought  she  had  taken 
cold,  and  was  then  complaining  of  great  stifihess  of  the  deei>  seated 
muscles  of  the  neck  and  throat,  with  difficulty  of  swallowing,  and  was 
unable  to  open  her  mouth  perfectly.  As  there  was  some  febrile  ex- 
citement, she  was  ordered  to  remain  in  bed,  and  to  take  a  saline  mix- 
ture with  an  aperient;  to  use  hot  fomentations;  afterwards  hot  moist 
bran;  to  steam  the  fauces;  and,  if  possible,  to  use  a  gargle. 

On  the  two  following  days,  Wednesday  and  Thursday,  the  jDainful 
tension  of  the  masseters,  as  well  as  the  muscles  of  the  neck  and  throat, 
had  so  greatly  increased  as  to  prevent  deglutition  and  bring  on  a  state 
of  perfect  trismus.  On  Thursday  afternoon  and  evening,  the  tetanic 
seizures  became  increasingly  frequent,  producing  great  muscular 
X'igidity,  contorsion  of  features,  and  slight  oiji-sthotono.s.  During  the 
paroxysm,  the  iDulse  was  small  and  feeble;  but  the  consciousness  was 
entire  throughout.  She  continued  in  this  state  until  Saturday  even- 
ing, the  tetanic  sjiasms  and  episthotonos  gradually  becoming  more 
severe,  when  she  died  from  exhaustion,  five  days  from  the  first  setting 
in  of  the  tetanic  symjitoms. 

Owing  to  the  clenched  state  of  the  jaws,  little  was  done  in  the  way 
of  treatment,  beyond  a  little  counter-irritation  to  the  spine;  the  ad- 
ministering of  a  turpentine  enema;  and  the  removal  of  fa5cal  accumu- 
lations, which  might  prove  a  possible  source  of  spinal  irritation. 

Puerperal  tetanus  is  a  very  rai-e  species  of  that  disease  in  this  cli- 
mate; and  this  must  be  my  apology  for  this  communication.  I  have 
been  in  practice  in  this  town  for  more  than  thirty  years,  the  greater 
part  of  wliicli  I  have  been  medical  officer  to  a  lai'ge  district  of  a  poor- 
law  union,  including  the  union  workhouse,  and  must  have  attended 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


75 


three  or  four  tLonsands  of  ■women  in  labor  at  different  i^eriocls  of  iitero- 
gestation;  and  this  is  the  first  case  that  has  occurred  in  my  public  or 
private  practice,  or,  so  far  as  lean  learn,  in  that  of  the  oldest  obstetri- 
cian either  here  or  in  Manchester,  with  the  exception  of  one  case  men- 
tioned by  Dr.  "Whitehead.  Dr.  Radford  considers  it  a  rare  disease, 
but  has  known  it  to  occur.  Mr.  Robertson,  of  the  same  city,  also  says 
that  obstetric  tetanus  is  a  novelty  to  him,  and  that  he  has  never  seen 
it  during  a  long  and  laborious  practice.  Nor  is  the  disease  one  usually 
recognized  in  treatises  on  midwifery  and  the  diseases  of  lying-in 
women.  The  extreme  rarity  and  infrequency  of  this  disease,  not- 
withstanding the  various  lesions  from  the  aijplication  of  instnaments, 
manual  interference,  turning,  and  other  violence  that  the  uterus  must 
often  sustain  in  in-otracted  and  difificult  labors,  points  to  a  very  differ- 
ent state  of  the  nervous  system  from  that  which  gives  rise  to  traumatic 
tetanus  in  the  various  external  injuries  to  which  the  body  is  subjected. 
Physiologii-ts  attribute  this  to  the  ixterus  receiving  its  nerves  from  the 
great  sympathetic.  It  may  be  so.  But  of  what  that  peculiarity  of  the 
nervous  system  consists  in  these  cases,  where  the  irritation  from  the 
uterus,  as  in  the  case  of  Mrs.  H.,  is  propagated  to  the  cerebro- spinal 
system,  is  still  shrouded  in  mystery.  We  can  only  say  that,  in  the 
case  of  my  i^atient,  cold  applied  to  the  body,  previously  lowered  by 
mental  anxiety  and  loss  of  blood,  may  have  given  rise  to  a  state  of  re- 
flex spinal  irritation,  followed  by  tetaniis;  though  probably,  in  ten 
thousand  other  instances,  the  same  exciting  causes  would  produce  no 
such  effects. 

I  regret  that  chloroform  was  not  tried,  as,  besides  the  good  effects  it 
is  said  to  have  in  convulsive  diseases,  it  presents  facilities  of  applica- 
tion where  no  internal  remedy  can  be  given. 

My  object,  in  this  communication,  is  rather  to  seek  than  to  give  in- 
formation, and  I  trust  that  some  of  our  more  learned  associates  will 
ere  long  throw  some  fresh  light  upon  this  class  of  diseases,  which  are 
yet  among  the  opprobria  medicorum. — British  Medical  Journal,  Sept. 

9,  1865. 

10.  Electro-magnetism  in  Posi-partum  Hemorrhage. 

In  a  communication  to  the  editor  of  the  Medical  Times  <£•  Gazette, 
Mr.  Parsons,  of  Liverpool,  relates  the  following  interesting  particu- 
lars: 

The  following  case,  illustrating  the  beneficial  effect  of  electro- 
magnetism  in  post-partum  hemorrhage,  is,  I  think,  worthy  of  record, 
for  it  more  than  answered  my  most  sanguine  expectations,  after  hand 
pressure  on  the  uterus,  pressure  on  the  abdominal  aorta,  ergot,  and 
the  cold  douche  had  failed.  Mrs.  B.,  a  fine  healthy  young  woman, 
twenty-seven  years  of  age,  was  suddenly  seized  with  violent  labor- 
pains,  at  1  o'clock  P.M.,  November  24,  1864.  She  sent  immediately 
for  me,  but  I  was  unfortunately  out  at  the  time.  Messengers  went  in 
every  direction  for  a  medical  man,  and  a  considerable  time  elajised 
before  any  assistance  could  be  i^rocured.  Dr.  Watters,  St.  Anne 
Street,  at  length  arrived,  and  found  one  child  born  and  Mrs.  B.  flood- 
ing a  good  deal.  He  detected  another  child  in  the  uterus,  made  press- 
ure bi\  the  fundus,  and ,  present.ation  being  natural,  delivery  was  easily 
and  rapidly  effected.  The  flooding  now  became  profuse  and  alarming, 
and  Dr.  W.,  finding  the  placenta  adherent,  introduced  his  hand  into 
the  uterus,  cleared  out  its  contents,  applied  a  bandage  and  pad  and 


76 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Oct., 


cold  to  the  vulva.  My  assistant,  Mr.  Burrows,  now  arrived,  and  Dr. 
W.  left  the  case  in  his  hands.  Notwithstanding  all  his  efforts  to  arrest 
the  hemorrhage,  Mr.  Burrows  saw  that  the  j^atient  was  sinking  rap- 
idly. He  tried  ergot  without  producing  any  uterine  contraction.  He 
then  removed  the  binder  and  grasped  the  uterus,  directing  the  at- 
tendants to  administer  brandy  freely.  He  tried  the  cold  douche;  but 
still  tlie  hemorrhage  continued.  He  then  made  pressure  upon  the 
abdominal  aorta,  and  for  the  first  time  he  observed  a  beneficial  result; 
the  flooding  was  arrested.  He  kept  up  the  pressure  for  an  hour.  I 
then  arrived,  (at  half-i^ast  three  o'clock,)  and  was  shocked  at  the  sight 
which  met  my  gaze  on  entering  the  room.  The  patient,  antemic,  cold, 
almost  ijulseless,  was  lying  in  a  pool  of  blood.  There  was  only  a 
slight  draining  from  the  uterine  sinuses.  I  felt  the  uterus  through 
the  abdominal  walls:  it  was  large,  flabby,  and  felt  empty.  I  passed 
one  hand  into  the  cavity  and  removed  a  few  small  clots,  at  the  same 
time  keeping  up  pressure  with  the  other  hand.  Finding  that  neither 
pressure  nor  the  irritation  of  the  hand  in  the  uterus  excited  any  mus- 
cular contraction,  it  occurred  to  me  that  electro-magnetism  was  our 
dernier  ressort.  I  relieved  Mr.  Burrows  in  keeping  up  the  pressure 
on  the  abdominal  aorta,  and  directed  him  to  drive  to  my  house  for  my 
electro-magnetic  apparatus.  He  arrived  in  a  few  minutes,  and  I  pro- 
ceeded without  delay  to  apply  one  jiole  inside  the  uterus,  while  the 
other  was  being  applied  externally  over  the  abdominal  walls.  The 
lowest  2iower  was  first  used,  aud  then  gradually  increased  to  a  me- 
dium. In  a  few  minutes  I  felt  slight  contraction,  and  after  continuing 
the  current  for  half  an  hour  I  was  enabled  to  grasp  the  whole  of  the 
uterus  in  my  hand.  I  retained  it  in  this  manner  for  better  than  half 
an  hour,  and  then  applied  a  tight  binder  and  pad.  After  clearing 
away  as  much  of  the  debris  as  possible,  Mrs.  B.  became  quite  con- 
scious, and  comi^lained  of  being  cold.  I  gave  some  brandy  and  hot 
water,  and,  feaiing  to  continue  hot  drinks,  I  \y\ii  extra  clothing  over 
her,  and  directed  a  female  to  lie  beside  her.  When  she  became  warm 
she  fell  into  a  doze.    I  left  her  for  a  short  time  now,  b  o'clock. 

At  6  o'clock  very  sick;  skin  warm;  pulse  140;  complained  of  binder 
being  very  tight.  Ordered  chloric  ether  and  spt.  ammon.  co.  every 
halt  hour;  the  binder  to  remain.    No  flooding. 

Half-i)ast  9. — Improving  in  every  respect.  Ordered  the  mixture 
every  hour;  cold  beef- water  for  drink. 

Mrs.  B.  continued  to  improve  daily,  and  was  afterwards  enabled  to 
nurse  both  children.  She  is  now,  August  16,  1865,  as  florid  and 
healthy  looking  as  ever. 

In  this  case  the  patient  owed  her  life,  in  the  first  place,  to  the  press- 
ure which  was  maintained  so  persistently  on  the  abdominal  aorta, 
and  most  assuredly  also  to  electro-magnetism.  Had  transfusion  been 
used  here  the  vital  fluid  would  have  permeated  the  system  only  to  find 
an  exit  through  the  patent  uterine  sinuses.  I  have  used  the  electro- 
magnetic fluid  in  one  other  similar  case  with  the  like  beneficial  result. 
Medical  Times  &  Gazelle,  Aug.  26,  1865. 

11.  Relention  of  Urine  in  the  Foetus. 

M.  Depaul  related  to  the  Societe  de  Biologic  a  case  in  which  a 
woman  was  delivered  of  an  eight  months'  child  presenting  a  great  en- 
largement of  the  abdomen;  there  was  very  little  amniotic  fluid.  The 
child  died  soon  after  being  born.  The  bladder  was  about  -t^.j  inches 
long  and  2}i  wide,  aud  was  fuU  of  urine.    The  ureters  were  also 


1865.] 


EDITORIAL. 


77 


irregularly  enlarged,  resembling,  at  first  sight,  the  intestinal  convolu- 
tions, and  contained  urine.  The  kidneys,  especially  the  left,  were  also 
much  distended;  they  were  transformed  into  cysts  with  thin  walls, 
filled  also  with  urine.  The  cause  of  this  distension  was  found  to  be 
an  imperfect  state  of  the  urethra,  at  the  junction  of  the  muscular 
and  prostatic  portions.  More  than  500  (/rrmwes  (upwards  of  a  pint) 
of  urine  were  removed. — Gaz.  Mid.  de  Paris,  July  15,  1865. 

12.  Relief  in  Cancer. 

Dr.  Brandini,  of  Florence,  has  recently  discovered  that  citric  acid 
will  assuage  the  violent  pain  which  is  the  usual  concomitant  of  cancer. 
One  of  his  patients,  aged  71,  at  the  Hospital  of  Santa  Maria  deUa 
Scala,  was  afflicted  with  cancer  on  the  tongue.  There  was  no  possi- 
bility of  performing  an  operation,  the  surface  attacked  being  far  too 
extensive,  investing  the  base,  the  sub-lingual,  and  the  sub-maxillary 
glands.  The  poor  man  in  the  midst  of  his  torments  asked  for  a  lemon, 
which  was  nothing  very  remarkable,  as  cancerous  patients  generally 
have  an  extraordinary  liking  for  acids.  But  the  seat  of  the  disorder 
being  in  the  mouth,  a  circumstance  was  observed  which  might  other- 
wise have  escajDcd  attention — the  juice  of  the  lemon  diminished  the 
pain. — Medical  Times  &  Gazette,  August  26,  1865. 


EDITOEIAL. 

The  Cholera  still  holds  on. — The  hesitancy  iu  its  march,  when 
first  it  appeared  in  Europe,  caused  those  who  chronicled  its  progress 
to  entertaia  the  hope  that  it  would  retire  to  its  Asian  home  and  leave 
broad  Europe  free.  Recent  accounts  have,  however,  dissipated  tliese 
hopes — for  the  hesitation  was  apparent,  not  real.  In  Marseilles  there 
have  been  a  suflScient  number  of  deaths  to  awaken  {^reat  alarm,  to 
cause  many  of  the  families  to  flee  the  city,  and  to  produce  great  con- 
sternation among  those  remaining.  In  Malta  and  Gibraltar,  in 
Ancona,  and  many  towns  along  the  Italian  coast,  it  still  prevails  with 
unrelenting  violence.  We  have  no  official  reports  that  it  has  ap- 
peared as  an  epidemic  in  Paris  or  Loudon,  though  in  the  latter  city 
cases  are  reported  in  the  jveekly  tables  of  mortality. 

Thus  far,  then,  no  faith  is  to  be  put  in  the  statements  that  this 
visitation  of  the  epidemic  will  expend  itself  in  its  original  haunts;  nor 
can  we  escape  a  fearful  responsibility  if,  with  these  warnings,  and 
this  favorable  period  of  the  year,  we  fail  to  set  our  house  in  order,  to 
prevent,  as  far  as  possible,  its  advent  during  the  next  year. 

—  The  Academy  of  Mediciue  opened  its  doors  after  the  summer 
vacation  on  Wednesday,  the  20th  of  September.  I)r.  Elisha  Harris  read 
a  paper  entitled  "  Hygienic  Observations  in  New  Orleans,"  iilustrat- 


78 


EDITORIAL. 


[Oct., 


ing  the  utility  of  efficient  sanitary  regulations  ;  and  Dr.  Jolm  H. 
Griscom  presented  an  historical  account  of  the  epidemic  cholera, 
showing  how  its  progress  can  be  checked  by  proper  and  prompt  atten- 
tions to  the  laws  of  hygiene. 

—  This  month  the  regular  courses  of  lectures  in  the  various 
medical  colleges  of  this  country  will  begin.  By  referring  to  our 
advertising  pages  it  will  be  seen  that  in  some  of  these  institutions  the 
effort  to  offer  a  thorough  course  of  instruction  can  not  be  other  than 
successful,  if  the  number  and  character  of  the  instructors  be  a  crite- 
rion of  success. 

The  Regular  Term  in  the  Bellevue  Hospital  Medical  College  com- 
mences Wednesday,  Oct.  11.  We  understand  that  the  vacancy  in 
the  Faculty,  occasioned  by  the  sudden  death  of  Prof.  T.  Childs,  has 
been  filled  by  the  temporary  transfer  of  Prof.  Stephen  Smith  from  the 
Chair  of  Surgery  to  that  of  Anatomy,  and  that  the  duties  heretofore 
devolving  upon  Dr.  Smith  as  Professor  of  the  Principles  of  Surgery 
will  be  "added  to  those  of  the  Chair  of  Military  Surgery,  filled  by 
Prof.  Hamilton. 

The  regular  course  of  lectures  in  the  College  of  Physicians  and 
Surgeons  will  commence  on  Monday,  Oct.  16. 

In  the  Miami  Medical  College  of  Cincinnati,  and  the  Medical 
College  of  Ohio,  the  regular  lectures  will  commence  on  the  1st  of 
November. 

—  The  operation  for  Ovariotomy  has  recently  been  performed  iu 
Italy  for  the  second  time.  Prof.  Bezze,  of  Modena,  has  operated 
with  success,  and  this  happy  issue  of  a  formidable  operation,  which  has 
been  heretofore  ignored  in  Italy,  will  probably  be  the  cause  of  many 
other  operations  in  that  country. 

It  would  seem  that  on  the  continent  of  Europe  the  success  of  this 
operation,  under  the  hands  of  the  local  surgeons,  has  been  any  thing 
but  satisfactory.  And  it  would  appear  that  English  surgeons,  who, 
at  home,  have  a  great  reputation  for  this  special  operation,  arc  not 
any  the  more  fortunate  when  operating  on  the  continent— for  Mr. 
Spencer  Wells,  who  enjoys  high  distinction  iu  England,  failed  in  an 
operation  he  performed  in  Brussels,  by  invitation  of  M.  Deroubaix, 
the  patient  dying  the  fourth  day  from  peritonitis. 

Dr.  Dutoit,  of  Wurzburg,  says  V  Union  Mddicale,  has  collected  all 
the  cases  of  this  operation  up  to  Nov.,  1863,  making,  in  all,  742,  of 
of  which  467  were  ui  England,  165  in  America,  74  in  Germany,  28  in 
France,  and  8  in  other  countries.  Dr.  Dutoit  attributes  the  successes 
of  the  English  surgeons  to  the  fact  that  they  enjoy  the  entire  con- 


18G5.] 


EDITORIAL. 


79 


fidence  of  their  patients — to  such  a  degree  that  they  have  but  to  pro- 
pose an  operation,  however  severe  it  may  be,  to  readily  gain  the  assent 
of  the  patient ;  while  on  the  other  hand,  the  continental  physician  has 
to  exhaust  all  his  resources  of  argument  to  convince  his  patient  of  the 
necessity  of  the  operation,  and  as  the  danger  to  life  is  not  immediate 
delays  arc  always  urged,  until  complications  arise  which  diminish 
greatly  the  chances  of  success. 

At  a  meeting  of  the  Physicians  and  Surgeons  at  the  Demilt  Dis- 
pensary, held  August  23d,  Dr.  D.  S.  Conant  in  the  chair,  on  the 
occasion  of  the  death  of  Dr.  Thomas  Sinclaire,  the  following  preamble 
and  Resolutions  were  reported  and  unanimously  adopted : 

Whereas,  In  God's  providence,  our  fellow-physician,  Thomas  Sinclaire, 
M.D.,  L.L.D.,  has  been  removed  from  us  by  death;  therefore, 

Besolvcd,  That  in  the  death  of  Dr.  Sinclaire,  the  Demilt  Dispensary, 
in  which  he  has  so  earnestly  and  so  disinterestedly  labored,  is  called  to 
mourn  one  who,  by  his  devoted  and  intelligent  efforts,  largely  con- 
tributed to  realize  the  benevolent  olyects  of  the  institution;  and  that 
we  have  to  individually  lament  a  friend,  who,  by  his  mature  scholarship, 
unfaltering  professional  zeal,  uniformly  courteous  and  unobtrusive 
manners,  simplicity  of  character  and  kindliness  of  heart,  had  won,  in  a 
high  degree,  our  esteem  and  respect. 

ResoLced,  That  we  tender  to  the  family  of  the  deceased  our  sym- 
pathy for  their  bereavement,  and  that  we  attend  the  funeral  in  a 
body. 

Resolved,  That  a  copy  of  these  resolutions  be  transmitted,  by  the 
Secretary,  to  the  bereaved  family,  and  copies  for  publication  to  the 
New  York  Times  and  to  the  New  York  Medical  Journal. 

Isaac  Cummings,  M.D. 
Wii.  B.  BiBBiNs,  M.D. 
Jas.  R.  Learning,  M.D. 

Committee. 

Henry  M.  Field,  M.D.,  Secretary. 

LoNGKviTY  IN  ENGLAND  AND  Wales. — The  retums  of  mortality  for 
England  in  the  year  1863  record  the  death  of  213  men  and  430  women 
registered  as  95  years  old  or  upwards  when  they  died.  Twenty-one 
of  these  had  reached  100  or  upwards,  and  one  at  Chelsea  was  109. 
Si.\ty-two  of  the  women  had  also  conij)leted  a  century  of  life  or  more; 
and  one  at  Liverpool,  in  the  district  of  West  Derby,  was  112  years  old 
Five  men  and  live  women  died  in  the  year  1863,  who,  if  the  register 
may  be  relied  on,  were  born  before  George  III.  was  king — that  is,  ijefore 
1161.  It  appears  that  longevity  is  lowest  in  the  North  Midland  di- 
vision of  England,  and  by  far  highest  in  Wales,  that  which  approaclies 
nearest  to  tin;  Welsh  being  the  South  Midland  division  of  England. 
The  ])roportion  of  those  who  I'caeii  the  age  of  100  years  in  Wales  as 
comiiaved  with  tlie  North  Midland  division  of  England  is  about  10  to 

1  in  favor  of  the  former,  wliile  \Vales  iuis  the  advantage  of  more  than 

2  to  1  above  England's  most  favored  district. 


80 


PUBLICATIONS  RECEIVED. 


[Oct. 


BOOKS  AND  JOURNALS  RECEIVED. 

Tlie  Medical  Register  of  the  City  of  New  York,  for  the  year  commencing 
June  1,  18G5.  Published  under  tbe  supervision  of  the  New  York  Medico- 
Historical  Society.  Guido  Furman,  Editor.  New  York:  Edward  O.  Jen- 
kins. 18G5. 

The  Use  of  the  Laryngoscope  in  Diseases  of  the  Throat,  with  an  Appendix 
on  Rhinoscopy.  By  Morell  Mackenzie,  M.D.,  Lond.,  M.R.C.P.,  &c.  Phila- 
delphia: Lindsay  &  Blakiston.  1865, 

The  Physician's  Visiting  List,  Diary,  and  Book  of  Engagements,  for  1866. 
Philadelphia:  Lindsay  &  Blakiston. 

On  the  ultimate  Nerve  Fibres  distributed  to  Muscle  and  some  other  Tissues, 
with  obsers  ations  upon  the  Structure  and  probable  mode  of  action  of  a  Nerv- 
ous Mechanism.  Being  the  Croonian  Lecture  for  1865,  delivered  by  Lionel 
S.  Beale,  M.B.,  F.R.S. 

Canada  Medical  JoumaL    Vol.  2,  Nos.  1,  2,  3. 

The  British  and  Foreign  Medico-Chirurgical  Review.    No.  71.    July,  1865. 

British  Medical  Journal.    August  19,  2C;  September  2,  9,  16. 

The  Lancet.    August  19,  2C;  September  2,  9,  16. 

The  Medical  Circular.    August  23,  30;  September  6,  13. 

Medical  Times  and  Gazette.    Augiist  19,  26;  September  2,  9,  16. 

The  Medical  Press,  Dublin.    August  9,  16,  23,  30;  September  6,  13. 

Archives  of  Medicine.    Nos.  14,  15. 

American  Journal  of  the  Medical  Sciences.   July,  1865. 

American  Druggists'  Circular.  July,  August. 

American  Journal  of  Pharmacy.    July,  1865. 

Boston  Medical  and  Surgical  Journal.     June  22;  July  6,  13;  August 
3,  10,  31 ;  September  U,  21. 
Buffalo  Medical  and  Surgical  Journal.  July,  August. 
Chicago  Medical  Examiner.    July,  August,  September. 
Chicago  Medical  Journal.    July,  August,  September. 
Cincinnati  Lancet  and  Observer.    July,  August,  September. 
Dental  Cosmos.  July. 

Nordamericanische  Deutsch  Medicinische  Zeitschrift  fiir  Praktische  Heil- 
kunde.    Buffalo.  Aug. 

Pacific  Medical  and  Surgical  Journal.    June,  July,  August. 

The  Medical  News  and  Library.    July,  August,  September. 

Braithwaite's  Retrospect.  Part  51.  July,  1865.  New  York :  W.  A.  Townsend. 

American  Literary  Gazette  &  Publishers'  Circular.  Philadelphia:  July 
1,  15;  August  1,  15;  Sept.  1,  15. 

Addresses  at  the  Fifth  Annual  Session  of  the  American  Dental  Association. 
By  W.  W.  AUport,  D.D.S.,  Daniel  Brainard,  M.D.,  and  N.  L.  Davis,  M.D., 
Chicago.  1865. 

The  Catholic  World.    July,  August,  September,  October. 

Annual  Circular  Bellevue  Hospital  Medical  College.    New  York:  13f5  66. 

Sixth  Annual  Announcement  of  the  Miami  Medical  College  of  Cincinnati. 

Twenty-third  Annual  Announcement  of  Rush  Medical  College,  Chicago,  HI- 

Annual  Circular  of  the  National  Medical  College,  Washington,  for  the 
Session  of  1865-66. 


]SrEW  YORK 

MEDICAL  JOURNAL, 

A  MONTflLV  RECORD  OF  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
NOVEMBER,   1  86  5. 


ORiaiNAL  COMMUNICATIONS. 

Contributions  to  Obstetric  Jurisprudence.  By  Horatio  R. 
Storer,  M.D.,  of  Boston,  Assistant  in  Obstetrics  and  Medical 
Jurisprudence  in  Harvard  University;  Surgeon  to  the  New 
England  Hospital  for  Women;  and  Professor  of  Obstetrics 
and  the  Diseases  of  Women  in  Berkshire  Medical  College. 

No.  IX.   A  Medico-legal  Study  of  Rape. 

Following  the  example  of  my  friend,  Dr.  Elliot,  who  has 
transferred  to  this  Journal,  from  the  now  silent  pages  of  the 
American  Medical  Times,  the  continuation,  in  regular  sequence, 
of  his  scries  of  Difficult  Obstetric  Cases,  I  recommence  my 
own  "  Contributions  to  Obstetric  Jurisprudence,"  which  were 
initiated  in  1859  in  the  late  North  American  3Icdico-GMrurgical 
Revieio,  of  Philadelphia,  and  interrupted  by  the  cessation  of  that 
journal.  The  articles  already  published  under  the  above  title 
are  the  following : 

I.  Is  Abortion  ever  a  Crime  ?  N.  A.  Med.-Chir.  Rev.,  Jan., 
1859,  p.  64. 

II.  Its  Frequency  and  the  Causes  thereof.  Ibid.,  March, 
1859,  p.  260. 

Vol.  II.— No.  8.  6 


82 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


III.  Its  Victims.    Ihid.,  May,  1859,  p.  446. 

IV.  Its  Proofs.    Ibid.,  p.  ^ib. 

V.  Its  Perpetrators.    IJnd.,  p.  4G5. 

VI.  Its  Innocent  Abettors.    Ibid.,  July,  1859,  p.  643. 

VII.  Its  Obstacles  to  Conviction.    Ibid.,  Sept.,  1859,  p.  833. 

VIII.  Can  it  be  at  all  controlled  by  Law?  Ihid.,  Nov., 
1859,  p.  1033. 

To  this  scries  of  papers  there  already  belong,  in  reality, 
six  others,  bearing  as  they  do  directly  upon  the  medico- 
legal relations  and  responsibilities  of  women  :  to  wit,  three 
articles  upon  Insanity  in  Women,  published  in  the  Boston 
Medical  and  Surgical  Journal  for  April,  October  and  Novem- 
ber, 18G4;  a  fourth  upon  the  same  subject,  that  will  be  found  in 
the  Transactions  of  tlie  American  Medical  Association  for  that 
year;  still  another,  read  before  the  Association  at  its  late 
session  in  Boston,  as  the  Report  of  the  Standing  Committee 
upon  Insanity;  and  a  sixth,  my  Prize  Essay,  upon  the  Physical 
Evils  of  Forced  Abortions;  both  of  these  latter  articles  being 
now  in  press.  I  have,  however,  preferred  to  take  the  thread 
up  Avhere  it  was  broken,  in  pursuance  of  my  original  plan,  with 
the  simple  prefatory  remark  that  in  no  department  of  Obstet- 
rics and  the  Diseases  of  Women,  or  of  Legal  Medicine,  is  there 
greater  need  of  investigation,  and  in  none  more  prospect  of 
practical  gain  to  our  science,  than  where  these  fields  join  each 
other,  namely,  in  Obstetric  Jurisprudence. 

The  subject  upon  which  I  desire  at  this  time  to  fix  the  atten- 
tion of  medical  jurists,  is  a  more  practical  and  important  matter 
than  might  at  first  be  supposed.  It  is  one  concerning  which 
much  conflict  of  opinion  has  arisen,  both  upon  abstract  points 
and  the  circumstances  of  individual  cases;  it  is  also  one  of  those 
happily  rare  questions  where  the  sympathies  of  a  jury  are  apt  to 
be  found  instinctively  tending  against  the  prisoner. 

It  may  be  supposed  that  a  topic  upon  which  so  much  has 
been  written,  and  which  possesses  an  interest,  even  if  uncon- 
fessed,  for  every  professional  reader,  must  long  ere  this  have 
been  exhausted.  In  reality,  however,  it  will  be  found,  that 
just  in  proportion  as  it  has  received  attention,  so  have  the 
mcdico-lcgal  opinions  concerning  it,  prevalent  at  any  given 
time,  been  modified.    The  crime  was  formerly  punished  by 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


83 


castration  or  by  death  ;  its  penalty  now  varies  in  different 
countries,  but  is  almost  everywhere  confined  to  fine  and  im- 
prisonment, either  or  both.  For  its  commission  it  was  formerly 
necessary  that  every  step  and  stage  in  sexual  intercourse 
should  have  been  completed;  now  the  mere  fact  of  contact  of 
the  genital  organs  would  seem  practically  to  constitute  the 
oifense.  So  that  the  literature  and  the  law  of  rape  have  alike 
become  effete  and  need  careful  rcyision. 

1  would  not  detract  from  the  labors  of  the  late  Casper  of 
Berlin,  and  his  many  predecessors  in  this  discussion,  and  freely 
acknowledge  tlie  excellence  in  many  respects  of  the  rulings 
and  reasonings  of  Wharton  and  Stills,  our  own  latest  author- 
ities; but  in  certain  material  points  I  am  compelled  to  differ 
from  them  all. 

A  case  that  has  lately  occurred  at  Boston,  where  four  young 
men  have  been  sentenced  to  the  State-prison  for  life  for  compel- 
ling intercourse  from  a  notorious  strumpet,  and  their  so  severe 
punishment,  apparently  indorsed  by  the  entire  community, 
warrants  my  examining  into  details  that,  though  repulsive  in 
themselves,  are  of  value  as  establishing  upon  a  firmer  basis  the 
right  of  a  woman  to  her  chastity,  however  infinitesimally 
small  this  may  be.  The  right  involves  that  of  distributing  her 
favors,  such  as  they  are,  or  withholding  them  altogether;  the 
right  to  refuse  to  obnoxious  purchasers  wares  that  may  have 
been  exposed  in  open  market;  and  the  right  to  cancel  or  con- 
tinue consent  to  an  act,  however  unlawful  in  itself. 

The  instance  to  which  I  have  now  referred,  that  known  as 
the  Bates  case,  has  created  such  intense  excitement  throughout 
New  England,  and  is  withal  so  directly  pertinent  to  conclu- 
sions I  may  hereafter  enunciate,  that  I  have  thought  best  here, 
at  the  outset,  to  present  a  brief  commentary  upon  its  more 
salient  points.  This  has  been  kindly  furnished  me  by  the  only 
medical  witness  called  for  either  side  at  the  trial  referred  to, 
my  friend  Dr.  John  Green,  of  Boston,  one  of  the  Surgeons 
to  the  City  Dispensary,  to  whose  interesting  experiments  and 
intelligent  deductions  concerning  certain  matters  connected 
with  the  case  I  may  take  occasion  subsequently  to  allude.  The 
case,  as  I  have  said,  was  that  of  a  courtesan,  abused  by  several 
men;  the  conviction  turning  upon  the  testimony  of  one  of  their 


84 


OBSTETRIC  JURISPKUDEXCE. 


[Nor., 


comrades,  incapacitated  by  acute  disease  from  sharing  in  the 
fray.  The  criticisms  now  oflFcred  I  believe  to  be  strictly  just. 
"  The  chief  points,  as  they  strike  me,"  says  Dr.  Green,  '•  are: 
"1st,  The  utterly  bad  character  of  the  prosecutrix  and  her 
bad  appearance  on  the  stand,  lying,  as  she  did,  upon  many 
points  which  could  be  proved  against  her  by  good  witnesses, 
but  being  supported  by  the  sick  soldier  as  to  the  particular 
points  necessary  technically  to  constitute  a  rape; 

"  2dly,  The  proof,  by  an  eye-witness,  of  those  essential  points 
which  are  usually  settled  by  presumption,  viz.,  the  unwilling- 
ness of  the  woman,  her  resistance,  and  the  use  of  force  by  the 
accused;* 

"  3diy,  The  insignificant  injuries,  if  any,  which  were  received 
by  the  woman,  and  which,  in  the  absence  of  other  positive 
testimony,  would  have  weighed  most  heavily  against  her  state- 
ment that  she  resisted. 

"  As  regards  the  character  of  the  woman,  there  can  be  no 
doubt;  married  to  a  man  named  Pettingill,  she  has  been  since 
publicly  known  as  the  concubine  of  Mellen  Bent,  and  now  of 
the  witness  Bates,  whose  names  she  has  successively  borne. 
She  has  been  proved  in  the  habit  of  walking  the  streets  at  im- 
proper hours  of  the  evening,  and  in  neighborhoods  and  upon 
routes  which  leave  no  doubt  that  she  was  also  a  most  degraded 
common  prostitute.  Her  visit  to  the  room  where  the  offense 
was  committed  was  against  her  will,^as  she  said,  but  entirely 
voluntary,  according  to  another  witness,  whose  appearance 
was  at  least  much  better  than  hers.  Her  desci-iption  of  the 
acts  of  violence  was  contradictory  in  important  points,  so  much 
so  that  it  would  have  been  easy  completely  to  have  demolished 
her  testimony,  had  it  not  been  confirmed  in  the  essential  points 
by  the  sick  soldier,  who  was  an  eye-witness  to  the  circum- 
stances attending  the  intercourse. 

"  The  facts  proved  by  this  witness  were: 
"  1st,  Much  rough  usage,  constituting  an  assault;  and 
"  2dly,  Connection  by  the  four  defendants  in  turn,  and  once 
or  more  repeated;  and 

*  On  the  other  hand,  it  ought  to  be  the  presumption,  in  any  case,  on  the 
ground  of  the  prisoner's  assumed  innocence,  that  the  woman  was  not  unwill- 
ing, but  consented. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


85 


"  3dly,  That  the  connection  was  effected  by  the  use  of 
superior  force,  to  which  the  woman  wisely  yielded  without 
very  violent  resistance — ^having  no  honor  to  defend,  and  conse- 
quently no  very  strong  instinct  to  save  herself  from  embraces 
to  which  she  would  willingly  have  sold  herself,  and  had,  per- 
haps, previously  bargained  for  with  one  of  the  accused. 

"  Tiiat  the  accused  had  probably  no  idea  of  the  terrible 
nature  of  the  offense  of  which  they  have  since  been  thus  tech- 
nically convicted,  is  shown  by  the  fact  that  they  retired  to 
rest  ill  the  very  room  in  which  it  was  committed,  and  where 
they  were  afterwards  arrested.  They  were  rough  boys,  and 
had  dealt  roughly  with  a  whore — a  crime,  it  is  true,  but  certainly 
one  not  to  be  compared  with  the  brutal  violation  of  a  virgin 
or  chaste  matron. 

"  As  regards  the  line  of  defense,  there  was  nothing  to  be 
done.  Enough  was  proved  to  show  that  technically  a  rape  had 
been  committed,  and  the  court  imposed  the  only  sentence  per- 
mitted by  the  statute.  In  reality,  the  case  lacked  every  feature 
of  horror  usually  belonging  to  the  crime,  and  seems  to  call  for 
the  exercise,  at  a  very  early  period,  of  the  pardoning  power 
vested  in  the  Executive. 

"  The  details  of  the  evidence  have  been  pretty  fully  reported 
in  some  of  the  papers;  and  will,  I  think,  fully  sustain  the  views 
which  I  have  expressed  ;  certainly  they  do  not  justify  the  con- 
gratulations of  the  daily  press  over  the  speedy  bringing  to 
justice  of  the  perpetrators  of  an  almost  unprecedented  outrage." 

It  is  not,  however,  the  merits  or  demerits  of  merely  isolated 
cases,  however  interesting,  that  I  would  at  this  time  discuss. 
The  war,  now  so  happily  over,  has  suddenly  loosed  from  the 
strict  bonds  of  enforced  discipline  hundreds  of  thousands  of 
able-bodied  men  whose  blood  has  been  heated  by  a  Southern 
gun  and  by  long  privations,  now  replaced  by  the  license  of 
victory,  of  return  to  their  homes,  and  of  freedom  from  the  hard 
but  necessary  thraldom  of  the  camp  and  field. 

At  no  time  in  the  history  of  tliis  country  have  the  self- 
restraint  and  moral  sense  of  the  masses  been  so  severely  tested 
as  at  the  present;  at  no  time,  if  we  may  believe  current 
reports,  have  so  many  forcible  attempts  been  made  upon  the 
chastity  of  women.    Allowing  that  flying  rumor  may  have 


86 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


magnified  every  instance  that  has  really  occurred  into  a 
hundred,  still  no  one  can  deny  that  there  has  been  abundant 
cause  for  general  anxiety,  if  not  alarm.  There  is,  therefore,  a 
twofold  reason  for  examining  into  the  subject  at  the  present 
time.  On  the  one  hand,  that  in  the  trials  that  are  just  now  so 
prevalent,  tho^e  exerting  themselves  in  the  interests  of  justice 
may  wield  a  sharper  sword;  and  on  the  other  that  the  accused, 
more  likely  to  be  the  deserter  or  bount3'-jumper  than  the  true 
soldier,  may  not  come  to  harm  greater  than  he  in  reality 
deserves. 

THE  ABSTRACT  NATURE  OF  THE  CRIME. 

The  exact  character  of  rape,  as  a  crime,  is  not  always,  even 
yet,  understood.  This  remark  is  true,  not  merely  of  lewd 
fellows  of  the  baser  sort  who  may  ignorantly  render  themselves 
liable  to  a  punishment  that  in  some  countries  is  still  death,  and 
in  others,  as  in  Massachusetts,  would  be,  in  the  absence  of 
reprieve,  a  worse  one  than  death,  but  of  juries  and  of  medical 
men.  In  these  trials,  more  tlian  in  many  others,  the  issue  may 
entirely  depend  upon  the  medical  testimony;  and  in  most  in- 
stances the  medical  expert  has  it  in  his  power,  where  he 
chooses  to  lend  himself  intelligently  to  the  purposes  of  justice, 
to  point  out  the  existence  or  the  absence  of  relevant  or  critical 
elements  to  the  counsel  by  whom  he  is  called. 

In  the  legal  classification  of  crimes,  rape  is  enrolled  among 
offenses  against  the  person,  the  element  of  violence  or  compul- 
sion being  present,  while  fornication,  or  willing  intercourse,  is 
only  considered  an  oflTense  against  society.  The  distinction 
that  the  law  has  dra^n  between  the  attempt  and  the  com- 
pletion of  the  crime,  marked,  as  was  formerly  the  case,  by  ex- 
treme and  at  times  disproportionate  difi'erences  in  punishment, 
was  based  not  upon  the  intrinsic  harm,  moral  or  physical,  to 
the  woman,  but,  as  it  were,  upon  her  market  value.  The  view 
to  which  I  refer  is  thus  stated  by  Chitty:  "  An  unmarried 
woman,  who  has  had  sexual  intercourse,  even  by  such  violence 
that  she  was  unable  to  resist  with  efi"ect,  is,  in  a  degree,  dis- 
graced, or  rather  no  longer  retains  her  virgin  puritj-  in  the 
estimation  of  society;  and  thei-e  is  a  natural,  delicate,  though 
perhaps  indescribable  feeling  that  deters  most  men  who  know 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


87 


that  a  female  has  been  completely  violated,  though  manifestly- 
after  every  efibrt  of  resistance,  from  taking  her  in  marriage, 
but  which  does  not  exist,  at  least  in  so  powerful  a  degree,  if 
he  be  certain  that  the  sexual  intercourse  was  incomplete.  Ac- 
cording to  the  ancient  law  of  rape,  which,  intending  to  dis- 
tinguish between  the  degrees  in  the  enormity  of  offenses  of  this 
description,  made  a  marked  distinction  between  ineffectual 
attempts  completely  to  violate,  and  cases  where  the  violation 
was  so  complete  that  the  female  could  no  longer  be  considered 
in  fact  a  virgin,  there  was,  therefore,  required  the  most  explicit 
evidence  of  such  a  completion  of  the  offense,  that  might,  under 
ordinary  circumstances,  occasion  conception;  without  which 
proof  it  was  supposed  that  no  man  could  object  to  the  female 
as  actually  contaminated  or  affected  in  her  virgin  purity."* 
The  law  resting  upon  this  unfounded  basis,  the  fallacy  of  which 
is,  in  part,  shown  by  the  well  known  readiness  with  which 
widows  obtain  a  second  husband,  it  was  very  natural  that  ob- 
jections should  be  made  to  its  modification  in  accordance  with 
the  teachings  of  medical  science.  The  most  unfounded  of  all 
these  objections  seemed  valid  to  the  high  authority  I  have  just 
quoted,  who  was  one  of  the  few  instances  of  a  medico-legal 
teacher  who  has  passed  the  double  curriculum  of  law  and 
physic.  A  change,  he  says,  "  may  unfortunately  have  had  the 
effect  of  inducing  some  offenders  to  comjjlete  the  outrage  in 
cases  where,  under  the  old  law,  the  fear  of  the  higher  punish- 
ment might,  especially  if  opposed  with  sturdy  resistance,  have 
prevented.  Under  the  existing  law,  capital  punishment  is  the 
result,  although  there  have  been  an  incomplete  assault  and  the 
slightest  introduction  of  the  male  organ  infra  labia,  without 
further  perforation  or  the  slightest  laceration  or  actual  injury 
to  the  vagina,  and  although  seminal  discharge  be  clearly  nega- 
tived.   An  offender,  under  such  circumstances,  knowing  that 

*  Chitty,  Med.  Jur.,  381.  If  the  argument  here  advanced  were  really 
valid,  one  ought  to  hear  or  see  more  of  a  "  natural,  delicate,  an  d  indescribable 
feeling"  that  would  "deter  most"  loymen  "from  taking  in  marriage"  a  man 
who  was  known  or  siipposed  to  have  previously  indulged  in  coition.  It  will 
not  do  to  answer  that  such  facts  are  never  known  or  discussed  by  women,  for 
the  gossip,  everywhere,  of  good  societj'  disproves  this;  nor  is  the  fact  that  a 
woman  who  has  been  dishonored,  willingly  or  by  force,  loses  more  in  caste 
than  an  immoral  man,  alone  sufficient  to  support  the  view. 


88 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


he  nmy  be  equally  punished  whether  he  complete  his  purpose 
or  not,  naturally  resolves  to  complete  the  really  greater  offense; 
and  thus  cases  may  have  occurred  where,  contrary  to  the  sound 
policy  of  legislators  in  framing  an  ascending  scale  of  punish- 
ment in  proportion  to  the  injury  or  evil  to  be  repressed,  the 
offender  is  not  induced  to  exercise  any  locus  penitentiae,  but 
completes  what  is  confessedly  a  greater  injury."* 

Elwell,  who  has  done  more,  perhaps,  than  any  one  else  to 
establish  for  medical  evidence  in  this  country  its  due  apprecia- 
tion by  the  bar,  has  defined  rape  as  the  violent  assault  (upon  a 
woman,  for  this  is  implied  by  his  context)  or  the  overcoming 
(her)  resistance  by  artificial  means,  by  which  (her)  chastity  is 
destroyed.!  To  this  definition  may  be  urged  the  following 
objections : 

1.  The  crime  is  not  confined  to  a  single  sex.  It  may  be 
committed  by  females  upon  males,  as  proved  in  repeated  in- 
stances by  the  infection  of  boys  with  the  venereal  disease  where 
the  lesion  was  directly  traceable  to  its  source. 

2.  The  term  chastity  is  uncertain.  It  may  mean  one  or  an- 
other of  four  distinct  though  correlative  states,  of  which  two 
are  moral  and  two  physical. 

a.  The  absence  of  all  previous  carnal  knowledge  or  con- 
nection whatever. 

h.  The  absence  of  all  to  which  the  party  herseif  was  not 
consenting. 

c.  The  state  of  virginity,  absolute. 

d.  The  state  of  virginity,  relatively  to  the  prisoner  alone. 
Now  the  offense  may  be  committed  upon  a  married  woman, 

or  even  a  notoriously  unchaste  person  or  prostitute — nay,  even 
upon  a  woman  with  whom  the  offender  had  himself  in  times 
previous  been  allowed  connection  by  her  own  consent — although 
a  husband  can  not  be  convicted  of  the  ofi"ense  upon  his  wife;:^ 
and,  on  the  other  hand,  no  destruction  of  any  physical  sign  of 
virginity  is  required,  nor  any  furtlier  carnal  penetration  of  the 
female  than  is  implied  by  the  slightest,  most  momentary,  and 
most  external  contact  of  the  respective  generative  organs  with 
each  other. 

•  Chitty,  382.         f  Elwell,  Malpractice  and  Medical  Evidence,  571. 
X  Wharton,  Criminal  Law  of  the  United  States,  sec.  1131. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


89 


3.  Violent  assault  is  unnecessary,  as  with  children,  or  per- 
sons whose  intellect  is  permanently  or  temporarily  in  abeyance, 
or  those  in  sleep. 

4.  Artifice  is  not  required,  for  similar  reasons. 

5.  Resistance  is  by  no  means  impliedly  present,  as  in  the 
cases  just  instanced,  and  those  of  excessive  fear,  or  mistake  as 
to  identity. 

Taylor,  the  present  leading  medical  jurist  of  England,  de- 
fines rape  as  "  in  law,  the  carnal  knowledge  of  a  woman  (still  a 
woman)  by  force  and  against  her  will."*  But  there  is  still  a 
simpler  definition.  It  is  as  follows:  Carnal  knowledge  without 
or  against  cousent.t 

There  must,  therefore,  to  constitute  the  crime,  have  been,  on 
the  one  hand,  carnal  knowledge,  and  on  the  other,  absence  or 
refusal  of  consent. 

I.  What  then,  in  law,  constitutes  the  carnal  knowledge  of  a 
woman  ? 

It  was  at  one  time  held  in  England  that,  to  constitute  rape, 
there  must  have  been  an  emission  of  semen  within  the  parts 
of  the  female.  By  the  statute  of  that  country  now  in  force, 
emission  is  not  essential.  It  has  always  been  held  that  the 
entrance  of  the  man  within  the  private  parts  of  the  woman, 
when  proved,  constitutes  rape.J  In  this  country  it  is  the  gen- 
eral rule  that  some  entrance  must  be  proved,  but  that  there 
need  be  neither  rupture  of  the  hymen  nor  emission.§  The 
English  statute  is,  in  the  18th  section,  thus  explicit  :  "  Carnal 
knowledge  shall  be  deemed  complete  upon  proof  of  penetration 
only."il  Doos  this  mean  not  unless  there  is  decided  proof  of 
penetration,  or  if  there  is  any  the  slightest  proof  of  penetra- 
tion? In  accordance  with  such  doubt  the  law  was  interpreted 
by  one  judge  as  follows  :  carnal  knowledge,  ?'.  e.  penetration, 
is  not  complete  unless  the  hymen  be  ruptured.  This  would 
not  only  rest  the  crime  upon  a  most  uncertain  and  deceptive 

*  Taylor,  Med.  Jurisprudence,  499. 

t  The  above  is  allowed  to  be  correct  byElwell,  but  he  .still  confines  its  ap- 
plication to  the  cases  of  women.    Loc.  cit.,  570. 

X  R.  V.  Allen,  9  C  &  P  ,  31;  K.  v.  Russell,  1  East  V.  C,  438,  4S9;  R.  v. 
Jordan,  9  C.  &  P.,  118;  R.  v.  Hughes,  8  C.  &  P.,  752;  R.  u.  Sims,  1  C.  &  K., 
393;  W.  &  S.,  Med.  Jur.,  sec.  432. 

§  Elwell,  572.  ||  9  Geo.  IV.,  c.  xxxi.,  sec.  18. 


90 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


sign,  the  frequent  absence  of  the  hymen  even  in  virgins  being 
now  so  well  established,  but  it  would  divide  penetration  into 
vulval  and  vaginal;  the  former  not  constituting  rape,  but  a  com- 
mon assault.  The  majority  of  judges,  however,  have  not  ad- 
mitted a  distinction  of  this  kind.  They  have  strictly  adhered 
to  tlie  obvious  meaning  of  the  words  of  the  law,  and  have  re- 
garded the  rupture  of  the  hymen  as  in  no  respect  essential. 
Tlie  question  of  penetration  U  not  for  the  medical  witness,  but 
for  the  jury  to  decide  from  the  whole  of  the  facts.  In  the  case 
of  a  child,  the  prisoner  was  seen  perpetrating  the  act,  and 
though  the  hymen  was  normal  and  unruptured,  the  crime  was 
yet  decided  complete.*  Actual  penetration  by  an  adult  without 
extensive  physical  injury,  inust  be  considered  impossible  in  a 
child  of  tender  age.  The  above  decision,  therefore,  settles  the 
true  character  of  the  penetration  in  law,  that  merely  a  contact 
of  the  genital  organs  is  sufficient  fully  to  effect  it. 

Upon  this  point  it  will  be  seen  that  I  am  at  variance  with  the 
doctrine  still  uplield  by  our  medico-legal  text-books.  I  have 
already  quoted  Elwell.  Taylor,  although  referring  to  a  case 
strongly  corroborative  of  my  position,  yet  avoids  committing 
himself  upon  the  subject.  Beck  avows  a  doctrine  entirely  at 
variance  with  the  knowledge  of  our  time.  I  have  stated  the 
opinion  of  those  best  placed  to  judge,  that  the  presence  or 
absence  of  the  hymen  is  a  most  equivocal  sign.  "  I  am,  how- 
ever," says  Beck,  "  unwilling  to  go  as  far  as  most  of  the  late 
writers  on  legal  medicine,  who  virtually  reject  it  altogether. 
While  it  must  be  allowed  that  it  can  very  often  be  destroyed 
by  causes  which  do  not  impair  the  chastity  of  the  female,  we 
are  justified,  I  think,  in  attaching  considerable  importance  to 
its  presence.  It  would  be  difficult  to  support  an  accusation  of 
rape  where  the  hymen  is  found  entire. "t 

Mr.  Wharton  has  expressed  himself  in  similar  language  : 
"  While  the  slightest  penetration  is  sufficient,  the  English  prac- 
tice is  decisive  that  there  must  be  specific  proof  of  some.X  It 
must  be  shown,  to  adopt  the  phraseology  of  Tindal,  C.  J.,  and 
afterwards  of  Williams,  J.,  that  the  private  parts  of  the  male 


*  Taylor,  539.  f  Beck,  i.,  1.53. 

t  K.  V.  Russen,  1  East  P.  C,  438;  R.  v.  Allen,  9  C.  &P.,  31;  R.  v.  Jordan, 
9  C,  &  P.,  118. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


91 


entered,  at  least  to  some  extent,  those  of  the  female.*  The 
law  may  nQw  indeed  be  considered  as  settled,  that  while  the 
rupturing  of  the  hymen  is  not  indispensable  to  conviction,  there 
must  l)e  proof  of  some  degree  of  entrance  of  the  male  organ 
within  the  labia  of  the  pudendum,t  and  the  practice  seems  to 
be,  not  to  permit  a  conviction  in  those  cases  in  which  it  is 
alleged  violence  was  done,  without  medical  proof  of  the  fact, 
wherever  such  proof  was  attainable. "| 

And  again  he  says:  "  It  has  been  said  that  penetration  may 
be  i)resunied  from  circumstances,  without  S])ecific  and  positive 
proof  of  the  organ  by  whicli  it  was  effected.  This  method  of 
proof,  however,  ought  never  to  be  resorted  to  except  in  extreme 
cases,  where,  from  the  nature  of  the  case,  no  other  evidence 
can  be  had."§ 

It  is  generally  ruled,  therefore,  that  proof  of  some  degree  of 
penetration  is  essential.  But  hov,-,  in  the  generality  of  cases,  is 
this  fact  to  be  ascertained,  save  from  the  testimony  of  the 
woman  herself,  who  is  often  a  very  unreliable  witness?  It 
can  not  be  reached  on  medical  grounds  merely,  for,  as  I  shall 
hereafter  show,  all  evidence  in  this  direction  may  bo  negative; 
nor  upon  the  evidence  of  eye-witnesses,  even  when  they  are 
present,  for  the  exact  local  relations  of  the  parties  are  concealed 
from  view,  and  may,  therefore,  give  rise  to  mistake  as  to 
whether  penetration  or  merely  close  approximation  has 
occurred. 

To  this  question  I  may  appropriately  apply,  with  only  one 
slight  modification,  the  language  of  Mr.  East :  "  A  very  con- 
siderable doubt  having  arisen  as  to  what  shall  be  considered 
sufficient  evidence  of  the  actual  commission  of  this  offense,  it  is 
necessary  to  enter  into  an  inquiry  which  would  otherwise  be 
offensive  to  decency.  Considering  the  nature  of  the  crime, 
that  it  is  a  brutal  and  violent  attack  upon  the  honor  and 
chastity  of  the  weaker  sex,  it  seems  more  natural  and  con- 
sonant to  those  sentiments  of  laudable  indignation  which  in- 

*  R.  V.  Russen,  1  East  P.  C,  438;  R.  v.  Allen,  9  C.  &  P.,  31;  R.  v.  Jordan, 
9  C.  &  P.,  118. 

t  R.  V.  Lines,  1  C.  &  K.,  39.-!;  Wharton  &  Stille,  Med.  Jar.,  seo.  432. 
■  X  Wharton,  Cr.  Law,  sec.  1138. 
§  Ibid.,  sec.  1139;  Com.  v.  Beale,  Phila.  Q.  S.,  Nov.,  1854. 


92 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


duced  our  ancient  lawgivers  to  rank  this  offense  among  felonies, 
if  all  further  inquiry  were  unnecessary.*  *  *  *  *  *  * 
The  quick  sense  of  honor,  the  pride  of  virtue,  which  nature,  to 
render  tlie  sex  amiable,  hath  implanted  in  the  female  heart,  as 
Mr.  Justice  Foster  has  expressed  himself,  is  already  violated 
past  redemption,  and  the  injurious  consequences  to  society  are 
in  every  respect  complete.  Upon  wliat  principle  and  for  what 
rational  purpose  any  further  investigation  came  to  be  supposed 
necessary,  the  books  which  record  the  dicta  to  tliat  effect  do 
not  furnish  a  tracc."t 

Formerly,  as  I  have  said,  proof  of  complete  penetration  was 
required;  now  evidence  of  partial  penetration  is  sufficient. 
But,  as  Wharton  has  admitted  in  a  statement  I  have  lately 
given,  this  may  be  presumed  in  extreme  cases.  Sucli  was  al- 
lowed in  the  famous  Philadelphia  case,  where  a  dentist  was 
convicted,  probably  unjustly,  of  rape  u})on  one  of  liis  patients. 
Let  me  prove  this  assertion  by  an  extract  from  the  judge's 
ruling  on  discharging  the  motion  for  a  new  trial. 

"  The  only  remaining  question  is,  whether  the  evidence 
given  by  the  prosecutrix  was  sufficient,  if  believed,  to  sustain 
the  verdict.  It  is  true  that  the  Commonwealth  failed  to  pro- 
duce the  corroboratory  evidence,  which  an  inspection  of  the 
person  of  the  witness  and  of  her  garments  might  possibly  have 
afforded;  and  it  is  equally  true  that  we  should  have  been  more 
fully  satisfied  if  such  evidence  had  been  produced.  There  is 
no  rule  of  law,  however,  which  imperatively  demands  that  the 
witness  shall  be  corroborated  by  such  evidence.  The  want  of 
such  corroboration  is  a  circumstance  to  be  considered  by  the 
jury;  and,  after  being  carefully  advised  on  this  point  by  the 
court,  if  they  regard  the  evidence  produced  as  satisfactory,  the 
court  should  not  interfere,  unless  satisfied  that  their  decision  was 
clearly  unjust.  This  we  are  not  prepared  to  say.  The  witness, 
it  is  admitted,  was  an  innocent,  pure-minded  girl;  she  told  her  sad 
story  with  apparent  candor;  detailed  all  that  occurred  from  the 

*  The  words  I  have  omitted  in  the  above  quotation  are  the  following:  "after 
satisfactory  proof  of  the  violence  having  been  perpetrated  by  actual  penetra- 
tion of  the  unhappy  sufferer's  body."  A  proof  that,  as  I  have  shown,  in  many 
undoubtable  instances  can  not  be  afforded. 

t  Wharton,  Cr.  Law,  622. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


93 


time  the  ether  was  administered;  the  feeling  of  her  pulse,  her 
arm,  her  bosom,  her  person,  the  fixing  of  her  feet,  the  drawing 
down  of  her  body  to  the  edge  of  the  chair,  and  finally  the  pain 
she  suffered.  It  is  not  strange  that  the  jury  believed  her,  for 
the  question  might  well  be  asked:  how  could  an  innocent  girl 
detail  such  occurrences,  and  with  such  precision,  if  it  had  not 
really  occurred  ?  There  is  nothing  that  appears  so  inconsistent 
in  her  story,  or  so  apparently  devoid  of  probability,  that  a  jury 
should  be  instructed  to  disregard  it,  or  that  the  court  should 
interfere  with  their  decision  upon  it.  But  it  is  said  that  even 
if  her  statement  be  believed,  it  shows  no  legal  evidence  of 
penetration. 

"  It  is  impossible  to  lay  down  any  general  rules  regulating 
the  nature  and  amount  of  proof  required  to  establish  the  com- 
mission of  such  an  offense.  Each  case  must  be  viewed  under 
its  own  circumstances,  and  legitimate  inference  drawn  from  all 
the  facts  proved.  Here  the  witness  states  the  preparation 
made  by  the  defendant — her  feet,  which  had  been  crossed,  were 
spread  apart,  one  on  each  end  of  the  stool;  her  body  was  drawn 
down  to  the  edge  of  the  chair,  the  defendant  was  before  her, 
she  felt  his  breath  upon  her  face,  which  sliows  that  the  position 
of  his  body  must  have  been  leaning  over  her,  and  at  that  time 
she  felt  the  pain  which  enabled  her  to  say  that  she  had  no 
doubt  that  the  defendant  entered  her  person.  If  this  evidence 
as  to  sensation  and  position  is  believed,  upon  such  an  issue  as 
here  presented  of  the  condition  and  knowledge  of  the  witness, 
may  not  the  jury  determine  from  it  whether  the  penetration 
sworn  to  was  such  as  the  law  requires  to  constitute  a 
rape?"* 

The  ruling  now  given  is  irrespective  of  the  main  point  in  the 
case,  that  the  patient  had  been  etherized,  and  was  probably 
laboring  under  an  entire  delusion  as  to  the  whole  matter.  It 
rests  the  proof  of  penetration  wholly  upon  the  patient's  allega- 
tions as  to  preparations  made,  position  taken,  and  pain  endured 
— all  of  whicli  do  indeed  bear  directly  upon  the  question  of 
an  attempt;  but  in  the  absence  of  corroborative  medical  testi- 
mony, which  is  often  wanting,  they  are  wliolly  insufficient  to 
prove  the  fact  of  penetration,  or  the  effected  crime.  On  the 
'  Wharton,  Cr.  Law,  623. 


94 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


other  liand,  allowing  the  truthfulness  of  the  witness,  there  was 
sufficient  presumption  for  the  alleged  relative  position  of  the 
parties,  to  satisfy  the  jury,  upon  this  supposition,  that  there  had 
occurred  a  certain  amount  of  penetration,  as,  indeed,  was  de- 
cided to  have  occurred  in  a  case  1  have  already  referred  to 
from  Taylor. 

Wharton,  while  challenging  the  decision  on  the  ground  of 
possible  delusion,  allows  the  point  now  made.  "  The  general 
result  of  both  medical  and  legal  opinion,"  he  says,  "  is  that 
while  the  learned  and  able  judge  who  tried  the  case  jjroporly 
left  it  to  the  jury  as  a  question  of  fact,  as  he  was  obliged  to  do, 
to  determine  whether  penetration  had  taken  place,  the  verdict 
was  not  sustained  by  the  evidence,  and  forms  an  unsafe  prece- 
dent for  the  future."* 

I  agree  fully  in  this  statement  as  regards  the  merits  of  the  spe- 
cial case  involved.  When,  however,  we  are  told  that,  save  in  ex- 
treme and  therefore  very  exceptional  cases,  penetration  can  not 
be  presumed,  "without  specific  proof  of  the  organ  with  which 
it  was  effected, "t  it  is  at  once  seen  that  the  prosecution  of  many 
otherwise  perfectly  simple  cases  ought  to  fall  to  the  ground. 
This  has,  indeed,  often  occurred,  and  may  again — witness,  for 
instance,  the  following  case,  tried  in  1844,  of  rape  upon  a  child, 
where,  as  is  well  known,  it  is  often  impossible  for  any  real 
penetration  to  occur. 

The  surgeon  here  deposed  that  "  the  hymen  of  the  child  was 
not  ruptured,  but  that  upon  the  hymen  was  a  venereal  sore,  which 
must  have  arisen  from  actual  contact  with  the  virile  organ  of  a 
man."^  Mr.  Baron  Parke  left  it  to  the  jury  to  say  "  whether,  at 
any  time,  any  part  of  the  virile  member  of  the  man  was  within 
the  labia  of  the  pudendum  of  the  prosecutrix;  for,  if  ever  it  was, 
no  matter  how  little,  that  Avill  be  sufiicient  to  constitute  a  pen- 
etration, and  the  jury  ought  to  convict  the  prisoner  of  the  com- 
plete offense."    The  verdict  was,  not  guilty.§ 

"  Wharton  &  Stille,  Med.  Jur.,  sec.  471.        f  Wharton,  Cr.  Law,  sec.  1139. 

I  I  shall,  hereafter,  call  attention  to  other  modes  than  the  usual  way  by 
which  syphilitic  inoculation  of  an  infant's  genitals  may  take  place.  In  the 
present  instance,  the  verdict  seems  to  have  turned  upon  the  question  of  degree 
of  penetration  only. 

§  R.  V.  Lines,  1  C.  &  K.,  393. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


95 


Tlie  same  is  shown  by  another  English  case,  where  the 
judges,  Bosanquet,  Coleridge,  and  Coltraan,  concurred  in  saying 
that,  "  when  that  which  is  so  very  near  the  entrance  has  not 
been  ruptured,  it  is  very  difficult  to  come  to  the  conclusion  that 
there  has  been  penetration  so  as  to  sustain  a  charge  of  rape." 
There  was  evidence  from  the  surgeon  in  attendance  that  the 
vulva  and  vagina  were  so  much  inflamed  as  to  render  it  im- 
possible to  ascertain  whether  or  not  the  hymen  remained 
entire,  yet  the  defendant  was  acquitted.* 

In  former  times,  when  it  was  necessary  to  prove  that  the 
seminal  fluid  had  been  discharged  within  the  vagina,  it  was 
very  naturally  allowed  that  impotence,  when  existing,  should 
be  considered  an  effectual  bar  to  the  consummation  of  the 
offense.  Now  that  seminal  ejaculation  is  no  longer  required, 
it  would  seem  that  the  mere  allegation  of  impotence  should  not 
be  allowed  its  former  protective  weight.  This,  however,  is 
still  permitted.  "  Impotency,"  says  Wharton,  "  is  un- 
doubtedly a  sufficient  defense  to  an  indictment  for  the  con- 
summated offense,  though  not  for  an  assault  with  intent. "f 

I  need  merely  refer  to  the  facts  that  the  power  of  erection, 
and  therefore  of  penetration,  may  be  retained  by  actual  eunuchs, 
and  that  some  men  may  be  impotent  towards  one  woman,  in  con- 
sequence frequently  from  some  displacement  of  her  uterus,  for 
instance,  while  perfectly  potent  in  the  case  of  all  others,  to  make 
tlie  impropriety  of  longer  allowing  the  excuse  alluded  to  per- 
fectly evident.  There  are  many  questions  in  Obstetric  Juris- 
prudence where  proof  of  absolute  impotence,  so  difficult  or  im- 
possible to  obtain,  may  be  of  great  importance;  but  now  that 
conception,  or  the  risk  of  conception,  has  nothing  to  do  with 
the  offense  of  rape,  and  inasmuch  as  every  woman  would  sup- 
pose from  the  attempt  at  coitus  that  the  person  attempting  at 
least  supposed  himself  virile  enough  to  complete  the  act,  the 
shock  to  her  modesty,  and  the  physical  violence  which  she  may 
undergo,  alike  demand  that  the  law  should  extend  to  her  the 
additional  protection  1  have  now  claimed. 

1  do  not  endorse  the  opinion  of  Chief-Justice  Carlton,  that 
it  is  always  enough  if  the  prosecutrix  swear  to  "  carnal  knowl- 


•  R.  V.  McRue,  8  C.  &  P.,  G-II. 


96 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


edge  of  her  person;"*  but  I  do  assert  that  rape,  and  attempts 
at  rape,  ought  not  to  be  separated  from  each  other  so  distinctly 
as  even  at  the  present  day  medical  jurists  would  do,  and  that 
convictions  should  occur  and  penalties  be  imposed  more  com- 
pletely in  accordance  with  the  merits  of  each  individual  case. 
Thi?,  as  I  have  proved  by  the  late  case  at  Boston,  a  summary  of 
which  has  been  given,  is  impossible  in  Massachusetts,  during 
the  continuance  of  the  present  statute.  That  the  laws  against 
rape  vary  in  the  different  states  of  the  Union  I  shall  soon  show, 
and  shall  j)oint  out  a  grave  inconsistency  in  the  New  York  code. 
I  shall  have  accomplished  good  work  if  I  prove  to  tlie  profes- 
sion the  necessity  of  insuring  uniformity  and  better  justice  by 
their  general  revision  throughout  the  country.  For  this,  the 
present  time  is  especially  favorable,  now  that  the  exigences  of 
returning  peace  are  submitting  the  statutes  of  so  many  of  our 
States  to  the  saving  influences  of  reconstruction. 

II.  With  regard  to  consent,  there  are  certain  parties  to 
whom  the  word  "  without "  directly  applies. 

These  are  : 

1,  Those  women  who  could  not  possibly  have  consented  for 
intrinsic  reasons — as  children  of  tender  age,  insane  persons, 
and  idiots. 

2.  Those  who  could  not  have  consented,  for  accidental 
reasons — as  those  in  deep  sleep,  natural  or  artificial,  from  the 
effect  of  stimulants,  narcotics,  or  auEesthetics — or  in  a  swoon 
consequent  on  disease  or  wounds,  recent,  or  of  long  standing, 
accidentally  or  intentionally  inflicted. 

By  the  former  of  these  cl  isses  consent  cannot  be  legally 
given;  if  granted,  it  is  invalid  for  removing  criminal  imputa- 
tion. By  the  latter,  it  would  seem  necessary  for  successful 
defense  that  the  sleep  or  swoon  should  have  followed,  not 
preceded,  the  intercourse — an  important  distinction,  as  it  is 
certain  that  with  many  women  of  extremely  sensitive  and 
irritable  nervous  organization,  loss  of  consciousness,  attended 
even  with  hystcriform  or  einleptic  convulsions,  may  ensue 
immediately  upon  or  during  ordinary  sexual  intercourse.  The 
support  that  these  accidents,  particularly  the  last  instanced, 
epilepsy,  might  lend  to  a  criminal  charge,  is  very  obvious. 

"  *  K.  V.  Lidwell,  1  McNally's  Evid.,  eOG. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


97 


As  to  the  other  word,  "  against,^''  its  character  as  valid  or 
not  in  an  indictment,  will  have  to  be  settled  by  the  circuin- 
stances  of  each  individual  case.  The  chance  of  wrongful 
allegation  is  so  great  that  these  circumstances  can  not  be  too 
closely  scrutinized,  by  the  parties  on  both  sides  having  the 
case  in  charge. 

The  frequency  of  rape  or  attempts  at  the  crime  is  not  to  be 
estimated  by  the  number  of  cases  brought  to  trial.  It  was 
formerly  everywhere  a  capital  offense.  In  Massachusetts,  the 
punishment  has  been  lately  lowered  to  imprisonment  for  life. 
In  New  York,  the  extreme  penalty  for  ravishing  a  woman  in 
full  possession  of  her  senses  is  only  a  ten  years  imprisonment,* 
while  if  she  has  been  drugged  or  otherwise  stupefied,  so  as  to 
be  rendered  wholly  incapable  of  defending  herself,  the  punish- 
ment, strangely  enough,  though  already  so  slight,  is  lessened  by 
one-half.t  So  in  England,  during  the  present  reign,  it  has 
been  changed  from  death  to  permanent  transportation  beyond 
the  seas.  J  Judging  by  the  remarkable  increase  in  prosecutions 
induced  in  Great  Britain  by  this  change,  57  per  cent,  on  the 
average  of  four  years  to  1845,  and  by  official  statement  in 
Parliament,  an  increase  of  90  per  cent,  to  1847,  it  would  seem 
as  though  the  crime  itself  were  frightfully  extending.  More- 
over, there  is  no  doubt  that  in  many  instances  the  woman's 
natural  shame  at  publishing  her  own  disgrace  prevents  dis- 
closure, where  there  are  no  other  witnesses  cognizant  of  the  fact. 
On  the  other  hand  it  must  not  be  forgotten  that  the  chance  of 
false  accusation,  always  great,  has  been  infinitely  increased  now 
that  the  death  penalty  has  been  abolished.  For  one  real  rape, 
it  has  been  remarked,  that  is  now  tried  on  the  English  cir- 
cuits, there  are  at  least  twelve  pretended  cases. 

I  have  already  alluded  to  the  danger  of  these  false  accusa- 
tions being  brought;  this  is  owing  to  a  variety  of  causes. 

If  the  charge  is  made  by  the  woman  herself,  it  may  be  from' 

1.  An  intention  to  extort  money,  the  technical  black-mail;. 

2.  Personal  hatred,  or  sexual  disappointment; 

3.  Unfounded  mental  delusions,  as  of  disease,  the  antesthetic 
state,  intoxication,  or  sleep; 


*  2  R.  P.,  663,  sec  22.        f  Ibid.,  sec.  23.       J  4  &  5  Vict.,  c.  Lvi.,.S.  3^ 

Vol.  IL— No.  8.  7 


98 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


4.  To  preserve  character,  so  called,  which  has  been  volun- 
tarily endangered. 

If  brought  by  a  third  party,  the  mother,  for  instance,  the 
charges  may  be  from  the  first  or  last  of  the  reasons  just  alleged, 
here  implying  a  conspiracy;  or  if  made  in  good  faith,  then  in 
consequence  of  mistake,  depending  in  the  case  of  a  young 
girl,  upon 

5.  An  unnatural  vaginal  discharge,  vulval  or  other  bruise 
or  abrasion,  the  result  of  disease,  accident  or  self-abuse. 

There  is  abundant  proof  that  on  each  of  these  false  grounds 
very  many  wrongful  convictions  have  been  effected,  and  that 
in  consequence  many  innocent  parties  have  perished  upon  the 
scaffold. 

In  these  papers,  treating  as  they  do  of  subjects  equally  in- 
tere-ting  and  important  to  lawyers  and  medical  men,  I  am 
compelled  to  cover  double  ground,  and  thereby,  I  trust,  while 
rendering  them  of  practical  advantage  to  either  party,  to 
advance  the  best  interests  of  both.  It  is  requisite  that  the 
attorney  should  know  what  medical  points  in  prosecution  or 
defense  are  tenable  in  law,  or  are  in  accordance  with  facts  or 
equity:  and  that  the  physician,  who  is  so  often  called  upon  to 
decide  doubtful  questions  in  cases  that  may  never  reach  the 
lawyer — often,  indeed,  to  decide  whether  tliey  shall  reach  him 
or  not — as  well  as  liable  to  testify  as  to  fact,  presumption  or 
probability  upon  the  witness-stand,  should  be  informed  what 
and  to  what  extent  the  law  assumes  and  the  law  requires. 

In  the  first  place,  it  is  a  presumption  of  law  that  innocence  is 
to  be  taken  for  granted  until  the  guilt  is  made  to  appear  by 
conclusive  evidence,  so  that  the  burden  of  proof  is  necessarily 
thrown  upon  the  prosecution. 

It  is  therefore  always  to  be  presumed  that  rape  was  not 
committed,  and  that  if  intercourse  were  effected,  it  was  with 
the  fuU  consent  of  the  female. 

THE  PROOFS  OF  COMMISSION. 

I  have  already  defined  the  character  of  rape  in  law.  It  is 
necessary  then  to  prove — 

1.  That  carnal  intercourse,  the  so-called  penetration,  or 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


99 


rather  the  reciprocal  contact  of  the  generative  organs  of  the 
two  parties,  really  took  place  at  the  time  alleged;  and 

2.  That  the  ■woman's  consent  was  wanting. 

To  apply  these  principles  to  any  given  case,  it  is  necessary 
in  a  trial  for  rape  to  prove,  in  the  first  place,  that  carnal  inter- 
course, as  defined  above,  has  been  eifected. 

Besides  the  allegation  of  the  woman,  as  I  have  said,  other 
direct  evidence  may  be  present,  tending  to  prove,  with  the 
attempt  at  the  act,  that  mutual  contact  of  the  genital  organs 
did  take  place.  Thus,  the  position  in  which  the  parties  were 
found  by  a  third  person,  or  which  it  is  admitted  did  for  the 
time  exist  between  tliem,  may  have  been  such  as  would  afford 
very  strong  presumption  that  the  contact  required  to  complete 
the  crime  was  really  effected.  Both  parties  may  have  been 
undressed  and  in  bed  together;  or  the  clothes  of  each  un- 
loosened or  disarranged,  the  place  they  were  in  under  such  cir- 
cumstances being  also  perhaps  retired  and  the  time  unusual,  or 
for  both  these  elements  of  privacy  there  may  have  been  the  use 
of  lock  and  key — the  parties  having  been  surprised,  or  seen 
through  a  keyhole  or  window. 

Such  evidence  as  this,  alleged  by  a  third  person  who  is  a 
credible  witness,  is  necessarily  very  strong.  It  is  almost  con- 
clusive as  regards  sexual  connection,  but  this  is  a  very  different 
thing  from  forcible  and  forbidden  intercourse  or  rape.  Where 
such  evidence  as  the  above,  however,  is  procurable,  the  same 
witness  is  generally  able  to  testify  as  to  the  existence  of  con- 
sent, that 's  if  he  or  she  were  present  at  the  time  the  assault  is 
alleged  to  have  been  committed,  and  not  merely  immediately 
subsequently  to  that  event. 

On  the  other  hand,  if  there  was  no  one  present  besides  the 
parties  themselves,  it  becomes  necessary  to  rest  this  point  of 
carnal  intercourse,  so  far  as  direct  evidence  is  concerned,  solely 
upon  the  testimony  of  the  woman.  In  these  cases,  it  will  be 
seen,  extreme  caution  is  necessary,  both  regarding  her  testi- 
mony and  any  presumption  from  the  circumstances  attending, 
which  are  necessarily  in  great  measure  of  a  strictly  medical 
character. 

The  medical  evidence  of  carnal  penetration  without  consent 
may  be  derived  from  four  sources: 


100 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


1.  Marks  of  violence  about  the  genitals  of  prosecutrix  or 
prisoner,  from  the  act  itself  or  its  repulsion. 

2.  Marks  of  violence  on  the  person  elsewhere  of  prosecutrix 
or  prisoner,  from  the  resistance  offered  or  from  general 
violence. 

3.  The  presence  of  stains  of  the  spermatic  fluid  or  of  blood 
on  the  clothes  or  person  of  the  prosecutrix  or  prisoner. 

4.  The  existence  of  gonorrhoea  or  syphilitic  disease  in  one 
or  both. 

It  is  unnecessary,  as  I  have  said,  to  prove  that  the  vagina 
had  been  really  penetrated  by  the  virile  member,  or  that 
seminal  emission  had  occurred  within  its  cavity.  The  law  has 
fortunately  saved  us  this  trouble.  Were  such  proof  required,  it 
would  have  been  in  many  cases  almost  impossible  to  furnish , 
for  the  following  reasons: 

1.  The  valvular  membrane  at  the  mouth  of  the  vagina, 
the  hymen,  so  long  considered  necessary  as  proof  of  virginity, 
is  often  congenitally  deficient  or  wholly  wanting; 

2.  It  may  have  been  previously  destroyed  by  disease; 

3.  By  accident; 

4.  By  self-abuse,  a  vice,  or  rather  habit,  not  at  all  uncom- 
mon even  among  women; 

5.  By  previous  intercourse.  "When  this  has  occurred,  and 
whether  the  complainant  is-  a  married  woman  or  not — for  fre- 
quent coitus  is  by  no  means  confined  to  those  legally  entitled 
to  such  privilege — the  hymen  is  almost  necessarily  absent; 
certainly  so,  cr  at  least  with  very  rare  exceptions,  if  she  has 
had  cliildren  at  the  full  time,  though  the  occurrence  of  an  early 
abortion  does  not  always  destroy  it. 

6.  And  on  the  other  hand,  complete  vaginal  penetration  is 
by  no  means  necessarily  followed  or  accompanied  by  intra- 
vaginal  emission  of  the  seminal  fluid.  It  is  now  notorious  that 
in  a  large  proportion  of  the  cases  of  illicit  intercourse,  and 
indeed,  of  conjugal  intercourse,  tlie  completion  of  the  act  within 
the  body  of  the  woman  is  purposely  withheld,  for  the  purpose 
of  preventing  or  avoiding  an  impregnation,  rightfully  or 
wrongfully  tliought  inconvenient,  destructive  as  this  method 
undoubtedly  is  to  the  health  of  both  parties  engaged.* 


*  I  cao  uot  too  strongly  express  my  belief  that  incomplete  intercourse, 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


101 


The  law  has  also  wisely  refrained  from  requiring  any  proof 
that  impregnation  has  been  effected,  it  being  now  well  known 
that  this  is  by  no  means  a  necessary  consequent  of  the  fully 
completed  act— indeed,  an  unlikely  consequent,  except  at  or 
very  near  the  monthly  period  of  ovulation  and  menstrual  dis- 
charge. It  was  at  one  time  supposed  that  the  fright,  disgust 
and  aversion  on  the  part  of  the  woman  attending  true  rape, 
would  of  itself  be  sufficient  to  prevent  conception,  and  that 
the  occurrence  of  this  was  so  far  proof  of  consent;  but  this 
theory  is  unfounded — the  most  frigid  and  apathetic  women 
being  often  extremely  fruitful,  and  conception  often  occurring 
with  vaginal  disease  that  induces  great  anguish  and  suffering 
during  coitus. 

"We  will  allow  then  that  the  four  medical  presumptions  of 
intercourse,  any  or  even  all  of  them,  are  present;  marks  of 
violence  on  the  genitals  or  other  parts  of  the  person  in  one  or 
both,  stains  of  spermatic  fluid  and  of  blood  on  the  clothes  of 
one  or  both,  and  the  presence  of  what  are  generally  supposed 
conclusive  signs  of  venereal  disease.  How  can  these  be  dis- 
proved or  rebutted  ?  I  shall  here  deal  in  general  statements, 
and  not  descend  to  the  details  of  proof,  some  of  them  micro- 
scopic— as  for  such,  accessible  in  every  medical  library,  we  have 
here  neither  space  nor  time. 

1.  It  is  of  course  presumed  that  an  alibi  can  not  be  proved. 

2.  The  next  point  of  importance  for  the  defense  is  to  ascer- 
tain if  the  party  alleged  to  have  been  outraged  is  really  a 
woman,  and  on  the  other  hand,  if  the  prisoner  is  really  a  man. 
Both  of  these  questions,  it  is  evident,  can  only  be  solved  by  a 
thorough  medical  examination.  Their  pertinency  and  validity 
miglit  easily  be  shown. 

3.  Regarding  marks  of  violence.  If  it  were  allowed  that 
sexual  connection  had  thus  been  conclusively  proved  on  the 
part  of  one  or  both  persons,  it  would  become  a  matter  of 

whether  effected  by  the  use  of  a  protecting  sheath  or  by  untimely  withdrawal, 
is  very  detrimental  to  the  local  and  general  health  of  both  men  and  women. 
As  regards  the  latter  of  these  classes,  I  am  constantly  seeing  the  effect  re- 
ferred to;  as  regards  the  former,  I  am  glad  to  find  my  views  concurred  in  by 
so  careful  an  observer  aud  so  competent  an  authority  as  my  friend  Dr.  Bum- 
stead,  of  New  York,  whose  work  on  Venereal  is  undoubtedly  the  best,  as  yet, 
in  any  language. 


102 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


no  little  difficulty  to  prove  that  this  causative  connection  was 
between  the  two  parties  now  in  court,  or  that  the  marks  of 
yiolence  evidenced  were  not  from  recent  connection  with  other 
parties  unknown.  Cases  illustrative  of  these  positions  readily 
suggest  themselves.  It  is  no  uncommon  thing  for  such  appear- 
ances to  exist  on  the  persons  of  women  newly  married,  who, 
suffering  acute  physical  pain  upon  the  first  conjugal  approach, 
at  times  are  inclined  to  resist  completion  of  the  act;  and 
again  it  is  often  for  tlie  interest  of  women,  married  or  not,  who 
are  yet  not  at  all  unfamiliar  with  sexual  intercourse,  to  play 
the  coquette,  and  by  an  appearance  of  refusal,  to  conceal  the 
loss  of  their  virginity.  In  either  case  the  blind  fury,  so  often 
brutal,  of  a  lustful  man,  might  overleap  and  violently  break  all 
barriers.  Suppose,  in  such  cases,  an  attempt,  soon  after,  at 
rape  upon  the  woman  by  another  party;  or  in  the  latter  of  the 
instances  suggested,  that  it  is  willfully  charged  upon  an  inno- 
cent person,  to  give  still  further  color  and  credit  to  an  attempt 
at  regaining  lost  repute  of  chastity — the  danger  of  an  unjust 
conviction  becomes  very  evident.  Moreover,  these  injuries 
have  at  times  been  intentionally  and  artificially  produced  for 
the  purpose  of  giving  support  to  a  false  charge  of  the  crime. 

The  marks  of  violence  referred  to  may  be  either  upon  or  in 
the  neighborhood  of  the  genitals,  or  upon  other  parts  of  the 
person.  If  of  the  latter  kind,  it  is  of  as  great  importance  as  in 
the  former  case  closely  to  scrutinize  their  character  and  loca- 
tion, to  search  for  their  direct  exciting  cause,  and  to  decide 
upon  the  probable  time  of  their  infliction.  Thus  injuries  upon 
the  man,  if  inflicted  by  no  weapon  of  defense,  would  have 
probably  been  caused  by  the  woman's  teeth  or  finger  nails,  or, 
indeed,  if  the  act  is  alleged  to  have  been  committed  in  bed, 
then,  perhaps,  by  the  nails  of  her  feet.  Tlie  probability  of 
their  having  thus  been  occasioned,  and  under  the  circumstances 
alleged,  can  only  be  reached  by  closely  examining  the  position 
and  extent  of  the  injuries  themselves,  and  comparing  these 
with  the  alleged  position  occupied  by  the  respective  parties. 
If  upon  the  person  of  the  woman,  these  general  injuries  would 
be  either  from  blows  for  the  purpose  of  stunning  or  disabling, 
from  efforts  to  tiip  or  throw  her  down,  from  forcible  attempts 
to  open  her  thighs  either  by  a  knee  or  the  hands,  or  from 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


103 


ligatures  that  have  been  applied  for  the  purpose  of  disabling 
her,  or  of  compelling  a  position  more  favorable  for  the  com- 
pletion of  the  felonious  assault.  The  possibility  of  these 
injuries  having  been  inflicted,  as  is  frequently  the  case,  by  an 
accomplice,  must  also  be  borne  in  mind.  Their  date,  to  a  cer- 
tain extent,  is  shown  by  their  condition  at  the  time  of  inspec- 
tion, the  existence  of  zones  of  discoloration,  etc.  And  it  is 
evident  that  any  marked  discrepancy  between  the  time  of  their 
alleged  occurrence,  and  the  physical  characters  that  they  pre- 
sent, ought,  so  far,  to  vitiate  the  charge. 

Thus  far  the  evidence,  so  far  as  it  goes,  tends  to  the  pre- 
sumption, not  that  intercourse  has  been  effected,  but  that  it  has 
been  attempted. 

Injuries  upon  the  genitals  are,  in  the  case  of  either  party, 
much  the  more  important.  As  I  have  said,  I  do  not  intend 
here  to  enter  into  minute  details,  and  will  content  myself  with 
merely  pointing  out  generally  the  more  obvious  sources  of 
deception  or  mistake. 

Contusions,  abrasions,  and  discolorations  around  the  male 
genitals,  and  injuries  inflicted  upon  the  organs  themselves,  are 
pretty  positive  evidence  to  the  end  borne  upon  by  the  class  of 
injuries  just  instanced,  that  coitus  has  been  attempted.  The 
local  injuries  that  we  are  considering  arc  caused  by  the  resist- 
ance of  the  woman,  who,  in  her  desperation,  has  sometimes 
sliced  off  the  male  member  with  a  razor  or  knife,  or  even  bitten 
it  off.  Almost  the  only  successful  rebutter  of  such  evidence  as 
this  that  could  be  alleged,  would  be  proof  of  the  previous  occur- 
rence of  some  unusual  accident  to  tlie  organs,  as  striking  upon  a 
sharp  or  projecting  body  during  a  fall,  or  that  the  prisoner  had 
himself  attempted  self-mutilation,  as  is  not  unfrequently  the  case 
during  an  attack  of  insanity,  or  that  he  had  recently  been  per- 
mitted intercourse  with  some  other  woman,  of  very  compact 
genitals,  not  easily  entered. 

The  result  of  disease,  as  we  shall  perceive,  must  be  borne  in 
mind,  and  carefully  distinguished  from  the  effects  noticed. 

Local  injuries  in  the  female,  on  the  other  hand,  go  further  to 
prove  that  intercourse  has  been  consummated.  They  are 
much  less  likely  to  be  in  the  neighborhood  of  the  organs  than 
directly  upon  or  within  them,  and  their  presence  is  in  great 


104r 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


measure  dependent  upon  the  ago  of  the  subject.  The  younger 
she  is,  the  more  liable  to  external  contusion  and  to  internal 
laceration  and  injury,  l»otli  the  outer  and  the  inner  tissues  being 
so  much  the  more  delicate  and  friable.  If  an  adult,  with  whom 
connection  liad  never  l>y  any  one  been  previously  efifected,  there 
would  be  a  great  deal  of  soreness  and  stiffness,  elements  chiefly 
to  be  ascertained  by  tlie  testimony  of  the  party  herself,  and  to 
a  certain  extent,  by  her  manner  of  carriage;  and  perhai)S, 
though  not  necessarily,  turgescence  or  abrasion  of  the  external 
parts,  the  outer  and  inner  lips  of  the  vulva,  the  labia,  and 
nymplia;. 

The  law,  properly  interpreted,  does  not  require  proof  that 
further  penetration  than  this,  or  even  as  much  as  this,  has  been 
effected.  If  such  proof,  however,  exist,  it  should  not  be  rejected. 
The  remnants  of  a  recently  ruptured  hymen,  carunculaj  myrti- 
formes,  as  they  are  subsequently  styled,  the  presence  of  visible 
hemorrhage,  arising  from  the  outlet  or  within  it,  or  the  detection 
of  the  so-called  seminal  animalcules  or  spermatozoa  within  the 
passage  itself,  or  in  the  discharges  issuing  from  it,  would,  within 
certain  important  limits,  be  acknowledged  presumptive  proof 
of  effected  coitus.  The  presence,  however,  of  mucous,  purulent 
or  even  hemorrhagic  discharge  should  of  itself  be  allowed  to 
possess  little  or  no  conclusive  weight. 

With  a  married  woman,  especially  of  some  little  standing  as 
to  the  time  she  has  held  this  relation,  these  signs  proportion- 
ately fail.  If  the  vulva  and  vagina  have  been  dilated  by  fre- 
quent intercourse,  and  especially  by  the  birth  of  a  child  or 
children,  coitus  being  infinitely  easier,  it  is  less  likely  to  leave 
any  visible  or  appreciable  trace  behind.  But  upon  all  these 
points  and  in  every  case  that  may  be  brought  to  trial,  it  must 
not  be  forgotten  that  however  favorable  the  circumstances,  and 
however  consenting  the  woman,  it  is  always  difficult,  and  in 
many  cases  impossible,  for  the  male  fairly  to  enter  the  vagina 
of  the  female  without  direct  manual  assistance  from  himself  or 
from  her.  In  rape,  the  man  can  seldom  attempt  this  assistance, 
both  his  hands  being  usually  required  to  overcome  the 
woman's  resistance;  so  that  if  complete  intercourse  is  alleged, 
or  is  proved,  or  indeed  is  even  admitted  by  the  defense,  it 
might  fairly  be  considered,  in  the  absence  of  extreme  local 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


105 


injury  or  complete  insensibility  on  tlie  part  of  the  woman,  and 
this  wliether  she  be  married  or  unmarried,  as  so  far  strong 
presumption  of  her  consent,  if  not  direct  assistance  in  the  act. 
To  this  point  we  shall  necessarily  again  return. 

4.  The  presence  of  stains  of  the  spermatic  fluid  or  of  blood 
upon  the  clothes  or  person  of  the  prosecutrix  or  prisoner,  has 
always  been  thought  among  the  most  conclusive  proofs.  It  is 
easy,  however,  to  show  that  this  is  not  actually  so,  except  in  the 
case  of  an  infant  or  a  person  legally  incapable  of  consent. 
Putting  aside  the  possibility  in  microscopic  examinations  where 
the  clothes,  etc.,  have  been  soaked  and  macerated  for  the  pur- 
pose of  freeing,  for  more  accurate  scrutiny,  the  base  of  a  sus- 
pected stain,  of  error  by  mistaking  minute  filaments  of  cotton 
fibre,  etc.,  for  the  true  spermatozoon,  and,  in  ordinary  cases,  of 
being  misled  by  stains  of  urine,  mucus,  or  a  blenorrhoeal  dis- 
charge, there  is  still  abundant  ground  for  successful  defense. 
While  it  is  not  necessary  to  prove  the  occurrence  of  a  seminal 
emission,  there  must  not,  on  the  other  hand,  be  too  much 
weight  allowed  to  the  fact  of  its  existence. 

We  grant  that  seminal  stains  exist  upon  the  clothes  of  the 
prisoner.  What  then  ?  With  the  lower  class  it  is  nothing 
uncommon  for  the  same  underclothing  to  be  worn  day  and 
night.  It  is  well  known  that  seminal  emissions  are  of  constant 
occurrence  during  erotic  dreams,  even  among  the  chastest  and 
most  ascetic  of  men.  It  is  as  certain  that  at  times,  especially 
if  the  person  has  been  of  a  sensual  habit,  these  same  involuntary 
emissions  may  take  place  in  tlie  daytime,  during  strong  sexual 
excitement  or  desire,  without  implying  sexual  contact  or  even 
the  woman's  presence;  and  that  in  some  men,  plethoric  or  de- 
bilitated as  the  case  may  be,  a  similar  discharge  may  occur, 
either  by  day  or  by  night,  without  the  consciousness  of  a  lust- 
ful thought.  Of  course,  if  the  stains  are  upon  the  external 
clothes  the  presumption  of  intercourse  increases.  If  the  sem- 
inal traces  are  detected  upon  the  prisoner's  person  they  prove 
nothing  more,  save  tliat  the  emission  was  with  greater  prob- 
ability or  certainty  of  recent  date. 

If  they  are  ujion  the  woman's  person,  their  evidence  is  merely 
to  the  same  effect,  that  coitus  has  been  attempted  by  the 
prisoner  or  some  one  else.    If  upon  or  within  the  genital 


06 


OBSTETEIC  JURISPRUDENCE. 


[Nov., 


organs,  there  is  merely  presumption,  not  positive  proof,  that 
complete  coitus  has  been  effected,  for  the  spermatic  jet.  during 
her  struggle,  may  have  been  thrown  from  some  little  distance, 
and  thus  have  entered  the  opening.  Tliis  supposition,  of  itself 
plausible,  receives  additional  weight  from  tlie  fact  that  im- 
pregnation has  been  effected,  in  tlie  known  absence  of  a  third 
party,  by  men  whose  appendix  was  nearly  or  indeed  entirely 
wanting,  or  hypospadial,  but  their  testicles  and  ejaculatory 
apparatus  yet  normal.  And,  moreover,  great  care  must  be 
exercised  that  the  spermatozoon  is  not  confounded  with  the 
Trichomonas  vaginae,  an  animalcule  of  somewhat  similar  ap- 
pearance, though  much  larger,  usually  present  only  in  cases  of 
disease,  but  that  may  occur,  it  is  alleged,  in  the  vaginal  mucus 
of  the  chastest  virgin. 

.  If  the  stains  are  upon  the  night-dress,  they  may  have  been 
there  some  little  time,  and  date  from  some  other  man  than  the 
prisoner.  If  upon  her  day-clothing,  of  course  the  presumption 
of  his  implication  is  increased,  except  that,  among  the  lower 
class,  the  same  carelessness  as  to  changing  the  underclothes 
from  day  to  night,  obtains  as  with  men. 

It  will  be  noticed  that  the  weight  of  presumption  regarding 
the  two  parties  in  court,  while  coinciding  in  some  points,  alter- 
nates in  others.    Thus,  spermatic  stains  upon  the  external 
clothing  of  either  of  the  parties,.or  of  both,  render  it  probable 
that  there  has  been  intercourse  between  them, or  an  attempt  at 
it.    Stains  upon  the  under  clothing  of  both  parties  also  imply 
intercourse  of  both,  probably  together.    Upon  the  undercloth- 
ing of  the  woman  alone,  the  approach  of  a  man,  some  man. 
Upon  the  underclothing  of  the  man  alone,  possibly  the  presence, 
probably  the  thought  of  a  woman,  either  when  awake  or  in  an 
erotic  dream.    This  latter  alternative  is  not,  however,  abso- 
lutely necessary,  as  in  weakened  subjects  such  emissions  do 
undoubtedly  take  place  unconsciously,  both  by  night  and  by 
day,  just  as,  on  the  other  hand,  the  stain  may  have  been  effected 
merely  by  self-abuse.     Upon  the  jjerson  of  both  parties,  and, 
therefore,  necessarily  quite  recent,  spermatic  stains  render  the 
assumption  of  attempted  coitus  more  certain;  effected  and  ac- 
complished, probably,  if  the  discharge  is  detected  upon  or  with- 
in the  organs  of  the  female. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


5.  The  presence  of  blood  stains  upon  the  clothing  is  of  weight 
similar  to  the  above;  much  greater  if  they  are  coincident,  not 
so  great  if  upon  the  person  of  one  alone,  no  matter  which  of 
them  it  may  be. 

There  are  bat  two  sources  whence  recent  blood  of  an  at  all 
arterial  character,  which  is  that  only  in  any  way  here  con- 
clusive, would  be  likely,  in  the  absence  of  a  noticeable  wound, 
to  stain  a  man's  clothing,  except  from  carnal  intercourse.  These 
are  some  forms  of  hemorrhoids  or  bleeding  piles,  the  existence 
of  which  could,  upon  examination,  be  ascertained  with  tolerable 
certainty,  and  hiematuria,  or  a  bloody  discharge  from  the 
urethra,  kidney,  or  bladder;  but  this,  as  with  that  from  the 
rectum,  more  certainly  if  from  the  intestine  above  it,  would  be 
likely  to  be  changed  in  character,  and  thus  afford  quite  decisive 
evidence  of  its  origin.  In  the  absence  of  either  of  these  alter- 
natives, the  blood  was  probably  derived  from  a  woman,  but  her 
identity  with  the  prosecutrix  ought  hardly  to  be  taken  for 
granted,  unless  she  be  proved  to  have  been  menstruating  at  the 
time  alleged — in  that  discharge  the  blood  being  ordinarily,  but 
not  always,  of  a  more  venous  character,  the  coagulum  of  the 
uterine  excretion  being  prevented  or  dissolved  by  the  acid  of 
tlie  vaginal  mucus;  or  to  be  affected  with  certain  forms  of  uter- 
ine disease,  more  especially  of  a  malignant  or  cancerous  type; 
or  to  have  received  positive  and  recent  laceration  of  some  por- 
tion of  the  genital  organs.  The  chance  that  the  hemorrhage 
camp  from  injury  inflicted  upon  the  penis  during  resistance 
must  also  be  borne  in  mind.  To  blood  stains  on  the  woman's 
clothing  I  liave  also  referred  in  the  above  remarks.  If  coinci- 
dent upon  the  clothes  of  both,  the  presumption  of  intercourse, 
as  I  have  already  said,  is  increased. 

6.  The  last  of  the  several  evidences  of  a  medical  character 
usually  relied  upon  in  trials  for  rape,  has  generally  been  con- 
sidered far  more  certain.  It  is,  however,  just  as  unreliable  as 
the  others.  I  moan  the  existence  of  one  or  other  of  the  three 
forms  of  venereal  disease. 

Respecting  their  value  as  signs  of  recent  intercourse,  there 
is  still  much  ignorance  prevalent  among  medical  men,l)ut  well 
autlienticat(;d  cases  enable  me  to  express  myself  very  decidedly. 
The  specific  characteristics  of  the  three  diseases  to  which  I  have 


108. 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


referred  are  now  well  known;  pox,  as  commonly  recognized, 
consisting  of  the  chancroid,  a  strictly  primary  lesion,  and  of 
syphilis  proper,  which  latter,  undergoing  a  period  of  incuVta- 
tion  at  whose  close  it  presents  an  open  sore  or  chancre,  has 
yet,  by  primary  absorption  of  the  virus,  become  a  constitutional 
and  general  disease,  while  gonorrhoea,  or  clap,  is  wholly  local 
in  its  seat — a  purulent  discharge  from  the  lining  membrane  of 
the  genital  or  genito-urinary  canals,  and  may  be  initiated  and 
be  found  contagious  in  character  from  a  connection  perfectly 
legitimate  and  without  suspicion. 

I  shall  enter  into  none  of  the  pathological  peculiarities  of 
these  three  affections,  or  ol  the  differences  between  tliem;  merely 
premising  that  they  can  not  beget  each  other — that  merely 
syphilis  is  taken  from  syphilis,  chancroid  from  chancroid,  and 
gonorrhoja  from  gonorrhoea;  and  that,  contrary  to  usually  re- 
ceived opinion,  both  stages  of  syphilis,  the  primary  and 
secondary,  the  latter  in  at  least  one  of  its  forms,  are  directly 
communicable,  the  mucous  tubercle  occasionally  or  always  en- 
gendering a  primary  sore,  the  chancre. 

If,  then,  both  parties  are  found  to  have  precisely  the  same 
form  of  disease,  the  evidence  is  so  far  conclusive  that  they  have 
carnally  known  each  other;  whereas,  if  they  are  both  diseased, 
but  in  a  different  way,  the  evidence  is  as  conclusive,  or  even 
more  so,  of  the  other  extreme,  namely,  that  though  both  have  be- 
come diseased  from  impure  connection,  they  have  done  nothing 
towards  infecting  each  other.  This  last  conclusion  can  not, 
however,  be  considered  as  positively  proved,  inasmuch  as  both 
syphilis  and  gonorrhoea  may  perhaps  coexist  in  the  same  subject, 
a  fact  the  possibility  of  which  is  yet  under  discussion. 

But  how  is  it  when  only  one  party  seems  infected  ?  and  are 
the  essential  signs  of  the  diseases  in  themselves  perfectly  re- 
liable ? 

In  the  case  of  the  male,  of  whatever  age,  I  have  little  hesitation 
in  saying  that  the  presence  of  any  form  of  venereal  disease 
upon  tlie  genitals,  is  so  far  positive  evidence  of  previous  sexual 
connection,  except  in  cases  of  inherited  taint.  It  has,  however, 
been  observed  that  Jewish  children  have  received  the  infection, 
and  presented  true  chancres  on  the  penis  after  the  division 
of  the  prepuce  during  circumcision,  by  the  organ  having  been 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


109 


sucked,  to  arrest  tlie  hemorrhage,  by  an  operator  in  whose 
mouth  there  existed  primary  lesions.*  Such  lesions  are  cer- 
tainly met  with  from  time  to  time  in  the  mouths  of  women  of 
the  lowest  class,  and  of  men  also;  how  they  were  originated, 
there  can  be  but  little  doubt.  If  a  prisoner  admit  that  he 
had  subjected  his  organ  to  such  unnatural  chance  of  infection 
as  I  have  now  implied,  it  is  more  than  likely  that  he  had  also 
exposed  himself  to  it  in  the  more  customary  manner. 

In  deciding  upon  how  recent  was  the  connection  that  had 
taken  place,  due  care  must  of  course  be  paid  to  those  medical 
signs  and  symptoms  decisive  of  the  age  of  the  venereal  lesion. 
On  the  other  hand,  it  must  be  borne  in  mind  that  all  affections 
of  the  male  generative  organs  are  not  necessarily  the  result  of 
coitus,  whether  excessive  or  impure.  Some  of  them  are  the 
effect  of  want  of  personal  cleanliness;  others  the  result  of  mas- 
turbation; or  of  malignant  disease,  general,  as  cancer,  or  special, 
as  the  scrotal  disease  of  chimney  sweeps;  or  of  over-fatigue  or 
structural  relaxation,  as  varicocele;  or  of  distant  irritation,  as 
infra-Poupartian  bubo;  or  of  accidental  violence  or  disturbance, 
as  swelled  testicle  from  horseback  riding,  exposure  to  cold,  or 
metastasis  from  another  portion  of  the  body.  These  and  others 
are  points  requiring  in  their  solution  the  aid  of  the  medical  man, 
but  it  is  nevertheless  important  that  the  lawyer  should  know  and 
recollect  the  fact  of  their  existence.  If  there  is  little  doubt  of 
the  specific  and  venereal  nature  of  the  disease,  and  there  can  be 
little  hesitation  in  their  diagnosis  by  an  expert,  judgment  must 
not  be  led  astray  by  unfounded  excuses,  however  plausible.  I 
refer  here  to  the  common  notion  that  it  is  possible  to  obtain 
syphilis  and  gonorrhoea  by  contact  with  foul  bed  linen,  or  with 
the  surfaces  of  common  privies,  as  at  hotels  and  the  like,  where 
the  virus,  if  deposited,  must  become  neutralized  by  cold 
and  the  action  of  the  atmosphere.  After  having  carefully 
studied  many  such  alleged  cases,  I  have  been  compelled  to 
believe  that  in  each  and  all  of  them  there  had  been  indiscretions 
by  which  inoculation  had  been  more  naturally  effected.  I  know 
of  no  means  by  which  syphilis  can  thus  be  accidentally  communi- 
cated to  the  male,  save  the  direct  ones  to  which  I  have  already 


*  Kicord,  Lettres  sur  la  Syphilis,  p.  98. 


no 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


alluded,  and  but  one  by  which  gonorrhoea,  or  rather  T  should 
say  bleiiorrhcea,  as  the  suspicious  purulent  discharge  from  the 
urethra,  occurring  under  such  circumstances,  should  more 
properly  be  called.  Tlie  case  to  whicli  I  refer  is  where  inter- 
course has  taken  place  while  tlic  woman's  monthly  courses 
were  upon  her,  the  menstrual  fluid  being  at  times  excessively 
irritating  to  the  mucous  membrane  of  the  male,  or  while  she 
was  suffering  from  some  one  or  another  of  the  forms  of  leucor- 
rhoea.  Even  here,  however,  such  purulent  discharge  in  the 
male  would  have  been  consequent  upon  coitus,  and  therefore 
evidence  of  its  occurrence.  I  know  that  it  is  alleged  that  the 
same  identical  condition  may  occur  in  chaste  bachelors  who 
have  never  touched  women,  but  I  doubt;  though  of  course  al- 
lowing for  the  effects  of  well  authenticated  injury,  or  organic 
lesion,  or  constitutional  disease. 

With  tlie  woman,  however,  there  is  far  more  necessity  for 
hesitancy  in  expressing  a  decided  opinion  as  to  any  given 
case. 

1.  In  the  first  place,  I  have  no  scruple  in  asserting  that  gon- 
orrhoea in  the  female  is  not  to  be  distinguished  by  the  micro- 
scope, by  chemical  analysis,  or  in  any  other  way,  from  purulent 
discharges  entirely  innocent  in  their  character,  and  that  may 
even  exis,t  in  the  chastest  virgin,  although  adult.  This  remark 
applies  to  all  stages  of  the  disease. 

2,  The  fact  that  no  external  chancre  or  chancroid  is  visible, 
is  no  proof  of  the  non-existence  of  actual  primary  syphilitic 
disease.  In  the  male,  these  signs  are  almost  necessarily  patent 
when  they  exist,  cases  of  such  lesion  strictly  urethral  being 
very  rare;  in  the  female,  on  the  contrary,  the  parts  are  chiefly 
concealed  from  easy  inspection,  so  that  the  most  virulent  and 
infectious  sores  may  be  upon  the  walls  of  the  vagina,  upon  or 
within  the  neck  of  the  womb,  or  even  just  internal  to  the  open- 
ing of  the  urethra,  requiring,  therefore,  the  most  careful  exami- 
nation, especially  when  the  disease  is  present  in  the  criminal 
at  the  bar.  It  is  possible  that  the  newly  suggested  endoscope 
may  go  far  to  clear  up  these  cases,  but  it  is  evident  that  a  drop 
of  pus,  or  mucus,  or  serum  may  here  prevent  success;  an 
obstacle  absent  to  the  ophthalmoscope,  and  but  seldom  present 
in  examinations  of  the  larynx. 


1865.] 


OBSTETRIC  JURIBPRUDENCE. 


Ill 


3.  The  charge  of  connection  is  often  made  by  or  in  behalf  of 
female  children  of  tender  age,  even  infants.  Young  girls 
whose  personal  cleanliness  is  neglected,  either  by  themselves  or 
their  parents,  are  not  infrequently  attacked  by  ulcerative 
affections  of  the  external  genitals;  in  some  cases  slight  in 
character  and  extent,  in  others  causing  their  death. 

4.  Besides  such  diseases  as  we  have  just  enumerated,  in  which 
the  circumstances  of  a  criminal  charge  would  very  naturally  be 
suggestive  of  carnal  and  infectious  intercourse,  there  is  another 
affection  to  which  young  girls  are  frequently  liable,  of  which 
complication  I  have  now  seen  many  instances,  as  also  several 
of  the  former.  A  catarrh  of  the  genital  organs,  consequent 
upon  ordinary  exposure  to  cold,  insufficient  clothing  of  the 
lower  extremities,  standing  over  furnace  registers,  or,  in 
younger  children,  arising  from  local  or  distant  and  reflex 
causes  of  irritation,  as  after  scarlatina,  during  dentition,  or 
from  the  presence  of  ascarides  or  the  scrofulous  diathesis,  often 
all  of  them  attended  by  a  purulent  discharge  from  the  vagina 
closely  simulating  that  of  gonorrhoea.  Convicted  upon  such 
evidence  as  this,  more  than  one  poor  fellow  has  been  condemned 
and  executed  for  rape,  of  which  he  was  undoubtedly  innocent. 
It  should  never  be  admitted  except — • 

1st.  When  the  accused  party  is  laboring  under  a  gonorrhoea! 
discharge  that  existed  previously  to  the  time  of  the  alleged 
intercourse: 

2d.  When  the  date  of  its  appearance  in  the  child  is  from  the 
second  to  the  eighth  day  after  this  time;  or, 

3d.  When  it  has  been  satisfactorily  established  that  the  child 
had  not,  previously  to  the  alleged  assault,  any  such  discharge. 
Though,  however,  any  or  all  of  these  conditions  be  present, 
they  do  not  disprove  the  innocence  of  the  prisoner,  for  they 
may  still  be  mere  coincidences,  or  the  child  through  mistake 
or  design  may  have  accused  the  v/rong  person. 

5.  In  the  instance  of  very  young  female  children,  who  have 
yet  furnished  the  occasion  of  very  many  of  the  reported  trials, 
there  is  still  another  possibility  of  error,  which  is  no  less  an  im- 
portant one.  I  refer  to  cases  where  there  is  undoubtedly 
present  the  venereal  disease,  yet  caused  by  no  attempt  at  sexual 
intercourse.    As  this  is  a  matter  as  yet  new,  in  great  measure. 


112 


OBSTETRIC  JURISPRUDENCE. 


[Nov., 


to  courts  of  law,  I  shall  give  other  and  well  authenticated  in- 
stances, in  addition  to  that  of  the  Jewish  children,  already 
quoted.  In  this  I  am  well  aware  that  I  am  at  variance  in 
opinion  with  Taylor,  now  tlie  leading  medical  jurist  of  Great 
Britain,  who  says  that,  "  if  a  child  is  really  laboring  under 
syphilis  or  gonorrhoea,  this  is  cocteris  paribus  evidence  of 
impure  (carnal)  intercourse,  either  with  the  ravisher  or 
some  other  person."*  Afterwards,  however,  he  contradicts 
himself  by  allowing,  in  the  case  of  gonorrhrea  at  least,  the 
chance  of  other  origin,  relating  the  cases  reported  by  Ryan,t 
where  two  sisters,  one  of  a  year,  the  other  of  four,  were 
infected  by  being  Avashed  with  a  sponge  used  by  a  young 
woman  who  had  a  profuse  gonorrhoeal  discharge. 

I  shall  now,  however,  instance  cases  of  syphilis,  or  chancroid, 
accidentally  occurring — a  matter  of  far  more  importance,  as 
the  possibility  of  their  thus  being  engendered  is  generally 
disbelieved. 

I  have  quoted  an  instance  from  Ricord.  Trousseau  saw  a 
little  girl  of  twelve  months  who  had  contracted  a  deep  chancre 
on  the  buttock.  He  learned  that  the  mother  took  the  child 
into  the  same  bed  with  herself,  and  as  the  cold  was  extreme, 
pressed  it  closely  to  her  body  to  warm  it.  This  woman  had 
primary  sores  in  the  vulva.J  It  will  be  seen,  recollecting 
what  I  have  already  said  upon  this  subject,  primary  sores  being 
only  directly  communicable,  that  the  infection  was  here  clearly 
by  contact,  and  not  by  inheritance. 

Bertin  instances  a  little  girl  four  months  old,  healthy  her- 
self, as  were  also  her  father  and  mother,  who  became  the  sub- 
ject of  a  chancre  on  the  upper  and  inner  surface  of  the  left 
labium. §  It  was  discovered  that  an  aunt  of  this  child,  affected 
with  syphilis,  tended  and  kissed  it,  sometimes  gave  it  the  breast 
to  quiet  it,  and  lastly,  that  she  washed  its  genital  organs  with 
water  which  she  had  previously  put  into  her  mouth  to  warm. 

Diday  treated  a  lady  witli  a  primary  chancre  on  the  lower 
lip,  communicated  to  her  by  her  husband  in  a  way  that  may  be 
imagined.    The  mother  of  a  child  four  months  old,  she  felt  it  a 

*  Taylor,  Med.  Juris.,  503.  f  Med.  Gaz.,  xlvii.,  741. 

X  Gaz.  des  Hop.,  184(;,  571. 

§  Tr.  de  la  Mai.  Veuer.  chez  les  Enf.  Nouveau  nez.,  77. 


1865.] 


OBSTETRIC  JTJEISPRUDENCE. 


113 


great  privation  to  defer  until  the  time  when  her  sore  should  be 
healed  the  kisses  with  which  she  had  previously  and  frequently 
covered  it.  She  one  day  lost  patience,  and  the  result  was  a 
deep  ulcer  upon  the  labial  commissure  of  the  poor  child.* 

Richet  mentions  a  little  girl,  born  of  healthy  parents  and 
suckled  by  a  healthy  nurse,  but  yet  affected  with  primary 
chancres  about  the  anus,  concerning  the  origin  of  which  the 
medical  attendants  were  much  puzzled,  until  it  was  ascertained 
that  a  clerk  of  the  house,  himself  infected,  had  been  in  the  habit 
of  holding  the  child,  bare,  on  his  hands,  which  were  frequently 
soiled,  and  wliich  he  had  not  always  taken  the  precaution  to 
wash. 

On  the  other  hand,  it  must  not  be  forgotten  that  in  attempts 
at  connection  with  young  children  or  virgins,  abrasions  and 
excoriations  necessarily  result,  which  afford  a  condition  espe- 
cially favorable  to  the  inoculation  of  the  contagious  matter  of 
syphilitic  disease.  So  that  in  the  case  of  its  presence  in  the 
prisoner,  its  absence  in  the  prosecutrix,  under  such  circum- 
stances, would  so  far  afford  some  presumption  of  an  unfounded 
charge. 

There  are  still  other  obscure  points  in  this  interesting  and 
important,  though  as  yet  little  understood  subject,  the  presence 
of  syphilitic  disease  as  proof  of  special  connection — two  of 
which  I  should  do  wrong  not  to  mention.    They  are  the  facts, 

1st.  That  a  woman  can  be  infected  vicariously  in  a  variety 
of  ways:  through  her  child  during  labor,  or  even  before,  it 
having  received  the  poison  directly  from  the  father  at  its  con- 
ception; by  suckling;  and,  as  in  the  case  of  the  male,  by  in- 
heritance— the  symptoms,  save  in  instances  from  nursing  or  in- 
fection during  labor,  being  of  the  so-called  secondary  type> 
which,  with  a  single  exception,  can  hardly  be  considered  conta- 
gious; and, 

2d.  That  in  cases  of  this  special  exception  just  referred  to, 
the  so-called  mucous  tubercle,  the  disease,  althougli  secondary 
and  although,  like  the  chancre,  not  auto-inoculable  by  the 
lancet,  is  yet  directly  communicable  during  connection,  and 
gives  rise  to  the  primary  lesion,  namely,  a  chancre.    This  is 


*  Syphilis  iu  New-born  CLildrcn,  51. 

Vol.  II.— No.  8.  8 


1X4  OBSTETRIC  JURISPRUDENCE.  [NoV., 

not  owing,  as  has  been  supposed,  solely  to  the  excess  of  heat  and 
moisture  attending  the  act,  as  is  proved  by  inoculation  m  a 
similar  manner  from  mouth  to  mouth.  Numerous  authorities 
admit  fully,  on  the  evidence  of  facts,  its  transmissi))ility  mthis 
manner,  by  sexual  contact,^'  and  it  must  therefore  be  borne  in 
mind  during  our  present  inquiry. 

One  other  point,  though  negative,  is  of  such  importance  that 
it  must  not  be  lost  sight  of,  namely,  that  connection  may  be  fully 
effected,  one  of  the  parties  being  extensively  diseased,  and  yet 
the  other  receive  no  infection,  nay,  even  that  the  disease  may 
be  thus  transmitted  by  an  uninjured  second  to  a  third  party. 
This  impunity  may  be  owing  to  a  variety  of  causes:  to  precau- 
tions taken  before  or  after  the  act,  protective  or  compensatory; 
or  to  unusual  toughness  of  the  mucous  membrane,  approximating 
in  character  to  ordinary  epidermis,  from  long  exposure,  per- 
haps to  external  agencies,  as  in  males  with  a  prepuce  constantly 
retracted,  more  certainly  if  it  is  entirely  wanting,  as  with  the 
circumcised  Jew;  or  to  idiosyncrasy-j«st  as  I  believe  that  the 
contagious  virus  of  erysipelas,  or  its  congener,  puerperal  fever, 
while  it  ought  theoretically  to  be  carried  from  house  to  house 
by  every  physician  who  has  it  in  charge,  does  in  reality  attach 
itself  to  the  persons  or  the  finger  of  certain  unfortunates,  thus 
more  fullv  indicating  its  claims  to  the  title  of  a  private  pesti- 
lence   This  I  believe  to  be  as  evident  as  that  there  are  indi- 
viduals who,  from  idiosyncrasy,  constant  or  increased  by  extra- 
neous causes,  special  or  general,  debilitating  or  exciting,  are 
peculiarly  prone  to  receive  the  disease;  a  fact  that  none  will 

There  is  a  single  class  of  cases,  to  which  it  is  necessary  that 
I  should  incidentally  allude,  those,  namely,  where  the  female 
has  been  found  dead.  It  would  seem  that  if  any  marks  of 
violence  were  present,  the  charge  of  murder  would  take  pre- 
cedence. In  a  case,  however,  tried  at  Edinburgh,  the  jury 
convicted  the  prisoner  of  rape,  and  yet  acquitted  him  of  the 
murder,  although  the  proof  of  the  latter  crime  was  much  the 
clearer  The  evidence  in  these  cases,  in  the  absence  of  other 
personal  testimony  than  that  of  the  woman,  must  of  necessity  be 

wholly  circumstantial  and  presumptive.   

*  Diday,  Loc.  Cit.,  132. 


1865.] 


OBSTETRIC  JURISPRUDENCE. 


115 


We  have  now  considered,  at  considerable  length,  the  various 
proofs  for  and  against  the  fact  of  sexual  connection  in  cases  of 
rape,  and  incidentally  those  also  which  bear  upon  the  existence 
of  the  attempt  alone.  Formerly,  before  the  abolition  of  the 
dcatli  penalty,  the  distinction  here  implied  was  one  of  extreme 
importance,  but  too  often,  however,  and  unfortunately,  lost 
sight  of  at  trials.  Whatever  opinion  may  be  entertained  as  to 
whether  or  not  that  penalty  was  greater  than  was  really  de- 
manded by  the  essential  nature  of  the  crime,  there  is  no  doubt 
that  many  convictions  have  been  effected  where  the  crime,  as 
defined  in  law,  had  never  been  accomplished. 

The  attempt  is  now,  in  Massachusetts,  punishable  or  not  to 
the  full  extent  with  its  completion,  at  the  option  of  the  Court; 
in  Pennsylvania,  imprisonment  may  be  inflicted  to  the  extent  of 
five  years  and  a  fine  of  a  thousand  dollars;  while  in  New  York, 
the  penalties  are  even  less.  It  may  seem,  therefore,  of  less  im- 
portance to  search  in  every  case  for  such  extenuative  evidence 
as  I  have  now  presented,  were  it  not  that  instances  are  liable 
to  occur  where  a  jury,  at  all  mindful  of  human  infirmity,  would 
be  glad  to  find  in  the  fact  that  tlie  completion  of  the  offense 
could  not  be  fully  proved,  opportunity  to  ward  from  the  sudden 
and  momentary  outburst  of  passion,  provoked,  perhaps,  by 
willful  temptation  from  the  prosecutrix,  the  terrible  penalty, 
possible  in  my  own  State,  and  there  compulsory  where  the  act 
has  been  really  effected,  of  life-long  im])risonment. 

I  agree  with  Chitty,  that  "  every  brutal  attack  upon  a  female 
deserves  very  severe  punishment,"  and  though  considering  that 
the  offense  should  be  punishable  as  an  injury  upon  herself  and 
her  own  moral  sense,  rather  than  in  deference  to  "  the  natural 
feelings  of  man  and  his  repugnance  to  form  a  matrimonial  con- 
nection with  a  female  who  has  been  completely  violated,"  yet 
I  do  not  "  hesitate  in  admitting  that  an  incomplete  attempt  is 
not  so  great  an  injury  as  that  which,  according  to  the  ancient 
law,  must  have  been  completed;  and  that  in  legislating,  some 
distinction  in  punishment  should  be  introduced;"*  but  I  con- 
tend that  this  distinction  and  the  degree  of  punishment  righteous 
in  any  given  case  should  be  left,  more  than  now,  to  the  discre- 
tion of  the  Court. 


•Cliitty,  382. 


116 


UNUNITED  AND  OBLIQUE  FRACTURES. 


[Nov., 


In  my  next  article  I  shall  proceed  to  tlie  second  of  tlie  ques. 
tions  involved  by  the  definition  of  the  crime.  Carnal  knowl- 
edge having  been  eflectod,  was  it  without  or  against  the  con- 
sent of  the  woman  ? 


A  Nexo  Instrument  for  Treating  Ununited  and  Oblique  Frac- 
tures. By  E.  S.  Gaillard,  M.D.,  Richmond,  Va.,  Medical 
Director  and  Inspector  in  the  late  Confederate  Army. 

The  treatment  of  ununited  and  oblique  fractures  has  always 
been  a  source  of  perplexity  and  annoyance.  In  the  whole  field 
of  surgery,  no  portion  of  it  is,  perhaps,  characterized  by  a  more 
unsatisfactory  cultivation  and  disheartening  return. 

The  literature  of  the  subject  alone  is  material  for  a  volume, 
though  this  be  but  a  record  of  promising  suggestions,  faithful 
trials  and  invariable  failures. 

The  starch  and  dextrine  bandages,  jolaster-cast  boxes,  fric- 
tion and  acupuncture,  Dumriecher's  railway  splints,  Warren's 
bow  and  Maisonneuve's  bridge,  iron-pins  and  leaden-wire, 
Diefenbach's  ivory  pegs,  with  the  infinite  and  complex  apparatus 
for  extension  and  counter-extension,  etc.,  have  all  been  ad- 
mired, praised,  tried,  and  comparatively  abandoned. 

In  a  recent  number  of  the  London  Lancet  it  appears  tliat 
this  subject,  again  revived,  is  engrossing  the  attention  of  the 
most  prominent  and  favorably  known  medical  men  in  Europe. 
Fergusson,  Bickersteth,  Fletcher,  Holmes  Coote,  Hilton  and 
Curling  have  all  recently  expressed  their  opinions  and  made 
their  suggestions  in  this  connection. 

It  was  from  reading  the  views  expressed  by  these  gentlemen 
that  more  than  incidental  attention  was  again  bestowed 
upon  this  subject,  and  that  the  instrument  now  to  be  described 
and  successfully  used  appeared  to  promise  sufficiently  valuable 
results  to  warrant  its  being  submitted  for  examination  and 
trial. 

There  is  a  peculiar  enthusiasm  which  usually  characterizes 
the  claims  and  writings  of  all  who  submit  any  original  con- 
tribution or  suggestion  for  the  general  good. 


1865.] 


UNUNITED  AND  OBLIQUE  FRACTURES. 


117 


This  enthusiasm  is  often  a  fruitful  source  of  endless  errors, 
and  can  only  be  corrected  by  the  caustic  touch  of  analysis 
and  criticism.  It  is  not,  however,  felt  in  regard  to  this  instru- 
ment, wliich  has  been  used  but  once,  and  thougli  the  results 
were  entirely  satisfactory,  there  is  a  full  appreciation  of  the 
fact  that  a  single  trial  is  an  insufficient  basis  for  either  com- 
mendation or  enthusiasm. 

If  this  instrument  answers  only  as  well  as  many  of  the  com- 
plicated pieces  of  mechanism  used  in  this  connection,  its  sim- 
plicity, economy,  and  easy  availability  wall,  it  is  believed,  give 
it  a  comparative  advantage  over  other  appliances,  and  will 
commend  it  to  the  attention  of  those  relatively  interested. 
The  sanguine  expectation  is,  however,  indulged,  that  this  un- 
pretending little  instrument  will  fulfill  all  of  the  indications 
usually  manifested  in  cases  of  oblique  or  ununited  fracture 
requiring  the  use  of  surgical  apparatus. 

In  so  very  brief  a  paper,  a  description  of  the  condition  of 
the  injuries  in  the  treatment  of  which  this  instrument  is  espe- 
cially applicable  must  necessarily  be  avoided.  The  anatomical 
relations  of  the  fractured  bone,  the  mechanical  problem  to  be 
encountered  and  solved  in  a  successful  adjustment  of  the  frag- 
ments, the  resulting  pathological  condition  of  these  fragments, 
when  all  attempts  at  adjustment  fail,  etc.,  must  be  omitted. 

The  chief  difficulty  to  be  encountered  in  the  treatment  of  all 
fractures  is  the  securing  of  an  accurate  and  constant  apposition 
of  the  fractured  extremities.  If  this  be  successfully  accom- 
plished, there  is  usually  complete  union,  without  shortening — 
the  degree  of  this  shortening  being  a  true  index  of  the  relative 
efficiency  of  the  apparatus  adopted. 

In  oljlifiue  fracture,  over-extension,  a  frequent  fault,  results 
in  a  false  joint  or  in  an  entire  absence  of  union.  Deficient 
extension  allows  an  overriding  of  the  fragments  with  conse- 
quent shortening. 

Any  instrument  whicli,  by  keeping  the  fractured  ends  in 
close  and  constant  apposition,  will  secure  the  patient  from  the 
misfortune  of  either  of  the  conditions  just  mentioned,  must  be 
regarded  as  entirely  successful. 

In  ununited  fractures,  close  and  continued  apposition  of  the 


118 


UNUNITED  AND  OBLIQUE  FRACTURES. 


[Nov., 


fragments,  with  slight  stimulation  applied  to  them,  is  all,  so 
far  as  is  known,  that  surgery  has  been  able  to  accomplisli. 

This  instrument,  it  is  believed,  will,  in  its  use,  fulfill  all  of 
the  indications  specified. 

The  important  fact  will  be  recollected,  that  in  the  treatment 
of  fractured  bones,  the  use  of  steel  or  wire  pins  has  never  pro- 
duced material  local  or  constitutional  injury.  All  oral  and 
printed  testimony  tends  towards  the  establishment  of  this  fact. 


This  instrument  is  composed  of  four  pieces:  the  handle  (a), 
the  screw  or  shaft  (b),  the  sheath  (c),  and  the  nut  (d).  The  shaft 
or  screw  is  six  inches  long,  the  lower  part  of  this  being  cut  with 
a  screw  similar  to  that  of  an  ordinary  gimlet,  and  the  upper 
part  being  furnished  with  an  ordinary  male-screw,  on  which 
works  the  nut  (d) ;  the  shaft  being  of  steel  and  the  nut  of  brass. 
The  sheath  is  made  of  silver  and  the  handle  of  the  instrument 
of  rosewood,  or  some  material  equally  hard.  The  sheath  is 
three  inches  long,  and  the  male-screw,  cut  in  the  upper  part  of 
the  shaft,  extends  from  the  handle  to  a  point  about  two  and 
one-half  inches  below  it.  In  the  plate  furnished  the  sheath 
and  nut  are  detached,  for  the  more  thorough  comprehension  of 
the  mechanism  of  the  instrument.  These  pieces  (the  sheath 
and  nut)  are  seen  elsewhere  in  situ. 

It  is  proper  to  say  that  the  instrument,  with  the  proportions 
given,  is  intended  for  treatment  of  a  fractured  femur;  in  treat- 
ing the  fractures  of  other  long  bones,  the  length  of  the  shaft 
and  sheath  would  be  proportionally  less.  The  diameter  of  the 
shaft  is  oiie-eighth  of  an  inch. 

The  instrument  is  thus  applied— it  being  supposed  that  the 
femur  is  the  bone  fractured,  and  the  fragments  in  apposition. 

Through  an  enlargement  of  the  orifice,  caused  by  the  injury 
sustained,  or  through  an  artificial  opening  immediately  over 


1865.] 


UNUNITED  AND  OBLIQUE  FRACTURES. 


119 


the  site  of  the  fracture,  the  silver  sheath,  detached  for  this  pur- 
pose, is  passed  down  to  the  bone.  The  shaft,  with  the  nut 
immediately  under  the  handle,  is  then  passed  through  the 
sheath,  until  the  point  of  the  shaft  rests  upon  the  bone.  The 
operator,  seizing  the  sheath  with  the  left  hand,  one  finger  of 
this  hand  being  under  the  fragments  of  bone,  slowly  turns  the 
handle  of  the  shaft  with  his  right;  the  sheath  should  be  held 
firmly  to  prevent  a  slipping  of  the  point  of  the  shaft  upon  the 
surface  of  the  bone.  The  process  of  turning  or  boring  is  then 
continued,  until  the  shaft  shall  have  descended  an  inch  and  a 
half,  or  until  it  has  pierced  both  fragments  of  the  bone.  The 
shaft  and  sheath  being  then  grasped  with  the  left  hand,  the  nut 
is  turned  until  it  reaches  the  superior  extremity  of  the  sheath, 
and  until  the  resistance  offered  is  greater  than  the  operator 
can  overcome,  without  using  undue  force.  The  forcing  down  of 
the  nut  brings  the  fragments  of  bone  in  apposition,  and  retains 
them  thus  so  long  as  the  instrument  is  allowed  to  remain — the 
duration  of  this  period  being  from  three  to  four  weeks  for  the 
femur,  and  a  proportionally  shorter  period  in  fractures  of  the 
smaller  bones. 

The  instrument  being  in  situ,  all  extending  and  counter- 
extending  forces  are  removed;  light,  lateral  splints,  as  a  pre- 
cautionary measure,  are  then  applied,  with  an  ordinary  roller- 
bandage,  and  the  process  of  adjustment  is  complete. 

The  instrument  is  allowed  to  remain  until  there  is  satisfac- 
tory evidence  of  bony  union,  when  it  is  withdrawn.  Its 
presence  will  have  been  found  to  cause  but  little  local  irritation 
and  no  perceptible  constitutional  disturbance.  All  who  are 
familiar  with  the  literature  in  regard  to  silver  sutures,  would 
of  course  anticipate  the  fact  that  the  contact  of  the  silver 
sheath  with  the  tissues  produces  no  material  local  injury;  and 
those  M'ho  have  seen  ivory  or  steel  pins  used  in  the  treatment 
of  fractures,  will  not  be  surprised  at  the  small  amount  of  dis- 
turbance caused  by  the  remaining  of  thesliaft  of  this  instrument 
in  the  fractured  bone  for  a  period  of  three  or  more  weeks.  As 
soon  as  the  instrument  is  withdrawn,  the  opening  through  the 
muscular  tissues  and  through  tlie  integuments  will  heal  without 
difficulty. 

It  is  evident  that  by  the  use  of  this  instrument  there  can  be 


120 


TUBAL  PREGNANCY. 


[Nov., 


neither  a  false  joint  formed  from  over-extension,  nor  tlie  occur- 
rence of  sliortening  from  an  overlapping  of  the  fiaginents. 
This  instrument  can  be  improvised  by  using  an  ordinary  gimlet 
for  the  shaft,  a  portion  of  a  silver  female  catheter,  or  the  canula 
of  a  large  trocar  for  tlie  slieatli,  and  a  few  bits  of  paste])oard 
to  act  as  the  nut — these  pieces  of  paste-board  being  sufficient  in 
number  to  fill  the  si^ace  recurring  on  the  shaft,  between  the 
superior  extremity  of  the  sheath  and  the  handle  of  the  instru- 
ment, after  both  fragments  of  the  bone  have  been  perforated. 

My  experience  with  this  instrument  is,  as  has  been  mentioned, 
very  limited,  indeed;  but  the  instrument  is  so  simple  in  its  prep- 
aration and  application,  and  so  satisfactory  in  its  results,  that 
it  is  presented  to  the  Profession  for  a  careful  examination  and 
a  fair  trial. 


Case  of  Tubal  Pregnancy.   By  Robert  Nelson,  M.D.,  N.  Y. 

Mrs.  K.  Y.,  38  years  of  age,  lived  in  a  most  respectable 
family  as  child's  nurse  more  than  ten  years,  not  given  to 
company,  and  particularly  chaste  in  habits,  married,  in  her 
thirty-eighth  year,  about  three  months  before  the  accident  that 
terminated  in  death.  The  catamenia  had  always  been  very 
regular  until  the  first  week  in  June,  when  they  ceased.  On 
getting  into  bed  the  evening  of  June  22d.  she  suddenly  felt  a 
sharp  pain  in  the  left  iliac  region,  referable  to  the  seat  of  the 
ovary,  followed  by  great  collapse,  cold,  clammy  perspiration, 
pale  and  anxious  countenance.  She  was  not  seen  by  her  medi- 
cal attendant  before  morning,  Friday  23d,  who  at  once  formed 
an  unfavorable  opinion  of  the  case.  I  saw  her  at  10  a.m.,  found 
her  excessively  pale,  blanched,  skin  all  over  cold  and  clammy, 
pulse  small,  very  feeble,  and  frequent;  her  senses  perfect, 
breathing  natural,  slight  thirst,  bowels  not  moved,  nor  ui-ine 
passed  since  the  accident — this  was  drawn  off  by  catheter  by 
her  medical  attendant. 

In  the  foregoing  mentioned  state  she  continued  throughout 
the  day  and  night,  and  next  morning  and  day  of  the  24th  only 
more  and  more  prostrate.  I  saw  her  at  4  p.m.  Shortly  before 
this  visit  she  asked  for  a  glass  of  bottled  ale,  which  she  relished 


1865.] 


TUBAL  PREGNANCY. 


121 


and  it  seemed  to  revive  her;  so  much  so  that  those  about  her 
and  herself  tliought  that  she  was  much  better,  until  I  dissipated 
their  illusion,  saying,  to  their  surprise,  that  she  could  not  live 
two  hours  longer — perhaps  not  more  than  one  hour.  There 
was  no  difficulty  in  arriving  at  the  prognosis,  for,  although  her 
senses  remained  perfect  and  she  spoke  as  in  health,  yet  the 
collapse  and  prostration  had  increased;  her  breathing  consisted 
of  one  slow,  long  inspiration,  to  end  in  a  short,  quick  expiration; 
no  pulse  could  be  felt  at  the  wrist  or  at  the  humerus,  and  only 
a  small  wave  was  perceptible  at  the  carotid.  After  twenty 
minutes'  continuance  of  this  kind  of  breathing,  she  drew  in  one 
very  long  and  slow  inspiration  followed  by  a  single  quick  and 
short  expiration,  and  ceased  to  breathe  at  a  quarter  past 

5  P.M. 

In  the  early  period  of  her  illness  it  was  supposed  that  intes- 
tinal perforation  and  effusion  into  the  peritoneal  cavity  might 
be  the  case,  a  cause  well  known  to  produce  sudden  and  great 
collapse;  but,  were  such  the  cause,  it  would  have  been  preceded 
by  some  intestinal  disturbance,  and  would  quickly  have  been 
followed  by  great  peritoneal  pain  and  inflammation-,  neither  of 
which  symptoms  existed.  Towards  the  last  it  was  suggested 
that  an  aneurism  might  have  burst;  but  in  this  case  death 
would  have  quickly  followed.  There  remained  another  idea, 
entertained  from  the  first,  that  an  ovarian  or  tubal,  or  any  form 
of  extra-uterine  pregnancy  had  ruptured,  or  become  detached 
permitting  of  a  slow  hemorrhage  into  the  cavity  of  the  per- 
itoneum, this  last  being  the  only  way  of  accounting  for  the 
sudden  seizure  and  collapse  during  perfect  health,  and  the  col- 
lapse and  prostration,  without  peritoneal  pain,  being  kept  up 
for  so  long  a  time  by  a  gradual  oozing  of  blood. 

On  opening  the  body  the  intestines  were  found  crowded  up, 
but  in  no  way  diseased.  Clotted  blood  filled  the  pelvis,  the 
iliac  and  lumljar  fossa  as  far  up  as  under  the  liver,  stomach  and 
spleen.  The  right  fallopian  tube  was  enlarged  to  the  size  of 
a  walnut;  near  to  the  horn  of  the  uterus  the  remainder  of  the 
tube,  over  two  inches  long,  with  the  fimbria;,  floated  free  in 
the  abdomen.  The  peritoneal  covering  of  the  tumor  had 
given  way,  as  if  gradually  ruptured,  to  a  diameter  of  a  third  of 
an  inch;  through  this  bulged,  like  a  large  staphaloma,  the  foetal 


122 


ANEURISM  OF  THE  IXNOMINATE 


[Nov., 


membranes.  On  opening  the  tumor,  inclosed  by  a  thick 
decidua  and  an  amnios,  was  discovered  a  foetus  tlie  size  of  a 
bee.  Tlie  hemorrhage  was  traced  by  a  clot  from  the  general 
mass  to  the  projecting  chorion  or  decidua.  Both  ovaries  were 
natural,  and  strongly  marked  with  the  usual  foveae,  said  to  be 
the  loci  whence  the  ova  escape  at  tlie  catamenial  periods.  The 
uterine  orifice  of  the  tube  was  excedingly  contracted.  The 
uterus  was  two-thirds  larger  than  usual,  thickened  and  lined 
with  a  decidua  one-third  of  an  inch  thick. 

It  has  been  noticed  that  she  was  suddenly  seized  with  pain 
in  the  left  ovarian  region,  a  pain  that  lasted  until  the  morning; 
but,  on  examination,  no  alteration  of  any  kind  could  be  detected 
there,  while  the  whole  trouble  was  too  evidently  confined  to 
the  right  side. 

As  this  woman  had  led  a  remarkably  chaste  life,  had  enjoyed 
perfect  health,  it  becomes  a  consideration  how  far  gene  trie  func- 
tions might  have  been  disturbed  by  copulations  so  late  in  life 
as  the  38th  year. 


Case  of  Aneurism  of  the  Innominate  and  Carotid  Arteries. 
Service  of  Dr.  A.  Flint.  Reported  by  Dr.  W.  D.  F.  Day, 
House  Physician,  First  Medical  Division  Bellevue  Hospital. 

Fred.  Wolf,  a  native  of  Germany,  50  years  of  age,  and  a 
pianist  by  profession,  was  admitted  to  ward  32,  July  13th,  1865. 
He  was  a  large  framed  man  and  in  fair  flesh,  but  his  complex- 
ion resembled  that  of  one  laboring  under  the  cachexia  of 
organic,  renal  or  cardiac  disease.  He  was  unable  to  give  any 
satisfactory  history  of  himself,  on  account  of  a  confused  condi- 
tion of  mind  and  a  difficulty  in  his  respiration,  which  was 
much  increased  by  mental  or  bodily  exertion.  He  said,  how- 
ever, that  he  had  been  complaining  for  the  last  two  years, 
during  which  time  he  had  had  frequent  attacks  of  epistaxis,  and 
that  for  a  year  past  he  had  been  trouljled  with  a  cough.  The 
patient  kept  his  bed  from  the  date  of  his  admission  to  hospital 
until  his  death,  a  period  of  thirteen  days.  He  was  usually 
found  cither  sitting  up  in  bed  or  resting  his  liead  upon  his  arm, 
the  preference  being  given  to  the  left  side. 


1865.] 


AND  CAROTID  ARTERIES. 


123 


The  cougli,  which  was  accompanied  by  a  moderate  amount 
of  frothy  sputa,  was  of  a  peculiar  brazen  and  sepulchral  quality, 
and  the  voice  was  grave  in  pitch  and  very  slightly  husky.  The 
respiration  was  always  somewhat  labored,  but  there  were  at 
times  paroxysms  of  dyspnoea  and  complete  aphonia. 

The  pulse,  which  remained  in  the  neighborhood  of  75  per 
minute,  was  feeble,  and  perceptibly  weaker  in  the  right  radial 
artery  than  in  the  left.  The  right  pupil  was  slightly  more 
contracted  than  the  left,  but  the  ditference  was  constant. 

Upon  percussion,  the  left  side  of  the  chest  was  more  resonant 
than  the  right.  The  labored  respiration,  and  the  tracheal 
rales  masked  the  auscultatory  signs.  From  the  character  of 
the  voice,  the  dyspnoea  and  aphonia,  together  with  the  in- 
equality in  the  radial  pulses  and  in  the  pupils,  an  aneurism 
pressing  upon  the  right  recurrent  laryngeal  nerve  was  sus- 
pected. The  patient  became  gradually  weaker  until  the  26th 
of  July,  when  he  died  from  an  attack  of  intercurrent  pneu- 
monia. 

An  examination  thirty-six  hours  after  death  disclosed  the 
following  appearances: 

The  pleural  and  pericardial  sacs  contained  a  moderate 
amount  of  clear  serum.  Both  lobes  of  the  left  lung  were  in  a 
state  of  red  hepatization,  and  at  the  apex  of  the  right  lung  was 
a  small  deposit  of  tubercle.  An  aneurism  of  the  innominate 
and  right  common  carotid  was  found,  measuring  five  inches  in 
length  by  three  and  a  half  at  its  broadest  part,  pyramidal  in 
form,  the  base  directed  downwards,  and  the  apex  reaching  as 
high  as  the  cricoid  cartilage.  The  aneurism  involved  the  re- 
current laryngeal  nerve  of  the  right  side,  and  pressed  against 
the  trachea,  which  was  flattened  from  side  to  side  to  the  extent 
of  half  its  diameter.  The  trachea  was  deflected  beyond  the 
median  line  towards  the  left  side,  so  that  the  base  of  the  tumor 
lay  pretty  well  under  the  sternum.  The  base  of  the  aneurism 
rested  upon  the  right  bronchus,  but  without  flattening  it.  The 
right  subclavian  artery  was  given  off  from  the  tumor,  and  above 
it  Avas  a  continuation  of  the  pouch  one  and  a  half  inches  in 
length,  forming  the  aneurism  of  the  common  carotid,  from  whose 
apex  four  arteries  were  distributed. 

On  the  left  common  carotid  was  a  small  aneurism  one  inch 


124 


COMPOUND  DISLOCATION  OF 


[Nov., 


by  one-half  inch,  from  which  four  small  vessels  were  also 
given  off.  The  mucous  membrane  of  the  larynx  sliowed  some 
slight  congestion,  and  two  points  of  superficial  ulceration. 

The  large  aneurism  was  lined  with  fibrin,  disposed  in  layers, 
leaving  a  small  cliannel  through  the  centre  which  accounted 
for  the  absence  of  thrill  and  murmur  and  for  the  diminished 
force  in  the  right  radial  artery. 

Remarks  by  Dr.  Flint. — This  case  is  of  interest  in  view  of 
the  fact  that  there  existed  sufficient  data  for  a  pretty  positive 
diagnosis,  exclusive  of  the  physical  signs  of  aneurism.  Aside 
from  the  habitual  labor  of  breathing  due  to  pressure  of  the 
aneurismal  tumor  on  the  trachea,  the  character  of  the  voice 
and  the  intermitting  aphonia,  attributable  to  paralysis  of  the 
laryngeal  muscles  on  one  side,  at  once  suggested  the  idea  of  an 
aneurismal  tumor  involving  the  recurrent  laryngeal  nerve. 
The  absence,  at  the  time  the  diagnosis  was  made,  of  the  physi- 
cal signs  of  pulmonary  disease  sufficient  to  account  for  the 
labored  breathing,  was  a  negative  point  of  importance;  the  dis- 
parity in  the  radial  pulse  between  the  two  sides,  and  the  con- 
traction of  the  pupil  on  the  right  side,  were  positive  points 
bearing  on  the  diagnosis. 


Case  of  Compound  Dislocation  of  the  Tibia  Foricarcl.  Brook- 
lyn City  Hospital.  Service  of  Prof.  C.  Hutchison.  Re- 
ported by  Dr.  Leroy  Milton  Yale. 

Joseph  Martin,  age  15;  nativity,  New  York;  laborer. 
Strumous  diathesis.  Admitted  to  ward  18  about  3  p.m.,  June 
21st,  1864.  At  10  A.M.  was  injured,  as  nearly  as  can  be  as- 
certained, in  the  following  manner: 

While  at  work  in  a  rope-walk  his  foot  caught  in  a  rope  and 
he  was  thrown  over  a  "  drum."  His  left  leg  passed  across  or 
into  the  top  of  the  "  drum,"  the  flexure  of  the  knee  catching 
upon  its  edge,  while  his  body  fell  outside  with  powerful  ex- 
tending force. 

Examination  showed  a  dislocation  of  the  left  tibia  forward. 
There  was  a  wound  in  the  popliteal  space  about  one  and  one- 
quarter  inches  in  diameter,  through  which,  on  the  introduction 


18G5.] 


THE  TIBIA  FORWARD. 


125 


of  the  finger,  the  condyles  of  the  femur  could  be  felt.  The 
articular  surfaces  of  the  tibia  could  be  distinctly  recognized  in 
the  front  of  the  thigh.  The  femur  was  denuded  of  its  periosteum 
over  a  space  extending  from  the  lower  end  upward  three  or 
four  inches,  and  in  width  about  one-third  of  the  circumference 
of  the  bone.  The  shortening  of  the  limb  wa^  one  and  one- 
quarter  inches.  No  other  injuries  were  detected  save  some 
contusions  on  the  back. 

After  etherizing  the  patient  the  dislocation  was  easily  re- 
duced by  passing  a  sheet  under  the  perineum  and  tying  it  to 
the  head  of  tlie  bed,  and  then  making  extension  from  the 
foot,  wliile  the  knee  was  slightly  flexed  and  pressure  made 
upon  the  tibia. 

A  posterior  splint  was  then  applied,  padded  in  such  a  manner 
that  the  wound  could  be  dressed  without  the  limb  being  dis- 
turbed. 

There  was  some  elfusion  about  tlie  knee,  and  the  sensibility 
of  the  foot  was  slight.  The  treatment  was  nourishing  and  sup- 
porting, with  anodynes  pro  re  nata. 

June  22d.  At  a  consultation  of  surgeons  it  was  decided  not 
to  amputate,  a  hope  being  entertained  that  the  limb  might  be 
saved. 

June  28th. — Suppuration  established.  Dressed  wound  with 
51  Kreasoti  3ij.,  aquae  §xij.  ft.  lotio. 

July  3d. — Considerable  irritation  and  hectic.  Gave  quinas 
sulph.  gr.  ij.,  and  pil.  opii  gr.  j.  every  six  hours. 

July  9th. — Burrowing  of  pus  about  three  inches  above  the 
knee;  free  discharge  of  greenish-yellow  pus  from  wound.  Put 
a  bandage  upon  thigh  from  above  downward. 

July  15th. — Burrowing  about  two  inches  below  the  knee; 
roller  applied  from  toe  to  knee,  and  bandage  on  tliigh  con- 
tinued. Substituted  light  side  splints  for  the  posterior  splint. 
Kreasote  water  continued.  Patient  takes  §xij.  of  whiskey  j^er 
diem;  beef  tea  and  milk  ad  libituin;  pulse  small,  patient  much 
emaciated;  bowels  move  once  a  day;  has  had  no  chills  since 
admission;  no  jjains  in  the  chest. 

July  nth,  2.^  p.  M.— Died. 

The  friends  removed  the  body  on  a  coroner's  order  before 
an  autopsy  could  be  made. 


126 


SUGGESTIONS  REGARDING  CHOLERA. 


[Nov., 


Suggestions  regarding  CJiolera.    By  A.  P.  Merrill,  M.D.,  of 
New  York  City. 

According  to  common  precedent  in  regard  to  epidemic  dis- 
eases originating  in  tlie  East,  the  cholera  seems  at  this  time  to 
be  tending  westward,  and  in  all  probability  it  will  again  cross 
the  ocean.  This  must  now  be  considered  the  common  and 
probable  course  of  all  the  eastern  epidemics  which  travel  wcst- 
Avard  into  Europe.  Formerly  it  was  not  so.  In  the  infancy 
of  American  settlements,  and  before  commerce  and  travel  had 
bridged  the  Atlantic  with  ships,  the  greatepidemicswhich  devas- 
tated both  Asia  and  Europe,  sometimes  extending  into  Africa, 
■were  arrested  on  the  shores  of  the  then  almost  impassable 
ocean.  Now,  the  non-contagious  epidemics  originating  in 
India  follow  the  course  of  commerce  and  pilgrimage  westward 
until  they  are  thrown  upon  the  shores  of  the  Mediterranean 
Sea  and  its  tributaries,  thence  to  be  thrust  forward  toward  the 
setting  sun,  until  the  earth  is  encircled  by  their  ravages.  Their 
strides  are  often  irregular  and  eccentric,  and  they  arc  some- 
what uncertain  in  their  times,  seasons  and  severities;  but  in 
spite  of  all  obstacles  and  hindrances  which  science  and  states- 
manship have  been  able  to  interpose,  their  tendency  is  steadily 
westward  and  northward,  and  hitherto  the  destruction  of  life 
has  scarcely  been  lessened  by  the  observations  and  experiences 
of  mankind. 

The  cause  of  cholera  being  as  yet  undiscovered,  no  effective 
plan  of  prevention,  either  as  regards  individuals  or  communi- 
ties, has  been  devised;  and  the  disease,  like  other  fatal  epidem- 
ics, invades  both  the  palace  and  the  hovel,  spreading  dismay 
and  destruction  among  all  classes.  It  would,  therefore,  seem 
to  be  the  part  of  prudence,  while  the  disease  is  traveling  toward 
us,  to  prepare  ourselves  for  the  threatened  encounter,  and  for- 
tify ourselves  with  all  the  means  of  cure  at  our  command. 

Since  the  first  appearance  of  the  disease  in  Europe  and 
America,  its  pathology  has  been  carefully  studied,  and  whether 
we  agree  to  call  it  a  peculiar  form  of  fever,  or  a  disease  sici 
generis,  we  know  that  an  early,  if  not  an  inceptive  condition,  is 
such  derangement  of  the  nervous  system  as  results  in  extensive 
congestion  of  the  mucous  tissues  and  the  skin.    Closely  simu- 


18G5.] 


SUGGESTIONS  REGARDING  CHOLERA. 


127 


lating  the  chill  of  fever  in  other  respects,  it  differs  from  it  in 
this:  in  fever  the  primary  congestions  from  which,  if  suffered  to 
continue,  we  have  so  much  of  mischief  to  apprehend,  are  located 
mainly  in  the  parenchymatous  structures,  while  in  cholera  they 
are  principally  confined  to  the  mucous  membranes,  extending 
by  sympathy  to  the  skin.  Extensive  and  violent  as  is  this 
morbid  lesion,  we  have  no  difficulty  in  recognizing  as  its  neces- 
sary concomitant  the  asphyxied  condition  of  such  alarming 
character,  with  coldness  of  the  body  and  breath,  while  the 
patient  complains,  as  in  other  ca^^es  of  extensive  congestions, 
of  sensations  of  heat  and  of  the  paiiifulness  of  hot  applica- 
tions. The  transpirations  of  serous  fluid  from  both  the  mu- 
cous tissues  and  the  skin,  the  painful  cramps  and  prostration 
of  strength,  are  all  legitimate  effects  of  these  congestions,  and 
have  been  noticed  as  common  results  of  similar  conditions  of 
the  dermatoid  tissues  in  other  forms  of  disease. 

Upon  occasions  of  the  appearance  of  cholera  in  tlie  south, 
I  have  witnessed  the  best  success  from  a  reliance  mainly  upon 
strychnia  and  citric  acid  as  remedies.  These  are,  indeed,  the 
most  successful  remedial  agents  in  tlie  treatment  of  diarrhoea, 
and  other  diseased  conditions  attended  by  watery  dejections 
from  the  bowels,  in  some  respects  resembling  cholera.  The 
remarkable  power  of  strychnia  in  these  cases  may,  I  suppose, 
be  attributed  to  its  action  upon  the  organic  nerves.  But  this 
is  an  unsafe  remedy  for  popular  use,  and  even  physicians  often 
meet  with  difficulty  in  its  employment  on  account  of  its  pro- 
ducing toxical  effects.  The  vomiting  which  attends  upon  most 
cases  of  cholera  is  generally  soon  relieved  by  this  remedy,  but 
while  it  continues  we  can  not  know  how  much  is  retained  in 
the  stomach,  and  either  too  much  or  too  little  may  be  given; 
and  when  severe  congestions  arc  relieved  by  it,  the  reaction 
which  follows  is  mostly  expended  upon  the  brain.  Tliis  it  is 
sometimes  difficult  to  relieve  without  blood-letting,  and  great 
caution  is  often  necessary  in  the  use  of  this  remedy  for  the 
purpose,  because  of  the  drain  which  has  been  made  ujjon  the 
blood  by  the  serous  purging  and  the  consequent  exhaustion  of 
vital  energy.  Still,  whatever  may  be  the  danger  attending 
upon  the  use  of  strychnia,  its  remedial  power  is  such  that  ab- 
stinence from  its  use  can  scarcely  be  justified  in  any  case. 


128 


SUGGESTIONS  REGARDING  CHOLERA. 


[Nov., 


Besides  its  influence  over  the  functions  of  the  spinal  cord  and 
the  ganglionic  nerves,  it  gives  tonicity  to  the  solids,  while  the 
citric  acid  has  a  tendency  to  restore  the  deteriorated  fluids  to 
a  healthy  condition. 

Now  i  hold— and  this  is  the  principal  suggestion  I  wish  to 
make— that  my  experiments  with  chloroform  administered  in- 
ternally, as  reported  in  the  journals  and  in  my  published 
"  Lectures  on  Fever,"  prove  its  great  efficacy  in  all  kinds  of 
congestion,  except  from  causes  purely  mechanical,  and  that 
therefore  we  have  abundant  reason  to  hope  for  successful  re- 
sults from  the  addition  of  this  to  the  other  remedies  mentioned 
in  the  treatment  of  cholera.    Chloroform  administered  inter- 
nally in  doses  of  a  fluidrachm  and  upwards,  and  repeated  until 
sleep  is  produced,  may  be  expected  to  relieve  whatever  of  con- 
gestion there  may  be  in  the  mucous  tissues  and  the  skin,  and 
thus  put  a  stop  to  the  exhausting  effects  and  spasms  resulting 
from  excessive  serous  discharges.    It  affords  us  the  peculiar 
advantage,  too,  of  equal  efficiency  when  given  by  enema  in 
proportionally  larger  doses.    No  apprehension  need  be  enter- 
tained, if  my  numerous  experiments  with  the  remedy  are  re- 
garded as  of  any  value,  that  injury  wall  be  caused  the  mucous 
membrane,  whether  given  by  the  stomach  or  the  rectum;  and 
it  may  be  administered  by  the  stomach  without  the  use  of  bulky 
vehicles,  thus  lessening  materially  the  chances  of  loss  by  vom- 
iting.   In  algid  congestions,  like  those  of  cholera,  there  is  no 
remedy  more  agreeable  to  the  patient  than  pure  chloroform, 
in  doses  of  a  fluidrachm.    Care  should  always  be  taken  that 
it  is  not  adulterated  with  alcohol,  which  renders  it  painfully 
irritating  to  the  mucous  tissues.    Without  this,  the  dose  above 
indicated  may  be  frequently  repeated  in  severe  congestion, 
without  any  inconvenience.    When  there  is  no  objection  to  an 
increase  of  bulk,  the  dose  is  rendered  more  agreeable,  how- 
ever, by  an  admixture  of  water  with  simple  syrup  or  sugar, 
made  at  the  moment  of  administration. 

While  epidemic  cholera  continues  to  baffle  the  best  medical 
skill,  and  cause  such  frightful  destruction  of  human  life,  I  may 
be  permitted  to  commend  these  suggestions  to  the  considera- 
tion of  the  profession,  both  at  home  and  abroad. 

141  Macdougal  Street. 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


129 


PROCEEDINGS  OF  SOCIETIES. 

IsEW  YORK  PATHOLOGICAL  SOCIETY. 
Stated  Meeting,  May  24,  1865. 
Dr.  GuRDON  Buck,  President,  iu  the  Chair. 

TUMOR  OF  THE  TESTICLE  DR.  L.  VOSS. 

Dr.  Toss  exhibited  a  tumor  of  the  testicle,  which  he  had  remoYed  a 
fortnight  before,  and  gave  tlie  following  history: 

The  patient  was  about  43  years  of  age,  presented  a  generally 
cachectic  appearance,  and  complained  greatly  of  pain  in  his  abdomen, 
which  was  attended  with  occasional  vomiting  and  a  fi'equent  desire  to 
urinate.  He  had  a  tumor  on  the  right  side  of  the  scrotum  the  size  of 
an  ostrich  egg,  oval  in  shape,  and  about  its  middle  and  outer  aspect 
and  also  on  its  lower  portion  there  was  to  be  seen  an  increased  promi- 
nence. The  tumor  was  hard,  weighty,  non-fluctuating,  and  not  trans- 
lucent. He  stated  that  it  had  been  growing  for  several  years,  and 
denied  positively  that  it  had  been  the  result  of  any  injury,  or  had  at 
any  time  suddenly  increased.  The  protuberance  at  the  lower  portion 
of  the  tumor  gave  distinct  evidences  of  false  fluctuation.  I  suspected 
that  this  was  the  testicle,  or  rather  what  was  left  of  it;  but  I  could 
not  give  rise  in  him  to  any  of  that  peculiar  feeling  which  is  experienced 
when  the  organ  is  pressed.  My  diagnosis  then  was  that  it  was  sarco- 
cele,  whether  malignant  or  not,  however,  I  was  only  able  to  conjecture. 
As  the  patient  was  suffering  very  much  I  proposed  to  him  to  have  the 
mass  removed,  to  which  he  consented. 

In  commencing  the  operation  I  made  an  incision  in  the  bulge  of  the 
lower  portion  of  the  tumor,  with  the  intent,  if  I  should  find  the  sound 
testicle  there,  to  make  an  effort  to  save  it.  On  making  the  incision  I 
found  that  this  false  fluctuation,  as  I  had  supposed,  was  due  to  fibrinous 
infiltration.  On  cutting  deeper  I  came  on  a  kind  of  tissue  which  cer- 
tainly did  not  resemble  the  tissue  of  the  testis;  I  thought  it  was  theu 
a  fibrous  tumor,  and  resolved  to  remove  it,  which  I  did  without  any 
trouble. 

After  its  removal,  when  I  cut  into  the  tumor,  I  fonnd  that  it  was  an 
hematocele  which  contained  a  fluid  like  thick  chocolate.  The  reason 
why  I  had  not  detected  the  testis  was  this:  instead  of  coming  on  the 
proper  tissue  of  the  testis,  I  struck  the  epididymis,  the  sound  tissue  of 
wliicli  I  (lid  not  recognize  as  belonging  to  that  part  where  I  had  ex- 
pected to  find  the  testicle;  this  latter  organ  was  at  the  end  of  the 

Vol.  II.— No.  8.  9 


130 


PROCEEDINGS  OP  SOCIETIES. 


[Nov., 


tumor  looking  with  its  face  upward,  and  tucked  away  in  a  very  small 
compass.  The  tunica  vaginalis  was  very  much  thickened,  which  ac- 
counted for  the  want  of  translucency  referred  to. 

Under  the  circumstances  the  testicle  was  removed  with  the  mass. 
If  the  proper  nature  of  the  tumor  had  been  recognized  in  time  to  save 
the  testis,  I  do  not  think  tliat  the  patient  would  have  been  able  to  stand 
the  suppuration  which  would  have  been  necessary  to  close  such  a  large 
opening  as  would  be  left.  The  scrotum  was  not  adherent  to  any  part 
of  the  tumor. 

This  variety  of  hematocele,  wliich  is  not  of  traumatic  origin,  is 
very  well  described  by  Virchow  in  his  late  work  on  tumors.  The 
wound  is  now  nearly  closed  and  the  patient  is  doing  well.  In  con- 
clusion, Dr.  Voss  remarked  that  the  error  in  diagnosis  which  had 
been  made  by  him  was  not  infrequent. 

Dr.  Buck  stated  that  he  could  recall  one  or  more  instances  in  which 
he  had  not  diagnosticated  that  condition. 

Dr.  Sands  remarked  that  such  cases  would  suggest  the  expediency  of 
using  an  exploring  needle  in  every  case  of  scrotal  tumor  in  which  a  diag- 
nosis is  not  very  certain.  He  saw  a  mistake  committed  at  Bellevue  Hos- 
pital a  few  years  ago  which  impressed  him  with  the  need  of  this  caution. 
A  man  was  admitted  with  supposed  hydrocele.  He  was  Ijrought  into 
the  Governor's  room,  it  being  a  public  day  of  some  sort,  aud  was  ex- 
amined by  quite  a  number  of  surgeons,  including  the  resident  and 
visiting  staff,  and  they  all  were  of  one  opinion,  viz.,  that  the  case  was 
one  of  hydrocele,  except  one  gentleman,  who,  having  his  doubts  as  to 
the  existence  of  true  fluctuation,  suggested  the  propriety  of  introducing 
a  trocar.  The  suggestion  was  not  heeded,  and  a  cut  was  made  with  a 
view  to  evacuate  the  contents  of  the  sac;  but  the  knife  entered  an  eu- 
cephaloid  tumor,  and  the  patient  had  to  be  taken  immediately  to  a 
ward  in  order  to  have  the  mass  removed.  He  had  several  times  tapped 
scrotal  tumors  in  doubt,  but  had  never  had  occasion  to  regret  the  oi> 
eration.  The  sense  of  fluctuation  under  such  circumstances  could  not 
be  relied  upon,  inasmuch  as  the  same  condition  of  things  existed  in 
encephaloid  tumors.  He  remembered  a  mistake  which  Nelaton  had 
committed  in  the  case  of  a  swelling  of  the  arm.  Nelaton  told  the 
class  which  was  assembled  at  his  clinic  of  the  difficulty  of  distinguishing 
between  solid  and  fluid  tumors,  and  mentioned  the  fact  that  soft  solids 
gave  the  sense  of  fluctuation;  but  that  in  the  case  before  them, 
although  there  was  fluctuation  present,  the  tumor  was  evidently 
adipose.  After  having  given  a  very  interesting  lecture  upon  the  sub- 
ject he  cut  into  the  mass,  when,  alas  !  it  turned  out  to  be  an  abscess. 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


131 


Dr.  Buck  remarked  that  the  feeling  of  fluctuation  was  very  decep- 
tive as  to  the  knowledge  which  it  gave  of  the  existence  of  pus  or  otiier 
fluid. 

He  remarked  that  his  attention  was  called,  a  few  days  before,  in  a 
patient  suffering  from  another  trouble,  to  a  tumor  of  the  shoulder, 
which  was  believed  to  be  a  case  of  cold  abscess.  He  was  struck  with 
the  sense  of  fluctuation  which  it  communicated.  It  occupied  the 
anterior  half  of  the  deltoid  muscle,  was  flattened  and  nearly  circular; 
but  he  noticed  that  in  stretching  the  skin  over  it  that  at  its  circum- 
ference there  were  to  be  seen  one  or  two  superficial  sulci  running 
towards  the  centre  and  crossing  it.  This  circumstance  pointed  out  the 
case  at  once  as  one  of  fatty  tumor.  He  remarked  that  fatty  tumors 
generally  consist  of  large  masses  which  are  separated  by  superficial 
sulci,  and,  ordinarily,  when  the  integument  is  loose  over  them,  they 
can  be  brought  into  view.  But  in  that  case  there  was  another  feature 
which  determined  that  the  tumor  was  not  an  abscess,  its  mobility  upou 
its  bed,  there  being  no  attachments  for  it  below,  and  the  fingers  could 
be  inserted  some  distance  under  it. 

A  few  years  ago,  contiuued  he,  I  made  a  mistake  in  supposing  a  cold 
abscess,  situated  below  the  edge  of  the  angle  of  the  scapula  and  under- 
neath a  layer  of  muscle,  to  be  a  fatty  tumor.  It  was  flattened,  indolent, 
and  slid  easily  under  the  surface ;  but  when  it  was  cut  into,  the  matter 
which  it  contained  was  evacuated,  proving  conclusively  the  error  in 
diagnosis  which  had  been  made. 

Dr.  Yoss  stated  that  Pirogofif  had  written  a  very  interesting  paper 
on  the  subject  of  fluctuating  and  non-fluctuating  tumors,  in  which  were 
detailed  many  mistakes  of  his  own  and  others. 

Dr.  Buck  said  that  Dr.  Alex.  H.  Stevens  used  to  relate  an  instance 
which  came  under  his  notice  when  visiting  p]dinburgh  in  the  day  of  Mr. 
Liston.  That  gentleman  called  Dr.  Stevens'  attention  to  a  tumor  of 
the  nates,  and  expressed  a  confident  opinion  as  to  its  nature.  When 
every  thing  was  ready  for  the  operation,  Dr.  Stevens  suggested  the 
propriety  of  introducing  an  exploring  needle;  the  suggestion,  however, 
was  not  heeded,  and  the  operator  came  down  upon  a  cold  abscess. 

SEPARATION  OF  THE  EPIPHYSES  OF  THE  FEMUR  DR.  LITTLE. 

Dr.  Little  presented  a  specimen  of  separation  of  the  epiphyses  of 
the  lower  end  of  the  femur,  and  gave  tho  following  history  of  the 
case: 

Willie  Bull,  aged  11.    On  April  18,  while  hanging  on  the  back  of 


132 


PROCEEDINGS  OF  SOCIETIES. 


[Nov., 


a  groc3ry  wagon,  his  right  leg  caught  in  tlie  spokes  of  the  wheel  and 
was  suddenly  twisted  around,  and  he  sustained  a  separation  of  the 
epiphysis  of  the  lower  extremity  of  the  femur.  On  being  called 
to  see  the  patient  a  few  miimtes  after  the  injury,  I  found  the 
upper  fragment  projecting  about  three  inches  through  an  opening  in 
the  soft  parts  on  the  outside  of  the  upper  i)art  of  the  popliteal  space. 
The  finger  could  be  passed  upward  and  downward  for  a  considerable 
distance,  showing  considerable  contusion  and  laceration  of  the  soft 
parts,  in  the  neighborhood  of  the  wound.  No  communication  with 
the  knee-joint  could  be  discovered.  The  patient  was  etherized,  and, 
assisted  Drs.  Church  and  J.  L.  Smith,  I  reduced  the  deformity, 
and  placed  the  limb  on  a  double  inclined  plane.  There  was  a  car- 
tilaginous but  no  bony  crepitus.  There  was  at  this  time  no  pulsation 
to  be  discovered  in  the  posterior  tibial  artery,  and  the  leg  was  cold. 

April  19th. — Consultation  with  Dr.  Parker.  Patient  was  again 
etherized,  and  the  injury  thoroughly  examined.  At  tliis  time  the 
warmth  had  returned  to  the  limb,  and  pulsation  of  the  posterior  tibial 
could  be  felt.  It  was  also  found  that  during  the  night  the  upper 
fragments  had  become  displaced,  and  that  they  could  be  kept  in  proper 
position  only  by  the  leg  being  flexed  upon  the  thigh.  As  it  was  deemed 
best  to  give  the  boy  a  chance  to  save  his  limb,  the  leg  was  secured  in 
this  position  by  a  band  of  adhesive  plaster  around  the  ankle  and  over 
the  upper  part  of  the  thigh,  and  then  allowed  to  recline  on  a  pillow. 
The  patient  suffered  considerable  from  the  irritative  fever  and  from 
swelling  about  the  joint,  which  began  to  subside  in  about  a  week. 

On  the  tenth  day  the  patient  had  a  slight  hemorrhage  from  the 
wound.  On  the  thirteenth  day,  about  10  in  the  morning,  while  dress- 
ing the  wound,  a  severe  secondary  hemorrhage  took  place,  which  pros- 
trated the  patient  very  much.  This  was  arrested  by  pressure  over  the 
femoral,  and  a  tourniquet  applied  as  soon  as  it  could  be  obtained. 
Amputation  of  the  thigh  was  then  decided  upon,  as  the  soft  parts  in 
the  neighborhood  of  the  wound  were  in  such  a  bad  condition  that  it  was 
deemed  useless  to  attempt  to  find  the  bleeding  point. 

At  8  in  the  evening  reaction  had  taken  place  sufficiently  to  warrant 
the  operation,  and  I  amputated  the  thigh  at  a  point  a  little  above  the 
middle.  There  was  but  little  hemorrhage  at  the  time  of  the  operation ; 
patient  rallied  slowly  from  the  shock.  The  wound  did  well,  and  the 
patient  is  now,  twenty-four  days  after  the  operation,  able  to  go  about 
on  crutches.    The  wound  has  almost  entirely  healed. 

An  examination  of  the  limb  showed  that  the  soft  parts  were  in  a  state 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


133 


of  decomposition — the  hemorrhage  proceeding  from  a  wound  of  the 
anterior  tibial  artery  at  its  origin  from  tlie  popliteal. 

The  knee-joint  was  involved  in  the  injury;  the  synovial  membrane 
was  intensely  reddened  throughout  the  joint.  The  bone  presented 
almost  a  perfect  separation  of  the  epiphyses. 

He  also,  in  this  connection,  presented  the  lower  end  of  the  hu- 
merus, with  a  portion  of  the  epiphysis,  which  he  had  removed  from  a 
patient  of  Dr.  Livingston.  The  injury  which  occasioned  its  removal 
was  a  fracture  which  extended  half  through  the  epiphyseal  line,  and 
then  across  the  lower  extremity  of  the  bone  higher  up.  The  patient 
recovered  with  a  stiff  arm. 

Dr.  Buck  remarked:  I  think  it  is  not  unusual  where  a  separation  of 
the  epiphysis  takes  place  to  find  that  the  separation  is  not  entirely  con- 
fined to  the  epiphyseal  line  of  junction;  there  is  generally  a  small  chip 
which  separates  besides.  I  am  reminded  by  Dr.  Little's  case  of  one 
that  I  can  not,  however,  give  suEBcient  particulars  of  to  have  much 
weight.  It  occurred  in  the  practice  of  the  late  Hugh  Walsh,  of  Ford- 
ham.  The  patient  was  a  boy,  aged  14,  whose  limb  was  also  twisted 
in  a  revolving  wheel  by  being  caught  in  the  spokes.  My  recollection 
is  n&t  sufficient  to  state  whether  the  fracture  was  compound  or  not, 
but  I  recollect  that  there  was  a  separation  of  the  epiphyses. 

Dr.  Yoss  stated  that  he  had  met  with  a  case  of  the  same  character 
as  that  presented  by  Dr.  Little.  The  fracture  was  not  compound  at 
the  time  of  the  accident,  but  subsequently  an  abscess  formed  and  the 
upper  fragment  protruded.  In  that  condition  the  doctor  saw  the  case, 
and  was  compelled  to  amputate.  He  also  stated  that  he  had  met 
with  another  instance  of  this  separation  of  the  epiphysis  at  the  lower 
end  of  the  tibia,  in  a  boy  about  14  years  of  age,  who  fell  down  from 
the  first  story  of  a  house,  and  caught  his  foot  between  two  pieces  of 
wood.  The  upper  fragment  protruded  through  the  skin,  was  reduced, 
and  the  limb  placed  on  a  double  inclined  plane.  A  portion  of  the 
epiphysis  became  necrosed,  and  was  afterwards  removed,  but  the  boy 
finally  recovered  with  the  use  of  his  joint.  In  conclusion  he  stated 
that  the  separation  of  the  epiphysis  from  the  diaphysis  was  most  fre- 
quent, as  the  result  of  inflammatory  processes — in  that  case  the  separa- 
tion always  occurring  before  advanced  age. 

Dr.  Buck  stated  that  when  such  a  separation  took  place  the  in- 
flammation was  generally  acute — at  least  such  was  the  experience  at 
the  New  York  Hospital. 


134 


PROCEEDINGS  OF  SOCIETIES. 


[Nov., 


BRAIN,  IN  A  CASE  OF  MENINGITIS  DR.  A.  JACOBI. 

Dr.  Jacobi  presented  a  specimen  of  a  brain  removed  from  a  man 
who  died  at  the  age  of  45,  and  gave  the  following  history  of  the  ease: 

I  know  very  little  of  his  previous  history,  except  that  he  had  not 
been  frequently  sick,  and  had  been  leading  a  rather  irregular  life.  He 
was  a  short,  stout  man,  with  a  short  neck,  and  had  exhibited  very 
violent  temper  all  his  lifetime,  especially  during  the  last  years  of  his 
life.  His  temper  would  sometimes  be  so  violent  that  he  would  treat 
his  family  not  only  badly,  but  cruelly.  About  a  year  and  a  half  ago 
he  was  taken  with  a  severe  attack  of  bilateral  pneumonia,  so  diagnos- 
ticated by  the  physician  then  in  attendance.  From  this  attack  he  re- 
covered after  some  time,  but  not  without  developing  some  unusual 
cerebral  symptoms.  He  was  once,  during  this  attack,  taken  with  a 
violent  convulsion,  which  lasted  for  an  hour,  followed  by  coma,  which 
lasted  from  twelve  to  tweuty-four  hours.  He  recovered  from  this 
slowly,  and,  it  was  thought,  completely ;  but  it  was  remarked  that  his 
temper  grew  more  and  more  violent  from  day  to  day.  About  a  year 
ago  he  was  taken  with  another  attack  of  what  appears  to  have  been 
pneumonia.  He  recovered  from  this  also,  when  he  commenced  to  show 
symptoms  of  insanity.  He  would,  for  days  and  weeks,  appear  quite 
rational,  when  of  a  sudden  he  would  exhibit  some  curious  mental 
phenomena.  Being  a  barber,  he  would  sometimes  leave  his  customers 
in  their  chairs,  partly  shaved,- and  walk  off  to  sit  down  on  the  stairs  in 
an  adjoining  hall.  This  mental  condition  increased  to  such  an  extent 
that  he  was  compelled  to  give  up  his  business  and  move  to  another 
part  of  the  city.  When  he  arrived  at  his  new  home  his  forgetfulness 
appeared  to  increase;  he  asked  his  son  if  all  the  baggage  on  the  walk 
belonged  to  him,  and  when  so  informed,  he  made  known  the  fact  to  all 
the  other  tenants;  he  also  seemed  very  curious  to  know  what  kind  of  a 
house  he  moved  to,  and  so  on.  It  was  thought,  subsequently,  best  to 
remove  him  to  a  lunatic  asylum.  I  called  to  see  him,  but  could  not 
convince  myself  of  his  being  insane.  He  talked  very  rationally;  said 
that  he  had  no  confidence  in  physicians,  talked  a  great  deal  concerning 
his  household  affairs,  and,  as  far  as  I  could  see,  there  was  no  insanity 
in  his  case,  at  least  at  that  moment.  I  went  off,  promising  to  return 
another  day,  when  I  hoped  to  be  able  to  detect  the  existence  of  his 
mental  trouble.  The  next  day  there  was  a  fire  in  the  neighborhood, 
which  he  attended.  He  stood  for  a  while  with  his  head  uncovered, 
looked  at  the  fire,  after  which  he  turned  round  in  the  direction  of  his 
residence.  When  he  arrived  there  he  was  evidently  bewildered,  and 
commenced  to  gallop  off  in  a  given  direction,  as  if  suddenly  conscious 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


135 


of  his  whereabouts.  He  was  watched  by  those  in  the  bouse,  but  he 
disappeared. 

The  next  that  was  heard  of  him  was  that  he  had  been  taken  with 
convulsions  in  Centre  street,  and  a  pohcenian,  who  supposed  liim  to  be 
intoxicated,  conveyed  him  to  the  Tombs,  from  which  place  he  was 
afterwards  transferred  to  the  New  York  Hosfjital,  where  I  saw  him 
the  next  day.  I  was  told  by  the  house  physician  that  the  patient 
came  in  with  fever  and  with  all  the  symptoms  of  inflammation  of  the 
brain,  and  also  had  a  slight  injury  on  the  left  cheek.  When  I  saw 
him  the  other  day  his  cerebral  irritation  had  disappeared ;  there  was 
very  little  fever,  his  pulse  being  106  and  pretty  regular,  and  there  was 
only  one  direct  cerebral  symptom  present,  and  that  was  dilatation  of 
the  left  pupil.  He  was  unable  to  speak,  and  remained  in  a  stupid 
condition.  In  that  condition  he  continued  for  another  day. 
He  had  been  very  violent  before  that,  so  that  it  was  neces- 
sary to  confine  him  in  a  straight-jacket.  Two  days  and  a  half  after 
he  was  received  into  the  hospital  he  was  attacked  with  pleurisy  of 
the  left  side,  and  died  twenty-four  hours  after  the  diagnosis  was 
made. 

•I  was  kindly  asked  by  the  house  staff  to  be  present  at  the  autopsy. 
There  was  an  abscess  in  the  lower  lobe  of  the  right  lung,  with  a  pretty 
thick  pyogenic  membrane.  There  was  a  hemorrhagic  effusion  in  the 
middle  lobe  of  the  right  lung.  The  middle  and  lower  lobe  of  right 
lung  and  lower  lobe  of  left  lung,  especially  the  anterior  portion  of  it, 
were  very  much  congested.  In  one  portion  of  the  middle  lobe  of  the 
right  lung  there  was  a  condition  which  nearly  approached  that  of 
gangrene,  giving  forth  an  intensely  foetid  odor.  The  right  heart  was 
full  of  blood,  the  left  heart  was  entirely  empty.  The  brain  showed 
evidences  of  an  old  and  also  a  recent  attack  of  meningitis.  There  was 
inflammation  not  only  of  the  dura  mater  but  of  the  pia  mater  and 
arachnoid.  The  gray  and  white  substance  of  the  hemispheres  of  the 
cerebrum,  the  cerebellum,  and  the  medulla  oblongata  was  found  in  a 
very  hypersEmic  condition.  There  was  a  moderate  amount  of  liquid 
iu  the  arachnoid  sac,  but  the  principal  lesions  were  those  which  ap- 
peared to  be  of  older  date. .  There  was  a  yellowish-greenish  discolor- 
ation of  the  whole  arachnoid;  this  latter  membrane,  too,  was  so  thick 
that  the  convolutions  of  the  hemispheres  seemed  to  be  flattened  in 
consequence.  When  the  specimen  was  fresh  the  exudation  was  so  thick 
that  it  presented  the  appearance  in  some  parts  of  an  uniform  smooth 
surface.  There  were  also  evidences  of  thickening  and  adhesion  of  the 
filamentous  tissues  between  the  dura  mater  and  araclinoid.  Further, 


136 


PROCEEDINGS  OF  SOCIETIES. 


[Nov., 


there  were  little  granular  bodies  to  be  seen  in  great  numbers  near  the 
adhesions  between  the  dura  mater  and  arachnoid;  these  bodies  were 
also  found  in  large  numbers  in  the  choroid  plexus  of  either  side.  There 
was  no  liquid  in  the  lateral  ventricles. 

I  forgot  to  state  that  he  had  another  convulsion  during  his  second 
attack  of  sickness,  about  a  year  ago. 

These  apparently  tubercular  bodies  in  the  arachnoid  and  choroid 
plexuses  are  not  tubercles,  but  are  found,  on  microscopical  examination, 
to  be  composed  of  notliiiig  but  connective  tissue,  with  a  numljer  of 
nuclei.  How  old  this  first  attack  of  meningitis  was  I  am  unable  to  say, 
but  the  last  attack,  of  which  he  died,  was  evidently  of  not  more  than 
three  or  four  days' duration.  The  old  exudation  appears  to  date  back 
to  his  first  attack  of  pneumonia.  It  is  very  common,  especially  in 
children,  to  see  brain  symptoms  supei-vening  on  inflammations  of  the 
lungs,  and  under  those  circumstances,  too,  yon  meet  with  these  tuber- 
cular bodies  on  the  arachnoid  which,  as  I  have  said  before,  are  com- 
posed entirely  of  connective  tissue.  I  should  have  stated  that  there 
were  some  old  adhesions  between  the  left  pleuraj,  and  there  was,  also, 
about  seven  or  eight  ounces  of  liquid  in  that  cavity,  thus  justifying  the 
diagnosis  of  pleurisy  already  referred  to. 

CRANIOTABES  DR.  JACOBI. 

Dr.  Jacobi  also  presented  the  cranium  of  an  infant  who  died  the 
day  before  at  the  age  of  a  little  more  than  five  months.  He  then 
gave  the  following  history: 

Some  five  days  ago  I  was  called  by  Dr.  Downs  to  see  this  infant 
with  him,  and  on  examination  we  found  that  the  child  was  apparently 
in  a  good  condition,  and  its  weight  was  not  below  the  average  of 
children  of  that  age;  but  its  skin  was  pale  and  sallow,  and  it  evidently 
had  more  fat  than  muscle.  There  were  eczematous  eruptions  over  the 
face  and  part  of  the  head;  there  was  some  hair  on  the  anterior  portion 
of  the  cranium,  and  but  very  little  on  the  posterior  portion.  The 
complaint  was  that  the  child  for  the  last  fortnight  had  a  large  number 
of  convulsions,  which  were  of  longer  or  shorter  duration.  The  parents 
stated  that  after  such  attacks  the  child  would  sleep  a  little,  then  have 
a  drowsy  spell,  and  finally  wake  up.  There  were  no  cerebral  symp- 
toms manifest  when  we  examined  the  child  together.  The  pupils 
seemed  to  be  normal,  there  were  no  contractions,  and  there  was  no 
paralysis.  The  mother  stated  that  the  convulsions  would  commence 
in  what  appeared  to  be  an  attack  of  laryngismus  stridulous;  the  child 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


13 


would  become  pale,  then  purple,  would  be  unable  to  breathe  for  a  time, 
then  a  slight  interrupted  inspiration  would  take  place,  resembling  a 
whoop,  when  the  patient  would  either  come  to  or  go  into  a  convulsion. 
An  examination  of  the  lungs  and  of  the  thymus  body  did  not  offer  any 
explanation  for  the  symptoms.  There  was  slight  dullness  over  the 
upper  portion  of  the  sternum,  but  certainly  not  enough  to  justify 
hypertrophy  of  the  thymus  body.  When  we  examined  further  we 
found  that  the  posterior  portion  of  the  cranium  was  easily  impressible 
with  the  finger;  it  seemed  to  have  no  more  resistance  to  pressure  than 
thick  paper,  and,  when  it  yielded,  would  give  a  crackling  sensation. 
The  anterior  portion  of  the  cranium  was  nearly  in  the  same  condition. 
The  large  fontanelle  was  very  large  and  the  sutures  were  evidently  not 
very  firm.  Neither  the  liver  nor  spleen  was  enlarged.  The  epiphyseal 
extremities  of  the  tubular  bones  were  enlarged.  Our  diagnosis  was 
craniotabes,  that  is  to  say,  rachitical  softening  of  the  cranial  bones, 
with  the  cotemporary  changes  in  the  brain  which  almost  always  ac- 
company such  a  condition. 

We  thought  if  the  child  could  live  a  month  or  two  in  order  to  allow 
time  enough  for  the  general  improvement  of  the  system,  recovery 
might  take  place;  but  it  died  a  few  days  after  in  a  convulsion. 

On  examination  after  death,  the  dura  mater  was  found  tightly  ad- 
herent in  the  situation  of  the  lamdoidal  suture.  The  upper  portion  of 
the  occipital  bone  and  the  lower  portion  of  the  parietal  bones  have 
been  removed,  and,  on  holding  them  to  the  light,  there  is  evidently  a 
great  many  places  in  which  there  is  apparently  no  osseous  tissue 
whatever — especially  is  this  the  case  on  the  right  side.  I  forgot  to 
state  that  the  occiput  of  the  child  appeared  at  one  portion  to  be 
flattened;  this  condition  can  now  be  appreciated  in  the  general  con- 
figuration of  the  bones.  The  right  parietal  is  evidently  the  one  which 
is  most  affected;  the  left  parietal  bone  shows  a  number  of  very  distinct 
softened  spots  in  which  there  is  no  appearance  of  bony  tissue.  Through 
one  spot,  where  I  had  previously  removed  the  pericranium,  I  was  en- 
abled to-day  to  see  a  large  letter.  There  was  softening  of  the  cere- 
bral substance,  and  there  was,  further,  some  efi"usion  in  the  arachnoid 
sac  wiiich,  judging  from  the  symptoms,  must  have  occurred  during  the 
last  days  of  life.  There  was  a  little  eff'usion  in  the  spinal  canal,  which 
would  flow  down  into  the  cranium  when  the  child  was  turned  over. 
Otherwise  there  was  nothing  abnormal.  The  lungs  were  quite  healthy, 
the  heart  normal,  and  the  liver  very  anasmic.  The  sjjleeu  exhibited  a 
very  small  polypus-like  excresence  in  the  middle  of  its  external 
aspect,  which  was  quite  pedunculated,  but  which,  on  examination, 


138 


PROCEEDINGS  OF  SOCIETIES. 


[Nov., 


proved  to  be  nothing  else  but  spleen  tissue.  The  noiinal  appearance 
of  the  lower  portion  of  the  intestinal  canal  was  somewhat  different 
from  what  we  usually  find.  As  a  general  thing  the  rectum  of  the 
infant  and  child  extend  upward,  and  a  little  to  the  right,  then  turns  over 
entirely  to  the  right  ilium,  there  forms  a  curvature,  then  turns 
over  in  a  straight  line  to  the  left  side,  forms  another  curvature,  and 
then  takes  its  course  upward.  Here  tliere  was  nothing  found  except 
the  normal  curvature,  as  is  seen  in  adult  life. 

There  is  one  other  point  to  which  I  wish  to  refer,  and  it  is  in  con- 
nection with  the  parietal  bones.  The  periosteum  was  very  easily  re- 
moved from  these  bones,  which  is  proliably  due  to  the  fact  that  the 
external  lamina  was  not  fully  developed. 

A  case  of  this  nature  (craniotabes)  has  been  presented  to  the 
Society  by  Dr.  Krackowizer,  in  which  the  softening  was  confined  to  the 
same  set  of  cranial  bones.  The  position  of  this  softening  is  explainable 
from  the  fact  that  those  bones  which  are  its  seats  are  most  exposed  to 
pressure  in  lying.  In  conclusion,  he  stated  that  he  once  met  with 
craniotabes  in  a  ftetus,  and  in  that  instance,  there  being  no  particular 
portion  of  the  cranium  exposed  to  pressure,  the  softening  was  general. 

CANCER  OF  THE  BREAST  DR.  BRADLEY. 

Dr.  Bradley  exhibited  a  tumor  of  the  breast  which  he  had  removed 
from  a  female  aged  56  years.  She  did  not  present  the  usual  cancerous 
cachexia,  and  the  tumor  appeared,  with  the  exception  of  one  or  two 
small  glands  in  the  axilla,  to  be  of  a  local  character.  These  glands 
were  removed  with  the  tumor.  The  disease  first  made  its  appearance 
about  a  year  ago,  and  towards  the  last  increased  quite  rapidly.  It 
was  confined  mostly  to  the  lower  and  outer  border  of  the  gland,  and 
occasioned  a  retraction  of  the  corresponding  side  of  the  nipple.  The 
texture  of  the  tumor  was  very  tough  and  cried  under  the  knife,  and, 
on  microscopic  examination,  was  found  to  consist  of  cancer-cells  and 
nuclei. 

INFLAMMATION  OF  THE  DUODENUM — DR.  LEWIS  SMITH. 

Dr.  Lewis  Smith  presented  a  specimen  taken  from  a  child  who  died 
at  the  age  of  10  years.  He  had  been  in  good  health  up  to  the  time 
of  his  last  sickness,  which  commenced  on  the  2d  of  May.  He  first 
complained  of  pain  in  his  bowels,  and  this  pain  continued  during  the 
whole  of  the  following  day,  though  he  was  able  to  get  about  the  house. 
On  the  third  day  he  ate  his  breakfast  as  usual  and  went  to  his 
business  down  town;  before  night,  however,  he  returned,  feeling  chilly, 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


139 


and  complaining  of  the  return  of  the  pain  in  his  bowels.  He  had  no 
appetite  for  food,  went  to  bed,  and  was  feverish.  The  family  being  in 
moderate  circnmstances  did  not  call  a  physician,  and  the  patient  con- 
tinued in  tlie  condition  described  during  the  two  following  days, 
Friday  and  Saturday.  On  Sunday  he  was  noticed  to  be  in  a  slight 
degree  yellow,  and  he  then  commenced  to  vomit  blood,  which  continued 
during  Monday  and  a  part  of  Tuesday,  and  which  was  estimated  in 
quantity  equal  to  a  pint.  Dr.  Smith  saw  him  for  the  first  time  on 
Tuesday,  and  found  him  then  with  a  very  sick  stomach,  very  tender 
abdomen,  and  with  tenderness  along  the  spine.  His  bowels  were  con- 
stipated, and  he  was  very  much  reduced,  partly  on  account  of  the 
blood  which  he  had  lost  and  partly  on  account  of  the  pain.  He  died 
within  the  next  twenty-four  hours,  and,  on  making  the  post-mortem 
examination,  the  thoracic  organs  were  found  healthy,  and  the  stomach, 
which  was  distended  with  gas,  was  found  to  contain  also  some  blood. 

On  following  down  the  alimentary  canal,  the  mucous  membraue  of 
the  duodenum,  below  the  situation  of  the  common  duct,  was  found 
very  much  thickened.  Below  this  thickened  portion  the  membrane 
seemed  healthy.  There  was  a  dark  substance  occupying  the  jejunum, 
which  appeared  to  be  decomposed  blood.  The  liver  was  about  the 
usual  size,  and,  upon  examination  under  the  microscope,  was  found  to 
contain  a  little  more  fat  than  usual.  The  membraue  lining  the  com- 
mon duct  was  inflamed,  a  little  aboxe  its  point  of  junction  with  the 
duodenum,  for  a  space  of  about  two  or  three  lines  in  circumference. 
There  was  no  noticeable  disease  in  the  gall  bladder,  and,  from  the 
absence  of  any  distension,  it  did  not  appear  that  there  had  been  any 
obstructions  in  the  common  duct  sufficient  to  dam  up  the  bile. 

BULLET  IMPACTED  IN  A  METACARPAL  BONE  DR.  GURDON  BUCK. 

Dr.  Buck  exhibited  a  specimen  of  impaction  of  a  bullet  in  the  lower 
half  of  the  metacarpal  bone  of  the  middle  finger.  The  patient  was  a 
soldier,  who  was  shot  at  by  a  guard  while  making  his  escape  from  a 
train  in  motion.  This  occurred  some  months  ago.  The  metacarpal 
bone  at  the  seat  of  the  injury  was  enlarged,  and  the  opening  which 
existed  there  communicated  with  a  rough  surface.  The  joint  was 
somewhat  rigid,  allowing  only  of  a  limited  motion.  A  second  opening 
existed  a  little  below  the  articular  extremity  of  the  first  phalanx, 
where  it  was  represented  to  Dr.  Buck  that  a  buckshot  had  been  re- 
moved. The  existence  of  the  ball  impacted  in  the  bone  was  not 
known,  and  the  patient  being  anxious  for  the  removal  of  his  finger,  an 


140 


PROCEEDINGS  OF  SOCIETIES. 


[Nov., 


operation  was  commenced  to  remove  dead  bone,  and  resnlted  in  the 
production  of  the  specimen  referred  to. 

FRACT0RE  OF  THE  THIGH  DR.  BUCK. 

Dr.  Bltk  presented  a  second  specimen,  which  was  one  of  fracture  of 
the  thigh  at  tlie  junction  of  the  shaft  with  the  condyles,  which  resulted 
from  the  patient,  a  vigorous  cartman,  thirty  or  forty  years  of  age,  being 
thrown  violently  from  his  cart  on  his  left  knee.  Twenty-four  hours 
after  the  injury  Dr.  Buck  saw  the  case;  it  was  then  reported  to  him 
that  there  was  a  diflference  of  an  inch  and  a  lialf  in  the  length  of  the 
limbs,  and  that  crepitus  had  been  felt  at  the  point  of  fracture.  The 
limb  presented  a  very  considerable  degree  of  swelling  of  a  uniform 
character;  there  was  no  remarkable  increase  in  the  breadth  of  the 
limb,  and  the  parts  around  the  fracture  seemed  to  retain  their  normal 
contour.  On  handling  the  parts,  the  false  points  of  motion  were 
readily  recognized  by  those  who  had  made  the  first  examination.  At 
the  time  Dr.  Buck  made  the  examination  no  crepitus  was  discoverable. 
The  question  in  regard  to  fracture  of  the  condyles  was  duly  considered; 
but  on  account  of  the  extreme  tension  of  the  soft  parts  which  came  on 
soon  after  the  accident,  no  lateral  motion  was  then  obtainable  be- 
tween the  fractured  portions.  The  existence  of  a  fracture  separating 
the  condyles  from  the  shaft  was  pbvious  enough,  and  there  was  an 
ecchymotic  discoloration  upon  the  anterior  aspect  of  the  limb.  The 
patient  died  a  week  after  the  injury,  with  delirium  tremens.  Upon 
examination  of  the  limb  after  death  it  was  found  that  the  shaft  had 
been  separated  from  the  condyles  in  an  oblique  plane  from  below, 
upwards,  and  from  before,  backwards.  The  extremity  of  the  upper 
fragment  was  very  sharp,  and  from  its  extreme  obliquity  caused  a 
fracture  of  the  inner  condyle.  The  two  condyles  were  separated  from 
each  other,  and  the  inner  condyle  had  attached  to  it  about  five  or  six 
inches  of  the  shaft.  The  pulsations  of  the  posterior  tibial  artery, 
strange  to  say,  were  not  mterfered  with  by  this  remarkable  fracture. 

Dr.  Buck  remarked  that  it  was  very  easy  to  see  how  such  a  sharp 
fragment  in  the  popliteal  space  might  perforate  the  artery,  and  also 
how  easy  it  would  be  for  the  sharp  edge  of  the  upper  fragment  to 
splinter,  and  afterwards  perforate  the  quadriceps  tendon.  Both  those 
conditions  were  obtainable  with  such  a  fracture,  and  when  the  latter 
existed,  the  two  portions  of  the  split  tendon  straddling  the  upper  frag- 
ment would  necessarily  interfere  with  union. 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


141 


EEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 

Lectures  on  the  Diseases  of  the  Stomach,  with  an  Introduction  on  its 
Anatomy  and  Physiology.  By  William  Brinton,  M.D.,  F.R.S., 
Pliysiciau  to  St.  Thomas's  Hospital.  American  Editioa.  Pliila- 
delphia:  Lea  &  Blanchard,  1865,  pp.  302. 

Diseases  of  the  stomach  are  popularly  supposed  to  be  more  frequent 
in  the  United  States  than  in  any  other  country  in  the  world.  Whilst 
we  are  disposed  to  doubt  the  correctness  of  this  belief,  we  can  not  deny 
that  the  class  of  affections  in  question  plays  a  very  important  part  in 
adding  to  the  discomfort  of  our  people  and  in  swelling  our  mortuary 
records.  It  is  somewhat  strange  that  no  one  of  our  own  physicians 
has  seen  proper  to  give  us  a  monograph  upon  so  fruitful  a  theme  as  that 
of  stomach  diseases;  but  in  the  absence  of  such  a  work  we  welcome 
with  great  pleasure  the  very  satisfactory  treatise  which  comes  to  us 
from  Dr.  Brinton's  pen. 

The  work  consists  of  an  introductory  chapter,  in  which  the  anatomy 
and  physiology  of  the  stomach  are  fully  dwelt  upon,  and  of  eight  lec- 
tures, devoted  to  the  consideration  of  the  functional  and  organic  dis- 
eases to  which  this  viscus  is  liable.  Dr.  Brinton  gives  it  as  his  opin- 
ion that  the  normal  acid  of  the  gastric  juice  is  the  hydrochloric,  and 
that  lactic  acid,  when  found  in  this  secretion,  is  a  secondary  product 
derived  from  the  food  ingested.  In  this  view  he  is  certainly  sustained 
by  the  weight  of  evidence. 

The  lecture  on  "  Ulcer  of  the  Stomach"  is  especially  full  and  inter- 
esting, and  the  remarks  on  the  treatment  are  characterized  by  much 
good  sense  and  sound  reasoning.  Dr.  Brinton  lays  more  stress  upon 
diet  than  upon  medicines;  of  the  latter  he  regards  opium  as  the  most 
valuable;  mercury  he  strongly  condemns.    Relative  to  it  he  says: 

"  It  would  be  a  dereliction  of  duty  in  me  not  to  express  the  strong 
opinion  I  entertain  against  the  employment  of  mercury  in  these  cases, 
in  any  form  and  under  any  pretense  whatever.  I  believe  that  I  have 
known  one  or  two  instances  in  which  the  ulcer  has  been  definitely  pro- 
duced by  the  administration  of  mercury  for  other  maladies,  and  am 
certain  that  I  have  witnessed  relapses  which  could  only  be  attributed 
to  a  similar  cause.  A  single  calomel  purgative  has  even  appeared  to 
undo  all  that  months  of  sedulous  treatment  had  been  able  to  effect 
towards  the  relief  of  a  gastric  ulcer." 

Dr.  Brinton  lias  not  a  great  deal  to  say  relative  to  dyspepsia — that 
wide-spread  affection  of  civilized  society.    He,  very  properly,  considers 


142  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [NoV., 


that  in  the  great  majority  of  cases  tlie  stomach  is  not  primarily  at  fault, 
and  yet  it  is  doubtful  if  he  gives  sufficient  prominence  to  the  nervous 
origin  of  the  disease.  We  all  know,  from  experience,  how  greatly  the 
function  of  digestion  is  influenced  by  the  mental  organization  of  the 
individual,  or  by  some  temporary  derangement,  or  shock  received  by 
the  nervous  system.  We  should  have  been  glad,  therefore,  had  he 
considered  the  matter  to  a  greater  extent  from  a  psychological  point  of 
view.  His  description  of  the  disease  is,  however,  graphic  and  full,  whilst 
at  the  same  time  it  is  sufficiently  concise. 

Relative  to  the  treatment  of  dyspepsia.  Dr.  Brinton  appears  to 
have  no  small  amount  of  faith  in  drugs.  Pepsine  has,  however,  dis- 
appointed him ;  tonics  he  has  found  generally  useful,  especially  quinine, 
and  the  preparations  of  iron,  zinc  and  bismuth ;  of  the  forms  of  iron  he 
prefers  the  citrate.  Aperients  he  regards,  when  properly  used,  as  of 
the  first  importance,  and  sedatives  can  scarcely  be  dispensed  with.  The 
benefits  to  be  derived  from  diet  and  regimen,  though  mentioned, 
are  not,  we  conceive,  sufficiently  insisted  upon.  Mineral  waters  are 
extolled  in  a  few  brief  words,  but  physical  exercise  and  the  proper 
regulation  of  the  intellectual  faculties  are  not  even  referred  to  as 
curative  agents. 

Upon  the  whole.  Dr.  Brinton's  book  is  a  very  excellent  treatise, 
which  should  be  in  the  hands  of  every  medical  practitioner.  We  re- 
gret, however,  that  the  American  publishers  have  brought  it  out  in  a 
style  so  inferior  to  that  of  the  English  edition.  The  paper  is  thin 
and  dusky,  and  the  whole  "  getting  up"  of  the  volume  is  of  the  cheapest 
and  most  common  description.  Physicians  are  just  as  fond  of  typo- 
graphical comforts  as  other  people,  and  are  fully  as  willing  to  pay  for 
them,  too;  and  yet  American  medical  books  are,  many  of  tliem,  printed 
in  a  style  that  would  disgrace  a  yellow-covered  romance  of  the  flash- 
iest kind.  Some  two  or  three  of  our  medical  publishers  manufacture 
their  works  in  a  highly  creditable  manner,  and  doubtless  find  that 
they  thereby  advance  both  their  pecuniary  interest  and  their  profes- 
sional reputation.  Messrs.  Lea  &  Blanchard  have  frequently  shown 
us  that  they  know  how  to  get  up  handsome  books;  and  therefore  we 
have  the  less  patience  with  them  when  they  give  us  one  which 
does  them  no  honor  by  its  appearance,  than  we  should  have  with 
those  from  whom  we  never  have  had  a  fine-looking  volume,  and  from 
whom,  therefore,  we  expect  nothing.  A  l)ook  that  is  worth  printing 
at  all,  is  worth  printing  well.  When  our  medical  publishers  uni- 
formly act  upon  this  maxim,  it  will,  we  think,  be  more  advantageous 
for  them,  as  it  certainly  will  be  better  for  the  readers. 


1865.]        BEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


143 


A  Dictionary  of  Medical  Science;  Containing  a  Concise  Explanation 
of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Ob- 
stetrics, Mediml  Jurisprudence,  and  Dentistry;  Notices  of  Climate  and 
of  Mineral  Waters,  Formula  for  Officinal,  Empirical  and  Dietetic 
Preparations;  with  the  Accentuation  and  Etymology  of  the  Terms,  and 
the  French  and  other  Synonyms,  so  as  to  Constitute  a  French  as  well 
as  English  Mediml  Lexicon.  By  Robley  Dunglison,  M.D.,  L.L.D., 
Professor  of  the  Institutes  of  Medicine,  etc.,  iu  the  Jefferson  Medi- 
cal College  of  Philadelphia.  Thoroughly  revised  and  very  greatly 
modified  and  augmented.    Philadelphia:  Blanchard  &  Lea,  1865. 

This  elaborate  title  relieves  us  from  the  necessity  of  giving  an  account 
of  the  extent  and  value  of  the  work  offered  by  Prof.  Dunglison  to  the 
profession  in  this  new  edition  of  his  Medical  Lexicon. 

It  would  be  a  work  of  supererogation  to  bestow  a  word  of  praise 
upon  this  Lexicon.  We  can  only  wonder  at  the  labor  expended,  for 
whenever  we  refer  to  its  pages  for  information  we  are  seldom  disap- 
pointed in  finding  all  that  we  desire,  whether  it  be  in  accentuation, 
etymology  or  definition  of  terms. 

The  constant  introduction  of  new  terms  into  scientific  language 
renders  a  revision  of  a  medical  lexicon  frequently  necessary.  In  the 
second  edition  of  "  Dunglison's  Dictionary,"  as  it  is  familiarly  known, 
several  thousand  terms  were  introduced  which  were  not  to  be  found  in 
any  other  medical  lexicon  in  use  in  this  country.  Each  subsequent  edi- 
tion has  been  augmented  by  a  large  addition  of  new  subjects  and  terms, 
and  although  it  is  Init  a  few  years  since  the  last  edition  appeared,  we 
are  informed  by  the  editor  that  over  sixty  pages  of  new  matter  have 
been  incorporated  in  the  present  one,  the  whole  having  undergone  a 
thorough  and  complete  revision.  In  fine,  there  is  no  more  complete  or 
better  medical  lexicon  extant. 

The  Medical  Register  of  the  City  of  Neio  York,  for  the  year  com- 
mencing June  1,  1865.  Published  under  the  supervision  of  the  New 
York  Medico-Historical  Society.  GuiDO  Furman,  M.  D.,  Editor. 
New  York:  1865. 

The  profession  of  this  city  is  certainly  indebted  to  the  Society 
nuder  whose  auspices  this  volume  is  issued,  and  to  the  editor  under 
whose  immediate  charge  it  has  been  carried  through  the  press,  for  a 
valuable  work. 

It  contains  an  account  of  the  various  Medical  Societies  of  this  city, 


144 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Nov., 


as  well  as  the  American  Medical  Association,  and  the  State  Medical 
Society,  and  gives  the  names  of  the  officers  and  members  of  the  city 
Societies.  It  also  gives  a  brief  record  of  the  several  Colleges,  Dispen- 
saries and  public  charities,  with  a  list  of  the  Faculties,  Officers,  and 
Trustees  of  the  same. 

A  few  pages  are  devoted  to  the  record  of  some  historical  facts,  among 
which  we  find  a  brief  account  of  the  origin  and  history  of  Dispensaries. 
This  is  followed  by  a  necrological  record  for  1862-(j5.  The  book 
finally  closes  with  a  directory  of  all  duly  qualified  practitioners  of 
medicine  in  the  city  and  county  of  New  York,  the  address  and  office 
hours  of  each  physician  being  given.  This  departmant  of  the  Register 
could  be  very  materially  increased  in  value,  i)ractically  as  well  as 
historically,  if  the  date  and  place  of  graduation  of  each  physician,  with 
the  titles  of  works  or  monographs  written  l)y  him,  could  be  added.  As 
it  is,  we  hope  the  enterprise  of  the  publishers  will  be  sustained,  for  we 
have  found  it  a  very  useful  and  convenient  book  of  reference  upon 
local  medical  affairs. 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 

I.— MATERIA  MEDICA  AND  THERAPEUTICS. 

1.  Effects  of  Iodide  of  Potassium. 

In  a  communication  to  the  editor  of  The  Lancet,  Mr.  Hodges  makes 
the  following  statements: 

I  was  attending  the  butler  of  a  gentleman  in  my  neighborhood  about 
six  years  ago,  and  found  it  necessary  that  my  patient  should  take 
iodide  of  potassium,  and  after  taking  it  for  three  or  four  days  he  had 
as  pretty  an  attack  of  erysipelas  of  the  face  as  I  ever  saw  in  my  life, 
which,  strange  to  say,  he  himself  attributed  to  the  medicine  I  had 
given  him.  After  this  he  accompanied  the  family  to  town.  On  his 
return  some  time  afterwards,  I  was  again  attending  him,  and  again 
gave  him  iodide  of  potassium,  and  with  exactly  the  same  result,  an 
attack  of  erysipelas.  Having  never  seen  erysipelas  follow  upon  taking 
iodide  of  potassium  before,  I  could  not  quite  make  up  my  mind  that 
the  drug  was  really  the  cause  of  the  two  attacks,  but  thought  that  each 
time  it  might  have  been  simply  a  coincidence,  and  resolved,  in  order 
to  satisfy  myself,  to  try  it  again,  which  I  did  after  an  interval  of 
several  months.  He  then  took  the  medicine  for  nearly  a  fortnight, 
and,  when  I  was  beginning  to  be  satisfied  the  former  attacks  were  not 
due  to  the  iodide,  he  was^again  attacked  with  erysijjelas  of  the  face, 
scalp,  neck,  &c.,  rather  severely.  I  may,  however,  mention  that  I 
have  frequently  had  the  same  patient  under  treatment  for  various 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


145 


ailments,  ami  on  one  or  two  occasions  I  have  given  him  alkaline  medi- 
cines, (liij.  potassic,  &c.,)  and  each  time  they  have  caused  him  much 
discomfort;  for  though  he  has  not  had  anotiier  attack  of  erysipelas,  he 
always  complains  of  great  heat  and  irritation  of  the  skin  generally, 
and  now  he  does  not  forget  to  remind  me,  when  about  to  prescribe  for 
him,  not  to  give  him  any  of  that  "  potash  stuff." 

With  regard  to  the  effects  of  iodide  of  potassium  on  the  uterus,  I 
may  mention  that  several  years  ago  I  had  under  treatment  a  young 
woman,  of  rather  easy  virtue,  for  general  debility,  ansemia,  and 
amenorrhci^a.  Her  general  health  was  completely  restored  by  the  use 
of  tonics,  steel,  (tc,  but  the  catamenia  did  not  return.  She  was  not 
pregnant.  Some  time  afterwards  it  became  necessary  to  give  her 
iodide  of  potassium  for  several  weeks.  During  that  time  she  men- 
struated imperfectly  once;  but,  though  several  years  have  elapsed,  she 
has  not,  as  far  as  I  know,  menstruated  since. 

Within  the  last  six  months  a  young  girl,  aged  thirteen,  was  under 
my  care  for  chronic  rheumatism.  '  She  had  been  regular  for  several 
years  up  to  a  few  months  before.  I  gave  her  iodide  of  potassium, 
•which,  although  it  did  not  cure  her  rheitmatism,  had  the  effect,  after 
taking  it  a  week,  of  re-establishing  the  catamenia,  which  have  since 
been  regular. — London  Lancet. 


2.  Remedy  for  Ili/drophohla. 

"  The  Messager  de  Provence  "  promulgates  the  following  remedy 
for  hydrophobia,  which  may  not  be  jjerfectly  new,  but  is  at  least  re- 
markable for  extreme  simjjlicity.  In  the  year  900  of  the  Christian  era 
a  mad  bear,  rushing  along  the  banks  of  the  Saone,  was  attacked  by  a 
number  of  watermen,  about  twenty  of  whom  were  more  or  less  severely 
bitten.  Six  of  these  men  became  affected  with  hydrophobia  and  were 
smothered;  the  remaining  fourteen,  who  leaped  into  the  river  and 
swam  across,  escaped  scatheless,  having  been  saved  by  contact  with 
the  water.  The  anonymous  author  of  this  story,  comparing  the  virus 
of  vaccine  with  that  of  rabies,  contends  that  if  the  2iunctures  of  vac- 
cine are  immediately  washed  with  fair  water,  no  effects  are  i^erce^itible 
from  the  operation;  and  that  if  the  bite  inflicted  by  a  rabid  animal  is 
also  at  once  washed  with  cold  water,  no  further  consequences  need  be 
aiiprehended  from  the  injury.  It  remains  to  be  seen  whether  this  is  a 
legitimate  comparison,  and  whether  it  is  an  ascertained  fact  that  lotions 
of  cold  water  have  the  jjower  of  neutralizing  the  effects  of  vaccination. 
— Journal  of  Practical  Msdicine  and  Surgery. 


3.  Powdered  Talc  as  a  Dressing. 

Dr.  Gouyon  recommends  powdered  talc  (silicate  of  magnesia  and 
alumina)  as  a  dressing  for  burns.  It  is,  he  says,  unaffected  by  temper- 
ature; when  applied,  it  calms  pain,  cleanses  the  wound,  and  excites  a 
rapid  growth  of  healthy  granulations.  It  is  also  applicable  to  wounds 
of  any  kind  and  in  any  situation;  and  it  may  be  combined,  according 
to  the  indications,  with  chloride  of  lime,  tannin,  alum,  calomel, 
quinine,  etc.  The  powder  is  dusted  over  the  jiart  with  a  dredge. 
Talc  is  also,  Dr.  Gouyon  says,  an  excellent  styptic  in  cases  of  venous 
and  capillary  hemorrhage;  such  as  the  bleeding  from  leech-bites  and 
epis taxis.  —  Gaz.  Med.  de  Lyon. 

Vol.  it.— No.  8.  10 


146 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Nov., 


4.  Solution  of  Venice  Turpentine  as  a  Dressing  for  Woiinds. 

AUudinf?  to  M.  Nekton's  approval  of  camphorated  spirit  as  a  dress- 
ing for  wounds  in  his  wards,  M.  Kcrner  states  that  this  has  the  disad- 
vantage of  being  expensive  and  easily  evaporable     He  states  that 
being  surgeon  to  the  Messrs.  Dolfuss"  factories  at  Mulhouse,  where 
from  3  ()()()  to  4,000  work  people  are  employed,  he  has  ample  experience 
in  treating  all  kinds  of  wounds,  and  finds  the  following  a  most  valuable 
as  weil  13S  a  cheap  application:  Venice  turpentine  21bs.  8  oz  troy;  bi- 
carbonate of  soda,  G>o  drachms;  water,  18  pints  Imperial     This  is  to 
digest  in  a  bath  for  six  days,  at  a  temperature  not  higher  than  to   O  , 
and  then  filter.    It  constitutes  a  highly  solul)le  turpentine  soap,  which 
is  very  cheap,  and  evaporates  slowly.    The  cicatrization  of  even  very 
large  wounds  under  its  use  is  wonderfully  rapid,  the  secretion  of  pus 
being  very  slight,  while  there  is  an  entire  absence  of  f.etidity.  A 
compress,  cons^ting  of  eight  folds  of  linen,  well  soaked  m  the  solu- 
tion is  applied  ovei- the  whole  bn^adth  of  surface,  and  left  on  (covered 
with  oiled  silk)  for  twelve  hours,  being  moistened  by  means  ot  a 
sponge  with  some  of  the  solution  every  four  or  five  hours  ^^Jl^^la- 
tions  speedily  shoot  forth,  re.iuiring  to  be  touched  with  mtra^te  oi 
silver;  but  the  discharge  is  <iuite  insignificant,  so  that  none  of  the 
encumbering  apparatus  required  when  cerates  are  used  need  be  re- 
sorted to.    When  the  wound  is  accompanied  with  crushing  or  contu- 
sion leading  to  the  fear  of  much  inflammation,  it  should  be  exposed 
to  a 'jet  of  cold  water  for  some  days  before  employing  the  turpentine. 
—Bull,  de  Therapeutique. 

5.  Dcatfjer  of  Suhcutaneovs  Injections. 

'  Professor  Nussbaum,  of  Munich,  has  just  published  an  interesting 
account  of  an  accident  which  happened  to  himself,  feufiering  Irom 
neuralgia,  he  had  injected  morphia  under  his  own  skin  more  than 
2000  thnes-sometimes  to  the  extent  of  five  grains  of  morphia  m 
twenty- four  hours.  Two  months  ago  he  injected  two  grains  ot  acetate 
of  morphia  dissolved  in  fifteen  minims  ot  watei%  and  accidently  sent 
°t  dh-ectinto  a  subcutaneous  vein  instead  of  into  the  cellular  tissue.  He 
gives  a  graphic  account  of  his  dangerous  position  for  two  l^o^^^-^' ^ 
Kh  the  efiect  passed  off.  He  has  seen  similar  effects  in  a  smaller 
Jeoxee  in  two  of  his  patients,  and  the  practica  lessons  are,  that  as  i 
may  be  impossible  to  avoid  veins  at  all  times,  and  one  may  be  punctured 
unJwares,^subcutaneous  injection  should  always  be  done  rer.y  . to 
The  effec  s  are  so  instantaneous  that  the  syringe  can  be  stopped  a  the 
first  sign  of  danger,  and  some  of  the  injected  fluid  mixed  with  blood 
may  even  be  sucked  out  again  by  the  syringe.  It  is  very  i;emarkable 
how  the  efiects  of  the  same  dose  of  the  same  substance  difler  when 
directly  injected  into  a  vein  and  mixed  with  the  venous  blood,  and 
when  they  filter  into  the  blood  from  the  cellular  tissue  through  the 
unbroken  coats  of  the  vessels.— i)/«//ca^  Times  &  ircuetle. 

6  A  Few  Words  Against  the  Habitual  Use  of  Purgatives.  By 
C  B  E.VDCLIFFE,  M.D.,  r.R.C.P.,  Physician  to  the  \\  e.tminster 
Hospital,  and  to  the  National  Hospital  for  the  Paralyzed  and  Epi- 
leptic. 

Not  a  fe  .v  persons  still  look  upon  purgatives  as  necessarie?  of  life. 
Thev  seem  to  thiuk  that  their  bowels  would  never  act  without  the  cais- 
tomary  pm  or  potion.    They  stare  incredulously  if  they  are  told  that 


18G5.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


147 


constipation  is  the  natural  result  of  some  error  of  diet.  They  scout 
the  idea  that  in  some  cases  the  bowels  are  habitually  constipated  with 
advantage  and  not  wit^  disadvantage.  Nor  can  it  be  denied  that  the 
conduct  of  not  a  few  medical  men  is  such  as  to  encourge  rather  than 
to  conti-adict  these  notions. 

I  object  to  the  habitual  use  of  purgatives  on  two  grounds  chiefly. 
In  the  first  place,  I  object  because  the  object  in  view  may  be  attained 
by  a  more  ready  and  rational  way;  that  is,  simply  by  regulating  the 
diet  in  a  jjroper  manner.  In  the  second  place,  I  object  because  the 
very  cases  in  which  purgatives  are  habitually  resorted  to  are  very  often 
those  in  which  the  constipation  which  it  is  intended  to  remove  is  a 
state  to  be  encourged,  rather  than  a  state  to  be  corrected.  To  show 
fully  why  I  make  these  objections,  is  not  possible  in  the  few 
minutes  at  my  disposal.  I  can  only  hint  at  the  reasons  which  have 
influenced  me;  and  thi.s,  in  fact,  is  all  I  propose  to  do. 

1.  Man  is  an  omnivorous  animal.  Originally  it  was  not  so.  Then, 
"  every  herb  bearing  seed  which  is  upon  the  face  of  all  the  earth,  and 
every  tree  in  which  is  a  fruit  of  a  tree  yielding  seed,"  was  ordained 
for  meat.  Now  it  is  very  different;  and  it  is  to  the  butcher,  rather 
than  to  the  gardener,  that  man  looks  for  his  daily  food.  And  what  must 
be  the  consequences,  so  far  as  the  bowels  are  concerned,  of  so  doing  ? 
What  must  be  the  consequences,  in  this  respect,  of  taking  too  mvich 
animal  food,  and  too  little  green  meat  ?  These  are  questions,  to 
answer  which  it  is  not  necessary  to  look  further  than  to  the  illustra- 
tion supplied  in  the  case  of  an  herbivorous  animal,  and  in  that  of  a 
carnivorous  animal — the  cow,  for  example,  and  the  lion.  The  cow 
grazes  on  grass,  and  has  a  semifluid  motion  every  hour  or  thereabouts. 
She  is,  so  to  speak,  in  a  state  of  habitual  diarrhcea;  and  this  is  her 
natural  state.  The  lion,  on  the  other  hand,  gorges  on  flesh.  He  eats 
seldom,  and  his  bowels  are  relieved  of  a  mass  of  little  more  than  dry 
earthly  matter  once  a  fortnight,  or  even  not  oftener  than  once  a 
month.  He  is  in  a  state  of  very  decided  constipation;  and  this  state 
is  natural  to  him.  As,  therefore,  the  food  of  man  departs  from  that  of 
the  lion,  and  inclines  to  that  of  the  cow,  it  may  be  expected  that  his 
bowels  will  act  more  and  more  after  the  fashion  of  the  cow;  and  so,  in 
fact,  it  is.  Supply  green  meat — salad,  fruit,  and  the  rest — and  the 
bowels,  as  a  rule,  will  act  well  enough:  withhold  it,  and  constipation 
will  be  the  result.  This  is  my  experience  in  this  matter.  At  any  rate, 
this  much  I  may  say,  that  I  have  been  always  able  to  disjjense  with 
the  habitual  use  of  purgatives  by  attending  to  this  point,  and  to  that 
which  I  have  next  to  consider. 

In  regulating  the  bowels,  it  also  seems  to  be  important  to  bear  in 
mind  the  composition  of  the  natural  food  provided  for  the  state  of  in- 
fancy. This  food,  of  course,  is  milk.  Now  milk,  especially  human 
milk,  contains  a  large  quantity  of  cream — contains  a  large  quantity  of 
that  ingredient  which  is  carefully  extracted  in  too  many  instances  from 
the  milk  which  too  often  has  to  do  duty  for  mother's  milk.  And 
what  is  it  which  this  cream  is  intended  to  do  ?  Part  of  it,  it  is 
probable,  has  to  be  burnt  in  the  respiration,  in  order  to  keep  up  the 
heat  of  the  body.  Part  of  it,  it  is  possible,  has  to  act  as  food  for 
nerve-tissue,  by  supplying  some  of  the  oily  matter  which  is  an  essen- 
tial ingredient  in  this  tissue.  And  the  rest — what  of  it  V  It  is  possible 
— nay,  it  is  probable — nay,  rather,  it  is  certain — that  it  will  further 
the  secretion  of  bile;  for  it  is  one  of  the  functions  of  this  secretion  to 
dispose  of  unused-up  "respiratory  fuel."  Hence,  to  feed  an  infant 
on  skimmed  milk  may  lead  of  necessity,  as  one  of  its  consequences, 


148 


PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Nov., 


to  constipation,  by  stinting  the  natural  outflow  of  bile  into  the  bowel; 
and  hence  the  natural  remedy  for  the  constipation  thus  arising  may 
be,  not  "  to  seek  to  regulate  the  secretions,'!*  but  simply  to  follow 
Nature's  lead,  and  restore  to  the  milk  used  as  food  what  had  been 
robbed  from  it — namely,  its  cream.  Hurely,  in  theory,  it  is  better  to 
be  secundum  nalurciin  than  scciaiiliim  artein;  and  most  assuredly  all  I 
have  seen  in  practice  has  taught  me  to  prefer  cream  to  gray  powder, 
or  any  other  abomination  of  the  kind,  as  a  means  of  correcting  the 
constipation  of  infants.  Indeed,  my  own  experience  amounts  to  this: 
that  sickly,  spoon-fed  infants  have  improved  in  health,  and  ceased  at 
the  same  time  to  be  sources  of  solicitude  as  to  the  condition  of  their 
bowels,  as  soon  as  care  was  taken  that  the  milk  used  in  their  food  was 
not  deficient  in  the  natural  amount  of  cream.  And,  if  this  be  so  with 
infants,  why  should  it  be  otherwise  with  persons  of  maturer  age  ?  If 
this  be  so  with  cream,  why  should  it  not  be  so  also  with  butter,  fat, 
and  oily  matters  of  other  kinds  ?  In  theory,  I  can  find  no  reason  why  it 
should  not  be  so;  and  still  less  can  I  find  a  reason  in  practice.  Prac- 
tically, indeed,  I  can  say  this  without  hesitation :  that  the  result  of 
insisting  upon  the  addition  of  a  due  amount  of  oily  and  fatty  matter 
to  the  food,  together  with  (at  jiroper  ages)  a  due  amount  of  green 
meat,  has  been  to  enable  me  to  dispense,  for  the  last  dozen  years  at 
least,  with  the  habitual  use  cf  purgatives  in  practice. 

In  i^roperly  regulating  the  bowels,  there  are,  of  course,  many  other 
things  to  be  attended  to;  as,  for  example,  the  proportion  of  bread  and 
potatoes  in  the  food;  the  question  of  brown  bread  v.  white,  and  coifee 
V.  tea;  of  alcoholic  drinks  v.  water;  of  exercise  v.  rest;  and  so  on. 
But  all  these,  as  I  believe,  are  of  minor  moment  only,  when  compared 
with  the  two  questions  which  have  been  considered.  Indeed,  I  have 
no  hesitation  in  saying  this  broadly,  as  the  result  of  an  exi:)erience 
extending  over  at  least  a  dozen  years,  that  in  any  ordinary  case, 
without  making  any  other  change,  the  habitual  use  of  purgatives  may 
be  dispensed  with  hy  taking  care  that  the  diet  contain  a  sufficient 
amount  of  oily  and  fatty  matter,  together  with  a  sufficiency  of  green 
meat  in  those  cases  in  which  green  meat  is  not  contra-indicated  by  age 
or  by  some  other  circumstance;  and  that  in  every  case  the  result  is 
most  unmistakably  beneficial. 

2.  A  sentence  or  two  will  serve  to  say  what  can  now  be  said  in  justi- 
fication of  my  second  objection  to  the  habitual  use  of  purgatives.  I 
objected  on  the  ground  that,  the  very  eases  in  which  purgatives  are 
habitually  resorted  to  are  vei-y  often  those  in  which  the  constipation 
which  it  is  intended  to  remove  is  a  state  to  be  encourged,  rather  than 
a  state  to  be  removed.  The  cases  I  had  in  my  mind  in  making  this 
statement  are  cases  of  old  age,  and  of  debility  generally — cases  in 
which,  most  assuredly,  constij^ation  must  be  looked  upon  as  the  rule, 
rather  than  as  the  exce^jtion.  Now,  in  cases  of  this  kind,  certain 
things  may  be  assumed.  It  may  be  assumed,  that  the  digestive 
powers  are  feeble.  It  may  be  assumed,  that  debility  of  digestion  im- 
plies inability  to  deal  with  the  more  innutritions  kinds  of  food,  green 
meat  especially — with  those  kinds  of  food,  that  is  to  say,  which  are 
favorable  to  frequent  stools.  It  may  be  assumed,  also,  that  debility 
of  digestion  implies  slowness  of  digestion ;  and  that  one  efi'ect  of  slow- 
ness of  digestion  is  to  lessen  the  number  of  stools.  It  may  be  assumed, 
in  fact,  that  constipation,  within  certain  limits,  ought  to  be  the  rule  in 
the  cases  in  question,  if  the  diet  be  of  the  kind  best  suited  to  the 
wants  of  the  system;  and  that  it  is  simply  foolish  to  attempt  to  bring 
about  a  contrary  state  of  things.    In  the  cases  in  question,  indeed, 


1865.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


149 


to  cause  the  bowels  to  act  every  day,  after  tlie  manner  of  many,  is,  as 
it  seems  to  me,  to  do  what  must  have  the  effect  of  starving  the  system, 
by  removing  the  food  from  the  bowel  before  digestion  and  absorption 
have  had  time  to  do  their  work — is  to  victimize  the  patient  as  Sancho 
Paiiza  was  victimized  by  his  pretended  jahysician  at  jBarataria;  that  is, 
to  take  away  the  dish  before  time  had  been  given  to  i")artake  of  it.  At 
any  rate,  be  these  reasonings  right  or  wrong,  of  this  I  am  sure  in 
practice — that  good  results  from  disregarding  in  a  great  degree  the 
habitually  constipated  condition  of  the  bowels  in  many  cases  of  de- 
bility, of  old  age  esj^ecially;  and  that  to  attempt  to  remove  constipation 
by  the  habitual  use  of  purgatives  in  these  cases,  is  only  to  increase 
debility  and  irritability. — British  3Iedical  Journal. 

7.  A  New  Poison. 

A  new  poison  has  been  examined  and  reported  on  by  M.  Pelikan  of 
St.  Petersburg.  The  plant  which  produces  it  comes  from  the  Gaboon, 
and  is  used  by  the  natives  of  that  locality  for  poisoning  arrows.  It 
belongs  to  the  natural  order  Apori/iince(F,  and  produces  its  injurious 
action  almost  exclusively  upon  the  heart.  M.  Pelikan's  experiments 
were  made  npou  the  common  frog,  and  they  have  led  him  to  the  fol- 
lowing conclusions: 

"1.  The  poison  produces  at  first  an  increased  action  of  the  heart. 
2.  After  a  while  the  pulse  decreases  in  frequency,  and  the  heart  soon 
entirely  ceases  to  beat.  3.  The  cessation  of  action  is  not  regularly 
progressive,  i.  When  the  ordinary  action  of  the  heart  has  been  com- 
pletely arrested,  the  ventricle  still  exhibits  peculiar  movements,  which 
appear  to  be  peristaltic.  5.  When  the  ventricle  has  completely  ceased 
to  act,  and  is  strongly  contracted,  and  em^jty,  the  auricles,  though  full 
of  blood,  continue  to  conti-act.  6.  Finally,  the  paralysis  of  the  heart 
has  nothing  in  common  witli  cadaveric  rigidity.  When  once  paralyzed, 
this  organ  does  not  respond  to  any  stimuli,  whether  mechanical,  chem- 
ical, or  electrical,  applied  either  directly  or  to  the  nerves." — Mudical 
Press. 

With  reference  to  the  subject  of  Prof.  Pelikan's  researches,  we  would 
state  that  several  years  ago  Drs.  William  A.  Hammond  and  S.  Weir 
Mitchell  iJublished  the  results  of  their  investigations  relative  to  a  new 
poison,  corroval,  the  effects  of  which  upon  the  heart  were  identical 
with  those  ascribed  by  Prof.  Pelikan  to  his  i^oison.  The  papers,  two 
in  number,  were  entitled:  "Experimental  Eesearches  Eelative  to  Cor- 
roval and  Vao,  etc." — American  Journal  of  the  Medical  Sciences,  July, 
1859.  "On  the  Physical  and  Chemical  Characteristics  of  Corroval 
and  Vao,  etc." — Proceedings  of  the  Academy  af  Natural  Sciences  of 
Philadelphia,  Biological  Department,  p.  4,  18(30.  Both  these  papers 
are  also  contained  in  Dr.  Hammond's  Physiological  Akmoirs.  It  is 
very  probable  that  the  active  principle  of  the  poison  studied  by  Prof. 
Pelikan  is  identical  with  Corrovalia,  the  alkaloid  extracted  by  Drs. 
Hammond  and  Mitchell  from  corroval. 


150 


PEOGEESS  OF  THE  MEDICAL  SCIENCES. 


[Nov., 


II.— PATHOLOGY  AND  PRACTICE  OF  MEDICINE. 

1.  On  the  Treatment  of  Fever. 

"  With  respect  to  the  treatment  of  fever,"  observes  Dr.  Wilks,  "I 
adhere  to  the  old  i^ractice  of  the  hospital— that  which  was  laid  down 
by  Drs.  Bright,  Addison,  and  Barlow,  in  their  lectures,  and  which 
tliey  adopted  for  so  many  years  with  success.  The  teaching  of  these 
professors  was  to  the  effect  that  a  large  number  of  cases  ran  their 
course  without  any  other  treatment  than  careful  watching  and  feeding; 
that  they  required  no  other  medicine  than  a  simple  saline;  but  that 
some  needed  a  stimulant  during  the  progress  of  the  disease,  and 
others  required  it  from  the  commencement.  The  question,  therefore, 
with  regard  to  the  administration  of  stimulus,  was  a-licn  to  give  it,  and 
in  what  quantity.  At  the  present  time  there  are  advocates  for  a  uni- 
versal method  in  favor  of  alcohol  in  all  cases  of  fever,  just  as  there 
are  those  who  indiscriminately  administer  ammonia  in  scarlet  fever, 
and  who,  when  failing  to  prove  its  value  in  all  cases,  fall  back  ujion 
the  explanation  that  if  alcohol  or  ammonia  be  of  real  service  in  a  bad 
case  of  fever  or  scarlatina,  and  if  these  remedies  do  no  harm  in  the 
milder  forms,  it  is  a  good  rule  to  administer  them  universally.  Such 
a  method  is  not  only  unscientific,  but  I  believe  positively  injurious; 
for  in  many  cases  of  tyijhus  fever  in  young  peojile,  where  the  bi'ain 
has  been  involved,  I  have  a  very  strong  opinion  that  the  brandy  which 
I  have  seen  given  in  such  cases  has  been  positively  hurtful.  In  my 
intercourse  with  medical  men,  I  judge  that  very  many  are  scarcely 
alive  to  the  fact  that  typhus  fever  is  very  rarely  fatal  in  young  per- 
sons— the  prognosis,  indeed,  only  becoming  serious  as  years  are  added 
to  the  age  of  the  patient — and,  therefore,  that  they  are  too  apt  to 
attribute  recovery  to  their  remedies.  Young  persons  always  do  well 
if  left  alone.  Of  this  fact  I  could  now  quote  a  large  number  of  cases 
in  proof ;  and,  on  the  contrary,  the  few  instances  which  I  have  seen 
end  fatally  have  been  those  in  which  a  large  amount  of  stimulus  was 
given  from  the  commencement  of  the  disease;  and,  what  perhaps  is 
even  more  to  the  jjoint,  the  withdrawal  of  stimulus  in  some  cases 
where  it  was  adopted  as  the  method  of  treatment,  has  been  attended 
with  the  most  decided  advantage. 

"Although  the  subject  of  fever  and  its  treatment  may  appear  ex- 
hausted, yet  this  difference  of  oj^inion  respecting  the  use  of  alcohol 
shows  that  this  therapeutic  struggle  must  continue  for  some  time 
longer:  for  whilst  we  are  witnessing  the  free  use  of  stimulants  in 
fever,  we  are  reading  that  it  was  Dr.  Graves's  plan  to  administer  anti- 
mony in  the  same  disease.  When  deliberating  on  the  merits  of  .such 
contradictory  treatment,  many  escape  the  dilemma  by  believing  that 
different  diseases  have  been  the  subject  of  treatment,  and  that  fever 
has  changed  its  type;  they  assume,  without  even  a  skeptical  thought 
passing  throiigh  their  minds,  tliat  the  favorable  issue  was  due  to  the 
remedy,  and  therefore  their  conclusion  is  a  logical  one.  Such  persons, 
however,  have  no  right  to  frame  this  or  any  other  opinion  as  to  treat- 
ment Txnle.ss  they  are  conversant  with  the  natural  history  of  the 
disease  ;  for,  did  they  quite  realize  to  themselves  the  fact  that  in 
young  2)ersons  typhus  fever  is  rarely  fatal,  they  miglit  with  great 
advantage  state  the  argument  in  another  form;  as,  for  instance.  Will 
a  few  doses  of  antimony,  or  a  few  daily  ounces  of  wine,  or  the  ab- 
straction of  a  few  ounces  of  blood,  be  sufficient  to  kill  a  patient 
suffering  from  a  disease  the  tendency  of  which  is  to  subside  spon- 
taneously in  the  course  of  a  few  days  ?    Surely,  too,  every  medical 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


151 


man  must  have  seen  cases,  either  under  his  ovm  charge  or  his  neigh- 
bor's, where,  from  a  mistaken  diagnosis  of  the  nature  of  the  ease,  a 
remedy  has  been  given  which,  above  all  others,  he  would  have  dis- 
countenanced had  his  opinion  been  otherwise.  He  must,  for  instance, 
have  seen  several  grains  of  opium  administered  daily  on  the  supposi- 
tion that  the  case  was  one  of  delirium  tremens  instead  of  fever,  and 
yet  the  patient  has  done  well.  If  he  saw  many  such  in.stances,  he 
might  consider  that  he  had  good  reason  to  believe  in  another  change 
of  type.  Without,  therefore,  denying  that  fever  may  annually  change 
in  ciaaracter  as  to  some  minor  features,  yet  I  believe  that  the  argu- 
ment of  its  great  alteration,  founded  upon  the  administration  of 
remedies,  to  be  a  most  fallacious  one. 

"  I  would  not  wish  to  dictate  rules  of  treatment  to  any  of  my 
medical  brethren;  but  my  own  opinion  is  that  expressed  in  the  first 
few  sentences  of  these  observations.  I  believe  that  support  and  a 
moderate  amount  of  wine  is  the  best  treatment ;  but  I  assert  that 
alcohol  is  not  an  antagonist  to  the  fever,  which  runs  its  course  in 
spite  of  the  administration  of  the  stimulant.  I  would  not  say  that  in 
many  cases  of  typhus  in  young  people  a  little  wine  may  not  be  useful; 
but  the  fact  still  remains,  which  can  not  be  gainsaid,  that  such  cases 
would  do  well  without  any  stimulant  whatever.  When  the  ground  is 
thus  cleared,  we  shall  know  better  what  we  are  doing.  I  might  men- 
tion that  the  only  two  cases  which  I  have  seen  fatal  of  late  have  been 
those  of  two  students,  to  whom  a  large  amount  of  stimulant  was 
given,  and  who  had  the  care  of  the  most  assiduous  nurses  both  night 
and  day.  In  one  of  these  there  were  constant  convulsive  movements 
during  the  last  five  days  of  life,  with  coma  vigil,  and  other  symptoms 
resembling  those  in  which  the  late  Dr.  Graves  would  have  adminis- 
tered antimony.  In  this  case  there  was  no  albumen  in  the  urine,  nor 
in  another,  which  recovered,  where  convulsions  were  most  violent. 
Albumen  has,  however,  been  very  frequently  present  in  other  in- 
stances.—(iancei.)    Half-ijearly  Abstract  of  the  Medical  Sciences,  etc. 


2,  On  the  Treatment  of  Malarious  Fever  by  the  Subcutaneous  Injection 
of  Quinine. 

Mr.  Moore  states  that  he  has  lately  employed,  with  great  success, 
the  hypodermic  method  of  administering  quinine  in  the  treatment  of 
malarious  fever. 

"I  use,"  he  says,  "  the  strongest  solution  of  quinine  which  can  be 
prepared,  viz. ,  thirty  grains  of  quinine,  ten  or  twelve  drops  of  sul- 
jjhuric  acid,  and  half  an  ounce  of  water.  Of  this,  previously  strained, 
I  inject  from  half  a  drachm  to  a  drachm,  the  former  quantity  con- 
taining somewhat  less  than  four  grains  of  the  active  agent.  With 
the  exception  of  a  little  sulphate  of  soda,  if  the  bowels  are  confined, 
I  have  used  no  other  remedies  in  complicated  cases  of  any  type  of 
malarious  fever.  When  the  spleen  is  enlarged,  or  a  leucocythemic 
condition  manifest,  I  prescribe,  as  an  additional  curative  agent,  one 
or  other  of  the  preparations  of  iron. 

"I  generally  inject  beneath  the  skin  of  the  outer  belly  of  the 
triceps,  and  sometimes  over  the  deltoid.  The  operation,  however,  is 
equally  effective  on  the  thigh  or  calf;  and  in  cases  of  large  spleen,  the 
action  of  the  remedy  appears  intensified  by  injection  over  that  organ. 
I  use  a  small  glass  syringe  furnished  with  a  silver  point,  and  introduce 
the  latter  beneath  the  integument  for  half  an  inch  or  less.    The  pain 


152 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Nov., 


is  not  more  than  the  prick  of  a  needle,  and  indeed  is  often  less  ob- 
jected to  than  the  bitter  taste  of  quinine.  I  have  never  oljserved  the 
slightest  irritation  following  tlie  oiieration,  excepting  when  ju  rformed 
■with  a  small  trocar  and  common  glass  syrings;  and  when  <iuiniue  has 
been  nsed  in  susjietiaion,  and  not  in  Holidion.  1  therefore  insist  on  the 
use  of  a  proper  instrument,  and  on  perfect  solution  of  the  alkaloid. 
If  the  quinine  is  not  invisible  the  jireparation  is  unfit  for  use;  the 
syringe  l^ecomes  clogged,  and  the  areolar  tissue  does  not  ap})ear  able 
to  absorb  the  solid  material,  which,  hence,  creates  irritation. 

"  The  best  time  to  inject  is  shortly  before  the  expected  cold  fit ; 
but  it  may  be  done  during  the  first  stage  with  the  effect  of  lessening 
and  occasionally  stopping  the  2)aroxysm.  When  an  accession  is  ex- 
pected during  the  day,  injection  in  the  morning  will,  almost  invariably, 
prevent  the  attack. 

"  In  cases  of  remittent  I  have  endeavored  to  inject  during  the 
remission  ;  ))ut  do  not  wait  for  this  period.  In  severe  cases,  the  in- 
jection should  be  repeated  at  intervals  of  four,  six,  or  eight  hours. 

"I  believe  four  or  five  grains  of  quinine,  injected  beneath  the 
integument,  are  equal  in  their  effects  to  five  or  six  times  that  amount 
taken  into  the  stomach  ;  also  that  the  results  are  more  certain,  and 
that  relapsing  attacks  will  be  found  to  be  less  common  ;  while  the 
economy  of  the  treatment  is  self-evident. 

"I  have  now  injected  a  considerable  number  of  cases  in  the 
European  General  Hospital,  Bombay,  and  elsewhere,  and  find  the 
number  of  those  who  lose  their  fever  after  the  first  injection  is  \\\)- 
wards  of  (30  jjer  cent,  of  all  classes  of  intermittents.  Some  cases, 
however,  require  two,  three,  or  four  injections,  and  remittent  attacks 
a  larger  number." — {Indian  Annals  of  Medical  Science.)  Half-yearly 
Abstract  of  the  Medical  Sciences,  etc. 

3.  On  a  New  Lesion  of  the  Brain  in  General  Paralysis. 

Dr.  Baillarger,  on  examining  the  brain  of  insane  individuals  who 

had  suffered  from  paralysis,  noticed  long  ago  that,  in  some  cases, 
when  the  gray  substance  of  the  anterior  lobes,  after  the  removal  of 
their  membranes,  was  scraped  with  the  back  of  a  scaljjel,  prolonga- 
tions or  ridges  of  the  white  matter  stopjied  the  knife,  and  were  cut 
away  with  some  dilBculty.  The  white  matter  could  be  thus  exposed, 
and  looked  of  a  firm  consistency  and  somewhat  yellowish.  Some  of 
its  iDrolongations,  elastic  and  tough,  resembled  the  e2>iglottis  in  color 
and  api^earance.  In  other  words,  a  process  of  induration  seemed  to 
have  gone  on  in  the  most  superficial  layers  of  the  medullary  substance, 
whilst  the  deeper  ones  retained  their  normal  consistency. 

M.  Regnard  endeavored  to  ascertain  whether  this  lesion  was  con- 
stant, or  at  least  frequent,  and  whether,  in  all  eases,  it  was  jrossible  to 
make  out  its  presence  or  absence.  He  made,  for  this  purpose,  twelve 
post-mortem  examinations:  in  eight,  he  found  the  lesion  well  marked; 
in  three,  it  was  indistinct  and  incomplete;  in  one,  it  was  totally  ab- 
sent. In  five  of  the  eight  cases  in  which  the  lesion  was  well  marked, 
the  disease  had  not  lasted  more  than  nine  months — a  fact  which  shows 
that  this  lesion  exists  in  the  first  stage  of  general  paralysis.  In  20 
of  the  same  class  of  cases,  the  white  matter  was  softened  beneath  the 
suijerficial  layers  that  were  indurated.  The  obvious  conclusion  is, 
that  the  lesion  is  entirely  resti-icted  to  the  superficial  layer  of  the 
white  matter.  In  the  cases  comprised  in  the  second  category,  there 
was  very  evident  softening  of  the  white  matter;  whilst  in  the  single 


1865.]  PROGRESS  OP  THE  MEDICAL  SCIENCES. 


153 


case  of  the  tliircT  series,  there  was  not  softening  only,  but  actual 
diiflueuce  of  the  white  matter.  It  would  aj^pear,  therefore,  that  the 
lesion  is  all  the  more  marked,  in  proportion  as  the  brain  substance  is 
of  diminished  consistency.  All  the  i^atients  whose  brains  were  ex- 
amined had,  during  life,  suffered  from  embarrassment  of  si^eech,  and 
M.  Eegnard  draws  attention  to  the  fact,  long  ago  i^ointcd  out  by 
Bouillaud,  that  the  anterior  lobes  were  diseased;  and  also  that  the 
third  left  frontal  convolution  was,  in  all  the  cases,  as  much  dis- 
organized as  the  rest. — (Aiinales  Medico- Psijcholofjiques.)  Hcdf-ye.arly 
Abstract  of  the  Medical  Sciences,  etc. 


i.  On  Scli'7-nsis  of  the  Lateral  Columns  of  the  Spinal  Cord,  in  an  Hys- 
terical Woman  whose  four  Limbs  had,  during  Life,  been  permanently 
contracted. 

This  case  formed  the  subject  of  a  paper  read  before  the  Society 
Me'dicale  des  Hojjitaux,  of  Paris,  25th  January,  1865.  The  author 
began  by  stating  that,  uj)  to  the  jjresent  time,  the  alteration  known 
by  the  name  of  sclerosis,  or  gray  degeneration  of  the  spinal  cord, 
had  been  only  studied  in  cases  of  progressive  locomotor  ataxy,  and  in 
that  complaint  the  lesion  is  almost  exclusively  limited  to  the  posterior 
columns  of  the  cord,  leaving  the  anterior  and  lateral  columns  in  a 
nearly  normal  state.  In  the  present  case,  on  the  contrary,  the  pos- 
terior and  anterior  columns  were  healthy,  whilst  the  lateral  columns, 
on  both  sides,  for  a  great  i^ortiou  of  their  thickness  and  throughovit 
their  length,  from  the  medulla  oblongata  as  far  as  the  lumbar  swelling, 
were  the  seat  of  the  gray  degeneration.  Several  of  the  anterior  roots 
were  also  atrophied,  biit  the  jjosterior  roots  were  all  normal.  There 
was  no  trace  of  spinal  meningitis.  The  characters  of  the  sclerosis 
were  very  distinct,  the  columns  had  a  grayish,  semi-transpai'ent,  gela- 
tiniform  look  ;  their  consistency  was  greater  than  usual ;  their  sub- 
stance was  infiltrated  Avith  a  transiJaront  amorphous  or  fibrillary 
substance,  throiigh  which  were  scattered  nuclei  of  connective  tissue 
and  corjjora  amylacea.  Lastly,  there  was  atrophy  of  the  nerve  tubes, 
which  i^reseuted  a  series  of  dilatations  and  constrictions.  The  gray 
matter  was  healthy.  The  nerve  cells  were  normal,  as  in  the  cases  of 
locomotor  ataxy,  j^reviously  examined  by  Drs.  Vulpian  and  Charcot. 

Sclerosis  of  the  lateral  columns  has  been  recorded  several  times, 
among  others,  by  Dr.  Tiirck,  (Academy  of  Sciences  of  Vienna,  185G. ) 
Dr.  Charcot  once  met  with  it  in  a  case,  the  history  of  which  he  could 
never  learn.  This  lesion,  therefore,  is  not  altogether  rare,  and  more 
carefully  made  iiost-mortem  examinations  will,  doubtless,  multiply 
instances  of  this  new  pathological  species.  Up  to  this  time,  the  cases 
on  record  have  been  chiefly  deticient  in  accurate  clinical  observation. 
The  present  case  of  Dr.  Charcot's,  however,  is  less  deficient  than  the 
rest  in  this  respect. 

The  patient  had,  from  the  age  of  14,  j^resented  the  most  charac- 
teristic symptoms  of  convulsive  hysteria.  Later,  the  convulsive  fits 
became  less  fre(pient,  and  were  replaced  by  permanent  motor  dis- 
orders. Thus  at  the  age  of  ;W,  after  an  hysterical  fit,  she  suffered 
from  contractiou  of  the  left  arm  and  leg,  which  lasted  a  fortnight, 
and  then  disappeared  all  of  a  sudden.  A  year  afterwards  the  same 
limbs  became  contracted,  and,  after  a  time,  the  right  limbs  were 
similarly  affected.  For  two  years  she  Avas  obliged  to  remain  almost 
completely  motionless,  with  scarcely  a  few  short  intervals  of  inter- 


154 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Nov., 


mission.  At  the  end  of  that  time,  a  marked  imiirovement  set  in 
spontaneously,  and  the  patient  was  able  to  walk  about  and  attend  to 
her  house.  In  1855,  however,  another  violent  fit  brought  on  con- 
traction again  of  all  the  limbs  and  the  muscles  of  the  trunk.  From 
that  time  the  condition  remained  persistently  until  18()i,  when  an 
inter-ciirrent  aifection  carried  her  off.  Her  intellect  was  never  im- 
paired, up  to  the  very  last. — ((ktzette  Hi-hd.  de  Med.  et  de  Chir.)  Half- 
y  early  Abstract  of  the  Medical  Sciences,  etc. 

5.  Double  Amaurosis,    Cure  coincident  with  the  Expulsion  of  a  7\pnia. 

A  mason,  28  years  old,  was  treated  in  18G1  for  tapeworm.  Being 
subsequently  exposed,  whilst  working  at  his  trade,  to  the  rays  of  a  hot 
sun,  he  became  affected  with  violent  headache,  dimness  of  vision,  and 
eventually,  in  the  space  of  eight  days,  lost  his  sight  altogether.  At 
his  entrance  into  hosjiital  blindness  was  complete,  and  there  was 
considerable  pain  in  the  eyes.  The  inilse  was  slow  but  regular,  and 
there  was  some  stiffness  of  the  neck.  Energetic  antiphlogistic  and 
revulsive  treatment,  together  with  contimied  mercurial  friction  to  the 
extent  of  producing  in-ofuse  salivation,  led,  in  fifteen  days,  to  a  very 
decided  improvement  in  the  vi-sion;  but  no  further  improvement  took 
place.  On  the  contrary,  symptoms  of  cerebral  congestion  ensued,  and 
two  mouths  after  the  appearance  of  the  disease  the  patient  was  seized 
with  vertigo  and  contractions  of  the  limbs.  The  pupils  became  fixed 
and  dilated,  and  there  was  acute  delirium. 

The  wife  of  the  2>atient  having  informed  the  attending  phy.sician 
that  her  husband  had  had  similar  attacks  before,  which  genei-ally 
lasted  several  days,  led  him  to  the  conclusion  that  the  cause  was, 
probably,  of  helminthic  origin.  He  accordingly  prescribed  pome- 
granate rind,  and  three  hours  subsequently  numerous  fragments  of 
tjenia  were  expelled.  The  following  morning  the  medicine  was  again 
administered,  and  a  tronia,  five  metres  in  length,  was  passed.  Ame- 
lioration of  the  general  symptoms  and  of  the  sight  at  once  took  place, 
and  the  latter  was  ultimately  completely  restored. — Ilecueil  de  Mem. 
de  Med.,  de  Chir.,  et  de  Pharm. 

6.  Etiology  of  General  Progressive  Paralysis. 

According  to  M.  Lagardelle,  hereditary  predisposition  exercises  a 
much  less  influence  in  causing  general  paralysis  than  in  giving  rise  to 
mental  alienation. 

General  paralysis  is  extremely  rare  before  the  25th  year,  whilst 
insanity  is  very  frequent  before  that  age. 

Women  are  more  subject  to  insanity,  and  less  disposed  to  general 
paralysis,  than  men. 

Individuals  of  sanguine  temperament,  and  of  strong  constitutions, 
seem  to  be  more  predisposed  than  others  to  inflammatory  affections  of 
the  brain. 

The  professions  which  furnish  the  largest  contingent  to  general 
paralysis,  are  those  in  the  exercise  of  which  a  habit  of  venereal 
excess,  and,  above  all,  of  the  inordinate  use  of  alcoholic  liquors,  is 
acquired. 

The  unmarried  and  those  who  belong  to  the  higher  classes  of  society 
are  predisposed  to  contract  this  disease. 

The  antecedent  diseases  which  predispose  to  general  paralysis  are 
those  which  are  most  often  followed  by  mental  alienation. 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


155 


Onanism  often  produces  imbecility  and  insanity,  whilst  in  a  large 
proportion  of  cases  general  paralysis  is  the  conseciuence  of  venereal 
excesses. 

Chronic  alcoholism  is  a  grave  and  frequent  cause  of  general 
paral.^sis,  whilst  it  exercises  no  influence  in  the  production  of  insanity. 

The  sujipression  of  some  natural  or  artificial  evacuation  is  rather  a 
cause  of  insanity  than  of  general  paralysis.  General  jjaralysis  ap- 
pears to  be  less  frequent  in  warm  than  in  cold  countries.  The 
autumn  and  spring  are  the  most  fatal  seasons  for  paralytics. 

Moral  causes  predispose  to  general  paralysis,  whilst  they  do  not  cause 
mental  alienation. — France  Mcdicale. 

The  statement  made  in  the  last  paragraph  is  certainly  incorrect. 
Every  physician  knows  the  reverse  to  be  the  case.  It  is,  probably,  a 
typographical  error. 

7.  Clinical  Remnrks  on  Cases  of  Aphflice  of  the  Mouth  and  Throat,  with 
Sickness  and  Diarrhaxi,  in  Adults. 

Dr.  Wilkes,  on  visiting  a  woman  in  his  wards  who  was  suffering  from 
an  ai3hthous  condition  of  mouth  and  throat,  with  sickness  and  diar- 
rluea,  stated  that  he  had  seen  during  the  last  few  months  several  cases 
which  were  so  much  alike  in  their  general  features,  that  he  considered 
them  deserving  of  a  distinct  name — or,  at  least  of  a  recognition  which 
should  i)lace  them  in  a  special  position  by  themselves.  He  was  anxious 
to  know  whether  such  oases  were  common  and  had  been  met  with  by 
other  medical  men.  The  malady  of  which  he  spoke  appeared  one  in 
which  the  whole  alimentary  canal  was  aifected,  as  far  as  one  could 
judge  of  the  throat  by  the  eye,  and  of  the  stomach  and  intestines  by 
the  sickness  and  diarrhtea.  Dr.  Wilkes  has  favored  us  with  the  fol- 
lowing notes  of  some  of  his  cases: 

One  of  the  earliest  and  most  severe  cases  which  I  witnessed  was  that 
of  a  young  man  in  consultation  with  Dr.  Waterworth,  of  the  New  Kent 
road.  I  found  the  patient  sitting  ujj  in  bed  dreadfully  ill,  making  in- 
effectual attemi^ts  either  to  hawk  up  tenacious  secretion  from  his 
throat  or  to  swallow  it,  It  was  evident  that  his  great  trouble  was  in 
his  throat;  this  was  with  difficulty  examined,  as  its  extreme  irritability 
produced  a  constant  dread  of  vomiting.  The  whole  mucous  membrane 
was  of  a  deep  red  color,  covered  with  white  specks,  patches  and  ten- 
acious mucus;  indeed,  it  was  in  a  state  which  might  be  called  follicular 
stomatitis,  or  even  thrush — using  the  term  in  its  most  general  sense. 
There  v/as  also  considerable  extension  of  the  malady  down  the  Viron- 
cliial  tubes,  as  evinced  by  the  rales  and  the  tenacious  expectoration. 
He  had  already  got  much  thinner,  and  his  jDulse  was  very  rapid  and 
feeble.  He  had  constant  sickness  and  diarrhoea.  It  should  be  said 
also  that  the  secretion  from  the  mouth  was  very  fretid.  If  an  exam- 
ination of  the  throat  had  not  shown  an  absence  of  false  membrane, 
the  case  in  other  respects  might  have  been  regarded  as  one  of  dijjhthe- 
ria,  judging  from  the  extreme  illness  of  the  patient.  Supporting 
remedies  were  evidently  indicated,  but  they  were  taken  with  much 
trouble.  He  remained  very  ill  for  about  two  weeks,  and  then  gradu- 
ally recovered,  but  has  scarcely  regained  his  strength  at  the  present 
time. 

Another  case  was  the  daughter  of  a  surgical  instrument  maker 
living  at  Lewisham.  She  was  suddenly  taken  ill  with  severe  febrile 
symptoms,  and  soon  became  aifected  with  a  very  bad  mouth  and 


156 


PROGRESS  OF  TUB  MEDICAL  SCIENCES.  [NoV., 


throat,  resembling  the  aphthous  conclition  seen  in  children.  She  also 
had  constant  sickness  and  frequent  diarrho-a;  the  skin  was  hot,  and 
the  pulse  very  quick  and  thready.  After  a  few  days  the  iirgent  symp- 
toms passed  off,  but  great  prostration  remained  for  a  long  time,  and 
the  disposition  to  sickness  and  diarrlicea  continued  for  some  weeks. 
She  is  now  in  a  very  precarious  state. 

A  third  case,  somewhat  resembling  these,  I  saw  with  Dr.  Butler,  of 
Woolwich;  the  onset  of  the  case  was  marked  by  delirium;  but 
here  the  bronchitis  was  more  severe,  and  the  patient  died  in  a  very 
few  days. 

Another  fatal  case,  with  similar  symptoms,  I  attended  at  Camber- 
well,  with  Mr.  Lacey,  but  here  the  young  man  had  been  very  dissi- 
pated, and  had  much  mental  depression,  so  that  his  previous  condition 
may  have  had  much  to  do  with  the  i-osult.  The  matter  expectorated 
in  this  case  was  so  offensive  that  the  house  was  scarcely  bearable,  and 
suggested  gangrene  of  the  lungs,  but  of  this  there  were  no  physical 
signs. 

A  lady  at  Croydon,  after  having  a  severe  illness  of  a  similar  charac- 
ter to  those  mentioned  above,  suffered  some  time  with  stomatitis  and 
bronchitis,  and  then  gradually  recovered. 

I  have  within  the  last  few  days  seen  a  sixth  case  at  Eotherliiflie  for 
the  second  time.  A  young  woman  was  taken  suddenly  ill  with  rigors, 
and  in  a  few  days  was  in  an  extremely  critical  condition.  She  had  the 
same  follicular  stomatitis  as  in  the  other  cases,  the  mucous  membrane 
being  of  a  deep  red  color,  and  covered  with  white  spots  and  patches  of 
secretion.  It  was  so  painful  that  she  could  scarcely  swallow;  at  the 
same  time  there  was  very  frequent  vomiting  and  much  diarrhcea.  After 
being  very  depressed  for  some  days,  and  giving  her  friends  and  the 
medical  man  much  anxiety  about  the  result,  she  slowly  began  to 
improve. 

If  one  had  witnessed  but  a  single  instance  of  this  kind,  the  disease 
might  have  been  attributed  to  some  sjiecial  exciting  or  individual 
causes;  but  when  half  a  dozen  cases  of  a  malady  come  before  the  same 
pi'actitioner  and  present  the  same  symptoms,  he  can  not  but  regard 
them  as  examples  of  a  particular  ty^je  of  disease.  I  believe, 
therefore,  that  I  am  witnessing  a  malady  which  can  not  be  referred  to 
any  one  name  in  the  category  of  disease.  It  has  points  of  affinity 
with  diphtheria;  and,  indeed,  if  the  latter  term  can  be  used  in  a  larger 
sense  than  that  which  implies  the  presence  of  a  membrane,  it  is  pos- 
sible that  very  similar  causes  may  be  in  operation  for  the  production 
of  the  two  diseases.'  I  have  used,  as  a  conventional  expression,  the 
term  "  gastro  enterite,"  on  the  supposition  that  the  whole  mucous 
membrane  of  the  alimentary  canal  was  in  a  state  of  morl)id  action. 
This  French  expression  I  have  never  Ijefore  adopted  except  in  the  case 
of  children,  in  whom  it  is  a  convenient  one;  and,  in  sjjeaking  of  children, 
I  think  I  can  not  do  better  than  explain  the  form  of  malady  to  which 
I  wish  to  draw  attention  than  by  saying  it  almost  exactly  resembles 
that  which  medical  men  are  in  the  habit  of  witnessing  in  infants,  but 
transferred  to  adults.  I  refer  to  the  very  common  cases  of  infants 
who,  from  error  in  diet  or  unknown  causes,  rapidly  fall  away  in  flesh, 
have  vomiting,  jjurging,  and  an  aphthous  state  of  mouth.  In  such 
cases,  the  nurse's  opinion  that  the  thrush  has  gone  "  through  them  " 
is  not  altogether  erroneous,  for  I  have  seen  the  stomach  and  intestines 
show  evident  signs  of  morbid  action,  and  the  cesophagus  covered 
with  an  adherent  white  secretion  like  that  of  the  mouth,  and  corres- 
ponding very  closely  to  a  plate  given  in  Cruvelliier's  "Morbid 
Anatomy"  under  the  head  "Sluguet." — Medical  Times  &  Gazette. 


1865.] 


EDITORIAL. 


157 


EDITORIAL. 

The  cholera  still  persists.  Its  inarch  has  been  slowly  but  surely 
forward  towards  the  crowded  cities  of  Central  and  Northern  Europe. 
It  has  declined  or  entirely  disappeared  in  the  East,  and  in  mr.ny 
places  along  the  Mediterraneau,  to  appear  with  equal  virulence  in 
others. 

lu  Gibraltar  the  present  epidemic  is  stated  to  be  the  most  severe 
which  has  ever  visited  that  place.  The  deaths  had  reached  380,  out 
of  a  population  of  24,000,  in  fifty-six  days. 

In  France  it  is  reported  to  have  appeared  at  Nice,  at  Aries,  Aix, 
Nimes,  Montpelier,  Lyons  and  Paris.  It  is  reported  to  be  on  tlie  de- 
cline in  Marseilles,  while  at  Toulon  it  still  rages  with  great  severity. 

It  has  also  appeared,  without  doubt,  in  England.  Several  deaths 
from  it  have  occurred  in  Southampton  and  neighboring  towns,  and  in 
London  three  deaths  have  been  referred  to  cholera,  while  diarrhoea 
marks  the  medical  constitution  of  the  season. 

—  Again  it  becomes  our  painful  duty  to  record  the  decease  of  a 
worthy  member  of  our  profession.  Dr.  David  S.  Conant  died  Oct. 
8th,  at  his  residence,  27  East  24th  street,  after  an  illness  of  one  week, 
at  the  age  of  40  years. 

Dr.  Conant  removed  to  this  city  from  his  native  state.  New  Hamp- 
shire, fourteen  years  since,  and  at  once  became  Demonstrator  of 
Anatomy  in  the  New  York  Medical  College,  which  office  he  retained 
for  six  or  seven  years.  On  Prof.  Peaslee's  resignation  of  the  Chair  of 
Anatomy  in  the  Medical  School  of  Maine,  in  1858,  Dr.  C.  was  elected 
Prof,  of  Anatomy  as  his  successor.  This  position  he  retained  till  1862, 
when  Prof.  T.  Cliiids,  who  had  succeeded  Prof.  Peaslee  in  that  institu- 
tion in  the  surgical  chair,  resigned;  and  since  then,  to  the  time  of  his 
death,  Dr.  C.  had  been  Prof,  of  Surgery  in  the  Maine  Medical  School. 
He  had  also  been  Prof,  of  Surgery  in  the  Medical  College  at  Burling- 
ton, Yermont,  for  the  last  five  or  six  years.  Besides,  he  had  given 
instruction  to  a  private  class,  in  the  various  departments  of  medicine, 
regularly  every  season  since  he  first  came  to  this  city,  in  addition  to 
the  two  public  courses  of  lectures  just  specified.  His  constant  ex- 
perience thus  had  rendered  him  a  most  accurate,  thorough,  and  suc- 
cessful teacher. 

He  had  also  been  one  of  the  surgeons  to  the  Demilt  Dispensary  for 
the  past  seven  years,  and,  both  from  his  varied  experience  there  and 
elsewhere,  and  {vum  an  enthusiasm  for  surgery,  as  well  as  a  native 


158 


EDITOKIAL. 


[Nov., 


quickness  and  dexterity,  he  bad  become  one  of  our  most  accomplished 
and  successful  operators.  Immediately  after  the  battle  of  Aiitietam 
he  volunteered  his  services  for  several  weeks,  and  on  that  field  he  con- 
tracted a  severe  intestinal  irritation  from  which  he  had  never  re- 
covered. 

Dr.  Conant  was  connected  with  several  of  the  medical  societies  of 
this  city,  and  was  ever  ready  to  contribute  his  full  share  to  their  ad- 
vancement. He  had  been  President  of  the  Tatholoo-ical  Society,  and 
had  held  important  ofBces  in  the  County  Medical  Society,  and  the 
Academy  of  Medicine. 

In  addition  to  the  labors  already  alluded  to.  Dr.  Conant  had  ac- 
quired an  extensive  private  i)ractice,  to  which  he  gave  the  most  faith- 
ful and  conscientious  attention. 

None  but  the  highest  physical  powers  could  endure  the  constant 
pressure  thus  incurred  during  the  last  five  or  six  years;  and  even  these 
were  at  last  found  insufficient,  though  he  never  seemed  despondent  nor 
declined  to  visit  a  fellow-being  in  distress.  During  the  month  of  August 
last  he  was  almost  constantly  occupied  by  night  and  by  day  in  his 
practice,  and  was  constantly  exposed  to  septicaemic  influences.  He 
had  had  but  little  opportunity  to  recuperate  in  September,  and  on  the 
last  day  of  that  month  had  a  small  furuncular  inflammation  on  the 
right  side  of  the  nose.  This  was  opened  freely  to  the  bone,  and  at 
once  faded  away.  The  next  day  but  one,  (Oct.  2,)  inflammation  re- 
curred above  the  incision  referred  to,  and  was,  in  its  turn,  apparently 
subdued  by  a  second  free  and  deep  incision.  It  returned  a  third  time 
around  and  over  the  lacrymal  sac,  extended  to  the  orbit,  producing 
exophthalmia  and  a  loss  of  sight  of  the  right  eye;  and  thence  pro- 
gressing backwards  tlirough  the  splienoidal  fissure,  it  attacked  the 
membranes  of  the  brain,  and  proved  fatal  on  the  8th  October. 

In  his  relations  to  his  professional  brethren,  Dr.  C.  was  frank, 
cordial,  genuine,  and  generous,  and  incapable  of  an  unprofessional  act. 
To  his  patients  he  was  kind,  faithful,  and  self-sacrificing  to  an  extreme 
degree.  As  a  citizen  he  yielded  to  none  in  public  spirit  and  patriot- 
ism. But,  more  and  Ijetter  than  all  else,  his  was  the  life  of  an  earnest 
and  sincere  Christian;  and  in  death  he  was  sustained  by  the  religion 
which,  from  his  youth,  he  had  professed. 

 Died,  at  his  residence,  Middletown,  Conn.,  suddenly,  September 

26,  1865,  Prof.  Chandler  II  Oilman,  M.D.,  of  the  College  of  Phy- 
sicians and  Surgeons  of  New  York. 

At  a  meeting  of  the  Central  Medical  Association,  held  at  Middle- 
town,  Wednesday,  Sept.  27,  tlie  following  resolutions  were  adopted: 


18G5.] 


EDITORIAL. 


159 


Resolved,  That  by  the  recent  sudden  decease  of  Prof.  Chandler  R. 
GiLMAN,  M  D.,  of  the  College  of  Physicians  and  Surgeons  of  New  York, 
our  profession  sustains  an  irreparable  loss,  a  loss  all  the  more  keenly  felt 
by  us  who,  during  the  past  two  years  since  he  took  up  his  residence 
among  us,  have  learned  to  love  and  honor  him  no  less  for  those  eminent 
professional  and  scientitic  attainments  for  which  he  was  so  long  and 
widely  distinguislie<l,  than  for  the  cheerful,  kindly,  genial  quidities  of 
mind  and  heart  which  he  ever  displayed  amid  all  his  physical  sufi'ering. 

lleso/rcd,  That  we  extend  to  his  afflicted  family  and  his  fellow  phy- 
sicians in  New  York  our  warmest  sympathy. 

Jxcsolrcd,  That  as  a  testimonial  of  our  I'egard  and  respect  for  our 
deceased  friend  and  his  bereaved  family,  this  Society  attencl  the  funeral 
services  to  be  held  Thursday,  Sept.  28,  at  his  late  residence. 

Resolved,  That  the  Seci  etary  be  directed  to  furnish  a  copy  of  these 
resolutions  to  the  family,  and  also  to  give  them  publicity. 

A  true  copy.  Geo.  W.  Burke, 

(S'ecV  Central  Med.  Association. 

At  a  meeting  of  the  Trustees  of  the  College  of  Physicians  and  Sur- 
geons of  the  City  of  New  York,  held  on  the  10th  inst.,  the  death  of 
Chandlek  R.  Gilman,  M.D.,  Professor  of  Obstetrics  and  the  Diseases 
of  Women  and  Children,  having  been  announced,  it  was 

Resolved,  That  the  Trustees  of  this  College  have  heard,  with  deep 
regret,  of  the  decease  of  one  of  the  most  eminent  of  its  Professors. 

Resolved,  That  duiing  the  long  period,  during  which  the  late  Dr. 
GiLMAN  has  taught  in  this  College,  the  talent,  earnestness  and  zeal 
with  which  he  has  devoted  himself  to  the  instruction  of  its  pu[)ils,  has 
always  secured  him  their  entire  respect  and  admiration;  and  the 
uniform  urbane  and  considerate  man.ner  of  his  association  with  his 
class,  has  equally  entitled  him  to  their  affection  and  good  will. 

Resolved,  That  these  resolutions  be  published  in  the  daily  papers, 
and  a  copy  transmitted  to  the  family  of  the  deceased. 

GuRDON  Buck,  M.D.,  Edward  Delafield,  MD,, 

Registrar.  President. 

At  a  meeting  of  the  President  and  Faculty  of  the  College  of 
Physicians  and  Surgeons,  held  Oct.  16,  1865,  the  following  Preamble 
and  Resolutions  were  unanimously  adopted: 

Whereas,  it  has  pleased  Almighty  God  to  remove  from  this  world 
our  friend  and  collengue,  Prui'essur  Chandler  R.  Gilman,  while 
humbly  bowing  to  this  dispensation  of  an  All-Wise  Providence,  we, 
who  have  shared  his  toils  and  witnessed  his  devotion  to  the  exalted 
duties  of  a  self-sacrificing  Profession,  may  be  permitted  to  give  some 
public  expression  to  the  feelings  that  so  sad  au  event  can  not  fail  to 
excite;  therefore, 

Resolved,  That  in  the  death  of  Dr.  Gilman'  this  Institution 
has  lost  an  aljle,  successfid  and  distinguished  teacher;  its  oilicers  an 
intimate,  tried  and  endeared  personal  friend;  the  medical  profession  a 


160 


EDITORIAL. 


[Nov. 


wise  and  trusted  counselor;  and  the  community,  a  learned  and  de- 
servedly (Muineut  physician,  a  profound  thinker,  and  a  great  and  good 

man.  , 

That  while  from  tlie  Chair,  which  for  twenty-five  years  lie  lias 
adorned,  he  has  eloquentlv  taught  the  true  principles  of  medical  science 
and  has  distinguished  himself  as  a  leader  in  scientific  progress,  he  has 
no  less,  in  his  blameless  life,  honorable  character,  genial  symiiathies 
reverence  for  truth,  respect  for  the  rights  of  others,  in  his  graceful 
literary  attainments,  in  his  faithfulness  and  zeal  in  all  professional 
duties  and  in  his  jealous  watclifulness  over  jirofessional  purity  and 
honor,'  left  an  example  worthy  the  imitation  of  the  thousands  who 
have  listened  to  his  teaching  and  cherish  his  principles. 

Tliat,  to  his  bereaved  family  we  tender  our  heartfelt  sympathy, 
invoking  for  them  Heaven's  choicest  consolations;  and  assuring  them 
that  we  shall  ever  cherish  in  our  hearts  pleasant  memories  of  his  life 
and  labors. 

J.  C.  Daltox,  M.  D., 

Secrelary  of  the  Faculty. 

Chicago,  III.,  Od.  Uth,  1805. 

Editor  New  York  Medical  Journal: 

In  the  report  of  the  criticisms  of  my  paper  on  the  use  of  pressure 
in  the  treatment  of  gonorrhoea!  and  purulent  ophthalmia,  published  in 
the  August  number  of  your  journal,  I  find  the  remarks  made  did  not 
partake  so  much  of  an  anahjiical  turn  as  I  had  hoped. 

The  paper  was  a  report  of  facts,  abundantly  witnessed  and  faitli- 
fully  recorded. 

I  must  regret  that  the  gentlemen  who  did  me  the  honor  to  criticise 
it  wandered  so  far  from  the  text. 

If  they  will  avail  themselves  of  the  means  I  have  there  recommended, 
experience  induces  me  to  believe  that  they  will  obtain  more  favoral)le 
results  than  would  seem  to  have  followed,  in  some  cases,  under  the 
treatment  advocated  in  their  remarks. 

Instead  of  a  reserved  and  doubtful  prognosis,  with  but  few  excep- 
tions, these  diseases  can  be  satisfactorily  controlled. 

Truly  yours, 

Jos.  S.  HiLDRETH,  Surg.  U.  S.  Y. 

—  New  York  Obstetrical  Society.— The  yearly  election  of  officers 
for  1866  was  held  Oct.  17th,  and  the  following  gentlemen  appoint^>d: 
T  G.  Thomas,  M.U.,  President;  Charles  Henschel,  M.D.,  Yice 
President;  John  G.  Percy,  M.D.,  Recording  Secretary;  Abraham 
jACom,  M.D.,  Corresponding  Secretary;  Fessesden  N.  Otis,  M.D., 
Treasurer. 


NEW  YOEIv 

MEDICAL  JOURNAL, 

A  MONTHLY  RECORD  OP  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
DECEMBER,  1865. 


OEIGINAL  COMMUNICATIONS. 

On  Amputation  at  the  Hlp-JolnL  By  John  H.  Packard, 
M.  D.,  one  of  the  Surgeons  to  the  Episcopal  Hospital,  Phil- 
adelphia. 

The  remarks  whicli  I  have  to  offer  to  the  readers  of  the 
JoURXAL  are  based  upon  a  case  -which  occurred  at  the  U.  S.  A. 
Hospital  at  Beverly,  N.  J.,  last  winter.  By  the  courtesy  of  Dr. 
Clinton  Wagner,  U.  S.  A.,  the  surgeon  in  charge,  under  whose 
orders  I  was  acting  as  Consulting  Surgeon  to  the  Hospital,  the 
manual  .procedure  was  entrustedto  me;  but,  as  Dr.  W.  justly 
remarks  in  his  (unpublished)  Report  of  Surgical  Operations, 
tlic  successful  result  was  mainly  due  to  the  surgical  skill  and 
the  kind  and  unremitting  attention  of  Dr.  J.  C.  Morton,  Ex- 
ecutive Ofhcer  of  the  Hospital. 

The  patient  was  a  private  in  the  11th  Reg't  Maine  Volun- 
teers, aged  19,  and  was  brought  to  Beverly,  August  22d,  1864, 
by  steamer,  having  been  wounded  at  Deep  Bottom,  Va.,  on  the 
16th.  The  ball  had  pa.ssed  through  the  head  of  the  tibia  from 
before  backward. 

Sept.  12th,  secondary  hemorrhage  having  occurred,  chloro- 
form was  given,  and  after  a  careful  exumiuation  it  was  thought 

Vol!  II.— No.  9.  11 


162 


AMPUTATION  AT  THE  HIP-JOINT. 


[Dec, 


proper  to  amputate,  which  operation  was  performed  through 
the  lower  third  of  the  thigh,  by  the  circular  method.  No  un- 
toward symptom  was  observed  until  October  17th,  when  bleed- 
ing was  again  set  up,  and  the  femoral  artery  was  cut  down 
upon  and  tied  in  Scarpa's  space.  The  ligature  came  away  in 
ten  days. 

November  5th,  the  end  of  the  femur  protruding  through  tlie 
retracted  soft  parts,  about  four  inches  of  the  bone  were  removed 
l)y  means  of  the  chain-saw.  Phortly  after  this,  the  stump  be- 
came enormously  swollen  and  painful,  and  abscesses  formed 
here  and  there  in  it. 

January  19th,  1865,  the  bone  was  exposed,  and  found  to  be 
greatly  enlarged,  and  in  a  state  of  necrosis,  as  high  up  as  the  tro- 
chanters. The  patient  being  already  under  chloroform,  the  fem- 
oral artery  was  at  once  exposed  and  tied  in  tlie  groin,  and  the 
disarticulation  of  the  hip  performed  by  antero-posterior  flaiJS. 
Some  slight  difficulty  was  experienced  in  controlling  the  artery 
accompanying  the  sciatic  nerve,  but  the  quantity  of  blood  lost 
in  the  operation  was  not  large.  Extreme  depression  was  ex- 
hibited, the  patient  being  of  necessity  kept  on  the  amputating 
table  for  two  or  three  days,  lest  tlie  effort  at  removal  should 
prove  fatal.  Large  quantities  of  stimulants  and  concentrated 
food  were  administered,  and  the  surface  temperature  artificially 
maintained. 

January  27th,  bleeding  again  occurred,  and  the  external 
iliac  artery  was  tied.  The  ligature  came  away  in  twenty-one 
days. 

February  19th,  two  days  afterwards,  the  lower  end  of  tlie 
divided  artery  poured  fourth  blood  furiously,  and  was  only 
controlled  with  great  difficidty  by  direct  pressure,  which  was 
kept  up  for  about  two  weeks. 

After  this,  recovery  progressed  steadily,  and  by  the  end  of 
March  the  man  was  well.  In  May,  on  the  breaking  up  of  the 
Beverly  Hospital,  he  was  transferred  to  that  at  Wliitehall, 
and  in  June  he  was  sent  to  his  home  in  Maine. 

Probably  most  of  the  readers  of  the  Journal  are  acquainted 
Tvith  the  case  lately  published  by  Dr.  Yan  Buren,  of  New  York, 
in  his  valuable  "Contributions  to  Practical  Surgery."  Here 
the  patient's  condition  was  much  more  favorable.    The  first 


18G5.] 


AMPUTATION  AT  THE  HIP-JOINT. 


1G3 


operation  was  done  for  disease  of  the  femur,  of  twenty  years' 
standing;  the  second  for  return  of  the  disease,  about  two  years 
after.  No  untoward  aocidcut  in  the  shape  of  hemorrhage 
occurred.  Death  took  place  five  years  later,  from  renewal  of 
the  disease  in  the  pelvic  bones. 

Dr.  Van  Buren  refers  to  three  other  cases  in  which  amputa- 
tion at  the  hip  was  successfully  done  after  previous  removal  of 
the  same  limb  above  the  knee:  one  by  Sir  A.  Cooper  in  1824, 
one  by  Mr.  Mayo  in  1841,  and  one  by  Mr.  Sands  Cox  in  1844. 

Another,  making  six,  has  been  published  by  Fayrer,  of  Cal- 
cutta. I  met  with  the  account  in  a  recent  number  of  the 
British  Medical  Journal;  the  exact  reference  has  escaped  me. 
It  is  so  interesting  that  an  apology  is  hardly  necessary  for  re- 
producing it  here.  "  The  operation  was  performed  when  the 
patient  was  very  low,  sutfering  from  clear  indications  of  blood 
contamination,  the  result  of  a  diseased  condition  of  the  medulla, 
which  is  unfortunately  frequent  in  India  after  section  of  the 
long  bones,  and  the  cau-e  of  many  unsuccessful  amputations. 
The  operation  was  performed  and  the  recovery  occurred  at  a 
very  hot  season  of  the  year,  the  thermometer  ranging  from  SG*^ 
to  104°.  Cholera  and  other  diseases  were  very  prevalent  at 
the  time. 

"  On  April  10th,  18G4,  a  native  boy,  16  years  old,  was  thrown 
from  a  horse;  at  the  inner  side  of  his  knee  the  soft  parts  were 
severely  injured,  but  the  joint  was,  apparently,  unhurt;  on  the 
12th  it  was  found  that  the  joint  was  oi)ened.  The  limb  was 
then  removed  at  the  lower  part  of  the  thigh.  After  the  ampu- 
tation, fever  and  extensive  necrosis  of  the  bone  followed,  sa 
that,  as  a  chance  of  saving  life,  the  limb  was  removed  at  the  hip- 
joint.  The  knife  was  entered  a  little  above  and  in  front  of 
the  great  trochanter,  and  emerged  at  the  root  of  the  scrotum. 
The  flap  being  raised,  the  femoral  artery  was  tied  before  the 
posterior  flap  was  cut.  On  dividing  the  bone  at  the  great  tro- 
chanter drops  of  pus  oozed  out  of  its  cancellated  tissue;  Dr. 
Fayrer  thereupon  seized  it  with  the  lion-forceps  and  dissected 
it  out  without  loss  of  time.  The  acetabulum  was  healthy.  All 
bleeding  points,  venous  and  arterial,  were  tied.  The  loss  of 
blood  was  very  small — less  than  eight  ounces.  His  pulse, 
which  was  over  15U  when  the  operation  was  commenced,  was, 


164 


AMPUTATION  AT  THE  HIP-JOINT. 


[Dec, 


very  little  weaker  after  it  was  over.  Stimulants  were  given 
and  hot  bottles  applied.  After  the  operation  the  patient  iin- 
niediatelv  improved,  and  eventually  recovered.  The  last 
report  of  him  is  as  follows:  '  He  goes  to  work  regularly  as  a 
tailor,  and  is  in  robust  health.  He  uses  crutches  and  gets  over 
the  ground  rapidly;  is  getting  fat,  and  is  much  grown  in  height 
as  well  as  circumference  since  his  accident.  He  was  admitted 
on  April  10th,  18G4;  thigh  amputated  on  April  12th;  hip  ampu- 
tated on  April  24th;  perfectly  cured  on  Jnly  13th,  1864-just 
one  hundred  davs  from  the  operation.'  " 

Dr.  Gross,  in'speaking  of  this  subject,  says:  "  Of  seven  cases 
of  this  kind,  in  the  hands  of  Astley  Cooper,  Textor,  Mayo, 
Cox.  Svmc,  Bradburv  and  Van  Buren,  all  were  successful.  In 
an  instance  in  the  practice  of  Mr.  Guthrie,  where  the  operation 
was  performed  on  account  of  gangrene  and  hemorrhage,  after 
amputation  of  the  thigh  for  a  gun-shot  wound,  the  result  was 

fatal." "  ^, 

Four  of  these  cases,  those,  namely,  of  Textor,  Syrae,  Lradl)nry, 
and  Guthrie,  I  know  of  through  this  quotation  only;  but  they 
brinsr  the  whole  number  of  cases  up  to  ten,  with  only  one  fatal 
issue!  From  them  it  seems  to  me  that  some  valuable  hints 
may  be  gained.  In  two  of  them,  my  own  and  Fayrer's, 
the  circumstances  were  most  unpromising;  in  the  former,  the 
great  natural  courage  of  the  patient,  and  the  untiring  assiduity 
with  which  he  was  watched  over  by  Dr.  Morton,  carried  him 
throuo-h  the  fearful  experience  which  has  lieen  detailed.  I 
know^f  no  parallel  case  on  record.t    Disarticulation  of  the 

*  Svstem  of  Surgery,  vol.  ii.,  p.  1046.    (3d  edition.) 

t  f  am  tempted  to  quote  here  a  curiou.s  passage,  xshich  I  met  ■«ith  a  few  days 
since  in  a  lecture  delivered  by  Mr.  (afterwards  Sir)  Charles  Bell,  at  the  school 
in  Great  Windmill  street,  London,  in  182-1:.    He  says: 

-The  mania  for  amputation  at  the  hip-joint,  which  has  of  late  years  pre- 
vailed I  have  seen  finely  exhibited  in  an  individual,  who,  when  the  subject 
was  mentioned,  actually  tore  his  hair,  and  exhibited  the  appearance  of  the 
deepest  distress;  one  might  have  supposed  that  some  of  his  dearest  fnends 
had  fallen  sacrifices  to  this  operation;  but  no,  the  feeling  was  excited  by  h,s 
recollections  being  awakened,  by  the  sight  of  a  carious  thigh  bone,  ot  an  op- 
portunity of  operating  which  he  had  lost." 

In  a  foot-note  Mr.  Bell  adds:  ,   ,  „  • 

A  friend,  on  reading  this,  reminded  me  that  he  had  been  present  at  this 
ingalar  exhibition  of  professional  zeal,  and  states,  what  I  had  forgotten,  that 


18G5.J 


AMPUTATION  AT  THE  HIP-JOINT. 


165 


hip  is,  Loth  !o  tlie  patient  and  to  the  operator,  one  of  the  most 
I'oi  midabie  procedures  in  surgery,  whether  we  look  upon  it  in 
its  immediate  surroundings  or  in  the  light  of  its  statistics.  The 
reason  does  not,  however,  clearly  appear  why  so  many  of  tliese 
cases  should  turn  out  badly.  Sedillot  says:  "  Its  dangers  are 
due  to  the  proximity  to  the  trunk,  the  extent  of  the  wound,  the 
mass  of  flesh  divided,  the  difficulty  of  obtaining  union,  and  the 
nervous  shock  arising  from  the  loss  of  a  member  representing 
nearly  one-fourth  of  the  entire  mass  of  the  body;  Avhich  shock 
is  so  great  that  the  patients  often  fall  into  a  complete  collapse, 
and  die  without  any  assignable  cause."  * 

On  the  other  hand,  Erichsen  says:  "  In  amputation  at  the 
hii)-joint  the  great  danger  to  be  apprehended  is  excessive 
hemorrhage,  tlie  incisions  being  made  so  high  up  that  no  tour- 
niquet can  be  applied,  nor  pressure  of  the  groin  trusted  to."t 

Dr.  Gross  says  that  the  great  risk  which  attends  this  opera- 
tion is  due  to  the  loss  of  blood,  suppuration,  erysipelas,  and 
pyogmia."^ 

It  would  take  up  too  much  space  to  adduce  other  opinions; 
those  quoted  embrace  the  views  of  leading  writers  of  the  pre- 
sent day  in  this  country,  England  and  France.  Some  of  the 
sources  of  danger  mentioned  may  be  set  aside,  as  not  especially 
belonging  to  amputation  at  the  hip. 

Pyaemia,  eryapelas  and  excessive  suppuration  may  ensue 
upon  much  slighter  operations.  Hemorrhage  may  be  altogether 
prevented  by  compressing  the  abdominal  aorta,  either  by  means 
of  a  large  clamp  tourniquet  or  by  the  fingers  of  assistants. 

Ovariotomy,  herniotomy,  the  Caesarean  section,  all  these 
show  a  larger  proportion  of  successful  results,  and  yet  they 


the  entluisiast,  in  alluding  to  the  particular  instance  in  which  he  might  have 
performed  the  operation,  told  us  '  that  as  the  child  had  previously  lost  the 
greater  part  of  the  limb  by  amputation  for  disease  of  the  lower  part  of  thigh- 
bone, there  would  have  been  little  danger  from  the  shock  of  separating  such 
a  mass  as  the  (juarter  of  the  body;  I  should  have  only,'  said  he,  '  had  to  pick 
out  part  of  the  bone  from  the  socket;  and  thus  I  should  probably  not  only 
have  been  the  first  of  the  few  whose  patients  have  survived  this  operation, 
but  have  been  even  the  first  to  have  performed  it.' " 

'  Truite  de  Medecinc  Operatoire,  etc.,  tome  i.,  p.  157.    (Paris,  1853.) 

t  Science  and  Art  of  Surgery,  p.  48.    (London,  1861.) 

t  Op.  cit.,  p.  1013. 


166 


AMPUTATION  AT  THE  HIP-JOINT. 


[Dec, 


■would  at  first  sight  seem  to  involve  even  graver  risk  than  the 
disarticulation  of  the  hip.  Against  the  exposure  of  the  large 
"wound-surface  in  the  latter,  we  have  to  set  off  the  opening  of 
the  peritoneal  cavity,  so  often  necessary  even  to  a  wide  extent 
in  the  other  operations  mentioned. 

Probably  the  true  cause  of  tlie  mortality  in  coxo-femoral 
amputation  is  to  be  found  in  the  great  mass  of  living  tissue 
removed,  and  the  shock  thereby  involved;  an  idea  which  is  sup- 
ported not  only  by  the  fact  that  the  statistics  of  amputation  of 
the  thigh  in  its  upper  tliird  are  nearly  as  unfavorable,  but 
also  by  the  far  better  results  attending  the  operation  when  the 
previous  removal  of  the  tliigh  has  done  away  with  the  circum- 
stance alluded  to. 

If  now  we  look  into  the  subject  of  the  ordinary  operation  of 
amputation  at  the  hip-joint,  we  shall  find  in  the  first  place  that 
the  greater  proportion  of  successful  cases  have  been  those  of 
disease;  and  that  the  patient's  chances  of  benefit  are  increased 
in  traumatic  cases  by  delaying  the  operative  interference  as  long 
as  possible.'"* 

To  quote  the  experience  of  American  surgeons  only,  I  have 
been  able  to  collect  eight  cases  of  successful  amputation  at  the 
hip-joint,  but  one  of  which  was  for  injury.  This  one  was  done 
by  Dr.  Edward  Shippen,  of  this  city,  while  in  the  army;  it  was 
performed  for  a  gun-shot  wound  of  the  femur,  received  six  hours 
previously.  The  patient  was  subjected,  a  month  afterwards,  to 
the  horrors  of  a  Richmond  prison;  and  yet  his  recovery  was 
perfect. 

Mott  operated  for  disease  following  a  badly  united  fracture; 
DufFee  for  coxalgia;  Gross  for  deformity  after  a  burn;  Pancoast 
once  for  osteo-sarcoma,  and  once  for  some  other  disease  to  me 
unknown;  Warren  for  osteo-sarcoma;  May  for  caries  of  tlie  upper 
part  of  the  femur. t 

*  Gross,  op.  cit.,  p.  10-16.  Legouest,  quoted  in  "  Longmore  on  Gun-shot 
Wounds,"  p.  115.  (The  principh;  as  laid  down  by  Legouest  was  confirmed 
by  a  Committee  of  the  Soci^it  de  Clnrurijie  of  Paris,  in  ISCO.) 

Baud  ens  puts  this  very  forcibly:  "  Let  us  remember  that,  while  the  disar- 
ticulation of  the  knee  should  be  done  at  once,  that  of  the  hip  seems  not  to 
succeed  (paralt  ne  pouvoir  reiissir)  unless  delayed  some  time  after  the 
receipt  of  the  wound."    La  Guerre  de  Crimei',  p.  132. 

t  I  have  been  told,  but  am  inclined  to  doubt  the  story,  that  amputation  at 


1865.] 


AMPUTATION  AT  THE  HIP-JOINT. 


167 


Contrasting  this  list  Avitli  those  so  much  more  fomiliar,  (fox- 
instance,  Lcgouest's,  of  thirty  primary  operations,  all  ending 
fatally,)  we  can  not  hut  regard  the  prognosis  in  cases  of  disease 
as  far  more  favorable  than  in  cases  of  injury.  The  ojiposite 
opinion  prevailed  uutil  set  aside  by  experience.  Dr.  Paucoast, 
in  his  "  Operative  Surgery,"  published  in  1844,  says:  '"It  may 
be  important,  however,  to  observe  that  nearly  all  the  success- 
ful cases  have  been  those  in  which  the  operation  was  practiced 
for  traumatic  injuries,  and  almost  immediately  after  their  inflic- 
tion; while  the  greater  number  of  fatal  results  have  been  con- 
sequent to  the  operation  on  subjects  previously  exhausted  to 
more  or  less  extent  by  disease.''  I  have  no  doubt  that  this 
eminent  surgeon  would  alter  this  statement  were  he  to  write  at 
present  on  the  subject,  and  mention  his  view,  as  expressed,  in 
order  to  show  by  how  high  authority  it  was  indorsed. 

If,  then,  wc  consider  tlie  cases  in  which  the  surgeon  may  be 
called  upon  to  undertake  the  coxo-femoral  disarticulation,  we 
find  them  divisible  into  four  classes,  according  to  the  degree  of 
probability  of  success. . 

(1.)  Those  in  whicli  the  same  thigh  has  been  previously  am- 
putated for  injury  or  disease. 

(2.)  Tliose  of  chronic  disease.  It  would  scarcely  be  fair  to 
place  cases  of  hip-joint  disease  in  this  class,  although  the  first 
successful  case  in  this  city  (Philadelphia)  was  of  this  character. 
It  so  often  happens  that  the  acetabulum  is  seriously  involved, 
that  in  many  cases  no  operation  could  be  of  benefit. 

(3.)  Those  in  which  an  attempt  has  been  made  to  save  the 
limb  after  injury,  and  this  operation  becomes  the  only  hope  of 
the  patient. 

(4.)  Those  in  which  the  desperate  character  of  an  injury 
recently  inflicted  renders  death  inevitable,  unless  this  slender 
chance  is  afforded. 

Even  in  the  most  favorable  cases  of  the  first  of  the  above  men- 
tioned classes,  amputation  at  the  hip-joint  is  not  to  be  lightly  un- 
dertaken. I  do  not  even  consider  it,  as  assorted  by  some  writers, 
one  of  the  easier  amputations  to  perform.  The  necessity 
should  be  stringent,  the  weighing  of  the  chances  careful,  the 

the  hip-joint  was  twice  performed  with  success  by  rebel  surgeons,  during  the 
late  war,  lor  guu-shot  injuries. 


1G8 


TREATMENT  OF  A  CERTAIN  FORM 


[Dec, 


decision  conscientiously  arrived  at.  But  it  docs  seem  to  me 
that  the  degree  of  success  attained  in  the  recorded  cases  is  such 
as  to  make  it  the  imperative  dut\'  of  the  surgeon  to  perform  the 
operation  under  the  circumstances  indicated.  In  other  words, 
it  is  not  a  matter  of  choice  for  him  whether  he  will  seek  to 
exhibit  his  prowess  witli  the  knife  or  avoid  the  risk  of  failure. 
He  is  not  only  justifialde  in  operating,  hut  he  would  be  un- 
justifiable in  not  doing  so. 

Should  the  result  be  unfavoralde,  he  may,  it  is  true,  have 
painful  doubts  as  to  tlie  propriety  of  the  course  he  was  led 
according  to  his  best  judgment  to  adopt.  Probably  all  honest 
and  conscientious  surgeons  have  known  what  it  is  to  be  so 
troubled— some,  from  their  mental  peculiarities,  more  than 
others.  And  such  doubts  would  be  more  likely  to  arise  when 
operative  interference  had  been  resorted  to  th.an  when  it  had 
been  decided  against.  Still,  this  is  one  of  the  elements  of  the 
responsibility  assumed  by  the  surgeon,  and  can  not  be  evaded. 

Before  concluding  these  remarks,  it  may  be  proper  to 
observe  that,  in  regard  to  all  operations,  a  larger  proportion  of 
the  successes  are  apt  to  be  placed  on  record  than  of  the  failures. 
And  such  may  be  the  case  with  the  amputations  at  the  hip  after 
previous  removal  of  the  same  thigh  at  a  lower  point.  But 
when  we  consider  the  very  extensive  discussion  of  the  general 
subject  of  coxo-femoral  disarticulation,  and  the  fact  that  an 
operation  of  such  magnitude  is  not  apt  to  be  confined  to  the 
knowledge  of  a  few  persons  only,  we  may  fairly  suppose  that 
the  known  cases  of  the  kind  just  spoken  of  afford  at  least  as 
correct  a  basis  for  the  estimate  of  a  patient's  chances  as  we 
have  for  our  guidance  in  regard  to  any  other  surgical  pro- 
cedure. 

1415  Spruce  Street,  Phila.,  Oct.,  18G5. 


On  tie  Treatment  of  a  Certain  Form  of  Paralysis  occurring 
hi  Children.  By  Wilijam  A.  Hammond,  M.D.,  of  New 
York. 

The  disease,  the  treatment  of  which  I  propose  to  consider  in 
this  memoir,  is  not  the  temporary  paralysis  of  infancy  wliich 


ISGf).] 


OP  PARALYSIS  IN  CHILDREN. 


169 


several  years  ago  was  so  well  described  l)y  Kennedy,  (Dul- 
lin  MeJical  Press,  September  29,  1841,  and  DuWm  Qiiarferhj 
Journal  of  3Iedicine,  February,  1856,)  but  that  of  wliicli  Du- 
chenne  has  treated,  ( DeV Electrisation  LocaliseeJ  as  consisting 
essentially  of  fatty  atrophy  of  the  muscles,  I  shall  not  at 
present  dwell  upon  the  many  points  connected  with  the  pathol- 
ogy of  the  affection  ia  question,  mainly  for  the  reason  that  I 
have  no  very  definite  ideas  upon  the  subject.  I  am,  however, 
disposed  to  regard  it  as  a  disease  in  which  the  muscles  are 
atropliied,  and  their  irritability  impaired  or  altogether  de- 
stroyed, without  any  necessary  conversion  of  their  tissue  into 
fat.  The  views  which  have  hitherto  been  expressed  upon  this 
subject  are  in  the  main  based  upon  conjectures,  and  I  do  not 
claim  for  my  own  any  more  solid  foundation. 

Case  I. — H.  J.,  male,  aged  five  years,  came  under  my  care 
April  19th,  1865,  to  be  treated  for  paralysis  of  both  lower 
extremities.  During  the  i)revious  summer  the  child  had  suf- 
fered from  hooping-cough,  and  when  the  disease  was  at  its 
height  motion  and  sensation  were  suddenly  lost  in  both  legs, from 
the  hips  down.  Medical  advice  was  at  once  obtained,  and 
various  measures  were  in  consequence  adopted,  Avitliout  any 
material  benefit.  Sea-bathing  was  then  recommended,  and 
this  was  faithfully  persisted  in  for  several  months,  with  the 
result  of  restoring  sensibility  to  both  limbs,  and  motion  to  the 
muscles  of  the  thighs.  Since  then  strychnia  had  been  admin- 
istered, both  by  the  stomach  and  by  subcutaneous  injections, 
without  the  least  improvement  being  effected.  Upon  examina- 
tion with  the  ffisthesiometer  I  found  the  sensibility  of  both 
limbs  tolerably  good.  The  mercury  of  a  delicate  thermometer, 
the  bull)  of  wliich  was  applied  to  the  thigh,  stood  at  90°, 
whilst  l)clow  the  knees  the  temperature  -was  but  82*^.  The 
child  was  able  to  flex,  extend,  rotate,  abduct  and  adduct  the 
thighs,  and  to  flex  and  extend  the  legs.  There  was  no  power, 
however,  over  the  feet,  and  upon  careful  examination  I  coidd 
not  find  that  a  single  muscle  situated  below  the  knees  was 
capable  of  contracting  from  strong  induction  currents.  Both 
legs  were  atrophied.  They  were  of  the  same  size,  being  at  the 
largest  part  six  and  a  quarter  inches  in  cii'cumfercnce. 

Aside  from  the  paralysis  the  child  appeared  to  be  in  good 


170 


TREATMENT  OF  A  CERTAIN  FORM 


[Dec, 


health.    Its  appetite  was  good,  there  was  no  pain,  and  it  slept 
well  at  night. 

I  directed  that  niglit  and  morning  both  legs  should  be 
put  up  to  the  knees  in  water  of  tlic  temperature  of  110'',  and 
kept  there  for  twenty  minutes;  that  they  should  then  be  well 
rubl)ed  for  half  an  hour  with  a  coarse  towel,  and  the  museles 
kneaded  for  the  same  period;  the  cliild  Avas  also  to  be  brought 
to  me  three  times  a  week  for  faradisation. 

This  treatment  was  contiinied  for  three  weeks  witli  but  little 
if  any  benefit.  During  this  time  I  had  continued  to  use  very 
strong  induction  currents  for  fifteen  minutes  to  each  leg  three 
times  a  week.  The  machine,  which  was  very  powerful,  was 
put  in  action  by  a  battery  consisting  of  three  Smee's  cells.  The 
current  excited  caused  the  most  intense  pain,  but  did  not  pro- 
duce the  slightest  apparent  contraction  in  any  muscle.  I  then 
determined  to  make  use  of  the  constant  current  derived  from 
a  voltaic  pile  of  one  hundred  pairs— and  consequently  pos- 
sessed of  great  intensity.  The  poles  were  apjdied  first  to  the 
tibialis  anticus  of  the  right  leg.  The  instant  the  circuit  was 
made  the  foot  moved  up.  By  continuing  the  experiment,  I 
found  that  contractions  could  be  induced  in  every  muscle  of 
both  legs.  I  then  had  an  arrangement  constructed  for  making 
and  breaking  the  circuit  rapidly,  and  persevered  with  the 
treatment  daily  for  a  week.  During  t!ie  whole  of  this  period, 
at  every  trial  contractions  were  invariably  induced  in  every 
muscle  upon  the  circuit  being  made  and  broken.  The  warm 
Avater  frictions  and  kneading  were  also  continued.  I  now 
found  that  the  temperature  of  the  legs  below  the  knees  was 
86^,  and  that  the  circumference  was,  at  the  former  place  of 
measurement,  seven  and  one-eighth  inches.  The  facts  that  the 
toes  could  now  be  slightly  flexed  and  extended  by  voluntary 
efforts,  and  that  there  was  some  little  power  over  the  gastroc- 
nemii  muscles,  assured  me  that  the  cure  would  ultimately  be 
complete.  In  this  hope  I  was  not  disappointed.  Amendment 
continued,  and  on  the  17th  of  August,  when  I  saw  the  child  for 
the  last  time  professionally,  power  over  all  the  muscles  of  both 
legs  was  almost  completely  restored.  Very  feeble  induction 
currents  now  caused  contraction.  The  tibialis  anticus  was 
still,  however,  weak;  but  I  have  no  doubt  that  by  exercise  it, 


1865.] 


OF  PARALYSIS  IN  CHILDREN. 


171 


as  well  as  all  the  rest,  will  become  Avell  nourished  and  strong. 
At  this  date  the  circumference  of  the  legs  was  eight  and  a  half 
inches,  and  the  temperature  90°. 

Case  II. — M.  W.,  female,  aged  three  years,  was  brought  to  me 
Dec.  6th,  1864,  suffering  under  paralysis  of  the  right  lower  ex- 
tremity, the  consequence  of  a  fever  with  which  she  had  been 
affected  the  previous  summer.  Upon  examination,  I  found  the 
temperature  of  the  leg  below  the  knee  six  degrees  lower  than 
that  of  the  other  limb.  The  circumference  at  the  fullest  part 
of  the  calf  was  an  inch  le?s;  sensibility  was  obtuse,  though  not 
entirely  abolished.  With  the  exception  of  the  flexor  brcvis 
digitorum,  there  was  complete  ])nralysis  of  all  the  muscles  which 
act  upon  the  foot  and  toes.  There  was  not  the  slightest  con- 
traction produced  in  any  other  by  strong  induction  cur- 
rents. 

Previous  to  my  seeing  the  child,  faradisation  had  been  im- 
perfectly used,  and  stiTchnia  and  stimulating  liniments  had 
been  em[)Ioyed  without  any  good  effect.  The  opinion  was  ex- 
pressed by  several  eminent  physicians  that  a  cure  was  impos- 
sible. 

I  determined  to  make  use  of  very  powerful  induction  cur- 
rents, hot  water,  rubbing  and  kneading,  as  in  the  case  described. 
I  continued  these  measures,  and  by  the  27th  there  was  \evy 
considerable  amendment.  Fai-adisation  had  been  employed  at 
intervals  of  two  or  three  days  throughout  the  interval.  The 
temperature  of  the  leg  had  increased,  and  contractions  of  the 
extensor  muscles  of  the  foot  and  toes  could  be  excited  to  a  slight 
extent.    There  was  no  increase  of  voluntary  power. 

On  the  20th  of  January  I  applied  a  battery  to  the  limb,  con- 
sisting of  a  plate  of  zinc  and  one  of  silver,  connected  l)y  an 
insulated  wire.  The  zinc  plate  was  kept  in  contact  with  tlio 
thigh,  whilst  the  silver  plate  was  placed  on  the  anterior  part  of 
the  leg.  The  arrangement  was  worn  constantly  for  several 
weeks,  whilst  the  other  measures  Avcro  not  discontinued.  By 
the  first  of  March  there  was  a  very  decided  improvement  man- 
ifested in  all  the  symptoms,  and  there  was  an  undoubted  in- 
crease of  voluntary  power.  Still  the  contractions  caused  by 
the  induced  current  were  very  feeble,  and  in  some  of  the 
muscles,  as  the  tibialis  anticus  and  peronei,  could  not  be  ex- 


172 


TREATMENT  OF  A  CEIITAIX  FORM 


I  Dec, 


cited  at  all.    I  therefore  determined  to  make  u<g  of  a  more 
powerful  continued  current,  and  had  the  battery  constructed 
which  has  been  referred  to  in  tlic  history  of  the  previous  case. 
As  soon  as  the  poles  were  applied  to  tlie  skin  over  the  tibialis 
anticus,  this  muscle,  and  others  in  contact  with  it,  contracted 
poAverfi'.lly.    The  ])Croiiei  also  acted  well  under  its  influence. 
I  continued  to  make  and  break  the  circuit  ovei-  difl'erent  points 
of  the  leg  for  fifteen  minutes,  every  time  causing  strong  mus- 
cular contractions.    The  treatment  was  carried  on  three  times 
a  week  till  the  1st  of  June,  at  which  time  voluntary  power  was 
restored  to  every  muscle  of  the  leg  and  foot.    The  tibialis 
anticus  and  peronei  were  still  feeble,  but,  witli  all  the  others, 
had  become  responsive  to  induced  currents.    During  the  months 
of  June,  July  and  August  the  child  was  sent  to  the  coast  and 
sea-bathing  was  used  every  day.    During  this  period  no  elec- 
tricity was  employed.    It  was  resumed  again  on  the  first  of 
September.    At  the  present  date  (October  20th.)  tlie  little  pa- 
tient is  almost  well.    The  posterior  muscles  of  the  leg  and 
those  on  the  side  of  the  foot  arc  perfectly  restored;  the  exten- 
sors of  the  toes  arc  also  quite  powerful,  and  the  peronei  act 
well;  the  tibialis  anticus  is  the  only  one  which  is  not  entirely 
subject  to  the  action  of  the  will.    Tlie  temperature  of  the  leg 
is  not  appreciably  below  the  other;  it  has  not,  however,  re- 
gained its  full  size,  though  it  is  gradually  improving  in  this 
respect.    The  lameness,  which  at  first  was  very  well  marked,  is 
now  scarcely  perceptible,  and  is  entirely  obviated  by  a  brace 
which  prevents  her  dropping  her  shoulder— a  habit  she  has  ac- 
quired through  the  limbs  being  Aveak.    Galvanism  and  fara- 
disation are  still  continued  once  a  week  to  the  tibialis  anticus. 

In  this  case,  I  am  very  confident  that,  but  lor  the  persist- 
ent use  of  galvanism  and  faradisation,  the  child  would  never 
have  recovered  from  the  paralysis. 

Case  III.— W.  S,,  male,  aged  four  years,  was  placed  under 
my  care  September  2d,  1805,  with  complete  paralysis  of  the 
left  deltoid  muscle,  which  had  persisted  for  over  a  year,  and 
which  had  ensued  upon  an  attack  of  measles,  attended  with 
great  pain  in  the  back.  Originally  the  whole  extremity  had 
been  paralyzed, .but  the  other  muscles  recovered  their  contract- 
ile power  in  a  few  days.    At  the  time  I  saw  this  child  they 


1865.] 


OF  PARALYSIS  IX  CHILDREN. 


173 


all  responded  actively  to  induced  currents  except  the  deltoid, 
"ft-hich  was  absolutely  devoid  of  all  irritability.  The  arm  could 
not,  therefore,  be  raised  from  the  side.  The  muscle  was  shrunk- 
en, and  the  shoulder,  in  consequence,  much  flattened. 

As  I  have  said,  induced  currents  failed  to  produce  the  slight- 
est action  in  the  muscle,  and  tliough  I  applied  the  full  power 
of  an  induction  apparatus  of  much  greater  strength  than 
Duchenne's  or  Rhumkorf  s,  or  any  other  I  have  ever  seen  used 
in  medicine,  no  perceptible  result  followed.  Upon  applying 
the  direct  current  of  my  voltaic  pile,  a  strong  contraction 
ensued,  and  similar  actions  followed  on  each  formation  and 
rupture  of  the  circuit.  This  treatment  was  continued  three 
times  a  week  till  the  24th.  At  this  time  slight  movements 
could  be  accomplished  by  the  exercise  of  the  will.  Induced 
currents  were  now  used  Avith  the  effect  of  causing  strong  con- 
tractions. Amendment  continued  to  take  place,  and  by  the 
lOtli  of  October,  the  muscle  had  acquired  almost  its  full 
power.  The  child  could  raise  the  arm  from  the  side  with 
case,  and  hold  it  in  this  position  for  half  a  minute.  The  atrophy 
had  also  nearly  disappeared.  The  treatment  was  now  discon- 
tinued, and  gymnastic  exercises  recommended. 

I  have  selected  the  foregoing  cases  from  several  others,  as 
presenting  a  fair  idea  of  the  action  of  the  continuous  galvanic 
current  of  great  intensity  in  exciting  muscular  irritability  when 
it  hatj  been  apparently  altogether  lost,  so  far  as  other  means 
enable  us  to  determine.  After  contraction  has  been  well 
established,  and  the  will  begins  to  assume  its  power  over  the 
affected  muscles,  I  prefer  to  use  the  induced  or  faradaic  cur- 
rents, as  being  more  local  in  their  effects.  Tlie  continuous 
(,'urrent,  as  I  propose  to  sliow  in  a  subsequent  memoir,  does  not 
limit  its  action  to  the  part  through  which  the  galvanism  passes, 
but  affects  distant  regions  of  the  body. 

The  voltaic  pile  of  which  I  make  use  is  one  which  I  devised 
myself,  and  which  I  find  to  possess  great  intensity.  It  is  con- 
structed of  perforated  zinc  and  copper  gauze  cut  into  square 
pieces  soldered  togetlier,  and  the  cou])les  separated  by  pieces 
of  woolen  cloth.  It  is  set  in  action  by  strong  vinegar,  a  few 
seconds'  contact  of  the  poles  (terminated  by  wet  sponges)  witii 
the  skin  will  ( aiise  vesication,    its  use;,  therefore,  requires 


174 


GUN-SHOT  INJURY  OF  NERVES. 


[Dec, 


caution.  It  can  not  be  apijlied  to  tlic  face,  or  any  ])ai  t  of  the 
head  and  neck  to  which  the  fifth  \n\'n'  of  nerves  is  distrihuted, 
■without  risk  of  causing  great  distui  banco  of  viaion  and  perhaps 
blindness  from  over-excitation  of  the  retina. 


Report  of  a  Case  of  Gun-sliot  Injury  of  the  3Iedtan  and  Inter- 
nal Cutaneous  Nerves  of  the  rujht  upper  extremity;  Ampu- 
tation, after  unsuccessful  Treatment  hy  Subcutaneous  Injec- 
tions (f  Morphia;  the  Dissection  of  the  Nerves  from,  the 
sitrrounding  Cicatrix,  as  done  hy  Warren;  and  Excision  of  a 
p)ortiun  of  the  Nerves.  liecovery.  By  George  A.  Mursick, 
M.D.,  of  New  York,  late  Asst.-Surg.  U.  S.  Vols. 

Trivatc  John  C.  Marks,  Co.  D.,  149th  Pa.  Volunteers,  aged 
28  years,  and  of  a  nervous  temperament,  was  admitted  to  the 
Stanton  U.  S.  A.  General  Hospital,  Washington,  D.  C,  May 
13th,  1865.  He  had  been  wounded  May  10th,  in  tin;  Battle  of 
the  Wilderness,  Va.,  by  a  musket-ball,  while  in  the  act  of  ram- 
ming a  charge  into  his  own  musket.  The  bullet  entered  the 
left  arm  above  tlie  external  condyle  of  the  humerus,  and 
passed  obliijuely  through  the  muscles,  anterior  to  the  bone.  It 
then  entered  the  inner  side  of  the  right  arm,  in  the  middle 
third,  and  passed  througli  it,  emerging  at  about  the  junction  of 
the  middle  with  the  upper  third,  antero-postericrly.  When 
admitted  he  was  in  good  condition,  and  suffered  from  no  con- 
stitutional disturbance.  He  complained,  however,  of  a  slight 
tingling  sensation  in  the  fingers  of  the  right  hand,  supplied  by 
the  median  nerve.  Water  dressings  Avcre  applied  to  the 
wounds,  and  they  healed  in  about  six  weeks.  During  this  time 
the  tingling  sensation  in  the  fingers  had  increased  to  decided 
pain.  As  the  consolidation  of  the  cicatrix  went  on  tlie  pain 
increased,  and  in  a  short  time  became  almost  unbearable.  He 
could  get  no  rest,  and  suffered  great  constitutional  irritation. 
The  temperature  and  sensibili'y  of  the  forearm  and  hand 
became  exalted;  the  skin  was  of  a  purplish-red  color,  the 
fingers  stiff  and  extended.  Nutrition  became  impaired,  and  he 
Avas  slightly  emaciated.  The  pain  in  the  fingers  and  hand  Avas 
increased  by  pressure  upon  the  cicatrix  of  the  wound. 


1865.] 


GUN-SHOT  IXJURY  OF  NERVES. 


175 


June  20th.  Yarious  applications  have  been  made  to  the  limb 
with  but  little  relief  to  the  pain.  To  have  morphia;  sulphat. 
gr.  ss.  in  solution  injected  under  the  skin  of  the  arm,  near 
the  cicatrix,  and  to  take  ferri  et  quin.  citrat.  gr.  v.,  three 
times  a  day.  The  iiijection  of  morphia  gave  decided  relief  to 
the  pain,  so  long  as  its  influence  continued,  which,  in  the 
beginning,  was  about  eighteen  hours,  when  the  pain  became  as 
severe  as  before  the  injection.  As  the  time  of  its  influence 
diminished,  it  became  necessary  to  increase  the  frequency  of 
the  injections. 

July  13th.  Pi,  Morphia?  sulphat.  gr.  ss.  in  solution  by  sub- 
cutaneous injection,  morning  and  evening.  Hand  and  forearm 
to  be  painted  with  tinct.  rad.  aconit.  twice  daily. 

August  20th.  Treatment  continued.  He  continues  in  about 
the  same  condition,  except  that  he  complains  of  some  stiffness 
of  the  jaws.  The  morphia  and  other  treatment  has  afi'orded  no 
permanent  relief  to  the  pain. 

August  23d.  The  stiffness  of  the  jaws  (trismus)  has  increased. 
He  can  only  open  them  about  half  an  inch,  and  can  take  no 
solid  food.  Exliibits  the  risus  sardonicus  in  a  slight  degree. 
Ji.  Subcutaneous  injections  of  morphia  to  be  increased  to  gr.  ij. 
daily.  Under  the  increased  quantity  of  morphia  the  trismus 
gradually  disappeared,  and  did  not  return  until  the  16th  of 
September. 

Sept,  16th,  The  treatment  thus  far  has  proved  to  be  of  no 
avail,  and  freedom  from  pain  only  continues  as  long  as  the 
effects  of  the  morphia  continue.  It  was  now  decided  to  per- 
form an  operation  for  his  relief,  wliich  was  done  by  Surgeon 
J,  A,  Lidell,  U.  S,  Vols,  After  being  etherized,  an  incision 
of  about  two  inches  in  length  was  made  througli  the  cicatrix 
down  to  the  median  nerve,  which  was  carefully  dissected  out- 
the  internal  cutaneous  nerve  was  also  found  to  be  involved  in 
the  cicatrix;  this  was  also  carefully  dissected  out,  together 
with  all  the  cicatritial  tissue  which  surrounded  both  of  them. 
There  was  no  apparent  injury  to  the  nerve  other  than  the  con- 
striction of  it  by  the  cicatrix.  The  neurolcma  of  them  was 
perhaps  a  little  redder  than  natural.  The  edges  of  tlie  wound 
were  brought  together  with  adhesive  straps,  and  cold  water 
applied.    During  the  exibition  of  the  ether  severe  spasms  of 


176 


OUX-SHOT  INJURY  OF  NERVES. 


[Doc, 


the  laryngeal  muscles  occurred,  and  lie  became  partially  as- 
pliyxiated.  The  ether  was  Huspended,  ammonia  applied  to  the 
nostrils,  and  the  spasms  ceased,  and  lie  soon  breathed  free 
again. 

Sept.  I7lh.  Has  passed  a  tolerably  comfortable  night  with- 
out morphia.  Says  he  feels  very  drowsy  this  morning.  The 
pain  in  the  hand  has  not  entirely  ceased.  Bowels  confined. 
Ji.  Sal  Rochellc,  Si.  P.  M.:  The  pain  in  the  hand  is  very 
severe,  almost  as  bad  as  before  the  operation.  H.  Morph. 
sulph.  gr.  i.  by  subcutaneous  injection. 

Sept.  ISth.  Says  he  has  felt  very  comfortable  since  the 
injection  of  the  morphia.  Had  a  good  night's  rest.  He  ex- 
hibits considerable  nervous  irritability,  and  has  some  stiffness 
of  the  jaws.    ijk.  Zmci.  sulph.  gr.  i.  every  six  hours. 

Sept.  19th.  The  trismus  has  entirely  disappeared.  Can 
open  his  jaws  to  the  full  extent.  Towards  evening  the  pain  in 
the  hand  increased  so  much  that  morphia  was  required  to  give 
relief  from  pain. 

Oct.  1st.  The  pain  in  the  liand  continues  as  before,  but  is 
more  severe  at  night.  The  subcutaneous  injections  of  morphia 
have  been  continued,  (gr.  i.  daily.)  The  severity  of  the  pain 
has  not  decreased  much  since  the  operation.  The  wound  has 
nearly  healed. 

Oct.  Gth.  The  wound  has  entirely  healed.  The  pain  is  as 
severe  as  before  the  operation,  and  at  times  he  sulfcrs  from 
severe  attacks  of  tetanic  irritation.  This  morning  he  suffered 
from  a  severe  attack.  The  previous  operation  having  failed, 
and  the  treatment  affording  only  temporary  relief,  his  general 
condition  being  much  worse  from  the  severe  nervous  irritation 
and  loss  of  rest  from  which  he  was  suffering,  it  ^vas  decided  to 
perform  excision  of  a  portion  of  the  nerve,  and  to  save  the 
limb  if  possible— as  it  is  well  known  that  the  nervous  tissue 
Avill  be  regenerated  after  a  time  and  the  functions  of  the  ])arts 
restored. 

I  made  an  incision  tliroiigh  the  old  cicatrix,  and  carefully 
dissected  out  the  nerves,  (the  median  and  internal  cutaneous.) 
The  anatomical  relations  of  them  had  been  disturbed  by  the 
previous  operation;  both  were  found  lying  side  by  side,  com- 
pletely surrounded  by  the  (-catritiul  tissue,  which  was  very 


1865.] 


GUI -SHOT  INJURY  OF  NERVES. 


177 


vascular.  The  sheaths  of  the  nerves  were  very  red  in  color, 
otherwise  they  presented  no  abnormal  appearance  to  the  eye. 
I  divided  them,  and  resected  the  portion  which  presented  the 
abnormal  color,  (about  |  of  an  inch.)  The  edges  of  the  wound 
were  approximated  and  retained  by  adhesive  straps,  and  a 
bandage  applied  to  the  whole  arm. 

Oct.  7th,  2  o'clock,  P.M.  Has  been  almost  free  from  pain 
until  the  present  time,  and  passed  a  very  comfortable  night. 
He  now  complains  of  a  severe  pain  in  the  hand  and  forearm, 
as  severe  as  at  any  time  before.  His  skin  is  cool;  he  is  sweat- 
ing profusely — large  drops  of  perspiration  stand  out  upon  his 
forehead  and  face.  Pulse  frequent  (120)  and  soft.  ^.  Morphias 
sulph.,  gr.  i.,  by  subcutaneous  injections. 

He  states  that  since  the  nerve  was  divided  he  feels  "  a  prick- 
ing sensation"  in  the  fingers,  to  which  it  is  distributed.  He 
thinks  that  he  can  feel  when  pressure  is  made  upon  the  fingers, 
though  the  sense  of  touch  is  lost,  and  the  hand  feels  "  heavy 
and  dead." 

Oct.  19th.  The  wound  of  operation  is  nearly  healed.  The 
pain  is  now  as  severe  as  before  the  nerve  was  divided,  and  is 
very  acute  and  nearly  constant;  it  is  situated  in  the  same  parts 
as  before,  viz.:  the  palm  of  the  hand,  the  thumb,  index  and 
middle  fingers.  The  treatment  by  subcutaneous  injections  has 
been  continued,  from  one  to  three  grains  having  been  injected 
daily.  No  treatment  appears  to  avail  any  thing,  and  there  ap- 
pears to  be  great  danger  of  the  occurrence  of  tetanus.  He 
expresses  a  strong  desire  to  have  the  arm  amputated  to  relieve 
him  from  the  pain.  Surgeon  J.  A.  Lidell,  U.  S.  Vols.,  ampu- 
tated the  arm,  by  the  double-flap  operation,  at  the  junction  of 
the  middle  and  upper  third,  the  patient  being  under  the  in- 
fluence of  chloroform.  Tiie  stump  was  very  vascular  and  re- 
quired a  large  number  of  ligatures,  and  the  free  application  of 
the  liquor  ferri  persulphat.  to  control  the  general  oozing  from 
it.  The  flaps  were  not  coaptated.  The  stump  was  dressed 
with  charpic  and  a  roller  bandage  applied  up  to  the  shoulder. 
9  o'clock,  P.M.  He  complains  of  great  pain  in  the  stump;  he 
says  that  it  feels  as  if  something  was  "  twisting  the  nerves;"  is 
very  restless  and  exhibits  great  nervous  irritation.  IJ.  Morphije 
sulph.  gr.  i. 

Vol.  n.— No.  9.  12 


178 


GUN-SHOT  INJURY  OP  NERVES. 


[Dec, 


Oct.  20th.  Has  passed  a  very  restless  night;  the  stump  is 
excessively  painful  and  is  slightly  swollen.  Tongue,  large, 
pale  and  flabby,  is  indented  on  the  edges  by  the  teeth ;  pulse 
frequent  and  irritable.  ^.  Morphias  sulph.  gr.  i.  by  sub- 
cutaneous injection;  ice  dressing  to  stump;  spts.  vini  gallici 
ii.  every  six  hours. 

Oct.  21st.  Dressed  the  stump;  has  suffered  a  great  deal  of 
pain  during  the  past  twenty-four  hours;  the  swelling  of  the 
stump  has  increased;  tongue  furred;  bowels  confined;  pulse  120 
and  feeble;  has  severe  spasms  of  the  muscles  of  the  stump,  and 
some  stiffness  of  the  jaws.  P;.  Pulv.  opii  gr,  i.,  ext.  belladonnse 
gr.  ^  in  pil.  every  two  hours;  lead  and  opium  lotion  to  stump; 
brandy  3iv.  every  two  hours. 

Oct.  22d.  Has  passed  a  very  quiet  night;  the  pain  in  and 
the  swelling  of  the  stump  is  much  less;  pulse  98  and  fuller; 
bowels  have  not  moved.  ^.  Sal.  Rochelle  §i.;  continued  other 
treatment.  P.  M.,  5  o'clock,  has  vomited  the  salts  which  he 
took  this  morning;  stomach  very  irritable:  1^.  Sinapism  to 
epigastrium,  and  an  enema  to  move  the  bowels. 

Oct.  23d.  The  enema  moved  the  bowels  moderately;  nausea 
continues;  has  vomited  several  times  during  the  night;  the 
stump  is  suppurating.  ^.  Hyd.  sub.  mur.  gr.  v.,  pulv.  rhei  gr. 
X.,  sodse  bicarb,  gr.  x.,  ft.  pulv.;  to  take  at  once.  P.  M.,  6 
o'clock,  bowels  have  moved  freely;  is  very  restless  and  irritable; 
stump  painful.  He  says  the  pain  occurs  in  paroxysms,  and  is 
very  "  sharp  and  cutting."  p.  Pulv.  opii  gr.  i.,  ext.  belladonnas 
gr.  5  every  three  hours. 

Oct.  24th.  Has  passed  a  quiet  night  and  slept  tolerably 
well;  discharge  from  the  stump  is  quite  free,  it  has  nearly 
cleaned  off,  and  florid  granulations  are  springing  up;  his  appe- 
tite is  improving;  pulse  90  and  moderately  full.  12  o'clock, 
A.M.  The  nurse  called  me  and  stated  that  the  patient  was  out 
of  his  head;  I  found  him  in  a  very  excited  condition,  exhibiting 
great  nervous  irrital)ility.  He  answered  questions  rationally 
when  spoken  to,  but  his  mind  wandered  from  the  subject.  He 
appears  much  depressed  in  spirits,  and  expresses  gloomy  fore- 
bodings of  the  future.  Skin  cool  and  moist;  pulse  110  and 
feeble,    p.  Sinapism  to  back  of  neck,  Hoffman's  anodyne  3ss., 


1865.] 


GUN-SHOT  INJUBY  OF  NERVES. 


179 


fluid  ext.  valerian  3ss.  every  hour;  spts,  vini  galliei  3iv.  every 
two  hours. 

6  o'clock,  P.M.  Pulse  110  and  fuller;  skin  warm  and  moist; 
is  much  less  restless  and  his  conversation  is  coherent  and 
rational.    li.  Magendics  solut.  gtt.  xv.  at  bed-time. 

Oct.  25th  A.M.  Has  passed  a  quiet  night  and  slept  consid- 
erable— expresses  himself  as  feeling  much  better.  His  bowels 
moved  freely  during  the  night.  He  still  exhibits  a  good  deal 
of  nervous  irritability  and  watchfulness,  but  the  depression  of 
spirits  is  mucli  less;  pulse  120;  9-  Fluid  Ext.  rad.  aconit.  gtts  i. 
every  two  hours  and  milk-punch  freely.  6  o'clock,  p.m.  Pulse 
110;  has  passed  a  quiet  day,  but  has  not  slept.  P:.  Magendies 
solut.  gtt.  XV.  at  bed-time. 

Oct.  26th.  Has  had  three  or  four  hours  of  sound  sleep  dur- 
ing the  night  and  feels  much  refreshed;  pulse  100,  moderately 
full  but  irritable.  All  the  ligatures  came  from  the  stump  this 
morning  except  the  one  on  the  brachial  artery.  The  face  of 
the  stump  looks  well,  but  it  is  still  swollen,  and  the  muscles 
protrude  beyond  the  skin  and  are  very  irritable,  so  much  so 
that  when  the  stump  is  dressed  there  is  a  constant  twitching  of 
them  which  continues  for  an  hour  or  more.  Bowels  confined. 
^.  Pil.  cathart.  co.  No.  2. 

6  o'clock,  P.M.  Says  he  feels  much  better  to-night,  and  as  if 
he  had  awakened  from  a  dream.  His  bowels  have  moved 
freely;  appetite  improved,  and  he  expresses  a  desire  for  food. 
Continue  morphia  at  bed  time. 

Oct.  28th.  He  continues  to  improve,  the  stump  suppurates 
freely;  the  swelling  and  irritabitity  of  the  muscles  is  much 
less;  pulse  100  and  of  good  volume.  He  says  that  the  "  dreamy 
sensation"  has  passed  away  and  that  he  feels  like  himself  again. 
The  ligature  came  from  the  brachial  artery  to-day;  bowels 
confined.    li.  Pil.  cathart.  co.  No.  2. 

From  this  time  he  continued  to  do  well.  All  the  nervous 
phenomena  subsided;  the  stump  healed  slowly;  he  gained  in 
flesh  and  spirits,  and  was  finally  discharged  from  the  hospital 
in  good  condition. 

The  autopsy  of  the  amputated  limb  revealed  no  apprecia- 
ble abnormal  condition  of  the  nerves.    Nothing  was  dis- 


180 


PROPRIETY  OF  INDUCING 


[Dec, 


covered  tliat  could  account  for  the  peculiar  nervous  phenomena 
exhibited. 

The  limb  was  abnormally  vascular,  and  the  muscles  ex- 
hibited fatty  degeneration  in  a  slight  degree. 

About  one  liundred  and  forty-five  grains  of  tlie  sulphate  of 
morphia  were  administered  by  subcutaneous  injections  in 
various  parts  of  the  body,  witliout  affording  any  permanent 
relief.  At  first  they  were  confined  to  the  arm  above  the  wound 
until  they  gave  rise  to  induration  of  the  cellular  tissue,  then 
to  the  arm  below  the  wound  and  in  the  forearm;  in  the  oppo- 
site extremity,  in  both  lower  extremities,  and  in  the  abdominal 
walls.  No  difference  was  found  in  the  effect  produced  by 
changing  the  locality  of  the  injections.  Relief  from  the  pain 
followed  in  from  twenty  to  thirty  minutes  subsequent  to  each 
injection,  and  the  trismus  and  other  tetanic  symptoms  were 
controlled,  temporarily,  by  increasing  the  quantity  of  morphia 
from  time  to  time  as  occasion  required. 


On  the  Propriety  of  Inducing  Premature  Delivery.  By  T.  G. 
Thomas,  M.D.,  Professor  of  Obstetrics  and  the  Diseases  of 
Women  and  Children,  in  the  College  of  Physicians  and  Sur- 
geons, New  York. 

[Bead  before  the  N.  Y.  Obstetrical  Society.] 

On  the  1st  of  June,  1865,  Mrs.  B.,  a  short  but  well  made 
woman,  aged  thirty-three,  applied  to  me  to  take  charge  of  her 
delivery,  which  was  anticipated  about  the  5  th  of  September, 
giving  me  the  follov/ing  history.  She  had  been  delivered  ten 
months  before  of  a  still-born  child  at  the  seventh  month,  labor 
being  ushered  in  by  a  violent  convulsion  which  destroyed  the 
life  of  the  child,  and  left  the  mother  in  so  precarious  a  condi- 
tion that  her  life  for  several  days  was  despaired  of.  During 
her  illness  she  was  attended  by  an  intelligent  practitioner  of 
Saratoga,  and  Dr.  Willard  Parker,  of  New  York,  in  consulta- 
tion. After  recovery  from  this  confinement,  she  was  amau- 
rotic for  three  mouths,  and  was  during  that  time  supposed  to  be 


1865.] 


PREMATURE  DELIVERY. 


181 


suffering  from  Blight's  Disease.  Becoming  again  pregnant, 
she  r.atiu  ally  dreaded  a  recurrence  of  convulsions,  and  fears  of 
a  fatal  issue  for  herself  and  offspring  filled  her  mind  with 
anxious  forebodings — more  especially  as  one  of  her  sisters,  an 
unmarried  lady,  had  since  that  time  died  of  Bright's  Disease. 

Upon  taking  cliarge  of  the  case,  I  made  a  careful  chemical 
and  microscopical  examination  of  the  urine,  and  found  it  free 
from  evidences  of  disease.  These  examinations  were  repeated 
weekly  with  the  same  result;  and  as  I  left  the  city  on  the  1st 
of  July,  to  be  absent  a  month,  I  left  my  patient  under  the  care 
of  Dr.  Charles  A.  Budd,  who  watched  the  secretion  as  I  had 
done,  and  reported  her  doing  well  on  the  1st  of  August. 
On  the  12th  of  that  month,  I  was  called  hastily  to  Mrs.  B.,  and 
found  her  laboring  under  some  dyspnoea,  considerable  confu- 
sion of  intellect,  dizziness  of  head  and  nausea.  (Edema  of  the 
feet,  hands  and  neck  was  discovered,  and  upon  examining  the 
urine,  which  was  scanty  and  high  colored,  I  found  it  loaded  with 
albumen.  After  this  I  saw  her  daily,  and  adopted  those 
measures  most  relied  on  in  such  cases  as  preventive  of  the  threat- 
ening climax.  From  day  to  day  the  symptoms  above  recorded 
steadily  increased,  the  oedema  of  the  neck  becoming  so  marked 
as  to  be  oppressive,  and  great  depression  of  spirits  superadding 
itself  to  the  array  of  morbid  signs.  On  the  16th,  Dr.  Thebaud 
saw  her  with  me  in  consultation,  agreed  with  me  in  the  pro- 
priety of  inducing  premature  delivery  for  prevention  of  con- 
vulsions, which,  from  the  peculiarly  marked  features  of  the  case, 
we  regarded  as  more  than  probable;  and  in  accordance  with 
the  result  of  the  consultation,  I  proceeded  to  accomplish  it  on 
the  17th. 

On  this  date,  at  1  p.m.,  I  introduced  into  the  cervix  a  large 
sponge  tent,  but  finding  it  impossible  to  retain  it  in  position 
I  removed  it  and  used  the  smallest  of  Barne's  dilators. 
After  twenty-five  minutes  I  had  dilated  the  os  to  the  size 
of  a  circle  whose  diameter  is  two  inches.  I  now  left  her,  and 
returned  to  her  at  4  p.m.  No  labor  pains  having  been 
excited,  I  introduced  the  largest  dilator,  and  after  dilating  to 
its  utmost  capacity,  introduced  a  No.  10  gum-elastic  catheter 
between  the  membranes  and  uterine  wall,  and  left  it.  At  7 
P.M.  I  was  sent  for  in  haste,  violent  expulsive  pains  being 


182       PROPRIETY  OF  INDUCING  PREMATURE  DELIVERY.  [DcC, 

established.  Upon  my  arrival  the  desired  process  was  found 
fully  inaugurated;  the  lady,  as  a  further  preventive  means,  was 
put  under  chloroform,  and  at  11^  p.m.  a  female  child  was 
born. 

Mother  and  child  did  well,  no  untoward  symptom  showing 
itself  in  the  case  of  cither. 

My  object  in  relating  this  case  is  to  call  out  the  views  of 
members  of  the  Society  upon  a  point  which  I  consider  one  of 
the  most  important  and  momentous  in  the  whole  field  of  ob- 
stetric practice;  and  before  closing  I  desire  to  give,  as  con- 
cisely as  I  may,  the  reasons  which  actuated  me  in  interfering 
in  the  case  which  I  have  brought  to  your  notice. 

First,  let  me  state  that  I  am  fully  aware  of  the  fact,  so  patent 
to  all,  that  a  large  proportion  of  women  affected  by  puerperal 
albuminuria  pass  through  labor  without  untoward  symptoms, 
and  rapidly  recover  after  its  accomplishment,  and  that  I  feel 
that  I  would  be  recording  a  mischievous  and  dangerous  pre- 
cedent did  I  by  this  history  lead  any  one  to  interfere  in  the 
progress  of  utero-gestation  merely  on  account  of  the  develop- 
ment of  this  condition. 

Albuminuria  in  the  pregnant  woman,  then,  let  me  premise, 
is  insufficient  as  a  ground  on  which  to  base  premature  delivery. 
In  the  case  under  consideration  I  was  influenced  and  decided  in 
my  course  by  the  following  considerations: 

1st.  The  patient's  previous  delivery  and  narrow  escape  from 
death  from  this  very  cause. 

2d.  The  fact  that  even  in  the  first  month  of  her  existing 
pregnancy  she  had  given  evidences  of  Bright's  Disease. 

3d.  The  sudden  appearance  of  grave  cerebral  symptoms 
coincidently  with  marked,  even  excessive  amount  of  albumen 
in  the  urine,  and,  what  I  omitted  to  mention,  tube  casts  tilled 
with  granular  epithelium. 

Believing  now,  (after  having  carefully  reflected  upon  the  case,) 
as  I  then  did,  that  I  was  saving  my  two  patients  from  a  great 
danger  by  incurring  a  comparatively  slight  one,  I  should  again, 
if  similarly  circumstanced,  act  as  I  did. 


1865.] 


MODIFICATION  OF  THE  SPECULUM. 


183 


Modification  of  the  Bivalve  Speculum  Vagince.    By  Fred- 
eric D.  Lente,  M.D.,  of  Cold  Spring. 

Among  the  various  modifications  of  the  speculum  vagincevf\\\c\i 
have  been  from  time  to  time  proposed,  there  is  none  which 
enables  us  to  introduce  into  the  uterus  with  facility  the  sound, 
when  required  to  be  much  curved,  or  other  curved  instru- 
ments by  means  of  which  applications  are  made  to  the  lining 
membrane,  except  the  modification  of  Sims.  This  instrument 
necessitates  the  employment  of  an  assistant  accustomed  to  hold- 
ing it  in  its  place  when  applied,  in  order  that  one  hand  of  the 
operator  may  be  left  at  liberty.  On  this  account  it  is  now 
seldom  used,  especially  in  private  practice, 
except  for  operative  procedures  when  skill- 
ed assistants  are  always  at  hand.  The 
ingenious  modification,  however,  of  my 
friend.  Professor  Thomas,  obviates  to  a 
considerable  extent,  this  objection.  This 
consists  in  the  attachment  of  the  retractor, 
previously  requiring  a  separate  hand  to 
hold  it  to  the  speculum.  Still  the  instru- 
ment is  inconvenient  to  carry  about,  and 
not  very  convenient  of  application  to  those 
not  thoroughly  accustomed  to  its  use. 

The  bivalve  .speculum  is, perhaps,  the  most 
convenient  for  allowing  the  introduction 
of  curved  instruments  into  the  uterus  with- 
out the  necessity  of  an  assistant — the  cases 
being  very  exceptional  Avhere  the  vagina 
is  so  relaxed  or  capacious  as  to  cause  its 
walls  to  fall  between  the 
blades  and  obscure  the 
view,  in  which  cases  the 
trivalve  is  our  next  best 
resource.      But  when 
there    is  considerable 
flexion  of   the  cervix 
uteri,  as  is  frequently 
the  case,  when  we  have  disease  requiring  the  application  of 


184 


MEDICINAL  USES  OP 


[Dec, 


remedies  through  the  whole  extent  of  the  cervical  canal,  or  to 
the  cavity  of  the  uterus,  it  is  necessary  to  curve  the  sound 
or  other  instrument  very  much,  sometimes  through  the  quarter 
of  a  circle  or  more;  in  this  case  it  is  very  difficult  of  introduc- 
tion on  account  of  the  small  amount  of  room  at  tlic  outer  por- 
tion of  the  speculum,  but  little  more  in  fact  than  we  have  in  the 
tubular  form.  To  obviate  tliis  difficulty,  I  propose  the  modifica- 
tion indicated  in  the  accompanying  engraving.  That  is,  to  cut 
away  half  of  the  width  of  the  right  hand  or  lower  blade  of  the 
instrument,  commencing  at  its  proximal  end,  and  extending  a 
little  more  than  half  the  length  of  the  blade.  This  blade  will 
still  act  more  effectively  in  keeping  tlie  walls  of  the  vagina 
apart  than  the  retractor  of  Sims  and  Thomas,  and  gives  abund- 
ant room  for  manipulation  with  curved  instruments. 

A  further  equally  important  modification  proposed  is  to 
reduce  the  weight  of  the  instrument  nearly  fifty  per  cent.,  and 
to  make  the  handle  much  shorter,  (but  very  slight  force  being 
required  to  dilate  the  vagina;)  also  to  reduce  somewhat  the 
length  of  the  blades,  so  that  as  little  as  possible  shall  extend 
beyond  the  vulva.  These  alterations  allow  the  instrument  to 
be  held  in  situ  by  the  vagina  itself,  and  thus  liberate  both 
hands  of  the  operator.  To  meet  the  case  of  relaxed  and 
capacious  vagina,  and  to  obviate  the  necessity  for  resorting  to 
the  trivalve,  it  is  proposed,  also,  as  the  engraving  shows,  to 
make  the  blades  wider  at  their  distal  extremity  than  is  usually 
the  case.  This  can  be  done  without  materially  increasing  the 
difficulty  of  introduction  through  the  ostium  vagin®,  since  they 
form,  when  closed,  a  tolerably  thin  wedge. 


Medicinal  Uses  of  Ptelea  Trifoliata.    By  0.  F.  Potter,  M.D., 
St.  Louis,  Mo. 

I  wish  to  call  the  attention  of  physicians  to  a  plant,  the  med- 
ical virtues  of  w^hich  I  have  been  familiar  with  for  some  years, 
and  from  personal  experience  would  recommend  it  to  the 
favorable  notice  of  the  profession. 


1865.] 


PTELEA  TRIFOLIATA. 


185 


The  plant  is  known  as  the  ptelea  trifoliata,  or,  commonly,  as 
the  wafer-ash  or  wingseed,  a  species  of  so-called  swamp  dog- 
wood, and  is  of  the  natural  order  Xauthoxylacea. 

It  is  a  shrub  of  from  six  to  eight  feet  in  height.  The  leaves 
are  trifoliate  and  marked  with  pellucid  dots.  The  leaflets  are 
sessile,  ovate,  short,  accuminate,  downy  beneath,  lateral  ones 
inequilateral;  terminal  ones  cunate  at  base,  from  three  to  four 
inches  long  by  one  to  one  and  three-fourths  inches  wide.  The 
flowers  are  polygamous,  nearly  one-half  inch  in  diameter,  of  a 
greenish-white  color,  and  of  a  disagreeable  odor.  Stamens 
mostly  four  with  style  short;  fruit,  a  two-celled  samara,  nearly 
an  inch  in  diameter,  winged  all  round,  nearly  orbicular.  It 
flowers  in  June.  It  is  common  to  this  country,  growing  more 
abundantly  west  of  the  Alleghanies  in  shady,  moist,  and  rocky 
places,  generally  at  the  edge  of  woods.  The  bark  of  the  root 
possesses  its  peculiar  medicinal  properties,  which  it  yields  to 
boiling  water,  but  alcohol  is  its  best  solvent.  The  bark,  when 
dried,  is  of  a  light  brownish-yellow  color,  comes  in  cylindrical 
rolls  or  quills  a  line  or  two  in  thickness,  and  from  one  to 
several  inches  in  length;  is  irregularly  wrinkled  externally, 
and  is  covered  with  a  thin  epidermis;  internally  it  is  of  a 
yellowish-white,  but  becomes  darker  on  exi)osure.  It  has  a 
peculiar,  rather  aromatic  smell,  and  a  bitter,  })ungent  and  rather 
acrid  taste,  yet  nothing  disagreeable;  the  pungency  is  persistent, 
which  is  owing  to  the  oil  which  it  contains. 

I  have  been  u.«ing  it  as  a  tonic  to  follow  the  use  of  quinine 
in  all  grades  of  fevers,  also  in  cases  of  general  debility  con- 
nected with  gastro-enteric  irritation.  It  is  mild,  unirritating, 
having  a  soothing  influence  on  the  stomach,  promoting  diges- 
tion. It  promotes  the  appetite,  enabling  the  stomach  to  endure 
suitable  nourishment,  and  favors  the  early  re-establishment  of  the 
digestive  functions,  and  will  be  tolerated  by  the  stomach  when 
almost  all  other  tonic  or  stimulant  remedies  are  rejected.  I 
have  found  it  especially  useful  in  cases  of  debility  following  a 
low  grade  of  fevers,  also  with  females  after  confinement,  or 
where  the  menstrual  functions  are  deranged,  frequently  by  sus- 
taining the  digestive  and  secretive  functions,  regulating  the 
menstrual  flow;  also  as  a  sustaining  and  strengthening  slimu  - 


186 


PROCEEDINGS  OF  SOCIETIES. 


[Dec, 


lant  in  debility  connected  witli  or  following  wasting  ulcers  or 
scrofulous  sores. 

I  have  been  in  tlie  habit  of  using  it  in  the  form  of  a  tincture, 
made  by  putting  six  ounces  of  the  bark  and  one-half  ounce  of 
ginger  to  two  quarts  whisky;  the  dose  from  one  to  two  table- 
spoonfuls  three  times  a  day  for  an  adult. 

I  feel  assured,  from  over  ten  years'  experience  in  using  it, 
that  it  will  be  found  a  most  valuable  and  reliable  remedy.  It 
has  been  used  occasionally  by  the  so-called  eclectic  physicians, 
and  also  by  the  negroes  of  tlie  South,  who  call  it  the  scrofula 
root,  from  its  usefulness  in  sustaining  the  system  when  debili- 
tated by  that  so  common  disease  amongst  them.  The  old 
Trench  inhabitants  near  St.  Louis  also  used  it  many  years  ago 
as  a  cure  for  the  intermittent  fevers  of  the  country,  long  before 
quinine  was  known.  When  used  for  a  great  length  of  time,  or 
in  very  large  doses,  it  occasionally,  in  some  persons,  occasions 
an  erysipelatous  inflammation  in  the  surface,  which,  liowever, 
only  lasts  for  a  short  time  if  its  use  is  persevered  in,  and  no 
ill  effects  follow  it. 


PSOOEEDINGS  OF  SOCIETIES. 

XEW  YORK  PATHOLOGICAL  SOCIETY. 
Stated  Meeting,  June  14,  1865. 
Dr.  Gurdo.v  Buck,  President,  in  the  Chair. 

BULLET  REMOVED  FROM  RAMUS  OF  JAW— DR.  A.  C.  POST. 

Dr.  Post  presented  a  flattened  ball  removed  from  the  left  ramus  of 
the  jaw  of  a  soldier  who  had  been  shot  at  Coal  Harbor.  The  ball 
entered  at  the  junction  of  the  right  ala  of  the  nose  with  the  upper  lip, 
passed  across  the  mouth,  and  was  lost.  There  was  a  large  swelling  in 
the  parotid  region,  and  also  a  sinus  whieli  communicated  with  dead 
bone.  In  the  course  ofthe  operation  the  bullet  was  felt  and  removed, 
along  with  a  molar  tooth  of  that  side,  to  which  roughened  and  dead 
bone  was  attached.  The  movements  of  the  jaw,  which  were  very  much 
interfered  with  before  the  operation,  were  afterwards  much  improved. 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


187 


WOUND  OF  BOTH  CAROTIDS  DR.  POST. 

Dr.  Post  also  presented  the  atlas  and  axis  removed  from  a  soldier 
who  died  from  hemorrhage  seven  days  after  a  gun-shot  wound  which 
he  had  received  during  the  month  of  February  last.  The  ball,  which 
was  a  Millie,  entered  the  mouth,  passed  through  the  tongue,  and  was 
lost.  The  patient  did  very  well  for  six  days,  but  on  the  seventh  the 
fatal  hemorrhage  referred  to  occurred.  At  the  autopsy  the  bullet  was 
found  lodged  upon  the  upper  surface  of  the  transverse  process  of  the 
atlas,  having  perforated  in  its  course  the  external  and  internal  carotid 
arteries.  Dr.  Post  stated  that  it  was  certainly  remarkable  that  two 
such  large  vessels  should  be  thus  wounded,  and  yet  not  bleed  for  so  long 
a  time  as  six  days. 

Dr.  Krackowizer  thought  that  the  arteries  were  not  perforated  at 
first,  but  only  became  so  as  the  result  of  the  slough  which  followed  the 
original  injury  to  their  coats. 

Dr.  CoNAMT  remarked  that  he  had  heard,  from  a  general,  that  the 
rapid  passage  of  a  bullet  through  the  air  caused  the  material  of  which 
it  was  composed  to  become  very  soft,  and  that  this  fact  offered  a  very 
reasonable  explanation  for  the  frequent  flattening  of  these  missiles  in 
parts  of  the  body  remote  from  bone  or  other  hard  substance. 

Dr.  Post  stated  that  the  flattening,  under  such  circumstances,  could 
generally  be  explained  by  the  missile  striking  a  rock  or  tree  before 
entering  the  body.  He  had  removed  a  bullet  very  much  flattened 
from  the  walls  of  the  abdomen  which  had  entered  in  the  neighborhood 
of  the  nates,  and  traversed  a  distance  of  nine  inches  under  the  skin, 
and  had  not  in  its  course  infringed  upon  any  hard  substance.  The 
wound  was  received  during  the  battles  of  the  Wilderness,  and  it  was 
fair  to  presume  that  the  ball  had  struck  a  tree  first. 

Dr.  CoNANT  remarked  that  a  few  days  before  he  had  occasion  to  re- 
move a  Minie  ball  which  was  situated  immediately  over  the  femoral 
artery,  and  which  was  flattened  in  such  a  curious  manner  that  he  could 
not  explain  its  condition,  except  on  the  supposition  that  the  theory  of 
the  general  was  correct.  It  seemed  that  the  ball  had  been  flattened 
simply  by  coming  in  contact  with  the  tendon  of  the  abductor  muscle, 
and  he  sui)posed  that  it  was  not  flattened  before  it  entered  the  body, 
because  the  wound  of  entrance  was  disproportionately  small. 

Dr.  Post  remarked  that  wounds  of  entrance  generally  showed  a 
a  strong  disposition  to  retract,  under  any  circumstance. 

Dr.  Geo.  T.  Elliot  stated  that  the  question  concerning  the  theory 
of  the  flattening  of  bullets  could  very  easily  be  settled  by  an  observa- 
tion of  the  state  in  which  spent  balls  are  found. 


188 


PROCEEDINGS  OF  SOCIETIES. 


[Dec, 


UTERINE  TUMORS— DR.  H.  B.  SANDS. 

Dr.  Sands  exhibited  a  mass  of  uterine  tumors,  and  gave  the  history 
of  tiie  case,  as  follows: 

It  is  my  painful  duty  to  exhibit  to  the  society  a  specimen 
obtained  from  a  woman,  whose  death  was  caused  by  a  surgical 
operation  to  which  she  submitted  by  my  advice.  She  first  came 
under  my  notice  about  three  months  ago,  having  been  sent  to  me  as 
the  supposed  subject  of  ovarian  disease,  by  a  medical  gentleman  in  this 
city,  with  a  view  of  having  an  operation  performed.  The  patient  was 
an  unmarried  woman,  45  years  of  age,  and  of  healthy  parentage. 
She  belonged  to  a  long-lived  family,  and  having  a  disease  which  she 
supposed  would  terminate  her  life  in  a  short  time,  felt  a  natural 
anxiety  to  be  cured,  if  possible,  and  to  live  as  long  as  her  ancestors 
had.  I  examined  this  woman  Avith  regard  to  her  history,  and  I  found 
that  an  abdominal  tumor  made  its  first  appearance  seven  years  before; 
the  patient  was  very  positive  in  saying  that  it  first  showed  itself  in  the 
left  iliac  fossa;  that  the  growth  was  at  first  gradual,  but  that  in  a 
year's  time  it  had  attained  a  very  considerable  size.  Just  at  the  time 
of  consulting  me  her  particular  grievance  was  the  weight  of  an  um- 
bilical hernia,  in  the  sac  of  which  was  accumulated  a  considerable 
amount  of  peritoneal  fluid.  She  represented  to  me  that  her  health 
was  suffering  severely ;  that  life,  under  the  circumstances,  had  no  at- 
tractions for  her,  and  that  she  desired  to  have  an  operation  performed. 
An  examination  of  the  tumor  led  me  to  suspect  that  it  was  not  of  ova- 
rian but  of  uterine  origin,  although  certain  facts  in  her  history  and  in  her 
physical  examination  pointed  strongly  to  the  existence  of  ovarian  dis- 
ease. On  inquiry  I  found  that  menstruation  had  never  been  excessive, 
but  that  occasionally  she  had  suffered  from  a  suspension  of  the  flow; 
at  no  time  had  there  been  any  thing  like  uterine  hemorrhage. 

The  enlargement  of  the  abdomen  was  very  great.  I  did  not 
measure  it  myself,  but  the  measurement  was  made  by  my  friend.  Dr. 
Sabine,  at  the  N.  Y.  Hospital.  He  found  the  greatest  measurement 
around  the  umbilicus  to  be  forty  inches.  The  umbilical  opening  was 
circular  in  shape,  two  inches  in  diameter,  and  there  was  considerable 
distension  of  the  sac.  In  order  to  prevent  the  protrusion  of  this 
hernia  the  patient  had  been  obliged  to  wear  a  truss,  and  it  was  this 
inconvenience,  added  to  that  caused  by  the  tumor,  which  led  her  to 
seek  relief  from  an  operation. 

This  set  of  tumors  (referring  to  the  specimen)  could  be  partly 
made  out  through  the  abdominal  walls,  which,  by  the  way,  had  no 
very  considerable  thickness.    I  could  distiuguish  this  swelling,  which  is 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


189 


a  fibrous  tumor  springing  from  the  fundus  of  tlie  uterus,  immediately 
below  the  umbilicus.  The  uterus  itself,  which  lies  beneath,  I  could 
not  distinguish  through  the  parietes  of  the  abdomen.  I  was  able  to 
feel  a  swelling  of  considerable  firmness  in  the  left  iliac  fossa,  and  a 
much  larger  oue,  in  fact,  the  largest  of  all,  existed  above  and  to  the 
right.  The  tumor  allowed  an  examination  through  the  open  umbilicus, 
and  the  larger  and  smaller  swellings  could  be  separately  distinguished. 
In  regard  to  fluctuation,  I  was  not  certain.  It  is  true  that  fluctuation 
existed,  but  the  presence  of  some  dropsical  fluid  in  the  abdominal 
cavity  so  masked  the  feeling  of  deeper  fluctuation  that,  as  I  said  before, 
I  could  not  be  positive  about  it.  I  made  a  vaginal  examination,  and 
with  great  difficulty  was  able  to  reach  the  os;  there  was  uo  vagi- 
nal cervix,  for  the  reason  that  the  uterus  bad  ascended  so  far  from 
the  outlet  of  the  pelvis.  The  uterus  was  very  decidedly  to  the  left  of 
the  median  line;  I  was  confirmed  in  this  opinion  by  the  uterine  sound, 
which  took  a  direction  upward  and  to  the  left.  The  instrument  pene- 
trated to  the  depth  of  3|  inches,  and,  during  an  examination  which 
Dr.  Krackowizer  had  the  kindness  to  make  afterward,  it  penetrated 
about  4  inches.  The  instrument  went  up  and  to  the  left,  and  there 
did  uot  seem  to  be  any  considerable  thickness  between  the  finger  out- 
side and  the  point  of  the  instrument  within  the  uterus.  On  endeavor- 
ing to  move  the  uterus  by  rotation  of  the  sound  it  was  found  impos- 
sible; but  on  taking  the  handle  of  the  sound  in  the  left  hand,  and 
moving  the  mass  upon  the  left  side  with  the  right  hand,  a  distinct 
movement  was  communicated  to  the  handle  of  the  instrument.  This 
made  me  believe  in  the  existence  of  a  uterine  rather  than  an  ovarian 
tumor.  I  subjected  the  woman  to  several  examinations,  but  was  uot 
able  to  arrive  at  any  more  satisfactory  conclusion.  I  was  induced  to 
operate  partly  on  account  of  the  woman's  urgent  request,  and  partly 
because  I  thought  it  very  manifest  that  her  health  was  suff'ering  from 
the  burden  of  this  swelling  and  the  additional  weight  of  the  hernial 
protrusion,  and  also  because  I  had  made  up  my  mind  that  uterine 
tumors  could  be  successfully  extirpated.  I  was  led  to  this  conclusion  by 
reading  the  two  cases  given  by  Mr.  Clay,  of  Manchester,  and  the  oue 
by  Koiberly,  of  Strasburg.  I  omitted  to  state  that  there  was  very 
decided  inol)ility  of  the  abdominal  swelling.  The  woman  went  to  the 
hospital  and  was  submitted  to  a  forijud  consultation;  an  operation 
was  decided  upon,  and  this  I  performed  on  the  12th  inst. 

The  patient  being  placed  under  ether,  the  operation  was  commenced 
by  an  incision  in  the  median  line,  abont  3|  to  4  inches  in  extent,  below 
the  umbilicus.    The  abdominal  cavity  was  reached  with  great  facility. 


190 


PROCEEDINGS  OF  SOCIETIES. 


[Dec, 


I  introduced  my  right  hand,  and  swe})t  it  over  the  left  surface  of  the 
tumor,  and  with  my  left  hand  felt  the  right  surface  of  the  tumor,  and 
could  detect  but  a  single  adhesion  of  about  three-quarters  of  an  inch  ia 
extent  to  the  greater  omentum.  I  should  state  that  at  this  time  the 
diagnosis  was  still  uncertain;  it  was  not  evident  to  those  who  saw  the 
swelling  through  the  incision  what  was  the  nature  of  the  tumor.  It 
was  considered  right  to  prolong  the  incision  upward.  I  accordingly 
enlarged  the  incit^ion,  and  thought  it  necessary  to  make  a  very  long 
one,  nearly  up  to  the  summit  of  the  tumor.  That  being  done,  I  was 
able,  by  placing  my  hand  behind  it,  to  dislodge  it  from  the  abdominal 
cavity,  and  bring  it  into  view.  It  thon  did  not  appear  to  be  a 
fibrous  tnmor,  and  I  was  so  much  in  doubt  of  its  character  that  I 
tapped  it;  but  no  fluid  was  found.  To  my  great  disappointment,  on 
passing  down  into  the  pelvic  cavity  I  found  that  my  hand  was  arrested 
by  large  and  firm  adhesions.  My  impression  was,  at  this  time,  that 
the  further  prosecution  of  the  operation  would  be  fatal  to  the  patient; 
yet  I  readily  yielded  to  the  advice  of  my  colleagues  to  proceed  with 
the  extirpation  of  the  tumor,  as  I  had  reason  to  believe,  with  the  other 
gentlemen  present,  that  if  the  mass  were  returned  the  woman  would 
certainly  die,  while  by  the  removal  of  the  mass  she  might  have  a 
chance  of  life.  We  accordingly  commenced  the  dissection,  which  was 
a  very  difficult  operation,  as  step  by  step  we  were  met  by  dangers  in 
the  shape  of  blood-vessels  of  various  sizes,  large  and  small.  Towards 
the  last  the  operation  had  to  be  hurried,  as  the  woman  showed  signs 
of  fainting;  and  after  much  trouble,  and  a  great  deal  of  embarrassment, 
this  tumor  was  finally  removed.  The  mass  was  removed  above  the 
line  of  implantation  of  the  vagina  into  the  cervix  uteri.  As  soon  as 
this  was  completed,  it  became  evident  that  there  was  very  alarming- 
exhausting  hemorrhage.  The  sponges  were  removed,  and  pressure 
made  upon  the  bleeding  points,  and  these  points  were  secured  as  fast 
as  possible.  The  main  hemorrhage  was  found  to  come  from  a  rent  in 
the  common  iliac  vein.  The  summit  of  the  bladder  was  unavoidably 
ruptured;  it  was,  however,  closed  again  by  the  application  of  a  ligature. 
The  operation  consumed  about  one  hour  and  a  half,  and,  notwithstanding 
the  free  use  of  stimulants,  the  patient  sank  and  died  a  few  minutes 
after  its  completion.  Death,  in  my  opinion,  was  mainly  due  to  hem- 
orrhage, taking  place  from  large  blood-vessels  in  the  pelvic  cavity,  which 
were  unavoidably  lacerated  during  the  operation.  Regretting,  as  I 
do,  the  unfortunate  termination  of  the  case,  I  am  still  inclined  to  re- 
gard the  disaster  as  one  which  might  happen  in  the  extirpation  of  an 
ovarian  as  well  as  a  uterine  tumor,  ai.d  tan  see  no  reason  why,  in  the 


1865.] 


PROCEEDINGS  OF  SOCIETIES. 


191 


absence  of  deep-seated,  extensive  adhesions,  the  removal  of  the  uterus 
might  not  be  accomplished  with  a  favorable  result. 

An  examination  of  the  mass  removed  shows  it  to  consist  of  the 
uterus  and  appendages,  the  former  being  the  seat  of  a  large  number  of 
fibrous  tumors,  some  of  which  are  developed  in  its  walls,  the  largest, 
however,  forming  nearly  independent  growths,  connected  with  the 
uterus  only  by  long  narrow  pedicles.  The  uterus  itself  is  nodulated 
externally,  but  preserves  nearly  its  regular  figure;  it  is  greatly  hyper- 
trophied,  however,  measuring  nine  inches  in  its  longest  diameter.  The 
uterine  sound  can  be  made  to  pass  over  seven  inches  through  a  some- 
what tortuous  canal.  The  mucous  membrane  lining  the  interior  is 
slightly  thickened  and  vascular,  but  otherwise  healthy.  The  principal 
outgrowths  from  the  uterus  are  three  in  number,  one  attached  to  the 
summit  and  one  to  either  side  of  the  body  of  the  organ — that  upon 
the  right  side  being  the  largest.  On  section  these  tumors  exhibit  the 
usual  appearances  of  the  softer  variety  of  fibrous  growth,  resembling 
in  many  places  cedematous  areolar  tissue.  The  largest  tumor — that 
in  the  right  side — is  the  seat  of  several  cysts  containing  serum.  The 
mass,  three  days  after  removal,  weighed  sixteen  pounds,  but  as  it  di- 
minished considerably  in  bulk  from  the  loss  of  fluid  during  the  interval, 
it  is  estimated  to  have  exceeded  twenty  pounds  in  weight  at  the  time 
of  the  operation. 

OVARIAN  TUMOR  DR.  GEO.  T.  ELLIOT. 

Dr.  Geo.  T.  Elliot  presented  a  specimen  of  ovarian  tumor,  with  a 
written  history. 

(For  a  full  report  of  this  case  see  the  September  number,  p.  409.) 

Dr.  Clark  stated  that  he  had  seen  the  patient  on  several  occasions, 
and  the  last  time  he  had  come  to  the  conclusion  that  there  was  nothing 
to  hinder  her  recovery.  She  had  no  well  marked  signs  of  peritonitis 
at  any  time,  and  during  all  the  period  which  she  was  visited  by  him 
there  were  no  symptoms  that  excited  any  special  anxiety.  In  con- 
clusion he  stated  that  he  would  like  to  add  one  fact  in  regard  to  the 
statements  of  Dr.  Sands  in  regard  to  the  removal  of  the  uterus. 
About  fifteen  years  ago  Dr.  Kimball,  of  Lowell,  operated  upon  a 
female  in  some  uncertainty  whether  he  had  a  uterine  or  ovarian  tumor. 
It  proved  to  be  a  fibrous  tumor  of  the  uterus;  he  removed  the  organ 
and  its  appendngcs,  and  the  patient  made  a  good  recovery. 

Dr.  CoNANT  referred  to  a  uterine  tumor  that  had  lately  been  re- 
moved in  Boston,  but  the  patient  survived  the  operation  only  twelve 
hours. 


192 


PROCEEDINGS  OP  SOCIETIES. 


[Dec, 


Dr.  Krackowizer  was  inclined  to  think  that  the  diarrhoea  which 
terminated  the  life  of  Dr.  Elliot's  patient  was  purely  of  accidental 
character,  and  unconnected  with  sej)ticirmia.  In  regard  to  Dr.  Sands' 
case,  he  believed  that  uterine  tumors  could  be  removed  with  safety,  the 
only  difficulty  being  to  decide  whether  or  not  there  were  any  extensive 
adhesions  to  the  pelvis. 

Slated  Meeting,  June  28. 
Dr.  GuRDON  Buck,  President,  in  the  Chair. 

CHRONIC  INTESTINAL  OBSTRUCTION — DR.  H.  B.  SAKD3. 

Dr.  Sands  exhibited  several  specimens  taken  from  the  body  of  a 
young  man  who  had  suffered  from  the  effects  of  chronic  intestinal  ob- 
struction during  life,  and  in  whose  case  he  had  performed  Amussat's 
operation  for  the  formation  of  an  artificial  anus.*  The  operation  was 
done  on  the  9th  of  January,  and  afforded  at  the  time  complete  relief 
from  the  distressing  symptoms  which  preceded  it.  The  swelling  of  the 
abdomen  subsided,  the  pain  disappeared,  and  the  feces  escaped  readily 
through  the  artificial  opening.  Meanwhile  the  patient  gained  strength, 
his  appetite  improved,  and,  towards  the  latter  part  of  January,  he  was 
able  to  got  up  and  walk  about  the  hospital  wards. 

For  about  ten  days  after  the  operation,  the  discharge  of  feces 
through  the  wound  was  nearly  constant,  ljut  subsequent  to  this  it  was 
intermittent  and  irregular,  sometimes  taking  place  spontaneously,  at 
other  times  by  the  aid  of  an  enema  of  warm  water,  or  after  the  ad- 
ministration of  a  laxative.  The  artificial  auus  showed  the  usual  ten- 
dency to  contraction,  to  obviate  which,  as  well  as  to  prevent  the 
involuntary  escape  of  fecal  matter,  the  patient  wore  an  instrument, 
constructed  at  my  request  by  Messrs.  Tiemann  k  Co.,  consisting  of  a 
cylindrical  plug  of  hard  rubber  attached  to  a  plate  of  the  same  sub- 
stance, which  covered  the  neighboring  skin,  the  whole  being  retained 
in  position  by  tapes  passing  round  the  waist.  This  apparatus  answered 
its  purpose  admirably,  and  was  worn  for  some  time  with  great  comfort; 
its  use  was  finally  abandoned,  however,  in  consequence  of  the  orifice 
of  the  intestine  becoming  inflamed  by  the  repeated  introduction  of  the 
syringe. 

On  the  27th  of  February  the  patient  had  so  far  improved  that  he 
left  the  hospital  and  paid  a  visit  to  his  friends  in  Rhode  Island.  On 


*  Case  reported  in  the  April  number  of  New  York  Medical  Jouenal,  18G5. 


1865.] 


PROCEEDINGS  OP  SOCIETIES. 


193 


the  third  of  March  following,  however,  he  returned  to  the  hospital, 
complaining  again  of  pain,  and  a  feeling  of  abdominal  distension. 
Feces  were  discharged  in  small  quantity,  and  at  irregftlar  intervals, 
from  both  the  natural  and  artificial  outlets,  yet  the  relief  thus  afforded 
was  incomplete.  A  careful  exploration  was  again  undertaken,  and  an 
attempt  made  to  dilate  the  strictured  intestine  by  an  elastic  bougie  in- 
troduced through  the  artificial  anus.  The  effort  was  unsuccessful,  the 
instrument  being  suddenly  and  completely  arrested  at  a  point  opposite 
to  the  situation  of  the  internal  abdominal  ring,  aud  about  eight  inches 
from  the  lumbar  opening. 

The  subsequent  progress  of  the  case  may  be  briefly  told.  The 
symptoms  were  mainly  those  which  had  existed  previous  to  the  per- 
formance of  Amussat's  operation,  and  pointed  to  the  presence  of 
mechanical  obstruction  at  some  other  point  than  that  for  which  the 
operation  had  been  undertaken.  Gradually  increasing  abdominal  dis- 
tension, obstinate  constipation,  loss  of  appetite,  emaciation,  and  par- 
oxyisms  of  iutense  pain  finally  exhausted  the  patient,  who  died  rather 
suddenly  in  the  night  of  May  1st,  less  than  four  months  after  the  op- 
eration. 

Autopsy,  thirty  hours  after  death.  Body  extremely  emaciated; 
abdomen  somewhat  distended,  and  tympanitic.  Head  not  examined. 
Thoracic  organs  healthy,  e.Kcept  the  right  lung,  which  presented,  near 
its  apex,  two  masses  of  tubercular  deposit,  each  one  being  a  little 
larger  than  a  hazel-nut.  In  one  of  these  masses  the  morbid  product 
was  iu  process  of  softening;  in  the  other,  it  had  undergone  calcifi- 
cation. 

On  opening  the  cavity  of  the  abdomen,  small  yellowish-white  nodules 
and  patches  were  found  scattered  abundantly  beneath  the  peritoneum 
lining  the  abdominal  walls,  and  that  covering  the  large  and  small  in- 
testine, and  also  in  tlie  substance  of  the  great  omentum.  These,  on 
subsecpient  examination,  proved  to  be  tuberculous.  The  omentum  was 
misshapen,  folded  upon  itself,  and  adherent  to  the  small  intestine. 
The  coils  of  the  latter  were  universally  adherent  to  one  another,  the 
union  being  iu  some  places  so  firm  as  to  resist  all  attempts  at  separa- 
tion. Immediately  above,  and  in  the  upper  third  of  the  pelvic  cavity, 
the  coats  of  the  small  intestine  were  greatly  thickened  and  indurated, 
from  chronic  infiannnatory  deposit,  so  that  its  convolutions  formed  a 
nearly  solid  mass,  which  was  firmly  adherent  to  the  posterior  abdom- 
inal wail,  and  to  the  anterior  surface  of  the  rectum.  The  coats  of 
the  latter  exhibited  the  same  kind  of  thickening  and  induration,  es- 
pecially just  above  the  promontory  of  the  sacrum,  where  its  calibre  was 

Vol.  II.— No.  9.  13 


194 


PROCEEDINGS  OF  SOCIETIES. 


[Dec, 


80  much  diminished  as  hardly  to  admit  the  tip  of  the  httle  finger.  In 
all  that  portion  of  the  small  intestine  included  in  the  mass  above  de- 
scribed, a  pprtion  embracing  several  feet  of  its  length,  the  canal  was 
narrowed  in  its  diameter,  and  in  three  or  four  places  was  only  large 
enough  to  give  passage  to  a  full  sized  steel  bougie.  Absolute  oblitera- 
tion of  the  mtestinal  canal  was,  however,  nowhere  to  be  seen.  The 
large  intestine,  with  the  exception  of  the  lower  part  of  the  sigmoid 
flexure  and  the  rectum,  was  but  slightly  thickened,  and  its  calibre  was 
normal.  A  careful  examination  failed  to  detect  any  evidences  of 
ulceration  of  the  intestinal  mucous  membrane,  either  past  or  present. 
The  artificial  opening  in  the  colon  was  found  to  have  been  made 
quite  behind  the  peritoneum,  and  no  traces  of  inflammation  were  ob- 
eerved  that  could  be  attributed  to  the  operation.  The  results  of  the 
post-mortem  examination  render  it  evident  that  the  symptoms  presented 
by  the  patient  during  life  were  due  to  chronic  intestinal  obstruction, 
caused  by  tubercular  peritonitis.  It  is  also  evident  that  the  obstruc- 
tion made  its  appearance  in  the  lower  part  of  the  sigmoid  flexure  of 
the  colon  at  a  time  when  the  passage  of  fecal  matters  through  the 
small  intestine  was  tolerably  free,  so  that  the  formation  of  an  artificial 
anus  afi'orded  complete  relief  immediately,  and  for  some  time  after  the 
operation.  Gradually,  however,  the  disease  extended  to  the  small 
intestine,  and  gave  rise  to  mechanical  obstruction  which,  not  admitting 
of  further  surgical  relief,  necessarily  hastened  to  a  fatal  termination. 


VESICAL  CALCULUS  DR.  D.  S.  CONANT. 

Dr.  CoNANT  presented  a  vesical  calculus  weighing  645  grains,  which 
he  removed  from  a  gentleman  in  Brunswick,  Maine.  A  year  ago  last 
spring  a  gentleman  presented  himself  at  the  college  with  severe 
trouble  in  the  bladder,  which  had  been  designated  as  chronic  inflamma- 
tion, he  having  been  under  treatment  for  that  aS"ection  for  six  months 
previously.  On  careful  examination  with  the  sound,  a  stone  was  found 
in  the  bladder,  but  the  patient  not  being  ready  for  its  removal,  the  op- 
eration was  deferred  until  the  26th  of  April  last.  The  operation  was 
performed  by  a  single  lateral  incision  on  the  left  side,  and  lasted  but 
little  over  four  minutes.  In  two  weeks  after  the  operation  the  patient 
was  out  riding,  and  in  three  weeks  he  was  able  to  be  about  the 
village.  The  patient  did  not  wear  the  catheter  for  a  single  day  at  a 
time  after  the  operation,  although  the  instrument  was  daily  intro- 
duced for  two  weeks  iu  order  to  see  that  the  healing  was  going  on 
rightly. 


1865.] 


PEOCEEDINGS  OF  SOCIETIES. 


195 


OSTEO-MYELITIS — DR.  WEIR. 

Dr.  Weir  presented  a  femur  which  he  had  removed  from  a  soldier, 
a  patient  of  St.  Luke's  Hospital,  on  the  7th  of  June,  by  amputation 
at  tlie  hip-joint.  Tlie  patient  was  wounded  at  the  first  battle  of 
Frederick,  December  18,  1862,  by  two  balls  which  entered  the 
right  thigh;  one  of  these,  a  minie,  fractured  the  upper  and  middle 
third,  and  a  number  of  large  fragments  of  bone  were  removed.  He 
was  transferred  from  one  hospital  to  another,  until  he  finally  entered 
the  St.  Luke's,  on  the  9th  of  June,  1864.  From  the  date  of  his 
entrance  into  the  latter  hospital,  several  abscesses  had  formed  which 
communicated  with  the  seat  of  fracture,  though  no  dead  bone  at  that 
point  was  felt.  He  kept  about  on  crutches  until  October,  1864, 
when  he  was  compelled,  by  a  repetition  of  abscesses,  to  go  to  bed. 
These  abscesses  were  discharging,  more  or  less,  all  the  time  well  formed 
pus.  In  May,  when  Dr.  Weir  went  on  duty,  a  new  abscess  formed, 
running  up  towards  the  trochanter,  and  the  patient  then  commenced 
rapidly  to  run  down.  A  consultation  was  called,  and  it  was  decided 
to  remove  the  thigh  by  disarticulation,  which  was  accordingly  done 
by  the  method  known  as  Van  Buren's.  Patient,  at  last  report,  wa.s 
doing  well.  The  specimen  was  a  very  interesting  and  beautiful  one  of 
osteo-rayelitis.  In  the  substances  of  the  head  of  the  bone  there  were 
two  small  abscesses  which  had  nearly  made  their  way  through  the  thin 
crusted  surface.  There  was  never  any  complaint  of  inflammation  in  the 
knee-joint.  About  six  ounces  of  blood  only  were  lost  during  the  oper- 
ation in  consequence  of  the  application  of  the  clamp  tourniquet  to  the 
aorta. 

Dr.  Buck  thought  that  the  case  was  a  very  favorable  one  for  opera- 
tion, and,  in  fact,  aflforded  a  good  illustration  of  the  good  effect  of  an 
operation  which  was  performed  for  chronic  disease  of  a  limb. 

SALIV.VKY  CALCULUS — DR.  L.  A.  VOSS. 

Dr.  Voss  presented  a  salivary  calculus,  removed  from  the  left  Whar^ 
ton  duct  of  a  patient  21  years  of  age,  who  came  to  him  complaining  of" 
pain  in  the  submaxillary  region.  On  examining  the  mouth,  Whar- 
ton's duct  was  seen  very  much  distended,  and  its  orifice  was  very  prom- 
inent. On  introducing  a  fine  probe  a  slimy  fluid  mixed  with  pus 
escaped,  and  the  instrument  soon  struck  upon  a  hard  substance  which 
proved  to  lie  the  calculus,  and  whicli  was  removed  by  a  siniple  inci- 
sion. Tiiis  calculus  was  confined  altogether  to  the  duct,  and  was  of 
course  more  easily  removed  than  if  it  had  been  in  the  substance  of  tho: 


196 


PROCEEDINGS  OP  SOCIETIES. 


[Dec, 


submaxillary  gland.  These  concretions  were  mostly 'made  up  of  phos- 
phate of  lime  and  chloride  of  soda. 

Dr.  Post  remarked  that  concretions  in  all  the  mucous  glands  were 
for  the  most  part  made  up  of  phosphate  of  lime. 

In  answer  to  a  question  from  Dr.  Buck,  as  to  the  size  of  these  cal- 
culi, Dr.  Voss  stated  that  he  had  seen  six  cases  of  the  sort,  and  in  all 
the  concretions  were  of  large  size,  except  in  one  instance.  Dr.  Det- 
mold  had  one  case  where  the  calculus  was  the  size  of  an  almond; 
another  one  which  Dr.  Voss  had  seen,  and  which  was  removed  by 
piecemeal  through  a  fistulous  opening  was  as  large  as  a  cherry.  It 
was  a  curious  fact  for  him  to  notice  that  all  the  salivary  concretions 
which  he  had  seen  were  connected  with  the  submaxillary  gland.  He 
further  remarked  that  these  concretions  were  not  unusual  in  horses, 
the  nuclei  of  which  were  formed  from  some  portions  of  the  fodder.  In 
conclusion  he  referred  to  a  case  of  concretion  in  the  submaxillary  gland 
which  occurred  in  the  practice  of  Dr.  Krackowizer.  A  probe  passed 
into  the  duct  could  not  detect  the  calculus,  but  a  needle  passed  from 
the  inside  into  the  tumor,  struck  the  hard  substance.  An  attempt 
was  made  to  remove  the  stone  by  an  incision  on  the  inside  of  the 
mouth,  but  failed  in  effecting  the  object;  but  finally  suppuration  and 
ulceration  in  the  parts  took  place,  and  the  stone  was  discharged  ia 
fragments. 

Dr.  CoxANT  stated  that  he  presented,  two  years  since,  a  calculus 
from  Wharton's  duct,  measuring  an  inch  in  length,  |  inch  in  width, 
and  I  inch  thick. 

ANECRISII  OF  THE  AORTA — DR.  A.  L.  LO0MI3. 

Dr.  LooMis  presented  a  specimen  taken  from  a  German  29  years  of 
age,  who  was  admitted  into  Bellevue  Hospital  on  the  3d  of  June. 
He  stated,  on  his  admission,  that  he  had  been  well  up  to  five  years 
ago,  when  he  had  an  attack  of  inflammatory  rheumatism,  which  con- 
fined him  for  about  six  weeks,  after  which  tune  he  was  well  up  to  six 
months  ago,  when,  after  making  an  exertion  in  going  up  stairs,  he 
noticed  that  he  had  shortness  of  breath,  with  palpitation  of  the  heart. 
Tnree  months  ago  he  noticed  that  his  feet  began  to  swell,  and  at  thus 
time  his  attacks  of  dyspnoea  became  more  frequent  and  severe  On 
admission,  his  general  appearance  indicated  that  he  was  suffering  from 
organic  disease;  his  countenance  was  anxious,  his  pulse  80  and  jerking, 
but  his  mind  was  clear.  On  physical  examination,  bronchial  rales 
were  heard  on  both  sides;  there  was  no  dullness  on  percussion.  The 
heart  was  found  hypertrophicd,  the  apex  beating  about  an  inch  and 


18C5.] 


PROCEEDINGS  OF  SOCIETIES. 


197 


a  half  to  the  h-ft  of  the  left  nipple.  On  auscultation,  three  distinct 
murnmrs  were  lujard,  one  at  the  apex  of  a  blowing  character,  and  one 
to  the  left  of  the  apex  and  behind  at  the  angle  of  the  scapula. 
A.nother  following  the  first  sound,  of  a  different  character,  heard 
at  the  base  and  conveyed  along  the  artery;  and  a  third  at  the  base, 
and  conveyed  downwards  and  to  the  right,  following  the  second  sound, 
and  heard  at  the  junction  of  the  third  rib  with  the  sternum  on  the 
right  side,  being  harsh  in  character.  From  this  time  his  dropsical 
effusion  went  on  rapidly,  his  feet  and  lower  extremities  became  more 
cedematous,  extending  up  so  as  to  involve  the  scrotum,  yet  the  rhythm 
of  the  heart  was  perfect  up  to  the  time  of  his  death.  The  murmurs 
were  distinctly  recognized,  and  they  were  so  different  in  character,  the 
two  murmurs  following  the  first  sound,  that  any  one  could  appreciate 
it.  Ee  died  from  sloughing  of  the  integument  of  the  lower  extremi- 
ties. At  the  autopsy,  all  the  organs  were  found  healthy,  except  the 
heart  and  kidneys.  It  is  proper  to  state  that  granular  casts  were 
found  in  bis  urine,  which  explained  the  advanced  stage  of  disease  with 
which  the  kidneys  were  affected.  They  weighed  together  18  oz.  The 
left  side  of  the  heart  was  markedly  hypertropied,  the  walls  of  the  ven- 
tricle being  |  of  an  inch  in  thickness.  The  left  cavity  was  dilated,  but 
not  very  extensively  so.  There  was  found  a  fibrinous  deposit,  which 
was  pretty  well  organized,  upon  the  endocardium  of  the  left  ventricle, 
and  also  upon  the  commencement  of  the  artery.  The  aortic  valves 
were  thickened,  and  were  slightly  insufiBcient,  the  mitral  valves  were 
also  thickened  but  were  not  insufficient,  and  it  seemed  to  Dr. 
Loomis  that  they  were  not  sufficiently  diseased  to  give  rise  to  the 
murmur  which  was  heard  at  the  apex.  At  the  commencement  of  the 
aorta  was  one  of  those  unrecognized  and  unrecognizable  aneurismal 
sacs,  with  an  opening  large  enough  to  admit  the  end' of  the  little  finger, 
and  capable  of  containing  about  two  ounces  of  fluid.  This  sac  had  not 
been  ruptured.  The  point  of  interest  with  Dr.  Loomis  was,  how  much 
the  sound,  which  was  heard  at  the  apex,  was  due  to  disease  at  the 
base  ? 

Dr  Flixt  thought,  that  inasmuch  as  the  murmur  with  the  sec- 
ond sound  was  heard  to  the  right  of  the  sternum,  which  is  not  true  as 
a  sign  of  regurgitation,  it  might  be  suggestive  of  the  existence  of  an 
aneurism. 

Dr.  Krackowizer,  in  this  connection,  thought  that  the  aneurism 
pointed  towards  the  right  side. 

Dr.  Looms  presented  a  second  specimen  taken  from  a  young  Ger- 
man girl,  who  was  received  into  the  Hospital  on  the  12  th  of  June. 


198 


PROCEEDINGS  OP  SOClETrES. 


[Dec., 


When  she  was  admitted  she  was,  to  all  appearances,  in  perfect  health. 
She  stated  that  she  had  been  well  up  to  a  month  before,  when  she 
became  disabled  on  account  of  a  pain  in  her  chest  and  limbs,  and  that 
this  pain  had  compelled  her  to  remain  in  bed.  On  examination,  her 
pulse  was  found  to  be  100,  and  very  nearly  natural  in  character;  her 
respiration  was  slightly  hurried,  and  she  complained  constantly  of  a 
sense  of  constriction  and  pain  across  her  chest.  The  physical  exam- 
ination revealed  a  murmur,  and  this  murmur  was  the  interesting  point 
in  her  case.  It  was  heard  at  the  apex,  following  the  first  sound,  and 
heard  with  equal  intensity  at  the  angle  of  the  scapula  behind.  There 
was  also  a  different  sound  at  the  junction  of  the  fourth  rib  with 
the  sternum,  preceding  and  following  the  first  sound;  this  was  of 
harsh  character,  and  it  resembled  so  closely  the  friction  sound  that  it 
was  mistaken  for  it,  and  a  diagnosis  was  accordingly  made  of  mitral 
regurgitation  with  pericarditis.  This  case  was  also  examined  by  Dr. 
Flint,  who  recognized  a  mitral  obstruction,  and  a  mitral  regurgitation 
murmur. 

Dr.  Flint  stated  that  he  had  a  recollection  of  examining  the  case 
and  recognizing  a  mitral  obstructive  murmur,  but  remarked,  in  that 
connection,  that  such  a  murmur  always  ceased  with  the  first  sound  of 
the  heart. 

Dr.  Clark  called  to  the  mind  of  the  Society  that  he  was  placed  upon 
a  committee  to  report  upon  the  question  as  to  whether,  in  diseases  of 
the  heart,  the  murmurs  ceased  to  be  heard  when  the  patient  was  suffer- 
ing from  pneumonia;  and  as  that  committee  had  been  instructed  to 
report  within  four  months,  and  as  that  time  would  expire  before  the 
next  meeting,  he  ventured  to  make  an  informal  report,  in  the  absence 
of  the  other  gentlemen  composing  that  committee. 

He  stated  that  he  had  seen  but  three  cases  of  pneumonia  with  heart 
disease.  In  one  of  them  the  heart  sounds  continued  from  beginning 
to  end,  and  in  two  the  heart  sounds  continued  all  the  time  that  the 
pulse  did  not  exceed  120  per  minute.  In  three  or  four  instances  of 
heart  disease  where  the  patients  were  suffering  from  other  troubles 
than  pneumonia,  and  where  the  pulse  wa.s  accelerated,  the  murmurs 
ceased  to  be  heard,  and  tliis  afforded  the  true  explanation  for  the  phe- 
nomenon, viz.:  that  any  disease  which  sufficiently  accelerates  the  pulse 
will,  in  patients  already  suffering  from  heart  disease,  render  the  mur- 
murs inaudible. 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  199 


EEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 

The  Practice,  of  Medicine  and  Surgery  applied  to  the  Diseases  and  Acci- 
dents incident  to  Women.  By  Wm.  H.  Byford,  A.M.,  M.D.,  author  of 
"  A  Treatise  on  the  Chronic  Inflammation  and  Displacements  of  the 
Uninipregnated  Uterus,"  and  Professor  of  Obstetrics  and  Diseases 
of  Women  and  Children  in  the  Chicago  Medical  College.  Phila- 
delphia: Lindsay  &  Blakiston. 

Prof  Byford  has  reason  to  congratulate  himself  on  the  favorable  and 
very  well  deserved  reception  that  has  been  accorded  to  his  "  Treatise 
on  Inflammation  and  Displacements  of  the  Uterus,"  and  the  present 
volume  from  his  pen  is  worthy  of  attentive  critical  examination.  The 
publishers  have  done  their  part  well.  The  paper,  type  and  binding 
are  in  every  way  acceptable.  In  the  preface  we  are  informed  that  the 
work  is  written  "  for  the  student  and  junior  practitioner;"  but  we  are 
not  informed  of  the  fact  that  the  present  volume  contains  the  whole 
of  the  "  Treatise "  referred  to,  verbatim  et  literatim.  Of  the  555 
pages  in  the  present  volume,  193  are  reprinted  from  the  author's 
previous  work,  leaving  us  but  362  to  consider  in  the  present  review. 
They  treat  of  the  following  topics:  Chap.  I.  Diseases  and  Accidents 
of  the  Labia  and  Perineum.  Chap.  II.  Diseases  of  the  Vulva.  Chap. 
III.  Vaginitis.  Chap.  IV.  Menstruation,  and  its  Disorders.  Chap.  V. 
Menorrhagia.  Chap.  VI.  Dysmenorrhoea.  Chap.  VII.  Metatithmenia, 
( MeTart0/j/^t /ijjv,)  or  Misplaced  Menstruation.  Chap.  VIII.  Acute 
Inflammation  of  the  Unimpregnated  Uterus.  We  now  pass  over  to 
the  middle  of  Chap.  XXII.,  where,  in  the  consideration  of  Displacements, 
their  Philosophy  and  Treatment,  the  latter  half  of  the  chapter  is 
devoted  to  Inversion  of  the  Uterus,  a  topic  not  studied  in  our  author's 
previous  work.  Chap.  XXIII.  Diseased  Deviations,  or  Involutions 
of  the  Uterus.  Chap.  XXIV.  Cancer  of  the  Uterus.  Chap.  XXV. 
Tumors  of  the  Uterus.  Chap.  XXVI.  Ovarian  Tumors.  Chap. 
XXVII.  Diseases  of  the  Mamma;.  Chap.  XXVIII.  Phlegmasia 
Alba  Dolens,  or  Crural  Phlebitis.  Chap.  XXIX.  Puerperal  Fever. 
Chap.  XXX.  Stomatitis  Materna,  or  Nursing  Sore  Mouth. 

These  important  topics  are  all  handled  vigorously  and  practically,  and 
the  earnest,  energetic  desire  of  the  author  to  advance  the  best  interests 
of  his  patients  and  the  profession  is  seen  in  every  page.  '"The  work 
can  not  fail  to  be  in  great  demand,  and  to  exert  a  material  influence  on 
clinical  practice  throughout  the  country.  While  we  cordially  recom- 
mend the  book  to  the  "student  and  junior  practitioner,"  as  well  as  to 


200  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [DeC, 


specialists,  we  are  convinced  that  such  a  general  and  hearty  recommen- 
dation needs  certain  qualifications ;  and  when  we  consider  the  deservedly 
high  position  which  the  author  holds  as  a  practitioner,  a  teacher,  and 
an  author,  we  feel  warranted  in  offering  a  running  commentary  on  such 
portions  of  the  book  as  seem  to  us  deficient  in  the  best  clinical  recom- 
mendations, without  incurring  thereby  the  risk  of  being  misunderstood. 
Such  comments  are  not  intended  to  detract  from  the  sincere  and 
hearty  favor  with  which  we  welcome  and  recommend  the  book,  or  to 
be  accepted  as  any  evidence  or  indication  that  the  points  to  which  we 
except  in  this  brief  article  are  other  than  exceptional  in  the  book 
itself.  The  author  and  the  profession  will  decide  whether,  after  all, 
the  views  of  Dr.  Byford  may  not  be  better  than  those  of  the  reviewer. 

In  Chap.  I.  the  subject  of  Rupture  of  the  Perineum  is  considered, 
from  an  operative  point  of  view,  in  strict  accordance  with  the  well 
known  principles  inculcated  by  Mr.  Baker  Brown.  For  this  gentle- 
man, indeed,  our  author  entertains  a  sincere  deference,  as  may  be  seen 
in  several  allusions  scattered  through  the  work  itself;  and  he  states 
that,  "  for  the  most  destructive  form  of  rupture,  the  operation  taught 
by  Mr.  Baker  Brown  is  so  perfect,  and  has  been  so  entirely  success- 
ful in  my  own  hands,  that  I  will  not  apologize  for  recommending  and 
describing  it  without  variation."  Dr.  Byford  has  also  reproduced  the 
well  known  plates  of  Mr.  Brown  illustrative  of  the  operation. 

Now  it  is  the  conviction  of  the  reviewer  that  the  operation  which 
has  been  performed  for  the  last  ten  years  in  this  city  by  Dr.  Sims  and 
Dr.  Emmet  is  a  much  better  operation  than  that  of  Mr.  Brown's,  and 
moreover,  in  an  American  book,  it  would  certainly  have  been  well  to 
have  recognized  an  American  operation.  The  objection  to  Mr. 
Brown's  operation  is  this,  viz.,  that  division  of  the  sphincter  is  not  at 
all  necessary,  much  less  the  double  division  inculcated  by  Mr.  Brown 
and  Dr.  Byford.  Division  of  the  sphincter  ani  is  a  very  simple  matter; 
the  safety  as  regards  blood-vessels,  and  the  secure  pads  of  fat  in  the 
ischio-rectal  fossae  encourage  the  inexperienced  operator;  but  we 
are  convinced  that  in  many  cases  the  subsequent  contraction  of  the 
cicatrices  interfere  with  due  retention  of  gases  and  fluid  feces,  and  we 
appeal  to  those  surgeons  who  have  followed  up  their  cases,  and  to 
those  who  have  been  the  subject  of  the  operation,  whether  these  con- 
siderations are  not  of  weight.  Now  the  operation  of  Dr.  Sims  and  Dr. 
Emmet  discards  division  of  the  sphincter;  and,  at  the  request  of  the 
reviewer,  Dr.  Emmet  has  kindly  furnished  the  following  brief  abstract 
of  their  operation  and  its  results. 

"In  the  operation  for  closing  a  lacerated  perinenm,  either  partially 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  201 

or  entirely  through  the  sphincter  ani,  it  is  unnecessary  to  divide  the 
muscle  or  to  make  incisions  into  the  soft  parts  for  the  purpose  of 
relieving  tension. 

"As  early  as  1855  Dr.  Sims,  in  the  Woman's  Hospital,  simplified 
this  operation  by  bringing  the  scarified  edges  of  the  laceration  together 
by  means  of  deep  interrupted  silver  sutures,  and  from  this  time  the  use 
of  the  quill  suture,  or  a  division  of  the  sphincter  ani,  has  been  aban- 
doned. Further  experience  demonstrated  a  necessity  for  the  use  of  a 
short  rectal  tube  for  some  ten  or  twelve  days  after  the  operation,  that 
a  free  escape  of  flatus  might  be  unobstructed.  Where  the  laceration 
of  the  perineum  has  extended  only  to  the  sphincter,  the  rectal  tube  is 
not  needed,  and  three  interrupted  sutures  are  generally  sufficient;  if 
more  extensive,  so  as  to  involve  the  muscle,  two  in  addition  are  re- 
quired. The  first  suture  passed  should  be  the  one  nearest  to  the  rectal 
mucous  membrane,  and  should  be  made  to  follow  the  laceration  entirely 
around,  so  as  to  bring  together  the  sphincter.  The  second  should  also 
Include  the  sphincter,  and  be  passed  in  the  recto-vaginal  septum,  just 
beyond  the  first  one.  The  remaining  sutures  are  introduced  (as  iu  the 
operation  for  a  partial  laceration  of  the  perineum)  through  one  labia 
about  half  an  inch  from  the  edge  on  one  side,  introduced  from  within 
outward  into  the  other,  and  withdrawn  at  a  point  equally  distant,  so 
as  to  approximate  perfectly  apposite  surfaces.  If  the  laceration  has 
extended  up  the  recto-vaginal  septum  for  some  distance  beyond  the 
sphincter  ani,  the  edges  should  be  brought  together  down  to  the 
sphincter  by  interrupted  silver  sutures,  at  a  distance  of  about  five 
sutures  to  the  inch.  On  introducing  the  fii'st  suture  to  clear  the 
perineum,  care  must  be  taken  that  it  is  passed  between  the  first  and 
second  sutures  uniting  the  septum,  and  the  next  one  in  turn  between 
the  second  and  third.  Without  this  precaution  an  opening  into  the 
vagina  will  be  produced  just  behind  the  sphincter,  from  the  fact  that, 
as  one  set  of  sutures  is  passed  at  a  right  angle  to  the  other,  on  twisting 
those  of  the  perineum,  tension  would  be  exerted.  This  is  a  weak  point, 
for  if  the  tube  is  allowed  to  become  obstructed,  a  small  recto-vaginal 
opening  will  always  result  from  the  escape  of  flatus  in  this  direction. 
I  always  scarify  by  means  of  scissors;  it  can  be  done  rapidly,  and  with 
less  hemorrhage.  The  knees  should  be  kept  tied  together  ten  days 
after  the  operation,  and  the  urine  drawn  with  care,  so  that  none  is 
allowed  to  escape  over  the  surfaces  brought  in  apposition. 
•  "  The  sutures  of  the  perineum  are  usually  removed  about  the  sixth 
day;  those  within  the  vagina  must  remain  for  two  weeks  or  longer, 
until  the  parts  are  strong  enough  to  admit  of  the  introduction  of  a 


202 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES,  [DcC, 


speculum.  The  bowels  are  to  be  constipated  for  two  weeks  at  least 
in  all  cases  where  the  sphincter  has  been  lacerated.  When  the  bowels 
are  acted  on  by  either  a  purgative  or  a  warm  mucilaginous  injection, 
the  success  of  the  operation  will  greatly  depend  on  the  dexterity  of  the 
nurse  in  properly  supporting  the  parts. 

"  During  the  past  ten  years,  in  the  hospital  practice  of  Dr.  Sims  and 
my  own,  this  operation  has  been  uniformly  successful.  There  has  not 
been  a  single  case  of  failure  in  uniting  the  sjjbincter  and  perineum  by 
the  first  operation.  I  have,  however,  occasionally  partially  failed  in 
private  practice,  where  the  laceration  has  been  extensive,  from  a  want 
of  care  in  keeping  the  rectal  tube  unobstructed,  or  in  not  properly 
supporting  the  parts  during  the  evacuation  of  the  bowels,  and  neces- 
sitating a  subsequent  operation  to  close  the  rectal  opening." 

We  also  dissent  from  the  brief  recommendations  of  the  author  re- 
garding the  operation  proposed  for  "  complete  prolapse  of  the  uterus." 
In  the  majority  of  these  chronic  cases,  simple  restoration  of  the  peri- 
neum will  merely  palliate  for  a  time.  If  the  tone  and  calibre  of  the 
vagina  be  not  restored,  the  uterus  w  ill  sooner  or  later  distend  and 
relax  the  newly  made  perineum  so  as  to  reproduce  the  prolapse. 

The  chapter  on  vaginitis  is  especially  good  in  its  practical  sugges- 
tions regarding  the  treatment  of  the  puerperal  form  and  the  tistulae  as- 
sociated therewith.  In  the  treatment  of  the  acute  form,  especially  la 
that  due  to  gonorrhcea,  no  allusion  is  made  to  the  practice  of  leaving 
within  the  vagina  lint  or  cotton  saturated  with  medicated  fluid  in  the 
intervals  between  the  injections,  a  practice  which  we  believe  to  be  very 
beneficial.  Without  desiring  to  be  hypercritical,  we  regret  that  in  an 
American  work  the  undoubted  claims  of  Dr.  Sims  to  the  originality  as 
well  as  the  popularization  of  the  operation  and  instruments  employed 
have  not  been  more  clearly  stated  for  the  information  of  the  student. 
Prof.  Syme,  in  his  address  before  the  British  Medical  Association, 
has  lately  ranked  the  labors  of  Dr.  Sims  with  those  of  the  intro- 
ducers of  sulphuric  ether. 

While  discussing  amenorrhcea,  Dr.  B.  sets  forth  very  happily  the 
action  of  the  so-called  emmenagogues,  "  as  producing  their  effects  ia 
two  different  modes;  one  is  to  cause  the  growth  and  discharge  of  the 
ova,  and  the  other  the  discharge  of  blood  as  a  hemorrhage.  It 
would  be  better,  then,  to  say  that  they  were  oviferous  in  their  nature 
in  the  first  case,  and  hemorrhagic  in  the  second." 

In  the  chapters  on  Menorrhagia  and  Dysmenorrhoea  the  recom-' 
raendations  for  full  dilatation  of  the  os  and  cervix  so  that  the  finger 
can  be  introduced  to  the  fundus,  and  the  subsequent  thorough 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  203 

cauterization  of  the  mucous  membrane  of  the  cavity  of  the  uterus 
witli  the  acid  nitrate  of  mercury,  are  adapted  to  do  a  great  deal  of 
harm  in  less  experienced  hands,  if  followed  closely.  Indeed,  we  venture 
the  prediction  that  if  Dr.  B.  will  keep  a  record  of  his  cases,  he  will  not 
long  continue  the  treatment  without  unfavorable  complications. 
Metritis,  perimetritis,  and  possibly  metro-peritonitis  will  attack  a 
certain  ])roportion  of  cases  similarly  treated.  We  do  not  object  to  the 
treatment  itself  in  experienced  hands  and  well  selected  cases,  but  do 
not  like  to  see  the  practice  recommended  with  so  little  caution  as  to  the 
risks  involved. 

Dr.  Byford  makes  three  divisions  of  Dysmenorrhcea,  viz.,  inflamma- 
tory, neuralgic  and  membranous.  He  classes  obstructive  dysmenor- 
rhcea under  the  first  division,  and  makes  a  further  division  between 
painful  menstruation  and  menstruation  attended  with  pain;  and  states, 
regarding  the  latter  class,  that  any  pelvic  organ  "  may  become  very  pain- 
ful by  having  the  inflammation  exaggerated  as  a  consequence  of  the 
menstrual  molimen,  or  any  pelvic  organ  with  strong  neuralgic  procliv- 
ities may  become  aff'ected  severely  by  the  hyperesthesia  of  that  period." 
The  views  -of  our  author  regarding  membranous  dysmenorrhcEa  are 
decided  as  to  the  existence  and  recurrence  of  a  membrane  without  con- 
ception. He  is  convinced  that  "it  will  not  be  long  until  {sic)  the 
profession  will  review  this  matter  and  exclude  obstructive  dysmenor- 
rhcea from  the  list  of  uterine  ailments,  or  else  find  it  to  be  exceeding 
rare  in  its  occurrence."  We  believe,  for  our  own  part,  that  the  tend- 
ency to  divide  the  cervix  has  been  carried  further  than  future  ex- 
perience will  justify,  and  that  many  who  have  been  prominent  in  a 
resort  to  this  operation  will  hereafter  perform  it  less  frequently;  we 
believe  that  in  the  vast  majority  of  cases,  while  the  operator  has 
assumed  that  the  obstruction  existed  at  the  os  internum,  and  that  this 
stricture  was  divided,  there  has  been  no  other  effect  than  division  of 
the  vaginal  portion  of  the  cervix.  We  know  that  the  healtliy  os  in- 
ternum is  always  very  small,  and  that  it  can  not  ever  be  divided  with- 
out very  gr^at  risk  of  hemorrhage,  and  that  the  men  who  divide  the 
cervix  in  their  office,  and  let  their  patients  walk  home  afterwards, 
either  conceal  their  knowledge  of  alarming  and  fatal  results,  or  else 
sin)ply  divide  the  vaginal  portion  of  the  cervix.  Still  we  believe  that 
the  profession  will  never  so  far  review  their  decision  as  to  exclude 
obstructive  dysmenorrhcea  from  their  classification;  we  believe  that 
division  of  the  cervix,  and  even  of  the  os  interiium  in  very  rare  contin- 
gencies, will  always  be  a  proper  procedure  in  well  sele(;ted  cases,  and 
that  such  division  will  increase  the  chances  of  pregnancy  iu  many  a 


204  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [DeC, 


sterile  woman.  This  advantage  does  not  appear  to  have  been  alhided 
to  by  Dr.  Byford.  We  venture  to  say,  however,  that  very  many  an 
operation  on  the  cervix  has  been  performed  on  account  of  the  conoid 
shape  of  the  cervix,  by  men  who  did  not  appreciate  that  such  was  the 
normal  shape  of  the  nulliparous  cervix,  and  that  the  only  conditions 
warranting  the  incision  are  those  in  which  the  tissue  is  the  site  of 
chronic  inflammation,  or  where  obstructive  dysmenorrhcea  is  proven  to 
exist.  We  are  glad,  however,  to  recognize  the  influence  of  Dr. 
Byford  in  counteracting  the  tendencies  towards  an  operation  that  is 
probably  performed  without  any  proper  indication  or  satisfactory 
result  as  frequently  as  any  other  for  which  we  have  a  name. 

j\  las  I  in  Chapter  VII.  Dr.  B.  has  exercised  the  right  of  every  popular 
author  in  coining  a  word,  and  in  resorting  to  the  Greek  dictionary  for 
its  derivation.  Metatithmenia  is  the  result  of  his  labor,  and  implies 
misplaced  menstruation.  The  unfortunate  student  has  this  one  load 
more  to  carry;  the  practitioner  who  conceals  with  effort  a  tendency  to 
stammer  has  one  more  trap  set  for  him,  and  gynajcologists  d'outre 
manche  recognize  in  the  Greek  0  their  old  stumbling  block  in  the  pro- 
imnciation  of  English.  Why  would  not  some  Indian  dialect  have  suf- 
ficed ?  Metamora  is  more  euphonious  than  Metatithmenia,  or  if  the 
"men"  be  essential,  why  not  keep  some  melodious  name  in  view,  like 
that  of  Mendelssohn  ?  We  are  tempted  further  to  say,  in  this  connec- 
tion, that  before  coining  new  Greek  words,  we  would  have  preferred  to 
see  more  attention  to  many  of  the  Latin  prescriptions  in  a  work  from 
an  educated  man  prepared  especially  for  the  use  of  students. 

We  now  pass  to  page  305,  to  the  (consideration  of  the  subject  of 
inversion  of  the  uterus,  which,  like  the  other  topics,  is  well  and  ably 
considered.  A  single  cardinal  omission  will,  we  hope,  be  supplied  in 
another  edition,  viz.,  the  advantages  to  be  derived  from  conjoined 
manipulation,  with  one  hand  or  part  of  a  hand  in  the  vagina  and  one 
over  the  abdomen,  in  both  diagnosis  and  treatment.  In  respect  to  the 
replacement  of  chronic  inversion  the  Doctor  very  correctly  states  that 
"the  great  thing  to  be  gained  is  the  commencement."  After  or  even 
before  this  is  gained,  we  suggest  that  there  is  a  great  advantage  in 
having  the  operator  relieved  rapidly  by  two  or  three  experts,  as  the 
hand  of  one  man  in  this  reposition  soon  becomes  too  tired  to  be  of 
much  service.  We  give  the  preference  to  the  hand  over  any  instru- 
ment, and  to  continued  efficient  effort  by  fresh  men,  rather  than  to  the 
long  continued  manoeuvre  of  one  most  excellent  operator  wiio  can  no 
longer  command  his  efforts  from  fatigue. 

In  the  chapter  on  ovarian  tumors,  Dr.  Byford  contributes  a  report 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


205 


of  three  cases  of  ovariotomy  which  he  has  performed,  of  which  two 
recovered.  One  of  the  chief  points  of  value  in  Dr.  B.'s  "  Treatise  on 
the  Uterus"  was  the  admirable  way  in  which  he  digested  and  presented 
the  views  of  recent  authors;  but  in  the  present  chapter  he  has  taken 
very  strong  ground — and  remarkably  strong  for  him — regarding  the 
inadvisability  of  returning  ligatures  of  the  pedicle  within  the  abdomen, 
lie  states  that  "  this  treatment  is  bad  and  can  not  be  justified.  Per- 
haps this  treatment  is  fraught  with  more  danger  than  any  other  of  the 
ordinary  parts  of  the  operation.  I  regard  the  dangers  here  mentioned 
against  tlie  ligature  as  adding  so  much  to  the  hazard  of  the  operation 
that  I  could  not  think  of  making  use  of  it,  unless  it  seemed  entirely 
indispensable  in  the  particular  case;  *  *  *  *  discard  scrupulously 
the  ligature  and  the  clamp." 

Dr.  Byford  uses  silver  pins,  which  are  passed  down  to  hut  not  through 
the  peritoneum. 

Dr.  Byford,  however,  provides  for  contingincies  in  which  the  clamp 

may  be  needed,  and  for  cases  where  the  stump  can  not  be  brought  out 
of  the  wounds.  In  the  latter  he  recommends  a  double  strong  hempen 
ligature  around  the  peduncle,  which  is  then  allowed  to  drop  back  into 
the  cavity  of  the  abdomen,  leaving  the  ligature  through  the  lower 
angle  of  the  wound. 

Now  we  think  that  many  of  the  points  involved  in  this  operation 
are  yet  undecided,  but  we  think  that  the  results  of  Tyler  Smith,  Clay, 
Peaslee,  Spencer  Wells  himself,  and  others,  in  operations  where  the 
ligature  has  been  returned  within  the  abdomen,  are  not  fully  set  forth 
in  Dr.  Byford's  book,  and  that  he  is  not  justified  in  his  wholesale  con- 
demnation of  the  practice.  It  so  happens  that  Spencer  Wells'  book, 
and  some  recent  numbers  of  the  London  Medical  Times  ij-  Gazette,  are 
on  our  table  at  this  moment,  and  a  casual  reference  gives  us  this 
result. 

In  Spencer  Wells'  case  No.  CI  ,  "a  small  pedicle  was  secured  close 
to  the  uterus  by  a  silk  ligature,  wliich  was  cut  off  short  and  returned." 
The  woman  recovered.  In  case  CIII.  where,  after  a  similar  procedure, 
the  woman  died,  and  the  case  strongly  impressed  Dr.  Wells  with  the 
disadvantage  of  returning  the  tied  pedicle  into  the  abdomen,  we  yet 
find  that  the  "  ligatured  stump  was  inclosed  by  a  capsule  of  lymph." 

In  the  London  Medical  Times  cf-  Gazette  for  July  29,  1865,  p.  117, 
there  is  a  report  of  a  case  in  wliicli  Mr.  Wells  operated  for  a  multi- 
locular  tumor,  with  a  very  short  pedicle.  "  An  attempt  was  made  to 
bring  it  outside  with  a  clamp,  but  that  made  such  a  pull  on  the  uterus 
that  Mr.  Wells  transfixed  tiie  pedicle,  tied  it  doubly  with  twine,  and 


206 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [DeC, 


relumed  the  stump  with  the  ligature  into  the  abdomen."  Tlie  patient  re- 
covered. We  have  quoted  this  last  case  as  illustrative  of  Mr.  Wells' 
present  views,  and  as  sliowing  that  he  no  longer  occupies  the  position 
given  him  by  Dr.  Byford,  who,  speaking  of  the  time  (in  1861)  when 
Dr.  Tyler  Smith  presented  his  cases  to  the  Obstetrical  Society,  re- 
marks that  "  Mr.  Spencer  Wells  very  justly  reprimanded  liim  for  it  in 
a  gentlemanly  way,  by  saying  that  the  procedure  ought  not  to  be  im- 
itated without  more  discussion."  It  appears  that  subseciuent  "  discus- 
sion" has  impressed  Mr.  Wells  more  favorably  with  the  procedure  than 
Dr.  Byford. 

Moreover,  it  is  not  fair  that  so  respected  a  teacher  and  author  as 
Dr.  Tyler  Smith,  whose  work  is  so  highly  prized  in  this  country,  should 
be  perpetually  represented  to  the  American  student  as  receiving  a 
"gentlemanly  reprimand"  from  Mr.  Wells;  the  more  especially  when  it 
is  most  probable  that  neither  Dr.  Smith  or  Mr.  Wells  ever  imagined 
that  the  remarks  could  be  interpreted  as  a  "  reprimand." 

We  also  think  that  the  experience  of  the  best  men  is  tending 
towards  passing  ligatures  through  the  peritoneum  so  as  to  bring  about 
prompt  adhesion  of  the  peritoneal  surfaces,  rather  than  to  introduce 
the  ligatures  (or  pins)  down  to  the  peritoneum  without  transfixion,  as 
recommended  by  Dr.  Byford.  And  we  may  express  our  surprise  that 
Dr.  B.'s  familiarity  with  Mr.  Brown's  practice  has  not  led  him  to  al- 
lude to  the  use  of  the  actual  cautery  to  the  stump  before  returning  it 
to  the  abdomen. 

The  space  that  we  have  already  occupied  in  the  study  of  this  inter- 
esting work  admonishes  us  to  close,  and  we  regret  our  inability  to 
allude  to  the  chapter  on  milk  leg  and  puerperal  fever.  Taken  as  a 
whole,  the  book  seems  to  us  to  present  evidences  of  a  more  hasty 
preparation  than  the  previous  one.  We  venture  to  predict  that  several 
editions  will  soon  be  demanded,  and  that  each  one  will  show  the  im- 
provements and  additions  that  Dr.  Byford  is  as  well  fitted  to  make  as 
any  man  in  this  country. 

Lectures  on  Fever,  delivered  in  the  Memphis  Medial  College  in  1853-56. 
By  A.  P.  Merrill,  M.  D.,  Professor  of  the  Principles  and  Practice 
of  Medicine.  New  York:  Harjier  &  Brothers.  18G5.  12rao. 
pp.  235. 

The  author  announces  as  the  object  of  this  well  printed  and  attractive 
looking  little  volume,  to  publish  the  results  of  his  "  own  long  experience 
in  the  treatment  of  Southern  fevers;"  while  at  the  same  time  he  claims 


1865.]  REVIEWS  AND    BIBLIOGRAPHICAL  NOTICES.  207 


to  have  made  "a  free  use  of  the  observations  and  teachings  of  others." 
The  subject-matter  is  sketchily  handled,  the  style  is  concise  and  unpre- 
tending, and  there  is  much  practical  matter  within  a  small  space.  Ba- 
con styles  epitomes  barren,  and  they  certainly  rarely  serve  to  enlarge 
the  views  of  the  student  and  practitioner,  or  extend  the  resources  at 
their  command.  We  can  not  but  regret  that  Dr.  Merrill,  with  his 
large  reading  and  abundant  opportunity,  has  not  thought  fit  to  revise 
and  enlarge  his  "  Lectures,"  or  even  to  expand  them  into  a  treatise  on 
what  he  regards  "as  one  of  the  most  difficult  subjects  of  our  profes- 
sion," and  "  the  most  common  of  all  diseases  which  afflict  mankind" 
— Idiopathic  Fevers.  There  are  thirteen  lectures,  or  short  chapters, 
two  of  which  treat  of  Fever  in  General — fever  considered  in  its  abstract 
relations;  three  of  Intermittent  Fever;  three  of  Remittent  Fever;  one 
of  Yellow  Fever;  one  of  Enteric  Fever;  one  of  Exanthematous  Fevers; 
and  a  supplementary  one,  the  thirteenth,  containing  some  "  general 
remarks"  on  certain  diseases  exhibiting  more  or  less  tendency  to 
periodicity. 

"We  can  not  conscientiously  say  that  these  "Lectures"  satisfactorily 
represent  the  present  state  of  pathological  knowledge  of  idiopathic 
fevers;  indeed.  Dr.  Merrill  tells  us  that  "their  pathology,  in  all  its 
forms  and  phases,  is  involved  in  obscurity;"  and  adds,  "from  the 
teachings  of  pathologists  you  will  derive  little  advantage,  except  as 
they  relate  to  local  lesions,  which,  in  general,  are  to  be  treated  as  the 
same  lesions  are  when  they  appear  as  primary  affections  arising  from 
local  causes;"  from  both  of  which  o})iuions  we  must  express  our  very 
decided  dissent,  and  we  regard  the  latter  one  as  mischievious,  and  calcu- 
lated to  mislead  and  do  harm  in  practice.  Though  Dr.  Merrill  would 
reject  all  the  innumerable  theories  of  fever,  he  very  candidly  says  that 
he  has  none  to  offer  in  their  place.  While  there  is  much  plausibility 
in  the  modern  phrase  of  humoralism,  he  does  not  think  that  the  doc- 
trine of  primary  disorder  of  the  blood  is  supported  by  either  positive 
or  negative  evidence;  but  he  inclines,  we  infer,  to  the  belief,  with  Vir- 
chow  and  Parkes,  that  the  blood  becomes  diseased  "through  the  agency 
of  disordered  innervation."  There  are  some  incongruities  in  this  lec- 
ture that  we  do  not  care  to  particularize  or  discuss. 

Since  tliese  "Lectures"  were  written,  large  and  solid  advances  have 
been  added  to  our  knowledge  of  the  natural  history  of  fevers.  Ex- 
actness of  observation,  enlightened  investigation,  aided  by  improved 
methods  and  instruments  of  research,  and  freedom  from  all  theoretic 
bias,  have  contributed,  witliin  the  past  decade,  to  determine,  with 
great  certainty,  the  causes,  modes  of  propagation,  development,  the 


/ 


208  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [DeC, 

progress  and  defervescence  of  fevers.  No  more  valuable  means  to  aid 
us  in  a  correct  and  practical  study  of  febrile  diseases,  their  inception, 
natural  course  and  termination,  is  the  determining  of  the  correlation  of 
temperature  with  other  morbid  phenomena. 

The  sole  constant  phenomenon  of  fever,  the  essential  symptom, 
is  an  elevation  of  temperature — the  calor  prater  naturam  of  Ga.\en — 
which  is  due  to  increased  activity  of  tissue  change;  and  there  are 
always,  in  the  presence  of  fever,  two  cardinal  points  demanding 
special  investigation:  1st,  to  measure  accurately  the  degree  of  this 
preternatural  heat  and  fix  its  significance;  and,  2d,  to  ascertain 
the  amount  of  the  tissue  change,  estimated  by  the  relative  amount 
of  all  the  excreta  to  the  body  weight.  It  is  as  incumbent  upon 
the  physician  in  treating  a  case  of  fever  to  measure  carefully  the 
degree  of  heat,  and  look  to  the  products  of  the  metamorphosis  or 
destruction  of  tissue,  equivalent  to  the  amoimt  of  heat  in  each  case,  as 
to  count  the  pulse  and  the  number  of  respirations  and  note  their  relative 
frequency.  Dr.  Merrill  passes  over  entirely  the  thermometry  of 
fever,  an  omission  which  uo  doubt  will  be  repaired  in  another  edition. 
The  observations  of  Wunderlich  of  Leipsic,  Ringer  and  Parkes,  of 
London,  and  Jones,  of  Augusta,  Ga.,  in  this  field  of  labor,  have  shown  us 
what  important  results  may  be  arrived  at  in  the  matter  of  the  diagnosis 
and  prognosis  of  fevers.  When  the  typical  range  of  temperature  of 
these  diseases  is  determined,  we  shall  probably  have  the  earliest  and 
best  indications  of  unexpected  complications  or  favorable  progress. 

In  the  chapters  on  Intermittent  Fever  there  is  nothing  to  arrest 
attention,  except  it  be  the  pathogenic  dogma,  "  that  it  is  not  debility 
with  which  you  have  to  contend  in  ague,  but  the  very  reverse,  plethora 
and  sthenic  congestion,"  and  the  natural  therapeutic  abundance  which 
follows — all  the  arms  of  the  materia  medica  being  marshaled  to  subdue 
what  is  universally  acknowledged  to  be  a  self-limited  paroxysm.  Dr. 
Merrill,  as  a  natural  consequence  of  his  doctrine  of  sthenic  congestion, 
is  inclined  to  regard  blood-letting  in  the  cold  stage  of  ague  much  more 
favorably  than  observation  and  reading  have  led  us  to,  and  we  fully 
agree  with  Sir  Ranald  Martin,  that  while  it  has  the  show  of  being  prompt 
and  energetic,  it  is,  in  eflfect,  "haphazard,  systemless,  operose,  and 
tedious."  Nor  cm  we  agree  with  our  author  when  he  says,  "  quinia 
I  consider  to  be  properly  a  contra-stimulant  remedy,  its  efficacy  as  an 
autipcriodic  depending,  in  some  measure,  upon  the  degree  of  sedation 
it  produces,"  (p.  69,)  or  when  he  r.inges  aconite  and  arnica  in  the  class 
of  narcotics,  (p.  59  )  The  secret  of  success  in  the  radical  treatment 
of  the  disease  is  very  truly  said  to  be  in  keeping  up  the  action  of  quinia 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


209 


without  interruption;  in  other  words,  until  the  system  is  thoroughly 
saturated  with  the  antidotal  remedy.  The  same  may  be  said  of 
arsenic,  which  sliould  be  persevered  in,  in  diminishing  doses,  until  toxical 
symptoms  appear.  No  special  directions  are  given  respecting  the 
treatment  of  malignant  or  pernicious  agues. 

On  the  subject  of  Yellow  Fever  there  is  nothing  which  calls  for 
especial  notice.  The  author  is  of  opinion  that  it  differs  only  from  the 
other  forms  of  periodic  fever  in  this,  "  that  for  some  unknown  reason 
it  has  its  prominent  and  characteristic  lesion  in  the  stomach."  He 
believes  it  attributable  to  the  same  cause  as  periodic  fever. 

The  chapter  on  "  Pneumonic  Fever"  will  repay  careful  perusal 
Those  on  "  Enteric  Fever"  are  the  most  unsatisfactory  in  the  book,  and 
will  require,  in  another  edition,  recasting  to  bring  them  up  to  the  level 
of  our  present  knowledge  of  this  common  and  universal  form  of  con- 
tinued fever,  and  which  Dr.  Merrill  perversely  classes  with  periodic 
fever.  What  can  justify  such  statements  as  these  ?  "  The  diagnosis  of 
enteric  fever  can  not  of  course  be  made  out  in  its  early  stages,  for  the 
plain  reason  that  its  characteristic  lesion  is  not  formed,  until  which  it 
does  not  differ  from  other  forms  of  periodic  fe"ver  to  such  extent  as  to 
enable  us  to  give  a  confident  diagnosis.  *  *  *  know  of  no 
symptom  in  any  case  which  gives  us  certain  assurance  that  Peyer's 
glands  are  especially  diseased,  until  we  come  to  the  autopsy.  *  *  * 
The  treatment  proper  in  the  early  stages  need  not  differ  from  that 
adopted  in  other  forms  of  periodic  fever.  The  anti-periodic  treatment 
will  of  course  be  adopted  and  prosecuted  with  a  vigor  proportioned 
somewhat  to  the  expected  violence  of  the  disease.  Whenever  this  is 
properly  applied,  and  at  the  proper  time,  there  will  be  no  enteric  or 
typhoid  fever  at  all;  for  the  simple  reason  that  the  fever  will  be  ar- 
rested and  cured  before  the  characteristic  local  lesions  are  formed," 
(pp.  190-1.)  Against  all  which  we  enter  an  earnest  protest,  believing 
such  teachings  to  lead  inevitably  to  the  doing  of  great  mischief. 
While  we  do  not  believe  that  "  carbonate  of  ammonia,  as  an  excitant, 
Is  mostly  to  be  preferred  to  alcoholic  fluids"  in  the  treatment  of  enteric 
fever,  but  think  it  objectionable  on  account  of  irritating  the  stomach 
and  bowels,  we  agree  with  our  author  that  the  best  food  for  general 
use  in  the  course  of  tlie  disease  "is  fresh  milk,  which  has  been  well 
boiled  as  soon  as  taken  from  the  cow,"  particularly  if  accompanied  by 
good,  pure  wine. 

We  are  quite  sure  that  the  statement,  at  p.  23,  that  "the  physicians 
of  Philadelphia  have  given  us  pretty  much  all  that  is  valuable  in  med- 
ical authorsiiip  in  America,"  will,  in  the  face  of  fact  and  common  jus- 

VoL.  IT.— No.  9.  14 


210  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Dec, 

tice  to  the  many  valuable  origiual  monographs,  as  well  as  compilations, 
which  have  been  contributed  by  members  of  the  profession  not  resident 
in  Philadelphia,  be  modified  in  another  edition,  to  which  we  would 
suggest  that  a  table  of  contents  and  index  be  added. 

Lectures  on  Surgical  Pathology,  delivered  at  the  Royal  College  of  Sur- 
geons of  E-nglawl.  By  James  Paget,  F.R.S.,  Surgeon  Extraordinary 
to  her  Majesty,  the  Queen;  Surgeon  in  Ordinary  to  H.  R.  H.  the 
Prince  of  Wales;  Surgeon  to  St.  Bartholomew's  and  Christ's  Hos- 
pitals. Revised  and  Edited  by  William  Turner,  M.  B.,  London, 
r.R.C.S.E.,  F.R.S.E.,  Senior  Demonstrator  of  Anatomy  in  the 
University  of  Edinburgh.  Third  American  Edition.  Philadelphia: 
Lindsay  &  Blakistou.    1865.  pp.  731. 

A  new  edition  of  this  standard  work  of  the  best  surgical  mind  in 
Great  Britain  can  not  fail  to  be  a  matter  of  interest  to  the  profession 
in  this  country,  by  whom  it  is  so  well  known  and  duly  valued.  The 
third  American  is  handsomely  reprinted  from  the  second  and  last  London 
edition.  Mr.  Paget  states  that,  when  the  time  came  for  a  new  edition 
of  these  Ijectures,  he  "was  anxious  that  they  should  be  revised  with  all 
the  light  of  the  knowledge  of  pathology  acquired  since  their  publica- 
tion;" but,  although  he  had  collected  materials  for  the  purpose,  he 
found  himself  unfitted  for  the  task  of  thorough  revision,  for  the  reason 
that,  in  the  active  duties  of  practice,  he  had  had  "no  sufficient  time 
for  either  studying  or  thinking  carefully  about  the  many  facts  and 
probabilities  and  guesses  at  truth  which  had  been  added  to  Pathology." 
The  revision  of  the  work  was,  therefore,  entrusted  to  his  former  pupil, 
Mr.  Turner,  but  Mr.  Paget  acknowledges  to  having  "so  worked  with 
him  as  to  be  equally  with  him  responsible." 

A  careful  comparison  with  former  editions  will  show  the  general 
and  valuable  revision  the  text  has  undergone,  probably  at  the  hands 
of  the  author  himself,  and  there  is  great  wealth  of  physiological  and 
pathological  knowledge  of  the  day  in  the  notes,  contributed,  it  is  un- 
derstood, by  the  editor. 

In  the  ^'  Lectures,"  where  all  the  subjects  treated  of  are  of  vital 
importance,  lying  as  they  do  at  the  very  foundation  of  medical  science, 
and  handled  so  thoroughly  and  philosophically,  it  is  difficult  to  indicate 
any  distinguishing  excellence  of  execution;  but  to  us  the  chapters  on 
tumors  have  always  seemed,  in  their  clearness,  thoroughness,  and 
soundness  of  views,  the  perfection  of  medical  composition.  Recurrent 
tumors,  including  "  fibroid"  and  "  fibro-nucleated,"  having  characters 


1865.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


211 


which  connect  them  on  the  one  hand  with  the  innocent,  and  on  the 
other  with  the  malignant  tumors,  are,  in  the  present  edition,  properly 
placed  in  a  group  intermediate  between  these  two  great  divisions — a 
connecting  link  between  benign  and  cancerous  growths. 

We  find  no  modification  of  the  previously  expressed  views  of  Mr. 
Paget  on  the  pathogeny  of  this  class  of  diseases.  He  adiieres  to  the 
division  into  innocent  and  malignant,  (adding,  as  we  have  seen,  an  in- 
termediate group,  named  recurrent,)  believing  these  terms,  "  though  not 
free  from  objections,  to  imply  a  more  natural  and  a  less  untrue  division 
than  any  yet  invented  to  I'eplace  them,"  and  in  this  respect  diflfering 
from  Virchow,  who  denounces  this  division  as  altogether  unscientific, 
declaring  that  the  classification  of  tumors  should  be  based  on  anatomi- 
cal characters,  not  on  physiological  relations.  While  Mr.  Paget  holds 
that  malignant  tumors  are  local  manifestations  of  a  disease  which 
already,  in  its  specific  material,  e.xists  in  the  blood — as  in  cancer,  a 
peculiar  or  cancerous  condition  of  the  blood— Virchow,  in  his  recent 
great  work  on  Tumors,*  the  complement  of  his  "  Cellular  Pathology," 
is  inclined  to  the  belief  that  this  dyscrasia  or  diathesis  is  pure  hypoth- 
esis, and  will  disappear  iu  a  more  advanced  state  of  our  knowledge; 
and  that  even  now,  in  the  vast  majority  of  cases,  the  change  in  the 
blood  is  to  be  regarded  as  a  secondary  phenomenon,  due  to  the  absorp- 
tion of  matter  from  an  existing  focus,  the  malignant  growth  being  due 
to  a  local  irritant.  He  supports  his  view  by  the  fact  that  the  greater 
number  of  malignant  tumors  are  met  with  in  those  parts  of  the  body 
most  exposed  to  injury,  and  sustains  it  by  the  history  of  epithelial 
cancer,  as  shown  in  the  incrusted  warts  on  the  scrotum,  face  and  lip, 
which  the  local  irritant  will  develop  into  the  worst  form  of  malignant 
disease;  while  our  author  would  explain  the  true  influence  of  the  soot 
in  chimney-sweep's  cancer,  not  to  be  the  determining  of  the  growth  of 
cancer  by  its  continued  contact,  but  by  producing  "  a  state  of  skia 
which  provides  an  apt  locality  for  epithelial  cancer  in  persons  of  oaor 
cerous  diathesis."  Whether  the  cancerous  cachexia  is  primary  or 
secondary,  the  existence,  under  any  circumstances,  of  a  true  blood- 
cause,  and  the  state  of  that  fluid  in  cancerous  states  of  the  body,  are, 
at  this  day,  with  all  the  lights  of  modern  pathology,  and  the  investiga- 
tions of  Bennett,  Ltibert,  Hannover,  P.iget,  Rokitausky,  Vinihow,  and 
others,  as  much  involved  in  obscurity  as  they  were  a  century  ago.  At 
present  we  must  be  content  to  accept  our  author's  ratlier  unsatisfactory 
conclusion — "the  reconciliation,  not  only  of  the  two  conflicting  opin- 


*  Die  Krankhaften  Geschwiilste.    Von  Rudolph  Virchow. 


212  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [DcC, 


ions,  but  of  the  seemingly  conQictlng  facts  upon  which  they  chiefly 
rest,  is  to  be  found  in  this,  that  the  complete  manifestation  of  cancer, 
the  formation  of  a  cancerous  growth,  is  suspended  till  such  a  time  as 
finds  both  the  constitutional  and  the  local  conditions  coexistent — till 
the  blood  and  the  part  are  at  once  appropriate." 

Die  Ohrenheilkunde  der  Gegenwart.  Berlin  :  1860.  Von  Dr.  W. 
Kramer.  Translated  by  Henry  Power,  for  the  New  Sydenham  So- 
ciety: 1863. 

A  former  edition  of  this  work,  translated  in  1831,  by  Dr.  James 
Risdon  Bennett,  contained  severe  criticisms  on  preceding  and  contem- 
poraneous writers,  each  of  whom  was,  in  the  author's  opinion,  guilty 
of  neglect  or  ignorance  in  reporting  or  treating  cases. 

Much  that  was  good  in  the  work  was  mingled  with  a  great  deal 
that  was  unpleasant  and  eccentric. 

These  characteristics  seem  to  exist  to  a  less  extent  in  the  present 
edition;  but  Erhard  and  Toynbee  come  in  for  a  large  share  of  severe 
criticism,  the  former,  more  especially,  as  the  German  expositor  of  the 
views  of  the  latter. 

The  post-mortem  researches  by  Toynbee  seem  to  be  considered  by 
our  author  as  of  little  benefit  in  arriving  at  a  correct  knowledge  or 
treatment  of  diseases  of  the  ear,  because  they  were,  for  the  most  part, 
made  on  cases  whose  history  was  unknown  to  Mr.  Toynbee. 
Throughout  the  work  we  are  strongly  urged  to  study  the  state  of  the 
Eustachian  tube  on  the  patient,  by  means  of  Kramer's  series  of  five 
catheters,  the  "gut"  and  caoutchouc  bougies,  and  the  otoscope  or 
"  diagnostic  tube." 

In  ear  diseases,  as  in  others,  prophylactic  treatment  is  desirable;  to 
this  end  Dr.  Kramer  recommends  the  use  of  plugs  of  wool  in  the  ear 
in  cold  weather,  in  mills  and  other  noisy  places,  and  "  ear-laps"  over 
those  organs  in  winter,  and  care  not  to  wash  the  ears  with  cold  water, 
all  of  which  precautions,  it  seems  to  us,  may  better  be  neglected. 

Among  the  symptoms  of  ear  diseases,  only  two — hardness  of  hearing 
and  noises  in  the  cars — are  of  general  signification. 

Among  1,000  cases  of  ear  disease  taken  at  large,  496  were  accom- 
panied by  noise.  The  cause  of  these  noises,  Dr.  Kramer  says,  is  irrita- 
tion of  the  chorda  tympaui  nerve,  produced  by  the  pressure  of  wax  on 
the  drum,  or  by  inflammation  of  the  membrana  tympani,  or  neighbor- 
ing parts. 


1865.]        REVIEWS  AND  BIBLIOGBAPHICAL  NOTICES. 


213 


The  most  fre(iuciit  causes  of  ear  diseases  are  cold,  change  of  temper- 
ature, and  t^xanthematous  and  catarrhal  diseases. 

For  examining  the  external  ear  we  are  advised  to  use  Kramer's 
ear  s[)eculuni  (which  is  valvular,  with  two  long  handles  and  unpolished 
interior)  and  direct  sunlight.  The  dullness  of  the  interior,  we  think, 
is  an  advantage,  as  thus  we  are  not  confused  by  reflections  from  the 
sides  of  the  instrument.  The  long  handles,  however,  seems  to  us 
inconvenient,  as  they  necessitate  the  employment  of  both  hands  while 
using  the  instrument,  thus  rendering  it  inconvenient  to  clean  out  the 
ear,  or  perform  any  operation  on  it  while  using  the  speculum. 

For  examining  the  middle  ear.  Dr.  Kramer  uses  and  recommends 
silver  catheters  of  five  different  sizes,  and  gut  and  caoutchouc  bougies. 
With  the  aid  of  these  the  permeability  of  the  Eustachian  tube  is  diag- 
nosed with  certainty.  In  treatment,  caustics  may  be  applied  on  the 
ends  of  the  bougies,  or  fluids  may  be  blown  through  the  catheters  into 
the  middle  ear. 

According  to  Dr.  Kramer,  diseases  of  the  drum  occur  in  about  one 
case  out  of  each  five  of  ear  disease,  he  having  found  them  in  218  cases 
among  1,000. 

In  discussing  perforation  of  the  membrana  tympani  artificial  drums 
are  very  slightingly  spoken  of.  In  our  experience  they  have  frequently 
proved  beneficial.  Patients  often  can  not  wear  them  constantly,  but 
for  a  lecture  or  some  amusement  of  an  hour  they  may  materially  im- 
prove the  hearing.  They  should  be  used  only  when  the  Eustachian 
tube  is  pervious. 

Inflammation  of  the  middle  ear  is  very  often  mistaken  for  nervous 
deafness.  Dr.  Kramer  divides  it  into  inflammation  with  (a)  sup- 
pressed, (i)  free,  (c)  free  and  interstitial,  and  (<i)  exclusively  inter- 
stitial exudation. 

Catarrhal  inflammation  with  exclusively  interstitial  exudation  is  the 
most  frequent  of  ear  diseases,  forming  about  40  per  cent,  of  all  cases. 
The  symptoms  are  slowly  increasing  deafness,  thickening  of  the  drum, 
(by  interstitial  exudation,)  redness  and  swelling  of  the  fauces  and 
tonsils.  This  is  the  disease  called  by  Troltsch  "  Chronic  Catarrhal 
Inflammation  of  the  Middle  Ear."  The  treatment  recommended  by 
Dr.  Kramer  is  the  application  of  astringents  to  the  throat  and 
Eustachian  tube. 

Of  nervous  diseases  of  the  ear  we  have  but  little  positive  knowl- 
edge. They  come  from  falls,  explosions,  apoplexy,  fevers,  etc.  Unless 
the  pathological  cause  of  the  disease  is  known,  we  can  do  but  little  in 


214  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Dec 


the  way  of  treatment.  If  the  affection  probably  depends  on  conges- 
tion, we  may  use  leeches  and  resorbents. 

Under  the  head  of  Diseases  of  the  Internal  Ear,  (that  is,  of  the 
bony  and  membraneous  labyrinth,)  are  placed  acute  and  elironic  in- 
flammation of  the  labyrinth,  acute  inflammation  of  the  facial  nerve 
within  the  fallopian  canal,  nervous  deafness,  and  deaf-mutism. 

Acute  inflammation  of  the  labyrinth  is  generally  caused  by  injury 
from  some  instrument  introduced  through  the  external  ear.  Its  symp- 
toms are  pain  in  the  temporal  region  and  deep  in  the  head,  drowsiness, 
vomiting,  etc.  It  is  to  be  treated  by  cool  applications,  purgatives, 
and  antiphlogistics  generally. 

Deaf-mutism  is  "congenital"  and  "developed."  The  distinction  of 
"early"  and  " late  development"  is  not  used  by  Dr.  Kramer.  He 
says  that  it  is  generally  congenital,  and  although  not  hereditary,  the 
parents  are  loth  to  acknowledge  that  it  has  existed  from  birth. 

The  successful  use  of  electricity  or  galvanism  in  these  cases  by 
Bamberger,  Ducheune  and  Blauchet,  as  well  as  that  of  ear-trumpets 
by  Toynbee,  is  much  doubted  by  Dr.  Kramer. 

Dr.  Kramer  is  one  of  the  most  noted  and  successful  of  the  aural 
surgeons  of  the  present  day,  and  his  work  would  perliajis  have  been 
more  interesting  and  useful  to  the  profession,  if  it  contained  at  greater 
ength  his  own  ideas  of  pathology  and  practice,  and  less  extensive  no- 
tices of  faults  (supposed  or  actual)  of  other  writers  on  aural  surgery. 

The  Science  and  Practice  of  Medicine.  By  William  Aitken,  M.D., 
Edin.  Professor  of  Pathology  in  the  Army  Medical  School,  &c., 
&c.  In  two  volumes;  third  edition;  revised  and  portions  re-written. 
London,  1864;  8vo.,  pp.  939,  993. 

This  work  first  appeared  as  a  Hand-Book  on  the  Practice  of 
Medicine,  written  for  the  Encyclopaedia  Metropolitana;  it  met  with  a 
ready  recognition  of  its  excellence  by  the  profession,  and  a  rapid  sale. 
The  second  edition  was  almost  entirely  re-written  and  expanded  into 
two  thick  volumes,  and,  so  favorably  was  this  received,  that  within  six 
months  of  its  publication  it  was  exhausted  and  a  third  called  for. 

Dr.  Aitken  is  the  Professor  of  Pathology  in  the  Army  Medical 
School  at  Netley,  and  during  the  Crimean  war  was  attached,  as  Pa- 
thologist, to  the  military  hospital  of  the  British  troops  at  Scutari. 

We  have  in  this  work  a  view  of  the  main  facts,  doctrines,  and  prac- 
tice of  Medicine  in  accordance  with  its  present  state.  It  is  an  admirable 
compendium  for  reference  or  study,  being  a  digest  of  all  the  recent 


1865.] 


CORRESPONDENCE. 


215 


treatises  and  monographs,  and  embodying  the  latest  discoveries  and 
improvements,  by  a  practical  man  of  large  opportunity.  The  knowl- 
edge of  the  day  on  the  science  and  practice  of  medicine  is  summarized 
with  care,  exactness,  lucidity,  breadth,  and  sound  judgment. 

The  department  of  Medical  or  Noso-Geography,  wliich  treats  of  the 
conditions  by  which  health  and  disease  are  distributed  over  the  globe, 
and  constitutes  the  basis  of  hygiology,  receives  attention  for  the  first 
time  in  a  manual  on  practice  of  medicine.  It  is  a  valuable  and  instruc- 
tive chapter,  revised  by  Dr.  T.  G.  Balfour,  Chief  of  the  Statistical 
Bureau  of  the  British  Army  Medical  Department.  The  practical 
importance  of  a  study  of  the  temperature  or  thermometry  of  disease  is 
insisted  on,  with  an  analysis  of  the  observations  of  Wunderlich,  Traube, 
Ringer  and  Parkes.  Indeed  we  suspect  that  for  the  prominence  given 
in  these  volumes  to  tiiis  important  but  neglected  means  of  diagnosis 
and  prognosis,  we  are  indebted  to  the  author's  colleague  at  Netley,  Dr. 
E.  A.  Parkes,  who,  as  Professor  of  Clinical  Medicine  in  University 
Medical  College,  devoted  so  much  time  to  the  teaching  of  this  im- 
portant topic. 

We  can  commend  Dr.  Aitken's  Science  and  Practice  of  Medicine 
most  heartily  to  the  profession,  and  as  deserving  of  a  place  in  every 
medical  library. 


CORRESPONDENCE. 

THE  EPIDEMIC  CHOLERA  OF  1849  AND  1854. 

Editor  of  iV.  Y.  Medical  Journal: 

"  The  medical  men  here  are  very  reticent  in  giving  opiaioas  on  the 
cholera." 

The  above  is  quoted  from  a  New  York  daily  paper  of  the  4  th  inst., 
and  the  statement  is,  perhaps,  too  true.  Every  man  should  now 
speak  out  and  tell  us  what  he  knows  about  cholera.  By  comparing 
opinions,  or  rather  by  comparing  observations  and  experience,  we 
may  arrive  at  some  practical  result. 

If  cholera  shall  visit  us,  we  must  be  ready  to  meet  it,  and  do  all 
we  can  to  stay  its  ravages. 

I  beg  to  give  you,  in  a  hurried  manner,  the  result  of  my  observa- 
tions during  the  ei)idemics  of  1849  and  1854.  The  mortality  in  1849 
was  great,  and  perhaps  great  because  of  much  bad  treatment.  The 
disease  was  considered  desperate,  and  desperate  remedies  were  admin- 


216 


CORRESPONDENCE. 


[Dec, 


istered.  Opium,  calomel,  qniniue,  sugar  of  lead,  strychnine,  etc.,  were 
given  alternately,  or  all  together,  as  the  ambitious  doctor  thought  best. 

The. scourge  passed  away,  and  we  knew  about  as  little  of  its  cause 
or  its  treatment  as  we  did  before  it  came.  In  1854  the  disease  was 
treated  with  better  success.  Perhaps  the  epidemic  was  not  as  severe 
as  in  1849. 

The  city  of  Williamsburg  (now  the  Eastern  District  of  Brooklyn) 
organized  a  Board  of  Health,  and  established  a  Cholera  Hospital, 
July  13th.  I  visited  my  first  case  of  cholera  that  year,  and  up  to 
July  29  I  had  treated  five  other  cases.  July  30  the  Cholera  Hospital 
was  opened,  and  during  August,  twenty-six  cases  were  admitted,  and 
in  September,  nine — making,  in  all,  thirty-five  cases.  There  were 
twelve  females  and  twenty-three  males — twenty-nine  over  20  years 
of  age,  and  six  imder  20  years  of  age;  seventeen  born  in  Germany, 
fourteen  in  Ireland,  three  in  England,  and  one  in  New  York.  A  large 
portion  came  into  the  hospital  in  an  advanced  stage  of  the  disease, 
and  some  in  complete  collapse.  Two  men  died  of  brain  disease.  They 
had  no  cholera  discharges  after  they  came  in. 

One  woman  was  received  with  a  babe  but  two  weeks  old,  and  both 
died.  Another  woman  was  convalescing  from  cholera,  and  died  of 
exhaustion  from  uterine  hemorrhage. 

The  cases  sent  to  the  hospital  were  of  the  most  destitute  class,  who 
could  not  be  cared  for  at  home,  and  most  of  them  had  been  largely 
drugged  before  they  came  in.  Some  were  drunk  with  bad  whiskey, 
and  some  were  drunk  with  opium.  From  the  class  and  character  of 
the  patients,  it  will  be  readily  inferred  that  most  of  them  died.  And 
Buch  was  the  fact.  Only  fifteen  out  of  the  thirty-five  recovered.  Those 
that  recovered  were  under  treatment  from  six  to  twenty  days.  Those 
that  died  were  under  treatment  but  a  few  days,  and  in  some  cases  but 
a  few  hours.  Five  or  six  died  soon  after  admission,  and  were  not 
treated  at  all.  The  last  patient  was  discharged  from  the  hospital 
September  9th. 

Cholera  made  its  appearance  in  Williamsburg  suddenly.  Nine  cases 
occurred  about  the  middle  of  July,  within  two  or  three  days,  in  one 
block,  and  in  a  respectable  locality.  From  that  time  isolated  cases 
were  found  all  over  the  city,  more  particularly  in  the  filthy  districts, 
and  where  the  people  were  huddled  together.  About  the  middle  of 
August,  eight  cases  occurred  in  one  tenement  house.  The  lower  part 
of  this  house  was  a  filthy  shoe-shop  in  front,  and  a  kitchen  back,  and 
the  whole  family,  four  in  number,  died.  Tenants  up  stairs  took  the 
disease  and  died.    The  Sanitary  Commission  visited  the  spot,  ordered 


1865.] 


CORRESPONDENCE. 


the  dead  to  be  buried,  sent  the  sick  and  dying  to  the  hospital,  toolv 
possession  of  the  house,  limed  it,  and  shut  it  up.  This  at  once  checlied 
the  spread  of  the  disease  in  that  locality.  Yet  it  is  a  fact  worthy  of 
mention  that  four  other  cases  can  be  traced  to  that  house.  One  was 
a  sister  to  the  shoemaker,  who  came  from  the  country  to  help  take 
care  of  the  sick.  She  returned  to  her  home  in  Astoria,  where  she  was 
at  service,  and  in  a  day  or  two  sickenened  with  cholera  and  died. 

Two  others,  who  lived  in  a  small  house  on  the  rear  of  this  lot,  took 
the  disease  and  died.  A  washerwoman,  who  washed  the  bed-clothes 
of  the  shoemaker's  family,  in  the  yard  of  these  premises,  went  to  her 
home  in  another  part  of  the  city,  and  died  of  cholera  in  a  few  days. 
Do  these  facts  help  to  prove  contagion  ? 

A  few  autopsies  were  made,  and  they  were  made  in  great  haste.  In 
those  that  died  in  the  algid  stage,  there  were  no  perceptible  traces  of 
disease,  except  a  more  or  less  injection  of  the  mucous  membrane  of 
the  whole  alimentary  canal.  In  those  that  died  some  days  after  re- 
action, and  with  more  or  less  of  fever,  there  were  unmistakable 
evidences  of  congestion  and  inflammation  of  the  solitary  and  aggregated 
glands  of  the  colon,  lesions  similar  to  those  of  typhoid  fever.  The 
elliptical  plates  were  elevated,  and  slight  patches  of  ulceration  were 
seen  extending  through  the  mucous  membrane.  My  notes  do  not  re- 
mind me  of  the  exact  number  of  autopsies  made,  and  I  can  only  recol- 
lect five  or  six.  My  private  practice  was  crowding  me,  and  my  work 
was  imperfectly  done. 

The  treatment  of  such  cases  as  could  be  treated  at  all  was  entirely 
experimental.  Astringents,  tonics,  and  stimulants  were  given  without 
limit,  but  the  vomiting  was  generally  incessant,  and  the  remedies  re- 
jected by  the  stomach.  Medicines  were  administered  by  injection 
only  to  be  pushed  away  in  a  few  minutes  by  a  large  watery  passage. 
I  observed  that  when  brandy  was  thrown  into  the  rectum,  the  next 
stool  would  be  less  in  (juantity.  I  then  ordered  brandy  and  strong 
coffee  injection  to  one  patient,  brandy  and  a  solution  of  sugar  of  lead 
to  another,  and  brandy  and  a  solution  of  tannin  to  another,  and  found 
they  were  all  retained  a  considerable  time,  and  each  j)assage  that 
followed  was  diminished  in  quantity.  These  injections  were  repeated 
after  each  passage,  and  each  time  the  stools  were  considerably  post- 
poned and  smaller,  and  in  a  little  time  the  bowels  were  checked  entirely. 
I  then  ordered  brandy  and  strong  tea,  and  afterwards  brandy  and 
water,  by  injection,  with  the  same  result,  and  found  that  brandy  was 
the  astringent  and  stimulant  that  controlled  the  watery  stools. 
Patients  would  be  brought  in  approaching  collapse.   They  had  passed 


218 


CORRESPONDENCE. 


[Dec, 


much  fluid  by  the  bowels,  and  were  continually  having  large  watery 
stools  every  few  minutes.  They  were  in  a  cold  and  clammy  sweat; 
the  skin  blue  and  shriveled,  the  tongue  cold,  the  voice  husky,  rolling 
and  tossing  in  bed,  and  screaming  with  cramps  in  the  legs.  The 
nurses  would  take  them  by  force,  and  give  tliem  injections  of  two  or 
three  ounces  of  brandy,  aud  as  much  strong  coffee  or  tea,  and  repeat 
the  injection  immediately  after  each  passage;  and,  usually,  three  or 
four  injections  would  control  the  passages,  reaction  would  come  on,  the 
pulse  would  increase  in  volume,  the  surface  of  the  body  would  become 
warm,  the  skin  assume  a  more  natural  hue;  in  short,  all  the  vital 
functions  improve,  and  the  patient  go  on  to  convalescence.  After  re- 
action had  been  established,  small  doses  of  calomel  and  Dover's 
powder  were  given  to  act  upon  the  liver,  and  also  to  relieve  the 
colic  or  pain  in  the  bowels  that  usually  follows  the  sudden  check  of 
the  cholera  stools.  If  the  colic  was  severe,  opium  was  given  in  full 
doses.  In  a  day  or  so  castor-oil  was  given  to  carry  off  the  calomel, 
and  produce  bilious  stools. 

The  distressing  cramps  in  the  extremeties  were  most  relieved  by 
dry  rubbing  with  coarse  flannel  to  get  up  capillary  circulation;  hot 
mustard  plasters  placed  over  the  stomach  and  liver  are  of  great 
value  in  arresting  the  vomiting  so  persistent  in  the  early  stages  of 
cholera. 

Mustard  may  stimulate  the  action  of  the  liver,  which  is  always 
desirable.  It  will  stimulate  the  skin,  and  did  very  much  in  bringing 
on  reaction. 

The  loss  of  a  number  of  gallons  of  fluid  by  the  bowels  is  a  direct 
drain  upon  the  blood,  aud  the  prostration  that  follows  almost  as  great 
as  from  a  true  hemorrhage.  The  circulating  fluid  is  so  much  reduced 
in  quantity  that  it  does  not  fill  the  blood-vessels.  Much  of  the  serous 
portion  has  leaked  away,  leaving  the  solids  of  the  blood  in  the  cavity 
of  the  circulation,  and  too  thick  to  circulate.  Hence  we  have  cramps 
in  the  extremities,  because  there  is  not  circulating  fluid  enough  to  go 
the  complete  rounds  of  the  circulation,  and  the  blood  too  thick  to  find 
its  way  into  the  smaller  blood-vessels. 

The  blood  is  the  natural  stimulus  of  the  body,  and  when  any  parts 
of  the  body  are  deprived  of  tlieir  stimulus,  the  nerves  of  tiiose  parts 
are  not  kept  under  healthful  or  physiological  control,  and  we  have 
muscular  contractions  and  muscular  spasms. 

Opium  given  in  large  doses  to  relieve  these  cramps  is  positively 
hurtful.  It  will  relieve  them  only  by  narcotizing  the  patient  and  de- 
stroying sensibility  to  pain. 


1 

i 


1865.]  PROGRESS  OP  THE  MEDICAL  SCIENCES.  219 

I  am  fully  satisfied  that  much  mischief  has  been  done  by  opium  in 
the  treatment  of  cholera.  It  may  be  given  iu  stimulant  doses,  com- 
bined with  strong  coffee,  to  assist  in  bringing  on  reaction,  watching 
carefully  its  effects  upon  the  brain.  Hot  lemonade  and  brandy, 
and  hot  coffee  and  brandy  in  small  quantities  given  by  the  stomach 
will  aid  very  much  iu  hastening  reaction,  and  in  supporting  the  ex- 
hausted patient. 

O.  H.  Smith,  M.D. 

"Nkw  York,  Nov.  13,  1865. 


PROGEESS  OF  THE  MEDICAL  SCIENCES. 

I.— ANATOMY  AND  PHYSIOLOGY. 

The  following  abstracts  of  papers  read  before  the  late  meeting  of 
the  "British  Association  for  the  Advancement  of  Science,"  will,  doubt- 
ess,  prove  interesting  to  our  readers. 

1,  On  the  Effects  of  Scanty  ami  Deficient  Food.    Dr.  Davt. 

The  author  had  never  found  any  instance  where,  in  the  adult  man, 
a  deficiency  of  food  had,  though  causing  temporary  weakness,  pro- 
duced any  permanent  iU  effects.  None  of  the  Arctic  or  African  trav- 
elers had  suffered  any  permanent  injury  through  shortness  of  food. 
There  were  some  in  whom  he  thought  fasting  was  beneficial,  and  even 
sound  healthy  men  might  be  benefited  by  an  occassional  long  fast.  He 
supported  the  view  of  a  somewhat  scanty  prison  diet,  to  keep  the 
criminal  in  a  state  of  healthy  activity  somewhat  below  par.  Excess  of 
diet  in  jails  tended  to  increase  the  prison  population,  as  vagrants  and 
others  were  in  the  habit  of  looking  upon  it  rather  as  a  place  of  refuge 
and  comfort  in  winter  and  bad  weather.  He  urged  an  inquiry 
to  determine  the  lowest  scale  of  diet  that  could  be  used  in  prisons, 
and  that  should  not  injure  the  constitution.  Dr.  Bennett  (of  Edin- 
burgh,) Dr.  Edward  Smith,  Dr.  Eolleston  and  others,  discussed  the 
subject.  There  was  great  diversity  of  opinion  upon  the  general  ques- 
tion of  prison  diet,  but  in  the  main  it  was  opposed  to  the  views  of  the 
author,  and  some  of  his  assertions  were  negatived. — Lancet, 

2.  On  the  Prevalence  of  Tapeworm  in  Birmingham.    Dr.  Fleming. 

As  compared  with  Edinburgh  and  London,  the  greater  frequency  of 
the  disease  in  Birmingham  was  very  much  marked,  and  this  was 
proved  by  statistics.  Dr.  Fleming  considered  the  chief  cause  of  this 
to  be  measly  pork,  especially  in  the  form  of  sausages,  largely  eaten 
imperfectly  cooktul  by  the  poorer  classes.  As  a  preventive  he  advised 
that  the  pigs  should  bo  supplied  with  thoroughly  clean  food  and 
drink,  and  kept  as  far  as  possible  from  dogs;  and  that  the  ofiiQial 


220  PROGRESS  OP  THE  MEDICAL  SCIENCES.  [DeC, 


inspection  of  living  and  dead  pigs  should  be  made  as  searching  as  pos- 
sible. Dr.  Crisp  had  heard  that  in  Germany  cooks  were  most  affected 
with  tfenia,  and  he  thought  the  immunity  from  it  in  Edinburgh  was 
due  to  the  use  of  oatmeal  as  a  diet.  Dr.  Cobbold  said  that  beef  and 
veal  were  equally  sources  of  it,  and  that  many  persons  were  affected 
with  no  outward  signs  of  it.  Mr.  Hughes  and  Prof.  Bennett  also  made 
some  remarks,  and  the  President  thanked  Dr.  Fleming  for  his  excel- 
lent paper. — Lancet. 

3.  Rigor  Mortis  not  Muscular  Contraction.    Dr.  Noeeis. 

The  author  said  the  commonly  received  theory  is,  that  it  is  an 
energetic  muscular  contraction,  which  is  erroneous,  as  proved  by  the 
following:  1.  The  rigor  of  opposing  sets  of  muscles  does  not  cause 
the  redisposition  of  limbs  in  obedience  to  the  superior  powers  of  the 
stronger  sets  of  opponents.  2.  It  does  not  cause  the  rupture  of  the 
weaker  set  of  opponents.  3.  If  either  of  the  flexors  or  the  extensors 
of  a  limb  be  divided,  and  the  limb  be  placed,  before  rigor  has  set  in, 
in  the  position  in  which  it  should  be  drawn  by  the  cut  set  of  muscles, 
and  the  action  of  these  been  unopposed,  the  uncut  set  of  muscles  do 
not  alter  that  position.  4.  Contraction  and  the  presence  of  irritabil- 
ity being  an  inseparable  association,  it  follows  that  if  irritability  be 
absent  for  a  long  time,  immediately  jirior  to  the  supervention  of  rigor 
mortis,  the  latter  can  not  be  regarded  as  a  contraction.  5.  The  micro- 
scopical appearance  of  muscular  tissue  affected  with  rigor  mortis  is 
entirely  different  from  that  of  muscular  tissue  in  a  state  of  contrac- 
tion. The  truth  of  these  arguments  he  had  demonstrated  by  a  variety 
of  experiments,  selections  from  which  were  set  forth  in  detail.  Pho- 
tographs of  some  of  his  results  and  examples  of  others  were  submitted 
to  the  section.  So  highly  important  were  these  considered  that  the 
committee  recommended  him  to  continue  his  experiments  and  obser- 
vations, and  a  grant  of  money  was  awarded  to  enable  him  to  carry 
them  out. — Lancet. 


4.    Influences  of  Civilization  on  the  Brain.    Mr.  Robert  Dunn. 

The  following  formed  the  basis  of  this  paper:  1.  That  the  brain  or 
encephalon  is  the  material  organ  of  the  mind.  2.  That  there  exists  a 
close  correspondence  in  form  and  size  between  the  cerebrum  and  its 
outward  bony  covering,  the  skull;  so  that  the  varying  forms  of  the 
human  cranium  indicate,  as  outward  and  visible  signs,  with  certain 
well-understood  qualifications,  corresponding  differences  or  changes  in 
the  shape  and  size  of  the  cerebral  substance  within.  3.  That  the 
genus  homo  is  one;  and  that  all  the  races  of  the  great  family  of  man 
are  endowed  with  the  same  intuitions,  sensational,  perceptive,  and 
intellectual — the  same  mutual  activities,  however  they  may  differ  in 
degree;  and  that  they  all  have  the  essential  constituent  elements  in 
common  of  a  moral,  religious,  and  intellectual  nature.  In  the  discus- 
sion Dr.  Hinds,  Dr.  Scott,  Mr.  Vivian,  Lord  Milton,  Dr.  Child,  Mr. 
Faulkner,  Dr.  Camps,  and  others  took  part.  Of  course  a  wide  dif- 
ference of  opinion  prevailed  amongst  the  speakers.  Viscount  Milton 
contended  that  the  action  of  the  brain,  like  that  of  any  bodily  organ, 
attracted  to  it  an  increased  flow  of  blood,  and  necessarily  led  to  an 
enlargement  of  bulk  as  regarded  the  nutritive  process,  and  an  increased 
vigor  of  function. — Lancet. 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


221 


5.  On  Variability,  as  Manifested  in  the  Construction  of  the  Human  Body. 
William  Turner,  M.B.,  F.K.S.E. 

On  this  subject  Mr.  Turner  read  a  very  able  and  interesting  paper. 
He  commenced  by  stating  that  as  there  was  a  considerable  amount  of 
variability  of  the  human  frame,  it  was  no  matter  of  surprise  that  differ- 
ences and  variations  should  exist  in  parts  of  the  body  not  outwardly 
visible.  The  internal  structural  variations  were  so  numerous  that  he 
would  be  compelled  to  confine  himself  almost  entirely  to  some  varia- 
tions he  had  observed  in  the  hands  and  feet.  There  were  many 
variations  not  outwardly  visible,  and  which  required  careful  study  and 
observation.  He  proceeded  to  notice  the  vax-iations  of  the  bands  of  the 
thumb  and  fingers.  These,  in  the  observations  he  had  made,  were 
very  variable,  and  by  aid  of  numerous  diagrams  he  pointed  out  the 
many  difi'erences  in  the  construction  of  the  muscles  of  the  hand.  The 
various  diversities  in  the  subdivisions  of  the  muscles  of  the  hand  were 
ably  and  clearly  explained  and  illustrated,  and  Mr.  Turner  then  pro- 
ceeded to  notice  the  variations  in  the  flexor  muscles  of  the  toes. 
He  gave  his  experience  of  fifty  examinations,  and  remarked  upon  the 
various  changes  that  had  come  under  his  observation.  Mr.  Turner 
made  some  remarks  iipon  the  different  opinions  and  statements  that 
had  been  offered  resijecting  the  anatomy  of  the  toes  and  hands,  and 
proceeded  to  observe  that  these  opinions  were  right  as  far  as  they 
went;  but  having  had  opportunities  of  studying  the  subject  of  the 
paper  extensively,  and  making  many  and  frequent  observations,  he 
was  enabled  to  go  further  into  the  subject,  to  add  something,  he 
hoped,  to  what  had  already  been  written  and  said  on  the  subject.  He 
concluded  by  noticing  that  the  variations  he  had  alluded  to  were  as 
numerous  as  they  were  peculiar;  in  fact,  that  neither  form  nor  structure 
were  stereotyped;  but  how  far  these  variations  affected  the  general 
condition,  and  whether  they  were  transmitted  from  parents  to  children, 
were  subjects  he  could  not  enter  into.  In  the  development  of  each 
individual,  a  morphological  specialization  occurs,  both  in  internal 
structure  and  external  form,  by  which  distinctive  characters  are  con- 
ferred, so  that  each  man's  structural  individuality  is  an  expression  of 
the  sum  of  the  individual  variation  of  all  the  constituent  parts  of  his 
frame.  The  illustrations  advanced  in  support  of  the  author's  opinions 
were  taken  from  the  flexor  miiscles  of  the  fingers  and  toes,  from  the 
modifications  in  the  form  and  size  of  a  foramen,  called  sTipracondyloid, 
which  is  occasionally  met  with  in  man,  and  of  the  objects  passing 
through  it.  It  was  also  shown  that  variability  in  construction  was  not 
manifested  merely  in  different  individuals,  but  that  in  the  same  indi- 
vidual the  corresponding  striictures  on  oiDposite  sides  of  the  body 
were  by  no  means  symmetrically  disposed. — Med.  Times  and  Gazette. 


G.  On  the  Relative  Weigld  of  the  Brain  in  relation  to  the  Intelligence  in  the 
Vertebrata.    Dr.  Crisp. 

Dr.  Crisp  illustrated  his  paper  with  a  large  number,  126,  of  plaster 
of  Paris  casts  and  drawings,  and  commenced  by  dividing  the  subject 
into  three  princijial  heads,  which  were  afterwards  subdivided  into 
many  more.  He  said  that  in  the  brains  of  mammalia  there  was  great 
uniformity,  but  in  fishes  the  brain  was  very  irregular.  He  thought 
much  error  prevailed  with  resjiect  to  intelligence  being  regulated  by 
the  number  of  convolutions  in  the  brain,  for  it  was  found  that  animals 


222 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Dec, 


with  few  convolutions  were  very  sagacious,  while  in  other  classes  there 
were  a  great  many  very  stupid.  The  brain  always  remained  of  the 
same  weight,  though  the  body  might  decrease  or  be  augmented  in 
bulk,  and  the  brain  of  the  smaller  animals  was  relatively  greater  than 
that  of  the  larger.  The  brain  of  a  man  weighed  about  thirty-eight 
ounces,  and  that  of  a  woman  four  or  five  ounces  less,  forming  a  pro- 
portion  of  l-35th  to  l-40th  of  the  weight  of  the  body.  After  entering 
into  comparisons  of  weight  of  brain,  illustrated  by  drawings  and 
models,  lie  said  his  researches  had  led  him  to  the  following  con- 
clusions: The  external  appearance  of  the  brain  in  most  animals  was, 
to  a  great  extent,  an  indication  of  the  comparative  amount  of  the 
intelligence  of  the  animal;  but  to  this  rule  thers  were  many  excep- 
tions, as,  for  example,  in  the  elephant,  dog,  seal,  and  many  birds. 
The  same  inference  might  be  drawn  from  the  covered  and  uncovered 
state  of  the  cerebellum,  as  instanced  in  the  animals  last  named.  The 
number  of  convohitions  was  to  some  extent  a  tolerable  indication  of 
the  amount  of  intelligence  in  mammals;  but  to  that  there  many  excep- 
tions. Looking  to  the  weight  of  brain  in  226  animals  which  he  had 
selected,  he  foiind  that  the  relative  weight  of  brain  in  proportion  to 
the  body  was  an  indication  of  intelligence,  for  he  had  ascertained  that 
there  was  no  example  of  any  animal  with  a  relatively  small  brain  that 
possessed  a  great  amount  of  intelligence.  — Med.  Times  and  Gazette. 

7.  Ozone.    Dr.  B.  W.  Richardson. 

The  following  are  the  reliable  facts  known  up  to  this  time  respect- 
ing ozone:  1.  Ozone  in  a  natural  state  is  always  present  in  the  air  in 
minute  proportions;  viz.,  one  part  in  ten  thousand.  2.  It  is  destroy- 
ed in  large  towns,  and  with  special  rapidity  in  crowded,  close,  and 
filthy  localities.  3.  Ozone  gives  to  oxygen  properties  which  enables 
it  to  support  lite.  In  this  respect  it  acts  like  heat;  its  efi'ects  are  de- 
stroyed by  great  heat.  4.  Ozone  diffused  through  air  in  minute  quan- 
tities produces,  on  inhalation,  distinct  symptoms  of  acute  catarrh. 
5.  When  animals  are  subjected  to  ozone  in  large  quantities,  the  symp- 
toms produced,  at  a  temperature  of  75^,  are  those  of  inflammation  of 
the  throat  and  mucous  membranes  generally,  and  at  last  congestive 
bronchitis,  which,  in  carniverous  animals,  is  often  rapidly  fatal.  6. 
When  animals  are  subjected  for  a  long  period  to  ozone  in  small  pro- 
portions, the  agent  acts  differently,  according  to  the  animal.  The 
carnivora  die,  after  some  hours,  from  disorganization  of  the  blood 
separation ;  but  the  herbivora  will  live  for  weeks,  and  will  sufi'er  from 
no  acute  disease.  7.  The  question  whether  the  presence  of  ozone  in 
the  air  can  produce  actual  disease,  must  be  answered  cautiously. 
Science  has  yet  no  actual  demoyistradve  evidence  on  the  point.  But 
the  facts  apijroach  to  demonstration  that  catarrh  is  induced  by  this 
agent.  All  else  is  as  yet  S2:)eculative.  8.  During  periods  of  intense 
heat  of  weather  the  ozone  loses  its  active  power.  9.  On  dead  organic 
matter  undergoing  putrefaction,  ozone  acts  rapidly;  it  entirely  deo- 
dorizes by  breaking  up  the  ammoniacal  products  of  decomposition. 
At  the  same  time  it  hastens  the  organic  destruction.  10.  There  is  an 
opi^osite  condition  of  air  in  which  the  oxygen  is  rendered  negative  in 
its  action,  as  compared  with  the  air  when  it  is  charged  with  ozone. 
Air  can  thus  be  rendered  negative  by  merely  subjecting  it,  over  and 
over  again,  to  animals  for  respiration.  The  purification  of  such  air 
from  carbonic  acid  and  other  tangible  imj^urities,  does  not  render  it 
callable  of  supporting  heaUhy  life;  but  ozone  restores  the  power. 


1865.]  PROGRESS  OF  THE  MEDICAL  SCIENCES. 


223 


In  a  negative  condition  of  air  the  purification  of  the  organic  matter  is 
greatly  modified,  and  the  offensive  products  are  increased.  Wounds 
become  unhealthy  and  heal  slowly  in  such  negative  air.  11.  There  is 
no  demonstrative  evidence,  as  yet,  that  any  diseases  are  actually 
caused  by  this  negative  condition  of  air;  but  the  inference  is  fair  that 
diseases  which  show  a  putrefactive  tendency  are  influenced  injuri- 
ously by  a  negative  condition  of  the  oxygen  of  the  air.  It  is  also 
probable  that  during  this  state  decomposing  organic  poisonous  mat- 
ters become  more  injurious.  12.  As  ozone  is  used  up  in  crowded 
localities,  and  as  it  is  essential  that  ozone  should  be  constantly  sup- 
plied in  order  to  sustain  the  removal  of  decomposing  substances  and 
their  products,  no  mere  attention  to  ventilation  and  other  mechanical 
measures  of  a  sanitary  kind  can  be  fully  effective,  unless  the  air  intro- 
duced be  made  active  by  ozone.  Fever  hospitals  and  other  large 
buildings  in  towns  should  be  artificially  fed  with  ozonized  air. — Brit. 
Med.  Journal. 

8.  On  the  Functions  of  the  Cerebellum.    Dr.  W.  H.  Dickinson. 

This  paper  was  founded  partly  upon  experiments  made  on  a  great 
variety  of  animals,  chiefly  of  the  lower  order,  and  partly  upon  obser- 
vations on  human  pathology.  The  general  results  were  as  follow: 
1.  The  addition  of  the  cerebellum  to  the  medulla  oblongata  gives  an 
increase  of  voluntary  motive  power  to  the  four  limbs— to  the  posterior 
in  a  greater  degree  than  to  the  anterior.  The  power  thus  obtained  is 
distributed  in  such  a  way  as  to  produce  even  and  balanced  move- 
ments, and  often  appears  to  be  exercised  in  a  continuous  and  auto- 
matic manner.  2.  The  removal  of  the  cerebellum  has  an  efiect  upon 
the  muscles  of  the  limbs,  which  increases  in  i^roportion  as  the  organ 
increases  in  size.  It  consists  in  a  diminution  of  voluntary  power  and 
of  muscular  adjustment.  When  an  inequality  of  eS'ect  can  be  no- 
ticed, the  loss  is  greater  in  the  posterior  limbs.  There  is  a  loss  of 
habitual  activity.  From  the  eifect  of  lateral  injuries,  it  must  be  as- 
sumed that  each  lateral  half  of  the  organ  has  an  influence  on  both 
sides  of  the  body,  but  to  a  greater  extent  \\\)on  that  opposite  to  itself. 
3.  The  removal  of  the  cerebellum  has  no  effect  upon  superficial  sen- 
sation, on  any  special  sense,  on  the  action  of  the  voluntary  muscles, 
or  on  reflex  movements.  4.  In  the  human  being  it  appears  there  is 
no  constant  efiect  from  loss  or  alteration  of  the  cerebellum,  but  fail- 
ure of  voluntary  muscular  power.  Disease,  or  deficiency  of  the  whole 
organ,  invariably  lessens  voluntary  power  in  the  limbs,  especially  in 
the  lower.  The  loss  of  one  lobe  produces  its  effect  more  on  the  oppo- 
site side  than  on  its  own.  Disease  confined  to  the  cerebellum  has  no 
eS'ect  upon  superficial  sensation,  on  the  intellectual  powers,  or  on  the 
action  of  muscles  supplied  by  the  cranial  nerves.  Hence  it  appears 
that  the  function  of  the  cerebellum  is  to  sujiply  the  voluntary  muscles 
of  the  trunk  and  limbs  with  self-regulating  motive  power.  This  is 
distributed  in  an  inverse  manner  to  the  influence  of  the  cerebrum. 
The  latter  has  the  sole  control  over  the  parts  supplied  by  the  cranial 
nerves,  and  the  chief  control  over  the  anterior  limbs.  The  cerebel- 
lum has  its  greatest  effect  upon  the  posterior  limbs,  less  upon  the 
anterior.  Thus  the  muscles  of  the  trunk  and  limbs  are  under  a 
double  rule,  while  those  of  the  head  and  neck  are  regulated  solely  by 
the  cerebrum.  It  appears  that  cerebellar  movements  are  apt  to  be 
continuous  and  habitual,  contrasting  with  the  emotional  character  of 
those  which  originate  in  the  cerebrum. — Brit.  Med.  Journal. 


224  PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Dec, 


9.  Experiments  confirmatory  of  llioste  of  Kilhne,  on  the  Non-existence  of 
Ammonia  in  Blood.    Dr.  A.  Gamgee. 

Few  questions  had  excited  greater  discussion  among  physiologists 
than  the  coagulation  of  the  blood,  and  few  researches  on  the  subject 
had  been  received  with  gi-eater  interest  by  the  scientific  world  tlaan 
that  of  Dr.  B.  W.  Eicliardson.  The  conclusions  Dr.  Richardson  had 
come  to  were,  that  the  blood,  whilst  circulating  in  the  living  body, 
contained  free  ammonia;  that  when  the  blood  leaves  the  animal  body, 
ammonia  escapes  and  coagulation  takes  place,  the  escape  of  the  am- 
monia and  the  phenomenon  of  coagulation  being  considered  to  stand 
in  the  relation  of  cause  and  effect.  He  (Dr.  Gamgee)  made  some  ex- 
periments which  were  in  direct  opposition  to  those  of  Dr.  Richardson; 
and  as  the  quantity  of  blood  which  Kiihne  and  Strauch  subjected  to 
analysis  was  comparatively  small,  he  determined  on  repeating  the  ex- 
periments in  the  most  rigid  manner  possible,  and  upon  a  larger  scale 
than  had  been  previously  attempted.  Having  described  these  experi- 
ments, Gr.  Gamgee  concluded  by  remarking  that  further  researches 
would,  he  believed,  confirm  the  results  of  the  experiments  which  he 
had  i^erformed,  and  satisfactorily  prove  that  Nersler's  reagent  was  as 
delicate  a  test  for  the  compound  ammonia  as  for  simple  ammonia. 

A  discussion  followed  the  reading  of  the  paper,  in  the  course  of 
which  Dr.  Richardson  controverted  the  views  of  Dr.  Gamgee. — Brit. 
Med.  Journal. 


10.  Cell-Pathology.    Dr.  J.  Hughes  Bennett,  F.R.S.E. 

Dr.  Bennett  stated  that  a  cell-pathology  had  naturally  sprung  from 
the  cell-theory,  as  originally  framed  by  its  founders,  Schleiden  and 
Schwann,  which  had  greatly  extended  the  boundaries  of  medical  sci- 
ence. The  cell-pathology  of  Virchow,  however,  was  based  upon  a  law 
he  sought  to  establish,  viz.,  that  every  cell  sprang  from  a  pre-existing 
cell,  and  that  we  must  not  transfer  the  seat  of  oval  action  to  any  jjoint 
beyond  the  cell.  This  supposed  law,  he  maintained,  was  opposed  by 
so  many  histological  facts  as  to  be  altogether  untenable.  He  begged 
esjiecially  to  draw  attention  to  the  origin  of  puss-cells,  which  Virchow 
and  some  of  his  followers  had  represented  as  originating  in  the  inte- 
rior of  connective  tissue  corpuscles.  Dr.  Bennett  and  his  pupils  had 
frequently  sought,  by  passing  setons  through  the  skin  and  muscles  of 
animals,  to  observe  in  the  inflamed  tissues  the  appearances  which  had 
been  figured  in  suj^port  of  Virchow's  views,  but  had  never  succeeded 
in  seeing  pus-cells  within  pre-existing  cells.  Henle  had  pointed  out 
that  the  error  had  originated  in  mistaking  the  triangular  spaces  ob- 
servable, on  a  transverse  section,  between  the  bundles  of  various 
fibrous  tissues,  for  cells;  as  in  these,  unquestionably,  pus  was  very 
likely  to  collect.  Dr.  Bennett  further  believed  that  the  tendency  of 
many  cells  to  enlarge  as  the  result  of  irritation,  and  to  multiply  them- 
selves endogenously,  as  shown  by  himself,  by  Roberts,  Goodsir,  Red- 
fern,  and  other  pathologists,  was  another  source  of  mistake  among 
the  younger  histologists.  The  granules  and  included  cells  so  formed 
were  mistaken  by  them  for  those  of  jius,  though  easily  separated  from 
them.  He  called  attention  to  a  series  of  preparations  (which  were 
exliil)ited,)  showing  suppuration  in  inflamed  eye-balls,  and  in  pneu- 
monic lungs,  in  which  pus-cells  might  be  seen  in  all  stages  of  forma- 
tion— originating  from  a  coagulated  molecular  exudation,  unconnected 
with  any  pre  existing  cells  whatever.    In  the  sections  of  lung  more 


1865,] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


225 


especially,  the  fibrous  tissue  of  the  organ  surrounding  the  air-cells 
might  be  seen  to  be  quite  healthy.  In  the  coagulated  exudation,  on 
the  other  hand,  the  molecules  might  be  observed  at  first  uniformly 
filling  up  the  air- vesicle;  then  formed  into  masses,  varying  in  size 
from  the  twenty-thousandth  to  the  one-thousandth  of  an  inch  in  di- 
ameter. The  latter  were  sounded,  and  were  identical  with  pus-cor- 
puscles. He  believed  that  these  bodies,  therefore,  were  formed  by  an 
aggregation  of  smaller  particles  or  molecules,  composed  originally  of 
the  coagulated  exudation.  It  was  certain  that,  in  the  situations  re- 
ferred to,  they  did  not  originate  in  i^re-existing  cells,  as  no  such  cells 
could  be  seen.  If,  as  might  be  supposed,  they  sprang  from  the  epi- 
thelial cells  lining  the  chambers  of  the  eye  or  the  air-vesicles,  such 
cells  would  be  seen,  enlarged,  and  containing  the  pus-bodies.  But 
his  preparations  and  numerous  examinations  of  the  part  when  dis- 
eased had  proved  to  him  that  no  such  cells  were  mixed  with  the  exu- 
dation, or  in  any  way  connected  with  the  formation  of  pus. — Brit. 
Med.  JournaL 


11.  Is  the  Opinion  that  a  Diet  of  Animal  Food  conduces  to  Leanness  loell 
Founded  on  Facts?    Dr.  John  Davy,  F.R.S. 

Dr.  Davy  said  those  who  have  advocated  the  opinion  that  a  diet  of 
animal  food  conduced  to  leanness,  had  supported  it  by  arguing  that  a 
vegetable  diet  was  commonly  richer  than  flesh  in  the  elements  from 
which  adipose  matter  is  formed,  such  as  starch,  &c.,  and  further,  that 
carnivorous  animals  were  commonly  leaner  than  herbivorous.  He 
disregarded  the  first  argument,  inasmuch  as  certain  kinds  of  animal 
food  abounded  in  fatty  matter.  He  instanced  the  case  of  animals 
subsisting  on  other  animals,  all  of  which  were  very  fat,  and  he  con- 
sidered that  tended  to  show  that  a  diet  of  exclusively  animal  food  was 
in  no  wise  incompatible  with  fatness.  Refei-riug  to  our  own  species, 
it  was  easy  to  fine  corroborative  instances.  Butchers  and  their 
families,  who  used  large  quantities  of  meat,  were  not  remarkable  for 
leanness;  and  fishermen  and  their  families  were  generally  stout.  The 
English,  as  a  rule,  had  always  been  considered  large  consumers  of 
meat,  especially  in  the  olden  time,  when  vegetables  -were  less  abund- 
ant; and  in  those  periods  they  were  notoi'ious  for  their  stoutness. 
Did  a  vegetable  diet  tend  to  the  production  of  fat  ?  The  Irish, 
living  mostly  on  potatoes,  should  be  distinguished  for  lustiness, 
though  they  certainly  were  not;  and  he  had  not  heard  fatness 
ascribed  to  vegetarians.  Amongst  our  soldiers  and  sailors  a  fat  man 
was  a  rarity;  but  that  was  no  wonder,  for  though  their  diet  contained 
a  large  pi-oportion  of  animal  matter,  their  meat  ration  was  never  in 
excess,  and  they  were  rather  underfed  than  overfed;  while  at  the  same 
time  they  had  a  great  deal  of  exercise.  His  opinion,  in  which  he  was 
supported  by  eminent  ^jhysiologists,  was  that  a  mixed  diet,  partly 
animal,  partly  vegetable,  was  best  adapted  to  tlie  wants  of  man,  as 
well  as  most  suitable  to  his  taste;  and  that  the  safest  way  to  avoid 
obesity  was  to  live  moderately,  observing  the  happy  medium  between 
a  too  sparing  and  a  too  copious  dietary;  and,  for  the  correction  of 
obesity,  attending  rather  to  quantity  than  quality  of  food. — Dublin 
Med.  Press. 


Vol.  IL— No.  9. 


15 


226 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Dec, 


12.  Physiological  Action  of  Carbonic  Acid. 

M.  Demarquay,  in  a  memoir  presented  to  the  Academy  of  Sciences, 
gives  the  following  conclusions:  1.  Carbonic  acid  has  an  irritant  action 
on  the  skin,  especially  in  the  more  secretive  parts,  such  as  the  peri- 
neal region.  2.  Analgesia  of  the  skin  is  obtained  only  by  the  intiu- 
ence  of  a  continuous  jet  of  the  gas  on  a  very  limited  part  of  the  body. 
3.  The  action  on  the  organs  of  sense  is  analogous  to  that  on  the  external 
integument;  there  are  lively  excitement,  sensorial  exaltation,  or 
nervous  perturbation — all  these  phenomena  being  generally  very 
transient.  4.  The  action  on  the  digestive  organs  is  stimulant,  and  is 
attended  by  slight  neuro-vascular  excitement.  5.  Injected  into  the 
veins,  carbonic  acid  is  absorbed  in  large  quantity,  and  is  rapidly 
eliminated  if  the  experiment  be  carefully  performed;  otherwise  it 
produces  distension  of  the  cardiac  cavities,  and  death.  6.  Carbonic 
aeid  introduced  into  the  air-passages  does  not  produce  the  toxic  effects 
commonly  attributed  to  it.  Mammalia  can  remain  for  some  time 
without  serious  inconvenience  in  an  atmosphere  of  common  air  or 
oxygen  mixed  with  from  20  to  25  per  cent,  of  carbonic  acid.  In  man, 
some  slight  disturbance  occurs  at  a  time  varying  with  the  suscepti- 
bility of  the  individual.  When  death  follows  the  inhalation  of  this 
gas,  whether  in  man  or  in  animals,  the  post  mortem  appearances  are 
different  from  those  produced  by  carbonic  oxide,  the  efiects  of  which 
have  often  been  confounded  with  ihone  of  carbonic  acid.  7.  Most  of 
the  accidents  produced  by  the  fumes  of  charcoal,  by  confined  air,  by 
the  vapors  arising  from  stoves  or  from  fermentation,  have  been 
erroneously  attributed  to  carbonic  acid;  they  ought  in  great  part  to  be 
laid  to  the  charge  of  carbonic  oxide,  sulphide  of  hydrogen,  alcoholic 
vapor,  and  other  imperfectly  known  gases.  8.  Carbonic  acid  is 
simply  irrespirable;  because,  being  of  the  same  nature  as  the  gas 
expired  from  the  lung,  a  physical  interchange  of  gases  can  not  take 
place.  Hydrogen  and  nitrogen  are  less  immediate  in  arresting  respi- 
ration than  carbonic  acid,  because  they  aUow  the  physical  interchange 
to  go  on  for  a  short  time.  9.  Anaesthesia  can  not  be  produced  in  man 
by  carbonic  acid  without  danger  of  asphyxia;  and,  even  if  it  could  be 
safely  produced,  it  would  be  too  transient  to  be  of  service  in  opera- 
tions.—  Gaz.  Med.  de  Paris. 


II.— SUEGEEY. 

1.  Two  Tumors  removed  fi'om  the  Laryn.x  in  a  Case  of  Aplionia  of  Six 
Years,  followed  by  immediate  Speech.    Dk.  Gibb. 

The  patient  was  a  single  lady,  of  thirty- eight,  who  had  had  a  bad 
throat  for  six  years,  the  voice  being  reduced  to  a  croupy  whisper. 
During  the  first  three  years  she  had  coughed  xip  pieces  of  "flesh," 
one  of  which  was  an  inch  long  and  the  shape  of  a  shrimp.  For  the 
greater  part  of  the  time  she  could  not  lie  down  at  night,  from  sup- 
posed cardiac  disease  with  dy.spnoea,  and  her  complexion  was  very 
florid.  On  examination  with  the  laryngoscope  in  April  last,  a  long, 
fleshy,  somewhat  bulbous  growth  was  seen  to  occupy  the  gi-eater  part 
of  the  sub-glottic  space,  springing  from  the  anterior  part  of  the 
larynx,  below  the  origin  of  the  true  vocal  cords,  and  quite  immovable. 
TJifi  larynx  in  other  respects  was  comparatively  healthy,  but  there  was 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


227 


much  irritability  and  spasm  of  its  proper  muscles.  After  six  weeks' 
preparation,  Dr.  Gibb  snared  a  growth  in  the  loop  of  wire  of  his 
laryngeal  ecraseur,  cut  its  pedicle,  and  withdrew  it  firmly  held  by  a 
piece  of  uncut  mucous  membrane  in  the  retracted  loop,  in  a  similar 
manner  to  the  outer  coat  of  the  artery  after  ligature.  He  now  found 
a  second  and  larger  growth,  which  had  formed  the  bed  of  that  already 
removed,  and  this  was  snared  six  days  later  in  a  similar  manner  to  the 
first,  the  tumor  being  likewise  withdrawn  in  the  retracted  wire  loop 
of  the  ecraseur.  The  voice  was  immediately  restored,  for  the  mechan- 
ical obstruction  was  got  rid  of.  In  a  few  days  the  little  wound  cica- 
trized, no  obstruction  was  visible,  the  trachea  was  normal,  and  the 
patient  left  for  the  North — cured.  The  composition  of  the  tumors 
was  wholly  eijithelial  cells,  and  to  the  naked  eye  resembled  a  conge- 
ries of  small  cysts;  they  were  of  the  size  of  small  beans.  The  tumors 
were  exhibited  with  the  wires  attached  to  the  mucous  membrane,  and 
Dr.  Gibb  remarked  that  when  the  loop  of  the  wii"e  was  not  violently 
or  spasmodically  drawn  home,  the  growths  invariably  were  withdrawn 
with  the  instrument  itself.  The  case  made,  he  believed,  his  fifteenth 
or  sixteenth  in  which  he  had  now  successfully  abstracted  growths 
from  the  larynx  by  means  of  wire  loops,  and  this  in  their  entirety,  not 
in  fragments.  The  shape  and  position  of  the  tumors  in  the  j^resent 
instance  were  well  illustrated  by  a  large  diagram. — 3Iedical  Circular. 

2.  Gase^  of  Erysipelatom  Infiammaiion  of  the  Scrotum  and  Penis,  Sim- 
ulating Extravasation  of  Urine,  with  Remarks.  Communicated 
by  F.  HowAED  Maksh,  late  House  Surgeon  to  St.  Bartholomew's 
Hosi^ital. 

The  following  cases  bring  to  light  no  fact  which  has  not  been  already 
observed  and  recorded.  They  are,  notwithstanding,  a  valuable  group, 
exemplifying  as  they  do  the  main  featui'es  of  a  rare  and  dangerous 
malady,  which  is  rendered  the  more  imjsortant  by  the  liability  which 
exists  that  those  who  have  to  deal  with  it  may  fail  at  first  to  recognize 
its  true  nature,  and  mistake  it  for  extravasation  of  urine,  to  wliich  it 
presents  in  many  of  its  symptoms  so  close  a  likeness.  The  affection, 
which  consists  of  erysipelatous  inflammation  of  the  tissues  of  the 
scrotum,  generally  involving  those  also  of  the  penis,  and  sj^reading 
more  or  less  widely  to  the  parts  around,  may  arise  either  as  a  primary 
disease,  met  with  as  such  chiefly  in  persons  above  middle  age,  whose 
health  is  reduced  in  many  instances  by  advanced  kidney  disease,  oi*- 
from  some  local  condition,  as  in  Case  2,  in  which  the  original  mischiei 
was  deep-seated  abscess  in  the  perineum.  It  is  described  under  the 
name  of  "inflammatory  ttdema"  by  Mr.  Liston,*  who  says  of  it  that 
"  it  often  follows  on  sores,  or  eruptions  situated  in  the  groin,  genitals,, 
or  inside  of  the  thighs,  or  on  fistulas  about  the  perineum  and  anus." 
The  mischief  spreads  rapidly  "  fi'om  the  infiltration,  apparently  of  a 
vei-y  acrid  and  fetid  sanies."  This  writer  adds  that  he  had  in  the 
Edinburgh  Hospital  "  no  less  than  six  cases  under  treatment  at  one 
time,  in  a  very  unhealthy  season,  and  in  different  stages  of  their  prog- 
ress." Mr.  Holmes  t  has  rejjorted  some  well  marked  examples  of  the 
disease,  and,  in  some  remarks  which  he  has  apijended  to  them,  he 
dwells  on  the  important  point  that  the  retention  of  urine  which  is. 


*  "Practical  Surgery,"  ISifi.  p.  V>0.. 
t  British  Medical  Journal,  1S55-JH56. 


228 


PROGRESS  OF  THK  MEDICAL  SCIENCES. 


[Dec, 


liable  to  occur,  as  was  the  case  with  the  patient  under  Mr.  Paget's 
care,  and  also  with  the  boy  in  the  Children's  Hospital,  and  which  ia 
so  likely  to  divert  attention  from  the  true  nature  of  the  case,  is  the 
result,  and  not  the  cause,  of  the  mischief  in  the  scrotum. 

Although  the  first  step  in  the  treatment  of  this  affection  is  the  same 
that  is  proper  in  the  management  of  extravasation  of  urine — namely, 
to  relieve  the  tissues  of  the  acrid  fluid  by  which  they  are  infiltrated, 
by  making  sufficient  incisions  for  its  escajje,  there  is  one  consideration 
which,  besides  tlie  love  of  a  right  diagnosis  for  its  own  sake,  makes  it 
highly  important  to  recognize  this  affection  in  its  early  stage.  In 
extravasation  of  urine  many  surgeons  deem  it  proi^er  that  a  catheter 
should  be  kept  in  the  bladder  for  a  certain  period.  There  is,  of 
course,  no  necessity  for  this  measure  in  the  disease  under  notice,  and 
to  avoid  it  is  of  the  first  moment,  when  the  patient  is  a  debilitated 
person  who,  as  experience  shows,  may  be  supposed  to  be  the  subject 
of  disease  of  the  kidneys.  Two  circumstances,  in  the  majority  of 
instances,  will  lead  to  a  correct  conclusion  as  to  the  nature  of  the 
disease.  There  will,  in  the  first  place,  be  no  history  of  previous  ob- 
struction, or  of  retention  of  urine;  and,  secondly,  a  large  catheter 
will  pass  into  the  bladder  without  encountering  any  obstruction.  The 
absence  or  presence  of  fullness  in  the  perineum  is  not  a  safe  guide; 
mere  erysipelatous  inflammation  may  have  its  origin  there,  as  in  Mr. 
Paget's  second  case,  and  so  resemble  in  one  of  its  chief  features  ordi- 
nary extravasation  of  urine;  or,  on  the  contrary,  extravasation  may 
occur  from  ulceration  of  the  urethral  wall  behind  a  stricture  situated 
in  the  anterior  portion  of  the  urethra,  in  which  case  the  jjerineum 
will  be  at  first  in  a  natural  condition,  and  will  only  become  involved 
as  the  extravasation  spreads  from  the  penis  to  the  parts  around. 

Case  I. — Erysipdatoux  Injiammation  of  the  Scrotum  and  Petiifs,  Sim- 
ulating Extravasation  of  Urine.  Under  the  care  of  Mr.  Paget.  J.  B., 
49,  a  laborer,  poorly  off,  and  in  the  habit  of  drinking  freely,  came  to 
the  surgery  on  SeiDtember  20.  He  was  in  a  state  of  such  great  pros- 
tration that  he  had  scarcely  been  able  to  reach  the  hospital,  and  on 
his  arrival  w.as  at  once  sent  into  one  of  Mr.  Paget's  wards.  Upon  ex- 
amination, the  scrotum  and  penis  were  found  greatly  swollen,  the 
scrotum  being  about  as  big  as  the  head  of  a  child  four  years  old;  the 
skin  of  it  and  of  the  penis  was  for  the  most  i^art  of  a  dull,  ash-gray 
color,  but  hei'e  and  there  were  greenish-black  patches,  where  gangrene 
was  already  comjilete.  Some  slight  brown  discoloration  of  the  integ- 
uments was  seen  creeping  up  over  Poupart's  ligament.  The  jierineum 
looked  in  a  natural  condition .  The  patient's  general  state  was  that 
of  great  exhaustion;  he  looked  pale  and  dej^ressed;  respiration  was 
rapid,  and  the  pulse  quick,  small  and  very  feeble.  He  was  very  con- 
fused in  the  account  he  gave  of  himself;  but  it  was  gathered  that  he 
had  never  had  any  difficulty  in  micturition  till  the  early  jjart  of  the 
previous  day,  (Seijtember  19.)  The  condition  of  the  scrotum  and 
penis  had  commenced  as  a  painful  swelling,  which  had  spread  from 
the  lower  part  of  the  scrotum,  and  which  he  first  noticed  about  two 
days  before  his  admission,  (about  the  morning  of  September  18;)  but 
of  this  he  was  not  clear. 

Before  proceeding  to  any  treatment,  Mr.  Paget  remarked  that,  at 
first  sight,  the  case  presented  the  ordinary  features  of  extravasation 
of  urine;  yet  he  believed  it  would  i)rove  that  the  patient  was  not  suf- 
fering from  this  condition,  but  from  erysipelatous  iuHammation  of  the 
scrotum  and  j^euis,  depending  either  on  defective  general  health,  or 
on  some  other  cause  not  connected  with  tlie  escape  of  urine  into  the 
cellular  tissue.    He  was  led  to  this  conclusion  by  the  fact  that  the 


18G5.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


229 


patient  had  experit'iiced  no  difficulty  in  passing  his  water  till  there 
was  Kiilfioient  swelliiis:  of  the  parts  around  the  urethra  to  account  for 
it,  and  by  the  condition  of  the  perineum,  which  was  quite  normal. 
Besides,  he  had  on  more  than  one  occasion  met  with  cases  which 
resembled  extravasation  of  urine  as  closely  as  this  did,  but  which 
proved  to  be  instances  of  erysipelatous  inflammation  occurring  inde- 
pendently of  that  accident. 

Mr.  Paget  then  proceeded  to  make  such  incisions  as  were  necessary 
to  relieve  the  tension  of  the  parts,  and  to  introduce  a  catheter  into 
the  bladder.  A  No.  10  passed  very  readily  without  meeting  with  any 
obstruction;  and  a  few  ounces  of  turbid  urine  were  removed.  The 
after  course  of  the  case  was  that  the  man  fell  rapidly  into  a  condition 
of  extreme  asthenia,  and,  although  he  took  a  large  amount  of  stimu- 
lants, died  at  4  a.m.  on  September  21. 

At  the  after-death  examination,  the  urethra  was  laid  open  in  its 
whole  length,  and  found  to  be  perfectly  sound.  No  sign  of  extravasa- 
tion of  urine  could  be  discovered;  and  the  tissues  immediately  sur- 
rounding the  canal  seemed  less  infiltrated  than  those  nearer  the  sur- 
face. The  heart  was  fatty,  though  only  to  a  small  extent;  the  lungs 
were  healthy;  the  liver  large  and  fatty;  the  kidneys  rather  large,  pale, 
and  indistinctly  granular. 

For  the  following  case  I  am  indebted  to  the  kindness  of  Mr.  Paget, 
who  has  allowed  me  to  copy  it  from  his  note-book. 

Case  II. — Perineal  Abscess,  with  Stricture — Imitating  Effusion  of 
Urine.  Under  the  care  of  Mr.  Paget.  A  man,  45  years  old,  intem- 
perate, jjoor,  and  dull-witted,  was  admitted  into  Kenton's  Ward  in 
September,  18G0.  He  had  had  stricture  of  the  urethra  for  many 
years,  for  which  many  instruments  had  been  imssed.  His  water- 
strain,  he  said,  had  not  of  late  been  worse  than  usual.  He  had  a  large 
and  painful  swelling,  of  severalr  days'  formation,  in  the  middle  of  his 
perineum.  His  scrotum  was  swollen  to  five  or  six  inches  in  diameter, 
tense,  pallid,  glossy;  similiar  swelling  extended  from  it  along  both 
groins,  and  the  tissues  felt  tense,  brawny,  and  edematous  nearly  to 
the  umbilicus.  The  pubes  was  also  swollen,  and  in  a  less  degi'ee  the 
integuments  of  the  penis.  It  was  not  doubted  that  this  was  a  case  of 
effusion  of  urine;  it  had  every  feature  of  a  very  bad  case  of  the  kind. 
An  incision  was  immediately  made  into  the  perineum,  and  this  let  out 
two  ounces  (about)  of  very  stinking  purulent  fluid.  It  came  from  an 
irregular  cavity  in  the  perineum,  which  extended  thence  as  far  as  the 
finger  would  reach  in  the  deep  subcutaneous  tissue  of  both  groins. 
As  it  seemed,  therefore,  that  the  one  incision  would  relieve  both  the 
perineum  and  the  groins,  no  cuts  were  made  into  them,  but  several 
small  punctures  were  made  into  the  scrotum.  The  man  had  imme- 
diate relief  from  his  pain  and  distress;  but  two  or  three  days  later 
separate  centres  of  suppuration  appeared  in  the  right  groin,  and 
though  these  were  opened,  extensive  sloughing  of  the  integuments 
and  subcutaneous  tissue  ensued,  exposing,  after  the  separation  of  the 
sloughs,  the  abdominal  muscles.  Similar  sloughing  afterwards  ensued 
in  the  scrotum  on  both  sides.  With  these  things  he  became  very 
feeble.  He  had  daily  sickness,  frequent  diarrhoea,  and  five  weeks 
after  his  admission  he  died,  very  emaciated  and  as  if  exhausted  with 
his  local  disease  and  with  unemia.  His  ui'ine -strain,  however,  he 
always  said,  never  troubled  him,  and  no  urine  passed  through  the 
perineum  at  any  time,  though  the  i^erineal  incision  remained  open. 

Mr.  Paget  here  remarks:  "Except  in  this  absence  of  the  usual 
escape  of  urine  by  the  perineum,  the  whole  course  of  the  disease  had 


230 


PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Dec, 


seemed  to  indicate  the  consequences  of  effusion  of  urine  in  which 
there  had  been  unwise  neglect  of  the  practice  of  cutting  freely  into 
all  the  parts  into  which  the  urine  had  penetrated;  but  on  examining, 
twenty-four  hours  after  death,  there  appeared  no  trace  or  any  indica- 
tion of  any  communication  between  the  urethra  and  any  part  of  the 
suppurating  or  sloughing  cavities  in  the  jjerineum,  scrotum,  or  groins. 
These  cavities  had  the  appearance  of  ordinary  irregular  abscesses,  and 
at  their  nearest  their  wall  was  about  a  quarter  of  an  inch  off  the  most 
anterior  part  of  the  urethral  stricture.  In  the  urethra,  just  behind 
the  triangidar  ligament,  was  an  irregularly  barred  stricture,  about 
two-thirds  of  an  inch  long,  which  would  admit  a  No.  G  catheter;  but 
its  walls  were  entire  and  tirm,  without  trace  of  iilceration  or  any  recent 
inflammatory  change,  both  in  front  of  it  and  behind  it." 

The  bladder  was  very  thick  walled,  and  its  mucous  membrane  mam- 
millated  and  blotched  with  vasculai'ity.  Both  kidneys  were  small, 
lobed,  and  seamed,  tough,  i^ale,  very  granular,  with  closely  adherent 
capsules,  several  small  yellow  cysts,  and  wasted  cortical  substance — 
marked  examples  of  the  last  stage  of  granular  degeneration. — Medical 
Times  and  Gazette. 


3.  Concussion  (?)  of  the  Spine. 

In  a  recent  number  of  T7ie  Lancet  we  referred,  under  the  above  title, 
to  the  case  of  a  man  now  lying  in  King's  College  Hospital  On  the 
7th  instant  Ave  again  visited  him,  and,  through  the  kindness  of  Mr. 
Bond,  the  house  surgeon,  were  supplied  with  further  information  up- 
on his  case.  We  found  him  materially  improved  as  regards  his  power 
of  speech,  but  unaltered  in  respect  to  the  paraplegic  symptoms  already 
recorded.  For  a  fortnight  previous  to  our  visit  galvanism,  applied  in 
a  variety  of  directions  through  the  body,  had  been  used  daily.  Two 
or  three  days  after  its  first  application  speech  returned.  He  can  now 
express  himself  clearly,  and  with  no  evident  difficulty,  except  in  one 
respect :  his  pronunciation  of  the  lingual  "th"  would  be  intolerable 
even  in  a  Frenchman.  If  we  examine  this  defect  it  presents  a  very 
interesting  feature.  The  tongue,  in  effecting  this  sound,  has  need  of 
greater  mobility  and  power  of  protrusion  than  in  the  production  of 
any  other.  It  is  advanced  so  that  the  upi^er  incisors  are  touched,  the 
tip  pi'ojecting  slightly  beyond  them,  and  is  then  retracted  suddenly. 
These  movements  are  necessarily  effected  through  the  hypoglossal 
nerve,  the  lowest  of  those  which  originate  in  the  cei)halic  prolonga- 
tion of  the  sjiinal  cord,  generally  known  as  the  medulla  oblongata, 
and  which  approaches  in  some  animals  so  closely  to  the  regular  type 
of  the  spinal  nerves.  We  have  here,  then,  imjiairment  of  a  portion 
of  the  spinal  nervous  system,  as  shown  by  the  paraplegia,  and  of  just 
that  jjart  of  the  cerebral  system  which  is,  as  it  were,  on  the  border 
territory  between  the  two. 

Three  weeks  since,  as  it  had  been  suggested  by  more  thru  one  ob- 
server who  had  visited  this  patient  that  he  was  shamming,  Mr.  Bond, 
with  a  view  to  the  elucidation  of  this  point,  placed  him  under  chloro- 
form. This  was  a  week  previous  to  the  return  of  speech.  Whilst 
insensible  he  struggled  violently  with  the  upper  poi-tiou  of  the  body, 
hitting  out  wildly  with  his  arms,  but  nerer  moved  his  leys.  He  made 
a  great  noise,  but  nothing  like  an  articulate  sound.  He  has  had  no 
recurrence  of  the  ei^ileptoid  seizui'es  described  in  our  jirevious  notice. 
There  is  absolutely  no  sensation  in  the  lower  extremities  when  they 


1865.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


231 


are  touched  or  piaclied;  but  he  tells  us  that  he  can  feel  the  passage 
«f  the  electric  current  quite  deeply,  and  as  though  in  the  bones. 

We  hope  shortly  to  publish  some  communications  which  we  have 
received  in  reply  to  our  request  for  cases  illusti-ating  the  subsequent 
history  of  patients  injured  by  blows  upon  the  back.  Meanwhile  we 
would  again  draw  attention  to  the  importance  of  such  cases  being  re- 
corded, and  invite  further  contributions.  Such  reports  should  include 
the  kind  of  violence  exerted,  the  immediate  symptoms,  and  the  after 
results,  whether  of  a  few  months'  or  years'  standing,  By  an  accumu- 
lation of  such  histories,  much  light  may  be  thrown  upon  a  subject  at 
jjresent  involved  in  obscurity,  and  great  assistance  rendered  in  the  fair 
estimation  of  the  amount  of  damage  inflicted  in  cases  of  railway  acci- 
dent.—  The  Lancet. 


4.  Remarkable  Repair  of  Extensive  Injuries. 

On  the  29th  of  July  last  we  saw  a  boy,  fourteen  years  old,  admitted 
into  St.  Bartholomew's  Hospital,  whose  condition  seemed  to  hold  out 
scarcely  a  hope  of  recovery.  He  had  got  entangled  in  some  cord- 
making  machinery,  and  had  been  rolled  by  a  revolving  cylinder  much 
as  linen  is  pressed  in  a  mangle.  The  ecchymosis  was  so  extensive 
that  his  face  was  enormously  swollen  and  of  a  dark  purple  color,  the 
conjunctivna  intensely  chemosed,  and  the  features  unrecognizable. 
The  aspect  resembled  that  of  a  very  bad  case  of  scurvy,  or  perhaps 
still  more,  as  Mr.  Paget  remarked,  that  condition  of  dark  tumefaction 
which  sometimes  precedes  the  eruption  in  malignant  variola.  The 
boy  had  sustained,  besides,  the  following  injuries:  oblique  fracture 
of  the  left  femur;  separation  of  the  epiphysis  of  the  right  femur; 
wound  near  the  left  elbow-joint,  possibly  entering  it;  dislocation  of 
the  right  humerus  into  the  axilla.  There  was  concussion  of  the  brain 
and  he  lay  for  many  hours  in  a  state  of  complete  collapse.  A  sixth  of 
a  grain  of  morphia  was  injected  subcutaneously,  and  this  was  contin- 
ued daily.  On  the  2Gtli  of  August  we  found  him  looking  cheerful  and 
comi:)letely  altered  in  appearance;  there  was  scarcely  any  ecchymosis 
remaining;  the  wound  about  the  elbow-joint  had  healed;  the  left 
femur  was  encased  in  a  gypsum  splint,  and  the  right  had  united. 
When  we  saw  him  last,  on  September  27th,  the  injuries  described 
were  repaired,  but  he  was  suffering  from  suppuration  in  the  neigh- 
borhood of  the  right  shoulder-joint.  Mr.  Eccles,  the  house  surgeon, 
who  had  ch.arge  of  him,  tells  us  that  after  the  reduction  of  the  dislo- 
cation, which  was  easily  effected,  inflammation  took  place,  and  a  large 
abscess  formed,  which  was  opened  over  the  pectoral  muscle  and  in 
the  outer  wall  of  the  axilla.  It  is  proable  that  extensive  extravasation 
of  blood  took  place  into  the  joint  at  the  time  of  the  accident.  He 
still  complained  of  stiffness  about  the  back. 

The  case  furnishes  a  remarkable  instance  of  the  elasticity  of  life  at 
this  particular  age.  A  few  years  later,  and  the  lad's  hardened  tissues 
would  have  been  crushed  probably  beyond  repair.  —  The  Lancet. 

5.  Painful  Ulcer  of  the  Rectum,  with  Contraction  of  the  Anal  Orifice, 

and  Vascular  Poli/pus. 

A  few  weeks  since  we  saw  Mr.  Henry  Smith  operate  in  King's  Col- 
lege Hospital  xipon  a  middle-agetl  female  who  had  been  suffering  for 
two  years  with  difficulty  in  evacuating  the  contents  of  the  rectum,  ac- 


232 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Dec, 


companied  with  great  pain  at  the  time,  -which  persisted  for  four  or  five 
hours,  and  then  ceased,  leaving  the  patient  free  until  the  next  actiftn 
of  the  bowels.  Mr.  Smith  expected  to  find  simply  a  fissure  of  the 
anus,  but,  on  examination,  he  discovered  that  the  anal  orifice  was  so 
contracted  as  scarcely  to  admit  the  point  of  the  forefinger.  On  in- 
specting the  parts  more  minutely,  a  small  linear  fissure  was  noticed 
just  within  the  sjihincter,  at  the  posterior  verge  of  the  anal  orifice. 
When  the  patient  was  placed  under  the  influence  of  chloroform,  the 
finger  could  be  passed  into  the  bowel,  and  it  was  then  discovered  that 
a  polypus,  about  as  large  as  a  nut,  was  attached  to  the  posterior  waD 
of  the  rectum,  three-fourths  of  an  inch  from  the  anus.  The  operation 
consisted,  first,  in  seizing  the  polypus  with  a  hooked  forceps,  bring- 
ing it  down  outside  the  anus,  passing  a  ligature  around  it,  and  then 
dividing  the  pedicle.  A  straight  probe-pointed  bistoury  was  next  in- 
troduced, and  the  sphincter  ani  was  thoroughly  divided  in  the  median 
line  posteriorly,  so  as  to  allow  of  the  free  introduction  of  a  bougie 
into  the  bowel.  The  patient  left  the  hospital  a  fortnight  after  the 
operation,  completely  relieved. — The  Lancet. 


C.  Case  of  Subcutaneous  Venous  Ncevus  of  the  CheeJc,  with  Phlebolites  in 
the  Interior.   Under  the  care  of  Mk.  Wood, 

Frances  S.,  aged  17,  admitted  September  5,  1865.  A  rather  deli- 
cate looking  girl,  with  a  large  swelling  on  the  right  cheek,  reaching 
from  the  orbit  to  the  lower  jaw,  and  from  the  corner  of  the  mouth  to 
the  ear.  The  tumor  is  soft,  yielding,  and  elastic,  and  can  be  com- 
pressed and  diminished  in  size  like  a  sponge.  At  the  upper  and  back 
part  is  a  bluish  area,  of  the  size  of  a  penny,  in  which  the  outline  of 
tortuous  veins  can  be  distinguished.  A  little  below  the  middle,  two 
hard  oval  movable  bodies  (phlebolites)  can  be  felt  in  the  interior  of 
the  tumor.  These  can  be  pushed  a  little  from  their  places,  but  after- 
ward assume  their  original  position.  The  action  of  the  muscles  on 
that  side  is  impeded  to  some  extent,  and  the  right  corner  of  the  mouth 
hangs  below  the  other.  States  that  she  has  had  a  swelling  there  from 
infancy,  but  that  it  has  increased  somewhat  rapidly  of  late. 

On  Saturday,  September  9th,  under  chloroform,  Mr.  Wood  applied 
his  subcutaneous  clove  hitch  to  the  tumor.  The  object  of  this  ligature 
is  to  strangulate  the  varicose  parts  with  as  little  damage  to  the  skin  as 
possible.  The  thread  was  introduced  through  the  skin  at  the  uj^per 
and  back  part  of  the  circumference  of  the  tumor,  and  brought  out  in 
the  inside  of  the  cheek,  at  the  lower  and  front  jiart,  in  such  a  way  as 
to  avoid  the  duct  of  the  parotid  opening  opi^osite  the  second  upper 
molar.  A  stout  semicircular  needle,  mounted  on  a  handle,  (Wood's,) 
was  first  passed  around  the  upper  half  of  the  circumference  of  the 
tumor,  close  under  the  skin,  and  brought  out  on  the  inside  of  the 
cheek.  A  stout  hemj^en  ligature,  well  waxed  and  soaped,  was  then 
attached,  and  drawn  back  with  the  needle,  lea\nng  one  end  in  the 
mouth.  The  needle  carrying  the  other  was  then  passed  deeply  across 
the  base  of  the  tumor  diametrically,  carrying  a  looj)  of  thread;  this 
was  seized  and  retained  as  the  needle  was  withdrawn.  Tlie  needle 
was  then  passed  close  under  the  skin  round  the  remaining  part  of  the 
circumference,  the  end  of  the  thread  seized  and  detached,  and  the 
needle  withdrawn.  In  each  case  the  needle  entei-ed  at  the  same  aper- 
ture in  the  skin,  and  emerged  by  a  single  opening  in  the  mouth. 
Through  this  latter,  both  the  ends  and  the  looi)  of  the  thread  were  at 


1865.]  PROGRESS  OF  THE  MEDICAL  SCIENCES. 


233 


this  stage  of  the  operation  hanging  out.  The  ends  of  the  thread  were 
then  passed  separately,  and  in  opposite  directions,  through  the  loop, 
and  then  tightened  up,  and  tied  in  abunch.  The  tightening  produced 
a  marked  impression  upon  the  bulk  of  the  tumor,  and  dejjressed  the 
skin  all  around. 

Two  days  .after  thei-e  was  a  considerable  amount  of  swelling  of  the 
face  and  eyelids,  which  were  (edematous.  Complained  of  much  pain, 
■which  was  relieved  by  Battley's  fluid.  Suppuration  then  set  in  pro- 
fusely, emerging  freely  at  both  oioenings,  but  chiefly  through  the 
mouth.  Shreds  of  lymph  were  occa.sionally  discharged.  About  ten 
days  after,  a  small  abscess  made  its  appearance  at  the  border  of  the 
lower  jaw  from  gravitation  of  pus.  This  was  opened  by  a  small  punc- 
ture, and  well  squeezed  every  day.  It  was  hoped  that  the  phlebolites 
would  become  squeezed  out  into  the  mouth  in  the  course  of  the  daily 
manipulations,  but  this  did  not  occur.  When  the  ligature  came  away, 
which  it  did  in  a  small  loop  about  fourteen  days  after  the  oiJeration, 
the  hard  bodies  could  be  felt  adherent,  and  not  movable,  close  under 
the  mucous  membrane  of  the  cheek,  whence  they  may  easily  be 
removed  by  a  slight  incision,  if  necessary.  The  whole  mass  has  now 
become  solidified  and  hardened  throughout;  a  slight  discharge  passes 
out  at  each  of  the  punctures.  The  movement  of  the  muscles  of  the 
cheek  and  mouth  is  considerably  impaired  from  the  division  of  the 
plexuses  of  the  portio  dura.  This  and  the  induration  will  doubtless 
be  in  time  entirely  overcome. — Medical  Times  and  Gazelle. 

7.  Complete  Crushing  of  all  Ihe  Soft  Pai-ls,  and  of  hoik  Bones  of  the 
Leg,  from  the  Passage  over  the  Limb  of  a  Hearilij  Laden  Wagon — 
Primary  Amputation  above  the  Knee — Recovtry.    Under  the  care 

of  Mr.  WoRMAIiD. 

E.  N.,  aged  48,  a  very  muscular,  rather  free-living  man,  was  ad- 
mitted into  the  hospital  on  August  22.  He  had  been  knocked  down 
by  a  very  heavy  wagon,  the  wheels  of  which  had  passed  over  his  right 
leg.  The  limb  was  completely  crushed  ;  the  tibia  and  fibula  could  be 
felt  broken  in  several  places;  the  calf  was  much  swollen  and  discolored 
from  effused  blood,  and  a  large  extravasation  of  blood  had  occurred 
round  the  knee.  Mr.  Wormald  at  once  amputated  through  the  mid- 
dle third  of  the  thigh.  The  method  of  amputation  was  by  skin  flaps, 
and  a  circular  division  of  the  muscles.  The  wound  was  not  closed  at 
first,  but  suture.-s  were  inserted  through  the  flaps,  and  left  loose,  to  be 
tightened  at  the  end  of  a  few  hours,  when  the  surfaces  should  have 
become  glazed,  and  if  tbere  appeared  to  be  no  threatening  of  hemor- 
rhage. ISo  hemorrhage  occurred,  and  the  sutures  were  tightened  ou 
the  following  day,  (August  23.) 

The  note  taken  on  August  24  says  :  "  The  patient  has  been  doing 
remarkably  well.  The  expression  of  his  face  is  almost  that  of  ordinary 
robust  health ;  pulse  84,  quiet,  rather  full ;  skin  only  modei-ately  hot 
from  reaction;  tongue  scarcely  at  all  coated.    He  had  a  good  night." 

After  this  date  the  patient  had  no  check  of  any  kind;  at  no  time 
after  the  amputation  was  his  pulse  above  90;  generally  it  was  below 
80.  He  took  an  ordinary  meat  diet  with  relish,  slept  well  throughout 
the  night,  and  always  said  ho  was  quite  well.  The  stump  healed 
quickly.  He  left  the  hosjjital,  at  his  own  request,  on  October  Uth. — 
Ibid. 


234 


PEOGRESS  OF  THE  MEDICAL  SCIENCES. 


[Dec, 


8.  Compound  Comminuted  Frnclnre  of  both  Bones  of  the  Leg,  with  Ex- 

tensive Laceration  of  the  Soft  Parts — Continued  Hemorrhage — Am- 
putation— Recovery.    Under  the  care  of  Mr.  Coote. 

J.  L.,  a  big,  heavy  brewers'  drayman,  drinking,  as  his  customary 
allowance,  two  gallons  of  beer  a-day,  had  his  leg  crushed  between  the 
wheel  of  his  dray  and  an  iron  post  at  the  corner  of  a  street,  on  Sep- 
tember 1.  A  compound  comminuted  fracture  of  both  bones,  with 
great  bruising  of  the  muscles  of  the  calf,  was  the  result.  He  was 
brought  about  four  hours  afterwards  to  the  hospital.  Hemorrhage, 
which,  it  was  said,  had  been  to  a  large  amount,  was  still  going  on. 
The  limb  was  jjlaced  on  an  iron  back  splint,  and  the  wound  (about 
two  inches  long)  closed  with  lint  soaked  in  blood.  As  both  the  main 
arteries  of  the  leg  could  be  felt  pulsating,  it  was  hoped  the  bleeding 
might  cease;  it  still  continued,  however,  and  the  calf  was  soon  much 
discolored  and  swollen  by  the  infiltration  of  blood  beneath  the  skin 
and  among  its  lacerated  muscles.  As  there  was  no  hope  of  saving  the 
limb  under  such  circumstances,  Mr.  Coote  proceeded,  twelve  hours 
after  the  accident,  to  amputate  just  below  the  knee.  The  operation 
was  pel-formed  by  making  a  short  anterior  and  a  long  posterior  flap  and 
a  circular  division  of  the  muscles.  The  flaps  were  brought  together 
by  a  single  central  silver  suture,  and  bands  of  strapping.  It  was 
found,  on  examining  the  leg  after  its  removal,  that  the  tibia  ;ind  fibula 
were  fractured  in  several  places,  and  the  muscles  laceratt  d  in  their 
whole  extent.  The  anterior  and  posterior  tibial  vessels  were  entire; 
the  exact  source  of  the  hemorrhage  which  had  occurred  could  not  be 
discovered. 

For  the  first  thirty-six  hours  after  the  ojieration  the  patient  re- 
mained quiet  and  veiy  drowsy;  reaction  then  commenced,  and  was 
well  established  on  September  3,  when  he  was  hot,  flushed,  and  still 
drowsy,  with  a  red  tongue,  rather  brown  in  the  centre,  and  a  full, 
bounding  l^ulse  of  120.  The  stump  looked  rather  sodden  and  oedema- 
tous,  and  a  large  amount  of  sanious  fluid  was  being  discharged.  No 
symiJtom  of  delirium  tremens,  to  which  his  previous  habits  had  made 
him  liable,  ajjpeared.  He  took  his  diet  well;  this  consisted  of  two 
pints  of  porter,  four  ounces  of  brandy,  beef-tea,  milk,  and  two  eggs. 

By  September  .5th  all  excessive  I'eaction  was  jjassing  off".  The  pulse 
was  quiet,  108;  the  skin  cooler;  and  a  healthy  suppuration  was  begin- 
ning in  the  stump;  the  patient  slept  well  at  night,  and  expressed 
himself  as  feeling  free  from  uneasiness.  From  this  date  he  went  on 
uninterruptedly  to  recovery,  and  was  able  to  leave  his  bed  on  Oct.  2d. 

A  few  days  ago,  when  the  amputation  wound  had  all  but  healed,  he 
fell  in  the  ward  and  injured  the  stump;  this  accident,  however,  prom- 
ises to  detain  him  in  the  hospital  only  a  few  days. — Ibid. 

9.  \Sympathetic  Oj^hthalmia. 

In  an  essay  on  Sympathetic  Ophthalmia,  Mr.  Lawson  gives  the 
following  as  his  general  conclusions:  1.  It  is  an  inflammation  of  one 
eye,  originating  solely  from  an  irritation  in  the  other.  2.  The  most 
frequent  cause  of  sympathetic  ophthalmia  is  a  wound  of  one  eye,  and 
that  those  wounds  which  involve  the  ciliary  region  are  especially 
liable  to  jiroduce  it.  It  also  frequently  arises  from  the  irritation 
communicated  to  the  sound  eye  from  a  lost  eye,  or  from  the  shninken 
stump  of  a  lost  eye,  which  has  become  subject  from  some  cause  or 
other  to  recurrent  attacks  of  inflammation.     3.  One  of  the  great 


1865.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


235 


peculiarities  of  sympathetic  inflammation  is  its  tendency  to  the  rapid 
effusion  of  lymph  into  all  the  tissues  of  the  eye  which  it  renders  in- 
cap  ible  of  speedy  organization.  4.  The  disease  once  started  is  very 
difficult  to  aiTest;  it  is  recurrent  in  its  nature,  and  even  if  the  first 
attack  he  arrested,  a  recurrence  is  almost  certain  to  take  place.  5. 
The  removal  of  the  injured  eye  affords  the  best  chance  of  arresting 
the  disease;  and  if  this  operation  is  resorted  to  in  its  very  early  stage, 
there  is  a  good  prospect  of  its  doing  so.  6.  If  the  symptoms  of  sym- 
pathetic oijhthalmia  are  fully  develoi^ed,  the  removal  of  the  injured 
eye  (the  source  of  the  irritation)  may  fail  to  arrest  the  disease,  though 
it  will  afford  a  chance  which  should  not  be  neglected.  7.  In  no  in- 
.stance  have  I  feen  symi^athetic  oj^hthalmia  originate  in  an  eye  after 
the  other  had  been  removed  on  account  of  an  injury.  I  have  fre- 
quently seen  it  continue  its  course  after  the  removal  of  the  injured 
eye,  but  in  each  case  sympathetic  sym^itoms  were  manifested  before  the 
eye  was  removed.  Hence  the  importance  of  diagnosticating  in  what 
cases  of  injury  symjiathetic  oijhthalmia  is  likely  to  follow,  and  the 
necessity  of  at  once  excising  such  injured  eyes  which  are  prone  to 
to  produce  it,  and  esi3ecially  if  they  are  already  lost  for  all  visual 
purj^oses.  8.  In  the  treatment  of  sympathetic  ophthalmia,  any  opera- 
tion whilst  the  eye  is  inflamed  is  positively  prejudicial;  but  when  all 
the  activity  of  the  disease  has  subsided,  much  may  often  be  done  by 
some  operative  procedure  to  regain  for  the  patient  some  of  the  sight 
he  has  lost,  and  often  also  at  the  same  time  to  prevent  a  recurrence 
of  the  attacks.  9.  In  the  early  stage  of  the  disease  the  tension  of  the 
globe  is  often  increased  to  +  T  1  or  2;  but  in  the  latter  stage  the  eye 
becomes  soft  from  atroj^hy  of  the  vitreous  body,  causing  a  diminu- 
tion in  its  consistence  and  bulk,  and  this  state  is  often  followed  by 
detachment  of  the  retina. — British  Medical  Journal. 


10.  Umbilical  Hernia;  Slougliing  of  Four  Inches  of  the  Small  Intestines; 
Complete  Recovery. 

The  following  case,  which  occurred  in  the  practice  of  Dr.  Nolan  of 
Wicklow,  was  read  by  Dr.  Benson,  at  a  meeting  of  the  Surgical  So- 
ciety of  Ireland.  James  Delany,  a  man  about  50,  was  admitted  into 
Wicklow  Infirmary  on  June  IBth.  He  had  an  umbilical  hernia  of 
about  a  twelvemonth's  standing.  Eight  days  before  admission,  in 
struggling  to  hold  a  pig,  he  felt  something  give  way  at  the  tumor,  was 
.seized  with  weakness,  followed  by  pain,  and  soon  after  had  vomiting. 
In  this  state  he  continued  for  seven  days,  using  such  means  as  his 
friends  suggested,  till  the  seventh  day,  when  the  medical  officer  of 
the  district  was  called  to  visit  him.  Seeing  the  state  of  the  case,  and 
the  man  being  in  a  remote  part  of  the  district,  he  recommended  him 
to  be  conveyed  to  the  infirmary,  to  which  he  was  brought  on  a  car,  a 
distance  of  about  seven  miles.  Dr.  Nolan  saw  him  on  the  eighth  day, 
and  found  a  hernia  at  the  umbilicus  about  the  size  of  a  largish  orange, 
a  black  mass,  with  a  line  of  separation  forming  at  the  base,  and  a  blush 
of  redness  in  the  surrounding  integuments,  especially  towards  the  left 
side;  the  pulse  was  weak,  the  countenance  pale  and  anxious,  the 
stomach  gulping  up  every  thing.  Manual  interference  was  out  of  the 
question.  He  therefore  determined  to  leave  to  the  adhesive  process 
the  repair  of  the  local  damage,  and  to  allay  irritation  and  support  the 
patient's  strength,  ordering  a  grain  of  opium  every  fourth  hour  till 
the  vomiting  ceased;  beef- tea,  and  brandy  and  water  in  small  quanti- 


236 


EDITORIAL. 


[Dec, 


ties,  and  a  linseed-meal  poultice  over  the  tumor.  Next  day  he  had 
slept  well,  and  was  free  from  pain;  the  vomiting;  had  ceased  after  the 
second  pill.  The  oi^ium  was  discoutinned.  Tlie  beef-tea,  etc. ,  had 
remained  on  the  stomach;  the  countenance  and  pulse  were  improved; 
the  whole  of  the  integuments  had  sloughed  away,  disclo.sing  between 
three  and  four  inches  of  small  intestine  completely  disorganized  and 
ready  to  slough,  which  it  did  in  two  days  after,  followed  by  a  dis- 
charge of  bilious  curdy  fluid.  The  treatment  from  this  time  consisted 
of  giving  as  much  beef-tea  and  brandy  and  water  as  he  could  take, 
and  thi-owing  up  an  enema  daily  of  strained  gruel  and  milk,  which 
was  generally  retained  till  next  day.  In  about  a  week  the  opening 
began  gradually  to  contract;  in  a  fortnight  it  had  closed;  the  man 
daily  improved  in  health  and  strength,  the  bowels  acted  naturally 
when  the  enemata  were  discontinued,  and  he  was  enabled  to  leave  the 
hospital  on  July  22d,  a  month  and  five  days  from  his  admission. — 
Dub.  Med.  Press. 


EDITORIAL. 

—  The  cholera  seems,  by  report  from  all  sources,  to  be  on  the 
decrease  in  Europe,  although  many  new  places  are  mentioued  as 
having  been  recently  infected.  No  satisfactory  accounts  are  given  of 
the  epidemic  in  France,  the  government  keeping  a  most  reserved 
silence  upon  the  subject.  We  learn,  however,  from  late  foreign  medi- 
cal journals,  that  there  are  no  more  new  ca.ses  in  Toulon  and  Mar- 
seilles, while  in  Paris  there  is  a  daily  diminution  of  cases. 

The  British  Medical  Jourml  of  the  11th  November,  quoting  from 
the  Union  Medimle,  says: 

"  The  cholera  decidedly  seems  to  be  disappearing;  not  suddenly, 
and  to  return  in  the  same  maimer,  as  was  seen  in  preceding  epidemics, 
but  gradually.  All  alarm  should  theretbrc!  cease,  but  without  salu- 
tary precautions  being  forgotten.  On  the  1st  instant,  the  total 
number  of  deaths  from  cholera  in  private  houses  and  in  the  hospitals 
was  only  92;  on  the  2d,  80;  on  the  Bd,  75;  and  on  the  4th,  10.  The 
civil  and  military  hospitals  are  down  for  only  about  a  quarter  in  that 
total.  The  number  of  admissions  to  the  hospitals  has  diminished  in 
proportion  to  that  decrease,  and  the  munber  of  home  cases  is  lessen- 
ing. The  epidemic  appears,  therefore,  to  be  fairly  dying  out.  If  the 
cholera  thus  stays  its  ravages,  it  will  have  been  relatively  mild  as 
compared  with  preceding  invasions;  and  this  satisfactory  result  nmst 
be  attributed  to  the  improvements  in  the  capital,  and  the  disapi)ear- 
ance  of  the  numerous  and  unhealthy  quarters  of  Paris  in  which  the 
epidemics  of  1832  and  1849  made  so  many  victims." 

In  England,  the  Registrar-General  reported  three  deaths  from 
cholera  for  the  week  ending  October  28.  No  mare  deaths  up  to 
November  1. 


1865.] 


EDITORIAL. 


237 


An  important  movement  has  taken  place,  instigated  by  the  French 
government,  for  the  investigation  of  the  epidemic  at  its  apparent 
source  in  tiie  East,  and  otlier  governments  of  Europe  have  been  urged 
to  join  in  the  movement.  Delegates  from  the  respective  European 
governments,  together  with  "such  men  of  science  thought  the  best 
fitted  to  assist  in  deliberations  by  their  especial  knowledge,"  will 
accoi'dingly  meet  in  Constantinople  for  this  purpose,  and  it  is  to  be  hoped 
that  some  system  may  he  devised  by  which  this  great  evil  may  be 
banished  from  the  abodes  of  men. 

Notwithstanding  the  apparent  reticence  of  the  French  government 
in  relation  to  the  rise  and  progress  of  the  epidemic  within  its  own  bor- 
ders, the  Public  Council  of  Hygiene  and  Salubrity  for  the  Department  of 
the  Seine  has  issued  a  series  of  instructions  in  relation  to  the  precau- 
tions to  be  adopted  against  attacks  of  the  epidemic. 

The  instructions,  signed  Jobert  de  Lamballe,  Vice-President,  Boit- 
telle,  Prefect  of  Police,  recommend:  1.  Tranquillity  of  mind;  2.  Mod- 
erate, healthy  and  regular  nourishment  of  due  substantiality;  3.  Cloth- 
ing which  will  protect  against  sudden  transitions  of  temperature; 
4.  Salubrity  of  dwelling  houses:  free  ventilation,  moderate  tempera- 
ture, avoidance  of  overcrowding;  5.  Avoidance  of  bodily  fatigue, 
lengtliened  studies,  late  hours,  and  abuse  of  pleasure;  6.  Attention  to 
the  earliest  symptoms  of  diarrhoea. 

"It  may  be  affirmed,  with  rare  exceptions,"  continue  the  instruc- 
tions, "  however  sudden  the  attack  may  be,  cholera  is  yet  preceded  by 
symptoms  which  may  induce  fears  as  to  its  development.  The  com- 
monest of  these  symptoms  is  diarrliaa,  however  slight,  and  such  is  its 
importance  that  the  removal  of  this  symptom  immediately  on  its  de- 
velopment will  suffice  to  prevent  the  malady.  It  would,  therefore,  be 
dangerous  to  let  the  diarrhoea  continue,  and  conse{iuently,  as  it  may 
be  arrested  hy  very  simple  meiins,  they  may  Ije  resorted  to  before  the 
arrival  of  the  doctor,  who  ought  always  to  be  sent  for  without  delay. 
'I'hese  means  are  as  follow:  Partial  or  complete  abstinence  from 
food,  the  use  of  rice  and  its  preparations,  an  infusion  of  chamomile  tea, 
and  copious  injections  with  a  decoction  of  marshmallow  and  unpre- 
pared starch.  The  majority  of  the  cases  observed  liitherto  show  that 
tiie  chances  of  recovery  are  lessened  or  increased  according  to  the 
length  of  time  that  may  elapse  between  the  lirst  manifestations  of  the 
disease  and  the  administration  of  relief  It  is,  therefore,  necessary  to 
specify  the  chief  symptoms  which  annouiK'c  the  attack,  and  to  indicate 
tiie  mode  of  relief  to  be  followed  immediately  on  the  appearance  of 
the  epidemic.  Cholera  is  usually  announced  by  a  i)rofound  and  sud- 
den feeling  of  lassitude,  colics,  diarrlnea,  with  stools  first  colored  and 
then  colorless,  resembling  rice  water,  nausea  and  vomiting,  a  very 
marked  change  in  the  features  of  the  face,  coldness  in  the  body  and 
the  tongue,  cramps,  and,  lastly,  a  bluish  appearance  in  the  lips  and 


238 


EDITORIAL. 


[Dec, 


face.  Tlic  instant  any  of  these  symptoms  show  themselves  a  ])hysiciaii 
must  be  called,  and,  while  awaiting  his  arrival,  the  means  adopted  must 
be  the  following:  The  skin  should  be  heated,  and  warmth  obtained 
by  placing  a  bottle  of  hot  water  or  heated  bricks  wrapped  in  sheets  at 
the  feet  of  the  patient  and  between  the  legs.  He  must  be  covered  np 
la  warm  sheets  and  several  blankets,  l)etvveen  which  hot  irons  or  a 
warming-pan  should  be  agitated  up  and  down,  so  as  to  act  upon  the 
whole  surface  of  tlie  body.  While  these  steps  are  in  preparation,  or 
even  in  progress,  the  limljs  should  be  rubbed  for  a  considerable  time 
witii  force  witli  the  palm  of  tlie  hand,  a  soft  brush,  or  a  piece  of  flamiel 
— which  latter  may  be  luoistened  with  camphorated  brandy,  brandy 
alone,  or  Eau  de  Cologne — and  this  should  be  done  by  two  persons 
seated  at  each  side  of  the  patient,  taking  care  not  to  uncover  him. 
The  drink  given  should  be  a  hot  infusion  of  linden  tea,  or  pe])per- 
raint  tinctured  with  a  few  drops  of  brandy.  Should  these  tisanes,  how- 
ever, appear  to  increase  the  vomitings,  gaseous  water  or  ice  in  small 
pieces  might  be  advantageously  resorted  to,  and  sinapisms  drawn  over 
the  legs  and  thighs.  It  will  always  be  well,  if  possible,  to  let  the  pa- 
tient lie  in  a  separate  room,  so  as  to  place  him  in  the  most  favorable 
conditions  for  saluljrity.  The  precautions  to  be  taken  during  con- 
valescence will  be  intimated  by  the  physician  who  may  be  called  in. 
The  urgency,  however,  can  not  be  too  strongly  impressed  upon  con- 
valescents of  rigorously  observing  the  rules  for  preservation  given 
above.  They  nuist  be  specially  careful  to  avoid  cold,  damp,  and 
change  of  regimen,  for  persons  who  have  been  attacked  by  cholera  are 
exposed  to  relapses." 

lu  relation  to  the  premonitory  diarrhoea.  Dr.  Chauffard,  of  tlie 
Children's  Hospital  at  Paris,  says:  "  That  the  present  epidemic  of 
cholera  was  not  preceded  by  diarrhoea  in  Paris,  and  that  the  same  is 
true  of  the  cholera  in  the  South  of  France.  The  diarrhoeal  affections 
appeared  immediately  subsequent  to  the  cholera.  The  statement,  there- 
fore, that  diarrhoea  always  precedes  the  advent  of  cholera,  can  not  he 
taken  as  true  " 

Following  the  avenues  of  commerce  this  disease  has,  at  last,  reached 
our  own  shores.  On  the  3d  of  November  the  Atlanta  arrived  at  this 
port  from  London  via  Havre,  bringing  a  goodly  complement  of  cabin 
and  steerage  passengers,  the  latter  mostly  immigrants,  from  Germany, 
many  of  whom  had  passed  through  a  portion  of  France,  and  had  re- 
mained for  a  longer  or  shorter  period  of  time  in  Paris.  During  the 
passage  across  the  Atlantic  the  disease  declared  itself,  several 
deaths  occurred,  and  by  the  time  the  vessel  reached  this  harbor  it 
had  assumed  a  severe  type.  It  was  limited,  however,  to  the  steerage, 
and  up  to  the  present  time,  by  proper  sanitary  precautions,  the  cabin 
passengers  have  been  spared  from  any  sickness  from  this  cause.  The 
vessel  and  its  passengers  were  immediately  \mt  into  the  closest  (juaran- 


1865.] 


EDITORIAL. 


239 


tine,  and  every  precaution  adopted  to  prevent  the  propagation  of  the  dis- 
ease, both  on  board  the  vessel  and  beyond  its  decks — thus  fur  with  most 
entire  success  in  Hmiting  it  to  the  infected  vessel. 

—  Trachestasis  in  a  Duck — Correction. — The  following  e.xtract 
from  a  communication  to  one  of  the  editors,  by  Prof.  Joseph  Leidy,  of 
the  University  of  Pennsylvania,  explains  itself.  Prof.  Jeffries  Wynian, 
of  Harvard  University,  has  also  noticed  the  same  error. 

"  In  perusing  tlie  June  number  of  the  New  York  Medical  Journal, 
my  eye  was  caught  by  the  heading,  '  Trachestasis  in  a  Duck,'  (vol.  I., 
p.  221.)  I  was  rather  amused  to  find  that  the  author  had  described 
the  normal  condition  of  the  inferior  larynx  and  other  parts  of  the  male 
duck  as  one  of  disease.  It  reminded  me  of  a  somewhat  similar  cir- 
cumstance which  occurred  several  years  since.  A  medical  student 
exhibited  to  several  of  the  professors  of  the  University  the  inferior 
larynx  of  a  duck,  as  an  ossified  heart  of  the  animal." 

—  Medical  Journalism  is  being  revived  in  the  Southern  States.  Two 
new  journals  are  announced,  one  in  Ricliniond,  Va.,  and  the  other  in 
Savannah,  Ga.  The  Virginia  journal,  which  is  to  be  called  the  Rich- 
mond Medical  Journal,  will  commence  vfith  the  new  year,  the  first 
number  appearing  early  in  December,  and  will  be  edited  by  Drs.  E.  S. 
Gaillard  and  W.  S.  McChesney.  The  journal  will  be  a  monthly  of 
80  or  90  pages,  octavo  form. 

The  Georgia  journal  will  be  a  revival  of  the  Savannah  Journal  of 
Medicine,  under  the  auspices  of  the  Georgia  Medical  Society,  and  will 
be  edited  by  Drs.  Juriah  Harris,  Jas.  B.  Read,  and  J.  G.  Thomas.  It 
is  to  be  published  bi-monthly,  and  will  consist  of  72  pages,  octavo  form. 

We  cordially  welcome  these  new  journals,  and  wish  them  every 
meed  of  success. 

—  The  Lectureships  in  the  Medical  Department  of  the  University  of 
Pennsylvania,  recently  endowed  by  Dr.  Geo.  B.  Wood,  of  that  city, 
have  been  filled  by  the  appointment  of  the  following  gentlemen: 

Dr.  J.  J.  Reese  to  that  of  Medical  Jurisprudence,  including  Toxi- 
cology; Dr.  Henry  Hartshornc  to  that  of  Hygiene;  Dr.  J.  C.  Hay- 
den  to  that  of  Mineralogy  and  Geology;  Dr.  H.  C.  Wood  to  that  of 
Botany;  and  Dr.  Harrison  Allen  to  that  of  Zoology  and  Comparative 
Anatomy. 

—  Prof.  Malgaigne,  who  was  seized  with  some  cerebral  disorder 
while  occujjying  the  chair  as  President  of  the  Paris  Academy  of  Medi- 
cine, a  year  since,  recently  died  from  a  third  attack,  not  yet  having 
reached  his  sixtieth  year. 


240 


PUBLICATIONS  RECEIVED. 


[Dec. 


BOOKS  AND  JOURNALS  EECEIVED. 

Lectures  on  Iiifliimmation:  being  the  first  course  delivered  before  the  College 
of  Physicians  of  Philadelphia,  under  the  bequest  of  Dr.  Miitter.  By  John  H. 
Packard,  M.D.,  &c.    Philadelphia:  J.  B.  Lippincott  &  Co.  18G5. 

Materia  Medica,  for  the  use  of  Students.  By  John  B.  Biddle,  M.D.,  Prof, 
of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College, 
&c.    With  Illustrations.    Philadelphia:  Lindsay  &  Blakiston.  18(3.5. 

The  Practice  of  Medicine.  By  Thomas  Hawkes  Tanner,  M.D.,  F.L.S.,  &c. 
From  the  Fifth  London  Edition.  Enlarged  and  Improved.  Philadelphia: 
Lindsay  &  Blakiston.  ISGO. 

Stimulants  and  Narcotics;  their  Mutual  Relations  with  Special  Researches 
on  the  Action  of  Alcohol,  ^ther,  and  Chlorofonn  on  the  Vital  Organism. 
By  Francis  E.  Anstie,  M.D.,  M.ll.C.E.,  &c.  Philadelphia:  Lindsay  & 
Biakiston.  I860. 

On  Wakefulness,  with  an  Introductory  Chapter  on  the  Physiology  of  Sleep. 
By  William  A.  Hammond,  M.D.,  <fec.  I?hiladel2)hia:  J.  B.  Lipiiincott  &  Co. 
1860. 

Chloroform :  its  Action  and  Administration.  By  Arthur  Ernest  Sansom,  M. 
B.,  Lond.,  &c.    Philadelphia:  Lindsay  &  Blakiston.  1866. 

Lectures  on  Epilepsy,  Pain,  Paralysis  and  Certain  other  Disorders  of  the 
Nervous  System.  By  Charles  Bland  Radcliffe,  M.D.,  &c.  Philadelphia:  Lind- 
.say  &  Blakiston.  1866. 

Epidemic  Cholera,  Diarrhoea  and  Dysentery.  Pointing  out  an  Effectual 
and  Expeditious  Method  of  Cure.  With  cases  submitted  to  the  Medical 
Council  of  the  Board  of  Health,  during  the  Epidemic  of  1854  By  Henry 
Jeanneret,  M.D.,  &c.    London:  George  Philip  &  Son.  1857. 

De  La  Guerison  Prompte  et  Facile  du  Cholera  Asiatique  par  la  Methode  de 
Henry  Jeanneret,  M.D.,  A'c.    Cheltenham.  1865. 

Experimental  Investigations  into  the  Action  and  Uses  of  the  Bromide  of 
Potassium.    By  Robert  Bartholow,  M.D.,  itc.  Reprint. 

Reports  of  the  Tnistees  and  Superintendent  of  the  Tennessee  Hospital  for 
the  Insane;  presented  to  the  General  Assembly,  April  3,  1865.  Nashville. 
1865. 

A  Report  upon  the  Epidemic  occurring  at  Maplewood  Young  Ladies'  In- 
stitute, Pittsfield,  Mass.,  in  July  and  Aug.,  1864,  including  a  discussion  of 
the  causes  of  Tj^^hoid  Fever.  By  A.  B.  Palmer,  M.D.,  0.  L.  Ford,  M.D.,  and 
Pliny  Earle,  M.D. 

Suggestions  relative  to  the  Pathology  of  Pneumonia.  By  S.  0.  Vanderpool, 
M.D.  Reprint. 

A  Catalogue  of  Medical  Works  on  Cholera,  in  the  Library  of  J.  M.  Toner, 
M.D.    Washington,  D.  C.  1865. 

Edinburgh  Medical  Journal.    July,  Aug.,  Sept.,  Oct. 
Glasgow  Medical  Journal.    Oct.,  1865. 

British  Medical  Journal.    Sept.  23,  30;  Oct.  7,  14,  21,  28;  Nov.  4,  11. 

The  Lancet.    Sept.  23,  30;  Oct.  7,  14,  21,  28;  Nov.  4,  11. 

The  Medical  Circular.    Sept.  6,  13;  Oct.  4,  19;  Nov.  1,  8. 

Medical  Times  and  Gazette.    Sept.  23,  30;  Oct.  7.  14,  21,  28;  Nov.  4,  11. 

The  Medical  Press,  Dublin.    Oct.  4;  Nov.  1,  8. 

American  Journal  of  Insanity.  Oct. 

American  Journal  of  the  Medical  Sciences.    Oct.,  1865. 

American  Druggists'  Circular. 

Boston  Medical  and  Surgical  Journal.  June  29;  July  20,  27;  Aug.  17,  24; 
Sept.  7;  Oct.  5,  12,  26;  Nov.  2,  9. 

Buffalo  Medical  and  Surgical  Journal.  Oct. 
Chicago  Medical  Examiner.    Oct.,  Nov. 
Chicago  Medical  Journal.  Oct. 
Cincinnati  Lancet  and  Observer.  Oct. 
Pacific  Medical  and  Surgical  Journal.  Oct. 
The  Jledical  News  and  Library.  Oct. 

American  Literary  Gazette  and  Publishers'  Circular.    Oct.  2,  16;  Nov.  1. 
Medical  and  Surgical  Reporter,  Vol.  XIII.    Nos.  1-21. 

.\nales  de  la  Real  Academia  de  Ciencias  Medicas,  Fisicas  y  Naturales  de  la 
Habana:  Agost,  Sept.,  Oct. 


]SrEW  YORK 

MEDICAL  JOURNAL, 

A  MONTHLY  RECORD  OP  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
JANUARY,  186G. 


ORIGINAL  COMMUNICATIONS. 

Remarks  on  the  Temperature  of  some  of  tlie  Invertebrates.  By 
J.  S.  Lombard,  M.D.,  Boston. 

The  temperature  of  the  invertebrates  has  been  more  or  less 
carefully  studied  in  Europe  by  Dutrochet,*  Becquerel,t  Valen- 
tin,t  Newport,§  J.  Davy,||  and  others.  In  the  United  States, 
however,  1  believe  that  no  particular  attention  has  been  given 
to  this  subject;  and  although  several  of  the  foreign  obser- 
vers have  made  use  of  thermo-electric  apparatus  in  their 
researches,  yet,  in  this  country,  so  far  as  I  know,  the  in- 
vestigations given  in  the  present  article  arc  the  first  in 
which  thermo-electricity  has  been  systematically  applied  to  the 
determination  of  the  temperature  of  the  animals  in  question. 

In  publishing  these  investigations,  1  am  fully  aware  of  their 
incompleteness,  and  my  reason  for  having  them  printed  is  not 
that  I  consider  tliem  of  so  much  value  in  themselves,  but  that 
I  may  in  this  way  call  the  attention  of  those  interested  in  phys- 

*  Ann.  cVHist.  Nat,  2(1  scries,  Zoologie,  t.  xiii.        f  Triiite  do  physique. 
X  Repert.  <lc  Anut.  et  de  Physiol.,  1839,  t.  iv. 
§  Phil(>s()i)h.  TviUisactions,  1HI57. 

II  Kescarchcs,  Physii'l<>f,'icul  and  Anatomical.    Vol.  1st. 

Vol.  11.— No.  10.  10 


242 


TEMPERATUBE  OF  SOME 


[Jan., 


iological  science  to  a  subject  that  has  been  very  much,  if  not 
•wholly,  neglected  here,  and  especially  to  the  application  of 
thermo-electricity  to  the  study  of  the  phenomena  of  animal  heat 
in  general. 

In  determining  the  temperature  of  the  invertebrate?,  we  may 
use  either  the  thermometer  or  one  of  the  various  forms  of  ther- 
mo-electric apparatus.  The  latter  are,  however,  always  to  be 
preferred,  being  far  more  delicate,  and  likewise  more  convenient 
than  the  former.  Bui  if  good  thermo-electric  apparatus  and  a 
sensitive  galvanometer  can  not  be  obtained,  we  may,  if  the  ani- 
mal be  sufBcieutly  large,  take  its  temperature  by  introducing 
the  bulb  of  a  very  delicate  thermometer  into  its  interior,  either 
through  the  natural  openings  or  through  an  incision  made  for 
the  purpose,  the  latter  of  the  two  methods  being  the  one  usually 
adopted  by  J.  Davy.-  If  the  animal  be  too  small  to  admit  of 
the  introduction  of  the  thermometer  in  either  of  the  above  wavs, 
Mr.  Newport's  plant  may  be  pursued,  which  was  to  apply  the 
external  surface  of  the  animal  (  in  his  experiments,  an  insect)  to 
the  bulb  of  the  thermometer  by  means  of  a  pair  of  pincers. 
These  latter  should  be  of  suflScient  length  to  prevent  the  radia- 
tion of  heat  from  the  bands  from  affecting  either  the  animal 
or  the  thermometer,  and  the  handles,  if  metallic,  should  be 
wrapped  with  some  non-conducting  material,  in  order  to  guard 
against  the  possible  transmission  of  warmth  by  conduction. 
To  avoid  the  effects  of  radiation,  not  merely  from  the  person  of 
the  observer,  but  also  from  surrounding  objects  generally, 
Mr.  Newport  enveloped  both  insect  and  bulb  with  wool. 

There  is.  however,  an  objection  to  this  last  procedure.  The 
air  entangled  in  the  wool,  not  being  changed  with  sufficient 
rapidity,  becomes  heated  by  the  insect,  and  in  turn  reacts  upon 
the  latter,  and  the  result  is,  that  the  animal  exhibits  a  degree 
of  heat  which  it  could  not,  under  ordinary  circumstances,  main- 
tain when  freely  exposed  to  the  atmosphere.  This  objection 
also  applies  to  those  cases  in  which  the  animal  is  examined  in 
a  glass  tube  or  other  vessel  of  small  capacity. 

There  is  also  another  objection  to  Newport's  method.  All 
investigations  made  by  placing  the  external  surface  of  the 


'  Op.  cit..  p.  195.     t  Op.  cit 


1866.] 


OP  THE  INVERTEBRATES. 


243 


animal  in  contact  with  the  thermometer  are  faulty,  for  the  very 
obvious  reason  that  we  do  not  in  this  way  obtain  the  tempera- 
ture of  those  portions  of  the  organism  in  which  the  production 
of  heat  is  greatest,  the  external  surfaces  of  all  animals  being, 
as  a  rule,  considerably  cooler  than  their  interiors. 

Experiments  conducted  in  the  manner  of  Mr.  Newport  can, 
therefore,  simply  prove  the  existence  of  a  heat-producing  power, 
but  can  not  give  us  the  proper  temperature  of  an  animal. 

If,  instead  of  the  thermometer,  we  use  thermo-electric  ap- 
paratus, we  have  our  choice  of  several  different  instruments. 

Nobili  and  Melloni'-'  employed  the  thermo-electric  pile,  and 
by  means  of  it  first  detected  the  presence  of  heat  in  insects. 
For  this  purpose  they  fitted  to  the  faces  of  the  pile  small 
chambers  of  brass,  in  one  of  which  the  animal  was  placed,  in 
the  focus  of  a  little  reflector.  The  heat  radiated  from  the 
animal  fell  upon  the  face  of  the  pile,  causing  a  deflection  of  the 
needle  of  the  galvanometer,  proportional,  of  course,  to  the  dif- 
ference in  temperature  of  the  two  faces.t  This  method  is 
manifestly  objectionable  on  the  same  grounds  as  that  of  New- 
port, inasmuch  as  the  animal  is  confined  in  a  small  volume  of 
air,  and  the  instrument  does  not  obtain  the  temperature  of  the 
interior  organs. 

Still  the  pile  is  a  very  useful  instrument  for  simply  proving 
the  existence  of  an  independent  source  of  heat  in  the  inferior 
animals,  when  all  other  means  have  failed.  Although  the  in- 
struments to  be  presently  described  possess  the  advantage  that 
they  can  be  introduced  into  the  interior  of  the  organism,  yet 
the  pile  is  so  much  more  delicate  that  it  is  capable  of  indicat- 
ing differences  of  temperature  which  the  other  instruments,  in 
spite  of  their  contact  with  warmer  organs,  are  unable  to  detect. 

Instead  of  following  the  plan  of  Nobili  and  Melloni,  I  have 
generally  secured  the  animal  (always  an  insect)  directly  to  the 
face  of  the  pile,  by  ligatures,  or  by  strips  of  adhesive  plaster. 
In  doing  this  great  care  must  be  taken  to  prevent  the  ligatures 

*  Treatise  on  Electricity  by  A.  De  La  Rive.  Vol.  ii.,  part  v.,  p.  571.  Also, 
De  la  Clialeur  produitc  par  les  etres  vivauts,  par  J.  Gavarett,  p.  117. 

t  This  is  not  strictly  true.  The  deflection  of  the  needle  is  exactly  propor- 
tional to  the  force  of  the  current  only  up  to  a  certain  number  of  degrees, 
which  has  to  be  determined  for  each  instrument. 


244 


TEMPERATURE  OF  SOME 


[Jan., 


or  plaster  from  touching  the  antimony  and  bismuth  bars,  and 
also  to  prevent  any  of  the  fluids  of  the  insect  from  coming  in 
contact  "^ith  these  bars;  in  the  case  of  grasshoppers  this  latter 
precaution  is  especially  necessary. 

Becquerel  and  Dutrochet  invented  instruments  much  better 
adapted  to  the  determination  of  animal  temperature  than  the 
pile,  excepting  in  extraordinary  cases. 

Becquerel"  employed  two  needles  precisely  similar,  each 
about  the  twentieth  of  an  inch  in  diameter,  and  composed  half 
of  steel  and  half  of  copper,  one  extremity  being  steel  and  the 
other  copper.  The  centre  of  this  compound  needle  consisted, 
therefore,  of  a  soldered  junction  of  two  dissimilar  metals,  and 
consequently  formed  a  thermo-electric  battery. 

One  of  these  needles  was  pushed  through  the  body  of  the 
animal  under  examination,  until  the  junction  reached  the  de- 
sired depth;  its  steel  point  was  then  connected  with  that  of 
the  other  needle  by  means  of  a  steel  or  iron  wire — this  second 
needle  being  left  exposed  to  the  air,  merely  taking  the  precau- 
tion to  protect  its  junction  from  disturbing  influences  by  means 
of  a  roll  of  dry  paper.  Lastly,  the  two  copper  extremities  were 
connected  with  the  galvanometer,  and  the  needle  of  this  latter 
instrument  indicated  by  its  deflection  the  difference  in  temper- 
ature of  the  two  junctions. 

These  needles  of  Becquerel,  although  often  serviceable,  are 
yet,  in  many  respects,  inconvenient. 

In  the  first  place,  we  are  always  obliged  to  push  the  steel 
point  entirely  through  the  part  the  temperature  of  which  is  to 
be  taken,  in  order  that  it  may  be  connected  with  the  other 
needle,  and  this  is  frequently  a  troublesome  thing  to  do. 

Their  are  other  inconveniences  attendant  upon  their  use,  that 
can  not  well  be  appreciated,  except  by  actual  experience. 

The  apparatus  of  Dutrochett,  like  that  of  Becquerel,  had  its 
source  of  electricity  in  a  copper  and  steel  junction,  but  this 
junction  formed  a  sharp  point,  which  could  be  inserted  into  the 
body  of  the  animal.  This  apparatus  is,  in  many  respects,  pref- 
erable to  that  of  Becquerel. 

*  Op.  eit,  t.  iv.,  p.  51,  and  Treatise  on  Electricity  by  A.  De  La  Eive. 
Vol.  ii.,  part  v.,  p.  579. 

*  Op.  cit.,  t.  xiii.,  p.  5. 


1866.] 


OF  THE  INVERTEBRATES. 


245 


After  a  long  and  careful  trial  of  the  instruments  just  de- 
scribed, I  devised  a  substitute  for  both. 

In  the  first  place,  I  have  substituted  German  silver  and  brass 
for  copper  and  steel.  The  iron  or  steel  of  the  other  instru- 
ments is  apt  to  rust,  particularly  when  exposed  to  an  atmo- 
sphere saturated  with  aqueous  vapor,  as  it  often  is  in  experi- 
ments upon  the  invertebrates.  The  metals  are  in  the  form  of 
thin  plates,  three-sixteenths  of  an  inch  in  width,  and  two  and  a 
half  inches  in  length,  to  the  place  where  they  meet.  They  are 
separated  from  each  other  by  a  piece  of  bone  rubber,  an  eighth 
of  an  inch  in  width  at  the  upper  extremities  of  the  plates,  but 
gradually  narrowing  down  to  the  junction,  at  which  point  the 
two  metals  are  welded  together,  so  as  to  form  either  a  sharp  or 
blunt  end,  according  to  the  particular  purpose  for  which  the 
instrument  is  intended.  The  insulating  rubber  runs  up  for  the 
distance  of  an  inch  and  a  half  or  two  inches  above  the  com- 
mencement of  the  plates,  forming  a  rounded  handle,  by  which 
the  instrument  can  be  conveniently  grasped. 

The  two  brass  plates  are  connected  (for  of  course  there  is, 
as  in  Becquerel's  needles,  a  pair  of  these  instruments)  by  a 
wire,  and  the  two  silver  plates  connected  each  with  a  pole-cup 
of  the  galvanometer.  Or,  if  we  choose,  we  can  connect  the 
silver  plates  with  each  othei',  and  the  brass  ones  with  the  gal- 
vanometer, merely  bearing  in  mind  that  the  current  is  always 
from  the  silver  to  the  brass  through  the  junction,  and  conse- 
quently from  the  brass  to  the  silver  through  the  coil  of  the  gal- 
vanometer. 

This  apparatus  is  not  only  more  convenient  than  those  of 
Becqucrel  and  Dutrochet,  but  also  much  more  delicate. 

Whatever  kind  of  thermo-electric  apparatus  we  use,  it  is 
necessary  to  exercise  the  greatest  care,  for,  as  a  rule,  the  evolu- 
tion of  heat  in  the  invertebrate  is  feeble,  and  it  is  only  by  sedu- 
lously avoiding  all  sources  of  error  that  reliable  results  can  be 
obtained. 

No  one  should  attempt  to  use  thermo-electric  apparatus  with- 
out a  thorough  knowledge  of  the  principal  facts  of  thermo- 
electricity and  of  electro-magnetism.  If  this  knowledge  be 
not  possessed,  the  indications  of  the  galvanometer  will  be  full 
as  often  interpreted  wrongly  as  rightly.    But  even  after  a 


246 


TEMPERATURE  OF  SOME 


[Jan., 


theoretical  acquaintance  with  the  subject,  it  requires  considera- 
ble practical  experience  to  use  the  apparatus  successfully  in  the 
more  delicate  experiments. 

We  must  always  bear  in  mind  that  we  have  not  merely  two 
sources  of  electricity  in  our  circuit,  viz.,  the  two  junctions,  but 
that  every  deviation  from  homogeneity  constitutes  a  battery. 
Every  twist  in  our  wires,  every  soldering,  and  finally  the  very 
brass  pole-cups  of  the  galvanometer,  all  may  give  rise  to  electric 
currents.  In  some  of  the  very  delicate  investigations,  the 
junction  of  the  copper  wires  with  the  pole-cups  of  the  galvan- 
ometer will,  unless  we  be  upon  the  watch,  mislead  us.  It  al- 
most always  happens,  when  a  very  sensitive  galvanometer  is 
used,  that,  at  the  moment  the  circuit  is  closed  by  connecting 
the  copper  wires  with  the  galvanometer,  the  needle  of  the  latter 
is  deflected  to  a  slight  degree  by  the  warmth  of  the  hands  com- 
municated to  the  junction  of  the  copper  and  brass,  the  current 
passing,  in  this  case,  from  the  brass  to  the  copper  through  the 
junction. 

Many  pages  could  be  written  on  the  modes  of  applying 
theimo-electrity  to  the  study  of  animal  temperature,  and  on  the 
errors  to  be  guarded  against;  but  the  limits  of  this  article  for- 
bid my  devoting  any  more  space  to  this  part  of  the  subject. 

Having  thus  glanced  at  the  different  methods  and  means  of 
investigation,  let  us  next  consider  the  particular  experiments 
performed  by  myself. 

Of  the  three  great  classes  into  which  the  invertebrates  are 
divided,  representatives  of  two,  viz.,  the  mollusca  and  the 
articulata,  have  been  examined  by  me.  Of  the  temperature  of 
the  radiata,  I  have  no  experimental  knowledge;  indeed,  about 
all  that  is  known  of  the  temperature  of  these  animals  is  derived 
from  the  experiments  of  Valentin  solely. 

Commencing  with  the  moUusks,  the  temperature  of  the  clam 
has  been  carefully  studied  by  me.  The  mode  of  procedure  was 
as  follows: 

My  thermo-electric  instruments  (those  with  blunt  junctions 
were  used)  were  secured  each  by  a  brass  claw,  lined  with  cork, 
and  fitted  to  an  upright  metallic  rod  in  such  a  manner  as  to 
admit  of  both  vertical  and  horizontal  movement. 

The  instruments  were  held  in  the  claws  by  their  handles,  in 


18G6.] 


OP  THE  INVERTEBRATES. 


247 


a  vertical  position,  with  the  junctions  down.  The  animal  was 
first  examined  in  the  air.  For  this  purpose  it  was  wiped  as 
dry  as  possible,  and  then  let  alone  for  half  an  hour  or  more. 
It  was  then  seized  by  means  of  a  very  long  pair  of  forceps,  and 
held  directly  under  one  of  the  the  thermo-electric  junctions. 
It  was  next  forced  to  open  its  shell,  when  the  claw  holding 
the  thermo-electric  instrument  was  moved  quickly  down  the  up- 
right rod,  until  tlie  junction  was  fairly  in  the  interior  of  the 
animal.  As  the  clam  invariably  closed  its  shell  tightly  upon 
the  instrument  the  moment  it  was  introduced,  the  latter  was 
held  firmly  in  position.  The  other  extremity  of  the  animal 
rested  upon  a  plate  of  glass.  The  second  thermo-electric  in- 
strument had  its  junction  protected  by  a  roll  of  paper  or  by  a 
piece  of  cork. 

After  waiting  for  a  short  time,  in  order  to  allow  all  effects 
produced  by  the  hands  to  pass  off,  the  connections  were  made 
with  the  galvanometer. 

Operating  in  this  way,  I  found  that  the  temperature  of  the 
clam  was  invariably  lower  than  that  of  the  air,  by  a  half  or  a 
quarter  of  a  degree  of  F. 

This  was  not  surprising,  considering,  on  the  one  hand,  the 
naturally  feeble  production  of  heat  by  the  animal,  and  on  the 
other  hand,  the  very  copious  evaporation  that  would  neces- 
sarily take  place  from  so  moist  a  body,  even  after  having  been 
freed  as  much  as  possible  from  moisture. 

In  the  next  place,  the  temperature  of  the  clam  compared  with 
that  of  the  water  was  obtained,  the  animal  being  in  the  air. 

To  do  this,  the  animal  was  quickly  removed  from  the  water, 
and  the  thermo-electric  apparatus  applied  as  in  the  former 
case,  with  the  exception  that  the  second  junction  was  lowered 
into  the  water. 

The  result  was,  that  the  temperature  of  the  clam  was,  in 
every  instance,  found  to  be  lower  than  that  of  the  water  by 
half  a  degree  of  F.,  or  even  more;  the  influence  of  evaporation 
being,  in  this  case,  even  greater  than  in  the  preceding,  inas- 
much as  the  clam  was  dripping  wet.  Finally,  the  temperature 
of  the  clam,  compared  with  the  water,  while  the  animal  was 
actually  immersed  in  the  latter,  was  taken. 

Now,  it  is  proper  to  remark,  tliat  although  by  taking  the 


248 


TEMPERATURE  OF  SOME 


[Jan., 


temperature  of  an  animal  in  water  we  put  a  stop  to  evapora- 
tion, yet  if  the  volume  of  water  be  at  all  considerable,  its  high 
specific  heat  and  better  power  of  conduction  render  both  its 
cooling  and  heating  properties  very  much  superior  to  those  of 
dry  air  of  the  same  temperature.  Thus  the  specific  heat  of 
dry  air  is,  according  to  Regnault,  for  equal  weights,  only 
0.2375  compared  with  water  as  1.000.* 

This  accounts  for  the  fact,  that  Valentin  found  the  tempera- 
ture of  marine  animals  to  be  sometimes  lower  in  the  water 
than  in  the  air.t 

Of  course  the  greater  the  mass  of  water  the  greater  will  be 
its  power  of  refrigeration,  and  consequently  we  can  reduce 
this  power  to  its  minimum  by  making  use  of  very  small  volumes 
of  the  liquid. 

A  glass  vessel,  but  little  larger  than  the  clam  itself,  was 
therefore  taken,  and  having  been  filled  with  water  of  the  tem- 
perature of  the  air,  the  clam  was  immersed  in  it,  and  left  un- 
touched for  several  hours;  at  the  end  of  this  time  the  animal 
was  seized  with  the  forceps,  and  lifted  only  so  far  above  the 
surface  of  the  water  as  sufficed  for  the  proper  introduction  of 
the  thermo-electric  instrument.  This  done,  the  animal  was 
again  submerged,  with  the  junction  still  in  its  bod3',  and  at  the 
same  time  the  second  junction  was  lowered  into  the  water. 

When  all  due  precautions  Avere  adopted,  it  was  generally 
found  that  the  clam  was  warmer  than  the  water,  this  excess 
never  amounting,  however,  to  more  than  a  quarter  of  a  degree 
of  F.,  and  being  usually  less  than  this. 

During  these  experiments,  as  well  as  during  those  previously 
related,  the  temperature  of  the  air  and  of  the  water  ranged 
between  75  and  95  degrees  of  F. 

It  may  appear,  at  first  sight,  that  this  mode  of  operating  is 
open  to  the  first  of  the  tAvo  objections  brought  against  Mr. 
Newport's  method.  It  may  seem  that  the  clam  is  examined 
under  circumstances  more  favorable  to  the  maintenance  of 
warmth  than  those  under  which  it  ordinarily  exists,  and  that 
therefore,  we  can  not  by  this  method  obtain  the  proper  temper- 
ature of  the  animal.    Such  is  not  the  case,  however,  for  in  its 


*  Miller's  Chemistry — Chem.  Physics,  p.  237. 


fOp.  cit,  p.  259. 


1866.] 


OF  THE  INVERTEBRATES. 


24» 


natural  state  the  clam  lies  imbedded  in  mud,  and  is,  if  any 
thing,  protected  in  greater  degree  from  loss  of  heat  than  in 
the  experiment  we  have  been  considering. 

There  is  another  point  of  interest  to  be  considered  in  this 
connection,  and  that  is,  that  it  is  not  necessary  to  find  in  a  liv- 
ing animal  a  temperature  superior  to  that  of  the  air  (provided 
the  latter  be  not  saturated  with  aqueous  vapor)  in  order  to 
prove  the  existence  of  an  independent  source  of  heat;  for  all 
animals  are  moist  bodies,  from  whose  surfaces  a  constant 
evaporation  is  taking  place,  and  this  evaporation  tends  to  keep 
their  temperature  below  that  of  the  air.  A  moist,  inorganic 
mass  would,  under  like  circumstances,  cool  down  a  little  below 
the  air,  and  therefore  when  we  find  an  animal  maintaining,  in 
spite  of  the  depressing  influence  of  evaporation,  a  temperature 
equal  to  that  of  the  atmosphere,  we  have  proof  of  the  existence 
of  a  heat-producing  power,  this  proof  being  more  or  less  conclu- 
sive according  to  the  degree  of  saturation  of  the  air. 

I  have  examined  the  temperature  of  several  other  mollusks, 
but  as  the  results  have  not  been  very  satisfactory,  I  have  not 
considered  them  worthy  of  publication,  until  the  experiments 
from  which  they  were  derived  shall  have  been  repeated  with 
more  care  and  on  a  larger  scale. 

Passing  next  to  the  second  great  division  of  the  invertebrates, 
viz.,  the  articulates,  we  will  consider  in  turn  each  of  its  sub- 
divisions.   First,  the  annelida. 

Of  this  subdivision,  the  earthworm  and  leech  have  been  ex- 
amined by  several  observers,  and  my  own  experiments  have 
also  been  made  upon  the  same  animals. 

Hunter*  introduced  the  bulb  of  a  thermometer  into  a  knot 
of  earthworms,  and  found  them  to  be  a  degree  and  a  half  or 
two  degrees  F.  warmer  than  the  air.  He  also  found  that  the 
ordinary  medicinal  leech  preserved  a  temperature  one  or  two 
degrees  above  that  of  the  air.  Dr.  J.  Davyt  took  the  temper- 
ature of  two  kinds  of  leeches  in  Ceylon,  and  found  it  to  be  the 
same  as  that  of  air.  Dutrochet^  and  Berthold  obtained  results 
similar  to  those  of  Davy. 

These  few  cases  are  about  all  that  are  recorded  of  the  tem- 
perature of  the  annelida. 


•Carpenter's  Comp.  Phys.,  p.  453.        f  Op.  cit,  p.  195.        J  Op.  cit. 


250 


TEMPERATURE  OF  SOME 


[Jan., 


In  the  experiments  performed  on  the  earthworm  and  on  the 
leech,  the  same  apparatus  was  employed,  and  the  same  general 
plan  pursued  as  in  the  case  of  tlie  niollusks,  with  the  exception, 
however,  that,  as  a  rule,  a  saturated  atmosphere  was  resorted 
to,  instead  of  water,  as  a  means  of  suspending  evaporation. 

The  temperature  of  these  animals  varied  very  considerably. 
In  many  instances  it  was  half  a  degree  of  F.  or  more  above 
that  of  the  atmosphere.  In  other  instances  the  temperature 
was  the  same  as  that  of  the  atmosphere,  and  again  in  some 
cases  it  was  cooler  than  the  air  by  a  quarter  of  a  degree  of  F. 
or  more.  In  all  these  latter  cases,  the  suspension  of  evapora- 
tion was  invariably  followed  by  a  rise  of  temperature,  which 
generally  continued  until  the  animal  was  warmer  than  the  air 
by  a  quarter  or  half  a  degree  of  F.  As  a  general  thing,  the 
leeches  were  a  little  superior  in  temjierature  to  the  earthworms. 

Concerning  the  temperature  of  the  second  subdivision,  the 
Crustacea,  but  little  is  known.  Valentin  has  recorded  in  four 
specimens  of  the  crab  the  following  temperatures  above  that  of 
the  surroimding  medium:  0.54",  1.08",  1.62",  0.18'',  F. 

Davy  found  the  temperature  of  a  large  cray  fish  to  be  79° 
F.  when  the  air  was  80^  F.,  and  that  of  a  crab  to  be  72"  F. 
when  the  air  was  at  72°  F.  likewise. 

I  have  studied  the  temperature  of  two  members  of  the  Crus- 
tacea, viz.,  the  lobster  and  the  shrimp. 

The  temperature  of  both  of  these  animals  is,  so  far  as  my 
own  experience  goes,  invariably  below  that  of  the  air  or  water 
by  half  a  degree  of  F.,  or  even  more.  Moreover,  although 
every  precaution  was  adopted,  I  never  succeeded  in  obtaining 
positive  proof  of  a  heat-producing  power  in  these  animals. 
On  stopping  evaporation  they  warmed  up  somewhat,  but  never 
in  any  case  attained  a  higher  temperature  than  that  of  the 
surrounding  medium. 

There  can  be  no  doubt  that  every  living  organism,  whether 
animal  or  vegetable,  produces  a  certain  amount  of  heat. 
These  crustaceans  must  not,  therefore,  be  considered  as  wholly 
destitute  of  a  heat-producing  power,  but  merely  as  cases  in 
which  this  power  is  at  its  minimum,  and  consequently  extremely 
difficult  of  detection. 

I  have  not  been  able  to  find  any  recorded  observations  on 


1866.] 


OF  THE  INVERTEBRATES. 


251 


the  temperature  of  the  third  subdivision,  the  arachnida;  but 
from  the  few  experiuients  that  I  have  made  upon  spiders,  I  am 
inclined  to  consider  tlieir  heat-producing  powers  as  quite 
active;  but  more  investigations  are  needed  to  establish  this 
point. 

Lastly  we  come  to  the  insects,  which,  as  a  class,  have  had 
their  temperatures  more  carefully  studied  than  any  other  of  the 
invertebrates. 

As  the  results  obtained  by  myself  have  been  in  the  main  con- 
firmatory of  those  of  previous  observers,  I  will  merely  mention 
a  few  points  that  appear  to  be  of  especial  interest. 

The  same  instruments  were  used  in  these  experiments  as  in 
those  previously  related,  and  in  every  case  both  insect  and 
thermo-electric  apparatus  were  covered  with  a  bell  jar. 

I  am  inclined  to  think  that,  as  a  rule,  the  temperatures  of 
the  insects  are  best  studied  when  the  thermometer  is  below 
70°  F.,  rather  than  when  it  is  above  that  point,  and  the  reason 
is  as  follows: 

We  know  that  in  the  use  of  thermo-electric  apparatus,  the 
degree  of  deflection  of  the  galvanometer  needle  is  proportional 
to  the  difference  in  temperature  of  the  two  junctions,  and  that 
no  matter  how  great  the  degree  of  heat  or  cold  may  be,  so  long 
as  bo  til  junctions  are  equally  heated  or  chilled,  no  indication  is 
afforded  by  the  galvanometer. 

Now  if  we  place  one  of  our  junctions  in  the  mouth  of  a  man, 
exposed  to  an  atmosphere  of  40°  F.,  we  obtain  a  deflection  of 
the  needle  proportional  to  the  difference  between  the  tempera- 
ture of  the  mouth  and  that  of  the  air,  for  the  second  junction 
which  is  exposed  to  the  air  of  course  acquires  its  temperature. 
One  junction,  therefore,  is  at  40-  F.,  and  the  other  at  99  ^  F.,  a 
difference  of  59  ^. 

But  suppose  we  wait  till  a  day  comes  when  the  thermometer 
is  at  90". 

The  junction  exposed  to  the  air  is  now  at  90^  instead  of  at 
40 but  the  temperature  of  the  mouth  is  still  99  ,  or  at  least 
has  risen  only  to  a  very  insignificant  extent.  Consequently 
the  difference  between  our  two  junctions  is  now  only  9^, 
instead  of  59  ,  and  the  deflection  of  the  needle  is  correspond- 
ingly less. 


252 


TEMPERATURE  OF  SOME 


[Jan., 


As  the  temperature  of  tlic  air  rises  higher,  the  deflection  of 
the  needle  grows  less. 

Finally,  if  we  place  the  man  in  an  oven  heated  to  130^  or 
140^  F.  temperature,  that  can  be  easily  borne  for  a  consider- 
able length  of  time,  we  find  that  the  galvanometer  indicates 
that  the  man  is  very  much  cooler  than  the  air. 

Now  it  is  true  that  the  cold-blooded  animals  do  not  possess 
by  any  means  that  same  power  of  maintaining  a  constant  tem- 
perature as  do  the  mammals  and  birds;  still  their  temperatures 
can  not  be  raised  or  depressed  indefinitely,  and  there  are  con- 
sequently limits  both  ways  at  which  they  exhibit  a  certain  re- 
sistance. 

Suppose,  for  argument's  sake,  the  higher  of  these  two  limits 
to  be  for  a  given  class  of  insects  about  90"  F.,  the  result  would 
be  that,  as  the  temperature  of  the  air  approached  this  point,  the 
body  of  the  insect  would  gradually  become  cooler  than  the  air, 
for  the  junction  exposed  to  the  air  would  have  its  temperature 
raised,  while  the  insect  would  not  warm  up  with  equal  rapidity. 
This  case  is  parallel  to  that  of  a  man  exposed  to  a  temperature 
gradually  rising  to  99"  and  above. 

Suppose,  on  the  other  hand,  the  lower  limit  to  be  near  60° 
F.,  as  the  atmosphere  cooled  down  to  this  point  the  insect 
would  gradually  become  warmer  than  the  air,  for  the  junction 
out  of  its  body  would  fall  with  the  air.  while  the  insect  itself 
would  not  have  its  temperature  depressed  quite  so  rapidly. 
This  case  corresponds,  therefore,  to  that  of  a  man  exposed  to  a 
temperature  falling  by  degrees  from  130^  to  98°,  or  there- 
abouts. 

We  see,  then,  that  the  same  insect  examined,  first,  when  the 
air  is  at  90°  F.,  and  second,  when  it  is  at  60°  F.,  would,  in  the 
former  instance,  be  cooler,  and  in  the  latter,  warmer  than  the 
surrounding  medium. 

I  was  led  to  these  conclusions  from  the  fact  that  all  the 
insects  examined  by  me  in  the  spring,  from  about  the  last  of 
March  to  the  middle  of  May,  when  the  weather  was  compara- 
tively cool,  gave  indications  of  a  temperature  decidedly  higher 
than  that  of  the  air.  But  soon  after  hot  weather  set  in,  their 
temperatures,  as  a  rule,  conformed  very  closely  with  that  of  the 
air;  and  as  the  mercury  rose  still  higher,  the  majority  of  them 


18G6.] 


OF  THE  INVERTEBRATES. 


253 


were  cooler  than  the  atmosphere.  A  single  series  of  observa- 
tions will  serve  to  show  this  change. 

On  a  day  towards  the  last  of  March,  wlicn  the  temperature 
of  the  air  was  60  ^  F.,  a  large  moth  gave,  with  Becquercl's  ap- 
paratus, a  deflection  of  40°  galvanometric  degrees*  on  the  hot 
side. 

In  the  early  part  of  July,  the  air  being  at  15'^  F.,  an  insect 
similar  in  all  respects  to  the  first,  caused  a  deflection  of  only 
3°  on  the  hot  side  of  the  galvanometer. 

During  the  first  part  of  August,  the  air  being  at  84^  F., 
another  insect  of  the  kind  caused  a  deflection  of  4P  on  the  cold 
side. 

A  few  days  after  this,  a  fourth  insect  was  also  cooler  than 
the  air,  which  had  the  same  temperature  as  in  the  last  instance, 
by  six  galvanometric  degrees. 

Similar  results  were  obtained  with  other  insects. 

To  verify  these  results,  an  attempt  was  made  to  examine  the 
insects  in  atmospheres  of  different  temperatures  artificially 
prepared.  Owing  to  unavoidable  interruptions  I  did  not 
succeed  in  carrying  out  my  plans  to  the  extent  that  I  had 
hoped;  but  the  few  satisfactory  results  that  were  obtained  were 
all  in  favor  of  the  conclusions  already  given. 

There  is  an  important  fact  to  be  observed  in  this  connection, 
viz.,  that  in  placing  an  animal  in  cither  a  high  or  a  low  tem- 
perature, the  extremely  poor  power  of  conduction  of  its  tissues 
renders  a  change  in  its  temperature  slower  than  in  the  major- 
ity of  inorganic  bodies  of  equal  size — of  course  this  is  also  true 
of  a  dead  animal. 

When,  therefore,  we  place  an  insect  in  a  higher  or  lower 
temperature  than  that  of  the  air,  we  must  always  allow  a 
certain  time  to  elapse  before  we  make  the  connection  with  the 
galvanometer,  in  order  that  we  may  eliminate  the  above  source 
of  error. 

With  the  approach  of  the  cool  weather  of  autumn  my  inves- 
tigations were  repeated,  but  unfortunately  circumstances  again 
prevented  me  from  performing  them  upon  a  sufficiently  exten- 
sive scale;  still,  so  far  as  they  went,  the  results  were  in  the 
main  confirmatory  of  those  already  given. 


*  Not  to  be  confounded  with  tliermometric  degrees. 


254 


TREATMENT  OP  BRIGHT's  DISEASE. 


[Jan., 


This  was  particularly  true  in  the  case  of  the  grasshopper,  an 
insect  whose  temperature  I  have  carefully  studied. 

Of  upwards  of  a  hundred  individuals  examined  during  the 
hot  weather  of  July  and  August,  not  a  single  one  had  a  tem- 
perature above  that  of  the  air,  and  the  great  majority  had  a 
temperature  below  that  point.  When  placed  in  air  saturated 
with  aqueous  vapor,  a  portion  had  their  temperatures  raised  as 
high  as  that  of  the  air;  but  another  still  larger  portion  fell 
short  of  that  point.  In  two  or  three  cases  the  suspension  of 
evaporation  was  followed  by  a  rise  of  temperature  on  the  part 
of  the  insect  above  that  of  the  air;  but  these  cases  were  so 
extremely  few  in  number  that  I  am  inclined  to  attribute  them 
to  errors  in  exjjerimenting. 

During  the  last  of  September  and  the  first  of  October 
twelve  of  these  insects  were  examined.  The  temperature  of  the 
air  was  70-'  F.  and  below.  In  every  instance  the  suspension 
of  evaporation  caused  the  temperature  of  the  insect  to  rise 
above  that  of  the  atmosphere,  and  in  eight  cases  out  of  the 
twelve  the  insect  exhibited  a  temperature  slightly  above  that 
of  the  air  before  evaporation  was  stopped.  In  the  remaining 
four  cases  the  insect  had  the  same  temperature  as  the  atmo- 
sphere. 

I  have  thus  given  a  synopsis  of  the  principal  part  of  my  ex- 
periments on  the  temperature  of  the  invertebrates,  and  trust 
that  in  so  doing  I  have  at  least  shown  how  much  remains  to  be 
studied  in  this  branch  of  physiology. 


Hints  about  the  Nature  and  Treatment  of  the  Active  Congestive 
Varietal  of  Bright'' s  Disease.    By  John  C.  Peters,  M.D. 

In  a  previous  article  we  have  had  our  attention  turned  to 
the  effects  of  the  retention  of  simple  perspiratory  fluid  in  the 
system.  We  have  seen  that  the  quantity  of  sweat  which  ought 
to  be  passed  off  daily  may  amount  to  5  pounds  as  a  maximum, 
to  pounds  as  a  minimum,  and  to  2.^  pounds  on  an  average. 
We  have  noted  how  an  accumulation  of  this  fluid,  going  on  for 
days,  weeks  or  months  together,  may  induce  general  dropsy, 
preceded  by  an  oedematous  condition  of  the  kidney;  and  have 


1866.] 


TREATMENT  OF  BRIGHT's  DISEASE. 


255 


cited  in  corroboration  the  case  of  a  dropsical  patient  who  was 
very  thirsty,  drank  largely,  and  gained  11  pounds  in  weight  in 
the  course  of  three  days  from  deficient  elimination  of  the  cuta- 
neous and  urinary  secretions.  But,  in  an  acute  or  chronic  check 
of  perspiration  there  is  much  more  than  a  simple  non-elimina- 
tion of  water  from  the  skin;  for  in  one  experiment  Funke  forced 
out  nearly  7  ounces  of  sweat  in  one  hour,  containing  7^  grains 
of  urea,  or  in  the  proportion  of  180  grains  of  urea  in  24  hours; 
in  another  experiment  the  perspiration  amounted  to  about  18 
ounces  per  hour,  containing  nearly  10  grains  of  urea,  or  at  the 
rate  of  nearly  |  ounce  of  urea  daily  from  the  skin  alone.  Hence 
a  contamination  of  the  blood,  with  an  excess  of  urea,  can  be  in- 
duced by  a  simple  check  of  perspiration. 

Again,  Schotten  has  demonstrated,  with  the  greatest  cer- 
tainty, the  presence  of  formic  and  acetic  acids  in  normal 
human  sweat,  and  very  large  quantities  of  formic  acid  have 
been  obtained  under  Lchmann's  own  inspection;  in  fact,  there 
is  a  great  preponderance  of  formic  acid,  a  far  smaller  quantity 
of  acetic  acid,  and  only  traces  of  butyric  or  any  other  acid  in 
natural  perspiration. 

Carbonate  of  ammonia  occurs  in  alkaline  sweat,  especially  in 
that  collect cd  from  the  arm-pits  and  feet.  Lehmann  infers, 
if  he  may  form  an  opinion  from  the  odor  of  different  kinds 
of  sweat,  it  is  very  probable  that  caproic  and  metacetonic 
acids,  which  arc  closely  allied  to  the  butyric,  are  also  often 
present  in  perspiration.  In  many  diseases,  especially  such  as 
arc  accompanied  by  an  acute  exauthematous  eruption,  there  is 
often  a  singularly  strong  smell  of  metacetonic  acid.  A  sul- 
phurous matter  must  be  contained  in  sweat,  for  if  fluid  perspira- 
tion is  kept  in  a  closed  glass  we  find  that  a  considerable  quan- 
tity of  sulphide  of  ammonia  is  formed.  But  the  substance 
whicli,next  to  water,  occurs  in  the  largest  quantity  in  this  fluid 
is  the  chloride  of  sodium.  Finally,  412  cubic  inches  of  car- 
bonic acid  gas,  and  about  200  of  nitrogen  gas  are  exlialed  per 
day  with  the  liquid  secretion  of  the  sudoriparous  glands.  The 
main  object  of  perspiration  is  the  elimination  of  an  excess  of 
water  and  of  certain  deleterious  substances  from  the  blood; 
still  Peaslee  is  inclined  to  believe  tliat  mischief  results  from  a 
check  of  perspiration,  far  more  because  carbonic  acid  and 


256 


TREATMENT  OF  BRIGHT's  DISEASE. 


[Jan., 


nitrogen  gases  cease  to  be  given  off,  than  because  urea,  formic 
and  acetic  acids,  chloride  of  sodium,  sulphurous  matter  and 
ammonia  are  retained.  However  this  may  be,  from  ^  to  ^ 
ounce  of  organic  and  volatile  matter,  and  38  grains  of  min- 
eral substances  should  bo  excreted  from  the  skin  per  day,  and 
this  does  not  happen  in  Bright's  disease;  for,  the  experience  of 
almost  every  physician  agrees  with  that  of  Goodfellow,  that  gen- 
erally, in  all  stages  of  Bright's  disease,  there  is  an  unusual  dryness 
of  the  skin,  and  even  during  somewhat  active  exercise  there  is 
but  little,  if  any,  perspiration— the  power  of  eliminating  water 
seems  not  only  impaired  on  the  part  of  this  great  emunctory,  but 
it  is  also  almost  certain  that  there  is  a  diminished  power  of  ex- 
creting some  or  most  of  the  other  constituents  of  the  perspira- 
tion. Johnson  says  there  is  generally  a  dryness  and  harshness 
of  the  skin;  the  cuticular  covering  seems  to  be  ill  nourished 
and  imperfectly  formed;  there  is  an  unusual  desquamation  of  the 
cuticular  cells,  and  the  exuviae  are  therefore  more  than  usually 
great.  He  is  often  anxious  to  point  out  the  fact  that  suppres- 
sion of  the  cutaneous  secretion  is  a  frequent  cause  of  such 
an  alteration  of  the  blood  as  produces  disease  of  the  kidneys. 
Not  only  is  the  skin  dry,  but  there  is  difficulty  in  some  cases  of 
inducing  free  diaphoresis;  now  and  then  a  patient  will  be  found 
whose  surface  becomes  very  red  under  the  influence  of  the  hot- 
air  bath;  an  artificial  fever  may  be  produced,  but  he  will  not 
perspire  afterwards. 

It  is  evident  from  the  above  that  from  either  an  acute  or 
chronic  suppression  of  perspiration,  irritating  substances 
enough  may  be  retained  in  the  blood  to  cause  a  blood  poisoning 
but  little  less  formidable  in  its  effects  than  the  inhalation  of  the 
paludal,  or  scarlatinal  miasms;  and,  in  consequence  of  these 
materials  being  conveyed  to  the  kidneys  more  rapidly  than 
they  can  be  eliminated,  they  continue  to  accumulate  in  their 
blood,  till  the  circulation  through  tlie  kidneys  is  retarded  and 
their  functions  impeded.  It  is  possible  that  the  excess  of  urea 
may  narcotize,  benumb  or  paralyze  the  renal  nerves  in  some 
cases  in  the  same  way  that  it  and  opium  do  the  brain,  thus 
allowing  passive  congestion  to  arise;  or  some  of  the  retained 
acids,  especially  the  formic,  may  so  irritate  the  kidneys  as  to 
produce  active  congestion,  or  subacute  inflammation.  How- 


1866.]  TREATMENT  OP  BRIGHt'S  DISEASE. 


257 


ever  this  may  be,  in  the  congestive  form  of  Bright's  disease, 
the  kidneys  are  more  or  less  turgid  with  blood,  and  are  of  a 
bright  red  or  a  dusky  brown  color;  the  surface  is  not  unfre- 
quently  covered  over  with  minute  ecchymotic  spots  dependent 
upon  the  extravasation  of  blood  into  the  tubes  in  their  convo- 
luted portions.  This  excessive  congestion  and  extravasation  of 
blood,  by  obstructing  the  tubes  and  interfering  with  the  secre- 
tory function  of  the  organ,  is  the  chief  source  of  danger.  Pro- 
fessor Alonzo  Clark  says  there  is  enlargement  of  the  kidney, 
with  no  tendency  to  a  white  or  light  color.  All  the  renal 
vessels  are  full,  and  in  a  thin  section  the  malphigian  bodies 
are  seen  often  as  bright-red  spots,  retaining  the  blood  while 
it  flows  out  of  the  veins.  The  kidney  is  loaded  and  distended 
with  blood,  but  the  characteristic  exudations  have  not  yet 
taken  place.  It  is  a  state  sometimes  seen  in  the  acute  variety 
when  death  occurs  early.  Were  it  not  for  the  symptoms,  viz., 
the  oedema,  the  pale  complexion,  the  albumen  and  often  the 
blood  in  the  urine,  the  varying  conditions  of  ursemia,  etc., 
it  might  (and  undoubtedly  should)  be  considered  as  conges- 
tion, and  nothing  more.  In  some  of  Dr.  Clark's  cases  the 
congestion  was  of  a  very  marked  character,  so  marked  that 
where  the  kidney  was  left  to  drain,  without  being  permitted  to 
dry,  (by  being  wrapt  in  oil  silk,)  the  weight  was  diminished 
1|  ounces  in  one  instance,  in  another  2,  and  in  a  third  3 
ounces. 

Watson  describes  this  state  of  the  kidney  as  one  of  sanguine 
congestion— the  whole  organ  is  gorged  with  blood,  which  drips 
freely  from  it  when  it  is  cut  open.  It  is,  in  general,  large, 
somewhat  flabby,  of  a  deep,  dark  red,  even  of  a  chocolate  or 
jmrplish  color,  nearly  uniformly  diffused,  except  that  the  cut 
surface  is  usually  diversified  by  still  darker  tuft-like  spots, 
which  have  been  ascertained  to  be  the  malphigian  bodies, 
tinged  with  blood.  This  change  from  the  natural  appearance 
of  the  kidney  is  evidently  of  a  recent  kind;  the  symptoms  are 
uneasiness,  a  dull  pain  in  the  loins,  nausea  and  vomiting,  a 
very  scanty  secretion  of  urine,  which  is  sometimes  palpably 
tinged  with  blood  and  always  albuminous;  occasionally  com- 
plete suppression  of  urine,  and  in  most  cases  sudden  and  general 
anasarca,  or  active,  acute  dropsy.    The  mischief  done  to  the 

Vol.  II.— No.  10.  17 


258 


TREATMENT  OP  BRIGHT's  DISEASE. 


[Jan., 


kidney  is  the  result  of  extreme  congestion,  and  its  actual  conse- 
quences, viz.,  the  oozing  forth  of  the  blood  in  substance,  or  of 
some  of  its  constituents,  into  the  interstitial  textures,  as  well  as 
into  the  excretory  tubes  of  the  kidney;  those  portions  of  the 
extravasated  fluid  which  have  no  outlet  of  escape  solidify,  and 
thus  obliterate  the  natural  texture  of  the  part  they  have  in- 
vaded; the  emergent  veins  of  the  kidney  are  often  obstructed 
by  firm  clots  of  blood;  blood  casts,  or  fibrinous  coagula  moulded 
in  and  discharged  from  the  urinary  tubules  and  covered  with 
blood  disks,  are  often  found  in  the  urine.  But  none  of  these 
are  necessarily  products  of  inflammation,  but  merely  of  acute 
and  severe  congestion. 

In  fact,  Dr.  Robinson  has  clearly  proved  this  experimen- 
tally, by  placing  a  ligature  on  the  renal  vein  of  a  rabbit; 
in  consequence  of  which  the  urine  became  albuminous  and 
bloody;  he  repeated  this  operation  several  times  with  almost 
uniform  results.  Frerichs  has  tested  Dr.  Robinson's  experi- 
ments with  a  similar  result,  and,  in  addition,  he  observed,  what 
Johnson  admits  might  have  been  anticipated,  that  the  urine 
which  was  albuminous  and  bloody,  also  contained  fibrinous 
casts  of  the  kidney  tubes. 

Braun's  description  is  still  more  minute;  he  says,  in  the  first 
stage,  that  of  hyperaemia  and  commencing  exudation,  the  sur- 
face of  the  kidney  is  smooth,  the  capsule  easily  removed,  the 
plexus  of  veins  on  the  surface  dilated  and  full  of  dark  blood; 
the  cortical  substance  is  brownish-red,  soft,  and  friable;  from 
the  surface  of  a  section  there  flows  a  sticky  fluid,  with  which 
the  parenchyma  is  infiltrated;  the  pyramidal  masses  are  like- 
wise hyperaeraic,  and  the  injection  is  striped;  the  mucous  mem- 
brane of  the  pelvis  and  infundibula  is  swollen  and  covered 
with  vascular  arborescence,  and  they  contain  a  bloody  fluid. 
Apart  from  hypersemia  the  finer  structures  of  the  kidney  do 
not  appear  to  be  essentially  injured. 

Hemorrhagic  effusions  are  very  frequently  observed,  which 
sometimes  take  their  rise  from  the  glomeruli,  sometimes  from 
the  vascular  plexus  of  the  tubuli  uriniferi,  sometimes  from 
the  veins  on  the  surface  of  the  cortical  substance;  the  generally 
regular,  round  vesicles  in  the  cortical  substance  originate  in 
convoluted  tubuli  uriniferi  being  distended  with  blood;  the 


1866.]  TREATMENT  OF  BRIGHT's  DISEASE. 


259 


epithelium  of  the  tubuli  uriniferi  is,  in  the  first  stage,  not  yet 
essentially  altered,  but  may  generally  be  distinguished  by  the 
ease  with  which  it  is  separated;  the  tubuli  uriniferi  are  filled 
witli  coagulated  or  fluid  exudation,  and  appear  as  homogeneous, 
transparent  cylinders,  and  sometimes  contain  blood  corpuscules. 
These  so-called  fibrin  cylinders  occur  less  frequently  in  the 
chronic  form  of  the  disease. 

It  is  in  the  decidedly  congested  kidney  that  we  are  most  apt 
to  find  blood  in  the  urine.  Heywood  Thompson  found  blood 
globules  present  in  fifty-seven  cases  out  of  seventy-five  of  recent 
albuminuria.  In  well  advanced  cases  the  blood  disappears,  or 
at  least  it  was  not  found  in  a  single  case  out  of  ten.  Dr.  Clark 
says  it  is  worthy  of  notice  that  very  often  in  the  beginning  of 
Bright's  disease  the  urine  is  sometimes  found  bloody  and  often- 
times of  a  smoky  hue.  The  smoky  urine  is  equivalent  to  the 
bloody  urine,  for  when  the  matter  that  has  produced  the  dark 
color  is  collected  into  a  sediment  it  is  found  to  be  blood  in 
some  degree  disintegrated;  a  portion  is  granular  matter,  and 
a  portion  blood  globules.  Tlie  granular  matter  is  of  a  brown 
color  under  the  microscope,  and  is  supposed  to  be  derived  from 
the  hematine  of  the  blood  converted  into  a  substance  known 
as  hematoidine.  The  only  difference  between  bloody  and  smoky 
urine  is,  that  the  blood  has  met  with  some  extractive  matter  which 
has  converted  its  hematine  into  hematoidine,  almost  always 
of  the  brown  granular  variety;  and  the  same  agent  often  causes 
shriveling  and  other  changes  in  the  appearance  of  the  corpus- 
cules. Dr.  Clark  considers  the  significance  of  smoky  urine  is 
the  same  as  that  of  the  bloody  urine,  so  far  as  the  condition  of 
the  kidney  is  concerned,  both  implying  a  congested  state. 

But,  according  to  Dr.  Henley,  urohcematin  may  be  passed  in 
large  quantities,  and  the  urine  neither  appear  bloody  or  smoky; 
for  it  is  sometimes  largely  discharged  in  the  almost  colorless 
urine  of  anasmia  and  chlorosis.  An  immense  destruction  of 
blood  globules  may  take  place  in  the  body,  and  their  debris  be- 
eliminated,  so  as  to  be  invisible  to  tlie  eye,  until  the  application 
of  an  acid  sets  it  free.  Normally  colored  urine  is  hence  often 
a  treacherous  guide  to  go  by.  The  subjects  may  be  well  fed', 
but  will  lose  flesh  and  strength  without  apparent  cause;  their 
urine  may  look  natural,  but  their  life's  blood  may  be  oozing- 


260-  TREATMENT  OP  BRIGHT's  DISEASE.  [Jan., 


rapidly  away  by  the  kidneys.  In  some  of  these  obscure  cases 
the  excess  of  urohaematin  is  so  great  that  when  set  free  by  an 
acid  and  taken  up  with  ether,  the  mass,  after  standing,  solidifies 
into  a  red-currant  jelly-like  mass,  and  may  actually  be  cut 
with  a  knife.  To  detect  urohaBmatin,  add  one  part  of  strong 
nitric  acid  to  three  parts  of  urine,  bring  it  to  the  boiling  point, 
and  if  there  is  much  urohamaetin  it  will  assume  an  intensely  red 
hue.  Or  boil  four  ounces  of  urine  with  some  nitric  acid,  to  set 
all  the  coloring  matter  free;  when  cool,  put  the  urine  in  a  six- 
ounce  bottle,  with  an  ounce  of  ether,  cork  the  bottle  thoroughly, 
shake  it  well,  and  place  it  aside  for  twenty-four  hours;  at  the 
end  of  that  time  the  ounce  of  ether  will  sometimes  be  con- 
verted into  a  red,  tremulous  mass  or  jelly.  In  one  case,  the 
urine  of  a  young  man  was  almost  colorless,  like  water,  while  in 
another  it  was  of  a  deep-red  color  from  haematuria;  when 
strong  hydrochloric  acid  was  added  to  the  colorless  urine  it 
rapidly  assumed  a  port-wine  red  tint,  while,  when  added  to 
the  bloody  urine,  the  acid  actually  destroyed  the  color  it 
already  had;  the  pale  urine  had  an  excess  of  urohaematin  which 
was  liberated  by  the  acid;  whereas,  the  red  urine  only  con- 
tained a  number  of  free,  blood  corpuscules,  which  became  co- 
agulated, and  as  the  coloring  matter  in  them  is  small,  no  sooner 
were  their  cell-walls  destroyed,  and  the  contained  haemato-glob- 
ulin  set  free  and  precipitated,  than  the  red  color  of  the  urine 
disappeared.  Sometimes  the  urohaematin  may  be  in  a  free  state, 
and  the  urine  will  be  red  before  any  acid  is  added,  or  pale- 
yellow  in  color,  or  brown.  Then  different  acids  may  act  differ- 
ently; in  one  case,  nitric,  sulphuric,  and  muriatic  acids,  may 
give  exactly  the  same  results;  in  others,  muriatic  acid  may 
turn  the  urine  red,  and  nitric  only  make  it  yellow;  in  other 
cases,  sulplmric  acid  may  develop  the  color  best.  Urohaema- 
tin patients  may  only  have  an  irregular  kind  of  dyspepsia, 
with  occasional  pain  in  the  epigastrium;  they  may  take  plenty 
of  food  and  be  in  easy  circumstances,  yet  lose  fifteen  or  twenty 
pounds  of  flesh  per  year,  and  grow  weaker  all  the  time.  The 
urine  in  the  worst  form  becomes  neutral  or  alkaline;  like  albu- 
minuria, it  is  apt  to  come  on  after  diphtheria,  pneumonia,  and 
fever  and  ague,  or  after  a  fit  of  gout,  and  during  convalescence 
from  all  severe  diseases.   But  it  is  in  the  anemia  and  chlorosis 


1866.]  TREATMENT  OF  BRIGHT'S  DISEASE. 


of  both  males  and  females,  and  the  many  obscure  affections 
of  that  class,  that  it  becomes  a  dangerous  symptom,  and  may 
precede  the  devclopement  of  Bright's  disease.  It  should  be 
looked  for  in  obstinate  cases  of  so-called  nervous  debility.  Dr. 
Clark  lays  some  stress  upon  the  occurrence  of  dyspepsia  in 
Bright's  disease;  he  thinks  very  few  cases  run  their  course 
without  the  occurrence  of  very  marked  dyspepsia,  and  that 
almost  always  of  the  flatulent  variety,  with  a  sense  of  oppres- 
sion, and  not  unfrequently  of  fullness,  or  sometimes  of  emptiness 
across  the  epigastric  region,  and  which  will  persist  not  unfre- 
quently for  weeks  and  months  together.  By  the  symptoms 
alone  we  can  not  distinguish  the  dyspepsia  of  Bright's  disease 
from  that  arising  from  loss  of  urohaematin;  but  an  examination 
of  the  urine  will  clear  up  the  matter  at  once. 

Basham  describes  another  form  of  discoloration  of  the  urine 
by  acid  of  a  different  significance  from  the  above,  viz.,  on  the 
addition  of  nitric  acid  to  urine  already  coagulated  by  heat,  the 
albumen  becomes  altered  in  color,  first  assuming  a  bhnsh  green 
and  subsequently  passing  into  a  greenish  black.  This  effect  of 
nitric  acid  on  the  albuminous  coagula  results,  he  thinks,  proba- 
bly from  the  oxydizing  agency  of  the  nitric  acid  on  the  coloring 
matter  of  the  urine,  but  adds  that  it  has  not  yet  been  satisfac- 
torily explained;  but  is  known  to  occur  most  frequently  in  the 
acute  form  of  Bright's  disease,  and  is  generally  of  very  un- 
favorable significance;  for  his  experience  tells  him  that  the 
development  of  this  pigmentary  condition,  in  combination  with 
albumen  in  the  urine  is  of  the  gravest  import.  It  is  always 
associated  with  a  rapid  and  advanced  state  of  renal  degenera- 
tion, and  has  always  been  quickly  followed  by  fatal  results.  He 
also  quotes  Lehmann,  who  says,  as  far  as  his  experience  goes,  it 
is  only  when  ura^mic  symptoms  have  or  are  about  to  manifest 
themselves,  that  this  peculiarity  of  the  urine  is  observable. 

Epithelial  cells  and  casts  are  also  often  found  in  the  urine  in 
simple  but  more  or  less  severe  and  acute  congestive  Bright's 
disease.  As  long  as  the  epithelial  cells  maintain  their  normal 
shape,  size  and  appearance,  congestion  only  is  present;  but  as 
soon  as  they  become  abortive,  or  undergo  some  other  morbid 
change,  or  are  accompanied  by  compound  cells,  (Gluge's,)  or 
other  evidence  of  fatty  or  granular  exudation,  then  either  the 


262 


NEW  INHALER  FOE  SULPHURIC  ETHER.  [Jan., 


inflammatory  form  of  Briglit's  disease  is  present,  or  has  been 
superadded;  or  fatty  or  some  other  degeneration  of  the  renal 
tissues  has  occurred. 

It  is  evident  from  all  that  has  been  proven  above,  that  the 
principal  part  of  the  treatment  of  the  acute  congestive  variety 
of  Bright's  disease  should  be  the  restoration  of  the  functions  of 
the  skin.  For  this  purpose  the  hot-air  bath  is  better  than  any 
vapor  or  water  bath;  but  I  have  seen  great  benefit  ensue  from 
the  addition  of  several  or  many  ounces  of  carbonate  of  soda, 
or  of  a  few  ounces  of  spirits  of  ammonia  to  an  ordinary  warm 
bath,  repeated  daily,  or  several  times  a  week.  Persons  who 
scarcely  recollected  ever  having  perspired  before  have  done 
60  after  these  baths  ;  the  skin  has  become  soft  and  moist,  and 
could  be  kept  so  if  the  patient  was  forced  to  wear  flannel 
clothing  from  head  to  foot,  with  or  without  the  superaddition 
of  a  complete  suit  of  oil-silk;  which  latter  often  becomes  very 
necessary  in  the  coldest  months  of  the  year. 

Dry  or  wet  cups  to  the  loins  are  often  useful,  but  perhaps 
not  more  so  than  stimulating  applications,  such  as  mustard 
water,  made  with  two  handfuls  of  mustard  tied  in  a  muslin 
bag,  placed  in  hot  water,  and  squeezed  with  the  hand,  until  all 
the  strength  of  the  mustard  is  extracted;  a  thick,  broad  flannel 
or  towel,  long  enough  to  reach  entirely  around  the  loins  and 
abdomen,  may  be  wet  with  this  infusion,  and  worn,  covered 
with  oil-silk. 

Of  the  remedies  for  internal  congestion,  the  most  efficient 
is  a  combination  of  tincture  of  root  of  aconite,  tincture  of  vera- 
trum  viride,  tincture  of  digitalis,  and  tincture  of  colchicum. 
All  these  medicines  tend  to  equalize  the  circulation,  while  aco- 
nite is  a  specific  antiphlogistic  diaphoretic,  digitalis  a  specific 
antiphlogistic  diuretic,  and  colchicum  unloads  the  biliary  and 
intestinal  capillaries ;  finally,  all  these  remedies  eliminate  urea 
from  the  blood. 


A  New  " Inhaler" for  Sulphuric  Ether.    By  F.  D.  Lente,  M.D., 
of  Cold  Spring,  N.  Y. 

With  a  view  to  facilitate  the  induction  of  anaesthesia  by 
sulphuric  ether,  and  to  overcome  some  of  the  objections  to  its 


1866.]  NEW  INHALER  FOR  SULPHURIC  ETHER. 


263 


use,  I  have  had  constructed,  at  Otto  &  Reynders',  No.  64  Chat- 
ham street,  a  very  simple  and  cheap  apparatus,  of  which  I  pro- 
pose to  give  a  brief  description,  premising  that  one  of  the 
principal  causes  of  delay  in  the  induction  of  anassthesia  by 
ether,  and  a  consequent  waste  of  the  material  in  the  hands  of 
most  operators,  has  been  the  necessity  of  withdrawing  the  ap- 
paratus from  the  face,  at  intervals,  in  order  to  replenish  the 
ether;  and,  I  may  add,  the  unnecessary  deliberation  with  which 
this  is  generally  done,  thus  allowing  the  respiration  of  pure 
air  to  a  greater  or  less  extent.  A  principal  aim,  therefore,  of  the 
new  contrivance  is  to  obviate  entirely  this  necessity. 

It  consists,  first,  of  a  light  wire,  helmet-shaped  framework, 
so  formed,  at  the  base,  as  to  fit  over  the  nose  and  chin,  but  not 
to  cover  the  eyes.  At  the  apex  of  the  cone  is  a  male  screw; 
over  this  framework  is  a  cone  of  double  flannel — a  hole  at  its 
apex  allowing  it  to  slip  over  the  screw.  Over  this  is  screwed 
an  arrangement  consisting  of  a  short  tube  half  an  inch  in  di- 
ameter, and  branching  into  three  small  tubes,  so  arranged,  when 
adjusted,  as  to  embrace  and  open  upon  the  flannel  cone  at  equal 
distances  from  each  other.  Over  the  tube  is  slipped  a  cone 
of  impervious  material,  not  easily  acted  on  by  the  ether,  as 
enameled  leather,  with  the  enamel  outside.  This  cone  is 
lined  with  tin-foil,  so  as  to  prevent  the  absorption  of  the  ether 
by  the  leather.  This  cone  is  kept  in  situ  by  a  nut  screwing 
over  the  tube;  over  the  extremity  of  the  latter  is  drawn  the 
end  of  a  vulcanized  India-rubber  tube,  the  other  extremity  of 
which  is  to  be  slipped  over  the  neck  of  a  suitable  bottle  con- 
taining four  or  five  ounces  of  ether,  as  soon  as  the  inhaler  is 
required.  Upon  placing  the  cone  over  the  patient's  face,  and 
inverting  the  bottle,  the  ether  runs  very  rapidly  through  the 
three  tubes  and  distributes  itself  equally  to  all  parts  of  the 
flannel  cone,  whether  the  inhaler  be  held  vertically  or  horizon- 
tally. 

In  using  the  inhaler,  it  is  first  to  be  accurately  adjusted  to 
the  face  so  as  to  exclude,  as  far  as  possible,  all  air.*  The 

*  By  placing  the  inlialer  over  his  own  face  as  firmly  as  possible,  without 
ether,  and  breathing  through  it,  the  operator  may  convince  himself  that 
there  is  no  danger  of  suffocating  the  patient  by  cutting  ofif  a  due  admixture  of 
atmospheric  air. 


264 


CONSTIPATION  CURED  BY  EXTERNAL  [Jan., 


bottle  is  then  to  be  inverted  and  about  a  couple  of  drachms 
of  ether  allowed  to  run  into  the  flannel;  after  the  patient  has 
respired  a  few  seconds  and  become  a  little  accustomed  to  it, 
about  three  drachms  more  are  to  be  supplied,  and  repeated 
about  every  half  minute;  if  a  superabundance  is  allowed  to  run 
in  it  will  be  found  running  down  the  neck  of  the  patient  at 
the  bottom  of  the  flannel  cone.  Experience  soon  teaclies  just 
how  much  is  needed  from  time  to  time.  In  case  the  patient 
struggles,  the  bottle  may  be  allowed  to  hang  by  the  India-rub- 
ber tube,  and  both  hands  used  to  keep  the  inhaler  closely  ap- 
plied to  the  face,  which  is  very  important;  or,  when  he  has 
become  quiet,  one  hand  may  be  employed  in  assisting  in  the 
operation,  if  necessary,  and  within  reach.  This  is  of  no  little 
importance  in  the  country  where  assistants  are  usually  limited; 
when  we  are  operating  by  candle-light  it  is  also  a  great  con- 
venience to  have  the  ether  bottle  so  arranged  as  to  preclude 
all  danger  of  explosion.  At  the  first  public  trial  of  the  inhaler, 
in  a  case  of  trephining,  for  epilepsy,  at  the  New  York  Hospital, 
recently,  the  patient  was  completely  insensible  in  a  minute  and 
three-quarters,  and  with  about  an  ounce  and  a  half  of  ether; 
but  a  longer  time  and  a  somewhat  larger  quantity  will  probably 
be  an  average.  As  soon  as  the  operation  is  over,  the  inhaler 
should  be  taken  apart,  and  the  flannel  washed  and  dried  well 
before  it  is  put  together  again. 

It  is  proper  to  add  that  my  friend,  Prof.  Thomas,  a  year  ago 
suggested  to  Mr.  Tiemann  the  construction  of  a  cone  similar 
to  this,  and  has  used  it  himself.  In  his  apparatus,  however, 
there  is  no  tubular  arrangement  for  supplying  the  ether  to  all 
parts  of  the  cone  at  once,  and  the  bottle  is  not  attached  to  the 
inhaler. 


Case  of  Constipation  of  nine  weeks  and  tivo  days  Duration 
Cured  hy  the  External  Applicat  ion  of  an  Aloetic  Preparation. 
By  Herbert  M.  Howe,  M.D.,  Episcopal  Hospital,  Phila- 
delphia, Pa. 

Lizzie  F  ,  aged  nineteen  years,  single,  admitted  into  the 

Medical  Ward  of  the  Hospital,  October  26th,  1865,  as  a  case 


1866.] 


APPLICATION  OF  ALGETIC  PREPAEATION. 


265 


of  phthisis.  Lived  on  a  farm  in  Columbia  Co.,  Pa.  Her  work 
consisted  in  performing  various  duties  about  the  farm,  sucli  as 
attending  to  the  dairy,  and,  when  the  weather  would  permit, 
she  found  her  employment  in  the  fields.  She  never  was  very 
strong,  though  she  came  of  healthy  parents.  Her  health  had 
been  perfectly  good  until  the  last  Monday  in  August,  when  she 
took  a  warm  bath;  having  finished  this,  she  turned  on  the  cold 
"  shower,"  and  stood  under  it.  From  that  time  she  became 
sickly;  her  menses,  which  were  formerly  regular,  stopped — 
cough  began,  accompanied  by  profuse  expectoration,  and  her 
appetite  left  her.  On  the  Thursday  following,  which  was  the 
first  day  of  September,  she  had  a  healthy  evacuation  of  her 
bowels.  Since  that  time,  September,  till  November  4th,  she 
had  not  had  her  bowels  opened  once.  This  statement,  at  first 
so  seemingly  improbable,  is  rendered  less  so  by  the  following 
facts:  she  has  eaten  very  little  during  the  whole  time,  and  she 
has  vomited  very  frequently,  at  times  every  other  day,  while  at 
others  several  times  during  the  twenty-four  hours.  The  matter 
vomited  has  been  digested,  generally  yellowish,  though  some- 
times greenish,  and  always  intensely  acid.  Under  these  cir- 
cumstances, as  might  be  expected,  she  lost  flesh  rapidly,  and  is 
now  quite  emaciated.  Her  chronic  constipation  she  attributes 
to  having  eaten  a  great  many  chestnuts,  on  several  different 
occasions,  at  about  the  time  of  her  commencing  illness.  Since 
the  1st  of  September  she  has  been  a  great  sufferer  from  head- 
aches, at  first  so  severe  as  almost  to  set  her  frantic.  There  has' 
been  no  pain  in  the  abdomen  or  stomach,  and  no  wind.  When 
she  first  made  known  her  constipated  condition  and  told  of  its 
duration,  I  discredited  her  statement;  but  on  subsequent  further 
questioning  I  find  her  story  to  be  so  accurate  and  complete, 
and  the  girl  to  be  one  having  very  good  abilities,  that  I  do  not 
doubt  the  truth  of  what  she  represents.  At  first  I  gave  her 
three  pil.  cath.  corap.  These  were  taken  on  the  morning  of 
November  3d.  Learning  that  there  had  been  no  passage  pro- 
cured by  the  following  morning,  she  had  given  her 

E. — Oleum  Tiglii,  gtts  ij. 

Panis  -    -    -   -  q.  s. 
M. — Ft.  mass,  ct  in  pil.  iv.  div. 


266         REMOVAL  OP  CARTILAGE  FROM  KNEE-JOINT.  [Jan., 

One  of  these  were  to  be  taken  every  two  hours,  accompanied 
by  frequent  enemas  of  soap  and  water.  The  first  was  given  at 
11  o'clock,  A.M.,  of  the  4th.  This  treatment  produced  but  a 
miserable  apology  for  an  evacuation,  probably  no  more  than 
the  injection  could  reach  and  remove  mechanically.  The  fol- 
lowing day,  finding  that  she  had  had  no  relief,  I  directed  that 
a  large  cloth  be  saturated  in  red  wine  of  aloes,  and  placed 
over  her  abdomen.  This  was  done  at  10  o'clock,  a.m.,  and 
kept  on  until  3.30,  p.m.,  when  she  had  a  copious  stool,  followed 
at  five  o'clock  by  another.  She  reported  herself  as  feeling  like 
a  different  person,  so  great  was  her  relief. 

One  could  hardly  suppose  that  the  stools  were  caused  by  the 
Croton  oil  given  on  the  previous  day,  especially  when  we 
remember  its  very  prompt  cathartic  action.  Prof.  Wood,  in 
his  work  on  Therapeutics,  says  of  this  medicine:  "  As  a  purga- 
tive, it  operates  with  great  rapidity,  often  in  an  hour  or  less;" 
and  he  is  of  the  opinion  that  "  there  can  be  but  little  doubt  that 
its  effect  is  due  to  its  direct  irritant  action  on  the  mucous  mem- 
brane." Any  irritation  that  could  have  been  produced  by 
giving  the  medicine  in  pills,  each  containing  only  half  a  drop, 
and  that,  too,  given  at  intervals  of  two  hours,  would  have 
passed  off  during  the  following  twenty-four  hours.  It  is  well 
known  that  aloes  sprinkled  over  the  surface  of  an  ulcer  will 
purge :  why  should  not  a  similar  effect  be  produced  by  the 
quantity  that  the  skin  would  absorb  when  the  medicine  is 
applied  in  a  liquid  form  over  an  extensive  surface  ?  And  in 
many  cases  may  this  not  be  a  convenient  mode  of  emptying  the 
alimentary  canal? 


Bemoval  of  a  Large  "Floating  Cartilage"  from  the  Knee- 
Joint,  with  Successful  Result.  By  James  Wilson,  Licentiate 
of  the  Royal  College  of  Surgeons  in  Ireland,  etc.;  late  Staff 
Surgeon  U.  S.  A. 

In  the  practice  of  our  profession  there  are  probably  few  sub- 
jects of  greater  interest  and  of  more  vital  importance  to  the 
reputation  of  surgery,  than  the  operative  treatment  of  moveable 
bodies  in  the  cavities  of  the  larger  joints,  and  especially  of  the 


1866.]       REMOVAL  OP  CARTILAGE  FROM  KNEE-JOINT.  267 


knee.  Obscurity  surrounds  their  pathology,  and  there  is  no 
operation  apparently  so  trivial  that  the  surgeon  will  be  more 
slow  to  recommend  and  more  solicitous  as  to  the  result.  Be 
the  intruder  small  or  large,  single  or  multiple,  fibrous,  carti- 
laginous or  calcarious,  the  result  will  be  to  an  extent  the  same; 
an  intolerable  annoyance  at  the  best,  producing  irritation,  in- 
flammation, and  eflfusion  into  the  synovial  cavity,  if  not  organic 
disease  itself,  and  at  times  giving  rise  to  such  excruciating  and 
insufferable  agony  that  the  patient  is  finally  compelled  to  sub- 
mit to  whatever  operation  the  surgeon  may  recommend  as 
being  best  adapted  to  the  exigency  of  the  case. 

Unfortunately,  there  is  no  method  of  procedure  by  which  we 
can  always  avoid  the  terrible  consequences  incident  to  wounds 
penetrating  the  larger  synovial  cavities;  but  since  Syme  and 
Goyrand  suggested  the  applicability  of  subcutaneous  surgery  to 
the  removal  of  these  bodies,  the  risk  has  been  so  materially 
diminished  that  in  most  instances  we  are  justified  in  entertain- 
ing a  reasonable  expectation  of  the  entire  success  of  a  properly 
executed  operation. 

Such  was  the  method  which  I  considered  the  most  favorable 
to  have  recourse  to  in  the  following  case,  and  I  think  the  re- 
sult is  worthy  of  record,  not  only  as  corroborative  of  the  tes- 
timony already  adduced  in  favor  of  this  peculiar  operation,  but 
as  illustrative  of  its  adaptability  to  the  removal  of  foreign 
bodies  of  the  largest  possible  size. 

Private  Finnerty,  99th  Reg.  N.  Y.  Vols.,  aged  24,  a  florid 
and  healthy  looking  young  man,  presented  himself  at  "  sick 
call,"  with  well  marked  symptoms  of  subacute  inflammation  of 
the  left  knee-joint.  The  history  of  his  case  is  briefly  as  follows: 
A  little  over  two  years  previously,  while  doing  guard  duty  at 
the  "  Rip  Raps,"  he  fell  from  a  considerable  height,  striking 
the  outer  side  of  the  affected  knee  against  a  rock,  and  injuring 
it  very  severely.  He  was  admitted  into  hospital,  where  he 
remained  for  a  month  under  the  care  of  Asst.  Surgeon  Rodgers, 
(now  6th  Regular  Cavalry).  No  fracture  was  detected,  and  he 
was  ultimately  discharged  from  hospital  with  an  apparently 
sound  knee-joint.  Four  or  five  months  subsequent  to  his  being 
returned  to  duty,  he  detected  a  small  "  tumor"  over  the  upper 
and  anterior  surface  of  the  inner  condyle,  which,  he  states,  was 


268  REMOVAL  OF  CARTILAGE  FROM  KNEE-JOINT.  [Jan., 

about  the  size  of  a  small  bean.  It  was  immoveable,  tender 
when  manipulated,  but  did  not  impede  locomotion  or  prevent 
his  doing  duty.  About  three  months  afterwards,  while  on  the 
march  from  "  Deep  Creek"  to  Suffolk,  he  again  injured  the 
knee  by  attempting  to  jump  over  a  fallen  tree;  he  distinctly 
felt  something  "  snap"  in  the  joint,  and  was  so  lame  as  to  be 
unable  to  do  duty  for  a  week  afterwards.  When  he  came 
under  my  charge  the  tension  from  synovial  efTusion  was  so 
great  as  to  render  the  detection  of  the  intruder  for  a  time  im- 
possible. Absolute  rest,  combined  with  ordinary  antiphlogis- 
tic treatment,  however,  soon  caused  sufficient  reduction  of  the 
swelling  to  enable  me  to  detect  the  offending  body.  It  was 
then  situated  at  the  upper  and  outer  side  of  the  joint,  and 
seemed  to  be  about  the  size  of  an  ordinary  patella.  It  was 
exceedingly  moveable,  and  could  be  made  to  glide  from  one 
side  of  the  joint  to  the  other,  under  the  tendon  of  the  quadriceps 
extensor,  with  the  greatest  ease.  The  pain,  however,  produced 
by  even  the  gentlest  manipulation,  was  excruciating,  and 
accompanied  with  a  sensation  of  nausea  and  faintness.  After  a 
protracted  and  careful  preparatory  course  of  treatment,  I  re- 
moved the  "  cartilage,"  by  the  subcutaneous  operation,  from 
the  cavity  of  the  joint  to  a  position  external  to  the  capsule, 
sealing  up  the  puncture  made  by  the  tenetome  with  a  small 
patch  of  lint  dipped  in  collodian.  No  untoward  symptom  fol- 
lowed this  first  and  most  important  step  of  the  operation,  and 
at  the  expiration  of  eight  days,  I  removed  the  cartilage  by  a 
direct  incision.  The  integumentary  wound  healed  rapidly,  and 
the  subsequent  progress  of  the  case  was  as  satisfactory  as  could 
possibly  be  desired. 

Finnerty  was  soon  returned  to  duty  and  served  the  remain- 
ing year  of  his  enlistment  without  experiencing  the  slightest 
annoyance  from  his  knee,  even  after  the  most  protracted  exer- 
tion and  fatigue. 

The  cartilage,  when  extracted,  proved  to  be  of  very  unusual 
size;  it  was  of  an  irregularly  oval  outline,  convex  on  one  side, 
concave  on  the  other,  osseous  in  structure,  and  exceedingly 
rough  and  irregular  on  all  its  surfaces.  It  measured  one  and 
a  half  inches  in  its  longest,  and  one  and  one-quarter  inches  in 
shortest  diameter;  it  varied  from  one-half  to  one-quarter  of  an 


1866.]       REMOVAL  OP  CARTILAGE  PROM  KNEE-JOINT.  269 


inch  in  thickness,  and  weighed  seventy-two  grains.  Attached 
by  a  slender  pedicle  to  one  edge  was  another  and  smaller  con- 
cretion of  an  almost  similar  structure,  and  about  the  size  and 
shape  of  a  small  buckshot,  but  so  rough  and  irregular  as  to  be 
almost  jagged.  The  presence  of  this  smaller  body  was  not  de- 
tected till  after  the  operation. 

In  the  first  volume  of  the  "  Principles  of  Surgery,"  by  James 
Miller,  Professor  of  Surgery  in  the  University  of  Edinburg,  the 
author  suggested  an  operation  by  "  transfixion,^'  which,  theo- 
retically considered,  seemed  as  feasible  and  safe  as  it  was  in- 
genious. The  operation  was  based  on  the  idea  that  the  foreign 
body  might  be  permanently  secured  in  a  safe  part  by  trans- 
fixion with  one  or  more  needles,  which  were  allowed  to  remain 
"  till  sufficient  excitement  is  induced  for  fibrinous  exudation  of 
a  plastic  kind  along  the  track  of  the  needle,  and  thereby  the 
previously  moveable  substance  is  fixedly  incorporated  with  the 
parts." 

At  a  later  date  a  case  was  brought  before  the  Medico-Chirur- 
gical  Society  of  Edinburg,  by  Professor  Miller,  for  the  purpose 
of  making  a  recantation  of  this  principle  which  he  had  incul- 
cated iu  his  work  on  surgery.    It  was  briefly  as  follows: 

A  young  man  was  admitted,  March  7,  1854,  with  a  loose 
cartilage  in  his  knee-joint.  After  tlie  most  careful  preparatory 
treatment  two  needles  were  inserted  over  the  external  condyle, 
and  the  cartilage  was  transfixed — not,  however,  without  great 
difficulty. 

March  18th.  Needles  withdrawn,  having  been  inserted  for 
one  week;  no  unfavorable  symi)toms. 

March  24th.  The  cartilage  suddenly  slipped  away  from  its 
position;  it  was  again  seized  and  transfixed,  but  only  with  one 
needle. 

April  14th.  Needle  removed  and  patient  got  up. 

May  2.  The  cartilage  again  slipped  from  its  place  into  the 
cavity  of  tlic  joint  while  tlie  patient  was  pulling  on  his  boot. 

May  3.  Professor  Miller  again  transfixed  the  cartilage,  but, 
in  two  more  days  violent  inflamation  set  in,  and  the  unfortunate 
subject  on  which  this  theory  liad  for  the  first  time  been  re- 
duced to  practice  left  the  hospital  minus  his  leg. 


270 


CANCER  OP  THE  LEFT  CHEEK. 


[Jan. 


A  Case  of  Epithelial  Cancer  of  the  left  Cheek  and  the  adjacent 
portion  of  the  Lips.  Removal  of  the  entire  substance  of  the 
Cheek,  and  successful  closure  of  the  opening  by  a  Plastic  Opera- 
tion. By  J.  C.  Hutchison,  M.D  ,  Professor  of  Surgery,  Long 
Island  College  Hospital,  Surgeon  to  Brooklyn  City  Hospital, 
etc.    Reported  by  J.  C.  Goodridge,  Jr. 

Mary  Sullivan,  aged  54.  Born  in  Ireland,  at  present  residing 
at  No.  —  Baxter  street,  New  York,  applied  for  treatment 
April  1st,  1864.  She  stated  that  two  years  ago  she  pulled  out 
a  long  hair,  which  grew  from  the  centre  of  the  left  cheek,  when 
a  small  quantity  of  matter  exuded.  The  skin  soon  began  to 
ulcerate  at  this  point.  The  ulceration  gradually  increased  in 
size  until  it  extended  over  a  surface  measuring  two  inches  in 
its  transverse  by  two  inches  and  a  quarter  in  its  vertical 
diameters. 

She  had  been  accustomed  to  keep  her  face  tied  up  with  a 
handkerchief,  (to  conceal  its  deformity,)  in  consequence  of  which 
the  motions  of  the  lower  jaw  were  limited  from  contraction  of 
the  masseter  muscles.  Her  general  health  is  good;  she  suffers 
no  pain  from  the  diseased  part.  There  appears  to  be  no  hered- 
itary tendency  to  disease. 

On  the  6th  of  April  the  following  operation  was  performed, 
in  presence  of  the  Medical  Class  at  the  Long  Island  College 
Hospital. 

The  entire  diseased  portions  were  removed  by  an  incision 
circumscribing  it,  and  extending  entirely  through  the  soft  parts, 
making  an  opening  into  the  cavity  of  the  mouth,  two  and  a  half 
inches  on  both  vertical  and  transverse  diameters.  Several 
ligatures  were  required  to  control  the  hemorrhage. 

The  soft  parts  around  the  opening  were  detached  with  a 
scalpel  from  the  upper  and  lower  jaws,  and  a  T-shaped  incision 
above  and  an  l-shaped  incision  made  below  the  wound.  The 
vertical  portion  of  each  incision  was  about  three-fourths  of  an 
inch  in  length,  and  opened  into  the  circular  wound.  The  four 
flaps  thus  made  were  brought  together,  and  the  lips  drawn  back 
to  fill  the  triangular  space  that  remained.  The  parts  were 
fastened  by  the  hair-lip  suture. 

There  was  no  great  amount  of  tension  in  any  direction.  She 


1866.] 


CANCER  OP  THE  LEFT  CHEEK. 


271 


received  the  most  nourishing  diet  in  a  liquid  form.  Warm 
water  dressings  were  applied  to  the  wounds. 

April  8.  The  needles  were  drawn  out,  the  threads  remaining. 
On  the  following  day  the  threads  near  the  mouth  came  off. 

April  10.  Suppuration  took  place  at  the  junction  of  the  flaps, 
and  they  separated  in  about  two-thirds  of  their  extent. 

April  12.  The  flaps  were  brought  together  by  silver  wire 
sutures,  which  soon  sloughed  out.  The  flaps  Avere  then  kept 
approximated  by  adhesive  straps. 

She  had  an  attack  of  erysipelas  in  the  face  and  head  for 
about  five  days.  The  inflamed  parts  were  circumscribed  by 
tine,  iodide,  and  washed  with  lotio.  plumbi.  acetatin,  and 
quiniae  and  wine  given  her. 

From  that  she  gradually  improved  in  general  health,  and  the 
flaps  united  throughout  their  whole  extent,  with  the  exception 
of  a  space  two-thirds  of  an  inch  in  size  at  the  angle  of  the 
mouth.    She  was  discharged  from  the  hospital  May  12. 

Prof.  Hutchison  expected  to  close  the  opening  which  in- 
creased the  width  of  the  mouth  by  about  two-thirds  of  an  inch 
by  a  subsequent  operation;  but  when  next  seen,  after  four 
months  had  elapsed,  it  had  closed  spontaneously. 

Noio  there  are  no  marks  of  the  operation,  except  the  cica- 
trices that  partially  show  the  line  of  the  incisions. 

She  opens  her  mouth  without  difiiculty.  There  is  no  doubling 
of  saliva;  her  general  health  is  good,  and  she  expresses  great 
satisfaction  in  being  thus  relieved  of  her  unsightly  disease. 

A  microscopic  examination  of  the  excised  parts,  by  Dr.  S. 
Fleet  Spier,  showed  it  to  be  epitheliel  cancer. 

When  we  consider  the  obstacles  which  tended  to  prevent 
union  in  this  case,  viz.,  the  free  hemorrhage  requiring  the  ap- 
plication of  several  ligatures,  the  suppuration  and  separation 
of  the  flaps  after  the  removal  of  the  pin,  the  attack  of  ery- 
sipelas, the  second  separation  of  the  flaps,  after  being  drawn 
together,  by  silver  wire  sutures,  and  the  necessity  of  approxi- 
mating them  a  third  time  by  adhesive  straps  which  were  being 
constantly  loosened  by  her  food  and  discharges  from  tlie  mouth, 
the  result  of  the  operation  was  far  more  successful  than  could 
be  anticipated,  and  inspires  us  with  increased  confidence  and 
respect  for  th*^  "  Vis  Medicatrix  Naturee." 


272  PROCEEDINGS  OP  SOCIETIES.  [Jan., 

PROCEEDINGS  OF  SOCIETIES. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meting,  October  ith,  1865. 

Dr.  Alfred  TJndekhill,  First  Vice-President,  in  the  Chair. 

A  communication  from  the  Academy  of  Medicine  of  Barcelona  was 
read,  expressive  of  tlie  great  loss  sustained  by  the  medical  profession 
throughout  the  world  in  the  death  of  Dr.  Valentine  Mott. 

DISLOCATION  OF  THE  HEAD  OF  THE  FEMUR  INTO  THE  ISCHIATIC  NOTCH. 

Dr.  Sayre  presented  the  following  case: 

I  wish,  Mr.  President,  to  present  to  you  a  case  of  rather  unusual 
interest — a  case  of  spontaneous  luxation  of  the  femur  into  the  ischiatic 
notch,  of  eight  mouths'  standing,  reduced  by  manipulation,  and  sup- 
ported by  an  artificial  contrivance,  by  means  of  which  the  person  is 
enabled  to  walk.  It  is  the  case  of  Col.  Win.  A.  Bullitt,  aged  twenty- 
four,  of  the  3d  Kentucky  Infantry.  He  was  wounded  May  9,  1864, 
at  Rocky  Face  Ridge,  Georgia,  in  two  places — first  at  a  point  five 
inches  below  the  anterior  sup.  spine  of  the  ilium  of  the  left  side,  and 
directly  in  front ;  this  ball  did  not  emerge.  The  second  shot  passed 
through  the  right  chest  obliquely,  from  above  downwards  and  before 
backwards,  and  was  received  while  in  the  act  of  rising.  The  first 
brought  him  to  his  knees;  tlie  second  threw  him  violently,  rolling  him 
over.  He  arose  immediately  and  walked  half  a  mile  to  the  rear,  and 
was  then  carried  on  a  stretcher  some  distance  further,  when  he  met  a 
surgeon  who  examined  the  wound  in  the  right  side,  and,  considering 
it  mortal,  did  not  dress  it.  He  was  then  transported  five  miles  fur- 
ther to  the  hospital,  arriving  there  four  hours  after  having  been 
wounded.  Here  another  surgeon  saw  him,  and  administered  some 
morphine.  The  next  day  he  was  sent  to  Chattanooga,  arriving  there 
at  5  P.M.,  twenty-four  hours  after  the  receipt  of  his  wounds.  There  he 
was  attended  by  the  surgeon  in  charge,  and  his  wounds  dressed  for 
the  first  time.  On  the  9th  day,  May  18th,  erysipelas  commenced  at 
the  wound  in  the  chest,  and  rapidly  extended  over  the  whole  body 
resulting  in  numerous  abscesses  in  the  subcutaneous  cellular  tissue. 

On  the  5th  of  June  he  was  removed  to  Louisville.  The  erysipelas 
was  succeeded  by  dysentery,  which  was  again  succeeded  by  another 
attack  of  erysipelas,  which  extended  over  the  whole  Ijody.  Al)out 
the  1st  of  August  he  Ijcgan  to  suffer  pain  in  the  left  iliac  fossa,  which 
was  at  first  i)aroxysmal,  and  continued  a  month  before  the  abscess 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


273 


which  occasioned  it  was  discovered.  The  abscess  was  opened  above 
Poiipart's  ligament,  and  a  large  quantity  of  pus,  estimated  by  the 
surgeons  present  at  half  a  gallon,  evacuated.  When  the  pain  com- 
menced, for  the  purpose  of  relieving  it  he  gradually  drew  up  his  knee, 
at  first  only  during  the  paroxysm,  which  came  on  about  5  p.m.  every 
day;  afterwards  he  kept  the  knee  closely  approximated  to  the  chest, 
and  the  attempt  to  straighten  it  caused  severe  pain.  The  abscess  con- 
tinued to  discharge  for  three  months.  About  the  20th  of  October 
he  began  to  lie  over  on  his  right  side,  (previous  to  this,  since  the 
formation  of  the  abscess,  he  had  lain  constantly  upon  his  back,)  and 
shortly  after,  upon  turning  over  from  his  back  to  his  side,  he  felt  the 
head  of  the  femur  slip  from  its  place,  causing  an  excruciating  pain. 
This  occurred  almost  daily  for  two  weeks,  and  the  attention  cf  the 
attending  surgeon  was  drawn  to  it.  About  the  1st  of  November  a 
protuberance  under  the  gluteal  muscles  was  noticed  by  the  patient,  and 
the  attention  of  the  surgeon  having  again  been  called  to  it,  he  recog- 
nized a  dislocation.  A  few  days  after,  Col.  Coolidge,  Medical  In- 
spector U.  S.  A.,  Dr.  Goldsmith,  TJ.  S.  A.,  Dr.  McDermott  and  several 
other  gentlemen  attempted  reduction,  with  the  aid  of  ether.  Their 
efforts  were  not  successful.    About  this  time  the  abscess  closed. 

In  the  latter  part  of  February,  1865,  four  months  after  dislocation, 
another  attempt  to  reduce  it  was  made  by  Prof.  Cook,  Dr.  Foree,  Dr. 
Cox,  Dr.  Gait,  and  Dr.  Garvin,  all  of  Louisville,  which  was  also  un- 
successful. A  few  weeks  after  he  got  out  of  bed  and  began  to  move 
about  on  crutches.  He  then  consulted  Prof  Miller  and  Dr.  Bullitt, 
of  Louisville,  who  advised  him  to  come  to  New  York  and  place  him- 
self under  my  care.  He  arrived  in  New  York  the  24  th  of  May,  and 
by  the  kindness  of  Col.  Sloan  was  accommodated  at  the  Central  Park 
Hospital.  I  saw  him  in  June,  and  found  him  in  the  following  condi- 
tion: his  general  health  was  good,  and  he  was  able  to  go  about  on 
crutches  very  well.  His  left  thigh  was  flexed  at  nearly  a  right  angle 
with  the  pelvis,  and  strongly  adducted  across  the  right  thigh  about 
the  junction  of  the  middle  and  upper  third.  The  leg  was  flexed  upon 
the  thigh  at  about  a  right  angle.  As  he  lay  upon  his  back  a  plumb- 
line  dropped  from  the  left  knee  fell  four  inches  from  the  outer  side  of 
the  riglit  thigh.  The  genital  organs  were  very  much. compressed,  and 
the  difliculty  of  urinating  was  a  very  serious  annoyance.  The  whole 
limb  was  much  colder  than  the  other,  bathed  with  perspiration,  and 
very  much  shrunken  in  size.  There  was  some  slight  perceptible  motioa 
of  the  hip,  and  only  slight  extension  at  the  knee,  even  by  considerable 
force,  which  was  always  attended  by  great  pain. 

Vol.  II.— No.  10.         18  ' 


274 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


Reduced  on  the  20th  of  June,  1865,  eight  months  after  disloca- 
tion. 

The  patient  was  placed  thoroughly  under  the  influence  of  chloro- 
form. Four  or  five  blankets  were  spread  upon  the  floor  as  a  solid 
basis  on  which  to  work.  Removing  my  boots,  and  placing  my  heels 
on  the  crest  of  each  ilium  for  the  purpose  of  fixing  the  pelvis,  I  suc- 
ceeded in  giving  mobihty  to  the  hip;  and  placing  my  finger  liigli  up 
in  the  rectum,  I  discovered  the  head  of  the  bone  moving  in  the  ischi- 
atic  notch.  This,  of  course,  settled  its  location.  Reduction  from  that 
position,  by  extension  across  the  pelvis,  was  out  of  the  question,  and 
reduction  by  manipulation,  according  to  Reid's  method,  was  interfered 
with  very  seriously  by  long  continued  contraction  of  the  adductor 
muscles,  and  at  the  same  time  adhesions  had  occurred  suljsequent  to 
the  extensive  suppuration  which  had  taken  place.  Whether  I  could 
succeed  in  reducing  it  was  questionable.  I  told  this  to  the  gentlemen 
present;  but  we  all  regarded  it  as  a  case  worthy  of  the  attempt.  If  I 
were  to  succeed,  very  well;  if  not,  I  should  leave  him  for  several 
weeks,  until  all  traces  of  inflammation,  which  would  result  from  such 
violence,  should  have  subsided,  and  then  make  subcutaneous  section  of 
the  tendons  of  the  contracted  muscles,  and  in  time  restore  the  limb  to 
parallelism  with  the  other,  leaving  the  head  of  the  bone  in  its  abnor- 
mal location.  Drs.  Sloan  and  Hamilton  agreed  to  this  plan  of  pro- 
cedure. The  patient  having  been  very  satisfactorily  anesthetized  by 
Dr.  Bradford,  I  succeeded,  after  considerable  effort,  in  restoring  the 
thigh  to  its  normal  position,  after  the  method  so  well  described  by  Dr. 
Reid,  of  Rochester.  The  thighs  were  now  parallel,  but  the  flexion  of 
the  leg  upon  the  thigh  by  the  contraction  of  the  hamstring  muscles  we 
were  not  able  to  overcome.  I  could  not  straighten  the  leg  thoroughly 
and  completely;  but  the  fact  that  it  became  very  much  nearer  straight 
than  it  was  before  induced  me  to  resort  to  a  continued  extension  by 
means  of  a  weight  and  pulley. 

He  was  placed  on  the  bed,  and  adhesive  plaster  applied  below  the 
knee  in  order  to  extend  the  leg.  Extension  was  also  made  by  adhe- 
sive plaster  on  the  thigh,  at  an  angle  four  or  five  degrees  higher. 
Another  weight  and  pulley  was  now  applied  to  a  band  surrounding 
the  knee,  in  such  a  manner  as  to  antagonize  the  adductors  of  the 
thigh.  The  foot  of  the  bed  being  raised  a  few  inches,  the  weight  of 
his  body  became  a  counter-extending  force.  The  hip  was  now  kept 
constantly  wet  hy  means  of  an  irrigating  apparatus.  The  first  two 
nights,  morphine  in  considerable  (|uantity  was  administered.  He  had 
no  constitutional  disturbance,  his  health  being  perfectly  good;  you 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


275 


scarcely  would  have  observed  that  any  serious  operation  had  been 
performed,  though  the  operation  was,  of  course,  one  of  great  severity. 

His  leg  came  down,  not  only  to  the  length  of  the  other,  but  when 
his  knee  was  extended  perfectly  straight  it  was  a  trifle  longer;  but 
upon  his  getting  up  to  bear  his  weight  upon  it,  it  immediately  receded, 
and  became  some  inches  shorter  than  the  other,  there  being  no  ace- 
tabulum for  the  head  to  rest  in.  Eight  months  having  elapsed  since 
the  dislocation,  the  acetabulum  had  become  obliterated  in  a  great 
measure  by  inflammatory  deposits.  The  trochanter  major  of  the 
luxated  side  was  some  lines  further  from  the  centre  of  the  pubis  than 
the  other,  showing  that  the  head  of  the  bone,  although  opposite  the 
acetabulum,  was  not  in  it. 

In  order  to  overcome  this,  and  to  permit  the  patient  to  have  the 
advantage  of  out-door  exercise,  I  first  took  a  plaster  cast  of  his  hip  and 
thigh,  in  the  improved  position.  The  object  of  taking  this  cast  was, 
by  it  to  construct  such  an  instrument  as  would  enable  him  to  bear  his 
weight  upon  the  limb  without  permitting  the  head  of  the  femur  to  ride 
by  the  acetabulum. 

This  instrument  consists  of  a  crutch  which  goes  under  the  perineum 
and  around  the  gluteo-femoral  fold,  accurately  moulded  on  and  embra- 
cing the  buttock.  This  crutch  is  stuffed  and  padded,  and  forms  an  easy 
seat.  Directly  opposite  the  tuberosity  of  the  ischium  is  a  socket-joint, 
and  from  it  emerges  a  steel  splint,  or  rod,  capable  of  being  extended 
or  shortened,  which  terminates  opposite  the  calf  of  the  leg,  in  a  fork. 
Each  prong  of  the  fork  is  continued  down  and  around  the  leg,  termi- 
nating opposite  the  ankle-joint,  on  each  side,  in  a  little  ball  or  knob. 
A  neatly  fitting,  comfortable  shoe,  which  he  now  wears,  was  then 
made  with  a  thick  buckskin  tongue,  to  prevent  injurious  pressure  of 
the  shoe-laces.  On  the  sole,  or  rather  in  the  shank  of  the  shoe,  is 
bolted  a  steel-plate,  with  rods  running  up  each  side  and  terminating 
opposite  the  ankle-joint,  in  two  little  cups,  destined  to  receive  the  balls 
of  the  splint. 

This  instrument  was  applied  in  the  following  manner:  The  shoe  was 
put  on  and  laced  up,  the  cratch  then  inserted  under  the  perineum  and 
tuber  ischii,  and  buckled  around  the  thigh  by  straps  provided  for  the 
purpose.  The  prongs  of  the  fork  wore  then  placed  in  the  sockets,  and 
extension  made  by  means  of  the  ratchet  and  key.  A  knee-cap  was 
then  buckled  on,  bringing  the  knee  back  towards  the  splint.  With 
this  apparatus  his  thigh  can  be  extended  to  the  length  of  its  fellow, 
and  he  is  enabled  to  stand  with  comfort,  to  bear  his  weight  on  the 
limb,  and  to  walk  tolerably  well.    This  was  put  on  twenty-nine  days 


j 


276  PROCEEDINGS  OP  SOCIETIES.  [Jan.,  I 

i 

after  the  operation,  and  for  two  or  three  days  he  walked  aboat  easily,  1 
and  it  was  almost  impossible  to  persuade  him  to  go  to  bed.  i 
He  unfortunately  had  from  this  time,  on  account  of  the  shoe  being  1 
too  tight,  an  inflammation  of  the  toe-nail,  which  eventually  required  < 
its  entire  removal.  About  this  time  he  was  removed  to  David's 
Island,  the  Central  Park  Hospital  being  closed  up  by  orders  from 
Washington. 

He  was  confined  to  bed  for  a  week  or  two  after  this  operation,  but 
has  now  recovered  entirely  from  it,  and  intends  leaving  for  Kentucky 
immediately.  He  is  able  at  this  time  to  cross  his  legs,  is  increasing  the 
mobility  of  his  limb,  and  can  put  his  leg  up  a  step  to  go  up  stairs. 

I  would  state,  Mr.  President,  that  I  looked  over  Gross's  Surgery, 
and  find  that  he  gives  three  months  as  the  longest  period  at  the  end  i 
of  which  an  attempt  at  reduction  of  the  humerus  would  be  justifiable,  i 
and  eight  weeks  for  the  femur.    He  also  lays  great  stress  upon  the  j 
immense  importance,  the  absolute  necessity,  in  fact,  as  he  states  it,  of 
a  course  of  preparatory  treatment  before  attempting  the  reduction  of  j 
an  ancient  dislocation — that  it  is  only  in  persons  of  lax  fibre,  and  iu  j 
old  patients,  that  it  should  be  attempted  at  all.    Now,  in  very  old  i 
persons  there  would  be  great  danger  of  producing  a  fracture  instead  i 
of  a  reduction.    He  says  the  system  from  the  first  must  be  prepared 
by  bleeding,  which  is  to  be  frequently  repeated,  and  by  the  constant  '■ 
use  of  mercury  to  the  point  of  ptyalism;  that  low  diet  should  be  used,  I 
movements  of  the  limb  every  day,  once  in  twenty-four  hours  at  first,  ! 
for  a  fortnight,  and  afterwards  once  in  twelve  hours.    I  do  not  know 
that  this  is  the  proper  time  and  place  to  discuss  this  question,  but  I  | 
may  state  that  in  this  particular  instance  I  adopted  the  plan  which  I  | 
have  always  adopted  since  I  have  been  engaged  in  the  practice  of  ] 
surgery:  to  consider  the  patient  best  prepared  for  an  operation  just  as  j 
soon  as  the  operation  becomes  necessary,  or  is  discovered  to  be  neces-  j 
sary.    I  believe  the  preparing  of  a  patient  for  an  operation,  by  any 
kind  of  treatment,  to  be  attended  by  so  much  anxiety  on  his  part  as  ; 
to  more  than  negative  any  benefit  which  the  preparation  might  in 
other  respects  confer.    The  anxiety  incident  to  the  knowledge  that  he 
is  being  prepared  for  a  great  and  critical  operation  must  necessarily  j 
be  wearing  upon  the  system.    In  the  case  before  you  there  was  no  j 
preparation  made,  except  simply  diagnosticating  the  case;  and  my 
position  is,  that  the  best  time  to  perform  such  an  operation  is  when  i 
you  find  it  is  necessary  to  be  done.  ' 

Dr.  Buck — It  was  not  by  violence  that  this  dislocation  took  place;  | 
and  there  was  a  gradual  process  resulting  from  the  peculiar  position  ' 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


277 


which  the  limb  had  then  occupied  for  a  long  time,  by  which  pressure 
was  exerted  upon  the  capsular  ligament  in  the  direction  in  which  the 
bone  escaped  from  its  socket,  the  capsule  having  become  relaxed  and 
extended.  Such  an  occurrence  has  taken  place,  and  I  recall  one  in- 
stance which  comes  directly  to  my  mind,  where  it  resulted  to  a  patient 
long  confined  to  the  bed  from  some  cause — gradual  relaxation  of  the 
capsular  ligament  in  the  direction  in  which  the  bone  escaped;  so  that 
in  this  dislocation  the  head  of  the  bone  had  been  displaced  from  its 
socket,  but  had  not  escaped  from  the  capsular  ligament;  and  I  don't 
think  we  are  warranted  in  deciding  that  in  a  dislocation  occurring 
from  violence,  in  which  a  rent  is  made  in  the  capsule  and  the  head- 
escapes,  that  reduction  is  possible  after  so  long  an  interval.  I  conceive 
that  one  great  obstacle  to  replacement  would  be  the  impossibility  of 
returning  the  head  of  the  bone  through  this  rent,  which  this  long 
interval  h  d  closed  up.  The  head  of  the  bone  might  be  brought  to 
correspond  with  the  acetabulum — might  be  brought,  by  the  applica- 
tion of  sufficient  force,  from  its  abnormal  position;  but  the  interposi- 
tion of  the  capsular  ligament  would  then  be  found  to  be  the  great 
obstacle  to  be  overcome  in  effecting  the  replacement.  The  case  is  a 
very  interesting  one,  sir,  but  I  do  not  know  whether  or  not  I  am  pre- 
pared to  agree  with  Dr.  Sayre  in  his  conclusion  in  regard  to  the  ace- 
tabulum being  filled  by  deposit  within  that  period  of  time.  That  is  a 
point  which  I  should  not  consider  as  demonstrated. 

Dr.  Sayre — It  can  not  be  demonstrated  till  the  person  dies,  and  we 
know  by  positive  examination. 

Dr.  Buck. — It  is  a  question  which  is  certainly  open  for  discussion. 
I  would  remark  that  a  case  has  occurred  in  this  city,  within  a  recent 
period,  in  which  a  congenital  dislocation  of  the  femur  has  been  reduced 
after  a  period  of,  I  think,  several  years.  It  was  somewhat  analogous 
to  this  in  the  fact  that  the  head  of  the  bone  had  not  escaped  from  the 
capsule,  though  dislocated  from  the  acetaliulum.  The  cure  was  effected 
by  a  i)rocess  of  gradual  extension,  in  the  hands  of  Dr.  Davis  of  this 
city. 

Dr.  Sayre. — I  would  like  to  ask  if  a  congenital  dislocation  has 
ever  occurred;  I  don't  mean  at  the  time  of  birth  by  the  doctor's  man- 
ipulations— I  mean  a  congenital  dislocation  occurring  in  utero  1 

Dr.  Buck. — ^That  was  not  my  meaning;  I  meant  existing  very  early 
in  infancy. 

Dr.  Savre. — That  is  what  I  mean,  too;  and  we  ought  to  understand 
definitely  about  this  congenital  dislocation  of  the  femur.  We  all  know 
the  formation  of  the  femur  and  the  construction  of  the  acetabulum, 


278 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


being  made  of  the  three  distinct  bones  which  in  early  life  are  not 
united;  at  a  certain  stage  of  development  there  is  au  arrest,  and  this 
arrest  of  development  prevents  the  formation  of  the  acetabulum;  we 
ought  not  to  call  that  a  congenital  displacement  or  a  congenital  luxa- 
tion. You  must  have  an  acetabulum  in  which  the  head  is  fitted  in 
order  to  luxate  it.  I  do  not  believe  that  any  gymnastic  exercise  of  a 
child  in  utero  can  be  carried  to  such  an  extent  as  to  displace  a  healthy 
femur  from  a  completely  finished  acetabulum;  and,  therefore,  this 
whole  subject  of  congenital  dislocations  should  be  looked  at  in  an 
entirely  new  light. 

Dr.  Krackowizer. — I  rise,  Mr.  President,  simply  to  speak  of  a  case  of 
spontaneous  luxation  of  the  femur,  which  reduction  I  effected  after 
about  five  months  had  elapsed.  The  subject  of  this  accident  was  a 
girl  about  sixteen  or  seventeen  years  of  age.  Early  in  April  she  was 
attacked  with  articular  rheumatism  invading  several  joints,  upon  her 
recovery  from  which  the  right  thigh  was  found  to  be  very  much  out 
of  the  usual  place,  and  it  was  impossible  to  move  it.  I  saw  her  in 
October  following,  and  as  I  did  not  think  manipulation  would  be  suf- 
ficient to  reduce  the  head,  I  resorted  to  the  usual  contrivances  for 
fixing  the  pelvis,  and  counter-extension  and  extension;  but,  although 
I  heard  and  all  heard  the  crackling  and  giving  way  of  adhesions,  yet 
the  head  was  not  returned.  I  should  mention  that  I  used  no  pulleys — 
had  the  assistance  of  nothing  but  the  hands  of  attendants.  After 
this  method  had  failed,  I  resorted  to  Fisher's  or  Gross's  method,  and, 
not  with  a  clear  snap,  but  with  a  sort  of  concussion,  which  could  be 
distinctly  heard,  the  head  returned  to  its  natural  place.  At  that 
time  I  was  not  familiar  with  the  method  of  elastic  extension,  which  is 
so  valuable  in  treating  displacements  of  joints,  but  merely  held  both 
legs  in  the  usual  manner  together,  and  in  two  or  three  weeks  the  girl 
could  rise  and  walk  about.  Whether  in  this  case  the  luxation  occurred 
suddenly,  or  by  degrees,  can  not  be  determined.  The  observation  of 
the  patient  and  attendants  is,  I  think,  entitled  to  great  weight  in  de- 
ciding this  question.  In  most  cases  of  spontaneous  luxation  that  I 
remember  to  have  heard  described,  the  dislocation  occurred  suddenly, 
a  fact  which  would  weigh  in  favor  of  the  idea  that  spontaneous  luxa- 
tions are  not  materially  different  from  rheumatic  ones.  The  theory 
that  luxation  occurs  in  consequence  of  the  capsule  being  very  much 
dilated,  and  the  head  slipping  out  of  the  socket,  and  yet  being 
within  the  capsule,  is,  in  my  opinion,  very  largely  a  speculative  one. 
I  think  the  same  difficulties  are  in  the  way  in  the  reduction  of  a  spon- 
taneous as  a  traumatic  luxation,  with,  perhaps,  this  difference :  if  a  rent 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


279 


in  the  ca])sulp  lias  been  a  more  or  less  surrounded  one,  the  probability- 
is  that  the  head  of  the  femur,  having  worked  against  a  certain  point 
of  the  capsule,  has  produced  a  sort  of  laceration,  so  that  the  head 
slips  out  of  the  hole,  which  then  can  not  contract  so  fast  as  a  slit  pro- 
duced in  a  traumatic  luxation;  and,  through  a  larger  loss  of  sulistauce, 
a  longer  time  is  required  to  reduce  the  luxated  head  than  if  it  had 
slipped  out  through  a  laceration  in  the  capsule. 

Dr.  Post. — During  the  past  week  I  had  occasion  to  reduce  a  dis- 
location of  the  shoulder-joint,  a  case  which  is  somewhat  remarkable 
from  its  great  antiquity,  and  for  its  being  reduced  without  the  aid  of 
instruments.  The  patient  was  a  laboring  man,  upwards  of  forty  years  of 
age,  who,  in  the  beginning  of  last  May,  fell  and  dislocated  his  shoul- 
der, the  head  of  the  bone  being  thrown  under  the  pectoral  muscle. 
He  was  told,  at  one  of  the  dispensaries,  that  it  was  only  a  sprain,  and 
the  physician  who  had  him  in  charge  told  him  he  could  do  nothing 
more  for  him,  and  no  further  treatment  was  adopted  until  he  applied 
to  me  last  week.  I  found  unequivocal  signs  of  the  location  of  the 
head  of  the  bone  under  the  pectoral  muscle.  I  made  the  attempt  to 
reduce  the  dislocation  without  much  expectation  of  success,  not  being 
provided  witli  instruments  at  the  time.  The  patient  was  first  placed 
upon  a  bed  and  brought  under  the  influence  of  ether  to  a  state  of  anajs- 
thesia.  I  made  an  extension  and  a  counter-extension,  and  afterwai'ds 
had  two  persons  employed  in  making  an  extension,  and  two  in  making 
a  counter-extension.  These  were  kept  up,  I  think,  a  little  more  than 
half  an  hour,  during  which  time  I  made  frequent  manipulations  with- 
out success.  At  the  end  of  that  time,  I  directed  the  extending  and 
counter-extending  forces  to  be  suddenly  suspended,  when  with  slight 
manipulation  the  reduction  was  readily  effected. 

The  time  that  elapsed  from  the  dislocation  to  the  reduction  was  141 
days;  and  I  am  not  aware  that  there  is  any  other  instance  where  the 
dislocation  of  a  shoulder  has  been  reduced  after  so  long  an  interval 
without  the  aid  of  mechanical  contrivances. 

Dr.  Savre.— I  would  simply  state,  in  regard  to  the  luxation  in  the 
ischiatic  notch,  and  in  confirmation  of  the  views  of  Dr.  Krakowizer, 
that  the  head  of  the  bone  would  drive  through  the  capsule,  and  there- 
fore a  rent  have  occurred,  from  the  fact  that  the  head  of  the  bone 
was  distinctly  detected  by  Dr.  Hamilton,  myself  and  others;  and  it  is 
impossible  to  place  the  head  of  the  bone  in  that  position  without  rup- 
turing the  capsule.  I  think  that  has  been  proven  by  Dr.  Bigelovv,  of 
Boston,  beyond  the  possibility  of  a  question.  In  taking  the  dead  sub- 
ject, as  I  have  frequently  done,  and  luxating  the  limb  in  different  posi- 


280 


PROCEEDINGS  OP  SOCIETIES. 


[Jan., 


tions  and  dissecting  it  afterwards,  it  will  be  found  that  yon  can  luxate 
the  limbs  upon  the  dorsum  of  the  ilium,  upon  the  pubes,  and  in  the 
femoral  ring,  without  tearing  the  capsule;  but,  so  far  as  I  have  tried, 
and  Dr,  Bigelow  confirms  the  opinion,  you  can  not  luxate  the  head  of 
the  femur  into  the  ischiatic  notch  without  tearing  the  capsule,  although 
the  other  luxations  may  occur  without  it.  And  the  fact  that  this 
bone  was  distinctly  felt  by  Drs.  Hamilton,  Sloan  and  myself,  in  the 
ischiatic  notch,  is  an  evidence  that  the  capsule  in  this  particular  case 
was  ruptured — I  suppose  by  laceration  from  constant  pressure. 

GUN-SHOT  FRACTURES  OF  THE  THIGH. 

Dr.  Post,  by  request,  read  the  following  abstract  of  a  report,  pre- 
pared for  the  information  of  the  Sanitary  Commission,  on  the  subject 
of  gun-shot  fractures  of  the  thigh. 

Gun-shot  fractures  of  the  thigh  involve  several  important  practical 
questions,  with  reference  to  their  prognosis  and  their  treatment. 
Many  of  these  injuries  are  complicated  with  lesions  of  important  blood- 
Tcssels  leading  to  the  speedy  death  of  the  patient  from  hemorrhage, 
on  inducing  gangrene  of  the  limb,  followed  by  a  fatal  result  within  a 
few  days  after  the  injury.  In  other  cases,  the  ball,  in  its  passage 
through  the  limb,  comes  into  contact  with  one  of  the  principal  arteries, 
contusing  its  coats,  and  causing  it  to  slough  within  one  to  three  weeks 
after  the  injury,  giving  rise  to  secondary  hemorrhage,  which  often  ter- 
minates the  life  of  the  patient. 

In  many  cases,  the  bone  is  greatly  comminuted,  and  the  fragments 
are  driven  with  great  force  into  the  adjacent  tissues,  giving  rise  to  ex- 
cessive and  exhausting  suppuration,  proving  fatal  to  the  patient  by  the 
long  continued  drain  upon  the  vital  powers,  or  terminating  life  more 
speedily  by  inducing  pyaemia.  When  the  injury  involves  either  of  the 
articular  extremities  of  the  bone,  communicating  with  the  hip  or  knee- 
joint,  the  inflammation  which  follows  is  more  severe  and  the  suppura- 
tion more  profuse,  there  is  a  greater  degree  of  constitutional  irritation, 
and  the  prognosis  is  more  unfavorable  than  when  the  fracture  is  con- 
fi;ned  within  the  limits  of  the  shaft  of  the  bone. 

When  gun-shot  fractures  of  the  thigh  occur  in  battle,  and  it  becomes 
necessary  to  transport  the  patient  to  a  considerable  distance,  especially 
over  rough  roads  and  with  imperfect  facilities  for  transportation,  the 
danger  of  the  case  is  greatly  aggravated.  The  danger  is  also  much 
increased,  when  it  becomes  necessary  to  crowd  a  large  number  of 
wounded  persons  in  narrow  or  ill  ventilated  apartments.  The  want  of 
proper  food  and  medicines,  and  of  comfortable  beds  and  bedding,  and 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


281 


of  suitable  dressings  for  the  wounds,  and  of  supports  for  the  fractured 
limbs,  increases  the  fatal  tendency  of  the  injury.  Dr.  Crosby,  of  Co- 
lumbia College  Hospital,  in  Washington,  informed  me  that  numerous 
cases  of  gun-shot  fraCture  of  the  thigh  had  been  brought  to  that  hos- 
pital after  the  second  battle  of  Bull  Run,  and  after  the  battle  of  An- 
tietara.  The  patients  had  remained  long  on  the  battle-field  without 
nourishment.  They  had  exhausting  suppuration,  and,  with  a  solitary 
exception,  they  all  died. 

The  want  of  good  nursing  is  also  a  very  serious  evil,  and  greatly  di- 
minishes the  chances  of  recovery.  Another  evil  of  serious  importance 
and  of  very  frequent  occurrence  in  armies,  is  the  want  of  proper  skill 
and  experience  on  the  part  of  the  attending  surgeon. 

From  one  or  more  of  these  causes,  gun-shot  fractures  of  the  thigh 
often  prove  destructive  to  life,  in  some  cases  very  speedily  after  the  in- 
fliction of  the  injury,  and  in  other  cases  at  a  more  protracted  period. 
In  cases  in  which  the  life  of  the  patient  is  not  sacrificed  his  health  is 
often  undermined  in  consequence  of  long  continued  suppuration,  of  pri- 
vation of  active  exercise,  and  of  other  depressing  agencies  which  occur 
in  connection  with  the  injury.  And  even  where  the  fractured  bone  has 
become  reunited,  and  the  accompanying  wound  has  perfectly  healed, 
and  the  patient  has  regained  a  good  degree  of  health,  the  limb  is  often 
so  deformed,  being  shortened,  bent,  or  twisted,  that  it  is  comparatively 
useless  to  the  patient  as  an  organ  of  support  or  locomotion.  Indeed, 
the  limb  is  often  deformed  to  such  a  degree  as  to  be  an  absolute  incum- 
brance to  the  patient,  and  he  looks  forward  with  satisfaction  to  the 
relief  which  can  only  be  afforded  by  the  amputation  of  the  offending 
member.  Independently  of  the  shortening,  bending  or  twisting  of  the 
bone,  the  muscles  often  become  so  wasted  and  agglutinated  together 
by  the  destruction  of  the  cellular  tissue,  in  consequence  of  long  contin- 
ued suppuration,  that  the  limb  is  of  little  or  any  service  to  the  patient. 
But,  on  the  other  hand,  there  are  some  cases  in  which  the  life  of  the 
patient  is  preserved,  the  constitutional  vigor  is  unimpaired,  and  the 
limb  is  sound  and  strong  and  capable  of  performing  its  functions  in  a 
satisfactory  manner. 

In  every  case  of  gun-shot  fracture  of  the  thigh,  the  first  question 
which  presents  itself  to  the  surgeon  who  has  charge  of  the  patient  is, 
whether  an  attempt  shall  be  made  to  save  the  limb,  or  whether  it  shall 
be  amputated.  There  are  several  important  circumstances  to  be  taken 
into  consideration  in  answering  this  question.  In  the  first  place,  is  the 
injury  of  such  a  nature  as  to  expose  the  life  of  the  patient  to  very  im- 
minent danger,  rendering  his  recovery  almost  hopeless  without  removal 


282 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


of  the  limb  ?  In  the  second  place,  would  the  amputation  of  the  limb 
afford  a  reasonable  prospect  of  saving  the  life  of  the  patient  ?  In  the 
third  place,  would  the  limb,  if  saved,  be  of  sufiBeient  utility  to  the  pa- 
tient to  justify  the  exposure  of  his  life  to  any  great  additional  hazard 
in  the  attempt  to  preserve  it  ?  Each  of  these  three  questions  may  be 
answered  affirmatively  in  some  cases,  and  negatively  in  others.  In 
each  individual  case,  the  surgeon  should  aim  at  a  correct  solution  of 
each  of  these  questions,  under  the  circumstances  in  which  he  is  placed. 
I  will  endeavor  to  lay  down  certain  rules,  which,  in  my  opinion,  will  be 
useful  in  solving  the  question  of  amputation. 

I.  When  an  army  is  engaged  in  active  military  operations  in 
an  enemy's  country,  and  at  a  great  distance  from  its  base,  or 
when  it  has  cut  loose  altogether  from  its  base,  as  in  Sherman's 
great  march  across  Georgia  and  the  Carolinas,  almost  every  case  of 
gun-shot  fractured  thigh  should  be  submitted  to  amputation,  as  the 
transportation  of  the  patient  with  his  fractured  limb  would  be  an  oc- 
casion of  extreme  and  protracted  suffering,  and  would  deprive  him 
almost  entirely  of  any  chance  of  recovery  which  he  might  otherwise 
enjoy.  Of  course,  numerous  exceptions  to  this  rule  may  occur,  where 
the  inhabitants  of  the  country  are  humanely  disposed,  and  where  the 
patient  may  safely  be  placed  under  their  charge.  There  is  no  great 
danger  in  transporting  a  patient  for  many  successive  days  after  ampu- 
tation of  his  thigh,  if  the  stump  be  properly  supported  and  the  trans- 
portation be  not  too  rudely  effected.  Indeed,  patients  often  do  better 
under  these  circumstances  than  when  they  are  crowded  together  in 
large  hospitals,  where  they  enjoy  entire  rest,  but  where,  at  the  same 
time,  they  breathe  a  more  or  less  infected  atmosphere.  I  conversed 
on  this  subject  with  Dr.  Thomas  J.  Watson,  surgeon  of  the  32d  Mis- 
souri Volunteers,  who  had  been  nearly  four  years  in  the  service,  and 
who  was  attached  to  Sherman's  army  in  its  long  march  through  Geor- 
gia and  the  Carolinas.  During  this  march,  amputation  was  performed 
iu  nearly  all  cases  of  gun-shot  fractures,  both  of  the  upper  and  lower 
extremities.  The  amputated  cases  did  better  during  transportation 
than  iu  hospitals.  Near  Macon,  seven  primary  amputations  were  per- 
formed for  gun-shot  fractures,  and  six  of  them  recovered. 

II.  Amputation  should  be  performed  in  nearly  all  cases  of  gun-shot 
fracture  of  the  thigh  in  which  the  femoral  or  popliteal  vessels  are 
wounded.  When  the  injury  is  so  high  up  as  to  admit  of  amputation 
only  at  the  hip-joint,  there  may  be  a  question  as  to  the  expediency  of 
the  operation,  as  primary  amputation  at  the  hip-joint  is  almost  inevit- 
ably fatal. 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


283 


III.  Amputation  should  be  performed  iu  all  cases  of  gun-shot  frac- 
ture of  the  thigh  in  which  the  ball  has  passed  fairly  through  or  into 
the  knee-joint,  or  in  which  the  bone  has  been  comminuted  at  its  infe- 
rior articular  extremity.  When  the  joint  has  been  but  slightly  ex- 
posed on  one  of  its  lateral  surfaces,  and  the  fracture  involves  only  the 
superficial  part  of  the  external  or  internal  condyle,  an  attempt  may 
be  made  to  save  the  limb,  although,  even  under  these  circumstances, 
the  issue  of  such  an  attempt  is  extremely  doubtful. 

IV.  Amputation  should  be  performed  iu  all  cases  of  gun-shot 
fracture  of  the  thigh  below  the  junction  of  its  middle  and  upper 
third,  when  the  bone  is  extremely  comminuted  over  a  space  of  four 
inches  or  more  of  its  length.  When  a  comminuted  fracture  is  very 
near  the  upper  extremity  of  the  bone,  there  is  reason  for  more  hesita- 
tion as  to  the  amputation  of  the  limb,  as  the  operation  at  the  hip-joint, 
or  in  its  immediate  vicinity,  is  followed  by  a  speedily  fatal  result  in  so 
large  a  proportion  of  cases. 

Y.  Amputation  should  be  performed  in  all  cases  in  which  the 
injury  is  inflicted  by  a  cannon  ball,  or  a  large  fragment  of  shell,  and 
in  which  the  soft  parts  are  so  disorganized  that  they  must  necessarily 
lose  their  vitality.  If,  however,  the  shock  of  the  injury  occasion 
extreme  depression  of  the  vital  powers,  from  which  the  patient  does 
not  rally,  it  is  better  to  let  him  die  in  peace  than  to  hasten  his  death 
by  the  performance  of  an  operation  which  he  has  not  strength  to 
endure. 

When  an  attempt  is  made  to  save  the  fractured  limb,  great  care 
should  be  taken  to  avoid  all  needless  sources  of  irritation,  to  keep  the 
limb  in  an  extended  position,  and  to  give  it  such  mechanical  support 
as  will  prevent  the  soft  parts  from  being  penetrated  by  the  sharp 
fragments  of  the  bone.  It  is  especially  important  that  the  limb  should 
be  well  supported  during  transportation;  and  the  preservation  of  the 
life  or  limb  of  the  patient  will  depend  on  the  attention  which  is  paid 
to  this  circumstance. 

At  an  early  period  after  the  injury  the  wound  should  be  carefully 
examined  by  the  introduction  of  a  finger,  and  any  loose  fragments  of 
bone  which  maybe  detected  should  be  extracted;  when  it  is  neces- 
sary, the  wound  may  be  enlarged  for  this  purpose.  The  fragments  can 
usually  be  extracted  more  readily  through  the  hole  of  exit  than  through 
the  hole  of  entrance.  When  the  ball  has  not  passed  entirely  through 
the  limb,  but  has  approached  the  surface  opposite  to  the  hole  of 
entrance,  it  may  be  advisable  to  make  a  counter-opening,  both  for 
the  extraction  of  the  ball  and  for  the  more  ready  removal  of  de- 


284 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


tached  fragments  of  bone.  Such  counter-opening  will  also  contribute 
to  the  more  effectual  drainage  of  the  wound.  If  there  be  sharp  spic- 
ulas  of  bone,  which  have  a  strong  tendency  to  protrude  through  the 
wound,  they  may  be  removed  by  means  of  a  saw,  or  of  a  cutting  or 
gnawing  forceps.  If  there  be  any  tense  bands  of  aponeurosis  stretch- 
ing across  the  wound,  it  will  be  well  to  divide  them  with  a  bistoury, 
guided  by  the  finger.  When  suppuration  has  become  established,  it  is 
a  matter  of  the  greatest  importance  to  secure  a  free  and  direct  outlet 
for  the  pus,  and  to  prevent  it  from  burrowing  among  the  tissues.  It 
is  also  important  to  prevent  the  surface  of  the  limb  from  being  con- 
tinually bathed  in  pus,  and  to  guard  the  clothing  of  the  patient,  as 
well  as  the  bed  and  bedding,  from  being  soiled  with  the  discharge. 
To  accomplish  these  indications,  free  counter  openings  should  be  made 
wherever  the  matter  approaches  the  surface,  coroijresses  should  be 
laid  over  the  spaces  between  the  openings,  and  bandages  should  be 
applied  with  moderate  firmness,  to  press  the  matter  towards  the  open- 
ings by  which  it  is  to  be  discharged.  Opposite  to  these  openings 
holes  may  be  cut  in  the  bandages,  and  lint,  flax,  or  oakum  may  be  in- 
serted beneath  the  margin  of  these  holes  to  prevent  the  discharge 
from  soiling  the  bandages.  The  bed  and  bedding  may  be  protected 
by  means  of  oiled  silk  or  India-rubber  cloth.  All  these  precautions 
were  taken  with  excellent  effect  by  Dr.  Geo.  K.  Smith,  in  the  Armory 
Square  Hospital,  at  Washington. 

The  interior  of  the  suppurating  cavity  may  be  thoroughly  cleansed, 
once  or  oftener  in  the  day,  by  a  copious  injection  of  soap  and  water, 
or  other  detergent  liquid.  During  the  period  of  suppuration  the 
strength  of  the  patient  is  to  be  supported  by  a  generous  diet,  and 
tonics  and  stimulants  are  often  required  for  the  same  purpose.  The 
safety  of  the  patient,  and  the  usefulness  of  his  limb,  will  depend  very 
much  on  the  care  and  attention  with  which  these  rules  are  carried  out 
in  practice.  The  importance  of  avoiding  any  mechanical  disturbance 
of  the  fractured  limb  during  transportation  is  illustrated  in  the  case 
of  Lieut.  Lowry,  of  the  146th  K.  Y.  Volunteers,  whose  case  is  the 
second  in  my  collection.  He  was  a  young  man  of  sanguine  tempera- 
ment, good  constitution,  and  regular  habits,  whom  I  saw  in  camp  on 
the  22d  May,  1865.  He  had  been  wounded  at  the  battle  of  Cold 
Harbor,  on  the  3d  June,  1864.  The  ball  had  entered  his  right  thigh, 
on  its  inner  side,  a  little  above  its  middle,  and  passed  obliquely  up- 
ward, outward  and  backward,  presenting  itself  under  the  skin  behind 
the  great  trochanter,  where  an  incision  had  been  made  and  the  ball 
extracted.  The  femur  had  been  broken  in  its  upper  fourth,  and  a  very 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


285 


unfavorable  prognosis  had  been  pronounced  at  the  time.  He  had, 
however,  been  placed  upon  a  stretcher,  upon  which  his  limb  had  been 
properly  sujjported,  and  upon  this  he  had  been  carried  by  hand  to 
White  House,  and  thence,  on  the  same  stretcher,  to  a  steamer,  and 
on  his  arrival  at  Washington  he  had  been  carried,  upon  the  same 
stretcher,  to  his  ward  in  Armory  Square  Hospital.  In  the  hospi- 
tal he  was  treated  by  placing  his  limb  in  the  fracture-box,  which  was 
in  ordinary  use  in  that  institution,  without  extension.  His  recovery 
had  been  rapid,  and  at  the  time  of  my  observation  he  was  in  good 
health.  His  limb  was  shortened  two  inches,  and  he  walked  with  a 
cane,  which  he  hoped  soon  to  be  able  to  lay  aside. 

If  he  had  been  changed  from  stretcher  to  ambulance,  from  ambu- 
lance to  steamboat,  from  steamboat  again  to  stretcher,  from  stretcher 
to  ambulance,  from  ambulance  to  stretcher,  and  thence  to  his  bed  in 
the  hospital,  as  was  too  often  the  case  with  patients  having  compound 
fractures  of  the  thigh,  instead  of  a  happy  recovery  with  a  sound  and 
useful  limb,  he  might  have  occupied  a  Southern  grave,  or  have  had  an 
imperfect  recovery,  with  a  shattered  constitution,  and  a  deformed, 
emaciated  and  useless  limb. 

Among  the  gun-shot  fractures  of  the  thigh  which  I  saw  in  the  hos- 
pitals of  Washington  and  Baltimore,  I  found  that  a  number  of  difTer- 
ent  methods  of  treatment  had  been  resorted  to.  The  method  which 
impressed  me  most  favorably  was  that  which  is  known  as  Dr.  Buck's 
method.  It  consists  essentially  of  extension,  made  by  a  weight  at- 
tached to  a  cord,  passing  over  a  pulley,  and  secured  to  a  block  of 
wood  below  the  sole  of  the  foot,  the  middle  of  a  long  strip  of  adhe- 
sive plaster  passing  across  the  block  of  wood,  and  the  ends  being  ap- 
plied to  the  sides  of  the  leg  and  thigh,  and  kept  in  place  by  spiral 
strips  of  adhesive  plaster  and  a  roller  bandage.  By  this  means  the 
pressure  of  the  extending  force  is  equalized  upon  the  sides  of  the 
limb,  and  no  injurious  pressure  is  made  upon  the  instep.  A  brick 
being  placed  under  each  foot-post  of  the  bed,  the  weight  of  the  body 
generally  secures  a  sufficient  amount  of  counter-extension.  I  had  long 
been  familiar  with  the  excellent  results  of  this  method  of  treatment 
in  simple  fractures  of  the  thigh,  as  they  occur  in  civil  practice, 
whether  in  adults  or  in  children.  This  method  has  been  found  ad- 
vantageous in  simple  fractures,  under  my  observation,  in  promoting 
the  comfort  of  the  patient  during  the  treatment,  and  in  securing  union 
of  the  fractured  bone  with  the  least  possible  amount  of  shortening  or 
other  deformity.  From  the  experience  which  I  had  had  in  the  treat- 
ment of  simple  fractures  of  the  thigh  by  this  method,  I  was,  in  some 


286 


PROCEEDINGS  OF  SOCIETIES. 


[J  an., 


measure,  prepared  to  appreciate  the  results  of  the  same  method  as 
applied  to  the  treatment  of  gun-shot  fractures.  And  I  was  very  much 
gratified  with  the  opportunity  which  J  enjoyed  of  observing  the  satis- 
factoiy  results  of  this  mode  of  treatment,  especially  in  the  practice  of 
Dr.  Geo.  K.  Smith,  in  the  Armory  Square  Ilospital.  Doctor  Smith 
is  a  graduate  of  the  University  of  New  York,  and  has  availed  himself 
of  the  opportunities  which  he  enjoyed  of  seeing  the  surgical  practice 
of  the  hospitals  of  this  city,  and  of  familiarizing  himself  with  the  de- 
tails in  the  management  of  fractures;  and  having  good  powers  of 
observation,  and  a  large  amount  of  mechanical  ingenuity,  he  has  de- 
voted himself  to  the  treatment  of  fractures  with  a  degree  of  industry 
and  skill  not  surpassed  by  that  of  any  of  the  other  surgeons  whom  I 
met  in  the  military  hospitals  which  I  visited.  Since  Dr.  Smith  has 
been  in  charge  of  the  principal  fracture  wards  of  the  Armory  Square 
Hospital,  Dr.  Buck's  method  of  treatment  has  been  adopted  in  almost 
every  case;  and  the  testimony  of  Dr.  Smith,  and  of  the  other  surgeons 
who  are  associated  with  him,  is  decidedly  in  its  favor.  In  most  cases 
the  patients  are  more  comfortable  with  than  without  the  extension; 
in  a  few  instances  it  is  a  matter  of  comparative  indifference  to  them, 
as  far  as  their  comfort  is  concerned.  In  only  one  instance  did  the 
extension  occasion  positive  distress,  so  as  to  compel  its  discontinuance 
for  a  time.  In  the  case  alluded  to  an  abscess  was  forming  in  the 
popliteal  space  when  the  patient)"  was  admitted  to  the  hospital,  and 
the  extension,  by  the  weight  and  pulley,  gave  rise  to  increased  pain; 
but  when  the  abscess  had  become  mature,  and  the  matter  had  been 
discharged,  the  weights  were  reapplied,  and  the  patient  was  made 
more  comfortable  by  their  use. 

The  testimony  in  favor  of  this  method  of  extension  was  not  as 
strong  in  some  of  the  other  hospitals  as  in  Armory  Square  Hospital, 
the  statement  being  made  that  a  number  of  the  patients  could  not 
bear  the  treatment.  My  own  impression,  in  these  cases,  was  that 
there  was  a  want  of  accurate  knowledge  as  to  the  details  of  'the  treat- 
ment, and  a  want  of  skill  in  carrying  it  out.  In  some  of  the  hospitals, 
this  plan  of  treatment  was  entirely  ignored. 

In  the  Armory  Square  Hos])ital,  the  fractured  limb  is  placed  on 
Hodgen's  skeleton  splint,  which  does  not  interfere  with  the  extension, 
while  it  facilitates  the  dressing  of  the  wounds  and  sores.  Some  of  the 
patients  whom  I  saw  in  the  hospitals  of  Baltimore  and  Washington 
had  been  treated  by  suspending  the  limb  by  means  of  Smith's  anterior 
splint.  In  some  of  these  cases  very  satisfactory  results  had  been 
obtained. 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


287 


I  will  now  present  a  summary  of  the  cases  which  came  under  my 
observation,  arranged  in  groups,  embracing  the  more  important  results 
of  treatment.  Tlie  first  group  embraces  those  in  which  there  was  no 
shortening  of  the  limb — viz,  cases  9,  11,  13,  and  30.  In  cases  9,  11, 
and  13,  the  two  limbs  were  of  equal  length.  In  case  30,  the  limb 
which  had  been  fractured  was  nearly  a  quarter  of  an  inch  longer  than 
the  other.  All  these  cases  were  treated  by  extension  in  the  Armory 
Square  Hospital,  since  the  beginning  of  the  year  1865,  when  Geo.  K. 
Smith  introduced  the  present  improved  method  of  treatment. 

The  second  group  embraces  those  in  which  the  shortening  did  not 
exceed  one  inch,  viz.,  cases  3,  IG,  24,  25,  28,  29  and  41.  The  short- 
ening in  these  cases  was  |,  ^  |,  less  than  one  inch,  a  little  over  i 
inch,  and  one  inch.  Nos.  3,  16,  24,  25,  28  and  29  were  treated  by 
extension  in  Armory  Square  Hospital  since  the  beginning  of  1865. 
Case  41  was  treated  first  at  Potomac  Creek  Hospital,  and  then  at 
Finley  Hospital,  in  both  which  institutions  the  limb  was  suspended  by 
means  of  Smith's  anterior  splint. 

The  third  group  embraces  the  cases  in  which  the  shortening  was 
over  one  inch,  but  did  not  exceed  two  inches,  viz.,  Nos.  2,  8,  14,  17, 
19,  20,  26,  31,  33  and  45.  Cases  Nos.  8,  14,  IT,  19,  20,' 26  and  31 
were  treated  by  extension  in  the  Armory  Square  Hospital  since  the 
beginning  of  1865.  Case  No.  2  was  treated  without  extension  in  the 
Armory  Square  Hospital  at  an  earlier  period.  Case  33  was  treated 
without  extension  in  Judiciary  Square  Hospital.  This  case  was 
remarkable  for  the  fact  that  there  was  so  little  displacement  that 
neither  patient  nor  attending  surgeon  was  aware  of  the  existence  of 
the  fracture  until  the  patient  had  Ijeen  in  the  hospital  a  number  of 
days.  Case  45  was  treated  at  Annai)olis  by  means  of  Smith's  ante- 
rior splint  for  four  weeks,  and  then  by  extension,  with  a  weight  of 
twenty-five  pounds,  for  fourteen  weeks. 

The  fourth  group  embraces  the  cases  in  which  the  sliortening  was 
over  two  inches,  but  did  not  exceed  three  inches,  viz..  Cases  Xos.  6,  12, 
15,  18,  21,  22,  32,  34,  38  and  46.  Nos.  6,  12,  15,  18,  21  and  32 
were  treated  by  extension  in  the  Armory  Square  Hospital  sin(!e  the 
beginning  of  the  year  1865.  No.  22  was  treated  at  City  Point 
without  extension.  No.  34  was  treated  at  Stanton  Hospital  with- 
out extension.  No.  38  was  treated  at  Carver  Hospital  without 
continued  extension.  No.  46  was  treated  at  Camden  Street  Hospital, 
in  Baltimore,  for  the  first  montli  by  means  of  Smith's  anterior  splint, 
and  for  the  second  month  by  extension  with  one  brick. 
The  fifth  group  embraces  the  cases  in  which  the  shortening  was 


288 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


more  than  three  inches,  but  did  not  exceed  four  inches,  viz.,  Nos.  5, 
36,  40,  42,  44,  47  and  48.  No.  5  had  been  treated  at  Armory 
Square  Hospital  from  October  3d,  1864.  No.  36  had  been  treated 
at  Campbell  Hospital  without  continued  extension.  No.  40  had  been 
treated  at  Lincoln  Hospital  without  extension.  Nos.  42  and  48  had 
been  prisoners  in  the  hands  of  the  rebels,  and  had  had  no  treatment. 
No.  44  had  been  treated  at  Annapolis  with  Smith's  anterior  splint, 
without  extension.  No.  47  had  been  treated  at  Camden  Street  Hos- 
pital, in  Baltimore,  by  Smith's  anterior  splint,  without  extension. 

The  sixth  group  embraces  all  the  cases  in  which  the  shortening 
exceeded  four  inches,  viz.,  Nos.  1,  4,  7,  10,  35  and  39.  The  short- 
ening in  these  cases  respectively  was  4^,  5,  4|,  6|,  5  and  4 J.  No.  1 
had  been  treated  at  Lincoln  Hospital,  without  extension.  Nos.  4  and 
7  had  been  treated  at  Armory  Square  Hospital,  without  extension.  No. 
10  had  been  treated  at  Hilton  Head  by  means  of  Smith's  anterior  splint, 
Hodgen's  splint  and  a  long  extension  splint.  No.  35  had  been  treated 
at  Campbell  Hospital,  without  extension.  No.  39  had  been  treated 
at  Carver  Hospital,  without  extension. 

In  reviewing  the  cases  which  have  been  presented,  it  appears  that 
twenty-five  of  the  whole  number  have  been  treated  by  extension  at 
the  Armory  Square  Hospital,  since  tiie  beginning  of  the  year  1865. 
In  two  of  these  cases  the  limbs  were  not  measured,  in  consequence  of 
the  feeble  state  of  the  health  of  the  patients  at  the  time  of  my  visit. 
In  the  remaining  twenty-three  cases,  there  were  four  in  which  there 
was  no  shortening;  there  were  five  others  in  which  the  shortening  was 
less  than  one  inch;  there  were  eight  in  which  the  shortening  was  more 
than  one  inch,  but  did  not  exceed  two  inches;  and  there  were  six 
in  which  the  shortening  was  more  than  two  inches,  but  did  not  exceed 
three  inches.  The  extent  of  the  shortening  did  not  exceed  three 
inches  in  any  of  the  twenty-three  cases,  and  it  only  reached  that 
amount  in  a  single  case.  The  average  shortening  in  the  twenty-three 
cases  was  less  than  an  inch  and  a  third. 

There  were  nineteen  cases  treated  without  any  methodical  extension. 
The  minimum  shortening  in  a  solitary  case  (No.  41)  was  one  inch. 
This  case  had  been  treated  with  Smith's  anterior  splint.  The  short- 
ening in  another  case  (No.  33)  had  been  only  an  inch  and  a  quarter; 
but  in  this  case  it  is  remarkable  tiiat  there  was  so  little  displacement 
from  the  begiiming  that  the  fracture  was  not  detected  until  several 
days  after  the  infliction  of  the  injury.  In  No.  2  the  shortening  was 
two  inches;  in  No.  7,  two  inches  and  a  quarter;  in  Nos.  22  and  38, 
each  two  inches  and  a  half;  in  No.  5,  tiiree  and  a  quarter;  in  No.  47, 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


289 


three  and  three-quarters;  in  Nos.  36,  40  and  44,  each  four  inches;  in 
No.  39,  four  and  an  eighth;  in  No.  7,  four  and  a  half;  in  No.  1,  four 
and  five-eighths;  in  Nos.  4  and  35,  each  five  inches;  in  No.  10,  six 
inches  and  three-quarters. 

In  two  of  the  nineteen  cases  which  were  treated  without  methodical 
extension,  there  was  no  measurement.  Of  the  remaining  seventeen, 
there  were  but  two  cases  in  which  the  shortening  was  less  than  two 
inches.  There  were  eleven  cases  in  which  the  shortening  exceeded 
three  inches,  and  of  this  number  there  were  nine  in  which  the  short- 
ening was  four  inches  or  more.  The  average  shortening  in  the  seven- 
teen cases  was  more  than  3.55  inches.  Excluding  the  two  most 
favorable  cases,  the  average  shortening  was  more  than  3.88  inches. 
There  were  two  of  the  cases  in  which  the  patients  fell  into  the  hands 
of  the  rebels,  and  in  which  there  was  no  surgical  treatment.  In  each 
of  these  cases,  union  occurred  with  a  shortening  of  four  inches. 

Of  forty-eight  of  the  cases  observed,  the  fracture  involved  the 
upper  third  of  the  thigh  in  twenty  cases;  the  junction  of  the  upper 
and  middle  third  in  five  cases;  the  middle  third  in  nineteen  cases;  the 
junction  of  the  lower  and  middle  third  in  two  cases;  and  the  lower 
third  in  one  case.  In  one  case,  the  precise  locality  of  the  fracture 
was  not  noted.  It  is  a  remarkable  fact  that  so  few  of  the  cases  in- 
volved the  lower  extremity  of  the  thigh.  It  is  very  improbable  that 
there  should  have  been  so  small  a  proportion  of  original  injuries  in 
that  situation.  It  would,  therefore,  appear  probable  that  a  larger 
proportion  of  cases  of  fracture  near  the  lower  part  of  the  thigh  had 
proved  fatal,  or  had  led  to  primary  amputation  of  the  limb,  in  conse- 
quence of  the  knee-joint  being  implicated.  The  knee-joint  is  more  fre- 
quently involved  in  fractures  near  the  lower  end  of  the  thigh  than  the 
hip-joint  in  fractures  near  the  upper  end. 

Dr.  Tripler. — Mr.  President:  In  regard  to  the  points  made  by 
my  colleague,  as  the  result  of  observations  made  in  the  hospitals,  I 
have  no  particular  objection  to  make ;  they  are  undoubtedly  entirely 
legitimate  conclusions  from  what  he  has  himself  observed.  I  don't 
know  that  there  is  any  thing  extremely  novel  in  them.  With  regard 
to  this  destruction  of  the  soft  parts  of  which  he  speaks  as  requiring 
amputation,  nobody  can  make  any  objection.  With  regard  to  ampu- 
tation generally,  as  required  by  gun-shot  fractures  of  the  thigh,  we 
were  taught,  before  the  Schlcswig-llolstein  war,  that  amputation  was  a 
necessary  resort  in  cases  of  fracture  of  the  thigh-bone  and  fracture  of 
almost  any  bone;  and  it  was  not  until  after  that  war  that  we  were 
taught  the  new  principle  of  exsection  in  contradistinction  to  amputa- 

VoL.  II.— No.  10.  19 


290 


PROCEEDINGS  OP  SOCIETIES. 


[Jan., 


tion.  I  know  that  in  the  Mexican  war  (I  was  not  in  the  first  battles, 
but  was  informed  by  my  colleagues  who  were  in  the  battles  of  Resaca 
and  Palo  Alto)  attempts  were  made  to  save  limbs  in  cases  of  gun- 
shot fractures  of  the  thigh,  but  almost  invariably  without  success,  and 
the  few  cases  that  did  recover  were  attended  with  great  suffering  and 
shortening  of  the  limb.  My  first  attempt  to  save  a  limb  in  that  way 
was  after  we  got  to  the  city  of  Mexico.  In  this  instance  the  patient 
was  carried  to  one  of  the  houses  in  the  city  and  recovered;  but  recov- 
ered with  shortening,  which  I  regard  as  almost  a  necessary  result  of 
all  fractures  of  the  thigh.  It  is  the  rule,  and  the  preservation  of  the 
limb  with  its  natural  length  the  exception.  From  the  time  of  the 
Schleswig-Holstein  war  we  have  come  to  look  upon  exsection  as  the 
rule  to  be  pursued,  and  amputation  as  the  exception.  Men  recover 
with  shortening  as  a  matter  of  course.  If  there  is  a  comminuted 
fracture,  we  attempt  to  remove  all  those  detached  spiculae  of  bone;  and 
those  spiculsE  are  placed  under  several  different  classes.  Dupuytren 
had  classified  them  as  primary,  secondary,  and  tertiary:  primary, 
those  which  are  perfectly  detached;  secondary,  those  which  are  still 
adherent  by  periosteum;  tertiary,  those  which  are  mere  splits  in  the 
bone,  still  adhering,  not  being  detached  from  the  periosteum.  These, 
of  course,  are  to  be  removed,  as  foreign  bodies.  We  attempt  to  save 
the  limb,  and  it  does  not  depend  exactly  upon  whether  the  man  is 
going  to  be  left  at  rest  or  whether  be  is  to  be  transported  over  roads. 
This  matter  of  transportation  is  one  of  no  little  importance.  We  have 
been  trying  to  introduce  vehicles  so  constructed  that  the  patient  will 
be  as  much  at  rest  in  transportation  over  rough  roads  as  he  would  be 
passing  up  Broadway,  or  over  one  of  the  beautiful  macadamized  roads 
in  Central  Park.  This  is  a  subject  which  is  unattainable.  As  long 
ago  as  1836,  during  the  war  in  Florida,  an  ofiicer  was  wounded  at  the 
battle  of  the  Wahoo  Swamp — his  thigh-bone  fractured.  He  was 
placed  in  a  baggage-wagon,  nothing  under  him  but  tents  and  bed 
sacks;  was  transported  over  as  rough  a  wood  as  you  ever  saw 
through  the  Palmetto  Swamps,  over  roads  in  which  the  palmetto  roots 
were  running,  making  deep  ruts;  he  was  transported  down  to  the 
little  town  of  Volusia,  and  I  expected  to  find  him  dead  when  we  got 
there,  but  he  had  made  the  journey  with  comparative  comfort.  There 
were  no  springs  under  those  wagons;  he  was  carried  over  that  rough 
road  on  a  rough  jolting  vehicle,  and  had  made  the  journey  with  com- 
parative comfort,  and  arrived  under  very  favorable  prospects  of 
getting  along  well.  He  was  going  by  boat  up  to  Black  Creek,  two 
or  three  hundred  miles  further  up  the  river;  but  the  steady  tremulous 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


291 


motion  of  that  steamer  was  sufficient  to  torture  him  to  death,  and  he 
did  die.  So  much,  then,  for  ease  of  transportation  in  respect  to  the 
comfort  of  the  patient,  I  am  persuaded  that  no  system  of  springs  that 
you  can  make,  I  don't  care  how  you  adjust  them,  will  insure  the  com- 
fort or  safety  of  a  wounded  man,  and  that  the  less  spring  you  have  to 
your  wagon  the  better. 

In  relation  to  the  treatment  of  these  fractures,  I  think  amputation 
should  very  seldom  be  resorted  to.  I  think  so  now.  I  did  not  in 
1856.  Exsection  of  the  fractured  extremities  of  the  bone  has  been 
resorted  to,  not  only  in  the  thigh  and  in  the  humerus,  but  in  all  the 
long  bones.  I  have  myself  seen  very  few  cases  where  there  has  not 
been  a  false  joint;  and  during  the  last  two  years  a  few  cases  have 
been  reported  by  the  surgeon  of  a  Michigan  regiment  where  he  has 
resorted  to  exsection  in  the  continuity  of  the  femur;  two  cases  in 
which  he  has  exsected  the  fractured  portions;  the  extremities  were 
brought  together,  and  the  result  was  a  solid  reunion  of  this  bone,  and 
his  patients  recovered  with  no  more  shortening  than  my  friend  Prof. 
Post  has  described;  3.88  I  think  he  mentioned  as  the  shortening  in 
certain  cases,  and  in  the  cases  that  fell  into  the  hands  of  the  rebels. 
While  Batewell  exsected  his  cases  he  had  shortening.  He  had  a  solid 
union,  and  his  patients  are  now  walking  about.  These  things  have 
been  done  once  and  can  be  done  again.  I  observe  that  Dr.  Howard 
has  been  reading  a  paper  before  the  Royal  Medico-Chirurgical  So- 
ciety in  London,  upon  the  subject  of  exsection  in  the  continuity  of 
bones,  and  bringing  the  bones  together,  not  by  the  simple  mechanical 
contrivance  Batewell  used,  but  in  using  a  wire  suture.  Now,  if  the 
reports  we  are  going  to  receive  hereafter  from  the  Surgeon-General's 
office  tell  us  that  such  means  have  been  resorted  to,  and  that  success- 
fully, it  will  introduce  altogether  new  principles  into  the  department 
of  surgery  relating  to  the  treatment  of  gun-shot  fractures  in  the  con- 
tinuity of  bones.  If  we  can  by  exsection  remove  the  fractured  bones, 
bring  the  two  ends  together,  fix  them  by  any  mechanical  contrivance 
whatever,  it  will  be  certainly  a  great  step  in  advance  of  the  old  method 
of  resorting  to  amputation. 

There  are  a  great  many  things  to  be  considered  in  regard  to  this 
adjustment  in  the  fracture  of  the  thigh.  I  suppose  everybody  is 
familiar  with  the  observations  of  Mr.  Vincent,  the  Senior  Surgeon  of 
St.  Bartholomew's  Hospital,  London,  in  regard  to  the  position  of  the 
thigh  in  the  njjper  third.  The  uj)per  fragment,  as  we  all  know,  rises 
above  the  lower,  and  there  is  no  sort  of  use  of  bringing  the  lower 
fragment  up  into  any  position  to  adjust  itself  to  the  ujiper;  because  if 


292 


PROCEEDINGS  OP  SOCIETIES. 


[Jan., 


the  upper  is  allowed  to  rise  to  a  certain  point,  the  muscles  are  in  the 
most  favorable  position  for  their  action.  If  you  bring  that  upper  frag- 
ment down  to  a  horizontal  position,  the  patient  lying  upon  his  back, 
you  bring  the  muscles  into  the  most  unfavorable  position  for  their  action. 
The  moment  you  begin  to  raise  them,  that  moment  you  begin  to  obtain 
greater  power  of  contraction — the  best  position  for  the  man  being  on  his 
back.  The  lower  you  bring  them  down,  the  less  power  the  muscles 
have;  and  if  you  bring  the  lower  portion  to  adjust  itself  to  the  upper, 
you  bring  them  to  the  most  favorable  position.  I  think  no  one  will 
dispute  the  fact  that  where  you  bring  these  muscles  in  a  position  so 
that,  associated,  they  have  the  greatest  possible  force,  there  you  will 
have  the  greatest  possible  displacement;  that  if  you  bring  down  the 
muscles  as  far  as  they  can  be,  there  they  will  have  their  minimum 
force,  and  the  lower  part  of  the  limb  being  placed  in  a  position  to  ad- 
just itself  to  the  upper,  will  have  the  less  disposition  to  displacement. 
Adjust  the  weight  so  that  it  will  be  exerted  in  the  direction  of  the 
axis  of  the  limb,  by  passing  the  cord  over  the  foot  of  the  bed  by  a 
pulley;  bring  every  portion  down  as  far  as  the  anatomy  of  the  parts 
will  permit,  so  that  the  muscles  will  have  the  least  possible  force,  and 
you  will  have  much  less  difficulty  in  preserving  the  limb  in  its  proper 
position  than  you  will  by  resorting  to  any  other  method.  This  is  the 
rule:  Amputation  where  the  soft  parts  are  extensively  destroyed;  am- 
putation in  all  cases  where  artery  aiid  vein  are  both  involved;  attempt 
to  save  the  limb  where  you  have  nothing  but  fracture  of  the  bone 
itself,  properly  adjusting  the  fractured  extremities,  removing  Dupuy- 
tren's  primary  spicula  of  bone,  with  proper  extension  keeping  the  limb 
down  in  a  horizontal  position. 

NEW  YORK  PATHOLOGICAL  SOCIETY. 
Stated  Meeting,  Sept.  13,  1865. 
Dr.  Austim  Flint,  President,  (pro  tem.,)  in  the  Chair. 

BOXY  TUMOR  OF  THE  FIXGER  DR.  A.  C.  POST. 

Dr.  Post  presented  a  very  hard  bony  tumor  which  he  had  removed 
from  the  sheath  of  the  flexor  tendon  of  the  little  finger  of  a  woman 
fifty  yeai's  of  age.  The  patient  ascribed  the  origin  of  the  growth  to 
some  contusion  which  she  had  suffered  twenty  years  before,  ever  since 
which  time  the  tumor  had  slowly  and  steadily  increased  in  size.  At 
the  lime  of  its  removal  it  measured  an  inch  and  a  quarter  in  its  long- 
est diameter  and  an  inch  in  its  shortest.    The  removal  was  accom- 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


293 


plished  without  difficulty,  and  the  mass,  which  was  of  ahuost  flinty 
hardness,  when  sawn  open  presented  the  appearance  of  cartilage 
densely  ossified. 

CASE  OF  CHOLERA  INFANTUM  DR.  LEWIS  SMITH. 

Dr.  Lewis  Smith  exhibited  the  intestines  taken  from  a  child  ten 
months  old,  who  had  been  a  patient  in  the  Infants'  Asylum.  The 
little  patient  was  brought  up  by  hand,  and  had  had  looseness  of  the 
bowels  nearly  or  quite  all  summer.  Dr.  Smith's  attention  was  not 
particularly  directed  to  it  until  about  the  first  of  the  present  month. 
The  evacuations  at  this  time  numbered  four  or  five  daily — were  some- 
times green,  sometimes  dark,  and  quite  offensive.  It  was  moderately 
emaciated,  and  there  was  no  vomiting  at  this  time.  It  began  to  be 
very  fretful,  and,  that  fretfulness  continuing.  Dr.  Smith  was  led  to 
attribute  it  to  the  brain.  There  was  no  decided  change  in  the  child, 
excepting  it  was  becoming  somewhat  weaker,  until  the  8th  of  Sep- 
tember, when  a  state  of  drowsiness  supervened.  On  the  9th  the  pa- 
tient began  to  sink,  and  on  the  10th  died  of  exhaustion.  There  were 
no  convulsions,  and  it  was  apparently  conscious  to  within  a  few  hours 
of  its  death. 

On  the  following  day  the  autopsy  was  made.  On  opening  the 
skull  the  membranes  of  the  brain  presented  their  usual  appearance, 
except  that  overlying  the  surface  of  the  vertex  and  between  the 
arachnoid  there  was  some  transparent  serum,  about  an  ounce  or  an 
ounce  and  a  half  in  quantity.  There  was  only  a  moderate  increase  in 
the  vascularity  of  the  organ,  and  there  was  no  undue  amount  of  serum 
in  the  ventricles.  The  thoracic  organs  were  healthy,  except  the  oesoph- 
agus, which  was  moderately  inflamed.  The  stomach  presented  no 
unusual  appearance  whatever — an  important  fact,  considering  that  it  is 
generally  believed  that  in  the  so-called  cholera  infantum  the  mucous 
membrane  is  softened.  There  was  nothing  abnormal  in  the  intestinal 
canal  until  within  a  foot  from  the  ileo-ccecal  valve;  here  patches  of 
thickened  mucous  membrane  showed  themselves,  and  at  a  distance  of 
four  or  five  inches  from  the  valve  the  membrane  was  uniformly  thick- 
ened and  red,  showing  that  it  had  been  the  seat  of  intense  inflammar 
tion.  The  ascending  colon  was  in  nearly  a  normal  state,  while  in  the 
descending  portion  the  solitary  glands  were  quite  distinct.  On  reach- 
ing the  rectum  the  condition  of  things  was  somewhat  similar  to  that 
of  the  ileum  already  described.  The  mesenteric  glands  were  but 
slightly  enlarged. 

The  points  of  interest  in  the  specimens  were,  first,  with  reference  to 


294 


PROCEEDINGS  OP  SOCIETIES. 


[Jan., 


the  condition  of  the  brain.  The  Dr.  stated  that  during  the  past  sum- 
mer, and  during  previous  seasons,  he  had  examined  quite  a  number  of 
children  under  the  ages  of  three  and  four  months,  during  that  period 
in  which  the  cranial  bones  were  not  consolidated,  and  had  uniformly 
found  that  serous  effusion  was  not  present.  This  absence  of  serum  he 
explained,  by  supposing  that  the  brain  during  the  progress  of  the  dis- 
ease became  shrunken,  and  that  the  cranial  bones  overlapped  and 
adapted  themselves  to  the  shriveling  organ,  thus  rendering  the  effu- 
sion of  fluid  unnecessary,  there  being  no  such  vacuum  formed  as  in 
those  cases  in  which  the  cranial  bones  were  consolidated  and  unyield- 
ing. The  second  point  of  interest  had  reference  to  the  unusual  situa- 
tion of  the  intestinal  lesion  in  such  cases,  it  being  for  the  most  part 
confined  to  the  lower  portion  of  the  ileum. 

In  answer  to  a  question  from  Dr.  Newman,  he  stated  that  he  had 
never  used  the  nitrate  of  silver  in  the  treatment  of  the  disease. 

Dr.  Newman  then  stated  that  during  the  past  summer  he  had  found 
that  the  administration  of  the  nitrate  of  silver,  in  doses  of  i\th  of  a 
grain  for  a  child  a  year  old,  every  three  or  four  hours,  was  attended 
with  marked  benefit.  If  there  was  much  restlessness,  he  was  in  the 
habit  of  adding  a  little  paregoric. 

In  reply  to  a  question  from  Dr.  Post,  Dr.  Smith  remarked  that  in 
cholera  infantum  there  is  generally  vomiting  present,  only,  however, 
within  a  day  or  two  of  death. 

Dr.  Post  stated  that  he  had  always  looked  upon  vomiting  as  a  very 
important  symptom  in  the  disease  described  as  cholera  infantum,  and 
from  that  fact  was  disposed  to  think  that  Dr.  Smith's  case  could  not 
properly  be  styled  any  thing  more  than  diarrhoea. 

Dr.  Smith  remarked  that  the  disease  of  which  the  child  died  was,  as 
he  understood  it,  generally  known  with  the  profession  in  accordance 
with  the  appellation  which  he  had  given. 

Dr.  Ellsworth  Eliot  agreed  with  Dr.  Post  in  reference  to  the 
proper  name  for  the  disease,  and  stated  that  he  looked  upon  cholera 
infantum  as  a  malady  which  had  a  very  rapid  progress,  and  was  attend- 
ed with  watery  discharges  and  severe  vomiting.  Dr.  Eliot  asked  what 
was  the  highest  point  in  the  intestine  at  which  Dr.  Smith  in  his  post- 
mortem examinations  had  found  the  green  color  to  the  contents  of  the 
intestine,  and  also  referred  to  what  he  believed  was  the  generally  re- 
ceived opinion  in  the  premises  that  thoy  were  due  to  the  altered  bile. 

Dr.  Smith  did  not  think  that  he  could  mention  the  highest  point  at 
which  he  had  found  the  green  color  referred  to,  but  would  state  that 
he  had  seen  yellow  matter  in  the  jejunum  and  green  matter  lower 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


295 


down,  a  fact  which  would  seem  to  prove  that  the  bile  had  little  if  any 
thing  to  do  with  the  production  of  the  effect.  He  concluded  that  the 
green  color  was  due  to  some  alteration  which  was  suffered  by  the 
intestinal  mucus. 

Dr.  Post  suggested  that  it  might  be  due  to  the  bile,  notwithstand- 
ing, inasmuch  as  that  secretion  might  naturally  be  changed  in  charac- 
ter as  it  passed  down  the  intestine. 

ANEURISM  OF  THE  INNOMINATA  DR.  AUSTIN  FLINT. 

Dr.  Flint  exhibited  au  aneurism  of  the  innominata,  which  presented 
rather  a  special  interest  in  reference  to  a  point  in  diagnosis.  The 
trachea  was  flattened  and  pushed  to  one  side,  but  the  relative  position 
of  the  recurrent  nerve,  on  account  of  the  premature  drying  which  the 
specimen  suffered,  could  not  be  ascertained.  Inasmuch  as  Dr.  Day, 
of  Bellevue  Hospital,  intended  to  publish  the  history  of  the  case  in 
full,  he  did  not  think  it  worth  while  to  give  any  minute  account  of 
the  patient's  condition,  except  so  far  as  it  related  to  the  points  in  the 
diagnosis.  This  patient,  continued  he,  entered  Bellevue  Hospital,  and 
was  suffering  from  considerable  embarrassment  in  respiration,  requir- 
ing to  be  much  of  the  time  in  the  sitting  posture.  One  interesting 
point  in  connection  with  the  posture  was,  that  the  patient  experienced 
most  comfort  in  inclining  towards  the  left  side,  the  reverse  of  what 
would  be  expected  from  the  position  of  the  tumor,  pressing  as  it  did 
so  decidedly  upon  the  trachea.  The  patient  had  some  huskiness  of 
the  voice,  which,  however,  was  explained  by  the  existence  of  a  slight 
laryngitis.  There  was  also  a  peculiar  sound  in  the  respiration,  appar- 
ently referable  to  the  larynx,  which  I  can  not  well  describe,  but 
which,  having  observed  in  certain  cases  of  aneurism  involving  the  re- 
current nerve,  I  have  learned  to  regard  as  distinctive.  I  may  say 
here  that  from  this  symptom  I  was  enabled  to  suspect  the  existence  of 
an  aneurismal  tumor,  even  before  a  physical  examination  was  made. 
This  sound,  I  presume,  is  occasioned  by  the  paralysis  of  the  muscles  of 
one  side  of  the  glottis. 

On  proceeding  to  examine  this  patient  none  of  the  physical  signs  of 
aneurism  were  discovered;  we  could  not  even  make  out  distinctly  dull- 
ness on  one  side,  which  might  be  considered  surprising,  considering 
the  size  of  the  tumor,  which  can  only  be  explained  by  its  being  con- 
fined so  nearly  to  the  median  line.  There  was  no  bellows  murmur 
appreciated,  notwithstanding  repeated  examinations  were  made. 
There  was  a  disparity  in  the  pulse,  not  very  marked,  but  constant  and 
distinct;  the  radial  pulse  on  the  right  side  was  markedly  less  in  force 


296 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


than  the  pulse  of  the  left  wrist.  There  was  also  a  disparity  in  the 
size  of  the  pupil,  the  left  being  more  dilated  than  the  right.  There 
was  no  pulsation  or  thrill. 

I  present  the  specimen  to  illustrate  the  value  of  the  points  which 
led  more  particularly  to  the  formation  of  a  diagnosis,  viz.:  the  pe- 
culiarity in  the  respiration,  and  the  disparity  in  the  pulse  and  in  the 
pupils.  In  connection  with  this  case  it  is  interesting  to  note  that  a 
patient  is  now  an  inmate  of  Bellevue  who  presents  a  distinct  disparity 
in  the  radial  pulse,  habitual,  labored  breathing,  and  in  that  instance 
the  physical  signs  of  aneurism  are  also  very  indistinct;  there  is,  how- 
ever, distinct  dullness  on  the  right  side  of  the  sternum,  but  no  bruit, 
and  the  heart-sounds  are  very  much  more  distinctly  heard  on  the  right 
side  of  the  sternum,  at  the  base  of  the  organ,  than  at  any  other  point 
in  the  praecordia. 

In  answer  to  a  question  from  Dr.  Messinger,  he  stated  it  as  his  im- 
pression that  the  spasmodic  cough  was  not  a  very  common  accompani- 
ment to  aneurism. 

LARYNGEAL  SYMPTOMS  IX  ANEURISM  OF  THE  INNOMINATA  DR.  A.  C.  POST. 

Dr.  Post  referred  to  the  following  case,  which  had  presented  itself 
to  him  two  years  ago: 

A  patient  complained  at  first  of  some  irritation  of  the  throat,  which 
was  thought  to  be  owing  to  an  elongated  uvula.  This  organ  was 
accordingly  removed.  The  huskiness  of  the  voice  which  also  pre- 
viously existed,  however,  remained,  and  the  Dr.  lost  sight  of  him  until 
two  or  three  months  ago,  when  he  again  presented  himself,  and  it  was 
found  that  an  aneurism,  supposed  to  be  connected  with  the  innom- 
inata,  existed  in  the  situation  of  the  sterno-clavicular  articulation, 
causing  a  marked  protuberance  at  that  point.  Dr.  Post  supposed 
that  the  aneurism  had  been  forming  from  the  time  that  the  huskiness 
of  the  voice  tirst  showed  itself,  and  that  this  symptom  was  the  only 
one  at  the  time  which  pointed  to  the  existence  of  the  trouble.  He 
further  remarked  that  these  laryngeal  symptoms  connected  with  aneur- 
ismal  tumors  were  often  mistaken  for  those  which  were  due  to  laryn- 
geal disease,  and  that  tracheotomy  had  often  been  performed  for 
their  relief.  He  believed  that  this  operation  was  often  attended  with 
benefit,  even  when  the  mistake  in  diagnosis  was  made. 

Dr.  Flint  concurred  in  the  opinion  expressed  by  Dr.  Post  in  refer- 
ence to  tracheotomy,  and  alluded  to  a  case  which  he  had  published  in 
the  Mediail  Times,  in  which  a  patient  was  evidently  destroyed  by 
spasm  of  the  glottis,  induced  by  a  small  aneurism,  an  event  which 
might  have  been  prevented  had  the  operation  of  opening  the  trachea 
been  performed. 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


297 


Stated  Meeting,  Sept.  21,  1865. 
Dr.  GuRDON  Buck,  President,  in  the  Chair. 

WOUND  OF  THE  POPLITEAL  ARTERY — DR.  L.  A.  SAYRE. 

Dr.  Sayre  exhibited  a  specimen  of  wound  of  the  popliteal  artery, 
accompanied  with  the  following  history,  drawn  up  by  Dr.  W.  A. 
Lockwood,  House  Surgeon,  Bellevue  Hospital. 

John  Graham,  a  native  of  Ireland,  aged  26,  was  admitted  to  Belle- 
vue Hospital,  Friday  morning,  June  20th,  1865,  at  3  o'clock,  and 
gave  the  following  statement  in  regard  to  himself,  (which  is  not  to  be 
taken  as  truth.)  According  to  his  own  account  he  became  intoxicated 
on  Monday  evening,  June  19th,  and  when  in  that  condition  in  his 
house,  at  1 1  o'clock,  he  fell  from  a  chair,  striking  upon  a  large  knife 
so  placed  as  to  enter  his  left  leg.  A  gush  of  blood  followed,  and  a 
surgeon  was  called  who  plugged  the  wound  with  pieces  of  cloth,  and 
also  compressed  the  parts  firmly  at  the  point  of  injury  by  bandaging. 
He  was  then  sent  to  the  hospital,  and  I  saw  him  at  about  .S  o'clock, 
Tuesday  morning.  He  was  laying  in  bed  and  looked  as  persons  do 
after  a  severe  hemorrhage.  The  bleeding  seemed  nearly  arrested  at 
the  time  by  the  compression  which  had  been  made  by  the  surgeon  out- 
side. I  arranged  a  tourniquet  on  the  femoral  artery  in  Scarpa's  space, 
and  also  a  compress  lower  down,  and  removed  the  compression  from 
the  injured  parts.  This  was  followed  by  a  gush  of  bright  blood,  which 
was  instantly  arrested  by  screwing  down  the  tourniquet  above.  I 
then  proceeded  to  examine  the  wound,  and  found  it  to  be  a  cleanly 
cut  opening,  about  one  inch  in  length,  on  the  outer  aspect  of  the  left 
leg,  just  above  the  knee  joint,  and  anterior  to  the  tendon  of  the  outer 
hamstring  muscle.  It  penetrated  the  tissues  of  the  leg,  and  seemed  to 
go  in  a  direction  behind  the  thigh-bone,  and  just  above  its  condyles. 
Being  convinced  that  the  popliteal  artery  was  wounded,  I  continued 
to  control  the  femoral  with  compress  and  tourniquet,  and  having  ap- 
plied picked  lint  firmly  bandaged  over  the  wound,  the  limb  was 
bandaged  from  the  toes  upwards,  and  elevated  upon  an  inclined 
plane. 

Dr.  Lewis  A.  Sayre  arrived  at  11.40,  a.m.,  and  first  tied  the  circum- 
flex artery  in  the  wound,  which  he  found  filled  with  clotted  blood, 
and  with  the  pieces  of  rags  which  had  been  used  to  plug  the  wound. 
He  then  made  an  incision  about  five  inches  in  length  in  the  popliteal 
space,  and  having  brought  the  popliteal  artery  well  into  view,  found 
that  a  cut  about  one  eighth  or  more  nearly  one  quarter  of  an  inch 
long  had  been  made  through  the  wall  of  the  vessel  in  the  direction  of 


298 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


its  length,  without  dividing  it.  This  cut  gaped  open  and  a  large  flat 
stream  of  blood  was  poured  out,  which  was  arrested  by  digital  pressure, 
made  upon  the  wounded  vessel.  On  everting  the  edges  of  the  cut, 
the  inner  serous  coat  of  the  artery  could  be  plainly  seen.  Dr.  S.  tied 
the  vessel  on  each  side  of  the  wound,  which  was  then  left  open  at  its 
central  part  to  aflford  exit  for  the  blood  and  discharges.  The  original 
wound,  which  was  uot  dependent,  was  closed  by  strapping.  Stimulus 
being  indicated  was  freely  given  after  the  operation;  but  the  man 
seemed  to  have  lost  quite  an  amount  of  blood  before  entering  the  hos- 
pital, and  did  not  rally  well  at  any  time.  The  day  after  the  operation, 
(Wednesday,  June  21st,)  the  wound  was  dressed  with  oakum  soaked 
in  diluted  Labarraque's  solution.  There  was  some  bad  odor  present, 
and  considerable  blood  had  been  infiltrated  into  the  tissues  before  the 
artery  was  tied.  The  patient's  face  looked  white,  and  his  pulse  was 
not  strong.  Stimulus  continued.  At  4  o'clock  in  the  afternoon  of 
this  day  the  man  became  somewhat  delirious,  and  attempted  to  get 
up.  His  leg  was  examined  and  dressed  at  6.30,  p.m.,  and  did  not 
look  markedly  worse,  and  he  appeared  to  sleep  somewhat  during  the 
early  part  of  the  night.  At  4  a.m.,  Thursday,  it  was  very  evident 
that  the  man  was  growing  weaker  and  more  delirious,  and  when  his 
leg  was  uncovered  to  be  dressed,  about  two  hours  afterwards,  it  was 
found  looking  dead  and  black,  and  was  very  much  swollen. 

There  had  been  no  actual  sloughing,  but  the  whole  limb  seemed 
dead.  The  man  died  at  6.40,  a.m.,  Thursday,  June  22d.  After  death 
Dr.  Sayre  took  out  a  portion  of  the  popliteal  artery,  in  which  the 
wound  could  be  plainly  seen,  and  the  ligatures  were  found  well  placed 
on  each  side  of  it. 

ANEURISM  OF  THE  AORTA.  DR.  A.  JACOBI. 

Dr.  Jaoobi  presented  an  aneurism  of  the  arch  of  the  aorta.  The 
history  of  the  case  was,  from  the  attendant  circumstances,  necessarily 
very  incomplete.  The  gentleman  who  removed  the  specimen  only  saw 
the  patient  twenty-four  hours  previous  to  death.  A  man  aged  25 
years,  thin  and  emaciated,  was  found  by  him  in  great  dyspnoja, 
perspiring,  with  a  pulse  of  85  and  a  feeble  heart's  action.  There  were, 
however,  no  sounds  developed  on  auscultation  which  gave  the  physician 
any  suspicion  of  the  existence  of  an  aneurism,  but  he  found  a  dull  per- 
cussion sound  on  the  left  side  corresponding  with  the  position  of  the 
lower  lobe  of  the  left  lung.  The  following  day,  when  a  visit  was  made, 
the  patient  was  in  the  same  condition,  until  sometime  in  the  evening, 
when  his  dyspnoea  increased  all  at  once,  and  shortly  after,  uttering  a 


1866.]  PROCEEDINGS  OF  SOCIETIES.  299 

« 

sudden  cry,  he  was  dead,  A  post  mortem  examination  was  made 
when  the  cause  of  death  was  found  to  be  the  rupture  of  an  aneurism 
of  the  aorta.  The  rent  was  large,  part  of  it  being  covered  by  ad- 
herent lung. 

It  appeared  that  hemorrhage  had  taken  place  at  two  different 
periods.  Probably  the  first  one  occurred  when  the  physician  was 
first  called  to  the  patient,  but  this  rent  was  not  only  not  large  enough 
to  allow  much  blood  to  enter  the  pleural  cavity,  but  the  lung  adher- 
ing to  the  sac  prevented  much  blood  from  oozing  out.  Then,  it  ap- 
pears, at  the  time  when  the  patient  uttered  his  sudden  cry,  that  a 
complete  and  final  rupture  took  place,  filling  the  left  pleural  cavity  to 
that  extent  as  to  completely  compress  the  lower  lobe  of  the  left  lung, 
and  part  of  the  lobe  of  the  upper.  The  aneurism  was  of  the  sacculated 
variety. 

ARREST  OF  DEVELOPMENT  IN  THE  KIDNEYS  AND  OCCLUSION  OF  THE  URETERS 
AND  DUODENUM.  DR.  JACOBI. 

Dr.  Jacobi  also  presented  a  second  specimen  which  was  removed 
from  an  infant  who  died  when  four  days  old,  and  to  whom  he  was 
called  a  few  hours  subsequent  to  birth  for  the  purpose  of  being  con- 
sulted as  to  the  removal  of  a  congenital  anomaly  about  the  elbow 
joint;  the  thumb  of  the  left  hand  was  wanting,  and  there  was 
an  absence  of  the  flexors  of  the  forearm.  I  saw  the  child,  said  he, 
and  went  away  with  the  intention  of  calling  again,  inasmuch  as  my 
attention  was  directed  to  the  fact  that  it  had  not  yet  passed  any 
meconium.  I  at  that  time  introduced  my  finger  into  the  anus,  and 
also  a  probe,  and  after  a  good  deal  of  effort  succeeded  in  removing 
some  of  the  contents  of  the  intestine;  I  then  left,  feeling  quite  sure 
that  some  more  meconium  would  follow.  Until  that  time,  seven  or 
eight  hours  after  birth,  no  water  had  been  passed,  but  I  was  not  then 
made  aware  of  the  fact.  I  did  not  see  it  again  until  three  days  after- 
wards, when  the  father  came  for  a  certificate  of  death.  From  his 
description  of  the  case  since  I  saw  it,  viz.,  that  it  had  not  passed  any 
water,  neither  more  meconium,  and  that  it  had  vomited  for  the  last 
two  days,  I  concluded  that  death  had  resulted  from  some  congenital 
anomaly,  probably  from  some  occlusion  of  the  intestinal  tract  some- 
where above.  1  accordingly  declined  giving  a  certificate  until  a  post- 
mortem should  be  obtained. 

I  opened  the  infant  and  found,  first,  a  rather  small  bladder.  The 
parents  and  nurse  knew  positively  that  the  child  had  not  passed  water 
during  life.    The  bladder  as  seen  here  is  well  formed,  but  has  only  the 


300 


PROCEEDINGS  OF  SOCIETIES. 


[Jan., 


Size  of  that  organ  as  seen  in  a  child  six  months  old.  The  two  ureters 
could  be  filled  up  to  a  certain  extent  by  means  of  inflation  with  a 
small  probe-sized  canula,  but  when  a  short  distance  from  the  kidney 
were  entirely  lost  in  the  surrounding  connective  tissue.  The  kidneys 
were  both  very  small,  and  seemed  to  be  made  up  principally  of  a  pelvis, 
while  the  other  more  solid  substance  gave  no  marked  distinction  be- 
tween a  cortical  and  tubular  portion.  They  were  evidently,  from  their 
size  and  structure,  unfitted  for  the  secretion  of  urine.  The  stomach 
was  much  dilated,  as  was  also  the  upper  portion  of  the  duodenum. 
Below  this  dilated  portion  of  the  duodenum,  there  was  an  abrupt  con- 
struction, beyond  which  point  the  intestinal  tract  could  not  be  inflated 
from  below.  At  times,  as  in  this  instance,  I  have  succeeded  in  inflat- 
ing the  gall-bladder  through  the  ductus  communis,  showing  that  the 
obstruction  must  exist  above  that  point  where  this  duct  empties  into 
the  intestine. 

I  am  inclined,  from  the  length  of  the  intestinal  tract  below  the  ob- 
struction, and  from  the  condition  in  which  the  bladder  is,  to  thmk 
that  the  inflammatory  process  which  was  the  cause  of  both  the  obstruc- 
tion of  the  iotestine  and  ureters  as  well  as  the  apparent  atrophy  of 
the  kidneys,  took  place  at  about  the  same  time,  say  the  sixth  or 
seventh  month  of  pregnancy.  At  all  events,  the  bladder  is  about  the 
size  of  a  six  months'  foetus,  and  the  fact  that  there  was  well  formed 
meconium  below  the  obstructed  portion  also  goes  to  prove  that  the  in- 
testinal tract  performed  its  full  function  until  the  obstruction  took 
place.  That  this  is  only  the  result  of  an  inflammatory  process  is  certain, 
and  I  am  also  convinced  that  the  arrest  cf  development  in  the  kidneys 
and  occlusion  of  the  ureters  can  in  a  like  manner  be  explained. 

The  child  had  been  carried  to  full  term,  but  was  rather  puny.  I 
should  not  have  taken  it  for  more  than  an  eight  months'  child,  and  do 
not  suppose  that  it  could  have  weighed  more  than  five  and  a  half 
pounds. 

PHOSPHORUS  NECROSIS  DR.  J.  J.  HULL. 

Dr.  Hull  presented  a  specimen  of  two  halves  of  the  jaw  removed 
for  phosphoric  disease,  together  with  three  photographic  views  of  the 
patient  before  the  operation.  The  following  is  the  history  of  the  case 
and  operation. 

Catharine  K.,  aged  22,  a  native  of  Germany,  and  unmarried,  entered 
St.  Luke's  Hospital,  September  6th,  18G5,  with  the  following  history: 
She  had  been  in  this  country  eighteen  years,  was  of  a  healthy  family, 
and  had  always  been  well  herself  until  the  trouble  for  which  she  came 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


301 


to  the  hospital  commenced.  Two  years  ago,  after  having  been  em- 
ployed in  alucifer  match  factory  about  five  years,  she  had  three  carious 
teeth  (two  molars  of  the  right  and  one  bicuspid  of  the  left  side) 
extracted,  remaining  at  home  two  weeks  afterwards,  when  she  resumed 
work  in  the  packing-room,  in  which  department  she  was  employed 
during  her  entire  stay  at  the  factory.  At  the  end  of  nine  months 
(fifteen  months  since)  she,  for  the  first  time,  experienced  pain  in  the 
right  side  of  the  lower  jaw;  she  then  went  to  a  dentist,  who  removed 
the  remaining  molar,  telling  her  that  the  jaw  had  been  injured  by  the 
barber  who  had  extracted  the  other  teeth.  From  this  time  she 
remained  at  home,  never  going  to  the  factory  again,  recognizing  her 
trouble  as  one  arising  from  the  business  in  which  she  had  been  engaged, 
being  familiar  with  the  disease  from  seeing  it  in  others  working  at  this 
trade. 

On  admission,  she  presented  a  marked  cachectic  appearance.  The 
face  was  very  much  disfigured  by  extensive  swelling,  more  marked  on 
the  left  side.  An  exceedingly  offensive  odor  came  from  the  mouth, 
from  which  saliva,  mixed  with  pus,  constantly  dribbled.  Diseased 
bone  could  be  felt  through  two  fistulous  openings  on  the  right  side  of 
the  neck,  and  one  upon  the  left.  The  periosteum  was  much  thickened, 
and  easily  detached  from  the  jaw  on  both  sides  as  far  as  it  could  be 
reached — this  being  impracticable  to  any  great  distance,  owing  to  the 
limited  extent  to  which  the  two  jaws  could  be  separated.  The  teeth 
were  very  loose,  and  some  of  them  the  patient  removed  and  replaced 
at  pleasure.  Much  pain  was  caused  by  any  examination  of  the  dis- 
eased parts.  She  was  placed  on  a  nourishing  diet  and  tonics,  and  a 
mouth-wash  of  a  weak  solution  of  permanganate  of  potash  ordered. 

On  Wednesday,  September  13th,  1865,  I  proceeded  to  remove  the 
entire  lower  jaw  without  external  incision,  being  induced  to  operate  in 
this  manner  in  consequence  of  the  success  attending  similar  cases  in  the 
practice  of  Drs.  Wm.  Hunt  and  C.  S.  Boker,  of  Philadel[)hia,  {vide 
American  Journal  of  the  Medical  Sciences,  April,  1865,)  and  of  Dr. 
Weir,  at  St.  Luke's  Hospital,  in  this  city,  on  the  2d  of  last  August. 
In  Dr.  Boker's  case,  the  entire  lower  jaw  was  removed;  in  the  other 
cases  rather  more  than  one-half  only.  Dr.  Weir,  however,  proposes  to 
remove  the  remainder  in  his  case  at  an  early  date.  These,  as  far  as  I 
can  ascertain,  are  tiie  only  instances  in  which  the  lower  jaw  has  been 
removed  without  external  incisions.  The  patient  being  etlicrized,  and 
the  tongue  secured  by  a  strong  ligature,  and  this  held  by  an  assistant, 
the  jaw  was  divided  at  its  symphisis  by  the  chain-saw,  this  being  intro- 
duced by  means  of  its  needle  through  a  puncture  just  below  tlje  point 


302 


PROCEEDINGS  OP  SOCIETIES. 


[Jan., 


of  tlie  chin,  and  carried  beliind  tlie  diseased  bone.  The  mouth  was 
forced  widely  open  by  Gross's  lever  and  a  cheek-holder,  and  by  nieana 
of  a  cranial  elevator  and  a  curved  bluut  instrument  about  the  width 
and  thickness  of  an  ordinary  scalpel  at  its  middle;  the  right  side  of  the 
jaw  was  stripped  of  its  periosteum  over  nearly  its  entire  extent,  within 
and  without — this  process  having  been  in  part  accomplished,  with  a 
view  to  facilitate  the  operation,  a  few  days  previously.  The  ascending 
ramus  was  then  seized  with  a  powerful  bone  forceps,  and  by  a  series  of 
twisting  movements  the  whole  of  the  right  half  of  the  bone  was 
removed.  The  left  half  was  then  subjected  to  the  same  treatment,  but 
this  was  found  to  be  much  more  difficult  of  removal,  owing  to  tlie  firm 
attachment  of  the  tendon  of  the  temporal  muscle  to  the  coronoid  pro- 
cess, and  that  of  the  external  pterygoid  to  the  condyle,  the  disease  ap- 
parently not  having  extended  quite  to  the  articulations  on  this  side. 
After  a  number  of  vigorous  efforts  made  to  remove  this  half,  like  the 
other,  with  the  forceps,  the  tendon  of  the  temporal  muscle  was  finally 
divided  with  a  blunt  pointed  straight  knife,  carefully  guided  by  the 
forefinger  of  the  left  hand;  it  was  then  removed  with  the  forceps,  the 
pterygoid  muscle  having  been  ruptured  by  the  previous  traction  exerted, 
as  is  shown  by  the  specimen.  During  the  latter  half  of  the  operation, 
a  small  vessel  was  wounded,  which  bled  freely  for  a  while,  but  soon 
ceased  spontaneously.  An  examination  of  the  removed  jaw  shows  it 
to  be  necrosed  throughout,  except  at  the  articulations  on  the  left  side. 
It  should  be  remarked  that,  in  performing  this  operation,  it  was  origi- 
nally intended  to  leave  only  the  periosteum  behind;  but  in  attempting 
to  detach  it  from  the  necrosed  bone,  the  end  of  the  instrument  used 
got  between  this  and  the  involucrum,  the  latter  being  very  adherent  to 
the  periosteum.  This  having  taken  place  to  some  extent  before  being 
discovered,  it  was  decided  that  it  would  be  better  to  proceed  with  the 
operation  in  this  way,  and  leave  the  involucrum  as  a  support  for  the 
soft  parts,  as  well  as  to  see  to  what  extent,  if  any,  it  would  assist  in 
the  formation  of  the  new  bone.  It  was  accordingly  left  entire  on  the 
right  side,  and  on  the  left  as  far  as  the  angle — it,  beyond  this  point, 
adhering  firmly  to  the  bone,  as  may  be  seen  by  the  specimen.  Thus, 
the  position  of  the  face  was  not  much  altered  by  the  operation.  On 
the  following  day  considerably  increased  swelling  of  the  face,  par- 
ticularly on  the  left  side,  was  observed,  with  some  febrile  action,  but 
nothing  untoward  took  place  until  forty-eight  hours  after  the  operation. 
Then  a  slight  friction  sound  was  heard  over  the  lower  portion  of  the 
left  lung,  anteriorly,  attended  with  the  usual  constitutional  symptoms. 
A  large  fly-blister  was  at  once  applied,  and  by  the  next  day  the  patient 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


303 


was  much  better,  being  able  to  fill  her  lungs  more  freely,  the  friction 
sound  having  disappeared.  On  the  following  day,  however,  she  became 
much  worse,  and  on  the  19th  died,  very  extensive  effusion  having  taken 
place  in  the  left  pleural  cavity. 

I  regret  that  a  post-mortem  examination  could  not  be  had,  though 
every  effort  was  made  to  obtain  permission  from  the  friends. 

Dr.  Buck  remarked  that  the  pumice-stone  excrescence  could  hardly 
be  considered  as  made  up  of  true  bone.  Generally,  this  excrescence 
was  very  adherent  to  the  bone,  and  came  away  with  it;  in  Dr.  Hull's 
case,  however,  there  was  an  exception  to  this  rule. 

Dr.  Krackowizer  believed  that  this  pumice-stone  deposit  was,  in  the 
first  place,  well  formed  bone,  which  had  afterwards  become  necrosed, 
and  suffered  a  granular  degeneration.  This  degeneration  of  the 
involucrum,  he  thought,  was  quite  peculiar  to  the  disease,  and  might 
be  explained,  in  part,  by  presupposing  the  existence  of  a  pecuhar  action 
in  the  bone  before  the  necrosis  took  place,  and  partly  to  the  condition 
of  the  periosteum  on  the  bone.  At  all  events,  it  was  clearly  shown 
that  such  deposits,  which  remained  adherent  to  the  periosteum,  were 
capable  of  being  transformed  into  healthy  bone. 

DOUBLE  COMPLICATED  HAIR-LIP — DR.  GURDON  BUCK. 

Dr.  Buck  exhibited  a  specimen  which  was  one  of  abnormal  de- 
velopment, and  consisted  of  a  cast  taken  from  the  face  of  a  girl  10 
years  old,  who,  though  otherwise  well  constituted,  had  the  misfortune 
to  have  a  double  complicated  hair-lip.  The  complication  consisted  in 
the  presence  of  a  rather  remarkably  prominent  intermaxillary  bone, 
supporting  three  incisor  teeth,  the  cleft  passing  entirely  through  the 
uvula  as  well  as  the  velum. 

An  operation  was  performed,  which  consisted  in  dissecting  up  the 
flap  attached  to  the  nose,  the  median  central  flap.  That  was  detached 
then  as  the  first  step,  and  held  in  reserve.  The  projecting  inter- 
maxillary bone  was  then  pared  off  on  a  horizontal  line.  That  flap 
was  then  trimmed,  and  the  edges  squared,  so  as  to  cover  the  inferior 
edge  of  the  fresh  cut  septum.  The  lip  on  either  side  was  very  freely 
detached  as  far  outward  as  the  molar  teeth,  so  as  to  facilitate  the 
advancing  forward  of  the  two  sides,  and  bring  them  into  approxima- 
tion. The  edges  were  then  trimmed,  and  secured  by  twisted  and 
interrupted  sutures.  The  sequel  of  the  case  was  in  every  way  favorable. 
Within  a  week  all  the  sutures  were  removed,  and  a  photographic  view 
shown  proved  how  complete  the  result  of  the  operation  had  been. 

Dr.  Sayre  referred  to  a  case  of  deformity  very  similar  to  the  one 


304  REYIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Jan., 


presented  by  Dr.  Buck,  and  stated  that  in  that  instance  he  had  left 
the  septum,  crowding  it  back  somewhat,  to  form  a  support  for  the  base 
of  the  nose.  The  nose,  under  these  cireumstances,  would  be  turned  up 
a  little,  but  the  advantages  gained  in  the  support  more  than  counter- 
balanced it.  This  case  was  operated  upon  ten  years  ago,  the  third 
day  after  birth,  and  the  result  showed  the  wisdom  of  the  decision  to 
interfere  thus  early.  Although  two  incisor  teeth  were  removed  at  five 
years  of  age,  the  bone  was  firmly  adherent,  and  at  ten  years  of  age 
every  vestige  of  the  operation,  as  far  as  the  bone  was  concerned,  had 
disappeared.  He  advocated  the  practicability  and  propriety  of  per- 
forming all  such  operations  as  soon  after  birth  as  possible;  the  child 
for  the  first  two  or  three  days  would  sleep  a  great  deal,  was  very 
quiet,  and  the  healing  of  the  soft  parts  was  generally  so  rapid  that 
the  mouth  would  be  in  a  condition  to  perform  the  function  of  nursing 
when  the  mother's  breast  should  be  ready.  He  was  informed  by  Dr. 
Jacobi  that  authorities  agreed  in  recommending  the  practice  of  early 
operating,  and  was  delighted  to  know  that  his  experience  of  ten  years 
ago  was  finally  substantiated  and  recommended. 


EEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 

The  Principles  of  Surgery.  By  James  Syme,  F.R.S.E.,  Surgeon  in 
Ordinary  to  the  Queen  in  Scotland,  Professor  of  Clinical  Surgery 
in  the  University  of  Edinburgh,  etc.,  etc.,  etc.  To  which  are  ap- 
pended his  Treatises  on  "  The  Diseases  of  the  Rectum,"  "  Stricture 
of  the  Urethra  and  Fistula  in  Perineo,"  "  The  Excision  of  Diseased 
Joints,"  and  numerous  additional  contributions  to  the  Pathology 
and  Practice  of  Surgery.  Edited  by  his  former  pupil,  Donald 
Maclean,  M.D.,  L.R.C.S.E.,  Professor  of  the  Institutes  of  Medicine, 
and  Lecturer  on  Clinical  Surgery,  Queen's  University,  Canada. 
Philadelphia:  J.  B.  Lippincott  &  Co.,  1866.    8vo.,  pp.  880. 

This  work,  says  the  author,  in  his  preface,  "  was  the  text-book  of  my 
systematic  course,  and  contains  the  principles  which  I  have  endeavored 
to  illustrate  in  my  clinical  lectures  during  the  last  thirty -four  years. 
In  its  composition  my  aim  has  not  been  to  collect  all  that  might  be 
said  in  regard  to  each  subject,  but  rather  to  select  what  seemed  of 
most  importance,  and  arrange  it  in  a  convenient  order  for  teaching  or 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  305 


study,  so  as  to  constitute  a  framework  of  surgical  science,  which  might 
be  filled  up  through  the  gradual  acquisition  of  professional  knowledge." 
Of  course  reference  is  had  in  these  remarks  to  the  general  portion  of 
the  work  only— the  appendix,  comprising  349  pages,  embracing  various 
monographs  and  other  surgical  papers. 

Mr.  Syme's  reputation  and  influence,  it  need  hardly  be  said,  are  very 
great;  and  a  book  from  his  pen  can  not  but  command  respect.  He 
has  diligently  used  large  opportunities;  he  is  a  man  of  decided  opinions, 
and  knows  how  to  express  them  forcibly.  In  looking  over  the  pages 
of  the  volume  before  us,  we  are  struck  with  the  terseness  and  energy 
of  tlie  language,  and  the  practical  character  of  the  matter  conveyed. 
One  can  easily  imagine  the  charm  as  well  as  the  value  of  the  oral 
teachings  of  a  man  who  writes  thus. 

We  have  here  an  embodiment  of  the  views  and  experience  of  one  of 
the  most  eminent  and  successful  teachers  and  practitioners  of  surgery 
in  Great  Britain.  Like  many  other  writers  of  force  and  originality, 
Mr.  Syme  gives  no  extended  quotations,  or  long  list  of  references.  He 
offers  his  own  results,  evidently  with  a  firm  conviction  of  their  sound- 
ness; and  we  believe  they  may  be  consulted  with  profit  by  any  one 
who  will  weigh  them  uuderstandingly.  Our  reason  for  so  speaking  is 
that,  in  our  opinion,  so  many  jwactitioners  err  in  following  blindly  the 
authorities.  It  is  easier  to  adopt  an  idea  than  to  test  it;  and  the 
history  of  medicine  is  full  of  instances  in  which  errors  have  been  propa- 
gated, and  the  advance  of  science  hindered,  by  too  great  a  reverence 
for  ancient  landmarks.  At  the  present  day,  perhaps,  the  tendency 
among  our  leading  writers  is  rather  toward  skepticism;  but  the  timo 
will  never  come  when  there  shall  be  no  masses  feeling  the  need  of 
guidance.  The  surest  road  to  the  development,  for  these  masses,  of 
sound  principles  and  successful  practice,  is  through  the  free  and  intelli- 
gent  canvassing  and  comparison  of  theories. 

In  glancing  over  the  first  portion  of  Mr.  Syme's  work,  we  notice 
that  the  pathological  views  set  forth  tliereiu  are  not  of  the  latest  date. 
They  are,  however,  perhaps  better  adapted  to  tlie  purposes  of  an 
elementary  teacher  than  those  of  the  present  day,  which  deal  less  with 
the  differences  which  strike  the  eye  of  a  student. 

It  is  diflicult  to  select  points  for  notice  in  a  work  so  concisely  writ- 
ten;  but  we  may  mention  two,  taken  at  hazard.  Ulceus  which  do  not 
tend  to  heal  are  divided  into  three  classes:  "  1.  Ulcers  which  are 
prevented  from  healing  by  defect  of  action.  2.  Ulcers  which  are  ])re- 
vented  from  healing  by  excess  of  action.  3.  Ulcers  which  are  i)re- 
veuted  from  healing  by  peculiarity  of  action."    Again,  mammary  tu- 

Vol.  II.— No.  10.  20 


306 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Jan., 


mors  are  classed  as  "simple,  fibrous,  cystic,  carcinomatous,  ami  medul- 
lary sarcomata."  In  regard  to  plans  of  treatment,  also,  the  work  be- 
fore us  is  not  fully  up  to  the  times.  So  far  as  it  goes  it  is  excellent; 
but  it  needs  to  be  suppiemcuted  by  otlier  and  more  modern  writings. 

The  monographic  portion  of  the  volume  is,  as  might  be  supposed, 
more  entirely  satisfactory.  Besides  the  papers  mentioned  in  the 
title-page,  there  are  here  to  be  found  numerous  clinical  observations 
of  the  highest  value.  Among  these  we  are  particularly  struck  with 
the  cases  reported  of  amputation  at  the  ankle,  of  excision  of  the  entire 
scapula,  and  of  excision  of  the  tongue.  They  are  all,  however,  de- 
serving of  attentive  perusal,  and  it  is  matter  of'  congratulation  that 
they  have  been  collected  in  a  permanent  and  attractive  form. 

Mr.  Syme's  name  is,  perhaps,  most  closely  associated  with  the  method 
proposed  by  him  of  amputating  at  the  ankle,  by  sawing  oS  the  malleoli, 
the  posterior  flap  being  formed  of  the  skin  of  the  heel.  This  was  ex- 
tensively adopted  in  this  country,  and  with  great  success,  and  is  better 
suited  to  very  many  cases  than  any  other  procedure.  Of  late  years, 
however,  PirogofPs  operation,  the  os  calcis  being  sawn  through 
obliquely  downwards  and  forwards,  and  its  cut  surface  brouglit  up 
against  that  of  the  tibia,  has  been  more  fashionable.  Our  own  ex- 
perience would  lead  us  to  regard  the  two  plans  as  of  equal  merit; 
selecting  one  or  the  other  according  to  the  special  case  to  be  dealt 
with. 

Of  excision  of  the  joints  for  disease,  Mr.  Syme  is  an  ardent  advocate. 
In  America  this  practice  has  not  perhaps  been  sufficiently  tested.  Our 
impression  is  that  the  number  of  these  cases  in  this  country  is  smaller 
than  it  is  abroad.  The  shoulder,  elbow,  and  knee  are  the  joints  in 
which  the  best  results  have  been  attained.  Mr.  Syme  very  justly  ob- 
jects to  the  operation  at  the  hip,  on  account  of  the  frequent  involvement 
of  the  acetabulum,  and  thinks  that  a  favorable  issue  in  disease  of  the 
wrist  and  ankle  is  of  such  exceptional  occurrence  that  amputation  is 
preferable  when  these  joints  are  concerned. 

The  external  incision  for  the  relief  of  urethral  stricture,  an  opera- 
tion original  with  Mr.  Syme,  is  discussed  not  only  in  the  general  por- 
tion of  the  work  before  us,  but  also  in  one  of  the  monographs  in  the 
appendix.  It  is  undoubtedly  the  easiest  metiiod  of  dealing  with  many 
cases,  and  sometimes  offers  the  only  chance  of  safety  for  the  patient. 
Our  autlior  seems  to  have  had  better  success  in  avoiding  tlie  subse- 
quent occurrence  of  perineal  fistula  tlian  would  be  supposed  possible; 
his  recorded  cases  look  so  favorable  that  many  surgeons  will  be  apt  to 


1866.]  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  307 


imitate  his  practice.  Tlie  plan  should  not,  however,  be  indiscriminately 
employed. 

In  the  foregoing  brief  notice,  we  have  tried  to  present  the  impres- 
sions made  upon  us  by  the  examination  of  this  excellent  addition  to 
medical  literature,  with  fidelity.  To  sura  them  up,  we  may  say,  that 
while  it  would  not  answer  as  the  sole  surgical  guide  of  the  young  prac- 
titioner, it  contains  matter  of  the  greatest  value  and  importance  to 
any  one  who  would  acquaint  himself  thoroughly  with  the  views  of  the 
leading  men  of  the  century. 

The  typography  of  the  volume  is  not  only  elegant,  but  remarkably 
correct;  and  the  monographs  are  here  and  there  illustrated  by  means 
of  wood-cuts  of  great  merit. 

Tin  Diseases  of  the  Ear — their  Diagnosis  and  Treatment.  A  Text- 
Book  of  Aural  Surgery  in  the  form  of  Academical  Lectitres.  By 
Dr.  Anton  von  Troltsch,  Aural  Surgeon  and  Lecturer  in  the 
University  in  Wurtzburg,  Bavaria.  Translated  from  the  German 
and  Edited  by  D.  B.  St.  John  Roosa,M.D.,  Assistant  Surgeon  in 
the  N.  y.  Eye  Infirmary. 

Any  new  book  at  present  appearing  on  the  subject  of  ear  diseases, 
must  be  carefully  examined  by  our  profession,  as  in  that  branch  of 
surgery  clear  ideas  of  pathology  and  treatment  are  especially  desirable. 
Among  the  authors  in  the  English  language,  Wilde  and  Toynbee  have 
undoubtedly  done  most  for  the  advancement  of  aural  surgery.  The 
books  -of  these  gentlemen  are  at  present  difficult  to  procure,  and  are 
somewhat  too  voluminous  to  be  carefully  read  through  by  general 
practitioners.  The  work  before  us  contains  in  all  but  254  pages,  and 
comprises  the  diagnosis,  pathology,  and  treatment  of  diseases  of  the  ear. 
In  its  clearness,  simplicity,  and  brevity  it  differs  much  from  monograms 
generally.  Technicalities  are  not  numerous,  and  an  extensive  knowl- 
edge of  the  subject  treated  of  is  not  presupposed. 

We  shall  try  to  notice  the  cliief  points  wiierein  this  work  differs 
from  others  of  its  kind,  and  to  state  any  variation  from  formerly  received 
opinions. 

The  autlHjr  explains  the  modes  of  examining  the  external  ear — com- 
paring the  advantages  of  direct  and  re/lccted  light — and  giving  the 
preference  to  the  latter.  As  a  reflector,  Dr.  T.  uses  an  invention  of 
his  own:  a  concave,  silvered  mirror  of  about  six  inches  focus,  with  a 
central  perforation  for  the  surgeon  to  see  through.  The  patient  is 
placed  between  the  surgeon  and  the  source  of  light,  (window  or  lamp,) 


308 


REVIEWS  AND  BIBLIOGBAPHICAL  NOTICES. 


[Jan., 


an  ordinary  ear  speculum  is  introduced,  and  the  mirror  being  placed 
before  the  eye  of  the  surgeon,  it  is  so  directed  that  the  light  shall  be 
reflected  through  the  speculum  upon  the  membrana  tyrapani.  This 
means  avoids  the  necessity  of  a  bright  day  for  examinations;  the 
surgeon's  head  does  not  cast  a  shadow  in  the  speculum.  For  cleaning 
out  the  ear  previous  to  examinations  or  applications,  a  syringe,  or 
"angular  forccjis,"  and  cotton,  may  be  used;  while  using  these  forceps, 
or  any  instrument,  we  are  cautioned  to  have  the  meatus  illuminated  by 
direct  sunlight,  or,  better,  by  the  mirror  attached  to  the  forehead. 

A  chapter  is  devoted  to  cenminous  collections,  etc.,  which  we  are 
advised  to  remove  by  syringing.  Foreign  bodies  should  be  dislodged 
in  the  same  manner,  very  serious  injury  being  often  caused  by  attempts 
at  their  removal  with  instruments,  especially  when  -these  are  used  with- 
out proper  illumination. 

Otitis  externa,  very  often  called  scrofulous,  is  declared  to  be  a  simple 
local  disease,  often  caused  by  an  extension  of  skin  disease  or  a  foreign 
body  in  the  meatus,  and  it  will  be  cui-ed  by  local  treatment — the 
term  "  scrofulous"  being  merely  a  cloak  for  ignorance  of  its  pathology. 
This  disease  often  results  in  "otorrhcea,"  which  is  not  a  disease  itself.  In 
treatment  of  otitis  externa,  or  other  inflammation  of  the  ear,  if  poultices 
be  used,  we  are  in  danger  of  perforation  of  the  membrana  tympani. 
For  relief  of  pain  we  are  advised  to  pour  in  warm  water  frequently, 
leaving  it  in  the  meatus  about  five  minutes  at  a  time,  or  to  hold 
the  ear  over  steam.    All  applications  to  the  ear  should  be  warm. 

Writers  speak  of  "myringitis"  as  a  frequent  complaint.  Br.  T. 
considers  pure  myringitis  a  very  rare  disease.  The  membrane  of  the 
tympanum  generally  becomes  inflamed  by  the  extension  of  inflammation 
from  the  meatus,  or  from  the  middle  ear.  Acute  myringitis  he  has 
observed  on  one  side  only-  Kow  pure  myringitis  would  most  likely 
arise  from  some  injury  or  exposure  affecting  one  membrana  tympani. 
If,  however,  the  disease  described  as  myringitis  be  an  accompaniment 
of  inflammation  of  the  middle  ear,  we  know  it  would  be  likely  to  afi'ect 
both  membrana  tympani,  as  it  is  ordinarily  described  as  doing.  The 
prognosis  in  myringitis  is  stated  as  favorable;  even  perforations  of 
the  membrana  caused  by  this  disease  heal  readily. 

In  regard  to  the  use  of  the  Eustachian  catheter.  Dr.  T.  speaks 
approvingly,  except  in  case  of  children,  where  the  width  of  the  Eusta- 
chian tube  does  not  render  it  necessary.  It  may  be  used  advan- 
tageously where  there  is  a  collection  of  mucus  or  pus  in  the  middle 
ear,  and  in  closure  of  the  Eustachian  tube.    It  is  useful  both  for  di- 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


309 


agnosis  and  treatment.  By  its  means  we  may  inject  various  vapors 
into  the  middle  ear.    The  dangers  of  its  use  have  been  overrated. 

Various  instruments  recently  introduced  are  described  and  their 
uses  stated:  Toynbee's  "  otoscope"  for  auscultation  of  the  middle 
ear,  Eustachian  tube,  &c.;  Politzer's  "  tympanimeter,"  for  showing  the 
amount  of  mobility  of  the  drum;  "Troltsch's  pump,"  for  throwing 
vapors  into  the  middle  ear  through  the  Eustachian  catheter.  Liquid 
injections  are  not  spoken  well  of.  Diseases  of  the  middle  ear  arc  very 
fully  discussed.  Acute  and  chronic  catarrh,  and  acute  and  chronic  puru- 
lent inflammation,  are  each  separately  examined;  their  pathology  and 
treatment  are  given  at  length.  So-called  myringitis  is  generally  an 
inflammation  of  the  middle  ear,  in  which  one  part  of  the  process — 
inflammation  of  the  drum — is  taken  for  the  whole.  Catarrh  of  the 
middle  ear  almost  always  occurs  on  both  sides;  it  comes  suddenly;  it 
is  accompanied  by  increased  pain  at  night,  and  in  swallowing;  it  does 
not  hurt  to  move  the  auricle;  noise  in  the  ear  is  rarely  wanting  in 
this  disease,  hence,  and  on  account  of  accompanying  vertigo,  &c.,  there 
is  supposed  to  be  disease  of  the  brain  and  nervous  deafness.  In  acute 
catarrh  of  middle  ear,  on  examination,  we  find  the  auricle  and  meatus 
externus  normal,  the  drum  reddened  or  infiltrated,  the  "light  spot" 
absent.  The  handle  of  the  malleus  often  remaining  visible,  shows  that 
the  inflammation  is  deeper  than  the  membrana  tympani.  The  throat 
is  found  swollen  or  injected,  "  cold  in  the  head"  is  often  present,  and 
other  catarrhal  symptoms.  Among  the  bad  results  of  this  catarrh  of 
the  middle  ear  are,  thickening  of  the  mucous  membrane  of  the  cavity 
of  the  tympanum  and  adhesions  between  various  jiarts,  perforation  of 
drum,  &c. 

The  treatment  advised  is  the  earh/  introduction  of  tlie  catheter, 
local  blood-letting,  and  a  cathartic  of  calomel  and  jalap.  If  this  does 
not  ease  the  pain,  keep  warm  water  in  the  ear  for  fifteen  minutes  every 
hour;  let  patient  stay  in  bed,  and  give  diaphoretics. 

Chronic  aural  catarrh  often  occurs  without  pain.  Noise  in  ears, 
deafness,  mental  dei)ression,  feeling  of  pressure  in  the  head,  being  the 
chief  symptoms,  and  tliese  are  often  placed  to  the  account  of  "  nervous 
deafness."  The  only  visible  signs  of  it  being,  sometimes  a  calcareous 
deposit  on  the  nusmbrana  tympani,  or  a  change  of  size  in  the  "  light 
spot."  Post-mortem  examinations  often  show  thickening  of  the 
mucous  membrane  of  the  tympanum,  extending  to  the  articulations  of 
the  little  bones,  or  to  the  membrana  tympani  secundaria,  (membrane 
of  fenestra  rotunda.)  This  disease  is  often  caused  by  extension  of 
pharyngeal  catarrh,  or  follows  typhus  and  the  exanthemata.    In  car 


310  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Jan., 


afifections  it  is  always  well  to  examine  the  throat,  as  the  disease  often 
extends  thence.  As  in  simple  "catarrhal  inflammation,"  Dr.  T. 
divides  "  purulent  inflammation"  into  acute  or  chronic.  In  its  acute 
stage  the  disease,  from  its  s3"mptoms,  is  often  mistaken  for  myringitis. 
In  autopsies  on  infants,  evidences  of  purulent  inflammation  were  found 
remarkably  often,  they  being  absent  in  only  thirteen  out  of  forty-six 
ears  examined.  (Tliese  cases  were  among  the  lowest  classes,  very 
poorly  nourislicd.)  If  the  disease  occurs  so  often  among  infants,  it  is 
fortunate  for  their  raembrana  tympani  that  the  Eustachian  tube  is  very 
wide,  else  perforations  would  frequently  occur.  Among  the  results  of 
purulent  catarrh  of  the  middle  ear  are  mentioned  post  and  pre-aural 
abscesses,  pus  in  mastoid  cells,  &c.  Trephining  of  the  mastoid  process 
has  been  performed  several  times  successfully. 

The  existence  of  "  nervous  deafness"  is  doubted.  As  we  advance 
in  pathological  knowledge,  this,  as  well  as  other  purely  nervous  dis- 
eases, is  less  frequently  diagnosticated.  Otalgia  is  considered  a  rarity, 
and,  when  occurring,  as  being  often  dependent  on  carious  teeth. 

"Deaf-mutism"  is  considered  under  three  heads — "congenital," 
"early  acquired,"  and  "late  acquired."  The  first  is  often  attended  by 
a  partial  or  entire  lack  of  semicircular  canals.  The  second  occurs  in 
children  who,  answerably  to  their  age,  hear,  but  can  not  speak.  The 
third  comes  later  in  life.  The  latter  two  often  result  from  diseases  of  the 
cavity  of  the  tympanum,  when  no  abnormity  of  the  internal  ear  can 
be  discerned. 

From  the  above  abstracts  it  will  be  seen  that  "  otorrhoea,"  "  myrin- 
gitis," and  "  nervous  deafness"  do  not  form  the  chief  diseases  of  the  ear 
in  Dr.  Troltsch's  estimation.  Several  interesting  cases  and  many 
notes  have  been  added  by  the  editor.  It  seems  to  us  that  a  few 
pages  on  the  anatomy  (normal  and  pathological)  of  the  ear  would 
have  been  an  advantageous  prefix. 

The  translation  in  some  places,  we  think,  has  been  made  quite  too 
literal.  As  a  thoroughly  practical  and  very  readable  book,  we  con- 
sider this  volume  an  important  addition  to  the  literatm'e  of  aural 
diseases. 

On  Wakefulness.  With  an  Introductory  Chapter  on  the  Physiology  of 
Sleep.  By  William  A.  Hammond,  M.D.,  Fellow  of  tlie  College  of 
Plivsicians  of  Thiladelphia,  of  the  American  Philo-sophical  Society, 
&c.    Philadelphia:  J.  B.  Lippincott  &  Co.,  1866.     12mo,  pp.  93. 

This  monograph  is  an  enlarged,  and  in  parts  re  written,  essay  "Ou 


I 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  311 

Sleep  and  Insoimiia,"  published  in  the  May  and  June  numbers  of  this 
Jouriiiil.  It  is  divided  into  four  chapters.  The  first,  Introductory,  on 
the  Physiology  of  Sleep;  the  second,  on  the  Pathology  of  Wakeful- 
ness; a  third,  on  the  Exciting  Causes  of  Wakefulness;  and  a  fourth, 
on  the  Treatment  of  Wakefulness.  The  physiological  views  respect- 
ing the  ivimediatc  cause  of  sleep,  maintained  by  Dr.  Hammond,  are 
known  to  our  readers,  and  are  at  variance  with  those  of  most  physi- 
ologists.  He  claims  that  the  doctrine  of  a  diminished  supply  of  blood 
in  the  cerebral  tissues,  during  natural  sleep,  is  established  by  exact 
observation;  and  that  congestion  of  the  vessels  of  the  brain  is  the 
necessity  in  coma,  a  condition  in  which  the  causes  and  phenomena  are 
distinct.  The  pathology  of  wakefulness,  in  connection  with  its  excit- 
ing causes,  is  ably  and  sensibly  treated  of;  and  the  influence  of  the 
wear  and  tear  of  our  modern  life  in  causing  insomnia,  with  its  frequent 
termination  in  mental  derangement,  and  often  in  confirmed  hisanity, 
shown  by  convincing  precepts  and  examples.  Whatever  difference  of 
opinion  may  exist  regarding  Dr.  Hammond's  physiology,  there  can  be 
none  respecting  his  therapeutics.  The  treatment  of  M^akefulness  rec- 
ommended by  him  is  sound  and  rational,  and  must  command  the 
assent  of  every  physician  who  has  any  experience  with  this  distressino- 
disorder.  ° 

1.  Report  of  the  Council  of  Hygiene  and  Public  Heallh  of  the  Citizen's 
Association  of  New  York,  upon  Epidemic  Cholera  and  Preventive 
Measures.    New  York,  November,  1865.    Pamphlet,  pp.  48. 

2.  On  Epidemic  Cholera,  the  Phenomena,   Causes,  Prevention,  and 
Treatment,  with  an  Appendix  relating  to  the  Brooldyn  City  Sewer- 
age.    By  Nelson  L.  North,  M.D.,  Surgeon  Metropolitan  Police 
&c.    Reprint  from  the  Transactions  of  the  Medical  Association  of 
the  Eastern  District  of  Brooklyn.    1805.    Pamphlet,  pp.  39. 

The  Report  of  the  "  Council  of  Health"  of  the  "  Citizen's  Asso- 
ciation" is  by  Dr.  Elisha  Harris,  an  enlightened  and  practical  sanita- 
rian. In  sketching  the  progress  and  aspects  of  the  epidemic  of  1865 
a  retrospect  of  the  course  and  history  of  the  four  preceding  epidemics 
IS  taken,  with  the  view  that  the  lessons  taught  l)y  them  may  be  made 
profitable.  Tlie  present  epidemic  in  Europe  and  Africa  "appears  to 
be  as  clearly  connected  with  the  epidemic  wliich  has  been  prevailing  in 
India,  as  any  former  visitation  of  the  cholera  westward  has  been  con- 
nected with  the  outbreak  and  diffusion  of  the  epidemic  from  its  oriea- 
tal  birth-place."  It  has  followed,  too,  the  laws  established  in  previous 


I 


312 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


[Jan., 


epidemics,  as  regards  tlie  physical  and  hygienic  conditions  that  precede 
and  exist  wlierever  cliolera  elects  its  principal  seats  of  prevalence  and 
mortality.  The  usual  forerunners  of  the  scourge,  it  is  claimed,  have 
heralded  its  advent.  In  spite  of  the  rigorous  enforcement  of  quaran- 
tine regulations  in  the  ports  of  southern  Europe,  cholera  has  pursued 
its  regular  march.  The  practical  value  of  sanitary  works — cleanli- 
ness, public  and  personal,  ventilation,  drainage,  disinfection  of  foul 
places; — has  been  constantly  shown  in  the  progress  of  the  epidemic; 
and  the  consoling  deduction  can  be  safely  made  that  wiiile  Asiatic 
cholera  is,  lilve  other  epidemics,  "subject  to  certain  general  laws  of 
diffusion  and  progress  by  atmospheric  influences,  some  of  the  causes  of 
wliich  are  not  wholly  subject  to  human  control,  we  should  also  bear  in 
mind  that  those  causes  which  give  to  cholera  a  pestilential  and  exten- 
sively destructive  character,  are  known  and  preventable." 

In  all  the  previous  cholera  epidemics  in  New  York,  we  find  that  the 
cholera  fields  and  the  fever  haunts  are  the  same.  This  holds  true  of 
London  and  other  towns  in  Great  Britain.  The  localizing  causes  of 
cholera  are  found  to  be:  1.  Decaying  organic  matters,  bone,  hide,  fat 
and  offal  houses,  neglected  stables,  putrescent  mud  and  filth.  2.  Bad 
drainage,  local  dampness,  malaria.  3.  Obstructed  sewers,  filthy 
streets,  gutters,  stables,  garbage,  and  cesspools.  4.  Water  and 
bever.nges  in  any  manner  contaminated  by  putrescent  organic  matter, 
particularly  by  any  soakage  from  privies.  5.  Neglected  privies  and 
putrefying  excrements.  6.  Overcrowding  aJid  neglect  of  ventilation. 
These  have  always  been  the  most  active  of  the  exciting  causes  of  the 
pestilence,  and  are  all  obviously  controllable,  and  should  be  prevented 
and  removed  by  authority.  The  conditions  necessary  for  domestic 
and  public  health  can  not  be  disregarded  by  municipal  bodies.  A 
duty  is  involved  which  can  not  be  shirked  or  unheeded  without  crim- 
inality, and  should  be  insisted  on.  One  of  the  particular  duties  indi- 
cated in  this  report  is  district  and  house-to-house  inspection.  The 
experience  of  tlie  two  last  cholera  epidemics  in  England  has  demon- 
strated signally  the  usefulness  of  house  visitations  by  skilled  medical 
men,  and  their  practical  value  was  shown  in  this  city  during  last  winter 
by  the  sanitary  inspections  made  under  the  direction  of  the  "  Council 
of  Hygiene,"  when  ty[)hus  fever  and  small-pox  were  prevailing.  Certain 
restrictions  and  provisions  for  the  segregation  and  proper  care  of  per- 
sons arriving  in  vessels  on  l)oard  which  there  are  cliolera  cases,  are 
obviously  reasonable  enough;  but  it  is  absurd  to  hazard  the  protec- 
tion of  a  city  exclusively  upon  any  quarantine  restrictions.  The  well 
should  be  immediately  separated  from  the  sick,  and  the  latter  removed 


1866.]  PROGRESS  OP  THE  MEDICAL  SCIENCES. 


and  properly  cared  for;  prompt  measures" should  be  taken  to  prevent 
the  spread  of  the  pestilence  by  means  of  the  clothing  or  evacuations  of 
the  infected;  and  the  vessels  should  be  cleansed  and  disinfected  with- 
out loss  of  time.  But  public  attention  should  not  be  diverted  from 
the  chiefest  sources  of  danger:  1.  The  ejected  fluids  and  evacuations, 
and  besmeared  clothing  of  those  ill  with  cholera.  2.  The  overcrowd- 
ing of  human  beings,  whether  on  shipboard  or  in  unventilated  houses. 
3.  Filth,  dampness,  and  foul  air.  These  exciting  causes  of  cholera 
must  be  provided  against  by  appropriate  sanitary  regulations  and  un- 
ceasing vigilance  on  the  part  of  the  public  authorities. 

Dr.  Harris  has  appended  to  his  report  some  valuable  notes  on 
cleansing  and  disinfection. 

In  Dr.  North's  essay  we  find  nothing  deserving  of  special  notice.  If 
it  succeeds  in  directing  the  attention  of  the  authorities  of  our  sister 
city  to  "  making  preparations  to  meet  this  terrible  enemy  in  his  onward 
march  towards  us,"  it  will  have  done  good  service,  for  the  picture  he 
gives  of  the  state  of  things  in  Brooklyn  directly  bearing  on  the  incu- 
bation and  propagation  of  pestilence  is  by  no  means  reassuring  to  the 
inhabitants  or  encouraging  to  the  property  holders.    He  says: 

"  Uur  streets  are  filthy,  our  tenements  overcrowded,  our  sewer- 
age, what  there  is  of  it,  is  but  a  miserable  apology  for  the  thing  it 
should  be,  having  a  stinking  reservoir  for  filth  at  every  street  corner, 
which,  when  it  becomes  too  bad,  is  dipped  out  and  carted  off  through 
the  streets  because  the  sewer-pipes  are  not  of  sufficient  size  to  allow 
any  thing  but  the  strained  water  to  run  off  through  them.  And  our 
olfactories  meet  the  stench  from  pig  styes,  and  goat  pens,  and  hide 
tanneries,  and  fat  and  slaughter  liouses;  and  even  the  bone-boiling 
establishments  can  hardly  be  said  to  be  out  of  town,  and  one  can 
scarcely  tell,  in  fact,  why  it  is  that  wc  have  not  always  some  epidemic 
upon  us." 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 

OBSTETRICS  AND  DISEASES  OF  WOMEN  AND 
CIIILDIIEN. 

1.  On  the.  Fdcilitnlion  of  the  First  Stage  of  Labor.    By  Andhew  Inglis, 
M.D.,  F.K.C.S.E.    Bead  before  the  Edinburgh  Obstetrical  Society. 

At  present  many  different  means  are  in  use  for  favoring  the  progress 
of  the  first  stage  of  labor.    Simple  dilatation  with  the  finger  has  from 


314 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Jan., 


time  to  time  been  alternately  praised  and  decried.  Just  now  the 
voice  of  the  majority  is  in  its  favor;  and  I  am  certain  that  it  does  good 
in  some  cases,  but  only  where  the  resistance  to  dilatation  is  not  excess- 
ive. "Within  the  last  few  years,  india-rubber  dilaters  have  been  tried 
pretty  extensively,  and  they  also  have  been  found  of  service.  How- 
ever, not  only  is  considerable  difficulty  experienced  in  their  use,  but 
that  difficulty  is  usually  great  just  in  proportion  to  the  ui'gency  of  the 
case.  Sponge  tents  also  have  been  used  in  such  cases,  but  I  have 
never  seen  them  produce  any  great  result.  While  these  our  direct 
surgical  means  are  so  scanty,  there  is  no  lack  of  therapeutic  agents 
which  have  been  tried.  Injections  have  been  used  extensively,  both 
per  vaginam  and  per  anum,  consisting  of  warm  water,  as  well  as  con- 
taining opium,  belladonna,  and  other  drugs.  Medicinal  ajjplications 
to  the  same  parts,  in  a  more  concentrated  form,  have  also  been 
used. 

Remedies  intended  to  act  through  the  general  system  are  frequently 
given.  Chloroform,  which  is  the  most  valuable  of  these;  opium, 
which  also  certainly  sometimes  does  good;  tartrate  of  antimony, 
bleeding,  emetics,  purgatives,  and  ergot,  have  all  been  in  turn 
pressed  into  the  service;  but  I  think  little  need  be  said  about  their 
general  inefficiency.  My  experience  supports  what  I  believe  to  be 
the  general  oi^inion — that  it  is  precisely  where  dilation  without  inter- 
ference is  most  tedious,  that  the  foregoing  means  are  most  nearly 
inert. 

To  show  that  there  is  good  reason  for  believing  that  another  means 
— namely,  separation  of  the  membranes  for  some  distance  round  the 
OS — will  promote  dilatation  much  more  efficiently  than  any  hitherto 
proposed,  is  the  object  of  this  jiaper;  and  I  believe  that  where 
attempts  at  direct  dilatation  have  been  successful,  the  success  has 
been  in  great  j^art  owing  to  unintentional  separation  of  the  mem- 
branes. In  pursuance  of  my  object,  I  shall  call  attention  to  the 
effect  on  the  character  of  labor  of  such  a  sei:)aration,  either  as  occur- 
ring spontaneously  or  effected  artificially  for  its  induction  or  facili- 
tation. 

In  the  first  stage  of  labor  coming  on  and  proceeding  without  inter- 
ference, there  are  two  opposite  conditions  of  the  jjassages — one  in 
which  there  is  a  copious  discharge  of  viscid  mucus,  and  which  is 
often  called  a  "  wet  labor;"  and  another,  in  which  there  is  hardly  any, 
and  labor  is  called  "  diy."  At  the  full  time,  the  first  seems  to  occur 
normally  in  the  cow,  mare,  bitch,  etc.,  and,  I  am  inclined  to  believe, 
is  natural  also  in  the  human  female.  I  consider  the  following  as 
being  the  natural  jirocess  in  women:  The  ovum  having  become  ripe, 
the  membranes  sei^arate  fi'om  the  cervical  portion  of  the  uterus,  if 
not  from  the  whole  surface.  They  then  by  their  weight  press  more 
heavily  against  the  cervix,  even  when  the  patient  is  lying  down;  and 
as  the  pressure  is  soft,  equable,  and  continuous,  the  cervix  gradually 
yields  to  it  and  becomes  quite  slack,  and  this  takes  place  without  the 
occurrence  of  jjain.  Next,  when  relaxation  has  become  complete,  the 
mucous  discharge  commences,  i^roceeding  from  the  uterus.  Finally, 
a  i^ain  comes  on  and  terminates  the  first  stage.  That  the  discharge 
comes  from  the  uterus  is  shown  by  its  protruding  from  the  os  previous 
to  its  ajspearance  in  the  vagina.  Besides,  it  is  only  found  when  the 
membranes  are  already  separated,  and  is  very  often  tinged  with  blood 
before  pains  have  been  felt.  A  process  resembling  this  form  of  the 
first  stage  may  bo  seen  where  the  other  muscular  canals  are  con- 
cerned, and  perhaps  most  prominently  in  the  case  of  the  rectum.  If 


1866.]  PROGRESS  OP  THE  MEDICAL  SCIENCES.  315 


the  finger  or  bougie  is  gently  and  cautiously  inserted  past  the  sphinc- 
ter ani,  and  kciDt  there  for  some  time,  comj^lete  relaxation  gradually 
ensues,  a  jirofuse  discharge  from  within  the  sphincter  comes  on,  and, 
if  the  bougie  is  allowed  to  remain  long  enough,  the  muscular  fibres 
above  begin  expulsive  action. 

The  foregoing  explanation  seems  equally  applicable  to  "wet"  cases 
of  abortion  or  miscarriage  in  the  human  subject,  except  that  in  such 
cases  health  yripening  of  the  ovum  can  not  be  said  to  be  the  cause  of 
the  separation  of  the  membranes. 

The  other  form  of  the  first  stage,  which  T  have  designated  "dry," 
is  very  different.  Preliminary  to  labor  there  is  no  separation  of  the 
membranes,  and  consequently  no  slackening  of  the  cervix,  and  there 
results  a  great  increase  in  the  amount  of  uterine  exertion  required, 
even  where  nothing  worse  is  entailed;  for,  though  separation  and 
dilatation  generally  at  last  take  j^lace,  they  do  so  only  at  the  expense 
of  multii^lied  and  more  distressing  pains.  At  best,  the  pains  may 
stop  for  a  time  after  causing  some  separation,  and  labor  on  their 
return  may  thereby  then  come  to  take  on  the  "wet"  form;  but  very 
often  no  such  intermission  occurs,  and  dilatation  costs  a  long  series 
of  wearing-out  pains.  Moreover,  the  membranes  may  rupture,  requir- 
ing dilalation  to  be  effected  by  the  foetus,  and  therefore  even  slower 
and  more  painful.  Again,  sometimes  the  imperfectly  dilated  cervix 
is  forced  into  the  jjelvis  along  with  the  head,  and  becomes  jammed 
between  the  two,  increasing  greatly  the  pain  and  delay.  Lastly,  the 
resistance  to  dilatation  may  cause  permanent  cessation  of  the  pains, 
or  the  cervix,  or  body  of  the  uterus,  or  both,  may  rupture. 

For  some  time,  when  first  in  i^ractice,  I  was  in  the  habit  of  inducing 
premature  labor  in  cases  requiring  such  interference,  either  by  intro- 
ducing a  catheter  between  the  membranes  and  the  viterus  and  leaving 
it  there,  or  by  using  sponge  tents.  In  these  cases,  labor  often  came 
on  very  soon,  though  a  few  resisted  for  a  long  time  the  action  of  both 
means  combined,  and  the  membranes  had  to  be  i-uj^tured  before  jjains 
could  be  made  to  come  on  regularly;  but  in  all  cases,  whether  labor 
followed  at  once  or  came  on  only  after  great  expenditure  of  time  and 
trouble,  the  first  stage  was  slow  and  painful,  and  in  some  the  pains 
continued  for  days  before  dilatation  was  comi^lete. 

About  eighteen  months  ago,  I  attended  a  case  where  Dr.  James 
Sidney  brought  on  premature  labor  by  the  late  Dr.  Hamilton's  method. 
By  means  of  Dr.  Hamilton's  uterine  bolt,  he  sejiarated  the  membranes 
for  some  inches  round  the  cervix,  and  the  instrument  was  passed  in  and 
turned  around  every  twelve  hours.  About  forty-eight  hours  after  the 
first  separation  of  the  membranes,  the  os  was  soft  and  dilatable,  and  a 
little  discharge  was  apparent  at  the  top  of  the  vagina.  Six  hours  later, 
I  found  the  discharge  copious;  a  few  minutes  after  I  had  ascertained 
this  by  examination,  labor  came  on  suddenly;  and  in  three  or  four 
pains  the  fii'st  stage  was  completed,  and  the  head  well  down  in  the 
pelvis. 

Soon  after  this  I  induced  i^remature  labor  in  the  same  manner  in 
another  case.  In  about  forty-eight  hours  the  discharge  was  coi)ious,  and 
the  OS  soft  and  dilatable,  but  no  pains  had  appeared;  but  immedi- 
ately after  my  examination  one  pain  came  on  and  completed  both 
stages. 

Since  the  first  of  these  cases  I  have  never  emiiloyed  any  other 
means  for  inducing  premature  labor,  being  convinced  that  it  is  the 
easiest  for  the  patient,  though  not  always  the  speediest.  The  first 
stage  of  labor  induced  by  it  seems  identical  in  all  respects  with  that 
of  the  "  wet"  form  of  labor  occurring  si)ontaneously. 


316 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


[Jan., 


The  circumstance  of  the  first  stage  of  labor  so  induced,  presenting 
so  favorable  a  character,  has  led  me  to  use  that  separation  also  for  the 
facilitation  of  labor  already  begun  in  cases  rendered  tedious  by  so- 
called  rigidity  of  the  os.  The  number  of  cases  in  which  I  have  had 
recourse  to  this  mode  of  procedure  is  perhaijs  not  yet  sufficiently  con- 
siderable to  entitle  me  to  lay  much  stress  on  these  as  bearing  on  my 
argument;  but  I  may  state  that  all  of  them  which  can  be  considered 
as  affecting  the  question  seem  to  support  the  practice  I  am  advocat- 
ing.   The  following  are  particulars  of  a  few: 

To  recajoitulate — 

1st.  The  easiest  form  of  the  first  stage  of  labor  is  characterized  by 
protrusion  of  the  membranes  and  a  copious  discharge. 

2d.  These  are  always  direct  consequences  of  separation  of  the  mem- 
branes. 

3d.  The  result  of  artificial  separation  seems  precisely  similar  to 
that  of  spontaneous. 

The  following  is  the  practice  I  would  recommend  in  regard  to  sepa- 
ration of  the  membranes:  1st.  That  it  should  always  be  the  initial 
mea.sure  in  the  induction  of  premature  labor;  and  that  until  complete 
relaxatiou  of  the  os  has  resulted  from  it.  there  should  be  no  further 
interference  of  any  other  kind;  2d.  That  when  labor  has  begun 
without  jirevious  separation  of  the  membranes,  and  these  are  still 
adherent,  tliey  should  always  be  at  once  separated,  as  the  best  means 
of  overcoming  the  rigidity  of  the  os,  and  the  painful  and  prolonged 
first  stage,  which  almost  invariably  accompany  such  a  state  of  matters. 

In  the  latter  of  these  two  cases,  if  the  pains  are  severe  and  ineffect- 
ive, I  should  be  inclined  to  recommend  sedatives  to  be  given  at  the 
same  time,  in  the  hoiJe  of  gaining  time  for  painless  relaxation  to  take 
place. 

With  regard  to  the  means  of  separating  the  membranes,  I  have  in 
most  cases  been  able  to  do  it  with  the  finger,  though  in  one  or  two  an 
instrument  was  required.  In  one  case,  which  I  have  not  reported,  I 
could  not  at  first  get  the  finger  far  enough  in  to  effect  any  extensive 
separation;  but  the  small  portion  round  the  os,  which  was  thus  denu- 
ded, was  so  relaxed  an  hour  after  that  I  was  able 'to  insert  the  whole 
finger  and  sej^arate  to  the  desired  extent. — Edinburgh  Med.  Journal. 

2.  The  Management  of  the  Third  Stage  of  Labor.  By  Dr.  H.  Eastlake. 

Having  briefly  described  the  opinions  which  existed  amongst  the 
accoucheurs  of  times  gone  by,  the  author  proceeds  to  give  an  account 
of  the  modern  views  and  princijDles  which  govern  the  placental  stage 
of  labor.  Dr.  Eastlake  lays  great  stress  upon  the  hand  being  i^laced 
firmly  on  the  fundus  uteri  at  the  moment  the  child  is  being  exijelled, 
the  uterus  being  thus  followed  down,  and  the  contraction  maintained 
by  gentle  jDressure.  He  states  that  external  manipulation,  judiciously 
applied,  was,  in  the  majority  of  instances,  quite  sufiicient  per  se  to 
effect  the  expulsion  of  the  afterbirth,  without  any  traction  whatever 
on  the  funis.  He  believes  that  the  great  secret  is  to  exert  the  pressure 
during  a  contraction;  in  short,  to  act  in  unison  with  nature  as  we  did 
in  the  application  of  forceps,  where  we  applied  our  chief  force  at  the 
moment  of  a  jjain.  Dr.  Eastlake  says  he  had  no  doubt  that  many 
would  imagine  that,  after  all,  this  was  no  modern  idea;  but  he  de- 
monstrates that  this  teaching  was  not  definitely  described  and  insisted 
on  in  our  manuals  of  obstetrics.  Dr.  Crede,  the  Professor  of  Midwifery 
at  Leipsic,  ajjpeared  to  be  the  only  one  who  had  advocated  this  doc- 


1866.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


317 


trine  and  brought  it  prominently  before  the  profession.  The  author 
next  considers  the  subject  of  retained  i^lacenta,  and  alkides  to  the 
various  causes  which  arrest  nature's  process  of  extruding  the  after- 
birth. The  three  steps  in  the  natural  expulsion — namely,  (1)  the  de- 
tachment from  the  wall  of  the  uterus,  (2)  its  extrusion  from  the  uterine 
cavity,  and  (3)  its  expulsion  from  the  vagina — are  duly  recognized  and 
dwelt  \ipon.  Regarding  the  subject  of  morbid  adhesion  of  the  pla- 
centa. Dr.  Eastlake  throws  out  a  suggestion  as  to  the  possibility  of 
being  able  to  diagnose  this  condition  by  means  of  auscultation  He 
reasons  by  analogy  in  stating  that  for  a  long  time  he  had  been  fully 
persuaded  that  by  means  of  auscultation  we  often  possess  not  only  a 
negative  but  a  positive  sign  of  foetal  death.  He  describes  a  peculiar 
modification  of  the  uterine  souffle,  which  to  his  ear  was  very  charac- 
teristic when  fa3tal  life  had  been  extinct  for  any  time.  The  alteration 
in  tone  suggested  the  idea  of  a  muffled  sawing  noise,  very  different  to 
the  gentle  blowing  murmur  heard  in  normal  cases,  where  a  living  child 
existed  in  utero.  How  soon  th6  modification  took  place  the  author  is 
unable  to  state,  from  want  of  sufficient  field  for  observation.  He  con- 
siders that  no  ergot  of  rye  should  be  given  in  cases  of  retained  pla- 
centa, unless  we  were  quite  sure  that  no  abnormal  adhesion  or  irregu- 
lar contractions  existed.  In  cases  of  spasm  of  the  os  uteri,  where  the 
placenta  became  encysted,  the  admini.stration  of  chloroform  is  recom- 
mended. Another  point  of  interest  alluded  to  by  Dr.  Eastlake,  bear- 
ing upon  the  subject  of  his  paper,  is  the  occasional  existence  of  a  sup- 
plemental afterbirth,  which  was  spoken  of  by  Dr.  Barnes,  Dr.  M'Clin- 
tock,  and  other  authors,  under  the  name  of  placenta  suvcenturiata  or 
placenta  spuria.  Dr.  Eastlake  has  seen  a  specimen  of  such  an  after- 
birth in  the  museum  of  the  Lying-in  Hospital  in  Dublin,  obtained 
from  an  ovum  of  five  months.  When  such  a  mass  remained  in  the 
uterus  after  the  true  placenta  had  been  expelled,  it  often  gave  rise  to 
secondary  hemorrhage,  and  an  impression  arose  that  due  caution  had 
not  been  exercised  in  the  extraction  of  the  afterbirth.  He  agrees  with 
Dr.  M'Clintock  that,  remembering  the  possibility  of  such  an  occur- 
rence, we  should  be  slow  to  utter  any  opinion  which  would  damage 
the  character  of  a  professional  brother.  In  conclusion,  the  author 
alludes  to  the  several  conditions  which  generally  authorize  us  to  have 
recourse  to  a  sf)eedy  removal  of  the  placenta,  such  as  posti:)artum 
hemorrhage,  convulsions,  rupture  of  the  uterus,  and  possibly,  under 
certain  circumstances,  where  the  uterus  was  inverted,  with  the  after- 
birth still  adherent. — {Proceedings  of  Obstetrical  Society  of  London.) — 
Medical  Times  and  Gazette. 

3.  On  Dilatation  of  tlie  Os  Uleri  during  Labor  brj  Licisions.    By  Dr.  H. 
HiLDEBRANDT,  of  Konigsbcrg. 

The  author  commences  by  a  brief  account  of  nine  labors,  in  seven 
of  which  primipariB,  advanced  in  life,  suffered  from  rigidity  of  the  os 
uteri;  against  which  ipecacuanha,  opium,  poultices,  baths,  bleedings 
and  chloroform  were  all  unavailing.  Incisions  were  made,  after  which 
all  the  cases  were  fortunately  terminated.  Incisions  were  also  made, 
with  a  like  favorable  I'esult,  in  one  case  of  convulsions,  and  in  one  of 
prolapsus  of  the  cord. 

He  proceeds  to  consider  the  supposed  risks  that  have  deterred 
accouclieurs  from  the  performance  of  the  operation.  It  has  been 
feared  that  the  pain  of  incisions,  in  a  part  already  irritated  by  fcetal 
pressure,  and  in  persons  inclined  to  nervous  disorder  by  prolonged 


318 


EDITORIAL. 


[Jan., 


labor,  might  be  productive  of  mischief.  This  fear  is  wholly  ground- 
less; the  incisions  themselves  being  scarcely  felt  by  the  patient,  and 
the  relief  actually  afforded  by  them  being  very  great.  Others  have 
dreaded  an  extension  of  the  incisions  during  pain,  so  that  they  might 
come  to  involve  the  sitbstance  of  the  uterus,  and  produce  the  fatal 
effects  of  rupture.  This  is  visionary.  The  incisions  do  sometimes 
yield  a  little,  but  never  so  far  as  to  reach  even  the  cervical  portion  of 
the  womb;  and  the  operator,  by  relieving  an  impediment  to  the  ad- 
vance of  the  fojtus,  diminishes  instead  of  increases  the  danger  of  rup- 
ture. Lastly,  it  has  been  feared  that  excessive  hemorrhage  might 
attend  or  follow  the  incisions,  but  this  fear  is  never  realized  in  prac- 
tice. In  cases  that  require  such  treatment,  the  os  uteri  is  morbidly 
changed,  and  so  bloodless  that  the  hemorrhage  from  the  incisions 
does  not  exceed  a  few  drops.  Where  incisions  are  made  into  a  healthy 
uterus,  in  order  to  effect  rapid  delivery,  the  bleeding  may  be  greater, 
but  its  source  is  always  accessible,  and  it  may,  therefore,  always  be 
readily  controlled,  while,  in  such  cases,  which  are  almost  limited  to 
eclampsia  and  placenta  prievia,  the  danger  from  hemorrhage  can 
never  be  equal  to  the  danger  of  delay.  The  operation  is  chiefly  indi- 
cated, however,  in  morbid  conditions  of  the  vaginal  portion  of  the 
cervix,  such  as  rigidity,  hypertrophy,  and  malignant  disease.  For 
forced  delivery,  with  a  healthy  cervix,  the  incisions  should  be  six  or 
eight  in  number,  and  not  more  than  three  lines  in  depth. — Half-yearly 
Abstract  of  the  Medical  Sciences. 


EDITORIAL. 

The  record  in  relation  to  cholera  at  this  port  remains  about  the 
same  as  last  month.  We  have  no  well  authenticated  case  reported  as 
having  occurred  beyond  the  vessels  which  have  arrived  in  the  outer  har- 
bor. All  suspected  vessels  have  been  rigidly  quarantined,  and,  when 
the  evidences  of  disease  have  been  marked,  passengers  with  their  cloth- 
ing, the  cargo  and  the  vessel,  have  been  subjected  to  a  species  of  dis- 
infecting fumigation  by  the  health  officers.  This  is  one  fact,  and  an- 
other is  that  the  disease  has  not  spread  beyond  the  vessels  and  their 
living  freight. 

It  is  reported  that  the  epidemic  has  made  its  appearance  in  the  island 
of  Guadaloupe,  West  Indies,  not  far  distant  from  our  Southern  ports. 

la  Europe  the  excitement  has  more  or  less  subsided.  England  has 
thus  far  comparatively  escaped,  notwithstanding  the  constant  commu- 
nication between  it  and  the  infected  places  of  Continental  Europe,  of 
both  travelers  and  articles  of  merchandise.  Medical  writers  do  by  no 
means  suppose  that  the  epidemic  has  expended  itself,  but  look  for  a 
fresh  outbreak  of  the  disease  during  the  coming  spring. 

The  total  number  of  deaths  in  Paris,  officially  returned,  from  Oct.  1 
to  Dec.  3,  inclusive,  amounts  to  6,011;  of  these  4,602  occurred  in 


1866.] 


EDITORIAL. 


October,  1,365  in  November,  and  44  iu  December;  of  the  whole, 
3,845  were  in  prisons  and  hospitals,  and  1,835  in  private  hospitals; 
the  rest  are  not  acconnted  for. 

Thns  far  the  disease  has  shown  itself  in  its  most  virulent  form.  We 
can  give  no  better  account  of  it,  as  it  has  prevailed  in  Eg-ypt,  along 
the  Mediterranean  coast  and  in  Paris,  than  is  portrayed  in  the  com- 
munication to  the  Medical  Times  and  Gazette,  Nov.  18,  of  John  Pat- 
terson, M.D.,  of  the  Egpytian  medical  service,  On  the.  late  Pestilence 
in  Cairo,  from  which  we  make  the  following  extracts: 

In  its  most  fatal  forms  the  disease  presented  the  following  charac- 
ters: Sudden  and  acute  pain  in  the  epigastrium,  with  a  feeling  of 
great  nervous  depression  and  chilliness ;  a  large  bilious  motion  sud- 
denly passed,  frequently,  but  not  always,  followed  by  a  large  watery 
motion  within  a  few  minutes,  having  mucous  flocculi  floating  on  it; 
nausea,  with  or  without  vomiting,  tlie  vomited  matter  being  the  same 
as  that  of  the  last  motion.  The  bladder  was  emptied  with  tlie  first 
motion;  afterwards  no  urine  was  passed.  In  the  worst  cases  no  more 
purging  or  vomiting;  ljut  if  the  latter  contined,  it  was  not  at  all  spas- 
modic, the  patient  simply  ejecting  the  fluid  from  the  mouth  in  a  full 
stream,  and  without  effort;  pulse,  from  the  first,  scarcely  perceptiljle; 
tongue  white  and  cold;  breath  cold;  voice  husky  and  weak;  skin  cov- 
ered with  a  viscid  moisture,  which  often  appeared  suddenly  and  at  dif- 
ferent stages  of  the  malady.  In  an  hour,  or  less,  dead  collapse  set  in, 
and  the  patient  expired  within  six  or  eight  hours,  showing  great  rest- 
lessness. In  all  the  cases  the  mental  faculties  were  perfectly  clear  to 
the  very  last  moments.  In  many  of  the  cases  the  collapse  was  more 
sudden;  the  patient  was  struck  down  as  if  by  a  blow;  there  was 
neither  purging,  vomiting,  nor  cramps — all  the  functions  were  sud- 
denly suspended,  yet  the  intelligence  remained  perfect.  Of  thirty-four 
deaths  in  this  class,  more  than  half  died  within  eight  hours;  the  long- 
est period  was  eleven  hours,  only  excepting  three  or  four  who,  after 
coming  out  of  collapse,  died  from  exhaustion  and  want  of  functional 
power.  A  second  mode  of  invasion  was  ecpially  well  marked:  Sud- 
den purging,  and  vomiting;  mild  cramps  of  the  leg  and  abdomen; 
great  oiipression  of  breathing,  and  feeling  of  heavy  weight  at  epigas- 
trium; marked  diminution  of  the  pulse;  coldness  of  the  surface  of  the 
body;  restlessness  and  anxiety.  The  Skin  assumed  a  dark  leaden  hue, 
which  was  wanting  in  the  more  sudden  cases.  Collapse  gradually 
came  on.  Tlie  purging  and  vomiting  seemed  always  to  cease  in  these 
cases  just  as  the  collai)se  was  fairly  established,  or  a  little  before;  no 
secretion  of  urine.  This  form  was  as  fatal  as  the  first,  only  a  few 
hours  longer  continued,  death  generally  occuring  within  twelve  hours; 
intelligence  also  ))crfect. 

The  tiiird  form  of  invasion  varied  somewhat.  Cramps  were  gener- 
ally the  first  symptom,  more  or  less  violent;  the  i)nrging  and  vomiting 
severe,  innnense  (luaiitities  of  a  whitish,  whey-like  fluid  being  i)a.ssed, 
with  mucous  epithelium  floating  on  it;  function  of  kidneys  suspended. 


320 


EDITORIAL. 


[Jan. 


In  all  these  cases  engorgement  of  the  liver  was  more  or  less  manifest; 
the  organ  itself  could  often  be  felt  distinctly,  and  seen  bnlgiiig  much 
beyond  its  natural  limits.  The  pain  in  the  epigastrium  was  not^scvere 
in  these  cases,  nor  was  the  sensation  of  weiglit  mucii  complained  of. 
The  collapse,  though  well  pronounced,  did  not  ])artake  of  tlie  same 
deadly  characters  as  in  eitiier  of  the  t'^o  former  modes  of  invasion. 
The  greater  number  of  these  cases  recovered  from  tlic  collapse;  many, 
however,  died  from  congestion  of  the  brain  and  other  organs,  and  in 
all  the  convalescence  was  comi)licated  by  local  congestions.  '  In  one 
case  no  urine  was  passed  for  five  days,  "yet  the  patient  recovered. 
Several  had  severe  jaundice. 

These  are  three  well  marked  modes  of  invasion  observed  in  a  varied 
practice  amongst  almost  every  variety  of  tlie  human  race.  Many 
cases,  of  course,  could  not  be  referred  to  any  distinct  class,  yet  one 
circumstance  marked  a  great  difference  between  this  ei)idemi'c  and  a 
previous  one  in  Egypt  in  1855,  viz.,  that  pi'eraonitory  diarrlioea  was 
not  a  distinctive  character  of  the  disease.  The  majority  of  tlie  cases 
had  no  premonitory  diarrhea;  they  were  men  and  women  struck  down 
in  the  prime  of  life  and  in  good  health. 

Post-mortem  examinations  have  thrown  no  new  light  on  the  true 
nature  of  tliis  malady, — pulmonary  and  hapatic  engorgement;  heart 
loaded  with  black,  thick  blood;  stomach  and  intestines  generally 
bloodless,  containing  more  or  less  of  a  thin  milky  fluid;  a  giairy  sort 
of  mucus  adhering  to  the  mucous  membrane  of  the  intestinal  canal. 
The  memljrane  itself  had  a  sodden,  cedematous  apj)earance,  and  could 
be  as  easily  separated  from  the  subjacent  tissues  as  the  rind  from  a 
mandarin  orange;  the  kidneys  healthy;  urinary  bladder  firmly  con- 
tracted. The  medicines  were  found  in  the  stomach  as  tliey  had  been 
administered  a  few  hours  before,  clearly  proving  how  little  good  they 
could  do  in  such  cases.  As  a  rule,  the  secondary  fever  presented  a 
marked  typhoid  character,  not  admitting  very  active  treatment.  It 
was  more  severe  in  the  cases  where  the  collapse  had  been  milder,  but 
longer  continued;  more  active  where  the  collapse  had  l^een  sudden, 
and  of  shorter  duration.  The  most  marked  symptom  during  recovery 
from  true  cases  of  the  pestilence  was  the  enormous  quantity  of  black, 
oily  looking  matter  passed  by  stool. 

—  More  medical  journals  are  announced  in  the  South.  Dr.  Frank 
Ramsey,  of  Memphis,  Tenn.,  has  issued  a  prospectus  for  a  Medical  and 
Surgical  Monthly,  to  be  published  in  that  city.  Dr.  Beunet  Dowler 
purposes  to  revive  the  New  Orleans  B'ledical  and  Surgical  Joimial,  of 
which  he  was  for  many  years  the  editor.  It  is  rumored  that  a  fort- 
nightly medical  journal  will  soon  appear  in  this  city.  Its  title  has  not 
been  announced.    It  is  said  that  Dr.  Geo.  F.  Shrady  will  be  the  editor. 

—  The  attention  of  the  Alumni  of  the  College  of  Pliysicians  &  Sur- 
geons is  called  to  the  advertisement  in  this  issue  of  the  Journal. 

—  Dr.  Richet  succeeds  Prof.  Malgaigne  in  the  Chair  of  Surgery  at 
the  Paris  School  of  Medicine,  made  vacant  by  the  death  of  the  latter. 


ISTE  W  YORK 

MEDICAL  JOURNAL, 

A  MONTHLY  RECORD  OP  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
FEBRUARY,   1  8  6  6. 


OEIGINAL  COMMUNICATIONS. 

Paralysis  from  Peripheral  Irritation,  loith  Reports  of  Cases. 
ByS.  Weir  Mitchell,  M.D.,  Philadelphia. 

The  writings  of  many  of  the  older  physicians,  as  "well  as 
those  of  a  later  day,  contain  numerous  cases  of  palsy,  local  or 
general,  which,  upon  cadaveric  section,  revealed  no  material 
lesion.  To  such  cases  various  names  have  been  affixed,  with 
the  intention  of  grouping  a  set  of  unexplained  facts,  or  of  indi- 
cating by  the  nomenclature  the  writer's  view  of  the  mode  in 
which  the  malady  was  produced. 

It  thus  happens  that  the  cases  referred  to  have  been  classified 
under  such  terms  as  idiopathic  paralysis,  essential  paralysis, 
functional  paralysis,  inhibitory  palsy,  paralysis  by  exhaustion, 
reflex  paralysis. 

The  industry  of  modern  clinical  observers  has  increased  the 
number  of  these  cases,  and  it  has  gradually  become  apparent 
that  they  difTer  very  widely  as  to  their  original  causation,  and 
perhaps  also  as  to  the  condition  of  the  neural  organs  which 
corresponds  to  the  various  groups. 

Of  late,  however,  the  temptings  of  an  ingenious  theory,  set 
forth  by  a  neurologist  of  great  ability,  has  led  many  physicians 

Vol.  II.— No.  11.  21 


322 


PARALYSIS  FEOM 


[Feb., 


to  follow  him  in  a  view  of  these  cases  which  unites  them  all 
in  one  single  class,  whose  nomenclature  is  meant  to  point  out 
the  pathological  mechanism  which  gives  rise  to  their  occur- 
rence. 

Numerous  cases  of  paralysis  without  apparent  lesion,  are  to 
be  found  scattered  throughout  the  older  writers,  as  Forestus, 
"Willis,  Abercrombie,  Brctonneau  and  Ollivier.  Whytt,*  Avho 
gave  larger  development  and  a  new  direction  to  the  theory  of 
sympathies  held  by  Willis  and  others,  does  not  report  any 
case  of  palsy  as  due  to  sympathy. 

In  the  year  1833,  Mr.  Stanley  published  a  paper,  entitled, 
"  On  Irritation  of  the  Spinal  Cord  and  its  Nerves,  in  connection 
with  Disease  in  the  Kidneys."  (Med.-Chir.  Tr.,  vol.  xviii.,  p. 
260.)  He  gives  instances  in  which  irritation,  commencing 
in  the  nerve  of  an  internal  organ — the  kidney  or  bladder — has 
been  transmitted  through  the  spinal  cord  to  the  motive  and 
sentient  nerves  of  the  limbs,"  so  as  to  cause  paralysis  of  the 
legs. 

About  the  same  time,  or  rather  later.  Dr.  Graves  reported  a 
set  of  cases  of  paraplegia  due  to  intestinal  and  other  enteric 
maladies.  Here,  for  the  first  time,  the  term  reflex  is  used  as 
applied  to  palsies  occasioned  by  a  morbid  cause  acting  on 
some  peripheral  part  of  the  body. 

In  1841,  Rayer  (Maladies  des  Reins)  reported  a  number  of 
paralyses  without  observed  lesion,  and  due,  as  he  supposed,  to 
pre-existent  disease  of  the  genito-urinary  organs,  but  notably 
of  the  kidneys.  He  did  not  theorize  at  all  upon  the  mode  of 
their  production. 

Important  sets  of  cases,  presumed  to  be  paralysis  without 
lesions,  and  of  peripheral  origin,  are  to  be  met  with  in  papers 
by  Leroy  d'Etiolles,  1857,  Landry,  1855,  and  Macario,  1857. 
The  principal  literature  of  the  subject  is  completed  when  we 
enumerate  the  two  essays  by  Brown-S^quard,  1860  and  1861, 

*  On  page  165  of  Brown-Sequard's  Lecture  on  the  Physiology  and  Pathology 
of  the  Cerebral  Nervous  System,  Phila.,  1860,  he  states  that  Whytt,  on  Nervous 
Diseases,  etc.,  p.  18,  quoting  Hildanus,  records  cases  of  paralysis  caused  by 
pressure  on  a  sensitive  nerve  or  by  wounds.  I  have  been  unable  to  discover 
this  reference.  Whytt  does  not  give  any  case  of  sympathetic  paralysis,  although 
to  sympathy  he  attributes  a  great  number  of  other  morbid  phenomena.  Jac- 
coud,  p.  312,  also  ascribes  to  Whytt  the  mention  of  sympathetic  palsies. 


1866.] 


PERIPHERAL  IRRITATION. 


323 


in  Avhich  he  used  the  term  reflex  paralysis,  attributed  it  to  con- 
traction of  spinal  vessels,  induced  by  peripheral  stimulus,  and 
claimed,  as  thus  created,  a  vast  number  of  cases  of  palsy,  in- 
cluding the  bulk  of  those  previously  reported  as  without  lesion. 

This  work  called  forth  a  l)rilliant  critical  paper  by  Mr. 
Gull,  (Med.-Chir.  Tr.,  vol.  xviii.,)  who  had  already  objected, 
in  1856,  to  the  urinary  paraplegia  of  Stanley.  Dr.  Brown-S4- 
qnard  lias  also  been  met  with  objections  by  Nasse  and  Vallen- 
tin,  whose  papers  I  regret  not  to  have  seen. 

I  propose  in  this  present  essay  to  examine,  as  far  as  possible, 
the  sets  of  cases  attributed  to  peripheral  causes  acting  through 
afferent  nerves,  and  so  ascertain  which  of  them  it  is  reasonable 
to  presume  may  have  been  otherwise  brought  about  than  in  the 
manner  just  mentioned.  I  shall  then  consider  with  care  the 
etiology  of  those  cases  which  still  remain  to  us,  with  a  view  to 
determine  whether  they  are  due  to  reflex  paralysis  of  spinal 
blood-vessels,*  or  to  over-excitation  and  exhaustion  of  the 
central  ganglia,t  the  two  views  which  are  now  most  favorably 
entertained  by  neurologists. 

The  following  varieties  of  paralysis  have  been  claimed  as  of 
peripheral  origin: 

1.  Paralysis  arising  during  diseases  of  the  genito-urinary 
organs. — (Stanley,  Graves.) 

2.  Those  which  occur  during  or  just  after  dysenteries, 
diaj-rhoeas,  super-purgation  or  in  connection  with  worms. 

3.  Such  as  arise  during  or  after  pneumonia  or  pleurisy. 

4.  Such  as  are  seemingly  brought  on  by  dentition. 

5.  The  paralysis  of  diphtheria,  fevers,  eruptive  disorders. 

6.  Such  as  seems  to  be  occasioned  by  cold  or  by  cold  and 
moisture. 

7.  Paralysis  due  apparently  to  external  injuries. 

All  of  the  above  named  cases  have  been  thought  to  be  owing 
to  a  peripheral  impression  setting  out  from  some  organ  or  part, 
and  in  some  manner  affecting  the' nerve  centres  more  or  less 
largely,  so  as  to  occasion  loss  of  motion  or  sensation,  or  of 
both  at  once. 

It  is  impossible,  however,  to  admit  that  all  of  the  cases  which 


*  Bi'own-Sciquard. 

t  Tie  conimou  opin'ou.    Gull,  Jaccoad.    Med.  Circ,  No.  G,  op.  cit. 


324 


PARALYSIS  FROM 


[Feb., 


we  have  for  convenience  grouped  together  were  produced  by 
peripheral  irritations.  It  will,  therefore,  be  requisite  to  scru- 
tinize their  pretensions  and  to  reject  such  as  are  more  reason- 
ably to  be  explained  in  any  other  manner. 

In  the  criticisms  which  follow  I  have  received  valuable  aid 
from  the  excellent  work  of  Jaccoud  on  paraplegia,  and  from 
the  admirable  essays  of  Dr.  Gull. 

Class  First. — Paralysis  arir-ing  during  disease  of  the  genito- 
urinary organs.  Since  much  that  I  have  to  say  in  regard  to 
this  group  has  a  wide  critical  application  to  members  of  the 
other  classes,  I  shall  dwell  upon  it  with  especial  care. 

It  appears  to  me  that  both  Gull  and  Jaccoud  are  correct  in 
their  idea  that  very  many  cases  of  apparent  palsy  from  vesical 
or  renal  disease  reported  by  Leroy  d'EtioUes,  Jun.,  and  also 
some  of  the  reputed  instances  of  paraplegia  from  uterine 
affections,  were  not  entitled  to  be  looked  upon  as  other  than  in- 
stances of  such  feebleness  of  the  legs  as  we  often  meet  with  in 
long  continued  disease  of  the  pelvic  organs. 

As  Dr.  Gull  remarks,  many  of  Leroy  d'Etiolles  cases  which 
have  the  heading  "  Paraplegia,"  show  no  further  evidence  of 
this  condition  than  such  terms  as  "  faiblesse  dans  Ics  jambes," 
"  faiblesse  des  membres,  telle  qu'elle  ne  perniet  plus  au  malade 
de  se  tenir  debout  sans  appui,"  &c. 

"  If,"  he  adds,  "  we  bear  in  mind  how  much  the  activity  of 
the  lower  limbs  depends  upon  an  unfettered  action  of  the  ab- 
dominal and  lumbar  muscles,  and  of  the  psoje,  iliaci  and  glutaei, 
we  can  not  but  recognize  a  fertile  source  of '  pseudo-paraplegia,' 
in  that  impairment  of  muscular  activity  which  necessarily  at- 
tends the  malaise  of  chronic  pelvic  affections,  whether  vesical 
or  uterine." 

Let  us  also  recall  the  fact,  that  the  members  whose  weakness 
was  made  a  test  of  palsy,  are  called  upon  to  support  the  trunk 
constantly,  as  well  as  to  perform  locomotion,  and  we  shall  be  well 
able  to  conceive  that  a  person,  desirous  of  making  the  worst  of 
his  cases,  might  find  in  these  patients  enough  of  excuse  to  enable 
him  to  label  that  as  palsy  wliich  was  in  reality  but  simply  gen. 
eral  weakness  most  frankly  expressed  in  the  lower  limbs,  as 
indeed  want  of  power  nearly  always  is.  That  it  is  not  in  every 
instance  easy  to  decide  as  to  whether  or  not  excessive  feeble- 


1866.] 


PERIPHERAL  IRRITATION. 


325 


ness  be  paralytic,  is  best  shown  after  diphtheria,  where,  expect- 
ing paralysis  to  occur  and  finding  great  weakness,  we  are  puz- 
zled as  to  its  true  nature. 

One  other  fact  of  general  interest  and  application  calls  for 
notice.  It  is  impossible  to  read  thoughtfully  the  many  cases  of 
paraplegia  originating  during  or  after  visceral  disease,  without 
suspecting  that  in  some  of  them  the  disorder  of  the  nerve  centres 
has  preceded  the  malady  which  has  been  supposed  to  occasion  it. 

Dr.  Gull  has  stated  this  point  with  great  ability,  pointing 
out  the  dependence  of  the  viscera  upon  the  sympathetic  nerve, 
and  of  this  upon  the  spine.  No  fact  in  neurology  is  to-day 
better  established,  than  the  readiness  with  which  the  viscera  be- 
come diseased  after  their  sympathetic  nerves  have  been  injured. 
Every  physician  has  seen  paralytic  affections  preceded  by  func- 
tional trouble  of  gastro-intestinal  and  other  organs.  When  we 
consider  these  statements  in  connection,  we  can  understand  how 
the  effect  may  be  taken  for  the  cause,  the  child  for  the  parent. 

The  cases  of  Mr.  Stanley  and  Dr.  Graves  have  acquired  an 
almost  classical  value,  as  authority  for  the  existence  of  certain 
of  the  forms  of  peripherally  induced  paralysis,  and  their  etiology 
has  been  scarcely  questioned  until  Dr.  Gull,  and  more  lately 
M.  Jaccoud,  examined  critically  certain  of  those  which  seemed 
to  them  the  weakest. 

Mr.  Stanley's  paper,  op.  cif.,  begins  thus  :  "  In  the  following 
paper  cases  will  be  related  of  disease  in  the  kidneys  existing 
in  connection  with  tenderness  of  the  spine,  and  paralysis  of  the 
lower  limbs,"  &c.  On  turning  to  Brown-S^quard's  table,  sympto- 
matically  defining  urinary  paraplegia,  we  find  that  pains  in  the 
spine,  either  spontaneous  or  from  pressure,  shock,  heat  or  cold, 
are  very  rare."  So  that  what  Mr.  Stanley  defined  as  a  general 
feature  of  his  cases,  is  just  what  Dr.  Brown-S^quard  declares 
to  be  very  rare  in  this  particular  class  of  patients. 

The  latter  authority  also  describes  anaesthesia  as  uncommon 
in  urinary  paraplegia.  I  find  that  in  four  of  Stanley's  seven 
cases  sensation  was  lost  or  much  lessened,  and  in  four  others, 
of  which  he  gives  a  brief  account,  and  for  which  Mr.  Hunt  is 
responsible,  there  was  numbness. 

It  will  be  worth  while  to  examine  in  detail  the  cases  which 
Mr.  Stanley  reports. 


326 


PARALYSIS  FROM 


[Feb., 


No.  1  was  admitted  with  paraplegia,  combined  with  reten- 
tion of  urine.  Sensation  and  motion  were  lost.  Autopsy, 
abscesses  of  one  kidney,  eiigorgment  of  the  other.  No  disease 
of  cord  or  brain. 

Here  there  is  absolutely  nothing  to  show  that  the  paraplegia 
did  not  precede  the  renal  troubles,  and  therefore  no  reason  to 
ascribe  tlie  paraplegia  to  the  diseased  kidneys. 

No.  2  had  partial  loss  of  power  in  his  upper  and  lower  limbs, 
irritation  of  bladder,  and  occasional  retention  of  purulent  urine. 
Autopsy,  small  renal  abscesses  on  one  side,  diseased  bladder, 
spine  and  brain  healthy.  Here  again  we  are  unable  to  say 
which  came  first — the  disease  of  the  genito-urinary  organs  or 
the  palsy.  It  is  also  remarkable  that  he  should  have  had  so  ex- 
tensive a  paralysis.  In  this,  as  in  most  of  these  cases,  the  pre- 
vious history  is  incomplete,  and  not  a  word  is  said  as  to  any  of 
the  many  constitutional  causes  which  might  account  for  the 
conditions  present. 

This  is  the  more  notable,  because,  in  general,  diseases  of  the 
male  genito-urinary  organs  arise  from  gonorrhoea!  maladies, 
and  occur  in  just  such  persons  as  are  most  likely  to  be,  or  to 
have  been,  exposed  to  the  syphilitic  poison. 

Case  3,  set.  22,  had  a  fall  and  bruised  his  back,  but  is 
said  to  have  recovered.  Some  weeks  later  he  was  chilled  after 
exercising,  which  was  followed  by  severe  pain  in  the  loins, 
relieved  to  a  certain  extent  by  cupping.  The  pain  continuing, 
he  lost  sensation,  motion  and  the  power  to  retain  urine.  Au- 
topsy, large  abscess  in  one  kidney,  small  ones  in  the  other;  no 
disease  of  spine  or  brain. 

I  fancy  that  most  physicians  would  have  been  unwilling  to 
refer  this  paraplegia  to  the  renal  malady.  There  is  nothing  to 
show  that  the  kidneys  were  first  diseased,  and  much  in  tiie 
history  of  the  case  to  make  us  suspect  that  the  fall  was  the 
primary  cause  of  both  maladies,  or  that  the  spiual  disea.'^e  and 
the  kidney  complaint  were  both  due  to  the  exposure  to  cold. 

Case  4  had  a  fall,  followed  by  paraplegia.  There  are 
no  further  particulars.  Autopsy,  abscesses  of  both  kidneys, 
thickened  bladder,  enlarged  ])rostate,  brain  and  spine  nor- 
mal, except  an  unusual  vascularity  in  the  membranes  of  the 
latter,  below  the  first  lumbar  vertebra.    In  this  case  renal 


186G.] 


PERIPHERAL  IRRITATION. 


327 


disease  was  not  suspected  during  life,  and  there  seems  to  me 
no  difficulty  in  supposing  that  here,  as  in  the  last  case,  the 
fall  caused  the  paraplegia.  This  at  least  would  be  the  pre- 
sumption. 

Case  5  is  given  in  fuller  detail.  Gonorrhoea,  retention  of 
urine,  incontinence  of  urine,  with  increasing  paralysis  of  mo- 
tion and  sensation  in  the  lower  limbs;  death  in  two  weeks. 
Autopsy,  kidneys  very  vascular  and  full  of  minute  purulent 
deposits,  pus  in  their  cavities,  inflamed  bladder,  no  spinal  or 
cerebral  disease.  In  the  absence  of  information  as  to  the 
man's  habits  and  previous  history,  we  can  only  affirm  that  the 
double  maladies  seem  to  have  run  a  course  together,  and  that 
it  is  impossible  to  feel  confident  that  the  spinal  disease  followed 
the  secondary  troubles,  which  grew  out  of  the  gonorrhoea. 

Case  6  seems  to  have  been  an  ordinary  gonorrhoea  in  pro- 
cess of  cure;  sudden  paraplegia  ensued;  death  in  sixteen  hours. 
Autopsy,  the  membranes  and  substance  of  the  lumbar  cord 
were,  to  some  extent,  turgescent,  and  there  were  a  few  drachms 
of  transparent  fluid  in  the  theca.  Liver  enlarged  and  in- 
durated, both  kidneys  intensely  congested,  as  well  as  the  blad- 
der and  ureters;  some  fluid  in  the  ventricles  of  the  brain.  The 
probability  of  there  having  been  spinal  disease  in  this  case 
seems  to  me  so  very  great,  that  it  is  likely  that  a  microscopi- 
cal examination  would  have  revealed  extensive  lesions.  I  am 
not  sure  that  it  was  not  a  case  of  peripherally  induced  palsy; 
but  the  strong  likelihood  of  there  having  been  undiscovered 
neural  lesions,  and  the  death  having  followed  the  paralytic 
attack  in  sixteen  hours,  make  me  hesitate  as  to  the  true  pa- 
thogenesis. 

Case  7  had  for  two  years  incontinence  of  urine  and 
pain  in  the  back,  as  well  as  difficulty  in  his  breathing.  The 
only  paralysis  was  that  of  the  vesical  sphincter,  until  the  ap- 
proach of  death,  when  he  also  passed  foeces  involuntarily. 
Autopsy,  a  considerable  quantity  of  serum  was  found  beneath 
tlic  arachnoid  membrane,  covering  the  brain.  Serum  was  also 
found  in  the  theca  vertebralis,  and  the  pia  mater  covering  tlie 
lumbar  portion  of  the  cord  was  very  vascular.  The  kidneys 
were  mottled,  and  their  cavities,  as  well  as  the  bladder,  con- 
tained puriform  fluid.    In  this  case  the  utter  want  of  dates 


PARALYSIS  FROM 


[Feb, 


defies  critical  inquiry.  Probably  it  was,  at  the  close,  a  case 
of  serous  apoplexy,  with  precedent  congestion  of  the  mem- 
branes of  the  cord;  at  all  events,  we  do  not  observe  that  the 
paralysis  distinctly  followed  the  extra  spinal  disease.  In  fact 
the  loss  of  power  of  the  vesical  sphincter,  was  the  only  para- 
lytic phenomenon  present  until  near  to  the  close  of  the  case. 

The  cases  of  palsy  here  quoted  certainly  do  not  force  us  to 
conclude,  that  they  grew  out  of  the  renal  or  other  afiFection 
to  which  the  author  ascribes  them.  In  some  of  them,  there  is 
distinct  evidence  of  spinal  disease,  and  I  have  little  doubt  that 
the  microscope  would  have  revealed  still  deeper  and  more 
general  lesions.  Without  it  such  an  examination  would  have, 
to-day,  but  little  value.  But,  apart  from  this,  it  is  also  clear 
that  the  autopsies  were  imperfect.  In  none  do  the  renal  and 
spinal  veins  seem  to  have  been  looked  at  with  care,  and  yet 
these  are  just  the  channels  through  which  suppurative  disease 
might  be  expected  to  propagate  itself  to  the  spine.  In  fact, 
this  is  exactly  what  has  been  seen  to  occur  in  such  cases  as 
Gull*  and  Kussmault  have  reported. 

While,  therefore,  I  am  inclined  to  suppose  it  possible  that 
renal  or  vesical  disease  may  occasionally  determine  a  loss  of 
spinal  power,  I  am  unable  to  admit  that  the  relation  has  been 
clearly  made  out  in  any  single  one  of  Stanley's  cases,  or  that 
any  were  so  thoroughly  studied  as  to  make  it  unlikely  that 
they  could  have  been  induced  by  the  material  propagation  of 
visible  lesions,  by  the  toxic  activity  of  certain  well  known 
maladies,  or  by  defects  of  nutrition,  consequent  upon  a  blood 


*  Dr.  Gull.    Mtd.-Chir.  Trans.,  1856. 

t  Ku.»smaul.  Zur  Lehro  von  der  Paraplegia  Urinaria.  (Wurzbnrger  Med. 
Zfitfclirift,  vi.,  1863.)  As  I  do  not  find  this  journal  accessible,  I  quote,  trans- 
lated, M.  Jaccoud's  summary  of  Kussmaul's  very  important  case.  A  man,  »t. 
58  years,  becaine  paraplegic  during  an  attack  of  chronic  cystitis.  At  the  au- 
topsy, Kufsmaul  found  lesion  of  bladder,  peritonitis  by  propagated  inflamma- 
tion,  atheromatous  degeneration  of  the  two  hypogastric  arteries,  and  fatty  trans- 
formation of  most  of  the  nerve  tubules  in  the  two  sciatic  trunks.  The  pre- 
tended functional  paraplegia  was  then  an  organic  paraplegia  of  peripheral  cause. 
Two  conditions  had  produced  it — altered  nerves  and  altered  arterie.s.  Tlie  author 
remarks,  w  ith  reason,  that  the  latter  malady,  if  severe,  would  alone  account  for 
the  palsy,  owing  to  the  nutritive  troubles  in  the  sacral  plexus,  which  might  be 
thus  occasioned. 


1866.] 


PERIPHERAL  IRRITATION. 


329 


altered  by  long  continued  previous  disease  of  important 
viscera. 

Dr.  Graves'  case  of  urinary  paraplegia  has  always  been  con- 
fidently quoted.  Tlie  subject  was  a  sailor,  who  had  suffered 
from  a  strain  in  the  back,  from  gonorrhoea,  excessive  fatigue, 
great  exposure  to  weather,  and  deprivation  of  usual  stim- 
ulus. He  had  stricture,  painful  micturition,  and  increasing 
feebleness  of  the  legs,  resulting  in  considerable  loss  of  motion. 
"  A  few  days  after  the  first  introduction  of  a  bougie,  a  re- 
markable amendment  took  place  in  his  back  and  legs.  In 
fact,  it  was  almost  sudden."  Warm  baths,  frictions,  etc.,  com- 
pleted his  cure,  about  a  month  after  his  admission  to  the 
hospital. 

Except  the  sudden  improvement  after  use  of  the  bougies, 
there  is  nothing  to  point  decisively  to  the  urethral  disease  as 
the  cause  of  the  paralysis.  Tlie  case  reads  more  like  one  of 
exhaustion,  aided  or  hastened  by  the  weakening  influence  of 
disease;  and  in  fact  very  nearly  resembles  a  type  of  cases 
which  our  recent  war  produced,  and  which  were  familiar  to 
the  staff  of  the  Hospital  for  Diseases  and  Injuries  of  the  Nervous 
System.  Dr.  Graves  is  only  responsible  for  this  history  from 
having  adopted  it  from  Dr.  Hutton,  who  attended  the  patient. 
It  is  not  a  full  account,  does  not  tell  us  how  complete  was  the 
palsy,  and  leaves  untouched  the  question  as  to  tlie  conditon  of 
sensation,  which  may  or  may  not  have  been  lost,  but  which, 
according  to  my  experience,  is  rarely  deficient  in  persons  who 
have  incomplete  paraplegia  from  over-exertion  as  a  principal 
■cause. 

The  cases  reported  by  Rayer  are  also  cited  as  palsies  of 
peripheral  origin.  The  first  is  quoted  briefly  from  Ammon. 
(Preuss.  Medic.  Zeitung,  1832,  No.  6.)  An  inflammation  of  the 
intestines  was  followed  by  obstinate  constipation  and  hema- 
turia, pain  in  the  left  leg  succeeded,  and  paraplegia  ensued. 
After  death  the  left  kidney  was  found  enlarged  and  tubercular 
—  a  very  suspicious  fact,  especially  as  no  examination  of  the 
brain  or  spine  seems  to  have  been  made.  It  is  needless  to 
criticise  the  case  any  further. 

The  second  case  was  a  chronic  cystitis,  with  suppurative 
disease  of  both  kidneys,  followed  by  paraplegia  and  death 


330 


PARALYSIS  FROM 


[Feb., 


eleven  days  later.  No  leison  was  found;  but  with  Gull's,  and 
especially  with  Kussmaul's  cases  before  us,  it  is  impossible  to 
admit  absence  of  lesion,  without  microscopical  inspection  of 
the  tissues  having  been  employed.  As  1  shall  point  out  here- 
after, it  is  not  improbable  that  cases  of  induced  palsy  from 
peripheral  irritation  may  result  in  material  lesions,  yet  other 
evidence  of  the  pathogenesis  of  the  case  would  be  needed  than 
was  present  in  the  instance  before  us.  Perhaps  I  should  add, 
that  the  body  of  the  fifth  dorsal  vertebra  contained  a  small 
tubercular  mass.  The  surface  of  the  spinal  column  opposite 
to  this  presented  no  peculiarity,  although,  as  I  have  urged,  the 
value  of  this  statement  is  lessened  by  the  want  of  an  examina- 
tion with  the  lens. 

Case  third  was  scarcely  entitled  to  be  termed  paralysis. 
The  limbs  were  feeble,  and  there  was  great  pain  in  walking. 
It  was  probably  a  pseudo-paralysis. 

In  all  of  these  cases — and  the  remark  applies  equally  to  most 
of  Stanley's — there  must  have  been  more  or  lessurtemic  poison- 
ing. I  am  not  prepared  to  say  how  far  this  affected  the  result, 
as  I  have  never  seen  in  an  adult  this  form  of  toxication  deter- 
mine distinctly  a  paralysis  of  the  legs,  although  twice  in  the 
post-scarlatinal  urtemia  of  childhood  I  liave  observed  such  a 
termination. 

It  would  be  needless  to  analyze  the  cases  of  other  authors. 
As  a  rule  they  fail  to  exhibit  the  characters  which  Brown- 
Sequard  has  given,  in  tabular  shape,  as  defining  his  conception 
of  palsy  from  genito-urinary  disease,  and  when  subjected  to 
more  rigid  tests  as  to  their  having  indubitably  originated  from 
this  form  of  peripheral  irritation,  they  yet  moi-e  signally  fail. 

From  this  condemnation  I  should  except  Dr.  Echeverria's* 
singular  case  of  temporary  palsy  from  uterine  irritation,  and 
some  of  the  reports  made  by  Le  Roy  d'Etiolles. 

Class  second — Includes  the  paralyses  which  ensue  during 
or  after  dysentery,  diarrlia;a,  or  superpurgation,  Avorms,  <kc. 
All  of  this  class  have  been  claimed  as  cases  of  functional  par- 
alysis from  extra-central  disease,  or,  as  Brown-Sequard  would 
label  them,  reflex  paralysis. 


*  New  York  Medical  Times,  1863. 


1866.] 


PERIPHERAL  IRRITATION. 


331 


We  may  start  here  with  the  admission  that  in  rare  cases 
worms  occasion  paralysis  which  is  relieved  by  their  removal. 
The  few  cases  on  record  are  more  free  from  the  chances  of 
mistaken  observation  than  the  complicated  histories  witli 
which  we  have  last  had  to  deal.  In  some,  however,  a  fuller 
description  of  symptoms  and  of  the  after-history  would  have 
been  desirable. 

Before  closing  this  brief  discussion  I  will  relate  a  case 
which  may  suffice  to  show  that  in  the  cases  of  central  nervous 
disorder,  apparently  caused  by  worms,  there  may  be  a  chance, 
at  least,  of  a  mistake.  The  case  in  question  occurred  several 
years  ago,  and  was  triumphantly  noted  at  the  time  as  an  in- 
stance of  reflex  paralysis. 

L.  P.,  male,  set.  six  years,  a  strong,  healthy  looking  child, 
born  of  parents  one  of  whom,  the  father,  had  suffered  from 
syphilitic  accidents.  The  child  teethed  without  trouble.  In 
the  fall  of  1854  he  had  a  malarious  fever,  whicli  gave  way 
under  the  use  of  quinia.  He  was  not  quite  well  from  this 
date — September,  1854;  but  I  could  find  no  special  disease. 
He  was  indisposed  to  move  about,  lacked  appetite,  and 
awakened  often  with  a  cry  as  though  dreaming.  A  little 
later — about  the  end  of  October — he  complained  at  times 
of  pain  in  the  stomach,  and  two  days  after  passed  a  large  worm 
— A.  Lumbricoides.  Upon  this  I  laid  aside  the  tonics  he  had 
been  taking,  and  directed  his  mother  to  give  him  a  tablespobn- 
ful  of  castor-oil,  with  twenty-five  drops  of  turpentine.  The 
evening  of  the  same  day,  while  being  undressed,  he  complained 
of  weakness,  and,  suddenly  slipping  down  on  the  floor,  had  a 
very  trifling  spasm  of  the  facial  muscles,  and  became  insensible. 
I  was  sent  for  at  once,  but  did  not  see  him  until  two  hours 
later.  At  this  time  he  was  capable  of  being  roused  with  diffi- 
culty, but  on  placing  him  in  a  hot  bath  he  revived  still  further, 
so  as  to  speak  and  ask  for  a  drink  of  water.  I  now  observed 
that  he  had  a  slight  drooping  of  the  left  eye-lid,  and  that  both 
of  his  legs  were  partially  paralyzed  as  to  motion.  The  want 
of  power  was  nearly  absolute  on  the  right  side,  but  the  same 
defect  was  also  sufficiently  obvious  in  the  other  leg.  Sensation 
may  have  been  deficient.  I  can  not  be  sure  as  to  this  point, 
since  nothing  is  more  difficult  than  to  determine  in  children  the 


332 


PARALYSIS  FROM 


[Feb., 


degree  of  feeling  present  when  it  happens  not  to  be  totally 
lost.  Reflecting  on  the  case,  I  ordered  the  mother  to  give  the 
child  three  grains  of  calomel  at  once,  and  to  follow  it  with  the 
oil  and  turpentine  eai'ly  the  next  morning.  I  saw  the  cliildthe 
following  day,  before  the  medicines  had  occasioned  more  than 
a  single  small  stool,  and  carefully  examining  the  legs  observed 
no  notable  change.  About  seven  hours  later  I  found  the  boy 
on  liis  mother's  lap.  As  I  entered  he  called  my  attention  to  his 
legs,  saying  he  could  move  them,  and,  in  fact,  doing  so.  It 
seemed  that  the  purges  had  actsd  freely,  and  that  he  had  passed 
four  worms  and  a  good  deal  of  slimy  mucus.  I  was  so 
astonished  at  this  sudden  relief  that  I  was  careful  to  see  how 
far  the  improvement  went.  I  found  that  he  could  stand  with 
very  slight  aid.  The  following  night  he  passed  a  worm,  and 
within  a  week,  under  the  use  of  worm  tea,  several  others,  while 
at  the  same  time  he  continued  to  improve,  until,  at  the  close  of 
a  month,  he  was  as  well  as  usual,  except,  perhaps,  a  little  limp 
in  his  gait  and  slight  but  continued  ptosis.  I  set  the  case  down 
as  palsy  from  worms  until  March,  1855,  when  he  had  a 
series  of  convulsions,  for  which  I  could  see  no  especial  cause. 
They  ended  in  a  much  more  complete  paralysis  of  both  legs. 
I  confidently  repeated  my  former  treatment,  but,  to  my  amaze- 
ment, no  worms  came  away  at  any  time  afterwards,  yet  a  per- 
sistent purgative  course  so  far  improved  the  boy  that  in  three 
weeks  he  could  stand,  holding  fast  to  a  chair.  During  the 
spring  and  summer  he  took  iron  and  quinine,  and  was  some 
time  at  the  sea  side.  These  measures  completed  his  recovery 
so  far,  that  he  seemed  to  me  better  than  at  any  time  since  the 
first  attack.  Early  in  October,  1855,  he  had  a  repetition  of  the 
fits,  followed  by  coma  and  resulting  in  paraplegia,  complete  as 
to  motion  and  nearly  so  as  to  sensation,  which  latter,  however, 
gradually  improved,  but  without  any  like  gain  in  movement. 
The  means  which  at  first  had  answered  now  failed  entirely,, 
unless  the  change  in  sensibility  be  regarded  as  evidence  of  good 
done  by  the  purgation.  As  before,  no  worms  escaped,  al- 
though several  anthelmintics  were  used  in  succession.  Soon 
afterwards  the  family  went  to  the  West,  and  I  lost  sight  of  my 
patient.  Three  years  later  I  learned  that  he  had  continued  in 
the  same  condition  as  when  last  seen  by  me,  until  he  had  died 


1866.] 


PERIPHERAL  IRRITATIOX. 


333 


of  dysentery,  two  aud  a  half  years  from  the  date  of  his  final 
attack  of  paralysis. 

Was  this  a  case  of  central  disease  from  peripheral  irritation 
of  worms,  or  was  it  an  instance  of  congestion  of  the  centres  re- 
lieved by  the  derivative  agency  of  purgatives  ? 

As  regards  paralysis,  the  result  of  dysentery,  M.  Jaccoud 
remarks  that  in  many  cases  this  latter  malady  is  to  be  looked 
upon  as  a  blood  disease,  productive  of  dyscrasial  conditions, 
which  alone  may  occasion  defects  of  nutrition,  and  so  give  rise 
to  spinal  or  cerebral  disease.  These  remarks  apply  with  much 
force  to  epidemic  dysenteries.  I  myself  have  seen  in  the  wards 
of  the  U.  S.  A,  Hospital  for  Diseases  of  the  Nervous  System  many 
cases  of  palsy,  chiefly  paraplegia,  following  upon  dysenteiy, 
acute  or  chronic  ;  but  in  nearly  every  case  there  had  been  many 
possible  causes,  such  as  long  marches,  bad  diet,  malaria  or  in- 
juries to  the  spine — these  being  so  common  that  almost  any 
patient  long  in  service  had  some  such  to  relate.  It  was  thus 
difficult,  or  even  impossible,  to  fix  upon  any  single  factor  as 
most  important  or  essential,  where,  as  in  the  mass  of  cases,  it 
was  likely  that  several  contributed  to  influence  the  final  result. 

It  is  no  new  remark  that  diseases  of  exhausting  discharges, 
such  as  diarrhaea,  (and  the  same  remark  applies  also  to  hyper- 
purgation,)  may  so  profoundly  deplete  the  system  as  to  affect 
injuriously  the  nutrition  of  certain  organs,  and  at  least  favor,, 
if  they  do  not  produce,  alterations  sufficient  to  destroy  func- 
tion. It  is  for  this  reason  that  I  hesitate  to  accept  as  a  palsy, 
peripherally  induced,  every  case  which  follows  diarrhaja.  In  my 
experience  at  the  hospital  above  mentioned  these  histories  were 
by  no  means  rare.  In  some  of  them  the  enteric  malady  occa- 
sioned spinal  effusions  or  softening.  In  others  the  patient,  worn 
out  by  long  continued  and  constant  evacuation,  became  para- 
lyzed during  a  trying  march,  or  upon  exposure  to  great  heat 
and  fatigue.  Such  were,  as  I  viewed  them,  cases  of  exhausted 
centres,  and  were  so  easily  relieved  by  tonics,  good  diet,  and 
stimulants,  that  wc  came  at  last  to  predict  this  result  with  a 
confidence  not  common  as  regarded  other  forms  of  paralysis. 
When  reduced  by  depletory  treatment,  or  when  the  patients 
were  scrofulous  or  scorbutic,  spinal  softening  or  chronic  my- 
elitis was  apt  to  occur,  but  even  in  these  instances  nothing 


334 


PARALYSIS  FROM 


[Feb., 


was  more  remarkable  than  the  restorative  value  of  wine,  fresh 
meats,  and  bark. 

As  with  diarrhffia,  so  with  hyper-catharsis.  A  paralysis  fol- 
lowing either  need  not  of  necessity  be  due  to  transmitted  irri- 
tation, since,  in  some  cases  these  agencies  so  alter  the  blood, 
and  so  impair  its  nutrient  value,  as  to  give  rise  to  serous  effu- 
sions, or  to  still  graver  structural  ills.  Where  there  is  a  weak 
point,  it  is  the  one  likely  to  be  assailed,  when  by  any  means 
the  circulation  has  become  depleted  beyond  the  point  of  en- 
durance consistent  with  functional  activity.  The  following 
case  is  an  instance  of  such  a  result: 

A  young  seamstress  was  for  two  or  three  years  subject  to 
terrible  menstrual  hemorrhages,  from  Avhich  she  became  ex- 
cessively feeble  and  antemic.  At  this  time  an  apothecary  told 
her  that  her  liver  was  out  of  order,  and  advised  a  dose  of  calo- 
mel and  jalap.  I  do  not  know  how  much  she  took,  but  it  acted 
on  her  bowels  with  great  violence,  so  much  so  that  on  the 
second  day  she  took  to  her  bed  and  sent  for  me.  I  found  her 
still  purging  at  intervals  of  an  hour  or  two,  and  perfectly  worn 
out.  I  ordered  an  injection  of  laudanum,  and  directed  a  drachm 
of  paregoric  to  be  given  after  each  stool.  Before  I  left  she 
told  me  that  her  sight  was  very  dim,  that  it  had  been  weak  for 
a  long  while,  owing  to  incessant  needle-work  by  gas  light,  and 
that  since  taking  the  purgative  it  was  much  worse.  Upon  this 
I  examined  her  ankles,  which  I  found  to  be  slightly  oedematous; 
as  was  determined  that  evening  and  afterwards,  her  urine  con- 
tained no  albumen. 

The  next  day  she  was  unable  to  distinguish  faces,  and  com- 
plained of  dizziness  on  trying  to  raise  her  head.  She  had  no 
other  notable  symptoms  in  connection  with  the  eye.  Upon 
awaking  from  sleep  the  sight  was  always  materially  worse,  but 
would  so  soon  improve  as  to  enable  her  within  a  few  minutes 
to  tell  light  from  darkness,  and  to  be  aware  if  a  person  came 
between  her  and  the  light.  One  eye  was  always  much  better 
than  the  other,  but  I  do  not  find  that  my  notes  record  which  it 
was.  Although  the  purgation  w^as  at  once  checked,  and  she 
was  put  upon  stimulants,  iron,  <tc.,  no  change  fur  the  better 
was  noted  until  at  least  eleven  days  after  the  occurrence  of  the 
loss  of  vision.  Recovery  complete  within  three  months,  when 
she  became  able  to  use  the  needle  in  the  day-time  only. 


18G6.] 


PERIPHERAL  IRRITATION. 


335 


Was  this  mere  functional  disorder,  induced  by  the  irritating 
influence  of  over-purgation  ?  Was  it  sub-retinal  eifusiou,  or  did 
it  happen  that  the  optic  centres,  exhausted  by  long  and  con- 
stant over-work,  were  tlie  first  to  feel  and  the  longest  to  show 
the  eliects  of  a  great  and  tudden  drain  on  the  economy  ?  One 
of  the  two  latter  explanations  appears  to  me  the  correct  one. 

Paralysis  following  pneumonia  or  pleurisy  is  regarded  by 
Dr.  Browu-Sequard  as  functional,  and  explained  under  his 
theory  of  reflex  impression  on  the  spinal  vessels.  I  have  met 
with  a  number  of  such  cases,  but  as  all  were  in  soldiers  who 
had  seen  much  service,  I  am  not  prepared  from  my  own  ex- 
perience to  admit  reflected  irritation  from  diseased  lung  or 
pleura  as  tlic  only  possible  cause.  Where  great  fatigues,  ex- 
tremes of  climatic  exposure,  and  bad  or  irregular  diet  have 
previously  acted  upon  the  victims  of  malaria,  it  is  probable  that 
the  exhausting  influence  of  an  acute  malady  may  with  justice 
be  regarded  as  the  final  determining  cause  of  defective  nutrition 
ill  tlie  nerve  centres.  Such  of  these  cases  as  I  have  seen  were 
of  a  nature  to  induce  this  belief,  merely  from  a  study  of  their 
symptoms  and  mode  of  onset,  which  was  sudden  in  ^ery  few 
of  them. 

While,  however,  I  should  explain  many  in  this  manner,  I  am 
quite  willing  to  admit  that,  in  others,  the  palsy  has  appeared  to 
me  to  arise  from  an  influence  exerted  on  the  spine  by  the  irritat- 
ing efl'ects  of  a  diseased  viscus,  and  that  in  such  instances  there 
might  have  been,  at  least  in  the  early  stages  of  the  neural 
malady,  no  distinct  organic  lesion  of  the  central  ganglia,  of 
such  a  nature  as  to  have  been  readily  visible  had  a  post  mortem 
examination  been  possible. 

As  regards  nervous  diseases  arising  from  dentition,  there  is 
less  doubt  in  the  miuds  of  the  profession  in  general,  than  in  re- 
gard to  most  of  the  supposed  causes  of  functional  palsies.  For 
my  own  part,  I  confess  that  it  has  very  rarely  been  my  lot  to  meet 
with  cases  in  which  the  convulsions  or  the  paralysis  of  child- 
hood seemed  to  be  distinctly  traceable  to  irritation  of  the  gums, 
arising  out  of  the  growth  of  the  teeth.  Indeed  I  miglit  go 
still  further  and  add,  that  of  the  many  instances  of  convulsions 
and  infantile  paralysis  which  I  have  encountered,  L  do  not  recall 


336  PARALYSIS  FROM  [Feb., 

one  case  in  which  section  of  the  gums  at  once  occasioned  a  ces- 
sation of  the  symptoms  in  question. 

It  is  curious  to  notice  in  this  connection  how  much  less  cutting 
the  gums  is  practiced  on  the  Continent  than  in  England  or  this 
country,  Romberg  specifically  refers  to  this  fact.  Yet  when 
we  consider  instances  such  as  Brown-S^quard  and  others  have 
related,  where  incising  the  gums  did  manifestly  relieve  the 
patient,  or  where  the  neural  malady  recurred  anew  as  each 
tootli  appeared,"'  I  am  unwilling  to  assert  that  it  is  always 
useless,  though  I  am  well  convinced  that,  nine  times  out  of  ten, 
the  gums  are  needlessly  lanced,  and  that  in  severe  neural  mal- 
adies there  are  usually  other  and  graver  influences  at  work 
than  those  Avhich  arise  out  of  the  process  of  dental  development. 

M.  Brown-S6quard  has  included  among  reflex  paralyses,  and 
therefore  regards  as  due  to  perijiheral  irritation,  the  large  class 
of  palsies  connected  with  eruptive  fevers  and  diphtheria. 

Dr.  Gubler,  who  has  made  tlie  most  elaborate  study  of  these 
paralyses,  divides  them  into  those  which  arise  during  the  acute- 
ness  of  the  parent  disease,  and  those  which  follow  it  at  great  or 
less  distances  of  time.  M.  Jaccoud,  in  his  remarkable  work  on 
paraplegia,  briefly  sums  up  these  views,  which  I  will  still  more 
briefly  analyze  here,  as  I  have  not  before  me  the  concluding 
portion  of  Gubler's  essay. 

The  first  class  of  paralyses  is  most  common  after  typhus 
fever  and  variola,  very  rare  in  other  exanthemata  or  in  inter- 
mittents,  and  unknown  as  yet  in  diphtheria  and  in  cholera.  By 
general  opinion  they  have  been  held  to  be  due  to  organic  dis- 
ease of  the  centres;  nor  is  it  astonishing  that  this  should  be, 
when  we  reflect  how  marked  are  the  early  symptoms  which, 
in  the  diseases  first  named,  may  be  held  to  indicate  effects  upon 
the  spine  and  brain.  Nor,  altliough  rare,  have  autopsies  been 
wanting  to  support  this  view,  and  to  demonstrate  the  existence- 
of  early  organic  lesions  amply  sufficient  to  explain  the  prece- 
dent palsy,  and  of  course  referable  to  the  direct  action  of  the 
poisons  peculiar  to  the  several  parent  maladies. 

As  regards  the  secondary  palsies,  it  is  difficult  to  see  haw 
we  can  regard  them  as  due  to  a  peripheral  in  itation,  or  why 

*  iMi'i-yo.i  on  Paralysis,  p.  178. 


1866.] 


PERIPHERAL  IRRITATION. 


337 


we  should  need  to  explain  them  as  Brown-S^quard  has  done 
Like  M.  Jaccoud,  we  feel  "  that  hydrorachitis,  oedematous  infil- 
trations, and  passive  congestions,  which  result  from  enfeeble- 
ment  of  vascular  coutractibility,  have  been  far  too  much  lost 
sight  of  in  the  pathogenetic  appreciation  of  these  paraplegias." 

Wg  may  add  that  the  state  of  the  blood  which  some  of 
these  maladies  occasion  is  enough  to  account  for  any  condi- 
tion of  the  spine  or  brain  which  deficient  or  perverted  nu- 
trition may  develop,  and  that  these  results  will  be  ever 
most  likely  to  obtain  in  constitutions  predisposed  by  heredita- 
tion  or  other  influence  to  scrofulous  conditions. 

Just  such  palsies  have  been  seen  to  follow  the  intense  blood 
poisoning  from  the  bites  of  venemous  reptiles,  as  Fontana  had 
already  asserted,  and  as  I  myself  have  once  seen  in  man,  and 
twice  in  dogs,  who  had  been  poisoned  by  the  rattlesnake. 

It  will  thus  appear,  from  what  we  have  witnessed,  that  it  is 
in  a  high  degree  improbable  that  the  palsies  which  occur 
during  fevers  and  exanthemata,  are  due  to  a  reflected  irrita- 
tion from  the  diseased  surfaces,  or  from  the  viscera  afi"ected. 
Although  the  author  so  often  quoted  styles  the  palsies  in 
question  reflex,  it  is  remarkable  that  he  does  not  indicate  the 
part  or  parts  of  the  body  from  which  the  irritation  may  be 
presumed  to  proceed.  From  whence,  for  example,  in  typhus, 
do  these  impressions  set  out  to  afi"ect  the  spinal  vessels  and  so 
cause  the  loss  of  function  ? 

Still  more  fully  does  this  criticism  apply  to  the  cases  which 
follow  fevers,  and,  most  of  all,  as  M.  Jaccoud  observes,  is  it 
difiicult  to  conceive  of  any  such  point  of  departure  as  regards; 
diphtheria,  whose  sequelae  often  follow  the  acute  attack  at  very- 
long  intervals. 

I  should  not  have  thought  it  worth  while  to  dwell  s©  long 
upon  this  subject  if  it  were  unimportant  in  practice,  whether 
we  regarded  febrile  and  post-febrile  palsies  as  functional  or 
not.  Many  observers  have  shown,  and  Gubler  most  clearly, 
that  the  pathological  conditions  which  are  observed  post  mor- 
tem in  these  cases,  are  varied  in  their  charactcj;,  so  that  in 
some  the  palsy  has  been  plainly  due  to  cedema,  or  to  mere 
congestion,  with  or  without  efl'usion,  and  in  others  to  raeningo- 
myelitis  of  the  gravest  type.    Any  view,  then,  which  would 

Vol.  II.— No.  11.  22 


338 


PARALYSIS  FROM 


[Feb., 


group  all  these  multifarious  cases  under  one  head,  with  a  pre- 
sumption that  they  are  functional  and  involve  no  material 
lesion,  would,  we  think  with  M.  Jaccoud,  be  productive,  if 
generall)'^  received,  of  the  most  serious  errors  in  practice. 

Among  other  supposed  causes  of  disease  of  the  centres, 
brought  on  by  a  peripheral  influence,  are  the  numerous  instan- 
ces of  palsy  which  follow  exposure  to  cold  and  moisture,  all 
of  which  Dr.  Brown-S^quard  claims  as  reflex  paralysis.  In 
accordance  with  my  treatment  of  other  classes,  1  shall  show, 
that  in  this  one,  also,  it  is  not  a  reflected  irritation  from  the 
skin  which  alone  can  be  called  on  to  explain  the  disease. 

The  records  of  cerebral  or  other  palsies,  from  cold  or  ex- 
posure to  wet  and  cold,  are  common  in  medicine  since  the 
days  of  Galen,  but  Dr.  Graves  seems  to  have  first  attempted 
to  explain  more  precisely  the  mode  in  which  he  believed  them 
to  have  been  caused. 

This  class  of  cases  presents  two  species.  Those  in  which 
sudden  palsy  follows  temporary  exposure  to  cold,  and  those  in 
which  the  palsy  has  been  brought  about  in  persons  whose  oc- 
cupations subject  them  habitually  to  the  inclemency  of  the 
weather.  Many  cases  of  the  tirst  species  are  on  record.  In 
some  of  them,  there  was  plainly  an  apoplectic  condition,  in 
others,  limited  local  palsies  occurred.  The  best  and  clearest 
instances  of  the  latter  result  were  probably  due  to  the  periph- 
eral irritation  of  cold. 

The  second  set  of  cases  were  first  referred  to  cold  as  a 
cause  by  Dr.  Graves,  who  reported  three  histories  of  this  na- 
ture. His  first  case.  Clinical  Medicine,  p.  422,  is  too  long  to 
quote.  It  is  in  some  points  a  very  remarkable  one.  It  began 
in  Jan.,  1829,  with  an  attack  of  disordered  stomach  and  bowels. 
At  this  date  the  patient  abandoned  the  field  sports  which 
subjected  him  to  the  influence  of  bad  weather.  In  March, 
1832,  having  had  many  such  paroxysms  in  the  interval,  he  first 
felt  some  numbness  and  loss  of  power  in  the  legs.  In  August, 
1832,  he  became  suddenly  paraplegic,  and  died  Sept.,  1833. 
We  observe  that  the  palsy  began  three  and  a  quarter  years 
after  he  ceased  to  expose  himself  to  cold  and  wet.  With  what 
reason  can  we  claim  that  these  agencies  occasioned  his  palsy  ? 


1856.] 


PERIPHERAL  IRRITATION. 


339 


No  lesions  were  found,  but  of  course  there  was  lacking  a  mi- 
croscopic inspection. 

Case  second  is  described,  as  a  waterman,  frequently  exposed 
to  cold  and  wet,  and  in  the  habit  of  drinking  freely.  If  we 
ask  lor  a  cause,  here  were  two  to  choose  from.  Autopsy,  cauda 
equina  slightly  softened,  small  tumor  external  to  sheath  of 
cord,  some  slight  degree  of  vascular  injection  around  it.  Dr. 
Stokes,  the  reporter,  considered  these  lesions  incompetent  to 
produce  the  paraplegia.  No  statement  is  made  as  to  which 
columns  of  the  cord  were  opposite  to  the  tumor — a  fact  of 
moment  in  the  decision,  because  sensation  was  merely  lessened, 
motion  destroyed. 

Case  third  was  a  gentleman  fond  of  field  sports,  and  thus 
greatly  exposed  to  wet  and  cold;  while  under  the  influence  of 
a  "long  mercurial  course"  he  got  his  feet  wet,  and  numbness 
and  weakness  of  the  legs  ensued.  He  recovered  imperfectly. 
The  liistory  is  clear  enough,  except  that  we  do  not  learn 
why  he  was  under  the  use  of  mercury. 

Without  wishing  to  be  considered  as  hypercritical,  I  really 
do  not  see  how  the  above  cases  can,  in  fairness,  be  regarded  as 
of  necessity  due  to  the  exposures  described. 

Paralysis  from  Wound  or  Injury  of  Nerves.  —  Within 
this  class  are  to  be  found  the  most  convincing  instances  of 
motor  palsy,  from  a  peripheral  agency  acting  through  nerves 
upon  the  central  ganglia.  In  the  best  cases  an  injury  is  sud- 
denly followed  by  paralysis  in  a  remote  limb;  changes  in  the 
wound  occasion  increase  or  lessening  of  the  palsy,  and  relief 
of  the  wound  is  very  speedily  followed  by  that  of  the  motorial 
defect. 

So  far  as  I  am  aware,  no  case  of  motor  palsy  has  been  thus 
far  reported  which  precisely  comes  up  to  this  standard,  al- 
though, in  cases  of  spasms  from  peripheral  irritation,  every  con- 
dition of  the  ideal  case  stated  has  been  fulfilled.* 

Perhaps  the  best  histories  are  those  in  which  palsy  of  ocular 
muscles  has  followed  an  injury  to  the  infra  or  supra  orbital 
nerve.  Brown-S6quard,  so  industrious  in  his  collating  of  cases, 
alludes  to  many  where  palsy  followed  upon  dental  disease,  and 

*  Hrown-Sequard,  in  Holmes'  Syst.  of  Surgery.  Diseases  of  Nerves,  vol.  iii., 
p.  87y— cases  given  by  Dr.  Laing,  Dr.  Kimball,  and  others. 


340 


PARALYSIS  FROM 


[Feb, 


■was  cured  soon  after  the  removal  of  the  teeth.  He  has  also 
given  numerous  statements  of  neuralgia  of  the  fifth  nerve, 
which  occasioned  amaurosis,  mydriasis,  anaesthesia,  &c. 

Some  of  these  instances  are  very  convincing  as  to  the  periph- 
eral causation.  It  is  needless  to  add  that  in  many  of  them 
elements  of  doubt  exist,  which  have  not  the  same  application 
to  paralysis  from  a  wound  or  a  blow  on  a  part  remote  from  that 
in  which  loss  of  function  ensued. 

Reports  of  this  class  of  cases  are  very  rare.  In  Brown-S6- 
quard  on  Paraplegia  none  are  given.  In  his  lectures  on  the 
central  nervous  system  he  says  :  "  Pressure  on  some  sensitive 
nerve,  or  a  wound,  may  cause  extensive  paralysis.  So  it  was 
in  a  case  that  I  have  observed  with  my  friend  M.  Charcot,  and 
in  cases  recorded  or  mentioned  by  Fabricius  Hildanus  (quoted 
by  Whytt,  p.  18)  and  by  Barthez,  {loco  citaf,  vol.  ii.,  pp.  41, 
42,  notes,  and  p.  127,)  1852."  I  have  already  pointed  out 
that  the  reference  to  Whytt  is  inaccurate,  and  that  he  reported 
no  case  of  palsy.  As  regards  M.  Charcot's  case,  no  particulars 
are  given,  which  is  much  to  be  regretted,  as  it  is  now  impos- 
sible to  compare  it  with  other  cases.  The  reference  to  Barthez 
is  incorrect,  if  Rilliet  and  Barthez'  "  Sur  les  Maladies  des 
Enfants  "  be  the  book.  In  the  work  of  these  authors  I  can  find 
no  such  cases,  either  at  the  pages  mentioned  or  elsewhere.* 

If,  then,  we  except  the  cases  of  amaurosis  from  a  blow  or  in- 
cised wound  of  a  branch  of  the  fifth  nerve,  we  shall  find  his- 
tories of  palsy  occasioned  by  a  wound  or  mechanical  injury  to 
a  peripheral  nerve  extremely  rare.  Dr.  Brown-S^quard  re- 
ports one  only  in  his  paper  on  diseases  of  nerves  in  Holmes' 
System  of  Surgery,  vol.  iii.  The  case  in  question  was  due  to  a 
blow  on  the  elbow,  and  was  followed  by  paralysis  of  both  arms, 
the  uninjured  limb  being  most  affected.  The  length  of  time 
which  elapsed  between  the  injury  and  the  palsy  of  the  other 
arm  is  not  stated,  and  the  case  is  wanting  in  almost  every 
necessary  or  usual  detail.  In  quoting  well  known  histories  of 
disease  such  brevity  is  allowable,  but  surely  not  where  the 

*  Dr  Brown  Sequard,  Lect.  on  the  Central  Nervous  System,  p.  164,  quotes  this 
book  as  Rilliet,  and  since  be  gives  a  reference  elsewhere  to  Barthez — Scionce  de 
I'nomme — the  mistake  may  be  here.  The  latter  treatise  has,  I  believe,  but  one 
volume. 


i 


1866.]  PERIPHERAL  IRRITATION.  341 

author  is  reporting  for  the  first  time  a  case  of  great  value  and 
importance.  Dr.  Meryon,  who  favors  the  theory  of  reflex 
paralysis  of  Bro\vii-S6quard,  has  related,  no  instances  of  this 
nature  caused  by  wounds. 

Dr.  Julius  Althaus,  in  a  recent  little  volume  on  neuralgia, 
etc.,  lias  reported  three  cases  of  paralysis  following  trau- 
matic injury.  In  the  first  case,  p.  155,  the  patient  lost  use 
of  the  arm  after  an  amputation  of  the  left  forefinger  for 
gangrene.  When,  after  three  months,  the  stump  healed,  the 
patient  had  entirely  lost  the  use  of  her  hand,  the  fingers  being 
stiff  and  extended.  The  forearm  could  be  bent  with  difficulty 
and  pain.  The  stump  was  sensitive,  and  she  was  subject  to  a 
neuralgia  which  increased  towards  evening,  and  was  referred 
to  the  lost  member.  These  troubles  were  all  readily  relieved 
by  faradization. 

I  do  not  feel  sure  that  this  was  a  palsy  from  peripheral  dis- 
ease acting  on  the  centres.  It  is  very  likely  that,  as  is  usual, 
the  hand  was  a  long  time  at  rest  and  on  a  splint,  which  alone, 
with  the  inflammation,  would  account  for  tlie  stiffness  and  the 
rigid  extension  of  the  fingers,  so  rare  in  palsies  of  any  kind. 

But  there  was  also  neuralgia,  with  evidence  that  the  cause 
existed  iar  up  the  limb,  so  that  there  may  have  been  a  disease 
of  the  nerve,  which,  passing  inwards,  at  length  attacked  the 
main  trunks,  and  lessened  motility  in  the  member. 

I  should  not  have  ventured  to  state  that  post-inflammatory 
stiffness  and  long  use  of  splint  might  explain  this  case,  if  it  had 
not  chanced  to  me  more  than  once  to  see,  at  the  U.  S.  A.  Hospital 
for  Nervous  Diseases,  men  who  had  seemingly  lost  power  from 
nerve  wounds,  but  who,  on  closer  study,  proved  to  have  only 
that  pseudo-paralysis  which  grows  out  of  disuse  and  local 
disease. 

In  case  second,  p.  157,  the  history  is  incomplete,  and  is 
defective  in  clinical  details.  It  is  said  to  have  been  cured 
entirely,  in  two  sittings,  by  faradization. 

An  ill  set  radius  was  rebroken  and  put  straight,  but  the  cure 
was  protracted  over  ten  months.  At  the  close  of  this  time, 
"the  arm  remained  painful  and  entirely  useless."  Was  this 
limb  ten  months  out  of  use?  Were  no  passive  motions  made 
in  all  this  period,  and  was  the  arm  kept  at  rest  on  a  splint,  or 


342 


PARALYSIS  FROM 


[Feb., 


not  ?  Before  deciding  in  favor  of  Dr.  Altliaus'  diagnosis  of  the 
case  as  "  reflex  paralysis,"  we  should  like  to  be  satisfied  as  to 
these  points. 

Case  third,  p.  158,  is  described  as  "  reflex  paralysis  after 
rupture  of  capsular  ligament."  It  is  so  utterly  wanting  in 
every  thing  which  we  may  reasonably  ask  of  a  medical  history, 
that  it  is  vain  to  criticise  it. 

Before  closing  this  part  of  our  subject,  I  should  point  out  one 
source  of  possible  error  in  diagnosing  paralysis  or  other  dis- 
ease as  due  to  a  wound,  bruife,  neuralgia,  &c.  The  chances  of 
mistake  are  pei-haps  confined  to  instances  where  an  injury  af- 
fects one  nerve  of  a  plexus,  and  where  the  resultant  phenom- 
enon (choreal,  paralytic,  neuralgic)  follows  at  a  later  date  and 
involves  parts  supplied  by  other  nerves  of  the  same  plexus.  In 
some  of  these  cases  it  is  probable  that  an  inflammation  of  the 
nerve  wounded  may  pass  up  its  trunk,  and  involve  one  or  more 
branches  of  the  parent  plexus.  I  think  that  I  have  seen  this 
happen  in  several  patients.*  Whether  such  inflammations 
may  travel  backwards  so  far  as  to  involve  the  ganglionic  and 
central  origins  of  nerves  is  a  question  which  can  not  yet  be 
answered,  and  which  has  indeed  been  scarcely  thought  of  as  a 
possible  cause  of  disease.  Needless  to  add  that  I  do  not 
refer  to  the  passive  nutritive  changes  which  occur  in  nerves 
after  section,  but  to  active  inflammatory  or  congestive  con- 
ditions. The  extent  to  which  those  latter  affections  may  pass 
along  a  nerve  is  admirably  illustrated  in  a  case  lately  published 
by  Dr.  J.  C.  Nott,  of  Mobile,  and  which  is,  perhaps,  in  some 
respects,  unique  of  its  kind.t 

*  Wounds  and  other  Injuries  of  Nerves — Drs.  Mitchell,  Morehouse,  and 
Keen.    Lippincott  &  Co.  1864. 

t  Bone  and  Nerve  Surgery.  Lippincott  &  Co.  1866.  Philadelphia:  pp.  91. 
In  this  extraordinary  case  neuralgia  followed  an  amputation  of  the  leg.  To  re- 
lieve him,  three  amputations  were  done.  Finally,  Dr.  N.  cut  down  in  the  popliteal 
space,  exposed  the  iscbiatic  trunk  and  took  out  an  inch  of  it  and  portions  of  the 
popliteal  and  peroneal  nerves,  altogether  about  three  inches  in  length.  These 
nerves  were  all  enlarged.  No  relief  followed.  Next  Dr.  N.  cut  down  on  the 
stump,  and  dissected  out  its  nerves.  Still  no  relief  Amputation  of  the  thigh 
came  next  with  as  little  good  resulting;  and,  tinaliy,  Dr.  N.  cut  out  an  inch  of 
the  sciatic  nerve  below  the  pyriformis  inu>cIo.  The  nerve  removed  at  this  time 
was  the  first  whicii  had  appeared  sound,  but  it  does  not  seem  to  have  been 
microscopically  examined.    Partial  relief  followed.    Curiously  enough,  the  paia 


1866.] 


PERIPHERAL  IRRITATION. 


343 


Thus  far  I  have  sought  to  point  out  which  of  the  cases  usually 
explained  as  functional  paralysis,  or  presumed  to  be  caused  by 
peripheral  irritations  might,  with  more  reason,  be  assigned  to 
other  causes.  Yet  after  every  rational  exclusion  has  been 
effected,  we  still  have  found  numerous  cases  of  palsy  to  which 
we  can  assign  no  possible  cause,  except  an  external  irritation 
in  some  way  acting  through  nerves  upon  nerve  centres,  to  occa- 
sion loss  of  function.  Especially  is  this  true  of  the  cases  caused 
by  mechanical  injury,  for  here  there  are  none  or  at  least  few  of 
the  difficulties  which  present  themselves  in  connection  with 
visceral  disease.  But  even  if  a  doubt  still  existed  in  our  minds, 
it  could  hardly  resist  the  evidence  already  offered  elsewhere  by 
us,*  and  which,  in  fuller  shape,  I  shall  presently  re-state. 

In  one  of  the  cases  referred  to  a  man  is  shot  in  the  right  neck  ; 
he  falls  with  palsy  of  both  arms.  The  ball  has  passed  out ;  it 
has  hit  no  large  bone  on  which  it  could  split,  so  as  to  make  in 
its  after-course  a  double  injury,  and  thus  account  for  the  loss 
of  power  in  the  left  limb.  The  right  arm  traumatically  palsied, 
remains  so  for  years ;  the  left  recovers  spontaneously  within  a 
few  weeks.  Here  the  palsy  is  instantaneous,  occupies  a  re- 
mote limb,  and  is  to  me  inexplicable,  unless  I  admit  that  tlie  im- 
pression made  by  the  wound  of  the  right  cervical  plexus  was 
transmitted  inwards  to  the  spine,  and  gave  rise  to  loss  of  power 
in  those  parts  of  the  medulla  which  give  origin  to  the  left  cer- 
vical plexus.  Otlier  circumstances  of  this  case,  and  the  addi- 
tional instances  which  I  shall  relate,  strengthen  this  view — so 
strengthen  it,  indeed,  as  to  leave  little  doubt  in  my  mind  that 
an  injury  of  a  nerve  may  give  rise  to  sudden  palsy  of  distant 
regions  of  the  body. 

I  have  almost  as  little  doubt  that  an  acute  or  chronic  malady, 
or  a  sudden  impression  on  the  skin,  may  also  give  rise  to  paral- 
ysis; but  the  evidence  in  these  cases  does  not  place  them  on  a 
level,  as  to  credibility,  with  the  palsies  from  mechanical  injury; 
nor,  in  strictness,  is  it  fair  to  infer  from  the  latter,  that  if  an 
injury  may  produce  loss  of  power  in  remote  parts,  an  acute 


was  ill  every  case  rcferrod  to  the  extremity  of  the  existing  stump,  anil  not  to  tbe 
lost  foot  or  leg.    We  should  like  to  know  tlie  future  history  of  this  patient. 
•  Circular  No.  6, 1864,  Eeflex  Paralysis,  Drs.  Mitchell,  Morehouse  and  Keen. 


344 


PARALYSIS  FROM 


[Feb., 


malady,  as  pleurisy,  may  do  so.  The  cases  are  too  unlike,  and 
each  must  stand  upon  its  own  evidence. 

Let  us  admit  both  classes,  however,  as  I  think  we  have  reason 
to  do,  and  what  further  explanation  can  we  give  of  the  mechan- 
ism of  their  production  ? 

The  older  writers  attempt  none  beyond  what  is  involved  in 
the  term  sympathetic,  and  even  Whytt  relates  no  case  of  palsy 
to  be  thus  explained,  although  he  uses  his  famous  theory  to 
account  for  so  many  other  morbid  phenomena. 

Mr.  Stanley ••■  says,  in  substance:  an  irritation  from  a  diseased 
organ  is  propagated  by  sentient  nerves  to  the  spinal  cord,  and 
through  the  motive  and  sentient  spinal  nerves  to  tlie  limbs, 
occasioning  in  them  loss  of  sensation  and  the  power  of  motion. 

Dr.  Gravest  thus  explains  himself :  "  The  impression  made 
by  inflammatory  derangement  on  the  nervous  filaments  dis- 
tributed to  the  mucous  coat  of  the  intestines  is  propagated  to 
the  spinal  cord,  and  from  this  reacts  on  the  muscular  functions 
of  the  lower  extremities." 

Mr.  Stanley  is  speaking  of  cases  of  palsy  from  genito-urinary 
disease,  Dr.  Graves  of  those  arising  from  intestinal  disorder. 
Neither  explanation  is  satisfactory  to  the  physiology  of  to-day, 
and  neither  goes  practically  beyond  the  step  in  advance  made 
by  Whytt,^  when  he  conceived  the  idea  that  sympathetic  morbid 
phenomena  are  effected  through  the  agency  of  the  nerves  and 
the  brain  or  spine. 

Two  theories  remain.  The  first  explains  cases  of  palsy  from 
peripheral  irritation,  by  supposing  that  long  continued  or  sud- 
den and  violent  irritation  of  a  centre  through  its  afferent  nerves 
may  exliaust  it  so  entirely  as  to  occasion  palsy  of  the  external 
parts  which  depend  upon  it  for  their  endowments.  This  view, 
less  distinctly  formularized,  was  no  doubt  held  by  many  authors, 
and  paralysis  by  irritation  and  consequent  exhaustion  sufficiently 
recognized.  It  was  plainly  set  forth  by  Drs.  Morehouse,  Keen 
and  myself,  in  March,  1864,  and  more  elaborately,  tliough  not 
more  distinctly,  by  Jaccoud,  in  December  of  the  same  year. 


*  Med.-Chir.  Tr.,  vol.  xviii. 
t  ClinicLil  Lectures  p.'  415. 

t  Woiks  of  Robt.  Whytt,  M.D.,  ud.  ITCS,  p  503  et.  s'q. 


1866.] 


PERIPHERAL  IRRITATION. 


345 


Dr.  Handfield  Jones,  1861,  and  Eiscnmann,  1860,  are  cited  by 
Jaccoud  as  having  ascribed  some  of  tlie  paralyses  from  abnor- 
mal peripheral  influence,  such  as  cold,  to  a  shock  {un  clioc) 
which  abolished  nerve  power  for  a  time.  In  this  shape  the 
theory  would  certainly  rest  upon  no  fair  physiological  basis, 
and  would  be  open  to  the  criticism  which  M.  Jaccoud  so  liberally 
deals  out  while  asserting  his  own  claim. 

If  there  be  any  great  credit  involved,  the  latter  author  was 
certainly  anticipated  by  Dr.  Gull,  and  also  in  the  paper  above 
referred  to.  Whether  M.  Jaccoud  has  fairly  presented  the 
claims  of  Jones  and  Eisenmann  I  can  not  say,  as  I  have  no 
access  to  their  essays. 

The  remaining  theory,  that  of  Brown-S^quard,  was  first  set 
forth  in  his  lectures,  printed  in  The  Lancet,  1860,  and  more 
fully  in  his  little  volume  on  paraplegia,  published  in  Phila- 
delphia in  1861.  His  opinions  were  controverted  by  Dr.  Gull 
in  1860,  and  by  Drs.  Morehouse,  Keen  and  myself  in  1864,  as 
well  as  by  JM.  Jaccoud.  Nasse  and  Valentiner  have  also  written 
against  M.  Brown-S^quard's  theory,  but  I  have  been  unable  to 
obtain  their  papers.  Romberg,  at  one  time  a  believer  in  reflex 
paralysis,  is  said  to  have  been  influenced  to  a  change  of  view 
by  the  criticisms  of  the  authors  last  named. 

I  will  endeavor  to  state,  with  all  possible  brevity,  Dr. 
Brown-.-^equard's  theory,  the  evidence  adduced  in  its  favor,  and 
the  opponent  criticism. 

The  fullest  exposition  of  Brown-Sdquard's  ideas  exists  in  the 
volume  on  paraplegia,  by  which,  therefore,  they  may  best  bo 
tested.  He  discusses  at  length  the  question  as  to  whether  there 
is  a  reflex  paraplegia.  With  exceptions  and  much  reservation 
as  to  cases  and  sets  of  cases,  we  have  already  admitted  the  ex- 
istence of  palsy  from  peripheral  irritation,  which,  in  other  terms, 
is  as  far  as  his  first  proposition  goes. 

To  comprehend  the  future  argument,  it  must  be  remembered 
that  under  the  term  reflex  paralysis,  the  author  whose  views 
are  in  question  includes  all  the  cases  of  palsy  which  have  been 
supposed  to  proceed  from  acute  disease,  exanthenis,  dentition, 
worms,  cold,  injuries,  &c. 

The  following  paragraphs  include  all  that  Dr.  Brown-S6- 


346 


PARALYSIS  FROM 


[Feb., 


quard  has  here  seen  need  to  explain  in  regard  to  his  theory  of 
the  mode  in  which  peripheral  irritations  act. 

They  occasion,  he  says,  a  permanent  spasm  of  the  spinal  ves- 
sels, and  the  want  of  blood  and  tho  insufficient  nutrition  which 
follows  occasion  palsy,  from  loss  of  function  in  the  centres 
aflected. 

"  1st.  Reflex  Contraction  of  Blood- Vessels. — As  it  is  now  well 
established  that  blood-vessels  contract  with  energy,  and  some- 
times even  are  seized  with  a  real  and  prolonged  spasm,  whether 
by  a  direct  influence  of  their  motor  nerves,  or  through  an 
excitation,  which,  from  some  centripetal  or  excito-motor  nerve, 
has  been  reflected  upon  them  by  the  cerebro-spinal  axis,  there 
is  no  need  of  showing  here  that  blood-vessels  are  just  like 
muscles  of  animal  life  as  regards  their  relations  with  the  nerv- 
ous system.  This  being  the  case,  it  is  extremely  easy  to  un- 
derstand how  a  paralysis  of  the  lower  extremities,  as  well  as 
that  of  any  other  part  of  the  body,  may  be  caused  by  a  reflex 
action.  In  three  different  places  a  contraction  of  blood-vessels 
may  cause  paraplegia  :  1,  in  the  spinal  cord  ;  2,  in  the  motor 
nerves ;  3,  in  muscles.  A  contraction  of  blood-vessels  in  the 
spinal  cord  I  have  seen  (in  the  vessels  of  the  pia  mater)  taking 
place  under  my  eyes,  when  a  tightened  ligature  was  applied 
on  the  hilus  of  the  kidney,  irritating  tlie  renal  nerves,  or  when 
a  similar  operation  was  performed  on  the  blood-vessels,  and 
nerves  of  the  supra-renal  capsules.  Generally,  in  those  cases, 
the  contraction  is  much  more  evident  on  the  side  of  the  cord 
corresponding  with  the  side  of  the  irritated  nerves,  Avhich  fact 
is  in  harmony  with  another,  and  not  rare  one.  observed  first  by 
Comhaire,  (as  regards  the  kidney,)  and  often  seen  by  me  after 
the  extirpation  of  one  kidney  or  one  supra-renal  capsule,  /.  e.,  a 
paralysis  of  the  corresponding  lower  limb.  It  is  probable  that 
irritations  starting  from  the  urinary  and  other  organs,  produce 
a  paraplegia  by  a  contraction  rather  of  the  blood-vessels  of  the 
spinal  cord,  than  of  those  of  the  motor  nerves  and  muscles. 
However,  in  this  form  of  paraplegia,  it  is  not  rare  that  a 
notable  diminution  of  temperature  of  the  paralyzed  limbs  shows 
that  the  blood-vessels  of  these  parts  are  also  contracted. 

"  2d.  3forbid  Reflex  Influence  on  Nutrition. — This  influence, 
proved  by  many  experiments  on  animals,  and  by  pathological 


1866.] 


PERIPHERAL  IRRITATION. 


347 


facts  of  daily  occurrence,  seems  usually  not  to  exist  in  reflex 
paraplcoia,  except  in  that  form  in  which  muscles  become  pro- 
gressively and  rapidly  atrophied  and  altered.  (  Wasting jMlsy .) 
But  this  morbid  influence  may  take  place  at  ai  y  moment  in  the 
course  of  a  reflex  paraplegia,  so  long  as  the  irritating  cause 
has  not  ceased  to  act,  and  a  myelitis  or  some  other  affection 
may  be  generated  by  it. 

"  We  think  that  it  will  now  be  considered  possible,  if  not 
probable,  that  the  production  of  reflex  paraplegia  is  due  to  a 
contraction  of  blood-vessels,  and  to  the  insufficiency  of  nutri- 
tion that  follows  this  condition  of  the  vessels."  (Lect.  on 
Paraplegia,  p.  23,  Phil.,  1861.) 

Against  the  idea  of  spasm  of  vessels  lasting  for  days,  months, 
or  years,  every  author  who  has  criticised  this  view  has  in  turn 
protested,  as  in  essence  singularly  unphysiological. 

Dr.  Gull  was,  I  think,  the  first  to  oppose  this  explanation  of 
the  etiology  of  palsy  from  external  irritation.  His  paper, 
which  is  a  model  of  medical  criticism,  we  shall  again  refer  to. 
M.  Jaccoud  has  very  fully  treated  the  subject  in  a  theoretical 
point  of  view,  and,  as  his  statement  is  inclusive  of  the  former 
critic's  opinion,  1  will  resume  it  here.  Certain  additional  argu- 
ments will  be  found  in  a  quotation  from  Med.  Circ,  No.  6, 
1864,  at  another  place  in  this  paper. 

To  cause  palsy,  says  M.  Jaccoud,  the  contraction  of  the 
arteries  must  be  permanent,  or  last  as  long  as  the  palsy;  but 
exhaustion  follows  abnormal  excitement,  and  wherever  vessels 
are  concerned,  passive  dilatation  succeeds  to  active  contrac- 
tion, and  comes  the  sooner  as  the  primary  stimulation  has 
been  the  more  severe. 

Thus  the  stern  physiological  law  of  rest  after  labor,  of  re- 
laxation after  contraction,  stands  in  the  way  of  any  idea  which 
presupposes  long  continued  vasal  spasm.  M.  Jaccoud  thinks 
that  the  spine  is  so  rich  in  vessels  that  it  would  not  be  possi- 
ble by  a  local  contraction  of  blood-vessels  to  cut  off  the  vascu- 
lar su|)i)ly  from  any  considerable  section.  I  myself  fancy  that 
it  would  be  hard  to  conceive  of  any  spasm,  such  as  would  be 
competent  to  annihilate  function,  and  yet  occasion  none  of 
those  visible  defects  of  nutrition,  such  as  arc  seen  in  the  brain 


348 


PARALYSIS  FROM 


[Feb., 


when  embolus  occurs,  or  in  rare  cases  after  ligature  of  one 
of  its  main  vessels. 

As  Brown-S(^'quard,  a  brilliant  experimentalist,  has  appealed 
to  observed  facts,  created  purpo.-ely  in  animals,  so  his  critics 
have  replied  by  a  like  appeal  to  direct  experiment.  Para- 
plegia, says  Brown -S^quard,  may  be  brought  about  in  animals 
by  excision  of  the  kidney  or  supra-renal  capsules — a  result 
which  he  himself  has  repeatedly  obtained,  in  accordance  with  the 
much  older  experiments  of  Comhaire,*  to  whose  observations 
all  the  writers  refer  briefly,  without  giving  any  further  ac- 
count of  tlicm.  Raoul  Le  Roy  d'Etiolles,  experimenting  with 
great  care,  has  since  failed  of  this  result.  Dr.  Gull,  aided  by 
Dr.  Pavy  and  Mr.  Durham,  repeated  these  experiments,  taking 
great  pains  to  avoid  injuring  the  lumbar  and  psoas  muscles. 
In  no  instance  did  paralysis  of  the  hinder-limbs  result,  nor 
could  it  be  told  from  the  gait  of  the  animal,  afcer  the  operation, 
which  kidney  had  been  removed.  Dr.  Hammond  t  informs  me 
that  he  himself  was  not  less  unfortunate,  and  in  numerous  ab- 
lations of  the  renal  organs  met  with  no  instance  of  paraplegia. 

M.  Brown-S(5quard,  as  quoted  above,  tells  us  that  when  he 
irritated  the  nerves  of  the  kidney  or  supra-renal  capsule,  he 
saw  the  blood-vessels  in  the  spinal  pia  mater  contract,  and  that 
generally  tiie  contraction  was  most  marked  on  the  side  upon 
which  the  nerves  had  been  irritated.  Now,  it  docs  not  seem 
that  the  vessels  remained  in  a  state  of  spastic  contraction, 
despite  the  violence  of  the  irritant  used.  Nor,  from  what  we 
know,  should  we  expect  such  a  result  ?  In  the  meninges  of 
the  brain  direct  irritation  is  followed  in  succession  by  contrac- 
tion and  dilatation,  Avhile  the  same  result  obtains  with  no  less 
clearness  when,  the  sympathetic  nerve  being  stimulated,  the 
cerebral  vessels  first  narrow  and  then  enlarge,  as  Van  dcr  Beck 
Callenfels  and  Donders  have  shown. 

On  the  faith  of  direct  observation.  Dr.  Gull  discredits  Brown- 
Sequard's  statement  as  to  visible  contraction  of  the  spinal  blood- 
vessels or  irritation  of  renal  nerves.    He  failed  to  get  such  a 


*  Corahairc,  Dissertation  sur  rExtirpation  des  Reins.  Paris,  1803.  I  bavc 
been  unable  to  obtain  this  essay. 

t  Dogs  and  rabbits  were  used  by  all  of  those  experimenters. 


1866.] 


PERIPHERAL  IRRITATION, 


349 


result  himself,  and  is,  we  think,  rather  too  decided  in  his  cen- 
sure of  the  French  physiologist. 

Jn  point  of  fact,  neither  party  has  given  their  experiments 
with  the  precision  demanded  in  records  of  scientific  investiga- 
tions. As  an  instance.  Dr.  Gull  does  not  say  how  long  he 
waited  after  opening  the  spine  before  acting  on  tlie  kidneys, 
nor  does  he  tell  us  how  much  blood  was  lost.  Yet  these  points 
are  of  the  first  moment,  because  it  does  often  happen  that  after 
the  spine  is  exposed  some  time  elapses  before  its  nerves  are 
fully  sensitive.  As  to  the  vessels,  which,  of  course,  must  be 
arterial  to  have  any  influence.  Dr.  Brown-Sequard  says  he  saw 
them  contract,  and  Dr.  Gull  says  there  are  none  large  enough 
to  be  visible.  This  latter  statement  may  be  affected  by  the 
conditions  of  the  individual  experiments;  but  since  they  are 
insufiiciently  reported,  we  must  refer  the  dispute  back  again 
to  the  field  of  experimentation,  where  only  it  can  be  settled. 

It  is  difficult,  I  think,  to  adhere  to  a  theory  which  presents 
defects  so  obvious.  In  one  respect  only  has  it  been  unfairly  dealt 
with  by  the  critics.  Brown-S6quard  has  loaded  it  with  one 
condition  which  I  believe  to  have  been  unnecessary,  and  which, 
as  I  have  said,  has  been  mercilessly  handled.  I  refer  now  to  the 
question  of  the  existence  of  material  lesion  in  cases  of  reflex 
palsy,  or,  as  I  prefer  to  call  it,  of  palsy  from  peripheral  irrita- 
tions. Its  importance,  however,  is  not  thus  limited,  for  it  ex- 
tends to  the  whole  class  of  so-called  functional  maladies,  and 
whatever  view  we  take  of  the  palsies  from  external  irritants 
must  deal  with  this  subject  of  immediate  or  ultimate  material 
changes  in  the  affected  centres.  Throughout  his  works,  Dr. 
Brown-S^quard  holds  that  paralysis  from  peripheral  irritation 
exhibits  no  central  lesion.  If  we  exact  of  the  autopsic  examin- 
ation that  it  shall  have  been  aided  by  the  microscope,  we  shall 
discover  scarcely  a  case  which  will  stand  this  test,  if  we  except 
that  related  by  Dr.  Gull,"  and  claimed  by  Brown-S^quard  as 


*  Guy's  Hospital  Reports.  Third  series.  Vol.  iv.  Case  17,  p.  174.  As  re- 
gai'ds  this  patient,  in  whom  paraplegia  occurred,  it  does  seem  clear  that  tiiere 
was  no  spinal  lesion  found  by  a  very  competent  observer.  The  man  died  on  the 
sixteenth  day  fioin  the  dale  of  the  paraplegic  attack.  There  was  but  one  omis- 
sion at  the  autopsy.  The  head  was  not  examia'.'d,  nor,  of  course,  was  the 
medulla  oblongata  inspected. 


350 


PARALYSIS  FROM 


[Feb., 


a  type  case  of  reflex  palsy.  With  more  justice  may  it  be  regard- 
ed as  a  case  of  asthenia  of  the  cord,  which  is  what  its  reporter 
claims  it  to  have  been.  Were  Ave  to  admit  that  palsy  may  be 
occasioned  by  spasm  of  the  spinal  vessels,  it  is  quite  conceiva- 
ble that  if  death  should  occur  very  early,  no  lesion  might  be 
found;  but  it  does  seem  to  me  quite  certain,  that  when  there  is 
prolonged  want  of  blood  in  a  part,  material  lesions  must  arise. 
For  this  case  Brown-S^quard's  theory  in  a  measure  provides, 
since  he  states  distinctly  enough  that  the  palsy  will  be  due  to 
contraction  of  vessels  and  to  the  insufficient  nutrition  which 
this  produces.  Now,  it  is  inconceivable  that  want  of  nutrition 
great  enough  to  paralyze  could  long  continue  without  origi- 
nating lesions,  which  the  microscope,  at  least,  would  detect. 
Nevertheless,  we  find  Brown-Sequard  insisting  on  absence  of 
material  lesion  as  one  of  the  proofs  of  his  cases  having  been 
due  to  spasm  of  the  vessels. 

I  hold,  myself,  that  where  a  continued  or  violent  irritation 
has  acted  on  the  nerve  centres  through  their  afferent  nerve 
channels,  the  palsy,  occasionally  induced,  is  due  to  loss  of  irri- 
tability in  the  ganglionic  masses  concerned,  and  I  am  not  unwil- 
ling to  apply  the  remarks  I  have  just  made  to  this  theory,  under 
which  I  should  explain  most  of  the  cases  of  paralysis  which 
Brown-S(^quard  terms  reflex. 

Material  injury  involves  defect  or  loss  of  function.  Prolonged 
loss  of  function,  to  my  mind,  involves  also  material  change;  and 
I  firmly  believe  that  the  future  history  of  this  subject  will  bring 
us  to  this  conclusion,  so  soon  as  a  more  exact  study  is  made  of 
the  tissues  of  those  who  die  after  having  been /or  a  length  of 
^me  the  victims  of  paralysis  from  external  irritation.  If  we 
conceive  that  spasm  of  the  vessels  occasions  the  result,  it  were 
easy  to  imagine  the  kind  of  lesions  to  be  expected.  If  exhaus- 
tion from  over-stimulation  of  the  centres  be  received  as  the 
etiology  of  such  cases,  it  is  impossible,  in  the  present  state  of 
our  knowledge,  to  suspect  what  form  of  structural  change  would 
arise. 

If,  again,  we  conceive  that  external  irritations  may  occasion 
loss  of  power  through  long  continued  paralytic  dilatation  of 
spinal  vessels,  as  elsewhere  pointed  out,  we  should  also  expect 
to  find  material  lesions  in  old  cases ;  but  whether  there  may 


1866.] 


PERIPHERAL  IRRITATION. 


351 


be  in  some  recent  ones  congestion  enough  of  this  kind  to  occa- 
sion death,  without  being  great  enough  to  be  visible  post  mor- 
tem, is  a  question  which  as  yet  has  not  been  fully  answered. 

Further  and  more  careful  examinations  of  undoubted  cases, 
recent  or  of  long  continuance,  must  be  looked  to  for  enlightening 
us  as  to  the  existence  or  non-existence  of  lesions.  Meanwhile, 
it  is  encouraging  tliat  in  epilepsy,  insanity,  and  lately  in  tetanus, 
rigid  scrutiny  has  detected  alterations  of  tissue  which  will  soon 
or  late  enable  us  to  erase  these  maladies  from  the  catalogue, 
now  far  too  long,  of  merely  functional  disease. 

Before  concluding  this,  the  critical  portion  of  my  essay,  I 
will  quote  at  length  the  objections  to  Brown-S^quard's  theory, 
which  were  made  by  myself  and  my  friends  Drs.  Morehouse 
and  Keen,  (May,  18G4,)  in  the  Array  Medical  Circular,  No.  6, 
1864.  The  language  of  this  extract  I  feel  no  inclination  to 
change.  It  states  Avith  sufficient  fullness  the  views  which  I 
still  hold  in  regard  to  the  production  of  peripherally  induced 
paralysis,  whilst  in  many  respects  the  arguments  employed  by 
us  differ  remarkably  from  any  of  those  made  use  of  in  the  able 
papers  of  Dr.  Gull  and  M.  Jaccoiid. 

"  A  gun-shot  wound  occurs,  involving  large  nerves  or  not, 
and  we  have  instantly  a  paralysis  of  motion  and  sensation,  or 
of  either  alone,  in  some  part  of  the  body  more  or  less  remote. 
How  sliall  we  explain  this?  Although  we  have  long  been 
aware  that  certain  forms  of  disease  are  capable  of  causing  par- 
alysis of  distant  organs,  of  altering  secretions  and  affecting 
nutrition,  we  have  had  no  plausible  theory  of  the  causation  of 
these  effects,  until  Dr.  Brown-S^quard  attempted  to  account  for 
them  in  a  manner  equally  simple  and  ingenious.  Eecallingthe 
fact  that  irritation  of  theM  aso-niotor  nerves  is  capable  of  pro- 
ducing contraction  of  the  blood-vessels,  he  inferred  that  when 
an  external  nerve  is  violently  or  permanently  excited,  it  may 
be  able  to  produce  contraction  of  the  vessels  of  the  nerve 
centres,  and  thus  give  rise  to  paralysis.  It  seems  unlikely, 
even,  if  we  admit  his  explanation,  that  the  arteries  could  re- 
main contracted  for  any  great  length  of  time.  But  it  is  possible 
that  the  alteration  of  nutrition,  which  this  temporary  anajmia 
causes,  may  give  rise  to  one  of  two  results,  either  a  continued 
disturbance  of  nutrition,  which,  however  slight,  would  occasion 


PARALYSIS  FROM 


[Feb., 


grave  results  if  it  existed  in  a  nerve  centre,  or,  secondlv,  to  a 
paralysis  of  the  vessels  of  the  nerve  centre  involved. 

"  We  suppose,  first,  the  existence  of  an  exterior  nerve  lesion; 
secondly,  a  consequent  irritation  of  the  vaso-motor  nerves  in  a 
limited  part  of  the  spine;  contraction  of  its  vessels,  anaemia, 
nutritive  changes,  and,  finally,  a  relaxation  of  these  tubes, 
which  would  be  more  apt  to  be  a  lasting  condition,  and  would 
in  fact  constitute  congestion.  Such  a  series  of  consequences 
may  very  possibly  occur,  and  would  no  doubt  be  competent  to 
cause  a  paralysis,  whose  site,  extent  and  character  would  depend 
upon  the  part  of  the  nerve  centres  affected  by  the  excitation. 
With  so  satisfactory  an  hypothesis  before  us  in  this  modified 
shape,  it  would  seem  needless  even  to  suggest  any  other  explana- 
tion. But  in  a  region  of  research  so  little  explored,  it  may  be 
allowable  to  point  out  the  fact  that  another  mode  of  explana- 
tion is  at  least  possible,  and  the  more  so  since  there  exist  cer- 
tain objections  to  Dr.  Brown-S^quard's  manner  of  viewing  the 
subject. 

"It  is,  to  our  minds,  improbable  that  contraction  of  the 
vessels  can  continue  for  any  great  length  of  time.  There  is 
no  experiment  on  record  to  show  that  this  can  be,  or  that  it 
ever  occurs  in  a  nerve  centre.  We  have  tlicrefore  added  the 
suggestion  of  consequent,  and  why  may  we  not  say  primary 
paralysis  of  these  channels  ?  Here  we  have  firmer  ground  for 
opinion,  since  it  has  been  most  distinctly  shown  that  in  section 
of  the  sympathetic  nerve  this  result  does  take  place,  and  is  sin- 
gularlv  persistent.  But  whether  the  blood-vessels  remain  con- 
tracted or  dilated,  nutritive  changes  would  occur,  and  these 
the  pathologist  has  failed  to  find. 

"  If,  now,  we  ask  ourselves  the  question,  whether  it  may  be 
possible  to  blight  or  exhaust  utterly  the  power  of  a  nerve  cen- 
tre, without  the  intervening  mechanism  of  contracted  or  dilated 
blood-vessels,  we  are  tempted  to  think  that  such  a  result  may 
bo  producible. 

"It  appears  to  us  possible  that  a  very  severe  injury  of-a  part 
mav  be  competent  so  to  exhaust  the  irritability  of  the  nerve 
centres,  as  to  give  rise  to  loss  of  function,  which  might  prove 
more  or  less  permanent.  A  strong  electric  current  is  certainly 
able  to  cause  such  a  result  in  a  nerve  tiunk,  while  a  general 


1866.] 


PERIPHERAL  IRRITATION. 


353 


electric  shock,  as  a  stroke  of  lightning,  is,  as  we  well  know, 
quite  competent  to  destroy  the  irritability  of  every  excitable 
tissue  in  the  economy.  Now  if  the  former  of  these  results  can 
occur  in  a  nerve  so  insulated  as  practically  to  have  no  circu- 
lation, the  loss  of  irritability  can  not  be  set  down  as  due  in 
such  a  case  to  a  defect  of  circulation.  Reflecting,  then,  upon 
the  close  correlation  of  the  electrical  and  neural  force,  it  does 
not  seem  improbable  that  a  violent  excitement  of  a  nerve  trunk, 
however  brought  about,  should  be  able  to  exhaust  completely 
the  power  of  its  connected  nerve  centre.  The  central  change 
thus  occasioned  would,  no  doubt,  involve  the  consequent  or 
immediate  occurrence  of  nutritive  changes,  which  would  gradu- 
ally yield  as  time  went  on.  While  this  view  seems  to  us  ade- 
quate to  explain  the  facts,  the  notion  of  vaso-motor  irritation 
and  capillary  contraction  (Brown-S6quard)  does  not  appear  to 
be  competent  to  cover  all  the  facts. 

"  We  have  pointed  out  that  no  one  has  ever  shown  that 
vasal  contraction  can  exist  as  a  permanent  state  in  a  nerve 
centre.  While,  on  the  other  hand,  it  has  been  proven  that 
section  of  a  sympathetic  nerve  involves  permanent  dilatation  of 
blood-vessels;  but  in  the  brain,  which  is  supplied  by  the  sympa- 
thetic of  the  neck,  division  of  this  nerve  gives  rise  to  no  dis- 
turbance, although  the  side  of  the  brain  on  which  the  section 
occurs  grows  warmer.  However,  it  is  probable  that  the  whole 
supply  of  vaso-motor  nerves  to  the  brain  does  not  come  from 
the  neck,  while  other  organs,  whose  whole  supply  we  can  cut 
ofiF,  as  the  kidneys,  do  certainly  suffer  nutritive  changes  as  a 
consequence  of  such  sections. 

"  One  or  other  of  the  two  theories  we  have  offered  must, 
therefore,  be  called  on  to  explain  the  central  changes  which 
give  rise  to  reflex  paralysis.  Either  the  shock  of  a  wound 
destroys  directly  the  vital  power  of  a  nerve  centre,  or  it  causes 
paralysis  of  the  vaso-motor  nerves  of  the  centre,  with  conse- 
quent congestion  and  secondary  alterations.  But  tlvere  is  no 
reason  tvhy,  if  shock  bs  competent  to  destroy  vitality  in  vaso- 
motor nerves  or  centres,  it  should  be  incompetent  so  to  affect  the 
centres  of  motion  or  sensation." 

Before  concluding,  it  is  but  just  to  call  attention  to  a  third 
view  of  the  causation  of  palsies  of  peripheral  origin.  Dr. 

Vol.  II.— No.  11.  23 


354  PARALYSIS  FROM  PERIPHERAL  IRRITATION.  [Feb., 


Handfield  Jones  (British  Medical  Journal,  1859,  Feb.  5th,  and 
Functional  Nervous  Diseases,  1864.)  proposed  to  use  the  term 
inhibitory,  as  applied  to  certain  functional  palsies.  He  is  of 
opinion  that  the  reflex  palsies  of  Brown-S^quard  and  others 
are  to  be  included  in  it.  Dr.  J.  mentions  the  experiments  of 
Pfluger,  Lister,  and  the  older  observers,  on  the  pneumogastric 
nerve.  He  agrees  in  part  with  Lister,  modifying  his  views  so 
that  it  is  not  merely  the  energetic  operation  of  an  afferent 
nerve  that  is  supposed  to  cause  inhibitory  action,  but  its  being 
injuriously  affected  by  some  impression  made  upon  it.  The 
enfeebled  state  of  the  nerve,  or  the  nerve  centre  to  which  it 
proceeds,  or  the  severity  or  malignity  of  the  impression,  may 
give  rise  to  the  peculiar  effect. 

Against  this  view,  as  explaining  functional  paralysis  from 
peripheral  irritation,  it  may  be  urged,  that  in  health,  inhibi- 
tory phenomena  are  only  known  to  occur  in  the  pneumogastric 
nerve,  and  within  the  range  of  the  sympathetic;  and  hence 
that  we  have  no  right  to  stretch  the  case  so  as  to  cover  patho- 
logical phenomena  involving  the  spinal  centres  and  nerves,  or 
the  voluntary  muscles.  That,  finally,  there  is  reason  to  suspect 
that  the  so-called  inhibitory  phenomena  are  due  to  exhaustion  of 
nerves,  or  ganglia,  by  over-excitation.  In  fact,  Dr.  Jones 
admits  that  the  paretic  condition  of  the  centre  persists  for  an 
indefinite  time  after  the  removal  of  the  morbid  cause  which 
affected  it.  In  this  respect  only,  he  says,  inhibitory  palsy 
differs  from  reflex  paralysis,  which,  according  to  M.  Brown- 
Sequard's  definition,  increases,  diminishes,  or  disappears  as  the 
morbid  cause  is  greater  or  less,  or  absent. 

It  is  plain,  however,  that  this  definition  applies  to  but  few 
cases,  and  that  in  his,  as  in  Dr.  Jones's  cases,  the  paralysis 
often  remained  when  the  supposed  cause  had  been  taken  away. 
Finally,  Dr.  Jones  briefly  urges  against  Brown-S^quard's 
theory  of  vaso-motor  influence  mucli  the  same  arguments  as 
those  employed  more  fully  by  Dr.  Gull,  M.  Jaccoud,  and  in  our 
paper  already  referred  to. 

If  I  were  now  to  sum  up  the  probabilites  in  the  way  of 
causation  of  palsies  peripherally  induced,  1  should  be  disposed 
to  refer  some  cases  to  exhaustion  from  too  constant  or  ex- 
cessive exercise  of  normal  functions,  and  others  to  irritation 


1866.] 


TUMOR  OF  TESTIS. 


355 


from  disease  or  injury,  and  to  consequent  exhaustion  of  the 
centres;  while,  as  regards  the  intervention  of  vascular  agency,  I 
should  reject  the  idea  of  prolonged  vasal  spasm,  and  consider 
it  possible  that  in  some  instances  over-excitation  might  result 
in  dilatation  of  the  vessels,  in  which  case  some  material  lesion 
would  surely  result,  if  the  condition  in  question  were  of  long 
continuance. 


On  Tumor  of  Testis,  co7itaining  "Fostal  Remains,'"  ivith  a  Case. 
By  W.  H.  Van  Buren,  M.D.,  Prof,  of  Anatomy,  University 
of  New  York,  &c.,  &c. 

A  male  child,  two  years  and  five  months  old,  was  brought  to 
me  in  the  month  of  October,  18G4,  with  a  tumor  of  the  scrotum, 
apparently  involving  the  left  testicle,  about  the  size  of  a  large 
hen's  egg.  The  child  was  healthy  at  birth,  and  the  swelling 
of  the  testis  was  not  noticed  until  he  was  three  months  old, 
when  a  physician  was  consulted,  who,  regarding  the  disease  as 
a  hydrocele,  passed  a  seton  through  the  tumor,  in  the  form  of 
a  worsted  thread.  So  much  pain  followed  this  operation  that 
the  seton  was  withdrawn  in  three  hours,  a  glairy  fluid  escaping 
with  some  force,  but  in  small  quantity,  and  the  tumor  remain- 
ing hard,  and  subsequently  growing  harder  under  the  very 
severe  inflammation  which  followed.  After  the  subsidence  of 
the  inflammation  the  tumor  remained  about  at  its  original 
size,  but  somewhat  harder,  for  nearly  a  year,  when  several  ab- 
scesses formed  and  discharged  themselves  consecutively;  and 
finally,  after  quite  a  large  abscess  had  opened,  a  red,  fungous 
mass  protruded  from  its  orifice,  which  gradually  reached  the 
size  of  an  English  walnut. 

I  found  the  tumor  presenting  fully  one-half  of  its  mass  in  the 
shape  of  this  fungous  protrusion,  which  was  covered  with  un- 
healtliy  granulations  discharging  watery  pus,  hard  to  the  touch, 
and  occupying  its  lower  and  larger  portions.  Its  upper  portion, 
towards  the  spermatic  cord,  was  generally  smooth  upon  its  sur- 
face, of  a  soft  solid  consistence,  the  skin  adherent,  and  not  very 
painful  when  grasped.  It  had  never  been  painful  except  when 
the  abscesses  were  forming,  and  when  it  was  punctured.  There 


356 


TUMOR  OF  TESTIS. 


[Feb., 


were  no  enlarged  glands  in  the  groins.  The  child  was  weakly 
and  pallid,  and  suffering  from  diarrhaea. 

Dr.  Valentine  Mott  liad  seen  the  case,  suspected  that  the  dis- 
ease was  malignant  in  its  nature,  and  advised  its  removal. 

I  suggested  to  the  father  that  he  should  take  the  child  to  the 
sea-side  for  a  month,  and  pay  close  attention  to  his  diet.  At 
the  end  of  this  time  his  health  was  very  much  improved,  but  the 
tumor  was  unchanged.  I  was  able  to  form  no  positive  opinion 
as  to  its  nature,  but  felt  no  doubt  as  to  the  propriety  of  its  re- 
moval, and  I  therefore  removed  it,  by  castration,  in  the  usual 
manner. 

The  child  made  a  rapid  recovery  after  the  operation,  and  I 
have  heard,  within  a  few  days,  that  he  is  in  excellent  health 
and  growing  finely. 

On  examination  of  the  tumor,  after  removal,  the  portion  al- 
ready described  as  a  fungous  protrusion,  and  which  occupied 
the  lower  part  of  the  tumor,  was  found  partially  covered  at  its 
lowermost  surface  by  integument,  and  upon  this  integument, 
posteriorly,  was  a  surface  half  an  inch  in  diameter  thickly 
covered  with  hairs,  some  of  them  an  inch  in  length,  and  pre- 
senting, under  the  microscope,  the  characteristic  appearance  of 
hairs  from  the  head.  Upon  the  surface  of  the  protrusion  was 
the  orifice  of  a  fistula,  and  on  introducing  a  probe  into  the  fis- 
tulous tract  it  came  in  contact  with  a  very  hard,  smooth,  ap- 
parently bony,  surface.  When  laid  open  by  the  scalpel,  a 
cavity  was  disclosed  about  an  inch  in  diameter,  containing 
pus,  and  in  contact  with,  and  adherent  to  its  walls,  a  fragment 
of  bone,  covered  by  periosteum  resembling  in  shape  a  fragment 
of  the  body  of  a  foetal  lower  jaw-bone.  The  length  of  this 
fragment  of  bone  was  five-eighths  of  an  inch,  its  breadth  three- 
eighths  of  an  inch,  and  its  thickness  about  the  same.  Im- 
planted somewhat  irregularly  upon  one  of  its  margins  were 
found  four  teeth,  slightly  altered  from  their  normal  shape,  but 
distinctly  recognizable  as  two  incisors,  one  canine,  and  one 
molar,  in  their  normal  relation,  and  appropriate  in  size  to 
that  of  the  fragment  (of  jaw-bone)  in  which  they  were  im- 
planted. On  withdrawing  the  molar  tooth  from  its  alveolar 
socket,  which  was  normal  in  its  proportions,  it  was  found  to 
present  the  crown  of  a  well  formed  molar,  hollow  within,  and 


1866.] 


TDMOR  OP  TESTIS. 


357 


destitute  of  fangs.  At  the  bottom  of  the  alveolar  socket  the 
dental  sac  was  distinctly  visible,  and  protruding  from  its  floor 
was  the  well  formed  surface  of  a  second  (permanent)  molar 
tooth,  which,  when  touched  by  a  probe,  was  soft  and  evidently 
not  yet  encrusted  by  enamel.  It  was  with  one  of  these  teeth 
that  the  probe  came  in  contact  when  introduced  into  the  fistu- 
lous tract.  Both  the  tooth  and  bone  structure  were  ex- 
amined microscopically,  the  former  showing  enamel  prisms, 
and  the  latter  the  lacunse  and  canaliculi  of  true  bone. 

Situated  above  the  cavity,  which  inclosed  the  bone  and  teeth, 
was  a  second  cavity  containing  turbid  fluid,  and  lined  by  a 
smooth,  apparently  serous,  membrane — the  probable  remains  of 
the  tunica  vaginalis.  In  contact  externally  with  the  walls  of 
this  cyst  was  the  testicle,  normal  in  size  and  appearance,  with 
the  exception  of  an  abscess,  the  size  of  a  large  pea,  situated  in 
its  substance.  The  glandular  elements  of  the  testicle  were  rec- 
ognized under  the  microscope.  The  mass  of  the  tumor  situated 
above  and  around  the  testicle,  and  constituting  about  one-half 
the  tumor's  bulk,  was  found  under  the  microscope  to  consist  of 
the  elements  of  connective  tissue,  consolidated  by  inflammation. 

The  microscopic  examination  of  the  specimen  was  made  by 
Dr.  J.  W.  J.  Gouley. 

It  is  evident  that  the  tumor  is  an  example  of  that  rare  patho- 
logical condition  known  heretofore  by  the  English  as  "  foetal 
remains  in  the  testicle,"  and  by  the  French  as  "  inclusion  scrotale 
et  testiculaire."  The  latter  designation  is  the  more  intelligible 
of  the  two,  as  it  indicates  the  nature  of  this  curious  growth, 
which  is  an  imperfect  effort  at  the  production  of  a  double 
monster,  or  "  monstrosity  by  inclusion,"  or  fcetus  infoetu  of  the 
older  writers.  It  is  described  as  one  of  the  varieties  under 
this  latter  head  in  Vrolik's  classification  of  foetal  deformities, 
and  he  remarks  that  "  it  is  most  probable  that  the  foetus  in 
fcetu  is  an  incomplete  effort  to  form  a  double  monster."  (Cy- 
clopJEdia  of  Anatomy  and  Physiology,  art.  Teratology.)  The 
term  "  monstrosity  by  inclusion"  belongs  to  the  great  French 
teratologist,  Geoffrey  St.  Hilairc,  and  has  been  adopted  by 
Cruveilhicr  in  his  "  Pathologic  Gdndrale,"  and  applied  to  tu- 
mors containing  foetal  remains  which  have  occurred  in  different 
parts  of  the  body,  c.  g.,  in  the  perineum,  over  the  sacrum,  in 


358 


TUMOR  OP  TESTIS. 


[Feb., 


the  thoracic  and  abdominal  cavities,  the  liver  and  ovaries,  as 
well  as  in  the  scrotum. 

This  explanation  of  the  pathological  nature  of  these  tumors 
has  been  more  recently  disputed  by  Lcbert,  who  endeavors 
to  include  them  in  his  class  of  "  dermoid  cysts,"  or  misplaced 
growths  of  normal  tissues.  The  pathological  law  under  which 
all  these  growths  are  developed  is  thus  stated  by  Lebcrt, 
(Trait(^  d'Anat.  Path.,  t.  i.,  p.  260.)  "That  both  simple  and 
compound  tissues,  and  even  more  complicated  organs,  are  capa- 
ble of  developing  themselves  in  parts  of  the  body  where  nor- 
mally they  do  not  exist."  This  he  considers  that  he  has  estab- 
lished, and  its  truth  is  generally  admitted  by  pathologists. 
But  Lebert  does  not  entirely  exclude  tlie  theory  of  inclusion, 
as  will  be  inferred  from  the  following  quotation:  "  I  have 
brought  together  three  cases  of  dermoid  cysts  of  the  scrotum, 
and  endeavored  to  establish  the  points  of  difference  which  dis- 
tinguish them  from  true  cases  of  foetal  inclusion  occurring  in 
this  same  locality — in  which  undoubted  debris  of  the  skeleton 
are  recognizable."  (V.  ut  supra,  p.  257.) 

The  theory  of  inclusion  of  St.  Hilaire  has  also  been  disputed 
by  the  latest  authority  on  the  subject.  Dr.  George  Murray 
Humphry,  lecturer  on  surgery  and  anatomy  in  the  Cambridge 
University  Medical  School,  the  author  of  the  article  on  "  Dis- 
eases of  the  Male  Organs  "  in  Holmes'  System  of  Surgery,  who 
considers  that  Lebert's  theory  of  "  heterotopic  plastique "  is 
entirely  suflBcient  to  explain  the  nature  of  tumors  connected 
with  the  testicle  containing  fcetal  remains.  (Holmes'  Surgery, 
V.  iv.,  p.  600.) 

The  question  as  to  the  real  origin  of  these  tumors  appears, 
therefore,  to  be  still  an  open  one,  and  it  may  be  stated  suc- 
cinctly as  follows:  Is  a  scrotal  tumor,  containing  so-called 
"  foetal  debris,"  the  result  of  a  local  plastic  effort  determined 
by  injury  or  inflammation,  and  liable  to  occur  at  any  period 
of  life;  or  is  it  the  production  of  a  fecundated  Groeffian 
vesicle  accidentally  included  in  the  scrotum  of  a  twin  foetus, 
and  thus  arrested  in  its  development,  and  of  necessity  congeni- 
tal ?  This  question  is  more  curious  than  practically  useful,  for, 
as  Dr.  Humphry  concludes,  the  only  remedy  for  these  tumors 
is  to  remove  them  by  operation.    Those  desirous  of  pursuing 


1866.] 


TUMOR  OP  TESTIS. 


359 


it  furtlier  will  find  it  elaborately  discussed  by  Lebert,  (as  above,) 
by  Cruveilhier  in  his  Pathologie  G^ndrale,  t.  i.,  p.  370,  and 
t.  iii.,  p.  582  et  seq.,  and  by  Verneuil  in  the  paper  referred  to 
below. 

It  follows,  if  Cruveilhier  is  right,  that  tumors  connected  with 
the  testicle  of  this  character  must  be  always  congenital,  and 
such  appears  to  be  the  fact.  M.  Verneuil  has  collected  all  the 
authentic  cases  on  record,  to  the  number  of  ten  in  all,  and 
treated  the  subject  very  ably  and  exhaustively  in  a  series  of 
papers  published  in  the  Archives  G^n6raledeMedecineinl855. 
The  earliest  recorded  of  these  cases  is  the  only  one  of  the  ten 
in  which  the  congenital  character  of  the  tumor  is  not  clearly 
demonstrated.  "  A  young  man  of  quality,  after  exposure  to 
sexual  excitement,  was  seized  with  a  sudden  pain  in  the  right 
testicle;  this  soon  subsided,  but  shortly  afterwards  he  dis- 
covered an  unnatural  growth  connected  with  the  testis,  which 
rapidly  increased  to  the  size  of  the  head  of  an  infant  of  six 
months,  and  within  the  year  was  removed  by  a  surgeon  of 
Sisteron,  in  France,  named  St.  Donat.  On  opening  the  tumor, 
after  its  removal,  it  was  found  to  contain  the  somewhat  altered 
remains  of  a  foetal  cranium;  the  testis  was  compressed  and  al- 
tered in  appearance,  and  the  foetal  remains  seem  to  have  been 
enclosed  in  a  cyst  attached  externally  to  the  testis."  The  case 
was  transmitted  by  St.  Donat  to  Pierre  Amand,  a  member  of 
the  Faculty  of  Paris,  and  published  by  Amand  in  a  volume  on. 
Obstetrics,  at  Paris,  in  1715. 

In  a  case  reported  by  Prochask,  "  an  otherwise  well  formed 
male  infant  was  born  with  a  small  tumor  in  the  groin,  which 
was  taken  for  a  hernia.  When  three  years  old  it  commenced 
to  grow,  rapidly  filled  the  scrotum,  and  in  a  few  weeks  reached 
as  low  as  the  middle  of  the  thigh,  when  an  abscess  formed 
and  discharged  a  fetid  fluid,  together  with  several  portions  of 
the  skeleton  of  a  foetus,  after  which  the  child  rapidly  got  well." 

The  following  case,  reported  by  Ollivier,  (D'Angers,)  pre- 
sents some  features  similar  to  mine:  "  Ovide-Emile  Caze,  well 
formed  at  birth,  was  discovered  by  his  parents,  when  a  year 
old,  to  have  the  right  testicle  larger  than  the  left,  and  six 
months  later  was  operated  upon  by  Dr.  Capon,  for  hydrocele. 
A  little  serous  fluid  followed  the  puncture,  but  the  testicle  re- 


360 


TUMOR  OF  TESTIS. 


[Feb., 


mained  larger  than  before,  so  that  two  years  afterwards  an- 
other operation  was  talked  of,  but  as  the  swelling  was  painless 
nothing  was  done.  During  his  seventh  year,  the  testis,  haying 
reached  three  times  its  natural  size,  became  painful,  and  an 
ulceration  having  taken  place,  a  reddish  mass  protruded,  in 
which  Dr.  Andr6  having  discovered  a  hard,  white,  polished 
surface  resembling  a  tooth,  diagnosticated  a  tumor  connected 
with  the  testis,  containing  foetal  remains.  The  protrusion  in- 
creasing it  was  tied  ofiF,  and  afterwards  examined  by  Ollivier, 
and  found  to  contain  four  teeth  and  a  piece  of  spongy  bone, 
contained,  apparently,  in  a  sort  of  cyst.  The  child,  who  was 
left  mainly  to  nature,  was  thought  likely  to  get  entirely  well. 
(Mdmoires  sur  la  Monstruosit^  par  Inclusion;  Archives  G6n6- 
rales  de  Medecine,  t.  xv.,  p.  540.) 

In  Velpeau's  celebrated  case,  which  occurred  in  La  Charity 
Hospital,  in  Paris,  whilst  I  was  an  externe  in  that  institution, 
in  1840,  the  patient,  who  was  27  years  of  age,  had  a  tumor  the 
size  of  the  fist  on  the  right  side  of  his  scrotum,  which  had  ex- 
isted since  his  birth.  It  was  painless,  and  presented  several  fis- 
tulous openings,  from  one  of  which  a  tuft  of  hair  projected,  and 
this  circumstance  suggested  the  true  nature  of  the  tumor. 
Velpeau  made  it  a  point  of  saving  the  testicle,  which  could  be 
distinguished  from  the  tumor,  although  closely  connected  with 
it,  and  this  necessitated  a  long  and  difficult  dissection.  The 
tumor  contained  much  foetal  debris  and  a  number  of  easily 
recognizable  bones  of  the  foetal  skeleton.  The  patient  died  of 
purulent  infection.  The  case  is  recorded  in  the  Gazette  Medi- 
cale  de  Paris,  Feb.  15th,  1840. 

In  M.  Yerneuil's  case,  which  occurred  in  the  wards  of  M. 
Guersant,  in  the  Children's  Hospital  of  Paris,  the  foetal  debris 
were  very  carefully  examined  by  the  microscope,  and,  amongst 
other  tissues,  the  histological  elements  of  the  gray  substance  of 
the  brain  were  distinctly  recognized. 

Of  the  ten  cases  collected  by  M.  Verneuil  but  two  were  di- 
agnosticated; those  of  Andr^  and  Yelpeau.  If  the  congenital 
character  of  these  tumors  is  admitted,  it  constitutes  their  most 
valuable  diagnostic  feature.  The  diagnosis  would  lie  between 
hernia,  hydrocele,  encephaloid  cancer  and  tubercular  dis- 
ease of  the  testis.    It  would  seem  easy  to  exclude  the  two 


1866.] 


SIMULATED  AMAUROSIS. 


361 


former,  although  two  of  the  cases  noted  in  this  paper  were  mis- 
taken for  liydroceles.  Robert  speaks  of  a  case  of  congenital 
soft  cancer  of  the  testis;  and  I  once  saw  a  well  marked  case  of 
syphilitic  enlargement  of  the  gland,  in  a  child  of  eighteen 
months,  who  also  had  periosteal  swellings  and  other  evi- 
dences of  inherited  disease. 

It  is  not  unlikely  that  there  are  other  cases  of  this  curious 
aflfcction  which  have  not  yet  been  placed  on  record,  and  if  this 
imperfect  notice  of  the  subject  should  lead  to  any  further  ad- 
ditions to  our  knowledge  by  eliciting  unrecorded  cases,  or  by 
rendering  their  nature  more  apparent,  it  will  have  attained  its 
object. 

New  York,  Jan.  15th,  1866. 


On  Simulated  Amaurosis.    By  Dr.  C.  Schweigger,  Professor 
at  the  University  of  Berlin. 

[Read  before  the  New  York  Ophthalmological  Society.] 

The  detection  of  simulated  amaurosis,  by  involving  the  indi- 
vidual in  contradictions  with  the  simplest  laws  of  physiology, 
and  thereby  compelling  him  to  speak  the  truth,  while  he  im- 
agines himself  to  be  giving  support  to  his  false  assertion,  af- 
fords an  interesting  illustration  of  the  exactness  of  ophthalmo- 
scopical  science. 

The  means  we  have  on  hand  for  this  purpose  are  very  simple, 
but  of  course  differ  somewhat  according  to  the  alleged  morbid 
symptoms.  Mostly  it  is  monocular  amblyopia  or  amaurosis 
"which  is  simulated,  very  seldom  binocular,  and  only  the  more 
experienced  and  skillful  simulators  choose  to  pretend  a  mod- 
erate degree  of  binocular  amblyopia,  or  a  narrowing  of  the 
field  of  vision.  With  men  we  are  generally  able  to  find  a 
more  or  less  obvious  reason  for  the  simulation;  not  so  with 
women,  however,  who  often,  to  gratify  some  inexplicable  whim, 
resign  for  years  and  years  every  sort  of  social  enjoyment  only 
for  the  sake  of  pretending  a  non-existing  disease. 

The  suspicion  of  a  simulated  amaurosis  is  raised  whenever 
we  find  a  high  degree  of  amblyopia,  together  with  an  iris  act- 
ively contractile  in  dim  illumination,  and  a  perfectly  normal 


362 


SIMULATED  AMAUROSIS. 


[Feb, 


state  of  the  optic  disk  and  the  retina,  shown  by  the  ophthalmo- 
scope. It  is  important  to  know  that  a  perfectly  normal  state 
of  the  ophtlialmoscopic  image  may  be  combined  with  amaurosis 
or  amblyopia  of  both  eyes,  not  only,  for  example,  in  cases  of 
alcoholism  or  urajmia,  but  also  without  any  other  perceptible 
disease;  but  in  the  latter  cases  there  is  either  a  speedy  recovery 
of  vision,  or  the  fundamental  disease  of  the  optic  nerve  becomes 
visible  by  the  ophthalmoscope. 

Simulated  amblyopia  of  a  medium  degree  is  best  detected  by 
the  use  of  Snellen's  test  types,  by  an  accurate  determination  of 
the  degree  of  amblyopia,  and  by  repeating  the  experiment  with 
letters  of  different  size,  and  at  different  distances.  We  have, 
for  instance,  a  diminution  of  vision  of  ^Vi  then  No.  200  ought 
to  be  seen  at  10',  No.  100  at  5',  No.  75  at  3|',  No.  50  at  2|', 
and  so  on  as  far  as  No.  10  at  6  inches.  It  will  be  a  pretty 
difiBcult  task  for  a  simulator  not  to  entrap  himself  in  contra- 
dictions, if  care  be  taken  to  measure  accurately  the  distances  at 
which  the  different  types  are  made  out,  and  to  note  down  every 
single  statement.  If  we  have  to  deal  with  a  narrowing  of  the 
field  of  vision,  the  best  plan  will  be  to  sketch  the  letter  accu- 
rately on  a  large  sheet  of  paper.  In  order  to  keep  the  same 
distance  for  all  designs,  I  use  a  rod  of  about  12  inches  in 
length,  which  the  patient  himself  fixes  with  his  head  against 
the  paper,  so  as  to  make  it  impossible  to  alter  the  position  of 
the  head  in  such  a  manner  as  to  render  the  projection  of  the 
field  of  vision  larger  or  smaller.  On  repeating  this  experi- 
ment carefully  several  times  in  the  course  of  some  days,  and  on 
comparing  the  different  projections,  we  shall  soon  discover  a 
marked  discrepancy  between  the  patient's  separate  statements 
in  cases  of  simulation.  If  the  field  of  vision  is  alleged  to  be 
contracted  in  one  direction  near  the  point  of  fixation,  we  have 
a  very  elegant  method  of  testing  at  once  the  truth  of  the  as- 
sertion. After  having  drawn  the  projection  of  the  visual  field, 
we  leave  the  patient  in  the  same  position,  but  with  both  eyes 
open.  Now  if  we  hold  a  prism  before  one  of  his  eyes,  double 
vision  is  the'natural  consequence;  and,  holding  the  base  of  the 
prism  in  the  right  direction,  we  may  approximate  one  of  the 
doubly  seen  points  of  fixation  to  the  limit  of  the  alleged  field  of 
vision.    Adding  then  a  stronger  prism  in  the  same  direction, 


1866.] 


SIMULATED  AMAUROSIS, 


363 


we  can  bring  one  of  these  double  images  beyond  the  alleged 
limits,  when  double  vision  must  cease,  and  only  one  point  can 
be  seen  if  the  contraction  of  the  iield  of  vision  really  exists — 
double  sight  being  of  course  impossible  if  one  of  the  double 
images  is  formed  on  an  insensitive  part  of  the  retina.  The  de- 
gree of  the  prism  necessary  to  make  the  experiment  conclusive 
may  be  found,  by  ascertaining  the  linear  distance  of  double  im- 
ages produced  by  our  prisms  in  the  same  distance  we  use  for 
projecting  the  field  of  vision.  After  having  ascertained  this, 
we  may  easily  arrange  matters  so  as  to  make  it  entirely  im- 
possible for  a  simulator  to  know  when  he  must  see  single  and 
when  double.  One  thing  more  ought  to  be  taken  into  account, 
namely,  the  fact  that  double  images  produced  by  prisms  with 
their  base  outwards  may  be  united,  and  single  vision  procured 
by  a  corresponding  convergency  of  the  visual  axes;  by  diver- 
gency, prisms  of  medium  strength  with  their  base  inwards  can 
be  neutralized,  while  only  the  weakest  with  their  bases  above 
or  below  can  be  overpowered  by  a  contraction  of  the  inferior 
and  superior  recti  muscles. 

The  detection  of  simulated  amaurosis  of  one  eye  by  prisms 
was  first  taught  by  v.  Graefe.  After  having  examined  the 
alleged  amblyopia,  we  carefully  try  the  sight  of  the  other  eye, 
and  holding  a  prism  in  front  of  it  with  the  base  upwards  or 
downwards,  inquire  whether  a  small  point  or  a  fine  line  ap- 
pears simple  or  double.  Most  of  the  simulators,  imagining  that 
we  are  dealing  merely  with  the  sound  eye,  at  once  acknowledge 
double  vision,  and  in  this  manner  I  have  several  times  made 
them  read  the  smallest  print  with  the  alleged  amaurotic  eye 
alone,  covering  the  sound  eye  by-and-by  without  their  knowing 
it.  In  some  cases,  however,  I  tried  the  prisms  without  effect; 
either  the  simulators  were  already  aware  of  their  use  and 
would  not  acknowledge  the  double  images,  or  there  was  indeed 
no  simultaneous  vision  with  both  eyes.  Thus  we  see,  for  in- 
stance, exceptionally  in  cases  of  squinting,  that  each  eye  sep- 
arately sees  well  enough,  while  both  eyes  never  work  simul- 
taneously, so  as  to  make  it  entirely  impossible  to  bring  on 
double  vision  by  prisms.  It  is  also  possible,  though  not  very 
probable,  that  similar  cases  may  occur  without  squinting.  In 
cases,  therefore,  where  there  is  nothing  to  be  done  by  prisms,  I 


364 


SIMULATED  AMAUROSIS. 


[Feb., 


tried  to  procure  other  means  to  detect  simulation,  and  found 
them  in  the  use  of  the  stereoscope.  In  this  instrument  each 
eye  has  a  separate  field  of  vision,  quite  inaccessible  to  the 
other  eye.  This  separation  is  the  essential  point  of  the  in- 
strument; convex  lenses  are  added  only  for  the  purpose  of  ap- 
proximating the  stereoscopical  designs,  allowing  at  the  same 
time  a  relaxation  of  accommodation  and  nearly  parallel  lines  of 
vision;  in  myopics,  therefore  the  convex  lenses  might  be  dis- 
pensed with.  Prisms  with  their  base  outwards,  combined  with 
the  convex  lenses,  have  only  the  effect  of  enlarging  the  outer 
side  of  both  fields  of  vision.  For  all  the  purposes  we  now 
speak  of,  this  combination  of  prisms  with  convex  lenses  is  quite 
superfluous,  even,  in  some  respects,  troublesome. 

Knowing,  now,  that  in  simultaneous  vision,  both  separate 
fields  of  the  stereoscope  are  united  in  one,  simulation  becomes 
evident  if  we  find  this  union  in  a  case  of  alleged  monocular 
amaurosis.  We  have,  for  instance,  in  the  one  field,  horizontal 
parallel  lines  about  one-quarter  of  an  inch  apart;  in  the  other, 
vertical  parallel  lines,  separated  by  the  same  distance;  then,  in 
the  united  field  of  vision,  we  see  both  systems  of  lines  united  in 
regular  squares.  As  soon  as  these  squares  are  seen,  therefore, 
it  is  evident  that  there  can  be  no  monocular  amaurosis.  We 
may  even  go  a  step  further,  and  use  the  stereoscope  qiiite 
independently  of  the  existence  or  non-existence  of  simultaneous 
vision,  and,  in  this  respect,  it  is  superior  to  the  prisms.  If  we 
draw  in  each  separate  field  of  vision  that  vertical  line  whose 
image  goes  through  the  centre  of  the  retina,  then,  in  the  united 
stereoscopical  field,  not  only  both  lines  are  seen  as  one,  but  every 
object  situated  to  the  right  of  one  of  those  lines  is  projected  to 
the  right  side  of  the  field  of  vision,  and  appears  as  if  it  were 
seen  with  the  right  eye.  The  same,  of  course,  is  the  case  with 
the  left  side.  This  gives  the  means  of  determining,  in  cases  of 
simulated  monocular  amblyopia,  the  acuteness  of  vision,  and,  if 
we  choose,  even  the  range  of  accommodation.  For  this  purpose 
we  arrange  matters  as  follows  :  We  have  at  the  bottom  of  the 
stereoscope  a  sheet  of  paper,  marked  only  with  the  two  lines 
above  mentioned.  Now  if  we  have  to  deal,  for  instance,  with 
an  alleged  amblyopia  of  the  left  eye,  we  place  in  the  left  field 
of  the  stereoscope,  but  to  the  right  side  of  the  vertical  line, 


1866.] 


SIMULATED  AMATOOSlg. 


365 


any  object,  say  a  piece  of  a  printed  paper — ^with  this  exception, 
the  whole  of  the  bottom  of  the  stereoscope  is  left  blank.  In 
the  united  stereoscopical  field  the  paper  will  then  appear  as 
the  right  side,  and  will  make  so  strong  an  impression  that  it  is 
seen  with  the  right  eye,  that  I  doubt  whether  anybody  can 
resist  it;  with  a  stereoscope  which  allows  the  convex  lenses  to 
be  approached  to  or  withdrawn  from  the  bottom  of  the  stereo- 
scope, we  can,  if  we  choose,  at  the  same  time,  ascertain  the  range 
of  accommodation. 

I  take  this  opportunity  of  showing  you  another  interesting 
stereoscopical  phenomenon,  namely,  Prof.  Dove's  method  of 
detecting  counterfeit  paper-money  by  means  of  the  stereoscope. 
On  uniting,  stereoscopically,  a  genuine  note  with  its  counterfeit, 
we  see  a  very  peculiar  appearance  of  the  small  print  or  the 
system  of  fine  lines  with  which  those  papers  are  usually 
adorned.  The  united  stereoscopical  images  seem  not  to  be 
situated  on  the  same  level,  but  offer  striking  irregularities. 
Some  of  the  small  lines,  letters  or  words,  are  elevated  above 
the  level  of  the  corresponding  ones;  others  are  drawn  back- 
wards. Not  having  been  able  to  procure  a  bad  note,  I  prefer 
demonstrating  the  phenomenon  in  another  way.  If  we  unite, 
stereoscopically,  two  copies  printed  with  the  same  set  of  types, 
the  whole  of  the  stereoscopic  image  is  seen  in  the  same  level. 
But  if  the  copies  are  not  printed  with  the  same  set  of  types,  as 
is  the  case  if  we  take  two  different  editions  of  the  same  book, 
then  we  see  clearly  the  difi"erence  alluded  to,  in  the  level  of 
different  letters  or  words.  It  is  necessary,  however,  to  look 
through  the  stereoscope  for  some  time,  in  order  to  see  the 
phenomenon  in  all  its  distinctness.  The  following  remarks 
may  serve  as  an  explanation. 

In  two  papers  printed  with  the  same  set  of  types,  the  dis- 
tance between  one  letter  and  any  other  one  is  the  same  in  both 
fields  of  vision.  After  having,  therefore,  united  two  identical 
letters,  we  use  the  same  relative  position  of  the  axis  of  vision 
to  unite  any  other  indentical  letters.  This  we  can  not  do  if 
we  have  to  deal  with  two  diflferent  sets  of  types,  because  in  the 
latter  case  the  relative  distance  from  one  letter  to  any  other  is 
not  the  same  in  both  fields  of  vision.   Therefore,  we  have  to 


366 


PROCEEDINGS  OF  SOCIETIES. 


[Feb., 


use  different  relative  positions  of  the  axis  of  vision  to  unite  the 
identical  letters,  and  this  necessary  change  in  the  position  of 
the  axis  of  vision  accounts  for  the  apparent  differences  of  the 
level  at  which  the  lines,  words  and  letters  appear. 


PROCEEDINGS  OF  SOCIETIES. 

NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  Odoler  11,  1865. 
Dr.  GuRDON  Buck,  President,  iu  the  Chair. 

THE  DEATH  OF  DR.  D.  S.  CONANT. 

The  President  announced  the  death  of  Dr.  Conant,  a  former  Presi- 
dent of  the  Society,  and  remarked  that  it  had  heretofore  been  the 
custom,  under  such  circumstances,  of  taliing  some  official  notice  of  the 
Bad  occurrence  by  the  passage  of  suitable  resolutions. 

On  motion,  the  following  gentlemen  were  duly  appointed  to  prepare 
such  resolutions,  and  present  the  same  for  adoption  at  the  next  meet- 
ing of  the  society:  Drs.  Markoe,  Bradley  and  Eliot. 

Dr.  BiBBiNS,  having  been  invited  so  to  do,  then  proceeded  to  give, 
as  far  as  he  was  able,  an  account  of  the  last  illness  of  Dr.  Conant.  A 
week  ago  last  Sunday,  said  he,  one  week  before  he  died,  1  noticed,  on 
his  returning  from  the  afternoon  service  at  church,  on  the  right  side 
of  the  bridge  of  his  nose,  what  appeared  to  be  cellulitis,  which  was 
progressing.  The  part  had  been  opened,  I  think,  that  day,  and  I 
heard  no  more  of  him  until  Wednesday  evening.  On  returning  home 
late  that  evening,  I  found  a  message  on  my  slate,  requesting  me  to  see 
him  at  once.  On  going  to  his  house  I  found  him  very  ill,  and  in  bed. 
The  disease  had  progressed  to  a  considerable  degree,  and  he  had 
marked  typhoid  symptoms,  although  he  was  perfectly  rational.  I  saw 
liim  again  on  Thursday  evening — his  pulse  was  then  108,  and  he  was 
suffering  more  from  depression  than  the  evening  before.  As  he 
had  a  number  of  medical  gentlemen  at  that  time  in  attendance,  I  did 
not  offer  any  professional  assistance.  On  Friday  morning  Dr.  Parker 
was  met  coming  out  of  the  house,  and  said  that  Dr.  Conant's  case  was 
a  very  grave  one,  and  that  he  thought  that  the  prognosis  was  exceed- 
ingly unfavorable. 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


367 


Dr.  Bradley  remarked  that  the  pustule  was  opened  on  Monday 
evening  by  Dr.  Peaslee,  who  stated  at  the  time  that  there  was  no  dis- 
charge from  it  to  any  extent,  save  blood,  about  four  ounces  of  which 
escaped.  After  the  bleeding  stopped,  the  part  appeared  to  dry  down. 
The  inflammation  after  this  seemed  to  follow  up  the  nasal  bones  towards 
the  orbit.  On  Monday  I  saw  him  first;  his  right  eye  was  somewhat 
swollen.  He  was  attacked  at  that  time  with  pleurodynia,  which  Dr. 
Peaslee  considered  as  indicating  the  absorption  of  matter.  Those 
pains  were  relieved  somewhat  by  the  application  of  mustard  to  the 
spine,  and  other  rubefacients.  Dr.  Peaslee  did  not  like  to  give  the 
anodynes,  for  fear  of  disturbing  the  capillary  circulation.  Dr.  Conant, 
however,  had  taken  some  morphine  on  his  own  account,  before  Dr. 
Peaslee  saw  him.  On  Tuesday  the  eye  was  very  much  distended.  Ou 
Friday  night  Dr.  Parker  made  some  free  incisions  into  the  lids  of  both 
eyes.  The  wounds  bled  freely,  but  no  pus  was  discharged.  The  con- 
junctiva were  everted  and  presented  the  appearance  of  a  diphtheritic 
membrane.  The  disease  on  Sunday  attacked  the  left  eye,  and  he  was 
not  much  delirious  until  Sunday  morning.  At  that  time  the  sight  of 
the  right  eye  was  entirely  destroyed.  The  lids  were  then  very  much 
swollen.  About  eleven  o'clock  he  began  to  be  delirious,  and  continued 
in  that  condition  until  a  quarter  of  eight,  when  he  died. 

Dr.  Sands  then  gave  the  following  account  of  the  post  mortem  ex- 
amination, presenting  at  the  same  time  the  brain  of  the  deceased  for 
inspection.  He  made  the  examination  with  the  assistance  of  Dr.  Ball, 
and  it  was  commenced  with  the  impression  that  it  would  be  impossible 
to  proceed  with  any  investigation  of  the  brain,  as  it  was  said  that 
by  the  process  of  embalming  a  sharp  instrument  had  been  thrust  into 
the  organ  through  the  nostril,  and  injections  had  been  thrown  into  the 
cranial  cavity.  The  examination  then  was  made  with  a  view  simply 
of  inspecting  the  parts  within  the  orbit.  A  section  of  the  scalp  was 
made,  and  it  was  turned  down  over  the  eyes.  The  cellular  tissue  of 
the  orbit  was  sjjongy  and  infiltrated  chiefly  with  blood.  The  blade  of 
a  scalpel  was  passed  deep  into  the  orbit,  and  a  small  amount  of  pus 
mixed  with  blood  escaped.  The  eyes  were  not  examined,  as  it  was 
desirable  not  to  disfigure  the  face.  Dr.  Sands  felt  very  curious  to 
know  whether  the  inflammatory  action  found  in  the  orbit  had  extended 
backward  into  the  cranium,  and,  at  a  venture,  a  section  of  the  cal- 
varium  was  made.  On  cutting  through  the  dura  mater  covering  the 
anterior  lobe  of  the  right  cerebral  hemisphere,  abundant  traces  of 
severe  inflammation  were  there  found  in  the  shape  of  a  thin  layer  of 
pus  over  the  inner  surface  of  that  membrane.    The  upper  surface  of 


1 


868  PROCEEDINGS  OP  SOCIETIES.  [Feb., 

the  anterior  lobe  of  the  cerebrum  of  that  side  was  bathed  in  pus  and  i 
lymph — chiefly  pus — which  presented  externally  and  beneath  the  ' 
arachnoid  membrane.    This  part  of  the  brain  presented  an  unusual  de-  ' 
gree  of  palor.    This  effusion  was  traced  over  that  side  of  the  brain  to 
the  under  surface  of  the  organ,  where  it  was  found  equally  abundant. 
Pus  was  not  only  present  on  the  anterior  lobe,  but  also  in  tlie  fissure  of 
Sylvius.    There  was  little  or  no  matter  beyond  the  middle  lobe.    The  ] 
cranial  bones  corresponding  with  those  parts  of  the  cerebrum  were 
found  also  diseased.    There  was  a  patch  of  lymph  covering  the  lesser 
end  of  the  sphenoid,  as  it  forms  the  roof  of  the  orbit,  and  was  about 
as  thick  as  oil  silk  or  thick  paper.    There  was  also  in  this  situation  a 
small  quantity  of  pus.    In  the  middle  fossa  of  the  skull  the  purulent 
exudation  was  very  abundant,  and  it  was  present  not  only  upon  the 
inner  surface  of  the  dura  mater,  but  between  the  dura  mater  and  bone. 
An  examination  was  then  made  in  order  to  ascertain  through  what 
channel  the  inflammation  extended  into  the  cranium.    The  spongy 
tissue  on  the  right  side  of  the  sphenoid,  when  cat  into,  was  found  infil-  . 
trated  with  pus,  just  as  was  the  case  with  the  cellular  tissue  in  the  i 
right  orbit,  showing  that  the  diseased  action  had  extended  through 
the  sphenoidal  fissui'e  into  the  cranial  cavity.    The  optic  nerve  pre-  j 
sented  nothing  abnormal.    The  spongy  tissue  on  the  left  side  of  the  j 
sphenoid  bone  also  presented  traces  of  the  inflammatory  action  in  the  | 
shape  of  pus.    In  addition  to  these  purulent  deposits,  there  were  scat-  i 
tered  over  the  brain  various  ecchymotic  spots.    The  results  of  the 
post  mortem  examination  proved  that  death  was  caused  by  inflamma- 
tion of  the  meninges  of  the  brain.    The  brain  weighed  three  pounds 
and  three  ounces  after  its  removal,  and  it  was  fair  to  presume  that  at 
least  three  ounces  of  fluid  had  escaped  before.    The  periosteum  cover-  j 
ing  the  frontal  bone  ia  the  neighborhood  of  the  right  orbit  was  ele- 
vated, but  not  detached.    There  were  no  traces  of  inflammation  of  the  ^ 
veins  about  the  face. 

Dr.  Parker  next  gave  the  following  account  of  the  case.    My  first 
knowledge  of  Dr.  Conant's  case  was  on  Thursday  morning,  when  his  j 
sister  called  at  my  office  with  the  request  that  I  should  see  him,  as  he  ; 
was  supposed  to  be  suffering  from  the  so-called  malignant  pustule.    I  ' 
made  an  appointment  to  meet  Dr.  Peaslee  in  consultation  at  1  o'clock. 
I  obtained  the  following  history  of  the  patient.    He  had  lectured  on 
Friday,  and  on  the  day  following  he  noticed  a  pustule  on  the  side  of  I 
his  nose.    He  consulted  Dr.  Peaslee  the  same  day,  who,  on  examiua-  ' 
tion  of  the  part,  concluded  to  open  it.    An  incision  was  made,  but  I 
whether  with  a  thumb  lancet  or  not  I  do  not  know;  and  whether  it 


I 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


369 


was  made  directly  down  to  bone  or  not,  I  am  not  positive.  I  found 
the  patient  under  the  influence  of  morphine,  which  had  been  taken  to 
alleviate  the  pain  which  existed  about  the  orbit.  His  pulse  was  96 
and  rather  quick,  and  his  respiration  was  about  normal.  He  had 
taken  some  medicine  and  his  bowels  had  been  relieved.  His  kidneys 
were  acting  well  enough,  his  skin  was  warm,  and  hands  a  little  dry; 
his  tongue  was  also  dry,  which  was  ascribed  to  the  anodynes  he  had 
taken  the  night  previous. 

The  swelling  had  passed  from  the  point  of  beginning  on  the  right  side 
of  the  nose  to  the  right  upper  and  lower  eyelid;  the  lids  were  a  little 
tumefied,  yet  they  could  be  easily  raised;  in  fact,  he  was  able  to  open 
the  eye  himself. 

There  was  tenderness  just  above  the  orbit  near  the  inner  canthus 
and  in  the  neighborhood  of  the  supra-orbital  nerve.  Thei'e  was  also 
some  tenderness  on  pressure  in  that  situation.  There  was  some  pain 
present,  but  it  was  not  oppressive  in  character;  there  was  no  heat,  no 
disturbance  of  the  intellect,  nor  rigors.  The  room  was  ordered  to  be 
kept  well  ventilated,  and  all  intercourse  with  friends  strictly  interdicted. 
He  was  taking  stimulants,  and  the  quinine,  which  he  had  also  been 
taking  on  account  of  the  stimulating  effect  which  it  produced,  was 
changed  for  cinchona  bark. 

We  arranged  to  meet  the  next  day,  on  Friday,  at  about  the  same 
hour.  I  sent  up  my  man  in  the  evening,  not  being  able  to  go  myself, 
to  inquire  how  the  Doctor  was,  and  the  answer  returned  was  that  he 
was  about  the  same.  The  next  day  we  met,  at  one  o'clock,  and  we 
found  that  he  had  a  fair  night's  rest  and  that  he  had  slept  quiet- 
ly. His  pain  was  less  that  day  than  it  had  been  the  day  before; 
his  skin  was  moist,  and  pulse  86.  His  tongue  also  was  moist,  and 
the  thirst  which  he  had  suffered  had  abated.  There  seemed,  on  the 
whole,  to  be  some  improvement  in  his  general  symptoms;  although 
there  was  then  some  tumefaction  of  the  right  eye.  There  was  no 
exophthalmus,  and  vision  was  perfect.  At  three  o'clock,  on  Saturday, 
I  saw  him  again  and  found  his  symptoms  all  aggravated;  he  was  in 
more  pain,  his  pulse  had  become  more  rapid  and  frequent,  his  skin  was 
warm,  and  the  tumefaction  about  the  eye  was  very  great  indeed,  in- 
volving the  whole  orbit — the  eye  itself  protruded  very  perceptibly  and 
the  conjunctiva  gushed  out  between  the  palpabric.  Vision  of  that 
eye  was  then  entirely  gone.  The  swelling  extended  nearly  to  the  roots 
of  the  hair  on  the  right  side  of  the  forehead,  and  over  on  the  temples, 
the  whole  pitting  on  pressure.  An  examination  of  the  face  showed 
none  of  tiiose  appearances  which  are  referred  to  an  affection  of  the 

Vol.  II.— No.  11.  24 


370  PROCEEDINGS  OF  SOCIETIES.  [Feb., 

veins.  No  symptoms  of  inflammation  within  the  cranium  showed  them- 
selves, excepting  perhaps  that  there  was  a  little  more  pain  than  before, 
and  that  he  had  had  a  little  delirium  for  a  short  time,  about  four 
o'clock  that  morning,  which  manifested  itself  in  a  desire  to  look  after 
some  of  his  patients.  His  pulse  in  the  afternoon  was  130;  his  breath- 
ing had  markedly  changed,  and  had  become  irregular  in  character  and 
was  accompanied  with  a  moan.  I  tried  to  see  Dr.  Peaslee  and  confer 
with  him,  but  could  not  succeed  in  finding  him,  and  called  again  in  the 
evening,  after  dinner,  when  I  was  more  fortunate.  We  went  together 
to  see  him,  and  found  him  asleep.  There  was  no  incoherence,  some 
pain  in  the  head,  and  the  pulse  was  140.  The  respiration  was  rapid 
and  moaning,  and  the  tumefaction  had  extended,  but  not  sufficiently  to 
interfere  with  the  other  eye.  The  question  was,  whether  there  was 
any  matter  in  the  right  eye  which  had  destroyed  that  organ,  and  we 
decided  to  explore  it,  and  three  openings  were  made  into  its  upper  sur- 
face ,  and  two  into  its  lower  portion.  No  pus  escaped  as  the  result  of 
the  incisions.    Tliis  was  on  Saturday  evening  about  ten  o'clock. 

At  quarter  before  nine  on  Sunday  morning  we  saw  him  again,  and 
found  that  the  case  had  advanced  very  rapidly  in  the  wrong  direction ; 
the  left  eye  was  very  much  swollen,  and  it  was  then  very  clear  that 
there  was  but  one  event  to  look  for,  and  tliat  was  death.  He  died  in 
the  evening.  We  did  not  look  upon  the  case  as  a  serious  one  until 
Thursday. 

Dr.  Steele,  in  answer  to  a  question  from  Dr.  Bibbins,  remarked 
that  the  weight  of  the  brain  could  not  be  perceptibly  increased  by  the 
injection.  He  further  remarked  that  he  believed  that  what  was  mis- 
taken for  pus  was  really  the  injection,  and  the  red  appearance  of  the 
membranes  and  brain  was  also  to  be  explained  on  that  supposition. 

Dr.  Sands  stated  that  he  recognized  the  injection  very  distinctly, 
but  the  appearances  of  pus  were  to  him  unmistakable,  and  furthermore 
the  matter  had  been  examined  microscopically  by  Mr.  Wynkoop,  who 
substantiated  the  assertion. 

Dr.  Steele  remarked  that  he  had  thrown  the  injection  into  the 
membranes. 

Dr.  Sands  stated  that  the  membranes,  on  postmortem  examination, 
were  found  uninjured,  and  were  dry,  except  in  those  portions  where  the 
creamy  substance,  which  he  called  pus,  was  found. 

Dr.  Draper,  who  was  present  at  the  autopsy,  confirmed  Dr.  Sands' 
statement  with  reference  to  the  existence  of  purulent  effusion.  It  pre- 
sented precisely  the  same  character  which  he  had  often  seen  in  that 


I 


I 


1866.]  PROCEEDINGS  OP  SOCIETIES.  371 

situation,  and  it  did  not  occur  to  him  bow  it  could  be  any  thing  else. 
It  was  upon  the  meninges,  and  between  the  dura  mater  and  cranium. 

Dr.  Buck  suggested  that,  if  the  substance  were  really  injection,  it 
could  scarcely  be  found  lodging  outside  the  dura  mater,  when  it  had 
been  introduced  by  way  of  the  nose. 

Dr.  Sands  did  not  see  how  a  sharp  instrument  could  be  passed 
through  the  nostril  into  the  brain,  without  showing  some  evidence  of 
its  passage  on  post  mortem  examination.  There  were  no  evidences 
whatever  of  an  instrument  having  entered;  the  ethmoid  bone  was  in- 
tact, the  cribriform  plate  was  entire,  and  the  base  of  the  brain  was 
uninjured. 

Dr.  Bradley,  who  was  present  during  the  embalming  process,  said 
that  he  saw  Dr.  Steele  thrust  the  instrument  through  the  nostrils,  and 
that  it  passed  up  in  the  direction  of  the  brain,  evidently  through  bone, 
to  a  distance  of  at  least  four  or  five  inches.  His  impression  at  the  time 
was,  that  it  had  passed  into  the  cranial  cavity;  but,  judging  from  the 
report  of  the  post  mortem,  he  was  forced  to  conclude  that  the  instru- 
ment had  passed  under  the  dura  mater.  Two  or  three  syringefuls  of 
the  liquid  were  thrown  in,  but  a  good  deal  of  it  escaped  when  the  in- 
strument was  removed. 

Dr.  Buck  remarked  that,  after  the  removal  of  the  brain,  any  perfo- 
ration that  had  been  made  through  the  base  of  the  cranium  could 
scarcely  escape  notice. 

Dr.  Draper  stated  that  if  the  injection  had  really  entered  the  cranial 
cavity,  the  appearances  said  to  be  caused  by  it  would  be  the  same  on 
both  sides;  whereas  they  were  described  by  Dr.  Sands  as  being  cir- 
cumscribed. 

Dr.  Markoe  did  not  think,  inasmuch  as  there  was  no  proof  that  the 
injection  had  entered  the  cranial  cavity,  that  it  was  very  evident  that 
the  injection  could  not  be  invoked  to  explain  the  appearances. 

Dr.  Buck. — Was  any  injection  thrown  into  the  great  trunks  ? 

Dr.  Steele. — About  two  quarts  and  one  pint  were  thrown  into  the 
femoral. 

Dr.  Parker  remarked  that  there  must  have  been  some  deception  as 
to  the  passage  of  the  instrument  into  the  cranium.  The  turbinated 
bones  were  not  so  easily  broken  through.  He  had  tried  the  experi- 
ment of  introducing  au  instrument  through  the  cribriform  plate,  and 
had  failed  to  succeed. 

Dr.  Steele  stated  that  the  instrument  which  he  had  used  was 
fashioned  like  a  hypodermic  syringe,  but,  of  course,  of  much  larger 
size. 


j 


372 


PROCEEDINGS  OP  SOCIETIES. 


[Feb., 


Dr.  Otis  asked  if  it  were  not  possible  that  the  instrument  had  en- 
tered the  frontal  sinus  ? 

Dr.  Bradley  stated  that  the  point  of  the  instrument,  after  it  had 
been  introduced,  could  be  freely  moved. 

Dr.  Parkek  did  not  sec  how  such  a  thing  was  possible  under  the 
circumstances — that  if  it  had  gone  through  the  cribriform  plate  of  the 
ethmoid  its  point  would  be  virtually  fixed.  He  was  forced  to  con- 
clude, in  the  absence  of  proof  to  the  contrary,  that  the  injection  had, 
for  the  most  part,  passed  down  the  pharynx. 

Dr.  Eliot  inquired  concerning  the  history  of  Dr.  Conant's  case  im- 
mediately preceding  his  attack.  He  had  been  informed  that  shortly 
before  his  death  the  doctor  had  been  in  attendance  upon  a  bad  case  of 
6mall-pox,  which  had  afterwards  become  purpuric,  and  that  he  had 
been  inoculated,  and  again  that  he  had  a  patient  with  phlegmonous 
erysipelas,  and  had  been  poisoned. 

Dr.  Otis  remarked  that  the  case  of  small-pox  transpired  three  weeks 
before  the  doctor's  death. 

Dr.  Parker  stated  that  for  some  time  previous  to  death,  the  patient 
had  been  much  broken  down  by  hard  work,  especially  during  the 
months  of  July  and  August,  in  tending  upon  cases  having  typhoid 
fever,  erysipelas,  small-pox,  &c.  It  seemed  to  him  that  the  disease  of 
which  the  doctor  died  belonged  to  that  class  which  we  had  been  in  the 
habit  of  meeting  during  the  past  fifteen  years,  and  spoken  of  under  the 
head  of  malignant  pustule.  It  is,  of  course,  not  the  malignant  pustule 
of  English  authors;  but  it  is  a  very  peculiar  form  of  disease  which  is 
met  with  more  frequently  in  young  persons  from  twenty  to  thirty  years 
«f  age.  The  face  is  the  seat  of  the  attack,  and  the  lower  lip  is  its 
most  favorite  seat.  He  had  never  seen  the  pustule  on  any  of  the  ex- 
tremities. It  is  very  often  mistaken  for  erysipelas,  but  it  differs  from 
it,  in  that  instead  of  commencing  in  the  skin  and  working  its  way 
into  the  cellular  tissue,  it  first  shows  itself  underneath  the  epidermis 
and  attacks  the  periosteum.  It  first  shows  itself  as  a  small  white  spot 
formed  of  a  creamy  substance,  which  shines  through  the  skin.  The 
color  of  the  surrounding  tissues  is  livid,  and  they  are  very  hard.  It  is 
"  cakey "  in  character,  and  shows  no  disposition  to  diffuse  itself. 
When  cut  into  it  is  inelastic,  and  the  cut  surface  presents  numerous 
hardened  white  spots.  It  seemed  to  him  to  belong  to  the  carbuncular 
class  of  diseases,  and  to  require  much  the  same  treatment,  as  far  as 
the  knife  was  concerned,  viz.,  free  incision  down  to  the  bone.  He 
knew  of  no  remedy  except  the  knife,  used  early  and  thoroughly. 

Dr.  Sands  stated  that  the  few  cases  of  this  disease  which  he  had 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


373 


seen  were  very  distinctly  circumscribed,  and  when  there  was  extension 
of  the  disease  it  was  through  the  medium  of  the  veins.  In  one  case, 
which  proved  fatal,  this  was  a  distinct  feature,  and  on  post  mortem 
examination  the  coagulated  masses  in  these  vessels  rolled  easily  under 
the  finger.  In  Dr.  Conant's  case,  the  post  mortem  showed  the  disease 
to  be  a  sort  of  erysipelatous  mischief,  a  low  grade  of  inflammatory 
action  without  plastic  effusion,  traveling  through  the  cellular  channels 
of  the  orbit,  and  finally  involving  the  brain,  as  was  distinctly  shown 
by  the  appearance  of  the  pus  and  false  membrane  already  described. 

INFLAMMATtON  OF  THE  CESOPHAGUS  IN  AK  INFANT  DR  LEWIS  SMITH. 

Dr.  Lewis  Smith  presented  an  oesophagus  taken  from  a  child  who 
died  the  day  before  at  the  Infants'  Asylum.  The  patient  was  a  found- 
ling, six  or  eight  weeks  old,  and  when  admitted  into  the  institution 
was  placed  with  a  wet  nurse,  and  a  few  days  after  was  noticed  to  be 
failing  gradually,  and  to  be  losing  flesh  without  assignable  cause.  The 
emaciation  gradually  progressed  until  it  reached  that  degree  which  is 
generally  known  as  marasmus.  There  was  no  fever  and  no  accelera- 
tion of  the  pulse,  and  very  little,  if  any,  vomiting.  The  evacuations  of 
the  bowels  numbered  only  two  or  three  daily  during  its  sickness. 

A  post  mortem  examination  was  made,  and  the  only  lesion  found 
was  an  inflammation  of  the  oesophagus.  There  was  no  sprue  or 
stomatitis  in  this  case.  In  conclusion,  he  stated  that  during  the  past 
summer  he  had  frequently  met  with  cases  of  children,  three  or  four 
months  old,  who  had  died  of  this  simple  oesophagitis.  None  of  these 
seemed  to  have  any  difficulty  in  swallowing. 

TUMOR  OF  THE  RECTUM  DR.  WILLARD  PARKER. 

Dr.  Parker  presented  a  mass  removed  from  the  rectum  of  a  gentle- 
man fifty  years  of  age.  About  six  months  ago  the  patient  first  began 
to  be  troubled  about  the  rectum.  After  each  stool  a  mass  would  be 
protruded  per  anus,  and  although  it  would  easily  return,  he  was  con- 
stantly aimoyed  with  the  desire  to  pass  something  more,  and  this  diffi- 
culty increased  upon  him  until  became  under  Dr.  Parker's  observation, 
about  two  weeks  since.  On  placing  him  in  a  position  to  force  it  down, 
a  mass  of  considerable  magnitude,  vascular  in  character  and  red  in  ap- 
pearance, was  protruded,  showing  itself  attached  to  the  mucous  mem- 
brane, about  an  inch  and  a  half  above  the  sphincter,  over  a  space  of 
an  inch  in  diameter  in  one  direction,  and  three-quarters  of  an  inch 
in  another  direction.    The  wire  of  the  ecraseur  having  broken  during 


374  REVIEWS  AND  BIBLTOGEAPHICAL  NOTICES.  [Feb., 


the  operation,  a  ligature  was  passed  around  the  base  of  the  mass, 
which  latter  was  afterwards  severed  with  the  knife.  Dr.  Pnrker  re- 
marked that  it  was  an  unusual  form  of  disease  of  the  rectunfi,  and  one 
which  he  had  never  seen  before.  Examined  under  the  microscope,  it 
was  found  to  consist  of  columnar  epithelium  upon  a  fibrous  base. 

Dr.  Sands  stated  that  he  had  been  able,  after  a  limited  amount  of 
research,  to  find  no  account  of  such  tumors  occurring  in  the  rectum. 
In  Virchow's  last  work  there  was  a  figure  of  such  a  growth,  which  had 
been  found  attached  to  the  lining  membrane  of  the  gall-bladder  of  a 
cow.    In  structure  they  resembled  the  uterine  mole. 

Dr.  Parker  was  under  the  impression  that  Quain  had  described  a 
case  similar  to  the  one  which  he  had  reported. 

Dr.  Draper  recollected  that  Dr.  Dalton,  some  few  years  ago,  pre- 
sented such  a  tumor  attached  to  the  mucous  membrane  of  the  stomach. 
It  seemed  to  be  a  sort  of  villous  growth  from  that  membrane. 


KEVIEWS  AND  BIBLIOGEAPHICAL  NOTICES. 

The  Renewal  of  Life :  Lectures,  Chieft.y  Clinical.  By  Thomas  King 
Chambers,  M.D.,  Honorary  Physician  to  H.  R.  H.  the  Prince  of 
Wales;  Physician  to  St.  Mary's  and  the  Lock  Hospitals.  From  the 
third  London  Edition.  Philadelphia  :  Lindsay  &  Blakiston,  1865. 
8vo,  pp.  638. 

The  medical  profession  of  this  country  are  under  obligations  to  the 
American  publishers  for  this  reprint  of  Dr.  Chambers'  "  Lectures,"  a 
work  whose  "  time  is  forever,  everywhere  its  place" — admirable  in  tone, 
full  of  valuable  instruction  and  practical  teaching,  and  written  in  clear, 
compact,  literate,  and,  often,  epigrammatic  English.  We  can  offer  but 
a  brief  notice  of  this  intrinsically  good  book,  which  is  certain  of  finding 
a  wide  circle  of  readers,  and  we  should  hope  a  place  in  every  medical 
library,  and  must  restrict  our  comments  to  a  few  of  the  most  impor- 
tant topics  treated  of. 

There  are  many  who  believe  that  medicine  as  a  science  is  falsely 
so  called,  and  that  it  can  never  claim  to  rank  higher  than  an  empiric 
art.  It  has  been  well  remarked  by  M.  CI.  Bernard,  in  his  latest  con- 
tribution to  medical  literature — "Introduction  a  PJ^lude  de  la  Mc'dccine 
£xperimcntale" — that  "  beside  those  who  deny  medicine  to  be  a  science 


1866.] 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


375 


because  there  is  nothing  absolute  known  in  it,  we  find  others  who  deny 
it  by  an  entirely  opposite  process — by  admitting  that  medicine  is 
learnt,  one  knows  not  how,  and  we  become  possessed  of  it  by  means 
of  instinctive  science,  which  they  call  medical  tact.  Now,  it  is  not  to 
be  denied  that  there  may  exist  in  medicine,  as  in  all  other  practical 
sciences,  that  which  is  called  tact,  or  coup  (Vail.  Every  one  knows  that 
babit  may  give  one  a  sort  of  empirical  knowledge  of  things,  capable 
of  directing  the  practitioner,  although  he  may  be  unable  at  once  to 
follow  the  process.  But  what  we  regard  as  blamable  is  voluntarily 
to  remain  in  this  state  of  empiricism,  and  not  attempt  to  get  loose.  By 
close  observation  and  study,  one  can  always  attain  to  the  comprehen- 
sion of  what  one  has  done,  and  finally  be  able  to  teach  others  what 
one  knows."  The  question  arises,  by  what  means  and  on  what  condi- 
tions may  medicine  become  an  exact  science  ?  By  becoming  a  science 
of  observation  and  experiment,  for  it  will  never  be  perfect  whilst 
based  on  obs'ervation  alone.  Its  only  true  basis  is  physiology,  in  its 
most  comprehensive  sense.  It  must  be  made  not  only  the  firm  founda- 
tion, but  the  key-stone  and  binding  link  of  our  all  knowledge  regard- 
ing the  nature  of  disease  processes. 

"  I  am  sure  "  says  our  author,  "  that  physiology,  as  it  is  now  taught 
in  our  schools,  is  enough  to  clear  away  the  remaining  mists  of  these 
superstitions.  They  can  not  stand  before  the  light.  To  us  now  health 
is  that  nicely  adjusted  balance  of  vital  functions  which  is  convenient 
for  the  uses  men  put  their  bodies  to,  or  ease\  that  disordered  balance 
which  is  inconvenient  is  bad  health,  or  f/w-ease.  There  are  no  foreign 
forces  to  be  studied,  but  simply  varied  relations  arising  from  deficiency 
of  one  or  other  of  the  ordinary  functions  of  life,  and  a  consequent  want 
of  balance  between  them.  Is  it  not,  then,  obvious  that  the  only  sure 
mode  of  arriving  at  a  knowledge  of  the  deficiencies  of  vital  powers,  or 
diseases,  is  by  a  knowledge  of  tliose  powers  of  which  they  are  deficien- 
cies ?    The  physiologist  is  the  only  true  pathologist,"  (p.  636.) 

There  are  no  new  modes  of  nature's  acting  brought  into  play  by 
disease;  its  chemistry  is  the  organic  chemistry  of  health;  the  same  me- 
chanical laws  are  exhibited;  the  relations  of  the  material  and  spiritual 
world  therein  are  the  same.  The  difference,  our  author  contends,  and 
we  are  not  disposed  to  join  issue  with  him,  "consists  in  the  deficiency 
— that  is,  the  temporary,  or  permanent,  subtraction — of  substance  or 
power,  and  not  in  its  unwonted  increase."  Again: 

"  Tiiere  are  two  departments  carried  on  simultaneously — the  de- 
structive and  constructive;  and  upon  tiieir  harmony  and  completeness 
depends  the  perfection  of  life  which  we  call  health.  Botii  are  neces- 
sary; and  the  deficiency  of  either  or  both,  or  the  preponderance  of  one 


376  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Feb., 


over  the  other  in  various  parts,  or  their  deficiency  in  one  part  while 
other  parts  remain  active,  constitutes  a  tleficiency  of  life — a  disease. 

"Tills  deficiency  the  physician  is  called  upon  to  remedy;  and  it  is  of 
the  utmost  importance  to  his  usefulnes  that  he  should  recognize  that  it 
is  a  deficiency,  and  act  upon  the  recognition.  He  must  look  at  his 
pharma(;opoeia  with  this  thought  constantly  present  before  him,  with 
an  eye  to  the  ultimate  benefit  of  the  patient,  to  a  goal  beyond  that  of 
the  immediate  effects.  He  should  make  his  chief  thought  how  each  of 
the  reagents  employed  will  finally  touch  life;  whether  they  are  calcu- 
lated to  add  to  or  diminish  the  vital  functions,  to  add  to  or  diminish 
the  vitalized  substance  of  which  his  patient  is  made — whether  by  tem- 
porarily diminishing  the  functions  or  substance  he  may  not  remove  an 
impediment  to  their  balanced  actions,  so  as  to  lead  to  a  final  increase 
— or  whether  this  artificial  diminution  of  functions  or  substance  may 
not  become  permanent,  and  inflict  permanent  injury  on  his  patient. 
This  final  goal  of  life  renewal  must  be  consciously  or  unconsciously  in 
the  heart  of  the  physician,  or  in  the  heart  of  his  guides;  otherwise  I 
am  sure  he  contributes  more  to  the  ill  health  than  to  the  good  health 
of  mankind,"  (pp.  40-1.) 

Healthy  life  consists  in  a  continuous  and  equally  balanced  repetition 
of  the  two  necessary  parts  of  the  renewal  of  the  body,  constructive  and 
destructive  assimilation — in  other  words,  "growing  and  moulting." 
The  essential  nature  of  disease,  that  which  makes  it  disease,  is  a  defi- 
ciency of  either  construction  or  destruction  in  one  or  more  points 
The  cure  of  disease,  natural  or  artificial,  consists  in  a  new  birth,  or  re- 
newal of  the  deficient  life.  The  morbid  phenomena  classed  under  the 
head  of  deficiencies  of  nutrition  or  form-building  are  most  simply 
shown  by  starvation  in  healthy  bodies.  Graves,  Chossat,  Marshall 
Hall  and  others  have  abundantly  and  satisfactorily  illustrated  the  re- 
sults of  autnphagism,  or  the  sum  of  mordid  manifestations  resulting 
from  prolonged  abstinence  of  food.  When  a  person  has  nothing  to  eat, 
says  Trousseau,  he  lives  on  himself  Numerous  observations  have  de- 
monstrated that  a  great  number  of  patients  suffering  from  acute 
disease  have  died  from  intercurrent  autophagism,  when  subjected  to 
a  rigorous  diet.  Dr.  Chambers'  remarks,  on  this  point,  we  can 
bear  witness  to  from  personal  observation  in  the  same  hospital: 

"  I  have  a  most  lively  and  painful  recollection  of  seeing,  when  I  was 
a  student  in  Paris,  M.  Chomel  and  others  treating  pneumonia.  I 
could  not  at  first  understand  why,  in  France,  so  much  more  marked 
and  more  hurtful  effects  were  produced  by  venesection  than  in  Eng- 
land. At  that  period  we  had  at  home  ample  opportunities  of  seeing 
it  practiced;  but  I  never  witnessed  such  prostration  follow  at  St. 
George's  as  I  did  at  the  Hotel  Dicu.  I  was  puzzled  for  a  week  or  two, 
till  at  last  I  noticed  that  the  order  for  '  saigne'e'  was  accompanied  by 
'  diete  absoluc'    I  almost  doubted  my  knowledge  of  French,  and  was 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


377 


obliged  to  ask  of  the  by-statiders  before  I  could  believe  that  this  meant 
an  utter  deprivation  of  all  food  !  Here  was  an  immediate  explanation 
of  the  seeming  toughness  of  my  countrymen;  for  never  in  our  worst 
days  did  we  carry  the  Saugrado  practice  so  far  as  that.  Our  teachers 
did  not  give  food  enough,  but  they  never  bade  it  to  be  willfully  kept 
beyond  their  patient's  reach,"  (pp.  614-15.) 

There  is  much  wisdom  and  practical  teaching  in  the  underlying 
therapeutic  views  of  our  author,  logical  consequences  of  his  doctrine  of 
disease.  The  object  of  medical  treatment  is  cure.  The  end  of  the 
physician's  labor  and  care  is  accomplished  by  the  patient  getting  well. 
What  is  this  cure  or  getting  well  ?  It  is  a  restoration  of  the  disordered 
body  to  its  natural  state  of  ease  or  health.  It  sometimes  comes  to 
pass  independently  of  any  interference  from  without,  by  what  is  called 
an  efi'ort  of  nature.  Wounds  heal,  diseases  cease  in  men  and  animals 
who  have  none  to  help  them,  the  diseased  organs  resuming  their  nat- 
ural functions. 

"  Now  diseased  organs  must  necessarily  have  less  power  in  them 
than  liealthy  ones;  and  it  is  obvious,  therefore,  that  the  curative  vitality 
must  plainly  be  due  to,  and  proceed  from,  those  which  remain  healthy. 
It  is  to  their  having  some  sound  action  to  spare  that  the  sick  man  owes 
his  recovery.  The  vital  force  at  the  same  time  removes  the  retained 
products  from  the  tissues,  and  replaces  them  by  new  material.  This 
is  the  true,  teaching  of  nature's  cure,"  (p.  55.) 

Cures  by  art  are  effected  in  the  same  way.  The  action  of  a  remedy 
is  a  series  of  vital  acts  of  the  body  itself.  "The  true  art  of  healing 
consists  in  the  establishment  of  vital  acts  tending  toward  the  renewal 
of  the  body,  toward  a  new  birth  of  deceased  tissue,  and  in  the  encour- 
agement and  aiding  of  those  vital  acts  after  the  removal  of  their  origi- 
nal excitant,"  (p.  56.) 

The  lecture  on  "Blood-letting"  will  abundantly  repay  careful 
reading,  from  its  fairness  and  sensible  tone.  Our  author  thinks  "it  is 
time  to  have  done  with  the  reactions  for  and  against  letting  blood, 
which  have  been  going  on  throughout  the  period  of  the  Christian  era; 
the  wave  which  has  swelled  backward  and  forward  to  a  dangerous 
height,  ought  to  settle  down  into  a  steady  stream.  We  ought  to  know 
clearly  -why  we  bleed,  and  then  we  shall  know  when  to  bleed." 

"  The  history  of  opinions  on  the  subject  of  blood-letting  shows  us 
four  sects  or  parties,  each  one  of  which  has  at  various  times  outweighed 
its  rivals  in  number  of  adherents.  First,  the  followers  and  prede- 
cessors (for  'virere  fortes  ante  Agamemiifma')  of  Hippocrates,  who 
sometimes  bled,  but  always  fed,  their  patients.  Second,  the  disciples 
of  Erasistratus,  who  denounced  bleeding  as  robbery,  and  prescribed  in 
its  place  a  complete  starvation  for  several  days — ddrpiTog  doiria. 


1 


378  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.         [Feb.,  j 

Third,  the  French  practitioners  of  tlie  two  last  centuries,  immortalized 
but  not  checked  by  the  satire  of  Moliere  and  Le  Sage,  who  both  bled  | 
and  starved  at  once.    Fourth,  the  followers  of  Brown,  who  re[)laced 
bleeding  by  alcohol.    From  what  has  been  said  it  will  be  seen  that  I  ! 
should  find  myself  a  member  of  the  first  named  sect,  if  the  unhappy  | 
mania  of  party  spirit  were  again  to  afflict  our  profession  as  it  has  doue  | 
of  old.    And  were  hero-worship  again  to  become  one  of  our  failings, 
I  should  probably  select  as  the  bible  of  my  medical  faith  Hippocrates'  i 
'Regimen  of  Acute  Diseases.'    For  if  it  might  be  allowed,  out  of  con-  I 
sideration  for  the  differences  between  Athens  and  London,  to  substi- 
tute beef-tea  for  gruel,  there  is  very  little  in  that  capital  course  of  I 
lectures  which  does  not  accord  with  the  daily  practice  of  those  I  think  i 
wisest  among  us  in  the  present  day,"  (pp.  625-5.) 

Dr.  Chambers  classes  alcohol  as  an  ana;sthetic  whose  primary  action 
is  on  the  nervous  system,  and  to  that  action  is  attributed  its  effect  in 
staying  destructive  metamorphosis.    A  series  of  experiments  made  by 
him  would  seem  to  indicate  that  a  moderate  dose  of  alcohol  acts  by  | 
temporarily  augmenting  the  digestive  power  of  the  stomach,  helping  it  j 
to  appropriate  more  thoroughly  the  food;  but  if  advantage  is  not  taken  i 
of  this  first  action,  its  secondary  effect  is  a  diminution  of  the  vital  ' 
functions  in  general,  and  digestion  among  their  number.    It  decreases  | 
the  excretion  of  the  phosphates,  and,  as  their  chief  source  is  nerve-  ! 
tissue,  alcohol  must  be  an  arrester  of  nerve-life,  and  conseqUjCntly  a  con-  I 
troUer  of  nervous  action  on  the  rest  of  the  system.    The  clinical  rules 
which  he  lays  down  for  the  administration  of  alcohol  are,  that  it  is  to 
be  given  whenever  you  find  the  nervous  system  exhausting  itself  and 
the  body  by  an  activity  in  excess  of  the  other  bodily  functions — when 
constructive  life  is  low,  as  in  typhoid  fever,  surgical  injuries,  low  forms 
of  pneumonia,  erysipelas,  &c.    Give  it,  increase  it,  leave  it  off  under 
the  guidance  of  the  appetite  for  food.    Divide  the  daily  allowance  into  | 
two  or  three  doses  only,  giving  enough  at  once  to  produce  a  decided  | 
effect.    Abstain  from  its  use  altogether  when  the  marked  feature  of  ; 
the  disease  consists  in  the  retention  of  effete  matters  which  ought  to  ' 
be  discharged. 

In  accordance  with  these  general  therapeutic  views,  we  find  Dr. 
Chambers'  treatment  of  special  morbid  states  in  the  main  such  as  will  i 
command  general  acceptance  by  right  thinking  practitioners  for  their 
soundness  and  common  sense.    He  puts  faith  in  physiological,  temper- 
ing, and  restorative  treatment,  and  discourages  an  inconsiderate  resort  i 
to  spoliative  and  destructive  expedients.    He  stands  an  alert  and  obdu- 
rate sentry  against  the  fatal  fascinations  of  polypharmacy.    "  When 
'serum  laclis'  will  suffice,  why  use  vena  scdio  ?"  We  would  particularly  in-  i 
dicate  the  Lectures  on  Fever,  Rheumatic  Fever,  Pericarditis,  Capillary  ' 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


379 


Bronchitis,  and  Pneumonia  as  particularly  deserving  of  careful  study 
by  the  profession. 

We  are  sorry  that  the  American  publishers  have  thought  fit  to  re- 
store the  somewhat  fanciful,  and  to  us  objectionable,  title  of  "  The 
Renewal  of  Life,"  used  by  the  author  in  the  earlier  editions,  and  wisely 
abandoned  in  subsequent  ones,  at  the  suggestion  of  his  most  friendly 
reviewers.  It  is  to  be  regretted,  too,  that  the  index  added  to  the  last 
— fourth — London  edition  has  not  been  reprinted  in  this,  by  means 
of  which  much  facility  would  have  been  gained  for  the  purpose  of  easy 
and  frequent  consultation. 

Lectures  on  Inflammation ;  being  the  First  Course  delivered  before  the 
College  of  Physicians  of  Philadelphia,  under  the  bequest  of  Dr. 
Mutter.  By  John  H.  Packard,  M.D.,  author  of  a  "  Manual  of 
Minor  Surgery,"  Secretary  of  the  College  of  Physicians,  etc.,  etc. 
Philadelphia:  J,  B.  Lippincott  &  Co.  1865.  pp.  276. 

The  title  tells  us  to  what  circumstances  we  owe  this  little  book. 
By  an  agreement  entered  into  in  1858,  the  late  Dr.  Mutter  bequeathed 
to  the  College  of  Physicians  of  Philadelphia — the  oldest  association  of 
American  physicians — his  pathological  museum,  together  with  a  fund 
for  its  preservation,  and  the  endowment  of  a  Lectureship.  The  Col- 
lege appointed  Dr.  Packard  to  deliver  the  first  three  courses  of 
lectures  under  this  bequest,  and  we  have  here  the  first  series. 
Dr.  Packard  says:  "  In  them  I  have  endeavored  to  set  forth  the  sub- 
ject of  Inflammation  in  the  light  of  modern  pathology.  As  a  matter 
of  course,  within  such  limits  it  would  be  vain  to  attempt  to  exhaust 
a  topic  of  sucli  magnitude  and  importance;  but  my  aim  has  been  to 
take  up  the  principal  points  in  regard  to  it,  and  to  give  a  plain  and 
succinct  history  of  their  present  aspect."  (Preface.) 

How  far  the  author  has  been  successful  will  be  appreciated  by  those 
who  may  read  the  work.  We  do  not  think  that  he  has  been  fortunate 
in  the  choice  of  his  subject,  which,  to  be  intelligently  and  attractively 
treated  by  the  "  light  of  modern  pathology,"  requires  more  ample  hand- 
ling. While  the  "  Lectures  "  fairly  present  the  views  of  Mr.  Paget  and 
Virchow  on  the  sulyect  of  inflammation,  as  set  forth  in  their  writings, 
we  can  hardly  say  that  Dr.  Packard  does  full  justice  to  all  their  co- 
laborers  in  this  branch  of  pathology  during  the  past  twenty  years,  and 
who  have  really  given  such  important  momenta  towards  the  develop- 
ment of  the  current  theory  of  Inflammation.  The  views  of  Mr.  Paget, 
which  Dr.  Packard  quotes  from  the  first  edition  of  his  "  Lectures  on 
Surgical  Pathology" — originally  delivered  before  the  Royal  College  of 


380 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Feb., 


Surgeons  during  the  six  years  between  1847-52 — merely  represented 
those  of  the  German  school  of  a  quarter  of  a  century  since,  and  to  it, 
and  not  to  tlie  English  surgeon,  should  the  credit  be  given.  We  look 
in  vain  for  the  names  of  Lister,  Simon,  C.  J.  B.  Williams,  Bennett, 
Goodsir,  Toynbee,  Redfern,  Parkes,  Beale,  and  many  others  in  Great 
Britain,  and  a  number  in  Continental  Europe,  to  whose  studies  on 
this  subject  we  are  indebted  for  substantial  progress.  The  valuable 
researches  of  Mr.  Goodsir,  published  in  1845,  in  wiiich  he  maintained 
that  disintegration  of  inflamed  tissue  results  from  dynanical  disturbance 
of  the  tissue  itself,  that  veins  and  lymphatics,  in  reference  to  ulceration 
and  absorption,  are  mere  ducts  for  the  conveying  away  the -products 
of  action,  and  that  ulceration  involves  profuse  endogeny  and  shedding 
of  germs,  were  a  most  important  step  towards  the  comprehension  of 
the  pathogeny  of  inflammation,  and  should  not  be  overlooked  by  any 
one  who  undertakes  to  present  a  digest  of  our  knowledge  of  the  subject. 
The  same  may  be  said  of  the  want  of  mention  of  the  observations  and 
experiments  of  Mr.  Joseph  Lister,  Professor  of  Surgery  in  the  Univer- 
sity of  Glasgow,  presented  to  the  Royal  Society  in  1857,  and  the 
most  directly  valuable  contribution  to  the  study  of  inflammation,  to 
our  mind,  made  for  a  long  time,  and  which  perfectly  illustrate  the 
series  of  complex  changes  through  which  the  inflammatory  process  is 
seen  to  move,  and  especially  the  cause  of  the  "stasis"  and  exudation 
of  the  liquor  sanguinis,  phenomena  hitherto  of  such  difficult  and  varia- 
ble explanation. 

Dr.  Packard  tells  us  "  that  a  part  which  is  inflamed  has  its  tempera- 
ture raised  above  the  normal  standard  for  that  part  can  not  for  a  mo- 
ment be  doubted;  but  the  degree  of  this  elevation  is  generally  much 
less  than  could  be  supposed  either  by  the  patient  or  by  the  observer." 
"  Certain  it  is  that  the  thermometric  changes  produced  by  this  condition 
are  much  slighter  than  would  be  supposed.  Hunter  held  the  view 
that  the  temperature  of  an  inflamed  part  never  exceeded  that  of  the 
central  portions  of  the  body,  and  the  statement  is  confirmed  by  Andral 
and  Gavarret,  and  by  most  other  writers,"  (pp.  59, 60.)  Now,  does  this 
statement  fairly  represent  the  state  of  our  knowledge  on  the  subject, 
and  what  do  we  find  "  in  most  other  writers  ?"  We  have  no  mention 
made  of  the  experiments  performed  in  1835  by  Messrs.  Becquerel  and 
Breschet,  which  went  to  prove  that  an  inflamed  part  was  actively 
calorific — that  it  is,  or  tends  to  be,  warmer  than  the  blood  which  sup- 
plies it — in  opposition  to  Hunter,  who  believed  that  an  inflamed  part 
is  passive  in  the  alleged  change  of  temperature,  which  can  not  exceed 
that  of  the  blood  which  supplies  it.    We  believe  that  no  value  can  be 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


381 


attached  to  either  set  of  experiments;  and  the  question  remained  open 
for  decision  whether  "  heat  is  a  symptom  of  inflammation  only  in  ex- 
ternal parts,  and  only  as  a  passive  result  of  their  over-fullness  with 
blood  ?  or  is  the  inflamed  part  actively  productive  of  heat  ?"  Its  solu- 
tion, we  are  of  opinion,  has  been  practically  made  by  the  thermo-electric 
observations  made  in  1860  by  Mr.  John  Simon  and  Dr.  Edmund  Mont- 
gomery, of  St.  Thomas'  Hospital,  and  which  go  far  to  prove  satis- 
factorily that  an  inflamed  part  is  no  mere  passive  recipient  of  heat,  but 
is  itself  actively  calorific.  We  have  among  the  observed  results,  first, 
that  the  arterial  blood  supplied  to  an  inflamed  limb  is  found  less  warm 
than  the  focus  of  inflammation  itself;  second,  that  the  venous  blood 
returning  from  an  inflamed  limb,  though  found  less  warm  than  the  focus 
of  inflammation,  is  found  warmer  than  the  arterial  blood  supplied  to 
the  limb;  third,  that  the  venous  blood  returning  from  an  inflamed 
limb  is  found  warmer  than  the  corresponding  current  on  the  opposite 
side  of  the  body.* 

We  are  told  that  the  system  at  large  passes  into  a  febrile  condition 
under  the  influence  of  local  disturbances,  and,  "as  one  element  of  this 
disorder,  the  temperature  of  the  whole  body  rises  in  some  degree." 
Surely  our  author,  in  speaking  of  the  increased  temperature  of  the  blood 
in  the  constitutional  aff"ectioii,  which  runs  its  course  in  connection  with 
local  inflammation,  and  is  known  by  the  name  of  "inflammatory  fever," 
might  have  alluded  to  the  positive  contributions  of  Montgomery, 
Parkes,  Ringer,  Wunderlich,  Traube,  Eilroth,  van  Barensprung,  &c., 
ou  the  thermometry  of  fcbrility,  and  who,  with  the  aid  of  exact  ther- 
mometric  observation,  have  scientifically  established  so  many  facts  of 
practical  use,  both  in  idiopathic  fevers,  visceral  inflammations,  and 
surgical  disorders,  tending  to  demonstrate  that  increased  bodily  calo- 
ricity  is  a  uniform  attendant  on  febrility,  whether  sympathetic,  con- 
tinued or  intermittent;  that  it  is  as  constant  in  ague  and  hectic  as 
in  typhus  or  pneumonia;  that  febrile  rigor  denotes  a  more  rapid  heat- 
ing of  the  blood,  and  as  it  occurs  in  ague  and  pyjemia,  is  distinctively 
the  sign  of  a  sudden  rise  of  temperature. 

Materia  Medica,for  the  Use  of  Students.  By  John  B.  Biddle,  M.D., 
Professor  of  Materia  Medica  and  General  Therapeutics  in  Jefterson 
Medical  College,  etc.,  etc.  Witli  Illustrations.  Philadelphia:  Lind- 
say &  Blakiston.  1865.  8vo,  pp.  359. 

This  is  a  second  edition  of  the  author's  "  Review  of  Materia  Med- 
•  Holmes' System  of  Surgery.  Arlicto,  "  Inflammation."  Vol.  i.  London,  18C1. 


382 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Feb., 


ica,"  revised,  enlarged  and  adapted  to  the  United  States  Pharmaco- 
poeia of  1860.  It  belongs  to  a  class  of  books  which  severely  try  the 
critic's  charity,  their  contents  being,  for  the  most  part, 

"  Drawn  from  the  mouldy  rolls  of  Noah's  ark," 

embalming  the  relics  of  a  by-gone  age,  and  ignoring  all  scientific  prog- 
ress. The  catalogue  of  veteran  stock-remedies  which  we  have  here 
spread  before  us  demands  no  small  stock  of  courage  to  face,  and 
we  soon  become  satisfied  they  should  long  ago  have  been  mustered 
out  of  service  on  account  of  general  worthlessness,  and  that  their  re- 
tention is  a  fraud  on  the  junior  members  of  the  profession  and  the 
public. 

Professor  Biddle  states  that  "  numerous  additions  have  been  made 
to  the  list  of  articles  treated  of,  and  the  work  has  been  remodeled  and, 
in  many  parts,  rewritten.  Although  not  designed  to  take  the  place 
of  the  more  voluminous  and  systematic  treatises  upon  the  subject,  it  is 
believed  that  it  will  be  found  to  contain  a  succinct  account  of  all  the 
articles  of  the  Materia  Medica  in  use  in  this  country."  Yet  we  have 
looked  in  vain  for  mention  of  the  bromide  of  ammonium,  cerium  and 
its  salts,  pepsine.  Calabar  bean,  (physostigma  venenosum,)  apiol,  car- 
bolic acid,  the  alkaline  and  earthy  sulphites,  and  other  recent  reme- 
dies now  in  general  use. 

We  will  extract  a  few  plums  from  our  author's  pudding: 

"  Bromide  of  potassium  has  been  used  as  a  substitute  for  the  iodide 
in  bronchocele,  scrofula,  chronic  cutaneous  affections,  secondary  syphilis, 
&c.,  but  it  is  inferior,  in  these  diseases,  to  the  iodic  salt.  It  has,  how- 
ever, proved  a  very  efficacious  remedy  in  diseases  of  the  nervous  cen- 
tres, as  whooping  cough,  infantile  convulsions,  and  especially  epilej)sy, 
over  which  it  is  now  believed  to  exert  more  control  than  any  other  arti- 
cle of  the  Materia  Medica.  It  is  found  also  to  be  the  most  efficient 
remedy  which  we  possess  in  allaying  venereal  excitement,  and  hence  its 
employment  in  nymphomania,  chordee,  &c.,  and  as  a  preventative  of 
masturbation  in  prisons,  barracks,  &c.  Dose,  from  three  to  five  grains, 
several  times  a  day,"  (p.  21i.) 

We  have  here  no  mention  of  the  wonderful  anaesthetic  powers  of 
bromide  of  potassium  over  mucous  membranes  generally,  and  those  of 
the  pharynx  and  larynx  especially — thus  becoming  a  powerful  aid 
in  laryngoscopic  examinations  and  operations;  of  its  repeatedly  attested 
value  in  enlargement  of  the  spleen;  its  prompt  efficacy  in  removing 
congestive  headaches;  and  its  jjositive  hypnotic  qualitits.  Its  manner 
of  administration  is  given  very  vaguely. 

Of  the  uses  of  muriate  of  ammonia  Prof  Biddle  says:  "  It  is  not 
much  employed  in  Great  Britain  or  the  United  States,  but  it  is  exten- 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


383 


sively  used  in  Germany  as  a  refrigerant  sedative  in  mild  fevers,  attended 
with  stoppage  of  the  secretions — as  a  resolvent  in  organic  enlarge- 
ments— in  amenorrhcea,  and  in  catarrhs,  urethritis,  &c.  Dose,  gr.  v.- 
XXX.  every  two  or  three  hours,  in  powder  or  mucilaginous  solution," 
(p.  283.)  This  salt  is  very  largely  employed  in  Great  Britain,  and 
has  been  for  the  past  quarter  of  a  century,  and  we  believe  the  same 
to  be  true  in  this  country.  Its  value,  in  certain  forms  of  hemicrania — 
the  only  instance  in  which  we  know  of  its  administration  in  thirty- 
grain  doses  being  recommended — is  entirely  overlooked,  as  well  as  its 
recognized  efiBciency  in  parenchymatous  and  mucous  inflammations,  in 
small  and  repeated  doses.  Many  physicians  use  it  in  their  practice  to 
the  utter  exclusion  of  mercury,  and,  from  a  long  and  extensive  expe- 
rience with  it,  we  look  upon  it  as  invaluable  in  gastric,  bronchitic, 
pneumonic,  and  hepatic  derangements,  and  have  seen  it  repeatedly  act 
with  miraculous  results  in  acute  iritis. 

Admirers  of  our  indigenous  podophyllum,  so  well  known  and  so  gen- 
erally used,  will  think  that  it  deserves  something  more  than  this  "  curt 
epitome."  "This  is  an  active  hydragogue  cathartic,  analogous  in  its 
operation  to  jalap,  for  which  it  might  very  well  be  substituted.  It  is 
an  ingredient  in  several  cathartic  nostrums,"  (p.  212.)  No  word  for 
it  as  an  accredited  cholagogue.  In  summarizing  the  employment  of 
ipecacuanha,  no  mention  is  made  of  its  success  in  large  doses  in  dys- 
entery, so  well  proved  within  a  few  years  in  British  India  and  in  our 
own  army. 

We  regret  to  have  felt  it  our  duty  to  indicate  the  general  defects  of 
this  work,  and  a  few  of  its  shortcomings.  The  difficulty  lies  in  the 
nature  of  the  book  itself,  more  than  in  defective  execution.  We  can 
not,  with  impunity,  turn  our  back  on  the  rapid  strides  that  physiology, 
pathology  and  chemistry  have  made  and  are  making.  The  substantial 
progress  of  medicine  must  be  owned.  Such  is  not  the  scope  of  a  work 
like  this,  which,  instead  of  an  aid,  is  a  hindrance  to  the  spread  of  real 
knowledge,  encouraging  the  pouring  in  hap-hazard  of  the  most  power- 
ful and  dangerous  drugs. 

Tht  rradicc  of  Medicine.  By  Thomas  Hawkes  Tanner,  M.D.,  F.L.S., 
etc.,  etc.  From  tlie  Fifth  Loudon  Edition,  Enlarged  and  Improved. 
Philadelphia:  Lindsay  &  Blakiston,  1866.   Svo,  pp.  835. 

The  well  known  "Manual"  of  Dr.  Tanner  is  now  expanded,  in  the 
fifth  edition,  to  a  volume  of  over  eight  hundred  pages,  with  the  more 
ambitious  title  of  "  The  Practice  of  Medicine,"  and  yet  it  only  remains 
a  Manual;  but,  with  some  insignificant  imperfections,  a  very  good 


384  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [Feb., 


Manual.  The  author,  in  attemptuig  so  much,  incurred  the  seri- 
ous risk  of  compromising  the  usefulness  of  a  work  of  intrinsic 
value.  Dr.  Tanner,  in  the  present  compilation,  displays  great 
industry,  intelligence  and  practical  knowledge.  Ilis  descriptions  are 
terse  and  clear,  and  fairly  representative.  His  therapeutic  fertility 
will  delight  the  student,  and  satisfy  the  young  practitioner.  There  is 
an  "Appendix  of  Formula?,"  marshaling  several  hundred  prescriptions, 
which  will  probably  prove  the  most  attractive  feature  of  the  work. 
The  chapter  on  "Climates  for  Invalids"  is  well  condensed,  and  con- 
tains in  few  pages  much  valuable  information  on  a  subject  generally 
but  little  understood;  and  the  same  may  be  said  of  the  concluding  one 
on  "  Mineral  Waters." 

Without  invidious  prejudice  to  the  excellent  handling  of  many  im- 
portant diseases  in  the  "Practice  of  Medichie" — for  it  is  quite 
impossible  for  us  to  follow  Dr.  Tanner  through  his  bulky  volume — we 
would  indicate  "  Pneumonia  "  as  written  in  the  author's  happiest  man- 
ner. His  remarks  on  the  treatment  are  sensible  and  just,  and  go  as  far 
as  our  present  knowledge  permits. 

"Bleeding,  tartar  emetic,  and  mercury,  are  the  agents  on  which  we 
have  been  mainly  taught  to  rely;  but  these  remedies  will,  I  feel  con- 
vinced, do  much  more  harm  than  good  if  applied  to  the  treatment  of 
pneumonia  in  the  present  day.  It  is  the  more  necessary  to  insist  upon 
this  point,  because  some  of  our  text  books  still  advocate  depletion.  In 
recommending  the  adoption  of  a  very  simple  line  of  practice,  I  am 
only  doing  that  my  experience  has  taught  me  is  much  the  best,  not 
only  for  the  ultimate  safety  of  the  patient,  but  even  for  diminishing 
the  duration  of  the  disease.  I  am  quite  alive  to  the  argument  that 
whereas  our  ancestors  bled  too  much,  we  may  fall  into  the  opposite 
error  and  bleed  too  little  ;  but  whatever  may  be  said  upon  this  head 
it  can  only  be  replied,  that  the  practitioner  is  advised  not  to  have 
recourse  to  anti-phlogistic  remedies  in  the  treatment  of  pneumonia, 
because  it  is  firmly  believed  that  their  use  always  retards  and  often 
prevents  restoration  to  health,"  (pp.  363-4.) 

The  work  is  well  printed  in  large,  clear  type,  on  thick,  white  paper. 
Indeed,  all  the  medical  publications  of  Messrs.  Lindsay  &  Blakiston 
are  issued  in  a  most  creditable  manner. 

Chloroform  ;  its  Action  and  Adminisiralion.  By  Arthur  Ernest  San- 
son, M.B.,  London.  Philadelphia:  Lindsay  &  Blakiston.  1866. 
12mo,  pp.  279. 

The  subject  of  this  volume  is  one  which  is  always  attractive  to  prac- 
tical medical  men,  requiring  almost  daily  consideration,  and  involving 
great  responsibility.    The  author  was  educated  in  a  good  school,  the 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


385 


King's  College  Hospital  of  London,  under  Fergusson,Todd  and  Johnson, 
and  was  associated  frequently  with  the  late  Dr.  Snow,  the  author  of 
the  most  philosophical  and  exhaustive  work  on  the  same  subject.  His 
object  in  the  present  work  is  to  present  a  "  brief  resume  of  our  pres- 
ent knowledge  of  chloroform  and  its  effects;"  and,  on  perusal  of  his 
book,  we  are  free  to  say  that  he  has  accomplished  it  in  a  highly  cred- 
itable manner.  He  has  stated  concisely  and  ably  all  that  the  student 
and  practitioner  requires  to  know  of  the  history  and  applications  of 
the  great  remedy,  introducing  nothing  novel  or  original,  but,  as  far  as 
we  observe,  omitting  nothing  that  is  useful.  He  prefers  chloroform  to 
ether  as  an  anaesthetic,  and  seems  to  have  had  no  personal  experience 
in  the  use  of  the  latter,  suggesting  that  a  statue  should  be  erected  to 
Prof.  Simpson,  and  seemingly  not  disinclined  to  lose  sight  of  the  fact 
that  anaesthesia  was  given  to  humanity  by  America. 

Our  author  considers  that  the  principal  dangers  attending  the 
administration  of  chloroform  are  to  be  averted  by  employing  its  vapor 
for  inhalation  in  a  state  of  dissolution,  and  by  means  of  an  inhaler,  and 
describes  one  of  his  own  invention  for  this  purpose.  British  opinion 
seems  to  be  unsettled  upon  this  point,  as  we  notice  Mr.  Lister,  in 
Holmes'  recently  published  "  System  of  Surgery,"  expresses  his  con- 
viction that  "  the  cloth"  is  as  safe  as  any  apparatus.  Dr.  Sansom  also 
thinks  favorably  of  diluting  chloroform  with  alcohol  under  certain  cir- 
cumstances, and  "  is  quite  sure  that  the  administration,  by  the  stomach, 
of  a  little  alcoholic  stimulant  acts  beneficially." 

His  discussion  of  the  modes  in  which  chloroform  causes  death,  and 
of  the  means  of  avoiding  accidents  and  of  effecting  resuscitation,  is 
concise  and  exhaustive. 

In  conclusion,  we  think  that  this  work  is  well  calculated  to  be  useful 
and  popular  with  the  medical  profession. 

Schonberg^s  Improved  Map  of  the  United  States  and  Canada,  carefxdlyi 
compiled  from  the  latest  and  best  Authorities.  New  York:  Schbn- 
berg  &  Co.  1866. 

There  is  no  better  sign  of  educational  progress  than  the  growing 
popular  demand  for  maps.  Geogra])hy  is  one  of  tlie  most  important 
hiiidmaids  of  history  and  general  knowledge.  The  map  now  before 
us  is  the  latest  publication  of  its  kind,  and  embraces  the  most  recent 
geograpiiical  and  hydrographical  points  of  interest,  including  the  prin- 
cipal Ijattle-gi'ounds,  together  with  railways  and  canals,  and  aflbrding 
a  full  and  convenient  means  of  reference.    The  map  is  5  ft.  wide  and 

Vol.  IL— No.  IL  25 


386  PROGRESS  OP  THE  MEDICAL  SCIENCES.  [Feb., 

51  ft.  long,  and  extends  from  Halifax  on  the  East,  to  the  Pawnee 
Reservation  and  Galveston,  Texas,  on  the  West;  and  from  the  mouth 
of  the  St.  Lawrence  on  the  North,  to  the  Florida  Keys  and  Nassau, 
N.  P.,  on  the  Soutii.  It  is  on  the  large  scale  of  thirty  miles  to  the 
inch.  These  geographers  arc  not  like  those  described  by  Plutarch,  in 
his  life  of  Theseus,  who  "  crowd  into  the  edges  of  their  maps,  parts  of 
the  world  which  they  do  not  know  about,  adding  notes  that  all  beyond 
lies  nothing  but  sandy  deserts,  full  of  wild  beasts  and  unapproachable 
bogs;"  for  the  marginal  space  we  find  filled  with  the  western  portion 
of  the  United  States  and  British  Provinces,  from  the  94th  degree, 
W.  L.,  to  the  Pacific  Ocean,  California,  Neveda,  Oregon  and  Texas,  in 
counties,  the  world  on  Mercator's  projection,  comparative  height  of 
the  principal  mountains  in  the  world,  with  a  variety  of  interesting 
statistics,  etc.  The  projection  is  rectangular  polyconic,  the  scale  is  of 
such  size  as  to  admit  of  fullness  and  distinctness,  the  authorities  con- 
sulted are  the  best,  the  drawing  has  been  carefully  and  critically  made, 
the  engraving  is  clear,  the  names  legible,  and  the  whole  work  is  in  the 
most  creditable  style.  We  can  recommend  it  to  our  readers  for  trust- 
worthiness and  easy  reference. 


PEOGEESS  OF  THE  MEDICAL  SCIENCES. 

I.— DISEASES  OF  WOMEN  AND  CHILDRBX. 

1.  A  New  Mode  of  Effecting  Delivery.  I 

Although  the  various  measures  in  which  consists  what  M.  Senn,  of  1 
Geneva,  calls  his  method,  are  to  be  found  described  in  all  works  on 
obstetrics,  yet  their  simultaneous  application  is,  in  reality,  a  suggestion  ' 
which  originates  with  M.  Senn.    The  question  of  prior  invention  is 
here,  however,  of  no  imjjort;  the  system  is  a  sound  one,  and  we  con- 
ceive it  our  duty  to  make  it  known.    The  following  remarks  on  the  , 
subject,  by  the  learned  practitioner  we  have  named,  are  borrowed 
from  the  pages  of  the  "lievue  de  Therapeutique. "  , 

This  method,  adopted  of  late  years  by  M.  Senn,  and  which  appears 
to  him  to  afford  all  desirable  security,  is  founded  on  practical  experi-  I 
ence  and  logical  induction,  and  is  a  combination  of  three  elements: 

Injection  into  the  placenta  of  the  blood  contained  in  the  cord,  and  j 
of  the  blood  of  the  infant;  gradual  and  permanent  pressure  of  the  : 
abdomen  by  means  of  a  very  simple  bandage;  and  entire  immobility  ' 
of  the  mother  in  the  horizontal  attitude  for  two  hours  after  delivery. 

As  soon  as  the  child  is  born,  the  accoucheur  grasps  the  cord  at  about  j 
an  inch  from  the  navel,  in  order  to  protect  the  latter  from  any  injuri- 
ous dragging,  and  with  the  finger  and  thumb  of  the  other  hand 


i 


1866.] 


PROGRESS  OF  THE  MEDICAL  SCIENCES. 


38t 


forces  back  into  the  placenta  the  blood  contained  in  the  funicular 
blood-vessels. 

By  pressure  with  the  finger  and  thumb  the  blood  is  thus  forced 
back  and  retained  in  the  placenta,  while  the  fingers  of  the  other  hand 
are  loosened,  and  allow  the  arteries  of  the  funis  to  fill.  The  operator 
then  Sbfain  presses  on  the  cord,  near  its  insertion  at  the  navel,  and  the 
injection  is  repeated  with  the  other  hand.  This  procedure  should  be 
renewed  three  or  four  times,  according  to  the  condition  of  the  child, 
its  more  or  less  plethoric  appearance,  its  screams,  &c.  Of  course,  in 
the  case  of  an  anemic  infant  this  jilan  should  never  be  attempted. 

In  every  instance,  M.  Senn  performs  this  little  operation  so 
promi^tly  as  to  prevent  the  mother  being  aware  of  it.  When  the 
injection  has  been  completed,  and  the  placenta  is  filled  with  blood,  a 
ligature  is  placed  on  the  cord,  between  the  vulva  and  the  fingers  of 
the  surgeon.  It  is  then  divided  half  way  between  the  umbilicus  and 
the  ligature,  the  child  is  removed,  and  the  cord  secured  as  usual. 

Thus,  artificially  tumefied,  the  placenta  becomes  incapable  of  fol- 
lowing the  retraction  of  the  womb,  its  attachments  are  necessarily 
loosened,  and  the  pi'ocess  of  delivery  is  restored  to  its  most  desirable 
conditions,  viz.,  the  simultanous  expulsion  of  the  infant  and  of  the 
afterbirth.  If  the  organ  is  retained  more  than  five  or  six  minutes 
above  the  vulva,  it  can  easily  be  removed  by  gentle  traction . 

The  second  measure  advocated  by  M.  Senn  is  the  permanent  and 
gradual  compression  of  the  abdomen.  The  pressure  is  not  effected 
with  the  hand,  but  with  a  soft  cloth  in  several  folds,  previously  laid 
under  the  woman's  loins  in  the  early  stage  of  labor. 

"  During  the  progress  of  labor,"  says  M.  Senn,  "the  extremities  of 
the  cloth  are  folded  under  the  mattress.  But  immediately  after  the 
birth  of  the  child.  I  rapidly  ascertain  the  situation  and  size  of  the 
uterus,  and  wrap  one  side  of  the  cloth  round  the  abdomen,  while  the 
nurse  draws  the  other  extremity  horizontally  towards  her,  in  order  to 
support  the  abdomen,  to  give  a  fulcrum  to  the  muscles,  and  maintain 
the  womb  in  its  position. 

"  The  nurse  then  hands  over  to  me  the  extremity  of  the  cloth  which 
she  previously  held,  and  with  this  I  again  envelop  the  abdomen.  The 
tightness  of  the  bandage  should  be  gradually  increased  in  proportion 
as  the  size  of  the  body  diminishes,  first  on  the  expulsion  of  the  after- 
birth, and  again  after  au  interval  of  half  an  hour,  when  it  should  be 
permanently  secured  with  pins.  This  dressing  prevents  all  displace- 
ment or  dilatation  of  the  uterus;  the  viscus  can  neither  rise  in  the 
abdominal  cavity,  nor  be  distended  by  coagula,  and  internal  htemor- 
rhage  becomes  impossible  on  account  of  the  permanent  pressure, 
which  forms  an  unconquerable  obstacle  to  its  occurrence. 

"  The  venous  circulation  is  also  thus  promoted  by  the  support  given 
to  the  body;  the  circulation  in  the  venous  system  is  rendered  more 
active,  and  the  chances  of  syncojie  are  thereby  greatly  diminished." 

With  regard  to  the  third  measure  recommended  by  Dr.  Senn,  viz., 
perfect  immobility  in  the  horizontal  attitude,  it  is  imperatively  re- 
quired by  the  necessity  of  avoiding  any  cause  likely  to  disturb  the 
first  fibrinous  coagula  which  fill  the  vagina  and  prevent  iinnecessary 
loss  of  blood.  The  head  of  the  patient  should  lie  as  low  as  possible, 
and  for  two  hours  after  the  conclusion  of  labor  she  should  drink  from 
the  sucking-bottle,  so  as  to  render  all  muscular  effort  unnecessary. 

If,  after  an  interval  of  eight  or  ten  minutes,  the  placenta  is  not 
found  lying  in  the  vagina,  M.  Senn  conceives  that  it  must  be  attached 
to  the  womb  by  morbid  adhesions,  and  its  removal  should  at  once 
attempted.    But  even  under  these  unfavorable  circumstances,  delivery 


388 


PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Feb., 


will  always  be  effected  in  less  than  a  quarter  of  an  hour  after  the 
expulsion  of  the  infant,  and  all  danger  of  flooding  will  have  been 
averted. — Medical  Circular. 

2.  Remarks  on  the  Diet  suitable  after  Child-birth.  By  Henet  Lowndes. 

When  I  began  i^ractice,  and  for  some  years,  I  used  to  go  by  those 
precepts  that  almost  all  agree  in,  giving  gruel  and  other  thin  .slops  for 
the  first  few  days;  and  I  can  remember  what  repugnance  many  patients 
had  to  this  substance,  which  resembles  no  ordinary  article  of  human 
food  in  this  country.  I  had  to  preach  sermons  to  them  on  the  extra- 
ordinary virtues  of  this — I  do  not  know  what  to  call  it.  We  are  told 
by  Edgar  Poe  of  beings  that  are  ' '  neither  man  nor  woman ;  they  are 
neither  brute  nor  human,  they  are  ghouls;"  and  this  material  is  neither 
food  nor  drink,  it  can  only  be  described  as  gruel.  It  can  neither 
satisfy  the  cravings  of  hunger,  nor  minister  to  the  sense  of  taste  or 
that  of  smell.  It  is  unknown  who  first  invented  such  an  unlikely  arti- 
cle of  diet.  However,  I  found,  in  many  cases,  that  patients  would  not 
be  persuaded  by  my  eulogies  of  this  preparation,  and  would  sometimes 
take  broth,  sometimes  beer,  and  sometimes  meat,  and  would  confess 
to  it,  and  certainly  used  to  look  all  the  better.  Gi'adually,  whether  it 
■was  from  this  experience,  or  from  something  I  had  read,  or  from  see- 
ing some  one  else's  practice,  I  can  not  tell,  I  began  to  try  a  good  diet, 
without  over-stimulating.  For  at  least  three  years,  I  have  acted  in 
nearly  all  cases,  except  after  first  labors  or  labors  unusually  severe, 
on  the  following  system. 

I  give  some  stimulus,  either  wine  or  ale,  directly  after  the  labor  is 
ovei".  On  the  day  of  confinement,  I  restrict  the  patient  to  tea  or  (if 
she  likes,  indeed)  gruel,  with  toast  or  bread  and  butter.*  On  the  fol- 
lowing day  the  same,  with  a  large  breakfast-cup  of  good  strong  broth 
for  dinner.  The  third  day,  a  small  lean  chop  or  a  little  chicken.  The 
next  day  the  same,  with  a  little  wine  and  water  or  ale,  if  the  patient 
be  accustomed  to  these  beverages.  Of  course,  all  cases  can  not  be 
treated  alike,  and  a  lower  diet  may  sometimes  be  necessary;  but  I  much 
more  frequently  find  it  useful  to  begin  with  stimulants  rather  sooner 
than  I  have  indicated. 

In  first  cases,  and  in  cases  of  severe  protracted  labor,  we  know  that 
the  soft  parts  must  have  undergone  great  pressure  and  bruising;  and  I 
generally  keep  these  patients  a  longer  time  without  alcoholic  stimulus. 

I  shall  not  trouble  you  with  a  series  of  cases  and  their  results;  but 
lean  say,  with  confidence,  that  I  have  met  in  no  case  with  any  incon- 
sequences following  the  mode  of  diet  I  have  mentioned.  It  is  true 
that  I  have  seen  mischief  occur  in  more  than  one  case  where  the  pa- 
tient has  thought,  because  she  might  have  a  chop  for  dinner,  she  might 
therefore  have  one  for  supper  also,  and  so  forth;  but  the  evil  results 
of  excessive  indulgence  are  not  to  put  a  stop  to  all  moderate  use  of 
good  things.  By  this  mode  of  diet,  I  believe  the  patients  escape,  in  a 
great  measure,  those  muscular  pains  that  are  so  frequent  when  a  pa- 
tient begins  to  move  about,  and  also  those  affections  of  the  breast  and 
nii:)ple,  in  which  the  pain  is  out  of  all  proportion  to  the  actual  lesion. 

As  it  is  always  agreeable  to  make  one's  theories  and  practice  agree, 
I  will  submit  a  few  considerations  in  favor  of  a  more  "feeding" 
system. 

Supposing,  for  a  moment,  that  we  even  take  labor  to  be  what  it  has 
been  called,  a  severe  traumatic  lesion,  do  we  condemn  a  patient  that 
has  sufTered  from  a  compound  fracture  to  an  immediate  course  of  gruel 


■^lu  addition  to  these  I  find  a  little  bread  and  milk  very  desirable. 


1866.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


389 


and  tea  ?  and  if  we  did  adopt  such  a  course,  should  xve  render  him 
more  likely  to  escape,  or  better  able  to  bear,  the  inflammatory  action 
that  will  sooner  or  later  occur  ?  Experience  proves  the  reverse.  I 
will  speak  again  of  a  severe  compound  fracture.  For  some  time  after 
the  accident,  no  change  of  any  consequence  takes  place  in  the  dam- 
aged parts;  they,  in  common  with  the  whole  system,  have  received  a 
shock.  In  a  varying  time,  inflammatory  action  shows  itself  in  the  part, 
and  if  the  external  wound  do  not  close  at  once,  that  action  will  be 
violent  and  the  whole  system  suffer  great  febrile  disturbance.  Now, 
a  cooling  and  restricted  diet  may  be  necessary;  but  the  patient  will  be 
much  better  able  to  bear  the  shock  of  the  inflammation,  if  that  first  in- 
terval of  repose  has  been  employed  in  overcoming,  by  suitable  diet 
and  stimulants,  the  shock  of  the  accident.  Indeed,  nothing  is  so 
certain  to  bring  on  one  evil,  traumatic  delirium,  as  too  low  a  diet  after 
a  severe  surgical  shock. 

There  are,  however,  many  points  that  sufficiently  make  a  distinction 
between  the  process  of  labor  and  a  severe  traumatic  lesion;  and  I 
need,  I  think,  only  refer  to  one,  viz.,  the  absence  after  labor,  as  a 
rule,  of  any  inflammatory  reaction. 

Then,  instead  of  considering  labor  as  a  severe  surgical  accident, 
let  us  consider  it  in  the  light  of  a  great  physiological  process;  one  of 
those  processes  in  which  the  voluntary  and  reflex  nervous  systems  are 
both  concerned.  No  one  would  think  of  calling  the  act  of  micturition 
or  of  defaecation  a  traumatic  lesion,  and  yet  these  acts  seem  hardly  to 
differ  from  the  act  of  labor,  except  in  degree  and  in  frequency  of  oc- 
currence. The  frequency  of  these  troublesome  acts  deprives  them  of 
the  terrors  that  might  perhaps  invest  them  if,  like  labor,  they  came 
at  distant  intervals.  The  act  of  sneezing  may  be  quoted  as  a  most 
alarming  convulsive  phenomena  to  which  we  have  got  quite  used. 

Labor  differs  from  these  other  actions  in  being  generally  of  a  much 
more  severe  character;  it  is  often  accompanied  with  much  severe  mus- 
cular effort,  and  it  is  necessarily  followed  by  much  fatigue.  This 
fatigue,  and  the  waste  of  tissue  that  has  taken  place,  must  be  recruited 
by  stimulants  and  nutriment;  and  these,  I  believe,  in  moderate  amount, 
may  be  given  during  labor  when  that  is  long  continued,  and  imme- 
diately after  labor,  with  the  greatest  advantage. 

Puerperal  fever  is  perhaps  the  only  complication  of  an  inflammatory 
character  that  we  need  have  much  fear  of  during  the  first  few  days; 
and  this  disease  is  of  so  low  a  type,  and  bears  so  much  resemblance  in 
its  nature  to  typhus  and  typhoid  fevers,  that  we  may  very  well  suppose 
that,  like  these,  it  will  be  more  apt  to  attack  those  who  are  in  a  low 
feeble  state  than  those  who  are  in  better  condition.  That  good  feeding 
does  not  conduce  to  this  disease,  my  own  limited  experience  would 
certainly  show. 

Beyond  the  evideuces  of  its  contagious  nature,  the  causes  of  this  in- 
sidious and  fatal  disease  seem  wrapped  in  obscurity;  but  we  suppose 
that  a  good  diet  and  a  cheerful  mind  must  be  powerful  prophylactics 
to  those  exposed  to  this  contagion. 

At  one  time,  all  the  apertures  for  the  entrance  and  exit  of  air  from 
the  lying-in  room  were  carefully  stopped  up,  on  the  idea  of  the  patient 
being  now  especially  liable  to  suffer  from  cold;  bed-clothes  were  heaped 
on,  and  at  one  time  spiced  cordials  were  diligently  given.  Now  we 
take  pains  to  ventilate  the  room  well;  but,  while  we  do  not  keep  off'  the 
access  of  cool  air,  we  are  very  apt,  if  wo  keep  to  another  part  of  the  old 
system,  to  have  our  patient  in  a  very  unfit  state  to  bear  the  air.  For 
a  constant  course  of  gruel  in  vast  quantities  and  tea  relax  all  the 
tissues,  and  the  skin  among  the  rest.    The  female  acquires,  after  a 


390  PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Feb.,  ' 

time,  a  perfectly  sodden  appearance,  ■which  is  quite  characteristic. 
The  flesh  pale  and  soft  and  moist;  the  abdomen  full  of  flatus. 

But  we  are  told  that  such  a  diet  is  good  for  the  flow  of  milk.  In 
the  early  period  of  lactation,  however,  there  is  likely  to  be  too  much  j 
rather  thau  too  little  milk;  and  with  regard  to  the  quality  of  that 
milk,  if  we  compare  it  with  other  secretions,  we  must  suppose  that 
it  will  be  most  perfect  in  its  character,  and  so  most  suitable  to 
build  up  the  child,  when  the  general  health  of  the  mother  is  in  its 
most  perfect  state.  And  here  I  would  say  a  word  of  milk-fever, 
■which  perhaps  I  ought  to  have  mentioned  before.  We  read  much 
of  it;  but  I  believe  that,  except  in  primipane,  the  secretion  of 
milk  commences  without  any  febrile  phenomena  whatever,  and  in  the 
case  of  primipara?,  I  have  already  explained  that  other  causes  lead  us 
to  adopt  a  rather  more  severe  regimen  than  in  other  cases. 

The  whole  subject  of  diet  is  so  extensive,  for  it  must  be  adapted  to 
the  season,  the  constitution,  and  the  habits  of  life,  that  I  shall  be  ex- 
cused if  I  have  only  on  this  occasion  dipped  a  little  into  the  matter;  I 
and  I  shall  be  glad  to  know  from  those  who  have  a  more  extended  ex- 
perience in  midwifery  what  line  of  practice  they  adopt;  and  whether 
there  are  any  who  still  adhere  to  the  rigid  rules  that  we  seem  to  have 
learnt  rather  from  Celsus,  or  some  of  his  predecessors,  than  from  j 
Nature. — British  Medical  Journal. 

I 

3.  On  the  Causes  Endangering  the  Life  of  the  Foetus  During  Labor.  By 

C.  K.  H.  Patekson.  j 

In  general  domiciliary  midwifery,  it  will  not,  I  trust,  be  disputed  for  ' 
a  moment  that  occasionally  is  witnessed  the  occurrence  of,  or  if  not,  j 
the  tendency  to  "hazardous  states,"  in  certain  kinds  of  labor,  calcu- 
lated to  endanger  fcetal  life.    Doubtless  not  a  few  labor  cases  during  , 
a  year,  when  seen  at  the  first  visit  by  the  obstetric  practitioner,  are,  | 
to  the  best  of  his  judgment,  in  their  early  stage  favorable;  while 
frequently,  when  an  examination  has  been  made  later,  they  have 
become  either  diflicult  or  complicated  labors.    Accordingly,  it  will  be 
allowed,  from  the  occasional  uncertainty  of  the  result  in  the  latter, 
that  it  is  an  important  and  valuable  attainment  in  midwifery  practice 
to  be  able  to  make  a  right  discrimination  between  the  nature  of  the  \ 
presentation,  in  each  individual  case,  from  that  of  others  known  to  ' 
happen,  as  well  as  to  determine  in  time  when  to  proceed  in  aiding  the  I 
parturient  woman.    Whether  it  be  in  administering  needful  nourish- 
ment or  other  means  internally,  or  by  the  mouth,  or  by  having 
recourse  to  artificial  interference  with  the  same  end  in  view,  namely, 
to  procure  her  delivery  safely  for  herself  and  child.    Having  thus 
premised,  I  shall  now  proceed  to  state  my  views  in  detail,  though 
briefly,  as  follows: 

How  far  the  tendency,  oftentimes  in  difficult  and  complicated  labors, 
to  endanger  ftctal  life  may  be  obviated,  must  undoubtedly  depend 
much  on  the  kind  of  presentation,  and  how  such  may  be  managed.  i 
The  putting  off  too  long,  or  not  sending  for  proper  medical  assistance 
in  time,  often  endangers  fcetal  life. 

The  management  of  cases  of  lingering  or  difficult  labor,  although  | 
there  is  no  occasion  for  over-anxiety,  provided  they  are  seen  in  time,  j 
and  when  properly  attended  to,  often  ends  well  to  the  foetus.    Cases  | 
of  difficult  labor  have  hithei-to  often  come  under  my  notice,  with 
cephalic  presentation  chiefly,  not  a  few  of  which,  as  might  be  expected, 
were  accompanied  in  priniipani;  with  rigidity  of  parts,  and  as  the 
labor  difficulty  gradually  went  on,  owiug  to  the  os  uteri  and  other 
parts  taking  in  some  of  these  a  much  longer  time  than  ordinary  to 


1866.]  PROGRESS  OP  THE  MEDICAL  SCIENCES. 


391 


dilate  and  relax  before  the  foetal  head  was  sufficiently  advanced  for 
delivery,  notwithstanding  previous  means  were  used  internally. 

Where,  on  the  other  hand,  there  were  present  (rendering  the  labor 
for  the  time  they  lasted  more  than  usually  difficult)  signs  in  maternal 
passages  of  coiling  of  the  foetal  cord  round  the  neck,  and  when  ergot 
of  rye  was  early  made  use  of,  and  before  the  head  was  pretty  well 
advanced,  I  have  seldom  seen  the  expected  results  accruing  from  the 
latter  favorable  to  the  foetus.  In  my  own  practice,  coiling  of  the  cord 
round  the  neck  or  body  of  foetus  has  been  found  only  in  the  child- 
births  of  multiparous  woman,  and  I  have  observed  such  an  occurrence 
frequently  to  endanger  foetal  life  in  no  small  number  of  cases. 

Misplacement  or  unnatural  shortness  above  of  the  cord,  when  the 
foetal  head  is  in  the  pelvis,  and  there  is  found  plenty  of  room  for  the 
latter  to  pass  through,  may  be  suspected  to  exist,  if,  during  the  con- 
tinuance of  pretty  strong  and  regular  pains  for  some  time,  the  head 
slowly  advances  in  a  given  time,  and  it  is  ascertained  that  it  retreats 
after  each  pain,  while  the  os  uteri  has  become  well  dilated.  Never- 
theless, and  although  relying  a  good  deal  on  the  above  sign  of  the 
existence  of  twisting  of  the  cord,  I  have  used  ergot  less  than  formerly, 
preferring  non-interference  instead  of  pushing  cases  of  this  kind  when 
there  was  no  urgent  symptom  calling  for  active  and  immediate  aid, 
and  I  have  never  had  to  regret  doing  so.  But  should  the  cord  be 
supposed  to  be  round  the  neck  of  the  foetus,  and  notwithstanding  it 
may  be  the  chief  cause  of  retarding  the  progress  of  the  labor,  when 
not  continuing  beyond  a  reasonable  time,  it  is  even  safer  to  omit  than 
to  have  recourse  to  ergot,  and  there  is  less  danger  to  foetal  life,  except 
the  labor  is  near  its  termination,  and  then  it  may  be  found  very  ser- 
viceable at  times.  Still  there  are  cases,  doubtless,  in  which  it  is  often 
necessary  to  give  ergot,  and  with  excellent  results,  as  when  the  labor 
is  hindered  by  insufficient  uterine  action — membranes  previously 
broken — the  os  uteri  being  well  dilated  at  the  same  time,  and  also 
ample  pelvic  room,  no  discordance  between  the  bony  parts  and  foetal 
head,  the  latter  having  descended  to  the  lower  pelvic  outlet  or  hollow 
of  the  sacrum.  While,  on  the  contrary,  when  ergot  is  given  too  early, 
or  sometime  before  delivery  can  be  safely  effected,  or  after  the  liquor 
amnii  has  flowed  away  spontaneously  and  prematurely,  or  has  been 
too  soon  let  off  artificially,  and  the  os  uteri  not  much  dilated,  nor  soon 
dilatable,  the  head  not  advancing  in  proportion  to  the  length  of  time 
the  parturient  woman  has  been  in  labor,  and  more  especially  if,  after 
administering  ergot,  the  labor  is  not  within  a  reasonable  time  after- 
wards terminated,  or  should  it  be  allowed  to  linger  on  instead  of 
adopting  artificial  interference  as  soon  as  the  case  is  favorable  for  or 
demands  it,  and  the  measure  is  not  had  recourse  to,  at  a  period  of 
delay  of  this  kind,  it  is  rare,  in  my  humble  experience,  to  have  a  live 
child  born  in  a  labor  managed  as  just  described.  Hence,  when  the 
aforementioned  signs  are  found  in  the  maternal  passages  of  the  hind- 
ranee  of  the  f(Etal  head,  during  labor,  from  coiling  or  twisting  of  the 
umbilical  cord  round  the  neck  or  other  parts  of  the  body  of  foetus,  as 
the  cord  must  consequently  be  much  shorter  from  this  circumstance, 
but  if  not  so,  at  any  rate  it  is  generally  longer  in  its  duration  and 
more  difficult;  and,  to  my  mind,  it  has  seemed  to  be  both  safer  and 
better  jjractice  to  omit  ergot,  in  such  kind  of  eases,  until  towards  the 
close  of  the  labor,  on  account  of  the  occasional  subsiding  of  the 
maternal  pains,  when,  at  this  stage,  its  administration  in  the  usual 
form  and  doses  will  tend  less  to  endanger  twtal  life,  and  it  will  also 
shorten  the  labor. 


392  PROGRESS  OF  THE  MEDICAL  SCIENCES.  [Feb., 


In  reference  to  the  above  remarks,  my  usual  practice  for  years  past 
has  been,  and  is  still,  to  let  Nature,  for  a  reasonable  time,  do  her  own 
work,  and  to  render  extra  aid  only  if  requisite  for  the  safety  of  both 
mother  and  child. 

I  shall  merely,  at  present,  add  a  few  of  the  causes  in  the  maternal 
passages  that  have  conduced  more  or  less  to  endanger  fcctal  life  in 
cases  attended  by  me,  viz. : 

The  fcetal  head,  when  it  had  rested  too  long  on  an  unyielding  peri- 
neum, or  when  there  is  rigidity  of  parts,  especially  early  and  late  in 
life,  (fir.st  pregnancies  at  full  time.) 

In  presentation  of  the  head,  it  being  only  expelled,  and  while  imme- 
diately after  its  expulsion  is  attended  with  too  much  delay  in  delivery, 
on  account  of  want  of  sufficient  pains  to  expel  the  shoulders  when 
large. 

In  flooding  and  breech  cases  from  not  getting  the  head,  when  large, 
speedily  delivered.  In  unusual  projection  of  the  promontory  of  the 
sacrum,  in  preventing  the  head  from  descending  in  consequence  of  too 
little  space. 

Foetal  head  too  long  delayed  in  pelvis  during  labor,  from  inefficient 
uterine  action,  or  unusual  rigidity  of  one  or  more  parts. 

Prolapse  of  cord  by  side  of  head,  or  coiled  round  the  neck  or  other 
parts  of  the  body  of  foetus. 

Fcetal  umbilical  hernia  when  large. 

Fcetal  head  (male)  firmly  ossified,  and  also  rather  larger  than 
ordinary,  and  I  may  mention,  in  addition,  maternal  mental  impres- 
sions. 

With  all  these  complications,  we  have  certainly  a  wide  field  for 
highly  important  and  valuable  investigation,  as  well  as  interesting 
questions,  obstetrical  and  physiological,  and  especially  in  a  medico- 
legal point  of  view. — Medical  Circular. 


4.  Mortality  of  Childbed  as  Affected  by  the  Number  of  Labors. 

Dr.  Matthews  Duncan,  in  a  carefully  prepared  statistical  paper, 
gives  the  following  as  the  result  of  his  investigations.  1.  The  mor- 
tality of  first  labors  is  about  twice  the  mortality  of  all  subsequent 
labors  taken  together.  2.  The  mortality  from  puerj^eral  fever  following 
first  labors  is  about  twice  the  mortality  from  puerperal  fever  following 
all  subsequent  labors  taken  together.  3.  As  the  number  of  a  woman's 
labor  increases  above  nine,  the  risk  of  death  following  labor  increases 
with  the  number.  4.  As  the  number  of  a  woman's  labor  increases 
above  nine,  the  risk  of  death  from  piierperal  fever  following  labor 
increases  with  the  number.  5.  If  a  woman  have  a  large  family  she 
escapes  extraordinary  risk  in  surviving  her  first  labor,  to  come  again 
into  extraordinary  and  increasing  risk  as  she  bears  her  ninth  and  sub- 
sequent children. — Edinburgh  Medical  Journal. 

5.  Precocious  Pziberty, 

M.  Ramon  de  la  Sagra  related,  at  a  meeting  of  the  Academy  of 
Sciences,  the  case  of  a  negro  child  who,  at  birth,  was  observed  to  have 
the  breasts  much  developed,  and  in  whom,  a  few  mouths  later,  a  san- 
guineous discharge  from  the  genital  organs  took  place,  and,  in  the 
second  year,  recurred  at  regular  monthly  intervals.  When  M.  Ramon 
de  la  Sagra  saw  her,  at  the  age  of  thirty-two  months,  she  had  passed 
through  dentition  favorably;  and  the  throat,  and  the  genital  organs. 


1866.] 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


393 


"which,  as  well  as  the  axillic,  were  covered  with  a  fine  down,  gave  her 
the  ai^pearance  of  a  girl  of  thirteen  of  the  negro  race.  M.  Ramon  de 
la  Sjgra  continued  to  s^e  the  child  up  to  the  age  of  seven,  at  which 
time  she  was  in  good  health,  the  development  having  steadily  con- 
tinued.—  Gaz.  Med.  de  Paris. 


II.— MATERIA  MEDICA  AND  THERAPEUTICS. 

1.  Notes  on  the  Use  of  Astringents,  Stimulant-Astringents,  and  Caustics, 
in  Affections  of  the  Eye.    By  D.  AEGTLii  Robertson. 

There  are  no  remedies  which  are  so  much,  and  but  few  too  often 
indiscriminately,  employed  in  diseases  of  the  eye,  as  astringents, 
stimulant-astringents,  ofidi  caustics.  Under  these  heads  are  included 
sulphate  of  copper,  nitrate  of  silver,  alum,  corrosive  sublimate,  and 
the  active  ingredients  of  almost  all  the  ordinary  collyria.  They  may 
conveniently  be  divided  into  the  three  classes  I  have  already  specified, 
for  although  many  of  them  possess  properties  enabling  them  to  be 
ranked  under  all  the  three  heads  according  to  the  strength  of  the  prep- 
aration employed,  yet  some  possess,  in  a  higher  degree,  the  one, 
some  the  other  action.  This  division  is  of  essential  practical  import- 
ance, for  cases  constantly  occur  in  which  the  use  of  a  stimulant- 
astringent  application  aggravates  the  disease,  while  the  employment 
of  an  astringent  preparation  rapidly  effects  a  cure.  On  the  other 
Land,  many  chronic  inflammatory  affections  yield  much  more  rapidly 
to  a  stimulant-astringent  than  to  a  purely  astringent  lotion.  It  is 
almost  needless  to  observe  that  the  use  of  a  caustic  solution  to  such  a 
tender  organ  as  the  eye  is  applicable  only  in  a  few  special  cases. 

Under  the  term  Astringents,  I  would  reckon  solutions  of  tannin  (gr. 
V.  ad.  or  acetate  of  lead  (gr.  i — ij.  ad.  drops  of  nitrate  of  silver 
(gr.  ii.  ad.  §i,)  and  infusion  of  tea  (jg.  ad.  Oi.)  A  remedy  I  have 
found  an  excellent  astringent,  and  for  which  I  am  indebted  to  my 
friend  Dr.  Andrew  Inglis,  is  the  resin  of  the  Argemone  Mexicana 
(yellow  thistle)  dissolved  in  glycerine.  It  is,  I  believe,  much  employed 
by  the  native  oculists  of  India.  A  weak  ointment  of  the  red  oxide  of 
mercury,  consisting  of  one  part  of  the  Pharmacopoeial  ointment  and 
seven  of  lard,  well  mixed,  also  forms  a  useful  astringent.  The  class  of 
stimulant-astringents  includes  solutions  of  sulphate  of  zinc  (gr.  i — iii. 
ad.  alum  (g.  iv.  ad.  §i,)  sulphate  of  copper  (gr.  i.  ad.  §i,)  corrosive 
sublimate  (gr.  i.  ad.  §vi,)  nitrate  of  silver  drops  (gr.  x — xx.  ad.  §i,)  and 
vinum  opii,  either  pure  or  diluted,  with  equal  parts  of  water. 

As  caustics,  the  solid  nitrate  of  silver,  either  pure  or  fused,  along 
with  nitrate  of  i^otass,  (either  equal  parts  or  two  parts  of  the  latter  to 
one  of  the  former,)  as  recommended  by  Professor  Von  Graefe,  and  a 
crystal  of  sulphate  of  copper,  are  those  most  usually  employed. 

I  hav(i  now  only  a  few  suggestions  to  make  regarding  their  use.  I 
would  first  remark  that  the  employment  of  all  the  three  classes  of 
remedies  should  be  limited  almost  exclusively  to  the  most  superficial 
affections  of  the  eye.  Thus  we  find  them  of  most  service  in  inflamma- 
tory affections  of  the  conjunctiva.  In  the  earlier  stages  of  acute 
inflammation  of  that  membrane,  great  benefit  will  be  derived  from  the 
use  of  purely  astringent  washes,  while  in  the  chronic  stages,  and  in 
its  chronic  inflammatory  affections,  the  stimulant-astringents  are  more 
particularly  indicated.  In  the  common  aff'ection,  granular  lids,  it  is 
advisable  to  vary  the  application  according  to  the  nature  of  the  granu- 


394 


PROGRESS  OP  THE  MEDICAL  SCIENCES. 


[Feb., 


lations;  in  those  cases  in  which  the  granulations  are  large,  soft,  and 
flabby,  consisting  of  the  papilla;  of  the  conjunctiva  much  distended 
and  highly  vascular,  and  in  which  the  whole  of  the  conjunctiva  is 
congested  and  thickened,  the  use  of  strong  astringent  washes,  such  as 
those  of  tannin  or  nitrate  of  silvei%  are  of  most  use;  whereas,  in  other 
cases  in  which  the  granulations  are  small,  hard,  and  light  colored, 
more  stimulant  applications,  such  as  a  crystal  of  sulphate  of  copper, 
rubbed  gently  over  the  granular  surface,  answers  best. 

In  affections  of  the  cornea,  astringents  and  stimulant-astringents 
must  alike  be  used  with  great  caution.  They  should  never  be  used  in 
acute  inflammatory  afifections  of  that  structure,  and  they  must  be  used 
very  cautiously,  even  where  the  inflammation  is  chronic  and  super- 
ficial, where  their  application  is  frequently  of  great  service.  If  used 
too  early  or  too  freely,  inflammatory  reaction  is  certain  to  occur,  and 
the  afi'ection  aggi'avated.  The  same  rule  applies  to  ulcers  of  the 
cornea.  The  application  of  cold  water  is  a  good  method  of  testing 
whether  the  eye  is  in  a  condition  to  bear  the  use  of  these  remedies  or 
not.  Where  its  application  is  grateful  to  the  patient,  the  use  of  mild 
astringent  washes  will  generally  be  found  to  answer  well.  I  may  here 
repeat  a  caution  which  is  to  be  found  in  all  ophthalmic  works,  to  avoid 
the  use  of  lead  washes  in  ulcers  of  the  cornea,  as  the  chloride  of  lead, 
which  is  formed  by  the  union  of  the  wash  with  the  lachrymal  secre- 
tion becoming  deposited  at  the  foot  of  the  ulcers,  forms  a  permanent 
opacity.  To  hasten  the  absorption  of  corneal  opacities,  a  weak  stimulant- 
astringent  wash  may  be  freely  used. 

Stimulant-astringents  and  astringents  should  never  be  employed  in 
iritis,  or  any  of  the  deeper- seated  inflammations  of  the  eye;  as,  so  far 
from  doing  any  good,  they  invariably  aggravate  the  disease.  In  fact, 
the  worst  cases  of  iritis  a  surgeon  can  be  called  upon  to  treat,  are  those 
in  which  such  lotions  have  been  employed  in  the  earlier  stages. 

Caustic  applications  are  not  required  in  many  affections  of  the  eye. 
I  have  already  referred  to  the  use  of  sulphate  of  copper  in  one  variety 
of  granular  lids.  They  may  also  be  employed  in  chronic  enlargement 
of  the  caruncle — in  eversion  of  the  lids  from  inflammatory  thickening 
of  the  conjunctiva,  and  to  remove  the  fungoid  growth  which  often 
forms  at  the  conjunctival  wound  after  the  operation  for  strabismus; 
but  in  most  of  these  cases  the  knife  or  scissors  are  to  be  preferred. 
In  a  case  of  chronic  fistula  of  the  cornea,  I  found  the  application  of  a 
fine  point  of  the  solid  nitrate  of  silver  induce  closure  of  the  aperture. 
Caustics  are  occasionally  employed  in  prolapsus  iridis  to  remove  the 
prolapsed  portion  of  the  iris.  It  is  a  highly  dangerous  practice,  as 
the  amount  of  irritation  thus  set  up  is  very  apt  to  give  rise  to  suppu- 
rative inflammation  of  the  iris  and  its  consequences.  The  use  of  the 
scissors  is  attended  with  far  less  risk,  and  better  results. 

These  jottings  are  the  results  of  experience  and  observation,  and,  I 
trust,  may  prove  serviceable  in  leading  to  a  correct  use  of  these  valu- 
able but  often  misapplied  remedies. — London  Medical  Press  and 
Circular. 


2.  On  the  Ancesthetic  and  Sedative  Properties  of  Bichloride  of  Carbon,  or 
Cliloro- Carbon.    By  J.  Y.  Simpson,  M.D. 

The  bichloride  of  carbon,  or  chloro -carbon,  is  a  transparent,  color- 
less fluid,  having  an  ethereal  and  sweetish  odor,  not  unlike  chloroform. 
Its  specific  gravity  is  great,  being  as  high  as  1-56,  whilst  chloroform  is 
1-49.    It  boils  at  170^  Fahrenheit,  the  boiling  point  of  chloroform 


1866.]  PROGRESS  OF  THE  MEDICAL  SCIENCES. 


395 


being  141°.  The  density  of  its  vapor  is  5-33,  that  of  chloroform 
being  4''2.  Besides  trying  the  anaesthetic  effects  of  bichloi-ide  of 
carbon  upon  myself  and  others,  I  have  used  it  in  one  or  two  cases  of 
midwifery  and  surgery.  Its  primary  effects  are  very  analgous  to  those 
of  chloroform,  but  it  takes  a  longer  time  to  produce  the  same  degree 
of  anaesthesia,  and  generally  a  longer  time  to  recover  from  it.  Some 
experiments  with  it  upon  mice  and  rabbits  have  shown  this — two  cor- 
responding animals  in  these  experiments  being  simultaneously  ex- 
posed, under  exactly  similar  circumstances,  to  the  same  doses  of  chloro- 
form and  chloro-carbon.  But  the  depressing  influence  of  chloro- 
carbon  upon  the  heart  is  greater  than  that  of  chloroform;  and  conse- 
quently, I  believe  it  to  be  far  more  dangerous  to  employ  as  a  general 
aniBsthetic  agent.  In  a  case  of  midwifery  in  which  it  was  exhibited  by 
my  friend  and  assistant,  Dr.  Black,  and  myself,  for  above  an  hour  with 
the  usual  anaesthetic  effects,  the  pulse  latterly  became  extremely  feeble 
and  weak.  In  another  case  in  which  it  was  exhibited  by  Dr.  Black, 
the  patient,  who  had  taken  chloroform  several  times  before,  was  unaware 
that  the  new  anaesthetic  was  different  from  the  old;  the  pulse  con- 
tinued steady  and  firm,  although  she  is  the  subject  of  valvular  disease 
of  the  heart.  The  surgical  ojierations  in  w  hich  I  have  used  chloro- 
carbon  have  been,  the  closure  of  a  vesico-vaginal  fistula,  the  division 
of  the  cervix  uteri,  the  enlargement  of  the  orifice  of  the  vagina,  and 
the  application  of  potassa  fusa  to  a  large  flat  ntovus  upon  the  chest  of 
a  young  infant.  In  all  of  these  cases  it  answered  quite  well  as  an 
anaesthetic.  The  child  did  not  waken  u^j  for  more  than  an  hour  and  a 
half  after  the  employment  of  the  caustic,  which  was  used  so  as  to  pro- 
duce a  large  slough.  Its  pulse  was  rapid  and  weak  during  the  greatest 
degree  of  anaesthetic  sleep.  One  of  the  mice  exposed  to  its  influence, 
and  which  was  removed  from  the  tumbler  where  the  experiment  upon 
it  was  made  as  soon  as  the  animal  fell  over,  breathed  imperfectly  for 
some  time  after  being  laid  on  the  table,  and  then  died. 

Chloro-carbon,  when  applied  externally  to  the  skin,  acts  much  less 
as  a  stimulant  and  irritant  than  chloroform,  and  will  hence,  I  believe, 
in  all  likelihood,  be  found  of  use  as  a  local  anaesthetic  in  the  composi- 
tion of  sedative  liniments. 

In  two  cases  of  severe  hysteralgia  I  have  injected  air  loaded  with 
the  vapors  of  chloro-carbon  in  the  vagina.  The  simplest  ai^jiaratus 
for  this  purpose  consists  of  a  common  enema  syringe,  with  the  nozzle 
introduced  into  the  vagina,  and  the  other  extremity  of  the  apparatus 
laced  an  inch  or  more  down  into  the  interior  of  a  four-ounce  jihial, 
containing  a  small  quantity — as  an  ounce  or  so — of  the  fluid  whose 
vajjor  it  is  wished  to  inject  thi'ough  the  syringe.  Both  patients  were 
at  once  temporarily  relieved  from  the  pain.  The  first  patient  told  me 
her  relief  at  the  first  application  of  the  anaesthetic  vapor  was  so  long 
that  .she  slejit  during  the  following  night  far  more  soundly  than  she 
had  dene  for  weeks  previously. 

The  injection  of  the  vapor  of  chloro-carbon  into  the  rectum  does  not 
prove  so  irritating  as  the  vapor  of  chloroform.  In  one  case  it  removed 
speedily  pains  in  the  abdomen  and  back. 

Chloroform  vapor  applied  by  sprinkling  a  few  drops  on  the  hand, 
and  held  near  the  eye,  is  one  of  the  very  best  and  most  sedative  col- 
lyria  in  some  forms  of  conjunctivitis,  ulceration  of  the  cornea,  with 
photophobia,  &c.  I  have  not  yet  tried  the  vapor  of  chloro-carbon,  but 
perhaps  it  may  answer  still  better,  as  less  irritant,  and  almost  as 
strongly  sedative. 

I  have  found  ten  or  twenty  drops  injected  subcutaneously  by  Dr. 


396 


EDITORIAL. 


[Feb, 


Wood's  syringe  repeatedly  relieve  local  pains  of  the  walls  of  the  chest, 
abdomen,  &c.,  without  being  followed  by  the  distressing  nausea  so 
frequently  the  result  of  the  hypodermic  injection  of  preparations  of 
opium  and  morphia. 

Internally  I  have  only  hitherto  tried  it  in  small  doses  in  gastrodynia, 
where  it  has  the  same  efifect  as  swallowing  a  capsule  of  chloroform. 

The  specimen  of  chloro-carbon  which  I  have  used  was  made  by  Mr. 
Hansford,  who  sent  it  down  to  Messrs.  Duncan,  Flockhart,  &  Co.,  of 
Edinburgh,  under  the  idea  that,  by  a  chemical  substitution,  it  might 
be  converted  into  chloroform,  and  make  a  cheap  medium  for  the 
manufacture  of  the  latter  drug.  And  perhaps  I  may  be  permitted  here 
to  remark  that  the  quantity  of  chloroform  used  is  now  becoming  very 
great,  and  might  possibly  he  rendered  greater  if  it  could  be  produced 
at  a  still  cheaper  rate.  We  have  two  or  three  manufactories  for 
chloroform  in  this  city.  The  chief  of  these  manufactories  for  it — that 
of  Messrs.  Duncan,  Flockhart,  k  Company — now  make  upwards  of 
7,000  doses  of  chloroform  every  day,  counting  two  drachms  as  a  full 
dose;  they  thus  send  out  nearly  2,500,000  doses  a  year.  Are  every  two 
million  and  a  half  full  doses  which  are  used  of  opium,  antimony,  aloes, 
epsom  salts,  &c.,  attended  with  as  little  danger  and  as  few  ultimate 
deaths  as  these  annual  2,500,000  doses  of  chloroform? — Medical  Times 
and  Gazette. 


EDITORIAL. 

Medical  Department  of  the  Army. — We  have  neither  the  space  nor 
the  de.sire  to  enter  into  any  extended  examination  of  that  portion  of 
Senator  Wilson's  bill  for  the  reorganization  of  the  army  which  con- 
cerns the  Medical  Department ;  but  there  are  two  points  that  we  feel 
it  our  duty  to  notice,  as  well  as  to  enter,  as  we  believe,  an  unavailing 
protest — for  it  is  understood  this  section  of  the  bill  will  pass  as  re- 
ported, it  having  undergone,  iu  the  Military  Committee,  the  proper 
amount  of  manipulation  by  the  Surgeon-General's  office,  where  the 
good  old  rule  sufficeth, 

•'  That  they  should  take  who  have  the  power, 
And  they  should  keep  who  can." 

We  have  no  hope  that  the  public  will  ever  adequately  recognize  the 
value  of  the  services  of  the  medical  staff  of  the  army,  or  that  Congress 
will  cease  to  manifest  indifference,  and  even  impatience,  when  called 
on  to  legislate  in  its  behalf.  The  medical  officers  of  our  army  have 
always  had  to  contend  against  the  prejudices  and  intolerance  of  the 
officers  of  the  line,  and  other  staff  departments.  They  were  "  doctors," 
and  nothing  more;  any  pretension  to  be  military  officers  was  to  be  re- 
buked and  checked.  Whilst  they  might  command  enlisted  men  by 
virtue  of  their  commission,  they  in  their  turn  could  be  commanded  by  a 
brevet  second  lieutenant.  We  have  heard  an  officer  of  the  old  army,  who 


1866.] 


EDITORIAL. 


397 


during  the  rebellion  was  on  "bomb  proof  duty,"  and  never  heard  the 
whistle  of  a  hostile  bullet,  boast,  that  when  a  fledgeling  from  the  Mili- 
tary Academy,  with  the  rank  of  second  lieutenant,  and  temporarily  in 
command  of  a  post  on  the  frontier,  he  had  threatened  to  put  one  of 
the  senior  surgeons  of  the  army,  with  the  rank  of  major,  in  irons,  if  he 
left  the  post  without  his  permission.  This  injustice  and  narrow-mind- 
edness are  born  of  the  notion  that  the  "doctor"  is  a  non-combatant* 
— a  tolerated  civilian  in  the  army  organization,  with  only  nominal  rank. 
This  prejudice  against  the  medical  officer  is  not  peculiar  to  our  service 
— it  flourishes  to  the  same  degree  in  the  British,  French,  Russian,  and 
German.  It  prevails  with  greater  intensity  in  the  navy,  and  the  naval 
medical  officer  often  suffers  gross  insults  from  the  quarter-deck  autocrat. 
This  anomalous  and  unfortunate  position  of  the  army  surgeon,  and 
which  exposes  him  to  frequent  indignities,  is  due  simply  to  the  absence 
of  substantive  rank,  which  it  is  not  desired  should  confer  any  military 
command  outside  the  hospital  or  beyond  the  specific  sphere  of  duty 
— for  no  medical  officer  would  contend  for  an  authority  he  is  not 
qualfied  for.  A  step  was  taken,  about  a  year  ago,  by  the  War  De- 
partment in  the  right  direction,  by  which  the  status  of  the  medical 
army  officer  was  materially  improved,  and  the  conferring  of  brevet 
rank  was  another  mark  of  actual  progress,  and  went  far  towards  assur- 
ing to  him  a  respectful  recognition  of  rightful  position.  We  had 
hoped  to  see  this  action  of  the  Department  sustained  by  legislative 
enactment;  but  we  have  looked  in  vain  for  any  such  provision  in  the 
present  bill.  Even  the  old  grades  remain  the  same.  Tradition  and 
fossilism  have  triumphed,  and  the  medical  officer,  after  serving  forty 
years,  finds  himself  no  further  advanced  in  rank  than  he  might  have 
been  thirty  years  before.  A  majority,  to  which  he  is  entitled  after 
five  years  of  service,  is  the  limit  he  may  reach.  He  sees  all  his  brother 
officers,  who  entered  the  service  with  him,  promoted,  as  they  advance 
in  years.  But  he  is  met  with  the  inexorable  stay-law  of  "  thus  far 
shall  thou  go,  and  no  farther."  For  him  to  mount  upwards  becomes 
as  impossible  as  for  a  frog  to  bound  through  a  flag-stone.  The  evils 
of  such  a  system  are  too  palpable  to  need  remark,  and  yet  there  is 
every  reason  to  believe  that  this  injustice,  and,  as  we  know,  great  in- 
jury to  the  service,  are  to  be  perpetuated  in  the  new  army.  The  argu- 
ment "it  has  been,"  therefore  "it  ought  to  be,"  has  won  the  day. 
Deprived  of  substantive  rank,  debarred  from  promotion,  after  arduous 


*  During  the  late  rebellion,  tiiirty-six  medical  officers  were  either  killed  or  died 
from  wounds  received  in  action. 


398 


EDITORIAL. 


[Feb, 


and  dangerous  service,  and  its  welcome  and  needed  attendant,  increase 
of  pay — au  ever-present  sense  of  imposed  inferiority,  keenly  felt,  with 

"no  spur 

"To  prick  the  sides  of  their  intent " — 

is  it  to  be  wondered  at  that  medical  youth  of  conscious  ability  hesitate 
before  entering  the  army,  or,  at  the  period  when  matured  experience 
makes  them  useful  to  the  country,  have  to  resign,  and  seek  in  civil  life 
more  solid  rewards  ?  A  surgeon,  after  ten  years  of  active  service  in 
that  grade,  should  have  the  rank  of  Lieutenant-Colonel,  and  after  fif- 
teen years,  the  rank  of  Colonel. 

A  general  order  was  issued  by  the  War  Department,  dated  October 
31st,  1865,  by  which  all  the  officers  created  by  the  Act  approved 
April  18th,  1862,  for  the  reorganization  of  the  Medical  Department  of 
the  Army,  with  the  exception  of  the  Surgeon-General,  were  dis- 
banded— the  appointments  from  civil  life  were  mustered  out  of  service, 
and  the  surgeons  of  the  old  army  returned  to  their  former  position  in 
the  medical  staff.  This  was  done,  as  expressly  stated  in  the  order,  on 
the  recommendation  of  the  Surgeon -General;  the  alleged  plea  was, 
their  services  being  no  longer  needed.  Had  the  Assistant  Surgeon- 
General,  the  Medical  Inspector-General,  and  the  sixteen  Medical  In- 
spectors become  offensive  to  certain  "  startled  hopes,"  and  was  it  neces- 
sary to  call  in  the  willing  and  friendly  hand  of  power  to  brush  them 
away  and  "  tread  upon  'era  ?  " 

"  He  that  stands  upon  a  slippery  place, 
"Makes  nice  of  no  hold  to  stay  him  up." 

The  section  of  the  new  bill,  as  introduced  by  Mr.  Wilson,  provided 
for  five  Inspectors  in  the  new  organization  of  the  Medical  Depart- 
ment, to  be  appointed  in  the  usual  way;  but  the  bill,  as  reported 
by  the  Military  Committee,  makes  these  Inspectors,  as  well  as  one 
Medical  Purveyor  with  the  rank  of  Colonel,  and  four  Assistant  Medi- 
cal Purveyors  with  the  rank  of  Lieutenant-Colonel — in  all,  ten  officers 
of  rank — details  to  be  made  by  the  Surgeon-General,  and  during  his 
pleasure:  thus  giving  to  the  chief  of  the  Medical  Bureau  a  degree  of 
patronage  exercised  by  no  other  head  of  a  staff  department  in  the 
army,  and  which,  no  matter  how  wisely  used,  must  give  rise  to  more  or 
less  ill  feeling,  and  tend  to  cause  heart-burnings,  and  discontents,  and 
jealousies.  It  puts  an  amount  of  power  in  the  hands  of  the  Surgeon- 
General  which,  used  to  reward  docility  or  punish  independence,  is  in 
direct  variance  of  all  precedent,  and  full  of  danger  to  the  service.  We 
do  not  understand  the  need  for  an  Assistant  Surgeon-General.  A 
chief  of  the  Purveying  Department  is  necessary,  and  he  should  have 


1866.] 


EDITORIAL. 


399 


rank  commensurate  with  his  responsibility.   Why  increased  rank  should 
be  given  to  Assistant  Medical  Purveyors  we  are  at  a  loss  to  guess. 
This  duty  should  not  be  imposed  on  medical  officers  at  all.  Trained 
business  men  should  be  appointed  as  medical  storekeepers,  to  take 
charge  of  and  distribute  the  supplies.    We  would  have  three  subdi- 
visions— Medical  and  Surgical,  Sanitary,  and  Statistical— in  the  Sur- 
geon-General's office,  with  a  competent  chief  in  charge  of  each  division, 
who  should  work  the  routine  details  of  his  division,  and  they  together 
should  form  a  consultative  council  to  assist  the  Surgeon-General  on  the 
subjects  coming  within  their  respective  branches,  the  Surgeon-General 
being  the  sole  responsible  and  administrative  head.    There  should  be 
an  adequate  number  of  Medical  Inspectors,  attached  to  the  Medical 
Bureau,  and  detailed  for  special  service  from  thence  to  make  frequent 
visits  of  inspection  throughout  the  different  Military  Divisions,  consult- 
ing with  the  chief  medical  officers  on  all  measures  for  the  prevention 
and  mitigation  of  disease,  and  making  reports  direct  to  the  Surgeon- 
General  on  the  sanitary  condition  of  troops  in  garrison,  stations, 
camps,  barracks,  hospitals,  and  attaelied  to  armies  in  the  field  in  time 
of  war,  to  assist  and  advise  with  the  chief  medical  officer.    For  obvi- 
ous reasons  Medical  Directors  of  Departments,  Army  Corps,  and 
Armies,  should  have  temporary  or  local  rank,  as  provided  in  the  Act 
approved  February  23,  1865. 

The  late  Bvt.  Liedt.-Col.  Richard  11.  Coolidge,  Surgeon  TJ.  S. 
Army.* — As  we  are  going  to  press  the  sad  intelligence  comes  to  us 
that  Bvt.  Lieut.-Colonel  Richard  H.  Coolidge,  Surgeon  U.  S.  Army, 
died  at  Raleigh,  North  Carolina,  on  the  22d  of  January.  We  have 
learned  no  particulars  in  connection  with  the  melancholy  event. 

In  the  death  of  Dr.  Coolidge  the  Medical  Department  of  the  Army 
has  lost  a  shining  ornament.  As  an  officer  he  was  surpassed  by  none 
in  his  corps  for  culture,  intelligence,  industry,  conscience,  and  the  best 
moral  attributes.  He  had  a  clear  head,  excellent  judgment,  quick  per- 
ception, and  though  his  mental  character  was  essentially  reflective,  it 
was  also  fairly  receptive,  liberal,  and  progressive.  He  was  a  discreet 
and  sagacious  reformer,  and  an  honest,  steady,  but  not  boisterous 
champion  of  the  rights  of  the  army  medical  officer.  Many  of  the 
ameliorations  in  the  condition  of  the  army  surgeon  which  have  been 
gained  within  a  few  years  originated  with  him,  as  the  records  of  the  Sur- 

*  Entered  the  Army  as  Assistant  Surgeon,  1811;  promoted  Surgeon,  18G0; 
appointed  Medical  Inspector,  18C2;  disbanded,  and  reduced  to  Surgeon, 
October  31,  18()5;  assigned  as  Medical  Director,  Department  of  North  Carolina, 
November,  1865. 


400 


EDITORIAL. 


[Feb. 


geon-Geueral's  office  will  bear  witness.  His  valuable  and  laborious 
contributions  to  Army  Medical  Statistics  arc  known  and  appreciated. 
He  had  pride  and  faith  in  his  profession,  and  kept  apace  with  its  litera- 
ture. In  both  ofiBcial  and  social  intercourse,  Dr.  Coolidge  showed  a 
high  sense  of  honor,  native  courtesy,  and  a  kindly  and  genial  disposition. 
His  manners  were  quiet  and  engaging.  In  conversation  he  was  a  good 
listener,  as  well  as  a  good  talker.  His  amiable  qualities  and  social 
instincts  made  him  a  general  favorite  wherever  he  chanced  to  be,  as 
well  without  as  within  the  professional  circle.  In  Philadelphia,  where 
he  was  stationed  for  a  period  of  two  years  before  his  transference  to 
the  Department  of  North  Carolina,  he  secured,  by  his  modest  but  solid 
worth,  troops  of  friends,  who,  regretfully  parting  witli  him,  now  mourn 
the  loss  of  him  they  shall  know  no  more.  In  naming  his  personal  and 
moral  qualities,  let  it  not  be  forgotten  that  he  traveled  on  the  common 
way  "  in  cheerful  godliness,"  his  piety  being  earnest,  true,  and  simple, 
and  he  had  a  full  comprehension  of  the  humanities  of  religion. 

Thus  has  died  an  accomplished  physician,  an  exemplary  ofBcer,  a 
worthy  gentleman,  a  faithful  Christian.  And  though  "his  sun  went 
down  while  it  was  yet  day,"  life  to  him  had  been  no  empty  dream,  but 
an  ever-present  reality,  for  his  part  in  it  had  been  pleasing  and  well 
acted,  and  those  whom  he  loved  .so  well  may  be  comforted  in  their 
great  grief  by  the  thought,  that  while  they  have  "  lost  this  friend  out 
of  sight,"  the  store  of  Paradise  has  gained. 

Photographic  Line  Engraving  on  Steel — We  have  recently  seen 
specimens  of  morbid  anatomy,  geology,  and  natural  history,  almost 
instantly  engraved  by  this  process  on  steel,  securing  plates  which  will 
give  any  number  of  copies  of  the  object  required,  with  all  the  delicacy 
and  minuteness  of  detail  of  photography,  and  the  force  and  trans- 
parency of  line  engraving.  We  have  good  reason  to  think  that  diffi- 
culties which,  but  a  short  time  ago  were  looked  upon  as  insurmountable, 
have  been  conquered,  and  that  photographic  line  engraving  on  steel 
has  become  a  practical  and  reliable  art.  The  process  is  accomplished 
by  two  means — optical  and  chemical.  A  photograph  is  taken  from 
nature,  and  by  optical  and  chemical  means  converted  into  a  line  en- 
graving. Former  essays  to  preserve  photography  on  metal  have  been 
limited  to  aquatinto — a  variety  of  engraving  defective  in  transparency 
and  incapable  of  producing  any  large  number  of  prints.  To  Baron 
Egloffstein,  well  known  in  connection  with  the  topographical  surveys  of 
the  Pacific  coast,  and  who  served  with  distinction  in  our  army  during 
the  first  years  of  the  war,  belongs  tlic  credit  of  the  discovery  and  appli- 
cation of  this  art,  from  which  we  look  for  valuable  results  in  photoiui- 
cography. 


NEW  YORK 

MEDICAL  JOURNAL, 

A  MONTHLY  RECORD  OP  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
MARCH,  186G. 


ORIGIML  COMMUNICATIONS. 

Paralysis  from  Peripheral  Irritation,  tvith  Reports  of  Cases. 
By  S.  Weir  Mitchell,  M.D.,  Philadelphia. 

[Continued  from  p.  355  ] 

Pakt  Second.  —  Gim-shoi  xcounds  giving  rise  to  paralyses  of  remote  por- 
tions of  the  bodi/.    A  theory  of  shock  from  physical  injuries. 

The  following,  and  concluding  portion  of  my  paper,  will  be 
chiefly  made  up  of  the  language  and  cases  already  made  use  of 
in  Circular  No.  C,  for  which  I  am  jointly  responsible  with  my 
former  colleagues,  Drs.  Morehouse  and  Keen. 

Together  with  these  gentlemen,  I  enjoyed  the  privilege  of 
studying  hundreds  of  cases  of  gun-shot  and  other  injuries  of 
nerves  in  the  U.  S.  A.  Hospital,  set  aside  for  these  cases  by 
the  order  of  Dr.  Hammond,  late  Surgeon-General. 

The  wisdom  of  the  policy  which  founded  special  hospitals 
in  Philadelphia  was  amply  justified  by  the  medical  results, 
while  without  such  a  classification  of  disease  and  injury  as 
these  hospitals  efiectcd,  it  was  scarcely  possible  to  loolt  for  any 
careful  scientific  study  of  rare  instances  of  disease  or  wounds. 

In  the  original  manuscript  of  our  paper  on  reflex  paralysis. 
Dr.  Hammond  was  credited  with  having  established  the  Hospi- 
tal for  Diseases  of  the  Nervous  System.    His  name  was,  how- 

VoL.  IT.— No.  12.  26 


402 


PARALYSIS  FROM 


[March, 


ever,  omitted  in  the  published  copy,  which  was  distributed  by  the 
U.  S.  A.  Medical  Bureau.  I  have,  therefore,  the  more  pleasure 
in  rendering  this  late  act  of  justice  to  this  distinguished  phy- 
sician. 

In  making  the  following  quotations,  I  have  very  rarely 
altered  the  language  employed;  I  make  here  this  explanation, 
because  nearly  throughout  we  employed  the  term,  Reflex  Paral- 
ysis. It  was  so  used  as  expressing  clearly  enough  to  most  physi- 
cians what  Ave  meant,  and  not  because  we  felt  confident  as  to  the 
theory  on  which  this  nomenclature  was  based,  and  which,  indeed, 
we  criticized  and  rejected  at  the  close  of  our  report  of  cases.* 

The  text  of  the  original  circular,  so  often  alluded  to,  will 
hereafter  be  inclosed  in  parentheses,  to  distinguish  it  from  my 
own  additions. 

(So  far  as  we  are  aware,  the  medical  histories,  which  we  are 
about  to  record,  stand  alone  as  the  first  reports  of  sudden  reflex 
paralysis  from  mechanical  injuries.  How  they  differ  from  the 
paralytic  affections  which  result  from  disease  of  organs,  and 
which  have  been  so  ably  treated  of  by  numerous  authors,  we 
shall  presently  consider.  That  they  have  thus  far  escaped 
notice  may  be  easily  accounted  for.  In  the  first  place,  they  are 
rare;  among  some  two  hundred  or  more  of  carefully  studied 
instances  of  wounds  of  nerves,  we  have  met  with  only  seven 
cases  of  reflex  paralysis  of  remote  organs,  in  which  the  influ- 
ence was  prolonged  or  severe.  In  the  majority  of  cases,  the 
effect  was  either  very  slight  or  very  transient,  and  for  one  or 
both  of  these  reasons  unlikely  to  attract  notice  from  surgeons 
on  the  battle-field,  or  in  division  or  corps  hospitals,  where 
their  brains  and  hands  are  taxed  to  the  utmost  by  the  palpable 
misery  of  wounds  in  the  early  stages  of  treatment.  Had  it 
been  otherwise,  we  do  not  doubt  that  numerous  cases  of  reflex 
paralysis  from  injuries  to  nerves  would  have  been  recorded. 

The  various  effects  produced  upon  the  nervous  system  by 
gun-shot  wounds  have  received,  it  seems  to  us,  far  less  atten- 
tion and  far  less  study  than  their  interest  and  importance 
appear  to  call  for.  Among  them  are  some  which  must  clearly 
be  classified  with  the  rare  results  illustrated  by  the  cases  re- 


*Med.  Circ.  No.  fi,  1864,  p.  15  et  seq. 


1866.] 


PERIPHFUAL  IRRITATION. 


403 


ported  in  this  paper;  but  there  are  also  others  which  are  far 
more  numerous,  in  fact  very  common,  and  which  are  signally 
exemplified  on  every  battle-field. 

These  have  been  more  or  less  vaguely  treated  of  as  shock, 
commotion,  stupor,  etc.  The  larger  part  of  those  who  receive 
flesh  wounds  involving  no  important  organ  are  but  little  aifected 
at  the  time,  or  may  even  be  unconscious  of  having  been  hit,  and 
exhibit  no  well  marked  immediate  constitutional  disturbance. 

In  other  cases,  and  particularly  in  wounds  of  graver  nature, 
the  patient  instantly  falls  senseless,  and  so  remains  during  a 
few  minutes,  or  many  hours,  when  he  revives  again,  either  com- 
pletely, or  to  suffer  from  a  continued  state  of  depression  known 
as  the  shock,  and  marked  by  the  usual  features  of  great  weak- 
ness, feeble  circulation,  pallor,  etc. 

In  other  cases  the  last  named  symptoms  come  on  at  once, 
and  without  the  intervention  or  accompaniment  of  uncon- 
sciousness. 

These  very  interesting  states  of  system  may  be  due,  it  seems 
to  us,  either  to  an  arrest  or  enfeeblement  of  the  heart's  action 
through  the  mediation  of  the  medulla  oblongata  and  the  pneu- 
mogastric  nerves,  or  to  a  general  functional  paralysis  of  the 
nerve  centres,  both  spinal  and  cerebral,  or,  finally,  to  a  combina- 
tion of  both  causes. 

Arrest  of  the  heart  movements  is  producible,  as  is  now  well 
known,  by  any  violent  irritant  directly  addressed  to  the 
trunks  of  the  pneumogastric  nerves,  or  to  the  medulla  ob- 
longata, and  it  is  conceivable  that  such  an  effect  may  be  brought 
about  by  any  very  severe  injury  of  an  external  part. 

In  fact,  it  has  long  been  known  that  the  sudden  crushing  of 
a  limb  in  inferior  animals  will  stop  the  heart,  or  make  it  act 
slowly,  for  a  greater  or  less  length  of  time.  Now,  if  we  add 
to  this  M.  Bernard's  experiments,  in  which  he  showed  that  irri- 
tation of  the  posterior  roots  of  spinal  nerves  suddenly  checks 
the  cardiac  motions  for  a  time,  and  that  like  irritation  of  the 
anterior  or  motor  roots  gives  rise  to  no  such  result,  we  shall 
be  able  to  see  how  it  is  possible  that  a  gun-shot  wound  of  a  large 
limb  may  be  competent  to  occasion  a  like  effect.  We  should 
remember,  too,  that  in  nearly  all  of  these  cases  the  liemorrhagc 
from  large  vessels,  such  as  are  usually  opened  by  accidents  of 


404 


PARALYSIS  FROM 


[March, 


this  nature,  is  sufficient,  even  during  syncope,  to  add  to  or 
deepen,  so  to  speak,  the  effects  of  the  reflected  nerve  impres- 
sion. Where  small  vessels  only  have  been  wounded  this  might 
not  occur;  hut  it  is  proper  to  state  that  men  who  have  fallen 
senseless  at  the  instant  of  the  wound,  frequently  awaken,  after 
a  time,  to  find  themselves  drenched  with  blood. 

Supposing  such  an  arrest  of  the  heart  movements  to  have 
taken  place,  a  continuance  of  their  stoppage,  even  for  a  brief 
period,  would  naturally  give  rise  to  cerebral  anaemia,  pallor, 
unconsciousness,  and  the  remaining  phenomena  of  shock. 

Again,  as  we  have  said,  a  severe  injury,  as  a  gun-shot  wound 
of  a  limb  or  the  neck,  may  produce  its  effects  of  unconscious- 
ness and  loss  of  power,  by  greatly  weakening  or  for  a  time  de- 
stroying, with  various  degrees  of  completeness,  the  functions  of 
all  the  nerve  centres,  and  of  their  conducting  cords. 

The  influence  of  shock  in  causing  temporary  paralysis  of 
nerve  trunks  is  very  well  known  to  every  experimenting  biol- 
ogist. Thus,  after  opening  the  spinal  cavity,  it  is  very  com- 
mon to  discover  that  the  sensitive  nerves  are,  for  a  time,  unim- 
pressible  by  irritants.  But,  as  a  general  thing,  this  is  not  so  as 
regards  the  nerve  centres  within  the  skull,  which  are  rarely  so 
disturbed  by  the  operation  of  uncovering  them  as  to  refuse  all 
reply  to  irritations. 

The  majority  of  physicians  will  no  doubt  be  disposed  to 
attribute  the  chief  share  in  the  plieuomena  of  shock,  in  its 
various  forms,  to  the  indirect  influence  exerted  upon  and 
through  the  heart.  There  are,  however,  certain  facts  which, 
duly  considered,  will,  we  think,  lead  us  to  suppose  tliat  in  many 
cases  the  phenomena  in  question  may  be  due  to  a  temporary 
paralysis  of  the  whole  range  of  nerve  centres,  and  that  among 
these  phenomena  the  cardiac  feebleness  may  play  a  large  part, 
and  be  itself  induced  by  the  state  of  the  regulating  nerve 
centres  of  the  great  circulatory  organ. 

The  loss  of  consciousness,  and  the  appearance  of  a  state  out- 
wardly resembling  syncope,  prevent  us  in  most  cases  from 
feeling  sure  that  the  great  nerve  centres  suficr  loss  of  function 
primarily,  and  not  through  want  of  nutrition  from  feeble  or 
arrested  heart  action.  But  there  do  exist  certain  cases,  more 
rare,  it  is  true,  in  which  singular  affections  of  the  nerve 


18G6.] 


PERIPHERAL  lEEITATION. 


405 


centres,  other  than  those  of  the  heart,  occur  as  a  consequence 
of  wounds. 

These  are  well  described  by  Legouest,  in  his  Surgery  of  the 
Crimean  War,  p.  219.  In  somewhat  varied  shapes  they 
must  have  been  seen  by  all  who  are  familiar  with  the  early 
history  of  gun-shot  wounds. 

The  patients  to  whom  we  refer  do  not  fall  when  struck,  but 
become  insanely  excited  or  almost  hysterical.  The  author 
above  alluded  to  supposes  that  this  form  of  nervous  excitement 
occurs  chiefly  among  those  who  are  already  stimulated  by  im- 
mediate conflict,  and  who  are  actively  engaged. 

One  well  known  instance  has  been  related  to  one  of  the 
authors  of  this  paper,  as  having  taken  place  in  the  Mexican  war, 
in  1846.  An  of&cer  was  wounded  in  the  heel,  and  was  thrown 
at  once  into  a  state  of  alarm,  which  caused  him  to  exhibit  signs 
of  the  utmost  trepidation.  His  character  for  courage  was  such 
that  the  favorable  verdict  of  a  subsequent  court  of  inquiry  was 
scarcely  needed.) 

In  the  following  case  there  was  primarily  excitement  of 
brain,  and  finally  general  loss  of  power. 

Col.  P.,  xt.  41,  P.  V.  In  good  health  previous  to  date  of 
wound;  June  3,  1864,  while  standing  behind  the  line  of  his 
regiment,  which  was  not  then  actively  engaged,  he  received  a 
large  slug  in  the  right  wrist  joint.  When  struck  he  whirled 
half  around,  and  then,  with  a  sense  of  confusion  and  bewilder- 
ment, began  to  run  along  the  back  of  the  line  with  some  vague 
intentiort  of  reaching  a  hospital.  After  running  about  fifty 
yards  he  fell  insensible.  He  describes  himself  as  feeling  "  ex- 
cited, half  crazed."  He  revived  within  a  quarter  of  an  hour, 
and  soon  after,  in  fact  within  one  hour,  suff'ered  amputation  of 
the  forearm.  His  after  history  is  most  curious,  as  he  became 
tlie  subject  of  violent  and  extensive  choreal  movements  of  the 
stump  and  arm,  on  account  of  which  he  consulted  me.  Not- 
withstanding this  annoying  malady,  he  led  his  regiment  through 
Sheridan's  valley  campaign  and  the  final  battles  in  front  of 
Richmond. 

I  should  be  very  glad  if  surgeons  who  are  aware  of  cases 
like  this  one,  or  who  are  cognizant  of  any  of  the  less  common 
plienomcna  of  shock,  were  to  put  them  on  record.    Having  had 


406 


PARALYSIS  FROM 


[March, 


no  experience  in  the  field,  I  have  been  obliged  to  limit  myself 
to  such  cases  as  have  accidentally  fallen  in  my  way.  No  doubt 
others,  far  better  illustrating  my  views,  are  within  the  experi- 
ence of  those  who  have  actually  served  under  fire. 

(We  are  tempted  to  add  the  following  case  as  a  still  better 
proof  that  cerebral  disturbance,  the  result  of  a  shock  other  than 
traumatic,*  may  give  rise  to  the  most  profound  prostration. 

A  well  known  apothecary  in  Philadelphia  was  making  a 
mixture  of  certain  medicines  in  a  large  mortar,  when  they  ex- 
ploded with  such  violence  as  to  break  the  windows  of  the  store, 
crack  bottles  and  jars,  and  deeply  indent  the  board  on  which 
stood  the  mortar.  Both  he  and  his  assistant  were  thrown  down. 
Both  sufi'ered  rupture  of  the  tympanal  membrane  of  the  right 
and  left  ears.  The  assistant  felt  no  marked  constitutional 
efi'ects,  and  got  well  with  good  hearing,  but  with  a  constant 
buzzing  in  the  left  ear.  The  apothecary  himself,  of  a  more 
nervous  temperament,  and  perhaps,  also,  because  he  was  stand- 
ing nearer  to  the  point  of  explosion,  was,  he  thinks,  insensible 
for  a  moment.  When  seen  by  one  of  us,  a  few  minutes  later,  he 
was  lying  on  a  bed,  with  a  pulse  of  rather  remarkable  strength, 
but  now  and  then  losing  a  pulsation,  and  altogether  irregular 
as  to  rhythm,  beating  one  minute  seventy  and  eighty  the  next. 
His  manner  was  excited  and  hysterical.  He  talked  incessantly, 
and  his  limbs  were  in  continual  agitation,  with  occasional 
twitching  of  the  facial  muscles.  The  tympanal  membrane  was 
split  across  in  his  left  ear,  and  on  the  right  side  presented  a 
triangular  opening.  He  had  no  headache,  but  complained, 
of  roaring,  hissing,  etc.,  which  seemed  to  be  sources  of  the 
utmost  annoyance.  Despite  his  desire  to  move  about,  his 
muscles  were  extremely  feeble,  and  for  twenty-four  hours  he 
was  unable  to  walk  without  aid.  He  recovered  readily,  both 
membranes  healing  completely,  and  his  hearing  being  none  the 
worse  for  the  accident. 

The  patient,  it  should  be  noted,  was  not  injured  by  his  fall, 
and  as  we  have  seen  showed  no  signs  of  concussion.    He,  as 

*  Iq  fact,  there  was  traumatic  injury,  rupture  of  botli  tympanal  membranes,  but 
the  effect  in  the  way  of  violent  stimulation  of  the  uervc  of  hearing,  in  all  proba- 
bility, overbalanced  the  influence  of  the  wounds,  and  gave  occasion  to  the 
Bymploms  which  arose. 


I 


1866.]  PERIPHERAL  IRRITATION.  407 

well  as  his  medical  attendant,  attributed  the  phenomena  "which 
he  exhibited  to  the  shock  given  to  the  auditory  nerve.  This 
opinion  has  since  been  confirmed  by  the  cases  reported  by  M. 
Brown-Sdquard  and  others. 

Further  on  we  shall  show  that  in  rare  cases  gun-shot  wounds 
cause  partial  or  very  general  paralysis  of  grave  type  and  pro- 
longed duration  in  parts  not  directly  injured;  we  shall  also 
show  that  these  protracted  paralyses  must  be  due  to  an  equally 
permanent  affection  of  the  nerve  centres.  Now,  if  this  be  pos- 
sible, there  is  every  reason  to  believe  that  a  temporary,  though 
general,  paralysis  may  take  place  in  a  large  number  of  gun-shot 
wounds.) 

I  shall  now  proceed  to  relate  instances  of  gun-shot  injury 
which  were  immediately  productive  of  paralysis  of  parts  more 
or  less  remote  from  the  seat  of  the  wound. 

(Case  I. — Ball  wound  of  right  side  of  the  neck,  probably  involving  no  im- 
portimt  nerve  directly;  fracture  of  hyoid  bone;  wound  of  throat. 
Reflex  paralysis  of  left  arm  ;  probable  reflex  paralysis  of  right  arm; 
early  recovery  of  left  arm ;  partial  and  remote  recovery  of  right  arm. 

Captain  R.  N.  Stemble,  U.  S.  N.,  ast.  49.  While  command- 
ing the  ram  Cincinnati,  May  10,  1862,  the  ship  was  attacked 
by  two  rebel  rams.  Captain  S.  was  aiming  a  pistol  when  a 
ball  entered  his  right  neck,  broke  the  hyoid  bone,  and  traversing 
the  neck  emerged  three  and  a  half  inches  from  the  middle  line, 
above  and  to  the  right  of  the  superior  angle  of  the  scapula, 
through  tlic  edge  of  the  trapezius  muscle.  He  fell,  half  con- 
scious and  confused,  but  soon  reviving,  felt  that  both  arms  were 
paralyzed.  His  first  impression  was  that  he  was  shot  through 
both  arms.  He  was  carried  below  in  great  pain,  and  spitting 
blood  freely.  The  pain  in  the  arms  was  made  worse  by  move- 
ment and  by  passive  motion.  Pressure  gave  pain  in  the  right 
arm  and  shoulder  only,  and  in  the  right  chest.  Sensation  was 
never  entirely  absent  from  either  arm,  but  was  dull  in  both. 

His  medical  attendant,  Dr.  Judkins,  of  Cincinnati,  who  took 
charge  of  his  case  on  the  19th  of  May,  1832,  writes  as  follows: 
"  When  first  seen  by  me  the  anterior  wound  was  discharging 
mucus  and  pus,  with  saliva.  His  voice  was  hoarse;  deglutition, 
which  returned  in  part  on  the  third  day,  was  still  difiicult  and 


408 


PARALYSIS  FROM 


[March, 


painful.  He  experienced  severe  pain  in  the  supra-hyoidean 
group  of  muscles,  and  in  the  pharynx.  His  left  arm  was  still 
slightly  paralyzed,  having  rapidly  improved.  On  the  right 
side  the  deltoid,  biceps,  triceps,  and  brachialis  anticus  were 
completely  paralyzed,  and  up  to  the  date  of  this  account,  July 
9,  1862,  have  improved  very  little.  The  muscles  of  the  right 
forearm  are  nearly  as  much  paralyzed  as  those  of  the  arm,  and 
the  sensibility  of  the  right  arm  has  became  painfully  acute. 
Captain  S.  seems  also  to  have  lost,  to  a  great  degree,  the  use 
of  most  of  the  shoulder  muscles  on  the  right  side." 

The  left  arm  was  nearly  well  in  four  weeks,  the  sensibility 
and  movements  of  both  improving  equally,  so  that  now,  July 
18,  1863,  he  has  no  loss  of  function  in  the  member,  except  slight 
want  of  tactile  sensation  in  the  ultimate  distribution  of  the 
ulnar  nerve.  The  right  arm  was  but  little  better  at  this  date, 
but  the  forearm  had  acquired  every  movement  except  supina- 
tion, which  seemed  to  be  limited  about  one  half,  not  by  paralysis, 
but  by  contraction  of  the  opponent  group  of  pronating  muscles. 
At  this  period  sensation  was  entire  in  the  right  limb,  but  there 
was  soreness,  on  pressure,  in  all  the  anterior  arm  muscles,  and 
neuralgia  in  the  arm  and  forearm.  The  nutrition  of  both  arms 
was  good,  but  the  right  was  the  smaller,  measuring  at  the 
biceps  9j  inches,  while  the  left  measured  1()|  inches. 

During  the  slow  progress  of  his  case.  Captain  Stemble  lost 
several  small  pieces  of  the  hyoid  bone,  and  although  hoarse  for 
many  months,  has  recovered  his  voice,  without  serious  change 
in  its  tone  or  power. 

His  convalescence,  interrupted  by  many  accidents,  and  by  an 
attack  of  pneumonia,  continued,  up  to  the  summer  of  1863,  and 
was  largely  due  to  the  skill  and  care  of  his  able  medical  at- 
tendant, Dr.  Judkins.  When  placed  under  treatment,  in 
Philadelphia,  by  Dr.  Mitchell,  July  18,  1863,  Captain  S.  was 
still  suffering  from  constant  pain  in  the  right  arm.  The  left 
was  well  except  as  to  the  trifling  loss  of  sensation  mentioned 
above.  The  right  forearm,  though  weak,  possessed  every 
movement  except  supination,  as  did  also  the  hand,  but  the  arm 
hung  at  the  side  useless,  because  there  was  scarce  any  abducting 
power  and  very  little  flexion  at  the  elbow,  both  the  biceps  and 
long  supinator  being  greatly  enfeebled,  and  the  former  muscle, 


1866.] 


PERIPHERAL  IRRITATION. 


409 


as  well  as  the  brachialis  anticus,  almost  entirely  atrophied 
and  lost  to  view.  Excepting  the  trapezius  and  rhomboid 
muscles,  all  the  shoulder  group  was  nearly  useless  and  was  par- 
tially wasted. 

From  July  18  to  September  9  he  was  faradized,  at  first  every 
day,  and  then  every  third  day— active  and  passive  movements, 
which  had  already  been  employed,  being  of  course  continued. 
The  result  was  a  steady  gain,  ending  in  a  cure  as  complete  as 
could  be  hoped  for  in  a  case  so  severe.  He  regained  every  lost 
motion,  and  could  raise  his  hand  to  his  chin  and  abduct  the 
arm  about  fifty  degrees.  The  pronators  alone  remained  in- 
tractable, despite  every  effort,  but  as  the  supinators  and  biceps 
developed  themselves  largely,  even  pronation  gained  somewhat, 
though  not  to  such  an  extent  as  the  other  movements.  The 
pain  and  hypera?sthesia  diminished,  but  the  former  still  exists. 
It  is  believed  that  a  second  course  of  similar  treatment,  about 
to  be  instituted,  will  further  amend  this  case,  in  which  all  other 
means  have  utterly  failed. 

Dr.  Judkins  is  of  opinion  that  the  entire  paralysis  was  due 
to  reflected  irritation.  We  incline  to  this  belief  for  anatomical 
reasons;  but  even  though  we  admit  that  the  paralysis  of  the 
right  arm  may  have  been  caused  by  commotion  of  the  brachial 
plexus,  it  is  impossible  to  suppose  that  the  loss  of  power  in  the 
left  meml)cr  could  have  been  similarly  produced.  The  only 
permanent  lesion  on  that  side  was  the  loss  of  feeling  on  the 
ulnar  side  of  the  palm  and  fourth  finger.  With  this  exception, 
it  regained  its  normal  functions  within  three  or  four  Avceks.' 
Whatever  niay  have  been  the  cause  of  injury  to  tlie  right  arm^ 
it  appears  to  have  involved,  more  or  less,  nearly  all  the  strands 
of  the  plexus,  which  is  unusual  in  cases  of  traumatic  injury 
from  a  ball.  Its  results  were  also  more  lasting  than  in  the 
other  arm.  A  year  and  two  months  after  the  accident,  the 
right  arm  was  a  useless  member.  Faradization  of  the  muscles 
affected  restored  their  power  very  rapidly,  so  that  the  patient 
regained  every  movement  of  the  limb,  which  is  still  improv- 
ing-electricity  having  been  temporarily  laid  aside  in  September 
1863.*  ^ 


*  This  gentleman  continued  to  improve  up  to  October,  1865.  when  he  passed 
from  under  my  care,  having  taken  command  of  a  ship  and  gone  to  sea. 


410 


PARALYSIS  FROM 


[March, 


Case  II. — Flesh  woundof  rirfht  Ihirih,  without  xoound of  any  Inrrje  nerve; 
compkle  paralysis  of  all  four  limbs;  speedy  recovery  of  the  left  arm, 
tardy  recovery  of  the  other  limbs  ;  subsequent  analgesia  of  the  right  side. 

Jacob  Demniuth,  a;t.  21,  Swiss,  enlisted  July,  1861,  Company 
"  D,"  lOSth  New  York  Volunteers,  a  man  somewhat  below  the 
average  standard  of  height,  of  lymjjliatic  temperament,  and 
moderate  intelligence.  Reports  himf-elf  as  healthy  up  to  the 
date  of  his  wound,  which  took  place  at  Fredericksl)urg,  De- 
cember 13,  1862.  He  was  marching  at  double-quick  when  a 
fragment  of  shell,  as  large  as  a  musket  ball,  struck  his  right 
thigh,  at  the  junction  of  the  upper  and  middle  thirds,  directly 
over  the  femoral  artery.  The  fragment  did  not  enter  deeply, 
but  merely  lodged  in  the  leg,  and  was  removed  a  day  later 
without  injury  to  the  vessel. 

Effect  of  icound. — He  fell,  half  conscious,  and  although  aware 
that  he  was  wounded,  he  could  not  fix  on  the  site  of  the  injury 
until  he  had  examined  the  limb.  He  felt  instantly  a  burning 
pain  in  both  feet,  in  front  of  the  right  chest  and  in  tlie  right 
arm,  and  in  the  right  thigh  about  the  wound.  At  first  he  was 
entirely  powerless,  but  after  a  few  minutes  the  power  of  the 
left  arm  returned,  leaving  him  paralyzed  as  to  motion  in  the 
right  arm  and  in  both  legs.  He  lay  on  the  field  twenty -four 
hours,  the  weather  being  very  cold. 

Sensation  was  defective  in  all  the  parts  paralyzed  as  to  motion. 
He  had  no  pain  in  the  back,  but  the  burning  pains  alluded  to 
above  continued  for  a  long  time,  and  were  always  eased  by 
cold  applied  to  the  wound.  While  the  wound  was  healing  he 
had  headache  and  difficult,  painful  micturition.  The  wound 
closed  in  four  weeks.  During  this  period  he  regained  the 
power  to  move  the  right  arm,  feebly  and  slowly,  althougli  per- 
fectly as  to  extent.  The  pain  in  the  side  and  feet  also  diminished, 
and  the  former  disappeared  altogether  at  a  later  period.  He 
could  not  stand,  however,  or  lift  his  legs  from  the  bed  at  the 
time  the  wound  healed,  but  there  was  then  no  headache  or 
difficulty  with  the  bladder  or  rectum. 

January  28,  1863,  he  was  sent  to  Washington,  where  he  im- 
proved so  as  to  be  able  to  walk  with  the  help  of  a  cane.  His 
subsequent  transfer  to  West  Philadelphia  caused  a  relapse;  the 


1866.] 


PERIPHERAL  IRRITATION. 


411 


pains  returned,  the  paralysis  increased,  and  he  walked  with 
difficulty  on  crutches. 

June  4,  entered  Christian  Street  Hospital. 

Present  state.  Movement. — The  patient  is  partially  paraplegic. 
He  has  some  power  to  move  the  thighs  Avhen  lying  down,  but  can 
not  lift  the  legs  from  the  bed.  Below  the  knee  all  motion  is  lost, 
except  a  slight  power  of  flexing  the  smaller  toes  in  both  feet. 
Pressure  upon  the  cicatrix  causes  feeble  twitching  of  the  ante- 
rior muscles  of  the  right  thigh;  both  legs  are  subject  to  cramp 
and  twitchings,  which  increage  at  night.  The  left  arm  is 
strong;  the  right  arm  has  all  the  normal  movements,  but  all 
are  slowly  and  feebly  executed. 

Sensation. — He  has  shooting  pains  which  start  from  the  seat 
of  the  wound,  and  dart  down  the  thigh  to  the  knee.  No  other 
pain  exists  at  present,  but  there  is  still  a  good  deal  of  burning 
sensation  in  both  feet  alike.  Localizing  sensibility  perfect 
everywhere.  Tactile  sensation  normal,  or  very  nearly  so,  in  all 
parts  of  his  body.  No  loss  of  sense  of  pain  in  the  skin.  Pres- 
sure or  pinching  of  the  muscles  gives  him  more  than  the  usual 
pain,  so  that  the  muscles  (of  both  legs,  especially  below  the 
knees)  may  be  regarded  as  affected  with  hyperaesthesia  of  com- 
rnon  sensation.  The  left  arm  is  in  all  respects  norijaal;  the 
right  arm  is  also  free  from  lesions  of  sensibility. 

Nutrition. — There  is  no  special  atrophy  of  individual  groups 
of  muscles,  but  both  legs  are  slightly  wasted,  the  right  arm  not 
at  all  so.  The  legs  below  the  knees  are  relaxed  and  cold,  the 
feet  are  congested,  but  not  swollen  to  any  marked  extent. 
Along  the  edges  of  both  soles  there  are  singular  purple  and 
blue  mottled  spots,  which,  he  says,  existed  from  the  time  his 
boots  were  first  taken  off,  twenty-four  hours  after  he  was 
wounded.  It  is  possible  that  these  marks  are  due  to  frost- 
bite. The  muscles  of  the  legs  are  about  equally  irritable 
to  induced  electric  currents.  Unfortunately,  no  very  per- 
fect electric  examination  of  their  condition  was  made  at  this 
period. 

Treatment. —lio^ixviWwg  the  case  as  one  of  reflex  paralysis 
chiefly,  he  was  ordered  to  have  rough  frictions,  with  cold  to  the 
spine,  and  to  take  the  twentieth  of  a  grain  of  strychnia  three 


412 


PARALYSIS  FROM 


[March, 


times  a  day.  Under  this  treatment  the  cramps  and  twitchings 
increased,  so  that  after  three  weeks  the  stryclinia  was  aban- 
doned. Every  future  attempt  to  repeat  its  employment  caused 
the  same  increase  of  annoyance,  without  corresponding  benefit, 
and  it  was  finally  laid  aside  as  useless  or  worse.  About  the 
middle  of  August  a  blister  was  placed  on  the  cicatrix,  with  the 
effect  of  greatly  relieving  the  burning  in  both  feet.  At  the  same 
time  he  was  ordered  to  use  the  hot  and  cold  douche  to  the  spine 
alternately,  and  to  be  faradized  daily.  The  electricity  was 
persistently  employed  during  two  months,  and  a  month  later 
he  was  also  treated  with  iron  and  quinine,  porter  and  liberal 
diet.  The  electric  treatment  caused  a  rapid  amelioration  of  his 
case,  so  that  he  soon  left  his  bed  and  began  to  walk  on  crutches. 
Early  in  November  he  ceased  to  improve,  and  the  treatment 
was  abandoned.  At  this  time  he  could  use  his  right  arm  well 
and  quickly,  and  walked  unaided,  although  with  a  little  un- 
steadiness of  gait. 

No  close  examination  was  made  as  to  his  sensibility  until 
December  3,  1863,  because  during  tliis  time  he  had  been  able 
to  give  aid  in  the  wards,  and  made  no  complaint,  except  of 
more  or  less  constant  aching  in  the  dorsal  and  lumbar  regions 
of  the  spine.  About  December  3,  he  was  closely  inspected  for 
discharge,  when  the  following  notes  were  taken: 

Motion. — Good  in  left  arm;  not  so  perfect  in  right  arm. 
Both  legs  somewhat  weak,  so  that  he  shuffles  a  little  in  walk- 
ing, the  worst  moveirient  being  that  of  extension  in  the  toes  of 
the  right  foot. 

Sensation. — Tactile  sensibility  feeble  in  the  riglit  leg  and 
right  arm,  but  nowhere  entirely  lost;  it  is  normal  in  the  left 
leg  and  left  arm.  The  sense  of  touch  is  first  found  to  be  feeble 
below  the  navel  on  the  right  side.  It  lessens  in  perfection  to 
the  knee,  and  is  better  below  that  part,  especially  on  the  inside 
of  the  calf,  being  wo;*st  in  the  foot.  Irritating  the  sole  causes 
no  sensation  of  tickling  on  either  side. 

Fain. — There  is  absolute  lo.-s  of  sense  of  pain  in  the  right 
leg,  belly,  chest,  and  arm,  with  somewhat  lessened  sensibility 
to  pain  on  the  left  side  also.  In  many  localities  he  was  able 
instantly  to  tell  by  the  altered  sensibility  when  the  needle 
point  crossed  the  median  line;  in  others,  this  was  more  diffi- 


1866.] 


PERIPHERAL  IRRITATION. 


413 


cult.  So  complete  was  this  analgesia,  that  the  most  intense 
faradization  of  the  nails  of  the  right  hand,  or  of  the  right  nip- 
ple, caused  not  the  least  sensation.  The  penis  remained  sensi- 
tive, but  all  over  the  right  side  of  the  body  he  could  be  cut  or 
stuck  full  of  needles  without  evincing  the  least  consciousness  of 
any  thing  but  a  touch. 

The  sense  of  temperature  was  good  in  the  left  leg,  confused 
and  uncertain  at  the  upper  third  of  the  riglit  thigh,  and  lost 
below  the  knee,  where  a  heat  of  110''  Fahrenheit  was  felt  as  a 
touch  only,  when  the  sponge  wetted  with  hot  water  was  ap- 
plied. On  the  foot  of  the  right  side  this  degree  of  heat  was 
unfelt  in  any  form.  Higher  heat  caused  reflex  movements 
which  did  not  tend  to  remove  the  limb  from  the  irritant,  but 
were  merely  convulsive  in  their  character.  Intense  cold  also 
gave  rise  to  these  irregular  movements. 

Electric  Examination. — ^Tliere  was  some  difficulty  in  deter- 
mining the  state  of  the  muscles  as  to  their  electric  sensibility, 
owing  chiefly  to  the  want  of  intelligence  in  the  patient,  and  to 
the  fact  that  he  spoke  an  impure  German  patois,  which  made  it 
no  easy  task  to  obtain  from  him  a  clear  statement  of  his  feel- 
ings. The  electro-muscular  contractility  was  slightly  dimin- 
ished in  the  right  leg  and  arm;  it  was  much  impaired  in  the 
extensors  of  the  toes  on  both  sides;  everywhere  the  muscles 
responded  slowly.  The  patient  was  discharged  December  14, 
1863.) 

This  case  is  one  of  unusual  interest,  and  as  the  patient  spoke 
English  badly,  we  were  at  great  pains  to  ascertain  that  we 
understood  liim  perfectly,  and  that  his  case  was  correctly  re- 
ported. Repeated  examination,  and  the  evidence  of  a  comrade 
who  belonged  to  his  regiment,  enabled  us  fully  to  satisfy  our- 
selves that  the  history  of  his  case,  as  he  gave  it,  was  perfectly 
truthful. 

It  began  with  an  extensive  paralysis  from  perij)heral  irrita- 
tion. Strychnia  disagreed  witli  hiin  remarkably,  causing  always 
an  increase  in  the  symptoms.  This  fact,  and  the  later  history, 
induces  me  to  suppose  that  lie  had  then  begun  to  suffer  from 
chronic  myelitis,  which  developed  itself  more  fully  as  his  case 
proceeded. 


414 


PARALYSIS  FROM 


[March, 


(Case  III.  —  Wound  of  rigid  thujlt,  willi  jjrobahle  commotion  of  rigJit 
sciatic  nerve;  partial  parabjsis  of  riijltt  leg ;  reflex parabjuiH  of  right 
arm;  speedy  recovery  of  arm  ;  history  unfinished. 

William  W.  Armlin,  aet.  28,  born  in  New  York,  farmer,  en- 
listed August,  1862,  in  Company  "  D,"  134th  New  York  Vols. 
Healthy  before  enlisting,  and  except  a  slight  typhoid  fever  in 
the  fall  of  1862,  healthy  up  to  the  date  of  the  wound,  July  1, 
1863,  at  Gettysburg.  While  kneeling  on  the  left  knee,  the 
right  knee  bent  at  a  right  angle,  he  was  shot  in  the  right  thigh, 
on  a  line  with  the  internal  condyle  of  the  femur,  ten  inches 
above  it,  and  a  little  anterior  to  the  artery.  The  ball  passed 
upwards,  backwards,  and  outwards,  and  emerged  two  inches 
below  the  tuber  ischii,  and  one  and  a  quarter  inches  external 
to  it,  just  above  the  fold  of  the  nates.  Dropping  his  musket, 
he  fell  on  his  face,  weak,  but  not  insensible;  the  right  leg  vio- 
lently flexed  for  a  moment.  He  felt  very  feeble,  but  especially 
so  in  the  right  arm,  with  which  he  vainly  tried  to  aid  himself. 
After  a  half  hour  the  bleeding,  which  was  not  excessive, 
ceased,  and  he  was  able  to  stand  on  the  left  leg,  but  not  on  the 
right  leg,  and  had  scarcely  any  use  of  the  right  arm,  which,  it 
should  be  noted,  was  in  no  way  hurt  when  he  fell. 

He  managed  to  bind  up  the  wound  with  a  water  dressing, 
and  occasionally  renewing  it,  lay  two  days  on  the  field.  When 
hit,  he  perceived  no  pain,  but  within  an  hour  a  burning  attacked 
his  instep,  and  has  never  left  it,  remaining  neither  worse  nor 
better.  Sensation,  he  is  sure,  was  unaltered,  except  on  the 
sole;  motion  improved  slowly,  except  in  the  flexors  and  exten- 
sors of  the  foot  and  toes.  To  his  surprise,  the  feebleness  of  the 
right  arm  increased  after  he  was  put  in  bed,  and  indeed  notably 
after  the  second  day.  Up  to  October  28  it  improved  slowly, 
but  at  this  time  he  went  home  on  furlough,  and  began  to  use  a 
crutch,  which  again  so  weakened  the  arm  as  to  alarm  him,  and 
deprive  him,  as  at  first  had  happened,  of  the  power  to  feed  him- 
self. Rejecting  a  crutch  on  this  side,  he  used  a  liniment  on  the 
arm,  and  it  has  now  gained  so  much  as  to  have  about  one-fourth 
the  force  of  the  left  arm.  It  did  not  lose  sensation  at  any 
time. 

Present  State,  Decemher  14,  1863. — General  health  good. 
Nutrition. — Wounds  healed.    Leg  below  knee  wasted,  foot 


1866.] 


PERIPHERAL  IRRITATIOX. 


415 


swollen,  toes  blue.  Contraction  of  great  toe  in  flexion.  Meas- 
urements: 8j  inches  above  internal  condyle  the  thigh  measures, 
right,  16,  left,  17§  inches;  middle  calf,  right,  11|,  left,  13 
inches. 

Voluntary  motion. — He  lifts  the  right  thigh  well,  but  com- 
plains of  its  weight.  Knee  motions  very  fair;  has  no  extension 
or  flexion  of  the  foot  or  toes. 

Sensation. — Tactility  absent  in  sole  of  right  foot,  feeble  in 
second  toe  on  its  dorsal  face,  absent  on  top  of  third  toe,  but 
elsewhere  complete.  Localization  extremely  confused,  so  that 
a  touch  on  the  toes  is  felt,  but  is  referred  to  the  instep.  Sur- 
face analgesia  of  the  sole,  but  deep  pricking  with  a  needle  is 
felt  in  the  sole.  Hypersesthesia  of  the  posterior  thigh  muscles 
to  a  slight  degree;  marked  soreness  on  pressure  in  the  calf 
muscles,  the  short  extensors  of  the  foot  and  its  whole  dorsal 
surface,  as  well  as  the  inside  of  the  sole. 

Pain. — The  pain  lies  deep  in  the  calf  and  extends  outside, 
under  and  in  the  perineal  muscles,  down  the  front  of  the  leg, 
and  over  the  dorsum  of  the  foot  and  to  the  external  side.  It 
is  intense  in  the  dorsum,  but  nearly  absent  in  the  sole.  Water 
does  not  seem  to  ease  the  pain,  which  is  of  a  burning  character, 
"  like  mustard."    Hitherto  nothing  has  aided  it. 

Electric  test. — The  thigh  muscles  respond  well.  The  right 
tibialis  anticus  has  no  electro-muscular  contractility,  but  its 
electro-sensibility  is  highly  exalted,  as  is  the  case  in  all  the 
muscles  down  to  the  foot.  In  the  foot  the  electro-muscular 
contractility  and  sensibility  are  both  lost,  except  that  in  some 
parts  of  the  dorsum  the  sensibility  can  not  be  tested  readily  for 
various  reasons.  It  is  certainly  lessened.  The  right  arm  is 
still  very  feeble,  especially  below  the  elbow,  and  has  lost  in 
size.    It  measures,  comparatively,  as  follows,  Dec.  20th: 

RIGHT  ARM.  LEFT  ARM. 

Forearm,  8§  inches.  inches. 
Arm,  9      "  9|  " 

He  is  not  left-handed.  The  arm  is  improving;  the  leg  has 
remained  unchanged  during  some  time  past. 

Ordered — First,  a  blister  over  the  whole  dorsum  pedis. 
Dec.  23. — Tills  has  caused  great  relief  to  the  burning  pain, 
and  is  to  be  repeated.) 


416 


PARALYSIS  PROM 


[March^ 


The  hand  and  arm  recovered  easily  and  speedily  under  the 
use  of  faradization.  The  pain  in  the  dorsum  of  the  foot  was 
several  times  relieved  by  blisters,  and  as  often  returned,  being 
to  some  extent  affected  by  the  weather.  It  was  not  entirely 
well  at  the  date  of  his  discharge  from  service,  in  March,  1864. 

The  two  cases  which  follow  were  observed  in  Filbert  Street 
Hospital,  Philadelphia.  I  regret  that  no  fuller  notes  of  them 
were  taken,  but  of  the  facts  as  stated  there  can  be  no  doubt. 

(Case  IV. — A  sergeant  was  shot,  during  the  battle  of  Malvern 
Hill,  in  the  right  testicle.  This  organ  was  nearly  entirely 
destroyed  by  the  ball.  He  fell,  without  pain,  believing  himself 
wounded  in  the  back.  A  few  moments  later  he  became  sense- 
less. Kecovering  after  a  few  minutes,  he  discovered  that  he 
could  walk,  but  that  the  right  foot  dragged  when  he  attempted 
to  lift  it  during  the  effort  to  get  to  the  rear.  This  weakness 
remained  permanent  for  several  months,  and  was  relieved  by 
faradization  and  shampooing  soon  after  the  testicle  healed, 
the  flexors  of  the  left  foot  were  completely  paralyzed  to  volun- 
tary control,  but  responded  to  the  irritation  of  the  induced 
electro-magnetic  currents.)  There  was  no  loss  of  sensibility. 
The  paralysis  gradually  improved,  but  the  scrotum  healed 
before  the  power  to  lift  the  foot  returned. 

(Case  V. — Shell  woundoflefl  thigh.    Analgesia  and  Ancesthesia  of  apart 
of  the  right  thigh  symnietrically  related  to  the  seat  of  xoound. 

An  officer,  Lieut.  ,  was  struck  by  a  small  fragment  of 

shell  upon  the  external  side  of  the  left  thigh.  He  felt  pains  of 
a  smarting  character  in  both  thighs,  at  or  about  the  same  spot, 
and  was  impressed  for  a  time  with  the  conviction  that  he  had 
been  shot  through  both  thighs.  The  shell  wound  healed  in  the 
course  of  three  or  four  months.  During  this  time  he  had  occa- 
sional smarting  on  the  outside  of  the  sound  thigh.  This  grad- 
ually disappeared,  and  at  length  he  noticed,  accidentally,  that 
there  was  a  space  of  skin  aliout  iive  inches  square,  on  the  outer 
part  of  the  sound  thigh,  in  which  there  was  neither  sense  of 
touch  nor  of  pain.  When  examined  by  us,  without  being 
allowed  to  see  the  part  he  could  indicate  the  boundaries  of  the 
anaesthetic  space  very  readily,  by  the  loss  of  tactile  sensations 
when  a  body,  mov  ed  while  in  contact  with  his  skin,  was  made  to 


1866.] 


PERIPHERAL  IRRITATION. 


417 


cross  the  line  on  to  the  numb  parts.  These  bo'unds  were  always 
very  accurately  the  same.  He  returned  to  his  regiment  with- 
out any  improvement  having  taken  place  in  regard  to  the  anass- 
thesia.  The  interest  of  the  case  just  now  recorded  lies  partly 
in  the  fact  that,  at  the  time  of  the  wound,  the  patient  felt  a  sen- 
sation which  he  referred  to  the  part  which  afterwards  became 
deprived  of  feeling. 

The  following  case  is  instructive  from  its  resemblance  to 
Case  No.  3,  that  of  Armlin,  in  whom  a  gun-shot  wound  of  the 
right  leg  also  caused  paralysis  of  motion  in  the  arm  of  the  same 
side. 

Case  VI.  —  G un-shot  wound  of  rigid  thigli;  lesions  of  motion  and  sewsa- 
iion;  reflex  paralysis  of  right  arm  as  to  motion. 

Daniel  Kent,  ast.  24 ;  Pennsylvanian;  farmer.  Enlisted 
August,  1862,  Company  "B,"  145th  Pennsylvania  Volunteers. 
Healthy  until  wounded.  At  Gettysburg,  July  2d,  1863,  while 
charging  at  a  full  run,  the  leg  raised  up,  he  was  shot  in  the 
right  thigh,  10.^  inches  above  the  edge  of  the  patella,  directly 
over  the  rectus.  The  ball  made  its  exit  on  the  postero-internal 
surface  of  the  thigh,  one  inch  below  the  fold  of  the  nates.  It 
seems  to  have  passed  inside  of  the  bone,  and  could  not  have  hit 
the  sciatic  nerve.  He  fell  at  once,  quite  conscious,  and  feeling 
an  instant  stinging  pain  all  over  the  right  side  of  his  body,  and 
especially  in  the  arm.  He  lost  a  great  deal  of  blood,  and 
found  that  he  could  not  sit  up  without  giddiness.  His  wound 
was  dressed  in  six  hours,  and  he  was  on  the  field  thirty-six 
hours.  The  leg  lost  all  motion  and  some  sensation,  and  the 
tingling  pain  in  the  arm  left  him  within  twelve  hours,  the 
member  remaining  very  feeble.  He  was  in  bed  six  weeks,  and 
then  was  able  to  walk  on  crutches.  The  sense  of  touch  changed 
but  little  during  the  time  which  has  since  elapsed,  and  the 
power  of  movement  in  the  leg  has  remained  unaltered  since 
August  1st,  1863.  The  wound  healed  in  October,  with  some 
previous  loss  of  bone.  Since  October  the  wounds  have  twice 
reopened  to  give  exit  to  small  pieces  of  bone.  Except  an  at- 
tack of  ague  in  October,  his  general  health  has  been  good. 

Present  Condition,  December  26, 1863.  Nutrition. — The  leg 
is  healthy  in  color;  the  foot  swells  when  hanging  down.  The 

Vol.  II.— No.  12.  27 


418 


PARALYSIS  FROM 


[March, 


right  thigh,  eighf  inches  above  the  patella,  measures  19  inches 
ia  circumference;  the  left  measures  19|  inches.  The  right  calf 
measures  14^  inches;  the  left  calf  measures  15  inches. 

Sensation. — No  pain  anywhere  ;  tactile  sensibility  entire; 
sense  of  locality  healthy. 

Motion. — The  thigh  is  voluntarily  flexed  very  slightly,  and 
only  through  the  agency  of  the  psoas  muscle,  the  anterior  thigh 
muscles  refusing  to  obey  the  will;  abduction  and  adduction  of 
the  thigh  normal;  extension  of  the  thigh  is  normal;  extension 
of  leg,  none.  The  foot  is  almost  moveless,  except  that  the  will 
can  cause  feeble  flexion  of  the  toes,  and  slight  eversion  and  in- 
version of  the  foot. 

Electric  examination. — The  rectus  muscle  has  its  electro-mus- 
cular contractility  somewhat  lessened;  that  of  the  two  vasti 
muscles  is  lost  until  the  wet  conductors  reach  the  upper  parts 
of  the  muscles,  (three  inches  above  the  wound,)  where  this  prop- 
erty becomes  normal.  The  sartorius  has  its  electric  contrac- 
tility diminished.  Below  the  knee  the  peroneus  longus  re- 
sponds very  well;  but  with  this  exception,  none  of  the  leg  mus- 
cles stir  under  the  most  powerful  induced  currents.  The  short 
extensor  of  the  toes  and  the  interossei  still  possess  some  power 
to  contract  under  electrical  stimulus.  Throughout,  the  elec- 
tro-muscular sensibility  is  diminished  in  all  the  muscles  which 
have  suffered  in  their  contractile  power,  and  the  sense  of  pain 
seems  also  to  be  materially  lessened,  since  dry  electric  conduc- 
tors, with  strong  currents,  cause  no  pain  when  applied  over  the 
bones  or  nails  of  the  foot. 

The  history  of  the  arm,  which  was  reflectively  paralyzed,  has 
been  reserved  for  separate  detail  here. 

After  three  days  from  the  date  of  the  wound,  the  right  arm, 
which  had  remained  feeble,  became  so  completely  paralyzed 
that  the  patient  could  no  longer  raise  it  to  his  lips;  under  the 
use  of  a  stimulating  liniment  it  grew  better  until  he  used 
crutches.  Probably  owing  to  tlieir  employment  he  became 
much  worse,  but  gradually  improved  again  up  to  this  present 
date  of  January  6,  1864.  The  right  and  left  arms  measure 
nearly  the  same;  power  of  right  arm  one-fourth  that  of  left. 

Electric  examination. — Electro-muscular  contractility  nor- 
mal; electro-muscular  sensibility  somewhat  lessened. 


186G.] 


PERIPHERAL  IRRITATION. 


419 


Treatment. — Faradization  of  arm  daily;  alternate  hot  and 
cold  douche,  and  active  motion. 

On  close  examination,  soon  after  admission,  some  evidence 
of  tubercle  was  found  in  the  right  lung,  and  the  patient  was 
therefore  ordered  to  be  discharged,  January  20,  1864.) 

Case  VII.  of  the  circular  rested  almost  entirely  upon  the 
statement  of  the  patient  himself.  As  it  is  not  of  much  value, 
clinically,  I  have  omitted  it  here. 

The  remaining  case  was  not  recorded  in  our  original  paper. 
It  happened  in  the  person  of  an  officer  with  whom  I  am  well 
acquainted,  and  whose  case  was  referred  to  me  for  examination 
and  treatment. 

Case  VII.— Lieut.  W.  F.  G.,  set.  39,  16th  U.  S.  I.  Healthy 
up  to  date  of  wound.  At  Chickaraauga,  Sept.  19th,  1863,  while 
lying  down  in  front  of  a  battery,  his  head  towards  the  enemy, 
a  conoidal  ball  struck  his  right  thigh.  The  ball  entered  pos- 
terioi'ly,  two  inches  below  the  gluteal  fold,  half  an  inch  to  the 
inside  of  the  central  line  of  the  limb.  It  emerged  anteriorly, 
four  inches  above  the  patella,  one  inch  to  the  inside  of  the 
central  line  of  the  limb.  He  felt  a  general  sense  of  shock,  but 
no  pain,  and  was  only  conscious  that  he  was  struck  somewhere. 
He  did  not  feel  faint  or  lose  consciousness.  A  few  minutes 
later  the  battery  ceased  to  fire,  when  he  arose  and  saw  the 
blood  streaming  down  his  leg  and  foot.  He  walked  a  little 
way  and  then  fell,  feeling  faint  and  dizzy.  The  enemy's  line 
passed  over  him  and  fell  back  again,  when  he  was  carried  to 
our  rear.  The  following  day  the  ball  was  cut  out,  being  imme- 
diately under  the  skin,  and  a  water-dressing  applied,  and  re- 
newed until  the  wound  healed,  which  was  within  about  two 
months.  At  no  time  was  there  much  pain  in  the  wounded  leg, 
unless  it  was  handled.  Even  this  ceased,  soon  after  the  ex- 
traction of  a  shred  of  clothing. 

From  the  time  he  reached  the  hospital  he  was  conscious  of 
a  feeling  of  intense  cold  in  the  left  (unwoundcd)  leg,  and  with 
this  existed  a  distinct  and  very  vivid  impression  that  the 
wound  was  in  the  left  leg.  This  impression  was  so  strong  that 
he  mistook  the  unwoundcd  leg  for  that  which  was  hurt,  when 
questioned  by  the  first  surgeon  who  saw  him.  This  singular 
delusive  sensation  was  strengthened  by  the  more  or  less  con- 


420  % 


PARALYSIS  FROM 


[March, 


stant  pain  in  the  left  thigh,  and  by  the  general  absence  of  this 
annoyance  in  the  wounded  part.  He  has  been  so  often  exam- 
ined and  so  much  questioned  as  to  this  feature  of  his  case,  that 
he  is  somewhat  indisposed  to  own  how  decided  and,  as  he  says, 
how  almost  irresistible  is  the  false  reference  of  the  site  of 
injury. 

The  coldness  to  which  I  have  referred  was  such  as  to  make 
him  think  the  part  was  frozen.  A  servant  rubbed  it  at  frequent 
intervals  during  the  night  which  followed  the  battle,  and  such 
warmth  was  applied  as  could  then  be  made  use  of  The  next 
morning  he  observed  that  the  left  leg  was  bloodless  and  white, 
from  the  knee  down.  This  condition  improved  and  alternated 
with  flushes  of  heat  and  redness  of  surface.  The  pallor  and 
coldness  disappeared  in  about  three  weeks,  returning  after- 
wards at  intervals  more  and  more  remote  until  the  early  spring, 
when  it  was  felt  but  very  rarely. 

The  night  after  he  was  wounded  he  became  aware  that  his 
right  arm  was  so  weak  as  to  give  way  under  him  when  he  tried 
to  move,  and  that  the  tactile  sense  was  deficient  in  the  right 
hand,  to  such  an  extent  that  he  could  not  button  or  unbutton 
his  garments.  The  double  defect  .of  sense  and  motion  became 
very  evident,  when,  a  short  time  after  he  was  shot,  he  attempted 
to  write,  but  found  that  his  pen  constantly  fell  from  his  fingers, 
owing  to  its  being  unfelt.  He  thinks  that  like  troubles  ex- 
isted, in  a  very  much  less  degree,  in  the  left  hand.  About  the 
second  week  he  began  to  have  pain  in  the  small  of  the  back, 
and  soreness  in  the  precordial  region  upon  pressure  or  deep 
expiration.  During  the  process  of  cicatrization  he  lost  twenty- 
two  pounds  of  his  weight,  and,  since  then,  nine  pounds  more. 

While  the  wound  was  healing,  the  superficial  veins  of  the 
right  leg  enlarged  considerably.  By  careful  bandaging,  this 
appearance,  which  was  chiefly  above  the  knee,  was  much  less- 
ened, but  it  was  succeeded  by  similar  and  rather  remarkable 
enlargement  of  the  veins  of  the  left  thigh. 

At  the  date  of  June  2, 1864,  Lieut.  G.  reported  at  the  U.  S.  A. 
Hospital  for  Injuries  and  Diseases  of  the  Nervous  System. 

At  tliis  time  he  was  a  tall,  thin  man,  looking  prematurely 
old,  very  pale  and  feeble,  and  somewhat  bent.  He  had  twice 
attempted  light  office  duty,  and  each  time  had  fallen  ill.  His 


186G.] 


PERIPHERAL  IRRITATION. 


421 


general  liealtli  was  bad.  He  was  so  weak,  as  to  be  unable  to 
walk  more  than  two  or  three  squares;  had  dyspepsia,  bad  appe- 
tite, Avas  very  costive,  liable  to  attacks  of  dizziness  on  exer- 
tion or  when  stooping.  No  headache,  but  frequent  pain  in  the 
small  of  the  back,  but  no  tenderness  in  any  part  of  the  spine, 
from  pressure,  cold,  or  heat.  Had  constant  pain  in  the  legs, 
chiefly  in  the  left  thigh,  but  more  in  the  right  than  he  formerly 
had.  No  urinary  troubles.  His  morale  was  good.  Occupied 
himself  in  reading,  and,  of  necessity,  spent  most  of  his  time  on 
his  back,  since  the  least  exertion  on  foot  entirely  prostrated 
hin}  and  increased  the  feebleness  of  his  limbs.  All  his  pains 
were  worse  in  bad  weather,  and  in  the  afternoons.  He  was 
still  losing  ground. 

Lieut.  G.  remained  under  my  care  during  the  autumn  of  1864, 
and  up  to  February,  1865.  During  this  interval  he  took  con- 
stantly, thrice  a  day,  pills  containing  a  grain  of  lactate  of  iron, 
half  a  grain  of  cxtr.  ignat.  amar.,  and  a  grain  of  quinine.  After 
a  month  of  this  treatment  I  added  to  it  six  grains  of  quinine 
daily,  and  three  ounces  of  whisky.  Bandages  were  also  ap- 
plied to  the  legs,  and  finally  an  elastic  stocking  from  the  groins 
to  the  toes.  Under  tlie  use  of  these  means,  with  occasional 
diminution,  for  a  week  or  two,  in  the  amount  of  quinine,  he 
slowly  gained  ground.  On  February  20th,  1865,  although  far 
from  well,  he  had  lost  all  trace  of  weakness  in  the  arms,  and 
was  able  to  walk  two  or  three  miles  without  much  fatigue.  The 
pains  in  the  legs  also  disappeared  to  a  great  degree,  but  the 
mental  impression  of  the  bullet  wound,  as  existing  in  the  left 
leg,  still  remained. 

March  20th,  1865,  I  heard  from  Lieut.  G.,  to  the  effect  that 
he  was  still  improving.  His  case  has,  I  am  informed,  continued 
to  progress  favorably. 

I  should  have  added,  that  when  examined  in  Cincinnati  by  a 
board  of  medical  officers,  their  president,  Dr.  Head,  U.  S.  A., 
regarded  Mr.  G.'s  case  as  one  of  reflex  paralysis. 

The  above  stated  cases  were  undoubted  instances  of  paralysis 
from  injury  to  some  region  remote  from  that  whose  function 
eufTercd  loss.  Two  of  the  cases.  Numbers  I.  and  VII.,  have 
been  under  observation  up  to  this  present  date.  The  other 
histories  arc  more  or  less  incomplete,  the  patients  having  been 


422 


PARALYSIS  FROM 


[March, 


discharged  the  service  or  otherwise  removed  from  the  wards. 
Within  the  limits  reported,  the  cases  were  watchfully  studied, 
not  only  by  myself,  but  also  by  my  able  colleague,  Dr.  George 
Morehouse,  and  by  our  assistant,  Dr.  Keen,  who  resided  in  the 
hospital.  I  quote,  Avith  such  corrections  as  were  needed,  the 
following  summary  from  our  original  analyses  of  the  cases 
already  stated. 

RELATION  OF  WOUND  TO  THE  PART  SECONDARILY  AFFECTED. 

(Case  I. — The  wound  involved  the  muscles  of  the  neck  or 
throat,  and  the  hyoid  bone.  Result.  Paralysis  of  both  arms 
and  of  the  neck. 

Case  II. — Fragment  of  shell;  wound  of  muscles  over  and 
external  to  the  right  femoral  artery.  The  injury  may  have 
caused  concussion  of  the  crural  nerves,  and  thus  much  of  trau- 
matic paralysis.  Eesult.  Paralysis  of  the  right  arm  and  leg, 
and  the  left  leg. 

Case  III. — Probable  injury  of  the  sciatic  nerve,  (commo- 
tion.)   Result.    Paralysis  of  the  right  arm. 

Case  IY. — Ball  wound  of  right  testicle;  paralysis  of  right 
anterior  tibial  muscles  and  peroneus  longus. 

Case  V. — Wound  by  fragment  of  shell  in  external  side  of 
left  thigh;  anaesthesia  and  analgesia  on  a  corresponding  part 
of  right  thigh. 

Case  VI. — -Ball  wound,  probably  involving  the  crural  nerves. 
Result.    Paralysis  of  right  arm. 

In  four  of  these  cases  the  leg  was  hit,  and  the  arm  of  the 
same  side  was  paralyzed.  In  three  cases  the  paralysis  affected 
the  opposite  side  of  the  body,  and  in  one  the  paralysis  of  tact 
and  pain  was  observed  to  have  fallen  upon  a  space  symmetri- 
cally related  to  the  wounded  spot. 

No  general  law,  therefore,  can  be  deduced  from  these  records; 
nor,  from  what  we  see  in  the  causation  of  reflex  paralysis  from 
disease,  should  we  expect  to  find  any  inevitable  relation  between 
the  part  injured  and  the  consequent  paralysis. 

The  constitutional  condition  at  the  time  of  the  wounding,  as 
to  excitement,  mental  and  physical,  may  possibly  have  to  do 
with  causing  the  resultant  paralysis. 


1866.] 


PERIPHERAL  IRRITATION. 


423 


Of  the  seven  cases  above  reported,  two  were  in  active  move- 
ment, two  were  standing,  about  taking  aim,  one  was  kneeling, 
one  lying  down,  and  of  two  we  have  no  information  as  to  this 
point.  It  may  prove,  upon  examining  a  larger  number  of 
cases,  that  a  man  wounded  when  moving  violently,  or  when 
excited,  is  more  than  another  liable  to  reflex  paralysis,  but  as 
yet  we  are  not  entitled  to  such  an  inference. 

In  most  of  oui'  cases  the  constitutional  effects  were  instant 
and  severe,  and  could  not  therefore  have  been  due  to  the  loss 
of  blood,  which  in  some  of  them  was  copious.  Four  of  the 
seven  cases  had  stinging,  smarting  or  burning  pain  in  the  part 
paralyzed.  The  pain  was  an  early  symptom,  which  disappeared 
in  all  of  them  after  a  time.  In  three  cases  no  such  pains  were 
complained  of. 

The  after-history  of  these  cases  is  extremely  curious.  How- 
ever grave  the  lesion  of  motion  or  sensation,  it  grew  better 
early  in  the  case,  and  continued  to  improve  until  the  part  had 
nearly  recovered  all  its  normal  powers.  In  almost  every 
instance  some  relic  of  the  paralysis  existed,  even  after  eighteen 
months  or  more  from  the  date  of  the  wound.  In  some  the  part 
continued  weak,  in  others  a  slight  loss  of  sen?ibility  remained, 
and  in  two  the  loss  of  power  and  of  sensory  appreciation  was 
very  considerable,  even  at  a  late  period.) 

I  do  not  propose,  at  this  time,  to  consider  the  subject  of  the 
treatment  of  these  cases.  So  far  as  we  could  judge,  faradiza- 
tion afforded  good  results.  It  was  usually  combined  Avith  good 
diet,  tonics,  and  gentle  use  of  stimulus — agents  such  as  were 
sure  to  afford  good  results  in  men  who  had  been  long  exposed 
to  every  hardship  of  warfare.  In  the  case  of  Lieut.  G.  no 
electricity  was  employed;  but  the  good  effects  of  rest,  with  the 
use  of  tonics  and  stimulants,  were  very  striking.  It  will  be 
observed  that  the  indications  were  derived  rather  from  the 
general  condition  of  our  patients  than  from  any  theory  enter- 
tained by  us  as  to  the  peculiar  condition  of  the  centres  which 
induced  the  palsy. 


424 


BONY  GROWTHS  IN  THE 


[March, 


On  Bony  Growths  in  the  Meatus  Auditorim  Externvs.  By  D. 
B.  St.  John  Roosa,  M.D.,  Clinical  Lecturer  on  Aural  Sur- 
gery and  Oplitlialmology  in  the  University  of  the  City  of 
New  York. 

Case  I. — Mr,  C,  aet.  39,  was  seen  in  April,  1864,  in  consul- 
tation with  Dr.  C.  R.  Agnew,  under  whose  care  he  had  been 
for  some  time.  He  had  lost,  before  coming  under  observation, 
the  hearing  of  his  right  ear,  by  inflammation  and  caries  of  the 
middle  and  internal  ear.  Previous  to  the  above  date  Dr.  A. 
had  removed  a  sequestrum,  consisting  of  the  cochlea  and  semi- 
circular canals,  from  the  depths  of  the  external  auditory  canal 
of  the  ear,  and  thus  terminated  the  inflammatory  action.*  In 
early  life  Mr.  C.  had  also  sufi"ered  from  "  inflammation"  of  the 
left  car,  producing  the  bony  grovrths  in  the  external  auditory 
canal  which  render  his  case  the  subject  of  present  description. 
He  now  hears  with  this  ear  a  Avatch  tick  at  a  distance  of  five 
inches.  In  the  auditory  canal,  near  the  meatus,  are  two 
bony  enlargements,  which  rise  from  the  anterior  and  posterior 
walls,  and  project  in  a  conical  form,  so  as  to  occupy  at  least 
three-fifths  of  its  caliber.  These  tumors  have  all  the  physical 
appearance  of  exostoses,  and  seem  to  have  originated  in  peri- 
osteal inflammation.  They  have  been  steadily  treated  for 
many  weeks  by  the  local  application  of  the  saturated  tincture 
of  iodine,  and  certainly  not  diminished  in  size.  Pressure  upon 
them  excites  pain,  and  induces  an  increase  of  swelling  in  the 
skin  which  covers  them,  and  thus  temporarily  adds  to  the 
deafness.  The  entire  absence  of  hearing  in  the  fellow  ear,  and 
the  failure  of  simple  means  to  render  the  exostoses  smaller, 
have  suggested  the  propriety  of  some  surgical  operation  for 
their  removal. 

Such  a  proceeding  has  been  thus  far  postponed  by  the  occur- 
rence of  an  acute  attack  of  inflammation  in  the  part,  and 
extending  to  the  tympanum,  with  symptoms  of  more  than  usual 
cerebral  irritation.  From  this  disagreeable  complication  he 
has  entirely  recovered,  under  Dr.  Agnew's  care. 

His  general  health  being  impaired  he  went  abroad,  and  while 
in  London  consulted  Mr.  Toynbee,  who  used  bougies,  hoping 


*  TroltBcli's  Diseases  of  tlio  Ear,  p.  210. 


1866.] 


MEATUS  AUDITOEIOUS  EXTERNUS. 


425 


to  dilate  the  canal;  but,  according  to  Mr.  C.'s  statements,  they 
caused  much  pain  and  accomplished  nothing.  Through  Dr. 
Agnew's  courtesy  I  again  saw  the  patient  in  the  spring  of  1865, 
and  found  that  the  growths  had  so  increased  that  only  a  small 
probe  could  be  passed  between  them,  and  the  hearing  more 
impaired.  The  patient  could  still,  however,  hear  the  watch 
tick,  but  only  when  laid  on  the  auricle.* 

Case  II. — A  gentleman,  sot.  40,  whom  I  saw  but  once,  in 
June,  1864.  He  states  that  he  had  a  "  running  "  from  his  right 
ear  for  a  number  of  years.  For  some  two  or  three  years  past 
he  had  observed  that  the  ear  was  stopped  up.  He  was  accus- 
tomed to  remove  the  accumulating  discharge  by  thrusting  in  a 
match  armed  with  cotton.  There  is  seen  a  bony  growth  arising 
from  the  posterior  wall  of  the  meatus,  and  involving  the  whole 
caliber  of  the  canal,  except  a  space  large  enough  to  admit  an 
ordinary  sized  silver  probe.  Through  this  opening  a  slight 
amount  of  purulent  discharge  constantly  makes  its  way.  There 
was  some  hyperajmia  of  the  pharynx,  and  there  was  a  small 
ulcer  on  one  of  the  tonsils.  The  patient  was  in  excellent 
general  health,  was  rather  a  free  liver,  and  said  he  had  con- 
stitutional syphilis,  but  no  good  evidence  of  its  existence  now 
existed.    The  patient  had  never  had  rheumatism  or  gout. 

Case  III. — Mr.  S.,  set.  25,  Conn.,  February  6, 1865,  (a  patient 
sent  to  me  by  Dr.  Alfred  North,  of  Waterbury.)  When  the 
patient  was  three  or  four  years  of  age  he  had  scarlet  fever,  at 
which  time  his  ears  began  to  discharge,  and  they  have  continued 
to  do  so  at  intervals  ever  since,  with  attacks  of  pain  in  the 
ears,  which  sometimes  lasted  for  weeks,  and  prevented  him  from 
any  occupation  for  the  time.  Eight  years  ago  his  cars  were 
examined  and  polypi  discovered,  one  of  which  was  removed  by 
caustics.  The  attacks  of  pain  have  continued  to  occur,  the 
discharge  continues,  and  his  hearing  is  becoming  more  and 


*  Since  the  above  article  was  written,  and  while  it  was  in  the  priulor's 
hands,  the  patient  whose  case  is  here  f,'ivou  has  died  of  inflammation  of  the 
membranes  of  the  brain,  induced  by  suppuration  in  the  cavity  of  the  tym- 
panum, the  pus  not  being  able  to  find  an  outlet,  on  account  of  the  presence 
of  the  exostoses.  Dr.  Agnew  exhibited  the  brain  and  temporal  bones  before 
the  New  York  Pathological  Society,  and  projjoscs,  at  some  future  time,  to  pre- 
sent to  the  profession  a  complete  history  of  this  unique;  case. 


426 


BONY  GROWTHS  IN  THE 


[March, 


more  impaired.  He  is  just  now  suffering  from  acute  pain  re- 
ferred to  the  left  car.  He  hears  the  watch  about  one  inch 
from  each  ear. 

In  the  right  meatus  there  is  seen  a  bony  growth  reaching 
nearly  out  to  the  orifice  of  the  external  meatus,  and  arising 
from  the  posterior  wall.  The  space  between  the  growth  and 
the  anterior  and  upper  wall  is  about  large  enough  to  admit  of 
the  introduction  of  a  camel's  hair  brush.  In  the  left  meatus 
there  is  seen  a  gelatinous  granulation,  also  reaching  nearly  out 
to  the  orifice  of  the  meatus. 

On  blowing  air  into  the  cavity  of  the  tympanum,  by  means 
of  the  eustachian  catheter,  air  and  fluid  are  heard  making  their 
exit  into  the  external  meatus,  but  the  blocking  up  of  this  pas- 
sage prevents  their  emergence.  On  the  right  sight  pus  may  be 
seen  in  the  orifice  between  the  bony  growth  and  the  wall  of  the 
meatus. 

The  confinement  of  the  fluid  in  the  middle  ear  accounts  for 
the  pain  in  the  left  side,  and  the  indication  of  treatment  was  to 
secure  its  free  exit.  This  was  done  by  removing  the  gelatinous 
growth  by  torsion,  the  patient  being  etherized,  and  rendering 
the  eustachian  tubes  permeable  by  the  use  of  the  well  known 
means,  the  catheter  and  Politzer's  method.  The  granulation  was 
found  to  have  its  origin  from  a  general  bony  expansion  of  the 
meatus.  This  growth  had  no  one  point  of  attachment,  but 
involved  all  the  sides  of  the  meatus,  rather  more  expanded 
externally,  giving  the  bony  canal  rather  a  funnel-shaped  ap- 
pearance. The  bone  was  roughened.  The  pain  in  the  car 
disappeared  as  soon  as  these  means  for  securing  an  outlet  to 
the  pus,  constantly  secreted  from  the  cavity  of  the  tympanum, 
and  passing  through  the  perfoi'ated  membrana  tympani,  had 
been  taken,  and  the  hearing  was  so  much  improved  that  the 
watch  was  heard  about  four  inches  from  the  left  auricle.  He 
remained  under  treatment  for  a  few  days,  and  then  returned  to 
Waterbury,  and  has  been  under  the  careful  and  able  observa- 
tion of  Dr.  North,  who  has  applied  tincture  of  iodine  to  the 
exostosis  of  the  right  side,  astringents  of  various  kinds  to  the 
left  meatus,  the  patient  keeping  the  eustachian  tubes  permeable 
by  means  of  gargles  and  Politzer's  apparatus. 

The  last  time  I  saw  the  patient  was  in  October  of  this  year, 


1866.] 


MEATUS  AUDITORIUS  EXTERNUS. 


427 


(1865,)  when  the  following  note  was  made.  "He  has  had  no 
attack  of  pain  in  the  ear  since  the  first  date.  There  is  still  a 
considerable  discharge  of  pus  from  each  ear.  He  hears  ordi- 
nary conversation  well,  and  the  watch  ten  inches  from  his  left 
ear,  and  two  inches  on  the  right — a  gain  of  one  inch  and  nine 
inches  respectively."  The  bony  growth  on  the  right  side  has 
not  increased  any,  and  that  on  the  left  is  now  smooth  and  has 
a  somewhat  glistening  appearance. 

Case  IV.— Woman,  a^t.  27,  at  the  N.  Y.  Eye  and  Ear  In- 
firmary. No  reliable  history  could  be  obtained  from  the 
patient  as  to  her  ears,  except  that  she  had  been  occasionally 
hard  of  hearing  for  some  years.  She  was  quite  sure  that  she 
never  had  had  a  discharge  from  the  ears;  was  in  good  general 
health,  and  had  always  been  so.  She  could  hear  the  watch  two 
feet  from  the  left  auricle,  and  twelve  inches  from  the  right. 
The  left  membrana  tympani  showed  evidences  of  previous 
inflammatory  action,  there  being  thickening  of  its  mucous  and 
fibrous  layers.  There  is  a  bony  enlargement  of  the  posterior 
wall  of  the  right  meatus,  so  large  as  to  prevent  any  view  of 
the  membrana  tympani.  The  patient  was  seen  but  a  few  times, 
not  continuing  under  treatment. 

Remarks. — As  has  been  indicated  in  the  respective  histories, 
these  growths  were  rather  general  enlargements  of  the  perios- 
teum, and  of  the  bone  structure  immediately  beneath,  than 
tumors — true  exostoses.  Their  nature  seemed  to  be  inflamma- 
tory, or,  rather,  hypertrophic.  Perhaps  all  the  similar  growths 
recorded  in  the  literature  of  aural  surgery  are  of  this  character, 
i.  e.,  morbid  grotuths  consequent  on  local  irritation} — the  irritating 
cause  in  these  cases,  with  one  exception,  the  last,  being  clearly 
ascertained  to  be  the  contact  of  pus  passing  from  the  middle 
ear.  The  process  in  its  inception  was  probably  a  periostitis, 
which  may  exist  independently  of  any  dyscrasia.  Mr.  Toynbce 
details  nine  cases  in  his  well  known  work  on  the  Diseases  of 
the  Ear,  and  remarks  that  "  Ihoy  seem  to  be  the  result  of  a 
rlieumatic  or  gouty  diathesis."  This  certainly  can  not  he  said 
of  the  cases  here  given,  and  a  careful  examination  of  the  his- 
tories of  Mr.  Toynbec's  cases  has  caused  considerable  doubt,  to 
the  present  writer,  as  to  whether  they,  too,  were  not  rather  to 
be  ascribed  to  local  inflammatory  action  than  to  a  diathesis. 


428 


BONY  GROWTHS  IN  THE 


[March, 


Virchow's  views  as  to  the  etiology  of  bony  growths  in  general 
may  here  be  given.  "  With  respect  to  the  etiology  of  the 
hyperplastic  osteomata,  the  fact  can  not  be  lost  sight  of  that  local 
impressions  were,  in  very  many  cases,  the  exciting  cause. 
According  to  experience,  entirely  positive  and  generally  very 
I'ude  mechanical  injuries  form  the  ordinary  starting  point  of 
the  morbid  process,  and,  as  has  been  already  shown,  this  process 
presents  itself  substantially  as  an  irritative  one,  often  even  as 
inflammatory,  so  that  a  boundary  between  bony  products  of 
inflammation  and  osteomata  can  not  generally  be  drawn."* 

"  Some  have,  indeed,  educed  the  frequent  cases  where  certain 
constitutional  diseases,  especially  rheumatism,  arthritis,  syphilis, 
scorbutus,  rachitis,  have  produced  bony  tumors,  as  being 
something  opposed  to  these  local  causes.  Undoubtedly  the 
field  of  these  conditions  was  formerly  too  widely  extended,  and 
we  may  say  that  scorbutus  is  now  almost  entirely  excluded 
from  the  list  of  causes,  and  that  the  gouty  enlargements  of  bone 
are  no  growths,  (gewachse,)  but  only  deposits,  (ablagerungen.) 
But  we  may  not  deny  the  influence  of  the  other  so-called  dys- 
crasia,.  especially  of  the  rheumatic,  syphilitic,  and  rachitic 
conditions.  In  spite  of  this,  the  influence  must  not  be  over- 
estimated," etc. 

'"As  to  rheumatism  and  syphilis,  we  may  not  here  even  content 
ourselves  with  assigning  constitutional  causes,  for  the  affection 
of  one  single  bone  must  always  be  considered  as  dependent 
on  a  local  impression." 

As  also  interesting  in  considering  thi^  subject  of  bony 
growths,  parts  of  an  article  by  Professor  Welcker,  of  Halle, 
are  here  reproduced. t 

"  Professor  Seligmann  has  made  the  interesting  statement 
that,  in  the  various  American  skulls  found  in  different  collec- 
tions, skulls  known  as  Titicaians,  Huankas,  Aymaras,  and 
■which  have  been  elongated  by  pressure  during  infancy,  exostoses 
in  the  external  auditory  canal  are  very  common.  He  says,  of 
six  skulls  which  I  have,  up  to  this  time,  examined,  five  have 
such  exostoses.  In  the  very  similarly  deformed  so-called 
Avarian  skulls,  exostoses  did  not  exist.    This  is  certainly  a 

*  Die  Kraiikhaften  Geschvviilte.    11.  Band.,  I.  llalfte,  p.  73  et  seq.,  passim, 
t  Archiv  liir  Ohrenheilkunde.    I.  Baud.,  III.  llalfte,  18G-t. 


1866.] 


MEATUS  AUDITORIUS  EXTERNUS. 


429 


remarkable  phenomenon,  and  may  well  justify  the  inquiry,  are 
these  exostoses  a  peculiarity  of  race,  or  are  they  a  certain  pro- 
duction of  an  injurious  cause,  especially  efiBcacious  in  this  race  ? 
My  honored  friend,  Professor  Seligmann,  has  promised  us  a 
closer  examination  as  to  this.  Still,  I  do  not  think  that  he 
will  be  able  to  maintain  his  ])resent  opinion,  which  is  that  this 
abnormity  is  found  only  in  the  class  of  skulls  above  named. 
My  memorandum  of  the  examination  of  a  North  American  Fox 
Indian,  No.  229  of  the  Heidelberg  collection,  reads, '  exostoses 
in  the  auditory  canals.'  Of  nine  skulls  of  Marquesau  Islanders, 
which  neither  belong  to  the  American  race  nor  exhibit  a  trace 
of  artificial  deformity,  I  found  aural  exostoses  in  two,  one  of 
which  was  in  an  advanced  stage  of  development.  To  this  must 
be  added,  that  in  the  civilized  nations  of  Europe  these  exostoses 
arc  by  no  means  as  seldom  as  the  writers  on  aural  surgery 
indicate,  and  I  believe,  after  thoroughly  reviewing  the  collec- 
tion described  by  C.  0.  Weber,  (Die  Exostosen  und  Enchon- 
drome,  Bonn,  1856,)  that  the  meatus  anditorhis  exfernvs  may 
be  designated  as  a  peculiarly  favorite  position  for  these  growths. 
The  appearance  of  these  exostoses  as  one  of  the  well  known 
consequences  of  disease,  is  by  no  means  the  view  of  Professor 
S.,  but  he  regards  them  as  peculiar  to  the  Titicaian  skulls.  But 
I  can  not  agree  with  him  in  thinking  that  the  exostoses  of  that 
foreign  race  should  be  considered  as  any  thing  different  from 
the  same  well  known  object  appearing  on  the  German  skull, 
and  recognized  by  aural  surgeons.  We  are,  however,  indebted 
to  the  studies  of  Professor  b'eligmann  for  the  knowledge  of  the 
certainly  not  uninteresting  fact  that  these  exostoses  occur  much 
more  frequently  in  the  transatlantic  skulls  than  in  those  of  the 
population  of  our  own  continent.  Thus,  in  the  examination  of 
the  skulls  of  foreign  races,  I  have  found  the  three  before  named 
cases  of  aural  exostoses,  while  in  the  Caucassian  skiills,  which 
I  have  examined  in  a  much  larger  number,  1  have  not  as  yet 
met  with  an  aural  exostosis." 

As  to  the  treatment  of  these  morbid  growths  we  can  say  but 
little.  Constitutional  treatment  is  of  no  avail,  and  thus  far 
local  means  have  not  accomplished  much.  Considering  them 
as  consequences  of  long  existing  inflammation,  our  therapeutic 
resources  are  mainly  prophylactic.  If  the  primary  disease  of 
the  ear  be  attended  to  the  growths  will  not  occur. 


430 


HYPOSULPHITE  OP  SODA 


[March, 


Tka  Hjipo'iulphite  of  Soda  in  Scarlet  Fevzr.     Will  it  •prevent 
the  Disease?    By  N.  L.  North,  M.D.,  Brooklyn.  N.Y". 

There  is  a  great  popular  dread  of  scarlet  fever  in  all  civil- 
ized communities — more  than  of  any  other  of  the  so-called 
ordinary  exanthemata.  Vaccination  has  wonderfully  mitigated 
the  fear  of  small-pox,  and  measles  is  generally  looked  upon  as 
a  complaint  of  little  moment.  But  scarlatina,  having  cut  down 
the  favorite  flower  of  so  many  families,  and  left  its  incurable 
sequelae  to  mar  the  physical  powers  or  appearance  of  so  many 
other  loved  ones,  has  come  to  be  looked  upon  as  a  lion  in  the 
path  of  life  by  fond  parents  the  world  over.  Whatever,  then, 
may  be  found  in  the  way  of  treatment  to  lessen  its  virulence  or 
prevent  its  occurrence,  will  be  hailed  by  the  public,  as  well  as 
by  the  profession,  as  of  vast  importance. 

Belladonna  has  been  claimed  as  a  prophylactic,  and  very 
likely  does  exert  some  influence  in  that  direction;  but  it  is  so 
uncertain  in  its  effects  as  to  have  almost  entirely  fallen  into 
disrepute  and  disuse.  Domestic  remedies  to  "prepare  the 
system  for  scarlet  fever,"  or  to  prevent  it,  are  as  numer- 
ous almost  as  the  cases  themselves.  Some  seven  or  eight 
years  ago  I  was  attending  a  family,  when  one  of  the  chil- 
dren was  taken  sick  with  this  disease,  and,  as  usual,  the 
child  was  medicated  before  the  "  doctor"  had  been  sent  for, 
and  in  this  case  "  cream  of  tartar  and  sulphur"  was  the  cure-all, 
and  the  patient  had  liad  its  dose,  and  I  was,  upon  my  arrival, 
called  upon  for  permission  to  have  it  given  the  other  (healthy) 
children  as  a  preventive.  I  assented,  and  to  my  astonishment, 
and  to  the  great  gratification  and  pride  of  the  "  friend  of  the 
family,"  who  had  suggested  it,  none  of  the  other  of  the  nume- 
rous children  of  the  family  were  attacked  by  the  disease.  As, 
however,  that  was  no  uncommon  occurrence,  and  knowing  that 
scarlet  fever  does  often  attack  one  or  more  members  of  a  family 
and  not  all,  I  thought  very  little  of  the  circumstance  until  in 
the  same  neighborhood  I  saw  and  heard  of  the  same  thing  being 
repeated  several  times  with  the  same  result,  when  I  thought 
it  worth  while  for  me  to  try  it.  Accordingly  1  Ijegan  giving 
the  "cream  of  tartar  and  sulphur"  also,  to  "prevent  F-jarlet 
fever;"  and,  though  it  often  failed  in  its  work  of  prevention. 


1866.] 


IN  SCARLET  FEVER. 


431 


I  could  but  think  that  it  sometimes  had  prophylactic  power; 
and  believing  it  to  be  the  sulphur,  I  concluded  to  combine  that 
drug,  in  its  precipitated  form,  with  the  extract  of  belladonna, 
and  give  it  in  all  cases  where  children  coming  under  my  care 
had  been  exposed  to  the  scarlatinal  poison,  and  I  believe  often 
with  the  effect  of  preventing  the  disease. 

After  the  promulgation  of  Dr.  Pallis'  theory  of  the  use  and 
effect  of  the  sulphites  and  hyposulphites  in  the  zymotic  diseases, 
and  after  I  had  seen  something  of  its  use  in  typhoid  fever,  I  con- 
cluded to  give  this  remedy  a  trial  in  scarlatina,  and  have  since 
given  it  very  frequently  as  a  remedy  of  much  power,  as  I  be- 
lieve, in  controlling  the  symptoms  of  the  developed  disease,  by 
eliminating  or  destroying  the  poison,  and  also  as  a  prophylactic. 

On  the  12th  of  February,  1865, 1  was  called  to  attend  a  little 
child  of  Mr.  T.,  of  this  city.  The  child  was  about  one  and  a 
half  years  of  age,  and  suffering  with  a  severe  attack  of  scariatina- 
anginosa.  I  gave  five  grains  of  hyposulphite  of  soda,  dissolved 
in  syrup  and  water,  every  four  hours,  and  ordered  that  the  well 
child,  who  was  about  three  years  of  age,  should  have  the  same 
dose  three  times  a  day.  The  patient  improved  rapidly  and  with 
ordinary  attention  soon  recovered,  and  the  other  child  showing 
no  symptoms  of  the  disease,  the  medicine  was  discontinued 
after  five  days. 

In  the  early  part  of  June,  1865,  I  was  called  to  attend  Miss 
S.,  a  stout  girl,  of  fifteen  years  of  age,  who  had  been  exposed  to 
and  had  taken  scarlatina,  which  was,  when  first  seen  by  me, 
fully  developed.  I  used  the  same  remedy  in  ten-grain  doses 
every  three  hours,  and  gave  five  grains  three  times  a  day  to  a 
little  girl  of  four  years,  who  had  been  with  her  most  of  the 
time  since  she  had  been  complaining,  and  who  continued  to 
stay  with  and  around  her  during  her  whole  sickness.  The 
patient  recovered  rapidly,  seeming  to  be  favoi*ably  afi'ected  by 
the  hyposulphite,  and  the  little  girl,  with  whom  the  medicine 
was  continued  a  week,  had  no  symptoms  whatever  of  the  com- 
plaint. 

Again,  by  reference  to  my  notes,  I  find  an  interesting  case, 
commencing  April  4,  1865.  Mr.  F.  has  two  interesting  girls, 
cue  eight  and  the  other  two  years  of  age.  The  eldest  was 
taken  sick  with  scarlet  fever;  and  I  commenced  giving,  in  con- 


432  HYPOSULPHITE  OP  SODA  IN  SCARLET  FEVER.  [March, 

nection  with  other  remedies,  the  hyposulphite  of  soda,  in  five  to 
eight  grain  doses  every  three  or  four  liours,  and  three  grains 
three  times  a  day  to  the  little  one.  After  the  first  day's  treat- 
ment I  myself  was  taken  ill,  and  obliged  to  ask  a  neighboring 
physician  to  take  charge  of  my  patients,  which  he  very  kindly 
did,  including  the  scarlet  fever  patient.  After  three  days  I 
again  got  about,  and  was  advised  by  my  friend,  who  had  at- 
tended my  business,  to  be  sure  to  see  this  scarlet  fever  patient 
early,  as  he  thought  it  very  probable  I  should  lose  her.  I  did, 
and,  of  course,  as  I  had  not  urged  it,  the  hyposulphite  treat- 
ment was  not  followed  either  for  the  child  with  the  fever  or 
the  one  exposed  to  it.  I  immediately  returned  to  the  plan  of 
treatment  I  commenced  upon,  and  in  twenty-four  hours  there- 
after my  patient  was  much  improved.  I  also  gave  the  medi- 
cine to  the  little  child,  but  not  to  my  satisfaction,  as  it  pro- 
duced a  cathartic  effect,  and  I  was  obliged  to  discontinue 
it.  About  seven  days  from  the  time  I  was  first  called,  the 
older  child  was  fairly  convalescent,  but  the  younger  began  to 
complain,  and  show  symptoms  of  the  approaching  malady,  so 
that  I  now  gave  to  her  the  medicine  in  smaller  but  frequently 
repeated  doses,  and  after  some  three  days  of  listlessness,  with 
poor  appetite  and  slight  soreness  of  the  throat,  she  commenced 
improving,  and  had  no  further  symptom  of  the  disease.  About 
the  ninth  day  from  the  attack  of  the  first  child,  one  of  the 
attendants,  a  miss  of  eighteen,  who  had  never  had  the  fever, 
began  to  complain  of  headache,  sore  throat,  &c.,and  was  much 
frightened.  To  her  I  gave  ten  grains  of  hyposulphite  of  soda 
every  two  hours,  and,  after  about  sixteen  hours,  catharsis  com- 
menced with  relief  of  the  symptoms.  She  continued  the  medi- 
cine, ten  grains  three  times  a  day,  for  four  or  five  days,  and  had 
no  further  symptoms  of  scarlatina,  except  that  the  throat  was 
not  entirely  well  for  four  or  five  days. 

Mr.  S.  has  a  family  of  five  children,  all  quite  young,  none 
of  them  ever  having  had  scarlet  fever.  Was  called,  June 
27,  1865.  to  see  the  youngest,  a  cliild  of  two  years  of  age, 
who  was  covered  with  the  scarlatinal  eruption,  had  a  very  sore 
tliroat,  and  who  otherwise  presented  unmistakable  symptoms 
of  scarlet  fever.  I  used  the  hyposulphite,  with,  however,  not 
very  marked  good  effect,  so  that  I  had  to  fall  back  on  old 


1866.]  VERSION  BY  EXTERNAL  MANIPULATION. 


433 


remedies.  The  child  finally,  after  a  very  severe  and  protracted 
sickness,  recovered.  The  peculiarly  interesting  part  of  this 
memorandum  is  that  the  other  four  children  were  given  the 
hyposulphite,  according  to  their  several  ages,  and  not  one  of 
them  took  the  disease. 

One  other  note  and  I  will  close.  A  Mr.  B.,  of  Wilson  street, 
this  city,  has  brought  up  a  large  family,  and  all  have  had 
scarlet  fever,  and  suffered  terribly,  except  two  of  the  younger 
ones.  I  was  called  in  haste,  on  November  24th,  1865,  to  see 
the  youngest  of  these  two,  and  found  a  well  marked  and  well 
developed  case  of  scarlatina.  I  immediately  resorted  to  the 
hyposulphite  of  soda  for  both  the  sick  one  and  the  well  one,  and 
had  the  satisfaction  of  seeing  the  sick  one  recover  rapidly  from 
a  severe  form  of  the  disease,  with  no  other  remedy  than  the 
one  mentioned  and  some  chlorine  water  as  a  gargle  for  the 
throat.  The  other  child,  although  in  the  room  with  the  sick 
one  most  of  the  time,  presented  no  symptoms  whatever  of  the 
complaint, 

I  am  not  so  sanguine  as  to  suppose  that  we  have  in  the  hypo- 
sulphite of  soda  an  unfailing  remedy  for  this  dreaded  malady, 
or  even  a  positive  prophylactic;  yet  I  have  a  strong  belief  that 
it  may  prove  beneficial  both  in  the  treatment  and  prevention 
of  scarlet  fever.  I  have  hastily  recorded  these  brief  notes  of 
cases,  with  the  hope  that  they,  may  have  the  efi"ect  of  inducing 
others  to  try  the  remedy  and  report  upon  its  effect. 


A  Case  of  Version  hy  External  Manipulation.  By  J.  B.  Rey- 
nolds, M.D.,  Physician  to  Demilt  Dispensary;  Visiting 
Physician  to  the  Colored  Home. 

Mrs.  C,  aged  35,  fell  in  labor  with  her  fourth  child,  having 
had  one  miscarriage.  From  her  former  physician,  as  well  as 
from  herself,  I  obtained  the  following  account  of  her  three 
previous  labors. 

First,  presented  breech,  child  lost;  the  second,  breech,  child 
born  nearly  asphyxiated,  but  was  resuscitated  and  is  now  living; 
and  the  third,  child  presented  transverse,  with  its  back  anterior 
and  the  head  in  the  left  side.    The  child  was  turned  in  the 

Vol.  11.— No.  12.  28 


434 


VERSION  BY  EXTERNAL  MANIPULATION.  [March, 


usual  way,  by  introducing  the  hand  within  the  uterus,  seizing- 
the  lower  extremities,  and  delivering,  but  the  respiration  could 
not  be  established. 

I  was  called  at  noon  of  November  9th,  1865,  and  having 
been  forewarned  that  she  had  never  had  a  natural  labor,  I 
went  prepared  for  trouble.  Saw  her  at  a  quarter  past  one 
P.M.,  and  found  her  in  labor  for  five  or  six  hours,  but  the  pains 
were  very  feeble,  and  at  long  intervals.  Examining  per  vagi" 
nam,  I  found  the  os  largely  dilated,  and  the  bag  of  water  pout- 
ing, but  could  feel  no  presenting  part.  Upon  introducing  my 
hand  into  the  vagina  and  pushing  up  the  membranes  in  the  in- 
terval of  a  pain,  I  could  feel  the  ribs,  but,  fearing  lest  I  should 
rupture  the  membranes,  I  withdrew  my  hand  to  examine  the 
abdomen  externally.  At  this  time  the  patient  informed  me 
that  I  need  not  fear  to  tell  her  that  it  was  a  cross-birth,  for 
she  was  fully  aware  of  it,  as  it  was  exactly  like  the  last,  where 
the  doctor  turned.  The  motion  of  the  child,  she  complained, 
was  very  severe  upon  the  right  side,  high  up,  and  opposite  to 
it  she  often  felt  and  could  see  a  large  round  mass,  or  ball,  as 
she  called  it,  roll  up  and  down,  causing  the  surface  of  the  ab- 
domen to  stand  out  in  bold  relief.  Upon  palpation,  I  found  a 
hard  round  mass  in  the  left  hypochondrium,  a  soft  mass  upon 
the  right  side,  and  a  hollow  between.  The  foetal  heart  was 
heard  over  the  whole  front  of  the  abdomen,  with  summum  of 
intensity  a  little  to  the  left  of  and  below  the  umbilicus.  Fear- 
ing the  ruptiire  of  the  membranes,  I  concluded  immediately  to 
try  to  turn  by  external  manipulation,  especially  as  the  pains 
were  not  strong,  and  about  ten  minutes  apart.  Being  upon  the 
right  side  of  the  patient,  and  having  the  knees  flexed  and  ab- 
dominal wall  perfectly  relaxed,  I  pressed  down  the  head  with 
the  right  hand,  at  the  same  time  pressing  up  the  breech  with 
my  left.  By  steady  pressure  and  moulding,  being  obliged  to 
desist  but  once  by  a  pain,  in  less  than  five  minutes,  and  with 
surprising  ease,  the  head  was  lodged  within  the  crest  of  the 
left  ilium,  in  the  pubic  region,  while  the  breech  occupied  the 
left  epigastric  region.  The  uterine  mass,  at  this  time,  formed 
a  concavo-convex  shaped  tumor,  with  concavity  looking  to  the 
left.  The  head,  deep  within  the  crests  of  the  ilijE,  could  be 
grasped  and  moved  by  the  hands  externally.    She  now  com- 


1866.]      CONGENITAL  HYPERTROPHY  OP  THE  TONGUE.  435 

plained  considerably  from  the  severity  of  the  foetal  movements 
in  the  epigastrium.  The  foetal  heart  was  now  most  distinct  a 
little  to  the  right  of  the  median  line.  Examining  again  with 
the  hand  in  the  vagina,  by  pressing  up  the  membranes  •  I  felt 
the  foetal  head.  The  membranes  were  quite  tough,  and  re- 
quired some  trouble  in  rupturing  them.  The  os,  before  well 
dilated,  contracted  down  to  the  size  of  a  half  dollar  after  the 
waters  came  away,  having  been  twisted  forward  closely  to  the 
pubis,  and  the  outlet  for  the  waters  seeming  to  have  been  carried 
up  within  the  edges  of  the  os  as  a  second  bag  began  to  pout,  but 
by  pressure  upon  it  the  liquor  amnii  flowed  away  from  within 
the  OS.  The  head  was  held  in  place,  though  there  seemed  no 
tendency  to  slip,  for  over  three  hours,  before  it  fully  engaged 
within  the  brim.  About  iive  p.m.,  I  thought  I  felt  a  fonta- 
nelle  and  suture,  but  could  not  make  out  the  position.  Two 
hours  later,  the  pains  still  being  feeble,  but  the  head  slowly 
descending  and  the  foetal  heart  beating  regularly,  I  became 
very  doubtful  of  the  presenting  part  being  the  vertex,  and  at 
eight  o'clock  the  chin  separated  and  the  face  soon  cleared  the 
vulvae,  the  chin  looking  up  and  to  the  left.  I  had  converted  a 
transverse  into  a  face  presentation.  The  mother  and  child  are 
doing  well. 


Congenital  Hi/pert rophy  of  the  Tongue.    Amputation.  By 
Alfred  Bolter,  M.D.,  Ovid,  N.  Y. 

The  subject  of  this  malformation  is  a  daughter  of  G.  K.,  a 
resident  of  Seneca  county,  of  this  state.  She  is  now  a  little 
over  three  years  of  age — is  of  large  physical  development,  and 
of  healthy  parentage.  With  the  exception  of  a  severe  attack 
of  diphtlieria  in  the  fall  of  1864,  the  child  has  always  been 
healthy. 

The  unusual  size  of  its  tongue  was  noticed  at  its  birth,  andi 
the  mother  says,  continued  to  grow  with  its  growth.  It  mate- 
rially interfered  with  the  process  of  suction,  but  did  not  wholly 
prevent  it. 

My  attention  was  not  called  to  the  case  until  after  the  pe- 
riod of  dentition.    The  tongue  was  then  protruding  from  the 


436  CONGENITAL  HYPERTROPHY  OF  THE  TONGUE.  [March, 

mouth  to  the  extent  of  something  more  than  an  inch.  Its  ap- 
pearance was  tumefied,  red  and  glossy,  as  if  inflamed.  But  I 
soon  discovered  that  this  was  not  the  case.  There  was  no 
unusual  heat,  or  tenderness,  or  febrile  excitement.  It  was 
obviously  a  case  of  preternatural  growth,  or  abnormal  enlarge- 
ment, and  not  one  of  disease,  any  more  than  an  extra  finger  or 
toe  would  be.  I  advised  nothing  to  be  done  except  the  remo- 
val, by  the  knife,  of  so  much  of  the  organ  as  prevented  the 
teeth  and  lips  from  coming  together.  After  explaining,  as  fully 
as  possible,  to  the  parents,  the  nature  of  the  operation — its 
dangers  and  probable  and  possible  results,  they  determined, 
after  long  deliberation,  that  it  should  be  done. 

Accordingly,  on  the  12th  of  December  last  I  proceeded  to 
the  work,  assisted  by  Doctors  Post,  Morris  and  Woodward.  I 
should  here  remark  that  the  child,  at  this  time,  was  in  perfect 
general  health.  But  its  tongue  had  become  a  much,  more  un- 
sightly and  disgusting  deformity.  It  was  constantly  dribbling 
with  saliva,  and  parts  of  the  exposed  surface  were  blackened, 
dried  and  shriveled.  Fissures  traversed  those  parts,  from 
which  flowed  considerable  quantities  of  bloody  serum.  This 
was,  no  doubt,  very  much  aggravated  by  the  child  frequently 
picking  the  surface  of  the  tongue  with  its  fingers.  The  coun- 
tenance of  the  child  was,  of  course,  filthy  and  revolting,  despite 
every  parental  effort  at  cleanliness.  From  the  size  of  the 
tongue,  the  orifice  of  the  mouth  appeared  nearly  circular,  and 
to  be  entirely  filled  when  the  features  were  in  repose.  The 
under  lip  was  everted  upon  the  chin,  and  the  lower  incisor  and 
canine  teeth,  covered  with  tartar,  were  projected  obliquely  for- 
ward. The  tongue  was  of  firm  and  cartilaginous  consistence, 
but  with  no  unusual  sensitiveness  to  the  touch. 

"When  every  thing  was  made  ready  for  the  operation,  the  pa- 
tient was  put  under  the  influence  of  chloroform  and  sulphuric 
ether,  in  the  proportion  of  one  part  of  the  former  to  two  of  the 
latter.  She  readily  became  insensible.  Her  limbs  and  body 
were  then  firmly  wound  with  strong  toweling,  so  that  all  mo- 
tion might  be  easily  prevented;  for  in  that  case  I  was  appre- 
hensive that  it  might  be  impossible^  or  very  difficult,  to  repeat 
the  anesthetic  on  account  of  hemmorhage.  The  child  was  then 
held  in  a  sitting  posture,  in  the  lap  of  an  assistant,  and,  taking 


1866.]      CONGENITAL  HYPERTROPHY  OP  THE  TONGUE.  437 


a  chair  directly  in  front,  I  first  passed  a  strong  ligature  through 
the  body  of  the  tongue,  for  the  purpose  of  enabling  me  to  hold 
it  with  more  facility.  Then  drawing  the  organ  forward,  I 
thrust  a  straight,  sharp-pointed  bistoury  underneath,  pushing 
it  obliquely  backwards  and  upwards,  and  bringing  out  the 
point  near  the  median  line,  and  then  cutting  obliquely  out- 
wards towards  the  canine  teeth,  thus  making  the  left  flap. 
After  securing  the  raninal  artery,  the  only  one  that  required 
ligature,  I  then  passed  through  this  left  flap,  laterally,  a  double 
suture,  for  the  twofold  purpose  of  joining  it  to  its  fellow,  soon 
to  be  made  on  the  other  side,  and  also  to  give  me  control  of 
the  organ  after  the  part  to  be  removed  was  entirely  separated 
and  the  tongue  retracted  within  the  mouth. 

The  instrument  was  then  again  passed  through  to  form  a 
corresponding  flap  on  the  right  side,  leaving,  however,  a  nar- 
row central  septum  uncut  until  the  bleeding  vessels,  two  in 
number,  were  tied.  This  part  was  then  divided,  and  the  piece 
removed  was  in  the  shape  of  an  inverted  letter  A. 

The  tongue,  now  forked  in  shape,  retracted  within  the  mouth. 
The  next  step  was  to  draw  it  forward  by  means  of  the  suture 
already  passed  through  the  left  flap,  and  then  to  pass  the  same 
suture  through  the  right  flap  from  its  inner  face  to  the  side, 
then  approximating  the  cut  surfaces  of  both  flaps  firmly  to- 
gether, and  securing  them  in  that  way,  by  dividing  the  suture, 
and  tying  one  part  on  the  dorsum  and  the  other  underneath  the 
tongue.  The  extremities  of  the  flaps  were  then  brought  to- 
gether by  a  single  suture  passed  from  side  to  side  and  tied  upon 
the  apex.  This  completed  the  operation,  and  a  pointed,  well 
formed  tongue  was  made,  witli  no  part  of  cut  surface  exposed. 
The  time  consumed  in  the  whole  of  this  work  was  about 
twenty-five  minutes. 

The  piece  removed  was  one  inch  and  five-eighths  in  length, 
one  inch  in  vertical  thickness,  and  five  inches  and  five-eighths 
in  circumference.    This  was,  relatively,  an  enormous  growth. 

All  the  cases  recorded,  that  have  fallen  under  my  observa- 
tion, have  been  those  of  adults,  and  while  they  have  been  de- 
scribed as  of  much  larger  proportions,  it  will  doubtless  be  con- 
ceded that  tlie  case  I  have  detailed  exceeds  them  all,  when  the 
age  and  development  of  the  parties  are  taken  into  the  account. 


438  CONGENITAL  HYPERTROPHY  OF  THE  TONGUE.  [March, 

The  hemorrhage  attendant  upon  this  operation,  although  con- 
siderable, was  quite  easily  controlled.  The  oozing  of  blood  was 
very  little  after  the  sutures  were  adjusted. 

The  iuflammation,  for  several  days,  was  severe,  causing  the 
tongue  to  swell  so  largely  as  quite  to  prevent  deglutition  even 
of  the  blandest  fluids,  and  rendering  the  child,  most  of  the 
time,  restless  from  pain.  This  acute  state  passed  pleasantly 
away  about  the  fourth  day,  when  the  ligatures  from  the  arteries 
came  off  spontaneously.  The  treatment  consisted  of  cold  ap- 
plications and  washings,  mainly,  with  a  very  limited  use  of 
antimonials  and  opiates. 

The  sutures  were  not  removed  until  the  tenth  day,  when  the 
union  was  nearly  complete. 

The  recovery  of  the  cliild  has  been  rapid,  and  the  indications 
now  are  of  a  perfect  success.  The  lips  can  already  be  closed, 
and  the  teeth  nearly  so.  There  is  every  prospect  that,  in  a  few 
weeks  more,  both  will  come  together  in  a  perfectly  natural 
way,  and  this  great  deformity  will  never  again  offend  the  sight 
of  the  patient  or  her  friends,  or  subject  her  to  the  numerous 
disabilities  which  its  existence  occasioned. 

Surgeons  have  generally  been  deterred  from  amputating  any 
considerable  portion  of  the  tongue  on  account  of  its  great  vas- 
cularity, and  the  danger  of  an  uncontrollable  hemorrhage.  The 
success  of  this  case,  and  of  others  that  have  been  reported, 
prove  that  this  peril  is  not  so  great  as  it  has  been  supposed 
to  be. 

Cases  of  this  kind  are  not  of  frequent  occurrence — at  least, 
few  have  been  reported.  Dr.  W.  G.  Delaney,  U.  S.  Navy,  in  a 
case  reported  by  him  in  the  American  Journal  of  Medical 
Sciences,  No.  32,  October,  1848,  says  that  his  case,  and  two 
others,  recorded  by  Dr.  Thomas  Harris,  Phila.,  in  the  same 
journal,  November,  1830,  and  May,  1837,  were  the  only  ones 
of  the  kind,  to  his  knowledge,  in  the  United  States. 

Since  that  time  few,  if  any,  cases  have  been  put  on  record. 
But  be  this  as  it  may,  the  case,  in  any  view  that  may  be  taken 
of  it,  will,  doubtless,  be  regarded  as  of  sufficient  interest  and 
importance  to  merit  a  place  in  the  annals  of  surgery. 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


439 


PEOCEEDINGS  OF  SOCIETIES. 

NEW  YORK  PATHOLOGICAL  SOCIETY. 
Stated  Meeting,  October  25,  1865. 
Dr.  GuRDON  Buck,  President,  in  the  Chair. 

DEATH  OF  DR.  D.  S.  CONANT. 

Dr.  Peaslee  expressed  a  desire  to  make  some  amendments  to  the 
minutes  of  the  previous  meeting,  so  far  as  they  referred  to  the  case  of 
Dr.  Couant.  He  had  not  been  aware  that  a  post  mortem  had  been 
made  till  the  day  succeeding  it,  and,  had  he  supposed  any  thing  had 
been  found  which  justified  the  bringing  the  brain  of  the  deceased  be- 
fore this  Society,  he  should  have  taken  pains  to  have  been  present  at 
the  last  meeting,  and  at  that  time  to  have  given  his  account  of  the 
case,  as  he  was  the  only  physician  who  had  been  in  regular  attendance 
upon  it  from  its  beginning  to  its  termination.  The  statements  given 
in  the  minutes  of  the  last  meeting,  he  said,  were  very  imperfect,  and, 
in  some  instances,  so  far  from  conveying  a  correct  impression,  that  he 
should  be  very  sorry  to  see  them  published  without  the  necessary  cor- 
rections. 

He  then  proceeded  as  follows: 

I  first  saw  Dr.  Conant  on  Saturday,  September  30th,  one  week  and 
a  day*  before  he  died.  He  called  on  me  at  my  office,  I  having  just  ar- 
rived from  the  country,  saying  that  he  was  pretty  well,  except  that  he 
had  a  headache  and  a  very  slight  boil  on  the  nose.  This  was  situated 
on  the  right  side,  at  the  junction  of  the  lateral  cartilage  with  the 
OS  nasi.  It  was  less  than  a  quarter  of  an  inch  in  diameter,  and  ap- 
peared in  itself  to  be  of  no  importance.  I,  however,  proposed  to  him, 
inasmuch  as  it  gave  rise  to  pain  in  the  head,  to  divide  it  freely,  and 
did  so.  About  half  an  ounce  of  blood  escaped.  This  was  done  with 
a  scalpel,  very  thoroughly,  and  down  to  the  bone.  I  do  not  know  of 
any  other  proper  way  to  treat  such  affections,  when  very  painful,  than 
by  dividing  them  freely  to  the  bone.  I  did  not  see  him  again  until 
twenty-four  hours  after,  when  we  were  leaving  church  together  on 
Sunday  afternoon,  when  I  observed  that  the  elevation  and  redness  had 
entirely  disappeared,  and  that  the  surface  was  of  natural  appearance. 
I,  however,  inquired,  "  How  are  you,  now  ?"  "  I  feel  very  miserably," 
he  replied;  "my  head  aches,  and  I  am  very  languid."  On  looking  at 
him  more  carefully,  I  saw  that  his  countenance  seemed  bloated,  that 


440 


PEOCEEDINGS  OF  SOCIETIES. 


[March, 


his  face  presented  a  bronzed  tinge,  and  that  his  expression  was  bad 
every  way.  I  advised  him  to  go  home,  bathe  his  feet  in  mustard- 
water  and  get  to  bed,  and  lie  there  until  he  should  feel  better,  telling 
him  that  I  thought  this  was  the  only  course  to  pursue  in  order  to  pre- 
vent a  serious  illness.  He  said  he  would  do  so.  I  was  subsequently 
kept  very  busy  until  nine  o'clock  in  the  evening,  when,  still  feeling  very 
anxious  about  him,  I  went  around  to  see  him.  I  then  found  a  very 
slight  flush  above  the  incision  I  had  made  twenty-eight  hours  before. 
The  incision,  I  may  say,  was  about  a  half  an  inch  in  length.  There 
was  no  tenderness  or  elevation  of  the  parts,  and  I  simply  suggested  a 
poultice,  and  advised  him  to  take  some  triplex  pills  at  10  p  m. 

I  engaged  to  see  him  the  next  morning  at  nine,  but  was  sent  for  be- 
fore that  time.  I  found  that  the  medicine  had  acted  thoroughly  upoa 
the  bowels  three  times;  but  he  then  said,  "  I  have  such  an  agonizing 
pain  in  the  left  iliac  region,  that  if  I  had  not  had  such  free  evacuations 
of  the  bowels,  I  should  feel  quite  sure  that  intussusception  exists."  I 
examined  the  parts  thoroughly,  and  assured  him  that  the  pain  was 
neuralgic  in  character.  He  had  already  made  use  of  an  enema  of 
twenty  drops  of  Magendies  solution  of  morphine,  and  remarked  that  he 
had  been  in  the  habit  of  using  it  somewhat  for  the  purpose  of  arresting 
discharges  consequent  upon  an  irritation  of  the  bowels,  from  which 
he  had  suffered  since  he  volunteered  his  services  at  Antietam.  He 
was  now  relieved  somewhat,  and  I  advised  him  to  use  no  more  of  it,  if 
he  could  get  along  without  it.  I  saw  him  again  soon  after  noon,  and 
found  that  the  pain  had  shifted  to  the  left  side,  at  about  the  course  of  the 
eighth  intercostal  nerve.  A  careful  examination  of  the  chest  was  made, 
but  there  were  no  indications  of  pleurisy.  Soon  after  the  pain  shifted 
to  the  top  of  the  left  shoulder;  then  it  attacked  the  right  shoulder, 
and  finally  disappeared.  I  at  this  time  made  a  second  incision,  dowa 
to  the  bone,  through  the  newly  inflamed  part.  I  should  say,  in  regard 
to  the  case  not  being  regarded  as  a  serious  one  until  Thursday,  that  I 
regarded  it  as  such  from  Sunday  evening,  and  it  was  on  Monday  even- 
ing that  I  expressed  the  idea  that  Dr.  Conant  was  doomed;  and  I  then, 
as  the  inflammation  had  again  commenced,  anticipated  one  of  three 
results — either,  first,  that  it  would  attack  the  eye-ball,  destroy  the 
sight,  and  then  become  arrested;  or,  second,  that  it  would  pass  on  and 
attack  the  brain,  and  prove  fatal;  or,  thirdly,  that  in  case  neither  of 
these  results  occurred,  the  septica;raic  condition  in  which  I  believed  him 
to  be,  would  probably  prove  fatal  at  the  end  of  ten  days  or  a  fortnight. 

After  dividing  the  tissues  down  to  the  bone  the  second  time  the  in- 
flammation again  diminished,  and  I  had  a  faint  hope  that  its  progress 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


4 


•was  arrested;  but  I  was  disappointed.  Twenty-four  hours  after,  the 
inflammation  showed  itself  higher  up,  attacking-  the  tissues  over  the 
lachrymal  sac,  which  presented  an  extreme  hardness,  greater,  I  think, 
than  any  swelling  I  had  ever  felt,  even  in  case  of  inflammation  of  the 
fibrous  tissues;  here,  however,  very  little  fibrous  tissue  was  involved 
in  the  process.  This  part  was  also  divided  freely,  and  the  angular  vein 
was  purposely  cut  into,  discharging  about  two  ounces  of  blood.  The 
inflammation  was,  however,  again  arrested  only  for  a  day,  and  on 
'Thursday,  it  lighting  up  again,  I  insisted  upon  a  consultation,  and  Dr. 
Parker  saw  the  case,  who,  after  examining  it  thoroughly,  remarked 
that  there  was  nothing  additional  to  be  done. 

In  regard  to  the  formation  of  pus,  I  should  say  that  none  at  all  was 
formed  within  the  first  forty-eight  hours;  and  when  formed  it  was  per- 
fectly healthy  in  appearance.  A  little  would  accumulate,  and  was 
twice  daily  pressed  out  of  the  incision.  On  one  occasion  a  little  pus 
had  collected  at  the  lower  portion  of  the  cut,  and  this  formed  a  little 
sinas  capable  of  admitting  a  small  probe,  which  extended  down  to  the 
tip  of  the  nose.  This  was  opened,  and  had  entirely  healed  np  two  or 
three  days  before  death.  The  site  of  the  original  inflammation,  also, 
was  then  entirely  healthy  again. 

The  pulse,  after  Monday,  when  it  was  108,  and  Tuesday,  106,  came 
down  to  80  or  85,  and  remained  so  most  of  the  time  for  three  days 
so  that  when  Dr.  Parker  first  saw  him,  on  Thursday,  his  condition  was 
comparatively  -ood.  There  was  also  not  much  swelling  around  the 
orbit  until  Friday,  when,  for  the  first  time,  it  became  soft  and  quaggy, 
much  as  we  see  in  a  low  case  of  erysipelas.  Exophthalmus  had  oc- 
curred Friday  evening,  and  the  sight  was  lost  by  Saturday  forenoon. 
The  other  essential  facts  of  the  case  were  detailed  at  the  last  meetin.r 
of  this  Society.  * 

In  regard  to  the  nature  of  the  local  aff-ection  there  has  been  a  great 
di^rersity  of  opinion.     We  may  often  very  accurately  appreciate  the 
pathology  of  a  case,  and  even  predict  the  progress  and  the  termination 
of  the  malady,  though  it  may  be  difficult  to  apply  to  it  a  name  A 
luime  is  nothing  but  a  term  applied  to  a  class  of  cases,  and  all  the 
cases  m  the  class  can  never  be  alike.    Still,  there  must  be  a  typical 
■case,  though  it  exist  only  in  the  mind— a  central  ir/m— around  which 
.all  must  be  grouped.    A  name  is,  then,  a  mere  band  for  a  bundle 
We  must  have,  from  the  nature  of  things,  some  cases  in  a  class  which 
we  not  typical;  and,  therefore,  ca.ses  which  it  is  difficult  to  assign  to 
ajiy  class,  since  they  touch  on  the  confines  of  two  or  more  cognate 
dassts.    When  the  sister  of  Dr.  Couant  came  to  Dr.  Parker  with  the 


442  PROCEEDINGS  OF  SOCIETIES.  [March,  j 

word  that  her  brother  had  the  so-called  malignant  pustule,  that  state-  | 
meut  was  not  based  upon  any  opinion  wiileh  I  had  formed  of  the  case. 
It  seemed  at  first  to  be  a  mere  furiiucular  inflammation,  and  never,  to  ' 
my  mind,  assumed  the  character  of  malignant  pustule.    The  inflamma- 
tion entirely  disappeared  from  its  original  site,  and  the  part  got  well  , 
in  three  or  four  days,  while  the  malignant  pustule  always  extends  j 
around  from  the  original  starting  point,  generally  producing  mortifi- 
cation and  sloughing.  ! 

Then,  again,  if  we  call  it  erysijjelas,  we  find,  though  like  it,  it 
traveled  from  point  to  point,  it  was  nevertheless  always  confined 
within  narrow  limits,  and  followed  every  where  tiie  fibrous  tissue,  and  i 
the  course  of  the  veins  and  lymphatics.    It  was  more  like  phlebitis,  in  ; 
most  respects,  and  if  I  were  obliged  to  call  it  by  one  name,  I  would 
call  it  phlebitis.    When  I  was  called  upon  for  a  certificate,  finding  \ 
that  I  could  not  express  my  ideas  of  its  pathology  without  a  circum-  ] 
locution,  and  it  being  evident  to  me  that  inflammation  of  the  mem-  j 
branes  of  the  brain  was  the  immediate  cause  of  death,  I  gave  a  j 
certificate  to  that  efi"ect.    I  said  inflammation  of  the  brain,  though 
that  by  no  means  expresses  my  whole  idea,  for  it  is  not  a  mere  case  of  \ 
cerebral  meningitis.    Diff'use  cellular  inflammation  is  another  term  j 
that  might  be  applied,  but  it  commenced  in  the  fibrous  structures,  and  i 
only  secondarily  involved  the  areolar  tissue.    I  should  say  that  the  I 
local  aff'ection  resembled  phlebitis  nearer  than  any  thing  else.    But  he  ! 
had  all  the  indications  of  blood  poisoning  from  the  onset,  and  I  think 
if  that  condition  of  the  blood  had  not  existed,  and  which  had  been  j 
produced  by  his  incessant  labor  and  exposure  in  August,  this  inflam-  ; 
mation,  call  it  phlebitis,  or  whatever  you  may,  would  not  have  pro-  > 
gressed  so  far  but  that  a  healthy  exudation  would  have  arrested  it.  i 
The  inflammation  passing  through  the  sphenoidal  fissure,  which  gives 
passage  to  the  ophthalmic  vein,  and  not  through  the  optic  foramen,  is  ' 
another  fact  in  favor  of  the  idea  that  the  local  afi'ection  was  phlebitis.  j 
In  regard  to  the  statement  that  pus  existed  at  the  base  of  the  brain,  . 
I  must  reserve  to  myself  some  doubt.     All  know  how  diflBcult  it  is  to 
distinguish  between  an  exudation  and  pus  in  cases  of  a  low  grade  of  I 
inflammation,  and  in  this  case  no  symptoms  of  meningeal  inflammation 
occurred  till  fifteen  hours  before  death. 

TUMOR  FROM  SHEATH  OF  SCIATIC  NERVE  DR.  L.  A.  SAYRE.  / 

I 

Dr.  Sayre  presented  a  bony  looking  mass,  which  was  rounded  and  j 
about  the  size  of  an  English  walnut,  which  he  had  removed  from  a  j 


I 


1866.] 


PROCEEDINGS  OF  SOCIETIES. 


443 


patient  forty-five  years  of  age,  with  the  following  history:  He  con- 
sulted Dr.  Sayre  during  the  month  of  July  last,  complaining  of  a  severe 
pain  in  the  left  hip  joint,  and  stated  that  he  had  suffered  from  the 
symptom  for  a  period  of  three  or  four  years.  Hypodemic  injections 
of  morphine  had  been  resorted  to,  with  other  local  remedies,  and  no 
relief  had  been  obtaiaed.  On  careful  examination  no  disease  of  the 
joint  was  made  out,  but  on  flexing  the  thigh  strongly  upon  the  pelvis, 
a  hardened  mass,  which  was  movable,  was  felt  behind  the  greater 
trochanter,  immediately  over  the  most  superficial  portion  of  the  great 
sciatic  nerve.  On  cutting  down  upon  it  for  the  purpose  of  removal, 
the  mass  was  found  connected  simply  with  the  sheath  of  the  nerve. 
Th^re  M'as  no  assignable  cause  for  its  appearance,  no  gouty  tendencies 
in  the  patient,  and  the  distressing  symptom  of  pain  entirely  ceased 
after  the  offending  substance  was  removed.  No  microscopic  examina- 
tion of  the  tumor  had  been  made. 

Dr.  Peaslee  remarked  that  if  the  tumor  were  found  to  be  made  up 
of  nothing  but  fibrous  tissue,  with  calcareous  deposit,  it  would  not  be 
so  unusual;  but  if  composed  of  true  bone,  possessing  lacunaj  and 
eanaliculi,  it  would  certainly  be  unique  in  being  developed  from  a  nerve 
sheath. 

On  motion,  the  specimen  was  referred  to  a  committee,  consisting  of 
Drs.  Sands  and  Draper,  for  microscopic  examination. 

Stated  Meeting,  November  Sik,  18G5. 
Dr.  H.  B.  Sands,  Yiee-President,  in  the  Chair. 

TUMOU  FROM  THE   NARES  DR.  KRACKOWIZER. 

Dr.  Krackowizer  presented  a  portion  of  a  tumor,  which  he  had  tried 
that  morning  to  remove  from  a  patient  twenty-five  years  old,  whom  he 
had  seen,  for  the  first  time,  about  six  years  before,  in  the  Jews'  Hos- 
pital. At  the  time  he  was  suffering  from  ozasna,  the  discharge  coming 
from  both  nostrils.  In  consequence  of  this  the  upper  lip  was  eroded, 
and  was  covered  with  a  crust  of  inspissated  matter.  In  the  course  of 
a  few  weeks  cauterizations  and  mild  astringent  applications  succeeded 
in  arresting  the  disease  of  the  nose  and  remedying  the  trouble  on  the 
lip.  There  were  no  hereditary  diseases  in  his  family.  After  he  left 
the  hospital  he  embarked  in  various  avocations  until  the  close  of  the 
last  year,  when  he  became  conductor  on  one  of  the  Philadelphia  rail- 
road lines.  Late  in  December  of  last  year,  in  pretty  cold  weather,  he 
.stood  for  some  time  in  the  sleeping  car,  when  he  found  it  quite  warm 


444 


PROCEEDINGS  OP  SOCIETIES. 


[March, 


there,  aud,  in  order  to  cool  himself,  went  out  upon  the  platform  and 
unbuttoned  his  coat.  Two  or  three  days  suljseqnently  he  was  taken 
with  a  violent  hemorrhage  from  the  left  nostril.  For  tlie  first  time  he 
then  noticed  a  swelling  in  this  nostril,  which  swelling  gradually  in- 
creased during  a  period  of  two  or  three  months  afterwards,  so  that  no 
air  could  enter  the  passage.  The  tumefaction  could  readily  be  seen 
by  him  with  the  aid  of  a  looking-glass,  and  could  be  easily  felt  with 
the  tip  of  the  little  finger,  and  was  covered  with  a  muco  purulent 
discharge. 

In  July,  about  the  si.xth  mouth  after  the  first  hemorrhage,  he  was: 
attacked,  and  was,  in  consequence,  left  very  weak.  From  that  time, 
he  says,  the  swelling  gradually  became  arrested,  so  that  he  could  not 
reach  it  at  all  with  the  finger.  About  that  time  a  little  tumefac- 
tion appeared  at  the  inner  angle  of  the  eye,  pushing  the  eyeball  for- 
ward and  downward.  This  swelling  increased,  so  that,  at  the  time 
Pr.  Krackowizer  saw  the  patient,  the  level  of  the  cornea  was  pro- 
truding beyond  the  orbital  margins,  and  the  eyeball  was  barely  covered 
by  the  lids.  The  eyeball  was  not  altered  in  appearance,  and  could  be 
moved  in  every  direction  at  will.  He  had  abandoned  his  position  as 
railroad  conductor,  and  had  settled  in  Virginia  for  several  months. 
Finally,  becoming  alarmed  at  his  condition,  he  came  to  this  city.  Dr. 
Krackowizer  saw  him  about  a  week  ago. 

He  seemed  to  be  in  perfect  health,  and  stated  that  he  had  never 
suffered  any  from  pain.  The  condition  of  the  eyeball,  as  just  de- 
scribed, was  noticed,  and  in  addition  a  marked  swelling  at  the  inner 
angle  of  the  eye,  which,  by  its  pressure,  interfered  with  the  absorption 
of  the  lachrymal  secretion  through  the  canaliculi,  aud  the  eye  was, 
consequently,  watery.  The  whole  left  side  of  the  face  was  a  little 
protuberant,  and,  on  feeling  into  the  mouth,  the  anterior  portion  of  the 
superior  maxillary  bone  was  discovered  to  be  unusually  full,  soft,  and 
elastic;  and  on  one  part,  in  the  region  of  the  canine  fossa),  it  seemed 
that  a  layer  of  thin  bone  was  spread  on  the  surface  of  the  swelling. 
The  interstices  between  the  coronoid  processes  and  the  outer  surfaces 
of  the  superior  maxilljB  were  equal.  The  temporal  fossaj  were  the 
same  on  both  sides.  On  looking  into  the  nose,  no  swelling  could  be 
seen.  The  soft  palate  was  normal.  Dr.  Simrock  examined  the  pos- 
terior apertures  of  the  nose  with  a  rhinoscope,  and  found  the  equina 
filled  with  a  mass,  as  is  usually  seen  in  cases  of  new  formations  in  the 
nasal  cavities.  The  submaxillary  and  cervical  glands  were  not  infil- 
trated. As  the  patient  had  had  two  or  three  pretty  smart  attacks  of 
hemorrhage  from  the  nostrils,  it  was  not  deemed  advisable  to  prolje 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


445 


the  parts  much.    The  opinion  was  that  it  was  non-malignant  in  char- 
acter, and  had  originated  in  the  walls  of  the  antrum. 

It  was  decided  to  remove  the  mass.  An  incision  was  made,  com- 
mencing at  the  root  of  the  nose,  along  the  median  line,  leaving  the 
septum  on  the  right  side  and  splitting  the  upper  lip.  The  flap  was 
then  dissected  from  the  neighboring  parts,  but  the  hemorrhage  being 
quite  considerable,  there  was  a  good  deal  of  necessary  delay  in  the 
operation  in  consequence.  After  the  flap  had  been  dissected  from  the 
anterior  surface  of  the  superior  maxillary  bone,  from  the  nasal  process 
of  this  bone,  from  the  nasal  bone  of  the  left  side,  and  from  that  part 
of  the  tumor  which  appeared  in  the  orbit,  always  taking  care  not  to 
wound  the  eyeball  or  its  muscles,  it  was  found  that  in  order  to  get  a 
good  access  to  the  mass,  another  incision  from  the  angle  of  the  mouth 
to  the  malar  bone  had  to  be  made.  This  flap  was  then  dissected  off 
and  turned  above,  Langenbeck's  saw  was  then  passed  through  a  hole 
in  the  outer  aspect  of  the  maxillary  bone,  and  a  transverse  incision 
made  along  the  floor  of  the  antrum  to  the  pyriform  aperture  of  the 
bone.  Then,  with  a  strong  bone  scissors  the  bridge  of  the  nose,  be- 
tween the  inferior  orbital  margin  and  aperture  of  the  nose,  was  cut  in 
two,  then  the  connection  between  both  nasal  bones  was  divided,  and 
this  bony  bridge  was  luxated  from  the  suture  which  connected  it  with 
the  OS  frontis.  The  tumor  was  then  exposed.  Another  incision  was 
then  made  in  the  floor  of  the  orbit,  from  between  the  outer  and  middle 
third  of  the  orbital  margin,  in  an  oblique  direction  towards  the  inferior 
orbital  fissure.  By  that  means  the  mass  became  movable,  and  was  ' 
twisted  from  its  surroundings.  After  this  was  done,  it  was  found  that 
the  whole  of  the  antrum,  as  well  as  the  nasal  cavities,  were  filled  with 
this  mass.  It  at  once  became  evident  that  it  would  be  impossible  to 
remove  all  of  the  disease,  and  so  as  much  was  taken  away  as  could 
be  conveniently  done  by  means  of  the  finger  and  scraper.  In  that  way 
it  happened,  not,  however,  as  the  result  of  any  force  used,  that  that 
portion  of  the  diseased  mass  situated  anteriorly  to  the  cells  of  the 
sphenoid,  and  taking  the  place  of  the  bone  in  that  situation,  was 
scraped  away,  laying  bare  the  dura  mater.  The  patient,  notwith- 
standing the  loss  of  a  good  deal  of  blood,  had  a  good  pulse  at  the  end 
of  the  operation.  The  flaps  were  brought  together  by  means  of  a 
twisted  suture. 

Under  the  microscoi)c  the  elements  of  tlie  tumor  consisted,  in  part, 
of  elongated  cells,  with  a  single  nucleus,  arranged  in  jjretty  regular 
parallel  courses,  and  also  elements  the  size  of  pus  corpuscles,  with  one 
nucleus,  all  of  which  proved  that  the  growth  was  entitled  to  be  cla.ssed 


446 


PROCEEDINGS  OF  SOCIETIES, 


[March, 


under  the  head  of  soft  sarcomas.  Though  tumors,  these  were  not  to 
be  considered  cancerous.  They  nevertheless  partake  of  the  malignant 
character  of  such  growths,  as  far  as  their  tendency  to  recur  was  con- 
cerned, more  especially  when  the  slightest  trace  of  disease  was  left 
after  an  operation. 

In  regard  to  the  prognosis  in  this  case,  it  was  evident  that  death 
must  ensue  from  meningitis,  the  result  of  the  accidental  injury  of  the 
dura  mater. 

ANEURISM  OF  THE  THORACIC  AORTA — DR.  C.  K.  BRIDDON'. 

D.  C,  age  38  years,  came  under  my  observation  about  six  months 
ago;  he  was  complaining  of  pain  shooting  through  the  chest,  from  a 
point  one  inch  to  the  left  of  the  sternum,  and  between  the  fourth  and 
fifth  costal  cartilages,  to  another  situated  below  the  angle  of  the  left 
scapula;  he  had  slight  cough,  with  little  or  no  expectoration,  expe- 
rienced some  uneasiness  in  the  stomach  after  eating,  had  a  coated 
tongue,  irregular  bowels,  and  the  usual  common  symptoms  of  derange- 
ment of  the  chylo-poietic  viscerte.  To  these  matters  he  appeared  to 
invite  little  attention;  his  chief  complaint  was  of  the  chest  pain,  and, 
on  close  questioning,  I  elicited  its  character;  it  was  situated  between 
the  two  points  above  mentioned,  did  not  radiate,  and  was  not,  prop- 
erly speaking,  lancinating,  but  was  steady,  persistent,  and  sufficiently 
severe  to  interfere  with  or  prevent  sleep.  It  was  not  influenced  by 
deep  inspiration,  position  or  motions  of  the  trunk  os  extremities;  there 
was  no  tenderness  in  the  intercostal  spaces,  either  in  the  immediate 
neighborhood  of,  or  at  a  distance  from,  the  seat  of  pain.  Physical 
exploration  gave  no  insight  into  the  nature  of  the  case;  anteriorly  and 
posteriorly  percussion  was  equally  clear  on  both  sides.  Auscultation 
revealed  no  rales  in  the  pulmonary  or  bruits  in  the  cardiac  region  of 
the  chest. 

The  patient  remained  under  my  care  a  little  while,  and  then  moved 
into  the  country  About  two  months  ago  I  visited  him  in  consultation 
with  the  physician  who  was  attending  him  at  Bayoune,  in  the  State  of 
New  Jersey.  He  had  had  a  severe  attack  of  gastralgia,  but  the  old 
chest  pain  was  still  present,  and  his  chief  complaint.  I  again  made  a 
careful  physical  examination,  and,  beyond  some  difference  in  the  per- 
cussion note  beneath  the  clavicles,  detected  nothing. 

I  next  saw  the  patient  in  this  city  on  the  26th  of  October,  when  he 
informed  me  that  he  had  consulted  Profs.  Parker  and  Clark,  and  had 
been  a  short  time  under  the  care  of  the  former.    When  I  visited  him 


1866.] 


PROCEEDINGS  OP  SOCIETIES. 


447 


he  was  suffering  severely  from  his  old  enemy;  during  my  conversation 
with  him  I  became  impressed  with  the  idea  that  he  had  some  grave 
trouble  in  one  of  the  mediastinal  spaces,  probably  aneurismal  in  char- 
acter, but  he  appeared  to  be  so  much  exhausted  by  pain  that  I  deferred 
an  examination  for  the  following  day. 

At  half-past  eleven  o'clock  on  the  night  of  the  26th,  I  was  again 
summoned,  and  on  reaching  his  house  found  that  he  had  died  about 
fifteen  minutes  before  my  arrival.  His  mode  of  death  was  sudden; 
after  an  hour's  aggravated  pain  he  cried  out  that  he  was  dying,  and 
fell  back  dead. 

Autopsy,  thirty-four  hours  after  death.  The  examination  was  con- 
fined to  the  contents  of  the  chest.  On  elevating  the  sternum,  I  found 
the  left  lung  irregularly  displaced  upwards,  backwards  and  inwards, 
by  a  coagulura  of  blood  estimated  at  six  or  eight  pounds,  and  a  quan- 
tity of  serum ;  there  were  a  few  old  adhesions,  but  they  were  neither 
numerous  nor  extensive  in  character.  There  were  a  few  solid  tubercular 
masses  in  either  apex,  and  another  deposit  of  the  same  character  in 
the  anterior  border  of  the  lower  left  lobe. 

On  removing  the  viscera^  from  the  chest,  an  aneurismal  dilatation 
was  found  occupying  the  anterior  wall  of  the  thoracic  aorta;  the  left 
bronchus  was  closely  applied  and  intimately  adherent  to  the  front  or 
external  surface  of  the  sac,  and  to  the  left  of  the  bronchus  was  a  rag. 
ged  opening  which  admitted  the  forefinger  into  its  interior.  On  slitting 
up  the  posterior  wall  of  the  vessel  which  was  the  seat  of  advanced 
atheromatous  deposit,  the  orifice  of  the  sac  was  disclosed ;  its  upper 
border  was  on  a  level  with  the  junction  of  the  arch  with  the  descending 
aorta.  It  measured  two  inches  and  three  quarters  in  its  vertical  and 
one  inch  and  a  half  in  its  transverse  diameter;  the  cavity  into  which  it 
led  would  contain  an  average-sized  lemon.  It  contained  neither  clot 
nor  laminated  fibrine,  and  projecting  into  its  cavity  could  be  seen  and 
felt  some  of  the  posterior  extremities  of  the  cartilages  of  the  left 
bronchus,  covered  by  the  lining  membrane  of  the  vessel. 

In  conclusion,  he  referred  to  a  case  of  abdominal  aneurism,  which 
strikingly  resembled  the  one  just  related,  in  having  a  persistent  pain, 
as  the  only  symptom  which  showed  itself  for  a  long  time. 

Dr.  O'Si'LUVAN  remarked  that  he  had  a  case,  then  under  treatment, 
which  resembled  the  one  related  by  Dr.  Briddon,  cxce])t  tliat  there  was 
no  pain  present.  He  could  detect  dullness  on  both  sides  of  the 
sternum,  high  up,  and  further  than  this  there  were  no  other  physical 
signs  appreciable.  Adjourned. 


448  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES,     [March ^ 


EEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 

Circular  No.  G.  War  Department,  Surgeon- Generar s  OJics,  Washing- 
ton, November  1,  1865.  Reports  on  the  Extent  and  Nature  of  tJie 
Materials  Available  for  the  Preparation  of  a  Medical  and  Surgical 
History  of  the  Rebellion.  Printed  for  the  Surgeon  General's  Office, 
by  J.  B.  Lipphicott  &  Co.    Philadelphia,  1865.  4to.  pp.  166. 

A  good  deal  of  coq^ern  has  for  some  time  been  felt  by  the  medical 
profession  of  the  country — a  large  part  having  a  direct  interest 
in  the  matter — about  the  progress  that  had  been  made  towards 
gathering,  preserving,  and  digesting  for  publication  the  mass  of  facts 
and  observations  in  military  medicine  and  surgery  which  it  was  known 
had  been  accumulated  in  the  Surgeon-General's  ofBce.  A  perusal  of 
these  opportune  "Reports"  will  put  to  rest  any  anxiety  or  doubt  that 
may  have  been  felt  as  to  the  means  taken  to  secure  the  early  and  full 
fruition  of  the  enormous  experience  gained  by  four  years  of  war,  car- 
ried on  by  armies  of  unparalleled  numbers,  and  its  utmost  utilization  for 
the  general  good.  It  will  also  give  assurance  of  the  fitness  of  the 
officers  to  whom  this  important  and  difficult  task  has  been  entrusted — 
the  Medico-Chirurgical  Historiographers  of  the  War;  and  check  any 
impatience  at  tardiness  of  publication,  by  revealing  the  magnitude  of 
the  subject,  showing  the  measures  adopted  to  secure  accuracy  and 
thoroughness,  and  bringing  the  conviction  of  the  absolute  necessity  of 
the  patient  investigation  of  many  points,  and  that  time  will  only  add 
increase  to  the  truth  of  these  mighty  stores.  The  "Reports"  are 
a  triumphant  vindication  of  the  Medical  Department  of  the  Army, 
and  a  noble  monument  to  the  courage,  zeal,  ability  and  acquirements 
of  its  officers. 

The  Report  on  Surgery  is  by  Bvt.  Lieut-Col.  Geo.  A.  Oris,  Sur- 
geon U.  S.  Vols.,  and  the  Report  on  Medicine  by  Bvt.  Major  J.  J. 
Woodward,  Assistant-Surgeon  U.  S.  Army.  A  full  analysis  of  them 
is  not  practicable  within  our  limits,  and  our  readers  must  be  content 
with  an  idea,  necessarily  imperfect,  of  their  scope  and  value. 

The  materials  in  the  Surgeon-General's  office  from  which  the 
Surgical  History  of  the  Rebellion  is  to  be  compiled,  and  whose  extent 
is  stated  as  "  simply  enormous," 

"  Consist  of  the  reports  of  the  medical  officers  engaged  in  it,  and  of 
illustrations  of  these  reports  in  tlie  shape  of  pathological  specimens, 
drawings  and  models.  The  documentary  data  are  of  three  kinds: 
first,  the  numerical  returns,  in  wliich  the  number  alone  of  the  difl'erent 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  449 


forms  of  wounds,  accidents,  injuries,  and  surgical  diseases  is  given; 
secondly,  what  may  be  called  the  nominal  returns,  in  which  are 
furnished  tlie  name  and  military  description  of  each  patient,  and  the 
particulars  of  the  case,  with  more  or  less  of  detail;  and,  thirdly,  the 
miscellaneous  reports,"  (p.  1.) 

We  have  the  gratifying  information  that  "  the  great  body  of  the 
medical  officers  have  made  the  I'cports  required  of  them  with  com- 
mendable diligence  and  promptitude,"  and  their  industry  and  zeal  are 
the  more  praiseworthy  when  the  absorbing  nature  of  their  hospital 
and  field  duties  is  considered. 

In  tlie  British  army  in  the  Crimea  there  were  12,094  wounded,  and 
2155  killed,  or  a  total  of  14,849.  In  the  French  army,  whose 
total  effective  force  was  809,268,  there  were  39,808  wounded,  and 
8250  killed,  or  a  total  of  48,118. 

"  In  the  late  war,  the  monthly  reports  from  a  little  more  than  half 
the  regiments  in  the  field  give,  for  the  year  ending  June  30th,  1862, 
an  aggregate  of  17,496  gun-shot  wounds.  The  reports  from  rather 
more  than  three-fourths  of  the  regiments,  for  the  year  ending  June 
30th,  1863,  give  a  total  of  55,974  gun-shot  wounds.  The  battle-field 
lists  of  wounded  for  the  years  1864-65  include  over  114,000  names. 
But  these  returns  are  to  I)e  completed  by  collating  with  them  the 
reports  of  general  hospitals,  where  many  w"ounded  were  received 
whose  names  the  recorders  of  field  hospitals  or  regimental  medical 
officers  failed  to  obtain,  and  by  adding  the  names  of  those  killed  in 
battle,"  (p.  2.) 

In  the  French  Crimean  army  there  were  459  gun-shot  fractures  of 
the  femur  reported,  and  in  the  British  array  194,  while  over  5,000  cases 
of  this  injury  in  our  armies  have  already  been  sent  in  to  the  Surgeon- 
General's  office.  The  Crimean  returns  give  10  exsectioiis  of  the  head 
of  the  humerus  in  the  British,  and  38  in  the  French  army,  "  but  the 
registers  of  this  [S.  G.]  office  contain  the  detailed  histories  of  575  such 
operations." 

"  The  surgical  specimens  of  the  .Army  Medical  Museum  number 
5480;  and  not  only  in  specimens  of  recent  injuries,  but  in  illustrations 
of  re])arative  processes  after  injury,  of  morbid  processes,  of  the  results 
of  operations,  and  of  surgical  a])paratus  and  appliances,  this  institution 
is  richer,  numerically  at  least,  than  the  medico-military  museums  of 
France  or  Great  Britain,"  (p.  3.) 

And  these  great  treasures  have  been  classified  and  arranged  so  as 
to  be  availal)le  for  present  scientific  study. 

Such  materials,  from  their  nature  and  extent,  must  necessarily 
throw  light  on  many  mooted  points,  and  go  far  towards  the  solution  of 
certain  surgical  probhsms,  comprising,  as  they  do,  on  some  subjects — 

Vol.  11.— No.  12.  29 


450 


BEYIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


excision  of  the  head  of  the  femur  after  gun-shot  injury,  for  example — 
larger  data  than  are  extant  in  the  whole  range  of  surgical  literature. 

We  will  now  proceed  to  notice  the  records  of  special  injuries, 
and  the  operations  done  for  their  relief. 

The  number  of  Gun-shot  Injuries  of  the  Head,  reported  to  October  1, 
1864,  is  5040,  and  they  have  been  recorded  in  two  classes:  first,  the 
gun-shot  fractures  and  injuries  of  the  cranium,  including  the  perforating 
and  penetrating  and  depressed  fractures,  the  fractures  without  known 
depression,  and  the  contusions  of  the  skull,  resulting  in  lesions  of  the 
encephalon;  and,  secondly,  the  simple  contusions  and  flesh  wounds  of 
the  scalp.  In  the  first  class  1104  cases  are  recorded.  Of  704  in 
which  the  results  have  been  ascertained,  505  died  and  199  recovered. 
In  101  of  these  terminated  cases  the  operation  of  trephining  was  per- 
formed, with  60  deaths  and  41  recoveries.  In  114  cases  fragments 
of  bone  or  of  foreign  substances  were  removed  by  the  elevator  or  for- 
ceps, without  the  use  of  the  trephine;  and  of  these  61  died  and  53 
recovered.  The  gun  shot  contusions  and  wounds  of  the  scalp  number 
3942,  of  which  103  terminated  fatally.  So  far  as  ascertained,  the 
fatal  results  were  due  to  concussion  or  compression  of  the  brain,  or  to 
the  formation  of  abscesses  in  the  liver  or  lungs,  in  consequence  of 
inflammation  in  the  veins  of  the  diploe.  Compression  resulted  either 
from  extravasation  of  blood,  or  inflammation  of  the  brain  or  its  mem- 
branes, or  from  suppuration.  In  a  case  of  scalp  wound  received  Nov. 
21,  1863,  no  cerebral  symptoms  occurred  until  Dec.  13th,  1863,  when 
the  man  was  suddenly  seized  with  convulsions,  followed  by  coma. 
The  skull  being  laid  bare  at  the  seat  of  injury,  and  the  bone  found 
diseased,  the  trephine  was  applied.  There  was  matter  beneath  the 
bone,  and  oozing  from  the  diploe.  "  It  was  thought  expedient  to  make 
five  perforations  with  the  trephine,  in  order  to  remove-  the  diseased 
bone  and  give  free  exit  to  the  pus.  Convulsions  did  not  recur,  but 
the  comatose  condition  continued,  and  the  case  terminated  fatally 
twelve  hours  after  the  operation.  The  autopsy  revealed  diffuse  inflam- 
mation of  the  arachnoid  and  of  the  dura  mater."  This  is  another  case 
proving  the  fallacy  of  the  doctrine  taught  by  Pott,  that  the  inflam- 
mation is  frequently  limited  to  the  outer  surface  of  the  dura  mater, 
and  supporting  the  views  of  Mr.  Prescott  Ilewett,  that  where  there  is 
found  inflammation  on  the  outer  surface  of  the  dura  mater,  there  is 
also  found  inflammation  on  the  free  surface  of  the  arachnoid.*  And 


*  Injuries  of  the  Head.  By  Prescott  Hewett,  Esq.,  Surgeou  to  St.  George's 
Hospital,  in  Holmes'  System  of  Surgery,  v.  ii.,  p.  101. 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


451 


he  adds:  "Indeed,  the  successful  issue  of  a  case  of  trephining  for  matter 
between  the  bone  and  the  dura  mater  is,  I  believe,  all  but  unknown  to 
surgeons  of  our  own  time." 

In  the  Army  Medical  Museum  there  are  eight  specimens  of  that 
rare  and  interesting  variety  of  fracture  of  the  cranium  in  which  the 
external  table  is  unbroken,  while  the  vitreous  table  is  fissured  and 
sometimes  depressed.  In  one  of  the  cases,  Surgeon  Bontecou,  who 
had  examined  some  of  the  specimens  already  collected,  inferring  the 
probability  of  a  depression  of  the  inner  table,  though  there  was  no 
apparent  fracture  of  the  outer  one — the  bone  being  only  denuded  of  its 
periosteum — verified  the  diagnosis  during  life,  by  the  application  of  the 
trephine.* 

"It  is  believed  that  this  accident  results,  in  most  instances,  from  a 
small  projectile  striking  the  cranium  very  obliquely,  or  possibly,  in 
some  cases,  from  a  comparatively  slight  blow  from  a  body  with  a 
large  plane  surface,"  (p.  12.) 

Closely  allied,  clinically,  to  these  cases,  are  those  in  which  a  ball 
produces  linear  fissure  of  the  external  table  with  displacement  of  the 
inner  table.  A  case,  with  an  excellent  illustration,  is  given.  Of  fractures 
without  depression,  the  cases  in  which  the  mastoid  process  is  knocked 
off  by  a  ball  alford  examples.  One  case  of  recovery  from  this  injury 
is  given.  Several  instances  of  undepressed  fracture  are  reported,  in 
which  a  ball  gouged  out  a  small  portion  of  the  external  table.  It 
often  happens  that  considerable  portions  of  the  calvaria  are  removed 
by  explosions  of  shell,  without  causing  depression.  A  remarkable  case 
is  related  where  a  musket  ball  produced  the  same  effect — entering 
"a  little  outside  of  the  left  frontal  protuberance,  and  passing  back- 
wards and  upwards,  removed  a  piece  of  the  squamous  portion  of  the 
temporal  bone,  with  brain-substance  and  membranes."  The  man 
"  recovered  perfectly,"  and  "  the  mental  and  sensory  faculties  were 
unimpaired." 

An  abstract  of  a  case  of  "  punctured  fracture"  of  the  os  frontis,  by  a 
pistol  ball,  is  given,  and  in  which  there  was  the  usual  absence  of  all 
alarming  symptoms  until  immediately  before  the  inevitable  fatal  result, 
when  trepliining  is  not  early  resorted  to.  "  Instances  were  not  un- 
common of  the  splitting  of  round  musket  balls  in  striking  the  skull  at 


*  Unhappily,  an  abscess  had  already  formed  in  the  brain,  and  the  opera- 
tion, though  done  as  soon  as  evidence  of  compression  existed,  was  too  late  to 
save  the  patient.  There  are  but  two  other  known  specimens  of  this  rare 
form  of  injury — one  in  the  Dupuytrea  Museum,  and  the  other  in  the  Netley 
Collection. 


452  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


an  acute  angle.  Conoidal  balls  were  less  liable  to  split  after  this  fash- 
ion, yet  such  instances  were  occasionally  observed,"  (p.  14.) 

Recovery  after  penetrating,  perforating  fractures  oj"  the  cranium  was 
exceptional.  In  rare  instances  the  fatal  termination  was  very  long 
delayed.  A  curious  case  is  narrated  where  the  presence  of  a  ball 
within  the  cranium  was  unsuspected  during  life.  It  had  entered  Dec. 
13,  1862;  there  were  no  cerebral  symptoms  until  Feb.  10,  18G3,  when 
delirium  set  in,  followed  by  coma,  and  death  at  midnight  of  the  15th. 

"  The  autopsy  revealed  a  conoidal  musket  ball  wedged  between  the 
sphenoid  and  the  left  orbital  plate  of  the  frontal  bone,  and  lying  in 
contact  with  the  dura  mater.  The  orbital  plate  was  pressed  inwards 
and  fractured,  and  a  fissure  extended  through  the  superciliary  ridge. 
Over  the  ball,  at  the  base  of  the  anterior  lobe  of  the  left  hemisphere, 
was  an  abscess  containing  two  draciims  of  pus.  The  ball  was  incrust- 
ed  by  callus,  and  the  opening  it  had  made  in  entering  through  the 
walls  of  the  right  orbit  was  greatly  diminished  by  osseous  deposi- 
tion," (p.  15.") 

The  following  is  a  remarkable  case  of  perforating  fracture  of  the 
skull,  with  recovery: 

"  The  ball  entered  a  little  to  the  right  of  the  occiput,  and  passed 
out  somewhat  below  and  to  the  left  of  the  vertex.  The  intervening 
bridge  of  bone  was  about  three  inches  wide.  There  had  been  a  cere- 
bral hernia  at  the  wound  of  exit,  and,  when  the  drawing  was  made, 
four  months  after  the  reception  of  the  injury,  there  was  still  a  small 
tumor,  covered  by  half-formed  cicatricial  tissue.  There  was  a  firm 
depressed  cicatrix  at  the  aperture  of  entry.  There  were  no  evidences 
of  impairment  of  the  cerebral  faculties.  The  man  was  employed  as  an 
orderly,"  (p.  15.) 

Eighteen  cases  of  Hernia  Cerebri  are  mentioned  occurring  in  gun- 
shot fracture  of  the  skull,  complicated  with  meningeal  and  cerebral 
laceration. 

"In  four  of  these  cases,  recovery  took  place  without  operative  inter- 
ference with  the  protruding  fungous  mass,  which,  in  these  instances, 
gradually  contracted,  was  then  covered  by  granulations,  and  finally 
cicatrized.  In  those  cases  in  which  bandaging  and  compression  were 
resorted  to,  cerebral  oppression  was  soon  manifested,  and  stupor  and 
coma  eventually  supervened.  In  those  in  which  the  tumor  was  sliced  off, 
as  usually  recommended,  at  the  proper  level  of  the  brain,  it  was  com- 
monly speedily  reproduced,  and  death  from  irritation  ensued,"  (p.  17.) 

In  the  treatment  of  cranial  fractures,  it  would  appear  that  "the 
general  tendency  was  to  the  practice  recommended  by  Guthrie  in 
regard  to  operative  procedures,  rather  than  [to]  the  more  expectant 
plan  insisted  upon  by  the  majority  of  modern  European  writers  on 
military  surgery." 


1866,]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES,  453 


Though  the  number  of  fatal  results  after  trephining  was  very  great, 
there  were  numerous  examples  of  success,  while  the  data  are  not 
sufficiently  complete  to  admit  of  a  fair  comparative  analysis. 

"  Still  it  is  difficult  to  avoid  the  impression  that  a  larger  measure 
of  success  lias  attended  tliis  operation  in  the  late  war,  than  the  previous 
experience  of  military  surgeons  would  have  led  us  to  anticipate.  Sur- 
geon D.  W.  Bliss,  U.  S.  Vols.,  alone  has  reported  eleven  successes 
after  the  use  of  the  elevator  or  trephine.  Even  in  those  almost  hope- 
less cases  in  which  compression  of  the  brain  follows  a  gun-shot  injury  of 
the  skull  at  a  late  date,  instances  of  recovery  are  reported,"  (p.  16.) 

Of  the  1329  entered  cases  of  Gun-shot  Wounds  of  the  Neck,  ultimate 
results  have  been  ascertained  in  546  only.  In  the  terminated  cases 
the  mortality  is  14  per  cent. 

"Several  instances  are  recorded  in  which  large  grapeshot,  on  strik- 
ing the  hyoid  bone,  were  deflected,  and  buried  themselves  in  the  supra- 
spinous fossa  of  the  scapula,  or  among  the  muscles  of  the  back.  These 
patieuts.  died  from  laryngitis  or  oedema  of  the  glottis,  and  might  have 
been  saved,  perhaps,  by  tracheotomy;  but  they  died  suddenly  when 
surgical  assistance  could  not  be  immediately  procured,"  ( p.  20.) 

In  187  cases  of  Gun-shot  Fracture  of  the  Vertebra,  all  but  seven  were 
fatal.  Six  of  these  were  fractures  of  the  transverse  or  spinous 
apophyses. 

"  The  seventh  case  is  that  of  a  soldier  wounded  at  Chickamauga, 
September  20th,  1863,  Ity  a  musket  ball,  which  fractured  the  spinous 
process  of  the  fourth  lumbar  vertebra,  and  penetrated  to  the  vertebral 
c:»nal.  The  ball  and  fragments  of  bone  were  extracted  at  a  Nashville 
hospital.  The  patient  was  transferred  to  Louisville,  thence  to  Jeffer- 
son Barracks,  Missouri,  thence  to  Madison,  Indiana,  and  finally,  on 
July  2Cth,  1864,  to  Quincy,  Illinois.  The  last  report  states  that  he 
was  likely  to  recover,"  (p.  21.) 

An  interesting  case  is  given  in  which  after  death  it  appeared  that  the 
spinal  cord  had  been  completely  severed  at  the  seat  of  injury,  and  to 
have  become  disorganized  above  and  below.  The  man  was  wounded 
on  the  3d  of  June,  by  a  conoidal  musket  ball,  which  shattered  tlie  trans- 
verse and  articular  processes  of  the  eight  and  ninth  dorsal  vertebra;, 
penetrating  the  vertebral  canal.  There  was  immediate  loss  of  all  sen- 
sation and  motion  below  the  wound.  He  remained  in  a  feeble  state, 
with  slow  pulse,  labored  respiration,  cool,  clammy  and  cyanosed  skin, 
and  involuntary  fecal  and  urinary  discharges,  until  the  27tli  of  June, 
when  excessive  gastric  irritability  came  on,  and  all  nourishment  was 
promptly  rejected  by  the  stomach,  and  he  died,  on  July  2d,  thirty  day.s 
after  the  reception  of  the  injury. 

"  Five  thousand  one  hundred  and  ninety-five  gun-shot  flesh  wounds  of 


454  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


the  back  hare  been  recorded,  of  which  a  large  proportion  are  injuries 
from  shell.  Troops  being  often  ordered  to  lie  down  under  a  shell  fire, 
this  region  becomes  particularly  exposed,"  (p.  21.) 

Results  have  been  ascertained  in  1272  cases  of  Penetrating  Chin-shot 
Wounds  of  the  Chest,  of  which  930  were  fatal,  or  73  per  cent. 

"  In  the  treatment,  venesection  appears  to  have  been  abandoned  alto- 
gether. Hemorrhage  was  treated  by  the  application  of  cold,  perfect 
rest,  and  the  administration  of  opium.  These  measures  seem  to  have 
proved  adequate  generally,  and  no  instances  are  reported  of  the  per- 
formance of  paracentesis  or  of  the  enlargement  of  wounds  for  the 
evacuation  of  effused  blood.  Hemorrhage  from  the  vessels  of  the 
costal  parietes  has  been  exceedingly  rare,  and,  in  the  few  instances 
recorded,  was  a  secondary  accident.  Hence  the  management  of 
bleeding  from  wounded  intercostal  arteries  has  presented  theoretical 
rather  than  practical  difficulties. 

"  It  has  been  the  commoa  practice  to  remove  splintered  portions  of 
fractured  ribs,  and  to  round  off  sharp  edges  that  were  likely  to  wound 
the  pleura  or  lung.  After  this,  with  the  exception  of  extracting  foreign 
bodies  whenever  practicable,  and  performing  paracentesis  when  em- 
pyema was  developed,  it  has  been  usual  to  leave  these  "cases  to  the 
natural  process  of  cure. 

"  The  records  of  the  results  of  the  so-called  method  of  '  hermetically 
sealing'  gun-shot  penetrating  wounds  of  the  chest  are  sufficiently  ample 
to  warrant  an  unqualified  condemnation  of  the  practice.  The  histories 
of  the  cases  in  which  this  plan  was  adopted  have  been  traced,  in  most 
instances,  to  their  rapidly  fatal  conclusion,"  (pp.  2I-2.j 

There  is  only  one  exception  of  reported  recovery. 

Where  the  track  of  the  ball  passed  near  the  root  of  the  lung  recov- 
ery was  rare.  The  cases  in  which  there  was  fracture  >of  the  rib  at  the 
wound  of  entry  were  very  dangerous.  There  was  ample  confirmation 
of  the  received  opinion,  that  penetrating  wounds  with  lodgment  of  the 
ball,  are  more  fatal  than  simply  perforating  wounds.  A  remarkable 
recovery  is  mentioned,  where  the  anterior  mediastinum  was  opened. 

"  A  private  was  struck  by  a  three  ounce  grape.shot,  on  the  morning 
of  May  3d,  1863.  The  ball  comminuted  the  sternum,  at  the  level  of 
the  third  rib,  on  the  left  side,  and  tore  through  the  costal  pleura.  It 
remained  in  the  wound  and  was  removed  by  the  patient.  Through  the 
wound  the  arch  of  the  aorta  was  distinctly  visible,  and  its  pulsations 
could  be  counted.  The  left  lung  was  collapsed.  When  sitting  up  there 
was  but  slight  dyspnoea.  Several  fragments  of  the  sternum  were  re- 
moved, and  the  wound  soon  granulated  kindly.  On  July  5th,  the 
patient  was  transferred  to  Washington,  convalescent.  He  ultimately 
recovered  perfectly,"  ( p.  23.^ 

Only  four  cases  are  recorded  of  Gun  shot  Wounds  of  the  Heart,  that 
came  under  treatment.    In  a  case  where  a  small  pistol  shot  entered  the 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


455 


left  ventricle  and  passed  out  through  the  right  auricle,  the  patient  sur- 
vived twelve  hours. 

Four  instances  of  recovery  from  a  formidable  gun-shot  wound, 
involving  both  the  thoracic  and  abdominal  cavities,  are  given.  la 
the  first,  a  conoidal  musket  ball  went  through  the  belly  of  the  biceps 
of  the  right  arm,  entered  the  chest,  traversed  the  base  of  the  right 
lung  and  the  diaphragm,  wounded  the  intestines,  and  passed  out 
above  the  anterior  superior  spinous  process  of  the  left  ilium.  Wheu 
admitted  to  the  field  hospital,  he  had  dyspnosa  and  bloody  sputa,  and 
there  was  a  fecal  discharge  from  the  wound  of  exit.  Treated  by  large 
doses  of  opium,  at  the  end  of  three  weeks  convalescence  was  fairly 
established.  In  the  course  of  a  few  months  his  wounds  had  entirely 
closed,  and  he  rejoined  his  regiment  for  duty.    In  another — 

"  A  round  musket  ball,  fired  from  a  distance  of  about  one  hundred 
and  fifty  yards,  entered  the  eighth  intercostal  space  of  the  left  side,  at 
a  point  nine  and  a  half  inches  to  the  left  of  the  extremity  of  the  ensi- 
forra  cartilage,  and  fractured  the  ninth  rib.  Without  wounding  the 
lung,  apparently,  the  ball  passed  through  the  diaphragm,  and  entered 

some  portion  of  the  alimentary  canal.    Captain  S  walked  a  mile 

and  a  half  to  the  rear,  and  entered  a  field  hospital.  On  examining  his 
wound,  the  surgeons  found  a  protrusion  of  the  lung  of  the  size  of  a 
small  orange,  which  they  unavailingly  attempted  to  reduce.  The  wound 
was  enlarged,  and  still  it  was  impracticable  to  replace  the  protruded 
lung.  Fruitless  efforts  were  again  made  to  reduce  the  hernial  tumor, 
after  which  a  ligature  was  thrown  around  its  base  and  tightened.  A 
day  or  two  subsequently  the  patient  passed  into  the  hands  of  Surgeon 
Toraaine,  who  removed  the  ligature  from  the  base  of  the  tumor.  A 
small  portion  of  gangrenous  lung  separated  and  left  a  clean  granulat- 
ing surface  beneath.    On  May  7th,  the  ball  was  voided  at  stool. 

"  There  was  an  entire  absence  of  general  constitutional  symptoms;  no 
cough,  no  dyspnoea,  no  abdominal  pain;  the  bowels  were  regular  and 
appetite  good.  The  protrudmg  portion  of  the  lung  was  carnified,  and 
and  there  was  a  dullness  on  percussion  and  absence  of  the  respiratory 
murmur  in  a  zone  an  inch  and  a  half  in  width  around  the  circumfer- 
ence of  the  base  of  the  tumor.    It  was  at  this  date  half  the  size  of  an 

egg,  and  covered  with  florid  granulations.   On  June  2d,  Captain  S  

was  transferred  to  Washington.  There  was  an  elastic,  partly  reducible 
tumor,  over  which  was  an  oval  granulating  surface,  an  inch  and  a  half 
by  three-quarters  of  an  inch.  The  vesicular  niurnmr  was  perfect 
throughout  the  lung,  except  in  the  immediate  vicinity  of  the  tumor. 

After  a  furlough  of  sixty  days.  Captain  S  was  again  examined. 

The  wound  had  entirely  healed;  tlie  respiratory  sounds  were  normal; 
there  was  still  a  slight  hernia  of  the  lung.  The  general  health  of  the 
patient  was  excellent,"  fp.  24.) 

In  a  third  case,  the  liver  as  well  as  the  lung  would  appear  to  have 
been  implicated.   On  the  27th  of  August,  a  man  was  struck  by  a  musket 


456  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 

ball  four  inches  above  the  crest  of  the  right  ilium,  and  six  inches  from 
the  spine,  it  passing  upwards  and  inwards,  and  lodging.  There  was 
cough,  with  bloody  expectoration  and  crepitant  rhonchi  in  the  lower 
lobe  of  the  left  lung;  a  profuse  discharge  of  bile  from  the  wound,  and 
severe  pain  and  tenderness  in  the  hepatic  region.  Acute  pulmonic 
symptoms  subsided  after  a  week,  but  cough,  with  purulent  expectora- 
tion, persisted  for  months. 

"  Early  in  October  the  discharge  of  pus  and  bile  from  the  wound 
began  to  diminish,  and  in  November  the  pain  ceased  in  the  hepatic 
region,  and  was  referred  to  the  immediate  vicinity  of  the  orifice  of  the 
wound.  The  patient  now  began  to  walk  about  the  ward.  Throughout 
the  treatment  there  was  great  tendency  to  constipation,  which  was  ob- 
viated by  enemata.  In  the  middle  of  December  the  cough  had  nearly 
disappeared,  and  there  was  but  a  scanty  discharge  from  the  wound. 
On  January  12th,  1863,  the  wound  was  entirely  healed,  and  the  patient 
was  discharged  from  service,"  (p.  24.) 

Of  210*r  Gun-shot  Wounds  of  the  Abdomen  reported  from  the  be- 
ginning of  the  war  to  July  1st,  1864,  there  were  2164  flesh  wounds, 
and  543  cases  in  which  the  peritoneal  cavity  was  penetrated  or  the 
abdominal  viscera  injured. 

"  Among  the  flesh  wounds,  114  fatal  cases  are  recorded,  which  were, 
in  most  instances,  cases  of  sloughing  from  injuries  of  the  abdominal 
parietes  by  shells.  The  number  of  recoveries  is  unexpectedly  large, 
but  includes  only  cases  in  which  the  reports  showed,  beyond  question, 
that  the  abdominal  cavity  had  been  involved. 

"  In  many  instances  fecal  fistulas  were  produced.  They  commonly 
closed  after  a  time,  without  operative  interference,  reopening  at  inter- 
vals, and  then  healing  permanently. 

"  Recoveries  after  wounds  of  the  large  intestines  have  been  much 
more  numerous  than  after  wounds  of  the  ileum  or  jejunum.  No  case 
has  been  reported  in  which  it  was  thought  expedient  to  apply  a  soture 
to  the  intestines  after  gun-shot  wounds.  Gun-shot  wounds  of  the  liver 
were  usually  followed  by  extravasation  into  the  abdominal  cavity  and 
rapidly  fatal  peritonitis.  Of  32  cases  in  which  the  diagnosis  was  un- 
questionable, all  but  four  terminated  fatally,"  fpp.  24-6.) 

All  the  cases  of  Gun-shot  Wounds  of  the  Spleen,  that  have  been  re- 
ported, were  fatal. 

"  Gun  shot  wounds  of  the  bladder,  when  the  projectile  entered  above 
the  pubes  or  through  the  pelvic  bones,  have  proved  fatal,  so  far  as  the 
records  have  been  examined.  There  arc  many  examples  of  recovery, 
however,  from  injuries  of  the  parts  of  the  bladder  uncovered  by  the 
peritoneum.  Several  examples  of  recovery,  after  protrusions  of  the 
abdominal  viscera  through  gun  shot  wounds,  have  been  reported.  In 
two  cases  in  which  loops  of  small  intestine  issued,  they  were  immediate- 
ly returned  and  retained  by  means  of  adhesive  strips  and  bandages, 


I 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


457 


and  the  patients  recovered  with  ventral  hernia.  The  escape  of  omen- 
tum, through  wounds,  would  not  appear  to  be  a  very  serious  complica- 
tion, for  iu  many  cases  portions  of  protruding  omentum  have  been  ex- 
cised, and  the  patients  have,  nevertheless,  recovered  promptly,"  (p.  21.) 

The  returns  corroborate  the  observation  of  Strc^eyer,  that  there  is 
great  liability  to  pyemia  after  gun-shot  injury  of  the  pelvic  bones, 
tedious  suppuration  usually  ensuing.  Slight  hurts  to  the  ilium,  as 
grooving  of  the  crest  by  a  musket  ball,  usually  did  well;  and  there  were 
many  examples  of  perforation  of  the  body  of  the  bone,  with  ultimate 
recovery. 

In  Gun-shot  Wounds  of  the  Upper  Extremities,  progress  to  any  ex- 
tent has  only  been  made  with  the  class  including  fractures  of  the  shaft 
of  the  humerus  and  either  of  its  articular  extremities. 

"  This  comprises  2408  cases  of  gun  shot  fractures  of  the  humerus 
that  have  l)een  examined  and  recorded.  Recovery  followed  in  1253 
cases,  death  in  486,  and  the  result  is  as  yet  undetermined  in  719  cases. 
In  the  1C89  completed  cases,  amputation  or  excision  were  practiced 
in  996,  and  conservative  treatment  was  adopted  in  693,  with  a  ratio  of 
mortality  of  21  per  cent,  in  the  former  and  80  per  cent,  in  the  latter. 
But  it  is  premature  to  make  deductions,"  (p.  29.) 

Gun-shol  Wounds  of  the  Lower  Extremities. — Only  those  cases  of 
gun-shot  fractures  of  the  femur,  iu  which  the  histories  of  the  cases  had 
been  carefully  scrutinized,  and  in  which  the  locality  and  extent  of  the 
injury  were  clearly  designated  on  the  reports,  have  been  entered  on 
the  permanent  records — numbering  1823  cases,  on  September  1st, 
1865,  or  about  one-third  of  the  total  number  that  have  been  reported. 
Of  these  1823  cases,  the  results  have  been  ascertained  in  1223.  Of 
the  1183  cases  of  gun-shot  wounds  of  the  knee  joint,  the  results  are 
known  in  770'.  Though  the  statistics  tending  towards  the  settlement 
of  some  of  the  most  important,  and  still  open,  questions  of  surgery,  are 
yet  too  incomplete  to  enable  results  to  be  discussed  uuderstandingly, 
it  has  been  "  thought  expedient  to  report  them." 

"The  only  recorded  recoveries  after  gun-shot  fracture  of  the  femur 
involving  the  hip  joint  are  those  in  which  excision  was  practiced.  In 
fractures  of  the  upper  third,  the  mortality  rate  is  greatest  for  the  cases 
treated  by  amputation.  There  were  43  of  these  cases,  and  in  19  of 
them  the  amputation  was  done  at  the  hip  joint.  Excision  gives  7  re- 
coveries after  fractures  of  the  u])pcr  third;  2  of  these  were  excisions  of 
the  head  and  a  portion  of  the  shaft  of  the  femur,  4  were  normal  exci- 
sions of  the  continuity,  and  1  was  a  removal  of  fragments  and  round- 
ing off  of  sharp  edges  of  bone,  which  was  admitted  among  the  excisions 
with  some  licsitation.  Under  conservative  measures  98  cases  of  frac- 
ture of  the  upi)er  third  had  survived  the  injury  a  year  or  more,  and  are 


458 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


reported  as  recovered.  The  mortality  rate  of  the  completed  cases  of 
amputation  for  gun-shot  wounds  of  the  knee  joint  is  large,  and  will 
probably  be  modified  when  tlie  results  of  the  numerous  unfinished  cases 
are  recorded.  It  depends  partly,  however,  upon  the  excessive  mor- 
tality of  intermediate  amputations  of  knee  joint  injuries.  With  six  or 
eight  exceptions,  tlte  50  recoveries  without  amputation  classified  with 
gun-shot  wounds  of  the  knee  joint  were  examples  of  fractures  of  the 
patella,  in  which  the  evidence  that  the  joint  was  opened  was  not  un- 
equivocal. Comparing  in  gross  the  822  finished  cases  treated  by  am- 
putation, with  the  1117  treated  by  conservation,  the  mortality  rate 
of  tlie  former  has  the  advantage  by  8  per  cent. — an  advantage  that  is 
maintained  in  the  different  regions,  except  in  the  upper  third.  It  must 
be  remembered  that  the  amputations  include  most  of  the  bad  cases, 
and  those  in  which  preservation  of  the  limb  was  attempted  and 
abandoned,"  (p.  32.) 

In  Stroraeyer'fi  classification  of  the  action  of  bullets  on  bone,  the 
fifth  division  is  that  in  which  the  ball  pierces  the  bone  and  forms  a 
canal  without  causing  further  splintering.  Examples  are  common  in 
the  upper  portion  of  the  tibia,  but  very  rare  in  the  upper  extremity 
of  the  femur.  Specimen  565  A.  M.  M.  shows  the  upper  extremity  of  a 
left  femur  perforated  by  a  conoidal  ball.  The  wound  was  received 
June  26th,  1862,  and  death  occurred  from  exhaustion,  August  19, 
1862.  The  near  proximity  of  the  ball  had  not  induced  any  disease  of 
the  hip  joint. 

The  degree  of  difference  in  the  effect  upon  bones  of  the  impact  of 
round  musket  balls,  and  of  cylindro-conical  ones,  has,  it  ia  believed, 
been  exaggerated.  Attention  is  called  to  one  curious  effect,  not  gen- 
erally noticed,  occasionally  caused  by  the  heavy  conoidal  ball  striking 
the  femur — the  bone  is  fissured  and  comminuted,  though  less  than  is 
common,  at  the  point  on  which  the  ball  impinges,  while  at  two  or  three 
inches  above  or  below  this  point,  according  as  the  point  of  impact  is 
below  or  above  the  middle  of  the  shaft,  a  nearly  transverse  fracture  of 
the  shaft  is  produced.  There  are  specimens  in  which  the  ball  has 
struck  the  condyles  anteriorly,  and  the  shaft  is  snapped  across  two 
inches  above.  In  several  of  these  specimens  the  transverse  fracture  is 
not  connected  by  fissures  with  the  comminuted  fracture  produced  by 
the  ball.  It  would  seem  that  these  injuries  were  produced  by  balls 
fired  at  short  range. 

The  series  in  the  Army  Medical  Museum  illustrating  the  repara- 
tive eflForts  of  nature  after  gun  shot  fractures  of  the  femur,  consist  of 
190  specimens,  and  is  of  great  interest.  Specimen  1042  A.  M.  M.  shows 
a  consolidated  fracture  of  the  femur,  in  which  the  ball  entered  a  little 
below  the  great  trochanter  of  the  right  femur,  shattering  the  upper 


1866.]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  459 


third  of  the  bone;  this  happened  September  ITth,  1862;  on  the  21st 
January,  1863,  the  fracture  was  firm.  The  man  died  9th  March  fol- 
lowing, with  phthisis,  which  had  begun  about  the  time  of  consolidation. 

We  are  told  that  the  records  contain  scores  of  fatal  cases  of  Gv/n- 
shot  Injuries  of  ike  Knee  Joint,  treated  by  free  incisions  into  the  articu- 
lation. "  Yet  amputations  for  gun-shot  injuries  of  the  knee,  that  have 
reached  the  second  period,  are  scarcely  less  disastrous,"  (p.  36.) 

"Three  patients  have  been  photographed  at  the  Army  Medical 
Museum  who  had  recovered  without  amputation  after  gun-shot  injuries 
of  the  knee  joint.  Four  or  five  additional  cases  appear  upon  the  records. 
In  scarcely  any  of  these  cases  could  it  be  asserted  that  the  danger  of 
consecutive  disease  of  the  knee  joint  was  passed.  The  '  curious  fact,' 
adverted  to  by  Surgeon  I.  Moses,  U.  S.  Vols.,*  '  that  more  men  had 
been  discharged  the  service  at  that  post  [Louisville,  Kentucky]  who 
had  received  gun-shot  wounds  of  the  knee  joint  with  recovery  than 
when  amputation  of  the  thigh  had  been  performed,'  is  directly  contra- 
dicted by  the  oflBcial  reports  from  that  post,"  (p.  37.) 

A  number  of  drawings  at  the  Army  Medical  Museum  exhibit  the 
course  of  balls  directly  in  the  track  of  the  great  vessels  of  the  neck, 
and  of  the  limbs,  illustrating  the  resiliency  of  large  arteries. 

We  are  informed  that — 

"  The  number  of  Sabre  and  Bayonet  Wo^mds  that  have  come  under 
treatment  has  been  comparatively  small;  105  cases  of  the  former,  and 
143  of  the  latter  comprise  nearly  all  that  have  been  reported  for  the 
first  tiiree  years  of  the  war.  Of  these  wounds,  two-thirds  were  received 
in  action,  and  the  remainder  were  inflicted  by  sentinels  or  patrols. 
There  are  11  deaths  from  sword  wounds  recorded,  and  6  from  bayonet 
wounds.  At  the  Army  Medical  Museum  there  are  9  specimens  of 
sabre  cuts  of  the  cranium,  a  specimen  of  punctured  fracture  of  the  skull 
by  a  bayonet,  and  a  preparation  exhibiting  a  bayonet  thrust  through 
the  stomach.  From  General  Sheridan's  campaign  in  the  Shenandoah 
Valley,  25  sabre  wounds  are  reported;  and  from  the  battle  of  Jones- 
borough,  in  Georgia,  30  bayonet  wounds,"  (pp.  39-40.) 

Of  Trmimatic  Tetanus,  363  cases  are  all  that  have  been  reported 
during  the  war;  336  terminated  fatally.  Of  the  2t  recoveries  the 
disease  was  of  a  chronic  form  in  23.  "  In  the  four  remaining  cases  the 
symptoms  were  very  grave.  In  two,  recovery  took  place  under  the  use 
of  opiates  and  stimulants;  in  two,  after  amputation  of  the  wounded 
part,"  42.; 

"The  great  majority  of  the  cases  were  treated  by  the  free  use  of 
opium,  conjoined  with  stimulants  and  concentrated  nourishment. 
Chloroform  inhalations  were  very  generally  employed  during  the  par- 


'American  Journal  of  Medical  Sciences,  vol.  xlvii.,  p.  341. 


460 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


! 


oxysras  of  spasmodic  contraction.  Subcutaneous  injections  of  the  salts 
of  morphia  and  atropia  were  frequently  used.  Cathartics,  quinia, 
camphor,  cannabis  iudica,  bromide  of  potassium,  strychnia,  belladonna, 
and  aconite  are  mentioned  among  the  remedies  employed.  Cups, 
blisters,  turpentine  stupes,  and  ice  were  among  the  applications  made 
to  the  spine;  and  fomentations  with  opium  or  tobacco,  were,  in  some 
cases,  applied  to  the  wound.  Amputation,  tiie  division  of  nerves,  and 
the  extirpation  of  neuromata  in  stumps  were  the  surgical  measures 
sometimes  employed.  The  results  have  not  modified  the  conclusion  of 
Romberg,  that  '  wherever  tetanus  puts  on  the  acute  form,  no  curative 
proceeding  will  avail,  while  in  the  milder  and  more  tardy  form,  the 
most  various  remedies  have  been  followed  by  cure.'  'J  he  value  of 
nicotine,  of  the  Calabar  bean,  and  of  curare*  as  curative  agents  in 
tetanus  was  not  tested,"  (p.  i2.) 

One  case  of  recovery  in  the  chronic  form  occurred  within  our  obser 
vation,  during  the  administration  of  large  and  frequent  doses  of  the 
extractum  cannabis. 

Autopsies  were  made  in  many  cases,  but  with  negative  results,  there 
being  no  microscopic  examinations.  Great  congestion  of  the  brain  and 
spinal  cord  is  "  frequently  mentioned,"  a  condition  on  which  the  con- 
stant anatomical  lesion  of  Rokitansky  and  Demme — proliferation  of 
the  connective  tissue  of  the  spinal  cord  and  portions  of  the  brain- — is 
believed  to  depend.  The  influence  of  sudden  vicissitudes  of  tempera- 
ture, of  unextracted  balls  and  other  foreign  bodies,  and  matter  confined 
under  fasciae,  in  developing  this  affection,  is  abundantly  sliown  in  the 
records. 

Of  650  examined  and  recorded  cases  of  Secondary  Hemorrhage  from 
Gunshot  Wouiids,  the  termination  was  fatal  in  330,  or  61  per  cent.  It 
would  appear — 

"  That,  during  the  earlier  part  of  the  war,  there  were  many  surgeons 
who  were  not  sufficiently  impressed  by  the  precepts  of  Bell  and  Guth- 
rie, and  who  frequently  treated  secondary  heraorihage  from  gun-shot 
•wounds  by  tying  the  main  trunk  at  a  distance  from  the  wound,  even 
when  the  bleeding  occurred  at  a  comparatively  early  period.  Later 
in  the  war,  however,  it  was  the  universal  practice  to  endeavor  to  .secure 
both  ends  of  the  bleeding  vessel  at  the  seat  of  injury,  and  .some  bril- 
liant examples  are  recorded  in  which  this  was  accomplished  in  wounds 
of  the  posterior  tibial  or  popliteal,  ^vhen  limbs  had  become  infiltrated 
and  swollen,  and  the  difficulties  of  the  operations  were  immense,  (p.  43.) 

On  the  subject  of  Pyamia  we  are  informed  that  the  histories  of  754 
cases  are  registered,  the  post-mortem  observations  accompanying  a 
large  proportion  of  the  fatal  ones,  which  numbered  119,  or  95.35  per 

*  According  to  H.  Demme,  of  22  cases  of  traumatic  tetanus  treated  by  the 
latter  agent,  8  recovered.    See  Schweiz.  Zeitschrift  fiir  Heilkande,  ii.,  35G. 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


461 


cent.  These  figures  by  no  means  represent  the  frequency  of  pyaemic 
poisoning,  which  was  one  of  the  great  sources  of  mortality  after  am- 
putations, "its  victims  being  counted  by  thousands."  The  statistical 
reports  on  treatment  "are  adverse  to  the  therapeutical  utility  of  the 
sulphites  and  hyposulphites  in  this  disease." 

The  form  according  to  which  all  Surgical  Operations  are  recorded 
on  the  registers  of  the  office,  though  involving  much  labor,  insures 
the  highest  attainable  degree  of  statistical  accuracy. 

"  The  name  and  military  description  of  the  patient  are  given,  the 
nature  and  date  of  his  injury,  an  account  of  the  operation,  a  notice  of 
the  local  lesions  which  made  it  necessary,  and  of  the  constitutional 
condition  of  the  patient  at  the  period  it  was  performed.  A  summary 
of  the  progress  and  after-treatment  follows,  and  the  result,  if  ascer- 
tained, tlie  name  of  the  operator,  and  the  post-mortem  appearances, 
when  known,  if  the  case  terminated  fatally.  If  the  case  furnished  a 
pathological  preparation  to  the  Army  Medical  Museum,  a  reference  is 
made  to  the  number  of  the  specimen  on  the  catalogue,"  (p.  44.) 

The  returns  of  Amputation  at  the  Knee  Joint  to  October,  1864,  give 
132  cases,  of  which  52  got  well  and  64  died.  Of  49  cases  of  primary 
amputation,  31  recovered  and  16  died,  a  mortality  percentage  of  34.9. 
These  results  support  the  opinions  of  Malgaigne,  Baudens,  and  Mucleod, 
in  opposition  to  Legouest.  The  objection  to  amputations  at  the  knee 
joint,  that  the  resulting  stump  is  ill-adapted  to  the  use  of  an  artificial 
limb,  is  disposed  of  by  the  positive  declaration  of  Hudson  and  other 
manufacturers,  "  that  the  stumps  from  the  operation  at  the  knee  joint 
give  a  base  of  support  far  better  than  any  possibly  to  be  gained  in 
thigh-stumps." 

In  1591  terminated  cases  of  AmpiUations  of  the  Thigh,  64.43  per 
cent,  died,  which  is  within  a  fraction  of  the  mortality  after  amputations 
of  the  thigh  in  the  British  army  in  the  Crimea.  In  the  French  army 
91.89  per  cent,  ended  fatally.  Of  these  1591  amputations,  423  were 
known  to  be  primary,  and  638  intermediate  or  secondary.  The  ratio 
of  mortality  was  54.13  in  the  former,  74.76  in  the  latter. 

There  have  been  reported  23  Amputations  at  the  Hip  Joint,  of  which 
9  were  primary,  with  2  recoveries,  and  14  were  secondary,  with  3 
recoveries. 

"  There  seem  to  be  but  three  conditions  under  which  early  amputa- 
tion at  the  hip  joint  is  admissible  in  military  surgery,  viz.,  when  nearly 
the  entire  thigh  is  carried  away  by  a  large  projectile,  when  the  totality 
of  the  femur  is  destroyed  by  osteomyelitis,  and,  possibly,  when,  with 
comminution  of  tlie  ui)per  extremity  of  the  femur,  the  femoral  vessels 
are  wounded.  As  to  the  method  of  operating,  it  may  be  observed 
that  the  anterior  ilap  shigle  procedure  has  of  late  been  generally  pre- 
ferred," (p.  52.) 


462 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


Nearly  all  of  the  cases  of  Excision  of  the  Shoulder  Joint  reported 
during  the  war  have  been  recorded. 

"  The  percentage  of  mortality  is  23.3  in  primary  cases,  38.59  ia 
secondary  cases,  or  a  mean  ratio  of  32.48.  The  ratio  in  amputations 
at  the  shoulder  joint  is  39.24,  a  percentage  of  6.16  in  favor  of  excision. 
Of  36  cases  of  gun-shot  fracture  of  the  head  of  the  humerus,  selected 
as  favorable  cases  for  the  expectant  plan  and  treated  without  excision 
or  amputation,  16  died,  or  44.4  per  cent.,  a  ratio  in  favor  of  excision 
of  11.96  per  cent,"  (p.  55.)* 

The  observation  of  Esmarch,  that  resection  of  the  left  shoulder  gives 
less  favorable  results  than  that  of  the  right,  is  not  confirmed  by  the 
returns.  The  method  commonly  preferred  was  that,  by  a  single  verti- 
cal incision,  though  some  operators  raised  a  V-shaped  flap,  and  all 
endeavored  to  include  the  wound  made  by  the  ball  in  the  incision.  It 
is  frequently  mentioned  that  the  long  tendon  of  the  biceps  was  pre- 
served. Where  the  shaft  of  the  humerus  had  been  extensively  shat- 
tered, five  or  six  inches  of  the  diaphysis,  along  with  the  head,  were 
frequently  removed,  in  spite  of  the  prohibition  of  Guthrie,  and  with 
excellent  results.    In  one  remarkable  case — 

"  After  an  incision  of  the  head  and  upper  third  of  the  humerus,  the 
remainder  of  the  bone  became  necrosed,  and  was  excised,  together 
with  the  articular  ends  of  the  radius  and  ulna,  and  yet  a  limb  was  pre- 


•  Prof.  A.  G.  Drachmann,  in  a  recent  communication  to  the  Eoyal  Medical 
Society  of  Copenhagen,  states  that  the  total  number  of  resections  of  the 
shoulder  and  elbow  joints,  from  gun-shot  wounds,  in  the  Danish  army  during 
the  late  war,  was  30 — 16  of  the  shoulder  and  14  of  the  elbow,  of  which  4  of  the 
shoulder  and  8  of  the  elbow  came  under  his  own  observation.  From  these  12 
cases,  as  well  as  from  12  others,  (4  in  or  near  the  shoulder  joint,  and  8  in  or 
near  the  elbow  joint,)  he  is  of  the  opinion:  1.  That  gun-shot  wounds  through 
the  shoulder  joint,  with  lesion  of  the  respective  bones  composing  the  joint,  may 
be  healed,  without  resection,  with  a  satisfactory  result  as  to  the  future  utility 
of  the  limb.  2.  That  gun-shot  wounds  in  the  immediate  neighborhood  of  the 
shoulder  and  elbow  joints,  with  injui-y  of  the  bone,  do  not  always  cause  the 
opening  of  the  joint,  and  may  be  healed  without  limiting  the  usefulness  of  the 
limb.  In  our  own  experience,  several  remarkable  cases  of  such  injuries  in 
the  neighborhood  of  shoulder  and  elbow  joints  have  made  excellent  recoveries 
without  operative  interference.  The  difficulty  is  to  decide  whether  the  joint 
is  implicated  or  not. 

Prof.  Drachmann  (op.  cit. )  believes,  from  his  own  experience,  and  that  of 
other  military  surgeons,  in  the  last  Schleswig-Holstein  war,  that  gun-shot 
wounds  through  the  elbow  joint,  with  lesions  of  the  several  component  bones, 
may  in  general  be  healed  with  anchylosis  of  the  joint,  and  with  a  result  far 
better  for  the  general  utility  of  the  arm,  than  that  following  resection,  without 
anchylosis.— [Rev.  ] 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


463 


served,  which,  with  the  aid  of  ingenious  apparatus,  is  very  useful," 
(p.  55.) 

It  appears  that  formal  Excisions  of  the  Ankle  Joint  were  rarely  suc- 
cessful. 

Prior  to  the  late  rebellion  tliere  were  but  seven  recorded  cases  of 
Excision  of  the  Knee  Joint  for  gun-shot  injury,  of  which  two  were  suc- 
cessful. Abstracts  of  11  cases  of  this  operation  are  given;  of  these 
2  got  well  and  9  died.*  Of  one  of  the  two  recoveries  the  remark  is 
made,  "  the  success  claimed  is  so  extraordinary  as  to  suggest  some 
doubts  of  its  authencity."  Three  excisions  of  the  patella  are  reported, 
the  patients  surviving  the  operations  twelve,  fifteen,  and  eighteen  days, 
respectively.  In  another  case  the  knee  joint  was  laid  open,  and  the 
fragments  of  a  patella,  shattered  by  a  musket  ball,  were  removed. 
The  patient  lived  ten  days.  In  two  cases  the  head  of  the  fibula  was 
excised,  and  portions  of  the  head  of  the  tibia;  both  recovered.  It 
does  not  clearly  appear  that  the  articulation  was  opened  in  either  case. 

There  were  12  cases  of  Excision  of  the  Head  of  the  Femur  on  record 
previous  to  the  war,  with  one  success — Surgeon  O'Leary's  (68th 
British  Foot)  case,  where  the  head  and  several  inches  of  the  shaft  of 
the  femur  were  excised  for  comminuted  fracture  of  the  great  trochanter 
by  a  shell.  [Med.  and  Surg.  Hist,  of  the  British  Army  in  the  Crimea, 
vol.  ii.,  p.  318.]  We  have  in  this  Report  a  tabular  statement  of  32 
cases  returned  to  the  Surgeon  General's  ofiBce,  of  which  28  died,  and  4 
got  well. 

Though  ample  materials  are  on  hand  for  arriving  at  definite  conclu- 
sions respecting  the  value  of  excisions  in  the  continuity  of  the  extremities, 


*  In  the  essay  on  excision  of  the  knee  joint,  submitted  to  the  Council  of  the 
Eoyal  College  of  Surgeons  for  the  Jacksonian  Prize,  by  the  late  Mr.  P.  C. 
Price,  lately  published,  of  291  recorded  cases  of  this  operation,  78,  or  1  in 
3.7,  terminated  fatally.  Among  these,  238  had  been  performed  by  British 
surgeons,  with  55  deaths,  showing  a  mortality  of  1  in  4.3.  These  calculations 
include  5  fatal  cases  in  which  amputation  was  performed  after  the  failure  of 
excision.  In  civil  practice,  Mr.  Butcher,  of  Dublin,  has  reported  five  cases 
of  excision  of  knee,  all  of  which  were  successful.  Mr.  Fergusson,  who  revived 
the  operation  in  1850,  says,  (London  Lancet,  18G4,  vol.  ii.,  p.  33:)  "I  have 
now  performed  this  operation  foHy  times,  and  of  these  no  less  than  fifteen 
have  died,  [37 J  per  cent.]  My  impression  is  that  excision  of  the  knee  is,  or 
should  bo;  by  proper  treatment,  us  little  destructive  to  life  as  amputation  of 
the  thigh." 

M.  Verneuil  lately  stated,  at  the  Society  Chirurgicale,  (18G5,)  the  operation 
has  proved  so  fatal  in  the  Paris  hospitals,  that  it  was  nearly  given  up.— [Rev.] 


464  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


compared  wit  .1  amputations,  they  have  not  yet  been  thoroughly  ana- 
lyzed; but  p  '^ar  as  examined,  they  are,  "on  the  whole,  unfavorable  to 
excisions ''IPWie  continuity,"  (p.  16.) 

Of  tU^  three  cases  of  Ligation  of  the  Common  Iliac,  all  were  fatal, 
the  patients  surviving  two,  four,  and  five  days  respectively.  Two 
cases  of  ligation  of  the  Internal  Iliac,  for  secondary  hemorrhage  after 
gun-shot  wounds,  are  recorded;  both  died.  Two  recoveries  of  the 
ligature  of  the  Ezternul  Iliac  are  mentioned. 

"Of  ligations  of  the  subclavian,  35  cases  are  recorded.  In  all,  the 
vessel  was  secured  outside  of  the  scaleni.  In  1(5  cases,  the  ofieraiion 
was  on  the  right,  and  in  14  on  the  left  side;  in  five  cases  the  particular 
vessel  is  not  mentioned.  The  operation  was  performed  in  13  cases  for 
secondary  hemorrhage  after  amputation  of  the  shoulder-joint,  with  four 
recoveries.  In  two  cases,  it  was  done  for  primary,  and  in  fifteen  for 
secondary  bleeding  after  gun-shot  wounds,  with  injury  of  the  axillary 
artery,  with  two  recoveries.  In  two  cases,  the  operation  was  per- 
formed for  axillary  aneurism.  In  two  cases,  with  one  recovery,  it  was 
required  by  secondary  bleeding  after  excisions  of  the  humerus,  and  in 
one  case  it  was  necessitated  by  a  secondary  hemorriiage  after  a  gun- 
shot wound  with  injury  of  the  subclavian,"  (p.  79.) 

The  vast  influence  e.xerted  upon  the  results  of  the  surgical  practice 
of  the  war  by  scorbutic  and  malarial  complications  is  thus  referred  to: 

"  It  can  not  be  doubted  that  the  frequency  of  osteomyelitis  after  am- 
putations, the  proneness  to  suppurative  inflammation  in  wounds  of  the 
head  and  splanchnic  cavities,  the  tendency  to  the  sloughing  of  flaps, 
the  delay  in  the  union  of  fractures  or  the  healing  of  wounds,  and  the 
great  prevalence  of  pyasmia,  observed  at  certain  periods  and  localities, 
were  intimately  connected  with  the  morbid  causes  above  mentioned, 
whicli  had  led,  in  many  cases,  to  such  an  impairment  of  the  general 
vitality  of  the  men  as  greatly  to  diminish  their  ability  to  resist  the 
effects  of  severe  injuries,"  (p.  86.) 

In  23,260  surgical  operations  performed  on  the  field  or  in  general 
hospitals,  in  which  anesthetics  were  used,  choloroforiji  was  adminis- 
tered in  60  per  cent.,  ether  in  30  per  cent.,  and  in  10  per  cent,  a  mix- 
ture of  the  two. 

"  At  the  general  hospitals,  the  greater  safety  of  ether  as  an  anaes- 
thetic was  commonly  conceded.  It  was  often  employed,  and  no  fatal 
accident  from  its  use  has  been  reported.  In  the  field  operations, 
chloroform  was  almost  exclusively  used.  The  returns  indicate  that  it 
was  administered  in  not  less  than  eiglity  thousand  cases.  lu  seven  in- 
stances, fatal  results  have  been  ascril)ed  with  apparent  fairness  to  its 
use,"  (p.  87.) 

True  Contagious  Hospital  Gangrene  was  comparatively  limited. 
The  Report,  modestly  claiming  to  give  "an  idea  of  the  nature  and 
extent  of  the  data  for  a  Medical  Ilistonj  of  the  War,"  embraces  I'e- 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  465 


marks  upon  the  medical  statistics  of  the  several  armi  and  general 
hospitals,  fully  prepared  for  the  two  first  years;  th  memoirs  and 
reports  on  the  causes,  symptoms,  and  treatment  of  the  u:  u  important 
camp  diseases;  the  series  of  medical  and  microscopical  specu.  nis  in  the 
Army  Medical  Museum;  and  the  results  of  pathological  studies  on  the 
basis  of  these  collections.  The  exemption  of  our  army  from  serious 
epidemics  is  attributed  to  an  abundant  commissariat,  and  also,  quite 
droliy,  to  liberal  medical  supplies.  The  opinion  is  hazarded  that  "  the 
mortality  of  our  soldiers  from  disease  has  been  far  less  than  that  of  any 
other  army  Ir  time  of  war."  Still,  the  deaths  "from  disease  were  far 
more  numerous  than  all  the  slain  m  all  the  battles,  and  all  the  wounded 
who  have  since  died  or  are  yet  likely  to  die  of  the  injuries  received  ia 
the  struggle;"  and  were  more  than  five  times  as  great,  not  counting 
deaths  among  prisoners  of  war  or  discharged  soldiers,  than  of  men  of 
the  same  ages  in  civil  life,  "  and  were  caused  by  diseases  which  are 
precisely  those  most  under  the  control  of  hygienic  means." 

"  The  mortality  of  the  armies  of  the  United  States  from  disease 
alone  was  48  1  per  1000  of  mean  strength  during  the  first  year  of  the 
war,  viz.,  the  year  ending  June  30,  1862,  and  65.2  per  1000  during 
the  second  year,  viz.,  that  ending  June  30,  1863,"  (p.  92.) 

It  was  considerably  greater  during  the  second  year  of  the  war  thaa 
during  the  first.  It  varied,  too,  in  the  three  great  regions,  Atlantic, 
Central,  and  Pacific,  in  which  the  troops  operated.  The  Atlantic  re- 
gion included  the  North-Eastern  and  Middle  Departments,  the  Army 
of  the  Potomac,  the  troops  in  North  and  South  Carolina,  and  in  Florida; 
the  Pacific  region  embraced  all  west  of  the  Rocky  Mountains;  and  the 
Central  Region  contained  the  great  base  of  the  continent  between  the 
Appalachian  and  the  Rocky  Mountains. 

'On  account  of  its  great  frequency  and  mortality.  Camp  Fever  was, 
during  the  two  years  under  consideration,  the  most  important  of  the 
diseases  of  the  army. 

"  In  a  general  way,  it  may  be  said  that  each  year  about  one-quarter 
•of  the  men  suffered  irom  some  form  of  the  fever,  and  that  the  deaths 
amounted  to  about  two  per  -cent,  of  the  strength.  The  whole  number 
•of  deaths  from  these  fevers  during  the  first  year  was  nearly  one-half 
the  total  mortality  from  disease:  during  the  second  year,  owing  to  the 
increased  mortnlity  from  other  diseases,  and  especially  from  diarrhoea 
and  dysentery,  only  about  one-third  the  total  mortality  from  disease, 
though  still  maintaining  nearly  the  same  ratio  to  strength,"  (p.  110.) 

Under  the  general  designation  of  Camp  ov  Typho-Malarinl  Fever  are 
included  all  those  ca.scs  which  were  reported,  "during  the  first  year  of 
Vol.  it.  —No.  12.  30 


4C6  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


the  war,  under  the  heads  of  Typhus,  I'^'phoid,  Common  Continued, 
and  Remittent." 

We  may  venture  to  express  a  regret  at  the  adoption  of  this  nomen- 
clature, and  a  fear  that  it  will  prove  as  confusing  as  the  old  compre- 
hensive title  of  "  Common  Continued  Fever,"  wliich  included  so  many 
types  of  fever  most  diverse  in  their  nature,  and  will  hinder  the  investiga- 
tion of  the  pathogeny  of  the  several  specific  fevers  which  prevailed  in 
our  army,  and  the  determining  of  the  varied  conditions  under  which 
they  were  generated  and  propagated. 

Modern  pathology  recognizes  certain  distinct  yarieties  of  idiopathic 
fevers,  whose  special  nature  is  well  defined,  whose  natural  history 
has  been  thoroughly  studied  on  fixed  scientific  principles,  and  whose 
aetic  poisons  have  specific  vital  attributes  peculiar  to  themselves,  and 
different  local  foci.  Bayle  remarks:  "  The  determination  of  specific 
characters  is  what  is  most  essential  in  nosology."  "  Words,"  say» 
Sauvages,  "  are  good  only  in  respect  to  their  signification."  Wo  con- 
sider the  correctness  of  this  classification  of  fevers  open  to  question,  as 
not  abreast  of  the  time,  and  as  necessarily  favoring  the  notion  of  iden- 
tity between  diseases  which  have  no  community  of  origin.  Wliile  any 
intention,  by  this  grouping,  "to  express  a  doubt  as  to  the  propriety  of 
regarding  typhus,  typhoid,  or  enteric  and  remittent  fevers  as  distinct 
affections,"  is  expressly  disclaimed ;  and  we  are  told,  rather  oddly,  too, 
that  "the  enteric  lesion  characteristic  of  typhoid  fever  enables  a  ready 
distinction  to  be  effected  between  it  and  genuine  typhus  or  true  remit- 
tent, on  the  autopsy  at  least  f  and  that  "undoubtedly  cases  of  simple 
enteric  and  simple  remittent  fevers  did  occur;"  yet  we  have  the  adop- 
tion of  the  "general  name,"  typho-malarial  fever,  and  all  the  fevers  of 
the  army  described  under  its  three  varieties — malarial,  scorbutic,  and 
enteric — the  following  reasons  being  assigned  for  this  violent  and  un- 
natural arrangement: 

"  As  the  diseases  have  occurred  in  our  army  during  the  present  war, 
dhe  phenomena  of  these  two  [three  have  just  been  named,  typhoid, 
genuine  typhus,  and  remittent]  affections  have  continually  complicated 
each  other  in  the  same  patient;  so  that,  in  fact,  the  enteric  fevers  have 
broken  out  among  men  campaigning  in  a  malarial  region,  with  consti- 
itutions  more  or  less  thoroughly  impregnated  with  the  malarial  poison; 
the  remittents  among  soldiers  peculiarly  prone  by  their  exposures  and 
mode  of  life  to  enteric  disease;  and  both  have  occurred,  almost  without 
exception,  in  men  whose  health  has  been  more  or  less  modified  by 
.  camp  diet,  and  who  were  therefore  suffering  in  some  degree  from  a 
condition  best  characterized  as  the  scorbutic  taint.  These  three  modi- 
fying conditions  or  tendencies,  each  of  which,  acting  alone,  might 
produce  simple  enteric  fever,  periodic  fever,  or  scurvy,  when  acting 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


467 


simultaneously  produce  mixed  types  of  disease  that  vary  infinitely  in 
uccordance  with  the  predominance  of  one  or  another  of  the  three  sets  of 
determining  conditions,"  (p.  109.) 

We  have  always  regarded  the  term  typho-malarial*  as  unfortunate, 
and  liable  to  lead  to  confusion  and  error.  We  fear  that  the  author  of 
the  Report  has  been  unduly  biased  in  favor  of  the  bantling  he  stands 
sponsor  for.  It  was  at  his  suggestion,  we  are  informed,  (p.  109,)  that 
this  "  general  name  was  adopted  into  the  statistical  nomenclature  of 
the  monthly  reports  of  sick  and  wounded."  Had  this  not  been  done 
so  early  as  June,  1862,  is  it  not  probable  that  subsequent  enlarged 
clinical  experience  may  have  modified  his  views  ? 

We  recognize,  to  their  fullest  extent,  all  the  modifying  influences 
enumerated,  but  we  hold  that  in  every  case  they  were  engrafted  on 
some  specific  admitted  type  of  fever,  and  were  accessory  phenomena. 
We  think  the  objections  that  we  have  suggested  to  this  nomenclature 
of  fevers  are  sustained,  when  we  come  to  the  imperfect  summaries 
of  the  symptoms,  and  the  scrupulously  accurate  descriptions  of  the 
recent  anatomical  characters  of  each  form.  They  strengthen  our 
belief  that  a  plurality  of  fevers  prevailed  in  our  armies  during  the 
rebellion,  and  prove  that  while  they  were  frequently,  and  under 
certain  circumstances,  constantly,  allied  by*certain  common  charac- 
ters, they  were  not  the  less  separable  by  peculiar  and  distinctive 
traits.  We  saw  regularly,  for  a  series  of  years,  every  autumn,  cases 
of  typhoid  fever  where  the  proper  symptoms  were  much  modified,  and 
often  greatly  masked  by  palludal  poisoning,  but  in  no  case  were  those 
symptoms  so  occult  as  to  prevent  a  correct  diagnosis  from  being  made. 
And  we  have  seen  the  same  state  of  things  constantly  among  the  fever 
cases  of  our  armies.  In  fairness,  it  must  be  admitted  that  the  fever 
which  was  so  prevalent  in  the  Army  of  the  Potomac,  when  it  was 
floundering  in  the  marshes  of  the  Chickahomhiy,  was  of  a  puzzling 
type,  so  far  as  its  easy  assignment  to  any  of  the  known  forms  of  fever 
which  had  existed  in  this  country  during  the  past  thirty  years,  at  least 
in  the  Northern  and  Middle  States.  In  men  saturated  with  m;ilaria, 
exhausted  by  long  exertion  and  insufficient  rest,  imperfectly  nourished, 
exposed  to  the  action  of  animal  effluvia  from  the  decaying  bodies  of 
botli  men  and  brutes,  and  daily  drinking  water  impregnated  with  the 
products  of  common  putrefaction — all  tending  to  lower  the  energies  of 
the  nervous  system  and  corrupt  the  blood — there  was  produced  a  dis- 

*  Why  was  the  scorbutic  clement  rofu.scd  fellowship  with  the  palludal  and 
idio-nii.ismatic  elements?  It  has,  and  properly  so,  no  moan  pathogenic  part 
assigned  to  it. 


468  REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


ease  in  which  the  combined  action  of  pythogenetic,  palludal  and 
scorbutic  causes  must  be  acl<nowledged.  But  there  was  really  nothing 
novel  in  either  its  symptoms  or  pathology. 

This  form  of  fever,  of  remitting  type  at  the  outset,  with  abdomi- 
nal tenderness,  diarrhoea,  enlarged  spleen,  and  often  cerebral  and 
pulmonary  complications,  (wc  summarize  the  imperfect  doscrii)tion 
of  the  Report,)  is  designated  the  "malarial  form  of  typho-malarial 
fever."  Had  the  use  of  the  term  typho-malarial  been  restricted  to 
this  variety  of  idiopathic  fever,  no  serious  objection  could  have  been 
made  to  it. 

"  The  characteristic  lesion  is  enlargement  of  the  solitary  follicles  of 
the  small  intestine,  and  especially  of  the  ileum.  Thickening  of  Peyer's 
patches  may  be  quite  absent,  or  may  be  present  to  a  variable  extent. 
All  degrees  of  enlargement  have  been  noticed,  from  the  slightest  change 
to  cases  in  which  the  follicle  attains  the  size  of  a  pea.  The  most 
characteristic  specimens  may  be  thus  described:  in  the  fresh  intestine, 
the  ileum  presents  patches  of  deep  congestion  of  variable  extent;  the 
solitary  follicles,  enlarged  to  the  size  of  large  pin-heads,  are  frequently 
black  with  pigment  deposits.  The  Peyer's  patches,  sometimes  quite 
healthy,  are  more  generally  the  seat  of  pigment  deposits  in  the  indi- 
vidual follicles  composing  the  patch,  which  appears  of  a  gray  color, 
dotted  over  with  blackish  point.s,  presenting  a  resemblance  to  the 
freshly-shaven  chin.  The  name  '  shaven-beard  appearance '  has  been 
quite  currently  bestowed  upon  this  condition.  In  other  cases,  the 
Peyer's  patches  are  somewhat  thickened,  and  occasionally  as  much  so 
as  in  ordinary  cases  of  enteric  fever,"  (p.  140.) 

The  second  and  rarer  form  of  the  disease,  styled  "scorbutic  form  of 
typho-malarial  fever,"  is  described  as  "  marked  by  the  extremely 
adynamic  character  of  the  symptoms,  by  petechias,  at  times  even  by 
the  characteristic  scorbutic  lesions  of  the^outh,  by  hemmorrhagc 
from  the  bowels,  and  other  hemmorrhages  which  complicate  the  dis- 
order and  often  prove  fatal."  In  the  specimens,  as  first  received  at 
the  Museum — 

"The  ileum  presents  intense  reddish-black  patches  of  congestion, 
which  sometimes  extend  throughout  its  whole  length.  The  patches  of 
Peyer  are  converted  into  livid,  blackish,  pulp-like  sloughs,  which  are 
often  remarkable  for  their  size  and  fungoid  appearance.  Petechia-like 
blotches  in  the  mucous  membrane  of  the  colon,  the  small  intestine,  and 
the  stomach  are  of  frequent  occurrence.  Similar  diseolorations  arc  at 
times  observed  in  other  organs.  The  cadaver  often  presents  petechia 
on  the  external  surface  of  the  body  and  scorbutic  alterations  of  the 
mouth,"  (pp.  140,  141.) 

In  the  "  enteric  form  of  typhc-malarial  fever,"  we  are  told,  in  some- 
what contradictory  language,  that  the 


186G.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


469 


"  Spocimens  of  the  tliird  group  are  quite  identical  with  those  obtained 
from  the  typlioid  or  enteric  fever  of  civil  life,  and  the  cases  in  many 
instances  are  undoubtedly  that  affection  in  its  ordinary  form.  As  it 
occurrecf  among  the  troops,  however,  the  course  of  the  disease  was 
generally  more  or  less  modified  by  the  influence  on  the  soldier  of  ma- 
laria, or  of  the  scorbutic  taint,  or  both,"  (p.  41.) 

A  comparison  of  the  reports  from  the  three  great  regions,  shows 
Camp  Fever  to  have  been  far  more  frequent  in  the  Atlantic  and  Cen- 
tral regions  than  in  the  Pacific. 

"  In  the  Atlantic  region,  during  both  years,  the  number  of  cases 
was  somewhat  less  than  one-fourth  the  strength;  the  deaths  for  each 
year  about  seventeen  per  1000  of  strength.  In  the  Central  region, 
the  ratio  of  both  cases  and  deaths  was  much  greater  during  the  first 
year  than  the  second.  During  the  first,  the  cases  amounted  to  nearly 
one-third  the  strength,  the  deaths  to  about  thirty-two  per  1000  of 
strength.  During  the  second  year,  the  cases  were  somewhat  less  than 
one-fourth  the  strength,  tiie  deaths  twenty-four  per  1000  of  strength. 
In  tiie  Pacific  region,  the  cases  for  each  year  amounted  only  to  be- 
tween seventy  and  eighty  per  1000  of  strength,  the  deatiis  somswhat 
over  one  per  1000  during  the  first  year,  somewliat  less  than  one  per 
1000  during  the  second,"  (pp.  110-111.) 

The  modifying  influence  of  region  on  the  mortality  is  more  strikingly 
shown  when,  instead  of  comparing  the  deaths  with  strength,  they  are 
compared  with  the  number  of  cases,  for  it  is  then  seen  that  "  the  dis- 
ease is  not  only  more  frequent,  but  more  fatal,  in  proportion  to  the 
number  of  eases,  in  the  Central  region  than  in  the  Atlantic,  and  in 
this  more  than  in  the  Pacific." 

The  occurrence  of  true  Typhus — the  Pestis  Bellica  and  scourge  of  all 
large  armies,  from  the  siege  of  Syracuse  to  that  of  Sebastopol — in  our 
armies,  during  the  late  rebellion,  has  been  doubted,  but  there  is  suffi- 
cient evidence  to  show  fliat  there  was  a  limited  number  of  cases  "  in 
connection  with  overcrowded  and  ill  policed  camps,"  and  especially 
among  "  those  of  our  soldiers  who  were  detained  as  prisoners  in  the 
enemy's  hands." 

Interesting  materials  on  the  subject  of  Cerebro- Spinal  MeningUis, 
called  also,  improperly,  we  hold.  Spotted  Fever,  have  been  contributed, 
but  the  fact  is  only  mentioned. 

Yellow  Fever  made  its  appearance  at  Key  West,  Florida,  in  18G2, 
fl,nd  subsequently,  in  the  same  autumn,  at  Hilton  Head,  South  Caro- 
lina. 

"  The  outbreak  was  limited  to  a  few  hundred  ca=cs,  and  the  deaths 
to  a  hundred.  In  both  places  there  was  the  most  decisive  evidence 
that  the  disease  was  imported  in  consequence  of  the  neglect  or  viola- 


470 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


tion  of  quarantine  regulations.  The  fear  that  yellow  fever  would  prove 
a  terrible  obstacle  to  the  operation  of  our  troops  in  the  Southern 
States  has  proved  wholly  unfounded.  It  may  here  be  mentioned  that 
the  only  subsequent  outbreak  of  importance  which  has  occurred  up  to 
the  date  of  writing,  was  the  epidemic  at  Newbern,  North  Carolina,  in 
the  summer  of  1864.  But  even  here  the  mortality,  so  far  as  our 
troops  were  concerned,  was  limited  to  a  few  hundred  men.  In  the 
case  of  this  outbreak,  Surgeon  D.  W.  Hand,  U.  S.  Vols.,  Medic.il 
Director  of  the  Department,  expresses  the  belief  that  the  fever  was  not 
imported,  but  that  it  originated  on  the  spot  in  consequence  of  the 
neglect  of  hygienic  precaution  by  the  citizens  of  the  place  and  by  the 
X'efugees  who  had  made  it  an  asylum,"  (p.  113.) 

The  severe  visitation  of  Key  West,  in  the  summer  of  1864,  seems  to 
have  been  overlooked,  and  there  is  no  doubt  that  there  were  cases  of 
Yellow  Fever  at  New  Orleans  during  the  autumn  of  the  same  year. 

The  total  number  of  all  forms  of  Inlermittcnt  Fever  reported  for  the 
two  years  was  262,807 ;  the  number  of  deaths,  including  the  so-called 
congestive  form,  for  the  same  period,  was  1,788. 

"  Besides  developing  intermittent  fever  [does  remitting  fever  own 
any  other  cause  ? — Rev.]  and  complicating  other  diseases,  such  as  camp 
fever  and  diarrhoea,  the  malarial  influence  manifests  itself  with  con- 
siderable frequency  among  troops  exposed  to  its  action  by  the  develop- 
ment of  a  peculiar  form  of  anemia,  which  may  be  designated  Chronic 
Malarial  Poisiouing.  This  condition,  attended  usually  with  enlargement 
of  the  spleen  and  frequently  with  an  increase  iu  the  number  of  the 
white  corpuscles  of  the  blood,  manifests  itself  externally  by  languor, 
feebleness,  and  pallor,  attended  commonly  with  neuralgic  pains,  and, 
as  it  actually  occurred  among  our  troops,  often  complicated  by  slight 
scorbutic  symptoms.  Attacks  of  fever,  pneumonia,  or  other  acute 
diseases  occurring  among  patients  in  this  condition  are  peculiarly  apt 
to  prove  fatal.  A  yellowish  complexion  is  a  frequent  phenomenon  in 
the  form  of  anasmia  here  referred  to,  and  often  amounts  to  decided 
jaundice. 

"Mild  epidemics  of  jaundice,  running  a  course  of  from  two  to  .six  or 
eight  weeks,  and  usually  terminating  in  recovery,  have  also  been  of 
frequent  occurrence  among  our  troops  in  malarial  regions.  That  this 
form  of  the  affection  also  stands  related  to  the  malarial  poison,  is  shown 
by  the  fact  that,  as  a  general  rule,  it  was  most  common  in  those  local- 
ities in  which  iutermittents  were  most  frequent,  (p.  111.) 

Diarrhoea  and  Dysentery,  disorders  of  great  frequency,  being  more 
than  one-fourth  of  all  the  cases  of  disease,  and,  next  after  Camp  Fever, 
the  chief  cause  of  mortality  from  disease,  we  find  reported  under  four 
heads — acute  diarrhoea,  chronic  diarrhoea,  acute  dysentery,  and  chronic 
dysentery.  The  terms  "diarrhoea"  and  "dysentery"  appear  to  have 
been  loosely  used  in  the  Reports.    "  The  disease  most  generally  called 


1866.]         REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


471 


chronic  diarrhcBa,  was,  in  fact,  usually  an  affection  of  the  large  intes- 
tine, which  was  thickened,  softened,  and  often  ulcerated.  The  term 
dysentery  would  have  been  more  exact,  and  was  bestowed  by  many 
surgeons  upon  the  same  affection  which  others  called  diarrhoea.  Hence, 
it  has  been  thought  advisable,  in  considering  the  figures,  to  grouji 
together  all  cases  reported  under  these  heads,"  (pp.  117-118.)  The 
annual  number  of  cases  for  the  whole  army  was  greater  than  three- 
fourths  of  the  mean  strength.  The  total  number  of  cases  reported 
during  the  first  year  was  215,214,  with  1194  deaths;  during  the 
second  year,  510,461  cases,  and  10,366  deaths — total,  725,675  cases, 
and  11,560  deaths.    Taking  the  total  of  the  several  forms — 

"It  will  be  seen  that  the  ratio  of  cases  was  765  per  1000  of  mean 
strength  during  the  first  year,  and  852  per  1000  for  the  second;  so 
that  considerably  more  than  three-fourths  of  the  whole  strength  was 
attacked  each  year.  The  mortality  was  4  per  1000  of  strength  during 
the  first  year,  and  16  during  the  second;  the  disease  being  just  four 
times  more  fatal  during  the  second  year  than  the  first,"  (p.  118.) 

The  greatly  increased  mortality  in  the  second  year  will  be  found,  on 
an  examination  of  the  tabulated  statistics,  to  be  explained  by  the 
comparatively  mild  form  of  the  acute  variety,  and  the  increasing  severity 
of  the  chronic.  The  deaths  from  acute  diarrhffia  and  dysentery  in  the 
first  year  were  1  to  every  331  cases,  and  in  the  second  year,  1  to  every 
245;  while  in  the  chronic  forms  the  mortality  increased  from  1  death 
in  every  30  cases,  in  the  first  year,  to  1  in  every  8  in  the  second. 

"  Like  camp  fever  and  intermittents,  diarrhaa  and  dysentery  were 
most  frequent  in  the  Central  region;  less  so  in  the  Atlantic,  and  least 
in  the  Pacific  region.  In  the  Cei.tral  region,  the  cases  were  more 
numerous  than  the  strength  during  the  first  year,  and  nearly  equal  to 
the  sfrength  during  the  second;  in  the  Atlantic,  they  were  more  than 
half  the  strength  duri,tig  the  first  year,  and  more  than  three  quarters 
during  the  second;  in  the  Pacific  region,  during  each  year  somewhat 
over  one-quarter  the  strength.  The  differences  between  the  ratio  of 
mortality  to  strength,  in  the  three  regions,  were  still  more  striking;  in  the 
Central  region  the  mortality  was  9  per  1000  of  mean  strength  during 
the  first  year,'  23  per  1000  during  the  second;  in  the  Atlantic,  1  per 
1000  during  the  first  year,  9  per  lOfO  during  the  second;  in  the 
Pacific  region  less  than  1  per  1000  during  each  year,"  (p.  119.) 

They  were,  by  far,  most  frequent  in  the  summer  and  autumnal 
months. 

As  in  the  case  of  camp  fever,  it  can  not  but  be  regretted  that  the 
acute  and  chronic  forms  of  diarrhoea  and  dysentery  have  been  grouped 
together  under  one  head  in  the  statistical  returns.    Still,  it  will  not 


472  EEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March 


materially  damage  the  practical  study  of  the  causes,  symptoms,  nature, 
and  treatment  of  that  scourge  of  our  armies,  camp  or  chronic  diarrhoea, 
as  it  was  almost  universally  called.  Although  no  attempt  is  made  in 
the  Report  to  present  any  analysis  of  the  vast  amount  of  material  that 
Las  been  contributed  on  this  important  disease,  some  general  views  of 
great  interest  are  hazarded,  which  we  regret  we  can  not  present  more 
fully  to  our  readers,  owing  to  the  great  length  this  article  has  already 
reached.  We  will  endeavor  to  briefly  mention  some  of  the  salient 
points.  The  causation  of  chronic  diarrhoea  is  to  be  found  in  no  one 
condition,  but  the  long  continued  and  co-operative  action  of  certain 
influences,  chief  amongst  which  are  the  scorbutic  taint,  due  to  camp 
diet,  malarial  poisoning,  the  filth  and  overcrowding  of  camp  and  bar- 
racks, excessive  and  prolonged  heat,  physical  fatigue  and  exhaustion 
during  active  campaigns,  and  impure  water.  "  Whether  there  has 
ever  existed,  in  addition  to  these  intelligible  conditions,  any  specific 
causative  momentum  deserving  the  designation  of  epidemic  influence, 
is  a  grave  question,  which  receives  no  affirmative  reply  from  any  expe- 
rience reported  during  this  war."  There  is  no  "  specific  cause,  or  set 
of  causes,  different  from  those  which  induce  the  acute  form."  Fre- 
quently, perhaps  usually,  repeated  attacks  of  acute  diarrhoea  preceded 
the  more  serious  and  continued  disorder;  hence  the  presumption  is 
warranted  "that  a  certain  length  of  time  is  required  before  the  influ- 
ences to  which  a  soldier  is  exposed  culminate  in  chronic  diarrhcea." 

To  the  statement  that  "  among  its  most  striking  phenomena  may  be- 
mentioned  the  usual  absence  of  fever  throughout  the  greater  part  of 
its  course,"  we  must  put  in  a  demurrer.  If  Galen's  definition  of 
fever,  "  calo>-  prater  naturam"  is  correct — and  it  can  not  be  disputed 
that  of  all  the  clauses  and  phrases  in  the  many  definitions  of. fever 
attempted  by  systematic  writers,  it  is  the  only  one  whose  accuracy  is 
unimpeachable — we  are  confident  that  febrile  phenomena  would  have 
been  found  present  in  every  case  of  chronic  diarrhcea  in  our  armies,  had 
the  amount  of  preternatural  heat  in  each  case  been  ascertained  by 
accurate  thermometric  measurement.  The  "  dnj,  harsh  condition  of  the 
skin"  is  admitted,  as  well  as  the  "  extreme  emaciation" — the  latter  symp- 
tom being  due  to  increased  amount  of  tissue  change,  another  constant 
phenomenon  of  fever,  and  one  exhibiting  a  certain  co-relation  to,  and 
association  with,  morbid  development  of  the  heat  of  the  body.  It  is  to 
be  regretted  that  the  products  excreted  by  the  lungs,  skin,  and  kidneys, 
as  well  as  by  the  bowels,  were  not  the  subject  of  frequent  examination 
and  investigation  in  this  disorder,  and  that  it  was  not  ascertained  in 
what  organs  increased  or  diminished  elimination  was  the  rule.  Our  own 


1866..]        REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


473 


observations  have  inclined  us  to  entertain  the  belief  that  camp  diarrhoea 
was  a  chronic  autophagic  disease,  induced  mainly  by  the  causes  heretofore 
enumerated — causes,  in  themselves,  affecting  and  impairing  the  proper 
nutrition  of  the  body,  inducing  a  condition  of  gradual  and  slowly  con- 
tinuous semi-starvation,  the  body  literally  feeding  on  itself,  and  that 
death  happens  in  a  state  of  extreme  debility  and  exhaustion,  except  in 
the  exceptional  cases  where  some  acute  accidental  complication  kills 
the  patient.  These  intercurrent  affections  were,  we  think,  much  less 
frequent  than  the  reporter  claims,  the  supervening  fever  and  acute 
dysenteric  symptoms  being  natural  terminal  phenomena  of  prolonged 
autopliagism.  It  is  not  to  be  denied,  however,  that  a  patient  suffering 
from  chronic  diarrhoea  may  be  attacked  with  camp  fever  or  acute  dys- 
entery, and  the  characteristic  lesions  of  these  diseases  be  found  vari- 
ously and  curiously  combined. 

The  pathological  anatomy  of  camp  diarrhoea  is  illustrated  by  over 
200  specimens  in  the  Army  Medical  Museum,  arranged  in  four  groups: 
1st,  examples  of  follicular  ulceration  of  the  colon,  with  thickening  of 
the  intestinal  coats,  which  ulcers  extend,  by  burrowing  in  the  submu- 
cous connective  tissue,  until,  in  extreme  cases,  the  mucous  membrane  of 
the  colon  is  destroyed  by  vast  erosions.  In  some  cases  the  surface  of 
the  gut  is  more  or  less  coated  with  a  yellowish,  or  greenish  yellow, 
pseudo-membranous  layer,  similar  to  the  membrane  formed  in  the  air- 
passages  in  diphtheria,  and  is  generally  found  after  the  sudden  super- 
vention of  symptoms  of  acute  dysentery.  In  a  few  cases  the  small 
intestine  is  implicated,  the  ileum  being  more  or  less  thickened,  particu- 
larly near  the  ileo-coecal  valve,  with  ulcers  of  variable  size  which  appear 
to  have  their  origin  in  the  solitary  follicles. 

With  respect  to  the  treatment  of  chronic  diarrhoea,  we  are  told,  the 
whole  range  of  vegetable  and  mineral  tonics,  and  alteratives,  and  astrin- 
gents have*  been  employed  with  variable  success,  and  subnitrate  of  bis- 
muth, strychnia,  and  arsenic  are  particularly  named. 

"The  utter  failure  of  these,  or  indeed  any  therapeutic  agents,  to 
command  general  confidence,  or  to  come  into  general  use,  w'ill  show 
how  subordinate  their  effect  is  to  be  regarded  to  that  of  proper  dietic 
and  climatic  conditions,"  (p.  126.) 

All  medical  men  wiio  have  had  large  experience  in  treating  this  dis- 
ease, will  admit  the  impotcncy  of  drugs  and  the  value  of  diet  and  cli- 
mate. The  latter  is  an  essential  element  in  the  treatment.  Its  influ- 
ence is  absolute.  Without  it  all  other  means  arc  but  palliative  and 
temporary;  it  is  the  only  one  which  is  followed  by  abiding  results. 
The  value  of  change  of  climate  in  the  treatment  of  chronic  diarrhoea 


474 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March^ 


was  recognized  in  tlie  Mexican  war,  and  during  tlie  late  rebellion  the 
Medical  Department  "was  fully  alive  to  the  advantages  to  be  derived 
from  that  source,  and  availed  itself  of  tiicin  as  far  as,  at  the  time,  with 
a  full  knowledge  of  all  the  circumstances  of  the  case,  it  was  believed 
to  be  practicable."  I'atients  suffering  from  chronic  diarrhoea  in  the 
middle  and  southern  districts  of  tlie  Atlantic  region  were  transported 
to  the  hospitals  in  the  State  of  Vermont,  and  with  success.  In  the 
West  such  cases  were  sent  to  hospitals  in  high  northern  regions,  as  at 
Keokuk,  la.,  Madison,  Wis.,  Chicago  and  Detroit. 

As  "  considerable  confusion  appears  to  have  existed  as  to  the  pre- 
cise signification  and  limits  of  the  terms  catarrh,  epidemic  catarrh,  and 
acute  bronchitis,  precisely  similar  cases  being  reported  by  different 
surgeons  under  each  of  these  heads,"  and  believing  that  the  causes  de- 
termining inflammatory  affections  of  the  several  portions  of  the  respira- 
tory apparatus  are  intimately  allied,  it  was  thought  "  advisable  to  bring 
together,  in  a  single  group,  all  the  disorders  of  this  class,"  designating 
them  Infl'immalory  Diseases  of  Ike  Respiratory  Organs,  and  including 
all  the  cases  reported  as  epidemic  catarrh,  catarrh,  acute  and  chronic 
bronchitis,  laryngitis,  pleurisy,  and  pneumonia;  again  this  violent  and 
artificial  grouping  may  have  been  necessary,  but  is  not,  for  obvious 
reasons,  the  less  regrettable. 

"  The  total  number  of  cases  during  the  first  year  amounted  to  more 
than  one-half  the  mean  strength;  during  the  second  year,  however,  to 
not  mucli  more  than  one-quarter  of  the  strength.  The  deaths  were 
between  8  and  9  per  1000  of  strength  during  each  3'ear,"  (p.  128.) 

Unlike  camp  fever  and  diarrhoea,  this  group  of  diseases  happened 
with  nearly  equal  frequency  in  the  three  regions.  The  proportion  of 
mortality  to  strength,  however,  followed  the  same  general  law  as  the 
other  camp  diseases,- being  most  frequent  in  the  Central,  and  least  so 
in  the  Pacific  region.  The  proportion  of  deaths  to  cases  was  likewise 
greater  in  the  Central  than  in  the  Atlantic,  and  in  this  than  in  the 
Pacific. 

"In  the  Atlantic  region  there  was  one  death  to  every  123  cases 
during  the  first  year,  one  to  every  7  I  during  the  second;  in  the  Central 
region  one  to  every  31  cases  during  the  first  year,  one  to  every  18 
during  the  second;  in  the  Pacific  region  one  to  every  291  cases  during 
the  first  year,  one  to  every  211  during  the  second.  The  average  for 
all  regions  and  both  years  was  one  death  to  every  38  case*,"  (p.  130.) 

The  greatest  number  of  deaths  from  the  inflammatory  afl^ections  of 
the  respiratory  organs  were  reported  under  the  head  of  Pneumonia. 
Out  of  a  total  of  8090  deaths  from  respiratory  diseases,  7091  are  due 
to  this  cause.    The  experience  of  the  two  years  gives  a  mortality  of 


1866.]         BEVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  475 


■one  death  to  every  seven  (6.8)  cases  in  the  Atlantic  region,  and  one  to 
■everyfour  (3.8)in  the  Central;  "and  this  proportion  is  so  great,  as  com- 
pared with  the  results  in  modern  civil  hospitals,  as  to  direct  attention 
to  the  general  want  of  success  which  appears  to  have  attended  the 
treatment  of  this  disorder,"  (p.  131.) 

This  startling  proportion  of  deaths  to  cases  was,  to  a  certain  extent, 
due  to  the  then  prevalent  types  of  the  disease,  called,  in  the  Report, 
'''Typhoid  Pneuujonia,"  and  "Adynamic  Pleuropneumonia."  The 
mortality  from  pneumonia  in  the  British  Army,  in  the  Crimea,  was  one 
death  in  every  3.6  cases.  We  are  surprised  to  find  not  one  word  re- 
specting capillary  bronchitis,  which  was  not  infrequent  among  the 
•white  troops  in  certain  regions,  and  very  common  among  the  colored 
soldiers.    It  was  usually  confounded  with  typhoid  pneumonia. 

Respecting  Sctbrvy,  we  are  informed  that  the  amount  reported  was 
comparatively  small. 

"  1328  cases  and  9  deaths  for  the  first  year;  7395  cases  and  90 
deaths  for  the  second.  To  this  may  {)robably  be  added  the  greater 
part  of  the  304  cases  and  31  deaths  of  purpura  reported  during  the 
second  year.  This  extremely  small  number  of  cases  of  scurvy  is  un- 
paralleled in  the  history  of  armies,  being  but  5  per  1000  of  mean 
strength  for  the  first  year  and  13  for  the  second.  It  undoubtedly 
stands  related  to  the  quantity  and  comparatively  good  quality  of  the 
army  ration, — to  the  immense  supplies  of  antiscorbutics,  of  medical 
stores  and  comforts  issued  to  the  men  by  the  Government,  and  to  the 
large  pay  of  the  private  soldier,  which  is  very  many  times  greater  than 
in  any  other  army  in  the  world,  and  whicli,  in  part  at  least,  was  often 
spent  at  the  sutler's  on  pickles,  apples,  pies  containing  dried  fruit,  etc. 
From  all  these  sources,  ours  have  undoubtedly  been  the  best  fed  soldiers 
in  the  world,"  (p.  134.) 

This  is  a  satisfactory  statement  to  read,  but  how  far  it  is  really  sup- 
ported by  facts,  we  leave  those  to  judge  whose  opportunities  were  large 
in  our  armies,  and  to  the  Report  itself  which  signally  contradicts  it. 
Besides  it  being  insisted  on  that  scurvy  was  a  constant  complication  in 
camp  fever  and  camp  diarrhoea,  we  find,  a  few  lines  after,  this  most 
extraordinary  assertion — "  a  scorbutic  taint,  more  or  less  pronounced,  was 
a  prominent  phenomenon  in  most  of  the  diseases  of  the  war,"  (p.  134.) 

Again:  "  The  scorbutic  taint  manifested  itself  very  generally  in  the 
*  form  of  rhenmatie  pains  in  the  back  and  limbs,  associated  with  the 
ecorbutiic,  clay-like  !ip|)earancc  of  the  skin,  sometimes  even  with  spongi- 
ness  of  the  gums,  much  more  rarely  with  petechias,  scorbutic  discolora- 
tions  about  the  flexure  of  the  knee.  etc.  Most  of  the  physicians 
called  upon  to  treat  these  cases,  having  had  in  their  previous  private 
practice  little  experience  with  scurvy,  reported  tliem  as  rheumatism, 
lumbago,  or  neuralgia,"  ^\^.  134.) 

Does  not  this  admission  account  for  the  amount  of  scurvy  reported 


476 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES.  [March, 


being  "  comparatively  small  ?"  The  records  of  the  two  last  years  of  the 
war  will,  we  suspect,  show  a  very  different  state  of  things,  and  lead 
tlie  Reporter  to  qualify  somewhat  his  inordinate  laudation  of  the  army 
ration. 

Of  Tubercular  Diseases  there  were  8.9  cases  per  1000  of  mean 
strength  for  the  first  year,  9.3  for  the  second.  The  deaths  were  1  to 
every  4.5  cases  during  the  first  year,  1  to  every  2.7  during  the  second. 

Kotwithstanding  the  length  of  this  notice,  we  have  been  able  to 
give  our  readers  only  an  imperfect  notion  of  these  Reports.  Many 
matters  of  interest  we  have  not  been  able  to  touch  upon,  from  want 
of  space  at  our  disposal.  They  are  sterling  productions,  and  singu- 
larly free  from  blemishes,  defects,  or  siiortcomings.  It  is  indeed 
difficult  to  measure  the  praise  that  is  honestly  due  their  authors, 
who  both  possess  fitness  for  the  perilous  and  laborious  tasks  assign- 
ed them.  The  "  Surgical  Report "  is  marked  by  clearness  of  lan- 
guage, precision  of  statement,  and  a  generally  quiet,  unassuming 
tone.  Dr.  Otis  has  been  remarkably  cautious  in  hazarding  prema- 
ture conclusions  from  statistics  which  are  daily  augmenting,  and 
tending  towards  completion.  Dr.  Woodward,  in  the  "Medical  Re- 
port," shows  great  acuteness  and  industry  in  his  intelligent  tabulation 
of  the  accumulated  data,  by  which  he  has  been  able  to  give  numeri- 
cal expression  to  the  sick  and  death  rates,  and  the  frequency  and  mor- 
tality of  certain  diseases;  and  patient  research  in  his  valuable  and 
original  investigations  in  micro-pathology.  He  seems  fully  to  appre- 
ciate the  practical  aspect  of  his  subject. 

The  Messrs.  Lippincott  have  produced  the  volume  in  a  most  credit- 
able manner,  leaving  nothing  to  be  desired  in  the  way  of  paper  and 
typography.  The  several  lithographs  and  numerous  wood  illustrations 
are  well  executed. 

In  conclusion,  it  must  be  remembered  that,  following  the  example 
set  by  the  Medical  Department  of  the  British  Army  after  the  Crimean 
war,  both  the  Medico-Chirurgical  History  of  the  late  war  and  the 
Army  Medical  Museum  originated  with  Dr.  W.  A.  Hammond,  when 
Surgeon-General,  and  their  inauguration  was  amongst  his  earliest 
official  acts.  Before  his  enforced  retirement  they  bad  both  made 
substantial  progress.  Nor  in  this  connection  must  be  forgotten  the 
claims  and  merits  of  a  gentleman  who  created,  organized,  and,  for  more 
than  two  years,  had  entire  charge  of  the  Museum;  who  was  the  Surgi- 
cal Historian  of  the  War  during  that  time,  and  who,  in  the  discharge 
of  every  duty  he  was  assigned  to  while  in  the  service — whether  in  the 
field,  the  general  hospital,  or  the  Medical  Bureau — exhibited  con- 
science, zeal  and  capacity — Dr.  J.  H.  Brixto.v,  of  Philadelphia. 


1866.J 


REVIEWS  AND  BIBLIOGRAPHICAL  NOTICES. 


477 


BJiinnscofy  and  Laryngoscopy.  Their  Value  in  Practical  Medicine. 
By  Dr.  Fredericii  Semeleder,  Physician  in  Ordinary  to  His  Majesty 
the  Emperor  of  Mexico;  Member  of  the  Royal  Medical  Society  of 
Vienna,  and  of  tlie  Medical  Society  of  the  Pantheon  in  Paris; 
formerly  Member  of  the  Medical  Faculty  of  the  University  of 
Vienna,  and  Surgeon  to  the  Branch  Hospital  of  Gumpendorf. 
Translated  from  the  German,  by  Edward  T.  Caswell,  M.D.  With 
Wood-cuts,  and  two  Chromo-Lithographic  Plates.  New  York: 
William  Wood  &  Co ,  1860.  pp.  191. 

The  work  before  us  consists  of  two  monographs  on  Rhinoscopy  and 
Laryngoscopy,  respectively,  with  an  Appendix  containing  the  record 
of  two  cases  of  Extirpation  of  Polypi  in  the  Larynx. 

It  is  from  the  pen  of  one  of  the  most  accomplished  and  successful 
laryngoscopists  of  Germany,  who  is  also  a  general  surgeon  of  no 
ordinary  rank,  as  was  evinced  to  those  who  had  the  good  fortune  to 
listen  to  the  private  instruction  of  Dr.  Semeleder,  or  visit  his  wards  in 
the  hospital  at  Gumpendorf,  a  suburb  of  Vienna. 

The  translator,  Dr.  Caswell,  of  Providence,  has  enjoyed  both  the 
instruction  and  friendship  of  Dr.  Semeleder,  and  "  his  task  has  been 
performed  with  additional  pleasure  and  zeal  from  the  recollection  of 
the  many  happy  hours  passed  with  his  good  friend  and  faithful  instruc- 
tor, the  author." 

In  the  author's  preface  it  is  stated  that  the  work  is  "  intended  to 
present  facts,  and  to  be  of  practical  use,"  and  if  the  reader's  judgment 
cohicidc  with  ours,  he  will  acknowledge  that  this  end  has  been  attained. 
Rhinoscopy,  its  history  and  performance,  is  quite  fully  given  in  the 
sixty-five  pages  allotted  to  it.  The  pathological  cases,  showing  what 
may  be  done  by  this  means  in  the  way  of  a  careful  and  accurate  diag- 
nosis, are  interesting.  The  difficulties  preventing  the  successful  use  of 
the  rhinoficope  are  freely  and  frankly  acknowledged.  The  author 
says:  "  Even  now,  wlien  so  great  a  number  of  examinations  have  been 
made,  we  can  not  determine  upon  a  comparative  percentage  (of 
success) ;  for  here  the  practice  and  the  adroitness  of  the  observer  are 
still  more  important  than  on  the  examination  of  the  larynx."  These 
difficulties,  which  can  not  be  urged  against  laryngoscopy,  which  is  an 
art  practiced  with  comparative  ease,  will  prevent  the  busy  practitioner 
from  accomplishing  much  with  the  limited  time  he  may  have  at  his 
command  for  this  mode  of  examination;  but  here  and  there  in  the 
profession  are  those  who  stop  at  no  difficulties  in  scientific  investiga- 
tion. Czermak,  Stork,  Voltolini,  and  Semeleder,  of  Germany,  and,  we 


478 


REVIEWS  AND  BIBLIOGRAPHECAL  NOTICES.  [March, 


may  say,  Simrock,  of  New  York,  liave  shown  us  that  rhinoscopic 
examiaations  may  contribute  very  much  to  our  knowledge  of  diseases  of 
the  pharynx,  Schiieiderian  membrane,  and  eustachian  tubes.  Tiie  part 
of  this  work  devoted  to  rhinoscopy  having  much  in  it  that  is  new 
to  tlie  American  reader,  will,  we  are  confident,  secure  the  careful  read- 
ing and  thouglit  which  it  deserves. 

Laryngoscopy  has  been  so  zealously  encouraged  among  us,  and 
we  have  so  many  faitiiful  workers  in  this  field  of  our  art,  that 
this  part  of  Dr.  Semeleder's  l)ook  will  jjerhaps  not  be  found  to  con- 
tain so  much  that  is  new.  Yet  in  the  sections  on  the  Physiology  of 
the  Larynx,  there  is  much  which  strikes  us  as  peculiar  and  interest- 
ing. Dr.  Semeleder  claims  that  "  tlie  i>hysiology  of  the  formation  of 
the  human  voice  has  been  greatly  elucidated  by  the  laryngoscope, 
and  especially  by  the  labors  of  Garcia,  Czermak,  Moura-Bataille,  and 
Merkel."  He  says:  "The  actual  retjuisites  for  the  production  of  tone 
are  approximation  of  the  arytenoid  cartilages,  (a  progressive  closure  of 
the  glottis  from  before,  backwards,)  tension  of  the  vocal  chords,  and 
finally  a  current  of  air  of  a  certain  intensity  and  rapidity.  Alterations 
of  one  or  more  of  these  qualifications  disturb  the  formation  of  the 
voice,  and  produce  hoarseness,  or  loss  of  voice,  which  are  for  us  the 
same  phenomena,  differing  only  in  intensity."  Again,  as  to  speech: 
"  If  we  consider  for  one  moment  speech  in  itself,  we  mvist  perceive  that 
what  we  generally  designate  as  speech,  is  actually  made  up  of  two 
parts,  of  a  succession  of  more  or  le.ss  musical  notes,  vowels  and  liquids, 
and  of  a  series  of  sounds  arising  from  the  closure  formed  at  diflFerenfc 
parts  of  the  mouth,  as  at  the  lips,  the  teeth,  the  tongue,  the  gums. 
If  this  closure  is  suddenly  interrupted,  or  if  it  exists  under  such  condi- 
tions that  the  current  of  air  produces  a  rubbing  sound,  or  that  the 
parts  forming  the  obstacle  vibrate,  tiieu  we  have  the  various  conso- 
nants of  different  languages  "  There  is  quite  a  complete  account  of 
the  affections  of  the  larynx,  diseases  of  the  mucous  membrane  of  the 
larynx,  of  the  sub-mucous  connective  tissue,  secondary  diseases  of  the 
larynx,  with  illustrative  cases.  In  the  two  pages  devoted  to  the 
negative  results  of  laryngeal  examination,  an  interesting  case  occurs, 
A  boy  was  brought  to  the  author  at  the  Gumpendorf  hospital,  whO' 
was  said  to  have  lost  the  power  of  speech.  Tlie  family  were  greatly 
excited,  and  the  mother  stated  that  the  patient  had  spasmodic  twitch- 
ings  in  the  arms  and  legs;  that  he  learned  with  difficulty.  The  face- 
was  greatly  reddened,  movements  of  the  heart  very  violent,  a  systolic 
murmur,  and  further  nothing  abnormal.  The  laryiigo.scopic  e.vnm: 
nation  showed  the  larynx  to  be  normal,  and  vocal  chords  readily 


1866.] 


BOOKS  AND  JOURNALS  RECEIVED. 


479 


movable.  On  seeing  tliis,  and  that  the  boy  grew  very  red  at  the  cross- 
questioning,  malingering  was  diagnosticated;  and  alter  a  severe  scold- 
ing and  a  promise  of  secrecy  on  the  part  of  the  surgeon,  the  patient, 
suddenly  restored,  said  that  he  had  been  beaten  at  school  for  having 
learned  nothing,  and  hoped  by  this  tragic  comedy  to  escape  instruction 
for  the  future. 

It  is  also  added,  as  a  negative  result  of  laryngeal  examination,  that 
catarrh  of  the  pharynx  has  been  very  often  found  in  patients  who 
feared  tliat  they  were  suflering  from  laryngeal  phthisis. 

As  to'  means  of  examination,  methods  of  illumination,  etc.,  in 
Rhinoscopy  or  Laryngoscopy,  Dr  Semeleder  is  not  over-s.trenuous  as 
to  any  one  method  or  set  of  appliances,  preferring,  however,  his  own 
illuminating  spectacles,  (which  arc  sold  by  the  instrument  makers  of 
New  York,)  and  a  good  moderator  lamp,  or  sun-light  converged, 
and  the  ordinary  glass  or  steel  mirrors,  which  should  be  thick,  in  order 
to  remain  warm  longer.  The  bibliographic  list  is  a  very  valuable  part 
■of  the  book,  and  Dr.  Semeleder's  original  one  has  been  made  more 
■complete  by  the  translator.  In  our  somewhat  careful  reading  of  this 
book  we  have  found  much  that  is  of  practical  value,  and  we  believe 
this  will  be  the  verdict  of  the  professional  public  to  whom  it  comes. 
We  should  have  been  glad  to  .see  a  little  more  fullness  iu  description 
'Occasionally;  and  a  few  more  engravings,  showing  the  e.^nct  shape  of 
instruments  and  the  manipulations  necessary  in  their  use,  would  have 
materially  increased  the  value  of  the  work. 


BOOKS  AND  JOURNALS  RECEIVED. 

Obscure  Diseases  of  the  Brain  and  Mind.  By  Forbes  Winslow,  M.D., 
B.C.L.,  Oxon.,  &c.  Second  American,  from  the  Tliird  and  Revised  English 
Edition.    Philadelphia:  Henry  C.  Lea,  186G. 

Lectures  on  the  Diseases  of  Infancy  and  Childhood.  By  Charles  West, 
M.D.,  &c.  Fourth  American  from  the  Fifth  Revised  and  Enlarged  Eugli.sh 
Edition.    Philadelphia:  Henry  C.  Lea,  1866. 

On  the  Diseases,  Injuries  and  Malformations  of  the  Rectum  and  Anns;  with 
Remarks  on  Habitual  Constipation.  By  T.  J.  Ashton,  M.D.,&c.,  with  Illustra- 
tions. Second  American  from  the  Fourth  and  Revised  English  Edition. 
Philadelphia;  Henry  C.  Lea,  186.5. 

The  Malformations,  Discixses  and  Injuries  of  the  Fingers  and  Toes,  and  thoir 
Surgical  Treatment.  By  Thomas  Annandalc,  F.Il.C.S.,  Edin.,  &c.  The 
Jacksonian  I'rizc  Essay  lor  the  year  1861.  Philadelphia:  J.  B.  Lippincott  & 
€o.,  1806. 

The  Physiology  of  Man:  designed  to  represent  the  Existing  State  of  Physio- 


480 


BOOKS  AND  JOURNALS  RECEIVED. 


[March, 


logical  Science,  as  applied  to  the  Functions  of  the  Human  Body.  By  Austin 
Flint,  Jr.,  M.D.,  Prof.,  &c.  Introduction;  The  Blood;  Circulation ;  Eespira- 
tion.    New  York:  D.  Applcton  &  Co.,  18GG. 

Bone  and  Nerve  Snrgerj-.  By  J.  C.  Nott,  M.D.  Philadelphia:  J.  B, 
Lippincott  &  Co.,  1806. 

The  Principles  and  Practice  of  Medicine,  for  the  use  of  Practitioners  and 
Students.  By  Austin  Flint,  M.D.,  Prof.,  &c.  Philadelphia:  Henry  C.  Lea, 
18GC. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Urinary  De- 
posits. Illustrated  by  numerous  cases  and  engravings.  By  William  Roberts, 
M.D.    Philadelphia:  Henry  C.  Lea,  18GG. 

The  Retrospect  of  Medicine:  Edited  by  W.  Braithwaite,  M.D.,  and  James 
Braithwaite,  M.D.,  Lond.  Vol.  LIL  July-Dec,  18G5.  Loudon:  Simpkin, 
Marshall  &  Co.,  18GG. 

The  Half- Yearly  Abstract  of  the  Medical  Sciences:  Vol.  XLII.  July-Dec, 
18G5.    London:  John  Churchill  &  Sons. 

Carrol's  Literary  Register,  November  25,  and  December  10,  1865;  January 
25,  and  February  10,  1866.  fc-  ^ 

The  Seventy-Sixth  Annual  Report  of  the  Board  of  Trustees  of  the  New  York 
Dispensary.    January,  1866. 

Tenth  Annual  Report  of  the  Trustees  of  the  State  Lunatic  Hospital,  at 
Northampton,  October,  1865. 

Hygienic  Experience  in  New  Orleans.  From  Bulletin  of  theN.Y.  Academy 
of  Medicine,  No.  30.    September,  1865. 

American  Literary  Gazette  and  Publishers'  Circular.  December  1,  15; 
February  1,  15;  January  1. 

Tableau  of  the  Yellow  Fevers  of  1853,  with  Biographical,  Chronological  and 
Historical  Sketches  of  t"he  Epidemics  of  New  Orleans,  since  their  origin  in 
1796.    By  Bennet  Dowler,  M.D. 

Deploteratology.    By  G.  J.  Fisher,  M.D.,  of  Sing  Sing,  New  York. 

Inoculation  in  Pennsylvania.    By  T.  W.  Toner,  M.  D. ,  of  Washington,  D.  C. 

Successful  Removal  of  the  Uterus  and  both  Ovaries  by  Abdominal  Section. 
The  Tumor,  Fibro-Cystic,  Weighing  Thirty-Seven  pounds.  By  Horatio 
Robinson  Storer,  M.D.,  of  Boston. 

On  the  use  of  Chloroform  as  an  Internal  Remedy.  By  A.  P.  Merrill,  M.D., 
New  York. 

Transactions  of  the  Twentieth  Annual  Meeting  of  the  Ohio  State  Medical 
Society,  held  at  Ohio  White  Sulphur  Springs.  June  20.  21,  22.,  1865.. 

Annual  Report  of  the  Resident  Physician  of  King's  County  Hospital,  for 
the  year  ending  February  31,  1865. 

First  Annual  Catalogue  of  the  Officers  and  Students,  and  Programme  of  the 
Course  of  Instruction  of  the  School  of  the  Massachusetts  Institute  of  Tech- 
nology, 18G5-G. 

Report  of  a  Special  Committee  of  the  Board  of  Health  of  the  City  of  Detroit, 
suggesting  measures  for  the  prevention  of  Asiatic  Cholera  and  the  promotion 
of  the  Public  Health.    By  Order  of  the  Common  Council.    December  12, 1865. 

Introductory  Lecture  Delivered  at  the  opening  of  the  N.  Y.  College  of  Vet- 
erinary Surgeons,  November  6,  1865.    By  Prof.  A.  S.  Copeman. 

Edinburgh  Medical  Journal.    November,  December,  ls65;  January,  186G. 


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