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Columbia (Hnitiersttp

College of J^tjps^iciansJ mh ^urgeonjEf

PROPERTY 0,^ I ni.
WOMANS' MEDICAL COL'
OF THE
HSU YORK INFIRMAHi-

THE

NEW YORK

MEDICAL JOUE]^AL.

Wil. A. HAMMOND, M. D., and E. S. DUXSTER, M. D.
VOLUME VIII.

NEW YOEK:
D. APPLETON & COMPANY,

90, 92 & 94 GRAND STREET.
1869.

PEIISrCIPAL COKTEIBUTOES TO YOL. YIII.

rORDYCE BAEKER, M. D., Professor Bellevue Hospital Medical College.
JOH^T BELL, M. D., Philadelphia.
A. B. ARNOLD, M. D., Baltimore.
R. K. BROWNE, M. I)., Boston.

W. H. VAN BUREN, M. D., Professor Bellevue Hospital Medical College.

ALFRED L. HASKINS, M. D., Boston.

JAS. A. JACKSON, M. D., Stoughton, Wisconsin.

JOSIAH S. WHITE, Memphis, Tennessee.

BENJAMIN HOWARD, M. D., Professor Long Island Medical College.
AUSTIN ELINT, Se., M. D., Professor Bellevue Hospital Medical College.
A USTIN ELINT, Je., M. D., Professor Bellevue Hospital Medical College.
AUGUSTUS F. ERICH, M. D., Baltimore.
MEREDITH CLYMER, M. D., New York.
A. RUPPANER, M. D., New York.

G. T. BROCKETT, M. D., Lowell, Mass.
A. J. CHADSEY, M. D., New York.

A. KESSLER, M. D., Hartford, Conn.
CHARLES C. LEE, M. D., New York.

E. J. MARSH, M. D., U. S. Army.
S. R. PERCY, M. D., New York.

H. D. NO YES, M. D., Professor Bellevue Hospital Medical College.

F. A. STEINFORD, M. D., Charleston, S. C.
LEROY M. YALE, M. D., New York.
WALTER LAMBERT, M. D., Ontario, Canada.

PEIlSrCIPAL CONTRIBTJTOES.

NATHAN BOZEMAN, M. D., New York.

LEWIS A. SxVYEE, M. D., Professor Believue Hospital Medical College.
E. N. HORSFORD, late Professor Harvard College, Cambridge, Mass.
W. H. DWINELLE, M. D., New York.
J. MARION SIMS, M. D., New York.
LOUIS BAUER, M. D., Brooklyn, N. Y.
J. THEUS. TAYLOR, M. D., New York.
STEPHEN ROGERS, M. D., New York.
A. D. HULL, M. D., Binghamton, N. Y.

E. C. HUN, M. D., Albany, N. Y.

F. D. LENTE, M. D., Cold Spring, N. Y. •
HENRY SHIFF, M. D., New York.

CHARLES A. HART, M. D., New York.

JNO. C. DALTON, M. D., Professor College Physicians and Surgeons,
New York.

F. C. BUMSTEAD, M. D., Professor College Physicians and Surgeons,
New York.

Wanted. — Copies of the Journal for October and December, 1867,
March and May, 1868. These numbers are out of print, and subscribers
who do not preserve their files will do us a great favor by forwarding
these numbers. The full retail price will either be paid in cash or allowed
on new subscription.

INDEX TO YOL YIIl.

A Blow to the Fungus Theory of Disease, .... 576

A Comprehensive Title, ...... 634

A Human Tripod, ....... 335

A N"eedle six and a quarter Inches long remaining in the Heart and

Thoracic Cavity thirteen Months, . . . . ■ 107

A Physiological Curiosity, . . . • . 97, 685

A Point of Ethics, ....... 448

A Woman's Estimate of Women, . . . . 332

Abscess in the Abdominal Walls from Inflammation of the Apj)endix

Vermiformis ....... 630

Abscess, Iho-Psoas, ...... 207

Abscess, Peri nephritic. Oases of, . . . . . 203

Academy of Medicine, F. Y., . . . . . 683

Academy of Medicine, Address before, by H. D. Bulldey, M. D., 633
Advice to Students on taking Kotes of Lectures and Cases, 661, 668

Amaurosis, double, after H^matemesis and Intermittent Spinal Neu-
ralgia, . . . . . ■ . . 552

American Medical Association, ..... 671

Amputation at Hip- Joint, . . . . . 428

Anaesthesia, Unusual Phenomena attending. By F. D. Lente, M. D., 622
Aneurism of Arch of Aorta, ..... 319

Aneurism on the Pacific Coast, ..... 332

Aneurism, Thoracic and Abdominal, .... 472

Anisometropia, . . . . . . .662

Aphasia, a Case, with Eemarks, . . . . . 239

Aphorisms for Bathers, . . . . . .562

Apparatus for Fractured Clavicle .... 206

Apparatus for Teaching Hernia, Description of. By Benjamin Howard,

M. D., . . . ... . . 46

Appointments, . . . 212, 329, 335, 442, 447, 557, 560

Army Personal, . . . . . . .213,682

PAGE

Arnold, A. B., M. D., On the DiajThoeas of Children during the Sum-
mer Months, ...... 129

Arsenic, Death from the Use of, by a Cancer-Curer, . . 328

Arsenic, Detection of, in Cases of Poisoning, . . . 568

Aspermatism, a Case of, . . . . . . 126

Atropia, Its Chemical, Physiological, and Therapeutic Action, 242

Bacteria, the Origin of, . . . . . . 222

Barker, Fordyce, M. D., on Sea-Sickness, . . . .113

Baths, Hot, in the Treatment of General Dropsy, . . 196

Battery, a i^ew Galvanic, ... . . . . 570

Bauer, Louis, M. D., Reply to Dr. Sayre's Paper on Bony Anchylosis

of the Hip- Joint, . . . . . .577

Bell, John, M. D., on the Gettysburg Mineral Water, . . 137

Bernard, Claude, and Brown-Sequard, .... 560

Biliary Calculi, ...... 93

Bladder, Polypus of, in an Infant, ..... 89

BUndness, Temporary, in Typhus and Scarlatina, . . 551

Blood, On the Supposition of Two Changes of Color in the Red, . 140

Blood-Stains, A New Test for, 679

Books received, . . . . . . 421, 656

Boracic Acid and the Borates, Discovery of, . . . 301

Bouillaud, Anecdote of, .... . . 223

Bozeman, Nathan, M. D., Supporting and Confining Apparatus, and

a New Self-retaining Speculum, etc., .... 484
Brickett, G. F., M. D.,a Case of Hernia in a New-born Child, 288
Bright's Disease consequent on Ague, .... 199
Browne, R. K.,'M. D., On the Supposition of Two Changes of Color in

the Red Blood, ....... 140

Bulkley, H. D., M. D., Address before the Academy of Medicine, 633

Caesarean Section, Cases of, . . . . 80,81,83

Calabar Bean, the Use of, in Fistula of the Cornea, . . 657

Calcification of the Choroid, Crystalline Lens and Capsule, . 286

Calcuh, Biliary, discharged through an Abscess in the Abdominal

Walls, .93

Canal of Fontana or Sclilemm, ..... 658

Cancer, Relief of Pain in, ..... 315

Carbolateof Lime and Scarlatina, ..... 674

Carbolic Acid Solutions, ..... 95

Carotid, Ligature of, . . . . . . 824

Carotid, Ligature of, for Pulsating Tumors of the Orbit, . 663

Castration for Epilepsy, ...... 680

Cataract, Extraction of, . . . . . 547, 549, 544

Chadsey, A. J., M. D. Cure of Stricture by the Magneto-Electric

Current, . . . . . . .574

vii

PAGE

Chloroform, Deaths from, . . . 104, 106, 442, 445, 681

Chloroform or Ether, 209

Cholera Fungus, . . . . . • .416

Choroid, Cancerous Sarcoma of, .... 554

Choroid, Tubercles in, ...... 549

Cinchonji, Cultivation of, in Jamaica, ... 571

Clavicle, 'New Apparatus for Fracture of, . . . ' . 206

Clitoris and Urethra, Absence of, . • . . . 85

Cornea, Fistula of. The Use of tlie Calabar Bean in, . . . 657

Cornea, Opacities of, ..... . 542

Cornea, Ulceration of, in Young Children, .... 543

Croup, The Pathology and Treatment of, . . . . 91

Deaths :

M. Monneret, Prof., . . . . . .224

Shipman, A. B., K D., 211

Bacon, Cyrus, K D., U. S. A., .... 213

McDowell, J. K, Prof., 327

Schonbein, Prof. C. F., ..... 330

Mackenzie, William, M. D., . . . . . 334

Griesinger, Prof., . ..... 334

Cummings, Isaac, M. D., . . . . . 443

Parsons, Usher, M. D., . ... . . . 558

Sicbel, M., Prof., ...... 558

Peticolas, A. E., M. D 558

Wright, H. G., M. D., . . . . . 684

Death from Mrs. Winslow's Soothing Syrup, . . . 212

Diabetes, Clinical Lecture on, by Prof. Oppolzer, . . 1

Diabetes in an Infant, . . . . . .87

Diamonds, Artificial, . . . . . .108

Diarrhoeas of Children during the Summer Months, . . 129

Dislocation of the Proximal End of the Second Metacarpal Bone, 444
Distinguished Madmen, . . . . . .567

Divorces in the United States, ..... 222

Doctors and Lawyers' Patrons, . . . . .560

Double Uterus and Yagina, . . . . . 75

Dropsy, General Treatment of, by the Hot Bath, . . .196

Drugs, the Administration of, .... . 224

Dwinelle, W. H., M. D. A Xew Method of Cure in Sea-Sickness, 390
Dysentery, Chronic. A Xew Treatment for, . . . 194

Effect on Man of a Residence at Great Heights above the Level of the

Sea, . . . . . . . .676

Effusions of Blood in the Op ticIsTerve, .... 660

Elephantiasis, Hindoo Remedy for, ..... 671

Embolic Diseases of the Eye. By H. Knapp, M. D., . . 589

Vlll

PAGE

Embolus of the Arteria Centralis Eetin 86, .... 661

" Ericli, A. F., M. D. A New Modification of Sims's Speculum, . 478
Errata, ........ 088

Ether and Etherized Cod-Liver Oil in the Treatment of Phthisis, 198
Ethics, a Point of, ...... 448

Experiments with the Poison of the American Copperhead, . 424

Extravasation of Urine from Bursting of the Urethra, behind a Stric-
ture, . . . . . . . .321

Eye, Troubles ot, depending upon Diseases of the Spinal Cord, . 553

Fallopian Tubes, Congenital Malformation of, . . . 79

Femur, Dislocation of Head of, in a Child four years of age, . 632
Fibro-plastic Tumor in a Rectus Muscle, . . . .536

Fibula, Fracture of, etc. By J. Theus. Taylor, M. D., . . 604

Fistula, Vesico- vaginal, ...... 484

Flint, Austin, Jr., M. D. Experiments undertaken for the Purpose of

reconciling some of the Discordant Observations on the Glycogenic

Function of the Liver, ..... 373

Flint, Austin, Sr., M. D., On the Mechanism of the Crepitant and Sub-

crepitant Rale, ....... 449

Fontana's Canal, ...... 658

Fracture of Nasal Bones and Right Superior Maxilla, with Sinking of

Eyeball into the Maxillary Sirms, .... 536

Fungi and Disease, . . . . . . 570

Fungus Theory of Disease, A Blow to, .... 576

Gangrene of the Heart, . . . . . . 200

Gastric Juice, Source of Free Hydrochloric Acid in, . . 384

Gettysburg Mineral Water, . . . . . 137

Glioma Retinge, ....... 554

Glycerine, Solvent Power of . . . . . 569

Glycogenic Function of the Liver, ..... 373

Hematuria in a New-born Infant, .... 90
Hart, Chas. A., M. D., a Case of Calcification of the Choroid, Ciliary

Processes, Crystalline Lens, and Capsule, . . . 286

Hart, Chas. A., On a Hindoo Remedy for Elephantiasis, . 671

Hart, Chas. A., M. D., A New Speculum Ocuh, . . . 562
Haskins, A. L., M. D., Translation of a Chnical Lecture on Diabetes

by Prof. Oppolzer, ...... 1

Headache, a Cure for, . . . . . .193

Heart, Gangrene of, . . . . . . . 200

Heart, Nerves of, . . . . . . .219

Heart, Polypus of, ...... 91

Hermaphroditism, 426

Hermaphroditism, Transverse, . . . . . 688

INDEX.

PAGE

Hernia, Five Oases of Strangulated. Operatioa witliout opening the

Sac, 316

Hernia of the Liver, in a New-born Child, . . . 288

Hernia of Ovary, . . . . . . .86

Hernia, Strangulated Inguinal, in an Infant seven months old, . 90
Hip-Joint, Amputation at, ...... 428

Hip-Joint, New operation for Artificial Anchylosis of, . 337
Homoeopathic Equine Vermifuge, . . . . .210

Homoeopathy in the University of Michigan, . . . 572

Horsford, Prof. E. N., Source of the Free Hydrochloric Acid in the

Gastric Juice, . . . . . . .384

Hospital, at Providence, E. I., . . . . . 214

How to test the Purity of Water, . . . . .564

Howard, Benj., M. D., Description of an Apparatus for Teaching Her-
nia, ........ 46

Hull, A. D., M. D., Operation of Artificial Joint for Fracture of the

Tibia and Fibula, ...... 626

Hun, E. C, M. D., Case of Abscess of the Abdominal Walls from In-
flammation of the Appendix Vermiform is, . . 630

Ileo-Psoas, Abscess, ...... 207

Infanticide, ....... 678

Influence of Marriage on the Duration of Human Life, . . 563

Intestine, Strangulation of, Operation by External Incision, . 322

Iodine an Antidote to Strychnia, . . . . .197

Irido-choroiditis, Treatment of, . . . . . 549

Iris, Anatomy of, ...... . 543

Jackson, Jas. A., M. D., Case of Punctured Wound of Thorax, . 38
Joint, Operation of Artificial, for Fracture of Tibia and Fibula, .' 626

Keratoconus, ....... 542

Kessler, A., M. D., Translation from Skoda, . . . 472

Kidney, Double Floating, ..... 628

Knapp, Hermann, M. D., On Embolic Diseases of the £ye, . 589

Lachrymal Sac, Treatment of Diseases of, ... 538

Lambert, Walter, M. B., On Phosphorus in Locomotor Ataxia, . 482
Lee, Chas. C, M. D., A Case of Aphasia, with Eemarks, . 239

Lens, Von Graefe's Method of eflfecting the Expulsion of the, . 545
Lente, F. D., M. D., On Some Unusual Phenomena attending Anases-

thesia, ....... 622

Ligature of the Common Carotid, ..... 324

Lithotomy in a Patient eighty years of age, . . . 205

Liver, Glycogenic Function of. Experiments upon, by Austin Flint,

Jr., . . . . .. . . .373

PAGE

Localization of the Eeflex Movements, .... 425
Long Island Medical College Hospital, .... 671

Marriage, Influence of, on the Duration of Human Life, . 563

Marsh, E. J., M. D., Dislocation of the Proximal End of the Second

Metacarpal Bone, ...... 444

Medical Colleges of Xew York and Philadelphia, . . 97

Monstrosity, a Eemarkable Human, . . . 102

Monstrosity, a Remarkable Human, by Defect, . . . 104

Monstrous Birth, . . . . . . 571

Musclefs, the Physiology and Physics of, .. . . . 422

Museum, Army Medical, at "Washington, . . . 687

Museum of the Royal Ophthalmic Hospital, . . . 659

Nelaton a Senator, ...... 331

iferve Force, the Velocity of, . . . . .110

!N"erve, Optic, Atrophy of, and Remarks on i^ormal Structure of, 552

!N"erves of the Heart, . . . . . . .219

Nerves, Structure of the Fibrous Envelope of, . . . 423

I^euritis Optica, E"euro-Retiniti3 and Retinitis, . . . 659

'New York State Medical Society, . . . . 670

^Tew Books, .... 74, 189, 312, 418, 654

ISTystagmus, . . . . . . . 535

Occlusion of Blood-Yessels of the Eye, . . . .661

Oppolzer, Prof., Clinical Lecture on Diabetes, . . 1

Optic Disk, Pigment in, . . . . . .660

Orbit and Globe, Tumors of, .... . 659

Ovary, Hernia of, . . . . . . .86

Ovariotomy, Cases of . . . . . . 76

Ovariotomy Statistics, ...... 675

Paracentesis Thoracis, Successful Result in Three Cases, . 42

Paralysis of both Sixth Nerves, ..... 537

Parasite of the Cheek, . . . . . , 101

Penetrating Wounds of the Eye, ..... 540

Percy, S. R., M. D., On Atropia, .... 242

Perinephritic Abscess, Cases of, .... . 203

Phosphorus in Locomotor Ataxia, .... 482

Phthisis, Treatment of, by Ether and Etherized Cod-Liver Oil, . 198

Pigment in the Optic Disk, ..... 660

Poison of the American Copperhead, .... 424

Polypus of Bladder in an Infant, .... 89

Polypus of the Heart, ...... 91

Prizes, ...... 100,223,331,570

Proceedings of Societies, .... 290,507,414,633

Procidentia Uteri of seventeen Years' Standing cured by Operation, 683

mDEX. xi

PAGE

Quacks, Treatment of, in the Fourteenth Century, . . . 109

Quinine, Artificial Sulphate of, . . . . . 447

Quinine, how to disguise the Taste of, ... . 56G

Rabies, ........ 566

Reception of Profs. Gross and Pancoast, .... 325

Reflex Movements, Localization of, ... . 425

Reply to Dr. Sayre's Paper on a new Operation for Bony Anchylosis

of the Hip-Joint, . . . . . .577

Report on Anatomy and Physiology, .... 422

Report on Diseases of Children, ..... 86

Report on Obstetrics and Diseases of Women, ... 75
Report on Ophthalmology, . . . . . 535, 657, 669

Report on Surgery, ..... 203, 316, 428

Report on Theory and Practice, . . . . .191

Report of Surgeon-General U. S. A., .... 678

Researches on the Structure of the Fibrous Envelope of Serves, . 423

Reviews axd Bibliographical N'otioes :

A Hand-book of Uterine Therapeutics, and of Diseases of Women.
By Edward John Tilt, M. D., . . . . 511

A Hand-book of Vaccination. By Edward C. Seaton, M. D., . 173
A Manual on Extracting Teeth. By A. Robertson, M. D., . 186
A Manual of the Pathology and Treatment of Ulcers and Cutane-
ous Diseases of the Lower Limbs. By J. K. Spender, M. D., 302
A Practical Treatise on the Diseases of "Women. By T. Gaillard
Thomas, M. D., . . . . . . 511

A Rational Treatise on the Trunkal Muscles, elucidating the Me-
chanical Causes of Chronic Spinal, Pelvic, Abdominal, and Tho-
racic Affections, etc. By E. P. Banning, M. D., . . 417
A Treatise on the Principles and Practice of Medicine, designed
for the Use of Practitioners and Students. By Austin
Flint, Sen., M. D., . . . . . . 304

Annals de Dermatologie et Syphili graphic. Par le Dr. A. Doyon, 650
Bartholow and Pro's Liberal Use of Prize Essays, etc., . 73, 182
Conservative Surgery in its General and Successful Adaptation
in Cases of Severe Traumatic Injuries of the Limbs, with a Re-
port of Cases. By Albert G. Walter, M. D., . . 176
Constipated Bowels ; the Various Causes and the Different Means
of Cure. By S. B. Birch, M. D., . ... 188

Consumption in New England and elsewhere ; or, Soil Moisture

one of its Chief Causes. By Henry L Bowditch, M. D., . 187
Criminal Abortion, its Nature, Evidence, and its Law. By H. R.
Storer, M. D., and F. F. Heard, .... 179

Dental Materia Medica. By James W. White, . . .55

Diseases of Children. By Thomas Hillier, M. D., . .170

Xll

INDEX.

PAGE

Doctor or Doctress? By Samuel Gregory, M. D., . 311

Essentials of the Principles and Practice of Medicine. A Hand-
book for Students and Practitioners. By Henry Hartsliorne,
M. D., . . . . . . .648

Extra Digits. By Bnrt G. Wilder, M. D., . . 182

History of the Medical Department of the University of Pennsyl-
vania, from its Foundation in 1765, with Sketches of the Lives
of Deceased Professors. By Joseph Carson, M. D., . 639

Lectures on the Study of Fever. By Alfred Hudson, ,M. D., . 650
Materia Medica for the use of Students. By John B. Biddle, M. D., 55
Microscopical Examinations of Blood and Vegetations found in

Variola, Vaccina and Typhoid Fever. By J. H. Salisbury, M. D., 70
On the Action and Use of Oxygen in the Treatment of Various
Diseases otherwise incurable or very intractable. By S. B.
Birch, M. D., ...... 652

On the Pathology and Treatment of Albuminuria. By ^Y. H.
Dickinson, M. D., . . . . . .60

Outlines of Physiology, Human and Comparative. By John Mar-
shall, F. E. S., etc., with Additions by Francis G. Smith, M. D., 649
Pathological Anatomy of the Female Sexual Organs. By J. Klob, 653
Physician's Hand-book and Visiting List,. . . 311

Pronouncing Medical Lexicon, containing tlie correct Pronuncia-
tion and Definition of Terms used in Medicine, and the Col-
lateral Sciences. By C. H. Cleaveland, M. D., . . 637
The Anatomy and Histology of the Human Eye. By A. Metz,

M. D., 66

The Diseases peculiar to Women, including Displacements of the

Uterus. By Hugh L. Hodge, M. D., . . .511

The Diagnosis, Pathology, and Treatment of Diseases of Women,

including the Diagnosis of Pregnancy. By Graily Hewitt, M. D., 511
The Medical Formulary. A Collection of Prescriptions, etc. By

Benj. Ellis, M. D. Edited by A. H. Smith, M. D., . 309
The Opium Habit, with Suggestions as to the Eemedy, . 647
The Science and Practice of Medicine. By Wm. Aitken, M. D.

Edited by Meredith Clymer, M. D., . . . 306

The Use of the Laryngoscope in Diseases of the Throat, with an
Essay on Hoarseness, Loss of Voice, etc. By Morell Mackenzie,
M. D. With Additions by T. Solis Cohen, M. D., . . 635

Therapeutics and Materia Medica. By Alfred Stille, M. D., 55
Transactions of the American Medical Association for 1868.

Vol. xix., ...... 651

Uterine Catarrh, frequently the Cause of Sterility. By H. E. Gan-

tillon, M. D., . . . . . . 417

Who discovered Anaesthesia? By S. Parsons Shaw, . . 186

INDEX. Xlii

PAGE

Elieunicatism, Syrup of Lime in, . . . . . 109

Kb ode Island Hospital, . . . . . . 214

Rogers, Stephen, M. D., Case of Coxo-fenioral Dislocation at four years

of age, ........ 632

Salt of Lemons, . . . . . . . 416

Sayre, Lewis A., M. D., A New Operation for Artificial Hip-Joint in

Bony Anchylosis, . . . . . .337

Scapula, Excision of, . ■ . . . . . 431

Scarlatina, Carbolate of Lime in, ..... 674

Sea-Sickness, . . . . . . . 113

Sea-Sickness, a New Method of Cure. By Dr. Le Coniat, . 390

Sensibility retained after Division of the Musculo-Spiral Nerve, 97, 685
Separation of Adherent Twins, ..... 329

Shiff, Henry, M. D., Case of Double Floating Kidney, . . 628

Sims, J. Marion, M. D., On the Microscope as an Aid in the Diagnosis

and Treatment of Sterility, . . . . . 393

Skoda, Prof., Clinical Lecture on Thoracic and Abdominal Aneu-
rism, ........ 472

Social Statistics of England, ...... 571

Something like a Stomach, ..... 685

Speculum Oculi, a New. By C. A. Hart, M. D., . . . 562

Speculum, New Modification of Sims's, . . * . 478

Speculum, Self-retaining, for Vagina, .... 484

Stanford, F. A., M. D., Case of Partially-encysted Stone of the Bladder, 625
Sterility, the Microscope as an Aid in the Diagnosis of, . . 393

Stone in the Bladder, Partially-encysted, . . . 625

Strangulation of Large Intestine, treated by Incision from without, 322
Stricture, Cure of, by the Electro-Magnetic Current, . . 544

Stricture, Extravasation of Urine from, . . . 321

Stricture of the Ductus ad Nasum, Cure of, by Internal Division, 537, 538
Stricture of the Urethra, . . . . . .225

Strychnia, Iodine an Antidote to, . . . . 197

Suicide, Deaths by, ...... 220

Sweating, Unilateral, ...... 191

Syphilis, Early History of, in China, ' . . . .96

Syrup of Lime in Rheumatism, ..... 169

Taylor, J. Theus., M. D., On Fracture of the Fibula, with Historical

Notice of Treatment proposed, .... 604
Tearing out of the Eyeball by the Ring of a Door-Key, . 536
The Mechanism of the Crepitant and Sub-Crepitant Rale, . . 449
The Medical Aspects of a Fast Life, .... 565
The Relative Claims of Magendie and Bell to the Merit of having dis-
covered the Functions of the Roots of the Spinal Nerves, . 326
The Velocity of Nerve Force, . . . . .110

xiv

INDEX.

PAGE

Thermometer in Typhoid Fever, ... . . .198

Thorax, Punctured Wound of, . . . . . 38

Tongue, Eemoval of the Entire, ..... 558

Torsion of Arteries as a Means of arresting Haemorrhage, . 318

Trachoma, Pathology of, ..... . 539

Transposition of Thoracic and Abdominal Viscera, . . 426

Trichinae in the Domestic Fowl, . . . . . 211

Tubercles in the Choroid, ..... 549

Tubercular Inoculation of the Human Subject, . . . 559

Tubercular Matter, Inoculation of, upon Plants, . . 574

Tumors of the Orbit and Globe, ..... 659

Tumors, Intraocular, ...... 554

Tumors, Pulsating, of the Orbit, Ligature of the Carotid for, . 668

Typhoid Fever, Therm ometrical Observations in, . . 198

Unilateral Sweating of the Head, ..... 191

Urethra and Clitoris, Absence of, . . . . 85

Urethra, Imperforate, in a Child, . . . . .86

Urethra, Stricture of, ..... . 225

Uterus, Case of Double, . . . . . . 75 *

Van Buren, W. H., M. D^, On Aspermatism, . . . 126

Van Buren, W. H., M, D., On the Treatment of Stricture of the Ure-
thra, ........ 225

Varicose Veins, Subcutaneous Injections in the Treatment of, 325
Viscera, Transposition of, ..... 426

Vitreous Humor, Track of Foreign Bodies entering, . 540,541

Water, how to test the Purity of, . . . .564

White, Josiah S., M. D., Three Cases of Paracentesis Thoracis, . 42

Whooping-Cough, Sulphuret of Potash in, . . . 444

Wound of Brain, by Penetration through the Orbit, . .535

NEW YORK

MEDICAL JOURNAL:

A MOXTHLT BE CORD OF

MEDICDsE AXD THE COLLATERAL SCIEJsCES.

Vol. YIIL] OCTOBER, 1868. [Xo. I.

Aet. I. — Clinical Ohservations upon Diabetes Mellitus.
By Prof. Oppolzee. Translated by Alfeed L.
Hasktns, M. D., Boston, Mass.

The true cause of diabetes meUitus is very obscure,
and will remain so, till we understand tlie material
changes whicli tlie economy undergoes in tlie disease.

The investigations in this direction have been, till
recently, very imperfect, and it is only within the last
ten years that special attention has been given to the
anomalies of this disease. The older writers had no
true knowledge of it. We find, indeed, a great num-
ber of cases of copious secretion of urine described by
them, but no mention is made that sugar was found
in the mine. In the year 1668, Willis had the great
merit of discoverino; the sweet taste of diabetic urine,
and, soon after, other English chemists succeeded in
demonstrating that sugar was present in the ui'ine.

CLINICAL OBSEEVATIONS

Indeed, to Englisli i^liysicians belongs tlie undisputed
honor of making the first and most important investi-
gations in this disease. At the end of the last century
an English physician, named Kollo, made the important
discovery that the primary cause of diabetes was not a
disease of the urinary organs, but a disturbance of the
whole vital economy, and more especially of the func-
tions of the stomach. Quite recently German and
French pathologists, Traube, Schiff, Briicke, and Claude
Bernard, have supplied very valuable contributions to
tlie pathology of diabetes, and it is now conceded that
no local disease of the kidneys, but a general disease
of the system, is the cause of diabetes. We know that
the blood of diabetic patients contains sugar, that it is
constantly found in the urine and the other secretions,
and may, indeed, be shown in the perspiration.

Notwithstanding all the careful investigations
which have been made heretofore, diabetes still re-
mains a very mysterious form of disease, and a clear
insight into its nature, in the present state of science,
is imj)ossible. In the first place, the question arises.
Upon what does the abnormal quantity of sugar in the
hlood depend ? U]3on this point there prevail the most
diverse and contradictory views. If we take the estab-
lished facts of physiology to assist us, we find that in
the process of digestion the nitrogenous food is changed
into albumen. A part of the albumen is absorbed and
conveyed to the organs and tissues ; the remainder, on
the contrary, is decomposed in a manner not yet per-
fectly kno^vn. The non-nitrogenous food, of which the
hydrocarbons are the greater portion, is changed into
dextrine and sugar. A part of the sugar as such, or
after a further change, is absorbed as lactic acid ; the
remainder is chan^ced in the intestines into carbonic

UPO]S- DIABETES MELLITTS.

acid and alcohol, and finally into water. The water is
given ofi' through the kidneys, and the carbonic acid
through the lungs. The fats also undergo a like oxy-
genation, and finally the same changes as the other
hydrocarbons. The formation of sugar in the economy
from the food is not, therefore, an abnormal process,
and hence it may be explained kow sugar apj)ears in
the urine of otherwise healthy persons, as was first
shown by Briicke. In a normal state of the economy
sugar is found especially in the vessels which come
from the liver, from whence it is conveyed to the
lungs. Concerning the causes which produce the
sugar in diabetic urine very diverse theories are ad-
duced. Some assume that the suo-ar in the blood of
diabetic patients arises from a defective digestion,
which produces an excessive amount of sugar at the
expense of the amylaceous food.

RoUo, therefore, in his distinguished work regards
the stomach as the seat of the evil and the abnormal
formation of sugar, and represents the affection of the
urinary organs as a secondary affection. Following
this theory, he proposed the exclusion of all food ex-
cept meat as the primary treatment of the disease.
Others assert that a defective decomposition of the
sugar taken into the blood is the cause of its extraor-
dinary accumulation in this fluid.

Claude Bernard considers diabetes a disease of the
nervous system. It is, indeed, a very remarkable fact
discovered by this investigator, that, when the floor of
the fourth ventricle is pierced, sugar ajDpears in the
urine. He founded his views upon ex23erimeiits made
upon animals. As the vagus nerve takes its origin on
the floor of the fourth ventricle, to the irritation of this
nerve, as well as the sympathetic nerve, a remarkable

CLESriCAL OBSEEYATIOIs^S

influence upon the formation of sugar in tlie urine is
attributed. The pneumogastric nerve takes its origin
from the corpus restiforme situated on the floor of the
fourth ventricle, and by means of the jugular ganglion
enters into connection with the superior cervical gan-
glion of the sympathetic nerve. Further experiments
upon animals have shown that irritation of the origin
of the pneumogastric nerve in the fourth ventricle is
transferred to the sympathetic nerve, and thereby the
quantity of sugar formed in the liver, which is under
the influence of the sympathetic nerve, is increased.
Schiff has, however, proved that irritation of other parts
of the nervous system may also render the urine of
animals diabetic. These facts cannot be denied ; yet,
experience teaches us that, in the examination of those
who have died of diabetes, these changes in the brain,
especially in the pons varolii and the fourth ventricle,
are not always found.

This discovery of the artificial production of dia-
betes, or rather glycosuria, by Claude Bernard, is very
interesting and remarkable, but the results of these
experiments are manifestly exaggerated, and have led
to very premature theories concerning the cause of
diabetes. Schiff has recently made some very interest-
ing researches concerning the formation of sugar in the
liver and the influence of the nervous system u|)on the
production of diabetes, and has thereby furnished some
physiological facts for the theory of the disease. Never-
theless the study of diabetes is by no means completed,
and these theories are all to be received with caution.

Other writers regard a disease of the spinal cord as
the cause of diabetes, and especially tabes dorsalis.
The spinal cord is regarded as the origin of the disease,
on the ground that diabetic patients are generally im-

UPOIT DIABETES MELLITUS.

potent. It is very questionable wlietlier tliese cere-
bro-spinal symptoms are to be regarded as tlie causes
of the disease, since they may also be the results of it.
Stotvis found the sugar in the liver increased 25 j)er
centum in diabetes, and thought he had discovered
the cause of the disease in a proliferation of the liver-
cells and the consequent hypersemia of this organ.
But further experience teaches that hypertrophy of
the liver is not a constant symptom in this disease,
and that atrophy is often found.

Oppolzer believes that atrophy of the pancreas
is simply a consecutive symptom of diabetes. The
theory adduced by Miahle, that a ferment produces
the decomposition of the sugar into its final products,
alcohol, carbonic acid, and water, is not valid, especially
as this ferment has not yet been discovered. The
same may be said of the assertion, that a deficiency of
oxygen and alkalies in the blood is the cause of the
prevented change of the sugar.

It is also to be mentioned here that glycosuria is
found in certain disturbances of the respiratory organs.
Reynoso examined especially the influence of disturbed
respiration in various troubles of the thorax, and he,
together with Dechambre, found that the urine con-
tained sugar in all the cases examined by them.

Following these investigations still further Keynoso
found that in all diseases with disturbed respiration,
as phthisis, bronchitis, asthma, pleuritis, etc., the urine
contained sugar. He also found sugar in the urine of
animals which had inhaled ether, chloroform, and other
gases. Oppolzer's examinations, however, have not
confirmed these views. But it is to be confessed that,
although a large amount of sugar may be found in the
urine in numerous other diseases, yet we do not by

CLmiCAL OBSERVATIONS

tMs means obtain a sufficient explanation of diabetes,
in whicli there is not only an increase of sugar in tlie
urine, but also an entire group of other symptoms.

Claude Bernard also found glycosuria in different
diseases of tlie liver, and especially in contusions and
wounds of this organ. He performed experiments
upon animals by exerting pressure upon the liver.
He mentions the case of a man who was kicked by a
horse in the region of the liver. In this case sugar
was found in the urine till the contusion had com-
pletely healed. Kayer has observed similar cases.
Monneret's testimony is to the contrary. He has
scarcely ever observed sugar in the urine in numerous
cases of disease of the liver. Frerichs also is not in-
clined to look upon hypertrophy of the liver as a con-
stant attendant of diabetes. Oppolzer admits that
glycosuria is often connected with diseases of the liver,
but this fact gives no sufficient explanation of the dia-
betic disease itself

As follows from the above discussion, it can rightly
be asserted, that glycosuria may exist under very dif-
ferent conditions. Many other conditions are not yet
accurately confirmed, and need a still further examina-
tion and observation. It is probable that these condi-
tions may be acquired in a way which will contribute
essentially to the advancement of our knowledge of
diabetes. To this end still further clinical researches
must be undertaken. Guilard has undertaken such
researches in a number of cases, and has arrived at the
following results : In one case of cerebral congestion
with strabismus, in two cases of amaurosis, in one case
of chronic hydroce|)halus, in two cases of bronchor-
rhoea, in one case of gangrene of the lung, and in one
case of progressive paralysis, sugar was plainly shown

upojS" diabetes mellitus.

iu the urine. In one case of gangrene, in two cases of
mania, and in one case of paralysis, the evidence of
suo;ar was doubtful. Su2:ar was found in four out of five
cases of tuberculosis. In three cases of epilepsy sugar
was found in the urine immediately after the attacks.
In small-pox, measles, carbuncle, hypertrophy of the
heart and spleen, paraplegia, cerebral haemorrhage,
senile gangrene, gangrene of the bladder, cancer of the
liver, pneumonia, cretinism, and idiocy, no sugar Avas
found in the urine.

Diabetes is on the whole a rare disease. It affects
both old and young. It appears most frequently be-
tween the ages of thirty and fifty years. There are in-
stances, however, in which diabetes has appeared in
children of one, three, nine, and twelve years of age.
Suo^ar is often found in the urine of children who have
partaken heartily of sweet food, or who are suffering
from whooping-cough, convulsions, and asphyxia. Be-
yond the age of seventy the disease is very rare.

The disease occurs more frequently among men than
women. Sugar is found in the urine of women during
pregnancy, but it is not dependent upon diabetes. It
is the glycosuria of the pregnant.

In respect to its geographical propagation, it is re-
markable that this disease is especially frequent in
Holland and England. The reason of this may be
partly the climate, and partly the manner of living of
these nations. With the exception of these two coun-
tries, statistics prove that the disease is more frequent
in hot than in cold climates. In Italy diabetes is
more frequent than in Germany. In France the dis-
ease is not rare, especially in Normandy. The cause
of the frequent occurrence of this disease in Normandy
has been attributed to the excessive use of cider.

CLmiCAL OBSEEYATIOIS^S

This explanation does not seem to be true, as in many
parts of Germany cider is used in great quantities, but
diabetes does not ap23ear more frequently there than
in other regions. It appears in about the same ratio
in ^\T.ne and beer countries. In some families it seems
to be hereditary. The inherit ability of diabetes is,
however, not established. The data for the solution
of this question are still wanting. Concerning consti-
tutional influences there are no data, but diabetes ap-
pears to develop itself in weak rather than strong per-
sons. It is not probable that a dissolute mode of liv-
ing, excess in venery, or want, has any influence upon
the development of this disease, as it is found just as
frequently among the wealthy and those leading a reg-
ular mode of life, as among the poor and those who
are irreg-ular in their habits. Accordins; to observa-
tions in German and French hospitals, traumatic le-
sions, especially concussions of the head and back, ap-
pear to have a real influence in the j)roduction of dia-
betes. If we consider the anatomical changes which
are found in diabetes after death, we must also confess
that investigations have not yet arrived at an absolute
knowledge of them. In the majority of cases Oppolzer
has found the kidneys enlarged and swollen. Their
weight was increased, and they were hyperaemic or in
a state of inflammation. The pyramids and cortical
substance were h^q^ertrophied. It is to be confessed
that there are many exceptions to this rule. There
are a considerable number of cases of this disease in
which the kidneys suffered no characteristic pathologi-
cal changes. There can be no positive rule given con-
cerning the condition of the liver. Sometimes it is
swollen and hypersemic. In one case observed by Op-
polzer, the liver was very hard and twice its usual size.

UPOJ^ DIABETES IMELLITi;^.

It extended almost to tlie umbilicus. The spleen in
tMs case was enlarged. In this case, however, it was
shown that the patient had for a long time suffered
from intermittent fever before the existence of glyco-
suria. A further examination of the liver sliowed that
it had undergone amyloid degeneration. When the
diabetes continues for a long time, other secondary
anatomical chano^es are found. In more than half of
the patients who have died with diabetes, signs of tu-
berculosis were found. A further secondary anatomi-
cal change is the hydrocephalic ependymitis,''^ which
has been repeatedly demonstrated by Lebert. March al
de Calvi has directed attention to the spontaneous
gangrene of the extremities, which occurs to^vard the
end of diabetes, an observation which has often been
confirmed by recent investigators. In a later work he
shows that in several instances cerebro-spinal changes,
especially apoplexy and congestions, arise in conse-
quence of diabetes.f In many subjects lobar or lobu-
lar pneumonia are found as complications. Stockweis
proved that the quantity of sugar in the liver was in-
creased in diabetes. In the muscular substance of the
heart, in the kidneys, spleen, and lungs, he also found
a small quantity of sugar. In the ]3ericardial fluid, in
the arterial and venous blood, he found only an inde-
terminate amount, while in the brain no sugar was
present.

Quite recently, accurate chemical examinations have
been made of the urine of persons suffering from dia-
betes and also of the blood, peritoneal serum, the flu-

* Ependymitis is an inflammation of the membrane lining the ventri-
cles of the brain.

t We must here mention that this ^Yell-known author, in his last work,
draws a parallel between the gout and diabetes, and regards both, together
•with rheumatism, as different manifestations of the uric acid diathesis.

CJLESnCAL OBSEEYATIOXS

ids of tlie eve, the muscles and internal oro-ans. The
results of these examinations are by no means positive,
and it would be hasty at the present time to draw con-
clusions from them. It deserves, however, to be men-
tioned that in most of the organs sugar was found
in increased quantities. In the brain no sugar was
found.

Especial mention deserves to be made of the crea-
tinin which occurs in diabetic urine. It is a nitroge-
nous substance, which was first shown by Liebig, and
later by Xeubauer, to be a kind of albuminous sub-
stance, which is also found in healthy urine. The se-
cretion of this albuminous substance in diabetic urine
has been recently the source of numerous researches.
At first a considerable quantity of this substance was
thought to be found in the urine (8i grains of creati-
nin in the whole amount of urine passed in t^\'enty-
four hours). There was thought to be some relation
between this enormous secretion of creatinin and the
secretion of sugar, and especially of the diabetic pro-
cess. The later examinations of diabetic urine which
were made at Op23olzers clinic proved that the views
in respect to the increased secretion of this material
were exaggerated. In three cases of diabetes the quan-
tity of creatinin was not sensibly diminished.

Among the symptoms of diabetes, the first and
most important is the large amount of grape-sugar
which ap2:)ears in the urine and the other secretions.
The quantity of sugar which is secreted in a day is
very variable, sometimes amounting to a pound or
more. The manner of living of the patient manifestly
and unquestionably has much influence upon the quan-
tity of sugar which is secreted, since an increase in the
quantity of fluid ^vhich is taken and the indulgence

UPON DIABETES MELLITUS.

in amylaceous food augment the amount of sugar in
the urine.

Tlie Tests for Sugar in the Urine. — ^There are very
many different methods, and a large number of chemi-
cal substances, by means of which sugar may be de-
tected in the urine.

(a.) Moore's Test. — A small quantity of the solu-
tion of potassa is added to the urine to be tested, and
then the urine is to be boiled. The upper part of the
fluid becomes brown if sugar is present. Or, an ex-
cess of caustic potash is added to the urine, and then
it is to be boiled. If sugar is present, a red color will
appear. Heller advises that, after boiling, a little ni-
tric acid should be added. If sugar is present, the
odor of caramel or molasses is detected.

(^.) Pett€nJcofer''s Test dej)ends upon the action of
gallic acid and sulphuric acid upon a solution of sugar.
It gives to the urine a dark- violet color. On the other
hand, the presence of gallic acid is proved by the ad-
dition of a solution of sugar and sulphuric acid. This
test is, however, not very reliable, and is not much
employed.

((?.) Trommer'* s Test. — A certain quantity of the
urine to be examined is mixed witli an excess of the
solution of caustic potash, and a few drops of a solu-
tion of sulphate of copper are added. If sugar is
present, the fluid assumes an azure-blue color. When
warmed, boiled, or allowed to stand for some time, the
oxide of copper is reduced to a suboxide, which is de-
posited as a red-brown powder. The reaction is made
known by the yellow color which the fluid assumes,
and which later becomes red, and finally dark brown.
If the fluid is heated still more, a thin shining coat of
co]3per is deposited on the walls of the test-tube.

CLimCAL OBSERYATIOI^S

(<:/.) Boetger''s Test. — A solution of carbonate of
potash or soda is added to tlie nrine to be examined.
A little nitrate of bismuth is then added. The fluid
is then boiled. If sugar is present, the oxide of bis-
muth falls as a black powder.

(e?) LowentliaVs Test. — To the urine to be exam-
ined, a mixture of tartrate and carbonate of soda and
chloride of iron is added. If sugar is present, the urine
assumes a dark color. This test is not very certain, as
oftentimes the fluid assumes a dark color when no su-
gar is present.

(/.) ItaspaiVs Test. — Urine containing sugar as-
sumes a violet color \vhen suljDhuric acid and albumen
are added. This color may aj)pear when no sugar is
present. It is, therefore, an imcertain test.

{g^ Runge's Test. — A small amount of urine is
poured upon a plate, and a drop of sulphuric acid add-
ed. The plate is then warmed over a spirit-lamp. If
sugar is present, a dark spot appears where the sul-
phuric acid was dropped. This test depends upon the
quality which a saccharine fluid mixed with sulphuric
acid j)c)ssesses of becoming black uj)on warming.
Other organic bodies have the same property as sugar,
and therefore this test is not sure. Reich recom-
mends hydrochloric instead of sulphuric acid. This
test has the same objection as that of Runge.

(A.) MeaumenSs Test. — A woollen substance (me-
rino) is moistened in a solution of chloride of tin and
then dyed. If a drop of urine containing sugar is
now placed upon the merino and then warmed, a dark
spot appears. This test is very simple and convenient,
as these pieces of merino can always be had. This
test also is not infallible, as other hydrocarbons be-
sides sugar produce the same reaction.

UPON DIABETES MELLITUS.

(^.) Anotlier test for sugar is that of Cutton with
chromic acid, which is reduced to an oxide of chro-
mium when sugar is present. Instead of the original
red color of the chromic acid, a green color now ap-
pears.

(j.) The test of Jones consists in allowing a drop
of urine to evaporate, and then the deposit is exam-
ined for the crystals of sugar. Besides the sugar
which is found in diabetic urine, there is also an in-
crease of the urea, nric acid, and other salts, all of
which contribute to its increased sj^ecitic gravity. In
some cases the siDecific gravity is 1042 and more. If
the urine stands a considerable time, spores are found
in it. The urine is clear, of a pale-yellow color, and
oftentimes evacuated in very large quantities (five to
nine quarts daily). The patients do not urinate in so
great quantities because they drink so much, but they
drink much because they have evacuated so much fluid
from the body, and in this way seek to compensate
the system for the great loss of water which it has suf-
fered. The cause of this enormous secretion of urine
is indeed not known to us, and we must for the pres-
ent seek it in the diuretic influence of the sugar. In-
asmuch as so much water passes through the kidneys
in diabetes, the secretions of the other organs are ne-
cessarily limited. The skin of patients is generally
rough and dry. Perspiration takes place very seldom
and with difficulty. There are, however, excej)tions,
and in febrile complications and in advanced phthisis
nio;ht- sweats occur. The intestinal evacuations are
generally retained, and the secretion of semen appears
to diminish considerably, and it is often observed that
diabetic patients become impotent. In women the
catamenia are often irregular and finally suppressed.

CLIKICAL OBSEEYATIOKS

Besides, it is often observed tliat tlie temperature of
the skin is decreased and the patients suffer from cold.

The further development of the disease extends its
effects and consequences to the whole system, whose
functions are greatly disturbed. The appetite is vora-
cious, and can never be satisfied. Patients suffer from
great thirst, and this is one of the first and most tor-
menting symptoms. It deserves the greatest attention,
as it makes itself known without any symptom of
fever or indisposition to explain its cause. This enor-
mous thirst is due mthout doubt rather to the large
loss of water, than to the secretion of sugar, as simple
prolyuria also occasions an increase of thirst. The
appetite, increased at first, is wont to disappear only
toward the fatal termination of the disease.

There are two forms of diabetes to be distin-
guished. The distinction of these forms has for the
practice an especial worth. ExjDerience teaches that
the anomalies of nutrition, ^vhich are manifestly the
source of the disease, may be very different. In the
first or light form of diabetes, the secretion of sugar is
present only so long as amylaceous food is supplied to
the body. If only carnivorous or non-amylaceous food
be eaten, the secretion of suo:ar as well as most of the
other symptoms of glycosuria ceases. In the second
and more serious form of the disease, the glycosuria
continues, although the food is of a non-amylaceous
quality. In many cases the diabetes shows itself in
the first form; but if the use of amylaceous food is
dispensed with, not only does the secretion of sugar
cease, but also the quantity of urine is diminished, the
tormenting thirst and insatiable appetite abate, and
the emaciation becomes less. In the second and more
serious form it is otherwise. The symptoms either

UPOISr DIABETES MELLITUS.

continue tlie same, or there is only slight alleviation.
These are to be regarded as the most serious cases of
diabetes. As a matter of course, there are various in-
termediate grades. Sometimes the light form is only
the beginning of the diabetes, which later passes over
to the more serious form, so that both forms are only
the different grades of one and the same disease.

In regard to tests for sugar, the test of Zwenger
ought to be mentioned on account of its completeness.
It depends upon the quality which nitrate of silver
possesses, when heated to 212° R, in an ammoniacal
solution of grape-sugar, of forming a bright metallic
mirror. For this purpose some urine is evaporated.
To the residue remaining after the addition of alcohol,
Avater is added, and then an excess of nitrate of silver.
The whole is then filtered, and the fluid resulting there-
from is saturated with ammonia. In order to render
the test more certain, a small amount of nitrate of silver
is now added, and the whole is then heated to 212° F.
If a small amount of sugar only is present, a blue mir-
ror of metallic silver is formed. If no sugar is present,
the fluid is only clouded.

There are also various methods of determining the
quantity of grape-sugar. The simplest method of
ascertaining the quantity of sugar originated with
Eoberts, in Manchester. The urine containing suo^ar
is submitted to fermentation. It suffers by this means
considerable loss of weio;ht, and from this loss of weio-ht
the quantity of sugar is determined. This method
requires only an accurate pair of scales. The other
methods require a great many instalments and test-
fluids, among which are the polarimeter of Biot, the
saccharometer of Soleil, the diabetmeter of Robiquet,
etc.

CLiraCAL OBSEEVATIONS

The test-fluids of Feliling are especially adapted
for determining the quantity of sugar. The instru-
ments of Biot, Soleil, and Robiquet, by a deviation of
the polarized light to the right, show very quickly and
correctly the amount of the secretion of sugar. An
idea can be formed of the amount of su2:ar in the urine
from the fact that every deviation of the polarized
light one degree on the circular scale corresponds to
one grain of sugar in a thousand grammes of fluid. All
of these methods require an especial apparatus. To
determine the amount of sugar by fermentation ac-
cording to Roberts's method, no particular apparatus
is needed. The specific gravity of the urine to be
tested is taken in the customary temperature of the
sick-room. Several ounces of the urine are then poured
into a vessel, and a piece of solid yeast of the size of
a hazel-nut added. The vessel is then lightly stoppered,
placed in a warm room, and subjected to fermentation.
When this process is completed, which usually hap-
pens in eighteen hours, the vessel is again brought
into the sick-room, and the fluid allowed to cool to the
same temperature as when the specific gravity was
taken. The urine is allowed to clear up, which takes
place in five or six hours ; it is then decanted, and the
specific gravity again taken. Every degree of loss of
weight corresponds to one grain of sugar in the ounce
of the urine. It is to be remarked that the percentage
of sugar in the urine is alone typical of the extent and
intensity of diabetes. To arrive at a correct knowl-
edge of the quantity of sugar secreted, the quantity
secreted within a definite time, for example, twenty-
four or forty-eight hours, should be determined. In
order to arrive at a proper judgment concerning the
signification of the sugar in the urine, the amount of

UPON DIABETES MELLITUS.

amylaceous food wliicli the patient consumes must also
be taken into consideration. For example, in one case
wLere the secretion of sugar amounts to only three or
four per cent., the disease may be much more serious
than in another case where six to eight per cent, of
susrar is secreted.

In most cases the quantity of urine is in exact pro-
portion to the quantity of sugar secreted, i. e., the
greater the quantity of sugar secreted, the greater also
is the amount of urine, and vice versa. There are,
however, exceptions to this rule, and Oppolzer has ob-
served cases where, the quantity of urine remaining
the same, the amount of sugar varied very much.

The specific gravity of the urine is also generally
proportionate to the quantity of sugar secreted. There
are, however, sometimes exceptions. The specific grav-
ity may be quite high, and, nevertheless, the quantity
of sugar is less than in another case where the specific
gravity is small. The specific gravity of the urine may
be increased by means of other ingredients than sugar.
Respecting these other ingredients of the urine there
was a long controversy Avhether they were present or
not in the urine of diabetic patients. At present,
however, it is conceded that the urea, uric acid, and
pigment of the urine, suffer very little if any absolute
diminution, but, on account of the enormously in-
creased quantity of the urine, they aj)j)ear relatively in
much less quantity.

The disturbances of nutrition in diabetes manifest
themselves by a remarkable emaciation, which makes
its appearance, although patients have a good appetite
and consume a great quantity of food. The muscles
disappear, and a remarkable weakness shows itself To
this 2:eneral wastino; are also associated nervous dis-

CLmiCAL OBSERVATIOIS'S

turbances with ttie character of ansestliesia and paraly-
sis. There are, however, numerous other symptoms of
nervous trouble, for example, pain in the head, in the
limbs, and lumbar region, a feeling of great uneasiness,
a sensation alternately of heat and cold, numbness and
weakness of the extremities, the mental condition is
very deplorable, and a timid, unquiet feeling takes
possession of the patient.

A very frequent symptom in the later stages of
diabetes, as has already been mentioned, is impotence,
the cause of which is, perha]3S, to be sought in the fre-
quently observed atrophy of the testicles. Finally, not
uufrequently there are observed a looseness or a cari-
ous destruction of the teeth, inflammation of the skin,
f jllowed by furuncles, excoriations of the genitals, in-
flammation of the bladder and urethra, croupous in-
flammation of the lungs, abscesses and gangrenous
destruction of the same, or inflammation of the serous
membranes which make their appearance as pleuri-
tis, pericarditis, and peritonitis. The heart generally
shows no change excej^t that it is sometimes found
atrophied. Finally, tuberculosis and morbus Brightii
are frequent complications, which exercise much influ-
ence upon the rapid termination of the disease.

That albuminuria may associate itself with diabetes
is a fact confirmed by many authors, and has also been
observed by Oppolzer. Indeed, the ajDpearance of al-
bumen in the urine is a very bad complication, and
points with great probability to a difiiise inflammation
of the kidneys. It is generally observed only a few
weeks or months before the fatal termination. In one
case of diabetes 0]3polzer found, at the autopsy, the
epithelium of the kidneys fatty, while the cortical sub-
stance showed the same characters as the kidneys of
morbus Brightii.

UPOJ^" DIABETES 5HELLITUS.

In diabetes death may occur in various ways. It
is generally occasioned by tlie complications. As we
liave stated, tliey are very numerous. Tuberculosis is
tlie most frequent complication. A serous effusion
into the ventricles of the brain, the pericardium, or
thoracic cavity, may likewise be the cause of death.
As terminal complications, are also observed hydro-
cephalic softening associated with delirium, and coma
preceded by convulsions. Broncho-pneumonia and
23leuro-pneumonia are not unfrequently observed as
fatal complications of diabetes. In these complica-
tions, especially when preceded by considerable fever,
the quantity of sugar may considerably decrease, but
this decrease should not be reo-arded as a favorable
symptom. Quite lately Marchal de Calvi has drawn
attention to a complication of diabetes which has not
previously been observed. He has shown that not
unfrequently in advanced stages of diabetes gangre-
nous inflammation, as well as spontaneous gangrene of
the shin, takes place. This observation has also been
confirmed by Oppolzer. Intestinal tuberculosis is also
one of the sequelae of diabetes.

Among the numerous complications of diabetes
the disturbances of the vision take a prominent place.
They appear as frequently in diabetes as in morbus
Brightii, so that they may, indeed, be regarded as
symptoms and not as comjDlications. For the diag-
nosis as well as the prognosis, they are of great value.
The disturbances of vision which assume the first rank
are amblyopia and cataract, second in order are amau-
rosis and diplopia. Authors disagree respecting the
frequency of amblyopia. Lecorche and Bouchardat
have observed it, at least, once in every four cases of dia-
betes. Others have observed it still more frequently.

CLCaCAL OBSEEVATIOIS^S

Two different forms of amblyopia may be distinguislied.
a light and a serious form. The light form manifests
itself in the initial stage of diabetes, and may veiy
early direct the observing physician npon the track
of the disease. This form of disturbance of vision
generally appears in the following manner : Both eyes
are attacked at the same time. The patient reads with
difficulty, and only with the aid of convex glasses. All
objects appear enveloped in a more or less thick mist.
The disturbance of vision presents the peculiar symp-
tom that durino; dis-estion it is much exao:s:erated.
Sometimes the patient sees objects double. The cause
of these complications is at present not known. Re-
course has been had to various explanations of the
cause of this amblyopia and amaui'osis. It is more
than probable that an affection of the retina, which at
first is attacked ^vith anaesthesia, and later with paraly-
sis, lies at the bottom of these complications. The
anatomical changes of the retina which are generally
found at the autopsy are not always in direct propor-
tion to the disturbances of vision which were mani-
fested in life. A\Tien considerable changes are found,
for example, apoplexy and inflammation of the retina,
they appear to depend upon morbus Brightii and al-
buminuria, and not upon diabetes.

From all w^hich has been observed up to this time
it appears that amblyopia may appear in different de-
grees. The light form of amblyopia is the most fre-
quent. Oppolzer has not unfrequently observed it
among the first symptoms at the commencement of the
disease. Very often he observed that it alternately
became better and then worse, at times completely dis-
appearing, but soon appearing again. He has not al-
ways found material lesions of the retina.

UPOIS" DIABETES IMELLITUS.

Cataract is a less frequent complication of diabetes
than amblyopia. The cloudiness of the lens appears
in the first stages of diabetes, but the complete matu-
rity of the cataract is generally observed only in the
later stages of the disease. Nevertheless they have
been observed to form very quickly, and complete their
development within a very few wTeks. It cannot with
certainty be asserted that the cataract is formed on ac-
count of the presence of sugar in the aqueous humor,
as, in some cases, though sugar was present, no cataract
was observed. The injection of sugar into the cham-
bers of the eye produced no cataract. Oppolzer be-
lieves that the cataract is mainly caused by the great
loss of water which the system suffers in diabetes.

It may be said of the etiology of the disease that
there are very few cases in which diabetes can be at-
tributed to any special cause. Concerning the influ-
ence of climate upon its development there are no ac-
curate statistics. The statistics which we have re-
specting its geographical extension are manifestly of
little worth. Most authors believe that glycosuiia is
more frequent in warm than cold lands. It is said to
be much more prevalent in Eg}q3t and Italy than in
Germany, but this statement is opposed to the fact
that diabetes occurs much more frequently in the cold
climates of England and Holland, than in other coun-
tries lying farther south. There are also no positive
facts concerning the influence of food and the manner
of living upon the development of diabetes. From
the statistics which have been thus far collected, it fol-
lows that the disease is much more frequent among
men than women. Of one hundred cases of diabetes,
twenty-five occurred among women, the remainder
among men.

CLmiCAL OBSEEYATIOTTS

It is also certain that the middle age (between
thirty and fifty) furnishes the greatest contingent for
the disease. Oppolzer, however, has observed a few
cases where the disease developed itself very early, and
also in very advanced age (between sixty and seven-
ty). Concerning the hereditary influences upon the
develoj)ment of the disease, nothing jDositive can be
said. There are a few not very trustworthy data from
which it appears that there is a certain family tendency
to this disease. There are wanting the necessary facts
concerning the influence of despondency, of misfor-
tune, and venereal excesses. Diabetes is found among
the wealthv and those leading: a res^ular mode of life,
quite as frequently as among the poor and those living
irregularly. In a few cases OjDpolzer has found con-
cussion of the brain and spinal cord a direct cause of
the development of glycosuria.

The i^rognosis of diabetes is always very unfavora-
ble. In the majority of cases it ends in death. It is
only in these cases where the secretion of sugar is not
very considerable, and where the general health is not
23ercej)tibly disturbed, that the life of the patient can
be much prolonged by a proper regimen. If the quan-
tity of sugar in the urine is considerable the prognosis
is hopeless. The patients succumb to marasmus. The
j)rognosis is also very doubtful when the glycosuria is
complicated with other diseases, as affections of the
lungs and liver. If the patient is very much reduced
and emaciated, or if tuberculosis of the lungs develops
itself in diabetes, the prognosis is very unfavorable.
If, together with albumen, sugar is also found in the
urine, the prognosis is not less unfavorable. If sugar
appears in the urine in consequence of cerebral lesions,
it is only a temporary symptom. In such cases, how-

UPON DIABETES MELLITUS.

ever, tlie cerebral lesions are generally of a very criti-
cal nature, and may be the cause of death. There is
here a double danger; danger from the wound itself,
and also from the glycosuria. There are also instances
known where, after concussions of the brain and blows
upon the head, a persistent diabetes was developed,
which occasioned death, although the wound in itself
was very little dangerous, and attended by no bad
symptoms.

None the less dangerous are the other complica-
tions of diabetes, broncho and pleuro-pneumonia, which
generally terminate fatally. Gangrene of the lungs
is of course very dangerous. The disappearance of the
sugar in such complications should by no means be
regarded as a favorable symptom. They cause for the
time the disappearance of the sugar, and also the other
symptoms of diabetes, but they produce no constant
favorable influence upon the disease, for either the pa-
tient succumbs to the complicating disease, or, when
this is overcome, the symptoms of diabetes return in
undiminished force.

The facts are wanting to establish a true theory of
the pathology of diabetes. In the normal condition
of the system, sugar is found in the blood of the ves-
sels coming from the liver, from whence it is conveyed
to the lungs. The views of Claude Bernard, recently
published, tend to confirm this physiological fact. Ac-
cording to his observations, tiie liver does not directly
secrete the sugar, but another substance, which has
much resemblance to starch. He calls this substance
glycogene. This glycogene possesses the quality of
being changed into sugar by the serum of the blood,
and it may itself be procured from the liv^er. It
constitutes the substratum of the liver-sugar which is

CLmiCAL OBSEEVATIO]S^S

formed in the blood. According to this view, wliich.
has by no means been positively confirmed, bnt which
is very probable, the glycogene is formed in the liver
principally from amylaceons food, but sometimes also
from albuminous substances. From the liver it is con-
veyed to the lungs, and is here employed and changed
in the process of respiration. It is not yet established
liow this transformation takes place, but that the sugar
is formed in the liver from the food, and later under-
goes a transformation, is fully established. According
to Claude Bernard, the sugar is not decomposed by a
process of combustion in the lungs. In the foetus,
where no respiration takes j)lace, sugar is formed in
the liver, and disappears again by some process.

These physiological facts, confirmed by Bernard,
throw but little light uj)on the pathology of glycosu-
ria. If the liv^er of an animal is strongly compressed,
the urine is found to contain sugar. The direct irrita-
tion of the liver also by means of contusions, wounds,
and injections of ammonia into the vessels of the liver,
produces an increased production of sugar. Indirect
irritation of the liver, through the nervous system and
the sympathetic nerve, has also produced a similar re-
sult. As has been mentioned, if the pneumogastric
nerve be irritated at its seat of origin in the brain, the
urine contains sugar. In the year 1855 Bernard dis-
covered this fact. Later Schiff proved that the irrita-
tion of other nervous centres, besides the floor of the
fourth ventricle, caused the appearance of sugar in the
urine. Frerichs cites three cases of diabetes, in which
a considerable hypertrophy of the liver was demon-
strated. Oppolzer is, however, in no way inclined to
regard the hypertrophy of the liver as a constant
symptom of diabetes.

UPOIT DIABETES MELLITUS.

Sugar may also appear in tlie urine under various
other circumstances. Reynoso found it in various dis-
turbances of tlie respiration, and establislied tliat in
many cases tlie influence of disease of the organs of
respiration produced sugar in the urine. Oppolzer has
also observed suo;ar in the urine for a short time after
a severe fright, strong mental excitement, or labor.

From all these facts it is established that the secre-
tion of sugar in the urine may be produced and in-
creased by means of numerous influences, and it may
with much probability be concluded that, in diabetes
in the initial stage, the sugar is formed at the expense
of the amylaceous food, and in its advanced stages at
the expense of the albuminous food. The consump-
tion and transformation of this material, which takes
place in a normal condition of the system, is in dia-
betes in some way prevented, so that the blood and
the most of the organs contain sugar. It is possible
that some disturbance or modification of the respira-
tion prevents the consumption of sugar. If the obser-
vations of Reynoso are accepted, who found sugar in
the urine in various disturbances of the respiratory
process, diabetes may be thus explained : that the sac-
charine material produced in the liver is prevented
from further transformation, and thus an oj)portunity
is given for its transfer into the blood.

Although the symptoms of diabetes are so remark-
able, yet the cases are not unfrequent where diabetes
is not recognized in practice ; at least this occurs very
often in the initial stao-e. The diasrnosis of diabetes is
not difficult, and as soon as we observe in a patient
constant thirst, a continual feeling of dryness in the
mouth, and later on polyuria, especially if there are
no febrile symptoms present, it becomes our duty to

CLmiCAL OBSERVATIONS

examine the urine for sugar. The physician should
endeavor to observe the disease at its very outset.
Amblyopia and retinitis, as well as various ulcerations,
caries, and necrosis, are v^'ont sometimes to introduce
the disease. All of these symptoms will be the better
estimated if an early examination of the urine is not
neglected. The early diagnosis is also of great value
for its treatment. The urine ought especially to be
examined during digestion, when the quantity of sugar
is generally increased. Especial attention should be
devoted to the condition of the respiratory organs and
the state of the liver, and this organ should be sub-
jected to a careful examination. The simple proof of
sugar in the urine does not always justify the diagnosis
of diabetes, as sug^ar has been found in the urine when
a large amount has been eaten, and Blot has shown
that pregnant women and patients suffering from gout
very often pass urine containing sugar. An increase
in the quantity of urine evacuated is also not a suffi-
cient 23roof of diabetes. This is simply polyuria, or
diabetes insipidus. This last disease, however, is veiy
unfrequent, and is to be regarded as an affection of the
vagus nerve. In this disease there is also great thirst,
the specific gravity of the urine is not high, and there
is neither grape nor muscle sugar present. When the
last-named sugar is present, the disease is called dia-
betes inorites. In diabetes insipidus the urine con-
tains but a very small quantity of the urinary salts,
and scarcely any urea ; there is also great dryness of
the tissues and increased thirst, and, as a large amount
of water is drunk, the ingredients of the urine are
much diluted. Oppolzer has observed polyuria or
diabetes insipidus among children who had the mea-

UPOK DIABETES J^IELLITUS.

sles, and administered in sucli cases the fased nitrate
of potash.

J}.. PotasssB nitratis fiis£e 3 i.

Aquas destillatae Oi.
M. et Sig. Drink in one day.

Tannin is also given. The Frencli administer bel-
ladonna, carbonic acid water, and good food.

To combat diabetes mellitus, it is necessary above
all things to regulate the diet and limit the patient to
the least possible amount of amylaceous food. The
treatment is purely dietetic and empirical. The reme-
dies recommended as specifics, upon this or that hy-
pothesis, have proved themselves wholly without ef-
fect. In many cases abstinence from amylaceous food
causes the secretion of sugar in the urine, and most of
the other symptoms, to cease. In such cases the sugar
is probably prepared only at the expense of the amy-
laceous food, and the elements of the tissues have not
yet been employed in its formation. Still more im-
portant are those forms of diabetes in which, in s^ite
of exclusive indulgence in animal food, the secretion
of suo-ar in the urine still continues. In these cases
the formation of sugar takes place at the expense of
the nitrogenous elements of the tissues. On account
of the abnormal change of these most important or-
ganic elements, those symptoms appear which in dia-
betes are of such sad significance : extreme emaciation,
such as scarcely any other disease exhibits, great weak-
ness, and complete prostration of the muscular strength.
For this excessive expenditure of material, the greatest
possible reparation must be rendered, and this can
take place only by means of a supply from the nitro-
genous substances. The longer the supply is able to
compensate for the waste of the system, the longer

CLINICAL OBSEEVATIONS

will the patient survive. If the patient indulges in
much amylaceous food, not only is the amount of su-
gar augmented, and many other troublesome symptoms
increased, as secretion of urine and thirst, but also
more power is demanded for the digestion of this food,
and the sujDply of nitrogenous food, compensating for
the organic elements which have been used, is limited.

The diet can exert no direct influence upon the dis-
ease itself ; it is only able to prolong the life of the
patient. Oppolzer sometimes employs benzoic acid in
diabetes, although its good effects are questionable.

Sodge benzoatis 3i.
Sacchari albi 3 i.
M. et Ft. piilver. div. in partes sequales ^"0. 6.
Sig. One powder every three hours.

If in the course of diabetes violent febrile symp-
toms appear, as they are not unfrequently wont to
attend the complications which have been mentioned,
quinine should be administered. The best remedies
which we know for this disease are empirical. They
are carbonic acid, the alkaline carbonates, and those
mineral waters which contain these alkalies. Among
these waters Carlsbad and Vichy take unquestionably
the highest rank. Carlsbad decreases the secretion of
sugar, but by no means produces a complete cessation
of its abnormal production.

As already stated, animal food is the best diet for
diabetic patients. It was regarded by Rollo as a very
appropriate diet, and ham was recommended by him.
But, in recommending this diet, the amylaceous food
should not be wholly forbidden. Bread and dessert
may be allowed in small quantities, as an exclusive
diet of meat becomes very repulsive. Care should be
given that the diet is composed principally of meat,

UPOIT DIABETES MELLITUS.

but iudeed wlien meat only is eaten, sugar is often
found in tlie urine. Instead of common bread, a gluten
bread lias been tried in diabetes. This, together with
meat, was given to diabetic patients, instead of the
common flour bread. With some patients this substi-
tute agreed very well. They were satisfied with it,
and ate it freely. OpjDolzer has, however, seen many
23atients to whom this bread was very repulsive, and
they positively refused to take it, so that small quan-
tities of common bread could not be denied them.
Quite recently attemj)ts have been made to bake a
good and palatable bread for diabetic patients, which
consists in part only of glue. This is given in small
quantities, in cases where the common bread cannot be
entii^ely dispensed with.

Care should be taken that there should be a va-
riety in the use of animal food. If it is always given
in the same form it becomes repulsive to the patient.
The diet may consist of meat in different forms, roast
meats, beef-steak, fish, ham, venison, and sausages of
various kinds. Diabetic patients may also eat eggs
prepared in different ways, and fatty substances, inclu-
ding fatty nuts and fruits. Of vegetables, cabbage,
asparagus, lettuce, carrots, and all kinds of salads may
be allowed. The food to be avoided is every kind of
grain, potatoes, all amylaceous legumes, all sweet fruits,
and the juices of fruit. Milk is also an improper food,
on account of the milk-sugar which it contains ; how-
ever, small quantities of milk, and especially good rich
cream, may be allowed.

Moderation is to be recommended to patients, in
satisfying the tormenting thirst from which they suffer
in diabetes. As a drink, cold water, acidulated water,
and lemonade, are good. Wine and brandy should be

CLINICAL OBSEEYATIOIS'S

allowed only in small quantities. Thus given, it is
useful to patients. When tlie pecuniary circumstances
of tlie patient permit, the daily use of a half or whole
bottle of the red French wine, or any astringent wine,
may be recommended. To poor patients, common red
wine or a little brandy may be given. All sweet
wines and beer are less useful. Tea and coffee, with-
out sugar, but with some cream, good meat broths,
vrith vegetables, gluten, and small quantities of mm,
are allowed. When the thirst is great, carbonic acid
water, soda and Seltzer water, are the best to be giv-
en. If these are not sufficient to satisfy the thirst,
drinks made from hops or other bitter substances may
be prepared. In the early stages of the disease a suit-
able diet generally succeeds in moderating the thirst.
The patient is then better able to heed the advice to
drink but little. Patients should also be advised to
take their food slowly and in small quantities. The
desu'e for food as well as drink must be controlled.

In order to complete the hygienic measures, diabe-
tic patients are advised to take regular exercise. Op-
polzer advises j)atients to guard against taking cold,
and to wear warm clothing. This should be especially
recommended to patients who suffer from cold and
have a diy skin.

Of the medicines which have been recommended
and extolled in diabetes, a few only have merited ap-
proval. Miahle has very highly recommended the al-
kalies in diabetes. He grounds his opinion upon the
supposed existence of acids in diabetes, which are neu-
tralized by the alkalies. Too much, however, must
not be expected from the use of the alkalies. A mod-
erate use of the alkalies in such quantities as are
found in the alkaline mineral waters, in order to aid

DIABETES MELLITUS.

digestion when tMs is mncli distm-bed, may indeed be
of use, and may aid the normal assimilation of the
food. Oppolzer, however, has not observed the good
effects of large doses of the alkalies. Miahle pre-
scribes them through several weeks.

Attempts should not be made to control or sup-
press the secretion of sugar, which aj^pears in the
urine after meals. If an attempt is made to suppress
this physiological function, more harm than good may
be done. The same may be said of the glycosuria of
pregnant and lying-in women ; but if disturbances of
the respiration, diseases of the liver, or lesions of the
brain are the cause of the glycosuria, attempts should
be made to remove them. Lesions of the cerebro-sjDi-
ral system have been very frequently regarded as the
cause of diabetes. This theory has for its foundation
experiments made upon animals, whereby diabetes, or
rather glycosuiia, was j^roduced by means of artificial
lesions of the cerebro- spinal system. If, in a case of
diabetes, any disease of the cerebro-spinal system was
found, this lesion was immediately regarded as the
cause of the diabetes. It is, however, difficult to main-
tain this view in all cases.

In numerous cases which we find recorded in medi-
cal literature, various nervous complications are men-
tioned. As complications of diabetes, Oppolzer has
observed many distui'bances of the various nervous
branches, as, paralysis of the fiicial nerve, neuralgia
of the trigemini, etc. These neuralgias appear to de-
pend upon an excess of urea in the system. In the
treatment of these complications, regard must be had
not only to the symptoms of the jDatient, but also to
the patient himself, who in this disease is much re-
duced and weakened. Bleeding, although local, in

CLINICAL obseetatio:ns

sucli cases should Le discountenanced, as the loss of
blood generally reduces the patient still more. The
benefit of the revulsives in some cases, however, is not
to be denied. They should, therefore, be preferred to
leeches and cups. In many cases of neuralgia, when
it cannot otherwise be relieved, resort may be had to
sinapisms and vesicants.

Oppolzer has observed in one case an obstinate
sciatica, which came on in the course of diabetes. The
patient was not able to sleep, and was in a condition
of great excitement on account of the severe pain.
The attacks attained such a violence that they were
more dangerous than the diabetes itself Laudanum
and quinine, which at first produced a temporary re-
lief, proved later of no use. Resort was had to the
revulsives, which occasioned much alleviation to the
paroxysms of pain. The patient, who was still more
reduced by the pain, again recovered, but the sugar in
the urine remained the same in amount.

Of the other remedies which are recommended in
diabetes, carbonate of ammonia deserves mention.
This was highly recommended by Bouchardat, and be-
fore him by Neumann and Barlow. He gave a solu-
tion of one to two drachms in four to six ounces of
water, which was the quantity to be used in a day.
OjDpolzer, however, has never been able to obtain any
good results with this medicine.

The use of opiiun in diabetes has been much
praised by several ^^hysicians. Since the experiments
of Bernard, who demonstrated the influence of the ir-
ritation of the nerves upon diabetes, this remedy ap-
pears in several respects to have done good service in
this disease. But Peter Frank and other older physi-
cians had j^reviously contended that opium was best

UPOIT DIABETES ]MELLITUS.

adapted to lessen the secretion of urine. According
to Oppolzer's experience, there are indeed some cases
of diabetes in which the use of opium is beneficial ;
nevertheless, it is of use only in the symptomatic treat-
ment of diabetes. It has by no means proved itself a
remedy for the disease. From a theoretical stand-point,
Bernard could indeed speak in favor of opium ; in the
practice, however, his views have been by no means
verified.

Many other medicines, for example yeast, have
been recommended in diabetes, but they have not been
approved in practice. It has been shown that, in ad-
vanced stages of diabetes, yeast is able to accomplish
little if any thing. Many astringent substances have
been highly praised ; experience, however, has not con-
firmed their beneficial effects, but has shown rather
that they frequently do harm by disturbing digestion.
Indeed, in diabetes, especially in the first stage, no
drugs should be employed excej)t in case of necessity.
For the first stage of the disease, a suitable dietetic
treatment is the best. In the second stage the treat-
ment should be symptomatic. If the strength of the
patient is much reduced, tonic medicines are indicated.
Oppolzer employs iron and quinine. The doses and
the preparation should be adapted to the individual,
the digestion, and the S23ecial case, whatever it may be.
Instead of quinine, a properly prepared wine of quinine
may be given with advantage.

A frequent complication of diabetes is j^neumonia.
It arises quite often from a very insignificant, acciden-
tal cause, as a slight exposure to cold. Although sim-
ilar exposures may produce a pneumonia in a healthy
person, yet in diabetes such pernicious causes more fre-
quently give rise to pneumonia than is the case in

CLnnCAL OBSEEYATIOI^^S

healthy subjects. It may he said that in diabetes,
-generally, slight causes are sufficient to produce an in-
flammation of the lungs. Such a complication is, how-
ever, of the greatest significance; for in diabetes the
appearance of pneumonia, however slight it may be,
is especially dangerous. In the majority of cases it
terminates fatally. The course of pneumonia in dia-
betes is quite different from that of pneumonia in a
healthy subject. The reaction is insufficient, and, as
the vitality is diminished, the patient soon dies. In-
deed, while the course of diabetes is generally chronic,
it is soon changed when pneumonia appears, which leads
rapidly to a fatal termination. The treatment is gen-
erally powerless, if the pneumonia be at all extensive.
Therefore in the treatment of diabetes, such dangerous
exposures should be avoided as much as possible. As
experience shows, diabetic patients are very sensitive
to the action of cold. Patients must therefore be pro-
tected as much as possible from such pernicious influ-
ences. This can be best accomplished by means of
reasonable prophylactic measures. The patient must
always dress warm, and be warned of the dangerous
influence of cold. A warm climate is more tolerable
to such patients than a cold climate, and if practicable
.'Such patients should be sent into a warm region. As
experience shows, diabetic patients are quite well in a
mild region near the sea, and when sent here improve
in health, and increase in flesh and strength. A damp,
misty climate is very unfavorable to diabetic patients.
If pneumonia attacks a diabetic patient, the treatment
is generally of no use. It runs a very rapid course,
and the patient generally dies within twenty-four
hours. Neither local nor general bleeding should be
resorted to, as the prostration of the system is ver}^

UPON DIABETES IVIELLITUS.

great. From otLer raedicines, as ipecac, calomel, and
the revulsives, very little is to be expected. Danger-
ous symptoms are to be treated as they appear, and
patients must be strengthened by tonics in so far as
they are able to tolerate them. Oppolzer has seen a
case of diabetes which overcame a light attack of
pneumonia. Liquor ammonige was given. Small
doses of opium were also administered to allay the
cough. Transpiration was promoted by suitable rem-
edies. The patient lived two years and a half after
recovery from the pneumonia, and died finally of tu-
berculosis.

In diabetes gangrene of the lungs not unfrequently
appears in consequence of the pneumonia. Such a
termination may be diagnosticated from the fetidness
of the sputa. They are blackish, rather adhesive, and
very abundant. From medicines in this complication
but little is to be expected. Tonics are mostly indi-
cated.

Sometimes other j)eculiar complications appear in
diabetes. Stomatitis and aphthae, and oftentimes ul-
cers on the mucous membrane of the mouth, throat,
tongue, gums, and lips, are observed. Extensive de-
struction of different parts also occurs. Oppolzer has
observed an obstinate case of stomatitis in diabetes
which defied all treatment. He employed as a Avash
for the mouth iodine in vain. Cauterization and scari-
fication were also of no use, and there followed a very
extensive gangrene of the mouth, gums, lips, and throat,
in consequence of which the patient died. In other
fresh and less obstinate cases, the above remedies and
also washes of peppermint and camphor render good
service. It is the presence of the primary disease
which renders these complications so obstinate. Such

CLINICAL OBSEEVATIONS

inflammations of the mucous membrane in diabetes
easily assume considerable dimensions and lead to
gangrene, as tlie power of reaction and the vitality of
the system are very low. When the mouth, therefore,
is attacked with these affections, it wdll often be im-
possible by any therapeutical treatment to afford relief.
Local treatment is of no avail so long as the primary
disease remains. A proper prophylactic treatment is,
however, of great utility. In fresh cases, where the
system is not much weakened by the general disease,
much good results from cleansing the mouth with the
above-mentioned washes. The first duty is to o23pose
the general disease, and, if this endeavor is successful,
the local treatment will be much more satisfactory.

As frequent comj)lications in diabetes, the affections
of the skin are to be mentioned. Erysipelatous in-
flammations are the most frequent. These inflamma-
tory complications were often observed by the older
physicians, and sometimes they assume a very serious
character, and give rise to extensive necrosis and de-
struction of the skin and cellular tissue. The termina-
tion of inflammation in diabetes is very frequently
gangrene, and such an event is always to be feared.
As complications in diabetes, other affections of the
skin are described by different authors. Marchal de
Calvi has directed attention to spontaneous gangrene
of the skin extending over a large surface. He has
also observed erythema of the skin. Fritz, Landouzy,
and Wagner, have published similar observations.
There are also numerous instances in which papular,
squamous, and pustular eruptions were observed as
complications of diabetes.

The gangrenous affections of the skin may be di-
vided into three groups, the phlegmonous, the gan-

UPON DIABETES ^^lELLITUS. 37

grenous, and tlie furunculous. There is mucli variety
of opinion as to tlie influence wliicli these complications
have upon the primary disease. It has been asserted
that these complications sometimes occasion an im-
provement in the general health, and a decrease in the
secretion of sugar. Prout and others have observed
the contrary. The observation of some physicians
who have found sugar in the urine of patients suffering
from carbuncles, or a number of boils, is of importance.
In the treatment of these cutaneous complications in
diabetes, the primary affection should not be neglected,
and the principal treatment should be directed to this.
The local treatment for the skin will vary according to
the different lesions.

In the second stage of diabetes complications on
the j)art of the digestive organs not unfrequently ap-
pear, while in the first stage perfect digestion is en-
joyed. Not unfrequently in diabetes cardialgia shows
itself. Oppolzer has observed such a case, in which,
hoAvever, the digestion was not disturbed.

Gastric catarrh is also observed as a complication
in the second stage of the disease. 023polzer observed
such a complication which made its appearance quite
vehemently. The patient vomited very often, became
much reduced in strength, and soon died. Oppolzer
has observed also catarrh of the intestines in this stage.
This hastens the fatal termination if astringents and
opiates are not administered to quiet the diarrhoea.
Especial attention should be given to the complications
at their very commencement. In the first stage ol
the disease, dryness of the intestines is a prominent
symptom, which is explained by the copious urinary
discharges. Mild aperients should be given in such
cases.

A CASE OF PUNCTUEED

111 the first stage of diabetes tliere are no disturb-
ances of the liver. In the second stage, however,
when the |)atient is much reduced and emaciated, an
atrophied condition of this organ is not unfrequently
observed. At autopsies, Oj^polzer has often seen this
organ atrophied, while in the beginning of the disease
it was for some time enlarged.

Finally, the complications on the part of the uri-
nary organs are to be mentioned. The kidneys are
generally enlarged, or, at least, in a condition of hyper-
trophy, in consequence of the increased diuresis. The
volume of the vessels and the Malpighian corpuscles
are increased.

In many cases albuminuria is associated with dia-
betes, and the kidneys then undergo the metamor-
phosis which takes place in this disease. The cortical
substance is then found in a condition of granular and
fatty infiltration.

The bladder, in diabetes, is found considerably en-
larged.

Art. II. — A Case of Piinctured Wound of tlie Thorax.
By Jas. a. Jacksoi^^, M. D., Stoughton, Wisconsin.

May 8, 1868. — James Murphy, aet. sixteen years,
was wounded this evening by stabbing with a jack-
knife, the blade of which is two and three-eighths inches
long and half an inch wide. He walked some little
distance, but, falling down faint, was carried home. I
saw him two hours after the receipt of injury ; shock
was not very severe ; coldness of extremities and slight
rigors; pulse not very frequent, full and regular;
respiration somewhat painful, but not much, if any, ac-
celerated. The knife entered between the eio'hth and

WOUTO OY THE THOKAX.

nintli ribs posteriorly, about one and a lialf inclies to
the left of spinous processes of vertebral column, wound
of integument being tliree-eigbtlis of an incli in length.
External hsemon^hage, though previously slight, was
now tolerably free ; emphysema of cellular tissue
around ^vound was manifest, and air Avas expelled for-
cibly from wound during expirations. Left lung clearly
resonant to the base, affording everywhere vesicular
respiratory murmur ; no cough nor expectoration. He
soon complained of pain in front over lower left costal
cartilage, increased by respiration. I now discovered
a murmur Avith both sounds of heart — churning in
character — heard much of time, although not constant,
and at times loud enough to be heard at a distance
from patient ; impulse and rhythm seemed normal ;
resonance, on percussion over prsecordia very clear.
I enjoined absolute quietude, applied cold, wet com-
presses to chest freely, and gave liq. ferri persulph. ; but
the pain becoming so severe as to extort cries from
patient, and to render respiration difficult and j^ainfal,
I gave moderate doses of morphine, after which, he
became easy and fell asleep ; temperature of skin rose ;
pulse 80, full; respiration 20; external haemorrhage
ceased, and no signs of any occurring internally.

May 9. — Easy excej)t a little pain in front ; skin
natural; pulse 75; respiration 18; tongue coated; ano-
rexia ; no external haemorrhage, no cough ; left lung
gave clear resonance on percussion and vesicular respi-
ratory murmur ; heart-sounds regular and accompanied
part of the time by murmur ; resonance over praecordia
appeared very clear ; patient unable to urinate, blad-
der being distended.

5 Magnesia sulphatis, f ss.
Ft. Haustus.

A CASE OF PTJNCTUEED

Pulv. opii. gr. viij.

Potass, nitratis 3 i.

Antiraonii et potass, tartratis gr. i.
M. et div. in chart I^o. 12.
Sig. Take one powder every three hours.

Barley-water allowed freely as drink, turpentine
stu^^es applied over prsecordia, with water dressing to
wound. I drew off a large quantity of clear nrine.

Evening. — Slight j)ain in front only, skin warm,
pulse 84, respirations 18, bowels not moved; retention
of urine ; patient desires to eat. Kepeated the saline
mixture, and continued powders ; hot fomentations to
h}^:>ogastrium ; a little food allowed.

May 10. — Feels comfortable, aside from some pain
and tenderness in jDrsecordial region and laterally ;
pulse 80; respiration 20; skin warm; tongue coated;
thirst ; no stool ; complete retention of urine ; ate some
food, and desires more; wound is suppurating; prse-
cordial space seemed duller, and cardiac murmur re-
mains ; percussion shows slight dulness with broncho-
vesicular murmur over posterior and inferior portion
left lung. Gave dose of jalap and calomel ; injections
per rectum.

Administered ipecac, gr. ss., potass, nitras gr. v., and antimon. et potass,
tartras gr. Jg- every four hours.

Morphine ^7r6> re ncita ; light food ; continue other
measures.

May 11. — Easy except slight pain and tenderness;
pulse 76 ; res|)iration 18 ; slight cough; bowels moved,
and passed a little urine ; has some appetite ; physical
signs about the same. Ordered a purge of jalaj) and
bitartrate of potassa.

Blister over heart ; continue injections.

May 12. — Has but little pain and soreness ; feels
comfortable and cheerful ; pulse 72 ;• resj^iration 18 ;

WOU]S"D OF THE THOEAX.

bowels loose, and urinates freely ; marked dulness, with
broncliial respiration and broDcliopliony over posterior
inferior part left lung, below wound; dulness over
prsecordia more marked ; heart's action and sounds
regular and accompanied with murmur ; wound is
closed ; continue treatment ; moderate diet, with but
little liquid.

May 13. — Feels well; pain only on deep inspii'a-
tion ; ajDpetite good ; pulse 60 to 64 ; respiration 18 ;
physical signs remain about same ; small doses nitre
and ipecac. ; moderate diet, restricting liquids ; tinc-
ture of iodine applied to prsecordia and back.

May 14. — Comfortable ; some pain near prsecordia
on deep inspiration ; slight tenderness here, laterally and
posteriorly ; appetite good ; pulse 60 ; respiration 16 to
18 ; heart-sounds are good and nearly free from mur-
mur ; lung about the same as before ; bowels not
moved, nor has he urinated to-day ; jalap and cream of
tartar renewed ; continue iodine externally.

May 15. — Feels very well; some soreness about
chest ; bowels loose ; urine fi^ee ; pulse 60 ; respiration
14 to 18 ; heart-sounds nearly free from murmur ; lung
shows improvement ; allowed to sit up in bed.

May 16. — Pulse 60; respiration 18; heart-soimds
normal and free from murmur ; physical signs show
progressive improvement ; wound remains closed. Con-
tinue iodine. Allowed to sit up in chair.

May 17. — Walking about ; physical signs show a
nearly normal condition of lung and heart.

May 26. — With exception of occasional soreness
about chest, and some debility, feels perfectly well ;
may be considered well.'

^ This case opens up a nice point on the question whether the peri-
cardium was wounded. The most probable source of error — pleuritis ex-

PAEACENTESIS THOEACIS.

Aet. III. — Paracentesis Tlioracis ; Successful 'Result
in Three Cases. By Josiah S. White, M. D., Mem-
pliis, Tenn.

A LADY twenty-one years of age, of nervo-sanguine
temperament, had enjoyed uninterrupted good liealtli
up to the winter of 1859, when she was attacked with
pneumonia, involving the left lung. The attack was
violent, and produced miscarriage on the fifth day,
she being^ at that time three and a half months ad-
vanced in pregnancy, and was followed by puer2:)eral
peritonitis of a very alarming character. In the third
week or beginning of the fourth the active fever symp-
toms began to subside ; and there were evidences of for-
mations of pus in the left pleural cavity.

The case was apparently hopeless. She was threat-
ened momentarily with suffocation, even should there
be a spontaneous discharge through the bronchi ; her
feeble condition and the large collection of matter
would, without doubt, produce death by suffocation.
The collection of pus being well defined, I felt that the
only chance of relief was by giving exit to the puru-
lent collection. With the assistance of the late Dr.
H. R. Robards, a, skilful surgeon, paracentesis was per-
formed in this manner : a semi-lunar incision was made
over the lower posterior part of the mammary gland,
the concavity looking forward and upward, the inner
cornu receding high up, near to the centre of the gland
and through the gland, and then separating its fatty
base and fascia suj^erfacialis from the pectoralis major

ternal to the pericardiam — was eliminated pretty carefully, as tlie physical
signs, recorded daily, seemed to sliow. It would be both interesting and
instructive to have reports of analogous cases from other physicians, in the
hope that some light may be thrown on the questions involved in the
diagnosis. — [Ed.

PAEACENTESIS THOKACIS. 43

muscle to the intercostal space of the third and fourth
ribs, one and a half inches from its sterno-cartilaginous
connection. Thence raising up the valve formed from
the glandj and inserting a trochar uj)ward and back-
ward through the muscles and intercostal space, on
reaching the pleura costalis, the hand was elevated,
and a direct entrance was made through that mem-
brane, and fortunately into the abscess; for, on the
withdrawal of the flattened stylet, the matter j)oured
freely through the canula. Thirty ounces was the re-
sult of the first drawing, which relieved for the time
the dyspnoea. A bandage had been placed around
the patient previous to the operation. This was tight-
ened on withdrawal of the canula, and the valvular
flap held in position by a compress.

The instrument was used a second time. After
this the pus would discharge freely on removal of com-
press, and on making a forced expiratory effort.

The discharges of pus at first were of a healthy
character, but afterward took on a degenerated condi-
tion ; and in a few days improvement would occur, only
to be succeeded by a recurrence of the unhealthy char-
acter of the pus. Gradually the ^^atient improved,
and in the twelfth week was well enough to sit up, and
in the fourth month to take moderate out-of-door ex-
ercise. The discharge, at times, was Very profuse and
exhausting.

The operation was performed in February, and in
the ensuing fall I recommended her to take a trip to
Europe, hoping the change might benefit her. I exacted
from her a promise that she would, through her physi-
cian, keep me posted as to her condition and the result
of the case. Communications were received from her
occasionally, to the effect that her condition was slowly

PAEACEXTESIS THOKACIS.

improving, tlie discliarge througli the wound continu-
ing, but varying mucli in quantity. In 1861 tlie civil
war put a stop to those communications, and in 1865 I
reojDened the correspondence, and learned, to my great
delight, that she had completely recovered. Accom-
panying this report, was a photograph of the chest and
head, which I had requested of her.

The left mammary gland was very much atrophied ;
there was a sinking in or contracted ap]3earance of the
walls of the chest in the same region. Her physique
otherwise, in consideration of the six or seven years'
illness, was good. She also reports that the discharge
continued wp to 1862, gradually diminishing, and that
she experiences but very little inconvenience. Has
borne no children since.

The second case was of traumatic orio^in. Private
Smith, of one of the Alabama regiments. Battle's brigade,
received a wound from a Minie ball, on the 3d day of
May, at the battle of Chancellorsville. The ball en-
tered two inches above and slightly outside of the
right nipple, passing through the lung and out at the
point of the scapula, lodging under the common in-
teguments, and was removed at the time by one of the
field- surgeons.

There was considerable haemorrhage for two days.
A severe attack of pneumonia followed, from which he
recovered sufficiently in two or three weeks to be sent
to his home on furlough, where he was to report every
two or three weeks to the nearest general hospital until
recovery. November 3d, six months afterward, my
attention was called to this case by one of the Board
of Examiners for Discharge and Extension of Furlough,
and, upon inquiry, found that he had latterly suffered
w^ith fever and much pain in the right lung. On ex-

PAEACENTESIS THOEACIS.

amination, an abscess was detected in the lower portion
of the upper division of the right lung, in the track
made by the jiassage of the ball through the lung ;
suspected that the ball had earned into the wound a
piece of clothing which remained in the cavity. The
exit and entrance of the wound having closed, the
patient could get rid of the accumulating matter only
by ex]3ectoration, which was now very free. The favor-
able result, in the j)i'evious case, more hopeless than
this, determined me to pursue the same plan of treat-
ment.

The operation was done by making a semi-lunar
valve from the common integuments and pectoral
muscles, and cautiously introducing the flattened
trochar. This was followed by a discharge of pus, and
on the eighth day a piece of cotton shirt, about the
size of an English shilling-j)iece, was found entangled
in the opening, and was removed with the forceps, and
from that time on there was a decrease in the discharge,
and final recovery of the case. Sixteen months after-
ward the patient was seen by me, and was then in
perfect health.

The thii^l case resulting from pleuro-pneumonia was
that of a lad fourteen years of age. The em23yema
followed an attack of pleui^o-pneumonia. I did not
see the patient until the day of operation. His fother
was a physician, and he, with others who had attended
the lad, had discovered the abscess in the middle di-
vision of the right lung, in the fifth ^veek from the in-
cej)tion of the disease. There was extensive jDleural
effusion, evidenced by the full and fluctuating intercos-
tal spaces. Making the same valvular flap oj^eration,
and introducing the trochar through the fourth and
fifth ribs and pleural investments, the abscess was

DESCEIPTIOTT OF AN APPAEATUS

reached, and on witlidrawal of the stylet eight or ten
ounces of thick pus were passed, and then a slight with-
drawal of the canula enabled the pleural effusion to
discharge itself to the extent of some twenty or twenty-
five ounces.

I saw this patient eight months afterward. His
father informed me that he had been afflicted with a
series of boils and superficial abscesses ; otherwise he
did quite well, and was fully recovered.

Aet. IV. — Descrvption of an Apparatus for Teaching
Hernia; its Anatomy^ and its Mechanism. By
Bexjamiis" Howaed, M. D., Lecturer on Operative
and Minor Surgery in the Medical Department of
the University of New York.

EvEEY teacher of surgical anatomy feels and
acknowledges that, about the anatomy of inguinal
hernia, more is told than taught. Students are more
often qualified to answer questions upon it, than to
treat it. Among the causes of this may be mentioned :
first, undue reliance upon didactic descrij^tion ; second,
obscurity of demonstration.

The surgical anatomy of hernia can be learned only
from teaching which is objective. For this drawings
are insufficient, it being impossible thus to show at
the same time the parts which overlie each other as
they do in this region. In order to communicate a
competent comprehension of this subject, plain demon-
stration is indispensable, and in this nothing can be
exclusively substituted for the cadaver. The cadaver,
however, especially in private tuition, is troublesome
to get, and inconvenient to keep. This, in the summer

FOE TEACHINa HEEmA.

montlis, is alike true even in our largest colleges. In
either case, the exj^ense is repeated at each demonstra-
tion.

Besides these obstacles to its use, there are two dif-
ficulties in its use. The first, in any case, is great and
embarrassing. The second, in the lecture-room, is
fatal to success. Both are inherent in the cadaver,
and are in its use insurmountable;

The first of these difficulties consists in the natural
order of superposition of the parts. This renders it
well-nigh impossible so to exhibit the parts con-
cerned, even to the smallest class, as to present a view
of their actual relations in situ / it being necessary to
remove one fascia in order to show another, the mind
is occuj)ied by each in succession ; meanwhile the gen-
eral relations are lost.

The second difficulty consists in the proportions of
the cadaver. This prevents even such dissections as
can be made, from being rendered visible to more
than a few of those who in the lecture-room, vainly
hope to learn, that which cannot thus be taught.

ThQ first difficulty, I find to be obviated by the use
of a model of the parts concerned in the surgical
anatomy of inguinal hernia which I have so con-
structed as to enable the teacher to exhibit all the im-
portant relations in situ at one view.

The second is overcome by making the model so
much larger than the natural size of the parts, that,
w^hen revolved upon its pedestal, the students at the
remotest parts of the lecture-room can plainly see
every part of the demonstration.

As this model was constructed to exhibit what
drawings could not show, it is impossible, by draw-
ings, fully to represent the model ; nevertheless, a de-

DESCEIPTIOI^ OF AN APPAEATUS

scription of its construction and use may perhaps be
somewhat aided by reference to the accompanying
eno^ra vinous :

Figure 1 represents the posterior view of the hypogastric
region of the abdominal walls : a, the anterior superior
spinous process; the inguinal fold; c, crest of pubis.

These constitute the outline or frame, and are made of stout
brass or wrought-iron rod ; d, d, sheet-tin to preserve the
natural contour ; e, e, another sheet of tin for same purpose,
but, at having a guttered shape corresponding to the
course of the inguinal canal ; stout wire passed through
holes in the tin plates to form the deep abdominal rings;"

fenestr£e representing ruptures of conjoined tendon op-
jDosite the superficial rings in direct hernia. The perforations
parallel with all the outlines of the tin plates are for the con-
venience of sewing thereto the sheets of linen after wardto
be attached ; A', stanchion ; m, its arm ; n, pedestal in which
stanchion revolves.

Figure 2, a, a, J, J, c, <?, are same as in figure 1 ; d
is a sheet of linen, glued over the entire surface of both tin
plates, stretched tightly over the interspace between them,
and, when dry, sewed at all the perforated points ; this repre-
sents tlie transversalis fascia, the opening in which, at e, is
the deep abdominal ring.

FOR TEACHING HEEXIA.

A narrow strip of stout muslin is now sewed tiglitly all
the way clown from f to the crest of the pubis to form the
linea alba. A sheet of linen, corresponding to the right half
of the model is now sewed to the entire rio-ht half of the
trame, and to the strip representing the linea alba. It is
then cut transversely across at the lower margin of the deep
abdominal ring; the upper section is detached, at its lower
part, from the linea alba, and the lower section, at its upper
part, from the frame or inguinal fold, near the deep abdomi-
nal ring, the object being to allow the lower end of the upper
sheet to be raised, and the upper end of the lower sheet to
slide a little downward. The linen is now sized, the lower
part of the upper section painted with vermilion in water-
color, representing the fibres of the transversalis muscle ^, on
the under side ; the surface being painted in a similar manner
to represent the internal oblique at /i, and the rectus abdomi-
nis at i', v»'hile the body of the linen sheet, left blank be-
tween them, represents the conjoined tendon, to form which
both muscles unite. In this the hook is seen to be fixed near
the margin of the rectus abdominis.

A piece of red silk or cotton cord is sewed to the lower
section of the conjoined tendon, representing the epigastric
artery which, upon the conjoined tendon, at this point,
is subject to motion downward and inward.

The superficial abdominal rings are seen at c>, o ; tliese

DESCEIPTIOlSr OF Als APPARATUS

are formed of stout copper ^ire, bent as represented, and
fastened to the frame, at the crest of the pubis only, the rest
being free ; thev are stont enough to maintain their position,
but pliable enough to yield a little before an advancing hernia.
Another sheet of linen is now stretched over the right half of
the model, and sewed to the frame along the inguinal fold
and crest of the pubis. Its upper margin is left free, its inner
margin being supplied with hooks answering to eves, by
which it can be neatly fastened to the liuea alba, or be folded
back at pleasure ; while the sheet is tightly stretched and
hooked, the section of canvas between the pillars of the
superficial ring is cut, folded back, and stitched, so as to cover
them.

The spermatic cord {2^,p) is made of woollen cloth covered
with blue silk. At its upper end it is stitched fast, just be-
low the interior of the deep abdominal ring {e), and occupy-
ing the course of the inguinal canal, it is passed through the
superficial abdominal ring (c*, o), and is stitched to the frame
at the crest of the pubis. The last mentioned linen sheet be-
ing hooked, stretched, and sized, the fibres of the lower part
of the belly of the external oblicpie (s) are then painted in the
same manner as the others, and with Indian ink or any neu-
tral color, the fibres of the tendon of the external oblique are
painted so as to show how, by their divergence, the superfi-
cial ring is formed. The left side of the model is reserved for
the more minute demonstration of the descent of the testicle,
and of the coverings of the hernise. Behind the deep abdomi-
nal ring is a shifting ]:>iece of blue silk for the peritoneum.
In front of the ring, a shifting loose fold of green silk for the
fascia propria ; over that, a told of pink silk for the fascia
transversalis. Some red elastic bands attached to the lower
border of the internal oblique, and transversalis muscles, form
the cremaster muscle.

At the superficial ring, the intereolumnar fibres, figure 2
(o), on the left side of the model, are made of elastic bands,
which may be unhooked, or be made to yield before a de-
scending testicle, or a protruding hernia, like the other fascia,
which stretch across their pathway. If it be found difficult to
make the testicle assume all these coverings, including the in-
tereolumnar, without tearing, it will suffice just as well to ex-
hibit these fascia i?i situ, in (colors corresponding to those
which, in the same order, may be reflected from a section of
the model of a testicle. If it be desired to provide for a simi-
lar demonstration of femoral hernia upon the same model,
it is easy to a^^pend (x) Poupart's ligament, the femoral ring,
and all the parts concerned, in its surgical anatomy, by a sim-

FOE TEACHING- IIEE^'IA.

-pie continuation witli tlie same materials. The same may be
said of nmbilical hernia, for either of which any particular
directions would be supei'fluous.

lu teacliiug the surgical anatomy of inguinal hernia
with this model, the muscle and tendon of the exter-
nal oblique is folded back as seen in Fig. 2, and at
once is brought into view the superficial abdominal
ring (o)j the deep abdominal ring the inguinal
canal and spermatic cord (p, ^j>) in their entire course,
as also the ej)igastric artery (?^, n) crossing beneath
the cord ; thus exhibiting clearly all the important
relations at one and the same time.

I am aware that this exhibition requires the epigas-
tric artery to lie upon, instead of beneath, the con-
joined tendon and transversalis fascia ; but, as it is the
course, rather than the location, of the artery which is
of paramount importance, the deviation is unobjection-
able and entirely advantageous.

I find it quickly understood when with accompany-
ing demonstration I say, the inguinal canal may be ,
looked upon as a tube formed of the fascia propria,
passing obliquely downward and in^vard through the
abdominal walls ; its upper end is the deep abdominal
ring, its lower eud the superficial abdominal ring ; be-
neath the floor of this tube at about its middle crosses
the e23igastric artery, passing upward and inward to
be distributed to the rectus abdominis muscle.

The Mechaxtsm of Herxia. — This is demonstrated
with this apparatus in tlie following way :

Fig. 3 is a silk or cotton bag of the same color as
the covering of the sj^ermatic cord, stufted loosely ^vith
cotton wool. This is passed from behind forward
through the deep abdominal ring, and made to simu-
late a large knuckle of intestine within the canal ;

DESCEEPnON OF AIS^ APPAEATTJS

which, by hooking tightly the tendon of the external
oblique, is converted into a bubonocele.

Continue to push it from behind forward, and it
makes its appearance, protruding through the superfi-
cial ring, assuming its distinctive shape, which is una-
voidably pyiiform; seeing it is an oblique inguinal
hernia.

Afterward, or at the same time, pass a similar
portion of intestine of a pink color from behind for-
ward through Fig. 1 (^), and through the supei-ficial
ring Fig. 2 (o), and the differential globular form of a
direct hernia is as distinctly demonstrated.

The changes of relation to which the epigastric ar-
tery is subject in some of these conditions, and espe-
cially in old cases of oblique inguinal hernia, we have
heretofore lacked the means to demonstrate. It will
be remembered that the upper j)art of the lower sec-
tion of the conjoined tendon. Fig. 2 (^), is partially
detached from the frame at the inguinal fold ; accord-
ingly, as the hernia is pushed onward, the conjoined
tendon, with the epigastric (^z, which is stitched
upon it, is crowded before it ; the artery therefore
increasingly embraces the inferior and internal portion
of the neck of the sac, while the lower and internal
margin of the deep ring slowly tends toward a j)ar-
allelism with the supei^ficial ring.

These demonstrated chano;es of relation in the ar-
tery suggest their own lessons in connection with the
operation for division of stricture in strangulation ; so,
the difference in the course of the hernise being clearly
understood, we come next to

The Peinciples and Methods of Reductiox. — To
demonstrate these, we require an exceedingly thin In-
dia-rubber gut. In Fig. 4 it is seen j^artly filled with

FOR TEACHIXa HEEISTIA.

water, its neck tightly tied around a fitting cork. For
water, contents of various densities may be substituted,
but the gut must not be made more than lialf or two-
tliirds full. The corked end of the gut is then made
fast by its string to a point near the interior of the
deep ring ; through this the other end is protruded,
the tendon of the external oblique is closely hooked
to the linea alba, and as it emerges through the su-
perficial ring a very natural-looking oblique hernia
with typical shape is made to appear.

The stanchion may now be lifted out of its pedestal,
and the frame turned partly or completely upside
down ; whereupon the contents of the gut immediately
gravitate, and a well-appreciated demonstration is
made of " Keduction by Position."

Taxis. — This may be taught to, and be practised by,
the student. Use the left hand to constrict the gut in
the canal, and with the fingers of the right press upon
the centre of the fandus of the protruded tumor;
and, notwithstanding the pressure be made in the right
direction, it will be shown you are thereby rendering
impossible that which you are attempting to per-
form; the pressure upon the centre of the tumor
increases its circumference, flattens it over the pillars
of the superficial ring, and prevents its return. The
left hand may now be shifted to constrict the neck
of the tumor, the method and advantage of traction
uj)on the tumor for breaking loose slight adhesions
being at this point shown if desired; then, the con-
striction being continued at the neck by the left
hand, and the fundus of the tumor being complete-
ly grasped by the right, the contents of the gut
recede with a gurgle ; with the right index and mid-
dle fingers the India-rubber gut is passed in pursuit.

DESCRIPTION OF APPARATUS

of its recent contents, and tlie demonstration lias been
completed of " Reduction by Taxis."

By adding tlie integument and scrotum, tlie vari-
ous operations for tlie radical cure of hernia may be
demonstrated, tlie parts beneatli the skin may then be
exhibited as fixed i/i situ after each operation, by the
particular method adopted.

It may be observed that, in speaking of the " rings,"
I use the term " superficial " and " deep " exclusively.
My reasons for this have been fully stated in a
paper read before the County Medical Society of i^ew
York, January, 1868, entitled " A new Method of teach-
ing the Surgical Anatomy of Inguinal Hernia" in
which the terminology is fully discussed. I will here
state, however, that I consider the total abandonment
of the terms " external rinor " and internal rino; " in-
disjDensable to prevent ambiguity and perplexity in
description ; by substituting therefor the terms su-
perficial ring " and " deep ring," the terms external "
and " internal " are left available for use in this, as in
eveiy other region of the body, with reference to the
median line only.

A general advantage gained in the use of this ap-
paratus is, that instead of a mere blind memorizing of
arbitrary terms, the student is at once imjDressed with
the facts, and sees how, and why, the coverings of the
respective hernias must be what they are, and could
not be otherwise.

The apparatus is simple in its constractioii, and
may be made by any person for himself.

From my own experience, combined with that of
others in difierent parts of the country, who have had
duplicates of it made, I would commend its exclusive

FOR TEACHma HEElSriA.

use as a 23rej)aration for, and its sul)sequent use as
an auxiliary to, dissections upon the cadaver.

This apparatus presents the following advantages
not possessed by the cadaver :

It is chea23er. It is convenient for any place and
season. It exhibits all the important relations of her-
nia at one and the same time.

Its ^proportions may be adapted to the largest class.

It allows of an exhibition of the process of descent
of the testicle ; of the occurrence, progress, and stran-
gulation of hernia, as well as of the methods of reduc-
tion, either by position, taxis, or operation.

It enables the student to learn, by actual manipu-
lation, the practical treatment of these conditions,
whether for their relief only, or for their permanent
and radical cure.

Art. I. — Therapeutics and Materia Medica. A Systematic
Treatise on the Action and Uses of Medicinal Agents, in-
cluding their Description and History. By Alfred Stille,
M. D., Prof, of the Theory and Practice of Medicine and of
Clinical Medicine in the University of Pennsylvania, etc.,
etc. Philadelphia : Henry C. Lea. 1868. 2 vols. 8vo, pp.
824-864

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, etc. Third edition, en-
larged, with Illustrations. Philadelphia : Lindsay & Blak-
iston. 1868. 8vo, pp. 381.

Dental Materia Medica. Compiled by James W. White.
Philadelphia : S. S. Wliite. 1868. 12mo, pp. 108.

So vast is the study of materia medica, so numerous the
additions constantly made to our knowledge of the medicinal

EEVIEWS.

properties of substances, "both inorganic and organic, and so
preposterous are the claims put forward by some enthusiastic
experimenters of the efficacy of this or that agent, that he is
truly a shrewd and clever compiler who can manage to keep
pace with the real progress, and not be drawn into indiscrim-
inate eulogy of what, after all, may be worthless. Dr. Stille
has attempted his work in this middle course, and has suc-
ceeded, all things considered, remarkably well.

He has seen fit, however, to omit some most valuable the-
rapeutic agents, and to notice others in the most meagre way,
far beneath the recognition which is almost universally con-
ceded to them ; and yet, with these shortcomings, the book
stands confessedly a most valuable addition to our literature,
and a reliable guide, so far as it goes, to the student. Therapeu-
tics must always be to a certain extent empirical, and yet the
known physiological effects of drugs, ascertained by experi-
ment upon animals, are of immense service to us, as giving
some rational ground on wdiich we may base our practice.
And at the present day these experimentations are so frequent
and the results obtained so positive and so valuable, that we
can only express our regret that Prof. Stille has not devoted
more space to them, although we observe that he has incor-
porated some even of the most recent, viz., we find the subject
of bromide of potassium worked up to the latest day, and all
the recent experiments and observations of any value brought
together. A little of this painstaking w^ould have added
materially to the worth of other portions of the book. "\Ye are
thus exacting in our demands, because Dr. Stille's work is be-
coming the best known of any of our treatises on materia med-
ica, and we as Americans naturally look to it, it being one of
our acknowledged authorities, for every thing worth knowing,
and sometimes we find ourselves sadly disappointed in the
search. In the mere matter of the uses of medicinal assents,
or therapeutics proper, it is not equal to Mr. Waring's book,
which, though less than one-half the size of Stille's, we consider
the most remarkable book of the Jcind ever written, and yet
the tw^o books are not comparable, for they cover quite differ-
ent ground. Dr. Stille's should, from its scope, include the
whole ground over which Waring with such untiring industry

EETIEWS.

has plodded, tliongli Tve could not ask for or expect the minute-
ness there displayed, and at the same time he goes far beyond
"Waring, and gives us the history, descriptions, and physiologi-
cal properties of the articles of the materia medica ; so that he
would err greatly, who, examining Stille by the text of Waring,
should pronounce the first the inferior of the second. Indeed,
looked at in its totality, as om* legal friends say, we consider
Stille's by all odds the most valuable work.

In the present issue of his book. Dr. Stille gives about one
hundred pages of reading matter more than are found in
the last edition;, and for the first time he treats of chromic
acid, permanganate of potassa, the sulphites of soda, etc., car-
bolic acid, nitrous oxide, rhigolene, and Calabar bean.

We do not choose to enter into a minute examination of
Dr. Stille's work. His attention has been very forcibly
directed by other reviewers to the special deficiencies apparent
in the book. Our remarks are based upon a careful estimate
of the whole scope and bearing of the work, and where we find
so much that is good, and so little that need be added to make
the book complete, we ventm*e to express the hope that in
forthcoming editions we shall see these deficiencies fully filled
up and rounded ofi", so as to give an unexceptionable stamp of
authority to what is even now one of the most valuable works
in the language on the subjects of which it treats.

De. Biddle, within the compass of one handy little volume,
attempts a description of the materia medica; and as we have
just seen, that Dr. Stille, with his two portly tomes of over
eight hundred pages each, has failed in many points to do full
justice to his subject, it may readily be inferred that even the
qualification for the use of students " does not protect this
book from a suspicion that it must necessarily be very imper-
fect. We object to books prepared expressly for use of stu-
xlents, and have previously and most emphatically put on
record our opinion that such productions are only an abomina-
tion^ and hinderance to knowledge. And yet Dr. Biddle's book
is less open to this charge than many other students' books. We
have used the previous edition of his book largely, and have
carefully examined this new issue, and speak advisedly. The

EEYIEWS.

trntli is, that the title of the book is a misnomer, and it more
nearly approaches the character of a syllabus of a course of
materia medica, although lacking in the systematic classifica-
tions we naturally look for in a syllabus, and in the hands of a
thorough student, or a judicious teacher, it can be made to do
good service.

How far the author has touched any thing like complete-
ness in his descriptions may readily be seen, Avhen we state
that, after devoting forty-two pages to a discussion of the
mechanical and imponderable agents, the mode of action of
medicines, their forms, the methods of application and admin-
istration, the circumstances modifying them, in other words to
the principles of the whole study both of materia medica and
therapeutics, the remaining three hundred and forty pages are
given up to the special articles of the materia medica, and
here we find enumerated no less than three hundred and four
different substances. We say enumerated, for in many in-
stances Inhere is nothing more than a mere allusion to a drug,
and in no small number of cases drugs of great value are dis-
missed with the most unceremonious brevity, that quite illy
accords with their real value. And yet the author is up to
time in the introduction of new substances, and we find intro-
duced for the first time notices of carbolic acid, bichloride of
methylene, the compounds of amy], tetrachloride of carbon,
iodoform, iodides of ammonium and sodium, nitrous oxide,
guanara, coca, and woorara. At the same time, the more than
usual curtness with which the author chronicles the virtues of
these articles, would seem to indicate that he has but little
faith in any thing new, or at all events that he desires time to
make good the claims of their virtue.

The classification of the substances in accordance with
their physiological effects is a good one, and special pains are
taken to indicate those articles whose action, varying under
different circumstances, would entitle them to a place in more
than one class. Thus one source of perplexity to the student
is provided for. To those who sit under the teachings of
Prof Biddle, we can readily perceive that this book may be
very serviceable, but to others who desire any thing like a com-

EEVIEWS.

petent knowledge of materia meclica and therapeutics, vre can-
not conscientiously recommend it.

Our dental friends certainly are under obligations to Mr,
White for the admirable little compilation which he has
here brought together under the title of "Dental Materia
Medica." He tells us that he prepared it as a ready-made
answer to the frequent inquiries received, "asking informa-
tion as to the properties, dental uses, and methods of applying
the various medicinal agents and preparations advertised for
sple or alluded to in the discussions of dental societies, and by
correspondents in the journals."

Many who practise dentistry (and the same will hold good
too, to some extent, of medicine) are not well grounded in that
preliminary education which thoroughly prepares them for a
full appreciation of all that pertains to their art, and they find
themselves frequently at a loss in estimating the value of the
infinite and many times useless claims that are put forward for
this or that article. This little book gives succinctly an account
of the really useful agents of the dental materia medica, and
as such cannot fail to be of value, not alone to the dentist, but
to that large class of physicians who, by reason of location, are
called upon occasionally to play the part of dentist. Indeed,
in our younger days we confess —

" Quamqnam animus meminisse horret lactuque refugit " —

to having " pulled " many a useless molar, and administered
to many an aching fang, and Ave should have been glad of so
concise a medium of information as Dr. White's book.

No classification, not even alphabetical, is followed, and eo
we find mercury treading upon the heels of prepared chalk,
and litmus sandwiched in between arsenic and chloroform ;
but a full index compensates for this defect, and we are bound
to admit that the compiler has succeeded well in carrying
out his plan of making the volume, " as far as it goes,"
convenient, useful, and reliable.

Although the little work is evidently intended in a
large degree as a medium of advertising Mr. White's own
stock in trade (for, as is well known, he is the proprietor of the

EEYIEWS.

largest house in the country for furnishing dental materials),
still we can overlook this little commercial dodo^e, in view of
the fact tliat he has given such valuable information to his
patrons.

Art. IL—On the Pathology and Treatment of •Albuminuria,
By William H. Dickinson, Cantab., F. E. C. P., etc. Lon
don : Longmans, Green & Co. 1868. 8vo, pp. 265.

Dr. Dickinson's book is one of the most valuable contr^
butions to the study of diseases of the kidney that have been
made of late years, and w^e base this positive assertion upon a
most careful reading of the entire volume.

The title is, we think, objectionable, for the book is de-
voted to a consideration only of those forms of disease which
are usually associated under the name of Bright's disease ; this,
however, is of small importance.

A description of the anatomical elements of the kidney
and its appearances in a healthy state are given as a prelude
to the subject proper of the book, and as essential to a right
understanding of the classification of the different forms of
disease, and attention is especially fixed upon the triple con-
stitution of the organ, viz., the tubes, the fibrous tissue, and
the blood-vessels. ]^ow, disease may attack either one of these
structures, and thus we have :

1. Tubal disease^ characterized by an extravagance of
cell-growth, for, like the bronchi and other secreting surfaces,
these channels are prone to take on this condition, usually
called inflammation, when under the influence of morbid
stimuli. The tubes become loaded with epithelium, and dis-
tended; the whole gland is enlarged. This is the large,
smooth kidney of Bright. The author terms it tubal ne-
phritis.

2. Disease of the fihrous tissue, characterized at first by
an increase of this structure, commencing at regular intervals
on the external surface, and followed by a slow contraction,
which produces little depressions, giving the kidney the ap-
pearance of being studded with small granulations. Ulti-

matelj tliese processes invade tlie whole organ, and we have
the small contracted granular kidney of Bright, or granular
degeneration.

3. Disease of the vessels. — This is a change not peculiar
to the kidney, bnt occurring in common with other organs,
and consists in the poming out from the minute arteries of a
glassy material, which permeates the whole tissue, giving the
organ at first a whitish or anaemic look, producing increase in
size and density, and a peculiar translucent aspect. This new
formation has a contractile power, so that slirinking of the
organ ultimately follows. The special characteristic of this
material is, however, its reaction by iodine, which gives to it
a dark-brown color, quite unlike the tint produced in the
healthy kidney by the same reagent. This is the so-called
" waxy " or " amyloid " degeneration. Dr. D. claims that
the infiltration of this peculiar material occm-s usually after
the system has been exhausted by a prolonged discharge of
pus, and hence he terms the disease dejnrrative — a most un-
fortunate (and of questionable etymology also) choice of terms,
as, by common usage, this word has assigned to it an entirely
different signification. And, besides this, the term is very
apt to mislead a cm-sory reader or a careless student.

Xow, these diseases difler widely in then- etiology and
svmptomology ; they affect different periods of life ; have spe-
cial methods of invasion and progress, and are imlike each
other in their danger and in the treatment they requii*e. The
author, therefore, takes them in the order above given, and
considers each one in all the relations we have just mentioned.

Such is a brief outline or skeleton of the book. TTe can-
not follow the author step by step, but will take some points
which presented themselves to us as worthy of note. In tlie
section devoted to the consideration of tubal nephritis, acute
and chronic, the chapter on the clinical history of this disease
is remarkably concise and explicit, and, not being loaded
down with technicalities, or obscured by theorizing, it is made
plain and readable. Eelying on his statistics. Dr. D. shows
that the male sex is more liable to tubal nephritis than the
female. In adult life this is unquestionably true ; but, at the
same time, it is questionable whether the sex is the predis-

REVIEWS.

posing cause. In cMlclliood there is not so mucli difference
between the sexes in the liability to the disease, Dr. D.'s
figures being, boys 37, girls 2-1. The* author infers from this
" the fact that the difference exists in children, where the habits
of the sexes are the same, is enough to prove that the mascu-
line gender is a predisposing cause." We question the validity
of this numerical reasoning, but, without entering into a dis-
cussion thereon, simply suggest that, as the disease is very
rare until after the second year of age, there is, in our expe-
rience, enough of difference between the habits of boys and
girls after this age to render the first as much more exposed
to the influence of the immediately exciting causes of the dis-
ease as will account for this actual difference.

Considering the causes in detail, it is, of course, apparent
to every observer, that, in adults, exposure to cold is the fre-
quent source of the disease, while scarlatina in the young is
the great producing source of the mischief. Even in child-
hood it is admitted that cold will occasionally, though very
rarely, produce tubal nephritis. Thus, of 61 cases under 12
years of age occurring in the Children's Hospital to which Dr.
Dickinson is attached, 50 were traceable to scarlatina, 2 to
measles, 3 to cold, 6 uncertain (page 65). Again (page 51),
Dr. D. refers to 43 fatal cases, but it is impossible to deter-
mine whether they are included in the above list, in which
the disease was traced to wet or cold in two. We have re-
cently had a very interesting case under our own care, in
which the most careful and varied investigation failed to
detect any thing more than exposure to a draft of air, while
the body was heated, as the exciting cause. The patient was
six years of age, in perfect health up to the beginning of the
dropsical symptoms, had measles when three years old, but lias
never had scarlatina. There was no eruption, no sore throat
preceding this attack, nor were there at any time any traces of
desquamation. Against all our teachings, impulses, and expe-
rience, we were compelled to admit that this case was one
in which the tubal nephritis was not preceded by any exan-
tliematous disease. The child made a good though slow
recovery, the treatment being hot baths of steam and water,
the salts of potassa, diluents, mild but continued counter-irri-

EEVIEWS.

tation over tlie kidneys, and, finally, the miiriated tinctnre of
iron in small doses.

The chapter on treatment is remarkably sound and in-
structive. We call attention only to one point, viz., the use
of distilled water, given very freely. While we most cor-
dially indorse this plan in practice, we are a little skeptical
as to Dr. D.'s explanation of the action of the remedy (for
remedy it is, as much as any drug, and vastly more reliable
than many we are taught to use) by a mere washing of the
accumulated cells thrown off from the lining epithelium of the
tubes. Is it not equally plausible to suppose that in some
way it modifies the changes of nutrition which are manifested
by this increased cell-growth ? Tlie use of antimony, which
Dr. D. disapproves of, and very justly, we call attention to
merely to say that in an epidemic of scarlet fever through which
we passed some years since, and when we had under our care
six or eight cases of consecutive albuminuria, we failed to pro-
duce any impression on the dropsical symptoms until we fell
back on the time-honored (?) remedy of antimony. It was
used with a view of acting on the skin only, and in very small
doses, the highest we gave being -^-^ of a grain. One case
proved fatal, from inflammatory complication of the respira-
tory organs. We might be induced to use this remedy again,
but we think we should first work -pretty faithfully with our
hot-air baths, digitalis, and distilled water.

We pass that section of the book devoted to the considera-
tion of the granular kidney, with reference to a single point
only. There is much difference of opinion as to the starting-
point of the degenerations found in this disease. Dr. George
Johnson being, perhaps, the chief advocate of the view that
the mischief begins in the epithelial cells of the tubes, and is
primarily a crumbling or disintegration of these cells. Dr.
Dickinson first advanced the view that the changes commence
in the intertubular fibrous structures, and that the epithelial
changes are no greater than is consistent with health. In the
very advanced cases the epithelium may sometimes be found
crowded together, as it were, and so altered somewhat in
shape, presenting more angular outlines than in health. The
presence of oil-globules in the cells is not more frequent than

EEVIEWS.

in the liealtliy kidney. This intertnbular contraction accounts
neatly for tlie formation of the cysts so frequent in the granu-
lar kidney, and the stringing together, end to end, of the
microscopic cysts points very plainly to the origin by constrict-
ing of the tubes. Altogether, we are of opinion that Dr. D.'s
views on this point will ultimately be acknowledged as correct.

Dr. D. holds sharply to the opinion that this form of dis-
ease, the small granular kidney of Bright, is not an advanced
stage of the large smooth kidney before described. The two
are entirely distinct. This opinion is generally shared in at
the present day -by the English pathologists, though the view
of Frericlis and Heinhardt, that the large white kidney will,
if the patient live long enough, eventually become red, granu-
lar, and contracted, is accepted by most Continental observers.
This view was adopted in Rosentein's recent work without dis-
cussion,^ as if there could be no room for question on this
point.

But the most novel and interesting part of Dr. D.'s book
is that wherein he takes up the study of the so-called " waxy "
or " amyloid," or, to use (under protest, however) the author's
own term, the " depurative " degeneration. As this subject
may still be considered siib judice^ we shall content om'selves
with giving a little more in detail the \dews of the author,
making use of his own words as far as possible, in order to
avoid any chance of misrepresenting those views.

The disease essentially consists of a general outpouring of
a certain material which differs from the proper constituents
of the body. This material can be distinguished by the action
of iodine upon it, producing a persistent and deep reddish-
brown color. As first observed, it is transparent and homo-
geneous, appearing in the walls of the small arteries and
gradually working its way into the surrounding tissues. This
deposit is not confined to the kidneys, but may affect the
liver, spleen, suprarenal capsules, lymj^hatic glands, the mucous
lining of the alimentary canal, etc. ; in sliort, almost any part
of the body to which bioocl-vessels are supplied, but the
changes resulting in the several organs are somewhat differ-
ent. It appears that the material is fibrine, which has been
deposited in this form in consequence of the loss of the alkali

^ See "Ivoberts on Urinary and Renal Diseases," p. 323.

EEYIEWS. 65

with which it is ordinarily combined, and which seems neces-
sary to hold it in solution. The residts of ultimate analysis
show the morbid deposit to agree in composition with fibrine
and albumen. That it is fibrine and not albumen is shown by
the facts that it has a strong tendency to undergo contraction
after its deposition, that it becomes converted into fibroid
tissue, a metamorphosis which is common with fibrine wlien-
ever it is deposited in small bulk, as a coagulum in the arach-
noid, or vegetations upon the valves of the heart, and, lastly,
that in certain cases it is identical in appearance and reaction,
as well as continuous in position, with the hyaline casts, which
are found in the renal tubes, the fibrinous nature of which it
is not possible to doubt.

The most striking characteristics of the fomiation are,
however, due to the absence of the free alkali. This defi-
ciency is not only proved by analysis, but, if we add potash or
soda to the diseased tissues, the characteristic reaction with
iodine is no longer obtained, and, furthermore, by artificially
depriving fibrine of its alkaline, we can produce a substance
identical in all its reactions with the amyloid or waxy mate-
rial. The material, then, which is poured out under certain
conditions, is dealkalized fibrine.

By far the most frequent condition which leads to the
separation of this material from the blood is protracted sup-
puration. The discharge must be copious and long continued,
and it is not connected necessarily with tubercle or any other
constitutional taint, or with disease of the bone. An analysis
of the table, which comprises all the cases that came under
Dr. D.'s observation, shows that five-sixths of his cases, taken
indiscriminately, were associated with the pm-ulent process,
and this connection is so frequent as to compel the belief that
they stand in the relation of cause and efiect.

Thus, of 66 cases under observation, there were 51 in
which there had been a positive history of protracted suppura-
tion, while five others gave presumptive evidence that sup-
puration had previously gone on. In four there had been
albuminuria, associated with some other form of kidney disease,
and six cases in which the causes could not be traced. All
the processes by which the blood is so altered as to contain
excess of fibrine with deficiency of alkali we cannot as yet
presume to be acquainted with, and it may be eventually
shown that there are diseases which act upon the blood so as

EEVIEWS.

to produce the same effect as a i^iirulent discharge and induce
the amyloid or depurative deposit, without the medium of a
suppuration.

This statement of Dr. Dickinson's views covers, we be-
lieve, pretty much the whole ground he has gone over, and
here we must leave it, for further observation is needed to
place the points in question beyond controversy.

One other chapter of Dr. D.'s book we must call attention
to, viz., that containing his views upon alcohol as a cause of
renal disease. There his opinion is quite counter to that
which usually obtains — at all events, in this country — on this
subject, and he claims that the use of alcoholic drinks is com-
paratively inoperative as causing disease of the kidneys. He
admits that the excessive use of such fluids may set up a renal
catarrh, although, compared with the other causes of tubal
disease, it is very infrequent. Again, certain liquors, by caus-
ing gout, may indirectly bring on granular degeneration, for
this we know is a frequent sequence of the gouty diathesis.
But alcohol, as a rule, attacks other structures in preference
to the kidneys.

The woodcuts and exquisitely-colored plates add much to
the beauty as well as the value of this volume, and we do not
remember to have anywhere seen more accurate illustrations
of the various diseased conditions of the kidneys. We again
commend the book as of unusual merit, and worthy of a care-
ful study by every physician.

Akt. hi. — The Anatomy and Histology of the Human Eye.
By A. Metz, M. D., Professor of Ophthalmology in Charity
Hospital Medical College, Cleveland, Ohio. 1868. Phila-
delphia, published at the office of the Medical and Surgi-
cal Hejporter. 8vo, pp. 181.
The author of this treatise states that he was induced to
write it because in teaching he " seriously felt the want of a
text-book on the anatomy and histology of the human eye.
There does not exist," he goes on to say, " to my knowledge, a
treatise on this subject that includes tlie results of the labors

EEVIEWS.

of the more recent liistologists to be found in oplitlialmological
journals and in memoirs on special subjects. It lias been my
aim to collect this material into a connected form, and in such
a manner as to adapt it alike to the requirements of the medi-
cal student and of the practising physician."

This statement bids us regard the book as a compilation,
and to judge it as it may or may not fulfil the duty of properly
presenting modern researches into the structure of the eye.
Two tables, viz., the list of illustrations and the list of authors
consulted, indicate that the author has not spared pains to
procure material. The illustrations are borrowed, and with
proper credit, from all the late text-books and memoirs, and
the list of authors includes almost, if not quite, every thing
which had appeared up to the date of publication. Krause
has since that time issued a paper on the retina, and Henle's
Handhuch der Anato?nie des Menschen^^ presents, in the
part w^iich appeared in 1866, a discussion of the anatomy of
the eye, which deserved mention and careful consultation.
Perhaps other treatises might be mentioned which are left out
of the author's list, but we are not disposed to find fault. We
are satisfied that the author made himself familiar with his
subject, and we are delighted to find so much good anatomy
in his pages.

We quote certain parts as samples — take the minute struc-
ture of the cornea. "Engelmann {Ueber die Hornhaut des
Auges^ Leipzig, 1867) says, that the cornea proper is composed
of the finest fibrillse, w^hich lie close to each other, and lying
between these are numerous cells and nerves. In the frog
these fibrils have a thickness of 0.0001 mm., and each one is
separated from its neighbor by an immeasurably small space,
filled with a fluid. These fibrillse are united into larger
lamellae, about 0.004 mm. in thickness, which are placed
into 15 to 20 layers concentric with the corneal surface. The
fibres of each layer run parallel wdth the corneal surface and
with each other. The fibres cross each other at an angle of
about 90° in two contiguous layers, resting on each other.
In some places the fibres run from one lamella into another.

" Between two contiguous layers are found, distributed at
equal distances apart, a large number of cells. These corneal

EEVIEWS.

cells consist of masses of protojplasma^ polygonal in form and
without nuclei {sic). They are vertical to the corneal surface
and flattened. In the centre of each mass is found a vesicular
nucleus, with a nucleolus. These masses that surround the
nuclei measure 0.02 mm., and have projecting from their
corners from six to twenty processes, which run in various
directions throughout the corneal substance. The majority
do not project beyond two contiguous lamellae ; some, how-
ever, pass through the layers at sharp angles. Some of these
processes terminate free in minute points ; others are con-
nected with neighboring cells. Each cell then is connected
with other cells in the same layer, and also with the cells of
the layers above and below, so that the whole corneal sub-
stance is connected by a penetrating net- work of this protein
material. Neither the cells nor processes have membranes,
but lie unenveloped within the inter-fibrillar spaces which
they completely fill."

In one sentence it will be remarked that the corneal cells
or corpuscles are said to be " without nuclei," and in the next
sentence we read that " in the centre of each mass is found a
vesicular nucleus with a nucleolus." This discrepancy must
be a lapsus^ and the last statement is what the author means
to put forth. The cornea has not yet revealed to us all its
histological secrets, and we must be thankful for the facts we
receive. The fibrillse which Engelmann finds have not been
seen by all observers, but we incline to believe in his view.
The remarkable ''^wandering cells^'' which Yon Reckling-
hausen first noticed, we believe, are duly mentioned, and how
they push their way among the fibrillse. The existence of
tubes or lymphatics is denied.

Of the crystalline lens, the minute anatomy is what
Becker has given us, and is the best we have. The origin of
the fibres from the marginal cells, and their termination on
the planes of the star, are better described than by any other
author. Mr. Hulke's labors on the structure of the capsule
are also quoted.

In the retina, the views of Hitter and Schultze are most
relied upon. We now know and were taught by H. Miiller
that connective tissue enters largely into the formation of this

EEYIEWS.

membrane. The problem is to identify the really nervous
elements and trace their connection with each other. Wheth-
er the retina contain six or nine layers is comparatively
unimportant, but to unravel the meshes of fibres which go
from the rods and cones, and trace them to the ganglion
cells, and finally to connect these with the optic nerve fibres,
is a most arduous task. It is interesting to compare the
various drawings which have been put forth as showing the
arrangement of the elements — to take the schemes in I^ysten's
dictionary and compare with the sketch as given by Hitter,
page 67, or rather Metz's diagram, to show Hitter's explana-
tion. The latter diagram is, of course, to some degree hypo-
thetical, but it brings out some facts now undisputed — that
the rods have an axial fibre, in which, at the base, is a gran-
ule, and the rod fibre runs into the mesh-work of the inter-
granular layer. The external granular layer differs in essen-
tial character from the inner granular, being composed of
ellipsoidal cells, each having three strisB, and round cells with
two striae. These granules are contained within the fibres of
Miiller. This term being applied by Hitter, not to the con-
nective tissue fibres, but to nerve fibres, which Miiller con-
founded with connective tissue, the two kinds of fibres being
inextricably mixed, and only lately distinguished from each
other.

The intergranular layer consists of the two kinds of
fibres, and then come the inner granules, which send off
processes, on the external side to the intergranular layer, on
the internal side to the fibrous layer. There they become
connected obscurely with the multipolar ganglion cells, and
with these the optic nerve fibres are distinctly seen to run.

Thus we gain some clearer notion of the complex relations
of the retinal nerve elements. Besides these, the connective
tissue remains, whose fibres are excessively minute and possess
nuclei, and spring from the membrana limitans interna. But
we cannot attempt a fuller description of the retina.

We have chosen those subjects which are confessedly the
most difficult, to test our author's skill. The whole book
deserves careful study, and will be found instructive and
satisfactory.

REVIEWS.

Art. IY. — Microscojpical Examinations of Bloody and Vege-
tations found in Variola^ VacG{7ia, and Typhoid Fever.
By J. H. Salisbury, M. D. ]^ew York ; Moorhead, Bond
& Co., Printers. 1868.
Any theory whicli j)roposes to trace to tangible causes
diseases of hitherto inexplicable origin, and to substitute for
indelinite " constitutional influences " physical changes and
parasitic organisms, ocularly demonstrable, cannot fail to
possess the greatest interest and fascination. For, beyond the
gratification of scientific enthusiasm, and the pleasure of an-
other assurance that medicine is rapidly advancing from
empiricism to exactness, its influence upon treatment, and
consequently upon the preservation of life, would be incal-
culable. We accordingly open Dr. Salisbury's book with
considerable eagerness, which is enhanced by the fact that the
author's name has been within a few years associated with a
large number of pathological discoveries, any one of which, if
established, would give it lasting fame.

In the first section, " On Blood Examinations," after stat-
ing the immense clinical experience from which his conclu-
sions are drawn, he enumerates about seventy points which
are a part of the things to be noticed in blood examinations.
The chief stress, however, is laid on tlie appearances presented
by the fibrine of freshly-drawn blood in the healthy and in
pathological states. The conditions of things in rheumatism,
pulmonary tuberculosis, and angemia, are illustrated by dia-
grams. In the former of these diseases the microscopical
appearances are not only peculiar and diagnostic, but ante-
date all symptoms, so that by timely examination of the blood
''the causes of the dreaded disease may be discovered and
removed before the patient is aware he is in danger,
thereby saving perhaps severe suffering and grave patho-
logical disturbance." We are unfortunately left in doubt as to
whether phthisis and anaemia can be with equal certaiuty
predicted and prevented. Xow, if we did not know that
medical writers are never betrayed into this fallacy, we should
really have supposed it a petitio pHncijni, to set down a per-
fectly sound man as a case of prevented rheumatism, simply

REVIEWS.

because his blood presented an appearance similar to that of a
patient known to be rheumatic. AVe should, on the contrary,
infer that the phenomena were in no way peculiar to the dis-
ease in question.

The second section, " The Blood Disk," contains experi-
ments to prove that the disk normally contains cholesterine,
which escapes along with the coloring matter, if the blood be
allowed to stand. In addition, four new cryptogams are de-
scribed, viz., Entophyticus hmmactus i Zymotosis regularis ;
Cryjpta ccwhuncnlata, which Dr. S. considers to be the cause
of carbuncles ; and Zymotosis escularis^ the characteristic
vegetable of an epidemic resembling remittent fever, which
prevailed last year among the horses in the vicinity of Cleve-
land.

The remaining sections are devoted to the cryptogams
which the author has found in variola and vaccina, and
in typhoid fever. He styles them respectively los variolosa
vacciola^ and Biolysis typlioides. The former, he claims,
presents two forms, a fungoid and an algoid. The fungoid
development is the cause of variola. If, however, the plant
finds a nidus in the tissues of the cow, it fails of its full de-
velopment, by reason of these tissues not being well adapted to
its growth. It there assumes an algoid condition, which pro-
duces vaccina, and cannot, when transferred to human tissues,
redevelop into the fungoid state. He assumes that the spores
of the same vegetable, if detected in fermenting substance,
would produce in the man variola and in the cow vaccina.
He illustrates his position by the similar conduct of the LejAo-
thrix huccalis and Sj)hcerotheca persica under analogous cir-
cumstances. Moreover, he deems it "highly probable that
very many of the minute entophytal algae are but special
phases of deA^elopment of parasitic mucedinous fungi." We
suspect that this surmise of the author's contains much truth ;
enough, perhaps, in connection with some other points of pre-
mature inference, to quite undermine his beautiful, but inse-
cure, pathological air-castle. The careful researches of some
foreign observers lead to the same conclusion, that organisms
hitherto esteemed distinct are but phases of the same thing.

Earnestly as we should welcome increased pathological

EEYIEWS.

knowledge, when we are asked to accept as fact tlie theory
that this or that cr}^)togam is the source of this or that dis-
ease, we have the right to require that the hypothesis shouL.l
have sustained at least the following tests : That different
experimenters should arrive at the same or similar conchisions
regarding the particular parasite at fault. That the parasite
should be found with a sufficient degree of constancy in con-
nection with the disease. That it should not exist in health,
or, if in health, under conditions sufficiently different to
account for the change in its effects, and that a perfectly
sound man should not be considered as diseased, simply for
the benefit of the hypothesis. That the fungi, etc., of differ-
ent diseases should be shown to be really distinct from one
another; and, finally, That the disease should be actually pro-
duced by inoculation of the parasite, due precaution being
taken that the disease should not be contracted in the ordi-
nary way. The hypothesis should satisfy at least these sources
of doubt before it can demand recognition. It does not ap-
pear, at least from the book before us, that any of these
requirements liave been complied with, unless we, perhaps,
may except the second.

Like the other essays which have recently been published
by the author, the book gives evidence of zeal, of hard work
with the microscope, combined with an eagerness and enthu-
siasm that hurry the author on to a theory faster than logic
will allow, or than the evidence, if he has given us all he pos-
sesses, will warrant.

The execution of the work, both in regard to press- work
and illustrations, is admirable.

BIBLIOGEAPHICAL AT^D LITEEAEY NOTES. 73

[Under this heading Ave purpose to set apart a portion of the Journal
for short notices and literary jottings of all sorts. We receive in the course
of the year a very large number of pamplilets, monographs, and small
books (many of them of great value), the notice of which, under the old
system of displayed titles and the use of large type, was simply impossible,
but, by adopting the plan of foot-note titles, with smaller type, we shall
save space enough to enable us to say something of these fugitive portions
of our literature.]

If we may place any faitli in tlie trutli of the old adage,
Udi virus ihi virtus^ we think that Cincinnati, at the present
writing, is entitled to the honor of holding two of the most im-
maculate of mortals, for we have rarely witnessed a more virn-
lent controversy than that jnst transpiring between Profs.
Blackman and Bartholow, of the aforesaid citv, and of which
controversy this little paper ^ is only a part. For the rest of the
story, like our friends of the Ledger^ we mnst refer to the col-
umns of the Medical RepertoTij. even at the risk of enormously
increasing the circulation thereof

How the trouble originated we know not, but this special
phase of the fight is a charge of literary larceny, by Prof.
Blackman against Prof. Bartholow, in that his essay on Loco-
motor Ataxy, published originally in the Cincinnati Jour-
nal of Medicine^ and subsequently reprinted as a monograph,
is nothing but a literal translation of Topinard's Prize Essay
presented to the Paris Academy of Medicine in 1861. Dr.
Bartholow acknowledged to having made a " liberal use " of
this essay, but Dr. Blackman thinks that it would require a
most extraordinary stretch of courtesy to entitle a literal trans-
lation to the scanty meed of only a " liberal use of another's
work. He (Dr. Blackman) gives us side by side long extracts
from Topinard and Bartholow, and, if these quotations be cor-

^ On Bartholow and Pro's "Liberal Use" of Prize Essays, or Prize Es-
saying made easy, and taught in a single Lesson. By George C. Black-
man, M. D., Prof, etc.

" When energizing objects men pursue,
The Lord knows what is writ by Lord knows who."

Cincinnati, Ohio, 18G8. Pamphlet, pp. 16.

74 BIBLIOGEAPHICAL Am) LITERARY I^OTES.

regt, there is much of truth in the charge brought against
Prof. Bartholow, and the case is really not far removed from
the celebrated one of Jose Pro, whose essay on stricture of the
urethra (which received the prize of the Societe de Chirurgie
of Paris in 1856) turned out to be only a literal translation of
Mr. (now Sir Henry) Thompson's well-known monograph on
that subject. This most " shameless and extensive " plagiarism
was, we believe, first shown up in this country by Dr. Atlee,
of Philadelphia.

We do not purpose to enter into the merits of the contro-
versy between the two belligerent professors, but we do most
earnestly enter our protest against the manner in which the
warfare is carried on. It is simply disgraceful to both parties,
and they alike deserve censure for forgetting the gentleman in
putting on the disputant ; and the severe terms in which their
course has been reproved by other journals (for the controversy
is not a mere private quarrel, but made public property) we
trust will incline them to more moderation.

" Pistols and coffee for two " are hinted at by one of our
contemporaries, but we fancy the valor of the combatants will
be expended and their ardor appeased with less unpleasantly
suggestive and sanguinary exploits. Between Hector and
Achilles,

" Ira fuit capitalis, ut ultima divideret mors ; "

but — the rest and the application we leave to our classical
readers.

]N"ew Books. — We have received from the publishers,
Messrs. Lindsay & Blakiston, too late for notice in this
number of the Journal, the first volume of Aitken's Practice
of Medicine. The exhaustion of the first edition within
twelve months speaks well for the character of the work, and
the estimate put upon it by the 'profession. It is, in our
opinion, the best body of practical medicine extant.

We have also, too late for review. Dr. Emmet's book on
Yesico-Yaginal Fistula, from the Messrs. Wm. Wood &; Co.,
of this city ; and Prof. H. K. Storer's work on Abortion, pub-
lished by Little, Brown & Co., of Boston.

BIBLIOGEAPHICAL AXD LITEEAET NOTES.

Among recent French publications we observe a work by
Ch. Renault, " On Syjphilis in the Fifteenth Century ^'^ and
Dr. L. Ancel's treatise on the " Kails in an Anatomical^
Physiological^ and Pathological LightP

Three books on Diseases of Children are announced — one
by Prof. Geo. T. Elliot, of this city, to be published by the
Messrs. Appleton. A second, by Prof. J. Lewis Smith, also
of Bellevue College, to be published by Henry C. Lea, of
Philadelphia. The third, by Thos. HiUier, M. D., of London,
has already made its appearance in a beautiful reprint by
Lindsay & Blakiston, of Philadelphia. TTe shall have a
review of this book in our next issue.

Dr. Grainger Stewart, of Edinburgh, who is already well
known by his valuable contributions to medical literature, is
engaged on a work on Brighfs Disease of the Kidney ^

Wunderlich's work on " Thermometry in Disease " has
appeared from the press of O. TTigand, at Leipzig.

Messrs. D. Appleton <fc Co. announce Dale's " Compen-
dium of Medicine^^ and Fenwick on the " Morhid States of
the Stomach and Duodenum^ and their Relations to other
Diseases.'^''

OBSTETRICS A^s^D DISEASES OF WOMEN.

1. — A case of DoiibU Uterus and Vagina [L'Evenement
Medicale, from the Monatschrift fiir Geburtskinde].

This case occurred under the observation of Dr. Rabe, of
Dresden.

Madelaine B., a peasant, twenty years of age, entered the
surgical department of the hospital of Dresden on account of
a vaginal discharge and some slight excoriations near the vul-
var orifice. Menstruation, which began at sixteen years, of
age, was always regular and sufficient. The external genitals
were natural, but there was no hymen. In introducing a specu-
lum of medium size, an obstacle was met with about a finger's
breadth from the entrance of the vagina. On pressing the in-
strmnent lightly against the obstacle, two funnel-shaped fossae
were seen through the opening of the speculum, separated from
each other by what appeared to be a vertical and prominent

EEPOETS OX PEOGEESS OF MEDICINE.

fold of mucous membrane. By merely separating the labia,
one might readily suppose that he was viewing a prolapse of
the anterior wall of the vagina, but such, however, is not the
case ; this mucous fold is the anterior border of a wall or par-
tition which separates the vagina into two lateral and equal
parts, a fact of which it is easy to convince one's self by intro-
ducing two fingers simultaneously. The two vaginal canals
are straight and provided at their entrance with a sort of a
mucous fold resembling a h^mien.

On the right side, as well as on the left, the exploring finger
reaches, at about a finger and a half's depth, a vaginal neck (of
the uterus), somewhat small, hard, and forming a prominent
23rojection ; on each side there is a transverse opening. The
vaginal portion of the right side is a little smaller than on
the left, and is directed rather against the wall, than in the
line of the entrance of the vagina : the anterior lij) of each of
the two necks is longer than the posterior. Between the two
exploring fingers, we readily feel the solid resisting wall, quite
down to the bottom of the vagina, and it is impossible to as-
certain the least communication between the two lateral halves
of the vagina. A sound (Simpson's) can be introduced into
the uterine orifice on the left side without difiiculty, but can-
not be introduced on the other side. The orifice of the right
side is so constricted, that it is impossible to determine whether
the uterus is double throughout. The patient shows no other
anomaly in the conformation of the other organs. According
to her own statement, coitus appeared never to have been per-
fectly and naturally performed.

2. — Cases of Ovariotomy , with some Remarlts upon the Opera-
tion. By Wm. Waeeen Greene, M. D., Prof, of Surgery
in the Medical School of Maine. [Boston Med. and Surg.
Jour., March, 1868.]
Dr. Greene has done ovariotomy eight times, and here

gives us a brief synopsis of each case :

Case I. Proved fatal on the third day, from hgemorrhage from
the pedicle. ]^o peritonitis ; tumor developed from right
ovary, weighed 40 lbs. ; adhesions to abdominal parietes,
stomach, and liver ; ligatures carried through posterior cul
de sac of vagina, passed out of the vagina and fastened to
thigh by adhesive plaster.

Case II. Tumor multilocular, adherent to abdominal walls,
intestines, stomach, and liver ; weight 38 lbs. ; j)edicle right
broad ligament ; ligatures disposed of as in Case I. ; abdom-
inal cavity washed out with artificial serum after Dr.
Peaslee's plan ; recovery slow but complete.

OBSTZTEICS AXD DISEASES OF TV03IEX.

Case III. Tumor multilocular, adherent finiilY to alxlominal
walls, intestines, and bladder ; pedicle left broad ligament,
treated with Storer's clamp shield, and ligatm-es, which
last were disposed of as in other cases ; external sutures car-
ried through the peritoneum; death on lifth day from
strangulation in act of vomiting ; tracheotomy ; body ex-
amined and no traces of peritonitis.

Case IT. Tumor multilocular, 58 lbs. ; recovery ; nothing
of special interest in the case.

Case Y. Tumor unilocular; weight not given, size small,
developed from right ovary ; slight peritonitis, controlled, as
in Case II., by injections into the abdominal cavity; re-
covery.

Case YI. Tumor multilocular ; weight 3i lbs. ; developed
from left ovary ; right also covered with little cysts, and
was removed ; recovery perfect.
This operation was done in October, 186 7, and February
20, 1868, the patient thus writes of herself: ''About the 15th
of December, I felt as if I was going to be unwell, and had a
slight colored discharge, lasting half a day. At the same time
in January I felt the same, and had again a bloody discharge,
but only a little, so it soiled my drawers. This month I have
had slight symptoms, but no discharge, and the symptoms
lasted only a day."

Case YII. Tumor multilocular ; weight 25 lbs. ; not stated
on which side developed ; mild peritonitis ; recovery perfect.

Case YIII. Multilocular cyst right ovary ; weight 20 lbs. ;
inner sm-face of wall of one cyst ulcerated ; peritonitis, prov-
ing fatal on thfrd day.
The operation was performed in the same manner in all

these cases. Dr. Greene's comments on the operation are so

judicious, that we quote them entii*e :

From a thorongh study of my own cases, and of those which I have
seen in the practice of others, with a somewhat careful examination of the
literature of ovariotomy, I am led to the following conclusions :

1. That, where the tumor is large, it is impossible to form any accurate
estimate of the extent or strength of adhesions that may exist, before re-
ducing the bulk by tapping, and even then extensive visceral adhesions
may be present which cannot positively be detected. It is not safe to
argue tlie absence of such attachments because the patient has not suftered
from marked symptoms of peritonitis, for the reason that such an inflam-
mation often occurs sufficient to produce very firm adhe?ions, and yet so
latent as to escape notice.

2. The existence of adhesions is no contra-indication for an operation,
but on the other hand, such cases, even when the bands are numerous and
strong, do the best as a rule. They sufl:er less sliock and are less hable to
peritonitis. The membranes seem, by the previous morbid action, to have

78 EEPOETS OK PEOGEESS OF MEDICIKE.

acquired a tolerance of sucli disturbing causes as would awaken inflamma-
tion in one that had never been diseased.

3. In preparing the patient, gi*eat care should be taken to secure a
healthy state of the secretions, and the system should be sufficiently im-
pressed with the muriated tincture of iron to insure plasticity of the blood.

4. The utmost gentleness and dehcacy should be observed in all ma-
nipulations by surgeon and assistants. Strange as it may seem, this most
important rule is too often violated, to my personal knowledge. There is
no excuse for unnecessary handling of parts by rough, dry, or cold hands,
or exposure to the air a moment after the operation is completed.

5. A most powerful prophylactic against shock and subsequent inflam-
mation is the free use of artificial serum (common salt 3 j., albumen 3j.,
pure water Oj.) at Mood heat. Keep the parts thoroughly and constantly
moist with it.

While I believe that this serum, acting as a mechanical protection to
the paj'ts, is in this way of great advantage, I still attach much more impor-
tance to the heat. A moment's reflection will convince any one, theoreti-
cally, that a delicate serous membrane suddenly exposed to the air, and its
temperature reduced twenty or thirty degrees, and maintained at that
point for any length of time, is much more liable to inflammation than one
which has been carefully kept at or very near its ordinary heat, and that
too by the application of a liquid almost precisely like its natural secretion ;
and my own cases of abdominal section aflford to me conclusive evidence
that this is true. In none of my cases has there been any thing like col-
lapse.

Nor is this application of heat to be restricted to this class of operations.
I have latterly discarded the use of cold water for sponging during any
operation which exposes a large raw surface. In large amputations, in
dissections for the removal of large tumors, especially about tlie neck and
trunk, I am thoroughly convinced that the shock is very much less, as also
the danger of inflammation, if hot water be used instead of cold. The
cases wliere haemorrhage requires the substitution of cold are so excep-
tional as not to invalidate the rule. I would much prefer multiplying liga-
tures to chilling the parts.

I prefer an elevated temperature of the room, but consider the moisture
of the atmosphere of little importance, comparatively.

6. The treatment of the pedicle in the cases reported seems to me more
reasonable than any other. The use of the clamp, for the fastening of the
pedicle in the external wound by any means is only applicable to long
pedicles, and even then, in case of peritonitis with much distension, is a
serious complication, as also in subsequent pregnancies. To this is to be
added the danger of intestinal strangulation. The same objections obtain
against Dr. Storer's recent proposal to pocket the pedicle with additional
ones in case primary union fails. The actual cautery is unreliable, and so
is the ecraseur, notwithstanding the few cases in which the latter has been
successfully used.

The cutting of the ligatures short and dropping the stump back into the
abdomen would of course be the plan, if safe. But in the first place the
immunity from sloughing is by no means established, and in very many if
not all the cases there must be, aside from any such process, a collection of
fluids, serous, sero-sanguinolent or purulent, more or less, which had much
better be readily discharged than left to the care of the absorbents. (I
know of one case that was reported cured by this operation, that died,
after all, of septicaemia.) In all my cases there was a vaginal discharge
from the first, usually slight and varying in character. By carrying the
ligatures down through the posterior cul de sac^ all danger from this

OBSTETEICS AND DISEASES OF TVOMErr.

source is obviated. The opening is made at the most dependent part of
the pelvic cavity where the fluids will naturally gravitate, and where they
will thus find a ready exit. The pedicle is more effectually secured by the
ligatures than by any other means, and if canied through the vagina they
produce no noticeable irritation, and after their work is done no foreign
body is left in the abdomen, and at the same time the external wound is
allowed to heal by first intention.

But another great value of the opening into the vagina is the facility
which it affords for washing out the abdominal cavity, to which procedure
I attach so much importance/

The after-treatment must be conducted upon general principles, and not
according to any fixed rules. I think the cases very rare where large
quantities of opium are required, or can be borne without harm.

Finally, the case must be a very peculiar and urgent one upon which I
would operate and leave the patient for after-treatment in the hands of
another person, except it be one who was expeneuced in the management
of such cases.

3. — Congenital Malformation of the Fallopian Txibes. By T.
Graingek Stewabt. [Jounial of Anatomy and Physiology,
May, 1868.]

In a patient who died of typhoid fever about the middle of May, 1867,
certain pecuhar morbid conditions of the i)elvic viscera were found. The
following description of the case is extracted from the Pathological Kegis-
ter of the Koyal Infirmary :

The pelvis was of natural size and foi-m. The Madder^ xagina^ and
rectum, were natural. The uterus was of natural size. The lower half of
the cervix was inclined backward and to the left ; but in the middle there
was a sudden bend, so that the upper half of the cervix and the whole of
the body of the organ was at an obtuse angle to the lower part, and was
so far inclined toward the right, that the fundus was considerably out of
the middle line. The cavity contained some reddish mucus. The walls
were natural. The right Fallopian title was connected with the uterus
in the usual way, and it presented a natural appearance for one inch and a
quarter from its commencement, but there it terminated abruptly in a cul
de sac, and a fibrous band of the same length as the tube stretched across
the space and connected it with the anterior wall of the rectum. The
left tube was also natural at its commencement; it extended along for three
inches; iu the first two it gradually expanded until, on being laid open, it
measured half an inch ; from that point it gradually narrowed, and ter-
minated iu a cul de sac, without trace of fimbriae, but with a number of
small cysts, mostly on slender stalks, which appeared to correspond to
fimbriae. Its outer third was connected by a firm but slender fibrous
membrane with the peritoneum covering the rectum. Both tubes con-
tained a reddish watery fluid. The left ovary was of natural size; on its
surface there were numerous cicatrices, both old and recent. It occupied
its natural position, but was partially concealed by fibrous adhesions. The

1 After trying several different metliods for passing the ligatures through the canal. I pre-
fer the following: Pass into the vagina a pair of common, uterine dressing forceps, Avith
the blades closed, and push their point upward in the cul de sac until, looking into the pel-
vic cavity, tlie surgeon sees the membranes stretched over them behind the uterus. While in
this position open the blades a little, pass a bistoury througli the septum between them,
close them, pass through the opening, seize the ligatures and drag them downward out
through the vagina.

I obtained the idea of thus disposing of the ligatures, as also of using artificial serum,
from Prof. E. K. Peaslee, of New York,

EEPOETS OX PROGEESS OF MEDICINE.

rigM otary was also natural in structure, but it was more completely con-
cealed by ad'.iesions, and by a group of cysts. On section both were found
to contain corpora lutea and Graafian vesicles. The cysts just mentioned
were situated to tbe right of the ovary, and somewhat behind it, quite
unconnected with it, but so closely connected with the hody of Eosen-
niuMer that it was evident that they had been formed by dilatation of some
of its tubes. Together they formed a mass of the size of a walnut. The
hody of Rosenmuller of the left side was natural. On the right side tbere
was a single group of small cysts on long pedicles (Hydatids of Morgagni).
There were numerous adhesions between its different peritoneal surfaces,
besides the two denser bands connecting the tubes with the rectum. The
most prominent Avere some which connected the fundus uteri with the
larger group of cysts, and some which deepened and narrowed Douglas's
space.

In this case it appears to me we have a congenital malformation of the
Eallopian tubes and a morbid development, in connection with the paro-
varium, as the original morbid conditions, while the numerous bands of
adhesions were results of the irritation of the ova which escaped from the
ovaries, and to them again the peculiar malposition of the uterus is refer-
able. In this view my friend and colleague. Dr. Matthews Duncan, con-
curs. The patient was a married woman, but was childless.

The only points which call for remark are the Fallopian tubes and the
position of the uterus.

I. The Fallopian tubes.

Klob mentions, in his excellent work on the morbid anatomy of the
female generative organs,^ that the congenital deficiencies of the tubes may
be reduced to three classes:

{a) Those in which the tubes are purely rudimentary, represented
either by traces of fibrous tissue or by bands of muscular substance.

(b) Those in which they are represented by a solid cord of fibrous
tissue.

{c) Those in which the development of the fimbrisB about the extremity
is defective.

It is evident that our case cannot be exactly referred to any of these
classes; and, so far as I am aware, it would appear to constitute a new
variety of malformation.

II. The peculiar flexion of the uterus.

Flexion more commonly occurs at the upper part of the cervix than at
the .middle, as in our case. Klob remarks 2 that in congenital lateral
flexions the position of the cervical portion remains natural, while in the
acquired it is inclined in a direction opposite to that of the body of the
organ. Our case confirms this statement, and shows that the same is true
in cases where the flexion is in the cervix, rather than between the cervix
and the body of the organ.

4. — Post-mortem Cmarean Section — Child sawed. By Peter
Brotherstox, F. K. C. S. E. [Edin. Med. Jour., April,
1868.]

This case is worthy of notice from the rarity of the occur-
rence, and from the fact that such prompt interference suc-
ceeded in saving one life, that of the child. Dr. B. was

^ Pathologische Anatomie der weiblichen sexual Organe. Wien, 1864.

Op. cit., p. ri.

OBSTETRICS A^D DISEASES OF WOMEX.

engaged to attend the ladv in lier confinement, and, recei^-ing
a linrried message to the effect that she had fallen in a lit,
from which she could not be aroused, he hastened to the honse
and found that she was already dead. The husband, being
assured of the death of his wife, readily assented to the prop-
osition of Dr. B. to open the abdomen, as offering a slight
chance of saying the child. The operation was at once per-
formed, another physician. Dr. Dickie, who had been sum-
moned at the time the patient had fallen, being present and
assisting. The child, a large healthy female, was extracted
with ease, but gaye no signs of life. Artificial respiration was
resorted to, and in about fifteen minutes the heart began to
beat, and the child gaye a conyulsiye sob or two. The surface
of the body being now quite cold, the child was plunged into
a hot bath, and cloths dipped in quite hot water were applied
to the head, artificial respiration being also perseyered in. In
about half an hour the child was struggling and crying, and in
perfect condition. At the date of the report, three months
after this occm-rence, the child was remarkably healthy and
robust.

An exan^iination of the parts of the mother showed that
there had been separation of the placenta for about two-thirds
of its surface, from the fundus of the uterus. This separation
had produced great haemorrhage, rupture of the membranes in
the vicinity of the placenta, and distension of the uterus. 'No
escape of blood vaginam and no sign of dilatation of the os.
Dr. D. estimates yery carefully the time Mrs. M. had been
dead before the operation was commenced, and places it at
twenty-three minutes.

5. — Case of Ccesarean Section — Mother and Child hoth saved.
By W. W. Greene, M. D. [Boston Med. and Surg. Jour.]

Mrs. B., aged 28 years, primipara, the subject of deformed
pelyis, resulting from rachitis during childhood ; the antero-
posterior diameter of the superior strait was less than two
inches. We deem it hardly necessary to giye our unqualified
approval of the procedure adopted in this case, but more espe-
cially do we consider that the early adoption of the operation,
without waiting for trials of forceps, or resort to the destruc-
tion of the child, to say nothing of the increasing danger to
the mother, was eminently sound and conseryative. In om'
estimation it was the only proper course to follow, and we
have not hesitated, in face of the recorded opinion of many of
the leading authorities in obstetrics, to advise this operation,
even with an antero-posterior diameter of two and a quarter
inches :

EEPOETS 01^ PEOGEESS OF MEDICmE.

Her pains were strong and frequent, and she began to exhibit marked
symptoms of exhaustion, to which her consciousness of peril contributed
not a little. The child was very active in utero. Upon explaining to her-
self and friends the probable impossibility of delivery per vaginam, and
that even were there a bare chance of success by evisceration, she would,
in her exhausted condition, incur greater risk from the operation under
such circumstances than from abdominal section, the latter operation was
assented to.

The case was so urgent as to admit of no delay, and w^e were therefore
obliged to proceed with less assistance than I could have desired.

The patient took a full dose of fluid extract of ergot with a little
brandy, after which ether was administered. When under its influence,
she was placed on a table, in the ordinary position for ovariotomy. I
now, standing at her right, and while the abdomen was carefully supported
on either side by assistants, with a common scalpel made an incision in
the median line frou) a little above the umbilicus nearly to the pubes,
w^hich was soon carried through the abdominal w^alls and the uterus
exposed. This organ was then incised from the fundus downward about
six inches, the knife being used very cautiously until the cavity was opened
and the liquor amnii evacuated. On carrying my right hand into the
uterus, I readily seized the feet (which were on the left side, it being a
vertex presentation), and with little delay extracted the body, but some
difficulty was experienced in delivering the head, occasioned by the power-
ful and unremitting uterine contractions, intensified, as I suppose, by the
ergot. This, however, was soon accomplished, and the little fellow — a
boy of eight pounds — cried lustily. Without waiting to sever the curd, an
assistant supporting the child, I again introduced the hand in search of the
placenta. This was attached on the left side, about midway between the
neck and fundus, and abo^^t one-third of it was detached. The remainder
was readily separated, but its extraction, which was soon accomplished,
with the membranes, was by no means an easy task. I had not antici-
pated so powerful muscular action in an organ thus mutilated.

There was considerable haemorrhage during the delivery, but not suffi-
cient to cause any serious apprehension, and it ceased at once upon the
removal of the placenta, the edges of the uterine wound being nicely
approximated by the conti-actions of tliat organ. Unquestionably the
ergot had fulfilled the indication for which it was given, namely, to con-
trol hfemorrhage and secure apposition of the cut edges by its action upon
the uterine muscular fibres.

After carefully cleansing the parts with sponges dipped in water at
blood-heat, and then thoroughly moistening them with artificial serum at
the same temperature, the external wound was closed by interrupted
sutures placed half an incii apart, and including the entire thickness of the
parietes except the peritoneum. These were of silk soaked in boiling wax,
as we had no silver wire at hand, a fact that caused me not a little anxiety
at the time, although I may say, not only from its use in this but in many
other instances, that smooth, well-twisted silk sutures, thus prepared,
api)roximate very closely in value to those of silver.

The abdomen, which had been unremittingly supported by the liands,
was now enveloped in a firm bandage, and the woman put in bed, well
covered, and dry heat applied to the extremities, which were rather cool.
They soon became w^^rm, however, and as soon as she could swallow she
got twenty-five drops of fluid extract of ergot and half a grain of morphia.
Alter the effect of the ether had passed away, the pulse was over 100 and
rather feeble. Countenance pale, with that peculiar expression which
indicates a marked shock. She was rather restless and walceful. iShe now

OBSTETEICS AND DISEASES OF WOMEN.

got morphia and brandy, with beef-juice, and from 6 p. m. till 3 a. m. she
took one grain of morphia and one quart of brandy. (This amount of
morphia in addition to the half grain which she took at five o'clock, just
after the operation.) Just after 8 a. m. she fell into a quiet sleep, which
lasted five hours, from which she awoke in excellent condition.

The treatment now instituted w^as perfect quiet; anodynes ^ro re natct^
ten drops of fiiiid extract of ergot and twenty-five drops of tincture of
muriate of iron every four hours, the two alternating — the former to be
omitted in forty-eight hours and the latter to be continued, if borne by the
stomach, until the external w^ound was healed.

The further history of the case contains nothing of special interest. The
external wound healed throughout by first intention. A moderate peri-
tonitis followed, but not suflScient at any time to require heroic doses of
opium. The iron wns well borne throughout, and the lochial discharge
occurred and continued as after an ordinary case of labor.

In a letter, dated August 30th (tenth day after the operation), Dr.
Emery says: "Have just returned from Oak Hill, and am happy to report
Mrs. B. in fine condition. I have removed the last stitch. There is very
little fulness or tenderness of the bowels." The mother and child are
now in excellent health.

6. — A Successful Case of Ccesarean Section. By Des. D'Aquin,

Medicine, July, 1868.]

This case is of peculiar interest on account of the condition
for wliicli the radical interference by abdominal section was
advised and undertaken. We are of opinion that the course
pursued was the proper one, though few at least of the older
obstetricians will agree with us there.

The following is Professor Brickell's account of the patient
when he first saw her in consultation with Dr. D'Aquin. She
had then been in labor about ten days, Dr. D'Aquin having
already been in attendance five days, and previously to this a
midwife had been with the patient for five days, during all of
which time the labor pains had been constant and severe :

Her condition, when I saw her at 2 p. m., was as follows : — Face ex-
pressive of great anxiety ; skin of dusky hue ; lips distinctly approaching
lividity ; tongue red, with a broken w^hite fur over the middle ; respiration
twenty-six; pulse one hundred and forty-three to the minute, of pretty
good volume, but losing force ; all uterine action ceased for fifteen hours
past. Examining jyer vaginam^ I found the vaginal secretion almost ar-
rested and the temperature of the parts much elevated. The lips of the
uterus were enormously swollen (probably three-quarters of an inch in
thickness), quite severely rent in three places, and were jutting promi-
nently into the summit of the vagina. They and the whole vaginal canal
were excessively sensitive, so much so as to cause loud complaints from the
patient, w^ho was certainly very courageous. The neck of the womb was
very long and admitted of the tolerably easy passage of two fingers, but a
third finger put the parts distinctly on the stretch, and, holding the three
in a line, and advancing them steadily, I could distinctly feel the tissues
of the neck breaking. Indeed, such was the friability of these parts, I am
sure that I could, by firm pressure, have broken down the tissue of the lips

[New Orleans Journal of

EEPOETS 0]S" PEOGEESS OF 3IEDICmE,

with my finger and thumb. The idea (listinctly conveyed to my mind
was, that the parts were on the verge of sloughing. The collapsed head
of a putrid child presented high above the unyieldhig neck, and a portion
of tlie scalp was lying in the vagina. The odor emitted was extremely
disagreeable.

In addition to all this, there existed a band across the posterior wall of
the vagina, alluded to by Dr. D'Aquin, and which appeared to me as an
extensive and strong cicatricial mass of semi-lunar shape, and very seri-
ously narrowing the canal.

My conviction was soon clear that the delivei-y of the woman per xias
naturales, would be a most difficult and tedious operation, and I promptly
recommended the Coesarean section on the following grounds :

1. No considerable part of the child could be drawn through the con-
stricted cervix uteri, now so friable, without laceration, the extent or di-
rection of which could not be controlled.

2. In consequence of the first proposition, the child would have to be
taken away piecemeal ; and the vaginal canal being dry, and of very
limited capacity, the opening into the uterus very Hmited, and the child
high up, this operation would be very tedious.

3. The excessively sensitive condition of the parts, and the necessarily
tedious nature of the operation would necessitate the use of chloroform,
and the prolonged administration of any anaesthetic would seem to be con-
traindicated by the rapidity of the circulation and respiration, together
"with the existing degree of carbonization, the result of greatly prolonged
labor.

4. The lips and neck of the uterus seemed already on the verge of
sloughing, and prolonged manipulation would hasten such result, and
would, in my opinion, endanger the woman very greatly.

These points wei'e urged in consultation, but some great fears of Csesa-
rean section being expressed, I proposed to try and demonstrate whether
any thing could at all readily be accomplished by instrumental means. I
first tried faithfully to apply a pair of delicately-made Hodge's obstetric
forceps to the head, but it was a failure, there being no adequate room for
the introduction and adaptation of the second blade. I then tried faith-
fully, during half an hour, to reduce the head piecemeal with Meigs's
craniotomy forceps, but there was so little room in the vagina and cervix
for both the hand and instrument, that the progress was lamentably slow.
To my mind the proposition was clear that many hours would be required
for piecemeal delivery, that an anjesthetic would be absolutely necessary,
and that the result of prolonged manipulation would be fearful.

The consent of the patient and her friends being obtained,
the operation of Csesarean section was performed in the usual
way. The points of interest in the operation were —

1. An almost entire absence of haemorrhage from the ab-
dominal incision.

2. Xo hgemorrhage consequent on stripping the placenta
from the surface of the uterus.

3. The failure of the uterus to contract after its contents
(the child had been dead some days) were removed ; of course
there was a free hgemorrhage from the incision through the
uterine walls, and to control this bleeding, silver sutures were
passed through the uterine walls — the ends being left about a
quarter of an inch in length, and folded smoothly down on the

OBSTETEICS AND DISEASES OF WOMEN.

uterine surface. Five montlis subsequently to the operation
no inconvenience in any way had been manifested by the
presence of the sutures in the abdomen. The mode of dressing
the external or abdominal incision is worthy of note, for we
believe that the accumulated weight of dressings often used is
only a hinderance to the prompt healing of the wound :

The surfaces of the abdominal wound were carefully sponged and
brought together with fine interrupted sutures of strong silver wire — tljc
same being phinged deeply through all the tissues, peritoneum inchided.
Above and below and between the sutures, broad adhesive strips were
placed, the same reaching across the abdomen ; at right angles and across
these four other strips were placed, one across the ends, and one on either
side of the wound ; and over this a light cotton bandage Avas placed to
support the abdominal walls, and the result was adhesion by the first in-
tention.

The original difficulty in this case is a matter of deep in-
terest. Dr. Briekell thinks it was rigidity of the soft parts,
which may have had its origin in some inflammatory action
previous to or soon after marriage. The existence of the
cicatricial band across the vagina lends credence to this view,
for we can readily imagine a cervicitis to have existed simul-
taneously with the vaginitis, and that the result was an im-
pairment or destruction of the dilating capacity of the lower
segment of the uterus.

7. — Absence of Urethra and Clitoris ; Incomplete Develop-
ment of the Nymphce and Labia ; Incontinence of Urine
in a Girl cet. 14. [Bull. Med. de I'Aisne, 1866— Gaz.
Med. de Paris, ISTo. 28, 1867.]

The only two parallel cases reported, it is believed, are by
J. L, Petit. !N"o mons veneris, no superior commissure, the
labia terminating in a depression, one centimetre and a half
wide upon the symphisis pubis, and continuous above with
the abdominal wall, the skin covering it being hairless, very
fine, resembling delicate cicatricial tissue, and lying directly
on the bone below. There are a few hairs on tlie labia, and a
few excoriations caused by contact of urine. Posterior com-
missure natural. The nymphs are rudimentary, hardly one
centimetre in length and breadth, about the middle of the
labia, and, anteriorly, on their inner face. JS^o trace of a
clitoris. 1^0 vestibule. Immediately under the symphisis
pubis there is a little briglit-red tumor, about the size of the
half a cherry, and very sensitive. Pressing upon it with the
finger, it yields, and the finger passes into a cavity, easily
explored, and the size of an egg, which is the bladder ; urine
immediately flows. The tumor is the mucous membrane of

86 EEPORTS Ol^ PROGEESS OF MEDICIKE.

the bladder, wliicli closes tlie entrance to the bladder, and
takes the place imperfectly of the sphincter, which is absent.

Petit thinks that the only means of avoiding the constant
dribbling of urine in such cases is a compress bandage.

8. — Hernia of the Ovary / Ojyeration / Death. [Lancet, June
20, 1868.]

Dr. Engliscb mentioned this case at the meeting of the Medical Society
of Vienna (April 3, 1868). The patient was thirty-two years old, had suf-
fered from a reducible tumor in the left groin for thirteen years, and pre-
sented, on admission into the hospital, all the symptoms of strangulated
hernia. As the taxis did not succeed, the usual operation was resorted to,
and, on opening the sac, the ovary and Fallopian tube were discovered,
but not a trace of intestine. The former were tied and removed. Twelve
days after the herniotomy tlie patient died of severe erysipelas and partial
peritonitis. At the next meeting. Dr. Weinlechner brought before the
notice of the society a woman of thirty-two, presenting ovarian hernia on
both sides. She had never actually menstruated, but at each period a raoli-
men was apparent, with swelling of the inguinal tumors. The vagina
ended above in a ceecal pouch, and absence or extremely small size of the
uterus was suspected. The patient was not deficient in sexual sensations.

DISEASES OF CHILDREN

1. — Congenital Imperforate Urethra in a Male Child. By
Dr. David Mtjreay. [Edin. Med. Jour., April, 1868.]

This class of malformations is very rare indeed. We have no cases re-
corded in which the urethra had been obstructed all through. The most
general form is that in which a sort of membrane covers and entirely oc-
cludes the passage. This structure may be either membranous or fibrous
in composition. It may vary both as regards extent and thickness. Some-
times it is so strong that it can only be overcome, if at all, by considerable
force; at other times it may be ruptured with the greatest ease. In regard
to its position, it may be situated at any part of the canal.

1. The most common situation is that immediately ovei' the external
orifice.

2. The second is that situated toward the vesical orifice. The catheter
may be introduced a certain distance, but cannot be passed into the blad-
der.

3. The third locality is immediately behind the bulb, about an inch
from tlie orifice. This form is very rare.

In regard to symptoms, the complete retention of urine is sufiicient to
indicate the necessity for prompt interference. This may vary. In those
cases where the obstruction is merely oiificial, an incision with a sliarp-
pointed bistoury, and the introduction of a small bougie or catheter occa-
sionally, if there is any risk of adhesion, is all that is necessary. When the
obstrnction is situated farther down the canal, a probe-pointed bougie may
be pushed through the obstruction, or, if this is not possible, the urethra
must be opened by an incision in the perineum, or the bladder niust be
penetrated.

DISEASES OF CHILDEEN.

T!ie case illustrating this class of obstructions occurred in mj own
practice, and is as follows : A. A, was born on the 2d day of November at
10 A. M. At birth nothing abnormal presented itself on a superficial view.
On calling, however, some twenty-four hours afterward, I was informed by
tlie nurse that the child had passed no water. On proceeding to examine, I
found that the penis and scrotum were well forined, but I could not dis-
cover any external opening, (considering that it belonged to the first class
of cases, those with a membranous obstruction over the orifice, with a
sharp-pointed bistoury I made an incision, after which I endeavored to
pass a catheter with considerable force. On that occasion, however, I
failed to pass it. On calling a few hours afterward, I was informed that
the child was still unrelieved, and was suffering much. Under the?e cir-
cumstances, it was thought advisable to call in the aid of Mr. Annandale.
That gentleman succeeded in passing a probe-pointed bistoury about an
inch, when he experienced a strong obstruction, which quite occluded the
canal at that point. On calling next day, about fifty-eight hours after
birth, and finding the child in much the same state, he reintroduced the
bougie, and with considerable force broke through the obstruction, but still
failed in passing the catheter. On calhng in tlie evening, however, the
nurse informed me that the child had passed its water freely in a full stream,
and, what could hardly have been expected, without any pain. Since then
every thing has gone on favorably, no further steps being taken. In this
case there can be no doubt that the principal obstruction was caused by a
band drawn across the urethra about an inch from the orifice, though the
two edges of the glans seemed to be glued together by some glutinous sub-
stance.

On inquiry, the child's father told me that he had suffered from a simi-
lar obstruction when young. I failed to get any details on the matter; he
states, however, that his mother, who resides in Aberdeen, told him that
he was operated on when young; that a tube or probe, as he calls it, was
introduced, and that he continued to wear it till he was about sixteen years
of age. During all that period he was seldom free from pain or annoyance
of some kind.

2. — A Case of Diabetes in an Infant. — By Jas. S. Bro^^^^,
M. D. [American Journal of Obstetrics, May, 1868.]
Diabetes in infancy is so extremely rare, tliat we cleem this
case worthy of careful note :

The subject of the disease was a little girl, who was horn of healthy
parents, and was herself remarkably healthy until about the twentieth
month of her age. She was weaned when about a yenr old, and from that
time was fed almost entirely upon farinaceous food. Her appearance was
that of a child in typical health, and she was always considered to be very
strong and robust. She had never suffered from any of the usual diseases
of childhood, sncli as measles, scarlatina, whooping-cough, etc., and had
never sustained any injury from falling or in any other way. 'When about
twenty months old her mother first noticed that she appeared to pass more
water than usual, especially at niglit, and that she drank a great deal ; but
as her health seemed to be perfect in every other respect, this did not at-
tract any particular attention.

It was not until five or six weeks after this time that her health seemed
to be perceptibly deteriorating, and that my attention was first called to
her. She was not even now ill^ and would hardly be said to be ailing.
Her appetite was less hearty than usual, but still good ; she drank a great

EEPOETS ON PROGEESS OF MEDICINE.

deal, and passed considerable r.rine; there was some iinpairnient of her
strength, and perhaps a very slight loss of flesh. Slje had no febrile attacks,
and in fact no other symptoms than those just mentioned. She would run
about and play pretty much as usual, but would grow tired sooner, and
waut to lie down and rest. On hearing the mother's statement, and ex-
amining tlie child at this time, I did not consider the ailment to be one of
any moment, and as the little patient was a relative of my own, I simply
proposed to watch the aflection until it should develop into something bet-
ter pronounced, or, as I rather anticipated, disappear as gradually as it had
come. I should here state that the symptom which was really the most
significant in the case, was mentioned only casually, and with reference to
what was supposed to be merely an incontinence of urine. The child used
to wet the bed every night, and wet it i^ery miicli^ and it was only in this
connection that any mention was made of the diuresis.

It was about a week or ten days after this that the mother's attention
was attracted to some white spots on the carpet, where a few drops of the
child's urine had chanced to fall, and impelled by some feeling of curiosity
she wet her finger, touched it to one of the spots, and tasting it, found it
to be sweet. This circumstance was at once communicated to me, and led
to an immediate examination of the urine, which was found to be of high
specific gravity and very saccharine. In the mean time the deterioi-ation
in the child's health had been progressive, and was now more distinctly
marked.

The appetite still continued to be good, but there was a more percepti-
ble loss of flesh, and a more obvious diminution in strength. The temper,
too, began to be fretful and peevish, and the child was evidently out of
healtli, though not appearing to be siclc. About this time an erythematous
eruption began to make its appearance on the buttocks and around the vulva,
and subsequently became a soui-ce of much discoHifort. There was also a
peculiar foetor of the breath not unlike the odor of chloroform, which became
stronger as the disease progressed, and was one of the most marked features
of the case. The child was still well enough and strong enough, however, to
run about and to engage in its usual amusements, but with much less than its
usual ardor. Her cheeks were still full of color, and her figure tolerably
plump, and she yet retained the appearance of quite a healthy child. In
three weeks more she was dead. There was a progressive loss of strength,
a rapidly increasing emaciation, a gradual failure of the appetite, occasional
febrile attacks of a few hours' duration, and death from simple exhaustion.
There was no cough, no diarrhoea, no symptom of cerebral disorder, and
in fine, no complication Avhatever. She was confined to her bed only four
days, and just a week before her death went out with her mother and
walked a couple of blocks. The amount of urine passed during the last
three weeks of her life averaged about five pints per day. Its specific
gravity ranged from 1030 to 103G, and it never contained albumen at any
time.

It is difficult to estimate the duration of a disease, of which the inva-
sion is so insidious; in this case the child lived about four weeks from the
time that I was first consulted about her, and about ten weeks after her
mother first noticed that she was passing more water than usual.

A post-mortem examination of the body was made by Dr. Jacobi, who
saw the child about two weeks before her death. He found the brain
large and well developed, having numerous and deep convolutions. That
part of the arachnoid covering the anterior two-thirds of the hemispheres
was not perfectly transparent, and there was considerable injection of the
dura mater, and in fact of nearly the whole enceplialon. There was some
thickening of the arachnoid in the fissure of Sylvius, and a few granula-

DISEASES OF CHILDREN.

tions having the appearance of very recent niihary tubercles. The ven-
tricles contained very httle flnid, and were entirely normal. The choroid
plexus contained hundreds of miliary tubercles. On tirst inspection the
lungs presented nothing abnormal, but a closer examination discovered a
number of little dots, just visible, which were evidently newly-formed
tubercle. The spleen was found studded with miliary tubercles, their num-
ber and development being much greater here than in any other part of the
body.

Nothing abnormal was found in the liver or kidneys, except that the
right kidney was somewhat larger than the left, and that the cortical sub-
stance of the left was more congested than that of the right. These
were the only lesions found, and being all of recent origin and obviously
secondary to the diabetes, the results of the autopsy, so far as the primary
disease was concerned, were entirely negative. In a disease of which the
pathology is so obscure, any circumstance that bears even remotely upon
it may prove of importance. As already stated, the diet of this child from
the time that she was weaned, consisted almost exclusively of food abound-
ing in starch ; she appeared to thrive so well upon it, and showed such a
marked preference for it, that but little else was given her.

3. — Pohjims of the Bladder in a Child tv:enty-tico months old.
[Ediii. Med. Jour., June, 1868.]

The following is a brief abstract of a case of great rarity which lately
occurred in the practice of M. Guersant :

The child was under the care of Dr. Penochaud, of Boulogne. It
seemed otherwise in good health, suffering only from difficult urination
with prolonged efforts. These symptoms were aggravated by an attack
of diarrhoea, which first induced the mother to seek medical aid. On be-
ing sounded, a fleshy mass was found in the bladder, and a small tumor
hke a nut was seen to project into the urethra during tiie cliild's efforts
to make water. The diagnosis of fleshy tumor of the bladder was made,
and the child was sent to Paris to be under M. Guersant. The fleshy
tumor at the urethra, the straining, and the absence of calculus, were then
made clearly out; soothing external applications were recommended, and
M. Demarquay was called into consultation. During four or five days, all
the symptoms were aggravated. The child became feverish, the eflbrts at
expulsion became more vigorous and frequent, so that the child's mother
compared them to the pangs of labor, repeated every five minutes. The
projection of the fleshy mass increased, and its surface appeared as if about
to slough, being evidently strangulated. The vulva became inflamed; the
urine, when drawn off, was muddy and fetid. It was obvious tluit some-
thing must be done to save the life and mitigate the sufferings of the poor
little child ; yet it was obvious that any interference would be dangerous.

The child was antesthetized with great ease by a mixture of equal parts
of chloroform and ether, and was placed on a table in lithotomy position.
The tumor being seized and drawn forward by Demarquay, M. Guersant
passed a metallic thread as far as possible round the neck of it, after gaining
access by dividing the urethra by the scissors. The thread was gradually
and slowly tightened by a serre-nmid, but broke before the tumor was
separated, so the operation had to be flnished by the ecraseur. The tumor
was very vascular, and under the microscope was found to be composed of
connective tissue, with numerous cells and nuclei. There was little bleed-
ing at the time.

Xext day the urine was bloody; there was no more effort at expulsion,
as it came away easily, but gave pain in its passage. The child gradually

REPORTS PEOaRESS OF JHEDICmE.

lost strength ; and thougli the bladder symptoms improved, the soft parts
became inflamed ; there was sloughing. It had diarrhoea, refused its food,
and died exhausted on the eighth day. Xo post-mortera examination was
obtained. — Gazette des Hopitaux^ Xo. 23, 1868.

4. — Strangulated Inguinal Hernia in an Infant seven months
old. [Ecliu. Med. Jour., Julj, 1868.]

The chikl was otherwise healthy and well developed. Two months
before admission to the hospital Saint Antoine, the mother had noticed a
small tumor in the right labium. This had been often reduced, and as often
reproduced, but never was larger than a filbert. The child had never worn
a bandage.

On the 28tli January, 1868, the tumor returned, and the mother was
unable to reduce it. No stools had been passed during the preceding night.
Vomiting came on, and unsuccessful attempts at reduction were made by
various medical men. Next day the child was brought to Saint Antoine,
but was not seen till the afternoon, when another unsuccessful attempt at
reduction was made. At 9 p. m. it was chloroformed, and a third attempt
at reduction made, still without success. The child was now very weak,
with small rapid pulse, and the characteristic fades abdominalis. No
stool. Vomiting constant and foecal. A rounded hard tumor existed in
the right labium. M. Panas was then sent for, who operated just before
midnight. The sac was exposed, of a reddish-brown color, and evidently
contained a loop of intestine, and a hard body. On being opened, it was
found to contain a fold of intestine about three inches in length, and the
Fallopian tube, ovary, and broad ligament of the right side. The constric-
tion was in the external inguinal ring, not in the neck of the sac. The
child was dismissed cured in a fortnight, but eventually died of diarrhoea.

• 5. — A Case of Hcematnria in a Kew-horn Infant. By J.
D. Smith, M. D. [I^fashville Jour, of Med. and Surg.,
June, 1868.]

This case, from its rarity, is deserving notice. A male in-
fant, large, well developed, and apparently healtliy, forty-five
hours after birth, while suffering much as does a child with
colic, passed about half an ounce of blood, from the urethra.
The haemorrhage recurred five times within twelve hours. At
the end of this time Dr. S. saw the case, and gave one drop of
tinct. ferri muriatis every hour, and continued the use of an
infusion of water-melon seeds, which had been adopted as a do-
mestic remedy. The haemorrhage recurred again twice within
the next twenty-four hours, wlien there was a copious flow of
urine, the first since the haemorrhage commenced.

The discharge of blood now gradually checked up, passing only in suf-
ficient quantity to color the urine, which in two days more was entirely
clear. The whole quantity of blood lost, Dr. S. thought, could not have
been less than four or five ounces, the father thinks much more. The
child took the breast freely during the entire attack, except when in pain
just before the passage of blood from urethra. The pulse remained very
weak and the child anccraic during the attack and for some days afterward,
but there were no other abnormal signs to be discovered.

THEOEY A:N"D PEACTICE.

K"ow, whence the source and what was the canse of the hfemorrhage?
It miijlit he said that if it had been from the kidneys it would have been
mixed with urine. But, little or no urine passed during the time, and
when the kidneys acted freely the haemorrhage measurably ceased, which
arrest of function is an indication that the kidneys were in a state of con-
gestion. Could it have been the result of unnary calcuhis formed in the
kidney during intra-uterine existence? If so, why has there not been
further evidence of such a formation ? Could it have been the result of the
haemorrhagic diathesis ? If so, would the blood have coagulated so rapidly ?
The mother, and the midwife who attended the case, both stated that it
could not have been from mechanical injury, for the child had received no
shock or concussion whatever.

6. — The Pathology and Treatment of Croup. B}^ A. Jacobi^
M. D. [Amer. Jour, of Obstetrics, May, 1868.]

Xo summaiy can do justice to this paper. It is a most in-
structive and carefully -prepared monograph, and especially
brings forward iu a forcible manner the arguments in favor of
tracheotomy in croup, for which Dr. J. is a strenuous advocate,
having operated sixty -seven times on children suffering with
this disease. Of the sixty-seven cases thirteen recovered, a
percentage of about nineteen and a half. Dr. Yoss of this
city has operated forty -three times, with ten recoveries ; and
Dr. Ivrackowitzer fifty times, with eighteen recoveries. The
late Dr. Waldeman von Roth, one of the first advocates in
this city for tracheotomy in croup, operated on forty-eight
cases with eleven recoveries. These cases, almost all occurring
in this city, show that even when there is a most positive cer-
tainty of a fatal result if the disease be left to run its course,
tracheotomy affords hope for relief in a considerable degree,
about twenty per cent, of the cases proving successful. And,
perhaps, were the operation earlier resorted to, a still more
iavorable record might be made. We regret that the great
length of Dr. J.'s paper will not allow us to transfer it to our
columns.

THEOEY AND PRACTICE.

1. — Case of true Polypus of the left Auricle of the Heai't.
By Dr. Douglas. [Edin. Med. Jour., April, 1868 ]

Cases of morbid growths in the interior of the heart are
very rare. Andral,' Cruvelhier,- and Dr. Bright," record each
one, and Dr. Douglas's case is of sufficient interest to war-

^ Anat. Pathologique, edit. 1829, vol. ii. ^ Do., liv. xxix.

^ Med.-Cliir. Trans., vol. xxii.

EEPOPvTS OX PE0GEE5S OF ^lEDICIXE.

rant quoting it. The patient was 35 years of age, of large
frame, and extraordinary physical power, ar-cnstomed to a
most active life ; in easy circumstances, temperate, but a large
eater. TThen first seen hy Dr. D., on the 2Sth of December,
186 7, he presented the following symptoms :

His breathing was laborious and jjantinir, and be bad an incessant, most
harassing dry cough. He made no compbnnt of pain, onlv of the exces-
sive breatblessness and increasing Aveakness. His surface presented a
uniform faint strau'-color, and his expression was anxious and dejected,
though there appeared to linger the aspect of ruddy health which he bad
formerly enjoyed. The pulse varied in frequency — about 120 in tbe
minute — and it was small and soft, but regular. Urine acid, diminished
in quantity, and bigb colored.

The impulse of the heart wanted distinctness, bad no heaving or force
of action; but it bad, especially to tbe ear, an apparent diflfused-jess and
strength, or irritability, which contrasted with the weak and small pulse
at the wrist. The exact situation of the apex cordis could not be well de-
fined. The space, dull on percussion, was scarcely extended — no dubiess
existed on the upper part of the sternum, nor to its right side. Tbe action
of tbe bt^art was regular.

The sounds of the heart were not well pronounced — tbe Jirst bad lost
its fulness; the second had acquired a degree of sharpness, so that the two
were assimilated in their "clang.'' They bad a greater loudness than tbe
state of the impulse led me to expect; they were free of murmur.

There was nothing in the state of percussion or of the sounds of respi-
ration to indicate any lesion of the lungs. There was progressive increase
of distress during the first week of January, with increasing cough and
dyspnoea, excessive sleeplessness, alarming and singularly vivid dreams,
overpowering feebleness, nausea, inability to take food, and occasional
paroxysms of excruciating, tearing, substernal pain. He suffered great
distress on lying down, and dreaded the nights: tbe little sleep he bad
was obtained in an arm-chair, sitting and leaning forward. His pulse rose
to 150, and was rarely under 120 in tbe minute— always small, but never
irregular.

Up to the time of his death, on the 2Sth of January, 1868,
he suffered from recurring attacks of dyspnoea, at times very
severe and painful, and occasionally attended witli semi-con-
vulsive seizures, leaving him in a state bordering on syncope.
(Edema of the legs commenced a few days before death, and
extended with great rapidity to anasarca.

Sectio Cadateris. — Fifty hours after death. Decomposition bad com-
menced. The bulk of the body and the volume of flesh were great. Tbe
only organs examined were tlie lungs and heart, and tbe liver and kidneys.

The lungs were in a normal condition. The heart was flabby, bulky,
and very slightly dilated. Its cavities contained well-coagulated blood.
Tbe right side presented no special abnormality.

On opening tbe left ventricle, tbe rounded nodulated extremity of a
tumor, to be described presently, was seen projecting through the mitral
orifice. On opening tbe left auricle, a tumor was found growing from its
posterior wall of such bulk as seemed nearly to fill the cavity of the auricle,
and banging downward, its point projecting into tbe left ventricle. The

THEORY A^^D PRACTICE.

tumor was 4|- inches long, 2| broad, and 1^ deep at its deepest part. Its
superficial and dependent part was coated with some layers of coagulated
fibrine. and it presented nodules of a translucent appearance; but its base
was organically connected with the auricular wall, and was dense in struc-
ture. On the outer side of the auricle, opposite the point where the tumor
had its attachment, there were small outgrowths of a structure identical
with that of the tumor itself. There was no coagulnm in the auricular
appendage, nor between the bands of the columnce carneae. The pul-
monary veins were open ; and the valves of the heart were healthy. The
aorta was slightly dilated in its ascending portion, and just above it pre-
sented an insignificant narrowing, with a small cicatrix at the part.

Microscopic Examination of the Tumor. — The tissue, at its base, was
rich in cells, many of them free, many of them resembling connective tissue
bodies with long processes projecting from them. Many had prominent
nuclei, but none presented the characters of typical cancer-cells. In some
parts the cells contained fat granules, and the intercellular structure, which
was mainly fibrous, was studded with similar elements. The muscular fibre
of the auricular wall was altered, containing elements similar to those found
in the mass of the tumor.

The liver was enlarged, reaching shghtly below the margin of the ribs.
It was intensely congested, and its cells contained fat granules and coloring
matter of the bile. The gall-bladder and ducts were much distended with
a dnrk-colored bile.

The kidneys were healthy.

Dr. D. appends to the case an elaborate discussion of the
symptoms presented in this case, and, comparing them with
those observed in the other cases referred to, suggests that the
following summary of signs may afford us seme indication of
the character of a case, and yet the records are too few to give
any positive certainty as to the clinical phenomena to be ob-
served :

1. Rapid development of the symptoms.

2. A previously robust state of health.

3. Dyspnoea, in the absence of signs of pulmonary obstruction.

4. Persistent hurry of the circulation, with regularity.

5. Reflex nervous irritation, with a quasi hysteric breathing; parox-
ysmal cough without expectoration ; retching, serai-convulsive attacks,
and tearing substernal pain.

6. Delayed obstruction of the circulation of the lungs^ the hidneys., and
the liter.

7. Anasarca delayed, but rapidly developed.

8. Pulse small and regular.

9. Contrast of a more marked cardiac impulse than radial pulse.

10. Absence of cardiac murmur.

11. Assimilation in the "clang" of the heart's sounds.

2. — Biliary Calculi discharged through an Abscess opening
in Abdominal Walls externally. By E. W. Boyles, M. D.
[Chicago J\[ed. Jour., Aug. 1, 1868.]

Called, June 6, 1867, to see Mrs. AY. ; aged 50 years; nervo-bilious tem-
perament. Found her suflfering intense pain in right hypochondriac region ;
nausea and vomiting ; pulse quick and feeble; bowels constipated ; urine light-

EEPOETS 01^ PEOGRESS OF MEDICmE.

colored. Upon examination found considerable enlargement and tenderness
in right hypocliondrium^ extending into the umbilical and right lumbar re-
gions. In fact, most all of the symptoms characteristic of acute hepatitis.
Owing to the suddenness of the attack and the paroxysmal cliaracter of
the pain, I was led to suspect the presence of gallstones. Stated my opinion
accordingly, and subsequently ordered the dejections examined therefor,
but none were found. I gave opiates, and ordered fomentation. Called
again next day and found my patient much relieved. She got up in a few
day's and attended her usual household duties, but tenderness and enlarge-
ment of the liver still remained to a considerable degree. I put her upon
the use of nitro-rauriatic acid — could not use mercurials, owing to the
great susceptibility of the system thereto.

In September she was again confined to her bed for a few days with an
attack similar to the first, though not so severe; after which she resumed
her household duties. Treatment continued, together with various local
remedies, such as iodine ointment, pustulation, blistering, etc.

January 4, 1868, I was again called to see her. Tumor in the side
larger, and more circumscribed, I became convinced that an abscess was
forming, and used means to hasten the process of suppuration, fomenta-
tions, and poultices, but the tumor remained hard — no fluctuation. I began
to fear scirrhus; patient considerably emaciated and weak, but no appear-
ance of jaundice. Digestion remarkably good, and. plenty of bile in the
stool.

The last of February tumor began to point at the upper border of right
lumbar, near the line of the umbilical region. March 1st, discharging
shghtly through two small sinuses about one and a half inches apart, which
openings I enlarged with the lancet, after which discharged freely a fluid
about the consistency and appearance of glycerine, which continued, pro-
ducing great prostration; gave supporting remedies freely, in which iron
predominated.

May 2d I was sent for again. Patient said to be sulFering a great deal
of pain ; discharges from the abscess ceased, bulging between the openings
— thought it must be lanced again. 1 was not at home at the time, and
did not call until next day, when I found four gallstones had been dis-
charged through the inferior opening, the first one being as large as a
bird's egg, irregular in shape, weighing grs. xvij ; the others about one-
half the size and pyramidal in shape, with smooth, bright surfaces. Upon
manipulation, four others were discharged while I was there. Others
were discharged from day to day, until one hundred and six had come
away, weighing, in the aggregate, two hundred and fifty grains. Most all
of them pyramidal in shape, with smooth, bright surfaces. What seemed
strange to me, there was no appearance of bile in the discharges from the
abscess until May 20th, and then for a few hours only, and twice since that
thue, and at each there was more pain and gastric disturbance.

The upper opening has entirely closed, and the discharge from the
other gradually growing less. The patient is rapidly improving, with
every prospect of complete recovery ; was at my house to-day (June 25,
18G8) visiting, having rode two miles in a spring-wagon.

MISCELLANEOUS Al^D SCIEOTIFIC Is^OTES.

To orii Eeadees. — After eighteen months' appearance in an antique
dress, we come back to modern type, a change which w^e believe will be
satisfactory to at least the majority of our readers. The use of smaller
sizes of type for all matter of the Journal, except the "Original Com-
munications," gives us a very large additional space, and affords us an
opportunity for incorporating into the Journal material that, under the old
management, we were compelled constantly to throw out. The amount
of reading matter thus gained is equivalent to about thirty pages of the
old Journal. In addition to this, we have enlarged the Journal, by adding
another "form," an improvement which we think will be received with
favor.

With this increase in the capacity of the Journal, we shall be enabled to
give it a more varied and practical character, and for this purpose we
respectfully sohcit from our subscribers reports of cases, items of medical
news, and short practical papers. Prompt acknowledgment of the same
■will be made.

On behalf of our publishers, we ask a little forbearance in the adjust-
ment of the perplexing entanglement of accounts which has resulted from
the former business management of the Journal. When once these ac-
counts are made correct, we pledge ourselves that our subscribers wiU
have no further cause of complaint, and, by way of enabhng the publishers
to adjust their subscriptions, we respectfully request attention to the fol-
lowing points :

Should there be any error in the bill for subscription, please return it,
with a copy of your last receipt from the former publishers, and the proper
corrections will be made. Inform, us promptly of any change in address,
or failure to receive the Journal in time.

Strength of Cakbolio Acid SoLrTioNS. — In view of tlie
fact that carbolic acid is now largely in use in medicine, with
a probability that its range of application will be increased, it
is well for prescribers to be very careful of the particular prep-
aration they employ. Instances are reported where much
damage has been done by the external application of this sub-
stance in solution, the prescriber not knowing the exact strength
of the solution, and we ourselves have seen carbolic acid ordered
from the apothecaries, in such a way as to evince plainly the
fact of a most blissful ignorance of whether the medicine was
a solid or a fluid, or in what proportions it was proper to use.
Dr. W. T. Channing, of Providence, reports to the Boston

96 MISCELLANEOUS AIS^D SCIENTIFIC NOTES.

Journal of Chemistry several cases of serious results, from the
use of the concentrated fluid acid, which is dispensed by some
under the name of "solution carbolic acid," when the prescri-
bers intended only a milder solution, which they had been in
the habit of using, but had obtained it from other druggists.
Until, therefore, some distinctive nomenclature shall be given
to the various preparations of this substance, and some ofiicinal
" solution " shall be decided upon, physicians cannot be too
careful in learning the strength of the solution employed, and
it would be advisable to give explicit directions where to pro-
cure it.

The Early History of Syphilis in China. — Dr. Geo.
Thin, of Shanghai, China, contributes to the Edinburgh Med-
ical Journal some interesting historical notes on this subject.
He was assured by many Chinese scholars that sypliilis has
been known to exist in China for many centuries, and he there-
fore undertook, with the assistance of a learned native anti-
quary, to hunt up the records. He finds that in the seventh
century the venereal chancre was described under a specific
name, which places its nature beyond a doubt, and that from
this time onward there are various allusions to it, although in
modern times the more ancient notices have been in a great
measure overlooked, partly from change of nomenclature and
partly from the fact that the works in which the notices oc-
cur are not likely to come before the general practitioner.
Even anterior to the Christian era, there are many traditions
and vague references, which are generally accepted as indi-
cating syphilitic diseases. The earliest of these is to be
found in a collection of odes made by Confucius five hundred
years b. c.

Instructive but Tardy. — A correspondent of the Medical
Hecord writes from Paris an account of an insane w^oman,
who swallowed a silver fork, with the view of committing
suicide. The fork was subsequently discharged through an
abscess in the abdominal walls, and the patient recovered.

Eighteen months ago we published a translation from one
of the Erencli medical journals, giving a full account of this

MISCELLANEOUS AND SCIENTIFIC NOTES.

case. This report was copied from our pages by some of the
very journals that are now reprinting it from the Record^ for
the instruction of their readers.

A Physiological Curiosity. — Lactation in a Lamh^.one
hundred and fifty days old, with absence of the Internal Or-
gans of Generation.

We are indebted to the kindness of Prof. Austin Flint, Jr.,
for the report of this curious case. The report is extracted
from a communication to him by Mr. AVm. H. Seward, stu-
dent of medicine, Walnut Grove, J^. Y. :

In June last my attention was called to a young lamb upon
my father's farm, apparently a perfect female, which pre-
sented a full flow of what appeared to be normal milk. This
animal was about one hundred and fifty days old, and, in view
of the extraordinary development of the lacteal function, I
made, assisted by my preceptor, a careful examination after
death.

The animal was bled to death in the usual way. Although
the external parts were perfect, the internal organs of gen-
eration were entirely absent. A probe was readily passed
through the meatus urinarius into the bladder, but the vagina,
lined by a smooth mucous membrane, terminated in a cul-de-
sac. Thinking that perhaps the opening might have become
occluded from some injury, I looked carefully for a cicatrix,
but none could be found, and on further and most careful dis-
section we failed to discover either uterus, ovaries, or Fallo-
pian tubes.

Medical Colleges oe IS'ew Yoek akd Philadelphia. —
Under this caption the Medical Iiej)ertory, of Cincinnati, puts
forth the following withering proclamation, to which we give,
without charge and without alteration or addition, the full
benefit of our circulation. We felt very bad after reading this
valuation of our merits, and have not yet quite recovered from
the overwhelming sense of shame and confusion that came
upon us on learning how low down in the educational scale we
really were. But even in the midst of the deep humiliation
in which we are plunged, we confess to a dim degree of faith
that we shall yet survive this crushiog extinguisher, and we
enter a feeble and penitent appeal that we may be allowed to

98 MISCELLAI^EOUS AND SCIENTIFIC NOTES.

pursue our bumble career unmolested by any furtlier impleas-
ant reminders of our unwortbiness.

We are not jet informed tbat tbe scbools of tbis city bave
determined to close tbeir doors, but, witb a raslmess tbat must
now seem suicidal to our Western confreres (we mean tbose of
tbe Medical Bejpertory)^ lectures will be resumed in a few
days, even at tbe risk of empty benclies and still emptier ex-
cbequer.

Furtbermore, we beg leave mildly to intimate (for our-
selves only), tbat we purpose to keep pulling away at tbat
transatlantic udder (tbat is more euplionious and refined tban
" sucking at tbe European teat ") wbicb, tbougb it may not be
calculated to make us "fountains of instruction," occasionally
furnisbes us w^itb a morsel of mental pabulum for wbicb we are
tborougbly grateful :

Altbougb we bave well-organized medical scbools in tbe
West yet many of our Western pbysicians bave a pencbant to
patronize tbe scbools of N^ew York and Pbiladelpbia, causing
tbeir students to incur double and sometimes even tbrible tbe
expenditures necessary for completing tbeir medical educations.
Tbat men wanting in sense — for tbe world is still not witbout
fools — wbo place a bigber estimate upon presumed eclat in tbe
qualifications of tbe pliysician tban tbey do upon substantial
knowledge, sbould be guilty of sucb folly we are not surprised,
but it is a matter of astonisbment wben we see individuals
from whom we would bave expected better tbings, doing like-
wise. Every correct observer know^s tbat tbe scbools of tbe
West, are in nearly every particular, superior to tbe scbools of
tbe localities mentioned. Tbe West afifords better teacbers,
men wbo are more disposed to observe and tbink for tbem-
selves and therefore impart tbeir instruction in a manner as
only one can wbo knows of wbat be speaks, besides, tbeir
knowledge is better suited to tbe wants of tbe Western phy-
sician. The pbysicians of our sister cities read and write much,
but think little. Few of them ever carry on any original in-
vestigations or make any discoveries. They fiood the country
with books, but tbey are mere compilations from European
works, oftentimes with very much tbat is valuable omitted.
Tbeir instruction is precisely of a kind we would expect of men
whose knowledge is second banded — dressed up and showy in
appearance, but not calculated to bear tbe wear of service ;
and just like its counterpart in merchandise, there is charged
for it very much more than it is worth. We do not desire to

MISCELLANEOUS AOTD SCIEOTIEIC NOTES. 99

disparage our Eastern brethren, but, always sucking at the
European teat, they are not calculated to be fountains of in-
struction.

Young men educated in any of the regular medical schools
of Cincinnati, Chicago, or St. Louis are far better prepared to
combat with disease as met with in the West than graduates
of Eastern colleges. Tlie people of the West are a hardier
people than those of some portions of the East, both physically
and intellectually, and in morals yery far superior — JRomce
omnia venum ire is more true of the latter than of the former.
Such being the fact, we would expect, as we find it, that dis-
eases would be of a different type requiring diflerent treatment.
Men whose whole experience has been in the diseases of a par-
ticular portion of country, and who are well acquainted with
the character of the inhabitants both physically and mentally,
are certainly, all other things being equal, the most competent
to giye instrQctions to those who propose to enter upon the
practice of medicine in such localities.

Phj'sicians trained up in schools where but yery little posi-
tiye knowledge is imparted, where yery much of the informa-
tion is of the Jack Bunsby kind (onr knowledge of Dickens is
obtained from Dr. Blackman) — Mayhap, do I say so ? which ?
y/hereby ? why not ? can any man say otherwise ? The bear-
ings of this obseryation lie in the application of it ? " — are but
illy prepared for the discharge of their duties. In many in-
stances where there seems to be a germ of truth in it, it is not cal-
culated to propagate in the soil of the West — first principles "
haye to be gone oyer again and learned anew.

A little reflection in the matter, with a disposition to act
for the best, we think, would stop the immense stream of medi-
cal students eastward bound that takes place eyery fall, and
direct it to our Western schools, where it properly belongs.

largely increased patronage, would be stimulated to renewed
efforts in usefulness, and be enabled to confer greater benefits
upon those in attendance upon their lectures. The fees for
instruction could be lessened, and yet sufiicient remuneration
be paid to those engaged in teaching that the chairs might be
filled by the best talent. Cincinnati, Chicago, and St. Louis
afford all the adyantages for medical instruction that any medi-
cal student could desire. We know from our own experience
that, in the matter of clinics, Cincinnati furnishes a yery much
larger amount than can possibly be made use of by a student
in attendance upon medical lectures ; while the opportunities
it supplies for the prosecution of the study of practical anat-
omy are unsurpassed anyw^here. Now that the new Cincin-

Under such circumstances

100 MISCELLAlSrEOUS AND SCIEKTITIC NOTES.

nati Hospital will be completed in a moiitli or two, which will
be unexcelled in size, convenience and elegance, by any hos-
pital in the world, it would certainly be the height of folly for
any one to pass this city by to seek for advantages in the study
of medicine in New York and Philadelphia, which can be had
in the greatest superabundance here.

The Trustees of the Fiske Fund, at the annual meeting of
the Rhode Island Medical Society, held in Providence, June
10, 1868, gave notice that no awards had been made on the
questions proposed b}" them the past year.

They olfer the following subjects for 1868 :

1. Bromides, their physiological effects and therapeutical
uses.

2. Cerebro-Spinal Meningitis, pathology and treatment.

3. Grave's disease" (so called), pathology and treatment.

4. Carbolic Acid, its therapeutical etlects and hygienic
uses.

For the best dissertation on each of these subjects they
offer a premium of one hundred dollars.

Every competitor for a premium is expected to conform to
the following regulations, viz. :

To forward to the secretary of the Fiske Fund Trustees,
on or before the first day of May, 1869, free of all expense, a
copy of his dissertation, with a motto written thereupon, and
also accompanying a sealed packet, having the same motto in-
scribed ujDon the outside, and his name and place of residence
wdthin.

Previously to receiving the premium awarded, the author
of the successful dissertation must transfer to the trustees all
his right, title, and interest in and to the same, for the use,
benefit, and behoof of the Fiske Fund.

Letters accompanying the unsuccessful dissertations will
be destroyed by the trustees, unopened, and the dissertations
may be procured by their respective authors, if application be
made therefor within three months.

Address,

S. Aug. Arnold, M. D., Providence,

Secretary of Fiske Fund Trustees

At the annual meeting of the Committee on the Boylston
Medical Prize Questions, on the first Wednesday in June, 1838,
it was announced that no dissertation had been presented on
cither of the questions proposed.

The following questions are proposed for 1869 :

>nSCELLAXEOUS AND SdENTmC NOTES. 101

1. Food in Disease, acute and chronic ; its variety, advan-
tages, dangers, and relation to appetite.

2. The Surgical Treatment of Haemorrhoids, and the Sur-
gical Treatment of Fistula in Ano, with its result.

The author of the best dissertation on either of the subjects
proposed for 1869 will be entitled to a premium of one hun-
dred and tifty dollars.

Dissertations on these subjects must be transmitted, post-
paid, to John Jeffries, M. D., on or before the first Wednes-
day in April, 1869.

The following are the questions proposed for 1870 :

1. The Modern Pathology of Tumors.

2. Aphasia, or the Relation of the Brain to Speech.
Dissertations on these subjects must be transmitted as above,

on or before the first Wednesday in April, 1870.

The author of the best dissertation considered worthy of
a prize, on either of the subjects proposed for 1870, will be
entitled to a premium of two hundred dollars.

Each dissertation must be accompanied by a sealed packet,
on which shall be written some device or sentence, and within
which shall be enclosed the author's name and residence. The
same device or sentence is to be written on the dissertation to
which the packet is attached.

The writer of each dissertation is ex]3ected to transmit his
communication to the President, John Jeffries, M. D., in a
legible handwriting, within the time specified.

Parasite of the Cheek. — Dr. G. H. Yance, of Oneida,
111., reports to the PhiladeljMa Med. and Surg. Bej^orter
the following curious case :

" In the month of February, 1867, a boy five years of age,
and of a scrofulous diathesis, came into my ofiice, accompanied
by his mother, who wished me to examine the little fellow's
left cheek. There was quite a protuberance manifested, in
character approaching that of a good-sized boil, which was at-
tended with redness, and at times a considerable pain, causing
irritableness of temper, sleeplessness, and anorexia. Thinking it
arose from an impoverished state of the system, I prescribed an
alterative cathartic, with a local application of ung. hydg. nit.
But at the expiration of a week, contrary to my diagnosis, and
much to my astonishment, upon slight pressure, a curious ob-
ject was developed, which, upon examination, proved to be
alive, three-foiLTths of an inch in lengthy nearly transparent,
and surrounded with several rings or joints. IJpon removal

102

MISCELLA]S"EOTJS A^^D SCEEJ^TIFIC IS^OTES.

of tlie object, the tumefaction subsided, and the cheek soon re-
turned to its natural appearance. "

The doctor naivelv adds, that he had no microscope, and
therefore his investigations were necessarily very limited and
unsatisfactory, and he begs to be informed what it was, " a
species of guinea-worm^ trichina sjnralis. acarus scahei^ or
wJiaV

The italics are our own. We should say " what," most de-
cidedly.

A Remarkable Monstrosity. — Profs. Joseph Jones and
Paul T. Eve, of the University of Xashville, have made a re-
port (in the HicTimond and Louisville MedAcal Journal)^ on
an infant whom they were called upon to examine, and who was
the subject of a very extraordinary malformation. Tiie infant,
J. Myrtle Corban, has four legs and two distinct external
female organs of generation, with two external openings of the
urethra and two external openings of the double rectum. The
external genito-urinary organs are as distinct as if they belonged
to two separate Imman beings. The fseces and urine are passed
(most generally simultaneously, particularly the urine) from
both external urinary and intestinal openings, situated respec-
tively between the left and right pairs of legs.

The head and trunk are those of a living, well-developed,
liealthy, active infant of about five weeks, whilst the lower
portion of the body is divided into the members of two distinct
individuals, near the junction of the spinal column with the
OS sacrum. As far as our examination could be prosecuted in
the living child, we are led to the belief that the lower portion
of the spinal column is divided or cleft and that there are two
pelvic arches suj)2)orting the four limhs^ which are situated
upon the same plane.

The mother recollects no fright or disturbance during her
last pregnancy. The presentation was fortunately the head,
which accounts for the j)reservation of the life of the child. It
would be curious to speculate on the trouble which might have
been produced had the feet or breech presented, while the re-
sult, in all probability, would have proved fatal to the infant,
and possibly to the mother. Mrs. Corban says that there was
nothing peculiar in the labor or delivery. AVhen three weeks
old the child weighed ten pounds. It now nurses healthily, is
thriving well, and we saw it urinate simultaneously, between
the two jjairs of labia of the two vagincB, situated about six

MISCELLAITEOUS AND SCIENTIFIC NOTES. 103

inches apart. From tlie crown of the head to the u7nbiUcus
the child measures twelve inches, and from this point to the
toes of the right and left external feet, eleven inches. From
the imibiliciis up, all is natural and well formed ; all below
this, extraordinary and unnatural. An inch below the navel
is a mark of an apparent failure for a second one. There are
four distinct, pretty-well developed lower extremities. They
exist in pairs on both sides of the median line which resem-
bles the cleft of an ordinary pair of legs ; but here there are
no marks wdiatever of antes or genital organs, and upon pres-
sure we discover no os coccygis or sacrum. The outer legs of
both sides are the most natural of the four (though the foot of
the right one is clubbed), but are widely separated by the two
supernumerary ones, which are less developed, except at their
junction with the body, from which they taper to the feet and
toes more diminutive and which are turned inward. One toe
is bifid on the left extra inward extremity. At birth these
extra legs were folded flat upon the abdomen. We are led to
believe that there are tico uteri as %oell as tvjo recti ; in fact
that the pelvic organs are double. Of course, a minute dissec-
tion would alone expose the true condition of these parts.

Should this infant reach maturity and the internal genera-
tive organs be double, there is nothing to prevent conception
on both sides. The first difliculty will, however, be in her
walking. The outer, or external legs, may be used for pro-
gression ; the inner or inturned ones, probably never. These
might be successfully amputated at the knee, or higher up.

One of us recollects of being in London in January, 1830,
at an exhibition of the Siamese Twins, when Sir Astley Cooper
gave an opinion adverse to an operation with a view to sepa-
rate them, but which has always api)eared to iis feasible and
without much risk oi jyeritonitis j an operation, too, which
should undoubtedly be performed in case of the death of one
them, for no medical man believes in the vulgar impression
that they must die simultaneously. In the present case all
surgical interference is, of course, out of the question, except
that alluded to — removal of the extra legs.

Cases somewhat similar to the above have occurred and
been described. Rokitansky refers to two completely distinct
bodies conjoined at their ossa sacra or coccyges, as in the well-
known Hungarian sisters, Helena and Judith, born in 1701,
who survived their twenty-second year.

Geoffrey St. Hilaire alludes to cases of a trunk with two
heads, some even Janus-like, having four upper and four lower
extremities.

The case, however, recalled most vividly by Josephine

104 MISCELLANEOUS Al^B SCIElS'TiriC NOTES.

Myrtle, is that of Rita-Christina, well known in Europe, and
accurately described in this country years ago by Prof. Meigs.
In this wonderful instance, there were two heads, two necks,
four arms, but only two legs ; and was thus the reverse of our
case. From the ^^mMUcus down, there was one well-formed
child, but above this all the organs were double; in reality
there existed two beings. The rectum and bladder were com-
mon to both, but all else in the trunk was double and distinct.
One would sleep while the other played, etc., for they had ^z^jo
spinal 7narrows^ two brains, two hearts, but the last two occu-
pied a common J9^r^mr^Z^^^m. Unfortunately, after surviving
a little over a year, one sickened and died, when the other,
then in health, instantly expired.

Rita and Christina were born in Sardinia, 1829, and de-
scribed by Dr. De Michaelis, Professor of Surgery in the Royal
University of Sassari, and lived eighteen months.

The late Prof. J. C. Warren, of Boston, first described the
Siamese Twins, when purchased of their mother by Captain
Coffin and Mr. Hunter (joint owners), and brought to that city,
in 1829.

Monstrosity by Defect. — While at the County Hospital
some weeks since, we were shown by the resident physician,
Dr. Garwood, a singular monster, to which one of the patients
gave birth. The lower extremities, the pelvis, and all that
portion of the body below the plane of the umbilicus, were
perfectly developed and normal; but these parts constituted
the child, if child it could be called. There ^vas nothing more
— all above the umbilicus was wanting. Evidently the em-
bryo from its earliest conception had consisted of nothing more
than the parts mentioned. The integument was intact and
perfect, and closed over what existed of the abdominal cavity,
in such a maimer as showed that there had never been any
thing like amputation m liter o. Xot a trace of a scar was
perceptible. At the same time with this monstrosity was born
a child with imperforate amis and faulty development of one
of its ears. Another most singular fact is, that of the tw^elve
children which the mother has had, not one has been perfectly
developed. We regret that circumstances have prevented our
obtaining a more satisfactory history of this most interesting
case. — Pacific Med, and Surg. Journal.

Death from Chloroform. — Dr. Bilh'oth, of Vienna, re-
lates, in the IViener Medizin. Wochenschr. of June G, 1868,
a case of death from chloroform which occurred in his prac-
tice two days previously. The patient, a man aged 26, was

MISCELLAT^EOUS AND SCIENTIFIC NOTES. 105

adinitted into hospital in consequence of having, on the pre-
ceding Monday, cut tlie palm of liis left hand with a piece of
broken porcelain. There had been much haemorrhage, and
the man was very an83mic ; and, on the removal of the coagu-
la and charpie, artei-ial haemorrhage occurred. In extending
the fingers, in order to tie the bleeding vessels, so much pain
was produced that chloroform was given. In about five min-
utes from the commencement of anaesthesia, there were con-
vulsive twitchings of the whole body. The chloroform was
discontinued for a moment, and then resumed ; and, when
perfect muscular quiet was obtained and the examination of
the fingers was recommenced, it was found that the haemor-
rhage had ceased, although the compression on the radial and
ulnar arteries had been removed. The patient, who was in a
semi-recumbent position, with his head bent back, w^as now
seen to be pale, with livid lips and weak respiration. Dr,
Billroth opened the mouth, and drew forward the tongue.
The pulse was now all but imperceptible ; but the respiratory
efforts were distinct, though irregular and weak. Tracheoto-
my was performed, and artificial respiration set up. In the
course of ten minutes, the patient made three hurried respira-
tory efi'orts ; but there were no signs of restoration of the
breathing or circulation. After the artificial respiration had
been kept up half an hour, tlie case was abandoned as hope-
less. Dr. Billroth attributes the death to very violent spastic
contraction of the heart in a subject weakened by loss of
blood. — Brit. Med. Jour.^ June 13, 1868.

Unkecoeded Deaths from Chloroform. — It is our duty to
record — and we do so with regret — that two unpublished
deaths have occurred quite recently in London from the ad-
ministration of chloroform — one, while it was being adminis-
tered, for the purpose of extracting teeth, to a lady of rank in
apparently good health, and who had taken it with impunity
on a previous occasion. In tlie other case, it was adminis-
tered for a secondary operation on the eye. In neither in-
stance has an inquest been held, as the coroners were in each
case satisfied that chloroform had been administered properly
and with due care and judgment, and that the deaths arose
from pure misadventure. We hear also this week of an
earlier unrecorded death from chloroform at Dublin, prior to
the performance of an opei'ation on the eye. It is, we think,
due to science and to humanity, that these deaths should be re-
corded in some form. The blessings and advantages of anaes-
thesia under the knife are so great, that it is not likely that
even the fullest knowledge of the risks attendant upon the

106 MISCELLANEOUS AI^D SCIENTIFIC NOTES.

use of anaesthetics will influence persons who have to undergo
serious operations to reject the opportunity of sleeping
through the ordeal. But it is right that the full risks should
be known both to the whole profession and to the pnblic ;
and it is especially iuiportant that the particular mortality of
each ansesthetic agent should be accurately ascertained.

We mentioned last week three recent cases in which the
administration of chloroform had caused sudden death in this
metroj)olis, under circumstances in which no blame could
attach to the administrators, as it was given with all possible
skill and precautions, and by able and experienced persons,
and in which, therefore, the coroners did not think it neces-
sary to hold inquests, nor had any pnblic record been made.
We regret to learn that subsequently to this another death
under chloroform has occurred in a metropolitan hospital.
The circumstances absolve the administrators from any
shadow of blame; and no inquest has been held. We are of
opinion, however, that it is the duty of all those to whom
deaths from chloroform occur in their practice to take care
that they are put upon record, with such details as shall ren-
der them instructive. The age, constitutional condition, and
peculiarities of the patient; the nature of the operation ; the
specitic gravity and chemical qualities of the chloroform ; the
apparatus used and mode of administration ; the symptoms of
the patient ; and the means employed toward resuscitation —
should all be described. We can well sympathize with the
pain which those feel in whose practice these untoward, and
at present unavoidable, accidents occur ; and the publication of
names may even cause unjust prejudice and injury to indi-
viduals and institutions. It is possible, however, to put the
case satisfactorily upon record without such detail ; and it
seems to us to be a duty to science and to society, which is
nmch neglected. In conversation this week, we hear of two
other autlientic but unrecorded cases, one in private practice
in London, and another in Birmingham. — Brit. Med. Joior.,
June 27, 1868.

Death fkom Chloroform administered for the Aiviputa-
TioN of a Finger. — A death from the inhalation of chloroform
has occurred at the Essex Lunatic Asylum, Warley. An in-
quest w^as held before C. C. Lewis, Esq., coroner. The pa-
tient was a man, aged 28, whose linger had to be amputated
from recent injury. The quantity administered was, it was
stated, only a drachm ; and the verdict of the jury, after hear-
ing the medical evidence, was — " That deatli resulted from con-
vulsions ; such convulsions resulting from fatty degeneracy of

MISCELLANEOUS AZS^D SCEEOTIFIC NOTES. 107

the heart." The stethoscope had disclosed no signs of this dis-
ease. The chloroform was administered on a handkerchief in
three doses of twenty minims, and maintained during the
operation. The patient became violently convulsed, and the
pulse ceased. There was tubercle at the base of the brain ;
the heart was soft and fattv, the liver heavy and soft. — Brit.
Med. Jour,, July 25, 1868.

Death from Chloroform. — Mrs. Elizabetli Haramon,
aged 35, mother of three children, apparently a healthy
woman, went to a dentist (Dr. McDowell) April 16, 1868,
for the purpose of having some teeth extracted. Think-
ing she could not endure the pain, she requested the
doctor to administer chloroform ; and, as he had given
it to her once before (about six months since) without any
bad efiect, he consented to administer it again, and, pour-
ing about two drachms of chloroform upon a sponge, held
it a short distance from her face. After she had made
three or four inspirations her respiration ceased ; he felt for
the pulse and found she had none. Artificial respiration was
commenced at once, and stimulating applications applied over
the heart and to the extremities, but to no effect. She made
but two or three eflbrts at inspiration after he first noticed
something was wrong. An autopsy could not be obtained.

A XeEDLE six AXD a quarter IxCHES LOXG REMAIXIXG IX

THE Heart ax'd Thoracic Cavity thirteex^ Moxths. — M.
Tillaux recently reported to the Imperial Society of Surgery
the case of a man, aged fifty-five years, aflPected with general
paralysis of the insane, who, having made a previous unsuc-
cessful attempt at suicide, had forced a three-sided needle, six
and a quarter inches long and about one-twelfth of an inch in
diameter, into the wall of the thurax. When seen the next
morning there was a very suiall puncture about one-fourth
inch below the left nipple, and just outside and above this the
skin was forcibly raised at each contraction of the heart, and
the impulse of a rounded foreign body was plainly perceptible
by the finger. There were emphysema and ecchymosis at the
same point. The patient being then in his right mind said
that he had forced in the needle the night before, pushing it
with his tobacco-box, and had felt no pain after the resistance
of the skin was overcome. iSTow his face was pale and anx-
ious, his thighs were flexed on the pelvis, and his body bent
forward so as to relax the thoracic and abdominal muscles ; his
respiration was difficult, and he complained of vague pain in
the chest. Over the chest, and especially the emphysematous

108

MISCELLANEOUS A^s^D SCIEOTIFIC NOTES.

portion, any pressure caused complaint, rather denoting anx-
iety than sharp pain. The respiration was feeble on the left
side, on account of the pain of movement. The sounds of the
heart were regular and normal, and with the first sound the
foreign body was pushed directly forward and outward. 'No
effusion was discovered in the pericardium ; except the em-
physema, there was no appearance of injury of any important
organ. M. Tillaux, through fear of exciting haemorrhage, and
in the absence of immediate danger, waited till the next day.

Meanwhile the patient had had several attacks of severe
pain with threatened syncope, and demanded immediate ex-
traction of the foreign body. This had, liowever, worked its
way farther into the tissues, and could scarcely be felt by the
finger, and as at the first incision of the skin the patient had
an attack of syncope, the attempt at extraction was aban-
doned.

Four days later all impulse of the foreign body had dis-
appeared ; there was some fever, pneumonic sputa, bronchial
rales, but no dulness ; the s]:)hygmograpli showed a regular,
but feeble and depressed pulse ; respiration was very irregu-
lar.

A month later, palpitation and great irregularity of the
heart's impulse. This general state of things continued with
occasional slight hsemoptysis, though he gained strength and
was able to walk about, till eleven months after the injury, at
which time there was a cardiac souffle with the first sound,
loudest at the base. All localized pain had disappeared,
though there were vague and erratic pains in the back and
sides. During the next two months the pains increased, the
cough and haemoptysis became more frequent, and finally
death ensued from syncope.

At the autopsy tlie needle was found traversing the whole
length of the posterior wall of the left ventricle, but not enter-
ing its cavity, passing between the spinal column and the
oesophagus and through the lower lobe of the right lung. The
tissue of the heart showed no trace of inflammation, but in the
lung the needle was surrounded by a membrane which separa-
ted it from the hepatized lung tissue. — Z' Union Medicate^
and Boston Medical and Surgical Journal.

There are no longer alchemists who believe in the trans-
mutation of metals, the base into the precious ; but those still
exist who hold it possible to make diamonds from worthless
materials. One of this class has proposed a solution of the
famous problem to the French Academy, and the august
body has smiled ujpon^ not at the project. M. Caliste Saix is

MISCELLAITEOUS Al^B SCIEOTITIC NOTES. 109

the liap])y discoverer who has found the way to cheat Xatiire
out of her riches, and with praiseworthy disinterestedness he
has given his method freel}^ to the w^orld. The process con-
sists in passing a stream of chlorine gas over fused cast iron, a
perchloride of the metal is formed and volatilizes, leaving the
carhon present in the mineral intact. According to the au-
thor, the carbon must, under the circumstances, crystallize
and appear as diamonds. Sixty grammes' weight of jewels
are to come from one kilogramme of iron ; the raw material
costing 20 francs and the precious product realizing 75,000
francs. The process is creating some stir in France, but we
cannot hear that any diamonds have actually been made by
it. — Gentlemen^ s Magazine,

How Quacks weke treated m London in the ForRTEENTH
Century.— The Corporation of London have published a very
interesting volume, which is edited by Mr. Riley, entitled
"Memorials of London and London Life in the Thirteenth,
Fourteenth, and Fifteenth Centuries." These memorials con-
sist mainly of a series of extracts from the archives of the City
of London. The condition of our profession at the time is il-
lustrated by a number of interesting facts. However much
we may have improved in many respects, it is certain that our
forefathers had a keen sei'ise of their duty toward unqualitied
persons who assumed to be possessed of medical knowledge.
They were punished with a rigor wliich would be incompati-
ble with modern customs, but which affords a striking con-
trast to the lenient way in which medical impostors are now
treated. The following instance, in particular, is worthy of
mention : One Roger Clerk professed to be learned in the art
of medicine, and prescribed, for a woman suiFering from fever,
the hanging of a certain document round her neck, containing
certain words which he stated were an antidote to the disease
under which she suffered. The charm did not work. He was
summoned before the mayor and aldermen in the Guildhall of
London, at the instance of the husband of the patient, to show
upon what authority he practised the art of medicine. His
own statement was sufficient to convict him of being a rogue
and an impostor, and he was forthwith ordered to be placed in
the pillory, and therein to be punished for the offence he had
committed against society. His progress to the pillory is thus
graphically described: ''It was adjudged that the same Roger
Clerk should be led through the middle of the city, with trum-
pets and pipes, he riding on a horse without a saddle ; the said
parchment and a whetstone, for liis lies, being hung about his
neck, an urinal also being hung before him and another
urinal on his back."

110 MISCELLA^^EOUS AXD SCIEIN^TIFIC IS^OTES.

The offence which Hoger Clerk committed was venial com-
pared with some of the flagrant crimes which quacks nowadays
too frecpently perpetrate. If he was righteously punished,
how should we mete out punishment to the harpies and villains
of our time who prey upon the weakness and credulity of the
miserable victims who are attracted by their infamous adver-
tisements to place themselves under their care ? — Lancet^ J^^lj
11, 1868.

The Yelocity of Nekve-Force. — The nerve-current which
transmits sensations to the brain, and the orders of the will to
the extremities of the body, requires a certain time to travel
in. Impressions coming from without are not perceived at the
instant they are produced, they travel along the nerves at the
rate of 20 to 30 metres (25 to 40 yards) in a second, which is
the same speed as that of the carrier-pigeon, of a hurricane, or
of a locomotive engine at its quickest, but very much less than
that of a cannon-ball. For instance, we can only be conscious
of an injury to one of our feet about one twentieth of a second
after it has actually occurred, and tlie commands of the will
proceed equally slowly from the centre to the peripheries of
the nervous system. In the human body the time thus occu-
pied is unimportant, but let us take the case of a whale, where
the telegraphic network of the nervous system is far more ex-
tensive. A boat attacks the whale, and a harpoon is driven
into its tail. The impression tims produced has to travel over
some forty yards before reaching the headquarters of the
will ; a second is thus lost. How long a time is then required
for reflection ? That must depend upon circumstances ; but at
any rate it is certain that the will has need of some definite
amount of time for its decision. The order to capsize the boat
is dispatched to the tail, but another second must elapse before
the telegram reaches its destination, and in the time thus em-
ployed the whaling-boat has pulled off" and escaped the danger.

Several methods have been devised by physiologists for
measuring the velocity with which nerve-force travels. Thus,
a physician of the middle ages,' mentioned by Haller, fancied
that this might be calculated by comparing the supposed di-
ameter of the nerve-tubes with that of the aorta, as he supposed
the velocities of the blood and " animal spirits " to be in the
inverse ratio of the vessels containing them, from which data

^ Tlie medijeval physicians and the schoolmen held as a consequence of
Aristotle's and Galen's theory of "animal spirits," that time was required
for their passage from one part of the nervous system to another ; and it
is even curious to remark how the later schoolmen opposed the Cartesians
who tliongrht the contrary — an exainple of the advantages derived by the
schoolmen from including even bad physiology in their scheme of philoso-
phy.—J. Pv. G.

MISCELLANEOUS AND SCLENTIFIC NOTES.

Ill

he calculated that nervous influence travels 600 times more
quiclvlv than light.

Haller's own mode of jDrocedure was scarcely more rational.
He counted the greatest number of letters he could articulate
in a given time, which he found to be 1,500 per minute. I^ow,
the letter r requires, according to him, ten successive contrac-
tions of the muscle which makes the tongue vibi*ate, whence
he concluded that this muscle can contract and relax 15,000
times, that is, can move 30,000 times in one minute. From
the brain to the muscle the distance is one decimetre ; if,
therefore, the nerve-force passes over that space 30,000 times in
a minute, it must travel at the rate of three kilometres per
minute, or fifty metres per second. We need not point out
that this process is a mere series of mistakes, but it is strange
that the result should happen to be so near the truth.

Xo attempt was made until 1850 to study this question in
a satisfactory manner, when one of the most distinguished of
modern observers, M. Helmholtz, undertook its investigation.
He at first employed Pouillet's " chronoscope," a machine in
which a galvanic current of very short duration makes a mag-
netic needle deviate, the duration of the current being meas-
ured by the amount of deviation ; by this means as short a
time as some thousandths of a second can be measured. M.
Helmholtz fixes one end of a muscle from the leg of a frog,
and attaches the other to a small lever which forms part of a
galvanic circuit, so that at the moment of contraction the cir-
cuit is broken and the time registered by the chronoscope.
The current is first sent directly through the muscle, and then
through a given length of nerve which has been left adherent ;
the diti'erence in time between the two cases gives the velocity
of the nerve-force, which by this process is found to be 26
metres (85 feet 7 inches) in a second.

In a second metliod, also employed by M. Helmholtz, the
lever raised by the contraction of the muscle has a point
which traces a line upon a sheet of blackened paper, which
is kept moving from the moment of excitation, and the curve
produced by the movement of the lever registers all the phe-
nomena of the muscular contraction. This apparatus, called
the "myograph," gives the velocity of nerve-force as equal to
27 metres (88 feet 10 inches) per second ; several modifications
of the instrument by difierent physiologists have given very
closely agreeing results, and have also shown that the velocity
is diminished by sending an electric current through the nerve,
or by a low temperature.

Experiments with the same object have been made upon
man in the following manner: An electric current is sudden-
ly applied to the skin, the moment of application being regis

112 ^ MISCELLANEOUS AND SCIENTIFIC NOTES.

tered by the turning cylinder of a chronoscope, and as soon as
the person experimented on perceives the slight prick pro-
duced by the current he touches an electric lever by which a
second mark is made upon the cylinder. The mterval between
the two, which can be thus measured, is made up of the fol-
lowing elements, viz., transmission of the impression to the
brain, the mental process there gone through, the transmission
of the voluntary impulse to the fingers, and tlie consequent
muscular contraction. But if this experiment be performed
on two different parts of the body, as, for instance, at the groin
and at the great toe, all the other elements of the delay will
remain the same except the time occupied by the transmission
of the impression upward, and the velocity of nerve-force in
man can be thence calculated. M. Hirsch, the director of the
!N"eufchatel Observatory, was the first person to make these
experiments, in 1861, and from them he concluded that nerve-
force in man passes over 34 metres (112 feet) in a second. Dr.
Schelske has repeated the same experiments, and deduces from
them a slightly less velocity, 29|- metres (97 feet) per second.
By similar means it has been shown that the rate of transmis-
sion tlirough the spinal cord is the same as through the nerve-
trunks, and that a reflex action requires from one-tenth to one-
thirtieth of a second more than the mere direct conduction of
excitement to the nmscles.

The time required for certain cerebral operations has been
measured by Dr. De Jaager in the following manner : It was
preconcerted that the person on whom the experiment was
made should touch the lever with his right hand when he re-
ceived an electric shock on the right side, and with the left
hand when he received a shock on that side. Tlie interval be-
tween the shock and the signal was found to be 0.20 of a
second when the subject of the experiment had been told be-
forehand on which side the shock would be given, and 0.27 of
a second when he had not been told ; 0.07 had therefore been
emj)loyed in reflection.

M. Hirsch, again, has found that on an average two-tenths
of a second must elapse before an observer can mark by a sig-
nal his perception of a sudden noise or flash of light, and MM.
Donders and De Jaager have varied their experiments thus —
one of them pronounced a syllable, the other repeated it as
soon as heard ; when the syllable had been agreed upon be-
forehand, there was an average delay of two-tenths of a second ;
when it had not been so agreed upon, of three-tenths of a
second. These are, however, only average results, and subject
to considerable individual variations, of which the "personal
equation " of different observers of a transit is an example well
known to astronomers. — Journal af Mental Science,

NEW YORK

MEDICAL JOURNAL:

A MONTHLY BECOBD OF

MEDICINE AND THE COLLATERAL SCIENCES.

Vol. YIIL] NOVEMBER, 1868. [No. II.

Aet. I. — On Sea-sichness. By Fordyce Barker, M. D.,
Professor of Midwifery and Diseases of Women, in
the Bellevue Hospital Medical College, etc., etc.

If we consider tlie number of persons who, either
for pleasure or business purposes, cross the Atlantic,
the many constantly going to and returning from Cali-
fornia and other j)arts of the Pacific coast, — if w^e esti-
mate the number on the steamers which run between
our N^orthern and our Southern ports on the Atlantic
coast, and on our Western lakes, I think the statement
Avill readily be accepted, that there are few maladies
which produce such an aggregate of human suffering
as sea-sickness. And yet it may be said, that there is
no malady which the medical profession has done so
little to relieve, and none for w^hich it is so seldom
consulted. There are several popular errors in regard
to this malady, which are current with the profession

114

SEA-SICKNESS.

as well as witli the public, and wliicli account, in
some measure, for the statement just made. For ex-
ample, I find the belief very general —

1. That sea-sickness is often beneficial, and that it
is never permanently injurious. Now, I have never
been able to convince myself that any one was really
benefited by the sea-sickness, but the improvement in
health from a sea-voyage is, as a general rule, propor-
tioned to the freedom from sea-sickness. I have known
many persons who have taken a- sea-voyage for health,
and, believing that the benefit they were to receive
fr'om the voyage would be in a ratio with the amount
of bile vomited, they have been greatly disappointed
because they were not sea-sick. In many instances I
have known serious and jDermanent injury to result
from sea-sickness. A gentleman in this city, whose
business as an importer obliged him to visit Europe
every spring and autumn, has been completely broken
down from the effects of a ten days' sea-sickness four
times a year. After the violent sickness and vomiting
have ceased, because of the arrival on land, the stomach
has remained greatly disordered, and a long time has
been required for the restoration of its tone and diges-
tive power. My advice has been fr^equently given in
strong and decided terms, to those of depressed vital
powers, with impaired and feeble digestion, whose past
experience has demonstrated an innate liability to sea-
sickness, to avoid the exposure to such a hazard.

Some twenty-five years since, I crossed the Atlantic
in the packet-ship St. Nicholas. We were eighteen
days fi^om Sandy Hook to Havre, having two or three
days of severe weather, but, on .the whole, a very
pleasant passage. One very corpulent gentleman, who
was in perfect health when we left the Hook, was in-

SEA-SICKNESS.

115

cessantly sick during tlie wliole passage. He was
wholly unable to retain any thing except the smallest
bit of sea-biscuit, soaked in wine or brandy ; and I do
not believe that, during the whole voyage, the aggre-
gate of all he swallowed would amount to a half-dozen
sea-biscuits. It may well be supposed that, on our
arrival at Havre, he was extremely prostrated and
excessively emaciated. I was called up to see him,
the second night after landing, as he was delirious and
had attempted to commit suicide. It was many days
before he recovered the capacity for retaining and
digesting food. While crossing the Atlantic in 1861,
I was asked by the surgeon of the steamer to see a
gentleman whom sea-sickness had reduced to a most
dangerous state of prostration and exhaustion. This
gentleman was obliged to remain in Liverpool two
weeks before he sufficiently recovered from the effects
of the sickness to be able to leave for London.

2. Another popular error is, that sea-sickness is
never dangerous to life. It does not often result
fatally, but I suspect that the number of deaths from
this cause is greater than is generally supposed, for
three have occurred within my personal knowledge.
The first was a young physician, of decided talent and
promise, who had at one time been a pupil of mine.
Feeling himself somewhat run down by overwork, he
thought to improve his health by taking a vacation of
a few weeks in an excvirsion to the fishing-banks of
Newfoundland. He was absent nearly four weeks,
during which time he was absolutely unable to retain
any thing on his stomach, and he died, delirious and
exhausted from starvation, two days after landing.
The second case was a young lady, who was to have
been married immediately after her arrival here, but

116

SEA-SICKNESS.

who died on the passage between Havre and New
York. Dr. A. H. Smith, the surgeon of the steamer,
told me that he could find no other cause for death
than the exhaustion from sea-sickness. The third case,
which I saw in consultation with the late Dr. Pratt, of
this city, was a young man tw^enty-tw^o years of age,
represented to have been perfectly healthy, who, in a
rough passage of sixteen days from Liverpool, had
been wholly unable to retain any thing on his stomach.
This condition continued after landing, and he died on
the fourth day after his arrival. Dr. Pratt, who had
a very large hotel practice, told me at this time that he
had known of three other deaths from this cause.

3. The belief is very general, both 'in and out of
the profession, that the medical art is powerless for the
mitigation, relief, or cure of this malady. It is true
that there are no specific drugs which will cure or even
prevent sea-sickness. It is often and truly said, that
the land is the only cure ; but I believe that every
physician ought to be com23etent to give such good,
sensible advice as will greatly contribute to dimin-
ish the tendency to this malady, and to mitigate and
relieve the suffering and evil resulting from it. Hav-
ing crossed the Atlantic many times, and, of course,
having experienced all sorts of weather, from the most
perfect calm to the most violent storm, not only on the
Atlantic, but on the Mediterranean and the English and
Irish Channels, I have had the opj)ortunity of studying
sea-sickness in all its different jDhases. Being myself ex-
empt from the slightest tendency to this affliction, but,
on the contrary, feeling at sea, particularly when it is
somewhat rough, an exhilaration of mind and an elas-
ticity and vigor of body which I do not feel on shore,
I have been in the best possible condition for studying

SEA-SICKNESS.

117

the disease objectively. I am not sure tliat it can be
called a disease, in the proper sense of the word, for the
phenomena constituting sea-sickness are purely physi-
cal. It is not confined to the human race, as animals also
are subject to the same malady. I have often noticed,
with great interest, its effect on dogs, and that during
rough weather they intuitively seek the centre of the
ship. The same law of individual susceptibility and
exemption from this affection exists in animals as in
the human race. In returning from Newport, a few
years ago, the sea was very rough in coming round
Point Judith. My coachman came to me in great
trouble, telling me that one of my horses was dying. I
found the horse lying down, wet with a cold sweat, and
groaning piteously. As he was perfectly well before
leaving Newport, and lively enough after we landed
here, it was evident that his whole suffering was due
to sea-sickness. The other horse did not seem to be
disturbed in the slightest degree.

I am unable to say to what extent the feathered
race are susceptible to this malady, but I once had the
opportunity of observing, on the Mediterranean, that
fowls are not exempt " from the ills that flesh is heir
to." One beautiful morning in June I was on a small
steamer going from Leghorn to Genoa. There was a
short, chopping sea, very trying for those of delicate
susceptibilities, and I was the only passenger up and on
deck. I observed on the forward-deck, near the bow,
a coop, containing fifteen or twenty hens and two cocks,
in watching which I became greatly interested and
intensely amused. Most of the hens exhibited unmis-
takable evidence that they were neither comfortable
nor happy. One of the cocks stood, balancing himself
with difficulty, with head, tail, and wings drooping.

118

SEA-SICKISHESS.

and winking with a decidedly sea-sick expression.
While watching him with sympathy, his fellow gave
an exultant crow, and immediately received from his
mate a spiteful peck on his comb. A few moments
after the crow was repeated, but this time his sick
mate could only express his disgust and reproach by
languid mnks. I had the curiosity to watch the coop
after it was landed, and found all the inmates restored
to their normal liveliness.

Sea-sickness is manifested by a great diversity of
symptoms in different individuals. Some suffer only
fi'om headache and a constant feeling of stricture across
the forehead and over the temples, during the whole
voyage, while they are free from nausea and vomiting.
Others do not suffer much from nausea, but are sud-
denly seized vdih vomiting, and after the contents of
the stomach are discharged they are free from all un-
pleasant sensations until the next recurrence of vomit-
ing. With many the nausea and vomiting entirely
disappear after being at sea for a few days. Others
again are so unfortunate as to suffer from all these
syroptoms during the whole time they are at sea,
whether the vovao-e be short or Ions:. There are some
who never can become habituated to the sea. I have
been told by some naval officers, that they were ahv^ays
sick in rough weather, and I know that this is the case
with two captains of Atlantic steamers. With some
the suffering produced by sea-sickness can hardly be
painted by words. I am sure that no personal induce-
ment would be strong enough to tempt me to cross the
Atlantic, if I were obliged to endure the terrible suf-
fering that I have witnessed in most voyages that I
have made. There is often a great change in the same
individual, in the course of life, as to the susceptibility

SEA-SICKNESS.

119

to this malady. Some, who in early life have been
martp's to sea-sickness, have ceased to be so as they
have grown older, while others, who have been so ex-
empt from this liability that they have been accus-"
tomed to reo:ard it as an affection which can be over-
come by the exercise of a strong will, have themselves
become most craven sufferers and pitiable victims.
And yet it is curious that strong mental emotions, as
apprehension, terror, fright, will suddenly and com-
pletely cure the most violent sea-sickness. It is often
true, as is said in " Don Juan," that

" fright cured the quahns
Of all the luckless landsmen's sea-sick maws."

I do not 23urpose at this time to discuss the great
variety of theories that have been suggested in ex-
planation of the cause of sea-sickness. I will only
observe that it seems to be due to the sudden and re-
curring changes of the relations of the fluids to the
solids of the body, and the nervous disturbances which
result from these changes. The liquids contained in
their vessels, as well as the solids of the economy,
obey equally the laws of gravitation, when the body
is subjected to alternate movements of ascent and de-
scent like those which are caused by the swing or by
the waves of the sea. The blood, by its fluidity,
yields more readily to the influence of descent, and
less easily than the solids to the ascending impulse.
Consequently, it does not return to the brain with the
same regularity as in the case where the body remains
stable, and leaves it more rapidly in the movement of
descent. There result, as to the circulation, alterna-
tions of afflux and delay in the arrival of the blood to
the different organs of the body, which disturb their
functions, and those of the brain especially, analogous

120

SEA-SICKNESS.

to that whicli follows tlie loss of blood, in some per-
sons who are nauseated and vomit after venesection.
This disturbance of function is more or less pronounced
•according to the susceptibility of each individual, and
in most persons it is overcome in a great measure by
a habitude to a rej^etition of the causes. No sensible
physician would therefore expect to cure sea-sickness by
medication addressed to the stomach, or even by drugs
which are supposed to act directly on the brain and
its functions. The horizontal position, which, to a
certain degree, modifies this disturbance of function,
is the only approximation to a cure. It, however, does
not follow that nothing can be done to prevent or at
least diminish these functional disturbances, and to
relieve or restore the system from their results.

To this end, it is of first importance that all the
conditions which tend to increase the intensity and
severity of the sickness should be thoroughly ap-
preciated. I will mention some of the most common
and prominent of these conditions :

1. An exhausted or depressed state of the nervous
system, the consequence often of loss of sleep, want of
food, excitement, or emotional causes, and bad air. I
have observed that a large proportion of persons come
on board the Atlantic steamers fatigued and ex-
hausted by their preparations for the voyage. They
have passed a large part of the previous night in
superintending the packing of their trunks and in
arranging their affairs for an absence from home, or
they have been travelling night and day to reach the
point of embarkation, or have badly slejDt in an ill-
ventilated and strange room in a hotel. Then there is
the excitement arising from separation from family
and friends, and the vague, undefined apprehension as

SEA-SICKNESS.

121

to the perils of tlie sea. Of course, sucli persons have
had no appetite, and have badly digested the little
they have eaten.

2. Thus badly prepared to resist the eifects of sea-
sickness, they speedily bring it on by keeping uj) and
staying on deck. They have an indistinct idea that it
is a kind of moral weakness, which they may conquer
by boldly doing the very things to bring it on. If
they have had a previous experience of the malady, it
is not strange that they should dread to be " cabined,
cribbed, confined" in their badly-ventilated berths.

3. In many the digestive organs have been irritated
by their previous habits of living, or by the action of
cathartic medicines Avhich have been taken as a sup-
posed proj^hylactic against the sickness. I do not
mean to say that those whose digestive functions are
feeble and imperfect are more liable to sea-sickness
than others ; but, if the constitutional susceptibility to
this affection exists, they are less capable of resisting
its effects, they suffer more, and their recovery is much
more tedious. Then, again, because bile- vomiting is
the result, bile is supposed to be the cause of the sick-
ness. " I expect to be sick, because I am bilious," or
" I am never sick, except when I am bilious," are re-
marks which I often hear. But, in reality, the bile has
as little to do with the sea-sickness as it has with the
evil consequences to a child of a fall down-stairs. In
both the bile-vomiting is not a cause, but a con-
sequence, of the cerebral perturbation. And so I
think it a great mistake to take cholagogue cathartics
as a preparation for a voyage, as any thing that irritates
or disturbs the functions of the system weakens the
power of resistance to the constitutional susceptibility.

I will briefly allude to some other points in con-

122

SEA-SICKNESS.

nection with this subject. It is a very prevalent error
that one never " takes cold " at sea. The fact is quite
the reverse, and the exposure to the causes of cold is
ohviously greater at sea than on land. My own ex-
perience is, that it is very difficult to get rid of a cold
when at sea.

I am often consulted in regard to the effects of a
sea- voyage and sea-sickness on menstruation and preg-
nancy. In former times, when emigrants came over
to this country in i3acket ships, having a voyage of
from thirty to sixty days, amenorrhoea was a very fre-
quent result, but I think that this was due rather to
the bad hygienic conditions of the voyage, the bad air,
and the poor and . insufficient food of those crowded
in the steerage, than to any special influence result-
ing from sea- air or sea-sickness. I am told that it is
much less common in this class, now that they gener-
ally have much better accommodations and much
shorter passages in the steamers. But I believe that
the function of menstruation is generally more or less
disturbed. From my investigations on this subject, I
am led to regard the law to be, subject of course to
numerous exceptions, as follows : When the voyage is
commenced near an approaching period, it is brought
on two or three days earlier, and the flow is more
abundant, than ordinary. But when the voyage is
commenced in the first half of the interval after a period,
the next appearance is retarded and sometimes sup-
pressed for one or two periods. I am often consulted,
both directly and by letter, as to the safety of a voyage
during pregnancy. Judging from what has been told
me by patients, I should infer that French physicians
generally, and many of the English, regard it as highly
perilous. Now, the same causes at sea as on land will

SEA-SICKNESS.

123

produce miscarriage, but I have never known of a case
of abortion from sea-sickness. I have, however, inter-
rogated many surgeons of steamers in regard to this
point, and find that occasionally abortion is induced
in pregnant women from sea-sickness. I have known
several who were always sea-sick when not pregnant,
and who were entirely exempt from it in a rough pas-
sage across the Atlantic during pregnancy. My advice
was sought for by a lady in Paris, who had four times
suffered severely from the sickness of pregnancy up to
the end of the fifth month, and who was excessively
sea-sick during the whole voyage over to Europe. She
was, at this time, in the third month of her fifth preg-
nancy, and very weak from constant nausea, vomiting,
vertigo, and nervous irritability. Imperative family
reasons required her return to this city, but her phy-
sicians had told her that it was out of the question
for her to attempt it. But she returned in the same
steamer with myself. On the second day out, all sick-
ness disappeared, her appetite returned, and she arrived
here in a very much better condition than when she
left Paris.

I will now offer a few suggestions in regard to the
prevention and management of sea-sickness, and the
treatment of its results. In short passages, as on our
lakes, and across the English or Irish Channel, all that
can be done is by way of prevention. Those liable
to be sick should make a good hearty meal not more
than two or three hours before going on board. They
should select a spot as near as possible to the centre
of the vessel, and lie down before she gets under weigh.
The horizontal position should be rigidly kept during
the whole passage. Any attempt to raise the head or
to stand erect will be sure, with the susceptible, to be

124

SEA-SICKNESS.

followed by an explosion, and then the case is hopeless
for the remainder of the passage. The person should
be well covered, not only to protect from cold, but to
shield from disagreeable sounds, sights, and smells. On
the packets on the English Channel I should advise
one not to go down in the cabins below, where the
sight of those lying round, with basins by their head,
is of itself exceedingly provocative to a sensitive
stomach, but rather to secure, by telegraphing before-
hand, one of the little cabins on deck. Although the
passage may not be more than an hour and a half or
two hours, I have often seen the neglect of the above
suggestions to be followed by very severe punishment.

For ocean passages one of the most essential points
is the selection of the state-room as regards position,
light, size, and ventilation. Of course, the nearer the
room is to the centre of the ship, the less will be the
motion. In going to Europe, it is better to be on the
starboard side, and in returning, on the larboard, which
will be the sunny side. Rooms near the furnaces are
objectionable, not only on account of the heat, which is
sometimes very disagreeable, but also from the noise,
which, at certain hours, is made by the donkey engines
in drawing up the ashes and cinders, and which is
very trying to those of sensitive nerves. In screw-
steamers, the inside rooms, as they are called, if of good
size, are often to be preferred to the outside ones, on
account of ventilation, as there is very little weather,
except in remarkable summer passages, when the port-
holes can be kept open, while the windows of the inside
room open on deck, and can generally be kept open.
As the air draws down the gangway, the nearer the
gangway the better the ventilation.

The following suggestions for the prevention of sea-

SEA-SICKKESS.

125

sickness were first written out some years ago for a
gentleman whose business required Hm to cross the
Atlantic often, and who was always kept in his room
by severe sea-sickness during the whole voyage. By
implicitly following the directions given, he has suffered
very little from sickness, and has been able to go on
deck by the second or third day, and has been entirely
exempt from sickness for the remainder of the voyage.
They have since been copied many times, and their
value thoroughly tested. The trouble, however, is,
that most persons do not appreciate how much easier
it is to prevent sea-sickness than to cure it ; and so,
none but those who have before suffered, will thor-
oughly carry out the directions, and, neglecting some
of them, are disappointed in the results :

1. Have every preparation made at least twenty-
four hours before starting, so that the system may not
be exhausted by overwork and want of sleej^. This
direction is particularly important for ladies.

2. Eat as hearty a meal as possible before going
on board.

3. Go on board sufficiently early to arrange such
things as may be wanted for the first day or two, so
that they may be easy of access ; then undress and go
to bed, before the vessel gets under weigh. The neg-
lect of this rule, by those who are liable to sea-sickness,
is sure to be reo-retted.

4. Eat regularly and heartily, but without raising
the head for at least one or two days. In this way,
the habit of digestion is kept up, the strength is pre-
served, while the system becomes accustomed to the
constant change of equilibrium.

5. On the first night out, take some mild laxative
pills, as, for example, two or three of the compound
rhubarb pills.

126

ASPEEMATISM.

Most persons have a tendency to become consti-
pated at sea, althougli diarrlioea occurs in a certain per-
centage. Constipation not only results from sea-sick-
ness, but in turn aggravates it. The reason has already
been given why cathartics should not be taken before
starting. The effervescing laxatives, like the Seidlitz,
or the solution of the citrate of magnesia, taken in
the morning on an empty stomach, are bad in sea-
sickness.

6. After having become so far habituated to the
sea as to be able to take your meals at the table and
to go on deck, never think of rising in the morning
until you have eaten something, as a plate of oatmeal
porridge, or a cup of coffee or tea, with sea-biscuit or
toast.

7. If subsequently, during the voyage, the sea
should become unusually rough, go to bed before get-
ting sick. It is foolish to dare any thing, when there
is no glory to be won, and something may be lost.

Aet. II. — Aspermatism, By "W. H. Va^ Bueei^^,
M. D., Professor of Princi23les of Surgery, and Dis-
eases of the Genito-urinary System, Bellevue Hos-
pital Medical College, New York.

A GENTLEMA1S-, 30 ycars of age, whose wife had not
conceived after four years of marriage, was brought
to me by the late Dr. C. E. Isaacs, in May, 1858, and,
being exceedingly anxious for a family, he desired to
ascertain if any thing could be done to improve his
sexual power.

He w^as a spare-built, undersized man, but healthy

ASPEEMATISM.

127

and strong, and very straightforward and trutliful in
his manner.

He complained of the occurrence, at intervals of
from two to six w'eeks, of erotic dreams, attended by
j^rofuse seminal emissions, and followed by a sense of
weakness ; also, of the escape of a clotted glutinous
fluid " — evidently seminal — from the urethra after j^ass-
ing water, about every other day, and most noticeably
in the morning on rising. Now comes the curious fea-
ture of the case : He had never been able, in sexual
intercourse, or in any other way, to bring about the
venereal orgasm, or to provoke a discharge of seminal
fluid. He had prolonged the effort, on many occasions,
to the fall extent that his sti^ength would permit, but
with no result. At present he experiences no jDleasure
in the sexual act, rather a feeling of disaj^pointment,
indulging (if this ex^^ression can be projDerly used in
such a case) but once in a month, and then only as a
matter of duty, and in the hojDe of a more successful
issue.

In his dreams he is conscious of a- full orgasm and
free emission ; but he has never had this happen to
him when awake, — so that the only knowledge he
possessed, as to the nature of the complete venereal
act, had come to him in his dreams. He had never at-
tempted to provoke an emission by unnatural means ;
had never experienced any temptation or desire to do
so, and would not know" how to go about it.

The case of this gentleman was a novel one to me,
and I was able to suggest no remedy but circumcision,
as his prepuce w^as very long, and I thought that it
might interfere with the physiological performance of
the sexual function. This was done by Dr. Isaacs, but
the result was negative. The patient returned some

128

ASPERMATISM.

two montlis afterward, to report to me tliat Hs dis-
ability was still unrelieved.

I have never encountered a second well-marked
case of this curious functional defect ; nor have I seen
any mention of it by any writer in the English lan-
guage ; but, in the Traite de V Impuissance et de la Steri-
lite of Dr. Felix Eoubaud (Paris, 1855), I find several
cases, evidently authentic, detailed at length. Their
features coincide very exactly with those of the case I
have detailed. The inability to accomplish the sexual
act at will, although with perfect erection, and the
occurrence of full emissions during the unconsciousness
of sleep, are mentioned in all.

Eoubaud's treatise is thoroughly scientific in its
character, and one of the best works on the subjects of
impotence and sterility of which I have any knowl-
edge. He gives the disease the rather unsatisfactory
name of " Aspermatism," which is not literally cor-
rect, for it is characterized not by absence of the semi-
nal fluid, but by the impossibility of its ejaculation
under circumstances necessary to secure impregnation
of the female. It is described as an affection entirely
distinct from " priapism," and also from " erotomania."

A case is related by a Scotch physician, Dr. Cock-
burn, in his JEssais et Observations de Medecine
WEdimbourg^^'^ Paris, 1740. And another is to be
found in the Gazette de Sante^ No. 52.

The only pathological explanation which accounts
for all of the phenomena in this unusual affection
would seem to be an exaggerated spasmodic contrac-
tion of the muscular fibres in the walls of the ejacula-
tory ducts, leading to their occlusion under extreme
excitement. If another case of this kind should occur
to me, I would suggest the trial of a suppository of

DIAERH(EAS OF CHILDEEN, ETC. 129

opium and belladonna, and an attempt at intercourse
under its influence.

Art. III. — The DiarrhceaB of Children during the Sum-
mer Months, as observed in Private Practice. By
A. B. Aei^old, M. D., Baltimore, Md.

The liability of children of tender age to suffer
with diarrhoea at any season of the year — which is not-
ably increased dui'ing the hot season — is the concur-
rent experience of observers. In what manner the
high state of temperature during the summer months,
in the latitudes embracing the Southern, Middle, and
some of the Western States, acts as an exciting cause
in producing the serious gastro-intestinal affections of
children, may not be easily determined. Whatever
may be the nature of the endemic influence which
causes the sudden attacks of cholera infantum or its
more insidious and chronic form, it is, nevertheless,
indisputable that the occun^ence of this tyjae of disease
is limited to the summer months. No fact is better
established than the certainty of the beneficial effects
which an interval of cool and pleasant weather will
exert in even the worst cases of infantile diarrhoea.
Much importance has been attached to the opinion
that the hot season induces a predisposition which
favors the development of grave disorders of the ali-
mentary canal of children from slight causes. These
have been sought for in errors of diet, the irritation of
dentition, and confinement in a close and damp atmos-
phere. All these conditions, as well as all unfavorable
sanitary influences, act undoubtedly as morbific causes,
but it still leaves unexplained in what this predispo-
sition consists which excessive heat induces. There is

130

DIAEEHOEAS OF CHILDEEN

some plausibility in the inference deduced from the
physiological law of vicarious functional action, that the
over-stimulation of great heat interferes with the se-
cretive powers of the skin, and thus excites the mucous
lining of the stomach and bowels to a morbid activity.
It is highly probable that this relation is far more in-
timate in children than in adults, which, perhaps, ac-
counts for the frequent intestinal catarrhs to which the
former are subject. In this connection the significant
fact should also be mentioned, that the altered state of
the liver, which is so constantly found in persons who
have succumbed to the j)ei'iiicious dysentery of the
tropical climate of the East Indies, has also been ob-
served with great frequency in children who have died
of cholera infantum. There is no difficulty in believ-
ing that a number of the common diarrhoeas met with
during the summer owe their origin to a cause of this
kind, but still the well-known peculiarities of our in-
digenous infantile diarrhoea cannot thereby be satis-
factorily explained.

A curious fact presents itself, in studying the etiol-
ogy of cholera infantum, with regard to age. While
this disease exclusively attacks children, it is strange
that Asiatic cholera, to which it bears a striking re-
semblance in many of its symptoms and pathological
changes, spares as a rule the period of childhood. Both
diseases, in even the rapidly-formed cases, are frequently
preceded by a slight diarrhoea or cholerine.

Among 63 carefully-noted cases during the months
of July and August of 1867, in which diarrhoea of
some degree of severity and obstinacy was the most
prominent symptom, I found that there were 22 male
and 41 female children. Their several ages ranged
from 3 J to 24 months. This number is, however, too

DUEma THE SUMMER MONTHS.

131

small to infer from it tliat sex exercises an etiological
influence in predisposing children to tlie diarrhoeas
prevalent in hot weather. Contrary to what might have
reasonably been expected, 38 of these little patients
suckled at the breast, and 23 were weaned.

Acute Cholera Infantum. — It is remarkable how
frequently children will rally from the terrible stage
of collapse which the sudden invasion of cholera infan-
tum causes in a very short space of time, although a
troublesome diarrhcea generally follows. The exciting
cause of this disease seems to act in the manner that
a corrosive poison primarily affects the mucous coat
of the stomach and bowels; and it is singular that the
indications of pain should be absent, for the jactitation
and restlessness, which alternate with short naps of
sleep, indicate the intense thirst which tortures the
little sufferers. No amount of drink is able to quench
this thirst, but the liberal allowance of cold water or
ice seems to satisfy it for the moment. The repeated
vomiting and purging seem to be accomplished by
spasmodic jerks and to drain the system like a profuse
haemorrhage. One of the most hopeful signs of a fa-
vorable reaction, according to my experience in these
cases, is the change of the great pallor of the face to a
lively yellowish tint.

A most treacherous form of diarrhcea is sometimes
met with, which greatly resembles this disease, but
which proves itself to be the brief prodromic stage of
a fatal meningitis. The victims of it are children
above two years of age, a circumstance which may aid
in the diagnosis. It commences either with a painless,
bloody diarrhoea, or with copious serous discharges
of an irritating quality. The vomiting comes on at
considerable intervals, but nausea or effort to vomit,

132

DIAEEHCEAS OF CHILDEEN

in younger children, is constant. Delirium, convul-
sions, paralysis, and coma follow each other in rapid
succession.

CHEomc Choleea IiTFAisTTUM. — Under this head I
intend to include all the diarrhoeas of children occur-
ring during the summer months, which pursue a pro-
tracted course, whether they be ushered in by acute
symptoms or gradually assume a serious character.
The mildest diarrhoea during the hot season should be
speedily arrested, and if such prompt medical interfer-
ence is insisted upon by Bouchut, who recommended
it to European practitioners, it applies with yet greater
force to the American physician, who has to dread the
insidious approaches of a notoriously intractable bowel
affection, that so often commences with a trivial diar-
rhoea. As long as the infant continues to emaciate and
retains the dryness and sallowness of the skin, however
much the evacuations may have lessened or improved
in appearance, it is not prudent to announce the es-
tablishment of convalescence. Exacerbations, amend-
ments, relapses, and complications, surprising recoveries,
and unexpected death, make up the history of this dis-
ease. At any moment the fearful symptoms of invagi-
nation of the intestines may show themselves, or the
ghastly features of the last stage of a fatal enteritis
may arrest attention, or the first unmistakable signs of
cerebral mischief may blast the hopes of the intelligent
and watchful mother.

Very little information can be gathered from the
state of the pulse, the febrile movements in this disease
being best judged by the rise and fall of temperature
which the back of the hand feels, when applied to the
head or over the abdomen. Neither do I believe that
much reliance can be placed on the nice diagnostic

DUEING THE SUMMEE MONTHS.

133

distinctions, based on the frequency, color, and con-
sistence of the evacuations, as there is little constancy
in these appearances. It is, for instance, just as likely
that the profuse serous discharges, or the colorless sago-
like bodies that smm in a watery fluid, may be owing
to some change of innervation of the sympathetic sys-
tem of nerves as to the morbid anatomy of some of the
abdominal viscera. Nothing positive is known con-
cerning the manifold changes of color which the biliary
secretion may undergo in the intestinal tube, in order
to determine the diagnostic value of the variable tints
of green and yellow which the excrements of the bow-
els so frequently exhibit in these chronic diarrhoeas
of children. No answer can be given, in explanation of
the clinical fact, why the pale-yellow, flat, and somewhat
round little cakes of fecal matter are nearly always
accompanied with colicky pains. The great probabil-
ity that the large mucoid discharges of a dark-brown
or reddish-looking color, and of a very offensive odor,
indicate a gangrenous condition of a portion of the in-
testinal mucous membrane, is inferred from the sudden
collapse and speedy death which have been so often
noticed to follow these untoward symptoms. Strain-
ing of the anus is often enough observed, especially if
the discharges are small, mucoid, and tinged with blood ;
but that degree of tenesmus characteristic of the dys-
entery of older childi^en and adults is seldom noticed
in the bowel affections of infants.

Ceeebeal Complications. — A great source of dan-
ger in these diarrhceas is the frequency with which the
brain becomes involved. This is probably owing, in
many cases, to the liability of the nerve-centres of
children to be sympathetically affected during the
course of any grave disease. In a number of instances,,

134

DIAEEHCEAS OF CHILDEEN

however, it will be found that, on close inquiry, no
urine had been voided for some time, and direct ex-
amination will prove that the bladder is empty. The
head symptoms, the convulsions, the coma, are here
owing to ursemic poisoning, which reminds one of a
similar state of things characteristic of the dangerous
reactive stage of Asiatic cholera. It requires consider-
able care and attention to interpret correctly the first
faint signs of brain complication in these cases. A
continued heat of head and abdomen, while the extremi-
ties feel cool, ought to cause much anxiety. The sink-
ing of the abdomen is very significant, and, when the
head at the same time is found to bend slightly back-
ward, convulsions are near at hand. The abrupt stop-
page of the diarrhoea for 24 hours is much to be dreaded.
The hydrocephalic cry, of course, cannot be misunder-
stood, but very frequently a somewhat similar symptom
makes its appearance, which is of equally serious im-
port. After the child has lain j)erfectly still and has
apparently enjoyed a sound sleep, lasting perhaps not
longer than ft^om three to five minutes, it will sudden-
ly arouse, look about as if afraid of something, become
very restless and moan, and no effort of the nurse or
mother can pacify it, until the paroxysm of pain in the
head, which it evidently is, shall have subsided. This
condition of things may last for days, but is sure to be
followed by the more declared symptoms of cerebral
complication. Sometimes the child wdll stuff its mouth
with the fingers and make attempts to cough ; or will
move one of its hands or arms in an unusual manner,
repeating the movement at regular periods. Occa-
sionally it bites the nipple and cannot be easily made
to relinquish it. These and other symptoms, which
are so often witnessed in cases of tubercular meningitis
of children, ought to direct attention to the head.

DTJEma THE SU3I1VIER MONTHS.

135

Peogi^osis. — There is a real phtliisis of tlie alimen-
tary canal in these summer diarrhoeas of childi'en. The
emaciation that attends them is frequently extreme,
and gives to these poor patients a hideous appearance.
Some of the signs of inanition and several other j)oints
of prognostic value in these cases deserve to be no-
ticed. The rough, wrinkled, dirty-looking skin, all
over the body, but especially when the temples and
forehead have the aspect of dried specimens of anatom-
ical preparation w^hich are covered by a pale glazing,
indicates the last degree of emaciation. If the skin
looks rather folded than wrinkled, and still feels soft
and yielding, the case is more hopeful. A dry, brown,
loaded tongue, or if it looks as withered as the lips, is
of evil augury. The same may be said of the pale,
pinky lips and gums, which appear as if they had been
smeared over by a thin layer of light-colored varnish.
When the partially-open eyelids during sleep remain
shut for some time after they have been closed by the
fingers, death is near. Ulceration of the cornea, aphthae
of the mouth, and excoriations of the anus, are, as usual,
the forerunners of a fatal termination. A cheerful look
and an occasional smile are hopefal signs, although the
diarrhoea may not have abated, and the emaciation be
considerably advanced.

Treatment. — I know of no remedy which is better
retained and puts a stop to the incessant vomiting of
cholera infantum sooner than often-repeated teaspoon-
fuls of mint julep. Cold water and ice ought to be
allowed ad libitum^ and no regard should be paid to
their immediate rejection by the stomach, for the sooth-
ing effects obtained and the relief they give will soon
become apparent. Sinapisms and irritating embroca-
tions to the epigastrium I consider worse than useless.

136

DIARRHCEAS OF CHILDRE1S-, ETC.

But soft woollen cloths, wrung out of warm water and
wrapped around the child from the axilla to the toes,
I found to be grateful to the little patients, and to pro-
mote in a short time a healthful reaction. From two
to five grains of the subnitrate of bismuth, every two
hours will be soon retained by a child under two years
of age. The dark stools, of much less frequency, show
that the medicine does good. The property of bismuth,
of adhering tenaciously to mucous membranes, makes
the drug very serviceable as a toj)ical sedative, be-
sides the constitutional medicinal effects which it is
believed to exercise on irritated and congested mucous
surfaces. In the protracted forms of diarrhoea, and
especially in cases accompanied with much pain, this
property of bismuth has the additional advantage of
enabling the physician to combine with it Dover's
powder in smaller doses than it is indicated ; for the
entanglement of the opiate with the bismuth allows of
its longer retention, and consequently fuller absorption
by the stomach, nor is it so apt to cause nausea, when
thus combined, as when given alone. The timidity
of administering opiates to very young children I do
not share, and I can add my testimony to the highly
beneficial effects often derived from them in the obsti-
nate diarrhoeas of children. When emaciation begins
to show itself, the mild ferrugiQous preparations as first
recommended by Dewees can safely be given. I give
the preference to the following prescription :

^ . Ferri et Ammoniaa citratis, 3 ss.
Tinct. Calumb^D, ) ^^^^^
Tinct. Nucis Vomicae, j
Saccli. albae, 3 iij.
Aquae, | iij.

M. et Sig. Give a teaspoonful three times daily for a child be-
tween one and two years of age.

GETTYSBUEa MTNEEAL SPEEtfG.

137

Frequent tepid baths and persistent sponging of the
head and abdomen, wlien these parts show any increase
of heat, do excellent ser^dce.

Art. IV. — ^'^otes on tlie Waters of tlie Gettysburg
Mineral Spring. By Johx Bell, M. D., Philadel-
phia, Pa.

Or the various fashions that bear sway at the pres-
ent time, the free diinkino; of the waters of mineral
springs is decidedly in the ascendant. Even if carried
to the extent of di^enching, it is vastly preferable to the
excessive di-ugging to which, it must be confessed, both
physicians and j)atients are too j^rone. We need not
enlar2:e on the collateral benefits derived from visitino-
mineral springs, in the change of air and scene, agree-
able society, and freedom fr^om the cares of business
and professional toil. But while thousands annually
turn these advantages to account, in the pursuit of
health and pleasure, a still larger number, the majority
in fact of oui' people, find it necessary to stay at home,
and, as they cannot go to the springs, they do the next
best thing, and have the waters brought to them.
Until recently, the chief mineral waters obtainable in
this way were the far-famed Saratoga, the Blue Lick,
and the Bedford. To these may now be added the
Gettysbui'g, the Welden, the Eockbridge Alum, the
Missisquoi, etc. To enter into a comparative view of
the therajDeutic value of these different waters would
lead us into disquisitions for which we have, just now,
neither time nor room ; and we shall content ourselves
with noticing one, ^t^z., the Gettysburg Mineral Sj^ring,
which of late makes large claims on public attention

138

WATEES OF THE

and receives large professional countenance. Putting
aside its fancied resemblance to the celebrated springs
of Vichy and Baden-Baden, both of which are highly
thermal, we see in the Gettysburg an alkaline water,
as is shown in the following analysis made by Profes-
sor Mayer, for a while assistant to Professor Henry, of
the Smithsonian Institute :

Bi-carbonate of soda

" lithia. . . .

" potash . .

" magnesia

" iron ....

" lime

Sulphate of lime

Chlorides

Silica

In an imperial gallon 266.30

This may be regarded as the maximum quantity of
solid contents of the water, the strength of which
varies, but the nature of the ingredients is unchanged.
It requires a knowledge of its mineral impregnation
to make us believe a priori^ that the Gettysburg water,
which has no more taste or smell than pure, common
water, possesses decidedly medicinal properties. But
after all, however much chemical analysis may seem to
indicate this fact, the proofs must depend on experi-
mental trials made with judgment and in good faith.
A summary statement of the cases of cure effected by
the use of the Gettysburg water, previously made by
myself, ' rests mainly on the averments of the patients
themselves, who write with evident sincerity and an
unmistakable conviction of their restored health being
due to the course pursued. When medical testimony

Grains Troy.

46.05

trace.

76.05
trace.

81.00

53.20
trace.

10.00

^ Medical and Surgical Keporter, Sept. and Oct., 1867.

GETTYSBUEG MINEEAL SPEING.

139

is offered, it is to the same purport. CoiQing down to
tlie plain matter-of-fact level, and closing onr eyes to
tlie wonld-be " marvellous " and " miraculous," as ap-
plied to the operation of this water, we cannot w^ell
deny its efficacy in the cure of certain not w^ell-defined
forms of dyspepsia and kindred disorders of the genito-
urinary apparatus, and also, in a more especial manner,
of chronic rheumatism and rheumatic gout, with often-
associated cardiac affections. A case of complication
of diseases of this nature, proceeding from uterine de-
rangement, has just been recorded by Dr. K. B. Weaver,
in which the drinking of the water at the spring was
soon productive of the happiest effects. The patient.
Miss M., when first taken to the spring, had to be car-
ried about like a child by her servants, owdng to extreme
debility and pain. She had a cough, which had been
pronounced by some of her physicians consumption.
Her first attack dated five years back, recurring at
intervals with greater or less severity, until it reduced
her to her present apparently hopeless condition. The
joints of the fingers, toes, and limbs were enlarged by
urate or chalky deposits." After the short period of
thirteen days in which Miss M. drank the water, " she
was enabled to walk with but little assistance from her
servant, and improved so rapidly in all respects that
she now appears to be permanently cured, being re-
lieved from the cough, general debility, and the irregu-
larities referred to, also the enlargements or chalky de-
posits around the joints. When she came to the
spring, she only weighed 61 pounds ; she now weighs
90 pounds. From a pale, sickly-looking, dispuited,
decrepit invalid, she has emerged from the chrysalis
condition into a young lady in the bloom of health,
youth, and beauty."

140

SUPPOSITIOI^^ OF TWO CHANGES OF

The direct operation from the Gettysburg water is
sometimes mildly aperient, but more generally diuretic.
One of its not infrequent effects is a slight vertigo,
which shows an action on the brain and nervous sys-
tem, that should prompt to trials of its curative powers
in the neuroses generally. While there are undoubted
advantages on the side of invalids who visit springs
and remain there to drink their waters, it must, at the
same time, be admitted that the stay-at-home drinkers
enjoy the benefits of a suitable and regulated regimen,
and regular hours, which are too generally denied to
the former or travelling class. The fact of the Gettys-
burg water retaining all its properties without change,
for any length of time, after its transjDortation from the
spring, is worthy of notice, and must serve to encour-
age those at a distance to its free use.

Aet. V. — On the Supposition of two Changes of Color
in the Bed Moocl—Bj E. K. Beowi^e, M. D., N. Y.

In the winter of 1861, duiing a term of study as
assistant of Prof. Austin Flint, Jr., I first had my at-
tention peculiarly fixed upon the subject I proceed
briefly to discuss. While I was intent upon a striking
experiment which that indefatigable physiologist has
made us familiar with — namely, the experiment of
passing defibrinated blood by injection through the
vessels of a pair of removed lungs — I was forcibly
moved by the question. Is there any other change of
color in blood than this being exhibited ? Since that
event, from time to time — occasionally for several
consecutive months nearly exclusively — ^the nature of
the change of color of blood has been a subject of

COLOK IN THE EED BLOOD. ' 141

study of always increasing interest. I was not long
in reaching conclusions in accord witli tliose I pre-
sent ; nor was I mucli longer in regarding the question
as being of commanding importance in the field of
physiology. But, in the end, I have come to regard
the proper knowledge of it as of superior importance to
that pertaining to any other subject of biological re-
search whatever, except, indeed, that of the nervous sys-
tem ; still I should never have ascribed the importance I
do to the truth, if new experiments, and thence a cor-
rection of the misapprehensions pertaining to former
ones, had not presented me with that various experi-
mental illustration which, I distinctly foresaw, would
be exacted to insure the conviction of other physi-
ologists.

Without this, I should have been excessively slow
to present what I conceive to be truths which not only
break up the fixed tenor of our beliefs in this direc-
tion, but show them to be fallacious in every particular
but one, and that unimportant.

Moreover, I was constrained to the conviction by
an invariable experience in such cases, that nobody
would be thanked, but rather the contrary, for bring-
ing others, whose sole consequence is based ujDon their
claims to knowledge, to a recognition of the errors
they had so long held.

Further, I felt confident that, if the truth, when
stated, came to be acknowledged, it w^ould be in such
an underhand way, either by an indifferent nod of
recognition, or one that " amounted to the same
thing," as would serve only to increase the sum of
what we already lament of this kind of scandalous
reception of imjDortant truths of science by reputed
adepts. However, the experiments to which I referred

142 SUPPOSITION OF TWO CHANGES OF

as recent are tlie first wMcli ever showed, in any obvi-
ous way, tlie precise fact of tlie character of tlie case
when oxygen leaves the globule, and the first which
spread such a light on previous experiments as to
make it perfectly easy to correct all the misapprehen-
sions they had in part confirmed.

What I have said of the importance of the sub-
ject is of itself plain, when it is considered that our
reputed knowledge of the blood is based upon our in-
variable belief in two changes of its color, and all date
from the days of Priestley. He is said to have demon-
strated that nitrogen, hydrogen, and carbonic acid, will
turn tlie hlood hlach ; and we hav e repeated the lesson
until the belief it embodies is so bound up in our
mental structure, that we shall probably begin by re-
garding the student who asserts the contrary as out of
his right mind.

Yet, Priestley's experiments never demonstrated the
reputed fact, for there is no such fact as that alleged,
and the blood is black without the slightest interven-
tion of either of these gases. Moreover, neither of
them will communicate from the air with the blood in
circulation, nor of themselves mingle with any part
whatever of it. It is not plain what fact Priestley's ex-
periments did disclose. The distinguished physiolo-
gist we named declares that " there is no evidence that
nitrogen enters into combination with the blood-cor-
puscle " (and might have as truly said the same of car-
bonic acid), while he quotes Priestley as showing that
nitrogen and other gases darken the blood by " dis-
placing the oxygen."

But, this much by way of preface. As it arose on
the occasion I named, seeing that the blood passed
dark red into the vessels of the insufflated lungs, and

COLOE IN THE EED BLOOD.

143

came out briglit red, the question was, Does any oilier
change of color occur in tlie blood ; or are there, as we
were taught, and believed, two changes of color ? Is
there, indeed, any change of color, except that made,
as here, by some normal constituent of the air ? This
was a question forced upon us, which traversed the
length, breadth, and depth, of all we had yet learned
upon the subject. We had all the learning pertaining
to it, which several years' rather diligent study of this
and other questions in physiology, and of authorities,
could give us, and yet here we were mentally waylaid
by a question as to whether this very knowledge was
true ; and from that moment we had no ease of mind,
until we had become as conversant with the subject
experimentally as we could. But our experiments did
not, at first, radically enlighten us ; for, as we after-
ward learned — a lesson the experiments did not teach
us — they started with unwittingly assuming, as a fact ^
the very thing itself which the experiment should
have determined, and which turned out to be the main
error in the case. This was, that the color of venous
blood is itself a change of color from another color.
We had not the requisite knowledge, then, nor for a
long time afterward, nor until we had experienced
many heartfelt bafflings, which enabled us to perceive
how it could be otherwise than we had learned.
Priestley supposed he demonstrated this, and all suc-
ceeding experimenters do the same. What he did, he
supposed, demonstrated the fact. To him, and to us
ever since, there seemed to be neither error nor sup-
position in the case, but a plaiu matter-of-fact " demon-
stration." Yet there loas such an error, as we shall
see.

The question then was. Has the blood two changes

144 suppositiojSt of two changes of

of color ? We believed, as all believed, that it had.
But it is j)lain that the first step toward an answer to
this question resolved itself into a second demand to
know what is the origin of these colors? We had
not, to begin with, the slightest suspicions respecting
them, except that the dark red was a change in the
bright red, and the bright red anoilier change in
the first. Had the blood a color which was not a
change ?

To find ourselves putting either of these questions,
was to give a character to the inquiry it had not be-
fore been endued with.

But, to abbreviate these private experiences in
quest of the truth. The answer which came to these
questions came to their eventual form, which was.
Have not the blood-globules a color from their very
biiih and formation — a color, namely, which is inherent
in their organic or anatomical unity ? The globules
which color the blood cannot have been originally
without color, because, in that case, they would now
be, like the white globules, uncolored. Muscular fibril-
Ise have a color. As the uncolored globules are in
constant contact with whatever gas the liquor san-
guinis contains, but have no color communicated to
them thereby, how can carbonic acid — one of these
gases — color the other globules? It cannot, unless
they have color beforehand. Of course I looked for
the substances ivithin the body and within the blood,
to account for whatever could be found respecting this
coloration of the globules, and not to a substance out-
ride of it, like oxygen.

By this time I began to suspect I had been look-
ing away from the true source of the color, for the
question recurred as to its origin. To this ques-

OOLOE IN THE EED BLOOD.

145

tion there could be but one answer, which was, that
the red globules had a definite and distinct coloration
from the beginning, i. e., by formation. In the nature
of the case there could not be the slightest misgiving
about this answer. I need not detail the further in-
tellectual operation which ensued uj)on this, but at
once proceed to state what I have long conceived to
be the truth in its completest form, and what abun-
dantly vindicates my assertions of the nature of the
suppositions we habitually hold upon the changes of
color in blood.

What is the fact, real or reputed, now, about the
colors of the blood ?

First of all, it differs from any other fact of color.
It is unlike common facts of color. About them there
is never any mistake nor uncertainty, nor any mys-
tery, except what may be alleged of the origin or ex-
istence of any thing. Sense notes one color here,
another there. It is a simple distinction which en-
tirely exhausts the facts in the case. Here is one kind
of coloration, there another, or other kinds ; there is
nothing unusual in the case ; there is no " change of
color." But the colors of the blood are different from
this — they are unusual^ and hence we speak of them
as a change of color.

But does this difference between these two cases
exist to the entire exclusion of any similarity or com-
munity, such, for instance, as exists between Prussian
blue and vermilion ? We have never supposed that
there was any such similarity ; for it is an invariable
supposition that color of the blood has not, like other
cases of colored bodies, an origin hy itself^ but that it
only exists, each from the other, by constantly-repeated
and frequent variations. And thus our invariable

146

SUPPOSITIOISr OF TWO CHANGES OF

(but erroneous) estimation is, tliat the bright red
arises from some cbange in tbe dark red, while that
arises from some change in the former.

But let us see if this coloration of the blood have
not an origin and existence too, similar to other in-
stances of color, outside of the circulation. Whatever
change it may have, whatever difference therefrom, let
us see if it have not^ at least in origin^ also a similar-
ity with other instances of color.

Where does this color of the blood reside ? In the
blood-corpuscles ! These are bodies which have been
made, formed, or constructed.

In being made, they are organically or structurally
endued with color. Otherwise, they are made miQol-
ored. But the globules made uncolored exist as
made ; and the striking difference between these and
the red globules is, that the latter are endued with
coloring matter or substance. And they^ being made
colored, will so continue to exist.

It thus turns out that the red globules, apart from
any change, are colored ; and that, in the origin and
incorporation or embodiment of this characteristic,
they have something in common wdth all other colored
things of distinct origin.

Yet we have believed the contrary ; we have in-
variably believed, not only that, besides something in-
trinsic to them, they have something incidental to them
which is peculiar, but also that cdl which pertains to
their existence is peculiar and entirely tmique. But he-
sides this, which they share with all other colored
things, besides being like the latter, they undergo some-
thing which the latter do not. This something is, that
they experience a change of color in the circulation.

And the precise deficiency in our physiology is,

COLOE m THE EED BLOOD.

147

that we were invariably totally unrecognizant of, and
without tlie slightest suspicion of, this historic event —
once for all, of this organically grown and developed
color of the red globules ; while the change of color,
their current experience, what was incidental and
peculiar to them, have been our sole idea.

What Priestley, then, and all succeeding experi-
menters needed to have done, was to have identified
this color ; and to have done this as a bare fact re-
quired very little experiment. Instead of assuming
and supposing that, where this color was, it was a
change of color^ and then, mingling certain gases with
it, mistakenly attributing this color to them, as induced
by them, he should have corrected that very error, and
ascertained the fact instead, which he could easily
have done by showing that this color exists when not
in communfiication with any one of these gases, nor any
other gas. Or, if he had used a reducing agent to re-
move this color, precluding its immediate recovery of
more, he would infallibly have found that, even when
carbonic acid was not near, the dark color would have
returned. He could not experimentally have shown
what the color existed from, for he could not renew
the process of its formation in the globule; but it
was incumbent on him to have shown that these
gases did not produce nor induce it, instead of con-
fining himself mistakenly in the supposition that they
did, and thus have given us at least the negative fact,
in lieu of the false supposition.

It seems to us that the reader must, by this time,
have his eyes so very wide open, that he could pro-
ceed to formulate the entire truth without further help
from us.

He supposed that color existed as a change, and.

148

SUPPOSITIOIS' OF TWO CHAIS^GES OF

finding tliat it existed wlien these gases were added,
he attributed it to them.

As ivith this color of the Wood, by physiological
genesis, no two colors by production of carbonic acid
or oxygen can exist, which of the tivo colors of the
blood is it thus made ?

An infallibly satisfactory answer to this question
need not occupy us long ; but still, as both are said to
arise by ^' change," or conversion, though one of them
does not, it is incumbent to show which of them exists
independent of any change. It must alread}', how-
ever, have been seen that, as there cannot be two col-
oi*s by " production " or change, two changes cannot
exist. It must also be distinctly recognized that we
still suppose the dark color to be a change, and it will
not be until we make plain loMch color exists by gene-
sis (and hence not by change), that we may substitute
the fact, in the case of one, for the error.

In the experiment of Prof. Flint, if the insuffla-
tion be suspended while the venous blood be passed
through the lungs, change of color ceases ; the blood
is without change ; the successive incomes of oxygen
by insufflation are susj^ended. With the discontinu-
ance of successive additions of oxygen, change of color
ceases.

This change of color, therefore, is admitted. It
exists. Of the two colors, one of which has been jDro-
duced by genesis, this bright-red color cannot be that.
But the experiment shows that this has to be he2yt itp
by successive additions of oxygen, a substance from
without the body. This color, induced by change,
cannot be that by genesis, and, as there is no other but
the dark red, it must be the color by genesis.

Now, what stands in the way of our regarding this

COLOE m THE EED BLOOD.

149

as a perfectly satisfactory solution of tlie question ?
Nothing but our traditional and invariable belief that
carbonic acid is in tbe globule of this dark blood.
Perhaps no one of my readers has ever considered
that, as Dr. Flint says, " there is no evidence that
nitrogen enters the globules ; " so there never has been
any that carbonic acid ever did so. Nor does it.

No carbonic acid ever darhens the hlood^ nor ever
enters its glohules. And we need no experiment, nor
any undertaking of any sort, to show the truth. We
might say, as conclusive, that, as there is a color of
the blood by genesis, which is not this change, the
dark red must be that color. But we proceed to shoAV
that this dark-red color will exist when the blood re-
ceives no carbonic acid, when it contains none, and
when carbonic acid is not in the case. Our invariable
su^pposition to the contrary — our supposition, namely,
that there is a nearly constant mvolution of carbonic
acid in the globule, from which it is only occasionally
absent, from the force of expulsion by respiration — is
j^r^sumed in every experiment, has never been shown
by experiment, though experiments made under the
^:>r^sumption have seemed to sanction it. This suppo-
sition, itself unproved, will of course demand dis-
proval, or exact it to be shown that carbonic acid does
not, as supposed, occupy the globule. And this in
presence of these facts — first, that carbonic acid is a
substance always evolved, and never like oxygen,
which by its oato act becomes mvolved. And it is
evolved, not because of any inherent property or
quality to combine with other substances, but, on the
exact contrary, to leave them, because it is extruded
by the processes in the substances which produce it.
All, indeed, which can be formulated to the exact

150

SUPPOSITION OF TWO CHATTOES OF

contrary of its being able to impose itself, after evolu-
tion, within any substance, as oxygen does, is true in
tlie strictest sense of carbonic acid. Tlie plant takes
it up in tlie exercise of its physiological power to ap-
propriate elements of nutrition, of its own behest, only
to take away from it its carbon — showing that there
is no power inherent in it to hold its own, or main-
tain its own identity, and showing that it is, in the
nature of the case, devoid of the power to merge its
identity into, or fuse, or form a union with, another
substance, and, above all, with substances complete in
their own composition, like the formed elements of the
body. They might appropriate its carbon, as the
plant does, not its carbon them. But this, which is its
destination, can only be done by the tissue, hecmtse
the carbonic acid itself will do nothing in the matter.
It does not, of itself, even seek contact, or to commu-
nicate itself to other substances, and will not, of it-
self, even freely commingle with them ; but, so far as
their nature permits, even when brought into the
apartment with them, will remain apart. It is dead in
its passivity, being the mere " site " of sepulture of the
incautious oxygen which has taken hold of carbon in
the exercise of its invincible nature to combine, when
uncombined with other substances. Not even other
oxygen will displace that in the globule. And how
can this imagined clash of atoms between the two oc-
cur to the displacement of oxygen by carbonic acid ?
It cannot.

And this brief exposition of the facts is not only
very much to the point, but solely to the precise point ;
because it is this very inert compound substance we
childishly suppose to combine with the red globule of
the blood — a full, grand anatomical form — while all

COLOE m THE EED BLOOD.

151

our idea of tlie supposed cliange of blood to dark red
turns upon (indeed, is nothing else than, under the
name of cliancje) the bare supposition that it displaces
the oxygen from the red- blood globule, and thus mahes
the blood dark or venous. And the absurdity, philo-
sophically speaking, is carried to an immeasurable ex-
tent, when, in supposing this, we suppose it to leave
the tissues, where it is produced, at a very sensible re-
move or distance in any situation, and to travel un-
combined from the outside of the blood-vessels into
their interiors, and thence, meeting the plasma, trans-
poses itself to the globules — since the globules seldom
communicate directly with the internal surface of the
walls of the vessels — there displacing the oxygen from
the globule, and taking its place. This oxygen, which
we invariably associate with the globule as forming a
union with it — and almost invariably as forming a
union so irreversible as to fnse with its carbon to form
carbonic acid — we as invariably suppose is displaced
by carbonic acid, which never yet formed a fusion or
union with any thing. It would not be so preposter-
ous as this — so plainly adverse to the truth of things
— to suppose that the carbonic acid of the plasma ap-
propriated, or affinitized with, the oxygen from the
globule ; for the only error in this supposition would
be one of fact, the carbonic acid being no substance to
do this, or to affinitize at all. But to suppose it, in face
of its reticent characters, to enter into the dense sub-
stance of the globule replete with oxygen, and thence
without delay to displace it, is certainly remarkable,
and stands to reason. The supposition respecting the
carbonic acid staying in the plasma, and affinitizing
with the oxygen, we said above, was not so unscien-
tific as the other ; and we said so, because, ^Z" the car-

152

SUPPOSITION OF TWO CHAIS^OES OF

"bonic acid were a substance like others in the body,
unlike what it is, if it were a substance, the same as
others in the plasma, of a nature or physiological
character to affinitize with the oxygen of the globule,
and it with them, there being considered no impedi-
ment to this in the relation of the oxygen and globule,
then the oxygen would change contact from the glob-
ule to these materials in the plasma.

Now, this supposition, excluding the carbonic acid
from the transaction, and substituting therefor the
oxidizable materials of the plasma in solution — ^fluid
materials — is an exact statement of the facts, put in
the amended, form of the supposition ; and, being this,
shows at once all the circumstances of the case — of
what transpires, in capillary situations, in the expe-
rience of the globule with its oxygen, after leaving
the lungs — not only the circumstances or particulars
involved in the jpassing relation of the oxygen with
the globule, but its eventual one in the plasma ; and,
by a definite disclosure of particulars, shows that one
ordinary notion of ^' exchange " — of the oxygen doing
precisely what we suppose the carbonic acid in an oj)-
j)osite direction to do, namely, to traverse the fluid
from the globule through the capillary tissue, thence
further through interstitial substance to tissue, is an
unphysiological fancy, having no character, except
that the one supposition is the invented contrast to
the other — a " harmonious " fancy, and, as fancy ^ void
of fact.

The tlieory of " exchange " is a compendious name
for the same supposition respecting the displacement
of oxygen. But the carbonic acid never enters the
plasma in this imagined way, nor does it ever enter
the globule. It enters the plasma — not at all by itself,

COLOE IN THE BED BLOOD.

153

but as in, and transposed by, the fluids whieli move
from the tissues into the plasma — almost entirely ; first
into the lymph-canals and vessels, and thence into
the blood. This, and not the globules, is its physi-
ological destination in the body. Neither, on the
other hand, does the oxygen traverse into the tissues
in this imagined way, nor first communicate with
them, nor ever appear amidst them in that free way,
but only as transj)osed to them in combination with
the materials of the plasma ; its eventual destination
is the latter, though, no doubt, it also, mth plasmatic
materials, goes to the tissues. Nor are we to suj)pose
the oxygen travels from the globule to new situa-
tions in the plasma; it does not travel away from
the globule, or make any excursion. The plasma is
on every side in contact with the globules, and with
it the oxygen unites or combines. That it is not
still is simply because the plasma moves, and the car-
diac impulses and arterial reactions cause interior com-
motion of the materials of the fluid.

But what is the case as we now regard it ? Suj)-
posing there is an impediment to the oxygen leaving
the globule (in case we do acknowledge that it does
leave the globule, which we not seldom contradict),
and seeing no exact unity of event between this leav-
ing and the dark color, but imagining an identity be-
tween it and the incoming of carbonic acid, we im-
agine the latter to arrive from the tissues, dispossess
the globule of oxygen, and establish an intermolecular
relation in it ; and all this without the slightest en-
couragement of the globule itself. And this also
when we imagine the same carbonic acid soon af-
ter to leave the globules, unimjDelled, undislodged
therefrom, for the air in the lungs. And this im-

154

SIJPPOSITIOIS^ OF TWO CHANGES OF

agined circumstance, closing in this imagined act, we
suppose, darkens the blood. How can we indulge our
imaginations to this extent in the presence of facts ?
One of the most rousing facts which strikes the stu-
dent, in conceiving our representations of this 'sup-
posed origin by carbonic acid of the venous hue, is
the confessed absence of any recognizable circum-
stance of a chemical character, or of any similar char-
acter in the globule ; and this absence of, or want of,
such character (which is, in truth, only another name
for the absence of any event as imagined), we call
" conversion ; " for both the globule and carbonic acid
confessedly maintain their complete integrity, and sep-
arate iinclianged.

This imao'ined chano-e from red blood to dark is
what Priestley " showed." But by the removal of oxy-
gen fr^om the globule with any reducing agent, to the
exclusion of any carbonic acid in the area of that opera-
tion, he would really have shown the fact, that the
dark exists in the absence of the latter. The truth is,
the blood undergoes no change at this time, being dark
because of cessation of j^rior change to red, and recon-
tinuing the same hue on cessation of tliat change. The
change occurs from access of oxygen ; and the recon-
tinuance of dark color, on loss from the globules of
oxygen.

After the reader has proceeded so far, let us ask
him what he now thinks of this notable want of any
change of a chemical character in this supposed change
of color by carbonic acid ? What does he make of
this want of change — the absence of any difference in
all the globules and in all its characteristics, after
the supposed change by carbonic acid ; such a differ-
ence as that which is signalized in converting starch

COLOE IN THE EED BLOOD.

155

into sugar, making it thereby another substance?
Nothing but the most entire inattention to this want
in the case, while we were alleging to exist what did
not exist in fact, could explain the absence of any
endeavor on his part to reconcile this lack of con-
verted substance with the rest of his theory, that car-
bonic acid enters and leaves the globule; for con-
sistency made it incumbent on him to explain that, as
the carbonic acid made no conversion of substance,
and made no change longer than it stayed in the glob-
ule— which was thereafter, as it had been, of uncon-
verted substance and color — the simple loss of the car-
bonic acid from the globule was all the antecedent
needed for the globule to be of the same color as it
was before — namely, the bright red. If he had given
any attention to this 23oint, he could not have failed to
see that, if this supposition of carbonic acid darkening
the blood was true, this also was true ; and, if true of
carbonic acid, was true of oxygen in making a change ;
for the globule remains precisely the same when the
oxygen has left it, as it Avas before, which is only
another name for saying that it remains dark red.

But to recur for an instant to our invariable habit
of supposing that between the atoms of oxygen in
the globules and the atoms of carbonic acid there
is a process of what we call " exchange " coincident
with the supposed darkening of the blood, meaning
thereby — as the elements of this transaction — the car-
bonic acid arriving at the globule, and, conversely, the
oxygen from the globule arriving at its destination in
the tissues. From the moment we became intellectu-
ally persuaded that this was fabulous, that there was
no such excursion of atoms of either one or the other,
we had not the slightest peace of mind until we had

156

SUPPOSITION OF TWO CHANGES OF

devised an experimental disproof of tlie alleged fact.
At first sight, and for a long time, it seemed im-
possible to make a demonstration of tlie trutli. The
things which we habitually, and indeed invariably,
believe and teach as knowledge, have rarely been de-
monstrated ; and so in this case. What was demanded
to appease the craving for truth was, to show whether
these atoms of carbonic acid on the one hand, and
oxygen from the globules on the other, did come
and go.

The exj)eriment w^e at length devised may be
briefly recounted thus :

If into the pulmonary vessels of a pair of removed
lungs, being insufflated, a stream of arterial blood from
the vessels of a living animal be transfused, the stream
traverses the lung-vessels, and quits the extremity of
the vein, without the slightest change of color, and
hence without loss of oxygen. This experiment shows
that oxygen w^ill not, under these circumstances^ leave
the blood-globules and traverse the tissues. It de-
monstrates additionally this, that it will not leave
the globides, and go from the blood, and make an ex-
cursion even into tissues, which, from the air-vessels, it
constantly traverses to communicate with the globules,
or CO enter the blood. But these are not the circum-
stances under which we generally suppose atoms of
oxygen leave the blood to traverse the tissues. No.
But they are circumstances under which these atoms
from the blood would traverse the tissue, if they pos-
sibly could do so under any circumstances, or be made
to do so. No objection can be imagined against the
demonstration on this score ; for what is alleged shows
even more conclusively the demonstrated fact. The
tissues are tissues which hold the same relation to the

COLOE IN THE BED BLOOD.

157

blood as in other situations ; and more tlian that, they
are tissues which always are traversed by oxygen, hut
not hy oxygen from the blood-globules.

But it may be said that the oxygen of the in-
sufflated 2ivc prevented or opposed the exclusion. Ah,
indeed ! if oxygen be brought into communication
with oxygen of globules, can it be supposed to pre-
vent the latter from leaving the globule ? How rea-
sonable to habitually supj)ose that carbonic acid
enacts the work of forcing it out of and away from
the globule !

But the experiment was the same if the lungs were
insufflated with air containing too small a percentage
of oxygen to oxygenate the blood.

Of course we were satisfied that what the reason
of the case had made plain, the experiment had demon-
strated. This experiment, moreover, infallil^ly taught
us that the respiratory process was not " diffusion."
Here were all the supposed conditions of diffusion, and
no respiratory process.

Nor, on the other hand, it was found at the same
time, would carbonic acid travel through the tissue
from its situation into the blood.

But we must draw to a close. The experiment we
mentioned near the beginning may, without further
consideration, for form, be thus stated :

Years ago, Brucke showed that blood saturated
with oxygen, and situated in a vacumn, lost its oxygen,
and the dark color appeared. He himself appears
never to have apprehended the import of this phenom-
enon, but probably attributed the dark color to the car-
bonic acid in the jDlasma.

In the recent experiment, if a solution of red blood-
corpuscle from arterial or oxygenated blood in the

158

SUPPOSITION OF TWO CHAIS-GES OF

serum be entirely excluded from tlie access of oxygen
or air, it will be found to part witb its oxygen, and
the dark color supervenes. If tbe same experiment be
now repeated witli anotlier quantity of blood in serum,
freed from carbonic acid, tlie same result occurs. If
shaken up with aii-, the bright red returns, but after
a time will again " become " dark.

In this experiment no carbonic acid can communi-
cate with the globules, and yet, in the entire absence
of such communication, it will be dark.

But our common experimental experience furnishes
as plain a proof of the truth that this dark color is
Twt caused by carbonic acid. So wholly inconsiderate
is the invariable belief that the blood darkens by car-
bonic acid, that we mp])08e it in our experiences,
when the experience itself proves that it is not
so.

Thus, if we expose a coagulum of venous blood
to the common air, the oxygen of the air reddens it.
Now, what is the supposition here ? and what, after
the change, still continues the presupposition ? This,
that it was dark by carbonic acid. And, if asked
what induces it to be otherwise than dark, prompted
by that supj)osition, we say, some of the oxygen of
the ail' has displaced the carbonic acid. But this is
'wnsaying precisely all we have hitherto said about
the matter ; for we are habituated to say that car-
bonic acid " displaces " oxygen. In this case, there
are the most favorable conditions possible to devise
for the carbonic acid, if it he there, remaining in statu
quo^ and the blood staying dark red. The globule
itself has ceased its movement, and the carbonic acid,
as an inactive gas, must at least be able to continue
its contact with the globular substance, either Avithin

COLOR m THE RED BLOOD.

159

or without. This would suffice to limit the close con-
tact of the oxygen. If it is able to displace oxygen,
it must at least be able to occupy its place. Does it ?
Not a whit. Why not ? because it has never entered
into the globule, Now change the case. The blood is
reddened, i. e., the surface of the coagulum is bright
red; place carbonic acid upon the surface. Will it
enter the globule ? By no means ; not an atom of it
will do so.

But, in deference to the limit of our due space, we
must close.

To say all in one word : —

The organic coloration of the blood is dark red,
and is precisely that we know as venous color. This
color is not due to carbonic acid, or any gas. Its
whole history is, that it is invariably of this color,
with frequent interruptions, called a change, by the
access of oxygen. This change is the one only change,
frequently and times without number repeated ; this
change is the only extraordinary feature it has ; the
color which marks it is wholly incidental ; it is a mere
phenomenal change of and in the dark color, which
itself is wholly intrinsic ; it does not involve any
conversion " of the coloring substance of that color,
it does not dispel it, but is a mere change or passing
affection of it. The most unmistakable of all the facts
in the case is, that the red globules which leave the
lungs are not changed in either substance or form.
The oxygen leaves the globule, and, in leaving it,
leaves it of the color it was^ i. e., dark red. The blood
reddens ; it never darhens^ being dark in its very con-
struction, and never ceasing to be so, except when sub-
jected to oxygen.

To suppose it becomes dark, or is made so, is our

160 SUPPOSITION' OF TWO CHANGES OF

invariaMe misappreliension ; but it is mere superstition
in scientific matters.

Summary, — In order that there may not be the
slightest obscurity upon my meaning, let me here say
what I mean by " change " of color.

I mean simply that no new property in substance
or form, at the expense of some old one thereby de-
ceased or " converted " (or " changed " in the sole sense
in which we always use the word), has been made.
I mean, in terms from common parlance, that the col-
oring of the globule j)reviously in statu quo^ previ-
ously dark red, und^ergoes some phenomenal change,
some agitation, molecular motion, among its particles.
This phenomenon is no new statu quo instead of the
old one, i. e., the dark-red ; nor is it the revocation of
the old static quo and its decease or obliteration;
but only a transient intermption of the statu quo it-
self, which will immediately be uninterru^^ted, or will
again be a statu quo^ until again interrupted by the
disturbing oxygen. Now, the dark-red state of colora-
tion will continue interrupted, unless the oxygen be
admitted. It is no disturbance of the light red, nor
any second disturbance supervening on it ; because
the light red is simply this — a transient interruption
of it. This dark red is the perpetual sine qua non of
the frequent taking place of the change by which
itself is or becomes light red. But by this the reader
will not suppose me to say that the dark red is hidden
under or masked by another color or coloration ; what
I say preoiudie^ such a notion. If it were so, how
would this dark color recontinue — this static quo re-
sume ? Or how, indeed, would this interruption of
this statu quo^ this interruption — namely, the light red
— take place times without number ? Nor will the

COLOR THE EED BLOOD.

161

reader suppose me to mean this interruption of the
statu quo to be a new and different statu quo or effect^
but simply a j)henomenal disturbance in it. Tliis
dark red or statu quo of color is the very siue qua non
of the innumerable recurrences of "change" in it.
The change by oxygen, i. e., the light red, is an in-
numerable repetition of one and the same change ; it
is not innumerable clianges apart from repetition, but
an innumerable repetition of one change; and what
" other " there is, we mistakenly call " another change,''
meaning thereby a change in alternation with this re-
peated one change, having a like character originated
in carbonic acid, as the latter arises from oxygen — is
the statu quo of the dark red itself It is not re-
j)eated by successive comings to it, and leavings of it,
of carbonic acid ; it is organically made, not by the
incorporation of any gas^ nor to last for an instant,
but for the whole time of the organic unity of the
globular substance ; it must exist precisely as made,
as the genetically-formed permanent condition of the
light-red change. What can possibly be more plain
than this ? What can be more plain than that this
chano^e " is a transient disturbance in it ?
If the reader supposes it otherwise, if particularly
he has no idea that this can be, let him try the ex-
periment— the exjDeriment, namely, of a change which
is not transient, which is not a disturbance, as we rep-
resent this to be — and make a permanent change. In
this case he will infallibly find he has made a neio
statu quo of color for the old dark-red one. He can
easily do this by permitting the chemical union of car-
bonic oxide ^vith the globule ; and now he has substi-
tuted new oro^anic condition of coloration for the old

one ; he has substituted for the latter organic condition^,
11

162 STJPPOSITIO^T OF TWO CHANGES OF

in wliicli a cliange can take place, anotlier condition of
coloring in which no change can take place. Of course,
in the interests of the carbonic-acid theory, the old the-
ory of change, he will be apt to say to the result of this
exj^eriment : " Nonsense ! You have fixed its coloring
j)recisely as it was in the act, with oxygen ; you have
destroyed the globule." But if you had, the fact is of
itself the most emphatic testimony of the difference
between the organic condition of the coloring of the
globule, as it is made a constitutional condition, which
is in its character adapted to " change," and the fixed
and static condition of the same coloration, when, by a
permanent addition of substance to it, you have made
it a new coloration, and by this act of addition fixed
its coloring matter beyond all its primary adaptability
to change, you have made another globule out of the
old one. But even this ex]3erimental experience of
yours, which ought as much as any thing to educate
us into a j^erception of the truth, you cannot accom-
plish without the old globule and all its coloration,
and more than that, without first having in its i^rimary
and genetically-made coloration the innate character
for change. This latter alone is what enables you to
make, or is the very condition of your making, the
j)ermanent change by carbonic oxide. And so if a
change is made not permanent, not by carbonic oxide,
but by carbonic acid, as you sujDpose it incessantly to
be, it also must take place in the same condition of
coloration of the globule, and cannot precede the ex-
istence of that, and induce or produce it.

Look at the case now for a moment as if for the
first time.

Here is blood bright red ; there is blood dark red ;
they are both the blood of one i:)erson. What mahes

COLOR m THE EED BLOOD.

163

these colors ? As we have invariably been taught to
regard it, we could only reply : The light color is made
by oxygen, the dark by carbonic acid. But, says some
one less merely literal than his fellows, How is this ?
Carbonic acid and oxygen cannot form of themselves col-
ors ; and more than that, here is soft solid substance —
coloring substance. Ah, yes ! but the oxygen and car-
bonic acid do not form this sitbstance^ but color it —
form the color. Well ; but there is no color which is
not identified with substance — colored substance — un-
less it be the impalpable and bodiless rays of the
spectrum ; and besides this, if these gases are colors,
or communicate color, these colors, you are supposing
the substance to be otherwise ^^?zcolored; and such
substance neither carbonic acid nor oxygen can su|)ply
with coloration.

Then he might further inquire : How is it two col-
ors arise in the same bodies ? Oh, these are changes
of color ! But cluing es of color cannot occur, except
in what is already colored. As yet there has been not
the faintest stir of recognition of any intrinsic color
in the case. But, you continue, One of these col-
ors is a change in the other. Well ; which one ? Why,
the light red. What has formed the dark red, then ?
Oh ! that also is a chano-e of color in the lis^ht red.
This is to leave entirely out of the question the ex-
istence of any color in itself) i. e., which is not a change
in another, and which other is not merely also a
change. But the very embodiment of any change -
must be a substance or body in which it occurs.

And this coloring: substance must have in one
both these colors, as there is no third in existence,
and when this colorino- substance was made it was not
of two distinct kinds.

164 SUPPOSITIOIT OF TWO CHANGES OF

If there is no third color, Qiot a cliaiige in wliicli
tliese two arise as clianges in it, and no distinct two
coloring substances, one of those must be tlie coloring
substance of tlie color in wliicli the change arises, and
the other must be a " change " in it. As there cannot
be two changes, nor two distinct colors, unless one is
a change, one of these two colors must be the change,
and one the color in which the change arises.

It may be confidently averred that in this very ex-
periment you su]3pose rather than otherwise that you
have ^6'colored the globule, imparted or incorporated in
it additional coloration or coloring substance ; for this
is precisely the supj)osition we entertain of the fancied
addition of carbonic acid to the globule : thus sup-
posing that not the old coloring matter changed (per-
manently) alone exists, but has had that increased by
so much as the quantity of carbonic oxide infused.
Thus you suppose that a colorless gas, which cannot
cease to be that and become colored matter by any in-
cident of this experiment, makes coloring additional
to that beforehand in the globule. You doubtless
suppose this because you always assumed that car-
bonic acid adds coloration to the globule, i. e. dark-
ens it.

But what can be more adverse to the truth of the
case, and the evident truth, too ? But, if you cannot
make any thing additional in the way of coloration to
the globules by carbonic oxide, you cannot by carbonic
acid. The error of the supposition is, however, far
the plainest in the latter instance ; for, if the addi-
tional coloration by carbonic acid be the adding of
itself to that of the globule, the abstraction of itself
by its leaving the globule, it must be the abstraction
of the color which makes the supposed difference be-

COLOE m THE EED BLOOD.

165

tween it and bright red. Hence our attributing tlie
latter to oxygen is supererogatory.

But, for instruction's sake, let us suppose we re-
move the carbonic oxide. What, then, is the color of
the globule ? Not the same color ; not, of course,
bright red, for the oxygen is removed ; neither the
dark red, if carbonic acid does cause that, because it
also has been removed, and is eliminated from the ex-
periment. But does any one doubt, if we accom-
plished this removal of the carbonic oxide, that cmy
color but the dark red would reap|)ear ?

But, indeed, the whole truth of the case must by
this time be sufficiently obvious.

What simply there is to recognize here, is a color-
ing substance which, in a certain state of its particles,
is seen, when impinged upon by light, to be dark red ;
but if the particles be disturbed by the active agency
of some substance capable of communicating its ener-
gies to them, as oxygen, then it makes during its pres-
ence amid them such a condition, that the relation to
light is changed, and the globules present the altered
hue — the light red — we call another color, though it
. is only the same color clianged.

We may close this long discussion by a single ref-
erence to the character of the fallacy of seeing this
dark red as produced. We are so little accustomed to
correct the misapprehension the imaginative power
ascribes to sense, that a single example may be pointed
out here.

We suppose we see this dark-red color made. We
do not see what we suppose ; what alone is sensibly
discerned is the dark color ; see this dark red we do,
but not at all what makes it, nor how it is made.
What we sensibly discern is the dark red precisely as

166

SUPPOSITION OF TWO CHANGES OF

it is ; but as to its making, we 8U])])ose that, and pro-
ceed to attribute that to sense. The error lies in the
supposition, not in the organic fact of sight ; the fallacy
exists in the mental suj^position, and the mental
ascription of it to sense.

Accordingly, when carbonic acid is added to the
drawn blood, and the oxygen ceases its exclusive con-
nection with the globule, the light color thereby im-
mediately ceasing (not as a color hy itself] but as the
cessation of the change), the dark red supervenes or
^"^continues ; then, we already assuming it, suppose
this to be a change of color by carbonic acid. To see
or sensibly discern thi^ dark color to be made (exclu-
sive of our false supposition) would be to see by the
eye the carbonic acid or oxygen enter the globule ; to
assume that we see this is of course, as the reader
knows, imaginary. We thus see that the error arises
in the imaginative power, wMcIi ascribes to sense as
eyesight what the sense does not and cannot rej)ort or
see. The error is not in the organic fact of sight, but
in the mind, and here (and not in the field of sense)
must it be reversed.

Thus the dark red has no anterior color, nor any
other and posterior color dark red, but only a change
in its own hue ; hence, if the blood never met the 0x3'-
gen from outside its own channels, it would never be
of changed color, but only colored without change.
Surely no illustration is needed of this assertion,
though we may make one sufficiently striking.

The mass of blood itself is a perfectly-colored cir-
cuit revolving in certain closed channels ; it is by
genesis of a distinct, i. e., dark-red color. A certain
part of these channels is sMrted by a deep natural
basin.

COLOR IX THE EED BLOOD.

167

This open basin is fitted with an atmosphere of
gases ; between the blood and this atmosphere there
intervene the substance of the sides of the basin
and that forming the sides of the closed vessels ad-
jacent to it.

A certain j)ortion of the gas leaks through this in-
tervening tissue, and enters the blood ; it has a certain
effect on the blood passing there ; its color, in passing
this locality, becomes bright red, while it is always
elsewhere dark red. The gas from the basin does not
at first diffuse " or spread itself through the fluid,
but only joins the coloring matter of the blood. The
moment the gas from the basin comes in contact with
them, a change comes over their color ; this change is
an active phenomenon purely incidental to the flow ;
it lasts but a short time, or only so long as the gas
makes special contact witli the red corpuscles. Mean-
while these bodies which move in the blood are j)ass-
ing away from that portion of its vessels adjacent to
this basin of gas, carrying along some gas in contact
with them, to spread or diffuse it throughout the fluid.
This absorbs the gas, breaking its sj)ecial contact with
the globules, which are now of the same color they
were before the gas communicated with them, that is
to say, they are dark red. The gas-basin is the long
cavity.

Let us for a moment suj)pose the gas to make no
excursion into the blood, j)assing in the channels in
its near vicinity, but simply to permeate the interven-
ing tissue, and establish itself within and along the
interior surface of vessels against which the blood-
bodies pass ; and further, to suppose its influence on
them strictly confined to that situation as they are
passing. The influence is supposed to be done and

168 SUPPOSITION OF TWO CHANGES OF

over, before the blood lias passed from tlie portion of
tlie vessels involved ; tliiis supjDosed, it vrould be of a
momentary eliaracter, and involve no actual going off
with, the globules of the gas. But, as in this case the
blood would continue on its course without further
change, and he dark for ivant of it, so in the actual
event which differs only in lasting a little longer ; it
is precisely what it loas — dark red — the only difference
between the supposed and the real event being that
the oxygen proceeds with the globules until it is lost
in the fluid blood.

Now, in this phenomenon a j)ortion of the circuit
of blood is bright red, because some portion of the
blood ahvays in circulating is passing the location of
the gas-basin ; but, if we stop the leakage of the gas,
or withdraw it from the basin, the phenomenon in the
blood is wholly non-existent ; and, in reality, shortly
after it occurs it is non-existent for that portion of the
blood in which it has taken place, so ceasing or be-
coming non-existent (which is identical) for that por-
tion which, therefore, is a uniform dark red, with all
the circuit of blood between it and that situation of
the part next the gas-basin.

The bright-red color is a wholly incidental ]3he-
nomenon of change — a change, truly speaking — and
is not color which begins and ends, but the change.

Most unfortunately, we have never discriminated
where it was most needed — namely, discriminated the
thing changed from the change, and we do not merely
identify them as we ought to identify color with col-
oring matter, but, invariably supposing this thing^ hav-
ing incorporated within it the gas, to be the " change "
itself, w^e utterly fail to discriminate the change as
a wholly incidental or accidental transaction or ex-

COLOE m THE EED BLOOD.

169

perience, and instead thereof are invariaLly prompted
to name the thing itself, i. e., the globular coloring
substance, a change.

Hence our invariable habit of namino; the dark-red
thing or color a change, and of naming the bright red
thing or color another change, embodies the prevailing
confusion of two changes.

We thus identify what is merely incidental to the
thing, when it is named, as the thing itself — the dark
color is a " chansre " of color, and the bris^ht-red is a
change of color. Then, again, we leave entii^ely un-
identified the colors and coloring substance, and hence
suppose the former (and so state it) to be put in and
out of one and the same coloring; substance at the
pleasure of the gases. If we did discriminate, we
would identify the one thing which is the one color-
ing substance identical with color, and one change in
that thing as strictly incidental to it, and thus have
come into possession of the truth.

Surely, the nature of this globule, its self or self-
hood, it^ as an embodiment of formed coloring sub-
stance, is not a change — any change, if we discrimi-
nate what it really is, being merely incidental to this
thing.

Syrup of Lime in Rheumatism. [Boston Med. and Surg.
Jour., July 2, 1868.]
In a forraer number of this Journal we noted Dr. Buckin-
ham's treatment of acute rheumatism by the syrup of lime ; and
Dr. Carl Smith, of Kenton, Ohio, now reports fifteen cases
treated upon this plan, " using no other remedy," with a cure
in each case in from ten to sixteen days. It would be well for
the profession to make public the results attained by the use
of this agent, and especially to state, what Dr. Smith omits,
whether there were any cardiac or other complications in the
cases.

170

EEYIEWS.

Bcbiettrs.

Aet. I. — Diseases of Children. A Clinical Treatise based
on Lectures delivered at the Hospital for Sick Children,
London. By Tho^^as Hilliee, M. D. Philadelphia :
Lindsay & Blakiston. 1868. 12mo, pp. 402.

Ix his preface the author remarks that it had appeared to
him " tliat, although several valuable manuals on the diseases
of childhood were in existence in Eno-land, there was room
for a book treating clinically of the same subject." The
scope being thus defined, a systematic work could not be ex-
pected, since the author has confined himself to such cases as
most frequently present themselves in a hospital for children
past the age of suckling. Xo particular order of arrange-
ment of the chapters has been followed. The topics treated
of are — Pneumonia ; Pleurisy ; Tuberculosis, with particular
reference to its cerebral manifestations ; Hydrocephalus,
Acute and Chronic ; Diphtheria, Scarlatina, and Typhoid
Fever ; Chorea ; Paralysis ; Epilepsy, and Convulsions ; Rick-
ets ; Pygemia ; Ascites, and Skin Diseases.

At the outset are given a few pages of general considera-
tions on the peculiarities of the diseases of children and of
their treatment. The whole book is characterized by a brevi-
ty of style, often amounting to abruptness, though not carried
to the deo^ree of obscurino: the meanino^. The cases are chosen
with the view of illustrating as far as possible all the varieties
of the disease under consideration ; and the comments upon
them often contain valuable hints. The articles upon individ-
ual afi'ections generally begin with statistics gathered from the
Registrar-General's Reports, as well as from foreign sources,
regarding their frequency, mortality, age of greatest preva-
lence, etc.

In the chapters upon Broncho- and Lobar-Pneumonia, very
little tliat is decidedly original appears, but a fair digest of the
researches of others, up to the present time. Among the
points noted is an unexplained increase in the mortality in
England from bronchitis in children under five years of age.

EEVEEWS.

171

Figures quoted from Ziemssen show another curious fact,
viz., that in about ninety per cent, of cases of lobar pneumo-
nia, the decline in temperature begins on uneven days.

The article upon Pleurisy contains quite a variety of cases ;
the chief interest of the section is, however, with regard to
the indications for paracentesis thoracis. His opinion in re-
gard to the time of the operation is, that it should be resorted
to as soon as we feel certain that internal remedies have failed,
the danger of empyema (in children) forbidding delay : " On
the other hand, in a case of many months' duration, if the
patient is not suffering from dyspnoea and hectic, it will be
wiser to leave the side unopened, although it is much distend-
ed." These positions he defends hj cases in point.

The section on Rickets is of less interest in this country,
owing to the comparative infrequency of the disease.

The chapters upon Chorea, Pyaemia, and its connection
witli Otorrhoea, Epilepsy, and Convulsion, and xlscites, are quite
brief, some of the articles being little more than comments
upon the cases introduced. The remarks upon Skin Diseases
are confined to treatment, the author having discussed the
subject more completely in his well-known manual.

The articles upon Typhoid Fever and upon Paralysis are
more extended and of greater value, the former as assisting
toward the recognition of a disease too often mistaken, and the
latter because relating to a subject little imderstood save by
specialists.

Tuberculosis in general occupies a short chapter, while
tubercle of the brain and its meninges, with acute and
chronic hydrocephalus, fill quite a large portion of the whole
book.

In the chapter on Diphtheria, Dr. Hillier advocates the
theory of the identity of the disease with true croup. He
says: "I can detect no distinction between membranous
croup and laryngeal diphtheria." Again, Epidemic croup
is always diphtheria." He reviews Mr. Squires's article in
Peynolds's " System of Medicine," as well as Dr. Jenner's re-
marks upon the two diseases :

" The pointB of distinction insisted on by Dr. Jenner are,
that croup is a local disease, not contagious ; that it does not

172

EEVIEWS.

occur as an epidemic ; tliat it does not affect any large pro-
portion of adults ; that there is no albumen in the urine, and
that there are no symptoms of disordered innervation conse-
quent upon it.

" Let us look at these points seriatim. It appears to me as
impossible to maintain that croup is merely a local disease as
that pneumonia is merely local, or catarrh, both of wliich are
generally indications of a morbid constitutional state. As to
contagion, diphtheria is only observed to be contagious where
an epidemic prevails, or when a number of cases are brought
together in ill- ventilated hospitals. Croup, as well as diphthe-
ria, has been described as epidemic ; sporadic diphtheria is not
uncommon. Albumen has been found in the urine of pa-
tients with croup ; it is only quite recently that it was found
in diphtheria. The other two points (its frequent occurrence
in adults and its symptoms of disordered innervation) have
most weight in establishing a distinction; but, in reference
to these, it must be remembered that where diseases become
epidemic they are more liable to attack adults, who escape
when the disease is only sporadic ; and that a certain set of
symptoms often prevails in one epidemic, which has been ab-
sent in other epidemics of the same disease. This is illustra-
ted in the history of scarlatina, in different epidemics of
which, renal complications may be very general, or may be
almost imknown. Even when epidemics of diphtheria pre-
vailed in former times, the nervous sequelae were not noted ;
we have no record of these phenomena till a comparatively
recent period. It is quite probable that even if symptoms of
disordered innervation had followed sporadic croup in as large
a proportion of cases as they follow epidemic diphtheria, they
would not have been connected with the previous illness."

For practical value the chapter on Scarlatina is perhaps
the best in the book.

The work, as a whole, will please the reader if he takes it
just as it is offered, as a record of clinical experience. He
will find it a book that will afford him much information in
short compass, and accordingly valuable if he desires to re-
fresh his mind upon certain topics without employing time in
going over a number of authorities. One already expert in

EEVEEWS.

173

cliildren's diseases will fail to find miicli that is new to him.
Those who desire to have one book to tell them the whole of
the subject, will be disappointed.

The American reprint is rather careless in proof-reading,
bnt presents a handsome appearance.

Akt. IL — A Iland-'book of Vaccination. By Edwaed C.
Seatox, M. D., Medical Inspector to the Privy Council.
Philadelphia : J. B. Lippincott Co. 1S6S. 12mo,pp. 383.

This is a reprint of an excellent work. Dr. Seaton has ex-
tended his article on Vaccination, contributed to the first vol-
ume of Pe}Tiolds's System of Medicine," and written a very
thorough text-book on the science and art of vaccination. The
subject is exhausted, and yet there is scarcely a line but has
practical value. Although a general view of vaccination is
given in most systematic works on medicine, no separate trea-
tise has been published in the English language since Bryce's
'•Practical Observations on the Inoculation of the Cow-
Pox," in 1809, now long out of print, and generally forgotten.
The success of the operation of vaccination, seemingly so
simple in itself, depends on many niceties, the value of which
are but too generally unheeded by the practitioner. These
are particularly insisted on by the author. The principles
on which a Public System of Vaccination should be based,
are of interest and importance to the Avhole profession, and
are given with much precision and clearness. In Chapter
X. the question of Alleged Degeneration of Lymph, and of
Pecurrence to the Cow, is discussed, and the opinion given,
that lymph will not degenerate if due care be employed,
and that the vesicles produced now by Jenner's lymph have
the same character and course he described. The fact is men-
tioned that the lymph chiefly in use throughout England is
mainly Jenner's lymph. Dr. Seaton adds : " Ceely, who has
more knowledge of the cow-pox in the cow, and the effects of
cow-lymph on the human subject, than any other man in Eng-
land, was requested by the Medical Department of the Privy

174

EEVIEWS.

Council, in 1862, to inspect all the stations from wliicli lymph
was contributed to the Establishment. He met with abun-
dant evidence of the perfectly satisfactory character of the
lymph in use." He indorses, from personal observation, the
statement made by the National Yaccine Board, in 1854,
" that the vaccine-lymph does not lose any of its prophylactic
power by a continued transit through successive subjects, and
that it is a fallacy to predicate the necessity of resorting to
the original source of the cow for a renewed supply."

The Protection which Vaccination affords against Small-
Pox is largely and thoroughly examined in Chapter XI. Dr.
Seaton writes at the close of the chapter : " The evidence, then,
is conclusive, that the vast majority of mankind may, by a
single properly-performed vaccination, be rendered wholly un-
susceptible of any subsequent action of the variolous poison ;
and that in the minority, whose susceptibility to that infection
has not been entirely exhausted by the vaccine process, the
small-pox will, with rare exceptions, be so modified, that if all
the population were completely vaccinated, i. e., vaccinated in
the best way, serious and spreading small-pox would be but
little known among us, and entries of fatal small-pox would
be all but banished from our death-registers." We are told
that the present practice of revaccination aims not only (l) at
repairing whatever was irregular in the course of a primary
vaccination, but also (2) at supplying what was imperfect in
the amount of infection in cases in which the course of the
disease was regular, and further, (3) at extinguishing the sus-
ceptibility to small-pox which may remain, or may rearise, in
an indeterminate number of persons whose primary vaccina-
tion may have been complete as well as regular. It should be
done on all persons after puberty ; not only where the primary
vaccination has fallen short of the highest standard, but be-
cause it seems certain that, at or after this period of life, it may
give additional security to many whose original vaccination
has been complete, but in whom the susceptibility to variola
has not been exhausted, and who may contract the disease
after growing up. Fifteen years of age is the best time, for
the age of most danger from post-vaccinal small-pox is from
fifteen to twenty-five; and it should not be left to periods

EEVIEWS.

175

when small-pox is epidemic. These views do not stand on
any speculative reasoning, but npon broad grounds of obser-
vation and experience. The ability to stamp-out local out-
breaks of the disease is incontrovertibly shown, and the opin-
ion expressed, that " the spread of fatal small-pox, let it occur
when it may, must be taken as in itself a sufficient indication
of the apathy, indifierence, or incompetence of the local au-
thority within whose jurisdiction it takes place."

The final chapter, of the Objections to Vaccination, and
the alleged Dangers of the Practice, is particularly clear, able,
and convincing, and we especially recommend to such as may
have had their notions befogged by reading the discussions
which took place in the French Academy of Medicine in
1864. The admirable chapter on the Alleged Drawbacks from
the Advantages of Yaccination, by Mr. Simon^, in his Preface
to " Papers relating to the History and Practice of Yaccina-
tion " (1856), has been largely utilized, and its facts and con-
clusions put within the reach of all. We have only space to
quote Dr. Seaton's practical and common-sense view of al-
leged Syphilitic Invaccination :

" Suppose, however, that there existed risks of vaccino-syphilitic in-
oculation greater than I can allow to have heen shown, and that the occur-
rence is one that, under some unknown condition, might take place in a
properly-performed and careful vaccination ; what, after all, looking at
the matter in a plain, practical, common-sense way, do these risks amount
to ? Suppose TYe assume that in all the cases that have heen advanced,
except those in which, on the very face of the story, there was manifest
malperformance, the vaccination had heen properly done, what proportion
do these bear to the millions upon millions of vaccinations that have been
performed ? If men who have been all their lives professional vaccinators,
as Marson, or Leese, or Tomkins ; if men whose professional lives have
been s{)ent in the midst of syphilis, as Lee, or Acton, or Langston Parker,
have met with no cases in which syphilis originated in this way, the con-
ditions under which the occurrence can take place must ])e indeed of rare
exceptionahty. During the eight years in which there has been systematic
inspection of public vaccination in England, some millions of vaccinations
have been performed; but the inspectors have no knowledge of any such
accident having occurred in any one instance .... Tho, i[n,ngQv^ if indeed
there l)e any at all^ of communicating through vaccine-lymph^ as in an or-
dinary weU-'performed njaccination^ any other infection than its own, must
be so infinitesimally small, that, for all practical purposes, we may regard
it as non-existent " (p. 374).

176

EEYIEWS.

Art. III. — Conservative Surgery in its General and Success-
ful Adaptation in Cases of Severe Traumatic Injuries of
the Lirtibs^ with a Bejjort of Cases. By Albert G. Wal-
ter, M. D. Pittsbiu'g: 1868. 8vo, pp. 213.

In a paper commimicatecl to the Academie cles Sciences
some eighteen months since, its author, the eminent French
surgeon, Dr. Maisonneuve, starts with the proposition, that,
out of 100 deaths after surgical operations, 95 of them are the
results of poisoning by the septic properties acquired by the
blood and other fluids of the body when they are exposed to
the air. As Ave are more or less able to hinder the absorption
of these putrid elements, in that degree will the sm-geon be
successful in the treatment of open wounds, whether the
effects of accident or following operations. The first object,
then, is to prevent the contact of atmospheric air — the putrefy-
ing factor — with the wounded surface ; if this can be effectu-
al, then the greatest surgical operations will be done without
risk. The surgeon of the Hotel Dieu is a strong advocate,
therefore, for subcutaneous incisions, when practicable, and, in
severe injuries of the extremities and after amputations, he
believes that a simple and practical means has been discov-
ered by " the method of continuous aspiration." His appa-
ratus consists of a cap of caoutchouc, placed over the wound or
stump, and connected with an air-pump, by which all the air
in the bag is exhausted, any collection of fluids stopped, and
their putrefaction arrested.

For thirty years Dr. Jules Guerin's hobby has been the
dangers from the " oxidation of wounds." All the perils
following wounds, he has zealously and perseveringly con-
tended, are due to the evil influence of the oxygen of the
atmosphere upon the effused fluids about them. If they can
be protected from the poisonous action of the air, and the ills
of suppuration avoided, all will go well. If the wound is an
open one, involving the skin and subjacent parts, place it as
far as possible in the condition akin to a subcutaneous one —
hence his " Treatment of Exposed "Wounds by Pneumatic
Occlusion." He uses an apparatus like that of Dr. Maison-
neuve: vulcanized india-rubber envelo^Des, of various forms

REVIEWS.

177

and sizes, and adapted to every part of the body, are applied
over tlie wound, and introduced into a metallic receiver, which
is kept constantly exhausted.

Mr. Lister and ]\Ir. Synie, believers in Pasteur's theory,
and attributing the decomposition of the fluids in and about
wounds to the organic germs floating in the air, are as stren-
uous advocates for the exclusion of the atmosphere as either
of the French surgeons, opposing their antiseptic, or carbolic,
occlusion to the organic air-dust. Mr. Lister writes : " The
essential cause of suppuration in wounds is decomposition,
brought about by the influence of the atmosphere upon blood
or serum retained within them, and, in the case of contused
wounds, upon portions of tissue destroyed by the violence of
the injury. ... To prevent the occmTence of suppuration, with
all its attendant risks, was an object manifestly desirable, but,
till lately, apparently unattainable, since it seemed hopeless to
attempt to exclude oxygen, which was universally regarded as
the agent by which putrefaction was effected." {The Lancet^
1867, and this Journal^ vol. vi., p. 265.) Dr. Bohm, of Yien-
na, lately stated that he believed the good efi'ects of this meth-
od to be mainly, if not entirely, due to occlusion, for he had
got the same results by using chalk-soil without carbolic acid.

Another Frenchman, M. Bouisson, of Montpellier, having
a wholesome awe of the eftect of the atmosphere on wounded
surfaces, proposes to cover them with a protective film, pro-
duced by means of a current of air blown upon the exposed
flesh by a common parlor bellows. {X. Y. Med. Jour.^ vol.
iii., p. 152.) These apprehensions of ill, from the disorganizing
action of air upon the fluids about the damaged smfaces, are
widely spread amongst the profession.

Our author, Dr. "Walter, does not, however, share this
dread of oxygen, or fear the septic property of the atmosphere,
or of the organic air-dust, upon what he calls " the extravasata
and secreta" of wounds. He believes, on the contrary, that
pure air, like the rain -drops descending from the great lab-
oratory of heaven, the air — sweet, pure, and healthful," is as
" refreshing, invigorating, and gladdening " to fresh wounds,
as it is to all the inhabitants of this beautiful globe. Its

178

EEVIEWS.

free and nnrestrained access to wounds and injuries, then, can-
not be the cause of those direful complications — erysipelas,
phlegmon, gangrene, tetanus, phlebitis or pygemia — which are
known to ensue in so many cases " (p. 200). He admits, how-
ever, that poison is mxingled with the air in hospitals, and that
" the only antidote is the prompt removal of the patient to a
place free from all contaminating influence ; " advice very sound
in its way^ we admit, but not always capable of being carried
out.

We come now to the details of the " principle and prac-
tice," which, after "years of study and toil and " humble, la-
borious, and protracted exertions," have enabled the author to

add one more laurel to the hrow of Conservatism — bright,
enduring, and priceless as any she wears," and " by which a
whole class of injuries is rescued from mutilation, danger,
and death " [sic\. These we shall give in as nearly tlie words
of Dr. Walter as possible. In the treatment of injured limbs,
with main arterial and nervous trunks intact, although not
hopelessly mangled, such as are produced by the wheels of
railroad-cars or heavy machinery, by which the bones are frac-
tured and comminuted and the soft tissues lacerated or crushed,
it is of the utmost importance, in these cases, if conservatism
be attempted, that tirst of all free vent be given, by long and
deep incisions, in the axis of the limb, for the escape of the
•effused blood, wherever it may be, and that all attempts to
b)ring the soft parts together, when lacerated or cut, by stitches,
be strictl]/ and absolutely discarded. " Free, deep, and early
incisions (the more timely made the better) are, I aver, the
only measures, deserving of the name conservative, in injuries
of this character " (p. 11). By these means, and '* under the
genial influence of warm aromatic jpoidtices or fomentations,
assisted by general and local [?] supporting measures, which
diet and medication can afford to the system," our author sub-
mits that unequal success will follow the treatment of this
class of injuries, and is " forced to tlie broad, yet truthful con-
clusion, that only a very small number of severely-injured
limbs ought to be excluded from its blessings " (p. 14).

Dr. Walter then proceeds to give the evidence which is

to establish beyond the shadow of a doubt the rationality,

REVIEWS.

179

correctness, and success of a practice, novel, yet preeminently
sonnd," by publishing a number of cases — how many, we can-
not say, for we have not had the patience to count them, and
there is neither contents nor index to the book ; but they oc-
cupy one hundred and eighty-two pages out of two hundred
and thirteen. These cases are fully and well given, and de-
serve careful consideration on the part of the practical sur-
geon.

Were the context a little less aromatic, and the author less
enthusiastic and iterative, the work would stand a better
chance of careful consideration by the profession ; even by
such of it as may not be inclined to admit, without fm^ther
evidence, all that is now claimed by its parent for this " emi-
nently conservative and highly successful " practice.

Aet. TV. — Criminal Abortion j its Nature^ its Evidence^ and
its Law. By Horatio E. Stoeee, M. D., LL. B., &c., &c.,
and Feaxklix Fiske Heaed. Boston : Little, Brown & Co.
1868. 8vo, pp. 215.

Foe nine years Dr. Storer has devoted a good part of his
energies to the subject of Criminal Abortion, which has cul-
minated, he has reason to believe, in an agitation which is now
shaking society throughout our country to its very centre "
(p. 2). Be this so or not, by the steady pursuit of his object, and
his unflagging enthusiasm, he has fairly earned the brevet of an
" especialist." (Good words, like evil deeds, will sometimes
return to plague the inventor.) Had not some of the author's
able and fearless writings on the matter come in rather ques-
tionable shape, we should have no mind to abate a jot of the
praise he is disposed, from the pride of honest purpose and
measurable success, to give himself. He writes :

" Eight years have passed. Xot only has the medical pro-
fession been stirred to progressive action, but the outside com-
munity. Paper after paper on the subject has been issued by
medical men ; the religious press has become deeply interest-
ed; political economists have found, as has heeii indicated in

180

EEVIEWS.

a jprevious editio7i of this hook^ an explication of otherwise in-
explicable problems ; an impetus of the most powerful char-
acter has been given to the movemeut by the publication of
the author's two hoohs .... The importance of the subject is
rapidly becoming recognized by the legal as well as by the
medical profession; and extracts from the author's writings
upon the subject . . . have already affected the rulings of the
courts " (p. 2). [The italics are our own.] Like Coriolanus,
Dr. Storer may well exclaim, "Alone I did it." If he has writ
his annals true, society owes him a deep debt, and may he long
hear the still small voice of its gratitude.

" To thee

Our gratulations flow in streams unbounded."

Nor should we be too nice in measuring the real value of the
services so modestly claimed, remembering that —

" To observations which ourselves we raake,
We grovr more partial for the observer's sake."

"We now and then meet with a book of excellent matter, but
" in the phrase which might indict the author of affectation,"
and which more or less mars its usefulness. Others remind
us of the Great Frederick's aversion to Diderot's writings,
which, " tout intrepide lecteur " that he was, he could never
stomach. He wrote : " Diderot rabache toujours la meme
chose ; il y regno un ton suffisant et une arrogance qui revolte
I'instinct de ma liberte."

The authors express the hope that this work "may secure
the approval of the two great bodies of professional men, for
whom, as a manual, it was written ; " and which, we may add,
it deservedly merits.

It is divided into two parts. Book I. considers tlie sub-
ject from the stand-point of medicine, and is by Dr. Storer.
Aside from certain idiosyncrasies of manner and style, it is
well written ; all that can be said is fully and w^ell said. Dr.
Storer contends that public opinion, both in theory and prac-
tice, fails to recognize the crime, and that it essentially denies
the true character of the offence. Of its great and increasing
frequency in this country, convincing proof is given. " The
crime is fast becoming, if it has not already become, an es-

EEVIEWS.

181

tablislied custom .... "What are tbe causes of this general
turpitude ? (1) Tlie low morale of tlie community as regards
the guilt of the crime. (2) The doctrines of political econo-
mists. (3) The fear of child-becl. (1) The ease with which
the character of the crime may. in individual cases, be con-
cealed. (5) The unwillingness of its victims to give testimony
that would also criminate themselves. (6) The possibility of
their inducing abortion on themselves without aid. (7) The
ease with which the laws, as at present standing, may be
evaded. (8) The lack or inefficacy of judicial preventives ;
such as statutes for registration, and those against concealment
of birth and secret burials. (9) The prevalent ignorance of
the true principles of its jurisprudence, in both government
officials and medical witnesses. (10) Social extravagance
and dissipation.

Dr. Storer concludes his portion of the work by examining
whether, and in what manner, the difficulties in the way of
suppressing the crime of abortion can be overcome. To the
question if it can be at all controlled by law, he does not
hesitate to give an unqualified answer in the affirmative. " It
is evident," he says, " that, in aiming to suppress this crime,
the law should provide not mereh^ for its punishment, but in-
directly as well as directly, and, so far as possible, for its pre-
vention . . . and this is to be accomplished by a twofold pro-
cess: by rendering, on the one hand, its detection more
probable, and, on the other, its punishment more certain" (p.
141). To effect these ends, the importance of strict registra-
tion laws, and laws against concealment of births and secret
burials, is pointed out. The establishment of foundling-hos-
pitals by the State governments, it is believed, will prove one
preventive of the crime. A control of the public press, so far
as the present system of openly advertising by abortionists is
permitted, is urged. And, finally, less technicality and more
directness in the statutes themselves.

Book II., by Mr. Franklin F. Heard, views the subject
from the stand-pohit of law, which is thoroughly, clearly, yet
concisely, treated of.

182 BIBLIOGEAPHICAL AND LITERAEY isOTES.

De. Wildee, wlio is well known for his valuable studies in
moi-pliologj and comparative anatomy, liere^ gives a most
interesting paper, the object of wbicli is to impress upon otbei*s
the value of every fact relating to this class of cases (poly-
dactylism), to suggest a general method of recording such
cases, and to indicate, in a general way, the direction which
we may expect will be taken by the final results of a much
larger number of cases than are now recorded.

In this paper Dr. Wilder confines liimself to what is
called sexdigitism, or the presence of a single supernumerary
finger or toe. Of such cases he has collected, from various
sources, one hundred and fifty-two instances, and from an
analysis of these he has deduced some most interesting con-
clusions. These studies at the present time, when the scien-
tific world is flooded with theories as to the nature, causes,
and significance of the variation of organized beings, have a
peculiar interest ; and now, of all times, is it necessary to
bring in careful observation and large collections of facts, by
which we may either test these existing theories, or upon
which we may fomi more rational conclusions.

To aid in this important study. Dr. W. has prepared a
blank form for the record of cases, and calls upon the profes-
sion to aid him in the collection of facts. Copies of this
blank may be procured of Dr. Wilder, by addressing him at
his residence, Cornell University^ Ithaca^ Xeio York. We
hope our readers will respond cheerfully to this request, and
thereby assist in the prosecution of a most instructive line of
study.

In the last number of the Journal we published a sharp
notice of a pamphlet by Dr. Blackman, of Cincinnati, said
pamphlet being mainly a charge of plagiarism against Dr.
Bartholow, of the same place. The whole tenor and purport

' Extra Digits. Bj Burt G. Wilder, K D. Extracted from the Pub-
lications of the Massachusetts Medical Society. Vol. ii., Xo. 3, 18G8;
pamphlet, pp. 22.

BIBLIOGEAPHICAL AXD LITEKAEY KOTES.

183

of that notice was directed against tlie style and manner of
tlie controversy between these two gentlemen, and was equally
severe on both. Dr. Bartholow, however, thinks we have
done him an injustice in the matter of the charge of the pla-
giarism. We therefore cheerfully insert the following circu-
lar, which he has been kind enough to send us, and which, we
are pleased to learn, has been accepted, by all parties con-
cerned, as a final adjustment of this unpleasant and unpro-
fessional controversy :

Peof. R. Baetholow, M. D.

Deae Sie : I understand that you are about to publish a pamphlet in
reply to one issued by Prof. Blactnian. The olfensive personalities wliich
have characterized this discussion are unprofessional in themselves, and
injurious to the Medical College of Ohio, in wliich you are both Professors.

I have therefore to request that you withhold the publication of your
pamphlet until a Committee of the Faculty, consisting of Profs. Graham,
Comegys, and myself, shall have determined in what way this controversy
shall terminate. Very trulv,

M.' B. WEIGHT,

Dean Fac. Med. Col. Ohio.

The Committee of the Faculty, consisting of the undersigned, adjudge
that the controversy between Profs. Blackman and Bartholow shall termi-
nate, by a reply from Dr. Bartholow to Dr. Blackman's pamphlet — said
reply to be free from personalities.

This reply is subjoined, and is considered by the Committee to be final.
The Committee have the pleasure to state, that both parties have agreed
to this conclusion of a verv unfortunate public controversv.

M. B. VrIGHT.
JAMES GRAHAM,
C. G. COMEGYS.

The Faculty of the Medical College of Ohio have interposed to termi-
nate the public controversy now going on between Dr. Blackman and
myself.

My colleagues entertain the conviction, as they inform me, that a con-
troversy, which has been inaugurated and conducted throughout in a
personal manner, is not only unprofessional but injurious to the Institu-
tion with which we are connected.

Feeling the force of these considerations thus urged upon me, I have
consented to withhold the publication of a pamphlet now printed, which
was written in reply to a pamphlet issued by Dr. Blackman. According
to the rules of controversy, I am entitled to a reply. I am content, under
the circumstances, to state the points of my argument as printed in my
pamphlet, in respect to the only material accusation contained in Dr.
Blackman's pamphlet — the charge of plagiarism.

My article on "Progressive Locomotor Ataxia" must be examined as
a whole. It consists of three parts : the case of Kelch ; a synopsis of tha-

184 BIBLIOGEAPHICAL AIS^D LITEEAEY ITOTES.

history and symptomatology, as contained in Topinard's essay; and a dis-
cussion of the views of Trousseau, ^Meryon, Hughlings, Jackson, etc., and
an examination of the original meaning of the term tabes dorsalis, as it
occurs in the works of Hippocrates and Celsus. It appeared in the num-
bers of the Cincinnati Journal of Medicine for April, May, and June,
1866. In the beginning of the article, in a foot-note, I expressed my obli-
gations to Topinard in the following language :

"I have made liberal use of the prize-essay by Dr. Paul Topinard, Be
VAtaxie Locomotrice^ et en particulier^ de la Maladie aiypellee Ataxic
Locomotrice Progressive^ Paris, 1864."

The second part of the article appeared in the May number of the
Journal, Drs. Blackman and Parvin being the editors. The manuscript of
this part of ray article had appended to it a foot-note in terms similar, and
in meaning identical, with the following:

This is a synopsis, chiefly, of the views of Topinard, De VAtaxie^ etc."

This acknowledgment does not appear attached to my article. The fol-
lowing statement from Mr. H. T. Ogden, of E. Morgan & Co., who printed
the Journal, will furnish information as to the disposition made of the
note attached to the second part of my article.

"The manuscript of Dr. Bartholow's second part of the article, Loco-
motor Ataxia^ was in hand at the time of the appearance of the Medical
Journal. There was a short note attached to it,* I think, to which I called
Dr. Blackman's attention after he had read the article in the first number
(April). On reading this he (Dr. B.) thought it not satisfactory, and ap-
pended some explanation to the same. This I showed to Dr. Bartholow,
who declined to permit the addition. I am clearly of opinion that the
article, with the note appended, was in hand before any thing had been
said of plagiarism ; Dr. Blackman had not yet read the article, when it
(the manuscript) was placed in my hands by Dr. Bartholow.

" Eespectfullv,

(Signed) "H. T. OGDEK

* The note, if I recollect correctly. Dr. Blackman tore up in my pres-
ence."

Mr. Robert Clarke, the piibUsher, says that Dr. Parvin carried off the
note appended to the second pai't of my article. Dr. Parvin, in answer to
my request to be furnished with this note, writes as follows:

" Mr. Clarke is mistaken in his statement that I carried off from the
printing-office a note appended to any of your contributions to the Cin-
cinnati Journal. I have never had such note in my possession, nor do I
remember ever to have seen it. You will thus see that it is impossible for
me ' to give you the note ' or ' to state its contents.'
" Yours truly,

(Signed) " THEOPHILUS PAEVIK"

I now come, in chronological order, to the letter of Mr. Eobert Clarke,
publisher. This letter explains itself.

" You ask me to state the circumstances under which you wrote the
note attached to your second paper on ataxia in the May (1866) number
of the Cincinnati Journal of Medicine.

BIBLIOGEAPHICAL A^B LITERAEY NOTES. 185

" The charge of plagiarism made against you hj Dr. Blackman on tlie
appearance of jour lirst article \vith the ' liberal use ' note, created consid-
erable talk in the circle of phvsicians, who took an active interest in the
journal. I spoke to you, as did also, I think. Dr. Pai vin and others, and
you promised to have an explanatory note in the next number. You took
the ' copy,' with your note attached, to the priuting-ollfice yourself. I did
not see it. Dr. BLackman. however, saw it there, thought it unsatisfactory,
and wrote an 'apology' over his own initials, to go among the 'miscella-
nies' of that number. The foreman had it set up, and sent a proof to me,
asking if it should go in. It was about fifteen lines long; it was very per-
sonal, in very bad taste, and evidently written under excitement and on
the spur of the moment. I sent word to Mr. Ogden, the foreman, not to
insert it. I wrote a note to Dr. Blackman, informing him that I could not
allow his note to go in, but would use my influence to obtain a satisfactory
one from you. I then addressed a note to you, requesting an interview.
You called at the store immediately, and I told you how the matter stood.
"We sent up to the office for your first note ; it could not be-found. Y'ou
then. sat down and w-rote the note as it at present stands; I sent it up and
had it inserted. Dr. Blackman did not see it till after the sheet was
worked off. He wanted the sheet suppressed, or another note inserted
from himself, to which I would not consent, as I considered your note
quite suflicient to cover the ground.

" The above are the circumstances, as I recollect them. Mr. Ogden, to
whom I have read the above, says they agree with his own recollections.
" Y^ours truly,

^ (Signed) ''KOBEET CLAEKE."

The second part of my article, then, has attached to it the note I wrote
at Mr. Clarke's suggestion, and not the note appended to the original man-
uscript, which was destroyed at the printing-ofiice.

It is thus apparent, I think, that I sought to give the author, from
whom I quoted, full credit. But the question now comes — Did I, or did I
not, make a synopsis of the author quoted? I affirm that I did. N'ow for
the proof of this statement :

Topinard's essay contains 575 pages. The history in the essay is found
from p. 135 to p. 142 inclusive. The leading facts of this, nearly in the
author's language, is contained in my article in two pages. The symp-
tomatology in Topinard's essay is comprised in 130 pages — from p. 143 to
p. 273. I have stated the principal points in the symptomatology in 10
pages, chiefly in the author's own language.

It is perfectly evident, therefore, that the utmost that may be said is —
I made a synopsis of a portion of Topinard's essay, and in the language of
the author.

In addition to the direct acknowledgments of the two notes appended
to my article, are there any internal evidences of the liberal use I have
made of the author ? There are many.

1st. I describe oiie case of this disease.

2d. The symptomatology of this case is contrasted — by a special refer
ence, too —with the symptomatology as described by Topinard, after an
analysis of 254 cases.

186 BIBLIOGEAPHICAL AND LITEEAEY NOTES.

3(3. The difference iu style, manner, and matter, and the references to
authorities not at all, or not readily procurable in this country.

4th. The use of the term our author," as in the following paragrapli :

Our author strongly objects to the so-called acute form of this dis-
ease, in which the total duration of it is limited to some months. The age
of the subject (referring to one of those cases reported by M. Burguignon),
the rapid succession of the accidents, the total duration of four months and
a half, the prompt and radical cure, are all in contradiction with the mass
of our observations." — Cincinnati Journal of Medicine, May, 1866.

Expressing at the outset the liberal use I intended making of the
author; informing the reader, in the second part, that what he was read-
ing was a synopsis of the views of Topinard, and not concealing the inter-
nal evidences of the liberal use I had made of the author, I think any
unprejudiced .person must agree with me, that evidence is wanting of a
design to mislead the reader. If I intended perpetrating a plagiarism, cer-
tainly all who knew me must do my understanding the poor credit to
believe that I could have executed it more skilfully.

EGBERTS BAETHOLOW.

In liis Manual on Extracting Teeth,' Dr. Eobertson has
given us an excellent and thoroughly practical little book —
one that should be in the hands of every dentist. If its pre-
cepts were generally studied and applied, there can be no
doubt that the aggregate of suffering, resulting from diseases
of the teeth, would be greatly lessened. The rules for decid-
ing when a tooth requires extraction, the chapter on the selec-
tion and proper shape of instruments, and that on the acci-
dents liable to occur in extraction, are particularly worthy of
attention.

Who discovered Ansesthesia is a question that has elicited
no small amount of acrimonious controversy, both in this
country and abroad, and the recent death of Dr. Morton, one
of the claimants to the honor, has given a renewed impulse to
the discussion of the question. In the little pamphlet before
us,^ by Mr. Shaw, a dentist of Manchester, England, but we

^ A Manual on Extracting Teeth, By Abraham Eobertson, M. D., J). D. S.
Second edition, illustrated. Philadelphia, Lindsay & Blakiston, 1868;
12tuo, pp. 200.

^ Who discovered Anaesthesia? By S. Parsons Shaw, author of
" Odontologia : its Causes, Prevention, and Cure," etc. Pamphlet, pp. 7.
London : Triibner & Co., 1868.

BIBLIOGEAPHICAL AND LITERAEY NOTES.

187

believe an American by birtli and edncation, the credit is
given to the late Dr. Horace Wells, of Hartford, Conn. This
is the view that we have always taken of the case, and we are
glad to see so candid and nnbiassed an opinion coming from a
foreign source. The author was personally familiar with the
history of the use of ether and nitrous oxide, and had, besides,
an acquaintance with both Drs. Wells and Morton. Due
credit is given to Dr. J ackson for the part he took in intro-
ducing ether to the notice of the profession.

De. Elliott Coues, Surgeon U. S. A., is engaged upon a
work on the ornithology of Arizona, of which he printed
what he called the Prodrome about two years ago, in The
Proceedings of the Philadelphia Academy of Natural
Sciences. Although a good deal of difficulty attended the
author's observations — " my operations," he says, " were con-
ducted at the most imminent personal hazard, from the con-
tinued presence of hostile Indians " — he still had very unusual
advantao^es. For the foundation of his investiorations he had
the collections of the government expeditions along the 35th
and 32d parallels of the Mexican Boundary Survey of the
Colorado Kiver, besides those of several private individuals.
The region about Fort Whipple, his headquarters, is re-
markably adapted to ornithological observations, so that the
list which composed the bulk of the original paper — including
215 titles, all of birds which had been actually detected in the
Territory, and many of which are followed by elaborate de-
scriptions— was actually, what it purported to be, " an exposi-
tion of the present state of om* knowledge of the Arizonian
Ornis." In general, however, the natural history of the
species was not enlarged upon — Dr. Cones reserving for his
more extended work ''the mass of omitted biographical
notes " he had accumulated. — Pound Tahle.

Since the publication of the first edition of this address ' in

^ Consumption in New England and Elsewhere ; or, Soil- Moisture one
of its Chief Causes. Address delivered lefore the Massachusetts Medical
Society. By Hexet I. Bowditch, D. Second edition. Boston, 1868.
12rao, pp. 154.

188 BIBLIOGEAPHICAL AIS^D LITEEARY ]S"OTES.

1862, in which Dr. Bowditch took the ground that consump-
tion, at least in I^ew England, was not equally diflPused, and
that certain spots owed their comparative immunity to the
dryness of the soil, whilst the " consumption-breeding districts "
were characterized by dampness of the soil, he has obtained,
from various sources, facts and statistics confirmatory of his
views, that soil-moisture is one chief cause of phthisis.

In 1865-'66, Dr. Buchanan having been directed by the
Medical Officer of the Privy Council, Dr. John Simon, " to
investigate the effect of drainage works, and other sanitary
regulations, designed to promote the public health," made
such a report of facts in connection with the etiology of con-
sumption, as to indicate a partial dependence of pulmonary
phthisis on certain unwholesome conditions, and to suggest the
important conclusion that the drying of the soil, which has in
most cases accompanied the laying of main sewers in the im-
proved towns, has led to the diminution, more or less consider-
able, of phthisis. " The facts," adds Mr. Simon, " which are
yet in evidence, seem most strongly to support this conclu-
sion, which, should it be substantiated, will constitute a very
valuable discovery " — which is, that by the artificial drying of
the soil of towns the mortality-rates from phthisis are less-
ened. The Privy Council has directed that further inquiry on
this subject should be made.

This is a reprint of a useful little book,^ which has gone
through three editions in England since 1863. The author
writes : " An endeavor has been made to take a rational view
of a very common and very troublesome ailment. 'No preten-
sions have been put forward to any great originality or nov-
elty. The intention throughout has been to bring together
every method of treatment, however apparently trivial; to
neglect no source of therapeutic expediency, however subject
to abuse, if impartial experience has proved it to be condition-
ally valuable." The great principle of successful treatment,

^ Constipated Bowels: the Various Causes and the Different Means of
Cure. By S. B. Bmcn, M. D., M. R. 0. P., London, etc., etc. From tlie
third London edition. Philadelphia : Lindsay and Blakiston, 1868.
12rno, pp. 181.

BIBLIOGEAPHICAL AND LITEEAEY NOTES. 189

viz., the management of each case on its ovm merits^ in con-
nection witli its sjpecial cause and any special complications,
has been steadily maintained as far as possible. Koutine in
every shape has been condemned. The abuse of aperients,
that most common and most injurious of all one-sided errors
in treating constipation, has unsparingly received its deserts ;
while, at the same time, the occasional necessity of a tem])o-
Tary recourse to gentle evacuants, and still more rarely ener-
getic cathartics, has been fully admitted.

" The lamentable habit of resorting to opening medicine
on every slight emergency, has been dwelt upon as indisputa-
bly the most flagrant cause of obstinate bowels, while the va-
riety of other agencies, which tend to implant a constipated
habit, have received their share of attention, in their twofold
capacity as single and as associate cause."

The suggestions regarding the management of this com-
mon and troublesome disorder, with its attending ills, are, in
the main, judicious, based on common-sense, and a rational
system of treatment.

]^Ew Books. — Among recent publications we notice, from
the house of Longmans & Co., London, Dr. Charles Murchi-
son's " Clinical Lectures on Diseases of the Liver^ JaimcUce^
and Abdominal Dropsy P These lectures have appeared in
serial form in the Lancet^ and are a very valuable addition to
our medical literature. The same volume appears here, with
the imprint of Wm. Wood & Co.

Messrs. Simpkin, Marshall & Co. have published a work by
Mr. Dunlop Durham, entitled " The Philosophy of the Bath^
or Air and Water in Health and Disease ; containing a His-
tory of Therapeutics and of the Hot- Water JBath, from the
Earliest Ages. With an Introductory Chapter, Hlustrative
of the Present Condition of the Medical Profession^ If the
book is as heavy as its title, we fear it will not meet with a
very lively reception.

From the press of John Churchill & Co. we have the
Lettsomian Lecture^'' for 1867, by Mr. John Guy, " On Va-
ricose Disease of the Lower Extremities and its Allied Dis-
orders, Skin Discoloration, Induration, and TJlcerP

190

BIBLIOGEAPHICAL AIS^D LITEEAEY Is^OTES.

Holdeii's Manual of Dissection^'' lias passed to a tliird
edition in England.

Dr. Y. Andhoni lias just issued, in French, a work on
" The General Pathology of Poisoning hy Alcohol."^' Dr.
II. Pemot a new work, entitled ''^Etudes sur les Accidents
produits imr les Piqures AnatomiguesP

Ponctian Vesicale Hyjpogastrigue^^ par M. le Dr. J.
Poiiliot.

Lindsay & Blakiston, of Philadelphia, have in press, and
will shortly issue, " A History of the Medical Department of
the JJniversity of Pennsylvania f rom its Foundation in 1765
to the Present Tinie^ illustrated hy Sketches of the Lives of
Deceased Professors^'' by Joseph Carson, M. D., Professor of
Materia Medica and Pliannacy in that institution. — The sec-
ond volume of Aitken's " Practice " will, it is understood, be
ready early this month. They will also publish, during this
month. Dr. Scelberg Wells's complete work on " Diseases of
the Eye, with Illustrations,^^ and Dr. Beale's new volume on
" Kidney Diseases, with DlustrationsP

They have also issued a copious catalogue of their own
medical publications, to which they have appended a classified
list of all the more important works on medicine and the col-
lateral sciences published in the United States, and now in
print.

They also announce Beasley's " Druggists Peceipt-BooTcP
Seventh revised edition. — Pichardson's '^Mechanical Dentis-
try P A new enlarged edition. — Trousseau's " Clinical Medi-
cine^^ vol. 2. — Pennsylvania Hosjntal Peports^^ vol. 2,
for 1869. — Holmes's '''Surgical Diseases of Children^ 2d
edition. — Beale on " Diseases of the Liver T l^ew edition.

Messrs. J. B. Lippincott & Co. will shortly issue ''Advice
to a Mother on the Management of her Children^ — Dr. E. C.
Seaton's " Hand-hooli of Vaccination''^ has just appeared from
their press.

Messrs. Wm. "Wood & Co. announce : " Troltsch on the
Diseases, <&c., of the Ea/rP Translated and edited by D. B.
St. John Eoosa, M. D. I^ew edition, illustrated. — " A Prac-
tical Treatise on Fistxdm of the Rectum and AnusP By
Dr. W. Bodenhamer. Illustrated. — " BrigMs Disease of the

EEPOETS ON PROGEESS OF MEDICINE. 191

Kidneys:' By T. G. Stewart, M. D. Illustrated.— On
" Epilejjsy:' By M. Gonzales Echeverria, M. D. Illustrated.
— Hassall's " Illustrations of Microscopic Anatomy P With
colored plates.

Messrs. W. A. Townsend & Adams announce " A Treatise
on OzoneP By Wm. Elmer, M. D. — " ^yoman's Complete
Guide to Health:' By M. E. Dirix, M. D.— A Practical
Treatise on the Trunhal Muscles:' By E. P. Banning, M. D.

In Yeterinary Medicine Messrs. Claxton, Kemsen & Haf-
felfinger, of Philadelphia, have in press, and will shortly pub-
lish, " A Treatise on the Horse's Feet / their Diseases and hoio
to Treat them:' By Dr. L. A. Braley, Chief Yeterinary Sur-
geon U. S. A. With sixty-live engravings, illustrating the
horse's foot in all its points, as well as the diseases io which it
is incident. 4-10 pp., 8vo. — " The Diseases of Sheep Ex-
plained and Described^ with the Proper Remedies to Prevent
and Cure the same. With an Essay on Cattle Epidemics ;
especially dedicated to the use of Farmers^ Sheep-owners^ etc:'
By Henry Clok, Y. S., graduate of the Koyal College at Ber-
lin, Prussia, and late Yeterinary Surgeon-in-Chief of the U. S.
A. 12mo, cloth. Illustrated.

THEORY xiND PRACTICE.

1. — Cases of Unilateral Sioeating of the Head. [Cincinnati
Lancet and Observer, Aug., 1868.]

In this Journal for August, 1866, we noted several cases of
this curious affection, which were reported in the Med. Times
and Gazette, and now call attention to the following, reported
by Prof. Bartholow^ :

Case I. — The first caf^e was that of a cachectic iodividual, who had a
tnmor, aneurismal or malignant, at the base of the neck, which liad grown
upward from within the thorax. Not having had an opportunity of exam-
ining this morbid growth, I cannot pronounce as to its nature; neither
is the determination of this point material to the inquiry. The facts of
importance are, 1st, the existence of a thoracic tumor on the right side of
the thorax; 2d, the occurrence of unilateral sweating on the right side of
the head. The sweating, which was profuse, tenninated abruptly at the

192

EEPOETS ON PKOGEESS OF MEDICmE.

median line. The pupil on the same side was contracted. No Iher-
moraetric observations were made upon the temperature of tlie affected
side; but tliere was considerable redness of the lobe of the right ear, and a
subjective sensation of warmth in the affected parts.

Case II. — A gentleman of Cincinnati, aged about 50, in robust health.

About a year ago he first observed that the right side of his head
sweated very freely, while the left side was almost free from perspiration.
This difference in the activity of the sudoriparous -glands on the two sides
became very marked indeed, so that he experienced great apprehension as
to the result, although his general health continued good. When he con-
sulted me, I explored the thoracic organs very carefully, especially the
heart and great vessels, but I was unable to discover a tumor or lesion of
any kind. The pupils were equal in diameter on the two sides, and there
was no apparent alteration of the circulation in the right eye. Mental
emotion or active exercise caused the sweat to break out on the affected
side, where it stood in enormous drops, almost no moisture being percep-
tible on the opposite side. A subjective sensation of heat preceded the
outbreak of sweat, but I could not perceive that there was a real elevation
of temperature. Neither the direct nor induction currents changed the
condition of the parts. Sensation — of toucli, of pain, of temperature —
remained unaffected over the whole sweating region. There was no appar-
ent disturbance in the function of any organ.

Case III.^ — S. M , aged 39; nativity, Ireland; occupation, laborer.

Two years ago was attacked with a severe cold, since which time cough
has been always troublesome. Has suffered once or twice from oedema of
inferior extremities.

Condition on Admission. — He is emaciated, feeble, and wears a cachec-
tic aspect; tongue almost clean ; pulse 90 and full; appetite poor; bowels
rather constipated; slight depression in right infraclavicular region with
marked dulness and much resistance on percussion ; prolonged expiration
in above-mentioned site, and abundant mucous and sibilant rales over both
lungs; rhythm of heart's action normal, as also the area of precordial dul-
ness. Careful examination of the great vessels detects no evidence of
aneurism or tumor. Hepatic and splenic dulness natural ; there appears
to be no particular fault in the digestive organs, except the want of appe-
tite, and the tendency to constipation.

The peculiarities for which the case is now reported are the state of the
left pupil and sweating of the left side, especially of the head. The left
pupil is more contracted than the right, and does not respond so readily to
the stimulus of light. When quiet, there is a perceptible difference in the
moisture of the right and left sides of the body. On taking active exercise
the sweat stands in large drops on the left side of the face and head, the
right being comparatively dry. The temperature of the right meatus audi-
torius is found to be 99^ degrees F., whilst the left is 99 degrees F. ; of the
right axilla 99 degrees F., of the left 98f degrees F. After active exercise
the temperature of right meatus is 98^ degrees F. and of left 98^ degrees
F. ; of right axilla 98^- degrees F., and of left 99 degrees F.

Dr. B. comments at length on these cases, and collates, in
addition to those we have above referred to, several others.
All these cases are associated with certain conditions : 1. With
aneurism al or other thoracic tnmor ; 2. With certain neuroses,
as epilepsy, progressive locomotor ataxia, etc. ; 3. With no

^ Keported by Dr. A. Gutlirie, Kesident Physician, Cincinnati Hospital,

THEOKY AXD PEACTICE.

193

ascertainable lesion or alteration in the function of any part,
except the skin affected. The explanation of the first class
is easy, as the experiments of CI. Bernard upon the sympa-
thetic paved the way for a right understanding of them. Dr.
Gairdner seems to have been the first to recognize the connec-
tion of unilateral sweating with thoracic tumors, and to attri-
bute the symptom to the pressure of the tumor upon the
cervical sympathetic, or its branches, thus inducing paralysis
of the vaso-motor nerves. In the second class Dr. B. thinks
that the influence upon the vaso-motor nerves, producing the
unilateral sweating, must be reflex, and derived from the ner-
vous system of animal life, and hence probably different in
character from the paralysis induced by du-ect influence. In
the third class, we can only fall back upon the supposition of
some distm-bance of the function of the trophic nerves (i. e.,
nerves exercising an influence over the nutrition of a part)
distributed to this part. Dr. B. seems to take a middle ground
between those who maintain that the sensory nerves are the
true trophic nerves and those who hold that the ganglionic
system alone monopolizes this function.^

In this connection we may note another case reported very
briefly by Dr. II. C. Bobbins, of Dement, 111., in the Boston
Med. and Surg. Jour.^ July 9, 1868 :

J. W., aged 22, while in the army, six years ago, contracted chronic
diarrhoea, which confined him to hospital for several weeks. Upon his
recovery, he first noticed the phenomenon of profuse perspiration of the
left side of his face, which condition still continues, nearly six years after
it was first observed.

His health is perfect in every other respect, and his mind is clear and
strong, but every few minutes, winter or summer, he is obliged to wipe
away the sweat from one side of his face. He is now a farmer, strong and
energetic.

2. — A Cure for Headache. By Geoege Kexxiox. M. D.,
F. E. C. P., etc. [British Islei Jour., June 13, 1868.]

I am desirous of bringing before the notice of the profession a very
simple, and at the same time a very remarkable, cure for many kinds of
headache. I have not the least claim to the discovery of this remedy, nor,
indeed, am I at all aware who was its originator; but I believe that it is
unknown to the profession generally; and having used it for nearly twelve
mouths in a very large number of cases, and very rarely without affording
immediate relief, I am desirous of making it more generally known. I
heard of it first from a gentleman whom I was attending last yeai*, and
who told me that he thought it was used by a French physician.' If this
should come under his notice, I hope that it may be the means of inducing
him to di-op his incognito, so that he may receive the thanks of many to
whom he has hitherto been an unknown benefactor.

^ On this point see Echeverria's paper in this Journal, April and Mav.,
1860.

194:

EEP0ET3 02^ PEOGEESS OF MEDICIXE.

The remedy, as I have already observed, is simple ; it is the bisulphide
of carbon in solution. Its mode of application is no less simple. A small
quantity of the solution (about two drachms) is poured upon cotton wool,
with which a small, wide-mouthed, glass-stoppered bottle is half filled.
This, of course, absorbs the fluid, and when the remedy has to be used, the
mouth of the bottle is to be applied closely (so that none of the volatile
vapor may escape) to the temple, or behind the ear, or as near as possible
to the seat of pain, and so held for from three to five or six minutes. After
it has been applied for a minute or two a sensation is felt as if several
leeches were biting the part; and after the lapse of two, three, or four
minutes more, the smarting and pain become rather severe, but subside
almost immediately after the removal of the bottle. It is very seldom that
any redness of the skin is produced. The effect of this application, as I
have said, is generally immediate. It may be reapplied, if necessary, three
or four times in the day.

The class of headaches in which tliis remedy is chiefly useful is that
which maybe grouped under the wide term of "nervous." Thus neuralgic
headache, periodic headache, hysterical headache, and even many kinds of
dyspeptic headache, are almost invariably relieved by it; and although the
relief of a symptom is a very difierent afl:air, of course, from the removal
of its cause, yet no one who has witnessed (and who of us has not seen?)
the agony and distress occasioned by severe and repeated headache but
must rejoice in having the power of affording relief in so prompt and simple
a manner.

As regards the modus operandi of this remedy, it is difficult, perhaps,
to form a certain opinion; but I am disposed to attribute it to the sedative
effect of the vapor of the bisulphide, absorbed through the skin, and acting
upon the superficial nerves of the part to which it is applied. The remarks
of M. Delpech {Annales d'' Hygiene, Jan., 18G3) point out very clearly the
remarkable prostration of the whole nervous system produced in workmen
who, in certain manufactures, are exposed to the vapor arising from a solu-
tion of the bisulphide of carbon ; and we can readily understand that a
somewhat similar effect, upon a small scale, may be produced by the appli-
cation of this vapor to a limited portion of the surface.

I always procure the bisulphide of carbon from Mr. Morson, the eminent
chemist in Southampton Row, Bloorasbury, who will also furnish the bottle
with which the vapor should be applied, and a wooden case — a very neces-
sary adjunct, on account of the offensive smell of the bisulphide.

3. — A Neio Treatment for Chronic Dysentery. By E. Mal-
colm MoESE, M. D., San Francisco. [California Medical Ga
zotte, Sept., 1868.]

In chronic simple nncomplicated dysentery, bj which are
meant those cases not kept np by organic disease of the heart, or
phthisis pnlmonalis, nor dependent on irremediable obstruction
of the liyer or spleen. Dr. Morse has met with marked success
by throwing up into the rectum and colon from two to fiye
pints of Labarraque's solution of chlorinated soda, largely
diluted. The theory of the treatment is based on rational
piinciples, and the remedy giyes little or no pain, while expe-
rience has demonstrated that it is perfectly safe, no bad efi'ects
thus far haying been obseiyed. Chronic dysentery is a disease

THEORY AND PEACTICE.

195

SO usually intractable and obnoxious to treatment tliat any plan
wbicli promises even moderate success is worthy of trial. Of
course, in the complicated cases above referred to, the j^rimary
treatment must be directed to the disease on which the dysen-
tery is dependent. Dr. Morse says :

"In order to get the patient into a proper condition to derive the most
benefit from these injections, I am in the habit of pursuing the following
method : I regulate his diet carefuUv, of course, and keep him in a recum-
bent position in order to assist the return of the blood from the engorged
mesenteric veins, and those smaller tributaries which are distributed along
the large intestine. This state of engorgement prevents the ulcers from
healing, and renders each ulcer an outlet from which, in blood and serum,
the stream of life ebbs out like water from the tubs of the daughters of
Danaus. At daybreak on every alternate or fourth day I give a mild
cathartic or aperient, in order to clear out the alimentary canal. The ordi-
nary contents of the intestine produce great irritation when it is in this
engorged and hyperaesthetic condition ; and it is better to get rid of the
faeces about the same time, instead of letting them run in driblets over the
raw surface every hour or two. After the cathartic or aperient has acted
sufficiently I inject very slowly from two to four pints of Labarraque's
solution of chloride of soda, diluted, into the large intestine. In this way
it becomes a topical application. The right strength for the first enema is
twenty parts of water to one of Labarraque's solution. I inject ns much
of this mixture as he can be made to retain. Two or three pints will
generally be enough. Sometimes as much as five pints may be given.
Each enema should be made a little stronger until the patient says that he
can feel it smart or burn. When this happens the solution is of the proper
strength. The patient should be on his right side, or on his knees with his
head low down, while these enemas are being administered. Occasionally
it is necessary for hiiXL to change his position several times in order that the
wash may reach every point where it is needed. Should there be much
tenesmus after the injection has been passed, I give an enema of the tinct.
opii, or an opium suppository. These applications of the chloride of soda
should generally be made once a day. Occasionally it is necessary to give
them twice a day, and sometimes, on account of the sensitiveness of the
ulcers as they begin to heal, it is better to leave them off for several days,
or give weaker solutions. The next indication in the treatment, after
cleaning out the alimentary canal and washing the ulcers with the medi-
cated solution, is to keep the bowels quiet, so that the ulcers may remain
clean and heal up under the topical application. In suggesting the means
of accomplishing this desideratum I am getting upon very debatable ground.
The old proverb tot 7wmi?ies tot sententiones'''' must certainly have been
Intended for physicians. Each one of us has his own way of using the
arms with which we combat disease. I generally give large doses of sub-
nitrate of bismuth three times a day; repeated opiate enemas and sup-
positories, in order not to disorder the stomach ; Dovei''s powders, repeated
if necessary; charcoal, or the mineral and vegetable astringents; the ant-
acids, leeches, and fomentations; taking great care to keej) up the effect of
the medicines by giving them every hour or two. If one drug fails I try
another, or give a combination of several of them, in order to have as
few stools as possible passing over the ulcerated surfaces while they ai-c
healing."

196 EEP0ET3 01^ PEOGEESS OF MEDICIXE.

4. — Treatment of General Dropsy hy the Hot Bath. By Dr.
Leo, Bonn. [Sitzungsber. d. niederrhein. Gesellschaft in
Bonn. 1867. From St. Louis Med. and Surg. Journal,
Sept., 1868.]

The case reported is that of a girl, ast. 13. She had, tliree years pre-
viously, suffered from articular rheumatism, and since then had been
attacked every winter by difficulty of breathing, which received no treat-
ment, however. In May, 1866, she received a fracture of the femur,
which healed in six weeks. In Sept., 1866, she complained of chilliness,
loss of appetite, and shortness of breath. She grew irritable, somnolent,
and the legs swelled. These phenomena increased to such a degree that
Dr. L. found her, at his first visit, 7th Xov., in the following state: The
dyspnoea compelled her to sit up in bed; pulse 140: impulse of the heart
hurried and indistinct ; fuce and hands cyanotic ; high degree of general
dropsy: hydrothorax, hydropericardium, ascites, and general anasarca,
especially in the labia pudendi and legs; urine contained much albumen;
pain in the chest and abdomen, cough and dyspnoea dispelled sleep. A
sure diagnosis of the cardiac affection was impossible under the circum-
stances.

The advice to transfer the child to the hospital was not followed till
8th Dec, 1866. The objective symptoms were unaltered; the debility
considerably greater. Patient had now been in bed for three months;
many remedies had been used in vain. Dr. Leo, therefore, concluded to
make methodical use of the hot bath as recommended by Liebermeister
and Ziemssen.

On account of the great debility of the patient baths were not given at
once, but tiie child was "packed" in clothes wrung out of hot water.
First packing, 9th Dec, followed by perspiration. At night, subcutaneous
injection of 1-6 grain morphine to allay the severe dyspnoea.

10th Dec. Second packing: free perspiration. Both legs discharged
fluid by drops from small excoriations.

11th Dec. Third packing. The perspiration in the blanket very un-
comfortable, increased the dyspnoea. Injection of morphine.

12th Dec Bath, 106° F., 15 minutes; followed by woollen blanket.
Profuse perspiration. Ordered 1 tablespoonful of infus. digitalis (3 i — | vi)
with § i roob juniperi, 4 times a day.

One bath daily until 20th Dec. (eight in succession), gradually lowering
the temperature to 99° F. ; perspiration always very profuse. The dyspnoea
dhninished, the nights became more comfortable. On the 16th the legs,
arms, and abdomen still much swelled, but the chest more relieved ; secre-
tion of urine increased. On the IStla the urine was free from albumen.
On the 20th the anasarca had left the arms. Digitalis increased to 3 ss in
the mixture. Baths henceforward only three times a week, 99° F. ; eight
baths until 9th Jan., 1867.

On the 22d Dec the abdomen was considerably smaller; the legs
slightly so. Action of the heart quieter; appetite and sleep good. Im-
provement progressed rapidly, the dropsy disappearing from above down-
ward. On the 25th the water had almost completely left the thighs and
legs also; only the feet were swelled to above the ankles. Patient walks
about after a treatment of 16 days, having been confined to bed for nearly
four months. The last traces of oedema disappeared by the 2d January,
and the patient left the hospital on the 9th. The cardiac trouble proved
to be insufficiency of the mitral valve, with stenosis of the orifice and dila-
tation of the heart. The kidneys, which had suffered considerably, were
relieved after the sixth bath.

THEOEY AXD PEACTICE.

197

This case shows that the hot hath, as recommended hy Liehcrraeister
and Ziemssen, is a highly vahiable remedy in general dropsy following upon
chronic disease of the heart with affection of the kidneys.

5. — Iodine an Antidote to Strychnine. Bj James I. Eookee,
M. D. [Cincinnati Lancet and Observer, Sept., 1868.]

An article appeared in the Lancet for June (reprint), by Henry Wm.
Fnller, M. D., Senior Physician to St. George's Hospital, entitled Iodine
an Antidote to Strychnine., and the Impropriety of Prescribing Quinine
or Strychnine with Tincture of Iodine.

The Doctor remarks : In the course of my practice it has often occurred
to me to prescribe a mixture containing quinine or strychnine, together
with tincture of iodine," and have not been aware of any incongruity in
the dispensing of it until last summer a chemist called my attention to the
fact that it is impossible to dispense a mixture containing strychnine and
tincture of iodine.

In whatever sequence the ingredients are mixed, I find that the whole
of the strychnine is precipitated by the tincture of iodine. Indeed, so
strong is tiie affinity between these two ingredients that the Uvo fluid
drachms of tincture of iodine are capable of decomposing six fluid drachms
of the liquor strychnise, producing an insoluble compound of iodine and
strychnine.

"]^ow, it is obvious that, for medicinal purposes, a mixture in which
such a precipitate occurs must be almost valueless. The patient not only
loses the benefit of the quinine or strychnine, but of the iodine also. It is
not unreasonable, therefore, to lay down as a rule that tincture of iodine
ought not to be prescribed in a mixture containing either of the above-
named alkaloids. Another question of practical importance arises out of
this observation. May not a dilute solution of iodine be advantageously
given in cases of poisoning by strychnine? Coming from so high authority,
the suggestion favorably impressed me, and, inasmuch as I had been called
a few times to administer to those suffering from strychnine poison, and
finding all my efforts proved futile, induced me to institute a series of ex-
periments on the lower animals. In order to further test its antidotal
properties, I therefore procured three healthy pups, of the same age, twelve
young rats, and two kittens. The first two experiments were upon two
pups. First took strychnine gr. water 3 ij, tincture iodine, 3 i, at a dose
for the first ten minutes. The only perceptible effect was frothing at the
mouth, gnashing the teeth, whining, and shaking the head. In fifteen
minutes faUs down, laborious respiration, heart's action increased. Twenty
minutes, tetanic spasms — violent; gave 3i tincture iodine, diluted with
water, at a dose. Thh-ty minutes, no perceptible change for the better; in
short, getting worse, a touch or noise producing violent spasms ; death
threatened from asphyxia. Forty minutes, much worse; commenced the
administration of chloroform by inhalation; breathing became regular;
heart's action more quiet ; appears as in a quiet sleep. As soon as the
effect of the chloroform passes off all the former symptoms return with
the same violence. The only effect of the chloroform is palliative. I con-
tinued the administration of chloroform for three hours ; it was then dis-
continued. Spasms returned at once with renewed force, and death came
to its reHef in a half an hour, from asphyxia.

Second pup, gave sulph. strychnise, gr. water, 3 ij ; attacked with the
peculiar spasms in five minutes. Twenty-five minutes, gave tinct. iodine
3 i, in water. Thirty-five minutes, still getting worse; chloroform admin-
istered for three hours; when discontinued, death followed in twenty
minutes.

198

EEPORTS O^f PKOGEESS OF MEDICINE.

Post-mortem examination twelve hours after death in each case. First
pup — Stomach fLill of indigested milk; mucous membrane healthy; could
not detect with starch any trace of iodine, or of strychnine, by the taste;
gall-bladder ruptured ; right heart contained dark blood, with fibrinous
clot; left empty; no further examination made. Second pup — Same con-
dition, except gall-bladder entire, but empty.

Third Experiment. — Pup — Gave sulph. strychnise, gr. water, 3 ij ;
attacked with tetanic spasms in two minutes; left to itself; died in two
hours, apparently from exhaustion and asphyxia.

Fourth Experiment. — Twelve young rats — Gave Hall's Solution Strych-
ni83, ten drops to the first six; the other six same amount strychnia, con-
taining equal amount tinct. iodine; all died in one hour.

Fiftli Experiment. — Two kittens, same age. First took 3 i, Hall's sol.
Second, Hall's sol. 3 i, tincture iodine, 3 i, water, 3 i; administered to both
at once. Botli died in two hours, in violent spasms.

Ee:maeks. — Tliese experiments were roughly made. Still they go so
far as to show the inertness of iodine as an antidote to strychnine poison.
But I do think that no intelligent physician, called to treat a case of this
kind, would be so blind as not to see the indication for chloroform.

6. — The Use of Ether and Etherized Cod-liver Oil in the
Treatment of Phthisis. [Lancet, Ang. 8, 18G8.]

At the recent meeting of the British Medical Association
at Oxford, Dr. B. W. Foster read a paper on this subject, of
which the following is a summary :

He began by referring to the great diflBculty of digesting fatty food
which distinguishes the great majority of phthisical patients. This de-
fective assimilating power had hitherto been treated by incorrect or insuf-
ficient means. The only true method of treatment to be adopted in such
cases should be directed to the organs whose secretions are at fault.
Physiology teaches tliat the digestion of fat is specially performed by the
secretion of the pancreas, and the glands of the small intestine. Dr.
Foster had long sought for a means of influencing these glands, and at
last had found most ample evidence in the works of Claude Bernard that
ether is capable of augmenting the pancreatic secretions to almost any
degree. Bernard is accustomed in his experiments to give ether to ani-
mals in order to obtain a good flow of pancreatic juice. Applying this
discovery to the treatment of phthisis, he had met witii most satisfactory
results. The ether was given in a mixture sometimes, but generally in the
form of etherized cod-liver oil. Of the patients treated in this way, and
all observed over some months, some over two years, 42 per cent, im-
proved while under treatment, 30 per cent, remained stationary, and
only 28 per cent.' became worse. Twelve per cent, of the cases treated
presented all the evidence of the arrest of the disease. In no case were
the symptoms of physical signs alone accepted as evidence of improve-
ment; every case was weighed from week to week, when under obser-
vation, and only a decided increase of weight in addition to other signs
received as evidence.

7. — Thermometrical Observations in Typhoid Fever. By Dr.
R. E. Thompson. [St. George's Hospital Eeports, and
Smmnary in Edinburgh Med. Jour., February, 1868.]

Dr. Thompson's observations extend over a period of three years, and
are made from a careful study of forty-seven cases. They tend to confirm

THEOEY AND PRACTICE.

199

Professor ■Wimdcrlicli's researches on tlie same subject. In tvplioid fever,
a decrease of temperature is not always a favorable sign, nor is a rapid fall
symptomatic only of a crisis. As a rule, the nocturnal increase of tem-
perature in this form of fever is very considerable, and amounts to two or
two and a half degrees. During the latter half of the first week, the heat
increases day by day, and varies between 102° and 103° in the morning,
and 104° or even 105° in the evening. These high temperatures are qnite
sufficient to distinguish typhoid fever from tubercular meningitis or from
peritonitis, these diseases seldom showing much increase over 102° Fahr.
During the second week, the temperature varies between 102° in the
morning, and 103° and 104° in the evening, tlie oscillations being influ-
enced by the amount of diarrhoea. The thermometer does not enable one
to say, by a longer prediction than twenty-four or forty-eight hours,
whether the case is likely to be fatal or not ; but a steady rise in the
temperature will often indicate the danger of ulceration of the bowels
twenty-four hours before the intestinal lesion is manifested by diarrhoea
and hcemorrhage. The mode of termination of the fever is characterized
by extraordinary oscillations in the temperature between morning and
evening, the difference being sometimes as great as nine degrees. This
feature distinguishes the thermograph of typhoid fever from that of
almost all other diseases. In one case of perforation of the bowel, which
was preceded by hsemorrhage, the heat of the body was reduced from
102° to 99.5°, and was followed by a rise to 102.2°, where it remained
for forty-eight hours, before death, during which period perforation took
place.

8. — Case of BrifjMs Disease consequent upon Ague. By J.
E. Bradbuey, M. B. [Brit. Med. Jour., April 18, 1868.]
This case is interesting from tlie fact that Bright's Kidney
is rarely found as an immediate sequela to ague. Dr. Roberts
states that he has never met with such a case, and quotes
Becquerel and Frerichs to the effect that, " in dropsies follow-
ing intermittent fever, they had never found evidence of kid-
ney-disease." The reporter omits all mention of the previous
habits of the patient, which miglit have had an important
bearing in the causation of this case. The heroic treatment
to which this patient was subjected we can hardly advise our
readers to follow :

W. B., aged 36, married, farm-laborer, living at TJpnell, was admitted
into Addenbrooke's Hospital, under the care of Dr. Paget, on September
8, 1866.

Previous History. — He was quite well till about twelve months ago,
when he had quartan ague, since which time he had done very little work.
The ague lasted for five or six months, and reduced his strength a great
deal. Soon after the ague left him, his legs and feet began to swell, the
dropsy gradually extending to the scrotum and abdomen. He was under
Dr. Latham as an in-patient in the summer, and left the hospital at his
own request before he was quite well. Shortly after returning home, he
caught cold, and his legs and feet began to swell again. Sickness and
severe headaches came on, and he lost his appetite. For seven weeks pre-
vious to his admission he had been confined to his bed.

State on Admission. — There were pallor and puffiuess of the face and
dropsy of the legs, scrotum, and abdomen. Tlie tongue was clean, but

200

REPORTS 0]S^ PROGRESS OF MEDICINE.

pale. Pnlse 90, very feeble. The urine was about normal in quantity ;
of specific gravity, 1017; it almost became solid with heat and nitric
acid. It contained hyaline, granular and fotty casts. He complained of
pain across the loins. There was no cardiac or pulmonary disease. After
his admission, he had four or five attacks of ague of the quartan variety,
each fit lasting three or four hours.

He was at first treated with half-drnchm doses of compound jalap-
powder every other morning, and five minims of tincture of perchloride
of iron three times a day. On the supervention of the ague, the iron was
changed for quinine in three-grain doses. Under this treatment, there was
very little diminution of the dropsy ; so on September 27th his legs were
punctured. He subsequently took quarter-grain doses of extract of ela-
terium every other morning for a week. Although the elaterium acted
very freely on the bowels, the abdomen did not become raucli softer, so
on October 8th he was ordered the following diuretic:

PotassEe bitart. gr, xx; tinct. digitalis, ttIx; aquee juniperi | iss.
M. Sumat bis quotidie.

After he had taken this mixture for a short time, there was consider-
ably less oedema of the legs and scrotum, and he got smaller in girth.
The urine became more abundant, but the quantity of albumen did not
alter.

He became so much better toward the end of ISTovember that he was
allowed to be made an out-patient. Dr. Paget informs me that the pa-
tient has presented himself from time to time at the hospital, and that the
last time he saw him the dropsy had quite disappeared, and the man Avas
able to work.

9. — Gangrene of the Heart. By D. S. Young, M. D., Profess-
or of Surgery in tlie Cincimiati College of Medicine and
Surgery. [Cincinnati Medical Repertory, May, 1868.]

Gangrene of the heart is a disease in regard to the existence of which
nearly all modern pathologists are in doubt. In fact, but few writers refer
to it ; or, if they do, it is only to express their conviction of the incor-
rectness of the diagnosis of cases reported, and of the impossibility of life
continuing until such a change could take place in so important an organ.
On reading these opinions and the history of the cases, I also entertained
the same impression, until I met with the following case:

Henry McNulty, a native of Ireland, aged 65, an inmate of the Cin-
cinnati Infirmary for several months. When first admitted he was sufifer-
ing from chronic rheumatism. He had been afflicted with this disease for
a number of years, and was permanently disabled.

He had never felt any diflficulty about the region of the heart, nor was
I ever enabled to discover any unnatural sounds, having frequently ex-
amined it upon his first admission into the house. His general health,
witli the exception of the rheumatism, was as good as men of his age
usually enjoy.

Some time about the middle of January, 1860, he injured the thumb
upon the right hand, and, a few days subsequently, the bone (distal pha-
lanx) was found to be necrosed, and was removed while the patient was
under the infiuence of chloroform. He took the chloroform well, and ral-
lied without any unpleasant symptoms, and the wound progressed without
any unfavorable indications. Two days after the operation he complained
to the nurse that there was soreness in his chest, and that his head felt
badly ; but, as these symptoms did not particularly distfress him, no report
was made to me. The next morning I found him with a hot skin, coated

THEOEY AND PEACTICE.

201

tongue, rapid pulse, and complaining of a burning sensation on the cbest,
with considerable difficulty in breathing. The action of the heart was
regular, but having a peculiar softness, which I had never before observed
in any patient. It was nearly as full as in health ; while the softness and
compressibility of the artery were very singular and characteristic. He at-
tributed his condition to the chloroform, and now, for the first time, said
that he had not felt right since he inhaled it. I gave but little attention
to the statement at the time, but during the following night and the next
day, when he began to cough and complain considerably of his lungs, I
gave it more consideration, although there were no indications that the
anaesthetic had any thing to do in exciting the symptoms present. These
continued to increase during the night and next day, and on the following
night he grew very restless — his lips became blue at times, and the veins
of his face and neck full and turgid with blood — he also suffered from ur-
gent dyspnoea occasionally. His breathing was constantly hurried, and, as
the disease advanced, the pulse grew weaker, and the brain gave decided
symptoms of a congested condition. The sensibilities grew dull, and he
ceased to complain. The pulse disappeared at the w^rist, and in a short
time he died. The action of the heart was always regular, and I never
could detect any abnormal sounds.

At 10 o'clock A. M., of the same day, seven hours after death, I made a
post-mortem. The corpse innnediately after death was removed to the
dead-room in the cellar, which was dry and well aired. The muscles were
slightly stiffened, but the body still retained some warmth. After eleva-
ting the sternum, my attention was attracted to the dark appearance of the
upper and front surface of the pericardium, and the tissues immediately
around it. On dissecting carefully the cellular tissue from it, I found it of
a dark color, but as firm and unyielding as when it was natural in appear-
ance. Upon opening it a quantity of gas escaped, and the cavity collapsed
— I had not observed that it was distended until this occurred. At the
same time a most disagreeable fetid odor was experienced. This was so
strong and characteristic of gangrene that it could not be mistaken for an
instant. It filled the room, and the passage outside for some distance, and
I had some difficulty in removing it from my hand. The cavity con-
tained about two ounces of a dark-colored, fetid fluid, of the consistency
of treacle.

The heart was dark colored, the right auricle being almost black. Upon
attempting to elevate it to examine its posterior surface, my finger pene-
trated the right auricle, although but slight force was used. I then re-
moved the lungs and heart from the thorax, and proceeded to examine
them critically. Found the whole anterior surface dark colored. This
hue was principally confined to the right side of the heart, and w-as most
marked over the auricle. A greater part of its surface was black, or in-
termediate between that and a dark-chocolate color, witli a tint of green-
ish blue. The color became lighter as the apex was approached, which was
very livid. The anterior wall of the auricle could be easily separated by
the fingers or forceps. At the point where it had been penetrated by the
finger, it appeared to be almost ready to fall in pieces. When the fibres
were torn and broken, they retained their shape, but w^ere very friable.
On making an incision from the rent to the apex, extending into the au-
ricle and ventricle of the right side, and examining the cut edges, they
were found to correspond in color to the external surface. The tissue was
softer than in the normal condition, until within about a quarter of an inch
of the natural surface — in some places rather more. This part appeared
somewhat denser than the unaffected portion of the organ, and was of a'
light-maroon color; and corresponded as nearly as could be expected to a

202

EEPOETS OX PEOGEESS OF 3IEDICES-E.

similar condition around the margin of gangrenous tissues, which I have
often since seen and divided in cases of traumatic hospital-gangrene. The
remaining portion of the heart was quite natural — perhaps a little flaccid,
but gave no evidence of fatty degeneration or inflammation. The whole
organ appeared smaller than usual, with a shrunken appearance. The
valves were perfect, except upon the right side — the outer portion of the
tricuspid being changed in color, and less firm than in the liealthy portion.
The vena cava and pulmonary artery were unchanged. The right side of
the heart was partly filled with blood — that in the ventricle was partly
coagulated. The left side was empty.

The vessels of the brain were engorged, and ventricles contained more
than their usual quantity of serum. The abdominal viscera were consid-
erably congested with dark fluid blood. Xo other traces of gangrene were
observed. The gall-bladder was full, and there was no transmission of
bile to the adjoining tissues by exosmosis.

Dr. Young appends to this history an elaborate discussion
of tlie nature of the case, and takes the ground, in face of the
recorded opinion of most pathologists, that this was an un-
doubted case of gangrene. He refers to Dr. Kennedy's Trell-
known case, which in several points quite resembled his own.
Dr. Gross, in the last edition of his Pathological Anatomy,
quotes Kennedy's case; btit states his belief that this and the
other so-called cases of gangrene are examples of softening
rapidly followed by putrefaction. This is the only authority
brought forward by Dr. Young in support of his view.

We incline very decidedly to the opinion that the case re-
ported was an instance of acute myocarditis — a disease, it is true,
of very rare occurrence, but of which we have a few recorded
instances. The celebrated case of Dr. Kadcliffe,' in which the
disease was diao;nosticated durino- life, is even more strikino^ in
its ]3arallelism to Dr. Young's case than the one which he
quotes from Gross. Dr. Stokes, who was the first to describe
the disease, and who met with a single case only, is inclined to
doubt the existence of gangrene, and to refer all these so-
called cases to inflammatory softening or disintegration in va-
rious stages of progress of the muscular structure of the heart.
No one of the recent works on practical medicine has more
than a passing allusion to this variety of disease ; but, on
the question of the actual occurrence of gangrene of the heart,
they are all silent. The point on whicli^Dr. Young lays the
weight of his argument is the presence of the gangrenous
odor, which was plainly perceptible ; but this odor is present
in certain diseases — for instance, of the lungs, where no gan-
grene coexists — and, on the other hand, the odor is sometimes
but very faintly marked in cases where no reasonable doubt
of the existence of the gangrenous process can be entertained.

'No microscopic examination of the tissues of the heart is

1 Medical Press and Circular, February 7, 1S6G.

SUEGEEY.

203

given — a fact wliicli is to be regretted, as the exact reporting
of these cases is quite essential to solve the existing doubts
of their pathogeny.

SURGERY.

1. — Three Cases of PerinephritiG Ahseess, complicated with
Pulmonary and Pleuritic Disease; Incisions into the
Penal Pegion ; Pecovery. Bv Henry I. Bowditcii, M. D.
[Boston Med. and Surg. Jour., July 9, 1868.]
These cases are of rare occurrence, and the history of the
three given by Dr. Bowditch is unusually instructive. They
are too long, however, to transfer to our columns, and any
summary would weaken their value. Dr. B.'s comments,
however, contain all the essential points in diagnosis and
treatment, and cover the whole of the teachings these cases
convey :

The'ie cases were tliree of the most interesting I have met with since
commencing my profession. Singularly enough, they are the only ones I
liave ever seen of this very rare disease, viz., of perhiephritic abscess, as
Trousseau calls it. Still further — rare as the disease is in the practice of
any one, these specimens all came under my notice during the brief period
of nineteen months, and the two severest were within one month of each
other. In all of them the abscess pushed upward into the thoracic cavity,
and in one instance the perinephritic origin of the thoracic disease was
marked by the severe thoracic symptoms that supervened after comj)ara-
tively mild signs of disease below the diaphragm.

Analyzing them, I find as follows: Patients all males, of the ages
27, 29, and 38 years respectively, and following the professions of physi-
cian, printer, and clerk. The disease commenced always near the right
renal and csecal region, and in all was preceded by some debilitating influ-
ences. Superadded to these, there were in two an unusual physical labor
and physical strain. In one there was a special strain (from digging) of
the psoas muscles, and in the other exposure to cold and wet in a swamp
while working.

The prominent symptom in all was pain^ generally in the back and at
the right renal region ; at other times it was more in front and near the
cascum. It was, however, usually felt in both of these places, and some-
times down the legs. This pain caused lameness, which at times was
severe and confined the patient to the bed with his knees flexed. At first,
this pain was in one case superficial, but gradually it went deeper, and in
two it was excruciating and attended with violent paroxysms of distress.
There was at times shght obstruction of the bowels, easily removed, how-
ever, by enemata or by gentle cathartics. With the dejections came relief
to the temporary urgent symptoms. The appetite was lessened or wholly
lost, and in two there was nausea; but, as a rule, there was no disturbance
of the alimentary canal, nor was there of the urinary functions, except
that the urine was in one case temporarily redder than normal. In one
case, where the urine was specially examined by chemistry and the mi-
croscope, no albumen, blood, or casts were noticed. No jaundice or other

204

KEP0ET3 PEOGEESS OF MEDICLNTE.

disease of tlie liver in any of tliem; no general peritonitis; no cephalic
symptoms.

In all three, a tumor was found which could be grasped between the
two hands placed in front and in the renal region, and filled up that space.
It was usually rounded, doughy, rather non-elastic, and generally non-
sensitive.

In all there were signs that the abscess extended up into the right
pleura, without apparently affecting the liver, after having probably forced
its way behind that organ and along the psoas muscles, under the right
crus of the diaphragm. This chest affection was in one case revealed only
by auscultation and percussion, the respiratory murmur being less in the
right back than the left, and some coarse mucous rales on friction were
heard at the very lowest part, while no subjective symptoms occurred in
that case. In another there were cough and a slight pleuritic effusion,
coming on during recovery, and ten days after the opening had been made
by the surgeon. Finally, in a third, the thoracic symptoms were so severe
that the patient was held to be dying of them, yet the history of the symp-
toms and the physical signs at examination proved that pleurisy existed on
the right side, while acute pneumonia had begun on the left.

In one, only, the breath was fetid, almost foecal.

The pnlse varied exceedingly, sometimes little accelerated, at others
being very rapid. In all there were marked chills with fever, and copious
night sweating. Emaciation and debility took place in all.

The treatment in all was tonic, with at times leeches, counter-irritants
and opiates, with laxative enemata generally when needed during the
earlier period. But the opening by the surgeon in the right renal region
was in all the first and prominent step toward a cure, which, as we have
seen, always took place. In aU the bistoury and a free opening were used
with great deference to the usual rules of surgery. I cannot but ask
whether a trocar, either a small one with a suction-pump or one of larger
size, might not be tried at least, and thus, perhaps, one great danger of
operating with the bistoury be avoided.

It will be remembered that very severe hemorrhage occurred in one of
our cases. Trousseau names this accident as being at times hazardous.
Certainly it was in our first case, the patient being very bloodless, with
ringing in ears, etc. Nothing but the promptest surgical skill apparently
saved the patient. In the second and third there was no haemorrhage,
and the happy influence of the operation was undoubted — immediate in
one, and more slow but unequivocal in the other.

In two the kidney could be felt, floating, as it were, at the bottom of the
abscess.

The recovery was prompt in tw^o, in about six weeks. In the other,
where the haemorrhage occurred, the patient had a longer convalescence,
and did not resume business till after six months.

A few words on the literature of this subject.

Great Britain seems almost wholly to have ignored the existence of this
disease, so far, at least, as it may be considered one to which physicians
would be summoned. Neither Graves, nor "Watson, Aitken, Todd, Tanner,
nor Chambers, alludes to it. Bennet, of Edinburgh, gives a few cases of
abscess of the kidney — but not outside of it, except secondarily. Neither
Dr. Wood nor Dr. Flint in this country notices it.

Trousseau^ (preceded by Rayer,^ Parmentier, and others, who have
given cases) first made an elaborate article upon the subject. Monsieur
Trousseau gives many causes : fatigue, strong muscular efforts, contusions,
repeated and violent shakings of the kidney, renal calculi, typhoid and
puerperal fevers, etc.

1 Clin. Med,, vol. iiL, p. 713. Paris. Maladies des Keins, 1839

SUEGEEY.

205

He speaks of the very great infrequency of the disease, and of its very
insidious approach. He alhides to most of the symptoms recorded in ray
cases. Among them he dwells chiefly on the swelling in the lumbar region,
the pain in the same part, the chills and fever, emaciation and debility. He
does not particularly allude to two prominent facts noticed in all of our
cases, viz. : the lameness in the movements of the right legs, owing to an
interference with the free play of the psoas muscles, and the extreme fre-
quency of pulmonary and pleuritic complications in consequence of the ex-
tension of the disease. And yet the anatomical structure of the parts con-
cerned proves that nothing can be easier than the transmission by con-
tiguity of the perinephritic abscess into the thorax. The psoas muscle
extends up into the thorax behind the pillar of the diaphragm. Hence
any abscess, pressing on or inside the muscle, will veiy readily gain access
to parts above the diaphragm. It was the remembrance of the serious
complications caused by this anatomical arrangement in the preceding
cases that induced me, in the last cas^, to urge a speedy operation, when,
according to the common rules of surgery and the absence of distinct
fluctuation, a delay would naturally have suggested itself. In fact, one
surgeon urged delay. Dr. Hodges, I think, was somewhat influenced by
representations from Dr. Blake and myself, urging him to explore, at least.

It is a singular fact, however, that notwithstanding the pus in these
eases goes directly back of the liver, jaundice was not seen, in our cases,
and is, I think, a rare complication of the disease.

In this connection we may add the following brief account
of a case of tlie same nature, wliich was reported at a recent
meeting of tlie Clinical Society of London, bj Dr. Sontbey :

The patient had previously suflfered from stricture with vesical catarrh,
subsequently passing pus in albuminous urine. A deep-seated swelling
formed in the left loin, which varied in size according to the greater or less
quantity of pus present in the urine. Presently a large amount of pus
was discharged after the fteces, and the patient began to suffer from ex-
treme exhaustion. The tumor pointed and was punctured ; almost five
ounces of deeply-seated pus escaped. Later on, symptoms of dysentery
caused much suffering, but after a time the discharge became less, and the
general health improved. Eventually the opening in the flank closed, and
the patient recovered, but the bladder was permanently drawn up toward
the left kidney, and there were pain and spasm in micturition. In the ab-
sence of any evidence of caries of the spine, or of embolism, or of renal
calculus. Dr. Southey concluded that suppuration began in or about the
kidney, and the disease was throughout of a local character.

2. — Successful Ojjeration of Lithotomy for the third time on
a Patient Eighty Years of Age. By Dr. Scott, Snrgeon
to the Dumfries and Galloway Royal Infirmary. [Edin-
burgh Med. Journal, March, 1868.]

William E., laborer, Annan, was admitted into the Infirmary on the 3d
of October, 1867, with undoubted symptoms of calculus of the bladder.
Patient stated that sixteen years ago, and again four years ago, he had
lithotomy performed by Professor Syme in the Edinburgh Royal Infirmary,
where he remained four weeks and eleven weeks respectively.

On the present occasion, as formerly, the lateral operation was per-
formed, and, on introducing the finger into the bladder, a fibrous polypus,

206

EEPOETS O^f PEOGEESS OF MEDICHSTE.

of the size of a cherrv, was discovered, which was easily twisted and re-
moved by forceps. Three calculi were removed without any difficulty, two
of which were of the size of marbles, and the third about the size and
shape of a walnut. The patient made an excellent recovery, and left the
house six weeks from the date of the operation, suffering, however, from
incontinence of urine, which he had done since the second operation.

The object in publishing the foregoing case is to show that the opera-
tion may be undertaken at an extreme old age, with prospects of a favora-
ble issue.

3. — ApjKfrahis for the Treatment of Fracture of the Claviele.

3, 1868.]

Dr. Boisnot's apparatus is so simple and easily adjustable,
that we have deemed it worthy of notice in the columns of
the Journal.

The conical shape of the forearm, with the apex at its most dependent
part, admirably adapts it for an attachment from which traction can be
made in an upward and backward direction. A leather socket, fitting and
laced around the forearm, is the simplest application which can be made
for this purpose, while its corresponding shape is a support ; the latter fea-
ture can be more fully developed by having a portion continued beneath
the ulnar border of the hand. The long band of webbing attached to this
leather socket or case, upon its front part and near the elbow, being car-
ried upward to and over the injured shoulder at the point of fracture, ele-
vates the shoulder, and prevents displacement of the fractured ends of the
clavicle when once coaptated ; having at its initial end a buckle with
swivel attachment, the arm may be placed in any suitable position, and the
forearm carried across the breast in any direction called for by the pecu-
liarity of the fracture. Xo pad in the axilla is required. A stip of adhe-
sive plaster should, and graduated compresses may, be applied over the
seat of fracture ; the latter near to or distant from the shoulder as may best
tend toward keeping the band in its correct position; this, as well as the
distance which the arm should be carried from, toward, or across the chest,
every surgeon will determine for himself The course of this band from
the injured shoulder is across the back to the opposite axilla, then by a
turn around this shoulder and again across the back to the opposite axilla,
then by a turn around this shoulder and again across the back to the sec-

SUEGEEY.

207

ond buckle at the elbow ; the terminal end is then carried forward and be-
neath the forearm, to the turn around the shoulder (not shown in the cut) ;
after forming a loop by passing through this turn, it can be pinned or
sewed ; a sling is thus formed, and the apparatus and parts contained kept
comfortably firm.

As it is applicable to either side of the body, it is merely necessary, in
sending for it, to state the age and sex of the patient.^ The simplicity of this
apparatus is evident, when compared with that of Dessault, or its modifi-
cation by Fox ; requiring for its impromptu preparation only a coat-sleeve
and a strip of muslin shaped to the forearm and fastened together by
needle and thread, I think it can be made anywhere and by any one under-
taking the treatment of a case of fractured clavicle.

A further use of this apparatus consists in its application to cases after
resection of the shoulder, and as a support after reduction of its disloca-
tions. The small amount of dressing constituting the apparatus, and the
manner in which it supports and retains the parts in tlie position natural
to them when uninjured, contribute alike to the comfort of the patient and
the attainment of favorable results.

4. — A Case of Ilio-Psoas Abscess, By A. Ha:m^iee, M. D.
[Humboldt Med. Archives, July, 1868.]

We refer to this case with the special view of calling at-
tention to the novel method of treatment adopted to relieve
the pain and discomfort caused by the prolonged confinement
in bed. The case also involved a nice question of diagnosis
in its earlier stages, and is altogether qiiite instructive :

The patient was a young man of about 3T years of age, who, previous
to the attack of illness under which he succumbed, had enjoyed excellent
healtii, and was rather noted for his vigor and ability as an amateur gym-
nast. During the winter he had been travelling in Illinois on business,
and had been much exposed to the inclemencies of the season, and on his
return to the city was taken ill on the 6th of December, and was treated
by Dr. Engleman for rheumatism, who afterward, from the symptoms and
complications, thought the attack to be morbus coxarius. Upon Dr. E.
leaving for Europe, the case was left in charge of Dr. Castlehuhn. Di*.
Hammer had been called in consultation about the middle of April, and
found the patient confined to bed. The left log was flexed and rotated in-
ward ; the hip and thigh were both enlarged, and he had severe pain
around the hip-joint, and extending to the knee ; there was an abscess
just below the greater trochanter, and fluctuation discoverable below
Poupart's ligament, on the anterior and internal side of the thigh (Scarpa's
triangle). Dr. H. was disposed to believe that the joint was diseased, but,
for the purpose of a more accurate investigation of the case, the patient
was put under the influence of chloroform, when no signs of disease of
the joint were discoverable, and the abscess was pronounced to be peri-
arthritic. Within the next few days fluctuation could be detected beneath
Poupart's ligament, within the pelvis, and could be traced along the crista
ilii. Dr. Hammer, under such circumstances, pronounced the abscess
retro-peritoneal, within the ilio-psoas muscle, and this diagnosis was fully
confirmed, when still a few days afterward fluctuation could be felt below
the twelfth rib near the spinal column.

1 Mr. D. W. Kolbe, 15 South Ninth Street, Philadelphia, and Messrs. Tiemann & Co.,
New York, are prepared to furnish the above apparatus.

208

EEPORTS OX PEOGEESS OF iNEEDICmE.

Both the abscess below the trochanter and that in the groin -were snb-
cutaneouslj evacuated hj the trocar, but, refilling rapidly, recourse was
had to drainage-tubes. The pus in the abscess below the trochanter be-
coming putrid from access of air, the drainage-tubes were removed from
both abscesses, and that below the trochanter was laid open its whole
length — about eight inches— and filled with dry charpie. An incision was
made below the ribs, and injections made, first of clear water, and followed
by diluted carbolic acid. The discharge not diminishing, tinct. iodine was
repeatedly injected, but without benefit.

"When Dr. H. first saw the patient he had large bed-sores on both
nates, and on the sacrum ; he was very weak and prostrated ; completely
emaciated; his tongue was covered with aphthae; had no appetite; re-
peated rigors followed by high fever, and unable to he in any position
without excruciating pain. To obviate this latter trouble it was finally
decided to suspend him in a permanent water bath of about 90°, in which
he remained with comparative comfort for twenty-seven days, when death
relieved him from his sufferings. In the beginning, the bath was decidedly
beneficial, as in combination with anti-septic remedies and stimulant treat-
ment all unfavorable symptoms were markedly ameliorated. The aphthfe
disappeared; the pulse fell from 130 to 85; bis appetite increased enor-
mously ; he slept comfortably, and for the. first time in many weeks could
rest with comparatively little pain. So marked was tiie improvement
that his friends felt confident of his final recovery; but the constant drain
upon his system from the profuse suppuration proved so exhausting that
he finally succumbed to inanition, and died in the bath, as though fall-
ing into a peaceful sleep.

The ])ost-mortem revealed an abscess extending along the ihacus and
psoas muscles, and diffusing itself between the soft parts surrounding the
joint, and even on the anterior external portion of the thigh. The capsule
of the joint was perfectly intact, thus giving positive evidence that the
suppuration had been entirely peri-arthritic. The joint on being opened
presented the interesting appearance shown in the specimen : The carti-
lage covering the head of tlie femur, and lining the cavity of the acetabu-
lum, was in a state of softening, in some places showing the cancellated
structure of the bone ; and near the centre of the acetabulum even the
osseous structure had been absorbed, leaving a spot about the size of a pea,
which, on tlie internal or pelvic side of the bone, was only closed by the
covering of periosteum. There was no pus in the joint, and only a very
small amount of a dirty-looking fluid, the detritus of the process of
softening.

Dr. H. expressed the opinion that the aftection of the joint had only
supervened during the last four or five weeks of the man's illness, inas-
much as the most careful examination, under the influence of chloroform,
when he first saw the patient, did not reveal any kind of morbid aftection
of the articulating surfaces ; and he furtlier believed that it was the mere
result of the pressure of the head of the bone in the acetabulum, caused
by the continued contraction of the surrounding muscles.

With regard to the so-called pathognomonic pain in the joint and in
the knee in the beginning of the disease, and which had led the first
physician to diagnosticate rheumatism and coxitis, he stated that a retro-
peritoneal abscess upon the ilio-psoas muscle would undoubtedly cause
such an irritation of the crural nerve by pressure, etc., as to give rise to
the same symptoms.

MISCELLAXEOrS AXD SCIEXTIFIC XOTES.

209

HlisaUiincous anb .Scientific |l'otes.

Chloeoform or Ether. — At a recent meeting of the Mid-
dlesex (Mass.) Xorth District Medical Society, Dr. Biirnliam,
of Lowell, read a paper o\\ " C hloi'oform : Its Advantages
over Ether as an AnrntheticP An abstract of the paper is
given in the Boston Medical and Surgical Joxmicd^ and we
find it there stated that Dr. Bnrnham " showed that chloroform
is safer, and is attended with none of the baneful after-results
which often follow the use of ether, such as insanity, epilepsy,
conyulsions, etc." TTe are quite at a loss to account for this
most astounding assertion, and, in view of the fact that the
medical journals are reporting almost daily cases of death from
the use of chloroform, we think such a statement as the above
can only be prompted by too close adherence to prejudice, or
by an ignorance of the actual facts of the case. Deaths from
chloroform are now on record bj the hundred, and, what is
worse, they are still occmTing with alarming frequency ; and,
while we do not claim positive and entire exemption from
danger in the use of ether, we challenge Dr. Burnham, or any
other ardent admirer of chloroform, to produce the proof of the
bold assertion that ''chloroform, if properly administered, is
devoid of danger," and safer than ether. We admit the ad-
vantages which, in some respects, chloroform possesses over
ether, but at the same tune we cannot for ourselves allow those
advantages to be purchased at the cost of an increased danger
to the patient's life, and we do not hesitate to deny, as emphati-
cally as Dr. Burnham asserts, that chloroform is the safer agent
of the two.

This subject is of the utmost practical importance, and
there ought to be no halting of opinions upon it. Either Dr.
B. is right or wrong, and an appeal to the records ought readily
to determine the issue. We trust that he will feel it his duty
either to make good his assertion or undo the injmy which, in.
the minds of the inexperienced, he may have wrought.

Again we beg leave to request that he may enlighten us on
the point of the frequent occurrence of insanity, epilepsy, and
conyulsions after the use of ether ; for this sweeping and un-

210 MISCELLAITEOUS ANT> SCIENTIFIC T^OTES.

qualified assertion comes upon us with a startling effect tliat
threatens to quite sweep away our accustomed belief of tlie
general innocuousness of this agent.

At the risk of converting our readers to the system of high
dilutions, we quote from the American Journal of Homm-
opatMc Materia Medica the following astounding cure. Eqiio
ne credits^ Teucri.

Some four years since, while practising medicine in ]^ew
York, I was called to a case in Flushing, L. I., and, on driving
me home the next morning, the gentleman, in speaking of his
horse, remarked that it was a very favorite animal, but he re-
gretted it was very much out of health — ate little, was languid,
and seemed to have no spirit or life. I said, " Sir, your horse
has dyspepsia ; I should give it JSfux vom^ At his request, I
did up for him half a dozen powders of the 200th, containing
about twice the quantity I should have given a man. " How
are these to be administered ?" Here was a poser. Never
having given medicine to animals of a lower type than the
genus homo^ I knew not what to say, and, in my inexperience
and embarrassment, told him to put the powder in a bottle of
water, and, after shaking it well, pour it down the horse's
throat. But it seems the animal was not to be persuaded.
And here the good common-sense of the owner came to the
relief of the physician's ignorance. The powder was put in
the pail from which the horse drank, and, thus deceived like
many a nobler beast, the medicine reached its destination.

After taking two or three powders in that manner, the
horse passed " enormous quantities of worms." Did you
give the medicine for worms ? " said the gentleman to me
afterward. And here was another poser, in a question which
I adroitly managed to set aside, Avithout either affirming or
denying, for I had not the least thought of such a result when
the prescription was given.

Finding the good effects after giving the last powder, and
suffering the horse to drink all that could be drunk from the
pail, the gentleman filled up the pail with water, and gave the
contents to his other horse, which was slightly ailing, though
not apparently to the same degree ; but the medicine was fol-
lowed by the same results. (What potency shall we call the
last ?) I learned afterward that these horses had been taken
to several veterinary surgeons of ^^ew York to be doctored for
worms, but without any relief.

The horses remained well for one year. The owner then
"wrote me a note, asking for some more of that same medi-

MISCELLANEOUS AIS^D SCIENTIFIC NOTES. 211

cine." Of course I sent it ; and, seeing liim the next winter,
learned the animals had been well ever since.

This case proves two things : that the beasts might have
been cured with much less medicine and in much higher po-
tency than that given, as the last had only the refuse of what
was left of the last powder given the first horse, and that at
one draught only.

From the same source we take a " Thekapeutic Hint. "

" Cina. — Children don't want to be touched. They can't
bear even to have you come near them."

We know a good many children who are troubled in this
way, and, as like cures like, we think our homoeopathic friends
have earned the lasting gratitude of thousands of anxious
parents.

''Angelica. — ^Women become melancholic after confine- *
ment, and will not go out, even to clmirchr

"We have met with a good many cases wherein the last-
named characteristic was dependent on the fact of having
nothing to w^ear. This is too horrible for contemplation, and
we beg to be informed what potency of what remedy will be
efficacious in such cases.

Speaking of women physicians, the Spectator wittily re-
marks: "If there be such a right as liberty, it includes a
woman's right to learn and teach anatomy if she pleases ; and
to forbid her by law is tyranny, and tyranny without excuse,
till we make both sexes modest by act of Parliament."

Teichinje m THE Domestic Fowl. — Dr. Geo. S. Bryant
reports, in the Richmond and Loidsville Medical Journal, the
finding, imbedded in the muscular coats of the stomach and in-
testines of the common domestic hen, of large numbers of ento-
zoa, coiled in cysts in every possible attitude, and not unlike
in appearance tlie trichinse found in the human muscle. He
suggests that the disease known as " chicken cholera " is de-
pendent upon the presence of these entozoa, and promises to
continue and report his investigations on the subject.

Dr. a. B. Shipman, of Syracuse, J^ew York, died in Paris,
France, on Tuesday, September 15, 1868.

212 MISCELLANEOUS ATTD SCIENTIFIC NOTES.

Death from Mrs. Winslow's SooTHmG Syrup. — ^The Medi-
cal and Surgical Rejporter^ of August 29tli, gives a report
from, an anonymous correspondent, in Washington, D. C*., of
tlie death of an infant, nine months old, from the use of Mrs.
Winslow's Soothing Sjrup. Between 10 o'clock in the even-
ing and 6 o'clock in the morning, eight hours, the child had
taken six teaspoonfuls. The symptoms, when the child was
seen by the physician, were " semicomatose condition, with
pallor of face, open eyelids, contracted pupils, cool skin, cold
extremities, increased heat of head about vertex, and thumbs
contracted into the palms. There w^as vacant expression of
the eyes, constant low moaning, and perfect indifference to
surrounding objects. The only movement was an occasional
closing of the eyelids."

Treatment adopted was stimulation externally by means
of mustard-heat and frictions. Internally, two-drop doses
each of aromatic spirits of ammonia and tinctm^e of belladonna
with brandy were administered. iTo reaction was observable,
save a slight temporary dilatation of the pupils, after ach
dose of belladonna. Slight convulsions preceded death.

The new law in Ohio, compelling all physicians who have
never received regular diplomas to suspend practice, took effect
on the 1st of October.

Appointments. — Prof. E. R. Peaslee, M. D., of this city,
has resigned the chair of Anatomy and Physiology, which he
has occupied for the past twenty-eight years, to accept the ^do-
sition of Professor of Diseases of Women and Children, in the
Medical Department of Dartmouth College, Hanover, IN'. H.
Dr. Lyman B. Howe, of Manchester, N. H., for several years
Demonstrator of Anatomy, succeeds Prof. Peaslee in the chair
of Anatomy and Physiology.

The following appointments have been made in the Long
Island College Hospital : Prof, of Obstetrics and Diseases of
Women and Children, E. S. Dunster, M. D. Prof, of Chem-
istry and Toxicology, George W. Plympton. Prof, of Opera-
tive and Clinical Surgery, Benjamin Howard, M. D. Phys-
iology and Microscopic Anatomy, William T. Lusk, M. D.
Materia Medica and Therapeutics, Andrew 1^, Smith, M. D.

MISCELLANEOUS AND SCIENTmC NOTES.

213

Xew Yoek CorxTY Medical Society. — At the Anniver-
sarv Meeting of tlie Society held Monday, Oct. 5, 1868, the
following Officers were elected for the ensuing year. Presi-
dent, George T. Elliot, M. D. ; Vice-President, A. Jacobi,
M. D. ; Eecording Secretary, A. E. M. Purdy, M. D. ; Corre-
sponding Secretary, Benjamin Howard, M. D. ; Treasurer,
^Y. B. Bibbins, M. D. ; Censors, E. K. Peaslee, M. D., Ells-
worth Eliot, M. D., E. S. Dunster, M. D., W. P. "Whitehead,
M. D., and W. T. White, M. D.

M. Gervais, Professor of Anatomy and Zoology, has been
appointed Professor of Comparative Anatomy at the Museum
of Natural History, Paris, France, to fill the vacancy caused
by the death of the late M. Serres.

Academie de Medecixe. — M. Alphonse Guerin has been
elected into the Section of Operative Medicine, in the place of
the late M. Lagneau, by the votes of 51 out of the 63 academi-
cians who were present.

Aemy Peesoxal. — The following changes have taken place
in the Medical Coi-ps, U. S. Army, since the date of the pub-
lication of the last official report, July 1, 1868 :

PTomoted. — Assistant Surgeon C. E. Goddard, to be Sur-
geon, to date January 6, 1868, ^^'ce Lewis Taylor, deceased.

Ajypointraents. — Lieutenant-Colonel Jede'diah H. Baxter,
Assistant Medical Purvevor, U. S. Armv, to be Colonel by
brevet, to date July 20, 1867. Brevet Colonel E. Swift, Sur-
geon, tJ. S. Army, to be Brigadier-General by brevet, to date
July 20, 1867. Brevet Lieutenant-Colonel B. J. D. Irwin,
Surgeon, U. S. Army, to be Colonel by brevet, to date March
13, 1865. Brevet Major J. H. Janeway, Assistant Surgeon,
IT. S. Armv, to be Lieutenant-Colonel by brevet, to date
March 13, 1865.

Ixe-commissimied. — Assistant-Surgeon H. J. Pliillips, to
date March 30, 1861:, to take rank on'the Official Army Kegis-
ter next above Assistant-Surgeon J. H. Kinsman.

Resigned, — Assistant-Surgeon G. L. Porter, Brevet Major,
to date July 16, 1868.

Died. — Assistant-Surgeon Cyrus Bacon, September 1,
1868, near Springfield, Illinois, while en route to his home,
Xiles, Michigan, of Bright's disease of the kidneys.

214

MISCELLA^^EOUS ANT> SCIEOTIFIC NOTES.

Dismissed. — Assistant-Surgeon P. J. A. Cleary, by sen-
tence of General Court-Martial, approved July 2, 1868, Gen-
eral Court-Martial Orders, ^No. 45, Headquarters oi tlie Army,
Adjutant-General's Office, Washington, D. C., July 2, 1868.

Desceiptiox of the Ehode Islaxd Hospital. — Wq are
indebted to tbe kindness of Dr. Chas. O'Leary, an old and
esteemed professional associate, for this interesting description
of tbe new Hospital at Providence, R. I. :

This new and beautiful hospital was publicly opened on
Thm'sday, the 1st of October. An address, appropriate to the
occasion, was delivered by Prof. Wm. Gamell. Having paid
a just tribute to the munificence of the benevolent citizens
who founded this noble work of charity, to the skill of the
architect who designed and completed the building in all its
details, and to the zeal and earnestness of the medical profes-
sion, who for years have been advocating the claims of a
charity of this kind on the people of Pro^ddence, the orator
made a strong, fervent, and earnest appeal to the citizens of
Phode Island in behalf of the permanent endowment of an
institution that is destined to shed blessings on the community
for all ages. Iso one, contemplating the noble structure, can
believe that the charity and humanity which have created it —
and of which it is a grand expression and embodiment — will
contract or decline under the lessons and teachings its presence
in our midst will constantly inspire. Liberal and generous as
the State of Phode Island has been to its patriotic and brave
soldiers, and to those invalided in the campaigns and bat-
tles of the country, it will not refuse to extend the hand of
humanity and charity to the invalids of labor and industry,
from which flow its wealth and prosperity. In this age, which
knows no masters and slaves, no patrons and dependants, no
landlords and serfs, no chiefs and retainers, when each citizen
is taught self-reliance — and enters on the struggle of life in-
spired with the belief and confidence that success depends on
himself alone — upon his own thrift and industry, a generous
community should regard each worthy member as one of its
family, and guard him from want and privation when disease
or injury stops his labor, the source of his maintenance. Hos-
pitals are no modern institutions ; but the conditions of society
that demand them, and the sj^irit that advocates their claims
and support, are different from those of earlier times. Then
it was that some princely bishop, or some lordly benefactor, or
Christian monastery endowed and founded hospitals of refuge
for the poor and friendless, of towns and cities, who could in

MISCELLANEOUS A^^^D SCIENTIFIC NOTES. 215

the days of sickness and distress claim no care from tlie lords
of wealth to wliom they had previously paid no service.
Then it was a spirit of almsgiving or bounty to beggars —
prompted by Christian charity — that guided one of the w^ealthy,
more benevolent than his fellows, to erect a home of refuge
for suffering and helpless fellow-beings. Now this Christian
sympathy is not exercised by the rich alone — it is diffused
through the whole community — and a feeling of common
brotherhood, of generous philanthropy, of Christian charity
pervades the whole people, and inspires them to provide that
their sons and daughters of toil, whom disease or injury may
compel to abandon the ranks of labor, shall suffer no w^ant or
privation. It is in the most enlightened and industrious com-
munities that examples of this generous philanthropy most
abound ; and writing of a I^ew-England institution we may
be pardoned for referring to tliat tribute of praise which
foreign writers — as Mill, Lyell, Dupin, and Chevalier — bestow
on the JS^ew-England States for their many examples of
charitable munificence, holding them up to other communities
as models of the benevolent use of wealth. Rhode Island will
not lag behind her sister States ; her people, proud of the
institution which private benevolence has founded, will pro-
vide that it does not fail for w^ant of means of accomplishing
all the good for which it was designed.

The hospital is beautifully located in a position which,
from its elevation and the nature of tiie soil, is remarkably
salubrious. An ample area of ground, with capacity for gar-
dens, lawn, and park, encloses it, and isolates it from the noise
and bustle of the busy streets, though the location has almost
a central position within the cluster of towns which compose
the city of Providence. The building displays great archi-
tectural beauty ; it is of the Lombardo-Italian Gothic style,
and in the hands of the architect, all that exquisite grace and
beauty, of w^hich this style from its inherent quality is sus-
ceptible, have been combined with the most thorough and per-
fect details of a hospital. The ventilation approaches nearer
perfection, perhaps, than in any building of the kind yet con-
structed ; and the arrangements for the comfort and hygienic
wants of the patients, as well as for the convenient, quiet,
and efficient administration of the hospital, have never been
surpassed.

The hospital consists of two pavilion buildings, three
stories higii, extending from the opposite sides of a central
building, and connected with it by corridors of corresponding
height. The sides of the two upper stories of the corridors
are of colmnns of exquisite beauty in their architectural effect.

MISCELLANEOUS AND SCIENTIFIC NOTES. 217

These corridors serve as passages between the correspon cling
stories of the central and pavilion buildings. The central
building, besides the superintendent's rooms and quarters for
the resident medical officers, with executive offices, contains
also a chapel and amphitheatre. The ground floor of the
pavilion building is occupied with kitchen, store-rooms, recep-
tion-rooms for patients, etc. The two upper floors are devoted
to wards, which hav'e each 24 beds, with an allowance of not
less than 1,500 cubic feet for each bed. Besides the four wards
which the building thus gives, there are a number of private
rooms intended for paying patients, and for such cases as it
may be necessary temporarily to isolate from the public wards.
At one extremity of the ward, and separated from it, are the
bath-room, water-closets, and a drop for soiled clothing. Tlie
water-closets are connected with the chimney of the steam
generator, which is built on the ground apart from the Hos-
pital. By this arrangement all effluvia are swept off by the
draught of the chimney, and there is never a back current into
the water-closet chamber. The soiled clothing, let down to
the lower floor, is conveyed by an underground passage to the
laundry, which, with the boiler and engine rooms, forms a
separate building. At the other end of the ward are the nurses'
room, a pantry, and closet for dumb-waiter, which commu-
nicates with the kitchen on the ground floor. The nurses'
room overlooks the whole ward. It is furnished with a
bureau, with compartments corresponding to the number of
beds in the ward, where clothing and articles for the patients'
"use are contained. Another set of compartments, wdth num-
bers corresponding to the numbers of the beds, is intended as
a receptacle for the medicine, drink, etc., of the patients re-
spectively. So there is little liability of giving, by mistake, to
one patient what is prescribed for another. In the ward and
close to or imder the beds of the patients no ntensils are allowed
to remain for a moment after being used. Near the floor at
the head of each bed there is an opening in the wall, with a
close-fitting slide, intended as a receptacle for the vessels that
are in use. These openings communicate with a common flue
in which a current is created by means of heated steam-pipes,
placed near the top of the building. Thus all noisome efflu-
via are removed, whilst any communication between this cur-
rent and the atmosphere of the ward is cut off by means" of
the slide above mentioned. The natural ventilation of the
hospital, favored as it is by its location, is made available to
its fullest extent in the construction and design of the build-
ing. Besides this, the artificial ventilation approaches as near
perfection as practical application has hitherto approached

218 MISCELLAIS^EOUS AND SCIEOTIFIC NOTES.

theoretical principles in this difficult problem ; there is a con-
stant stream of air introduced, which is warmed to the re-
quisite temperatm-e by flowing over heated steam-pipes, and
is filtered of all dust by j^assing through a fine spray of water
that descends in a shower through wire gauze. Tlie es-
cape-yentilators, placed in the wall near the ceiling, commu-
nicate with heated steam-pipes that are placed in two towers
that rise gracefully from the pavilion buildings. These
towers are stately decorations to the entire structure, and
would be worthy of being erected for their architectural effect
alone ; but the architect, who has so artistically combined
beauty of design with every useful purpose, has made these
graceful appendages subserve the most vital necessity of a
hospital. In the construction of the wards, in their appoint-
ments, and in all the subsidiary departments of kitchen, store-
rooms, etc., the various requirements of a hospital, so far as
sanitary science has demonstrated them, have never been more
skilfully and thoroughly complied with than in this new
Hospital of Rhode Island.^

This degree of success, next to the skill of the architect,
Mr. Morse, is due to the unceasing care and watchfulness
with which the President of the Board of Trustees, Mr. Ives,
and Dr. Sliepard, member of the Board, Lave follovv^ed the
work from first to last. Dr. Sliepard has even visited and
examined the hospitals of Europe, in order to learn any im-
provements in administration and internal arrangements it
may be still beneficial and desirable to adopt.

Besides contributing largely of their wealth toward it,
these gentlemen have watched this institution, in its growth
from the first stone laid, with as much fondness and care and
cheerful anticipations as ever did rich man the building of
the mansion destined to be the home of his family, and heir-
loom to his posterity. The honor paid in the community to
such examples of benevolence, and unselfish devotion to ob-
jects intended for the welfare and protection of their fellow-
beings, will not fail to inspire others to imitate their virtues,
and extend the blessings of benevolence where suffering hu-
manity needs them.

In an institution which seizes the mind of the observer
only by its completeness and admirable adaptation to its spe-
cial use, if there be any defect, it is in the arrangement designed

^ The internal arrangements of tliis hospital will be more readily appre-
ciated by a reference to the ground plans, which the reader will find
stitched in at the close of the reading-matter of this number of the Journal.
It was impracticable to procure them in season to insert them in the body
of the Journal, nor was it deemed necessary for the purpose of description.
—Ed. K Y.M.J.

MISCELLAISrEOUS Al^D SCIEOTIFIC NOTES.

219

for the consultation of outside patients. There is but one
chamber or hall for the reception and consultation of all
classes of patients, medical, surgical, male and female. To
one accustomed to the hospitals of Europe, and to the hos-
pitals of other cities in America, tl)is is a defect, and I appre-
hend will, on trial, be found so by the attending faculty.

The ^^"eeves of the Heart. — Let us now take a peep into
the mysterious laboratory of the College de France. Here we
fall into the company of a dozen soits-savcms^ the aids of the
learned professor and academician. They are called techni-
cally " the young savans of the College de France," simply
because they are younger than their master in science, for on
looking around we see gray beards among them. Those
men are the hope of the experimental school of physiology ;
they have banded together under the eye of the master to per-
petuate and glorify the name of the school of Paris. To-day
they are unknown ; to-morrow they will be illustrious.

One of them. Dr. Cyon, has just been awarded by the Im-
perial Academy of Sciences the annual premium for dis-
coveries in Experimental Physiology, for the discovery of two
nerves going from the spinal marrow to the heart, and belong-
ing properly to that organ. His paper is entitled, " Pe-
searches on the Innervation of the Fleart by the Spinal Mar-
row," and, besides a description of the newly-discovered
nerves, relates demonstrations of new phenomena produced
by these nerves in the functions of the important organ to
which they belong.

The first nerve, which he Qalls the special cardiac accele-
rator nerve, emerges from the spinal column with the third
branch of the cervical ganglion, and, when excited on the liv-
iug animal, the heart's pulsations are increased. The same
effect is produced whether the excitation is made on the root
of the nerve, or on the spinal marrow near the nerve. The
other nerve discovered by M. Cyon, uniting the heart to the
spinal marrow, is not a motor but a sensitive nerve. By the
medium of this nerve a reflex action is produced, starting
from the heart, and influencing the capillary circulation in all
the organs of the body. The most important facts in the
physiology and pathology of the heart may flow from this dis-
covery.

Here we have been going on these thousands of years,
without knowing that the heart had nerves of its own. We
have been wondering, this long time, how this mighty hydrau-
lic machine got power enough, from the feeble branches of the
sympathetic and pneumogastric nerves, to maintain with regu-

220

MISCELLANEOUS AND SCIENTIFIC NOTES.

larity its himclred thonsaiid beats a day. Was this mysterious
power liydranlic, or vital, or mixed ? The physiologists were
always quarrelling on the subject, and they will continue to
quarrel, perhaps, all the same, for one discovery brings
another, and thus continues to open new fields of discussion.

But, honestly speaking, do we not owe our hearts an
amende Jionorable f Where is there a friend so faithful ? We
23rofess w^onder at the faithful watch that keeps up its tic-tac
for a twelvemonth without stopping, but none for the heart
that keeps up its regular tic-tac for a hundred years ! The
ingratitude of man has no bounds. He will eat too much, or
drink too nmch, or run too much, without ever a thought for the
overwork lie is thereby giving his already overworked and faith-
ful friend. He wdll push it by excesses into disease, and then
complain when it grows tired, and threatens to stop. The physi-
ologists, on their part, have a world of reproaches to charge
themselves witli, for abandoning this important organ in
ignorance and doubt. " It will go on in its endless work any-
how", therefore let it go ! " They were pretty sure that the
feeble supply of nerves from the cardiac plexus did not supply
the whole power of this wonderful organ. They knew that
a great mystery hung over it, and that, whether its power
was vital, or mechanical, or both, there was not such a distri-
bution of nerves as accounted satisfactorily for all the phe-
nomena of its movements, ^[ow we know why. We have
got a reenforcement of nerve-power, coming tliis time directly
from the seat of locomotion and sensation in the spinal mar-
row. We have got two nerves, two telegraphic lines, going
straight, w^ithout relay or branches, from the spinal marrow to
the heart, one for motion and the other for sensation, and now
we begin to understand better the heart's action, and its vari-
ous manifestations in health and disease. M. Claude Bernard
is already at work with his band of colaborers at the new^
nerves, and some important indications have been established,
or nearly established, in relation to disease of the heart. —
Paris Correspondent of the Times.

Deaths by Suicide. — Suicide is on the increase, steadily,
alarmingly. The real number and the real increase, an-
nually, of suicides, is probably greater than would appear
from official records. Many deaths, recorded as accidental,
should, doubtless, be set to the intentional account. Par-
ents and friends willingly conceal what official recorders find
no call to scrutinize too narrowly. From 1827 to 1866, in
France, the increase of suicide has been annually, and by the
million of inhabitants, from 54 to 134 cases. The whole num-

IVnSCELLAITEOUS AiS^D SCIENTIFIC IS^OTES. 221

ber in the first five years, from 1827 inclusive, was annually
1,739 ; in 1866 it amounted to 5,119. , The increase in the
intervals is 118 per cent. ; the increase of population in the
same interval is a fraction under 20 per cent. The increase
is much more and proportionately much more with men than
with women. The test applied by countries and by the mil-
lion of inhabitants, shows 123 for Prussia, 110 for France, 69
for England, 43 for Austria, 32 for the United States.
Doubtless the greater accuracy in respect of the nature of
deaths, which is observed in the mortuary records of Prussia
and France, partly accounts for the comparatively small suici-
dal cipher set against Austria and tlie United States. But an
auxiliary explanation will offer itself presently. The most
suicidal people are the Danes and those of the J^S orth German
States. The test of sex shows, in 11 states of which more or
less perfect statistics are at hand, 30 females to 100 males ;
that of age shows an increase by years till the age of 60 or 70,
the term being later with men than with women. The test
by seasons shows for suicides, as for crimes committed on per-
sons, and for attacks of insanity, an augmentation in summer
over the winter months. The means of suicide are, in the
order of their frequency of use : strangulation and drowning,
fire-arms and cutting or thrusting instruments, poison. Poison
and drowning are the favorite means with females. It is
notable here again, in respect of seasons, that drowning is
much rarer in winter than in summer. The avoidance of
pain, at the first blush, is instinctive even with the seeker of
death. Women yield oftenest to moral influences — love,
jealousy, domestic troubles, excited sentiments of any kind ;
men to material trials — poverty, business losses, drunkenness
and debauchery, ^s^ote that these last two causes figure very
slightly as causes of female suicide. In Denmark one-third of
the male and but one-fifteenth of the female suicides are
attributable to drunkenness. Cities furnish an enormously dis-
proportionate number of volunteers of death. The seventh
part of all French suicides are committed in Paris. The pro-
portion of Berlin to all Prussia aud of Copenhagen to all
Denmark is still greater. Fewer married than siugle people,
but fewer maids and bachelors than widows and widowers ;
fewer agriculturists than mechanics and merchants ; still
fewer of these last than members of the liberal professions, and
yet fewer of these than of the remaining non-professional
population (of France especially, where the military, bu-
reaucracy, domestic and other emj)loyed more or less*^ senile
classes are enormously greater, notably of the male sex, than
in some other countries), the proportion of the agricultural to

222

MISCELLAIS^EOUS AND SCIEOTIFIC Is^OTES.

the non-professional class beings in 100,000 individuals, as 9
to 59 ; fewer Jews than Christians ; fewer Catholics than
Protestants, die by their own hand. — Pains Corresjpoiident of
the Tribune.

DivoKCES IN THE L^xiTED States. — Statistics, carefally com-
piled, shovr that divorces are on the increase iii the United
States. For instance, in Yermont, during the seven years
ending with 1866, the ratio of divorces to marriages was one
to twenty- one ; in the year 1866, one to nineteen. In Massa-
chitsetts, during the four years ending with 186-1, the ratio of
divorces to marriages was one to forty-four ; in the year 1864,
one to forty. In Ohio, in the year 1866, the rate of divorces
to marriages was one to twenty-six. In Connecticut, during
the eight years ending with 1867, tlie ratio was a little less
than one to eleven ; and the last of those years it was a little
less than one to ten. The Nutmeg State seems to have a very
considerable number of couples anxious to untie the matri-
monial noose. Illinois must look to her laurels.

The OEicm of Bacteeia. — A German lady, Frau Liiders,
of Kiel, has been investigating this matter with the micro-
scope, and has published her conclusions in Schultze's
Archiv. Her paper is one of very great interest, and her re-
searches have been ably and carefully conducted. She be-
lieves that she has proved — what many fungologists were pre-
pared for — that vibriones (leaving aside the question of there
being more than one species) are produced from the spores
and germinal filaments of various moulds or fungi, amongst
which are enumerated Mucor, Penicillium, Botrytis, Torula,
Manilla, Aspergillium, Leptosporium, Arthobotrys, Acremo-
nium, and Yorticillium. It is impossible here to give an
account of the precautions adopted in growing these fungi, but
they appear to have been satisfactory. Prof Hensen, of Kiel,
strongly supports all Frau Liiders says. She is also induced
to believe that the blood of living animals contains vibriones,
either in the catenated form, or in that of the constituent
granules ; but, during life and until putrescence commences,
these are always quiescent and show no signs of active exist-
ence. In support of this, the following experiment by Prof
Hensen is quoted : The extremity of a glass tube bent in the
form of a W, with the ends drawn out and quite closed, and
w^hich had been exposed for half aniiour to 200° C, was
thrust into the heart of a recently-killed Guinea pig and then
broken off. After the blood had sucked into the tube from
tlie other end, which was melted off in order to remove any

MISCELLANEOUS AND SCIENTIFIC NOTES. 223

fluid that miglit aclliere from the lips, the ends of the tube
were sealed, and it was kept at a temperature of from 13° to
15° C. From one c^f the several tubes thus prepared the
point was removed alter two days, and a drop of blood expelled
on the next day, which, when examined with the microscope,
showed large quantities of fungus-granules ; chains and rods ;
mobile rods were rare. Milk, eggs, the mouth, and many
oro^anic fluids, contain vibriones in this condition. Thouo^h
Prof. Hallier, the greatest authority on microscopic fungi,
does not accept Fran Liiders's results as to the connection of
"moulds" and " vibriones," yet her researches on the blood
have great importance in connection with his own. Prof,
llallier has recently announced that he has been able to isolate
and identify, from the blood of typhus-fever patients, a distinct
form of fungus ; Prof. Salisbury, of Ohio, U. S., made known
the observation of distinct fungi in the fluids of persons suffer-
ing from other contagious diseases. Are we not advancing to
a great fact as to the nature of such diseases ? Fermentation
and vaccination may come to mean much the same thing.
Frau Liiders has also shown that " yeast " may be grown from
many "moulds," as first demonstrated by Hallier. — Quarterly
Journal of Science.

Anecdote of Bouillaud. — Here is a good story told of M.
Thiers : M. Guizot gave, in 1846, a ball, at which the most
eminent people of Paris were present ; among them were M.
Thiers and Dr. Bouillaud. The yellow fever was then at
Marseilles, which M. Thiers represented in the Chamber of
Deputies. He asked Dr. Bouillaud to explain the disease.
The doctor gratified M. Thiers's request, but failed to satisfy
him. He exclaimed, "Doctor, I have studied that disease,
and I have seen nothing you have described." Dr. Bouillaud
replied : " M. Thiers, you are familiar with history, and write
it better than most men ; do you remember this historical in-
cident ? It is said that, when Hannibal was Prusias's prisoner,
he heard of a man named Fabius, who delivered admirable lec-
tures on military tactics and the art of war. Hannibal wished
to make Fabius's acquaintance ; he sent for him ; he heard
him, and exclaimed, ' JShiltos vidi delirare homines, sed num-
quam magis quam Fabium.'^ " — Am. Lit. Gazette.

A Pkize of £1,000.— The Marquis of Ourches has left the
above sum, to be given next year by the Academy of Medicine
of Paris to the discoverer of accurate means of distinguishing
apparent from real death. The full prize will be awarded if
these means may be understood and applied by any one ; but
it will be reduced to £200 if the method can only be used by
medical men.

224

MISCELLAIS-EOUS AND SCIENTIFIC NOTES.

The Administeation of Deugs. — I wish to offer a few sug-
gestions, concerning tlie administration of medicines, which may
tend to make this daily business of ours more available in in-
creasing therapeutical science. (1.) Let us aim at giving only
one drug at a time. I do not say this is always possible ;
but at all events let us keep the desire in our minds, and reckon
a prescription good in an inverse ratio to the number of ingre-
dients. This simplicity conduces not only to the good of
science, but of our individual patients, for it soon makes us
much more ready at suiting the special remedy to the special
case. (2.) It is important, when we change our treatment, to
allow a certain sufficient interval, different in different in-
stances, between leaving off one medicine and beginning
another. The experiments of Bocker and others have shown
us, first an action of the drug lasting after its apparent disap-
pearance from the body, and secondly, a reaction of the system
opposite to, though weaker than, the original action. Advan-
tage will accrue to the patient often from this rule too. For
instance: hyoscyamus, given for hypochondriasis or mental
depression, may be left off almost directly it has begun to pro-
duce its beneficial effects, and those beneficial effects will still
go on toward restored health. Hydrochlorate of strychnia
wdll continue to invigorate the peristaltic motions of the stomach
and intestines, so as to produce steady digestion and evacua-
tion, for days after such a soluble salt must have passed away.
(3.) It is advisable for each observer to have as short a pharma-
copoeia as possible. The best workmen use the fewest tools —
ay, and those who use the fewest tools become the best work-
men. They become more adroit with them, know them better,
and are able to instruct others in their employment. (4.) The
union and cooperation together of those who are working at
the same subject are of incalculable value. Incalculable — be-
cause you have not tried it. The skeleton of the machinery
exists in the British Medical Association. Why should not
each Branch or group of Branches take up a drug, and let us
know after two or three years their experience of its action ? —
From Address of Dr. T. King Chcmibers at the recent Meeting
of the British Medical Association.

M. MoNNEEET, Prof, of Internal Pathology of the Medical
Faculty of Paris, author of the " Compendium " and also of a
well-known work on Practice, which is still unfinished, died in
Paris, recently, of disease of the heart. It is somewhat singu-
lar that three members of the Faculty of the School of Medi-
cine, of Paris, have died during the i)ast year, leaving books
unfinished.

NEW YORK

MEDICAL JOURNAL:

A MONTHLY EECOBB OF

MEDICINE AND THE COLLATERAL SCIENCES.

YoL. VIII.] DECEMBER, 1868. [No. 3.

Aet. I. — On the Treatment of Strictnre of the UrethrcL
By Wm. H. Vatt Bueeis^, M. D., Professor of Prin-
ciples of Surgery and Diseases of the Genito-Uri-
nary System, in the Bellevue Hospital Medical
College. (Eead at the Meeting of the Medical So-
ciety of the County of New York, Nov. 2, 1868.)

By the request of our president, I have to ask your
indulgence while I lay before you my experience on
certain points in the treatment of stricture of the ure-
thra. The frequency with which this affection leads
to fatal disease of the bladder and kidneys, when not
controlled, renders its treatment always a matter of
interest to the practical surgeon. The familiar cases
of bladder disease with long-standing stricture, which
encumber the wards of every large hospital, prove that
this treatment is not yet perfect ; and the necessity of
watching their progress, without the power to arrest it

226

TEEATMENT OF STEICTTJEE

by prompt and certain roeans, is a constant source of
annoyance and regret to tlie hospital surgeon.

To ascertain the modes of treatment best calculated
to diminish the number of these unfoii^unate cases,
which have their analogues constantly recurring in pri-
vate practice, mil constitute the main object of my
remarks.

The numerous operations which have been devised
for the prompt and permanent cure of organic stricture
bear witness to the strong desire of surgeons to ac-
comj)lish this end. Each of these operations has
had its period of popularity, some of them under
the auspices of surgeons of great merit and large
experience; but as yet the desideratum has not been
attained. The prize offered by the old French marquis,
who died after years of suffering, from the conse-
quences of stricture, leaving his fortune in trust to the
Academy of Medicine of Paris, for the discoverer of
the best method of treating stricture, is still accumu-
lating its interest. The Academy voted a jDrize to Rey-
bard, the French surgeon, who so ably and enthusias-
tically advocated internal incisions as the method of
cure. But experience has not confirmed his claims.
His internal incisions were found to be too dangerous
when made large enough and deep enough to accom-
plish their object of securing j^ermanent enlargement
of the canal, and they have been abandoned by judi-
cious surgeons, exce]3t for strictures near its orifice.

More recently, the claims of Mr. Syme, of Edin-
burgh, were proffered and rejected by the French
Academy, for the operation by external incision which
bears his name — an excellent operation, but cramjjed
in its application by mannerism, and damaged by too
extravagant claims in its behalf.

OF THE UEETHEA.

227

Still more lately, Mr. Holt, of London, lias pro-
posed and largely employed forcible dilatation^ or
la^eration^ as it should be properly called, as tlie great
remedy for stricture. But time, the inexorable critic,
has demonstrated that Holt's operation requires peri-
odical repetition ; that it may secure a limited term of
relief, but that it cannot effect permanent cure of old
organic stricture. And this remark applies to all the
other modes which have been devised for the cure of
stricture by forcible stretching, or laceration.

For extrcDie cases of aggravated stricture, which
have led to retention or extravasation, the operation
of perineal section as described by Arnott — the hou-
tonniere of the French — is held in reserve — an o]3eration
regarded by most surgical authorities as a difficult and
desperate resource, and not coveted by operating sur-
geons.

My own experience has led me to think more favor-
ably of this operation — with certain modifications, of
which I will presently speak.

I should be glad here to introduce cases illustrating
these several operations for the cure of stricture, and
justifying the opinion I have expressed of their merits ;
but lack of time forbids. I have tried them all, and
sought to profit by the experience of others in addition
to my own, and I w^ill endeavor to give you the results
at which I have arrived.

It is a fundamental point in connection with the
treatment of stricture, that absolute cure of the disease^
by any of the ]?^"ocesses in use, is exceptional. As a
rule, a dilating instrument must be introduced at in-
tervals, after active treatment has ceased, in order to
prevent recontraction. This fact cannot, in my judg-
ment, be too strongly asserted. I never consider that

228

* TREATMENT OF STEICTURE

I have done my duty by a patient witli stricture until
I have tauo^ht liim to introduce an instrument for him-
self J with all due care and caution, and impressed him
with the conviction that the permanency of his cure
lies WITH himself. Many patients, before they fully
comprehend the serious nature of an obstruction in the
urethra, revolt at the drudgery of what they consider
an unnecessary and an unnatural proceeding. But,
when the surgeon is earnest and positive, the patient
rarely resists ; and I have never received an answer to
the argument that the introduction of a smooth steel
sound into the urethra every Sunday, for the purj^ose
of preserving the integrity of a damaged water-j^assage,
was no more unnatural a proceeding than the daily re-
moval of the beard from the face.

I feel pretty confident that most permanently-cured
strictures have been based upon faulty diagnoses. The
diagnosis of stricture in its earlier stages is not very
easy, especially in the deeper portions of the urethra.
An irritable and contractile compressor urethrw muscle
simulates stricture very closely ; and I am cognizant of
cases which have deceived very competent practitioners.
This sort of muscular irritability, which is generally
sexual in its origin, is usually benefited by the judi-
cious use of instruments; so that the cure of such
simulated strictures is apt to follow promptly, and,
where marriage intervenes, it is permanent.

For the positive diagnosis of stricture, a series of
bulbous bougies is indispensable. The preexist ence
of gleet, or, in its absence, the presence in the recently-
voided urine of floating filaments, which under the
microscope prove to be rolls of pus-corpuscles envel-
oped in urethral mucus, is a strong point of construc-
tive evidence.

OF THE UEETHRA.

229

I say nothing of tlie endoscope as an aid in the
diagnosis of forming stricture, for the use of this in-
strument requires an amount of j)ractical training
which interferes mth its general application.

For tlie great majority of cases of stricture of the
urethra^ especially of those occurring before middle life^
the proper treatment is hy sloio and gradual dilatation.

This, in my judgment, is effected preferably by
conical steel instruments, introduced with great gen-
tleness and care, every third, fourth, or fifth day, and
leffc in the canal not more than five minutes. The object
to be attained is the stimulation of vital absorption
in the newly-organized material which constitutes the
increased thickness of the urethral walls, and not
mere mechanical dilatation. This absorption often
goes on for a week affcer the use of the dilating instru-
ment, and therefore it should not be reintroduced
after too short an interval. Too frequent use of instru-
ments is liable to irritate and inflame the altered sur-
faces ; and inflammation is incompatible with absorp-
tion. I have seen serious injury to the urethra follow
the daily use of sounds.

Where a stricture will not readily admit a steel
sound of the size of No. 6, I prefer to employ the coni-
cal French gum-elastic bougies, as I recognize danger
of making false passages with smaller steel sounds.

In asserting that the great majority of strictures
occurring before middle life are amenable to cure by
dilatation, I must except strictures of traumatic origin
— limiting the rule to those caused by gonorrhoea.
Under the head of traumatic stricture I am in the
habit of including lesions of the urethra by the nitrate
of silver ; and, in my exjDerience, these are by no
means rare.

230

TEEATMEOT OF STEICTUEE

Wliether tlie result of meclianical or cliemical in-
jury to tlie uretliral walls, these traumatic strictures
have presented themselves to my observation much
more frequently than I had been led to expect from
the comparatively meagre details concerning them to
be found in works on surgery. And of all the varie-
ties of stricture, their treatment is the most difficult
and unsatisfactory. They are aj^t to be " irritable ; "
and often so sensitive to the contact of instruments
that a gentle exploration is liable to be followed by a
chill, or an attack of retention of urine. They are
generally very tight or narrow ; dense and cicatricial
in consistence ; yielding very slowly to dilatation, and
rapidly recontracting ; possessing the characteristic of
" resilience " in an eminent des^ree.

The gravest in its consequences, and at the same
time the most common in occurrence, is that variety
of traumatic stricture which results from falls upon
the jDerineum, in which the urethra is crushed against
the sharp edge of the pubic arch. This lesion occurs
^ of necessity always at about the same point of the
canal, nearer to the neck of the bladder than the deep-
est site of idiopathic stricture, and it is attended by
more or less transverse crushing; of the urethral walls.

In some experiments upon the dead body, made at
my instance, by my friend Dr. Gouley, several years
ago, we found that a pretty clean transverse cut of the
urethral mucous membrane was the first and most
constant lesion produced by a crushing blow upon
the perineum. The lining membrane of the canal was
in several instances comj^letely divided, like that of an
artery by the ligature, Avhile its more fibrous outer
coats escaped division.

Bad cases of stricture follo^viug this sort of injuiy

OF THE TJEETHRA.

231

are not very rare in practice. I have seen it from the
kick of a horse, from falls astride of a beam, a fence,
the wheel of a carriage, and in several instances from
falling with one leg through a coal-hole in the sidewalk. .
Boys are not nnft^equently victims of this accident;
and, for obvious reasons, they are the worst and most
uncontrollable cases of stricture we are liable to meet.

Traumatic strictures thus produced tend to occlude
the urethral canal very rapidly ; and they give rise to
retention of urine, over-distention and inflammation of
tTie bladder, perineal abscess, and extravasation of
urine, at an earlier period than strictures following gon-
orrhoea. Generally sensitive to the contact of instru-
ments, dilatation, ever so skilfully managed, makes no
headway against this kind of stricture, and is obviously
not the remedy.

For strictures of this class, and for those idiojDathic
strictures which, from neglect and long duration, have
involved the urethral walls in similar dense and cica-
tricial induration, it becomes the duty of the surgeon
to employ measures of a more prompt and effective
character.

Each of the operations for enlarging the narrowed
canal — by cutting, stretching, or laceration — to which I
have alluded, whilst falling short of universal applica-
bility, has left us in possession of valuable practical
knowledge. Thus, we learn, from Reybard's extensive
trial of cutting instraments within the canal, that a
certain degree of permanent enlargement of calibre
can be secured by free longitudinal incisions; and
that the new material thus added to the narrowed
circle can be prevented from contraction by the use of
the bougie or sound. And we learn incidentally, from
his cases and experiments, that transverse wounds of
the urethra are always followed by stricture.

232

TEEATMEXT OF STEICTUHE

Mr. Syrae lias tauglit iis tliat external incision is
the safe and proj^er remedy for bad strictures of tlie
deeper portions of tlie urethra ; and also that the cases
- are rare in which a delicate instrument cannot be intro-
duced, even through the tightest stricture, into the
bladder, to serve as a guide for the knife. We learn
also, incidentally, from the experience of this eminent
surgeon, that — in order to reap all the advantages from
the operation of external incision — it is not necessary
to keep a catheter in the bladder while the vround is
healing ; that the occasional introduction of a fall-sized
sound, at proper intervals, . is alone required. From
Mr. Holt's Inore recent exj)erience in forcible dilatation,
we have learned the valuable lesson that the urethra
is singularly tolerant of this sort of violence ; that the
longitudinal lacerations of the strictured portion —
which I believe always follow the apj^lication of his
instrument — are also well borne ; and that these lacer-
ations are followed by as good results — in apj^arently
permanent enlargement of the canal — in proportion to
their extent and dejDth, as the more dangerous internal
rs^cisiO]s^s of Eeybard.

From the occasional necessity of a resort to the
old operation of perineal section vrithout a guide to tlie
Uaclder^ there is no escape — unless by adojDting Mr.
Cock's practice of puncturing the urethra behind the
stricture, which, although jDreferable in some respects
to puncture from the rectum, like this latter operation,
affords at best but temporary relief.

But we have succeeded in rendering this necessity
still more rare since the French have supplied us with
bougies of imj^roved material and more slender propor-
tions. It is not often, with the invaluable aid of ether
or chloroform, that the practised surgeon fails in get-

OF THE UEETHEA.

233

tiuo' one of tliese delicate instruments into tlie bladder
to serve as a guide.

Availing himself of tlie broad facts gained by this
experience in the surgery of the urethra, it is the privi-
lege of the sui^geon of the present day, in undertaking
the treatment of a bad case of stricture, to select the
mode of ojDeration best suited to its peculiar features.

My own exjDerience has led me to adopt the follow-
ing modes of practice :

In all organic strictures situated at^ or near^ the ure-
tliral orifice^ where haemorrhage is controllable, I em-
ploy free incisions from within, and prefer for this
purpose the instrument known as Civiale's urethi'o-
tome — using, subsequently, the largest steel sound that
the urethra will admit, to j)revent contraction while
the wound is healing.

In strictures situated in tlie deeper ])ortions of tlie
iu'etlira^ which resist cure by gradual dilatation, and
throuo:h which an instrument can be introduced as
large as Xo. 4 of the ordinary scale, I employ forcible
dilatation, carried on slowly and gradually to the point
of rupture or laceration, and as much farther as to per-
mit the subsequent introduction, with entire freedom,
of the largest-sized conical steel sound which the
healthy portions of the canal will admit. For this
purpose I find the best instrument to be the "dilator"
devised by Sir Henry Thompson. It works by means
of a screw, and has an index on its handle pointing to
the size of the sound which the dilating j)ortion has
reached. In the use of this instrument Sir Henry
Thompson proposes to dilate as much and to tear as
little as possible ; he therefore perfonns the operation
slowly.

I see no advantage in the avoidance of laceration.

234

TEEATMEIS^T OF STEICTURE

and should not insist upon this point. I have always
found that, at a certain stage of the dilatation, the free
flow of blood indicates that laceration has taken 23lace ;
and I recognize that more is gained, in the end, by
carrying it to the fullest possible extent. There is
this advantage in the slowness of the oj^eration : that
it causes less pain ; and, in several instances, I have
left the patient to turn the screw himself as the pain
subsided. This diminishes markedly as soon as lacer-
ation occurs, and it is rarely so severe as to require
ether or chloroform. The subsequent introduction of
a full-sized steel sound speedily arrests bleeding by its
pressure. In some cases, in order to get the full bene-
fit from the forcible dilatation, I have also incised the
orifice of the urethra, before terminating the operation.

I have had reason to be well satisfied with this *
operation; but, as in most other surgical j)rocedures,
its best results are only to be secured by judicious
after-treatment. It possesses these iDositive advan-
tages : by affording, at once, free passage to the urine,
it diminishes the danger of progressive disease of the
bladder ; by its promptness it offers, in many instances,
a better prospect of more permanent relief to the hos-
pital patient who cannot or will not await the slower
results of ordinary dilatation ; and, finally, it causes
less dread than the knife, and is therefore more gener-
ally available.

In more aggravated cases, where the stricture, al-
though still permeable, is tighter or more unyielding,
resilient, or irritable, and complicated perhaps with
irritability of the bladder, false passages, threatened
retention, or urinary fistulae, or with perineal abscess
or extravasation of urine, actual or impending, I prefer
external incision of the stricture from the perineum.

OF THE URETHKA.

235

Introducing a fine bongie into the bladder as a guide,
a grooved staff, open at its extremity, is passed down
to tlie stricture, and held in contact with it by an assist-
ant. The bougie occupies the groove of the staff, and
projects beyond it, through the stricture, into the
bladder. Those of Benas, of Paris, containing whale-
bone, are preferable for this jDurpose. Commencing
with a free incision in the central line of the perineum,
the parts are successively divided until the extremity
of the staff and the bougie are brought in view, and,
guided by them, the stricture is divided longitudinally
and freely, by means of a delicate probe-pointed knife
— especial care being observed to carry the incision
for some distance in either direction beyond the strict-
ure, as this measure has great influence in preventing
subsequent contraction. I make it a point, in this op-
eration, to remove every obstruction to the easy intro-
duction of a steel sound of the largest size — which is
passed at once, and if any difficulty or obstacle is still
encountered it is sought for and removed, if necessary,
by more free division of the stricture. If, as often
happens, other strictures exist in the interior portions
of the urethra, they are removed at once by laceration,
or, if near the meatus, are incised from within by
Civiale's ui^ethrotome. No instrument is left in the
bladder ; but, after the second or third day, a full-
sized conical sound is introduced daily and immedi-
ately mthdrawn. The urine is allowed to escape by
the perineal wound, as after lithotomy. The scrotum is
elevated by a sling, to prevent infiltration or abscess,
which are liable to occur w^hen this precaution is neg-
lected.

In examining the records of the New York Hos-
pital some years ago, I was struck by the frequency

236

TEEATMENT OF STEICTUEE

with whicli clironic cystitis and perineal fistula fol-
lowed tlie operation of perineal section for stricture ;
and, on further investigation, I was led to ascribe these
consequences to the practice, which seems to have been
uniformly pursued, until lately, of tying a catheter,
generally of small dimensions, in the bladder, and
leaving it there for an indefinite period — with the ob-
ject, apparently, of facilitating the healing of the peri-
neal wound.

I had seen the same results follow in my own
operations, with others even more serious, and I finally
arrived at the conclusion that the presence of a cathe-
ter in the bladder, under these circumstances, accom-
plished no useful object, but was, on the contrary, an
unmitigated evil, keeping up inflammation in the
urethra and bladder, and preventing the closure of the
perineal opening.

Influenced by this conclusion, and also by Mr.
Syme's experience, I adopted the plan of after-treatment
I have just described, and am fully satisfied with its
advantages. Tlie liahitual passage of the urine through
the per ineal wound does prevent its healing stead-
ily and promptly^ hy the second intention^ provided that
there is no recontraction of the stricture. This is proved
by the results of lithotomy.

I have operated in this manner, I find, sometimes ;
and, although preexisting cystitis has in some cases
failed to get well after the operation, I have never had
a permanent fistula, except in the case of a boy, where
the clifiiculty of keeping up the regular introduction of
the sound was insuperable. The cure has been com-
plete generally in from one to two months, and per-
manent— -with this condition, that the patient intro-
duced his fall-sized sound every week.

OF THE UEETHEA.

237

Sir Benjamin Brodie held that a perineal fistula
will always close sj^ontaneonslj when the urethra is
restored to its normal dimensions ; and, more recently,
Sir Henry Thompson has asserted that the more
thoroughly a stricture has been dilated, the less the
prospect of its recoritraction. I have learned to regard
these as correct surgical 02:)inions, and I attach great
importance to the regular use of a sound of the largest
size after these operations, as well as after an apparent
cure by dilatation, and, whenever feasible, the instru-
ment should be introduced by the patient himself.

In those desperate cases, which are occasionally
thrust upon us, where extravasation of urine has oc-
curred, or is impending, and where no instrument, how-
ever delicate, can be carried through the stricture into
the bladder, the perineal section is to be undertaken
without a guide. This is the best course to be adopted,
because it promises not only immediate relief to the
bladder, by affording the least objectionable artificial
route for the urine ; but also, if successful, the division
of the stricture offers the best chance for its more per-
manent cure.

The question of delay, to secure a farther chance of
getting an instrument into the bladder, offers room for
the exercise of delicate judgment and skill. The con-
dition of the bladder and kidneys should be ascer-
tained by careful palpation of the hyj)ogastrium and
loins, and the patient's general condition kept steadily
in view. Injections of oil into the urethra, and the
various devices for avoiding false passages, the influ-
ence of the warm-bath, opium, and finally of ether or
chloroform, are all to be judiciously tried, with the aid
of the finer and more delicate bougies lately brought
into use, in the hope of securing- a guide to the bladder.

238 TREATMEl^T OF STEICTURE OF THE URETHEA.

When success in this respect is happily attained, the
operation is at once rendered safe and certain in its re-
sult.

If compelled- to operate without a guide, I have
found it a good rule, where the anatomical landmarks
have been obliterated by disease, to seek for the hole
in the triangular ligament, through which the urethra
escapes from the pelvis. And if the thickening and
induration of the perineum, by abscesses and fistula,
have added to the difficulty of the oj)eration, there is
another morbid change caused by the urethral obstruc-
tion, which materially aids the operator, and which I
do not remember to have seen noticed in the books.
I refer to the almost invariable dilatation of the ure-
thra behind the stricture. I have seen it frequently
large enough to admit the finger.

The first object in this operation should be to tap
the urethra behind the stricture, so as to afi:brd a free
outlet to the urine ; the second, to divide the stricture
or strictures, so as to admit a full- si zed instrument
readily into the bladder, and, if possible, to avoid the
necessity of tying in a catheter.

I have never had occasion to regret undertaking
this operation, and in some cases have attained very
satisfactory results.

I have thus briefly indicated the several modes of
treatment which seem to me best adapted for the re-
lief of stricture of the urethra, in the present state of
our knowledge. They may be summed up as — dila-
tation; incision from within the canal; laceration;
external incision^ or what would be better called
neal v/rethrotomy with a guide ; and, finally^ perineal
urethrotomy roithout a gnide. I have endeavored also
to suggest the class of cases to which each of these
modes of cure is especially applicable.

APHASIA.

239

Akt. n. — A Case of Ajyliasia^ tvitli Itemarlcs. — By
Chakles C. Lee, M. D., Attending Physician to
the Charity Hospital, etc.

Ix the Jannaiy and April numbers of the Psyciio-
logical Journal ioY the present year, apj^earedtwo high-
ly interesting articles on the pathology of aphasia. In
the first of these especially, which was an able and
exhaustive resume of the subject by Dr. E. C. Seguin,
of this city, an appeal was made to the profession to
place on record additional cases, that, by the compari-
son of a more extended series of observations, a near-
er apj^roach to solving the vexed question of aphasia
might be reached. AYith this object I offer the follow-
ing case, which occurred during my service last sum-
mer at the Charity HosjDital :

Case. — John W , aged 52, was admitted to the

Hospital for herpes zoster, August 16th. Upon exam-
ining him the following day, I was at once struck by his
inability to articulate, which was the more striking in
contrast with his intelligent expression and the readi-
ness with which the tongue was extended. He under-
stood perfectly all the questions put to him, and, on
being asked how long he had been speechless, he count-
ed on his fingers " one, two, three," etc., up to ten
years, naming the numerals in succession ; but no effort
on his part could compass the expression " ten years "
without counting on his fingers. He said " yes " and
"no" without difiiculty, and answered correctly by
those monosyllables all simply afiiiTaative or negative
questions. The reading and writing j^ower was quite
lost, although he could formerly write with ease ; but
there was not the slightest hemij^legia either of motion
or sensation. The case was, therefore, apparently one of

240

APHASIA.

the second gi^ade of aphasia, according to Trousseau's
classification, viz., amnesia of speech and of written
language, without loss of gesture. With some diffi-
culty the following history was elicited, partly from the
patient himself and partly from his wife.

Ten years ago, while in seemingly good health, he
was seized with convulsions during sleep ; these lasted
for tAvo hours, and were epileptifoiTa (as described),
being followed by stertorous breathing and partial
coma for three days. There was also retention of urine
during these three days, after which the patient grad-
ually regained his normal health, with the exception
of defective vision of the riglit eye and entire loss of
speech. His memory was also for a long time im-
paired, but now seems restored. He has never been
able to read or write since the date referred to, and
can now only say " yes " and " no," and count up to ten.
The right eye is sightless, and presents the sequelae
of general ophthalmitis ; the globe is " boggy " upon
pressure, which produces no scintillations, and no
sympathetic irritation has existed in the left.

No cardiac disease or fatty degeneration could be
detected, nor were the arteries atheromatous — no cir-
cus senilis in either eye ; the patient's appetite was
good, and his habits moderately active. His gait was
erect and steady, and, as above stated, not the faintest
evidence of hemiplegia existed. These points were
verified by repeated examinations, and the record is
transcribed from notes taken at the time.

The patient soon recovered from his attack of her-
pes, which was treated in the usual manner, and was
then placed on the use of bromide of j)otassium, more
for the purpose of keeping him under observation than
with the expectation of any therapeutic result.

APHASIA.

241

In a short time, however, lie became dissatisfied —
alarmed, doubtless, by tlie amount of attention lie re-
ceived from his 23hysicians — and insisted on leaving
the hospital, whence he was discharged SejDtember 2,
1868. The case is still under my observation, and ex-
hibits at the present date no change from the condi-
tion described.

The most noticeable feature in the above case is
the length of time (ten years) the aphasic condition has
lasted. Both the patient and his wife are positive in
fixing: the date of his seizure in 1858, which makes the
duration ten years without such an advance of the
cerebral disease as to cause hemiplegia. This, however,
is not without precedent ; for one of the two cases,
upon which M. Broca ventured to propound his re-
markable localization of the faculty of language, was
a patient of Dr. Aubuii:in who had been speechless
for twenty years. At the autojDsy of this case the le-
sion was found in the left frontal lobe, but was not
limited to the third fr^ontal convolution.

It is no part of the object of this paper to discuss
the literature of Aphasia. This has been thoroughly
done by Dr. Seguin, whose record includes all that has
been published on the subject fr'om the time when
Bouillaud located the faculty of sj)eech in the two an-
terior lobes of the brain (1825), to the present date,
with one exception. We allude to the essay of Dr.
Albert Carrier,' which contains an excellent historical
sketch of the subject, with an analysis of the cases of
Fabret, Hughlings Jackson, Vulpian and Charcot, Lan-
cereau, etc., and details some heretofore unj^ublished.
Dr. Carrier is a strong partisan of Broca's doctrine, in

^ Etudes sur la Localisation dans le Cervean de la Facnlte de la Lan-
guage articule. Par le Dr. Albert Carrier. 1867. Paris : Bailliere.

242

ATEOPIA.

spite of Trousseau's and Gratiolet's able arguments to
the contrary, and seems to tlirow some grave doubts
upon tlie j)riority of Dr. Marc Dax's essay. The au-
thor also makes an elaborate and ino^enious elfort to ex-
plain the frequent association of aphasia with disease
of the left cerebral hemisphere, based upon Gratiolet's
observations of the more raj^id development of the left
frontal convolutions than those of the right side ; but
he seems so warm an advocate of M. Broca's views as
to be unable to judge the question impartially.

Aet. III. — Atrojna : Its Chemical^ Physiological^ and
Thera])€iitic Action ; together loitli Ex])eriments in-
stituted to ascertain its Toxicological Properties^
By Samuel R. Peecy, M. D., Professor of Materia
Medica, Physician to Mount Sinai Hosj^ital, etc.

ATROPIA. C34 Hsa N Oe At.

SECTION FIRST.
Division Fiest. — History,

Ateopia is an alkaloid obtained from all parts of
the belladonna-j)lant, but in largest quantity from the
root.

It has also been inapproj)riately -called atropina,
atropine, atroi:>in, atroj^inum. The termination in ia
designates it an alkaloid, and, to avoid confusion and
the liability to mistakes, the term atropia only should
be used.

Vauquelin " made an analysis of the juice of the

^ An essay, for whi3li was awarded the prize for the years 18G7 and 1868 of the
Alumni Association of the Medical Department of Columbia College.
2 Annales de Chimie, tome Ixxii., p. 54.

ATEOPIA.

243

belladonna, but did not succeed in isolating any alka-
loid pi'inciple.

Brandes/ in 1819, repeated this analysis, but with
no better results.

The alkaloid atropia was first exhibited in 1828,
nearly simultaneously, by Geiger' and Hesse. In
1833, it was obtained by Mein.' Geiger and Mein
obtained by their method about 20 grains of nearly
pure atropia from 12 ounces of freshly-dried root of
two and three years' growth.

Von Planta* made minute chemical analysis of
atropia, and found that its chemical reactions were al-
most identical with daturia.

Schroff' repeated these analyses, and also tried
both alkaloids therapeutically. He says that their
chemical analyses are both alike, but that daturia is
nearly twnice as powerful as atropia.

Liibekind," in 1839, stated that he had s]3lit up
atropia, and had found in it a second alkaloid which
he named belladonin, which had different chemical re-
actions from pure atropia.

Divisioii Seco]n^d. — Processes for oUaining Atj^ojna
ami its Salts.

Mein adopted a process for obtaining atropia which
may be found in full in Journ. de Pliarm.^ tome xx.,
p. 87.

M. Rabourdin, an apothecary of Orleans, pub-
lished, in 1850, a formula for preparing atropia by

1 Annalen der Chemie und Pharm., Bd, i., p. 68.

2 Idem, Bd. vii., p. 269. 3 idem, Bd. vi., p. 67.
^ Cannstatt's Jahresbericht, Jahrg. x., p. 107.

5 Idem, N. A., Jahrg. ii., 1. Abth., p. 133.
^ Archiv fiir Pharm., 1839, Bd. xviii., p. 75

244

ATEOPIA.

means of cliloroform, wliich may be found in Gazette
Med, de Paris ^ 19 Octobre, 1850.

The process adopted by tbe U. S. and British
Pharmacopoeias may be found under their respective
heads.

Professor William Proctor read a paper before the
American Pharmaceutical Association upon the j)repa-
ration of atropia from American belladonna-root ; the
process recommended by him has, with slight modi-
fications, been adopted as the process of the U. S. Dis-
pensatory. Professor Proctor's process may be found
in the Proceedings of the Am. Pharm, Association.

When ophthahnic surgeons first used atropia, it was
their custom to order the atropia to be dissolved in a
sufficient quantity of water, by aid of sulphuric acid.
In almost all instances, more acid was used than was
required ; in fact, it was imj^ossible to dissolve it in
its j)roper combining proportion, and, if the alkaloid
was not pure, a very great excess of sulphuric acid was
used. This acid-solution was very irritating to the
eyes, and it soon became obvious that some formula
must be adopted to obtain a perfectly neutral sul-
phate.

With this view, M. Maitre offered a formula for
the preparation of neutral sulj^hate of atropia, which
may be found in the Am. Jour, of Plia/i'macy^ 1856,
p. 360.^

In the last edition of the " U. S. Pharmacopoeia "
this formula of M. Maitre's is followed veiy closely.

Both of these formulae give a sulphate of atropia
in powder, which is much more liable to be adulter-

^ In the manuscript all these various processes are given in full, with com-
ments. To publish this essay in a journal, it was necessary to abridge it ; the
works in which the processes are found are therefore given.

ATEOPIA.

245

ated tlian if in a crystallized form. M. Laneau,
deeming tliat an agent so important in ophthalmic sur-
gery should be of unquestioned purity, offered the fol-
lowing formula for its production in crystals :

"Take of crystallized atropia, . . 289 grains.
Absolute alcohol, ... 800 "
" The solution is effected by agitation, in a glass
capsule, aided by very gentle heat. Then weigh in a
small phial,

" Sulphuric acid, sp. gr. 1.85, . . 40 grains.

"Dilute this acid with 300 grains of anhydrous
alcohol, and add it, little by little, to the solution of
atropia. To complete the saturation, the solution is
stirred with a glass rod, moistened slightly with con-
centrated alcohol, until test-paper shows neutrality.
The solution is then suffered to evaporate sponta-
neously. The crystallization is effected in three or
four days in the summer, or five or six days in the
winter. The thinner the stratum of liquid, the more
quickly is the process effected. The crystals, which
may be dried without destroying their form, are in
colorless needles, more or less interlaced. When
chloroform is used instead of alcohol, the salt is ob-
tained in a gum-like mass. Crystallized atropia is
soluble in water, weak alcohol, and absolute alcohol,
but is insoluble in chloroform and ether."

Hydi'ochlorate and acetate of atropia may be ob-
tained as crystalline salts ; the valerianate as a thick
syrupy mass.

Division Third. — Physical Properties of Atropia
and of its Salts.

Atropia, as prepared by the U. S. Pharmacopoeia,
is impure ; but, when purified and crystallized from

246

ATEOPIA.

concentrated warm solutions, is in wliite, transparent,
silky, prismatic crystals ; when crystallized by very
slow evaporation, it is in needle-like crystals. In tlie
imjDure form, it is a fawn-colored j)owder. It is sol-
uble in 300 parts of water at 60° P., in 3 parts of
chloroform, in 25 parts of ether, and in less than 3
parts of absolute alcohol. In all these liquids, it is
much more soluble hot than cold. It is without odor,
but is of a very acrid bitter taste. It melts at 194°
R, and the greater j)art of it is volatilized at 285° F.
Heated for some time with potassa or soda, it is de-
composed, and gives out an odor of ammonia. It has
the property of left-handed circular polarization. It
is of alkaline reaction, and forms crystallizable salts
with sulphuric, hydrochloric, and acetic acids.

The sulphate of atropia of the U. S. Pharmacopoeia
is a white semi- crystalline powder. That prepared by
M. Laneau's formula is in clear white needles. Both
are neutral to test-j)aper, very soluble in alcohol and
water, but insoluble in pure ether and chloroform. A
solution of atropia can soon be known by its effect in
dilating the pupil of the eye.

Valerianate of atropia does not crystallize. It is
a thick syrupy liquid of a fetid valerianic odor, very
soluble in water and alcohol. It is readily decom-
posed by the weakest mineral acid, with evolution of
valerianic acid.

Divisiois" PouRTH. — JBeliavior of Atropia with Chemi-
cal Tests and Reagents.

A solution of atropia in hydrochloric acid fur-
nishes, with —

Potash,' a pulverulent precij^itate, if the potash solu-

^ A. von Planta, Liebig's Annalen, Bd, Ixxiv., p. 245.

ATEOPIA.

247

tion is concentrated and in slight excess ; a large
excess of potasli dissolves the precipitate.

Carbonate of potasli produces the same result.

Ammonia gives a precij^itate much the same as pot-
ash, but is more readily soluble in an excess of am-
monia than in potash.

Terchloride of gold gives an abundant yellow precipi
tate, which is soluble in an excess of hydrochloric,
acetic, or sulphuric acid.

Bichloride of platinum gives a dirty-yellow precipi-
tate.

Iodine, in iodide of potassium, an immediate, copious,
brown, amorphous precipitate, which slowly dis-
solves in a few drops of a strong solution of
potash.

Tannic acid, a dirty- white precipitate, soluble in a
strong solution of potash, and in hydrochloric acid.

Nitro-picric acid ' gives a sulphur-colored pulverulent
precipitate.

Carbazotic acid,' an abundant light-yellow precipitate,
readily soluble in acids.

Bromine, in bromohydric acid,' gives an immediate,
copious, bright-yellow" precij^itate, which soon be-
comes a mass of twig-like crystals. If there is a
deficiency of reagent used, the precipitate will dis-
solve, but is reproduced upon a further addition of
the reagent.

Concentrated nitric acid' dissolves atropia without
any change of color, upon heating the solution,
and, after cooling, the addition of a drop of chlo-
ride of tin-solution gives a copious white deposit ;
without heating the tin, salt produces no change.

1 A very full description of the various reagents in Micro-Chemistry of Poisons,
by T. G. Wormley, M. D.

248

ATEOPIA.

Peculiarities in the beliavior of atropia, with vari-
ous tests and reagents, may be found in Annalen der
Chemie unci Pharm.^ Bd. exxviii., pp. 273, 282 ; Lon-
don Cliem, JVews, May, 1864 ; Mayer, Am, Joui\ of
Pliarm., 1864, p. 234.

Von Planta,' in his analyses, determined that atro-
pia and daturia were chemically identical, answering
the same chemical tests and reagents. Wormley,"* in
his later and more elaborate chemical and micro-chem-
ical researches, arrives at the same results. Many of
the German ophthalmologists acknojvledge the chem-
ical identity, but assert that the two alkaloids differ
somewhat in their physiological and therapeutic ac-
tion.'

The chemical formula for atropia is :

C34 H23 N Og =: 289 At. ;
for sulphate of atropia :

C34 H23 N Oe S O3 = 329.

Mr. Scorby read a paper lately before the Sheffield
Literary and Philosophical Society, in which he set
forth the difficulties which the toxicologist encounters
in his efforts to prove a ease of poisoning by bella-
donna. These difficulties, he thinks, are obviated by
the use of the micro-spectroscope. " The spectrum of
the juice of the belladonna is very distinct, especially
when the coloring matter has been added to a solution
of carbonate of soda. A small fraction of a single
berry is sufficient to produce the spectrum-bands
characteristic of belladonna."

Whether this be correct or not with regard to the
fresh juice of the leaf or berry of belladonna, it would

^ Liebig's Annalen, Bd. Ixxiv. ' Micro-Chemistry of Poisons.
^Veratrura Viride, Trans. Am. Med. Ass., 1863, and Chem. News, 1864.

ATKOPIA.

249

still be of little value in examining the secretions of
persons poisoned by that j^lant, and would only be
serviceable jDroviding some of the juice or berry re-
mained in the stomach. It would be of no value in
detecting poisoning by atropia.

SECTION SECOND.

DiyisiojST Fiest. — Pliysiological Action of Atropia
upon Animals,

Since the disgovery of atropia, it has been used as
a substitute for belladonna chiefly on account of the
certainty of its action, but also because it is easier to
use, and much cleaner than extract of belladonna.

As to the relative strength of atroj^ia and bella-
donna, Pfitzner ' says that one part of atropia is equal
to 240 parts of extract of belladonna. Geiger'' says
that one grain of atropia is equal to 200 of extract
of belladonna, 600 grains of belladonna-plant, or 360
grains of powdered belladonna-root.

Whether used locally or generally, the effects of
atropia upon the system are similar to those produced
by belladonna ; but it is more quickly absorbed, and
produces its effects in shorter time than belladonna.

Reil ' says that both herbivora and carnivora are
readily brought under the action of atropia, but that
the latter are more easily and more quickly affected
than the former ; that sharp-sighted birds and cats are
exceedingly susceptible to its effects.

Cogswell' experimented ujDon frogs, injecting a
solution of one grain of atropia under the skin of the
right hind-leg,, which produced intercuiTent convul-

^ Dissertatio de Atropine, 1846. ^ Hagen, p. 601.

3 lb, p. 602. London Lancet, Xovember, 1852.

250

ATROPIA.

sions on tliis leg, while the other was entirely relaxed.
After a while, these convulsions ceased, but returned
at the expiration of twenty-four hours.

Michea observed that snails did not suffer from the
action of atropia, but that they were poisonous to ani-
mals that ate them.

The German physiologists have experimented with
atropia upon a large number and upon different vari-
eties of animals; they find its physiological action
similar to that of belladonna, but more certain.

Case 1. — I fidministered to a large, coarse dog, whicli had been kept
fasting for twenty hours, one quarter of a grain of the sulphate of atropia,
at 9 o'clock A.M. It was wrapped in a thin slice of meat, and was swal-
lowed greedily. The pulse at this time was 141 beats in the minute. In
half an hour the pulse had increased 11 beats in the minute. The tongue
was constantly thrust out, licking the lips, followed by masticatory move-
ments and frequent deglutition ; no saliva or mucus flowed from the
moutli. A marked dilatation of the pupils wasn^isible. Many efforts at
vomiting were now made, but nothing was thrown up, and the efforts at
vomiting did not cause a flow of saliva, as is most generally the case when
a dog vomits. These efforts at vomiting continued about half an hour.
A pail of water was then put by the dog, and he was allowed to drink as
much as he pleased. At 11^ o'clock he stood with his legs spread wide
apart, the eyes suffused, the pupils very widely dilated and staring ; the
respiration was accelerated, laborious, and abdominal. He made no effort
to move; but lapped greedily, if water was placed to his mouth. A stick
pointed at the eye did not cause the lids to close, and the lids did not close,
unless the eye was actually touched. He made no movement when called,
and seemed as though he was both deaf and blind. He would not eat,
when meat was placed to his nose. A large quantity of urine was passed,
but without moving from the position he was in.

At 12|- o'clock the dog was lying on its side, and did not move when
struck a smart blow with a switch ; the eyelids were open ; the pupils
enormously distended; the respiration rapid and abdominal; the pulse
thin, wiry, and not to be counted.

At 6 o'clock p. M., the dog was still in the same position ; the respira-
tion was much easier, the pulse slower and fuller. At 9 o'clock, the next
morning, the dog was walking about in a very dejected manner, the pupils
widely dilated, with frequent strabismus. He ate sparingly, and drank
freely. The next day he seemed quite well, but the pupils were still
large.

ATEOPIA.

251

Case 2. — To a dog somewhat smaller than the last mentioned, that had
been kept without food or w^ater for twenty-four hours, a quarter of a
grain of the sulphate of atropia was given in a small bolus of meat. The
symptoms that supervened were very similar to those last described ; but
the dog was allowed no water. Ten hours after taking the atropia, he
was seized with convulsions which lasted about fifteen minutes ; deep coma
then supervened, and he died in about half an hour. The tongue was
swollen, and indented with the teeth ; the mouth was full of a ropy mucus,
as were also the cesophagus and trachea. The mucous membrane of the
stomach was slightly reddened, the intestines looked healthy, the iieart
-was full of dark blood, as were also the arteries of the lungs ; the kidneys
w^ere highly congested, sufficiently so to have caused death by uraemic
poisoning. There was about half an ounce of urine in the bladder,
which, applied to the eye of another dog, caused dilatation of the pupil.

Case 3. — To a much smaller dog, which had been kept without food or
Tvater for fourteen hours, a quarter of a grain of sulphate of atropia was
given in meat. As soon as free dilatation of the pupils had taken place, a
third of a grain of sulphate of morphia was given in a small bolus of meat.
I>ro water was given. No convulsions took place. The animal lay quiet;
the respu-ations were full and deep, and not frequent ; the pulse was slow
and full; the pupils of the eyes as widely dilated as though no morphia
had been given. In seven hours the dog died. The heart, lungs, and
brain w^ere full of dark blood ; the kidneys were highly congested, and
there was hardly a teaspoonful of urine in the bladder.

Case 4. — To a dog of about the same size as that last mentioned,
which also had been kept for fourteen hours without food or water, a
quarter of a grain of sulphate of atropia was thrown into the stomach,
dissolved in half a pint of water. In half an hour this was followed by a
third of a grain of sulphate of morphia, dissolved in two ounces of water,
the pupils being widely dilated at this time. Mastication and deglutition
were constant, but there was no vomiting. The dog was stupid, aud un-
conscious to all noises, and it soon lay down. Four hours after giving the
atropia, he was brought into a bright sunlight. By quickly removing a
dark object, so as to aUow the sun to shine quickly upon the pupil, con-
traction could be plainly seen. Eight ounces of thin Indian-meal gruel
were thrown into the stomach. Xine hours after the first dose, the dog
ate voraciously and drank a large quantity of water. The pupils were not
largely dilated, and the animal seemed comfortable, though not playful.

I have repeated these experiments, and I find as a
rule that, if atropia is given without water, the effects
are much more irritative, and last much longer, than
when a sufficiency of water is allowed. T^Tien death
takes place where water is not allowed, there is always

252

ATKOPIA.

congestion of the kidneys. Morphia, although an an-
tidote to atropia in ordinary cases where water is freely
allowed, is hardly an antidote where fluid is entirely
withheld. A much larger dose of atropia may be
borne without danger, if care is taken to keep the sys-
tem well supplied with fluids ; and the effects of poi-
soning pass off much more rapidly if warm diluents
are prudently administered. Where diluents are freely
given, the kidneys perfoim their function, and gradu-
ally remove the poison from the system ; but Avhere
large doses of the medicine are given unaccompanied
with liquids, the kidneys are unable to eliminate
either the poison or the urea, and the animal conse-
quently dies, frequently only from ursemic poisoning,
at other times from the double effect of the poi-
soning from the alkaloid, and ui'aemic poisoning as
well.

Case 5. — Two drops of a solution containing ^ of a grain of the
neutral sulphate of atropia were thrown, by means of the hypodermic
syringe, beneath the skin over the supra-orbital nerve on the right side.
The pupil of the right eye began immediately to dilate, and iu one and a
half minute but a mere border of the iris was to be seen. The dog's head
was held so that a strong sunlight was shining in both eyes. Iu four and
a half minutes the pupil of the left eye began to dilate slowly, and con-
tinued to dilate for five minutes ; but it did not dilate to any thing like the
size of the pupil of the other side. The dog came when called, but his
steps were uncertain, and, when he attempted to go down-stairs, he fell all
the way down. The eyes had a lack-lustre, staring,- congested appearance.
The pupils were still dilated thirty-six hours after the injection.

Case 6. — A solution containing -j^ of a grain of sulphate of morphia
was thrown, by means of the hypodermic syringe, beneath the skin over
the supra-orbital nerve of the left side, while, at the same time, of a,
grain of the neutral sulphate of atropia was thrown in a corresponding
place on the right side. The dog's head was held in a strong sunlight.
Immediately the left pupil began to contract, and the right pupil to dilate,
and in two minutes and a half the left pupil was not much larger than an
ordinary shot, while the right had already dilated to its utmost extent.
No coaxing could induce the dog to take a step ; he lay down, with his
head between his paws. In the dusk of the evening, about eleven hours

ATEOPIA.

253

after the operation, lie ate, drank, and played quite freely. Upon apply-
ing a light to the eyes, they were still different in size.^

Case 7. — Six minims of a solution containing ^ of a grain of sulphate
of atropia were thrown by the hypodermic syringe into one of the large
veins of the ear of a dog. In 80 seconds he fell on his side, and died of
coma in minutes. The pupils of both eyes were widely dilated. The
dog tad been sick, so no post-mortem examination was made.

Divisiois' Second. — Physiological Action of Atropia

on Man.

Case 8. — To a gentleman of literary habits, who had used his eyes too
much, a solution of the neutral sulphate of atropia was dropped into both
eyes. In a few minutes the pupils were seen to be dilated, and in 45
minutes they were so widely dilated, that the iris was a mere border. He
complained that he could not walk correctly, as he had altogether lost the

^ On the Antagonistic Action of Opium and Belladonna. — Professor A.
von Graefe makes the following observations on the antagonistic action of opium
and belladonna injected into the cellular tissue : When a solution of atropine has
been injected hvpodermatically, three or four minutes afterward the pupil becomes
dilated, the pulse rises to 140-160, and other symptoms of narcosis by atropine
are observed. If morphia is then ^injected, all these phenomena, which would
otherwise last for hours, disappear in a very short time. After a hypodermatic in-
jection of morphia, a considerable myosis is observed, and the pupil cannot be
dilated. This is probably to be ascribed to an active irritation in the sphincter
muscle, just as mydriasis caused by belladonna is to be explained by active irrita-
tion of the dilatator muscle. A new fact, which Von Graefe has observed, is the
antagonistic action of these medicines upon the faculty of accommodation ; al-
though it has not occurred in all the cases in which he has operated. Atropine
causes paralysis^ and morphia a spasm of accommodation. In consequence of this,
the space allowed to accommodation becomes greatly limited, and myopia is the
result. All distant objects are indistinctly seen ; but, if concave glasses are used,
this is obviated. It is true that the myopia is not so considerable as it appears to
be when trials on both eyes are made, as, if only one eye is experimented upon,
distant objects are more clearly distinguished ; a circumstance which is, no doubt,
due to the weakening action of morphia upon the internal muscles of the eye. But
the phenomenon is only temporary, and is generally only observed three-quarters
of an hour after the injection. It is probable that, if a stronger dose of morphia
were used, it would last longer and also be more constant ; but it would not be
justifiable to do this in order to satisfy physiological curiosity. The symptoms'
described are to be explained in the following manner : Opium and belladonna
have an antagonistic efifect upon the muscular fibres of the tensor chorioideae, as
upon the muscles of the iris ; and the analogy would be quite complete, if a
double and antagonistic innervation of the tensor chorioidese, by both the third
pair and the sympathetic nerve, was just as certain as it is for the iris. — Medical
Times and Gazette.

254

ATEOPIA.

adaptability of distance. He could not walk up-stairs without holding to
the banister, and he would not walk down without assistance. When
brought into a bright sunlight, it caused continued sneezing — reflex
action.

For two days we kept him quite quiet, and under treatment for his
diseased state, by associating the use of atropia to the eyes for the
purpose of compelling him to be quiet; but, on the third evening, he
found he could read by using an old person's spectacles. On the next
day, the atropia was dropped into the right eye only, and a piece of gelati-
nized calabar-bean solution was placed in the left eye. The disturbance
of vision was greater than before, and the adaptability to arrange distances
was entirely lost ; he could not even feed himself from his plate correctly.
He could look at the bright sunlight, if the right eye was covered ; but,
if he did so when the left eye was covered, it caused him to sneeze fre-
quently, and gave him deep-seated pain in the eye-ball. This plan was
continued for the purpose of keeping him from study for about two weeks ;
proper exercise was given, and his health improved very much. After
discontinuing the use of the atropia, it was many days before the eyes
recovered their natural power.

Case 9. — The author, while in perfect health, took ^ of a grain of
sulphate of atropia in an ounce of water. It had a distinct, persistently
bitter taste, and produced a numb sensation upon the tongue, somewhat
similar, though less in degree, to that produced by aconite. In about ten
minutes it produced a sense of nausea, which continued to increase until
an effort was made to vomit. Although the effort at vomiting was made
several times, nothing was thrown up. To this, intense thirst succeeded,
and a frontal headache, which was lessened by closing the ejes. IsText, a
dryness was felt in the throat, and the tongue and mouth felt dry and
feverish. These symptoms were not relieved, and only mitigated for a
short time, by drinking water. This dryness of the throat increased, and
was persistent for several hours, causing at first almost constant degluti-
tion, and, toward the last, a strong effort to avoid deglutition, which had
become painful. During the first two hours the pulse was less frequent,
but afterward became smaller and more rapid. Tha eyes soon lost all con-
trol of distance ; a printed book, held at the usual distance, was a perfect
blur ; held at a long distance, letters could be distinguished, but the words,
upon looking- at them, soon ran into confusion. Objects at a distance
could be plainly seen, even a little more plainly than natural (hyperopia),
but near objects, though for a moment distinguished, soon lost their dis-
tinctness. A numb or crawling sensation, a formication, was felt down
the back, upon the arms, and back of the hands. This formication was
intense and very unpleasant upon the palate. Light became unpleasant
to the eyes, causing pain deep in the eyeballs. Motion became unpleasant,
and if the feet were lifted in walking, the floor seemed to recede from
them before they again were put down. A sliding of the feet along the

ATROPIA.

255

floor seemed to be the only safe way of locomotion. The head began to
be dizzy, and, for fear of falling, it was necessary to be seated in the easy-
chair. Thirst, at this time, was very great, but only little water could be
taken at a time, as the effort of swallowing was unpleasant. A languid
feeling came on, as tlie semi-recumbent position was assumed, and whether
sleep accompanied with wild dreams, or waking hallucinations, followed,
it was impossible to tell. Whether the brain was troubled with hal-
lucinations, or with wild, fantastic dreams, they were exactly the
opposite to those produced by cannabis indica, for all the imaginations
and conversations were of the long past — none of the future. Wliether
there was total blindness, or merely an imagination of blindness, could not
be remembered ; but, if there was blindness to the external eye, the mind
saw all its images with great distinctness, and the impress of them was left
with vividness. There was a consciousness of individuality, but the
actions were performed by others, who were embodied spirits of those
long since departed. Lengthy conversations of a most pleasant character
were held with Plato, Alcibiades, Aspasia, and others. How long this
state lasted, cannot be told; but sound, profound sleep must have followed,
for consciousness to external objects did not j-eturn till sixteen hours after
taking the atropia. Awaking took place suddenly; there was no pain,
no headache, nothing abnormal but a languor and disturbed vision. The
bladder had not been emptied during these sixteen hours, and, although a
large quantity of water had been drunk, but a moderate quantity of urine
was passed. The vision was not clear for several days.

The close liere mentioned is small, but I usually
take about half the amount of medicine needed by
other persons.

Mr. Warton Jones' has applied atropia to the
smaller arteries, and finds it to constrict them, and
states that the effects continue for several hours. This
and other medical solutions he applied also to the web
of the frog's foot. Other alkaloids produce ojDposite
effects."*

SECTION THIRD.

Tlierapeutics of AtropicL

Case 10. — A large lymphatic woman sent for me, stating that she had
been suffering very severely from facial neuralgia for some days; that,
within a few hours, the pain had increased to such an extent, that she

^ W. Jones, Sir Astley Cooper's Prize Essay.

2 S. Percy, Am. Med. Assoc. Prize Essay, pp. 35 and 80, 1868.

256

ATEOPIA.

feared she should go crazy. The face was suffused, the right eye blood-
shot, pain very severe if the face or neck was slightly touched with a
handkerchief, or brushed over with a feather; but the pain somewhat
lessened if the warm hand was pressed firmly on the parts affected. By
means of the hypodermic syringe, I injected ^ of a grain of the sulphate
of atropia beneath the skin under the angle of the jaw. Within two
minutes there was perfect relief from pain, but the headache of which she
complained was not in the least relieved. Dilatation of the pupil of the
eye on that side soon commenced, and in half an hour the pupil was very
large. The pupil of the other eye, at that time, was not at all dilated,
though subsequently it became dilated, but not so largely as the other.
The pulse was lessened over twenty beats in the minute. I gave a large
dose of aperient medicine, and sent her to bed. She slept the whole
night through, said she did not dream in the least, and did not awake un-
til her bowels disturbed her in the morning. She was well, except that
her vision was disturbed.

Mitcliell, Morelioiise, Keen, and others, deny that
the hypodermic introduction of atropia relieves -psdn.
Such has not been the result of my experience ; and
Tatum, Ogle, and other medical officers of St. George's
Hospital, are constantly using it with great relief

Case 11. — A young girl suffering from toothache applied to me several
times. The tooth was decayed and hollow. I applied a very small ball
of cotton, slightly moistened, and dipped into sulphate of atropia. It
probably contained ^ of a grain. It always gave instant relief. I think
I used it a dozen times before I could persuade her to go to the dentist.
It did not produce dilatation of the pupil.

A very large numloer of jDersons are troubled with
a passive constipation of the bowels. This is espe-
cially the case with many females of delicate health
and highly-nervous sensibility. With such persons, I
have in many instances given permanent relief by the
careful use of the sulphate of atropia. Sometimes
this alone will give relief, at other times tonics and
aperients are needed as well. But I can refer to a
large number of cases that have been permanently
cured by the following treatment :

ATEOPIA. 257

I make a solution of sulphate of atropia in the fol-
lowing manner :

Sulj^hate of atropia, ... 1 grain.
Distilled water, .... 5 drachms.
Alcohol, 5 " Mix.

It will be seen that to each 10 minims of this fluid
there is -gig- of a grain of sulj)hate of atropia.

Fleming ' has recommended a solution of the same
strength, but he uses instead the alkaloid atropia, and
dissolves it in water by adding dilute muriatic acid.
This is not so well, for a larger quantity of acid is al-
ways used than is necessary, and no two druggists
prepare it of exactly the same acidity. There is no
need of an acid-solution, as the sulphate is soluble in
water, and, if made according to the formula found on
page 248, is in a chrysaline state which the appearance
alone will prove to be pure.

In beginning the treatment for this form of consti-
pation, I give 20 minims in about a wineglassfal of
water early in the morning, either before getting up,
or the first thing on arising. By watching the eftects
of this, it will be seen whether it is necessary to de-
crease or increase this dose. I have found, in some in-
stances, 15 minims produce the same effect in one per-
son that 60 minims would produce in another. The
object is, to produce the first degree of the physio-
logical action of the medicine — dilated pupils, slight
confusion of sight, a dry throat, and a little thirst. It
is never advisable to go beyond this first degree of
physiological action, and, by carefully watching the
effects, this degree can be reached. If 20 minims pro-
duce no marked effect, it may be increased 5 minims
at a time, until the proper action of the medicine is

^ Edinburgh Medical Journal, Jan. 7, 1863.

258 ATEOPIA.

attained. Tliis quantity slionlcl tlien be given once
only in 24 hours, and then always upon an empty
stomach. In commencing the treatment, it is neces-
sary always to give it in the morning, because its
effects could not be noticed during sleep ; but, if,
after it has been given safely for a week or more, and
the proper dose has been correctly arrived at, the pa-
tient would prefer to take it on going to bed, there is
no objection to giving it at this time, and patients fre-
quently wish to avoid the unpleasant effects of it, and
sleep while the worst effects last. It is, however, al-
Avays necessary to give it upon an empty stomach,
for it does not have its desired effect with any cer-
tainty if given on a full stomach. There are few
medicines the effects of which are so permanent as
atropia; it is not safe to repeat it in less than from
16 to 20 hours, and for this disease I give it only once
in 24 hours; if given oftener, we are very apt to
produce the cumulative action of the remedy, and
produce more severe action than is required. The
effects of one dose should nearly be spent before an-
other is given, otherwise the accumulated action of
both doses may alarm the patient. It should also al-
ways be given in solution, never in pills, for pills fre-
quently lie in the stomach or intestines, entirely unacted
upon, and may suddenly become soluble and produce
alarming results.' I have continued this treatment for
a month, taking care that a proper effort is made to
empty the bowels every day after breakfast, and allow-
ing no excuse for neglect of this habit of regularity.
In nearly all cases, the first few days, the appe-
tite is much lessened, but it afterAvard becomes much
better than ordinary. As the bowels become regu-

^ Am, Med. Times, vol. iv.

ATROPIA.

259

lar in their action, the stools become softer, and liard-
ened masses are not passed. Occasionally I am obliged
to assist with a little rhubarb at meal-times. I give
the best of powdered Turkey rhubarb ; made into ordi-
nary-sized pills with a little honey — one or two of
these pills at meal-time, discontinued by degrees.

Atropia has been highly recommended in the treat-
ment of various other diseases, as in asthma, in rheu-
matism, in whooping-cough, in scarlet fever, in sj^as-
modic stricture of the urethra, in strangulated hernia,
in rigidity of the os uteri, etc. ; but these disorders are
more easily cured by other remedies that are less dan-
gerous in their use.

Atropia, as well as belladonna, has been very
highly vaunted as a projyliylactic against scarlet fever.
I have tried it many times for this purpose, but all my
success, if it can be called success, has been of a purely
negative character, and, in many instances where I have
used it, it has had no effect in preventing the disease.
Children bear a larger dose than adults, and the effects
pass off more ra^Didly. (Med.-Chir. Trans., vol. xlii.)

To the ojDhthalmologist, atropia, or its congener,
datui'ia, is indispensable.

A solution droj^ped on the conjunctivae dilates the
pupil, and this dilatation can be varied in quickness,
in intensity or duration, according to the strength and
the manner in- which the solution is a23j)lied. If it is
desired to dilate the pupil moderately, and have the
effect pass over quickly, a solution of one grain of the
neutral sulj^hate of atropia in ten drachms of water
may be used. A few drops of this may be put into
the eye, and allowed to remain for one minute, the eye-
cup with cold water may then be used. Such dilata-
tion takes place slowly, and generally passes over in

260

ATROPIA.

from fourteen to twenty hours. But if it is neces-
sary to dilate tlie 23upil more fully, tliree grains of
tlie neutral sulphate may be dissolved in ten drachms
of water, and a few drops of this solution put in
the eye. In a few minutes this will dilate the pupil,
and in an hour the ]3upil will be very largely dilated,
and the effect will not pass over for twenty-four hours,
and frequently it lasts from two to three days.

As the pupil dilates, the sight of the eye soon be-
comes impaired, there is a staring appearance, the lus-
tre is dimmed, and after some hours the conjunctiva
' frequently assumes a dull, dirty-bluish tinge. It is
not that the eye is congested with the red blood disks,
but it looks as if congested mth the serum of the
blood.

If the atropia is put into one eye only, the sight of
that eye only is impaired, and print that cannot be
distinctly read with this eye, or with both, may be
easily read if this eye is covered. The print seems
smaller to the atropised eye than to the other, and al-
though no difference is fr^equently observed with ob-
jects at a distance, near objects are not as clearly
defined with the atropised as mth the other. This
effect is due to the wide dilatation of the pupil, and
the inability of the eye to adapt itself to near vision.
Many refer it to diminished sensibility of the retina ;
and, although others are not willing to acknowledge
this to be any cause of the impairment of vision, I
think there is but little doubt the altered state of the
delicate arteries of the retina has a decided effect in
confusing or impairing the vision. But the dilated
state of the pupil is undoubtedly the principal cause ;
for, in an imperfect light, or in twilight, the impairment
in vision is but little noted ; the pupil does not then,

ATROPIA.

261

as in a bright light, receive too many and too diver
gent rays of light. Again, if a piece of cardboard is
placed against the eye, with a hole in it smaller than
the dilated pupil, the vision is much improved. But
that the vision is materially altered in the atropised
eye is proved by looking through a telescope ; ^ for
the eye, that may be so thoroughly atropised as to be
blind in all ordinary ways, can clearly distinguish
through the telescope, if the focus is rightly adjusted
by lengthening the instrument. In the use of the mi-
croscope also,'' the same thing may be noted, for the
atropised eye can clearly distinguish if the object is
removed a little farther from the instrument.

The atropised eye bears the sun's rays better than
the other. Upon dead animals atropia produces no
action on the pupil. The modus operandi of atropia
upon the eye has been discussed by nearly all the emi-
nent ophthalmologists and anat6mists, and, although
volmnes have been written upon the subject, it is yet
" vexata qusestio." Upon this point I have not room
to print within a reasonable space the various opinions
expressed ; I therefore act under advisement, and leave
all that I have written upon the action of atropia upon
the eye, and refer to Fleming's admirable paper " On
the Action and Uses of Atropia ; " to the researches
of Budge, Brown-Sequard, Von Graefe, Bernard, Har-
ley, Bell, and others ; to Donder's work " On the Anom-
alies of Accommodation and Kefraction of the Eye,"
which contains minute and useful information on my-
driatics, and also on the antagonistic action of myotics.

Atropia has been used quite extensively by the
German physicians in the treatment of epilepsy. Lus-

* Fleming uses an action of atropia. ^ Fleming, loc. cit.

262

ATKOPIA.

Sana ' cured a patient suffering from true cerebral epi-
lepsy, and also a case of chorea in a maniac. Namias '
used atropia in doses of -g^^ of a grain in epilepsy, and
in other spasmodic diseases, and obtained by careful
and prolonged use marked success. Volunterio ' gave
of a grain of atropia every two hours, mth the best
results in ej^ilepsy. Lange * cured three men who had
suffered several years from epilepsy, by small doses of
atropia continued fourteen weeks ; they had no relapse.
He also treated in the same manner six females suffer-
ing from epilepsy; of these two remained uncured,
one died, and three were cured after five to eleven
months' treatment. Reil ' says of the action of atropia
in epilepsy and chorea : " My own experience author-
ized me to say that atropia in both the diseases under
consideration is not only a safe palliative means, but
often a true and curative means," especially when the
disease is not yet inVeterate and the individuals are
young, particularly in young girls at puberty."

» L'Union Medicale, Xo. 17. 2 gd. Med. and Surg. Jour., 1851, p. 249.

3 Hagen, p. 607. '* Deutsche Klinik. 10. 1854. ^ Hagen. p. 608.

^ Belladonna and atropia are, according to the Medical Times and Gazette^ in
favor at the Hospital for the Epileptic and Paralyzed, as remedies for epilepsy. Un-
der these remedies the patients are benefited, and though many cases are not
cured, the number of fits is often diminished and the patient's general condition
much improved. Many who have suffered for years are rendered capable of re-
suming a comparatively active life. The prescription generally used is extract of
belladonna a quarter of a grain, quinine one grain, in a pill three times a day. Of
atropine, the of a grain is given three times a day. Both are gradually in-
creased in dose, yet the only physiological effects observed are dryness of the
throat and defective vision. The latter is in consequence of the ciliary muscle
being partially or totally paralyzed, by which the power of accommodation is im-
paired or altogether lost. One method of Dr. Brown-Sequavd is, to inject a solu-
tion of atropine and morphia into a part from which an aura starts. A solution
containing Jg- of a grain of atropine and ^ of a grain of morphia is injected with
AVood's syringe, sometimes with excellent results. He believes that belladonna
and ergot both act by producing contraction on the blood-vessels ; the former on
those of the brain, the latter on those of the spinal cord. In paraplegia from
myelitis, he gives a pill containing three grains of fresh ergot and a quarter of a
grain of the extract of belladonna, three times a day. The action of belladonna

ATEOPIA.

263

Professor Oppolzer/ in Vienna, in a case of inflam-
mation of the radial nerve, for wliich quinia, Fowler's
solution, colchicum, iodine, and other remedies, had
heen tried in vain, employed repeated subcutaneous
injections of atropia, and removed the pain and the
thickening of the nerve.

Bouchardat, Croserio, and Lussana, used atropia in
intermittent fever successfully, for which quinia had
been given in vain. Lussana treated with it two cases
of tertian intermitting fever, and says concerning it
the following : I beg the attention of physicians to
the cure which I have obtained, by atropia, of two
cases of intermitting fever existing for two months,
in which the sulphate of quinia had been given to no
purpose. Half a grain of atropia sufficed for the cure,
and with J- or even -^^ of a grain, such a modification

in arresting the secretion of milk, and causing dryness of the throat, may be ex-
plained on the hypothesis of its diminishing the supply ol" blood to those parts.
Thus, then, up to this point, fiye facts appear proved :

1. That, in cases of chorea, extraordinarily large doses of belladonna and
atropine are tolerated.

2. That the drug is absorbed into the blood, and therefore that the tolerance
of it is not attributable to its non-absorption, nor to its being decomposed in the
stomach.

3. That it does not accumulate in the blood, but passes out of the system
with the urine and faeces, and probably with the other excretions.

4. That it does not exercise that amount of control over the choreic spasms
which would have been expected from the readiness with which it is tolerated by
the system.

5. That the tolerance of the remedy is not in proportion to the severity of
the choreic symptoms.

The question, therefore, arises as to whether the existence of chorea had any
part in producing tolerance of the drug, or whether that tolerance may not have
been due to some other circumstances ? With the view of determining this point,
the author administered the extract of belladonna to two convalescent children,
whom he kept in the hospital for the purpose. To the one, aged seven, he ulti-
mately gave thirteen grains of the extract daily, and to the other, aged ten, twenty-
eight grains daily, without producing dryness of the tongue or fauces, or any
symptom indicative of the action of belladonna beyond some temporary dilatation
of the pupils.

1 Wiener Medic. Halle, 1861.

264

ATEOPIA.

of the attacks occurred, tliat tlie peculiar curative
action of tlie atropia was not to be mistaken. When
it is considered tkat atropia is an indigenous remedy,
and tliat mth it the sick can be cured witli little cost,
whereas the treatment by quinia in Europe costs mill-
ions, it is proper that the exjDeriments published by
me should gain the attention of physicians."

It is necessary to dwell for a few moments upon the
duration of the effects of atropia upon the system.

The effects of atropia remain longer in the system
than any medicine of its class. If we compare it with
the narcotics, we find that they are all eliminated from
the system in a quicker time than atropia. If w^e com-
pare it with the sedatives, we find the same result.
Medicinal doses of atropia of of a grain will produce
effects that will not subside in less than twenty-four
hours, and frequently they last for double that time.
Caution, therefore, need be used in administering this
remedy, and doses must not be repeated too often, other-
w^ise the system may be overwhelmed by the accumu-
lated influence of one dose, given before the effects of
previous doses have sufficiently passed over.

Unless patients can be very closely watched, it is
better not to rej)eat doses of atropia oftener than once
in twenty-four hours.

Of the various preparations of atropia, the best,
and that most easily obtained, is the neutral sulphate.
Atropia itself need never be used where one of its
soluble salts can be obtained. The formula above
given for the crystallized sulphate of atropia places it
Avithin the power of any good pharmaceutist to pre-
pare a perfectly pure, and a perfectly neutral salt, and
one that is readily soluble in all menstrua in which it
would be necessary to use it. The advantage of pur-

ATEOPIA.

265

chasing it in crystals is, tliat one is assured of its purity
mucli more readily ttan if it was in powder.

For the use of ophthalmologists the neutral sulphate
is the only preparation that should be used, and no
apothecary has a right to dissolve the pure alkaloid by
adding free acid for that purpose. The alkaloid is not
dissolved without an excess of acid, and frequently a
large excess, .and this free acid always becomes an irri-
tant to the eye, whereas the application of the neutral
sulphate does not inflame. No ophthalmologist would
order any thing but the neutral sulphate, and any
apothecary who would prepare the acid sulphate is
deserving of severe censure. Atropia, as well as all
other alkaloidl^, should never be given in pills, but
always in solution. Disks of pajier and of gelatine
properly atropised are to be purchased at druggists'.

In its effects upon the system, atropia may be
classed midway between narcotics and sedatives. Of
the class narcotics, together with stramonium and hyos-
cyamus, it most nearly approaches the sedatives. The
primary stimulating action is very slight, and it soon
passes over; the anodyne effect is soon felt, and a
sedative effect u23on the heart is soon noticed. It is
not soporific, but deliriant. It does not constipate
the bowels, and in medicinal doses it does not dimin-
ish the secretions. In poisonous doses, we see, by re-
ferring to cases quoted, that it checks the secretion of
urine by causing congestion of the kidneys. It always
produces dilatation of the pupil of the eye ; generally
a peculiar dryness of the throat accompanied with
thirst. In full doses it is nearly always a deliriant, ex-
citing and leading the mind astray, presenting unreal
objects and imaginary fantasies; hallucinations su23]3ly
the place of realities, and seem to be more permanent

266

ATEOPIA.

than realities. Unlike soporifics, the mind is not ex-
tinguished, there is no j)erfect loss of consciousness,
but the senses are deranged and deluded. Like the
sedatives it deranges or destroys the action of the
vagus nerve.

" Hahnemann and his followers have made the as-
sertion that the administration of belladonna produces
a rash similar in apj)earance to scarlatina, ajid, upon this
assertion, they use belladonna as a cure for scarlet
fever. Many eminent medical men accept this asser-
tion as a fact, and, in one of our latest and best works
on ^ Skin Diseases,' ' the author, in enumerating articles
that produce an erythema, states the reiterated asser-
tion that ' belladonna j)i'oduces a rash Of a rosy hue.'
Dr. Fuller, in a ^SL^^eY on the ' Action of Belladonna,' '
with a view to solve this question, gave belladonna to
a large number of patients for some months, ^ in doses
varying from a quarter of a grain of the extract up to
seventy grains daily.' The patients were examined
four or five times daily, and the occurrence of any rash
or eruption was carefully looked^ for. But in all these
cases no rash or eruption was perceived."

I have watched a large number of patients, both
in hosj^ital and in private practice, where belladonna
or atropia has been used with a like negative result.
There are many unfounded assertions on the actions of
medicines, but probably none so wide-spread and ut-
terly groundless as this. It is well worthy to be
classed with the other " facts " of Hahnemannic " prov-
ings."

^ Dr. Tilbury Fox. - Medk-o-Chir. Trans., vol. xlii

4lTR0PIA.

267

SECTION FOURTH.

Toxicology of Atropia,

Tlie effects of overdoses of atropia liave been
plainly shown in section second.

The toxicology of atropia is susceptible of two
divisions :

1. The means necessary to be employed to coun-
teract the effects of over-doses, in other words, the
antidotal effects.

2. The means of detectino^ the alkaloid in cases of
poisoning by it, as well as the means of recognizing
the s}Tii23toms of poisoning.

It was long supposed that the vegetable alkaloids
had no antidotes, and that antidotes were only found
in that class of remedies that could be rendered inert
by chemical decomposition ; but the therapeutist has
remedies that act as antidotes to symj^toms produced
by other remedies. The antagonistic actions of bella-
donna and opium are of this class. As the science of
therapeutics makes advances, these antidotal powers
will be better understood.

We see, by reference to cases 1, 2, 3, and 4,
where atropia was administered in full doses and all
fluids withheld, that the effects of the medicine were
much more severe than when diluents were freely
given. We see by these cases that the free use of
water alone enabled the system to recover from a
large dose, a dose that was large enough to destroy
life Avhere diluents were entirely withheld. We see
also in these cases that the kidneys were highly con-
gested and unable to eliminate the urea.

If a large dose of atropia has been taken, and time

268

ATEOPIA.

sufficient lias elapsed to liave it absorbed into the sys
tern, we sliould do more good to give diluents freely
than to give emetics as usually recommended.

The mutual antidotal powers of opium and bella
donna have been freely discussed in the medical jour-
nals, and many interesting cases are recorded. Of
these the most numerous and perhaps the most inter-
esting are reported by Dr. Norris, in the American
Journal of Medical Sciences^ October, 1862, p. 395.
Twenty-seven cases are here given of belladonan-poi-
soning treated by opium, and of opium-poisoning
treated by belladonna.

Another interesting case is reported in the same
journal, for April, 1866, p. 434, wherein grain of
atropia produced violent symptoms which were almost
immediately relieved by morphia. In the Philadel-
jpliia Medical and Surgical Reporter^ for September,
1866, p. 225, a case is reported where 3 oz. of lauda-
num were taken, and recovery took place by free use
of belladonna. Another case of the same description
is recorded, American Journal of Medical Sciences^
April, 1856, p. 541. In the same journal, for January,
1861, p. 288, a case is reported where two grains of
atropia were taken, and the patient recovered. I do
not believe that in this instance the atropia was pure.
There are several instances recorded where a grain of
atropia was taken, producing alarming symptoms,
fr^om which the patient ultimately recovered.

A paper by Dr. Downs, on the antagonistic effects
of opium and belladonna, is to be found in the Trans-
actions of the New Yorh State Medical Society for
1866.

Dr. Ogle, in the St. George^ s Hospital Reports., re-
lates a case of trismus that was relieved by subcuta-

ATEOPIA.

269

neous injection of meconate of morphia and sulphate
of atropia combined. Dr. Tatnm and others in this
hospital are in the habit of using these two alkaloids
in combination, and they state that they find more
benefit from their combined action than from either
substance alone.

There is, upon the whole, abundant evidence to
prove that opium and belladonna, morphia and atro-
pia, are mutually antidotal.

In the use of atropia for the purpose of dilating
the pupil, the action of the atropia can be more
quickly overcome if a solution of sulphate morphia,
containing four grains to the ounce of water, is applied
to the eye by means of the eye-cup.

A solution of calabar-bean, or the paper or gelatine
of the same, produces an antagonistic effect to atropia
when applied to the eye, and an eye that is atropised
quickly recovers from its dilatation if the calabar-
bean paper is applied within it, and, if a little stronger
than the atropia, it will soon cause contraction of the
pupil.

Calabar-bean has been used as an antidote to atro-
pia, and, it is reported, with success.

On the second division of this subject — "The
means of detecting an alkaloid in cases of poisoning
by it " — there is no question in the whole science of
medicine that needs more thorough research than this,
and I feel that time may be well spent in experiment-
ing, and in bringing together facts which will eluci-
date the difficult and yet unsettled points of the physi-
ological action, tie pathological conditions, the chemi-'
cal reactions, and microscopic appearances, which are
necessary to a full understanding of the medico-legal
science in each case of poisoning.

270

ATKOPIA.

Many medical men, and most of tlie public who
compose a jury, suppose that a poison must necessarily
be detected by a chemist before a criminal should be
convicted of poisoning. This error has arisen from
the fact that, until within a few years, the corrosive
metallic poisons w^ere the only ones used by poisoners,
and these poisons were always readily found by chem-
ical means. But the more educated j)art of the com-
munity now know that there are poisons that cause
death more quickly, less painfully, and with more dif-
ficulty of identification, than was formerly the case.
The chemist has given to the medical man the most
powerful vegetable alkaloids, several of which endan-
ger the life with fractions of a grain. To what ex-
tent has the toxicologist kept pace with the chemist,
and how far is he enabled positively to assert the
presence or action of an alkaloid in a case of poison-
ing ? As yet, we have not many cases of poisoning
with the alkaloids on record, but, as these powerful
agents become more commonly known, they will be
more frequently used. With what degree of certainty
are we able to detect them ?

Two interesting cases, with an opposite termina-
tion, have occurred within a few years in England,
and the points raised in these cases are just such as
need elucidation in all cases of poisoning by the alka-
loids, and we will endeavor to clear up some of these
doubtful points.

On the trial of William Palmer for the poisoning
of Cook by strychnia, upon a careful chemical investi-
gation after death, no strychnia was discovered ; but
the pathological conditions which strychnia induces,
and the unmistakable physiological actions of the al-
kaloids during life, were present. The juiy, satisfied

ATEOPIA.

271

with the scientific acumen of the therapeutist, found
the prisoner guilty, and he was punished for the
offence. The toxicologist here couhl only prove one
link in the chain of evidence — the action of the medi-
cine— the presence was not found ; it was only proved
to liave existed.

The other case to which I refer was the trial of a
surgeon by the name of Sprague, living at Ash burton,
in England, who was accused of placing atropia in a
rabbit-pie for the purpose of poisoning his wife.' r The
ph} siological action of atropia was produced. A por-
tion of the pie and some of the vomited matters were
subjected to chemical analysis by Mr. Herapath, of
Bristol. Mr. Herapath testified that atropia was dis-
covered by him in the i3ie as well as in the vomited
matters. The symptoms also, under which the poisoned
person suffered, corresj^onded, in his opinion, with the
symptoms produced by poisoning with atropia. The
methods of analysis resorted to were described to the
jury by Mr. Herapath, and a rigid cross-examination
was resorted to by the prisoner's lawyers ; but Mr.
Herapath demonstrated the presence of atropia. The
ground taken for the defence was, that rabbits and
some other animals occasionally eat belladonna-leaves
with impunity, and, therefore, there might exist in the
flesh of this rabbit sufiScient atropia to produce all the
effects described. It was not proved that this rabbit
had eaten belladonna, but that such a thing , might
have happened. The experiments of Eunge, of Ber-
lin, were quoted, and much stress laid upon them.
Some forty years ago, Runge, secteur in the University
of Berlin, stated in a paj^er published in the Journal
de Pharmacie^ x. 85, that he had fed a rabbit for

^ London Chemical News, vol. xii., p. '72.

272

ATEOPIA.

eight days on the leaves of belladonna, datura, and
hyoscyamus, and that the animal suffered no incon-
venience. He stated, moreover, that the poison had
not escaped absorption, for it was found by the physio-
logical test — viz., the dilatation of the pupil of a cat —
to be present in the rabbit's urine. The latter fact
would only show that some of the alkaloid — perhaps
a minute portion — had been absorbed ; but a fui^ther
observation showed that in reality all had been taken
ujD, for, when the rabbit was killed, the residue of the
food in the rectum was found, by the same test, to be
completely free from atropia.

Mr, Sprague was acquitted. This result seems to
have been arrived at by mystifying the jury, who
could not distinguish between the lawyer's special
pleading and the facts presented by a scientific chem-
ist. As a doubt existed in their minds, the prisoner
had the advantage of it.

In nearly all our works on materia medica these
experiments of Eunge's are quoted, and have been
generally accepted as accurate, or at least as probable,
as some of the ruminants have been known to eat
and suffer no inconvenience from medicinal plants that
produce dangerous effects upon man.

" Some years after Runge's paper had been pub-
lished, there appeared (in the Arcliives Generales^
xviii., 302) an account of some experiments made by
M. Eeisinger, who stated that the dose of atropine and
hyoscyamine — in his opinion identical substances —
which produced in half an hour symptoms of poison-
ing in a puppy of three months' age, produced no
effects at all on young rabbits, and he concludes his
paper with saying that ^ ces animaux paraissent insen-
sibles h Taction interne ou externe de ces substances.' "

ATEOPIA.

273

Dr. AV. Ogle, lecturer on pliysiology at St.
George's Hospital, witli a view to elucidate this case,
has performed a number of experiments upon rabhits
both with belladonna and atropia. He says :

" Can rabbits eat belladonna with impunity ?

"Experiment. — In the beginning of last August I was supplied, by
the kindness of Mr. Squire, with a large quantity of fresh-cut belladonna.
I first satisfied myself that the leaves contained atropine, by applying a
crushed one to the eye of a kitten for'a few seconds. The pupil was soon
enormously dilated. I then fed a healthy young rabbit, about four months
old, for six days exclusively on the plant. The animal ate the belladonna
with the greatest readiness, consuming all the leaves, blossoms, and young
green shoots, but leaving the harder stems and roots. It consumed sev-
eral times its own weight during the course of the week. During the
whole time it remained perfectly well. The pupils were very large at the
outset and remained so throughout. The only symptom observed was,
that, in running about, the animal occasionally gave a comical kick out
with its hind-legs, which was taken at the time, by myself and others w^ho
watched the rabbit, for an accidental exaggeration of a movement often
seen in rabbits, but which I have now no doubt was in reality due to the
belladonna. After six days, ray stock of belladonna being exhausted, the
rabbit was killed. The viscera were quite healthy, the stomach and intes-
tines full of debris of green leaves, the bladder empty.

"The rabbit, after skinning and cleaning, was given to a dog, in order
to ascertain whether the flesh was in any degree poisonous. But, though
the dog was kept for three whole days from all other food, it refused to
eat a morsel of the rabbit, so that this part of the experiment came to
nothing. I was not aware till then that some dogs will undergo starva-
tion rather than touch the flesh of rabbits.

" This experiment corroborates that of Runge, and
shows clearly that a rabbit can live, at any rate, for
six days on the leaves of belladonna without any in-
convenience.

" 2. When a rabbit is fed on belladonna, is the
atropine absorbed ?

" 3. Is atropine as distinctly poisonous to rabbits
as it is to man ?

"ExPEEDiEXT 1. — I administered to a healthy rabbit, three mouths old,
a grain of sulphate of atropine dissolved in water. The rabbit's mouth
was held open and upward, and the solution was passed down the oesopha-

274

ATEOPIA.

giis in a tube, great care being taken that none escaped. The animal
was watched carefully for many hours consecutively, and then visited and
examined at frequent intervals. No other symptom was produced than
dilatation of the pupils.

"ExPEEiMEXT 2. — To another rabbit of the same age, two grains of the
sulphate of atropine were administered in the same way. Dilatation of
the pupils was produced, and also the symptom that I noticed before in
the animal fed on belladonna, viz., a slight exaggeration of the action of
the hind-legs now and then, when the rabbit was running about. This
symptom had not the least resemblance to muscular paralysis. The rabbit
ran just as well as ever, and the movements of which I speak only oc-
curred now and then at intervals as it ran. In all other respects the rab-
bit seemed perfectly well, and ate its food as usual."

It results from tliese experiments tliat a rabbit of
three montlis' age can take by the stomach, without
inconvenience, a dose of atropine which w^oulcl kill a
man. I now come to the more severe test of hypo-
dermic injection :

" ExPEEiMENT 3. — To a rabbit, about three months and a half old, I
administered, by subcutaneous injection in the back, one grain of the sul-
phate of atropine. The rabbit, in a quarter of an hour, began to lick its
forepaws, as though there was some uneasy sensation in them. After
three-quarters of an hour it was seen again to lick its forepaws, as though
there was some uneasy sensation in them, and then to drum with them
rapidly for a few seconds, and this same spasmodic di-umming occurred
some half dozen times in the course of the next three hours. There was
also noticed now and then, when the animal was running about, the same
furious ' kick out ' with the hind-legs which I have before mentioned as
occurring in the rabbit fed on belladonna. There was no muscular paraly-
sis whatever. The animal ran about as well as before the injection,
playing with another rabbit, and from time to time nibbling at some let-
luce-leaves. The uneasiness in the paAvs was not manifested in any way
after four hours, and after that time no other symptom was observed than
dilatation of the pupils, which began soon after the injection was made,
and lasted till the next day."

I should say that I have produced the same symp-
toms— viz., dilatation of the pupils, drumming with
the forepaws, " kick out " with the hind-legs — with
half the dose used in this experiment. On the other
hand, these symptoms have sometimes been so slightly

ATEOPIA.

275

marked as almost to escape notice wlien tlie dose in-
jected has been mucli larger.

"ExPEEiMEXT 4. — I injected three grains of the sulphate of atropine
into each of two rabbits, one six months, the other three months old. In
each the same symptoms ensued as were described in the last experiment,
and, notwithstanding the tripled dose, there was no greater severity in the
effects produced."

In tlie next ex23eriment Dr. Ogle injected tliree
grains and a half of the sulphate of atro2:)ia in the
back of a rabbit, with the same effects as those last
described. A few drojis of urine, passed by the rab-
bit an hour and a half after the injection, were put
into the eye of a kitten and produced marked dilata-
tion. In the next experiment five grains of sulphate
of atropia were used with a like result, the urine pro-
ducing the same effect upon the eye of a cat.

Dr. Camus' has experimented with atropia upon
rabbits, and he says that one gramme — 15^ grains —
constitutes the minimum dose fatal to a rabbit. Dr.
Ogle has produced the same result mth three grains.

It will be seen, by these experiments of Dr. Ogle's,
that rabbits can tolerate enormous doses of atropia —
doses large enough to kill several men.

Dr. Ogle draws the following conclusions :

"1. That a rabbit of middle age can live for, at any rate, six days-
exclusively on belladonna without inconvenience.

"2. That a rabbit can tolerate enormous doses of atropine administered
either by the stomach or by subcutaneous injection, and that this toler-
ance is not due to non-absorption of the poison.

" 3. That this tolerance increases with the age of the rabbit.

'^4. That dilatation of the pupils is, however, produced just as readily,
if not more so, in an old rabbit, as it is in a young one."

These experiments of Dr. Ogle's are exceedingly
valuable; but it was a great misfortune that some
chemist was not associated with him to ascertain how

1 Gaz. Hebdom. de Med. et de Chir., Aug. 11, 1865. •

276

ATEOPIA.

mncli of the alkaloid could be detected in the uiine,
the intestines, and the tissues of the rabbity if killed
at any given time dnring the experiment. As the
matter now stands, we are but little better off than
when Runge left it : the knowledge that we possess is
but confirmed. The alkaloid is without doubt ab-
sorbed, and the question now to be answered is. Is
the meat of such an animal fit for human food, and
how much of an alkaloid can be retained in the flesh I
For toxicological puii^oses we need not at present dis-
cuss how much of an alkaloid can be retained within
the flesh of an animal when an alkaloid is given by
hypodermic injection, or by the mouth ; but the point
of importance is, how much alkaloid may at any time
exist in the flesh of an 'animal that has fed npon a
poisonous vegetable ? K, upon a case of poisoning, a
plea is to be ui'ged that the poisoned person partook
of meat from an animal that was 2>oisoned frc^m eating
food that was innocuous to it, Tjut that was poisonous
to man, we need to know with great exactness to
what extent and in what form that poison may be
found ill the flesh of the animal. "We need also to be
able to distinguish the poison that may exist in the
flesh of such animal eating such poisonous vegetable,
from a poison that may exist by being given as an
alkaloid to an animal while still living, either by way
of the mouth, or by injection of the alkaloid subcu-
taneously. Such questions open an entirely new field
in medico-legal science.

These ex[3eriments of Runge's, confirmed and
largely amplified by Ogle, prove that rabbits can eat
belladonna with impunity, and it is equally probable
that hares share this immunitv from dans^r; but it
is not at all probable that these animals would in a

ATROPIA.

277

state of nature eat sufficient to make their flesli danger-
ous to human beings. But, in this case of Sprague's,
the courts have established a precedent, and have ac-
knowledged that such probability exists. Does this
immunity exist with rabbits only? Is belladonna
the only vegetable poison that may be eaten without
injury ? May not these animals have a like immunity
with hyoscyamus, digitalis, aconite, lobelia, etc., etc. ?
I have tried the following :

ExPEEiMENT 12. — To a large she-goat, liaving two kids by its side, I
presented some freshly-gathered belladonna; the goat refused to eat it.
As the goat was tied where the grass was very scarce, I went to a field
and gathered a quantity of fresh grass. This I fed to the goat, mingling
with it the belladonna; both were eaten together until she had eaten two
ounces of the leaves of the belladonna. In two hours I again saw the goat ;
the kids had been suckling in the mean time. I could see no marked dila-
tation in the pupils of the eyes in either the old goat or the kids. I got
about an ounce of her milk, which was fed to a kitten, without any ill
eftect or without dilatation of the pupils. The next day I gave four
ounces of belladonna-leaves in the same way. In four hours, upon return-
ing, I found the pupils of the eyes in both the old goat and in the kids
dilated, but I observed no other effect.

About a week after, I gave four ounces of dried hyoscyamus alone to
this same goat, without observing dilatation or any other symptom follow
it.

To one of the kids I gave one ounce of dried digitalis, without pro-
ducing any noticeable symptom ; to the other I gave about f oz. of hyos-
cyamus, with the same result.

Experiment 13. — I passed down the throat of a kid, about four months
old, a bolus containing one drachm of extract of belladonna. In less than
an hour the pupils were very widely dilated, and the kid did not play or
eat. It remained lying down for some hours. When I saw it the next
day the pupils were still dilated, but in every other respect it seemed quite
well.

ExPEEiMENT 14. — To another kid, of about the same age, I gave one
drachm of extract of hyoscyamus. I did not see that it produced any
effect whatever.

Experiment 15. — To the same kid mentioned in experiment 13 I gave 6
drachms of extract of belladonna. It produced about the same effects as
those mentioned in experiment 13. The goat was not in any way injured,
the only unpleasant effect being the enormous dilatation of the pupils. All
the urine that this kid made for 15 hours after taking the^bolus was saved.

278

ATROPIA.

It amounted to 19 drachm?. This, with a syringe, was thrown into the
stomach of a young dog, about four months old. Within 10 minutes the
pupils of the dog's eyes were widely dilated. The dog was locked up and
not again seen for 16 hours. It was found dead. The stomach was
empty, the pupils of the eyes were enormously dilated, the heart was filled
with black, thick, uncoagulated blood. The bladder contained a small
quantity of urine. A few drops of this were placed into the right eye of
an old dog; dilatation took place, which did not pass over for three days.

This urine, amounting to 180 grains in weight, was put into a watch-
glass, and carefully evaporated. The residue was washed repeatedly with
small quantities of strong alcohol, filtered, and again evaporated on a
watch-glass. This residue was washed with a small quantity of chloroform,
and drawn up into a small pipette ; it amounted to ten minims. A drop
of this chloroform solution placed upon a glass slide, and mixed with a
drop of " an aqueous solution of bromohydric acid, saturated with free
bromine," ^ gave a peculiar agitated appearance under the microscope, with
yellowish streaks, which again became colorless and again reappeared ; as
the chloroform evaporated, a yellow amorphous precipitate continued to
appear, which after a while assumed a. crystalline form — these crystals first
, appearing upon the edges, but being more, distinct and more perfect in the
centre.

Another drop of the solution, mixed with a drop of alcoholic solution
of carbazotic acid,^ gave the same peculiar agitated appearance during the
evaporation of the chloroform ; a yellow precipitate soon formed, which,
stirred with a piece of fine silver wire, yielded distinct small crystals.

With a solution of terchloride of gold, a pale-yellow precipitate formed,
after a while assuming a crystalhne form.

With a solution of iodine in iodide of potassium, a reddish-brown pre-
cipitate formed. (Microscopic drawings of these crystals were shown to
the alumni.)

The heart of the dog, together with the blood it contained, and that
which could be collected fi'om the large vessels, was cut in pieces and put
into a beaker-glass, with four ounces of strong alcohol and ten minims of
pure sulphuric acid. This glass was held in hot water for ten minutes,
and constantly stirred with a glass rod. The fluid portions were strained
through fine muslin, and evaporated to one ounce. This was filtered,
evaporated to half an ounce, rendered distinctly alkaline by liquor potassse,
and then evaporated to dryness. This was three times washed with chlo-
roform, and the chloroform allowed spontaneously to evaporate. The
watch-glass was carefully washed with fresh chloroform, 'and this was
drawn up into a pipette. (Wormley's process.)

It yielded no evidences of atropia with either of the reagents above
mentioned.

Four ounces of the flesh of this dog, taken from the hind-leg, were

1 Wormley's process.

ATROPIA.

279

treated in the same manner as the heart and the blood. Xo evidences of
atropia were to be discovered.

ExpEPwiMEXT 16. — An old male rat, caught alive, was placed under the
influence of chloroform; a grain of the sulphate of atropia in solution
was thrown, by means of a proper syringe, into the stomach, and a liga-
ture was passed around the penis, so that no urine could be lost.

The i-at showed the usual symptoms of poisoning by atropia, and died
in a little over four hours. He did not vomit. The rat was skinned and
opened. The stomach was found empty, and the mucous membrane red-
dened in patches. The intestines were not examined. The heart was full
of black, thick blood. The kidneys were both highly congested. The
bladder was full ; it was tied and removed. The lungs were dark-colored,
and the pulmonary arteries were filled with dark blood. The skin, the
head, the stomach, and intestines were thrown away. The body was split
in half, and one part given to a young, active dog. The dog was watched
for 12 hours, and no ill effect was noticed ; the pupils of the dog's eyes
were not dilated.

The other half of the body, together with the heart and the blood it con-
tained, was treated in the manner recommended by Prof. Wormley, and
the residue subjected to the reagents used by him for the detection of
atrapia. I could discover no evidences of atropia.

The bladder was opened, and found to contain five drachms of urine.

Two dogs were selected, and a drop of this urine put into the right
eye of each ; marked dilatation took place in the eye of bothj but it was
not excessive, and had all passed over when next seen — about 14 hours.

The urine was subjected to analysis in the same manner as that men-
tioned in experiment 15, and with a like result, showing the presence of
atropia.

ExpEEiMENT 17. — A very large, strong male rat was caught in a trap.
He was a coarse, dirty-looking animal, so, before handling him, he was put
into warm water, and repeatedly thrust under it to wash him well.
Chloroform was administered. Upon taking him out of the cage, a large,
yellow circular crust was found upon the head, running down upon the
neck, another crust of the same character was found upon the right hip,
and another smaller one upon the outer portion of the right fore-leg.
These were the cup-shaped crusts of porrigo favosa, similar to those de-
scribed by Dr. iDraper, of ^ew York, to Bazin, as existing upon mice
caught by him, and proved by him to be true porrigo by transmission to a
cat, and from the cat to children. (A pen-and-ink sketch of the micro-
scopic appearance of a part of this crust was shown to the alumni.)

A subcutaneous injection of half a grain of sulphate of atropia was
used ; in a few minutes the pupils of the eyes were found to dilate, and as
the rat revived from the influence of the chloroform the pupils could be
seen steadily to dilate. In 15 minutes the subcutaneous injection was re-
peated upon the other side of the animal. The rat was so thoroughly un-

280

ATEOPIA.

(ler the influence of the atropia, and the pupils were so widely dilated,
that he made no attempt to escape when placed upon a shallow box on the
table. In 15 minutes more the subcutaneous injection of half a grain was
repeated. In one hour and five minutes from this last injection the rat
died. He was immediately skinned, excepting the head and feet, which
were thrown away with the skin. The stomach was empty, but was
deeply congested, the heart was full of dark, thick blood, the lungs were
dark-colored, the kidneys were deeply congested. The whole carcass of
this rat, divested of head, skin, stomach, intestines, heart, lungs, kidneys,
and bladder, was given to a large, coarse dog. The dog ate it readily.
He was immediately tied to the table and closely watched. The pupils
were but very little, if any, dilated, and the dog suffered no inconvenience
from his meal.

The carcass of this rat was in the same condition that the carcass of
the rabbit, in the pie we have mentioned, would have been had the rabbit
fed freely and fully upon belladonna ; it was in the same state that the
carcass of the rabbit was that Dr. Ogle fed upon belladonna-leaves for a
week, and which his dog refused to eat. "Within 45 minutes, one and a
half grain of sulphate of atropia was given hypodermically, and the rat
lived an hour after the last injection, evidently long enough, as the result
proves, to have eliminated or to have destroyed the activity of the poison.

In warfare tlie ship-builder lias constructed heavily-
plated vessels, that they may approach without dan-
ger near to fortifications and destroy them. The
artillerist, in self-defence, has not been idle or igno-
rant, and has made, to meet these iron-clad monsters,
balls of enormous weight and of enduring hardness,
propelled through rifled cannon, which are capable of
holding sufficient powder to force the ball with such
velocity that it will enter and rend the heaviest plate-
armor.

The toxicologist has not been as successful as the
artillerist. Fortunately, the knowledge of the alka-
loids and the skill to use them are as yet confined
to the better-educated class of the medical profession ;
l)ut, as they become more common, and bad men learn
their power, they will undoubtedly be more used for
purposes of poisoning. "When it is known that a sub-
cutaneous injection of a few droj)s of poison will take

ATEOPIA.

281

a life, leaving no trace whatever of tlie cause, and
wliich no toxicologist can discover, it is greatly to be
feared tliat sucli means will frequently be used. Every
thing, then, that can be done to elucidate the physio-
logical action of these alkaloids, the pathological con-
ditions they leave of their action, the chemical reagents
that will detect them in their minutest quantity, and
the physiological action of the collected secretions, or
collected poison, is of the utmost imjDortance to the
safety of society. It behooves us of the profession fre-
quently to look and inquire how far our knowledge
has advanced, and to give every aid and assistance in
our power to those who make a special study of these
matters.

Let us review what w^e know of the toxicology of
atroj)ia :

Atropia and strychnia are probably the most
easily detected of any of the vegetable alkaloids,
owdng to well-known peculiarities of their physiolo-
gical action. The first invariably causes dilatation of
the pupil of the eye ; the latter causes its own peculiar
spasm. As we have seen, in the preceding pages,
every man or animal to whom atropia has been ad-
ministered has exhibited this characteristic dilatation.
In the rabbit-pie analyzed by Herapath, he proved the
presence of atropia by this well-known physiological
action of the alkaloid upon the eyes of animals —
touched with a little of the substance recovered from
the pie, and from the matters vomited by the vic-
tim. Ogle collected urine from rabbits dosed wdth
atropia, and with it produced the physiological dila-
tation on the eye of a cat.

In experiment 15, we see that the urine, collected
from a goat dosed with belladonna, dilated the pupil

282

ATROPIA.

of tlie eye of one clog wlien placed in it, and, when
passed into tlie stomacli of another dog, destroyed its
life, and atroj^ia was found in sufficient quantity in
tlie urine of the poisoned dog to be recognized by the
chemical reagents pointed out by Wormley ; and that
a drop of this urine also produced dilatation in the
eye of another dog.

In experiment 16, we find that the urine of a rat,
poisoned with atropia, caused dilatation in the eyes of
two dogs.

If we are not, then, always able to recognize atro-
pia by chemical means, in cases of poisoning by it, we
have strong probabilities of recognizing it by the
"physiological test." Hyoscyamin and daturia pro-
duce the same effects, but daturia and atropia are
identical in their chemical reactions and physiological
effects.

Sprague was liberated on the plea that the rabbit
in the pie might have fed upon belladonna, and thus
have become poisonous. Herepath recognized atropia '
in the pie. Ogle did not carry his experiment far
enough to ascertain if the rabbit, fed by him on bella-
donna, was rendered j)oisonous thereby. In experi-
ments 15, 16, 17, where atropia was given to animals,
and death caused by its action, the flesh of the poisoned
animal was not poisonous, and failed to yield chemical
evidence of being poisoned. Wormley,' however, was
more successful, doubtless I should say more skilful,
for he recognized atropia in the blood of a dog poi-
soned by fluid extract of belladonna, and also in
that of a cat. But there is a difterence in these cases
of Prof Wormley's and those I have presented, and I
think an important difference. In the first instance,

1 Wormley's " Micro-cheaiistry of Poisons," p. 636.

ATEOPIA.

283

he killed tlie clog an Lour and a lialf after giving the
poison, and the cat died in three minutes after the
poison was injected into the lungs.

In the cases I presented, all the animals lived for
some hours, and died slowly from the natural effect of
the poison.

It will be seen, in nearly all instances where I have
experimented with excessive doses, that I have been en-
abled to prove the presence of the poison in the urine
where I could not discover it in either the blood or
flesh. The methods of analysis and the reagents used
are those so ably pointed out for our use by Prof
Wormley.

It will not do to dismiss this subject of the flesh
of animals becoming poisonous to man, or to other
animals, by food the animal may eat; we have too
many facts before us to prove this to be the case.

The " trembles," or milk sickness,"- of our West-
ern States is a strong evidence of this kind of ]3oison-
ing. The flesh, the milk, the butter, or cheese, from
one of these poisoned animals always produces sick-
ness in any animal that eats it, and often death, and
many men have died from cutting themselves in skin-
ning an animal suffering with " trembles."

All who have yet written upon this subject assert
that the cause of this sickness is a vegetable. Drake
supposed it to be the HJius toxicodendron, others have
asserted that the l^scidus OMoensis is the cause, and
latterly the Eupatorium ageratoides is said to produce
the disease.

The " foot poison " is another instance of the same
kind; several of the fungoid growths produce their
own peculiar effects. The partridge-berry is said to
render the flesh of birds poisonous, and the flesh of

284

ATEOPIA.

slieep tliat have eaten tlie laurel is said to produce
unpleasant symi^toms.

We cannot, then, deny that the tlesh of wild or
domestic animals may be 23oisonous to man, from some
poisonous vegetable eaten by the animal. We see
that rabbits and goats can eat belladonna without in-
jury to themselves, but there are very few instances on
record where persons have been atropised by eating
meats.

Since the introduction of the alkaloids, toxology
has become a science, and investigators in various parts
of the world have attained an accuracy in discrimi-
nating the different alkaloids that is truly surprising.
Wormley, in his incomparable work on " The Micro-
chemistry of Poisons," points out the characteristic
distinguishments of the various alkaloids, and their be-
havior with different reagents. He shows infallible
means of recognizing, not grains of poisons, but g-orJo-o-o
part of a grain, and, with a woman's delicacy of touch
and artistic taste, his patient wife has drawn and en-
graved the camera-lucida portraits that each poison
presents with the various reagents.

But even this excessive delicacy of recognition is
not sufficient to detect the presence of several of the
most potent alkaloids when given either by the mouth
or by hypodermic injection. Aconitia is now pre-
j)ared so pure, that " part of a grain " ' is a fatal
dose for an adult ; firo P^^'^ would be fatal if thrown
either under the skin or into a small vein. This
poison, if fatal, would of course be absorbed, and
it would be utterly impossible to recognize it either
by color, test, or by crystallization, with the most
l^owerful microscope. " Assuming only the blood con-

1 Proc. Am. Pharm. Ass., 1866, p. 239.

ATEOPIA.

285

tains it, this equals the -rr,w4",wo P^^'^ ^ grain. If
diffused through the whole body, it would then be
reduced to the 4T,Tro,"roo" P^^'^ ^ grain.

I have before referred to the recognition by
Wormley of atropia in the blood of a dog, poisoned
with five drachms of fluid extract of belladonna. Also
in that of a cat. Duffield says : " Among numerous
cases of poisoning by opium or its alkaloids, which
have fallen to my lot to examine and depose on, I
cannot conscientiously say that I ever detected ab-
sorbed morphia."

There are hundi^eds of cases scattered through the
medical journals, giving like negative results, and
proving the almost impossibility of detecting any of
the alkaloids when given in ordinary fatal doses —
doses that are absorbed into the circulation. No one
can deny that these medicines are absorbed, because
some few instances are given where they have been
detected in the blood and in the urine ; but the great-
er part of the poisons seem, so far as our present
knowledge goes, to spend their influence upon the
blood or tissues, and, in so doing, to be changed or de-
composed. It is only in excessive doses that the kid-
neys eliminate a j)ortion unchanged, or that the blood
contains a recognizable quantity. My experiments
are all with excessively large doses.

Dr. De Vry, who has made many experiments with
the alkaloids, thinks that those portions of the alka-
loids, which produce their peculiar action, are decom-
posed and changed.

With these facts before us, it behooves every medi-
cal man to become a better therapeutist ; for the con-
.viction of criminals who poison must be proved by
the symptoms which are noticed in the dying person.

286 CALCIFICATION^ OF THE CHOEOID, ETC.

Tlie various alkaloids j)roduce their well-known and
cliaracteristic symptoms ; these s}T2iptoms, if well
marked, are as fully entitled to consideration as the
facts presented by the chemist, which, after all, are but
evidences of another character.

Upon the literature of the subject, in addition to
the authors already quoted, I would refer to Cohn
& Koerner {BerlKlin. WcliscJir, 16, 1865); F.Evans
(British Medical Journal, September 21, 1861); T.
Hayden {DiMin Quarterly Journal^ August, 1863) ;
E. Rollett {Wien, Med. WschscJir. 95, 1865); Otto
( Vrtjhrschr. F, ger, Med. JV. F. 157, 1866) ; Schmidt's
Jahrh.^ cxx, 181, 1865 ; Rud. Hohl {De Atrojpinieffectu.,
Hal., 1863); {F Union, 85,1863); Chambers

{London Lancet., 1864) ; Lubelski {Gaz. Hehd., Sej)tem-
ber 7, 1864); Commaille (Jour, de Pliarm. et de
Cliim., April, 1865) ; Woodman (Medical Times., 385,
October, 1864). Bonder's work, above quoted, is
very full and instiaictive on all that relates to the
action of atropia on the eye, and Wormley's " Micro-
chemistry of Poisons " on all that relates to its toxico-
logical properties.

Aet. IV. — A Case of Calcification of tlie Choroid., Cili-
ary Processes, Crystalline Lens, and Capsule. By
Chas. a. Hart, M. D., New York.

J. Krissingee, aged about 55 years, was j)resented
to me June 25th by Dr. W. A. Garman, of Berlin,
Somerset County, Pa., Avho requested me to examine
the patient for a supposed cataract.

The lii story rendered was as follows : Twenty years
ago, he began to experience a loss of vision in both

calcificatiojS' of the choeoid, etc.

287

eyes, which, after a considerable period, rendered him
totally blind in the right organ, vision being still pre-
served to a limited extent in the left ; this condition
being attended with considerable pain, relief was
sought, and he presented himself to Dr. Gross, of Ber-
lin, who pronounced his case one of hard cataract, and
finally attempted the operation of depression, which
afforded no relief. He has been the sul)ject of fre-
quent rheumatic attacks. 01)jectively the appearances
presented, when I saw him, were as follows : The globe
was atrophic, the cornea presented evidences of former
inflammatory action, having a roughened and semi-
opaque appearance. The puj)illary space was occupied
by a dirty yellowish- white body. The iris having lost
its power of action, was uninfluenced by either light
or solution of atropia.

Neither the ophthalmoscope nor concentrated light
revealed any thing beyond the dense character of the
lens.

The patient was very much distressed by the con-
stant pain he was suftering, and there seemed to be no
chance of relief other than enucleation, which beins;
proposed, was accepted. Accordingly I performed the
operation on the 30th of June. The morbid changes,
found upon an examination of the eye, were a com-
plete calcification of the choroidal tunic, very dense
about the optic disk, gradually thinning oft' toward
the ciliary processes, which were also filled with calci-
fied deposits, though not in a perfect state of organiza-
tion ; none of the true choroidal tissue could be discov-
ered. The retina was thickened, and in several 23laces
detached ; the optic disk was atrojDhied, with no trace
of the vessels remaining. The vitreous body was broken
down and changed into a fluid mass, which contained

288

HEET^IA OF THE LIYER.

a quantity of crystalline matter resembling cholesterine,
though. I cannot assert that it was such, being without
a microscope at the time. The crystalline lens and cap-
sule were both found in the normal position ; the
capsule being thickened and opaque, and when opened
grated under the knife like sand, reyealing the lens
shrunken in diameter and completely calcified, to-
gether w^ith an unorganized white crystalline paste,
which, having since been examined with the micro-
scope, proves to be crystals of cholesterine with a few of
the phosphate, of lime. The lens was examined, by de-
flected light through the bull's-eye condenser, with
the one-inch objective ; the surface was a yellowish-
white color, perforated by numerous minute foraminse.
E^othing resembling the minute structure of bone could
be discovered. The patient recovered nicely from the
operation, and has since been entirely free from suf-
fering.

Aet. V. — A Case of Hernia of the Liver in a New-
horn Cliild. Reported by G. Frat^^k Brickett, M. D.,
Lawrence, Mass.

Cases of hernia of the liver are not often met with ;
yet the circumstance is well known among patholo-
gists, and mention is made of many cases in the works
on pathological anatomy.

Aug. 26, 1868, I was called to attend Mrs. H ,

in her sixth confinement. On my arrival, I was told that
the child was already born. I prepared to tie the cord,
when I found what ajDpeared to be a large tumor pre-
senting itself at the umbilicus of the child ; tied the
cord about three inches from the tumor, and gave the
child to the care of the nurse till I had further cared

HEKNIA OF THE LIVEE.

289

for tlie motlier. On examining the cliild, a female, it
appeared to be j)erfectly formed, witli tlie excej)tion of
this large tumor protruding througli an aperture on
the abdominal wall at the site of the umbilicus, ex-
tending from the lower edge of the sternum to near
the pubes, smaller at the base, or, as I would call it,
the neck or ring. The integuments were dark and ex-
coriated. I satisfied myself the tumor was not intes-
tinal, but a case of misplaced liver. At my visit Sat-
urday, A. M., Aug. 29, I found haemorrhage from the
tumor, near where it seemed to unite with the healthy
integuments. I invited my friend Dr. Sargent, of this
city, to see the case Saturday, 4 p. m. He was at a loss
to form a dias:nosis, but the child died at 7 p. m. from
haemorrhage, and I held an autopsy a few hours after.

I add the result of the post-mortem in the words
of Dr. Sargent, who assisted me in the same :

A few days since. Dr. Brickett invited me to see

the infant child of Mr. H , and a few hours after

I saw it the child died from haemorrhage from the tu-
mor. I assisted at the post-mortem examination. On
making a crucial incision over the abdomen, cutting
through the integuments and abdominal muscles,
which were very thin, giving the dark appearance to
the tumor — on cutting into the tumor it proved to be
an enormously large misplaced liver, the whole of
which was in front and covering nearly all the con-
tents of the abdomen, being above and anterior to the
diaphragm. The right kidney was large, all the other
organs were healthy and well formed.

In a practice of more than forty years I have never
seen or read of a similar case.

290

PEOCEEDmGS OF SOCIETIES.

^rnmtrmgs of Botxdm.

MEDICAL SOCIETY OF THE COUNTY OF NEW YORK.
Adjourned Anniversary and Stated Meeting^ I^ov. 2, 1868.
E. E. Peaslee, M. D., President, in the chair.

Aftee the reading of the minutes of the Comitia Minora
for the year, and the transaction of the usual business, Dr.
Peaslee, the retiring President, addressed the Society, viz. :

Fellows of the New Yorh County Medical Society: —
Before leaving the chair to give place to my successor, I should
thank you collectively and individually for that kindness which
has rendered my official relations to you so agreeable to my-
self, and my duties so easy of performance.

In two respects this Society deserves the highest commen-
dation, and its present prosperity is attributable mainly to these
two agencies:

1. Its organization is as perfect for the fulfilment of its
objects as I can conceive a similar organization to be. All its
ordinary business being transacted by a committee of ten per-
sons, elected specially for that purpose, the attention of your
whole body is very seldom diverted, by the discussion of mere
business matters, from the legitimate scientific and practical
subjects which should occupy us here. I think I may say
that not twenty minutes in all have been spent by this Society
on business matters, aside from the regular programme for each
evening, during the past year. "We have all seen, in other
similar organizations, how much time is lost in discussing reso-
lutions and parliamentary questions. Some gentlemen seem
ever on the alert to find a subject for a resolution, rather than
to elucidate a scientific question. I would by no means de-
prive any one of the privilege all possess in this respect, but it
is a privilege every member of a scientific body should be very
careful not to abuse.

I consider this Society, therefore, a model for all county
societies, so far as its organization is concerned.

2. But the present spirit of this Society also secures a

PEOCEEDII^GS OF SOCIETIES.

291

success like the present. I ^2^j jpresent spirit, not because it
has changed during the past year, but because I speak from
positive knowledge, and an intimate acquaintance with its
members during this period. This results in part from the
advantage in organization which I have specified ; but still
more, and mainly, from the character and habits of its mem-
bers. 1^0 one comes here merely to hear himself speak ; but all
for scientific and practical improvement. And I may say
that no reasonable expectations have been disappointed at a
single meeting the past year, in respect to the character and
quality of the papers here presented. There has been no
failure at a single meeting ; and some of the papers read have
already been highly eulogized in foreign medical journals.
During the past year also about fifty members liave been
added to this Society ; and it has for two or three years past
been the largest medical organization in this country, except
the American Medical Association.

Under the present influences, therefore, this Society must
continue to prosper. But should it get under the control of a
clique, or wander from its legitimate objects, from that moment
its decadence begins. I trust that personalities may never find
their way into discussions here. The provocation may some-
times be very great ; but the gentleman and scholar must not
yield to it. Science is not a personal matter ; not a thing of
to-day or to-morrow, or your property or mine, but belongs to
all, and for all time to come. Let, therefore, the present spirit
remain unchanged, and our exercises from month to month
will continue to be worthy of men, the motto of each of whom
should be that of this Society —

" Miseris succurrere disco."

The President then declared the Anniversary Meeting
adjourned. On motion of Dr. Van Kleek, a vote of thanks
was tendered to the retiring officers for the able, satisfactory,
and impartial manner in which they had discharged the
several duties of their offices dm-ing the year past.

The President-elect, Dr. George T. Elliot, then assumed
the chair, and delivered the following addi'ess :

Gentlemen : In accordance with custom, a short address

292

l EOCEEDINGS OF SOCIETIES.

is expected from the President-elect of this Society ; and it is
extremely gratifying to me to express my sincere thanks for
the honor which has been conferred upon me. It has been
spontaneous, iinsonght, unsolicited, nor had I any knowledge
or surmise that such a step was contemplated until I received
the official notification of my election.

Such kindness has inspired me with the warmest desire to
prove myself worthy of the expectations of my friends, and
with the earnest hope that during my year of office the Society
may not derogate from the high position to which it lias been
advanced by my predecessors, and by gentlemen well known
to you and within the reach of my voice.

For the accomplishment of these aims, I ask the cordial
cooperation of all, and indulgence for faults which may spring
from inexperience in the duties of a presiding officer.

As I understand these duties, they are chiefly :

To deal fairly and justly with all ; to resjDect individual
rights and susceptibilities while jealously guarding the rights
and the time of the Society ; to persuade the seniors to lay
before you the gathered treasure of their experience ; to stim-
ulate the young to condense within the limits of a short paper
the results of studies of the same subject published in different
languages by observers from different stand-points ; to encour-
age debate, since from its heated atmosphere a flood of light is
often thrown upon obscurp and vexed questions ; to develop
talent discouraged from lack of appreciation, or clouded by
modest doubts ; to bring together in this hospitable and metro-
politan city physicians of education and earnest purpose from
all nationalities, as well as those from all the States of our
common country, who have cast their lot here with us ; to
weld together these constituents into one solid and homoge-
neous mass, for the support and pride of our profession ; to
stimulate by our example our sister county medical societies
throughout the land, since on the full development of these
and the State Medical Societies, culminating in the J^ational
Medical Association, depends much of the influence for good
which we can wield for the community in which we live.

Nor can the greatest possible success in these endeavors
conflict with that mutual interest and sympathy which we feel

PEOCEEDINGS OF SOCIETIES.

293

for the other medical societies in the city working with us for
a common purpose. We are linked together for good, and it
is impossible for one to advance without aiding the others, and
raising the standard of our profession. It has become essential
for men to test the attainments of their fellows, and study their
characters in these meetings. In the village and the town the
evils of too great familiarity are often felt, in the great city
the tendency is to estrangement. i\Ien who do not join
medical societies, or labor in public positions, or write, or
teach, may live without the sympathy or the acquaintance of
then- "brethren.

Such professional hermits hide their light under a bushel,
though perhaps it may occasionally be as well that the amount
and character of that light be kept from view. Xor is the
value of these societies limited to the amount of professional
knowledge to be derived from their meetings. Prejudices are
often dissipated, misconceptions vanish, friendships are formed,
kindly feelings developed, the hard repelling exterior is often
shown to mark a strong intellect and generous sympathies,
talent is borne to the sm-face, pretension and sciolism stand
exposed.

With such feelings, then, we enter on the sixty-third year
since the organization of this Society. All but one of its found-
ers have passed away. Its archives teem with associations of
the past. It is identified with the interests of our profession.
God grant that from our labors we may reap a harvest fruitful
of pleasant and profitable memories for the futm-e, that we
may do something to encom-age and stimulate our successors.

The Chair then reported that certificates of membership
had been granted by the Comitia Minora to Di^. J. Marion
Sims, J. G. PeiTy, J. H. Griscom, Truman Mchols, Benjamin
F. Dawson, Adonii-am B. Judson, and Henry F. Walker.
Announcement was also made of the death, since the last
meeting of the Society, of Dr. John W. Shepard, a graduate
of the Coombe Lying-in Asylum of DubHn in 1846, and of
the Medical Department of the University of Xew York in
1852, and a member of this Society since 1861. Dr. Shepard
died suddenly October 5, 1868.

Of Dr. Eobert H. Maclay, a graduate of the College of

294

PEOCEEDmGS OF SOCIETIES.

Physicians and Surgeons in 1824, and a member of the Society
since 1831. Dr. Maclay had for some years been retired from
the active duties of the profession. He died October 15,
1868.

The paper of the evening was then read by* Professor
William H. Yan Buren, M. D., his subject being, " On Some
Points in the Treatment of Stricture of the Urethra."

(This paper is published in full in another part of this
number of the Journal.)

Dr. James R. Wood remarked that non-traumatic stricture,
although beginning as a urethritis, was not commonly seated in
the mucous membrane — indeed, structural lesion of this mem-
brane was comparatively rare. The urethral constriction was
commonly due to the deposit of organized fibrin in the sub-
mucous areolar tissue, simply corrugating the mucous mem-
brane itself. This deposit might be so extensive as to obliter-
ate the structure of the bulbous portion, as he had established
by numerous dissections. In the treatment by simple progres-
sive dilatation, therefore, exciting absorption of the inflamma-
tory deposit, the mucous membrane was not stretched, except
in the rare cases where it had itself become disorganized. He
heartily agreed with Dr. Yan Buren in considering this the
best mode of treatment for the great majority of cases.

He had lately had the opportunity of meeting several of
the distinguished surgeons named in the paper, and of observ-
ing their different modes of treatment. As a rule, each was
the advocate of some one method, almost exclusively. Syme
would hardly ever perform any operation but external ure-
throtomy. Holt would use his dilator in every case where he
could manage to insert it. The Holt men contended that the
infrequency of urinary infiltration, after the use of this instru-
ment, showed that the mucous membrane was rarely torn ; and
this confirmed the view just expressed, that the stricture de-
pends on submucous deposit. 8jme performed his operation
with a guide, having a very small grooved staff screwed to tlie
sound. He cut in the median line, to avoid haemorrhage, and
was careful to divide the stricture throughout its whole extent,
say from one-quarter to one-half an inch, claiming that after
this complete division the trouble never returned. The patient

PEOCEEDmGS OF SOCIETIES.

295

was taught to use the sound periodically, as in the practice of
every good surgeon after any form of operation.

Dr. Wood had for several years practised a modification of
Syme's operation, which he had never seen described. It con-
sisted in cutting cautiously down, through the fibrinous deposit,
to the mucous membrane, but not through it, thus freeing the
constricting bands, as in the operation for strangulated hernia
without opening the sac. On approaching the urethra, the
sound, which had been pressed close to the distal extremity of
the stricture, could be made gradually to penetrate it ; or, if a
slender instrument had already been passed through, this could
be replaced by a larger one. The method was not applicable
to all cases — not to those where the mucous membrane was
diseased, as in traumatic stricture produced by caustic or other-
wise. But where it could be employed, its advantage was
manifest, in completely obviating the danger of urinary infil-
tration, and resulting pyaemia, the chief cause of a fatal event
after perineal section.

Perineal section without a guide had been performed first
in this city, and probably first in this country, by Dr. David
A. Wells, whose operations the speaker, as his pup'il, had often
witnessed. Their uniform success was due, in great measure,
first, to his careful selection of cases; and, secondly, to his
careful preparatory treatment. The medical treatment was a
matter of great importance, and apt to be too much neglected.

Internal urethrotomy Dr. Wood would practise, as he had
often done, when the seat of stricture was within three inches
of the meatus, or even when deeper, if Civiale's urethrotome
could be introduced beyond it, so as to cut from behind for-
ward. Internal incision of a deep stricture from before back-
ward was very hazardous.

The occurrence of stricture of the prostatic m*ethra had
sometimes been denied. Dr. W. had never seen it as the
result of gonorrhoea ; but, within two years, he had operated
some three times, at BeUevue Hospital, for traumatic stricture
of this portion, in each instance with success. He might
never meet with another case.

Dr. Gouley said that constitutional treatment, in strictm-e
of the urethra, should not be lost sight of, though too much

296

PEOCEEDINGS OF SOCIETIES.

reliance liad been placed upon it alone, by some practi-
tioners.

He is in tlie habit of advising abstinence from spirituous
liquors, rest, tbe use of diluents, quinine, tlie tincture of cHo-
ride of iron, and opium, to allay spasm and to relieve pain.
This alone, he thought, was of little avail.

In his opinion, the main dependence of the surgeon should
be on the mechanical treatment, which might be summed up
as follows :

1. Grradual dilatation.

2. The immediate treatment — consisting of stretching, rup-
turing, and the internal incision.

3. The external division.

4. In certain cases of impassable stricture with retention,
he thought favorably of the operation employed by Mr. Ed-
ward Cock, of London, and gave a detailed account of the
mode of performing it.^

In support of the views expressed by the author of the
paper under discussion. Dr. Gouley gave the statistics of forty-
seven severe cases of stricture which he had treated within a
few years past. Of the forty-seven cases, forty-four recovered
and three died.

In twenty-six cases the ''immediate treatment''^ was re-
sorted to, and in twenty-one cases the " external division.^^
All of the twenty-six cases, in which the immediate treatment
was employed, were followed by satisfactory results.

Of the twenty-six cases, thirteen were treated by stretching
and rupturing. Thompson's dilator was used in six of these
cases.

In the thirteen remaining cases, the mternal division was
performed with Civiale's, Maisonneuve's, and Gouley's urethro-
tomes.

1^0 catheter was tied in, in any of the above cases, and
they progressed with scarcely any untoward symptoms.

Of the twenty-one cases of " external division," eighteen
recovered and three died.

In eleven of these cases a guide was used ; in the other ten

^ For a full description of this operation, see Guy's Hospital Reports,
vol. xii., p. 267, et seq.

PEOCEEDINGS OF SOCIETIES.

297

cases the operation was performed without a guide, as uone
could be passed. There were no deaths among these last ten.

In two cases a catheter was introduced into the bladder
after free division of the strictui'e, secured in position, and al-
lowed there to remain for fortj-eight hours. Urethral fever
followed in both cases.

In the nineteen remaining cases no catheter was tied in ;
they were treated as are patients after the operation of lithot-
omy. The urine flowed freely through the perineal wound, and
firm union, in the majority of cases, took place within three
or four weeks. In none of these did m-ethral fever supervene,
not even in the fatal cases.

The causes of death were, in the first, erysipelas and pyae-
mia ; in the second, advanced disease of the bladder, ureters,
and kidneys ; and in the third, thrombosis of the heart. Any
other surgical operation might have proved fatal in this last
case. The patient died within forty-eight hours after the
operation.

In the twenty-one cases of external division, the following
seemed sufficient indications for the performance of the opera-
tions :

1. JS^arrow traumatic stricture in sub-pubic curve.

2. Impassable mixed stricture (traumatic and gonorrhoeal).

3. Impassable stricture with retention.

4. Strictm-e with retention and extravasation.
6. IS'arrow stricture with perineal abscess.

6. Strictm-e with a perineal fistula, which would not heal
after persistent dilatation of the urethra.

T. Stricture which was undilatable, irritable, prone to
bleed on the most delicate exploration, and attended with
dribbling from overflow.

8. Stricture which, though dilatable to a considerable ex-
tent, recontracted very soon after cessation of the use of dila-
ting instruments, notwithstanding that they had been used for
a long time (the " resilient stricture of Syme ").

Dr. Buck remarked that he found nothing to dissent from
in the views presented by Prof. Yan Buren. The most ap-
j)roved methods of treating stricture of the urethra had been
brought before the Society, andj their application to practice

298

PEOCEEDIXGS OF SOCIETIES.

in special cases accurately and judiciously discriminated ; his
own experience confirmed tliese views. He would briefly ask
tlie attention of tlie Society to two or tliree points of practice,
wliicli might supplement Dr. Yan Buren's very complete
statement. Every experienced surgeon knows the formidable
difficulties encountered in the operation of perineal section
where no instrument, even of the finest size, can be passed
through the stricture to serve as a guide for incising it. In his
more recent experience, he had found great assistance in over-
coming this difficulty in the use of an expedient, which is as
follows : The largest-sized grooved sound, open at the end, is
passed down to the stricture in the perineal portion of the ure-
thra ; an incision is made along the raphe, and the urethra
opened a little anterior to the stricture. The sound being held
against the stricture, a fine-sized probe or director is introduced
into the wound and its point conducted along the groove,
which will guide it to the orifice of the strictm*e, and often its
passage through the stricture is accomplished with unexpected
facility. The instrument in use at the Xew York Hospital for
this latter step of the operation is found well adapted to the
purpose. It is a grooved silver sound of the size of the small-
est probe, and terminates in a fine probe point. When passed
through the stricture, the groove furnishes a very convenient
and sure guide for conducting the knife with which to incise
the stricture.

He further stated that in one instance, in which an impass-
able stricture coexisted with extreme distention of the bladder
from retention and accompanied with intense suffering, he had
punctured the bladder through the trigone per perinseum. The
case was that of a corpulent gentleman over sixty years of age,
with stricture of long standing, that had given rise to perineal
fistuloe at difierent times previously. An irreducible scrotal
hernia on the right side distended the scrotum and appropri-
ated to itself the integument of the penis, so as to completely
conceal that organ. An existing phjTHOsis still further compli-
cated tlie case. All effort to pass the stricture, or even to enter
it, having failed, and the extreme urgency of the patient's suf-
ferings not admitting of delay even till daylight (it being mid-
night), it was decided to puncture the bladder, and to do it

PEOCEEDmGS OF SOCIETIES.

299

per perinseum rather than per rectum. The operation was as
follows : A transverse incision was made across the raphe
one inch anterior to the anus, and, guided by the fore-finger
in the rectum and the thumb in the wound, the incision was
continued on between the urethra and rectum till the prostate
was reached and accurately identified in its limits. The inci-
sion was carried still farther on between the prostate and gut,
but the extreme depth of the perineum did not permit the end
of the finger to reach the posterior edge of the prostate. Be-
yond the end of the finger, however, a long-bladed, sharp-
pointed bistoury was conducted flatwise and carried at least
one inch farther, till it entered the bladder. Although no
urine followed the withdrawal of the knife, owing to the fall-
ing together of the opposite sides of the track, a female cathe-
ter, introduced along the wound, entered the bladder without
obstruction, and demonstrated the success of the operation by
an abundant flow of urine. The catheter was secured in situ,
and a bladder-skin attached to its outer end to serve as a
receptacle. Six months were spent in the subsequent treat-
ment, consisting of laying open the prepuce to facilitate ac-
cess to the urethra, dilating two or three strictures anterior to
the principal one in the perinaeum. Various expedients were
resorted to to overcome this last, till at length the patient con-
sented to submit to the operation of perineal section. This
was successfully accomplished, but not without encountering
the most formidable difficulties. The catheter was now left
out of the bladder, and the perineal track, that had been kept
open for six months, healed without delay. Eventually the
integrity of the m-ethra was restored, and the patient able to
hold his water two or three hours and discharge it normally.
He survived the operation more than two years, enjoying the
benefit it had conferred till the last, though it continued to be
necessary to introduce a full-sized sound once in four weeks
during the whole of this time. If delayed beyond it, difficulty
was experienced in passing the stricture.

Dr. IS'ewman called the attention of the Society to the use
of bougies of the laminaria digitata in the treatment of
stricture of the urethra, and stated that in his practice he had
met with marked success from them. He exhibited instru-

300

PROCEEDEs'GS OF SOCIETIES.

ments made of this material that lie had frequently used. The
advantages he claimed for this bougie were gradual yet some-
what rapid dilatation. The danger attending their use, from the
end of the instrument toward the bladder becoming enlarged by
the absorption of the fluids of the parts, so that the instrument
might with difficulty be withdrawn, can be overcome by thor-
oughly coating the bladder end of the bougie with varnish, so
that it caimot absorb moistm'e. The very gradual dilatation of
the laminaria bougie is not productive of any unusual pain. The
iubtrument will expand in a couple of hours to a size equiva-
lent to from two to three sizes larger in the common scale of
bougies. Of course, the patient must be immediately under
observation during the whole of this time.

Dr. Howard desired to call the attention of the Society to
one method of treatment, which had not been alluded to in
the paper of the evening, or in the discussion, but to which
he would advert in order to elicit the experience of the dis-
tinguished gentlemen who had preceded him as to its relative
merits.

It is intended for the more deeply-seated strictures, and is
called, by Sir Henry Thompson, the treatment by continu-
ous dilatation. It differs from simple dilatation in this : that,
instead of the momentary introduction of the largest bougie
the stricture can be made to admit, every two or tlu-ee days
a bougie of an increasing but much smaller size than the
strictm-e would admit is tied in ; the stricture is kept thus
loosely occupied for about twelve days, the patient being
meanwhile in a recumbent jDOsture. Dr. Howard regretted
that the term continuous dilatation, used by Sir Henry
Thompson, contradicted rather than described the process,
which to him seemed to consist in no dilatation at all, but
rather of continuous pressm'e without dilatation. He thought
the pressure thus applied, while insufficient to inflict damage
upon the mucous membrane of the m'ethra, might yet be great
enough to induce slow ulceration, or absorption of the more
lowly-organized constricting deposit beneath it. For these
reasons he had anticipated, from this method, results more
complete and permanent than from most of the other
methods which had been mentioned.

PEOCEEDD^GS OF SOCIETIES.

301

Dr. Chadsey naiTated a case, whicli came imder his ob-
seryation in 1844, in wbich, after free venesection and nse ot
hot fomentations, etc., he failed in introducing an instrument
into the bladder. Almost despairing of success, it occm-red
to him to apply the magneto-electric cm-rent from a small
battery Tvhich he had with him. Passing an elastic catheter
(with the end cut off) down to the seat of the stricture, he
then iu&erted through the catheter a common knitting-needle,
to which he attached the positive pole of the battery. The
electrode of the negative pole was then brought into contact
with the perinreum, and immediately the stricture appeared as
it were to melt away before the current ; in a few minutes
he was enabled to pass the catheter into the bladder.

Dr. Gouley remarked that the doctor had unwittingly per-
formed the operation of electrolysis, which had recently
been so largely resorted to by Mallez and Tripier, of Paris. ^

The Society then adjom-ned.

^ Mallez and Tripier's cases are reported in this Journal, for February,
1868. It will be observed that in Dr. Chadsey's case the interrupted or
so-called Faradaic current was employed, and the positive pole was ap-
plied to the seat of the stricture; while in electrolysis proper, as pointed
out by Althaus, the continued current is essential, and the negative pole
is brought into contact with the part to be operated on. The more prob-
able explanation of Dr. C.'s case is, t]iat it was a case of retention from
inflammatory stricture, in which the treatment, previously adopted by the
doctor, had brought the parts into a state so nearly approaching full relaxa-
tion, that it only needed the gentle stimulus aftorded by the application of
this magneto-electric current to give complete relief. E. S. D.

BoEAcic Acid and the borates have recently been discov-
ered to exist in the hot-water springs near Massa Maratima, a
town of Central Italy, 22 miles northwest of Grosseto, the
capital of the Maremma. The principal spring has a tem-
perature of 80 degrees Fahrenheit, and yields about 13,000
gallons per day. The minor springs yield about the same
quantity. The borax lagoons of the Maremma, with which
these new springs are supposed to be in connection, are the
sources of immense profit to the owners.

302

KEYIEWS.

Art. I. — A Mamial of the Pathology and Treatment of Ul-
cers and Cutaneous Diseases of the Loioer Lirahs. Bj
JoHX Kent Spexder, M. B., Loncl., etc. London: John
Chuechill & Sons, 1868. 8vo, pp. 89.

Some of om* older readers may remember a modest book,
entitled The Patliology and Treatment of Ulcers of the
Leg," long since out of print and now mostly forgotten.
That work, by the father of the author of the little manual
before ns, serves as the basis of the present work, and with
true filial piety Dr. Spender acknowledges to it his obliga-
tions.

Opening up his book by a short chapter on the causes of
ulcer of the leg, the author then proceeds briefly, but yet
with sufficient clearness, to describe the forms of ulcer most
frequently met with in practice, viz., the vancose, syphilitic,
scrofulous, and the traumatic. Then comes what is for
the reader the most interesting as well as in fact the most
valuable portion of the book, viz., that devoted to the ques-
tion of treatment. This he bases upon two principles : first,
the imitation, as far as possible, of the natural processes of
cicatrization ; and second, restoring or introducing a healthy
action of the parts. To accomplish the first object, we are
advised to apply such a substance as shall foim an incrusta-
tion over the edges of the sore resembling in its effects the
natural scab, and to distm-b the dressing as seldom as possible.
In the chalk-ointment the author claims to have found the
best substance for the production of this artificial crust, and,
though we are inclined to look upon the persistency with
which Dr. Spender advocates the use of this agent much as
we regard the enthusiasm of one riding a hobby, or afflicted
with a " mission," we must in candor admit that theoretically
the proposition is well put, and appears tenable. Practically
we have no knowledge of the efficacy of this special remedy,
though we purpose acquainting om'selves with its action, and

EEVIE^S.

303

advise our readers to do the same. The fonnula we give
below/

The indication in the second principle is best met by
" powerful and well-adjusted compression of the whole limb,"
and this compression is better accomplished bj the flannel
bandage tlian by strapping, or elastic stockings. In the follow-
ing chapter full details are given of the application of these
principles, and though we might at first thought consider that
too much space has been devoted to minutiae, a moment's re-
flection tells us that the success in the treatment of obstinate
ulcer of the leg can only be attained by the most careful
attention to details. In one point Dr. Spender is at variance
with most authorities : he does not deem it necessary to keep
the patient at rest, but claims that exercise, to an extent short
of absolute fatigue, so far from being injm-ious, only promotes
the cure, provided the chalk-ointment, etc., are used. This
does not accord with our own experience, and we can recall
many a case, in hospital and dispensary practice, in which rest
seemed the inducing agent in the citi'e, but we never used the
''chalk-ointment." Again, the extreme pressure which Dr.
Spender advocates and applies, in our estimation, unless most
accurately adjusted, can only be productive of harm. But we
must do our author the justice to say that precisely here he
makes his strongest point, and insists upon this accm-ate adjust-
ment. Were every one possessed of equal dexterity with him-
self, this would answer ; but so long as beginners, to say noth-
ing of veterans, will bungle, it will be wise to adopt a little
moderation in the application of pressure.

But this chapter, with the following one, on the hinderances
and difiiculties met with in the treatment of this class of cases,
is so fall of good sound sense and practical ideas that we are
not disposed to find fault. We feel sm'e that, if carried into
practice, the author's teachings must avail in combating the ab-
surd notions too generally prevalent, both among professional

^ The best method of preparmg the oiutinent is as follows : Take three
pounds of prepared chalk, and two pounds of lard. Reduce the chalk to a
very fine powder; melt the lard, and add gradual) j the chalk -powder.
Stir and mix thoroughly until cold. This makes a much more homogeneous
compound than can be procured by any process of trituration.

304

EEVIEWS.

and lay people, of the management of these cases. Who, that
has ever followed up the practice at one of our city dispensaries,
does not recall the soap and sugar, the pork-rinds, the cabbage-
leaves, villainous poultices, and all sorts of pet nastinesses
there in voo;ue ? It were worth a lifetime to have corrected this
popular ignorance, and the dissemination of correct views
among physicians is the first step in this laudable undertaking.

The reader must not understand that constitutional treat-
ment is lost sight of by Dr. Spender. On the contrary, he
insists upon it, and attaches to it its proper valuation. Finally,
the author quietly proceeds to knock the underpinning from
out the old-time belief that it is not always prudent or safe to
heal a chronic ulcer of the leg ; and this fanciful notion, which
happily has not now the importance accorded to it thirty
years since, is left without even a peg on which to hang a hope
of a claim to recognition. In one other point, viz., that it is
never necessary to resort to amputation — for this is the legiti-
mate deduction from our author's statement, that "the pro-
posal does not deserve a moment's discussion, but is recorded in
these pages as a curiosity of surgery " — Dr. Spender will find
many to differ from him ; but, with improved methods of
treatment, or, rather, with broader views of the true principles
of treatment, the necessity for such a sad resort must rarely
exist.

Elibris nemo evasit artifex^''^'X^^ our author most justly
at the opening of one of his chapters ; but we venture to say
buy this book and adopt its • precepts, and there be many we
know of wiio would at all events become hetter workmen
thereby.

Akt. II. — A Treatise on the Princijyles and Practice of
Medicine / designed for the Use of Practitioners and Stu-
debits. By Austin Flint, M. D., Professor of the Principles
and Practice of Medicine in the Bellevue Hospital Medical
College, etc. Third edition. Thoroughly revised. Philadel-
phia : Henry C. Lea, 1868. 8vo, pp. 1002.

Three times, now, within the brief period of two years, we
have called attention to the appearance of separate editions of

EEVIEWS.

305

Dr. Flint's admirable book. The edition before ns, by a
change in typographical execution, has been only slightly en-
larged in bulk, while it contains a very large amount of ma-
terial not found in the last edition. It is a satisfaction to see
a book so fully up to date, and also to see the attention paid
by the author to the contributions found in our periodical
medical literature. Many most valuable papers, appearing in
jom-nals of very limited circulation, naturally are brought to
the notice of comparatively very few. Dr. Flint has rescued
some such papers, perhaps, from oblivion — certainly has made
them available for all.

This book, diftering entirely from Aitken or Reynolds's in
its scope and character, must be — we are inclined to believe —
the text-book for students for some time to come ; and if each suc-
cessive edition is as carefully worked up as is the present, there
is no reason why it should not long continue to hold the very
front rank of books of its class. It is quite unnecessary for us
to enter into any review of the book. On its first appearance,
its merits were pretty well canvassed in our columns, and the
author has availed himself, in each succeeding edition, of the
criticisms of his reviewers, and has labored honestly, as well
as successfully, to keep fully abreast with the advance of
science, and has cheerfully corrected the deficiencies which are
inseparable from the first getting up of such a volume. The
sincere and hearty manner in which Dr. Flint has publicly
thanked his reviewers for calling his attention to omissions in
his earlier edition and the readiness with which he has availed
himself of their suggestions go far to prove that there is not
necessarily an antagonism between an author and his critics.
Further, still, they tend to show that the author is a truly lib-
eral-minded and catholic teacher of medicine. There are many
others, whose books we are familiar with, who would be the
gainers by the adoption of little more of this same spirit.

We have only to renew the commendation we have for-
merly made of Dr. Flint's book.

306

EEYIEWS.

Art. III. — Tlie Science and Practice of Medicine. By
Wm. Aitken, M. D., Edinburgh, Professor of Pathology in
the Army Medical School. Second American from the
Fifth enlarged and carefully revised London edition;
Adopting the new ^Nomenclature of the Poyal College of
Physicians of London. "With Large Additions, by Meredith
Clymer, M. D., ex-Professor of the Listitutes and Practice
of Medicine in the L^niversity of Xew York, etc. Philadel-
phia : Lindsay tfc Blakiston, 1868. 2 vols., 8yo, pp. 927,
1079.

Ox the appearance of the first American edition of Dr.
Aitken's Tvork, we gave a somewhat detailed analysis of its
contents. It is therefore unnecessary for us now to attempt a
review of this edition, for pretty much the same ground must
be gone over. But we desire especially to call attention to the
additions made both by the author and the editor, and to en-
deavor to make some estimate of the comparative value of
the English and the American imprints.

Dr. Aitken tells us that he spent fifteen months in revising
his book, and the result is, that the present edition has in-
creased in bulk upward of one hundred pages. The subjects
of Malignant Cholera, Paralysis, Epidemic Cerebro-Spinal Me-
ningitis, and Intestinal Obstruction, have been entirely rewrit-
ten. The new chapter on Cholera is admirably done. The ex-
periences of the late epidemic, as is well known, gave rise to
many new theories and accumulated a large amount of valu-
able observations and material. This Dr. Aitken has worked
up in such a way as to give an excellent resume of the existing
knowledge on this knotty subject. He is bound to no theory,
and hence he calmly canvasses the merits of theories and
views of the various investigators of the many questions per-
taining to cholera, its pathogeny, origin, and mode of trans-
mission, contagiousness, meteorological conditions, localizing
causes, etc. The fungus theory, which originated with Boehme
in 1838, but which has recently enlisted the labors of such dis-
tinguished observers as Klob, Ilallier, Thome, Parkes, De
Bary, and Berkeley, is discussed at great length by Dr. Ait-
ken ; but oiu' knowledge thus far is not sufiicient to warrant

KEVIEWS.

307

the opinion tliat the fungi are the cause of cholera or are the
means of its conveyance. This chapter is unquestionably the
most satisfactory of the changes mad e by the author in the
present edition.

He also announces that " the subjects of Progressive Loco-
motor Ataxy, Progressive Muscular Atrophy, Glosso-laryngeal
Paralysis, Aphasia, and Dilatation of the Bronchial Tubes,
the Application of the Sphygmograph and its Tracings in
Diseases where it has been of Use, are subjects considered for
the first time in this text-book." This statement, however, is
true only of the English edition, for all these subjects were
fully treated of in the first American edition by Dr. Clymer,
the editor. And furthermore, it appears that Dr. Aitken has
mainly condensed from Dr. Clymer the articles which he
(Dr. A.) has thus introduced — the only exception being the
article devoted to " Dilatation of the Bronchi," which, is an
abridgment of Dr. T. Grainger Stewart's paper in the JEdin-
hurgh Medical Journal for December, 1867.

Another improvement by the author is the incorporation
of the new nomenclature of diseases, adopted by the Commit-
tee of the Boyal College of Physicians. The labors of this
committee, comprising without exception the most distin-
guished representative men of the profession in England, ex-
tended over a period of ten years, and must be accepted as a
decided improvement upon the former nosological tables of Dr.
Farr, which are now abandoned. The proposed table, although
wonderfully accurate and precise in all its details, strikes us as
being quite too cumbersome — though this estimate may be
partly due to a long familiarity with and use of Farr's tables.
An equal acquaintance with the new table, which it is pro-
posed shall be revised every ten years, in accordance with
the advances made in pathology and nosology, and which is
therefore termed the " provisional nomenclature," would
doubtless impress us quite as strongly in its favor. Om- space
will not allow a comparative examination of the two nomen-
clatm'es ; but it is evident that the provisional table must be
foi: the present the accepted plan for the registration of dis-
eases. We strongly advise all interested in this subject to fa-
miliarize themselves with it.

308

REVIEWS.

These are tlie more important changes and additions result-
ino" from Dr. Aitken's fifteen months' labor. Let iis now see

what the American editor has done by way of still further in-
creasing the value of the work. First he has stricken out his
own elaborate articles on Aphasia, Locomotor Ataxy, Glosso-
lar)aigeal Paralysis, and the Sphygmograph — being content
with Dr. Aitken's abstract of the same — but he has reprinted
side by side with Dr. Aitken's chapters on Cerebro-Spinal
Meningitis, and on Bronchiectasis, his own papers on these sub-
jects as they appeared in the first edition ; and the contrast is so
strikingly in favor of the American editor, that we can readily
imagine the quiet — we had almost said malicious— sort of satis-
faction he must have experienced in thus collating the two arti-
cles. Then, besides numerous and lengthy additions and inter-
polations to the author's text, he (the editor) has written thirty-
six articles which have been incorporated in their proper places.
Several of the articles are on subjects never before treated of
in any text-book on the practice of medicine. These articles,
as will be observed by an examination of the titles which we
present below, are mostly upon practical topics, and essential
to the completeness of the book.^ We cannot enter into any
critical examination of these additions by Dr. Clymer, but they

^ 1. Camp Measles.

2. Spinal Symptoms in Typhoid

Fever.

3. Prognosis and Diagnosis of Ty-

phoid Fever.

4. Chronic Malarial Toxjemia.

5. Pernicious Eemittent Fever.

6. Typho-Malarial Fever.

7. Chronic Camp Dysentery.

8. Cholera Morbus.

9. Cholera Infantum.

10. Hereditary Syphilis.

11. Corpulence.

12. Gonorrhoeal Rheumatism.

13. Delirium of Inanition.

14. Chronic Alcoholism.

15. Epidemic Cerebro-Spinal Menin-

gitis.

16. Progressive General Paralysis.

17. Acute Centripetal Paralysis.

18. Myo-Sclerosic Paralysis.

19. Physical Diagnosis of Diseases

of the Cerebro-Spinal System.

20. Auscultation in Health and in

Disease.

21. Irritable Heart.

22. Disease of the Heart, how far

a Disqualification for Military
Service ?

23. Chronic Pyaemia.

24. Capillary Bronchitis.

25. Plastic Bronchitis.

26. Dilatation of the Bronchi.

27. Sclerosis of the Lung.

28. The Inoculation of Tubercle.

29. Curabilit}^ of Consunaption.

30. Acute and Rapid Phthisis.

31. The Neuroses of the Larynx.

32. Medication of the Throat and

Lungs by x\tomized Fluids.

33. Syphiloma of the Liver.

34. The Neuroses of the Stomach.

35. Addison's Keloid — Scleriasis.

36. Statistics of Tracheotonjy.

BIBLIOGEAPHICAL AND LITERAKY NOTES. 309

are all marked by two prominent characteristics, viz. : an un-
usually tliorougli acquaintance witli tlie bibliograpliy and
literature of the subject, and most accurate descriptions, so far
as known, of the pathology of the special diseases treated of.
Indeed, in these two respects, they are far in advance of Dr. Ait-
ken's chapters. Taken together, these additions amount to over
five hundred pages of the English edition. By the use, how-
ever, ot diiFerent type and of a larger page, there are actually
less .pages in the present edition than are found in the first.
Those additions are no insignificant item when mere quantity
is taken into consideration ; but, looking at the quality, we are
bound honestly to state our conviction that the American edi-
tion is, by all odds, the more valuable and more desirable,
of the two, both for student and practitioner. We have pre-
viously recorded the opinion that this work is in many respects
the best body of practical medicine extant, and now, after a
careful examination of the w^hole book, we have no reason to
alter that opinion.

Dk. Ellis's Medical Formulary' belongs to a class of
books which are our pet horror. They undertake by a short
cut to put a man on the road to practice, without grounding
him in the principles of medicine. We do not mean to say
that such is the intention of the authors of this class of works,
but practically this is just about what it amounts to. That
our opinion in the premises is worthless, and that the bulk of the

^ The Medical Formulary : being a Collection of Prescriptions derived
from the Writings and Practice of many of the most eminent Physicians
in America and Europe, together with the usual dietetic Preparations and
Antidotes for Poisons. To which is added an Appendix on the Endermic
Use of Medicines, and on the Use of Ether and Chloroform ; the whole
accompanied with a few brief Pharmaceutical and Medical Observations,
by Benjamin Ellis, M. D., late Professor of Materia Medica and Pharmacy
in the Philadelphia College of Pharmacy. Twelfth edition. Carefully
revised and much improved, by Albert H. Smith, M. D., Lecturer on Ob-
stetrics to the Philadelphia Lying-in-Charity, etc. Philadelphia: Henry C.
Lea, 1868. 8vo, pp. 3Y4.

310 BIBLIOGEAPHICAL AXD LITEEAEY XOTES.

profession are not of our way of thinking, is evident enough
from the announcement on the title-page, that the book has
passed into the twelfth edition. And we have not the slightest
doubt that these editions will continue to multiply, for our
young men will continue to buy that which furnishes a ready-
made treatment for all the ills that flesh is heir to. And so,
whether it be a colic or a chordee, a tapeworm or a tonsillitis, a
diarrhoea or a dropsy, it is all here, and you have only to turn
by index to the appropriate page, to select an " elegant and ju-
dicious " prescription. ^N'ow, there are upward of one thousand
such prescriptions contained in the book before us, and all can
be purchased for the moderate sum of what you would receive as
a fee for a single visit. What wonder, then, that the twelfth
edition has been reached ? There is, however, one redeeming
feature in this book. Tlie prescriptions, which are written in
Latin, are, as a rule, written correctly ; and if each owner of a
copy of all these twelve editions will only study style, the
result will be to elevate the standard of Latin scholarship, if
it does not make us any better doctors. Step into one of our
large drug-stores, and look over the prescription-book. The
liberties there taken with the Latin tongue fairly make one
of sensitive nerves shudder; provided, of course, he himself
knows any thing of, and has any regard for, the purity of the
language. If we must write our prescriptions in Latin, we
ought to write them correctly ; but, rather than display our
ignorance, we should prefer to see the good old Anglo-Saxon
universally adopted. Study, then, the orthography of these
prescriptions, my young friend, for it is plain enough that you
cannot resist the temptation of securing at one stroke a remedy
for every disease. And even if you do not successfully combat
every colic, etc., you will have the proud satisfaction of
knowing that you have not outraged the proprieties of the
classical tongue, which is imposed upon us as the only correct
medium for conveying our therapeutic wants, and the serene
consciousness will be yours that you have written an " elegant
and judicious prescription.

For sale, we presume, at all medical book-stores.

From the publishers we have received a copy of the

BIBLIOGRAPHICAL AND LITEEARY ^s^OTES. 311

Yisitino: List for 1869.' These little vade-mecums have be-
come so essential to tlie practising physician, that they need
no commendations of ours to assert their utility. It is a
matter of taste which variety of the Yisiting List a physician
may select ; but, liaving chosen one, he will generally continue
to use that particular kind. AU other things being equal, we
should prefer the simplest form, and, as a matter of fact, largely
due to habit, we admit, we have always preferred and used the
List published by Lindsay & Blakiston. It does not, however,
contain that varied material which most of the other Lists
present — material which is valuable, but which we have some-
times considered misplaced in a manual the primary object of
which is merely to answer the purpose of an account and
memorandum book. This material generally embraces lists,
and more or less complete descriptions, of diseases and their
remedies, the doses and uses of medicines, etc., and to one
whose memory is at all treacherous it may frequently prove
very serviceable. One's aim, however, we think all will admit,
should be to avoid the necessity of carrying a Practice of
Medicine or a Treatise on Therapeutics in one's pocket.

Dr. Samuel Gregory's mind is evidently quite severely
exercised on the question of the appropriate title to be given
to women physicians. And so, in the little pamphlet before
us,^ he discusses the question from various stand-points of view,
viz. : philological, diplomatical (so far as relates to the dear
creatures themselves), aesthetical, practicable, etc. And from
all this he arrives at the triumphant conclusion that Doctress"
(abb. Drss.) is the only correct and proper designation, and
this, too, without wishing to deprive his lady-friends of any
titular honors, or to throw any obstacle in the way of their
success.

Dr. Gregory, further admitting that the press is a potent

^Tbe Physician's Hand-Book for 1869. By Wra. Elmer, M. D., and
Albert D. Elmer, M. D. Xew York : W. A. Townsend & Adams.

The Physician's Yisiting List for 1869. Eighteenth Year of its pubH-
cation. Philadelphia : Lindsay & Blakiston.

^ Doctor or Doctress ? By Samuel Gregory, D., Secretary of the
iN'ew-England Female Medical College. Boston, 1868. Pamphlet, pp. 8.

312 BIBLIOGRAPHICAL AND LITER AEY IS^OTES.

agency in moulding forms of speech, calls upon editors and
other competent authorities for an expression of opinion for or
against liis views.

Our excessive modesty forbids our putting on record
whether or no we are devoted to Doctresses, we beg pardon,
Ave mean the title only, and not the seductive beings them-
selves ; but, perhaps, some of our numerous readers, less
diffident than ourselves, may boldly assume the responsibility,
and thus relieve Dr. Gregory's suspense.

" Under which king, Bezonian ? Speak, or " —

follow our example, and do not commit yourself.

By the way, wdiile the doctor is at this sort of work, we
w^ould suggest that a little patching up of the title of the col-
lege, of which he is the secretary, would indicate quite as high
regard for the purity of the Queen's English as is evidenced
in the question he has thrown out for the w^orriment of peace-
loving editors and other " competent authorities."

A LITTLE book, bearing the somewhat grim title of " Hur-
ried to Death," has been published in London, wherein the
author enters into the question of the geographical distribution
of heart-disease in England and Wales, and argues that the
proportion of deaths from this cause varies uniformly with
latitude, longitude, and aspect of the maritime and physical
character of localities.

De. Thomas Inman, of Liverpool, has written a very
curious book, of which the first volume (8vo, pp. 800) has just
been published by Trubner & Co., London, entitled " Ancient
Faith Embodied in Ancient Names ; or, an Attempt to trace
the Religious Belief, Sacred Rites, and Holy Emblems of
certain ISTations, by an Interpretation of the JSTames given to
Children by Priestly Authority, or assumed by Prophets,
Kings, and Hierarchs." It is illustrated w^ith many plates
and woodcuts.

New Books. — There is a special activity just at present in
the publication of medical books, as will be evident from the

BIBLIOGEAPHICAL AND LITEEARY NOTES. 313

lengthy list we present to our readers this month. It is grati-
fying, too, to observe that most of these works are of sterling
merit ; a fact which indicates pretty clearly the demands of
the profession for an elevated and substantial literature.

The papers of Dr. C. J. B. Williams, that have for some
months been passing through the Zcmcef, on the subject of
Pulmonary Consumption as it appears in private practice,
have been collected by Dr. Meredith Clymer, and will soon
appear, with the addition of an Introduction on the present
state of Pathology of Tubercle, etc. It will be remembered
that Dr. Clymer was the American editor of the well-known
works of Dr. Williams on Practice, etc. ; and there seems to be a
peculiar appropriateness in his now bringing forward this last
contribution of Dr. Williams to medical science. We shall
look wdth interest for the appearance of this little volume, as the
conflicting views of recent observers on the Pathology of Tu-
bercle have so shaken our accustomed beliefs, that, if called
upon to give an opinion on this subject, we should feel much
like resorting to the Bunsbyian tactics, and intrenching our-
selves behind a fortification of high-sounding but non-commit-
tal generalizations.

Messrs. D. Appleton & Co. announce that the translation
of Niemeyer, by Drs. Hackley and Humphreys, of this city, is
now passing through the press, and will soon appear. Dr.
Tilt's Work on " Uterine Thei^ajjeiUics " will be ready in a
few days. The numerous additions and emendations made by
the author to this edition, wdiich is not a reprint, but has been
expressly prepared by Dr. Tilt for the Appletons' edition,
virtually make it a new book.

Messrs. Wm. Wood & Co. announce a work on " Post-
mortem Exmnincvtiom^ for the %ise of Coroners and others^''
translated from the French, author not named. A new and
enlarged edition of ^' Flinfs Auscultation arid Percussion.''^
" Beard & PochwelVs Treatise on Practical Medical JElec
tricityP is"ew edition of " TiWs Diseases of Menst/ruation
and Ovarian Inflammation.''^

Messrs. John Churchill & Co., of London, announce the
following medical works : Pycemia, or Suppurati'oe Fe-

314 BIBLIOGEAPHICAL A^D LITEEAEY ]S^OTES.

mr^ by P. M. Braidwoocl. " Injuries and Diseases of the
Jaws^'' by Christopher Heath, M. D. Dictionary of Ma-
teria Medica and TJierajpeutics^^ by Adolphe Wahltuch.
" Clinical Lectures on Diseases of the Urinary Organs^"^ de-
livered at the University College Hospital, by Sir Henry
Thompson, M. D. This work is announced for republication
in this country by Messrs. D. Appleton & Co. Diseased
Conditions of the Knee-Joint^ which require Amjmtation of
the Limb or Excision of the Joint ^'^ by William Paul Swain.
" A Manual of Orthopcedic Surgery, by B. E. Brodhurst.
'^The Mechanical Treatment of Deformities of the Mouth,
Congenital and Accidental,^'' by Robert Pamsay & J. Oakley
Coles. Ether and Etherized' Cod-Liver Oil in the Treatment
of Pulmonary Consumption^ by Balthazar Foster, M. D.
" The Practice of Surgery, Clinical, Medical, and Operative^''
by Frederick J. Gant. " Lectures upon Practical Pathology
and Surgery^'' by Henry Lee.

By Messrs. Longman & Co. : " Clinical Lectures on
Chronic and Gouty Bronchitis, and on Pulmonary Em-
physema,^'' by E. Headlam Greenhow, M. D.

Among recent French publications, we observe a work by
Dr. J. Carriere, De la Tumeur Hydatigue Alveolaire^''
" A Treatise on Apparent Death and Real Death^^ by Dr.
F. Gannal ; and a monograph " On the Therapeutic Properties
of Picric Acid,^'' by Dr. F. Parisel. A new work by Dr.
Bergeret, " On the Urine : its ^Nosological, Pathological, a/rtd
Therapeutical Indications^

Du Diagnostic des Maladies des Yeux par la Chromatopsie
Petinienne ; precede d'une Etude sur les Lois Physiques et
Physiologiques des Couleurs. Par Dr. X. Galezowski, etc.
Avec 31 figures, une echelle chromatique comprenant 44
teintes, et 5 echelles typographiques tirees en noir et en
couleurs. Paris : J. B. Bailliere et Fils, 1868.

The Diagnosis of Diseases of the Eye by Means of Petinal
Chromatopsy (perception of color) ; preceded b}^ a Study of
the Laws Physical and Physiological of Color. By Dr. X.
Galezowski. With 31 figures, a chromatic scale comprising
44 shades, and 5 typographical scales in black and in color.
267 pages.

BIBLIOGEAPHICAL AND LITEEAEY NOTES. 315

In German medical literature we observe tlie following
recent publications :

Krieo-s-Musenm in WasliiDo-ton : eine Schilderuno; des Wash-
ingtoner Patliologischen Museums. Yon Dr. L. Horst, Kais.
Russ. Marine-Arzt. 1865. 8yo.

The Army Medical Museum at Washington : An account of
the Pathological Musenm at "Washington. By Dr. L. Horst,
of the Imperial Russian I^avy.

Die Frage liber die Heilbarkeit der Lungen-Phthisis, histo-
risch, pathologisch, und therapentisch nntersucht. Yon Dr.
J. B. Ullersperger. Wiirzburg : Stahel. 1867.

The Question of Curability of Phthisis Pulraonalis, in its His-
tory, Pathology, and Therapeutics. By Dr. J. B. Ullersper-
ger.

Loschner (Dr. und Prof. Joseph), Schlussbericht iiber die voni
21. Mai 1849 bis Ende December 1851 in Prag beobachtete
Cholera-Epidemie ; nebst einer Abhandlung : Die Cholera
der Kinder. Gr. 8. Mit zwei Tabellen und einer Epide-
mienverlaufskarte.

Loschner (Dr. and Prof. Joseph), Final Eeport on the Epi-
demic of Cholera, which occurred at Prague between May
21, 1849, and end of December, 1851 ; with a Treatise on
Cholera Infantum, and a Chart of the Course of the Cholera
Epidemic. Frederick Tempsky, Prague.

The Belief of Yain m OpEjir Cancer. — The field for ex-
perience in cancer at this hospital (Middlesex) is, as is well
known, an nnusually large one, and opportunity has therefore
been afforded for testing fairly the action of remedies in afford-
ing relief in this distressing disease. We learn that the exquis-
ite pain which belongs to open cancer is found to be best
relieved by the stramonium-ointment, which is employed at
this institution. The following is the formula for this in the
hospital pharmacopoeia : Half a pound of fresh stramonium-
leaves, and two pounds of lard. Mix the bruised leaves with
the lard, and expose to a mild heat until the leaves become
friable, then strain through lint. The ointment thus prepared
is spread upon lint, and the dressing changed three times a
day. — Lancet.

316 EEPOETS 01^ PEOOEESS OF MEDICmE.

§ltp0rts on ilg^ |Pr00nss 0f glebirin^.

SUEGEKY.

1. — Mve Oases of Strangvlated Hernia operated %ipon with-
out opening the Sac. By Eeskine Mason, M. D. [Medical
Eecord, August 1, 1868.]

Dr. Mason gives a careful history of the five cases, three
of which were femoral, oue oblique inguinal, and oblique in-
guinal (congenital). One only of the cases proved fatal. Ap-
pended to the nari^ative are some very judicious remarks on
the feasibility of this operation, from wliich we extract the
following :

These five cases I have transcribed from my note-book, for the purpose
of sliowing the readiness, even in small, as well as in large hernia, with
which the operation of not opening the sac can be performed, as well as
its giving promise of far better success than when the sac has been
opened, the gut exposed to the air, and subjected to handling. So seldom
do we find the stricture to be contained inside the sac, and so rarely does
real necessity occur for the opening of its peritoneal covering, that I think
"we can rarely be justified in choosing any other operation than the one
advocated in this paper. It has been contended by some, that this opera-
tion might lead to the reduction of the gut, when in a gangrenous condi-
tion. This objection, it appears to me, might be used with equal justice
against the employment of any means to etfect reduction short of a cutting
operation. Should the contents of the sac be such as to forbid their re-
duction, this could be determined both by the eye and by the sense of
smell, in the majority of cases, without Avounding the sac. If not, then
it would be time enough to resort to the old method of operation.

In one case we were tempted to resort to this practice, from the dark
appearance of the intestine and portions of the sac, but warm applications,
by means of sponges wrung out in hot water, proved sufficient, after the
stricture was divided, to restore the parts to their normal appearance.
The majority of deaths occurring after the operation for strangulated her-
nia are due to peritonitis, and this certainly seems far more likely to follow
after the sac, which is so often inflamed, is wounded, and the intestines
and omentum subjected to digital manipulation, than w^here these are care-
fully protected from such exciting causes. Again, should any vessels, as
the epigastric or obturator, become wounded, the risk of haemorrhage
taking place into the peritoneal cavity is avoided ; and the patient's
chances for recovery thus increased. Looking at these facts, and as we
shall show from statistics the very favorable results of this operation, it
seems surprising that surgeons should ever think of practising any other,
when the case would at all admit of it. This operation is the one I be-
lieve now advocated by English surgeons, but as yet not so much practised
in this country. Prof. Gross, in his System of Surgery, when speaking of
this operation, remarks that "in this country it has probably not attracted
as much notice as it deserves." As far as I have been able to learn, but
little has appeared in our literature upon this subject, and we are almost
wholly indebted to English surgeons for what has been written upon it.

SUEGEEY.

317

Some few years ago, Dr. Henry B. Sands published the histories of some
cases in the N'ew YorTc Medical Times, wherein he had performed this
operation, together with remarks on the same ; with this exception I do
not remember ever having seen this operation treated of in our medical
journal^!, though case after case of various kinds of hernia has been pub-
lished, operated upon after the old method. The operation of dividing
the stricture without the sac is generally supposed to be due to S. L. Petit;
but according to. South in his notes to Chelius's System of Surgery (Ameri-
can Eeprint, page 303), both Franco and Pare "had cut into the abdomi-
nal ring, and did not open the hernial sac, except when reduction could
not be etfected." To Jean Louis Petit, however, is due the honor of first
generally recommending this operation. According to Lawrence, this
operation was performed by Petit in 1718, who not only advised it in old
and large hernias which were adherent to the sac, but also recommended
its more general employment. In 1750 this procedure was brought forth
as entirely new by Eavaton in a Treatise on Gunshot Wounds, and he
speaks of having operated with success in three cases. Monro the second
was also an advocate of the operation, his first operation being in 1770.
Sir Astley Cooper recommends this method in his work upon hernia, in all
old ruptures, and believes surgeons will employ it more generally when
they have learned its advantages from experience. The revival of this
operation must be ascribed to Mr. Aston Key, who in 1833 published a
memoir on the "advantages and practicability of dividing the stricture in
strangulated hernia on the outside of the sac." Prior to this date, how-
ever, he called the attention of the profession to this method in a clinical
lecture, pubHshed in 1829. {London Med. Gazette, vol. iv., p. 193.) Mr.
Luke also strongly urges the practice of Petit, and gives the results of this
operation in his own hands. {London Med. Gazette, vol. i., 1839-40, and
Medico- CMrurg. Trans., vol. xxxi, 1848.) Mr. Luke says: "I have at-
tempted the performance of Petit's operation in eighty-four cases. Of
this number the operation was completely successful without opening the
sac, in fifty-nine. In twenty-five it was necessary to open the sac to effect
a reduction of the hernial contents, the operation generally varying in
extent from one-half to one-quarter of an inch. With respect to the
mortality among these patients, of the fifty-nine in whom the sac remained
unopened, seven died ; of the twenty-five in whom the sac was opened,
eight died. These cases included those of femoral, umbilical, and inguinal.
In three of these cases he states that Petit's operation was successfully
completed ; but the sac was opened after the reduction of the strangulated
parts into the abdomen, to remove some doubts as to their perfect libera-
tion. The proceeding in each case, however, was ascertained to be wholly
unnecessary. Mr. Erichsen, in his System of Surgery, p. 728, states that
of 77 operations for hernia, reported by Sir A. Cooper, 36 proved
fatal; and of 545 cases recorded in the journals, and collected by Dr.
Turner, 260 are reported to have died. The result, therefore, of Mr.
Luke's operation is most favorable, when contrasted with such as these."
According to the experience of those who have written upon this subject,
the operation appears to be more successful in femoral hernia, owing to
the stricture being found frequently in the neck of the sac in the ingumal
variety. In all cases it would appear to me that this operation should first
be attempted, and then, if found unsuccessful, only that portion of the sac
opened which involves the stricture. Certainly no operation has ever held
out greater inducements than the one so strongly advocated by Petit, Key,
and Luke.

318

EEPOETS OlS PEOGEESS OF MEDICIXE.

2. — The Torsion of Arteries as a Means of arresting Hcemor-
rhage. By T. Bryant, F. E. C. S. [Lancet, Aug. 15, 1868.]

Mr. Bryant read an important paper on this subject at a
recent meeting of the Royal Medical and Chirurgical Society.
He commenced by an historical sketch of the oj)eration, dating
from M. Amussat's original investigations in 1829, and then
detailed a series of experiments which he (the author) had
made with a view of determining the physiological effects of
torsion upon bleeding arteries. Two methods of employing
torsion are described — the ''free" and the ''limited." In
" free " torsion the end of the artery is grasped by a pair of
forceps and twisted freely. In " limited " torsion the end of
the artery is drawn out of its sheath and grasped transversely
with a pair of clasp forceps, about three-quarters of an inch
from the divided extremity, while, with another pair of for-
ceps, the free end is seized aud twisted freely, as in the former
method. Three or four complete revolutions of the forceps
are enough for small arteries, and six or eight for large. The
object of fixing the artery by the first pair of forceps is to limit
the twdsting of the vessel, and prevent too great separation of
.the artery from its vascular attachments. The following sum-
mary closed the paper :

1. That li^morrliage may, with certainty, be arrested by torsion, from
even the largest vessels. 2, That it is a safe and judicious practice in all
cases in which the vessels are small or of moderate calibre; and that, as
far as experiments and practice yet prove, it is equally so in arteries of the
first magnitude. 3. That torsion maybe "free" or " limited," the free
method being applicable to vessels of moderate size, and even to the largest
of the extremities, limited torsion being more adapted for the large and
loosely-connected vessels. 4. That in torsion, as in the ligature, the perma-
nent hcemostatic processes are alike due to the sealing of the divided inner
and middle tunics; but that in the ligature there is only an irregular divi-
sion of these tunics, while in torsion there is a complete division, separa-
tion, retraction, and valvular incurvation. 5. That in torsion the twisted
cellular coat forms, with the retracted and incurved middle coat, the direct
mechanical obstacle to the flovr of arterial blood, in the same way as the
compressed cellular coat does in the ligature, but that in torsion the twisted
cellular coat and incurved middle coat become subsequently a permanient
means of occluding the end of the artery, while the ligature of necessity
becomes subsequently a source of irritation, and, too often, a means of un-
doing what has been done by Nature's own hamiostatic processes. 6. That
in torsion the twist in the cellular coat of an artery, the division and subse-
quent retraction, incurvation, and adhesion of the middle coat, and tlac co-
agulation of the blood in the vessel down to the first branch, aT« the three
points upon which its temporary as well as permanent safety depends,
while the permanent safety of acupressure rests upon the last point alone,
and its temporary effects upon the pressure produced by the needle. 7.
That there is every reason to believe that when torsion has been successful on
its first application, the fear of subsequent haemorrhage is altogether ground-
less, for there is nothing, as there is in the ligature, to interfere with the

SUEGEET.

319

physiological processes set up by Xatnre to occlude the divided vessel, and,
unlike acupressure, the temporary obstacle to the flow of blood becomes a
permanent one. 8. That upon physiological grounds torsion has decided
advantages over the ligature and the acupressure-needle, and that, if sub-
sequent experience confirms what has been hitherto observed in the ex-
periments on animals and the application of the practice in the human sub-
ject, we shall have gained a point of no mean importance, and simplified
surgery in no slight degree. The paper was concluded by the author
stating his behef that the practice was a safe and valuable one in many
cases, if not in all; that it "was not a crude idea, based upon a theory spun
out of a fertile imagination, for it had its origin in observation of Xature's
own processes; that it was based on the well-recognized physiological
principles of natural haemostatics; and that it was artificial only so far as
the surgeon's art was employed in rendering these processes most available.

Dr. Humphry, of Cambridge, read a paper on tlie same
subject at tlie recent meeting of the British Medical Associa-
tion, of which the following is a summary :

The professor gave the results of his experience of torsion of arteries
after operations, as well as the results of experiments on animals, and
on the arteries of man and animals after death. For many months he
has practiced torsion after all operations, including three amputations in
the thigh, amputations in the leg, of the breast, excision of the knee, etc.
K has answered quite well. There has been no after-haemorrhage in any
of the cases; the wounds have liealed more quickly, and there has been
less pain, than after the ligature. The operation is rather more trouble-
some, and requires more care and time than the ligature. He simply seizes
the end of the artery with strong forceps, and, holding the forceps in the
axis of the vessels, twists till the portion included in the grasp is twisted
off" and the forceps are quite free. In the process of torsion, as observed
upon an artery twisted after death, the thick, inner, musculo-elastic coat
is first severed, often as though it had been cut by a knife or ligature. As
the torsion goes on, it is so compressed or squeezed by the twisting of the
outer coat that its divided edge is commonly turned up, reflected, into the
tube of the artery, to a greater or less extent, as the resistance of the outer
coat is more or less prolonged, forming a valvular or funnel-like projection
into the vessel. Thus there are the two things — the inversion of the inner
coat and the twisting of the outer. It is upon the latter that reliance is to
be placed for resistance to the flow of fluid from the vessel, inasmuch as
its pressure causes and fciaintains the valvular inversion of the inner coat,
and, further, by its own strengtJj, ofi'ers a direct obstacle to the escape of
the blood. This the professor has proved by injecting water, and connect-
ing a column of mercury with the vessel.

3. — Aneurism of the Arch of the Aorta ; Repeated Mistakes
in Diagnosis; Ptincture of the Sac j Death: Autopsy.
Reported by I^. S. Hichardsox, M. D., and A. ]VL Williams,
M. D., of Macon, Missouri. [St. Louis Med. and Surg. Jour.,
May, 1868.]

We quote this most extraordinary case of professional blun-
dering, leaving to our readers the opportunity of fonning such

320 EEPOETS ON PEOaEESS OF MEDICINE.

opinions as tliey may think indicated in the premises. We
must, however, remark that we are well aware of the difficulty
at times in making a diagnosis between abscess and aneurism,
and we recall several notable instances of mistakes by most
eminent surgeons. Mr. Dease, of Dublin, opened an aneurism,
which he supposed to be an abscess, and killed his patient.
Yelpeau tied the carotid of a patient on an account of sup-
posed aneurism, which turned out to be only a harmless benign
tumor, and his patient died from the operation ; and other
equally well-known cases could be given. But the onus in the
case before us rests upon the fact that, so far as can be gathered
from the report, no attempt at a differential diagnosis was ever
made, and the management was based upon a series of false
assumptions. Drs. Richardson and Williams deserve credit
for reporting the case, and in so doing they seem not to have
been influenced by any feelings of ill-will toward the physi-
cians who had charge of the case, and whose names are not
made public :

J. B., set. 39 ; married ; intemperate. One year previous to his death
he fell from a horse, since which time until his death he had pain in the

dorsal region of the spine. First attendance was given hitn by Dr.

for "nervous shock." Subsequently Dr. treated him by mercury

to ptyalism for "diseased liver." In turn, Dr. pronounced the

case "unimportant — not worthy of attention." Dr. A., next in charge,
after examination, declared the existence of "an anomalous tumor." On
the 11th of November last Dr. A. called Dr. S., one of the former attend-
ants of the patient, in consultation. Under the impression that the tumor,
for months previous apparent, was but a common abscess, a small incision
was made by Dr. A. through the integument, and a female catheter intro-
duced. Not finding pus, a bistoury was introduced beside the catheter,
and an incision three inches in length made. At the bottom of this was
found a very firm clot. Scarcely a moment transpired before this was
driven out, followed by a pulsating stream of blood. At this moment the
truth flashed on the minds of the operators. Promptly grasping the sides
of the wound and closing them firmly, they retained them in apposition by
stitches, then applied a firm wooden compress and a bandage. They were
thus enabled to control the haemorrhage; ,the amount of blood lost being
probably three quarts. Supposing the aneurism to be situated on one of
the smaller arteries, external to the cavity of the chest, and probably the
subscapular^ it was proposed by Dr. S. to ligate the left sub-clavian artery.
Time passed without an operation. On the morning of November 14th
the patient died. The reporters of this case were present at the post-
mortem examination, which revealed the following condition:

On opening the thorax some injection of the pleura of the left side was
observed; likewise adhesions of different degrees of firmness, and consid-
erable serous fluid in the cavity. An aneurism of the aorta, situated on
the posterior wall of the descending portion of the arch, was found, which
had by pressure caused the absorption of the left side of the bodies of the
third, fourth, fifth, and sixth dorsal vertebrje. About four inches of the
fourth rib were also entirely destroyed, with partial destruction of the third
and fifth ribs of tlie same side. There were adhesions of the sac and pleura
at the point where the bony walls of the chest had been partially destroyed.

SURGERY.

321

It can easily be seen by this that should the sac by any means open in its
posterior portion, where it was already protruding through the opening in
the ribs, there might still be no hremorrhage into the pleural cavity. Such
was really the case. The sac had opened posteriorly, and the blood had
been poured out under the muscles of the back, and between them and the
pleura costalis, forming in this manner a new tumor much larger than
the original sac. It was this new tumor formed by the bursting of the
aneurism, and not the true sac of the aneurism, which was incised. Both
the original sac and tlie new cavity were, to a large extent, filled with
white fibrinous clots, deposed in firm, strong layers, such as are always
noted in long-standing aneurisms.

The locality, disposition, and eftect of the aneurism described will un-
doubtedly enlist the attention of the profession; but, in addition, it is
worthy of note, that notwithstanding the extent and duration of this
remarkable lesion, its aueurismal character was not suspected by the medical
men in charge!

4. — Extravasation of Urine from Biii'sting of the Urethra
hehind a Stricture', Perineal Section 'j Recovery. Bj
Hexet Gkat Crolt, F. E. C. S. I., etc. [^ledical Press and
Circular, May 27, 1868.]

Yisited, in consultation with his medical attendant, Mr. , who

had been suft'ering for years from stricture of the urethra, for the relief of
which instruments had been introduced from time to time.

About a week before my visit he felt a swelling in the perinosum, for
which, however, he did not seek advice. He passed water (as usual with
difficulty) until the night before I saw him, when he felt an unusual and
painful sensation in the perinreum, "as if something had given way," and
soon afterward he found the scrotum becoming much enlarged. This
swelling increased rapidly, and he passed a restless night. Being alarmed,
he sent for his medical attendant in the morning, who recognized the serious
nature of the case, and recommended additional advice.

On examination, I found him in the following condition : Scrotum enor-
mously distended, and of a shining-red color, a fluctuating tumor, the size
of a hen's egg, occupying the median line of the perinjeum. He said that
he passed some urine with great pain and difficulty during the night, after
the sensation of ''something having given way." His pulse was 136 in
the minute, his tongue was furred, and other symptoms of constitutional
disturbance were present. The room had a strong smell of ammoniacal
urine. The urgent necessitjr for immediate operation was explained to the
patient, to which he readily consented.

Having placed hira on a table in the lithotomy position, and the pelvis
being raised on a pillow, I endeavored to introduce a catheter into the
bladder, but found a stricture (near the bulb) through which the instru-
ment would not pass. I then introduced ''Syme's stalf" down to the
stricture, and with a long straight bistoury made a deep and free incision
in the median line of the perinjeum, over the tumor. A large quantity of
pus escaped. I next introduced the forefinger of my left hand deeply into
the wound, and felt for the stafi", and, having reached it, I got the knife
into the groove, and op^ed the urethra freely from behind forward.
Scarcely any blood flowed from the incision.

I then made three long and deep incisions into the scrotum, which was
enormously infiltrated; a large quantity of fluid, smelling strongly of urine,
escaped. The edges of the incisions bled freely; pledgets of lint steeped
in oil of turpentine were applied, and a T bandage. The scrotum was

322

EEPOETS OjS^ PEOGEESS OF MEDICIXE.

kept elevated. The patient was placed in bed with a hot jar to his feet;
wine was given, and a full opiate administered. On the following day I
ascertained that the patient had a rigor, and vomited soon after the opera-
tion; pulse 100 in the minute. He expressed great relief; slept well;
urine passing freely through the perineal wound ; scrotum much reduced
in size. The pledgets of lint were removed, and the incisions were washed
thoroughly, and subsequently dressed with carbohc-acid lotion. Half a
grain of opium and a grain of quinine to be given every hour; also brandy
and eggs, with strong beef-tea.

On the third day I observed a superficial redness in the left iliac region,
along the track of the spermatic cord, tender on pressure, and at once
made a free incision into the part. This relieved the tension, and prevented
further mischief in that region.

The bowels not having been freed for several days, a turpentine eneraa
was administered with " O'Beirne's tube." Urine continued to pass freely
through the wound in the perinEeum, and in small quantities through the
urethra. Tincture of perchloride of iron in brandy and water was given
every fourth hour. The scrotum was poulticed with linseed meal and
solution of carbolic acid; a catheter was passed regularly to dilate the
urethra. The carbolic-acid dressing proved very valuable, and tended
materially to promote healthy granulation. The wonnds healed rapidly,
and the patient made a satisfactory recovery.

From the history of the foregoing instructive case there can be no doubt
that the urethra, which was dilated behind the stricture, communicated
Avith an abscess by ulceration, causing the infiltration of urine, and the
dangerous symptoms which resulted. The treatment in such cases must be
decided and prompt — the incisions must be free and deep, and the urethra
must be opened behind the stricture.

5. — Strangulation of the Large Intestine near the Junction of
the Descending Colon and Sigmoid Flexure; Successfid
Treatment hy an Operation. By K. L. Wildee, M. D.
[Boston Med. and Surg. Jonr., Jnly 23, 1866.]

March 30, 1868, was called to see Mr. G., aged 33, in consultation
with Dr. J. B. D. Stillman. Found patient vomiting incessantly a thin,
colfee-colored fluid. He had had no passage from the bowels for four
days. There was some swelling of the abdomen, and considerable tym-
panites. Great pain on pressure ; countenance pale and anxious ; pulse
130, thready and irregular. There were no appearances of hernia. The
patient referred his pain mostly to the right iliac fossa. This, with the
suddenness of the attack, led us to believe that the trouble was intus-
susception at the ileo-caecal valve.

Warm-water injections had been given every hour for the previous
twenty-four hours, but had come away without apparently entering the
colon. Insufilation was then proposed. Quite a large amount of air was
pumped in, by means of a Davidson's syringe. We suffered this air to
remain in for a time, in hopes that by distending the intestine gently
but fully, we might be able to bring things to a normal position and con-
dition. •

The air gave the patient so much pain that in about an hour it was
thought advisable to allow it to escape. On dilating the sphincter ani, no
air escaped. Tiie rectum and sigmoid flexure remained perfectly empty,
while the whole extent of the colon remained distended. This turned our
attention to the real cause of all these symptoms of obstruction, which we

SUEGEEY.

323

decided must be a stricture of the large intestine, situated near the junc-
tion of the descending colon and the sigmoid flexure. It also seemed most
probable that this obstruction was caused by a band of adhesion, suddenly-
inflamed; for the patient had had peritonitis about two years before, and
had since, as he says, been troubled with "colic."

A long enema-tube, carefully passed up, met with a decided obstruc-
tion about eighteen inches from the anus. After several attempts to jiass
the tube into the colon, which were unsuccessful, the tube being stopped
at the same place each time, we decided that his only hope of relief lay in
an operation.

Later in the day, Dr. Calvin G. Page, of Boston, Mass., saw the pa-
tient with us, and, after a careful examination, agreed as to the diagnosis,
and fully concurred with us in the opinion that an operation for the relief
of the stricture afforded the jDatient his only chance of recovery. This
statement being made to the patient and his friends, they consented to any
thing we might propose to do. As it was late in the day, and as the
symptoms were about the same as in the morning, we determined to post-
pone operative interference until the next day — in the mean time to give
the patient the benefit of treatment by position.

March 81s^. — The previous symptoms being more marked, and the ab-
domen having become more tympanitic and enlai'ged, the operation was
immediately decided upon.

Operation, by Dr. Wilder, assisted by Drs. Stillman and Page. Patient
etherized and j^laced upon his right side. Incision made about midway
between the last rib and the crest of the ilium, commencing at the edge
of the sacro-lumbar and long dorsal muscles, and extending horizontally
toward the umbilicus about four inches. The muscles were then care-
fully divided on a director, in both directions, the entire length of the in-
cision. A large amount of fat appeared and rolled up into the opening.
This I carefully dissected through with my finger and the handle of my
scalpel. The distended intestine now showed itself in the aperture. I
carefully passed my hand into the cavity of the abdomen, through the in-
cision, and at the same time introduced an olive-pointed oesophageal pro-
bang into the rectum j^er aniim. Carefully following this, with my finger
within the abdominal cavity, I passed the probang along till I arrived at the
stricture, which was found to be at the junction of the colon and sigmoid
flexure. The intestine below the stricture was loose and flaccid, while
above there was great distention, feeling like an inflated bladder with a
string tied around its neck. I felt what seemed to be a fihro-memlranous
hand surrounding the intestine and constricting it. By pushing the point
of the probang well up, an^ using my finger-nail, I succeeded in dividing
the stricture. Immediately upon the division of the band, the probang
slipped through into the colon ; at the same time an immense amount of
gas and fluid feces escaped with great force from the anus. A long enema-
tube was then introduced, which passed easily up the descending colon,
through which more gas escaped. Drs. Stillman and Page also satisfied
themselves, by an examination, that the stricture was divided, and that
the tube passed freely up the descending colon. I now withdrew the tube.
The flaps of the wound were brought together and the edges held by
sutures. Strips of adhesive plaster and a roller were then apphed.

Only one vessel w^as divided, and that was a small muscular branch,
scarcely requiring a ligature. The haemorrhage amounted to nothing..
The depth of the dissection, and the care necessary, made the operation
rather long and tedious. Ordered two ounces of brandy to be immediately
given by the mouth.

The patient rallied well from tlie operation, and for a num

324

EEP0ET3 OT^" PEOaEESS OF MEDICmE.

ber of days improved so that there was every expectation of a
recovery. On the second day after the operation there was
excessive tymj)anites, with delirium, and very rapid pulse and
respiration. The abdominal cavity was punctured with a
small trochar at two points, giving exit to large quantities of
gas, and relieving at once the urgent symptoms. The wound
made by the operation healed perfectly, the union being firm
over the whole line of the incision, and the abdomen present-
ing a natural appearance. The consulting surgeon, Dr. Page,
appends a note to Dr. Wilder's account of the case, stating
that the patient died of pyremia a few days after the con-
clusion of his (Dr. Wilder's) report. He remarks :

" The case above narrated by Dr. "Wilder terminated fatally a few
days after the conclusion of his report, death occurring from pyaemia.

" There are two points in the case that should go upon the record.
The first is, that the patient was subject to occasional attacks of epilepsy,
and had suffered some years previously from a fall through a scuttle, a
distance of three stories, since which accident he had had frequent attacks
of abdominal pain in the region of the liver. The post-mortem appear-
ances in this region showed old peritoneal inflammation, with adhesions
to the diaphragm, and a recent deposit of lymph and pus over a surface of
several inches, but entirely confined to that region.

" The second point is, the great relief given by puncturing the perito-
neum with the trocar and allowing the accumulated gases to escape. I
examined the peritoneal points of puncture post mortem^ and found no
trace of inflammation. The intestines Avere not touched by the trocar.

" The intestine at the point of stricture showed an ecchymotic line an
inch long by one-fourth inch wide, but was otherwise healthy. There
was considerable pus found behind the peritoneum, between it and the
line of incision, which had closed by first intention. It would, perhaps,
have been better to have kept the most dependent part of the wound
open, so that this pus could have escaped."

6. — Ligatitre of the Common Carotid Artery. By Dr. C.
PiLZ, of Breslau. [Archiv fur Klinische Chirurgie, Bd. ix.,
1868, and Brit. Med. Jour., June 27, 1868.]

The last number of Langenbeck's ArcJiiv contains a long article from
Dr. C. Pilz, of Breslau, on ligature of the common carotid. Included in
this are statistical tables of 586 reported cases, which are arranged in the
following manner : ligature for haomorrhage, 220 cases ; ligature for aneu-
rism, 86 cases; ligature for tumors, 138 cases; ligature before and during
the removal of tumors, 69 cases; ligature for nervous affections, 35 cases;
ligature for Brasidor's operation, 38 cases. The total amount of cases is
further increased to 600 by others, of which full details are not given. In
29 instances the common carotid was tied on both sides, in 257 on the
right side, and in 194 on the left. The sex of the patient is not given in
every case, but of 537 patients 403 were males and 134 females. The
sympathetic nerve was in one instance included in the ligature. Aftec-
tions of the nervous system followed the operation in 160 cases; hemi-
plegia occurred in 8 per cent. ; and 76 per cent, of the patients so aftectcd
died. Of the 600 cases, 319 were cured after the operation, and 259 died;

IVnSCELLAKEOUS AND SCIEOTIFIC NOTES.

325

the result in the remaining being unreported. The ligature in the majority
of cases came away between the thirtieth and fortieth days after the
operation. The nervous symptoms following deligation of the common
carotid are attributed by br. Pilz to deficiency of arterial supply and to
venous congestion, and also to nutritive changes brought about by the
establishing of the collateral circulation. In cases of aneurism, Dr. Pilz
advocates the application of digital and jnechanical compression, and holds
the opinion that deligation of the carotid should be performed only as a
last resource when all other methods of treatment have failed.

7. — /Subcutaneous Injections in the Radical Cure of Vari-
cose Veins. [Medical Eecord, Sept. 15, 1868.]

Dr. Stephen Smith, in the Medical Gazette, recommends the subcuta-
neous injection of the persulphate of iron in this troublesome affection.
The patient being in the erect position, from 5 to 15 drops of Squibb's
preparation of the persulphate may be forced into the cavity of the vein
by the use of the common subcutaneous syringe, the vein being pressed by
the finger. In a few minutes the clot may be detected by the finger and
the needle may be withdrawn. The patient should remain in bed several
days and cold applications be made to the puncture. To prevent the pos-
sible escape of a clot into the general circulation, a compress and roller
should be applied to the trunk of the vein on the cardiac side. The larger
trunks are usually injected, and at several points of the same sitting. The
clot at once perfectly occludes the vessel.

The reception given by the physicians of Philadelphia to
Professors Gross and Pancoast, on their return from Europe,
was a truly notable event. It was not alone a spontaneous
expression of the good-will and respect entertained for these
distinguished gentlemen, but it was an indication of the high
esteem in which our *noble profession is held, not only by its
own members, but by the educated and intelligent public. It
was no mere hero-worshipping — no clannish ovation to an
idolized chiet^ — for all sects and professions were represented ;
distinctions of race and place were forgotten ; and from all
sides, in no spirit of intrusion, but with a truly catholic rever-
ence for only the good and the true, came men to participate
in the honors of the occasion. It was a generous tribute paid
by education and refinement to honors well earned in the
pursuit of a profession that is but too often imperfectly
requited and unjustly estimated. By doing honor to these

326 mSCELLAI^EOUS AXD SCLEZ^^TITIC ]S"OTES.

her guests, Pliiladelphia lias done honor to herself; and Xew
York, we are glad to say, by being present thi-ough her
worthy representatives and participating in the ceremonies of
the day, shares in that honor.

Ox THE Eelative CLAms OF Bell axd Magexdie to the
Meeit of hattxg discovered the Fu:n'ctioxs of the Roots of
THE Spi^^al Xeeves. Bv Eobeet McDoxxell, M. D., F. E. S.
— Dr. McDonnell stated that he had been led to inquire care-
fully into this subject by the observations lately made by MM.
Yulpian, Claude Bernard and others, who, contrary to the
opinion generally received in this country and on the Conti-
nent, claimed the discovery for Magendie. The author felt
assured that however gladly British physiologists would claim
for a compatriot the honor of having made this discovery,
they would prefer doing what truth and justice required. Af-
ter carefully analyzing Bell's writings, he has come to the con-
clusion that, previously to 1822 (when Magendie made his
experiments, and published the results), Bell's written works
contained no evidence that he conceived the idea that the
posterior nerve-roots were sensitive, and the anterior purely
motor. He (Dr. McDonnell) assigned to Magendie and experi-
mental physiology the merit of having discovered this funda-
mental fact in physiology. He had some difficulty in obtain-
ing Bell's celebrated pamphlet of 1811, printed for circulation
among the author's friends, and, having obtained it through
the kindness of Professor Turner, of Edinburgh, he submitted
it to the judgment of several competent persons, who were in-
vited to give their opinions independently of each other. All
agreed that in this pamphlet, upon which Bell and his sup-
porters rest their claims to his priority, there was absolutely
nothing which could, in fairness, be supposed to indicate a
knowledge of the true functions of the nerve-roots. — British
Med. Journal.

The October number of the Psychological Journal con-
tains a very careful and well-elaborated article on this same
question by Professor Austin Flint, Jr., M. D., of this city.
Dr. Flint had access to the celebrated pamphlet of 1811, and,
conducting his investigations entirely apart from Dr. McDon-
nell, has arrived at almost identical conclusions. He says, by
way of simamary :

Like many great discoveries, the idea, and the experiments
by which it was carried out and elaborated, did not emanate
from a sinorle mind.

MISCELLAlSnOUS AIJ^D SCIEKTiriC NOTES. 327

In 1809, Alexander Walker proposed for the first time the
theory that the properties of motion and sensation in the
mixed nerves were derived from the tvro roots by which they
take their origin from the spinal cord. This idea was entirely
theoretical ; and sensation was assigned to the anterior root
and motion to the posterior root.

In 1811, Charles Bell, who was the first to experiment on
the spinal nerves in animals recently killed, ascertained by
experiment that the posterior roots of the spinal nerves had
little or no motor properties. He ascribed both motion and
sensation to the anterior roots, and supposed that the posterior
roots presided over what are now known as the vegetative or
organic functions. He knew nothing about the sensibility of
the posterior roots.

In 1822, r. Magendie, who was the first to experiment on
the spinal nerves in living animals, ascertained by experiment
that the anterior roots of tlie spinal nerves presided over move-
ment and the posterior roots over sensation. He believed
these to be the distinctive properties of these roots, but he
thought at that time that the anterior roots might be slightly
sensitive and the posterior roots might possess some motor
properties.

From the experiments of Magendie dates all of our posi-
tive knowledge of the physiological properties of the two
roots of the spinal nerves.

We may note here that Mr. Alexander Shaw, in a letter to
the British 2Ieclical Journal, claims that Mao-endie was in-
debted to Mr. John Shaw (the brother-in-law of Bell) for his
infonnation on the subject of the functions of the roots of the
spinal nerves. Mr. Shaw (J.) was in Paris in 1821, and in fre-
quent communication with Magendie, to whom he furnished
the various papers that:had been prepared by Sir Charles Bell
and himself. Mr. Alexander Shaw also asserts positively that
Mr. John Shaw performed for Magendie experiments on the
portio dm'a and fifth paii*, to convince him that the nerves of
motion were distinct from the nerves of sensation.

Pkof. Joseph IS^. McDowell, of the Missom-i Medical
College, died at the age of 63 years, in St. Louis, September
25, 1868, of congestive chill. Dr. McDowell was the founder
of the college, with which lie was connected at the time of
his death, and was prominently known as a practitioner and
teacher.

328

MISCELLAIS'EOUS AND SCIENTIFIC I^OTES.

Death from the Use of Arsexic by a Cancer-Cusee. —
The London Lancet reports the case of a lady suffering from
a simple abscess of the breast, who was induced by the repre-
sentations of her friends to employ a cancer-curer, one William
Patterson, who was reported to have cured some one of can-
cer. Patterson pronounced the patient's disease to be cancer,
and immediately proceeded to attack it heroically, applying
first a blister, and then an ointment, which on subsequent
analysis proved to consist of nearly one-half pure arsenic.
The patient w^as immediately seized with headache, vomiting,
excessive thirst, etc., and she died in ten days. Arsenic was
foimd in the various tissues and organs of the body, and no
trace of cancerous disease was detected on the closest examina-
tion. Patterson was held to trial ; his only defence was that
he had cured many cancers with this ointment, which had been
laid on a little thicker than he had ordered.

Singularly enough, the Court, while admitting that the
death of tlie patient had been caused by the arsenic, summed
. up in favor of Patterson, on the ground that the Court was
not sitting for the protection of the rights and privileges of
medical practitioners, and a man, though not licensed, was not
to be punished for culpable homicide, unless the jury is satis-
fied that he acted culpably, and that a mere mistake did not
imply culpability. The jury, however, took quite a different
vieAv of the case, and promptly found the prisoner guilty.

The characterizing of the conduct and ignorance of such a
pretender, as the man Patterson e^ddently was, as a " mere
mistake," is, in our estimation, the very sublimity of coolness,
or shall we call it audacity ?

Dr. E. W. Howard, of Akron, Ohio, reports, in the Cin-
cinnati Lctncet and 01jserve-/\ the birth of a male child weigh-
ing nineteen and a half pounds. The mother was forty-four
years of age, and had had ten children previously. On the
same day the doctor had another case of confinement at full
term, in which the child weighed oiily three pounds. The
labor was as long and severe in the last case as in the first.
A pretty good average for one day's work.

MISCELLAraOUS A]SrD SCIE^S-TIFIC NOTES. 329

The Medical College recently organized at Detroit, Mich-
igan, lias commenced operations with the following corps of
instrnctors :

Edward W. Jenks, M. D. (President of Faculty), Profes-
sor of Obstetrics and Diseases of Women and Children ;
Theodore A. McGraw, M. D. (Secretary of Faculty), Profes-
sor of Principles and Practice of Surgery and Clinical
Surgery ; George P. Andrews, M. D., Professor of Principles
and Practice of Medicine and Microscopy ; Samuel P. Duf-
field. Ph. D., M. D., Professor of Chemistry and Toxicology ;
C. B. Gilbert, M. D., Professor of Materia Medica and Thera-
peutics ; William H. Lathrop, M. D., Professor of Physiology
and General Pathology; James F. !N'oyes, M. D., Professor of
Ophthalmology ; W. Webber, M. D., Professor of General
and Descriptive Anatomy ; J. M. Bigelow, M, D., Professor
of Medical Botany ; P. P. Gilmartin, M. D., Adjunct Pro-
fessor of Obstetrics and Lecturer on Medical Jurisprudence ;
H. O. Walker, M. D., Demonstrator of Anatomy.

The report that the Siamese Twins are going to Paris to
be operated upon gives interest to the following case, which we
take from the Revue de TMrajpeutique Ifedico-Chirurgicale
of Auo^ust 1 :

Dr. Boehm has successfully performed the operation of
separation of twins that were adherent to each other by a
fleshy band. The junction between the two children, females,
who were very small, but in other respects well developed,
commenced at the inferior extremity of the sternums, which
were entirely distinct or separated, and, following ov^er the
xiphoid cartilage, terminated in a single or common umbilicus.
This connecting band was soft to the touch, not unlike a thick
cushion of cellular tissue ; but there could be felt as it were
some hard and knotty cords, which later on were found to be
formed by the cartilaginous branchings which, starting from
the two xiphoid appendages, joined together toward the middle
of the band, in order to form a cord, by the side of which
coursed the vessels of the umbilical cord. The operation com-
menced by dissecting up and isolating the vessels of the um-
bilical cord, which was single and had one enveloj)e, a single
sheath, closing in all the vessels. This sheath was divided by
a bistoury, and the vessels were dissected up three or four
inches from the umbilicus. In this way six arteries and one
vein were dissected out on each side and were ligated sepa-
rately. After this the operator made an incision upon the

330 miscella:xeous axd scrENTiric notes.

band, parallel to tlie surfaces of the thorax, and, taking care
always to keep in the median line, cut more deeply into the
cellular tissue, divided the union of the cartilaginous append-
ages, and, passing between the two points of insertion of the um-
bilical vessels, arrived finallv at the skin on the opposite side,
where a single stroke of the knife finished the operation.
Yerj little blood was lost. The two flaps had a length of
five and a half centimetres, and were united at three points
by suture. Union took j^lace by the first intention ; but one
of the infants, which from birth had shown less strength and
vitality than the other, died on the fifth day. The other is
now living, at the age of five years, is in perfect health and
well developed, except that there is a separation six centime-
tres in length in the linea alba below the xiphoid appendage.

According to the statistical researches of Foerster, out of one
hundred and fourteen similar and collected cases, this is only
the second where a successful result has followed the operation
of separation.

Death of Professor Schoxbein. — The Atlantic cable re-
ports that Christian Friedrich Schonbein, of Basle, died re-
cently at Baden-Baden.

He was born at Wiirtemberg, October 18, 1799, and at
an early age devoted himself to science ; but, being far from
rich, had to teach in order to get means to complete his
studies. In London, which he visited in 1826, he became ac-
quainted with Faraday ; and in 1828 was appointed professor
in the University of Basle, in Switzerland. He became famous
in a few years for the boldness and originality of his generali-
zations; and, although always inferior to several contempo-
raries, as an experimenter, has, perhaps, never had a superior
as a theorist.

In 1839 Schonbein made his great discovery of ozone, the
form which oxygen assumes under severe electric discharges,
and which gives to the air the peculiar odor which prevails
after a stroke of lightning. This discovery gave the first im-
pulse to those fruitful inquiries into the influence of difierent
conditions of the atmosphere upon health, which have occu-
pied the attention of M. Schonbein and other chemists for
many years.

Twenty years later, in 1859, M. Schonbein discovered
" antozone," another form of oxygen, which, however, is as
yet known only in such compounds as the peroxides of sodiimi
and potassium. These remarkable results are as prominent as
almost any in modern chemistry.

In 1815 M. Schonbein invented gun-cotton ; and for more

MISCELLANEOUS AND SCIENTIFIC NOTES.

831

than a year there was a general belief that the whole military
system of projectiles would be changed by it. But the ex-
plosive violence of the gon-cotton was found too great and
too uncontrollable for this use ; and it was employed chiefly
for blasting.

But, among the singular properties of gun-cotton, it was
found to be perfectly soluble in ether, and, after many experi-
ments by chemists, this solution, to which the name of collo-
dion had been given, was found to be the best material to
be " sensitized " for photographic impressions. Mr. F. Scott
Archer announced in the (Jlieinist of March, 1851, his success
in making iodized collodion for this purpose, and from that
time the art of photography may be considered a success.

M. Schonbein was the author of several treatises on iron
and its combinations with oxygen, on physical chemistry, on
combustion, and on the results of his own discoveries. In
private life he was universally esteemed. — Medical and Sur-
gical Rejporter.

The Medical Department of the University of Michigan
numbers about sixty students less than last year. This loss,
however, is not attributed to the homoeopathic agitation — the
chief result of which has been to take away from the Facul-
ty two of their ablest teachers — Profs. Armor and Greene.
Their chairs, though filled by able young men, are stripped of
something of their ancient dignity and authority.

■ Prize. — The Massachusetts Medical Society offers a prize
of Fifty Dollars for the Essay which shall best and in
plain language describe an effective and ready method of
ventilating sick-rooms— one that can be put into operation at
once, at the moment needed, with the least difficulty and ex-
pense, in houses of ordinary construction. Essays to be sent
before May 1, 1869, to the committee, care of D. Clapp and
Son, the publishers of the Boston Medical Journal.

IsTelaton a Senator. — Among the promotions of August
15th (a date habitually chosen by the Emperor of the French
for distributing his favors) we notice the name of M. J^elaton
as having been raised to the high dignity of senator. This is
the only example of a medical man in practice being promoted
to a seat in the Upper French House, whether Imperial Senate
or House of Peers. Until now it had been foolishly considered
that the dignity of a peer or a senator was scarcely compatible

332

mSCELLAI^EOUS AXD SCIEOTiriC IfOTES.

T^'itli the nature and bnsj occnpations of medical practice.
Under Lonis Philippe the peerage was offered to Dr. Double,
the King's physician, on condition that he would renounce
practising. Dr. Double's private circumstances were such that
he might easily, if he would, have accej^ted the sacrifice in favor
of the honor. But he refused through a feeling of pride, and
a most laudable concern for the dignity of his profession. We
are glad that the absurd prejudice has at length been destroyed,
and that such an event has taken place in connection with the
celebrated sm-geon we have named. — Lancet.

A Womain's Estimate of Women. — The Medical Times
and Gazette thinks that the naivete displayed by the charming
Miss Becker, in her address to the British Association, on the
mental superiority of the female sex, must have been some-
what amusing to that dignified body. It says :

" This lady's propositions were so well-rounded and so cate-
gorically arranged that they must have overpowered many of
our weaker brethren. Her utter disregard, however, of the
necessity for urging something in support of these propositions
was not a little characteristic of the lady debater, and the
illustrations afford a happy example of the kind of science
which is popular in the ranks of the ci-devant weaker branch
of the human family. ' The superiority of sex was not always
on the side of the male: witness bees.' said Miss Becker.
This was most infelicitous. What is the domestic economy of
the beehive ? True, the males are not considerately treated,
but then the really mentally superior and active members of
the commonwealth are creatures we should be sorry to see
Miss Becker selecting for her analogy — endowed with intelli-
gence, but devoid of sex. The only female in the establishment
leads a scandalous life of polyandry, is made a matron of as
soon as she reaches maturity, is allowed to take no share in
the affairs of the republic; and, finally, is kept hard at work
perpetuating the species during the term of her natural life.
Is this Miss Becker's notion of the female of the future ?"

Aneueism on the Pacific Coast. — The last number of the
Pacific Medical and Surgical Journal contains a rejDort of an
interesting discussion held at the San Francisco Medical So-
ciety, on the subject of aneurism. Dr. A. G. Soule presented
a series of statistics, showing that in 34: months there had been
in San Francisco 119 deaths from aneurism, a yearly average
of 42:

mSCELLANEOUS A:NT) SCIEOTIFIC NOTES. 333

" The average population of the city for that time being
about 126,000, there would be one death from aneurism for
each 3,000 inhabitants.

For a period of nine years, from 1856 to 1864: inclusive,
there were in Xew York Citj 213 deaths from aneurism, an
annual rate of 27. Under the supposition that the average
population of Xew York for the nine years was 720,000, there
was one death from aneurism to every 27,000 inhabitants."

Thus the relative mortality from aneurism is nine times greater
in San Francisco than in Xew York City.

As to the class of men affected with aneurism : They
have lived a rough, uncertain life, with no settled home or
steady vocation ; they have been tossed upon the sea of life
and wi'ecked upon the slioals of disappointment. All were,
necessarily in our young city, remote from their native land.
Thirty-five were Europeans, and but ten ]iatives of the United
States. Xearly all had ' tried the mines,' worked hard, lived
in a rough, exposed manner, imbibed freely of the ardent,
returned disappointed to the city, taken lodgings in the
rickety habitations of the city front, and worked by the hour
or by the day at heavy, laborious, unsteady labor alongshore.
Idle the most of the time, they indulged freely in drink, and,
when at work, stimulants were used to brace them up in their
heavy labor. Many complained of rheumatism; many did
not ; a large proportion had suffered from syphilis : autopsies
were made in all the cases, and degeneration of the arterial
coats, atheromatous, fatty, or calcareous, found."

Dr. Gibbons, Jr., presented some additional statistics, which
are both interesting and, valuable :

" In England for five years (1838-'12) there were 593 deaths
from the disease, or an "annual mortality of 1 for every 131,000
inhabitants. In the same country for four years beginning
with 1860, there were 1,516 deaths, an average of 1 a year for
every 52,000 people. In Xew York City for 21 months,
ending September 30, 1867, 29 deaths are reported, or 1 yearly
for about 4l,000 people. In Brooklyn for 18 months in lS66-'7,
there were 12 deaths — 1 yearly for 37,000 inhabitants. Phila-
delphia reports 8 deaths in 1863, and but 4 in 1861: — 1 to
76,000 and 1 to 150,000 people, respectively. Boston reports
7 deaths for two years, 1864 and 1865, or one death to 65,000
people ; while St. Louis, with a population of over 200,000,
reports but one death from aneurism in 1865. Xo deaths from
this disease occurred in Cliicao-o in 1865, in Pro\ddence, E. L,
in 1861:-'65-'66, or in the State of Ehode Island in 1863. For

334 mSCELLANEOUS AIS^D SCIEOTIFIC NOTES.

1858, San Francisco reported 6 deaths; for 1859, 10 deaths ;
for 1866, 35 deaths; for 1867, 35 deaths; for 6 months of
1868, 28 deaths. This would give a ratio to the population
for the years respectively, of 1 in 12,000 ; 1 in 8,000 ; 1 in
3,500 ; 1 in 3,700 ; 1 in 2,400.^ The per cent, of death from
aneurism to the total mortality is as follows : England, 1860-'4,
0.09 ; E'ew York, 1866-'7, 0.06 ; Brooklyn, 1866-'7, 0.09 ;
Philadelphia, 1863, 0.06—1864, 0.03; Boston, 1863, 0.06—
1865, 0.09; St. Louis, 1865, 0.02; San Francisco, 1858, 0.52
—1859, 0.70—1866, 1.39—1867, 1.40—1868 (6 months), 2.12."

De. Gael Yogt, of the University of Geneva, the pupil
of Liebig and Agassiz, is to deliver a course of lectures in this
country during this winter, on topics connected with Zoology
and Anthropology. After his political connection with the
Frankfort Parliament, of 1848, had forced him to resign his
chair of Zoology, in the University of Giessen, he delivered
at Keufchatel, and subsequently published in book form, the
Lectures oil Man, his Place in Creation, and in the History
of the Earth, which gave him a world-wide reputation, and a
high rank among men of - science in Europe.

Feom Glasgow is reported the death of Dr. William
Mackenzie, the eminent oculist, at the age of 74. He was a
fellow of the Hoyal College of Surgeons in England, and of
many learned and scientilic societies. Dr. Mackenzie was
well known to the profession in this country as the author of
two standard treatises, On the Physiology of Vision," and
" The Diseases of the Eye."

The death of Prof. Griesinger, of Berlin, the celebrated
alienist, is announced. jN^o particulars are given.

In consideration of the numerous victims of homoeo-
pathic treatment, a decree of the Emperor of Pussia pro-
hibits the practice of homoeopathy in the entire territories of
the Pussian empire, under pain of a tine of 500 rubles, and two
years' transportation to Siberia. — Le Courrier Medicate.

This report, we observe, is denied in the homoeopathic
medical journals, on the authority of the Pussian minister at
"Washington.

MISCELLATTEOUS AIS^D SCIENTIFIC NOTES. 335

Appointments. — Dr. Clias. E. Buckingham, Adjunct Pro-
fessor of Theory and Practice, in the Medical Department
of Harvard College, has been transferred to the chair of Ob-
stetrics and Medical Jurisprudence, made vacant by the resig-
nation of Prof. D. Humphreys Storer.

Dr. Clias. L.Ives, of !N^ew Haven, Gonn., has been ap-
pointed to the chair of Theory and Practice, in the Medical
Department of Yale College. This vacancy was caused, it
will be remembered, by the death of Dr. Worthington L.
Hooker.

Dr. Henry M. Field, of Newton, Mass., has been appointed
Assistant Lecturer on Materia Medica, in the Medical Depart-
ment of Dartmouth College. Dr. C. P. Frost, of Brattle-
boro, Vermont, Assistant Lecturer on Theory and Practice,
in the same Institution.

Dr. J. J. Chisholm has been appointed Professor of Mili-
tary Surgery and Pathological Anatomy in the Medical De-
partment of the University of Maryland, located at Baltimore.
The chair was created expressly for Prof. Chisholm.

Prof. Paul F. Eve, late of the University of ]^ashville,
has accepted the chair of Surgery in the Missouri Medical
College, St. Louis, Mo., made vacant by the death of Prof.
Joseph E". McDowell.

Prof Joseph Jones, also recently of the I^ashville Uni-
versity, has accepted the chair of Chemistry in the Medical
Department of the University of Louisiana, at N^ew Orleans.

Pennsylvania Hospital. — J. A. Meigs, M. D., Professor
of the Institutes of Medicine in the Jefferson Medical College,
has been elected one of the attending physicians to the Penn-
sylvania Hospital, in the place of Dr. James J. Levick, re-
signed.

A HuiviAN Tkipod. — This case will be read with interest in
connection with the account of the remarkable monstrosity
published in the October number of this journal. The case in
question is reported by an anonymous correspondent of the
Lancet

^\2a\QhQ Dumas was born at Segry, of perfectly healthy
parents, who had already had two healthy children, and noth-
ing special was noticed during the pregnancy of the mother

336

MISCELLANEOUS AT^TD SCIEI^TIEIC NOTES.

whicli resulted in the birth of this monstrosity. The child is
fairly grown for her age, and appears acute and sensible.
When dressed, the most remarkable featm^e is the great width
of the pelvis, and the fact that the left foot is clubbed, w^hich,
however, does not prevent the child walking with facility. On
closer examination, it appears that there are two pelves fused
in the median line, and that in connection with these there are
tv:)0 pairs of low^er limbs. The right leg of the right pelvis is
perfectly developed, but the left leg is quite rudimentary,
being represented only by a nodule of fat. Both limbs of the
left pelvis are fairly developed, and are both club-footed. It
is the left of this pair that is used in progression, the right
being twisted in front of the other, and not reaching the
ground. The development of the genital organs is most
remarkable. In the normal position on the left side there are
female genitals, urethra, and anus complete. On the right
side there are genitals and urethra, but no anus, there being
merely a depression in the skin at the point. The child mic-
turates through both urethras, and evacuates the bowels by
the single anus. In addition, how^ever, to these female geni-
tals, there is at the junction of the pelves, and at the posterior
part, a w^ell-formed penis, and below^ this is a cicatrix, result-
ing, as the mother says, from some operation performed in
Paris, by which a scrotum which existed at birth was removed.
The penis was so sensitive that examination was not permitted ;
but, as at birth the child micturated by some orifice in connec-
tion with it which is now closed, I imagine that there must
have been an hypospadiad opening which the operation has
successfully closed. The child now wears a sort of bandage
to support the part, and no urine passes.

The child has been exhibited in Belgium and France, and
has been examined by various medical men of eminence.
Professor Crocq, of the University of Brussels, regards the de-
formity as an instance of interposition of an abnormal pelvis
between the bones of the natural pelvis. Professor Schwrann,
of Liege, on the other hand, regards the deformity as an in-
stance of double pelvis, classing it in the category of double
monsters (aaitosites non par parasites) of M. Geoffroy Saint-
Hilaire. This latter view appears to be borne out by the
arrangement of the toes of the supernumerary leg, which
shows it to be a right limb, and to belong, therefore, to the left
pelvis.

I may remind the readers of The Lancet of the remark-
able case of the Portuguese youth described at length in that
journal of July 29, 1865, who ' exhibited the curious malfor-
mation of a third lower limb with double male genital organs
Avell developed.

NEW YOKK

MEDICAL JOURNAL:

A MONTHLY EE COED OF

MEDICINE AND THE COLLATERAL SCIENCES.

Vol. VIIL] JANUARY, 1869. [No. 4.

Aet. I. — A New Operation for Artificial Hip-Joint^
in Bony Ancliylosis. By Lewis A. Sayre, M. D.,
Professor of Orthopedic Surgery in tlie Bellevue
Hospital Medical College^ Surgeon to Bellevue Hos-
pital, etc.

PEEFACE.

The republication of my paper on " A New Operation for
Artiiicial Hip -joint in Bony Anchylosis" — which was placed
before the j)rofession by the State Medical Society in 1863,
and the addition to the same of the letters from the various
gentlemen who saw the case referred to — has become necessary
to vindicate scientific truth, and my own reputation, from the
false statements made by Dr. Louis Bauer, in his recent work
entitled Orthopedic Surgery," published by Wm. Wood &
Co., 61 Walker Street, New York, 1868.

In speaking of bony anchylosis, he says, on pages 324 and
325 : " The true bony anchylosis of the hip-joint finds its relief
in Ehea Barton's operation. I have never had occasion to per-
form it, and can therefore offer no suggestions drawn from

338

A KEW OPEEATION POR

personal ex|Derience, but it would seem to me that tlie attempt
at establishing an artificial joint at the line of division is un-
warrantable for two reasons :

" 1. An artificial joint could never give a sufiicient support
to the superstructure of the body.

" 2. It inevitably protracts suppuration, with its impending
danger of pyaemia.

" Sayre a few years ago performed this operation, as he
alleged, with success ; but his patient nevertheless died a few
months after, from pyaemia.

" The specimen derived from the case did not sustain the
assertion of that gentleman ; no cartilaginous covering — syno-
vial lining, or a new capsular ligament, having been formed."

As soon as I read this most extraordinary misstatement of
an important scientific fact — which was calculated to mislead
the professional mind, and prevent suffering humanity from
receiving the benefit of an operation which 1 had proved was
not only feasible, but perfectly successful, I immediately
wrote Dr. Bauer the following note.

285 Fifth Avenue, Fehrmry 17, 1868.

De. Lotris Bauee,

Cor. Clinton and Warren Streets, Brooklyn —

Deae Sie: I received a few days since from Messrs. Wood (publishers),
a copy of your Orthopedic Surgery," for which please accept my sin-
cere thanks.

I can hardly find language to express my surprise at your misstatement
of the facts in relation to the cases of "artificial hip-joint," particularly the
case of MissLosee, as I thought you had seen the specimen taken from lier,
and therefore knew that there was a perfect joint with a capsular liga-
ment^ cartilaginous and synovial covering, and also a bifurcated ligamen-
tous junction between the upper end of the lower extremity and the new
acetabulum.

The specimen is before me now. Has just been examined by two physi-
ologists of acknowledged authority, and fully substantiates the above de-
scription.

It is due to me, it is due to science, that you should come and see it, in
order to correct this error in another edition of your book, which I have
no doubt will soon be called for.

You only mention one case of artificial hip-joint, and neglect to make
any notice of Anderson's case, which is certainly doing the subject great in-
justice, to say nothing of the wrong attempted to be done to me.

ARTIFICIAL HIP-JOmT.

339

Believing that your object is the development and statement of scien-
tific truth, I send you another copy of these tico cases in order to refresh
your memory, and also a copy of my introductory lecture on Orthopedic
Surgery, where you will see that I have done you, as I always try to do to
every one, full justice, and have given due credit for your valuable contri-
butions to surgical science.

Trusting that you will see the importance of returning the same justice
to science, and to me.

I remain, etc.,

Lewis A. Satee.

This letter, and tlie two pamphlets, were sent to Dr.
Bauer's address, as found in the I^ew York Medical Hegister.

The pamphlets appear to have gone safely, as thej were
never returned, but the letter was returned to me a few weeks
after, from the Post-Office Department at Washington. This
letter is now before me, and the above is an exact copy of it.

Why this letter, bearing the doctor's proper address, never
reached its destination, or why it was returned to me, I have
never been able to ascertain.

I then called upon the Messrs. Wood, his publishers, in
Walker Street, and, stating the facts to them, requested them
to commmiicate them to Dr. Bauer, which they promised to do.

After waiting several weeks, and having no response to my
very considerate and just demands, I wrote to the different
gentlemen who had been present at the jpost-mortem examina-
tion of Miss Losee, and asked them to write to me their im-
pressions of the case as they recollected it. Many of these gen-
tlemen, as will be seen by their replies, had moved from the
city, were in different sections of the country, and it was with
some difficulty that I was able to find their different addresses.
Those at a distance responded promptly, as will be seen by the
dates of their replies, and this vindication would have been
placed before the profession at a much earlier date ; but Dr.
Parker was absent from the city most of the smnmer, and
wished to reexamine the specimen before giving his opinion,
which he did very thoroughly the day before he wrote me his
letter, a copy of which is annexed.

The operation of Dr. Ehea Barton, to which Dr. Bauer
refers, was not intended to produce an artificial joint ^ but

340

A XEW OPEEATIOlSr FOE

simply to anchylose the limb in an improved position, and is
referred to, as will be seen in my report. How Dr. Baner
could confound two such totally different operations, I am at
a loss to understand, unless it was sought as an opportunity to
bring my operation before the medical profession in the light
in which he has attempted to describe it.

If it were merely to defend my own personal reputation
against slander and detraction, I would feel that I owed an
apology to the profession, for thus coming before them ; but as
it is in defence of a great surgical principle, and of a new
scientific fact, I feel that not only is no apology necessary,
but that I would fail in my duty to science, and my profession,
were I to keep silent. It is probably fortunate for science that
this false charge has been made, as it enables me to add the
evidence of so many distinguished gentlemen to verify the
accuracy of my report ; and thus verified, I give my humble
contribution to the profession for their consideration and
judgment.

Case I. — Ancliylosis of hotli Hip- Joints — Tenotomy and
BiHsement force in one^ and in the otlier Exsection of
Semicircular Segment of Bone ahove Troclianter Mi-
nor, Recovery loith Artificial Joint. '

Robert Andeesot^, native of Lexington, Ky., age 26,
was admitted into Bellevue Hospital in May, 1862,
and gave the following history of himself : . During
the summer of 1849, when 14 years of age, he was ac-
customed to go in the river every evening to swim, and
on one occasion remained in the water some hours,
having previously taken very severe exercise in running
and jumping.

About the middle of September he was taken with
a dull pain in the right hip, which continued about

^ The portion of this paper from this point to the Appendix, page 366,
is reprinted from the Transactions of the Neu* York Medical Society for
1863.

ARTiriCIAL HIP-JOES^T.

341

one week, so gradually and imperceptibly develo23ed,
that tlie exact date of commencement is not known.
During tkis time lie continued in attendance at scliool,
and enjoyed the usual sports and games of his school-
mates. One day, after having exercised more freely
than usual, he ^vas attacked with fever, and the fol-
lowing day stupor set in, which lasted nearly three
weeks, with the exception of intervals ; when aroused
by the family, was totally indiiferent to any thing that
transj^ii^ed around him, except when thus diverted by
his friends. All this time he suffered intense pain in
the right hip, which was sharp and lancinating. The
hip was red, hot, and greatly swollen, the swelling ex-
tending; half-wav to the knee.

At the end of a month the swellino- had much sub-
sided, and the pain very greatly diminished, though
when the limb was moved it was still very intense, of
the same character, felt in the hip, and never at the knee.

About this time began to have pain in hip-joint of
left side, and also in tlie knee, which was dull, and
never of that sharp, lancinating nature which he suf-
fered in the other joint. This continued two months.

Ten days after the commencement of the disease,
pillows were placed "under his knees to relieve the
pain. These were increased in thickness and continued
all the time he remained in bed, which was six months ;
also duiing the next six months, whenever he was in
bed : but during this latter period he sat up occasion-
ally in a chair. From the jDosition assumed during
this prolonged confinement, the legs were flexed upon
the thighs, and the thighs upon the pehds, and have
been immovably fixed in that position ever since. Had
occasional i^ains all this time in both hips, but most se-
vere in the right.

342

A NEW OPEEATIOlSr FOR

At the end of two years from date of attack, an
abscess formed in the left groin, whidi remained and
discharged pus for two years. Abscesses also formed
about the right hi23 ; one beneath the gluteal muscle,
and another near the anus. These discharged very
freely, and continued open for nearly a year and a
half.'

At the end of the first year, began to use crutches —
compelled to use them ever since.

For the last six or eight years, general health has
been perfectly good.

On admission he had anchylosis of both hips in the
position seen in the annexed photographs :

Fig. 1. Fig. 2.

The left thigh was immovably fixed at nearly a
nght angle with the pelvis, by bony cementation of
true anchylosis. The right was very firmly attached
at an angle not quite so acute, and by a very careful
examination I thought some slio:ht motion could be

AETIFICIAL HIP-JOmT.

343

detected wliicli indicated that tlie attachments were
fibrons in character, or at most were osteophytes only,
and external to the joint, and that there was no agglu-
tination between the femoral head and the acetabulum,
whereas the opposite side seemed perfectly cemented
together. He could not walk; except by whirling him-
self in semicircles, first on one leg as a pivot, and then
the other — or else by swinging himself on his crutches
from the axilla. In order to get both feet upon the
ground at the same time, his back Avas curved inward
very much, at the sacro-lumbar junction, the left knee
flexed at an angle of about 135 degrees with the thigh,
and the right side of the pelvis was some inches higher
than the left. He could only sit, by assuming a most
awkward posture, half reclining on his side upon a
couch or sofa ; and in lying down, was curled up
either on one side or the other, or if upon his back, he
had to be supj)orted by j)illows under his knees, and
under the lumbar vertebraB. In fact, he was the most
pitiable object I ever saw, and one that would excite
the sympathy of any surgeon.

On the 4th of May I divided subcutaneously the
adductor muscles, th^ rectus, tensor vagina femoris,
and femoral facia of the right hip, and, breaking up
the adhesions by some considerable force, obtained a
very good motion of the joint. Extension was made
to the limb by a weight and pully, and the hip envel-
oped in cloths wet with cold water; no serious trouble
followed the operation, and in six weeks he could flex
and extend, ab- and adduct his right limb with consid-
erable freedom.

On the 11th of June, 1862, I removed a semicir-
cular sesrment of bone above the trochanter minor of
the left femur, for the purpose of establishing a new

344

A NEW OPERATIOI^ FOR

joint. Drs. I. P. Batclielder, Woodhull, and Osborne,
of this city, Drs. Hooker of New Haven, Ct., Hichborne,
of Mass., and Dr. James S. Green, of Elizabeth, ISF. J.,
were present at tlie operation.

As this is the first section of this kind ever made
in this bone at the 23lace indicated that I am aware of,
I will give a brief description of the oj)eration, and my
reasons for performing it in the manner I did.

It is well known that Dr. Khea Barton, of Phila-
delphia, first operated for a deformity of this kind by
making a \/ section in the shaft of the bone, and thus
bringing the leg from that point down parallel with
the other and obtaining anchylosis in an improved po-
sition. And the late Dr. J. Kearney Rodgers, of this
city, rej)eated the operation in another case, only higher
uj) in the shaft of the bone, with equally good results.

^^^^^ But my object was to go above the
^ / Ml ^ li trochanter minor, so as to retain the
m^^^^^-""^ ^ insertion of the psoas magnus, and
^p^^^^^g iliacus internus muscles attached to
the lower fragment, for the purj)ose
of flexion, and by cutting out a semi-
circular piece thus with its con
cavity downward, and then rounding
off the upi^er end of the lower sec-
^' tion I would more nearly imitate

1, head of femur; 2, tro- , n • • j i • i •

chanter major ; 3, trochanter the Uatural lOint, and OTVe llim a
minor; 4, line of insertion of 7 o

iSSUfPlfn^™^^^ fair chance for motion at that pomt,
;f™,!rierST7;,i-,,e°f Avith less danger of the parts slip-

transverse section ; 8, 8, dot- ., iii i i TIJ

ted lines indicatino; rounding pmO^ DV CaCU OtUCr WneU lie WaiKeCl,

off of lower fragment after re- 1 O »/

moval of the segment. t\\Si\\ thcrC WOuld bc if I CUt OUt a

parallelogram, or a V-shaped piece.

The plan of the operation will be seen in figure,
Ko. a.

AETIFICIAL HIP-JOINT.

345

Tlie description of tlie oj)eration, and notes of the
case, are taken from tlie hospital records, Avhich were
kept by Dr. Shaw, honse surgeon at that time, and at
present in the U. S. 'Navj :

An incision of about six inches was made over
the trochanter major, in the axis of the limb. The cut
was slightly lunate, with the concavity looking down-
ward. The lips were then separated, and the deeper
structures, including the periosteum, were detached
from the bone.

A curved instrument, armed with the chain saw,
was passed around the bone between the trochanters,
and the femur first sawn transversely across. A roof-
shaped piece was then sawn out of the upper frag-
ment.' The limb was then put upon moderate trac-
tion, longitudinal and lateral ; the margins of the
wound approximated by adhesive straps, and cold
dressings applied.

Jime 15tli. — Wound begins to suppurate, and looks
very well ; no constitutional excitement.

16tJi. — He has considerable j)ain in the limb, and has
been unable to sleep. Eelieved by increase of extension.

20//^. — Patient finds that pain is relieved sometimes
by less extension.

July AtJi. — He has less pain ; purulent discharge, free.

Sept 1st. — Since last report patient has experienced
no untoward symptoms ; discharge from the wound is
now very slight. All extension is removed, and he
begins to sit up. General condition very good, and
has improved very much in fiesh since admission.

Oct. 12th. — Since last report patient has been walk-
ing around the hospital on crutches, which had to be

^ In my second operation, see page 352, I sawed the curved section first,
and should advise the operation to be performed in that way, for reasons
which are there given.

346

A NEW OPEEATION FOR

lengthened seven inelies, as lie is that mucli taller than
he was before the operation, and is now quite straight,
except the lateral curvature of the lower lumbar ver-
tebrae, which raises one side of his pelvis more than
the other, and makes the right leg apparently shorter
than the one from which the segment of bone was re-
moved ; but this is easily rectified by a higher heel on
that side. He can sit down in a chair, and get up with-
out assistance, except such as he obtains from his
crutches. To-day he walked into the amphitheatre by
the aid of his crutches, and exhibited himself to the
class, and left the institution well, and with very good
motion at both hip-joints.

About three weeks after he left the hospital, he
was attacked with acute pain . in the region of the
wound, which became inflamed, and soon suppurated.
In a few days a small semicircular piece of bone came
away, and, four days after, another similar piece ; the
two together making almost a ring, and seemed to be
exfoliations from the lower fragment. All the pain
immediately left him, and the wound healed in a very
short time.

Mr. Anderson remained in the city until late in
December, when he left, very unexpectedly, for Ken-
tucky.

The night before he left he walked to my office,
and could go up and down the steps without any dif-
ficulty ; and could stand on either leg without either
crutch or cane ; could take a step with either foot
twenty-seven inches, and, when he supported his body
on his crutches, could abduct his legs so that his heels
were thirty-six inches apart. He could cross either leg
over the other below the knee, without assistance, but
could not cross them upon the thigh.

ARTIFICIAL HIP-JOINT.

347

'The following extract is from a letter of his, dated
the 20th January, 1863 :

" My leg is getting on famously, since I came to
Kentucky. The first day after leaving New York I
grew very tired, but continued night and day until we
arrived at Cincinnati. I believe that when I got to
Cincinnati I was fresher than when I started. We
were in the city about half a day, and then came on to
Lexington, stayed all night, and again resumed our
journey. So far from being exhausted at the end of
the trip, I started next morning in
a buggy, and drove some twenty
miles. I think if I had been com-
pelled to travel a thousand miles
before stop23ing, I could almost
have danced a jig at the termina-
tion of the trip. But to speak
seriously, I think I am doing very
well indeed, and my leg gains
strength continually."

Fig. 4 is engraved from a carte de
visite^ which was received after the
paper was sent to press, in a letter
dated Spring Station, Woodford
County, Kentucky, April 11, 1863, Fig.4.
in Avhich letter he states : " I can now ^ rough it ' a
little, without apprehension of having to suffer for it
afterward. I can bear my whole weight on my left
leg without inconvenience, and can walk very well
without other assistance than a walking-stick, and the
improvement is as great in a month now, as at any
previous time."

]S"oTE. — With, the exception of Figures 1, 2, 5, 9, all tlie drawings were
made by Gregory Doyle, medical student in my office, to whom I must
express my obligations.

348

A NEW OPEEATIOi^ FOR

Case II. — Anchylosis of Left Hip^ Section of Mlipti-
cat Segment of Femur above Troclianter Minor,
Recovery^ ivith False Joint and Good Motion,

Miss Susan M. Losee, of Buffalo, New York, aged
twenty-four, of healthy parents, and of a robust and
vigorous constitution, was attacked with pneumonia,
in March, 1856 ; attended by Dr. F. H. Hamilton.
After three weeks went down-stairs, contrary to the
advice of her physician, and the following day was
attacked with intense pain in the left hip and thigh,
which was constant, persistent, and most severe, for
several months. She did not fall or receive any injury
that she was aware of, l3ut it was supposed that she
must have wrenched her hip in some way going down-
stairs, as she was very w^eak, and went down without
any assistance. During the first few weeks her leg
was straight, and could not be flexed, abducted, or
adducted, without intense suffering. Bed-sores by this
time had become so extensive as to make it impera-
tive to change her position, and, in doing this, her
limb was forcibly flexed at the knee and hip, but with
the most intense pain ; and, when flexed in this posi-
tion, it could not be extended again without the great-
est suffering, and was therefore permitted to remain
in the flexed posture.

New sloughs appearing over the right trochanter,
she was placed in a large chair, and was not removed
for two months, when slouo^hins^ occurred over the
tuber ischii, and at the extremity of the coccyx, and
she was again compelled to assume the horizontal
position ; and, being forced to lie upon the riglit side,
the left thigh was thrown over the right, in a flexed
position, and thus became permanently and perfectly

ARTIFICIAL HIP-JOIOT.

349

ancliylosed, at tlie expiratiou of about seven montlis
from the commencement of the disease.

No local application was made to the hip, but
the pain and constitutional difficulty was combated
principally by morphine, and no extension was ap^^lied
to prevent the muscular contraction and deformity.

Fig. 5. Fig. 6.

"When she recovered, her left thigh was permanently
flexed, at about forty degrees with the pelvis, and
strongly adducted across the lower third of the right
thigh, as seen in the accompanying drawings, which
were taken from life. - Fig. 5 rej)resents her standing.
Fig. 6, in the act of walking.

In the erect jDOsture, the heel of the left foot was
ten and a half inches from the floor, and on the right
side of the right leg. In attempting to walk, it was
brought to the floor, still on the right side of the
opposite limb, or cross-legged ; and was made to
reach the floor by a remarkable curvature forward
of the lumbar portion of the spinal column ; but
walking was attended with great fatigue, and a pe-
culiar dull pain in the lumbar region. Urination pro-

350

A KEW OPERATION FOE

duced constant excoriation of tlie limbs, requiring
great care and trouble in di^awing a handkerchief or
soft rag between the closely-compressed thighs, to keep
them clean or comfortable. Several efforts were made
to insert a catheter, in order that the urine might be
led off without iiTitating her limbs ; but it was impos-
sible to insert the finger so as to reach the orifice of
the urethra, either from the anterior . or posterior posi-
tion, although every effort was made, and with great
perseverance.

She remained in this condition until the 6th of No-
vember, 1862, seven years. She came to New York
and placed herself under the care of Dr. C. F. Taylor,
in the fall of 1861, who thought the anchylosis was
simjDly fibrous, and capable of being relieved by pas-
sive movements. Dr. Van Buren saw her at this time,
and diagnosticated the case as one of true bony anchy-
losis. I saw her in AjotI, 1862, in consultation with
Drs. Taylor, Peaslee, and E. Lee Jones, and confirmed
the diagnosis of Dr. Van Buren ; but it was thought
by all present that I might possibly break up the ad-
hesions if I preceded the attempt by section of the
tendons of the contracted muscles.

Accordingly, on the 10th of April, assisted by Drs.
Peaslee, Taylor, and Jones, I divided, subcutaneously,
the adductors longus and magnus, the gracilis and pec-
tineus, the rectus, sartorius, and tensor vaginae femoris,
and immediately closed the wounds with adhesive
plaster, and applied a firm roller. No haemorrhage
followed the operation. The pelvis was then firmly
secured and every effort was made to give motion to
the joint, that was consistent with safety or prudence,
but without the sliditest benefit whatever, and we
were all satisfied that an entire section of the bone by

AETIFICIAL HIP-JOIT^T.

351

the saw was tlie only way that tlie limb could be
moved from its flexed and fixed position. Tlie pa-
tient was nnder tlie full influence of chloroform, ad-
ministered by Dr. Jones, and was entirely insensi-
ble during the whole operation: The wounds healed
kindly in a few days, without suppuration, and she
was then in exactly the same condition as she was pre-
vious to the operation. As the weather was getting
warm, I determined to leave her until fall, and then
make a section of the bone above the trochanter minor,
and give her a chance to form an artificial joint, similar
to Anderson's case.

On the 6th Nov., 1862, assisted by Profs. Peaslee
and Raphael, and in the presence of Dr. J. P. Batchel-
der and Mr. Done, medical student, I performed the
following operation: The patient having been put
under the full influence of chloroform, a longitudinal
incision six inches in length was made over the tro-
chanter major, commencing just above its crest, and as
near as possible to its centre, and carried directly down
to the bone. About the centre of the incision I made
another at right angles to it, in the posterior flap, but
only carried it through the tegumentary and adipose
tissue and the femoral fascia. The blade of the knife
was then laid aside and with its handle and an eleva-
tor something like an ordinary oyster-knife, I carefully
peeled off the attachments from the bone, on its ante-
rior surface, until my forefinger could reach the tro-
chanter minor in front. The same thing was then
done on the posterior surface of the bone, and the two
fingers could then surround the bone, with the excep-
tion of a thin, firm fascia, between them on the front.
This was readily pierced by a steel sound, curved to
fit the femur, at this part, and a chain saw was then

352

A NEW OPEEATIOI^ FOR

drawn through above the trochanter minor, which
could be distinctly felt and was my guide.

About half an inch above it I commenced to saw,
and carrying it first iipioard and outward, then out-
ward, and then doionioard and outward, I made a
curved section with its concavity downward thus
/^""^ The saw was again passed around the bone,
as at first, and inserted about an eighth of an inch below
the first section, and the bone sawed square oif, at
right angles with the long diameter of the bone. The
segment thus removed was one-eighth
of an inch in front or internal margin,
three-fourths at its middle, and nearly
Fig. 7. half au inch at its external margin, as

seen in Fig. 7.

The bone was very dense in text-
ure, almost eburnated, as seen in Fig. 8,
which represents the lower section.
View of lower Thcr c was uot morc than two ounces
of blood lost in the operation, and no
ligature was necessary.

The wound was brought together by two sutures
and adhesive plaster, except the posterior incision,
which was kept oj)en by a tent of oakum. Adhesive

^ It will be seen that in this case I reversed the order of the section of
the bone from what I did in Anderson's case, and made the curved section
Jirst^ and I should advise the operation to be performed in this way, as it
is much easier, and you are more certain to make your saw enter at the
part desired when the shaft is complete, besides having the limb to keep
the parts steady while the section is made. And as it requires some little
delicacy of manipulation to carry a chain saw in this position in the curve
required, it is well not to add to the complication by having a movable bone.

It may be asked, why not make both sections curved ? Because it is
so difficult to do it with accuracy, wlien one end of the bone is movable,
and, as the rounding olf of the lower secti(>n is more simple and equally
satisfactory, I prefer it.

AETIFICIAL HIP-JOINT.

353

plaster was applied below the knee, for the purpose of
making extension, and a roller ai:)plied tolerably firDily,
from tlie toes u]), over the entire limb, and around the
pelvis.

She was then jDut in bed, the foot of which was
raised some twelve inches higher than the head, and a
pulley applied, over which a weight was attached by a
cord to the adhesive i3laster, for extension, the same as
in a case of fracture of the thigh. Lateral extension
was also applied to the upper j)ortion of the thigh, to
keep the upper end of the femur from crowding against
the femoral vessels, by means of a broad band passed
around the thigh and a cord attached to its outer as-
pect, which played through a. pulley fixed in an upright
by the side of the bed, just below the pelvis, and a
weight attached. By this means the limb was brought
in its natural position, parallel with the other, and ap-
parently of the same length. Ten drops of morphine
were given, with instructions to repeat if necessary.

The folio wino; record of the case is an abstract
from my note-book : •

JS'ov. l7tJi. — Has had a very comfortable night ; uri-
nated without scaldino; her lunbs, for the first time in
seven years. No haemorrhage, or much heat of limb ;
pulse 94 ; complains of pain in the back, otherwise per-
fectly well.

11 p. M. — Pain in the back very severe, just at the
lower lumbar vertebrae, which is carried very muchi
forward, and can only be relieved by being well bol-
stered up, and by raising the head and shoulders al-
most to the sitting posture.

IStJi. — Slept well all night, with only 10 drops of
Magendie's solution ; pulse 94, and only complains of
her back, which requires to be pressed frequently and

354

A NEW OPERATION FOE

quite firmly to make her comfortable ; as it was diffi-
cult to use a bed-pan, and without it the urine soiled
the bed and excoriated her person, I drew it by the
catheter, which can now be inserted without the least
difficulty.

l^tJi. — Wound commencing to suppurate at the
tent, the rest of the wound united by first intention ;
removed the sutures without disturbing the adhesive
plaster; pulse 94; bowels moved naturally, and, with
the exception of pain in the lower part of the back,
feels well.

Dec. 1st. — No particular change since last report ;
suppuration healthy and not profuse. The only com-
plaint she makes is from her back, and the difficulty
she has in using the bed-pan. I put her to-day upon
Dr. Nelson's fracture-bed, which is a triple inclined
plane, with an opening for defecation, and it has made
her very comfortable indeed — and the extension was
accomplished by simply flexing the legs at the knee,
over the inclined plane, as seen in Fig. 9.

Fig. 9.

This fracture-bed was first constructed by Dr. Kob-
ert Nelson, of this city, formerly of Canada, and for
convenience and comforfc, as well as fulfilling all the

AETIFICIAL HIP-JOINT.

355

indications required, is the most perfect contrivance I
have ever used, and I cannot speak too highly in its
favor.'

From the time the patient was placed upon it un-
til she entirely recovered, a period of nearly four
months, she was perfectly comfortable — could be raised
or depressed to any desired angle, as often .as required,
without inconvenience, which greatly added to her
comfort, by the change of position. The wound healed
entirely within four weeks, except a very small open-
ing in the posterior cut, which was at the most depen-
dent position, and from which a small discharge of pus
escaped ; this discharge gradually diminished and final-
ly ceased about the 1st of March, four months after
the operation. Two small pieces of bone escaped dur-
ing this time, the size of a ^^in's head. For some weeks
before its stoppage the discharge consisted of only a
few drops in a day, of a very peculiarly whitish-yellow
semi-fiuid, of the consistency of thick starch water, and
upon examination proved to be nearly pure albumen.

Fig 10.— Dr. Nelson's Fracture-bed.

^ In Hesselbach's Handbuch der Chirurgischen, printed in Jena, 1845,
will be found an almost exact duplicate of Nelson's bed on plate xxxix,
with a description on page 1036, as having been constructed by "Weckert ;
but as Dr. Nelson made his bed in 1820, we must give him the preference
of priority.

356 A NEW OPERATION EOR

After tlie first ten days from tlie operation I made
slight movements of tlie limb very frequently, in order
to prevent anchylosis, and this was also accomplished
by the extension, which kept the severed bones from
coming in contact with each other, and thus prevented
osseous adhesion.

I gradually increased the extent of these motions,
until, about the first of February, I could flex and ex-
tend, rotate, ad and abduct the limb with almost the
freedom of a natural joint, and could also press the
bones together with considerable force without pain.

On the 8th of February, 1863, she got out of bed
for the first time — the limbs are perfectly symmetri-
cal and parallel — the left nearly three-quarters of an
inch shorter than the right, when her weight is put
upon it ; but when she stands erect upon the other
limb, it falls down, and is nearly, if not quite, as long
as its fellow. By pressing it up, you can shorten it a
fall half-inch, and by concussion it gives a smooth,
cushioned feel to the hands, without any
cre23itus or pain to the patient.

Jiihj 20tli, — She begins to have some
control over the movements of her limb
by voluntary muscular contraction, and
can bear nearly her whole weight U23on it
as seen in Fig. 11.

The motions are nearly as perfect as
those of the natural limb. From the per-
fect success attending the operation in
these two cases of true anchylosis, and
the freedom from all danger, as well as
ease of its performance, I feel justified in
Fig. 11. recommending it to the profession as safe,
and am satisfied that it will become established as one
of the proper 02:)erations in surgery.

ARTIFICIAL HIP-JOINT.

Sequel.

Tlie patient progressed rapidly and favorably dur-
ing several weeks, being able to bear her entire weight
on the affected limb, with perfect freedom to j)assive
motion, and gradual increase of control over the volun-
tary movements.

She was acquiring sufficient command over the
limb to enable her, as the result of practice, to walk
around her room, the exercise conducing to the im-
provement of her general health, as well as to the
education and development of muscles which had long
remained dormant ; when, about the 1st of February,
in opposition to my advice, she removed her flannels.
She remained with them off for several days, and, on
the 4th and 5th of February, being exposed for some
hours to the intense cold then prevailing, she had a
severe chill, followed by great difficulty in breathing,
pain in the chest, cough, etc., arising from congestion
of the lungs.

She neglected to send for me at once, and when
she did, I was out of town, and she refused other
medical attendance. * She grew worse rapidly, and
when I saw her upon my return, I at once recog-
nized her condition as one of extreme danger, and re-
quested the presence of Dr. Flint in consultation.

We found the left lung had become almost hepa-
tized, and for some days no respiration could be de-
tected on that side. Under treatment resolution
gradually took place, with the exception of an abscess
in the upper lobe of the left lung, which Dr. Flint
thought was the result of an apoplectic effusion. Dr.
Flint did not, at this time, diagnosticate tubercles, but
did at a later period.

358

A ]S"EW opeeatio:n" for

To the pneumonia was superadded, iii a sliort
time, pleurisy of tlie left side. The urgent synijotoms
of the j)neunionia were subdued, but the cough, which
was very distressing, continued. There was no expec-
toration at any time.

Under a sustaining j^lan of treatment, with sj)irits
of turpentine locally over the he]3atized lung, she im-
proved, and I was encouraged in the hope that the
abscess might become sacculated, and remain circum-
scribed.

The weather, up to about the middle of April,
had been too inclement to allow her the advantao-es
of passive out-door exercise, which, together with
nourishment, was now considered the j^i'incijDal treat-
ment reqrured.

Durino^ all this time the couo'h had remained of
the same racking, distressing character, and without
expectoration.

On the 20th of April, she complained of some ]3ain
in the vicinity of the cicatrix of the wound left by the
operation, and the lower part ^of the wound became
inflamed and puffed out, although it had been closed
several weeks.

On the 22d, an abscess having formed, the wound
opened, and a small cui'ved j)ieee of bone escaped,
about one- eighth of an inch long, and of the thickness
of an ordinary probe, quite rough and jagged.

The wound discharged a little bloody pus for a
few days, after which it gradually merged into the
same kind of oily fluid as had exuded during some
months subsequent to the operation.

This, in a few more days, began to diminish, and
gradually the wound again closed, leaving no tender-
ness upon ]Dressure, or from motion of the new joint.

AETIFICIAL HIP-JOIXT.

359

Slie could again bear lier whole weight u]oon the
limb without inconvenience, and her command of its
movements materially improved.

About the 1st of May she changed her residence,
and for a number of days improved raj)idly in strength
and flesh, the principal annoyance being the cough.

On the 10th of May, having business out of town,
I left the case in charge of Dr. Flint, who prescribed,
for the cough, codeia, four grains, to simple syrup, four
ounces, with directions to the nurse to give the pa-
tient a teaspoonfiil once in three hours while the pa-
tient remained awake, but to discontinue it while she
slept.

During the night, as the result of larger and more
frequently repeated doses of this mixture than had
been ordered — which appeared from the admission of
the nurse, and the small quantity left in the bottle —
the patient had become thoroughly narcotized, and
subsequently suffered for more than forty-eight hours,
with most alarming symptoms of narcotic poisoning.

The utmost exertions on the part of Drs. Flint,
Peaslee, and "Wells, were required to sustain life,- in
consequence of the sfomach rejecting stimulants, cof-
fee, etc.

The cough had now entirely ceased, a-nd never re-
turned.

Great distress in the lungs was complained of, and
partially relieved by counter-irritants. The stomach
continued so weak as not to retain even a teaspoonfiil
of iced water.

On the 12th she had recovered from the severe
symptoms, when a relapse occurred from the admiois-
tration of another dose of the codeia, in direct viola-
tion of orders that no more should be given, which it

360

A l^W OPERATIO^^ FOR

seems were misunderstood by tlie nurse. During tlie
niglit the patient was violently delirious, lier screams
arousino' and disturbino; the household until mornino:,
when Dr. Wells administered, by inhalation, a small
quantity of chloroform, which at once calmed the pa-
tient, and she slej)t for several hours.

I returned on the 13th, and found her still in a
wild and distracted state of mind, and excessively ]3ros-
trated, the stomach not having retained any thing for
several days.

The process of nutrition was necessarily suspended,
and the patient was dying in consequence.

The stomach had lost all tone as the result of pro-
tracted narcotizing induced carelessly, but with hu-
mane intent, and she was now sustained by enema.

On the 14th she had rallied, and become quite
cheerful, but had no recollection of the terrible ordeal
through which she had passed. Later in the day, while
I was sitting by her bed, she suddenly had two severe
convulsions, durino; which her lower limbs were flexed
at a right angle, and strongly adducted, the left one
requiiing almost as much force to straighten as the
rig:ht.

The nurse stated that the patient had had a simi-
lar fit during the preceding night, the limbs being fixed
in the same manner for a long time, and that when
the spasm passed off she voluntarily straightened her
limbs.

On the 16th she sat up about an hour, and after
getting back in bed, discovered that the wound had
again opened and discharged a few drops of bloody
serum.

She passed a remarkably good night, and on the fol-
lowing day felt so much better that she begged me to
allow her to take a ride the next day.

AETmCIAL HIP-JOIXT.

361

I tried to persuade her that she was too weak, but
she was quite iroportunate, and after I had left, in
order to test her strength in view of the anticipated
ride, she got out of bed, and sat up in a chair for two
hours.

The exertion was too much, and she fainted.

I was hurriedly summoned, and found her cold
and pulseless, excej)t at the carotids. Pupils much di-
lated; jaws relaxed; respiration very feeble and slow;
unable to swallow. Brandy was given in enema, but
not retained.

She gradually recovered consciousness and ability
to talk, which she did rationally, but grew weaker and
weaker until about six p. m., on the l7th, when she
died fi'om exhaustion.

Post MoPvTem. — An examination of the body was
made about thirty-six hours after death, in the pres-
ence of Profs. Bush, of Lexington, Ky. ; Parker and
Kaphael, of New York ; and Drs. Spencer, of Water-
town ; Batchelder, Dewees, Stone, Elsberg, Wells,
Swift, Doyle, and Peck, of New York.

The body was extremely emaciated ; the left leg be-
ing parallel with the right, the foot lying in the natu-
ral position, and was found to be half an inch shorter,
and admitted of free, j^assive motion in all directions
without crepitation. Upon opening the thorax, adhe-
sions were noticed of various portions of the pleura and
lungs, and a large abscess in the anterior portion of
the upper lobe of the left lung. Two quite small
abscesses were found in the lower lobe of the right
lung, but neither of them communicated with the
bronchi.

There was infiltration of deposit throughout the
substance of the upper lobe of the left lung, which.

862

A NEW OPEEATION YOU

under the microscope, was determined by Dr. Dewees
to be tuberculous.

Upon examination of tlie artificial joint, it was
found to be provided with a complete capsular liga-
ment, and the articulating surfaces were tipped with
cartilage, and furnished with synovial membrane. (See
Fig. 12.)

Fig. 12.— a, a, a, a, capsular ligament opened and reflected ; b, b, round ligament m
imitation of ligamentum teres ; c, articulating head of lower section, covered Avith car-
tilage ; d, d, new acetabulum, covered with cartilage ; both lined with synovial membrane.

There was a very small spicula of bone, which had
exfoliated from the lower section in the orifice of the
external wound, and which w^ould have escaj^ed in a
few days. Four other small fibrillse of bone, about
one-half inch in length, and the thickness of the lead

AETIFICIAL HIP-JOIXT.

363

of au ordinary pencil, were found attached at one of
tlieir extremities, by periosteum, to the margin of tlie
new liead of tlie femur ; tlieir three extremities were
thrust into the tissue around the joint. They were
easily pulled off, having nearly exfoliated, and doubt-
less would have come away as the other pieces had
done, had the jjatient lived.

All the other parts of the head and the new ace-
tabulum were smooth, and covered ^vith cartilage.

The conjunction of the articulating surfaces was per-
fected by the formation of two round ligaments spring-

Fig. 13.1

A. Anterior superior spinous process of ilium.

B. Posterior superior spine.

C. Anterior inferior spine.

D. Pubis.

E. Trochanter major, completely fasei by bony anchylosis with innominatum.

F and G. The capsular ligament— a piece having been removed to show the interior o
the joint.

H. New acetabulum, formed in the trochanter major.

I. Xew caput femoris.

From H to I, a ligament (lig. teres), in shape of a V or T, extends, as shown in the

drawing.
K. Shaft of femur.

^ This drawing, wMch represents the specimen in its present condition,
Tvitli the ilinm fixed in its proper position, has been prepared for me by
Dr. L. M. Tale. The view is taken in the reverse position to the one repre-
sented on the opposite page.

364

A NEW OPERATION FOR

ing from tlie surface of the new acetabulum, and by
tlieir convergence at the same point of attachment to
the new caput femoris formed a new ligamentum teres.

These converging portions of the ligament were
fan-shaped, and united at the sulcus of the new head
of the femur.

A portion of the ilium, together with the cotyloid
cavity, containing the anchylosed head of the femur,
Avas removed, and, upon section through the original
acetabulum and caput femoris, only a slight line of de-
marcation was discoverable, the whole joint being fused
into one solid, bony mass. (See Fig. 14.)

Note. — As I Lave recently exsected a perfect artificial joint, in a case of
ununited fracture, and Avhich was examined by Prof. Austin Flint, Jr., and
found to possess all tlie characteristics of the natural joint, and as I have
not been able to find an examination of this kind recorded, I publish it in
connection with this paper, as it illustrates the manner in which Nature
efi*ects a cure in these cases.

Fig. 14.

Exsection of Ununited Ulnar— Perfect False Joint, with Capsule and Cartilage.

Mrs. G., aged 34, was admitted into the medical wards of Bellevue
Hospital, in August, 1861, suffering from paralysis. In September she fell,
whilst attempting to get out of bed, and fractured both bones of the forearm.
She partially recovered from her paralysis, but the bones never united, and
she was sent to the Island Hospital, and came under ray charge in Feb-
ruary, 1863, seventeen months after the accident.

She had so far recovered from the paralysis as to be able to walk tol-
erably well, and the- upper extremities were as muscular and powerful as

AETinCIAL HIP-JOmT.

365

ever, -but the right arm was entirely useless on account of the ununited
fracture about tlie junction of the middle and upper third of the forearm.

On the 19th of February, 18G3, I cut down upon the bones at
this point, intending to saw off the ends of the ununited portions and
obtain reunion by a readjustment of the bones, but, when I came down
to the point of fracture, I found it had been
very obli(iue, and separated about a quarter
of an inch, thus, and had become attached
by a very firm ligamentous band, which
admitted of quite a free gliding motion,
without any crepitus whatever, and I de- \ /

cided to remove the entire portion, without 1/
severing the attachments of the artificial

joints. Fig. 15.

I therefore sawed out a portion half an inch in length, which embraced
the artificial joint, and brought the bones fairly together and dressed with
splints in the natural position, with the exception of the necessary short-
ening.

One of tho sections passed through the new joint at thus giving an
opportunity of examining its internal character and structure. B shows the

' Fig. 16.— Cartilage, Cavities and Cells.— A, cart, cavities without cells. B, car-
tilage, cavities and cells.

lines of the saw. The ligamentous attachment was more than one-eighth ot
an inch in length, very firm — tense, and of a silvery shining whiteness. On
looking at the open section, it had the smooth and oily appearance of a
natural joint, and the motions of the bones upon each other were per-
fectly gliding, without any friction or roughness.

Dr. Austin Flint, Jr., examined the specimen by the microscope, and re-
ports that the lining is true cartilage, and it is therefore as perfect in all its
physiological characters as any natural joint.

The annexed diagram (Fig. IG) shows the cartilage, cavities and cells, as
taken by Dr. Flint under the microscope.

366

A NEW OPEEATIOIsr FOE

APPEjSTDIX.

Letters received from gentlemen present at tlie
autoj)sy :

BixGHAMPTON, New Yoek, April 24, 1868.

Peof. Satee —

Deae Sie : In perusing the work of Dr. Bauer, on Orthopedic Surgery,
I was somewhat surprised to read there (page 325) as follows : " Sayre, a
few years ago, performed this operation (artificial hip-joint), as he alleged,
with success, although his patient died shortly after with pytemia. The
specimen derived from the case did not prove the assertion of that gentle-
man ; no cartilaginous covering, synovial lining, or capsular ligament hav-
ing been found."

This quotation refers to the case of Miss Losee.

As I frequently saw the patient, and took a particular interest in her
case, I feel it my duty to disabuse the pubhc of the false impressions which
Ills statements are likely to produce. You can therefore, if you deem it
proper, publish the following facts, to which I can clearly testify:

Miss Susan M. Losee, on whom you performed the operation for arti-
ficial hip-joint, was seen by me several times during the month previous to
her decease. As far as the operation was concerned, it seemed in every
way a complete success; but it was very evident to me that she was in the
last stage of phthisis pulmonalis, in consequence of which her death took
place on the 17th of May, 1863.

In company with several other medical men, I was present at the
autopsy, which revealed important facts, which go strongly to sustain not
only the feasibility, but also the justice, of the operation. On opening the
thorax, the lungs were found to contain a large amount of tuberculous de-
posit, much of which had broken down, leaving several cavities. Our
attention w'as next turned to the limb on which the operation had been
performed. It was found to possess the property of being moved, with
ease, in any direction, without crepitation ; the artificial joint was then
dissected down to, and was found to be provided with a capsule, very
much resembling the capsular ligament of the normal hip-joint, being
complete, and lined with a synovial surface. On opening the capsule, to
get an interior view of the joint, w^e found the articular surfaces covered
with cartilage, and provided with a double ligament, which seemed to
answer all the purposes of a veritable hgamentum teres. In order to leave
no doubt as to the substance on the articular surfaces being true cartilage,
a portion of it was examined under the microscope by an eminent physi-
ologist of New York, and found to contain cartilage cells. The ligament
was bifurcated, having a single origin in the head of the bone, and then
separating, and finding an insertion at two diff"erent points in the new
acetabulum.

Tlje specimen w\as taken from the body, and I prepared it for preser-

AETIFICIAL HIP-JOINT.

367

vation. I also made drawings of it while fresh, and took it to tlie photog-
raphers, and had a picture taken from it, in order, as you remarked at
the time, that there might be no room for any one to thhik that the draw-
ings were incorrect. Engravings made from the photographs were shortly
after published in the Transactions of the Medical Society of the State
of Neio Yorlc.

J^ow, the conclusion I draw from the case in question is this: if
the operation succeeded so well in a tuberculous subject, how much better
and more practicable would it have been in a perfectly healthy person !

Dr. Bauer makes large mistakes in his assertions as to there being no
cartilage, synovial lining, etc. He knows, as every surgeon ought to
know, tliat very often cases are met with where artificial joints are acci-
dentally formed, as a consequence of non-union of fractures — the distal
and proximal extremities being covered with true cartilage. jSTow, if
Nature, under all tlie disadvantages of accidental contingencies, can form
a new and nearly perfect joint, how much more effective would be her
reproductive powers, if judiciously assisted by the skilful resources of art!

In conclusion, then, I feel justified in saying that the case of Miss
Losee was a success, as far as the operation for artificial hip-joint was
concerned ; and it clearly illustrates the practicability of the operation,
and affords a precedent for similar operations, which will yet be performed
for the relief of suffering humanity.

I remain, as ever.

Yours truly,

Geegoet Dotle.

Prof. Sayre, Few York.

Lexington, April 23, 1868.

My dear Doctoe : Yours of 14th April just received. I was present,
with several professional gentlemen. Prof. Parker among the number, at
xhQ post mortem of your artificial hip case, w^hicli proved satisfactorily that
the patient died of tubercular consumption.

The specimen derived from the case offered a beautiful illustration of
artificial joint with cartilage, capsular, synovial, and ligamentous structures,
produced by the operations of Nature, after surgical skill had prepared
the parts. You may remember I pointed out the interarticular ligaments,
one of which had been separated at one of its attachments, by the too free
manipulations of the limb, by one of the gentlemen present. These inter-
articular ligaments were the most remarkable feature in the development
of the joint ; and you may not have forgotten my remark to you, upon the
examination of the specimen, subsequently, at your office — "How wonder-
ful and beautiful was Nature in this reproduction of even the ligamentum
teres, in constructing the new hip-joint for your patient, imitating so well
the anatomy of the normal articulation ! "

Most truly your friend,

J. M. Busii.

368

A NEW OPERATION FOR

Elizabeth, N. J., Api^il 29, 1868.

Mtdeae Doctoe : In a yolume entitled " Ortliopedic Snrgery," by Dr.
L. Bauer, at page 325, 1 am surprised to find the following sentences, which
are so entirely at variance with my personal knowledge of the facts of the
case referred to, and so unjust to you as an honest surgeon, that I desire
to add my testimony to that of others, who saw the perfect success of the
operation upon Miss Losee, while they in common with us regretted her
untimely decease, not from pycemia but irom phthisis j^ulmonalis.

The sentences referred to are these: "But it would seem to me, that the
attempt at establishing an artificial hip-joint, at the line of division, is un-
warrantable for two reasons : 1. An artificial joint could never give a
snfiicient support to the superstructure of the body. 2. It inevitably
protracts the suppuration, with its impending danger of pytemia. Sayre a
few years ago performed this operation, as he alleged, with success, but his
patient, nevertheless, died in a few months after from pyaemia.

"The specimen derived from this case did not sustain the assertion of
that gentleman ; no cartilaginous covering, synovial lining, or a new cap-
sular ligament having been found."

It was not my privilege to be present at the operation upon Miss
Losee, but I saw her frequently afterward, and watched with great inter-
est the progress and success of her treatment. It was in the spring follow-
ing the operation. I was present when you placed her upon her feet; and
she was able to bear the weight of her body upon the limb that had been
operated upon. She was gaining gradual control over the muscles of the
part, and the artificial joint yielded freely to passive motion without pain.

I was present at the wor^em of Miss Losee. Upon opening the
thorax, the upper lobe of the left lung was discovered to be infiltrated
with a tuberculous deposit, and a large abscess was found in the anterior
part of the upper lobe of the lung of the same side.

Upon opening the artificial joinjt, the upper end of the femur was
found to be rounded, and covered with a smooth white covering, which
looked to me very much like cartilage covered by a synovial membrane;
at any rate, it admirably answered that description; this was also true of
the new acetabulum. The capsular ligament was there to all intents and
purposes, formed out of the periosteum you had left, which had been
thickened by Nature for its new oflBce; and, more wonderful than all to
me, she had furnished this new joint with a ligamentum teres, and a bifur-
cated one at that.

To the mind of an honest medical observer of Miss Losee's case, either
during her life, or at her autopsy, there could be no question of the entire
icarrantability and success of the operation, of the fact that she did not
die ofpycBmia, as the result of the operation, and did die of phthisis pul-
monalis.

But before I close this letter, I wish to say one word about the case
of Robert Anderson (whom Dr. Bauer seems to be sadly ignorant of,

AETIFICIAL HIP-JOmT.

369

notwithstanding his case was reported in tlie same pamphlet as that of
MissLosee), upon whom yon operated in June, 18G2, for artificial hip-joint,
and who still lives, moves, and walks, with practical agility. I was pres-
ent at the operation. The left hip-joint was firmly anchylosed. Before
the operation, his only mode of locomotion was hy twisting himself from
side to side, first on one foot and then upon the other. I saw him a num-
ber of times, at Bellevue Hospital after the operation, and on the night
before he went home I happened to meet him at your oflace in Broadway,
into which he walked unassisted. He could step some twenty inches with
either leg, stand on either limb without artificial support, and abduct his
limbs with ease while on his crutches.

]^ow, all this I saw, and therefore I say I am surprised to find such
sentences as I have quoted from Dr. Bauer's work, since both these cases
prove that the artificial joint "give sufficient support," and that, as
far as experience goes, pyaemia is not an imminent consequence of the opera-
tion for the artificial hip-joint, and also that Miss Losee's autopsy did " sus-
tain the assertion of that gentleman," in regard to cartilage, synovial mem-
rane, capsular ligament, etc.

Very truly yours,

James S. Geeex.
Wateetown, May 21, 1868.

De. Sayee —

My deae Sie: According to a statement made in Bauer's new work,
you do not obtain much credit for the very valuable addition to the new
and beautiful operation for anchylosis of the hip. You will remember my
being present at the post-mortem examination, also at the meeting of the
surgical section at Prof. Wood's ; and, as I have paid some attention to cases
of hip-joint disease, I took great interest in the case mentioned, and I think
now as then, that the case was one of the most perfect cure. Both ends
of the femur, from which the block was sawed, were perfectly covered
with firm and solid cartilage, and Nature, in imitation of the ligamentum
teres, had formed one from the lower portion upward about half an inch
when it bifurcated, and each portion was attached to the upper portion of
the femur. She had also formed a complete capsular ligament with a
small fistulous opening, where she was attempting to throw out two or
three small spicula of exfohated bone, from the cavity of the newly-formed
joint.

If Dr. Bauer could talk with Dr. Parker, who made a very thorough
trial, by manipulation, before the joint was opened to obtain crepitus and
failed, he would, I think, be convinced of the genuineness of the cure.

It was decided at the examination and at the evening meeting, that
Miss Losee died of phthisis.

Yours truly, etc.,

H. GoEDOx P. Spexcee, M. D.

370

A N:EVi OPERATION FOE

Davenpoet, Iowa, J/ay, 1868.
Deae DooTOE Sayee : Your note of tlie present month in relation to
the j:>6>s^-«^cr^e/?^ examination of Miss Losee, at which I was present, and
on whom you had operated for an artificial hip-joint, is received. I had the
pleasure of seeing Miss Losee in company with you, wlien I was House
Surgeon at Bellevue, several times, and as a consequence was much inter-
ested in the result of the case, knowing minutely the number of difficulties
under which you labored, in operating upon and in the treatment of the
unusually interesting patient. I remember that there were pleuritic adhe-
sions in both sides of the chest, together with an abscess in the upper
right lobe, and, what we know to be very uncommon, two small abscesses
in the lower lobe of the left lung. There were also large quantities of
tubercular deposit in both lungs. On. making a careful examination of
the seat of operation, we found an extremely interesting pathological con-
dition, viz.: a perfect artificial hip-joint, with perfect anatomical rela-
tions ; a capsular ligament, two ligamentum teres, both of which were at-
tached to the articulating surfaces of bones. Each end of bone was, to my
surprise, covered with synovial membrane and genuine cartilage, as was
afterward corroborated by Dr. Flint, Jr. The original hip-joint was in a
condition of perfect cementation, and as a joint obliterated. The entire
specimen was removed, and if I mistake not you have it in your museum.
Should I come to New York this summer I shall hope to enjoy the pleas-
ure of giving it an examination. You remember how satisfactory the
movements were during life, and painless.

Very truly yours.

W. F. Peck, M. D.
Lewis A. Sayre, M. D., 285 Fifth Avenue, New York.

153 West 15th Street, JSew Yoi'h, June 3, 1868.

Peof. Satee,

Deae Sie : In the latter part of the year 1862, you showed me the case
of Susan Losee, upon whom you had performed your operation for artifi-
cial hip-joint; and in May, 1863, together with yourself and Drs. Batchel-
der. Bush, Dewees, Doyle, Parker, Raphael, Stone, Swift, and others, I
was also present at the post-mortem examination. On this latter occa-
sion, nothing abnormal could be detected in the position of the leg or foot
of the affected side, on external inspection ; though, on pushing the left
foot toward the trunk, some shortening of the limb was perceived. On
taking hold of it, it was found that all the various movements could be
executed as well on the left as on the right side, and the new joint was
perfect. Altogether, I can testify that the specimen is, in every respect,
correctly figured and described, on page 17 of your pamphlet (extracts from
the Transactions of the State Society, 1863, p. 125), from the words " upon
examination of the artificial joint " to "new head of the femur."

Very respectfully yours,

L. Elsbeeg.

ARTIFICIAL HIP-JOmT.

871

19 East Nineteenth Street, July 17, 1868.
Deae Doctoe ; I was present at the autopsy of Miss Susan M. Losee.
The description of the appearance of the artificial joint, which you
gave in the published account of the case, is correct in every particular.

B. I. Eaphael, M. D.

Prof. Lewis A. Sayre.

Bellevue Hospital Medical College,
April 29, 1868.

Peof. L. a. Satee —

Deae Sie : In May, 1863, 1 received from you a specimen of a portion
of the ilium, with the upper extremity of the femur, taken from a patient,
upon wliom you had operated, just below the great trochanter, for the pur-
pose of making an artificial joint, the natural hip-joint being completely
and irremediably anchylosed. *

The patient's name was Susan M. Losee, and she died, as I heard, of
tuberculosis, some time after the operation.

The specimen which I examined was the cut end of the femur, with a
portion of the pelvic bones, forming a new joint. I found this end of the
femur incrusted with true articular cartilage, and sent you, at the time, a
report of the microscopical examination, with a drawing, showing the
cartilage cavities and cells.

Yours very truly,

A. Flint, Je.

Lewis A. Satee, M. D. —

My deae Dootoe : I was present at the post-mortem examination of Miss
Losee in 1863. I can confirm your statement as regards the pathological
findings in the parts, as well as the physiological separations — viz., the re-
generation and replacement of synovial membrane, and of the necessary
cartilaginous formations, as well as the formation of a capsular and an
interarticular ligament — the latter of which had been reproduced in a
double or bifurcated prolongation.

I remain,

Yery truly,

H. P. Dewees.

New York, October 1, 1868.

40 East Thirtieth Street, October 16, 1868.
My deae Doctoe : I recollect being present, at your request, at the
autopsy of Miss Losee; that she died of phthisis; and that, in the limb on
which you had previously operated for the establishment of a false joint,
a new capsular ligament, interai'ticular cartilage, and ligamentum teres
were found.

Yery truly yours,

Fostee Swift, M. D.

Dr. Sayre.

372

A NEW OPEKATIO]^-, ETC.

New Yoek, October 15, 1868.
. Dear Doctor : Agreeably to your wish, I, with pleasure, give from
memory an account of what I saw at post-mortem examination of Miss
Losee.

The lungs were infiltrated with tubercles, which had caused her death.

The extremity of the femur, where it had been sawn, was covered with
cartilage, but there was a very small portion, rough to the touch, which
caused some discussion whether or not it was covered with cartilage.
These rough points were not like ulcerated bone, and the little dimples, or
depressions, between them, were satisfactorily covered with cartilage ; and
I believe that the whole sawn surface was, in the opinion of those present,
also covered with the same.

One of the most remarkable and interesting facts was the growth of
a ligament Qigamentum teres), which extended from the upper sawn
surface to the lower.

Externally, to the bone, there were also appearances of a new capsular
ligament.

The whole case, as to the operation and its results, was, to me, unique
and extremely interesting, and will be of invaluable use in illustrating
what may be done for such dreadful deformities, as well as showing, when
an artificial joint is sought for by an operation, that cartilage will not be
wanting to cover the bones, and that the necessary ligaments will be re-
formed to hold the joint together.

Very truly yours.
Dr. L. A. Sayre. . John O. Stone.

New York, September 29, 1868.

Dear Doctor : In reply to your inquiry, I beg to state I was present
at the examination of the body of Miss L , in the spring of 1863.

I made a full examination of the limb operated upon, and the motion
was free at the new joint. The parts were then laid open; the new joint
consisted of a firm structure surrounding the point of operation, and made
a capsular ligament. On opening this capsular ligament, the cavity was
found to be lined by a synovial membrane, smooth and lubricated. Be-
tween the sawed surfaces of the bone an interarticular ligament was found.
The case was of great interest, inasmuch as it verified views which we
had under discussion.

Yours, etc.,

WiLLARD Parker.

To Prof. L. A. Sayre.

Tlie following letter is from tlie father of Miss
Losee :

Jersey City, May 13, 1868.

Dr. Lewis A. Satre, New Y^ork —

Dear Sir : I saw in a medical book published lately, the author's name
I have forgotten, stating that my daughter, Susan M. Losee, died from the

GLYCOGENIC FUIS^CTION OF THE LIVEE. 373

effects of the surgical operation you performed on her, in November, 1862,
for the purpose of forming an artificial joint near the hip-joint. The state-
ment made by the author of that book is entirely unfounded and untrue ;
the operation was a perfect success.

The sore had healed up some time before her death. She was able
to stand upon and raise that limb some weeks before l;er death, as you
well know. She died of lung complaint, from the effects of a severe cold
she took in February of 1863, by the carelessness of her nurse, which
caused her death ; not from the effects of the operation.

"With great respect, I am.

Most truly yours,

S. LosEE.

Aet. II. — Experiments undertciken for the Purpose
of reconciling some of the Discordant Observations
upon the Glycogenic Function of the Liver. By
Austin Flint, Je., M. D., Professor of Physiology
and Microscopy, in tlie Bellevue Hospital Medical
College, New York, etc.

When it Avas announced by Bernard, in 1848, that
he had discovered a new and important function of
the liver, there being in this organ a constant produc-
tion of the same variety of sugar that had long been
recognized in *the urine of diabetic patients, the great
physiological and pathological importance of the dis-
covery, attested, as it was, by experiments which
seemed to be absolutely conclusive in their results, ex-
cited the most profound scientific interest. During tlie
present century, indeed, there have been few physio-
logical questions which have attracted so much atten-
tion ; and the observations of Bernard were soon re-
peated, modified, and extended by experimentalists in
different parts of the world. In 1857, Bernard dis-
covered a sugar-forming material in the liver, analo-
gous in its composition and properties to starch ; and
this seemed to complete the history of glycogenesis.

374 GLTCOGElvriO FUNCTIO^sT OF THE LIVEE,

I do not propose at this time to give an extended
review of the experiments which have "been made in
diiFerent parts of the world with the view either of
confirming or overthrowing the theory advanced by
Bernard; but will discnss the two opinions which
are now most prevalent in English and French physio-
logical literature. These two opinions are the follow-
ing:

Those who accept the experiments of Bernard
as conclusive assume that the substance of the liver
and the blood in the hepatic veins always contain
sugar. This sugar is believed to be formed in the so-
called hepatic cells, from the glycogenic matter con-
tained in them ; and to be taken up by the blood as
it passes through the liver, existing in the hepatic
veins, the ascending vena cava, and the right side of
the heart. It usually disappears from the blood in its
passage through the lungs. Sugar is believed always
to exist in the liver, the blood of the hepatic veins, and
the right side of the heart, independently of the kind
of food used. In the carnivora, the blood of the portal
system never contains sugar when the animal is con-
fined to a diet of nitrogenized and fatty matters ; but
sugar is found none the less invariably in the liver
and the vascular system between this organ and the
heart.

Others have accepted the view advanced by Dr.
Pavy, of Guy's Hospital, who professes to have demon-
strated that neither the liver nor the blood circulating
between the liver and the heart ever contains sugar
during life, but that the sugar which has been found
in these situations is the result of a 2^ost-mortem change
of the glycogenic matter, or, as it is called by Dr. Pavy,
the amyloid matter of the liver.

glycogejS-ic ruxcTio:^r of the liver. 375

These two opposite views are supported by experi-
ments wMcli seem to be conclusive ; yet it is evident
that, if tlie observations in both instances be entii'ely
accurate, tliey must prove precisely tlie same fact. It*
was in the hope of harmonizing these discordant opin-
ions, that I undertook some modifications of the ex-
periments of Bernard and Pa\'y. I will not discuss
the accuracy of the methods employed by these emi-
nent observers, but intend merely to follow out a
train of reasoning, which seems to me to be fully sus-
tained by experiment, and which I believe will lead to
a correct interj^retation of the aj)parently opposite re-
sults heretofore attained.

Since the summer of 1858, 1 have been in the habit
of rejDeating, several times each year, the experiments by
which Bernard demonstrated the glycogenic function
of the liver, performing the vivisections chiefly as class-
demonstrations. I have followed most of the modifica-
tions of these experiments, which have been published
by Bernard from time to time, and have almost always
confirmed in every particular the results obtained by
this eminent physiologist. I have never failed to
demonstrate the absence of suo:ar in the blood of the
portal system, when the specimens were taken with
proper precautions from carnivorous animals that had
taken neither starch nor sugar into the alimentary
canal. I have found it imj^ortant to apply a ligature
rapidly to the portal vein as it penetrates the liver, and
to make a very small opening into the abdominal cav-
ity in this step of the experiment. When I have de-
tected a trace of susrar in the clear extract from the
portal blood of an animal in the condition just men-
tioned, it has been consequent upon delay in seizing
the vein; and I have anticipated the probability of

376

GLYCOGEISriC FU]S'CTIO]S' OF THE LIVEE.

finding sugar from blood, which, nnder these circum-
stances, regurgitates from the liver. The necessity of
emj^loying these ^precautions is fully insisted upon by
'Bernard. I have never failed to find sugar in the blood
of the hepatic veins of healthy dogs that had taken
neither starch nor sugar into the alimentary canal.
In my earlier experiments, I never failed to find a
great abundance of sugar in the substance of the liver,
in dogs under the same conditions. In one instance,
however, in the winter of 1859-60, I failed to find
sugar in the liver of a dog that was affected with what
is known as " mange ; " but considered this to be due to
the peculiar condition of the animal.

On several occasions I have repeated Bernard's ex-
periment of analyzing, for sugar, the portal blood, the
substance of the liver, the hepatic blood, the blood
from the right side of the heart, the substance of the
lungs, the blood from the arterial system, and the sub-
stance of the muscles, the kidneys, and the spleen, all
the specimens being taken from the same animal. I
have always found that sugar existed only in the sub-
stance of the liver, the blood from the he2:>atic veins,
and the rio'ht side of the heart, and in no other situa-
tions ; showing, apparently, that sugar is constantly
being produced by the liver, and is carried by the cii'-
culating blood to the lungs, there to be destroyed.
Upon several occasions I have drawn the blood fi^om
the right side of the heart of a living animal, by
catheterization through an opening into the right
external jugular vein — a manipulation which presents
no difficulty — and have never failed to find sugar.
This experiment I have done w^ithout the administra-
tion of ether, following the operative procedure de-
scribed by Bernard.

GLYCOGEjN'IC FUIS^CTION OF THE LIVER. 377

I have also frequently repeated the experiment of
passing a stream of water through the liver from the
portal vein, by which all the sugar can be removed in
a short time, and testing the substance of the liver a
few hours after, it having been tept in the mean time
at a temperature of from 80° to 100° Fahrenheit. In
this experiment I have always found an abundance of
sugar. The glycogenic matter out of which this sec-
ondary formation of sugar is sujDposed to take place, I
have extracted and studied after the method proposed
by Bernard, and have confirmed his observations on
this substance in every particular.

In these experiments I have used the various cop-
per tests — viz., Trommer's, Barreswill's and Fehling's,
and have made my clear extracts, generally, by boil-
ing with an excess of sulphate of soda, but very often
by mixing the blood or the watery extracts of the tis-
sues with animal charcoal and filtering.

The theory advanced by Pa\y, that sugar is not
produced by the liver during life, and that, when this
substance is found in the liver, it is the result of ^j>(95^
mortem change of the glycogenic matter (which he calls
the amyloid substance), always seemed to me to be
invalidated by the experiment of catheterization of
the rio^ht side of the heart in a livino^ animal, without
the administration of ether ; for, in the blood taken
under these conditions, the presence of sugar is unmis-
takable. It beino; admitted that suo;ar is contained in
the blood passing out of the liver, when ether has been
administered, and the fact that sugar is sometimes
produced in the body, in cases of diabetes mellitus
(for there are undoubted cases in which sugar is dis-
charged in the urine, when neither starch nor sugar
has been taken as food), j^oint to the probable nor-

378 GLYcoaEmc function of the livee.

mal production and destruction of tMs principle in tlie
economy. Sugar can hardly be regarded as a heterol-
ogous substance, nor as a product of decomposition ;
and it constitutes an important article of food, from
the fact that it is consumed in the body in connection
with certain of the processes of nutrition. The hypoth-
esis, that all the sugar which may be taken as food,
and all that results of the digestion of amylaceous
matters, is deposited in the liver in the form of amyloid
matter, is inadmissible ; and the pathology of diabetes
cannot be satisfactorily explained by assuming that,
under this condition, there is a deficiency in the forma-
tion of amyloid substance, by the liver, out of the
starchy and saccharine alimentary principles.

Dr. Pavy, however, asserts that the liver never
contains sugar during life, but that, after death, it is
formed out of the amyloid substance, and its propor-
tion goes on increasing for a number of hours, particu-
larly when the organ is kej)t at about the temperature
of the body. The experiments of Bernard with a liver
washed out with a stream of water also show that
sugar may be produced after death.

I was led to perform the following experiments, from
the fact that, of late years, the ex23eriments in which I
have been in the habit of demonstrating the glycogenic
function of the liver have inclined me to the opinion
that the observations detailed by Dr. Pavy are en-
tirely accurate, and that the error consists in his inter-
l^retation of the facts. The circumstances which lead
to this view were as follows :

I formerly was in the habit of making my demon-
strations of the formation of sugar in the liver u])on
animals that had been etherized; and then I always
obtained a brilliant precipitate from a clear extract of

aLYCOGENIC FUNCTIO^^ OF THE LIVER. 379

the substance of tlie liver, boiled witli the test-liquid.
I j)erfornied the experiment in this way before I had
acquired sufficient dexterity to seize the portal vein
readily, and to go through ^vith the necessary manipu-
lations with rapidity. I subsequently made the opera-
tion by first suddenly breaking up the medulla oblon-
gata, then making a small incision into the abdominal
cavity, and seizing the portal vein instantly, and fol-
lowing out the remaining steps of the experiment with-
out delay. In this way, although I always found sugar
in the blood of the hepatic veins, I frequently failed to
obtain a distinct reaction in the extract of the liver ;
and the more accurately and rapidly the operation was
jDcrformed, the more difficult was it to detect sugar in
the hej)atic substance.

It occurred to me, in reflecting upon these facts,
that, inasmuch as no one has assumed that the actual
quantity of sugar produced by the liver is very con-
siderable, and as a large quantity of blood (in which
the sugar is very soluble) is constantly passing through
the organ, precisely as we pass water through its ves-
sels to wash out the suo-ar, the sus^ar mio:ht be washed
out by the blood as fast as it is formed ; and really the
liver might never contain sugar in its substance, as a
physiological condition, although it is constantly en-
gaged in its production. We know that the charac-
teristic elements of the various secretions proper are
produced in the substance of the glands, and are
washed out at the proper time by liquid derived from
the blood, which circulates in their substance during
their functional activity in very much greater quan-
tity than during the intervals of secretion. Xow,
the liver-sugar may be regarded as an element of secre-
tion ; and, possibly, it may be completely w^ashed out

380 GLYCOGENIC FUNCTION OF THE LIVER.

of tlie liver, as fast as it is formed, by tlie current of
blood ; the hepatic vein, in this regard, serving as an
excretory duct.

To put this hyj)othesis to the test of experiment, it
was necessary to obtain and analyze the liver in a
condition as near as possible to that under whicli it
exists in the living organism ; and, in carrying out this
idea, I made the following experiments :

Experiment I. — A medium-sized dog, full grown, in
good condition, not in digestion, was held upon tlie
operating-table by two assistants, and the abdomen
was widely opened by a single sweep of the knife.
A portion of the liver, weighing about two ounces,
was then cut off and immediately cut into small
pieces, which were allowed to fall into boiling water.
The time from the first incision until the liver was in
the boiling water was twenty-eight seconds. An ex-
cess of crystallized sulphate of soda was then added,
and the mixture was boiled for about five minutes. It
was then thrown upon a filter, and the clear fiuid
which passed througli was tested for sugar by Trom-
mer's test. The reaction was doubtful and presented
no marked evidence of sugar.

Experiment II. — A medium-sized dog, in tke same
condition as the animal in the first exjDeriment, was
held upon the table and a portion of the liver excised
as above described. The wliole operation occupied
twenty-two seconds. But ten seconds elapsed from the
time the portion of the liver was cut off' until it was
in the boilino: water. It was boiled for about fifteen
minutes, made into a paste with animal charcoal, and
thrown upon a filter. The clear fluid which passed
througli was tested for sugar by Trommer's test.
There was no marked evidence of sugar.

GLYCOGEmC FUNCTION OF THE LIVEE. 381

Experiment III. — A large dog, full grown, and fed
regularly every day, but not in digestion at tlie time of
tlie ex23eriment, was held firmly upon tlie table. This
dog had been in the laboratory about a week, and was
in a perfectly normal condition. The abdominal cavity
was opened, and a piece of the liver cut off and thrown
into boiling water, the time occupied in the process be-
ing ten seconds. Before the livei' was cut up into the
boiling water, the blood was rinsed off in cold water.
The liver was boiled for about seventeen minutes,
mixed with animal charcoal, and the whole thrown
upon a filter.

Immediately after cutting off a portion of the liver
and throwing it into boiling water, the medulla oblon-
gata was broken up ; a ligature was applied to the as-
cending vena cava just above the renal veins ; the chest
was opened, and a ligature applied to the vena cava
just above the opening of the hepatic veins. A speci-
men of blood was then taken from the hepatic veins.
This portion of the operation occupied not more than
one minute. A little water was added to the blood,
which was boiled briskly, mixed with animal charcoal,
and thrown upon a filter. The liquid which passed
through from both specimens was perfectly clear.

While the filtration was g-oinsr on, Fehlinor's test
liquid (a mixture of sul]3hate of copper, neutral tar-
trate of potash, and caustic soda) was made up, so as
to be perfectly fresh.

The two liquids were then carefully tested for sugar
with this preparation. The extract of the liver pre-
sented not the slightest trace of sugar. The extract
from the blood of the hepatic veins presented, a well-
marked deposit of the oxide of copper, revealing un-
equivocally the presence of a small quantity of sugar.

382

GLYCOGENIC FUNCTION OF THE LIVEE.

In tliese experiments I did not attempt to show tlie
absence of sugar in tlie blood of the portal system ;
for it would have been difficult, if not impossible, to
have demonstrated this, and at the same time to have
obtained the specimens of liver as rapidly as I desired.
The fact, that the portal blood in a carnivorous animal,
that has taken no saccharine or starchy matters into
the alimentary canal, contains no sugar, I regarded as
settled by the experiments of Bernard, which I have
repeatedly confirmed. Neither did I attempt to show
that sugar exists in the liver when a certain period has
elapsed after death ; for this fact has been demonstrated
by all who have experimented on the subject. I only
desired to ascertain whether the liver taken from a liv-
ing animal, and the change of the glycogenic matter
arrested before any sugar has had time to make its ap-
pearance— if its formation be post mortem — really con-
tained sugar. A few seconds only elapsed before the
liver was cut up into boiling w^ater (which will effectu-
ally arrest the transformation of the glycogenic matter),
and the presence of sugar in the decolorized extract
could not be demonstrated. In Experiment III., par-
ticularly, very delicate tests were employed with the
greatest care ; and, although the extract of the liver
contained no sugar, the presence of sugar in the blood
coming from the liver was unmistakable. This experi-
ment was peculiarly successful ; and I could hardly
expect to be able to collect the specimens with less
delay. Anaesthetics were not employed in any of the
experiments, and there seemed to be no circumstance
which could interfere with the normal character of the
specimens examined. The animals were perfectly quiet
when the experiments were commenced, and Avere
operated upon as soon as they were put upon the

GLrCOGE:N^IC FU]S"CTIOX OF THE LIVER.

383

table, tlie respiration and circulation being apparently
normal.

coxcLrsioxs.

Althongli these experiments are not entirely new,
my interpretation of them serves to harmonize, in my
own mind at least, the results obtained by Bernard
and by Pavy :

1. A substance exists in the healthy liver, which
is capable of being converted into sugar : and inas-
much as this is formed into suo;ar during: life, the suo-ar
being washed away by the l^lood passing through the
liver, it is jDerfectly proper to call it glycogenic, or
sugar-forming, matter.

2. The liver has a glycogenic function, which con-
sists in the constant formation of sug^ar out of the
glycogenic matter, this sugar being carried away by
the blood of the hepatic veins, which always contain a
certain proportion of sugar, and subserving some pur-
pose in the economy connected with nutrition, as yet
imperfectly understood. This production of sugar
takes place in the carnivora as well as in those ani-
mals that take sugar and starch as food; and is es-
sentially indej^endent of the kind of food taken.

3. During life, the liver contains only the glyco-
genic matter, and no sugar, because the great mass of
blood which is constantly passing through this organ
washes out the sugar as fast as it is formed ; but after
death, or when the circulation is interfered with, the
transformation of glycogenic matter into sugar goes
on ; the sugar is not removed under these conditions,
and can then be detected in the substance of the liver.

384

FEEE HYDEOCHLOEIC ACID

Aet. III. — Source of Free Hydrocliloric Acid in the
Gastric Juice, By Prof. E. N. Hoesfoed.

The long - disputed jDosition of Front, that tlie
gastric juice contains free hydrocliloric acid, was at
length established "by C. Schmidt, who, in an absolute
quantitative analysis of the juice, found about twice
as much hydrochloric acid as was required to neu-
tralize all the bases present.

The prolonged discussion of this subject, now since
1823, has brought to light, through the researches of
Lassaigne, Claude Bernard, Schwann, and numerous
others, the unmistakable evidence of the presence of
lactic acid and of acid j^hosphates in the gastric juice,
which latter might or might not be due to the pres-
ence of lactic or hydrochloric acid.

A point of special interest to the chemist and
physiologist still remained, and was this :

Hoio coidd free Imjdrocliloric acid he secreted from
tlte llood^ loliicli is an alkaline fluid?

The blood, freshly drawn, consists of a fluid (the
plasma), in which there are swimming myriads of ex-
ceedingly minute, irregularly spheroidal bodies (the
cor]3uscles). The plasma consists of two bodies — one
of which, the fibrin, spontaneously separates from the
other, the serum. The corj)uscles are little sacs of
delicate animal membrane, enclosing a fluid. This
fluid has an acid reaction, and its ash contains a mono-
basic alkaline phosj^hate. The fibrin of the plasma
contains, according to Yirchow, a glycero-phosphate
of liine, though the plasma, as a whole, has an alkaline
reaction, and contains, in its ash, a great measure
. (eleven per cent.) of chloride of sodium.

•

r^^- THE GASTEIC JUICE.

385

The moist corpuscles constitute about one-half of
the blood.

In healthy digestion, the blood - vessels of the
stomach are engorged. Engorgement is the equivalent
of obstruction. This must occur in the capillaries,
where the diameter of the blood-vessels is least. The
plasma, because of its fluidity, must move more
freely than the corj)uscles. The proj^ortion of the
corpuscles in the capillaries will be thereby relatively
increased. Under the pressure that follows, the fluid
contents of the corpuscles will pass through their
membranous walls, and, mingling with the relatively
lessened plasma, pass on through the walls of the
capillaries. This mixture will therefore contain acid
phosphates and chloride of sodium.

The mucous membrane of the stomach presents,
on its inner surface, the mouths of numerous micro-
scopic tubes, which, like stockings, are sometimes
single blind sacs, or, like gloves, terminate in several
blind sacs, like the glove-fingers. In the bottoms of
these tubes, and along their sides, are several closed
sjiherical sacs, containing other lesser sacs, and fluid
within. The tubes, as a whole, dip down into the
spongy tissue that underlies the mucous coat, where
they are surrounded by the fluid, poured from the
network of nutritive capillaries, which fluid, as re-
marked above, contains acid phosphates and chlorides.

Now, by pressure and osmosis, a portion of this
fluid will pass through the walls of the gastric tubes,
and the question is —

Whether the fluid that goes through loill contain
free hydrochloric acid ?

The experiments I have made are conclusive on the
principal point.

386

FEEE HYDEOCHLOEIC ACID

By employing acid phospliate of lime and common
salt, I had this advantage, that as increased acidity
on the one hand is a just inference from increased
alkalinity on the other, and as increased alkalinity
would be shown by the precipitation of j^hosphate of
lime — a visible white powder — I could determine the
qualitative fact without the difficulties and delay at-
tending on accurate quantitative analysis of the solu-
tions before and after the experiments, on both sides
of the membrane.

I employed an acid phosphate of lime of specific
gravity 1.117— of a constitution of 3 (CaO F0,)-{-2
PO5 — with an amount of phosphate of peroxide of
iron |)resent, as one to twenty-eight of the acid phos-
phate of lime. The other solutions employed were
the ordinary laboratory reagents.

On adding ammonia, in small quantities, to the so-
lution of acid phosphate, with alternate agitation, it re-
quired, as might be inferred, several rej)etitions before
the peroxide, with its phosphoric acid, became a per-
maneut j^recipitate, and still several more before the
precipitate of phosphate of lime became permanent.

In my earlier experiments, in which I employed
parchment-paper, I was embarrassed with the j)resence
of sulphate of lime in the precipitated powder, so that
what was at first supposed to be phosphates of lime
and iron, was found to be, in part, sulj)lmte of lime.
This sulphate was due to imperfectly-washed parch-
ment-paper, which still contained sulphuric acid. This
difficulty overcome, the experiments were made with
parchment-paper, prepared from German and Swedish
filter-paper, as well as with gold-beater's skin (animal
membrane).

T employed the acid phosphate of the formula

m THE aASTEIO JUICE.

337

above, with, (each by itself) chloride of sodium,
chloride of ammonium, chloride of potassium, chlo-
ride of magnesium, chloride of calcium and acetate of
potassa.

With all of these, there was obtained the same
kind of evidence of increased acidity on one side,
and of increased alkalinity on the other — to wit, the
powder thrown down from the mixture of acid phos-
phates and chloride. What successive additions of
ammonia had been required to effect, had been accom-
plished by dialysis.

The same effect took place from a mixture of acid
phosphate of soda and chloride of calcium.

It follows from the above, if these experiments
fairly represent the case, and from the known com-
position of the blood, its condition in the walls of the
stomach, and the structure of the gastric tubules, that
free or* uncombined hydrochloric acid must find its way
into the bottoms of the gastric tubules, and thence into
the cavity of the stomach.

It may be urged that I should show that the acid
phosphate, pressed from the corpuscles, more than
neutralizes the alkalinity of the plasma present. In
reply, it may be said that I present a condition of
things in whick there is the hind of physical change
required going on — namely, relative augmentation of
the corpuscles, under pressure, the concomitant of en-
gorgement.' Its degree must be inferred from the
effects on the secretions, which I have endeavored to
point out, by conducting an experiment under what I

^ I employ the word " engorgement " simply as implying the condition
of increased pressure in the capillaries. With constant elasticity of the
walls of the capillaries, increased pressure would accompany increased
flow of blood.

388

FEEE HYDEOCHLOEIC ACID

conceive to be essential!}^ like conditions, and obtain-
ing tbe result due to identical conditions.

The secretion of hydrochloric acid is, of course,
mixed with acid phosj^hates and alkaline chlorides.

That such a result, as I have arrived at, would
follow experiment, might have been predicted from
Graham's researches in dialysis. Phosphates of lime
and soda are colloidal, relatively, to more crystalloidal
hydrochloric acid. Graham found that bisulphate of
potassa, by dialysis, was resolved into two salts, or
mixtures, of greater and lesser acidity than the original
bisulphate. So he found that acetate of peroxide of
iron was resolved by dialysis into hydrated peroxide
of iron, and free acetic acid. It is possible, and prob-
able, that the albuminoid bodies present take part in
determining the contrast between colloid and crystal-
loid bodies. Graham found that, by dialysis, he could
separate free hydrochloric acid from the gastric juice,
thrown up by vomiting.

It "may be further objected that anatomists are not
agreed as to the structure of the corpuscles. But it
will be seen that there is no more required than may be
regarded as established. The corpuscles act in many
particulars, if not in all, as if they were membranous
sacs, more or less distended with fluid. They may be
swollen by immersion in a thinner (less colloid) fluid,
and reduced by immersion in a more colloid fluid ; that
is, they are susceptible of endosmosis and exosmosis,
as membranous sacs would be. In their ordinary con-
dition, as seen under the microscope, they present the
appearance of collapsed spherical or oval sacs or cells.
They appear as double concave disks. In swelling (by
endosmosis) the lowest part of each concavity is the
last to take on the sjjherical contour, just as they would

m THE GASTEIC JUICE.

389

do if they were membranous sacs. The corpuscles
sometimes so collapse (by exosmosis) that one-half of
the hollow sphere is reversed while the other half re-
tains its form unchanged, the former sitting like a cup
in the latter — a conformation inconceivable on the
theory of homogeneity of the corpuscles as a whole.
Crystallizable substances may be extracted from the
corpuscles by joressure and by endosmosis. They must
have been in solution in order to crystallization, and
solution involves a fluid.

The liquid expressed from the corpuscles has an
acid reaction and contains an organic acid and acid
phosphates. It contains among other bodies the hsema-
toidin of Virchow. The ash of these crystals consists
almost wholly of metaphosphates ' which point di-
rectly to tribasic phosphoric acid in solution, combined
with one atom of fixed base, which is inconceivable
unless separated by membrane from the plasma, which
is always alkaline.

In fine, whatever other peculiarities the blood-cor-
puscles may possess, they have the requisites for fur-
nishing acid phosphates in solution, under pressure
such as must attend engorgement of the capillaries in
the walls of the stomach.

Let us glance at what takes place in all probability
as the acid fluid enters the gastric tubules. Here are
sacs containing fluid at the bottom and along the sides
of the tubules. They are surrounded by a mixture of
hydrochloric acid, acid salts, neutral salts, and albu-
minoid bodies. Dialysis must be repeated and a

^ The ether extract of tlie blood-corpuscles yields, according to Schwann,
an ash containing acid phosphate of soda. Owen Reese and Berzelius
maintained the existence of oleo-phosphoric acid in the corpuscles. Andral
(Berzelius's Jahrs-Bericht, 1847-'8, p. 894) places the contents of the cor-
puscles among the acid fluids of the body.

390

SEA-SICKIS-ESS.

stronger acid solution pass into the sacs. Tlie sacs,
swelling by enclosmosis and corroded by the acid, must
at length burst, and the liquid contents, together with
the disintegrated and partially digested membrane of
the sacs, pass out to the stomach to constitute the gas-
tric juice — the free hydro.chloric acid, acid phosphates
and chlorides, and the albuminoid bodies and disin-
tegrated tissue (the pepsin ?) to act in the liquefaction
of food.

Aet. IV. — SeOrSichness, A Description of a New
Method of Cure. By Wm. H. Dwixelle, M. D.,
New York.

Dueijvtg a recent passage across the Atlantic in the
St. Laurent, one of the French line of steamers, I had
an opportunity of observing a new method of treating
sea-sickness as practised by Dr. Le Coniat, surgeon of
the Imperial French Navy, but temporarily surgeon
of the St. Laurent. Something more than curiosity
prompted my observations. I had a decided personal
interest in the matter, not only for myself, but for an
invalid sister who had hitherto been frightfully sea-
sick in all her journeyings from port to port.

As we left Brest, on Saturday afternoon. Dr. Le
Coniat requested me, in the event either I or any of
my friends should be taken ill by sea-sickness, to send
for him at once, as he felt confident that in a large ma-
jority of cases he could control the malady.

Strong head winds and a rolling sea soon devel-
oped sea-sickness in its worst form to many of our pas-
sengers, and none w^ere more ill than my sister and
myself. On Sunday eveniilg her illness assumed an

SEA-SICKIS^ESS.

391

alarming cliaracter; excessive vomiting and ^dolent
retching ^vere succeeded by convulsions, followed by
extreme prostration. In this extremity, Dr. Le Co-
niat was sent for, who, after a few minutes' manipula-
tion, arrested every symptom of sea-sickness, and gave
her entire relief The disposition to vomit was com-
pletely arrested, nor did it assert itself again during
the voyage, though the sea was as rough as before. She
ate her meals without intel-ruption, and with a relish,
until our arrival in New York.

Although I was so ill that, with the exception of
a single instance, I did not leave my berth from Satur-
day afternoon until Tuesday morning, during which
time I had been unable to retain the least food in my
stomach, I deferred resorting to the new remedy, think-
ing I would give time to Nature to come to my relief,
should she be disposed to do so. Despaiiing of any
such aid, I submitted to Dr. Le Coniat's treatment, the
effect of which so fortified my stomach and removed
all disposition to nausea, that I was enabled to eat my
breakfast and retain it ; nor did I vomit a2:ain durino;
the voyage. The effect of the remedy in my case was
not altogether complete and permanent, though I expe-
rienced great relief at the time. On submitting to the
treatment a second time, I was entii^ely cured.

Dr. Le Coniat applied his remedy to many others
during our passage, always producing great and imme-
diate relief, and generally an entire cure. I recollect
two instances where ladies had been confined to their
berths for several days, unable either to eat or to raise
their heads from the pillow. Lnmediately after the
Doctor's treatment, they took their seats at the dining-
table, and occupied them at every principal meal dur-
ing the rest of the passage. Dr. Le Coniat's theory

392

SEA-SICKNESS.

is, that sea-sickness is induced by electric disturbance
tbrougbout the system, and that vomiting at these
times is induced by an involuntary spasmodic contrac-
tion of the stomach from the pyloric to the cardiac ori-
fice, thereby emptying that organ. In order to reverse
this abnormal condition and restore the electric equi-
librium, he places his patient in a horizontal position,
uncovers the stomach, and applies to the skin, immedi-
ately over it, a solution of sulphate of atropine in
the proportion of one grain to an ounce of water ; he
then places the negative pole of a galvanic battery,
terminating in a flat disk, upon the stomach corre-
sponding to the pyloric region. Then, with the posi-
tive pole terminating in a moist sponge, he manipulates
' across the surface of the skin from the cardiac to the
pyloric orifice. These manipulations are kept up for
three or four minutes, occasionally varying them by
vertical passes downward. During the transit of the
positive pole across the surface, the muscles can be
seen to contract vigorously. The stimulus of galvan-
ism rendered to the stomach by these means is much
the same as that given to any other j)aralyzed or weak-
ened muscle of the body — certainly the elfect produced
justifies the theory. It appears to be not only local in
its influence, but pervading ; the whole system seems
to be brought under its control ; its effects are sooth-
ing and refreshing, and generally accompanied with
drowsiness, followed by refreshing sleep.

Dr. Le Coniat has been practising and improving his
new remedy for about three years past ; he has written
one or two minor articles on the subject, which have
been published in some of the French journals. On
his return home, he proposes to publish a treatise on
the subject for the benefit of science.

THE MICEOSCOPE AS AIS" AID, ETC. 393

He claims to cure at least 90 per cent, of Ms 23a-
tients suffering from vomiting and tlie pains of sea-
sickness. He also claims that lie is able, by the elec-
trization of the stomach, with the local application of
sulphate of atro]3ine, to control the vomiting and
sickness incident to the early period of pregnancy.

I am aware that electricity has heretofore been re-
commended for sea-sickness, but I think to Dr. Le Co-
niat alone is due the credit of perfecting a method
by which practical and permanent results have been
obtained.

The battery used by Dr. Le Coniat is one of the
ordinary vibrating, carbon, and amalgamated zinc or-
der, cajDable of double gradation. The solution for
the battery is made as follows : Take \ oz. of bichro-
mate of potash, dissolve it in 9 ozs. of warm water ;
when cold, add \ oz. of sulphuric acid.

All of the advice and remedies suggested in the
excellent article of Dr. Barker on the subject of sea-
sickness, in the November No. of the Journal, must
ever remain in full force, founded as they are upon
science and experience ; no subsequent discovery can.
militate against them, though it may transcend the ne-
cessity of their entire observance.

Aet. V. — On the Microscope, as an Aid in the Diag-
nosis and Treatment of Sterility. By J. Maeioi^"
Sims, M. D., New York.

(Read at tlie Meeting of the Medical Society of the County of iJTew
York, December 7, 1868.)

By the kind invitation of your President, I have
the honor of appearing before you, and of stating my
views on the subject of sterility; a subject always in-

394 OT^ THE 3nCE0SC0PE, AS AN AID IN THE

teresting, whether viewed in its bearings upon the
happiness of individuals or the prosperity of states.
It has engaged the attention of the profession for ages,
"but, till within the last twenty-five or thirty years,
little or no progress was made in its treatment.

The first step in the right direction was taken by
Mcintosh, when he dilated the contracted cervical
canal by bougies, and thus allowed the semen to pass
to the cavity of the uterus. Sir James Y. Simj^son fol-
lowed out the same idea, when he subsequently in-
cised the cervix to render its canal permanently larger.
As the Edinburgh school has, then, established the
fact that a dilatation of the cervix, whether by bougies
or incision, is sometimes followed by conception, I
claim to have established further facts in the same di-
rection, which facts constitute the basis of the present
j)aper " on the microscope in the diagnosis and treat-
ment of the sterile condition." I have been accused
of cutting Q-pen the cervix uteri recklessly and un-
necessarily. True, I have laid down rules for the j^er-
formance of this operation, under various circumstances ;
and I know that I have had some earnest and enthusi-
astic followers. If I have misled any of my brethren,
it is my duty to hasten to rectify the error. So far as in-
cision of the cervix uteri for dysmenorrhoea in the ab-
stract is concerned, without reference to the sterile state,
I wish it to be understood that I have nothing to recant,
nothing to undo. But, so far as this operation may be in-
dicated in cases of sterility, properly speaking, without
regard to the relief of physical suffering; I candidly
confess that I have a word of advice for my younger
brethren ; for I am now convinced that I have re-
peatedly cut open the cervix uteri, for the sterile state,
when the operation was both useless and unnecessaiy ;

DIAGNOSIS AlsJy TKEATMEOT OF STERILITY. 395

aucl I am sure tliat almost every otlier surgeon, who
lias performed this operation often, lias made the same
mistake. How frequently have we all heard it said in
consultation, " ISo operation is needed in this case, be-
cause the sound can be easily passed along the cervical
canal ! " And again, how often have we heard it said —
how often have I said it myself — "An operation is
necessary in this case, because the canal of the cervix
is too small to permit the easy entrance of the semen ! "
IS^ow, these imj)ortant questions cannot be determined
with any degree of accuracy in this hap-hazard
manner. For it is not always necessary to incise the
cervix uteri, simply because .it does not easily admit
the passage of an ordinary sound ; nor, on the other
hand, are we justified in condemning an operation,
simply because the sound can be passed easily. In
other words, a very small os does not always call
for operation, nor does a larger one always forbid it.
Do you not think, then, that a great service would be
rendered, if we could reduce this question of operation,
or no operation, from the broad domain of speculative
opinion to the narrow path of absolute scientific cer-
tainty I There is nothing easier, for the microscope
accomplishes this in the most perfect manner imagina-
ble. It settles the question of operation, or no opera-
tion, in an instant, leaving nothing whatever to be
guessed at, and nothing to be desu'ed.

Is it surprising that positive knowledge of this
sort should meet with opposition among honest, ear-
nest cultivators of medicine ? Not at all. For it is
ever so with any great truth. It must first be op-
posed, then ridiculed, after a while accepted, and then
comes the time to prove that it is not new, and that
the credit of it belongs to some one else. The truth

396 0]^" THE 3nCE0SC0PE, AS AX AID IN THE

liere announced lias liad its day of opposition, and it
must now soon take its stand as established and ac-
knowledged.

On tke subject of the microscopic examination of
the utero- vaginal secretions, I liave been misrepre-
sented, maligned, and positively abused by a few both,
abroad and at home ; and I have been misunderstood
by many who have not taken the trouble to read, to
investio^ate, to think, and to reason for themselves.
And, Mr. President, under these circumstances, I can-
not thank you too much for the high privilege of ap-
pearing here to explain and to defend my position by
laying the facts in the case before this learned Society,
this great gathering of my countrymen, whose deci-
sion, I am sure, will be in accordance with truth and
justice.

We may all differ honestly about abstractions,
and theories, and mere opinions ; but, when it comes to
facts and figures, there cannot long be a great differ-
ence among men of good common sense, with honesty
of purpose in pursuit of truth. I have never yet been
afraid of truth, however much it may conflict with
jDrejudices, find it where I may ; nor do I ever expect
to see the day that I would fear to publish my con-
victions on any matter of professional importance, be
the character of the opposition what it may ; and, par-
ticularly, when I feel that these convictions are based
upon facts that are immutable, and that lead to re-
sults of the gravest importance to the honor of medi-
cine, and to the advancement of knowledge. What-
ever gives to any department of medicine greater ex-
actitude, helps to raise it to the dignity of a science.
And this is what I claim to have done with the mi-
croscope in this dii^ection.

DIAGNOSIS AND TEEATMENT OF STERILITY. 397

The microscope has done, and is doing, a great
work in medicine, as well as in the collateral sciences.
But I know of no field in which it will be of more
practical use than in the diagnosis and treatment of
the sterile state. For, where every thing was a short
time ago in doubt and confusion, all is now made clear
by this wonderful instrument. Even in this day there
are many very honest cultivators of medical science,
who do not believe in the value of the teachings of the
microscope.

The great Velpeau died, having no faith whatever
in its practical utility. A few years ago,' I was one of
those benighted scoffers who believed it to be merely
a scientific toy, with which to while away leisure
hours. Fortunately, my ignorance was dispelled, and
I now look upon the microscope as essential to the
daily duties of the physician. •

With these prefatory remarks, I now beg leave to
give you some illustrations of its use in the treatment
of the sterile state.

In the investigation of any case of sterility, there
are three questions that must be settled at the outset,
if we expect to treat it understandingly :

^ About eight years ago, ray friend Dr. W. H. Dwinelle, of this city,
a very accomplished amateur microscopist, was showing me some organic
substances, under the microscope, in which I did not take any great in-
terest. Indeed, I felt positively bored by the pertinacity with which he
attempted to enlist me in his favorite study. When, at last, he said, "My
dear doctor, I see you are very tired, but here is something that you must
look at before you leave." He held the glass up, to show me there was
nothing that my eye could detect, and then placed it under the microscope,
adjusted the focus, and asked me to look. I am sure I was never more
surprised in all my life, than I was then, to see, and read the Lord's
Prayer. From that moment I was convinced that the instrument exhib-
ited things just as they were. And I have often said, that I supposed
this was not the first instance in which the Lord's Prayer was the means
of opening a man's eyes to the truth.

398 OjS" the miceoscope, as aist aid m the

1. We must be sure that we liave semen with
spermatozoa.

2. We must ascertain if the spermatozoa enter the
utero-cervical canal.

3. We must determine whether the secretions of
this canal are favorable or not to the vitality of the
spermatozoa.

For, if the semen does not contain spermatozoa, of
course the uterine condition does not call for any
tueatment whatever. But if it does contain sperma-
tozoa, and if they do not enter the cervical canal, then
there is the question of operation or not, to permit
their entrance.

On the other hand, if we should find spermatozoa in
the cervical canal, then, as a rule, no operation will be
needed ; and if we should find them there in abundance,
and all alive, then the case needs no treatment whatever.
But, if we should find them there, all, or nearly all,
dead, then it is evident that the secretions of the utero-
cervical canal poison them, and therefore the physical
condition, giving rise to this abnormal secretion, must
be searched out and treated.

The present advanced state of physiological knowl-
edge warrants us in saying that conception is impos-
sible without spermatozoa ; and that it is impossible
if the spermatozoa cannot pass into the cavity of the
uterus ; and, to these acknowledged truisms, I must
add another, viz., that it is equally impossible if they die
in the cervical canal^ or are dead when they reach the
uterine cavity. It is, then, self-evident that these three
points must be determined — it matters not what other
complications may exist. Fortunately, as I have said
before, they are all easily and quickly settled by the
microscope. Without the microscope, it is impossible

DIAGNOSIS AIS-D TREATMENT OF STERILITY. 399

to determine either of tliem. Without the microscope,
then, our treatment of the sterile state is simply blind
empiricism. With it, our diagnosis becomes absolutely
certain, and our treatment, at least, rational. What,
then, are the first steps in this investigation ? How
can we begin ? Where shall we begin ? Now, as it is
upon this very point that I have been so stigmatized,
I will tell you exactly how I manage this delicate
affair.

Given a case of sterility for investigation, the phy-
sician examines the state of the uterus and its append-
ages. His patient may have a frightful dysmenor-
rhoea, a flexed cervix, a contracted cervical canal, some
malposition, a polypus, a fibroid, or something that
would possibly prevent the passage of the semen to
the cavity of the uterus. He may feel convinced, in
his own mind, that conception cannot take place
unless some surgical operation be performed — perhaps
incision of the cervix uteri. This operation is usually
done to permit the passage of the semen into the
uterine cavity. But in this, or in any case, what right
have we to say that the semen does not or cannot
pass into the cavity of the uterus? We must not
take it for granted that it does not, simply because the
OS seems to be small ; for we know that cases are re-
corded where conception occurred when the os barely
admitted a small-sized probe ; and we know very
well that spermatozoa now and then pass along the
Fallopian tubes, which ordinarily admit a bristle. If
the semen enter the cervical canal, we may lay it down
as a rule, that a dilatation of the cervix by incision, or
otherwise, is not necessary ; but if it do not, it may
be necessary. We may perform any rational operation
for the relief of suffering, and for the restoration of

400 O]^ THE MICEOSCOPE, AS AIT AID IjS" THE

liealtli ; but I insist tliat we have no right to perform
any oj)eration, or to institute any treatment whatever,
solely with the view of the cure of the sterile condi-
tion, till we have first settled the three ]3ropositions,
above laid down, touching the presence and viability
of the spermatozoa. To find out all at once, and with
the least delay and trouble, I usually say to the hus-
band or wife, as it may be, " It is very important, be-
fore instituting any treatment, to be sure that the
seminal fluid enters the neck of the womb, for with-
out this conception is impossible. We must also as-
certain if the uterine secretions kill the semen ; if so, a
certain treatment will be necessary. If you ^^^11, then,
send your wife here, or come with her any day, five
or six hours after coition, it will be easy to settle
.these points at once." In nineteen cases out of
twenty, the wife presents herself the next day. The
speculum is introduced (and when I say the speculum,
I always mean the one that bears my name), and some
vaginal mucus is removed by the syringe, and placed
on an object-glass. Then some cervical mucus is
drawn out and placed on another object-glass. These
two specimens are then examined under the micro-
scope. If we find spermatozoa, well and good ; but
if we find none, neither in the vaginal, nor cervical
mucus, our fears are at once aroused. What then is to
be done ? I simply say that I am not quite satisfied
with the examination, and would like to see the wife
again, at some future time, under the same circum-
stances. But, suppose we find no. spermatozoa on this
second examination ? Then two questions immediately
arise: either, that there are no sj)ennatozoa, or that
the semen has all passed off before the case came under
observation. Sometimes the semen is all instantly

DIAGlSrOSIS Ami) TREATMEIS-T OF STERILITY. 401

thrown off by the vagina, and then it would not do to
pronounce the husband sterile till we are sure of a
specimen of his semen, for investigation. If I fail to
satisfy myself on this point, I then explain the possi-
bility of the semen all passing off, in the act' of rising
and dressing, and show the absolute necessity of
making the examination half an hour or so after
coition, and before the erect posture is assumed.
When the subject is presented in this plain, practical
manner, and treated seriously, no man or woman of
sense could oppose it ; and with me, it has never, in a
single instance, been objected to. When I am sent for
to make the examination, if I iind in the vaccina a
fluid with the characteristic seminal odor, I am satis-
fied with the microscopic examination. I have never,
in but two instances, been compelled to resort to Mr.
Curling's plan, of asking the man to squeeze a drop of
mucus from the urethra, on to a bit of glass, imme-
diately after sexual intercourse. But as this is some-
times necessary, it is well to remember it.

If we eventually find that the semen contains no
spermatozoa, then all uterine treatment is at an end.
But if we are at last satisfied that it contains sperma-
tozoa, then we must determine if these enter the
cervix uteri, and if so, do they there find a fluid favor
able to their existence alive? And all this can be
done only by the microscope.

The question of the entrance of the semen into the
cervical canal, and of the effect of its secretion upon
the sjDermatozoa, can be fully and satisfactorily ascer-
tained only during a very brief period. We are sure
to make a mistake if the microscopic examination be
made just before the expected return of the menses ;
and why? Because, there is always a certain amount

402 ON THE MICEOSCOPE, AS A]^ AID IN THE

of fulness of tlie uterus — of engorgement, so to speak
— wliicli precedes tlie menstrual flow ; and tlie cervical
canal may not admit the semen from mere turgescence
of its walls. Besides, at this time, its secretions are
almost sure to kill the spermatozoa even if they should
happen to enter this canal.

Physiologists are generally agreed that conception
takes place during the week following menstruation.
Avrard says we have fourteen days of active uterine
life and fourteen days of uterine hypnotism. He says
that conception can occur at any time after menstrua
tion up to the fourteenth day, counting from its com-
mencement. For instance, if menstruation should last
for three days, then we would have eleven days for the
possibility of conception. But, if menstruation should
last eight or nine or ten days, then we would have re-
spectively but six or five or four days as the time pos-
sible for conception. After this time, the uterus, ac-
cording to Avrard, lapses into the hypnotic state, when
conception is impossible. While I am disposed to ac-
cept Avrard's dictum as the rule, I think I have seen
exceptions to it, if we can always depend upon testi-
mony seemingly reliable. Be this as it may, I am sure
of this fact : if we wish to determine the effects of the
cervical mucus upon the spermatozoa, we must make
the experiment during the week that follows menstrua-
tion. About the fifth or sixth day after the flow is the
best moment ; for then the uterus is in the most favor-
able condition. The cervical mucus, which just before
menstruation was perhaps thick and opaque, then be-
comes clear and translucent. If, by examination made
at this particular period, we should find spermatozoa
in the cervical mucus, we could safely say that it will
not be necessary to incise the neck of the uterus. But

DIAG]S"OSIS AND TREATMENT OF STEEILITY. 408

if tlie sperm do not enter the canal, then the proba-
bilities are in favor of the necessity of some surgical
interference. The semen may enter the cervix in great
abundance, and we may find the spermatozoa all dead,
even but a few minutes after coition. Then, as said
before, we must find out the source of the poisonous
secretion, and remedy it ; for a vitiated secretion shows
some organic condition requiring a special treatment.

When I wish to examine the action of the cervical
mucus upon the spermatozoa, I order sexual intercourse
in the morning — the dorsal decubitus to be retained
for an hour afterward ; and I expect a visit from my
patient four or five or six hours after coition. Some-
times we find sj)ermatozoa in great abundance in the cer-
vical canal, and not one living. (I have occasionally
examined the mucus, six, eight and ten minutes after
coition, and found all the spermatozoa dead.) Some-
times, we find half of them dead ; again, only about a
third ; again, two-thirds. Sometimes, in one portion of
the mucus, every spermatozoon is dead ; while, in an-
other portion of the same sample with fewer epithelial
scales, we may find them alive. Now and then, after
treatment for a month or more, I have found the mucus
drawn from the lower segment of the cervical canal
full of living spermatozoa, and I have supposed that
the case was cured ; but when I came to examine that
drawn from the upper segment of the canal, near the
OS internum, they were nearly all dead. This was evi-
dently because the mucous membrane lining the lower
segment of the cervix, being more easily reached and
more thoroughly treated, had assumed a healthier char-
acter, and consequently its secretion was restored to a
normal condition ; while that higher up, and more dif-
ficult to reach, had not been so much improved, and

404 Ol!f THE MICEOSCOPE, AS AX AID IX THE

hence its secretion was still abnormal — a condition re-
quiring further treatment.

The vaginal mucus, by its natural acidity, kills very
quickly every spermatozoon. I do not now remember
ever to have found one alive in the vagina, except when
the examination was made very soon after coition;
when, indeed, the vagina was full of semen but slightly
mixed with other secretions. Examined three or four
hours after intercourse, the spermatozoa found in that
portion of the mucus of the vagina adhering to its
walls are always all dead. Indeed, the normal vaginal
secretion seems to be a perfect poison for the super-
abundant spermatozoa.

WheD, after a month's treatment, I wish to know
whether the case is cured or not — in other words,
whether all possible recognized barriers to conception
are removed — I order sexual intercourse (just after
menstruation) at night, and examine the cervical mu-
cus twelve or fourteen hours afterward. If the ma-
jority of the spermatozoa be alive and active, I have
great hope of conception. Before dismissing a case as
cured, I think it necessary to examine the mucus thirty-
six hours after coition ; and, if it is then all right, of
course I suspend the treatment, and patiently wait the
hoped-for result.

So much care is necessary in the removal of the
mucus for microscopic examination, that I may be par-
doned for referring to it again. The patient is placed in
the left lateral semi-prone position, as I have elsewhere
so minutely described, and my speculum is introduced,
and some of the vaginal mucus drawn up with a small
glass syringe, previously washed out with warm water.
This is deposited on the object-glass ; the vagina is then
cleared of all secretion, whether vaginal or cervical.

DIAONOSIS AND TREATMENT OF STERILITY. 405

tlie wliole of the- vagina and the os uteri being thor-
oughly wiped over mth a pledget of cotton. This is
for the purpose of guarding against the possibility of
mixing vaginal with cervical mucus, which would, of
course, spoil the whole experiment. The cervix is then
brought forward either by the depressor or a tenacu-
lum, if necessary, which enables us to look directly
into the cavity of the cervical canal. The syringe is
then to be again thoroughly rinsed in warm water ; its
nozzle is passed into the gaping canal for half an
inch, and the cervical mucus in its lower segment is
drawn out. The instrument is emptied, washed out
again with warm water, and reintroduced up to the
OS internum, and another portion of mucus is drawn
out, provided there is any left after the first effort.
Thus we have three specimens of mucus ; i. e., one va-
ginal, and two cervical. The cervical secretion should
be clear and translucent, and about the consistence
of the white of egg. If it contain any little opaque
specks of milky whiteness, it invariably poisons the
spermatozoa to a greater or less extent. We sometimes
find the cervical mucus perfectly clear, and yet poison-
ous to the spermatozoa. Here we ^vould naturally ex-
pect to find excessive alkalinity of the secretion ; but
I have not been able to detect it. In these cases, it has
seemed to me that the spermatozoa were killed —
drowned, as it were — by the very abundance of the se-
cretion. I do not here allude to cases of uterine catarrh,
where the secretion is very thick and albumino-puru-
lent ; for, of course, this is a deadly poison to the liv-
ing principle of the semen. But I allude wholly to such
cases as have been changed by treatment to a condition
giving rise to a secretion seemingly normal, so far as an
ordinary ocular examination is concerned. Here the

406 ON THE MICROSCOPE, AS AN AID IN THE

microscope is our unerring guide. Tlie mucus may be
clear, and perfectly normal in appearance ; but, if it
kill tlie spermatozoa, then there is still some point in
the canal of the cervix, or in the cavity of the uterus,
that gives out a vitiated secretion ; and this must be
found out and corrected before the case is wholly cured.
When we find living, active spermatozoa high up in
the cervical canal thirty-six or forty hours after coi-
tion, we can pronounce the case cured, so far as it can
be by surgical means, and not till then.

It is time for us to pause, and consider if there is
not something more to be done for the sterile condi-
tion, than to split up the cervix uteri. I look upon
this oj)eration as one of great importance, as one
of the most valuable in uterine surgery, but I think
that we have followed too blindly the example and
teachings of its illustrious author. Sir James Y. Simpson.
For myself, I am now sure that I have cut open the
cervix uteri, perhaps scores of times, when it was both
useless and unnecessary ; and I know that others have
done the same thing. Do not misunderstand me. I
speak here solely of the operation with reference to the
sterile condition, when it would be wholly useless if the
husband happened to be sterile, and certainly unjustifi-
able unless imperatively called for by considerations of
health. Incision of the cervix for dysmenorrhoea is one
thing ; incision of the cervix for sterility, even if there be
dysmenorrhoea, is another, and it behooves us to draw
the line of distinction in every case, and not to take it for
granted that every woman is sterile who may have
dysmenorrhoea or feeble health, or that every man is
prolific who may be vigorous and enjoy good health.
I am sorry to say that I have had the misfortune to
incise the cervix in half a dozen cases of sterility, where

DIAGNOSIS AND teeatme:xt of steeility. 407

I found afterward, to my great mortification, that tlie
husbands were incapable of procreation, because their
semen had no si3ermatozoa, and that, too, since I have
known the value of the microscope. In each case the
o]3eration was called for to restore health, but was
totally useless for the relief of its incidental accompani-
ment, sterility, and would not probably have been sub-
mitted to for considerations of health alone, Jiad it not
been for the hope of offspring afterward. I made the
mistake of operating on these cases, because the social
position, moral character, and appearance of health in
the husband, conjoined with the excessive dysmen-
orrhoea and utter prostration of the wife, led me to
operate without the preliminary step of ascertaining
whether there were spermatozoa or not. I wish others
to profit by my mistakes ; and I am less ashamed to
tell you of them, than I am to own them to myself.
However, this can never happen to me again, and
should not, after this warning, happen to any of my
brethren. I know many men who have no sper-
matozoa, and cannot therefore become fathers. They
are all strong, active men, in the prime of life, and
all perform the sexual function with vigor.- The
very fact of their natural vigor and strong passions
had been their ruin, for most of them had contracted
urethritis during their early and unmarried life, and
had suffered from its unlucky sequence, epididymitis.
To further illustrate the necessity of the microscope in
in this department of surgery, I shall a23pend a few
cases drawn up as succinctly as possible.

Xo. 1 had consulted two of the most eminent physicians in England,
and remained under the care of one of them for many weeks. She said
that during that time the neck of the uterus was repeatedly cauterized.
She got impatient, and went to another physician, who told her that the
caustic treatment she had submitted to was worse than useless ; and

408 OTT THE MICEOSCOPE, AS AIS^ AID m THE

that a surgical operation was the only thing to be done. She consented
to it, and he incised the cervix bilaterally. She did not conceive, and
two years afterward went to Paris to see me. I found the uterus nor-
mal in all its relations, the os tineas and cervical canal suflBciently patu-
lous. I explained to both husband and wife the importance of examin-
ing the cervical mucus four or five hours after coition. They returned
the next day; the cervical mucus contained spermatozoa ; therefore there
was no necessity for any further surgical operation. But the spermatozoa
were all dead ; therefore there was a necessity for a treatment to rectify
the vitiated cervical secretion. She remained in Paris a few weeks under
my care, was cured, and became a mother in a year after her dismissal.
^Tow. if the first physician had used the microscope, as I direct, he would
probably have found that the semen never entered the cervix at all ; and,
if the second one had done the same thing, he would certainly have found
that the mucus of the cervix poisoned the spermatozoa.

ISTo. 2, a lady, in the highest ranks of life, was sterile. The cervix
uteri was incised bilaterally. She had pelvic cellulitis afterward. Two
years after this I saw her, and she was still childless. The microscope showed
that the cervical mucus, examined four hours after coition, killed all the
spermatozoa. While this condition exists conception is impossible.

No. 3, sterile, was treated for sterility in America, for a long time (two
or three years). She went to Europe ; had the cervix cut open, and was
sent away with the promise of offspring. I saw her some time after-
ward. The microscope proved that the husband was sterile. Therefore,
the previous treatment at home and the operation abroad were useless.
I could relate several other cases like the above. But, as I have often
made the same mistake before I fully understood the value of the micro-
scope, I forbear.

!N^o. 4, married four years; sterile. She had dreadful dysmenorrhoea,
followed by discharge of a bloody brownish mucus, of an offensive odor.
The uterus was anteflexed; anterior wall hypertrophied ; os uteri small. I
was in doubt, at first, whether to recommend an incision of the cervix or
not. I told the husband that an operation would be necessary if the semen
did not enter the canal of the cervix; but, if it did enter, the case might be
cured without cutting. The wife came to see me the next day, some five
or six hours after sexual intercourse. A drop of mucus from the cervix
contained spermatozoa in great abundance. Here, the whole question of
diagnosis and treatment was settled at once, and in the only way possible,
by the microscope. For this one examination proved all that was essential
to know — viz., 1. That the semen was perfect; 2. That it entered the
cervical canal, and therefore there was no surgical operation necessary;
3. That the cervical mucus poisoned the spermatozoa, and hence a treat-
ment directed to the utero-cervical canal was indicated. After the next
menstruation (a month's treatment), the cervical mucus was considerably
improved, for it contained large numbers of active spermatozoa. At the
end of two months, I found living spermatozoa in the cervical mucus,

DIAGNOSIS A^T> TEEATMENT OF STEEILITY. 409

thirty-six liours after coition. All treatment was now suspended, and
after the next menstruation conception took place.

No. 5, married five or six years without ofispring. The uterus was
small, and retroverted by a fibroid, about the size of a walnut, on its an-
terior surface, just at the junction of the cervix and body. The os was
very small, so small that a most distinguished accoucheur advised incision
of the cervix, to admit the passage of the semen, although he was not in
the habit of performing the operation, and, as a general rule, was opposed
to it. In former years, I would have given the same advice without the
slightest hesitation. But now I .said, l^o. Let us first see if the cervix ad-
mits the semen. If so, the operation is hardly necessary. If not, it is. I
saw the wife the next day. A drop of cervical mucus, under the mi-
croscope, determined the question against the operation at once ; for the
mucus was full of spermatozoa, but they were all dead. During the treat-
ment of this case, I have seen the mucus in the lower segment of the cer-
vix full of hving spermatozoa, while that taken from the os internum was
full of dead and dying ones. Nothing but the microscope could have re-
vealed the truth in such a case as the above.

No. 6, married eight years, sterile, had been treated by several distin-
guished physicians for the sterile state ; and had been to Ems and other
watering-places, all for no result. At last she came to Paris, to see my
friend Sir Joseph Olliffe, and he called me in consultation. I found a long,
conical, indurated cervix, with a small cs — just such a case as I would have
pronounced sterile by necessity, and just such as I have over and over
again operated upon without further thought. But now I wished to be
sure, before recommending an operation. After explaining the necessity
for it, I requested this lady to come and see me, four or five hours after
coition. She returned the next day. I could find no spermatozoa in either
vaginal or cervical mucus. I requested her to come again. I saw her two
days afterward — no sign of spermatozoa. I then told her that perhaps
the seminal fluid all passed away in the act of rising and dressing. She
thought it did. After further explanations, she readily agreed to send for
me some morning, to verify the state of affairs. She was a very sensible
woman, and fully understood the reasons given. A day or two afterward,
I saw her in bed, about thirty minutes after sexual intercourse. The
vagina was full of semen ; and I removed about a drachm of it, and went
home immediately for the microscopic examination.. But, unfortunately,
there were no spermatozoa. Not very long ago (seven or eight years), I
had the idea that sterility was essentially a female infirmity ; that men were
never sterile, except when impotent ; and that any man, legally competent
for the married state, was physically so for procreation. But the micro-
scope unsettles and settles all such vague notions. It is natural to suppose
that a strong, vigorous man is more fitted for procreation than a weak or
puny-looking one. Some of the greatest lights of the profession have held
such views as this. It was only two or three years before the death of
the lamented Trousseau, that he said to me, in speaking of a case we had

410 ON THE MICROSCOPE, AS AN AID IN THE

under consnltation, " If our patient only bad a man for a husband, all would
be right." I subsequently found out that the husband's passions were
strong ; that his semen was perfect ; that it entered the cervix in great
abundance ; and that the spermatozoa were there poisoned by a vitiated
secretion. I mention this to show that we must not judge from appear-
ances, when it is so easy to settle the question by the microscope.

'No. T, married nine years, sterile, had consulted, several distinguished
physicians, one in Germany, who told her it was useless to try any
further treatment, as she was now well enough, and that it was the fault of
her husband that she did not conceive. I explained to her that there
was nothing easier than to determine that question at a single visit. She
came the next day. I removed some vaginal mucus; also a mass of cer-
vical, as large as a pea, that was just hanging from the os; also some
from within the canal. The vaginal mucus contained spermatozoa, but,
of course, they were all dead. The mass of cervical mucus that hung
out of the OS contained spermatozoa in abundance, all dead. The mucus
from the interior of the cervix was wholly devoid of spermatozoa.

Here tlie microscope settled the whole question.
There was no longer any guess-work. 1. It was not
the fault of the husband that there had been no con-
ception. 2. The seminal fluid did not enter the canal
of the cervix. 3. The spermatozoa were killed by the
cervical mucus, where the two came in contact. As
the shortest and best method of treatment, I incised
the cervix After the subsequent menstruation, semen
was found to enter the canal of the cervix. After the
next period, they were found there in abundance, and
all living. In three months thereafter, she conceived.
In another three months, she miscarried, in conse-
quence of a fall. Six months after this, she conceived
again ; and a 3'ear ago she became a mother.

So far I have related only cases of natural sterility,
and, were it necessary, I could give you scores more of
the like character, but, as you perceive, there is so
much sameness among them, that it would be super-
fluous. However, bear with me a moment longer,
while I give you one or two illustrations of the value
of the microscope in acquired sterility.

DIAGNOSIS AISTD TEEATMENT OF STEEILITY. 411

'No. 8, aged 36, had given birth to one child, ten years ago. Her
genera] healtli was perfect, but she did not conceive again. She was
anxious for more offspring — had been to various watering-places, and liad
consulted several distinguished physicians. At last she fell into the hands
of my friend Dr. Lheritier, who brought her to me. I found the uterus
liypertrophied, and somewhat retroverted. The os was rather small and
the cervix indurated, and I had some doubt whether the semen could enter
the cervical canal. But a microscopic examination proved that it did, and
that the cervical secretions killed all the spermatozoa. TJiis case was
under treatment in January and February, and again in May and June,
When she left in June, living spermatozoa were found in the cervical
mucus, in great abundance, thirty-six hours after coition. "We, there-
fore, pronounced the case cured. She conceived a month afterward,
and was safely delivered at term.

iN'o. 9. — We often fail to cure curable cases because the treatment is
sometimes so tedious that both patient and doctor get mutually tired, and

both are glad to quit. Madame , aged 34, had one child eight years

ago; subsequently had chronic cervical inflammation; was cauterized too
much. The cervix became indurated, and the os contracted. She wanted
more offspring. I was in doubt about cutting open the cervix. A micro-
scopic examination proved that the semen could not enter the cervix.
Accordingly, I incised the os. After this, the semen entered the canal of
the cervix, but its mucus killed all the spermatozoa. The mucus was not
as clear and limpid as it should be, and it had white milky specks in it,
looking as if it had been mixed with a little of the vaginal secretion.
The lining membrane of the cervix was too red and rather granular.
This was cauterized even up to the cavity of the uterus; and various
other local as well as general remedies were adopted and carried out
from time to time for twelve months. The character of the cervical se-
cretion gradually improved, and at times showed some living spermatozoa,
and again all were dead. This patient did not despair, notwithstanding a
fruitless treatment for so long a time.

A sponge-tent had revealed long ago a small flattened cystic tumor in
the canal of the cervix, situated on its posterior face, just at the os inter-
num. I had repeatedly suggested the propriety of extirpating it. After
all other means had been exhausted for restoring the cervical secretion to
a normal state, the operation was agreed to. In June, 1867, nearly two
years after we began the treatment, a sponge-tent was introduced ; the
canal of the cervix was fully dilated, and a cystic tumor, about the size
of the. end of the little finger, was extirpated. Three months afterward,
the cervical mucus was greatly improved; and in March last, after a
treatment of more than two years and a half, I examined the secretions
fifteen hours after sexual intercourse, and I had the satisfaction of say-
ing, "At last, madam, I find the cervical mucus perfect; it is full of sper-
matozoa, and all very active. We can now hope for conception. " Con-
ception dated from that period, for she did not menstruate afterward.

412 OJ^" THE MICEOSCOPE, AS AN AID m THE

Bnt for the microscope, I would have dismissed the case as cured after the
incision of the cervix uteri, and she would have remained, in all proba-
bility, sterile to the end.

Once I tliouglit that the most common obstacle to
conception was a contracted cervical canal, contracted
at its outlet, at the os internum, or throughout its en-
tire length. But, if I were now asked, " What is the
most frequent obstacle to conception ? " I should un-
hesitatingly say, " An abnormal utero-cervical secretion
that poisons or kills the spermatozoa." I can call to
mind numbers of cases where, in former years, I in-
cised the cervix, when the operation was satisfactorily
done, and yet the sterility persisted. In some of these
I have now not the least doubt that the husbands
were sterile, and in others I have as little doubt that
the cervical mucus was poisonous to the spermatozoa.
If I had then possessed the exact knowledge of to-day,
how much more satisfactory would it have been for
me — how much better for my poor patients !

I could go on for hours with cases to illustrate the
principles already laid down. The foregoing are taken
at random, and are sufficient for the purpose. I have
not treated a single case of sterility as sach in the last
six years, without determining the three questions so
essential to success that were stated at the outset of
this j)aper, except the half-dozen cases already alluded
to, and in these the microscope at last revealed the
truth.

Before closing this paper, pray allow me to say a
word personal to myself, which is, at the same time, in
vindication of the honor and progress of medicine.
When my book on " Uterine Surgery " appeared, in Feb-
ruary, 1866, it was noticed, generally favorably by the
medical press, and always honorably, with but one ex-

DIAG]S^OSIS ATs^D TKEATMEOT OF STEEILITY. 413

ception abroad, and two or three at home. The Medi-
cal Times and Gazette^ one of the most excellent and
influential journals of the day, conducted with great
ability, and usually with liberality and decorum, con-
demned, in the strongest terms, my investigation of the
seminal fluid, and said that "this dabbling in the
vagina with speculum and syringe " was incompatible
with decency and self-respect. Now, for myself, I see
no indelicacy or imj)ropriety in taking mucus from the
vagina and uterus for microscopic examination. It is
no more indelicate, no more impure, than to investigate
the character and properties of saliva, or bile, or urine,
or faeces, or pus. And where is the scientific physician,
nowadays, who could or would dare to give an opin-
ion on any obscure and complicated disease without
some such investigation ? To answer that question, I
have only to call to the witness-stand such men as
Beale, Hughes Bennett, Gull, George Harley, Sir
William Jenner, Bence J ones, George Johnson, Stokes,
and the immortal names of Addison and Bright ; and
in my own country, the great names of Alonzo Clark,
Austin Flint, John T. Metcalfe, and a host of others.
Opposition and ridicule are ever ready, but never yet
crushed out a great truth. With the simplicity of my
nature, and with the honesty of my purpose, there can
be no indecency, and no sacrifice of self-respect in
making any necessary physical examination whatever,
if it be done with a proper sense of delicacy, and with,
a dignified, earnest, and conscientious determination to
arrive at the truth — a truth without which every step
is in the dark, but with which all is as clear as the
noonday's sun. •

414

PEOCEEDINGS OF SOCIETIES.

MEDICAL SOCIETY OF THE COUNTY OF ^E^Y YOEK.
Stated Meeting^ Decemher 7, 1868.
Dr. Geo. T. Elliot, President, in the Cliair.

Aftek transaction of the nsual preliminary business, the
President announced that, at the last meeting of the Comitia
Minora, it was voted to grant certificates of membership to
Drs. Horatio Paine, Eustis F. Langdon, David Magie, Jr., D.
A. Goodwillie, Ernst Krackowizer, Emil Noeggerath, W. B.
E^eftel, Chas. A. Leale, F. A. Burrall, E. L. Keyes, Salvatore
Caro, A. B. Crosby, Hermann Knapp, and O. A. White.

The death of Dr. John O'Reilly, of this city, a member of
the Society since 1866, was announced by the Chair. Dr.
O'Peilly was born in Ireland, in 1813, and had been a resident
of this city, and engaged in the active practice of medicine,
since 1849. Dr. O'Peilly was favorably known to the profes-
sion of this city. He was the founder of the O'Beilly Prize,
offered by the ITew York Academy of Medicine.

After the presentation of the reports from the several com-
mittees, the paper of the evening was read by Dr. Marion
Sims, on The Microscope as an Aid in the Diagnosis and
Treatment of Sterility."

[This paper is piiblislied in full in another part of this number of the
Journal.]

The paper being accepted by the Society, Dr. Peaslee was
called upon by the President for remarks. He regarded the
paper just read as very complete in itself, leaving nothing
more to be said upon certain points. He had hoped, there-
fore, that some side issues might have been raised by others,
upon which he could base his own remarks. Though Dr.
Sims's investigations were not in all respects original, yet he
had pursued them further than any of his predecessors. And,
despite the misrepresentations of his maligners, he had just
reason to be proud of the manner and spirit in which he had
pursued them, and of the important practical truths he had
attained. Science was no respecter of persons ; and her faith-
ful votaries knew no such word as indecency.

PEOCEEDINGS OF SOCIETIES.

415

The speaker was delighted to hear that Dr. Sims no longer
advocated incision of the cervix, as a matter of course, in the
treatment of sterility. He had himself never practised it in
such cases, warned against it by its worse than useless effects
in several cases that had come into his hands. In some of
these, the incisions had been carried so far as to involve the os
internum, so that, if conception were to occur, miscarriage
would almost certainly follow. The paper had correctly indi-
cated the circumstances under which the operation was proper
But the criterion there given for considering the treatment
complete — that of finding the spermatozoids in an active state,
high up in the cervical canal, a considerable time after coition
— was hardly sufficient. There were cases of flexion in which
they might enter the canal, and find there the normal secre-
tions, and yet be unable to pass the point where the flexion
brought the walls into close contact. He had in these cases
brought about conception by simply raising the fundus uteri,
and thus partially straightening the bent canal.

The remarks in the paper upon the frequency of sterility
in the male were very important. After double epididymi-
tis, as long since stated by Lallemand, it was sure to occur,
the spermatozoids not appearing in the semen for several
months ; and they were very likely to disappear again on any
rekindling of the inflammation, from taking cold, for example.
The pliysician should, therefore, satisfy himself concerning the
husband's history in this respect, as the first step in his inves-
tigation of a case of sterility. Again, in some cases of urethral
stricture, the semen, unable to pass the point of stricture dur-
ing the turgescence of the organ, was regurgitated into the
bladder. The doctor had known a similar result produced in
a patient addicted to masturbation after a fashion certainly
original. Deeming that the ill effects of the habit were due
to the loss of semen, this man used to prevent its escape by
tightly grasping the penis at the moment of highest excite-
ment, thus causing regurgitation into the bladder. When he
afterward married, he found that, although he had suffered no
loss of sexual vigor, yet the seminal fluid persisted in following
the course it had before been compelled to take. There was
no emission attending the sexual act, but the spermatozoids

416 PEOCEEDES^GS OF SOCIETIES.

could be found in the urine. Of course, the urine speedily
destroyed the ^-itality of the spermatozoids. This man would
probably remain childless.

The speaker discussed at some length the physiology of
reproduction, dwelling upon the many obstacles to impreg-
nation, and upon the exhaustless resources of ^^'ature, which
could afford to waste millions of germs for one that came to
fruit. He indorsed the view that the uterus takes an active
part in the sexual act, contracting firmly during the period of
excitement, and, in that of relaxation, expanding, and so ex-
erting a suction power to draw the seminal fluid into the cer-
vical canal.

The President had seen it stated, on excellent authority,
that the mode of preventing emission of the seminal fluid,
practised in the case related by Dr. Peaslee, was common
among the French prostitutes, to avert the danger of concep-
tion ; and that it had given rise, in some cases, to permanent
impotence.

Choleea Fuxgus. — "We understand that the Director-Gen-
eral of the Army Medical Department and the Senate of the
Army Medical School have taken an important step with a
view to the final settlement of the Cholera Fungus question.
Acting on the advice of the professors of the School, the au-
thorities have consented to send two of the most distinguished
Sieves to Germany to study the subject under Professors Hal-
lier and De Bary. The young medical officers, after master-
ing the mode of investigation pursued in this diflicult inquuy
by the eminent men above named, are to proceed to India,
and to be set apart to investigate it in that great field of ob-
servation— in the very home of cholera. It is to be hoped
that this well-advised measure will meet with the success it
deserves. It is much to the credit of the Secretaries of State
for. War and India that they have consented to carry out this
measure in a wise and liberal spirit. — Lancet.

Salt or Lemoxs. — A serious accident recently occurred in
England from the incautious use of the article bearing the above
harmless name. Peroxalate of potash, as it is called by the
chemist, removes stains effectually, but its resemblance to
epsom salts renders it liable to be mistaken for that aperient
medicine. The London Medical Gazette warns all liouse-
keepers against this dangerous preparation of oxalic acid.

BIBLIOGEAPHICAL AXD LTTERAKY :S"OTES. 417

We are compelled, by the great amount of material accumulated on our
bauds, to omit all reviews in tbe present number.

The author, who ouce resided in this country, now lives in
Paris ; he is writing, in French, a work on the diseases of the
womb, and this ^ is a specimen chapter done into English hv
himself. He thinks that uterine catarrh is the most common
of all the womb disorders which cause sterility, and, moreover,
he asserts that it has always been materially bettered, and
generally radically cured, by the rational treatment he recom-
mends, which is, " first, general medication ; second, a direct
action on the organs affected, especially by means of intra-
uterine recm-rent injections." Of course. Dr. Gantillon has in-
yented, and now exclusiyely adopts," an instrument which
does away with all the risks of this method, and insures
the relief of this rebellious and pftentimes reputed incura-
ble affection " cito^ ticto, et jucunde. This plan has other
adyocates in France, although the general feeling is unfavor-
able to it, many disasters haying followed its use. We believe
that there is always risk in its employment, if the cervical
canal has not been preyiously dilated.

The ample title dispenses us from telling our readers the
contents of this well-printed yolume,^ which is addressed
more to the general public than to the profession. We were
not before aware that muscular laxity of the intestinal canal,
of urinary organs, hernia, and uterine displacements, were de-
rangements to which the clerical, legal, and musical profes-
sions were particularly obnoxious, nor has the eyidence in this
book conyinced us of the fact ; but we are satisfied, from look-

^ Uterine Catarrh frequently the Cause of Sterility. Xew Treatment
by H. E. Gantillon, M. D. 1868. Pamphlet, pp. 88.

^ A Rational Treatise on the Trunkal Muscles, elucidating the Mechan-
ical causes of Chronic Spinal, Pelvic, Abdominal, and Thoracic Affections ;
and of Bronchial and other Derangements incident to the Clerical, Legal,
and Musical Professions ; -with the Rationale of their Cure by Mechanical
Support. By E. P. Banning, M. D. New York : Published by W. A.
Townsend & Adams. 1868. 8vo, pp. 352.

418 BIBLIOGEAPHICAL AXD LITEEAEY IS^OTES.

ing over its tinted pages, that tlie author is given to in-
dulge in what Mrs. Malaprop styles " a nice derangement of
epitaphs."

The Sydenham Society pnblications for 1869 will com-
prise a second volume of Trousseau's Clinical Lectures ; the
second volume of Lanceraux's Treatise on Syphilis ; the
Biennial Retrospect of Medicine and Surgery, for 1867-'8 ;
and a Sixth Fasciculus of Hebra's magnificent Atlas of Skin
Diseases.

The Official Eeport of tlie International Medical Congress,
held at Paris in 186T, has appeared from the press of Y.
Masson & P. Asselin, Paris. It embraces all the discussions
and papers read at the Congress.

Feom Churchill's press, London, we have a new edition —
the tenth — of Fowne's Chemistry, edited by Drs. Jones &
"Watts ; also A Manual of Diseases of the Eye, by E. Mac-
namara, M. D.

GooDsiE, THE Great ANATo:snsT. — Messrs. Black, of Edin-
burgh, have published two volumes of the scientific remains
of the late lamented Professor Goodsir — one of the greatest
ornaments of the Edinburgh University in our time. The
volumes contain k Memoir by Dr. Henry Lonsdale, of Carlisle,
with the valuable papers which were published by Mr. Good-
sir in his lifetime; also, notes of two important series of
lectures — the one on the place which man has in creation, and
the other on comparative anatomy. The text is illustrated by
plates and wood engravings, and a fac-simile portrait taken
from a rare photograph which was found in the possession of
a friend.

LixDSAY & Blakistox, of Philadelphia, have in prepara-
tion a work on surgical diagnosis, by Addinel Hewson, M. D.
They have also imported in sheets, and issued with their im-
print. Dr. Lionel S. Beale's well-known work on '^Kidney
Diseases, Urinary Deposits, and Calculous Disorders : their
Nature and TreatnientP They also announce to be ready in
• January, 1869 : Cleaveland's Pronouncing Medical Lexi-

BIBLIOGRAPHICAL AXD LITERARY ^^OTES. 419

C071 / " a new and improved edition (the eleventh), a small
pocket-Tolume. " Spencers Lectures on Surgery^'' with col-
ored and other ilhistrations ; 1st fasciculus ; to be completed
in three parts. " Mackenzie on the Laryngosco])e and some
Diseases of the Throat^^ edited, with additions and an essay
on Rhinoscopy, by J. Solis Cohen, M. D. ; witli lithographic
and other illustrations. Buppaner on Hypodermic Injec-
tions; " a new and improved edition. " Clinical Lectures on
Chronic and Gouty Bronchitis^ and on Pidrnonary Em-
physema^^ by E. Headlam Greenhow, IT. D., F. R. C. P., etc.

J. Campbell, of Boston, has issued a second edition of Dr.
D. W. Cheever's monograph on " (Esophagotomy for the Iter
7)ioval of Foreign Bodies^

Messrs. Hurd & Houghton have in press " How not to he
sick / Oj Sequel to the Philosopjhy of Eating by Albert J.
Bellows, M. D.

From the press of Henry C. Lea, of Philadelphia, we are
. promised in a few days : " On Syphilis and Local Cutaneous
Disorders^^ by Berkeley Hill, Surgeon to the Lock Hospital,
London. A Complete. Practical Treatise on Diseases of
Children^'^ by J. Lewis Smith, Professor of Morbid Anatomy
in Bellevue Hospital Medical College. " Clinical Lectures
on Diseases of the Urinary Organs, delivered in LTniversitj
Hospital Medical College, by Sir Henry Thompson ; with
illustrations. "JL Conspectus of the Medical Sciences; em-
hracing Anatomy, Physiology, Chemistry, Materia Medica,
Practical Medicine, Surgery, and Obstetrics by Henry
Hartshorne, M. D., Professor of Hygiene in the University of
Pennsylvania ; 1 vol., royal 12mo., of about 1,000 pages, with
several hundred illustrations.

The magnificent edition of Cullerier, translated and edited
by Bumstead, is now completed.

In the January number of the Mediml News and Library
will be commenced tlie republication of Eustace Smith's work
On the Wasting Diseases of Children^'' just issued in Lon-
don.

Of German publications, we have observed notices of the
folio win o; :

420 BIBLIOGRAPHICAL Ali<B LITEEAEY jS^OTES.

Atlas des Menschliclien Gehororganes. Herausgegeben von

^ Dr. Eiidinger, k. Adjunct nnd Prosector an der Anato-
misclien Anstalt in Miinclien. E"acli der Xatur pLoto-
grapliirt von J. Albert. Erste Liefernng, entlialtend : 8
Tafeln Pbotograpbien mit 20 Fignren ; 4 Tafeln Litbo-
grapbien nnd den bescbreibenden Text. Zweite Liefernng,
entbaltend : 8 Tafebi PJiotograpbien mit 23 Figuren ; 4
Tafeln Litbograpbien mit 9 Figuren nnd bescbreibendem
Text. Atlas of tbe Hnman Ear. By Dr. Piidinger, Pojal
Adjunct and Prosector in tbe Institute of Anatomy at Mu-
nicb. Pbotograpbed from nature by J. Albert. Municb. First
Part, containing : 8 pbotograpbic pl&tes witb 20 figures,
and 4 litbograpbic plates witb descriptive text. Second
Part, containing: 8 pbotograpbic plates witb 23 figures, 4
litbograpbic plates witb 9 figures and descriptive text.
Municb, J. J. Leutner, 1867.

Gesammelte Abbandlungen liber Pbysiologiscbe Optik. Yon
Dr. August Classen, in Rostock. Berlin, August Hirscb-
wald, 1868. Collected Treatises on Pbysiological Optics.
By Dr. August Classen, of Postock. 175 pages. Berlin,
August Hirscbwald, 1868.

Der Intra-oculare Druck nnd die Innervations- Yerbiiltnisse
der Iris, vom augenarztlicben Standpunkte aus betracbtet.
Yon Dr. Karl Stelwag von Carion, in Wien. Wien, "Wil-
belm Braumiiller, 1868. Intra-ocular Pressure and its
Relations to tbe Xerves of tbe Iris, considered from tbe
opbtbalmological stand-point. By Dr. Karl Stelwag von
Carion, in Yienna. 100 pages. Yienna, "Wilbelm Brau-
miiller, 1868.

Der Mecbanismus der Accommodation des Menscblicben
Auges, nacb Beobacbtungen im Leben dargestellt von Dr.
E. A. Coccius, Leipzig. Mit einer Utbograpbirten Tafel.
Leipzig, G. B. Teubner, 1868. Tbe Mecbanism of Accom-
modation in tbe Human Eye, from Observations on Living
Subjects. By Dr. E. A. Coccius, oculist and professor in
Leipsic. 153 pages. 1868.

Die Querextraction des 2:rauen Staars der Erwacbsenen. Yon
Dr. H. Kiicbler, zu Darmstadt. Erlangen, Ferdinand Enke,
1868. Extraction of bard Cataract in tbe Adult by a

BIBLIOGEAPHICAL AXD LITERARY NOTES. 421

transverse Section of the Cornea. By Dr. 11. Kiicliler, of
Darmstadt. 37 pages.
Die Toeorie der Augenfehler nnd der Brille. Yon Dr. Her-
mann Sclieffler. Mit 6S Holzschnitten. "^yien, Wilhelm
Brauraiiller, 1868. Theory of Errors of Vision and of
Spectacles. By Dr. Hermann Schefiier. "With 68 wood-
cuts. 191 pages.
A translation of this book by Dr. Eobert B. Carter is an-
nounced for publication by Longmans, Green & Co., of Lon-
don.

Books Received. — "Prodrome of a TTork on the Ornithologj of Ari-
zona Territory." By Elliot Cones, M. D., Asst. Surg. U. S. Army. Pam-
phlet; pp. 64.

"Reeherches Experiraentales sur une Xonvelle Fonction du Foie, etc."
Par Anstin Flint, Fils, Doctenr en Medecine, etc. D. Appleton & Co.,
New York, 1868. 8vo. pp. 22.

This is a translation into French of Dr. Flint's article vrhich appeared
in October, 1862, in the Amej^ican Journal of Medical Sciences^ and which
attracted such marked attention from the scientific world. The compli-
ment paid to the author by the translation, which was nndertaken at the
instance of Prof. Ch. Robin, is as handsome as it is well merited.

Proceedings at the Opening of the Rhode Island Hospital, October 1,
1868." Pamphlet ; pp. 55. (From Dr. Geo. L. Collins.)

Our extended description in the November Jottexal of this beautiful
hospital renders unnecessary any notice of this pamphlet. The addresses
made at the opening ceremonies were appropriate to the occasion, and the
assurances of the substantial support of the hospital, furnished by the
prompt endowment of so many free beds, must be especially gratifying to
the originators and promoters of this admirable charity.

"Case of Excision of the Entire Scapula ; to which is added a History
of the Operations involving the Removal of all or considerable Part of
this Bone, etc." By Stephen Rogers, M. D. Reprint from the American
Journal of Medical Sciences. From the Author.

For a notice of this admirable monograph see the comments on a simi-
lar case, reprinted from the Lancet in the present number of the Journal.

"Report of the Proceedings of the Association of Medical Superin-
tendents of American Institutions for the Insane at their Twenty-second
Annual Meeting, held at Boston, Mass., June, 1868. Harrisburg, Pa.,
Thos. F. Scliceffer, 1868. Pamphlet ; pp. 207.

"Annual Report of the Officers of the Vermont Asylum for the In-
sane, August, 1868." Pamphlet; pp. 11.

" The Materia Medica in its Scientific Relations." (Anonymous.) iSTew
Haven, Conn., Judd & White. Pamphlet.

422

EEPORTS 0]Sr PEOGEESS OF MEDICmE.

" The Physiological and Therapeutical Effects of Compressed Air
Baths." By Charles A. Lee, M. D. Buffalo, K Y., 1868. Pamphlet;
pp. 34.

"Subjective and Objective Symptoms; a Preliminary Lecture delivered
at the Haimemann Medical College of Philadelphia, Pa." By C. G. Raue,
M.D. Pamphlet; pp. 16.

"These de Pharmacie pr6sent6e et soutenue a I'Ecole Superieure de
Pharmacie." Par Armand Fumouze, M. D., de la Cantharide Officinale.
Paris, Germer Bailliere, 1867. 4to. pp. 58. Avec planches.

^^parts on t\^t ^rngr^ss of ^tWxm.

ANATOMY AND PHYSIOLOGY.

1. — On the Physiology and Physics of the Muscles. [Jour-
nal de I'Anatomie et de la Pliysiologie. Janvier et
Fevrier, 1868, pp. 27.]

Dr. Jacob Chmoulevitch reports a series of experiments performed
with a view of ascertaining the active force of muscles when separated
from the body, and stimulated to contraction at different temperatures. He
used for this purpose the gastrocnemii muscles of the frog, placed in a
metallic vase, filled with an aqueous solution of chloride of sodium of the
strength of 0.65 parts of salt for 100 parts of water. This solution had
been found, by previous trials, to be the best for preserving the vital
powers of the muscle uninjured for a considerable time. The tendon of the
muscle was attached by a fine steel hook to the bottom of the vase, the
upper extremity was left adherent in the natural manner to the bones; and
a second steel hook introduced between the muscle and the bone, con-
nected it with the short arm of a lever, working upon an upright stand-
ard. The long arm of the lever carried the weight to be raised by the
muscular contraction, and was also provided with a pencil which regis-
tered the extent of its movements, and consequently the height to which
the weight was raised. Before applying stimulus to the muscle, its ten-
sion was regulated and the equilibrium of the lever secured by a smaller
weight attached to the middle of the short arm of the lever. The tem-
perature of the muscle was varied as the experiments required, either by
immersing the metalhc vase in ajar of warm water, or by adding to the
solution in w^hich the muscle was immersed. The stimulation of the mus-
cle was accomplished through the medium of the sciatic nerve, a portion
of which was included between the electrodes of an electric apparatus, so
arranged that an induced current could be produced at will.

The author distinguishes between the 'partial and total effect of the
muscular action. The partial effect is that produced by a single muscu-
lar contraction ; the total effect is the sum of all the separate actions pro-
duced by the muscle in successive experiments until the complete ex-
haustion of its contractile power. As the result of these examinations,
the author concludes :

1. The partial effect of the contraction of the frog's muscle increases
with the elevation of the temperature, up to 30 or 33 degrees Centigrade
(86 or 91.4 degrees Fahrenheit), according to its length and tension.

ANATOMY AND PHYSIOLOaY.

423

2. For each muscle there is a certain tension at which it preserves the
same length at different temperatures.

3. If the temperature of the muscle be raised above 30 to 33 degrees
C, its meclianical effect begins rapidlj to diminish. By contimiing the
elevation of the temperature a degree is then reached, at which the mus-
cle, when supporting a certain weight, will no longer contract under the
application of stimulus. Its mechanical effect is then reduced to zero.

4. Other things being equal, the muscle becomes more rapidly ex-
hausted at a high than at a low temperature.

5. On account of this more rapid exhaustion of the muscle owing to
the temperature, its total mechanical effect is always less when the tem-
perature is high than when it is low.

These experiments appear to have been very carefully performed, and
their results accurate and valuable. We cannot say as much for the con-
clusions, which the author desires to draw from thenj, in regard to "other
phenomena." As too often happens, when the physiologist leaves the
narrow path of direct experiment for the wide field of general speculation,
his inferences lose their virtue, from the neglect of a variety of new con-
ditions, which are very likely to influence the result.

"I hope," says Dr. Chmoulevitch, "that I shall also succeed in the
explanation of other phenomena besides those observed in my experi-
ments. At present, I only wish to call attention to certain facts which
are explained by what I have demonstrated above. It is, in this way, that
we can account for the greater energy and the rapid exhaustion of the
inhabitants of warm climates in manual labor. It also explains why the
inhabitants of the temperate zones cannot Continue at work for any great
length of time during summer weather; because, at a high degree of tem-
perature the muscle is comparatively incapable of producing a mechanical
effect. The temporary increase of muscular force by the use of alcohol,
is, perhaps, to be explained, in part, by the greater production of heat in
the muscle, consequent upon the increase of the molecular movements,
which are, themselves, a result of the accelerated circulation. We can
account in a similar way for the effect of a cold bath, which reestablishes
the vigor of the muscles, after they have been exhausted by an elevated
temperature.

"It apnears that the muscles of organic life are subjected to the same
laws as those which are composed of striped fibres. We see, accordingly,
why the inhabitants of warm countries are obliged to confine themselves
to light and easily digestible kinds of food; because the muscular fibres of
the alimentary canal are incapable of doing the necessary work to fur-
nish, on the one hand, the requisite quantity of the gastric and intestinal
juices, and, on the other, to effect the movement of the alimentary ma-
terials. The frequency of diarrhosa, dui-ing the summer season, may be
due to the same debility of the muscular fibres; its treatment, accord-
ingly, should consist in the adraiuistratiou of tonics (such as spirituous
liquors, strong coffee, etc)., which invigorate the muscles, Avhile opiates,
on the contrary, by debilitating the muscles, would be injurious."

2. — Researches on the Structure of the Fibrous Envelope of
the Nerves. [Journal cle I'ATiatomie et de la Pliysiolo-
gie. Janvier et Fevrier, 1868, pp. 47.]

Prof. Sappey contributes an article on the above subject,
in wliicli lie describes tlie structure of tlie neurilemma more
carefully and fully than it lias been done heretofore. This

424

EEPOETS ON PEOGKESS OF MEDICESTE.

envelope, Tvliich lias tlins far been considered -as a membrane
consisting only of laminated or condensed areolar tissue, with
a few vascular twigs ramifying in its substances. Prof. Sap-
pey describes as containing adipose tissue and elastic tissue,
mingled witli its other constituent parts, and as being supplied
with blood-vessels, which are remarkable both for their size
and their multiplicity. The most remarkable feature of the
neurilemma, however, according to Prof. Sappey, consists of
the nervous filaments distributed to its tissue, and described
by him under the name of the nervi nerrvoriim.

"This envelope," lie says, "also receives nervous filaments, which are
to the nerves what the 'casa vasorum are to the blood-vessels; Avhence the
naroe of nemi nervorum^ by whicli I propose to designate them. The
arrangement of these nervous filaments differs but little from that which
they usually present in the fibrous tissues. They also follow the course of
the principal arteries. Like the arteries, they give off and receive, during
the course, numerous anastomotic branches ; so much so, that at certain
points they even foi'm small nervous plexuses. They are to be seen, not
only on the common sheath of the nerve, but also on those of the smaller
nervous fasciculi. Nevertheless, they become at the same time more slen-
der, and less numerous, as the calibre of the fibrous sheath diminishes;
and very often they are no longer to be seen on the sheaths of the secondary
fascicuh. They are always wanting in the sheath of the primary fas-
.ciculi ; and accordingly they are not to be looked for in the sheath of any
nervous filament of less than half a millimetre of an inch) in diame-

ter. The nervous tubules of which they are composed, are in general
remarkable for their tenuity. Each one of them, notwithstanding, is com-
posed of an external envelope, or perineurion, a medullary layer, and an
axis-cylinder."

3. — Experiments with the Poison of the American Copper-
head (Trigonocephalus contortrix). [i^ew York Med-
ical Record, September 1, 1868.]

Prof. Joseph Jones, M. D., Professor of Physiology and
Pathology, in the Medical Department of the TJniversity of
jMashville, describes the specific characters of the copperhead,
and details the result of five experiments with the venom of
the serpent upon the dog, the kitten, and the cock. From
these experiments he draws the following conclusions :

1. The primary and chief action of the poison of the American copper-
head (Trigonocephalus contortrix) is upon the blood.

2. The poison of the copperhead is directly destructive to the colored
blood-corpuscle, altering its physical and chemical properties and rela-
tions, and rendering it unfit for the performance of its important oflices in
circulation, re>piration, and nutrition.

3. The poison of the copperhead appears to have an affinity more
especially for the coloring matter of the colored blood-corpuscles.

4. Under the action of the poison of the copperhead the animol tem-
perature is but slightly increased, notwithstanding the profound changes

ANATOMY AIS^D PHYSIOLOGY.

425

inaugurated in the blood; and after the establishment and propagation of
these pathological changes the temperature descends.

5. The action of the heart is increased in frequency, and diminished in
force, under the influence of the poison of the Trigonocephalus contor-
trix. Tliis increase in tlie rapidity of the pulsations of the heart is not,
as in the case of febrile diseases, attended by a marked rise of animal
temperature. This difference may be due to the peculiar and direct action
of the poison upon the colored blood-corpuscles.

6. In its action upon the cerebro-spinal nervous system, the poison of
the Trigonocephalus contortrix resembles a mild narcotic — while render-
ing the animal sluggish and stupid, it may produce death without the
establishment of profound coma.

7. The profound alterations induced in the constitution of the blood
by the poison of the American copperhead give rise to passive haemor-
rhages into the cellular structures, and from the intestinal mucous mem-
brane. This phenomenon recalls strongly the passive haemorrhages in
certain febrile diseases, and especially of yellow-fever. Some have sup-
posed that the black vomit of yellow-fever was the resultant of the effects
of the preceding intense fever. Do not the present experiments indicate
that it is rather the resultant of the action of a poison upon the blood and
gastro-mucous membrane ? We have here also an illustration of the mode
in which dysentery might be produced by a poison introduced into the
blood.

4. — Localization of the Reflex Movements. Bj Dr. J. Cat-
RADE. [Journal de I'Anatomie etde la Pliysiologie. Jiiil-
let et Aout, 1868.]

This article is for tlie most part a criticism of the conclu-
sions sometimes derived from experiments on frogs, by which
a certain degree of apparent intelligence or adaptiveness is
attributed to the reflex movements in the decapitated animal.
These experiments are more particularly those of Pfluger and
Auerbach, quoted from Yulpian's " Legons sur la Pliysiologie
de la Systeme Nerveux," as follows :

" Pfluger places a drop of acetic acid upon the upper part of the thigh of
a decapitated frog, and then sees the posterior limb of the animal bend
itself, so as to rub the foot over the irritated point. Ho tben amputates
the foot, and afterward repeats the experiment; the animal again begins
the movements as before, for the purpose of rubbing the irritated spot, but,
of course, without success; and after some moments of agitation, as if, says
Pfluger, he were trying to discover some other way of accomplishing his
design, he bends the limb of the opposite side, and succeeds in that man-
ner."

Auerbach has met with similar results. After amputating one of the
thighs of a decapitated frog, he puts a drop of acid upon the corresponding
side of the back. The animal at first makes efforts to reach it, but, as if
he recognized their inutility, soon becomes quiet. A drop of acid is then
applied to the back on the opposite side of the median line, and the frog
immediately rubs the spot with the corresponding foot; then, as if he saw
a means of reaching the spot previously irritated, he reaches over to that
side with the remaining limb, and rubs it with the foot.

Dr. Cayrade gives reasons for beheving that in all these cases the move-
ments of an intelligent nature, directed to the relief of an irritated spot,

426 EEPOETS OX PEOGEESS OF MEDICINE.

are dependent, not on the reflex action of the spinal cord itself, but on
that of a portion of the cerebral protuberance {le luWe) which is allowed
to remain after decapitation. He regards the following conclusions as
legitimate :

1. The phenomena of reflex action depend upon a preexisting arrange-
ment of nervous fibres in the spinal cord. They must, therefore, take
place in an invariable manner, and we cannot attribute to them any charac-
ter of spontaneity or of adaptation to a determined purpose.

2. In frogs, as well as in the superior animals, the destruction of the
cerebral lobes abolishes permanently all spontaneous motion ; that is, all
motion due to the express will of the animal.

3. Frogs from which the optic tubercles have been removed, still
retain the power of coordinating partial movements into general ones; but
they lose altogether the harmony and character of equilibrium of associated
movements, such as those of swimming, jumping, etc.

4. Frogs which retain a portion of the cerebral protuberance are still
able to direct partial movements, according to the irritation which has
been applied to them, but these have not the character of the true reflex
movements. The cerebral protuberance, in the frog, is the analogue of the
tuber annulare in the higher animals.

5. The name "reflex movements" should only be applied to those
which are executed by the frog wlien the medulla has been divided just
below the level of the cerebral protuberance, for these movements are per-
formed blindly, after the application of a stimulus, and are subject to the
influence of the spot excited, and the degree of the excitation.

6. If we make allowance for the effects produced by partial exhaus-
tion, it becomes evident —

First, that the reflex action takes place on the same side as that to
which the stimulus has been apphed.

Second, that if the stimulus is directly communicated to the opposite
side, it produces symmetrical movements in the two limbs, provided al-
uays that these limbs are in a symmetrical position at the time of trying
the experiment.

Third, the reflex movements are most intense upon the side of the irri-
tation.

Fourth, a reflex excitement has a manifest tendency to be localized on
that side of the medulla which received the original impression.

Fifth, a reflex excitement spreads in every direction within the medulla;
and longitudinally it is propagated as easily from below upward, as from
above downward.

Sixth, a reflex excitement, spreading through the nerve-cells of the
medulla, produces, by this secondary stimulus, various movements, corre-
sponding with the direction of the current ; but it usually puts the limbs
in the opposite position to that in which they were at the time the stimu-
lus was applied.

5. — Lateral Hermaphroditism. [The British Medical Jour-
nal, June 6, 1868.]

In the Liverpool Medical and Surgical Reports, October, 1867, Dr.
Eawdon describes a case of true lateral hermaphroditism, in which a
tolerably developed vagina and uterus were present. In the left broad
ligament a Fallopian tube, a round ligament, and apparently a parovarium
were found, but no trace of either testicle or ovary ; in the right broad
ligament a Fallopian tube and a distinct testicle, with an eimlidymis, and a
vas deferens, which was traceable on the side of the uterus as far as the

ANATOMY AND PHYSIOLOGY.

427

cervix, the junction between the testicle and the epididymis being very
feebly, if at all developed. The conformation of the pelvic cavity was
between the male and female types. It is alleged by the person that a
partial occm-reiice of tlie menstrual secretion took place regularly. The
case is of interest in its bearings on the development of the genital appara-
tus, and, from the coexistence of a Fallopian tube and a vas deferens on
the same side of the body, it supports the view that these ducts are devel-
oped from distinct embryonic structures, Viz., from the Milllerian duct and
the excretory duct of the Wolffian body.

Cases like the above are not, properly speaking, instances
of true but of false hermaphroditism. True hermaphroditism,
if it ever exist at all, is that condition in which the individual
is at the same time both male and female ; that is, in. which
•both testicles and ovaries, or one of each, coexist in a state
of complete development. An individual having either one
or both testicles fully developed is a male, no matter how im-
perfect may be the development of the accessory parts ; and
on the other hand, the presence of ovaries is alone sufficient
to mark the sex as female, though the uterus may be wanting,
and though the external organs, as sometimes happens, may
be so unnatm-ally enlarged as to present a deceptive resem-
blance to the penis and scrotum. The individual described
in the case detailed above was therefore a male, with but one
testicle (monorchia), in whom this single testicle had not
descended below the inguinal ring, and in whom the accessory
parts had taken on an unnatural development, so as to resemble
in form those of the female.

6. — Complete Transposition of the TlioraciG and Abdominal
Viscera. [American Jom-nal of the Medical Sciences,
January, 1868.]

Dr. Hickman, Demonstrator of Anatomy in the Uni-
versity of Pennsylvania, has met with the following case of
complete transposition in the dissecting-room of the univer-
sity :

In the thorax, the lungs were reversed, the left and larger consisting
of three lobes, while the right lung had but two. The heai't extended
obliquely fi*om left to right, the apex pointing to the intercostal space
between the fifth and sixth ribs of the right side. It was bound down to
the pericardium and diaphragm by three fibrous bands, probably the re-
mains of an old pericarditis.

The anatomical characters depending upon function were also reversed,
the right side being thicker in its muscular walls, the ventricle giving off
the aorta and the auricle receiving the pulmonary veins; while the walls
of the left cavities were the thinner, the auricle receiving the venae cavae
and the ventricle giving off the pulmonary artery. Judging from the
universality of these transpositions, it is inferred that the valves were also
transposed, the mitral separating the right auricle and ventricle ; while the
tricuspid separates the left ventricle and auricle. We are unable to state

428

EEPOETS ON PEOGEESS OF 3IEDICINE.

absolutely that this is the ease, because it is thought that to lay open the
heart will impair the value of the specimen as a preparation.

The aorta, after its origin from tlie right ventricle, arches first to the
left and then to the right, and descends on the right side of the vertebrca
to its bifurcation at the top of the fourth lumbar vertebra. The coronary
arteries arise as usual from the commencement of the aorta. The first
branch given ofi" from the arch is the innominate^ which subsequently
divides into the left common carotid and subclavian arteries. The next
one, the right common carotid and subclavian, which it will be seen is the
reverse of the usual distributions. The remaining branches of tlie aorta
are as usual, except the cceliac axis, wliich is wanting, its place being sup-
plied in part by the superior mesenteric which gives off the hepatic and
gastric, while the splenic arises directly from the aorta.

The ascending cava is on the left of the aorta, necessitating the right
common iliac vein to pass under the left common iliac artery, and the left
common iliac vein passes under the artery to join the cava. The cava, a^
it*ascends, receives its usual branches. The rigJit renal vein receiving the
right spermatic vein, crosses the aorta, and is therefore much longer than
the left. The left spermatic xein empties into the vena cava. The de-
scending cava is formed by the union of the right transverse vein (result-
ing from the union of the right internal jugular and subclavian veins) and
the left innominate vein, after wiiich it passes downward to terminate in
the left auricle.

In the abdomen, the viscera are also reversed. The liver is situated in
the left hypochondriac region, the larger lobe being under the ribs, while
the smaller extends into the epigastrium. The organ is in other respects
normal.

The spleen is situated deeply in the right hypochondriac region. The
stomach occupies its usual space, but has its larger or cardiac end to the
right and the pyloric in the left hypochondriac region, causing the small
intestines to pursue an opposite course and to join the large intestine
(caacum) in the left iliac region. The large intestine, also, is reversed in
its relations, and terminates in the rectum at the riglit sacro-ihac symphysis.

The j9a??c?'ms extends from the spleen in the 7*^^Ai hypochondrium to
the duodenum, beginning in the left.

The pneumogastric nerve on the right side descends in front of the arch
of the aorta into the poster:or mediastinum in front of the oesophagus and
stomach, thus taking the course usually followed by the left. The left
nerve passes posterior to the oesophagus and stomach.

SURGEEY.

1. — Amjputation at the Hip-Joint Twelve Days after Injury ;
Becovery. By TV. B. Beatson, M. D. [Med. Times and
Gazette, August 1, 1868.]

It is probable that in this case the amount of injury done was so great
that there was no chance of saving the limb, but had amputation been
resorted to in the first instance it is questionable if the tennination would
have been so favorable. The seat of fracture being at the centre of the
shaft, it would have been necessary to divide the bone in its upper third,
not far below the trochanters, and even then the flaps would have been

SUEGERY.

429

formed of soft parts injured by contusion. The sloughing of tlie integu-
ment would liave exposed the niuscuhir substance of the flaps; there would
have been profnse suppuration, and, in all probability, purulent infection
of the system through the divided bone, necessitating a secondary ampu-
tation at the joint. As it was, the delay allowed the extent of sloughing
to be defined, and a line of demarcation, as it were, to be formed, above
which there was a certainty of obtaining sound flaps. The limit in front
was so high that, had it been wise to divide the femur, the saw must have
been applied close to the trochanters; but had abundant soft parts been
available, amputation through- the joint was the only proceeding wliich
offered the patient a chance of life. The time the fi-actured portions had
lain bathed in pus, the separation of periosteum, the protrusion of the
medulla, and the daily increase of irritative fever, all made it certain that
osteomyelitis had commenced, and had any portion of contaminated bone
been left a successful result could not have been expected. Section of the
bone after removal showed that the view taken was correct, as the medulla
was found infiltrated with fetid pus. In performing the operation the
anterior flap was, in consequence of loss of integmnent by sloughing, of
necessity made smaller, and the posterior more bulky, than usual. This
was at first a disadvantage, as the retention of pus was favored by it; but
the ultimate eftect was good, as the cicatrix lies high in front, and is not
pressed upon in the sitting posture. The suppuration with winch the
healing process was attended in this case was somewhat profuse, and at
one time it seemed probable that the patient would sink under it, notwith-
standing the most active support. At the same period, also, the condition
of the acetabulum gave cause for grave apprehension, as the bone was felt
for some days lying bare and bathed in pus; no sequestrum, however,
separated, but from its feel I believe the surface of the cavity was cast off
by molecular disintegration. In the treatment of the case at this time
carbolic acid was found most useful; in watery solution it was injected
through the stump twice dail}', and, mixed with oil, it was applied as a
dressing to the surface. Although it did not suppress suppuration, I am
confident that it greatly diminished the amount of pus, while it completely
checked the evolution of fetid gases.

Jhubboo, cooly. Hindoo, male, aged 22 years, came under my care at
the City Hospital, Xagpore. on April 18, 1868. On the 12th he was en-
gaged in breaking down a brick wall, when the whole suddenly fell and
buried him in its ruins. On being released and brought to the hospital he
was found to have sustained several contused wounds on the head, a frac-
ture of the left clavicle, and a compound fracture of the left femur, besides
minor injuries. The seat of fracture was about the middle of the shaft,
and the communicating wound on the outer side of the limb was small. It
was therefore thought that the limb might be saved, and it was accordingly
put up with a long straight sphnt. There had, however, been great bruising
of the soft parts, and they soon began to take on unhealthy action, the
limb became swollen so that the splint could not be borne, and sloughing
commenced in the wound and integument of the front of the thigh,

When I first saw him,- six days after admission, the limb was slightly
shortened, the foot everted, and the thigh swollen. The skin of the fi'ont
of the thigh was sloughing, and tlie wound admitted the finger to the seat
of fracture ; the bone was found to be broken transversely, and the fractured
ends were partially denuded of periosteum. There was no doubt that
amputation was demanded, but to this the patient refused to submit. There
was very little constitutional disturbance; the skin was cool, the pulse 90,
the tongue clean, the facial aspect good.

On the 20th the sloughing had extended, the communication with the

430 EEPOETS ON PEOGEESS OF MEDICINE.

fracture was more patent, but the constitutional disturbance was still
remarkably small.

On the 22cl the sloughs were separating, and on clearing them away,
another opening, communicating with the fracture, was found on the inner
side of the limb. He had passed a sleepless night, the foot and leg were
becoming oedematous, and there was fever during the day. Pulse 96.

On the 23d all symptoms were aggravated; the pulse was 100 in the
morning, and 120 in the afternoon. The fractured ends of the bone were
felt entirely denuded, and lying bathed in pus, and the medulla protruding
from its canal in the upper fragment.

On the morning of the 24th he was much worse, had passed a sleepless
night, and the pulse had risen to 120. He was now willing to submit to
amputation. He was accordingly placed under the influence of chloroform,
and, assisted by Dr. John Law, of the Madras Medical Service, I proceeded
to remove the limb at the hip-joint. This was eflfected in the usual manner
by antero-posterior flaps. The anterior flap was managed by Dr. Law,
who followed the knife with his fingers, and grasped the flap so completely
that no blood escaped from the femoral artery. This flap had to be made
rather short, in consequence of the destruction of the integuments by
sloughing, and the posterior flap cor;"espondingly longer. The femoral
artery and vein were then tied with silken ligatures, and every bleeding
point was carefully secured. Very little blood was lost, but the shock was
very severe. He was therefore not removed from the table, and stimulants
were frequently given until reaction took place. At 2 p. m. there had been
no bleeding; reaction was established. Pulse 126.

On the morning of the 25th his pulse was 126, and respirations 24. He
Lad slept well, and took nourishment freely.

On the 26th the stump was dressed. On pressing it some dark sanious
matter exuded from the outer extremity of the wound. The pulse was
120; the hps and tongue rather dry. Toward evening there was an in-
crease of fever, and during the night some hiccup.

On the 27th, in the morning, the skin was cool, tongue moist, pulse 132,
respirations 32. The stump in part united, in part suppurating healthily,
while from the outer extremity of the wound there was still a discharge of
dark sanious matter. Some sutures in this part were therefore cut out,
several loose ligatures removed, and the cavity syringed with carbolic acid
lotion. The surface was also dressed with carbohc acid and oil. Toward
evening the pulse rose to 140 and the respirations to 40.

28th. — Had passed a bad night, and had four loose motions. A bed-sore
was also forming over the sacrum. Pulse 120 ; respirations 36 ; skin cool
and moist; stump discharging healthily. The evening febrile exacerbation
was much less ; pulse rising only to 120 ; respirations 30.

29th. — The ligatures came away this morning from the femoral artery
and vein. The discharge is free and healthy; the pulse 116; respirations
28 ; appetite good. He takes abundant nourishment.

May 1. — He is doing well. The last ligature came away to-day. The
pulse still ranges from 120 in the morning to 136 in the afternoon.

5th. — He is not so well; restless and more feverish; pulse rises to 138
in the afternoon. The discharge from the stump is decreased in quantity.

6th. — On examining the stump this morning a sense of fluctuation was
found in the posterior flap, and, by exploring the wound with the finger, a
considerable quantity of matter was evacuated. At the inner extremity
of the wound the finger passed to the acetabulum, which was felt bare of
cartilage.

On the 13th he had been daily improving. The cavities in the stump
had been daily washed out with carbolic acid lotion ; the discharge was

SUEGEEY.

431

much decreased. The acetahuhim can be felt covered with granulations,
except in the centre, where it has a rough and sandy feel, from disintegra-
tion of its surface.

On the 20th he was much improved. Cavities no longer admitted the
finger; discharge trifling; pulse 112; respirations 20.

2Tth. — The stump is now firm and entirely healed, with exception of a
narrow sinus leading to the acetabulum. Pulse 96. He is getting fat.

June 11. — During the last fortnight the last sinus has almost entirely
closed, and the stump is firm and sound throughout. He is fast gaining
flesh and strength, and is anxious to be allowed to go to his home. Dis-
charged cured.

2. — Excision of the Scapula for Enchondroma. [Lancet,
^^■ov. 21, 1868.]

This rare operation was performed by Mr. Sydney Jones,
at St. Thomas's Hospital, London, on the 2d of October :

Harry T , brickmaker, aged forty-three, was admitted on the 22d

September, 1868. For a rapidly-growing tumor of the shoulder he had
consulted Mr. Henry Morris, of 'Gosberton, who thought the case one ne-
cessitating surgical interference, and sent it to London, to be under the
care of Mr. Sydney Jones. The history wiiich the man gave was as fol-
lows : That he had had a swelling of the left scapula from about the age
of nine or ten ; that for the next twelve or fifteen years it had slowly in-
creased ; that then it seemed to remain quiescent; that during the last
three years growth had again occurred, an'd of late so rapidly that the
swelling had, during the last twelve months, quite doubled itself. Until
a year ago, he had felt but little inconvenience, except from a sense of
weight; but latterly the movements of the shoulder-joint had become
much impaired. He had no pain in the tumor, nor was it tender at any
point; but its projection forward into the axilla had caused much numb-
ness and aching of the hand, arm, and shoulder. The growth projected
much above and beyond the tip of the left shoulder, so as to give increased
breadth on this side when looked at in front; it projected considerably
forward into the axilla, and it was this part which had lately so rapidly
increased ; it also extended forward beneath the clavicle, displacing down-
ward and forward the brachial plexus and axillary artery, and so pressing
forward the latter as to make its pulsations visible where lying beneath
the clavicular origin of the pectoralis major. Transversely, from the axil-
lary to the vertebral border, it measured 19 inches ; vertically, from the
superior costa to the inferior angle, 15|- inches ; and obliquely, from the
superior external angle (where overlapped by the deltoid) to the lower
part of the vertebral border, 16 inches. The thickness, from the axillary
border to the most projecting point posteriorly, was 9 inches. TJie surface
Was nodulated, and the integuments posteriorly were thin and much
stretched over the tumor. The muscular development of the left arm
w'as somew' hat less than that of the opposite side. The scapula was per-
fectly movable upon the thorax; and the movements of the humerus
upon the scapula were so free as to induce the hope that the part of the
tumor above the shoulder might be simply overhanging, and that possibly
the shoulder-joint might be left intact.

The patient w^as aware that his arm was becoming more and more use-
less; and it was evident that an operation, if delayed, would take a more
serious form. The removal of the scapula was therefore proposed, and at
the same time the serious nature of the operation was explained to him.
Having been allowed to weigh the matter thoroughly, he expressed his de-
sire for the operation to be performed, and with as httle delay as possible.

432

EEPOETS ON PEOGEESS OF MEDICINE.

He seemed a strong, wiry-looking man, was of a quiet and apparently
good-tempered disposition, and was reported to be temperate. The opera-
tion was performed on tbe 2d of October, at 1.30 p.m., the patient having
been chloroformed before being brought into the theatre. He was placed
in an almost prone position, a block supporting the left side of his chest,
and brought well toward the right side of the operating table. Mr. Le
Gros Clark took charge of the subclavian artery. Mr. Sydney Jones,
standing on the right side, made a long transverse incision (in a direction
corresponding to the spine of the scapula, for this could not be continu-
ously traced) from near the acromial end of the clavicle to just beyond
the vertebral border of the scapula, and a second vertical incision from the
centre of this transverse one to below the inferior angle of the scapula.
The integuments were rapidly dissected off to the several costaa. The
trapezius and deltoid were detached as far as the acromion, and the latter
Avas at once sawn through just at its junction with the spine. All the
muscles connected with the vertebral costa (the levator anguli scapulas be-
ing especially large) were then divided close to the bone ; the latissimus
dorsi was raised from the inferior angle, and the teres major divided. The
disease being found to encroach quite up to the glenoid cavity, the shoul-
der-joint was laid open, and the tendons connected with the greater tube-
rosity then divided. The mass was then readily enucleated; the omo-
hyoid, coraco-clavicular ligaments, coraco-brachialis, biceps, subscapularis,
and, lastly, the long head of the triceps, having been successively divided.
Mr. Sydney Jones remarked that he had anticipated some difficulty with
regard to tlie parts attached to the coracoid process, but the separation of
these from behind had been a much more easy matter than he expected.
The amount of bleeding was very small ; perhaps three, certainly not four,
ounces of blood were lost. The subscapular artery, the last divided, was
at once ligatured, the posterior and suprascapular, as well as smaller, arte-
ries having been secured, as the operation progressed, by small spring-
forceps. Altogether six ligatures were used, the torsion-forceps sufficing
to control other bleeding points. The wound was sponged with ether,
and, all oozing having ceased, the edges were accurately adapted by wire-
sutures. Pads of dry lint were placed in the axilla behind the clavicle,
and in other situations where bagging might occur. These pads were
kept iji situ, and the arm was fixed securely to the side by a bandage. The
patient was then removed to bed. The operation itself occupied less than
ten minutes, but the patient was under the influence of chloroform until
all was adjusted — altogether nearly an hour.

The patient died on the fourth day after the operation.

His pulse had, ever since the operation, been feeble, rapid, and fluttering
— at tunes unaccountable and almost imperceptible, necessitating the pouring
in of stimulant and nourishment to keep up his flagging powers. But the
condition of the skin, the moist and for the most part clean tongue, his
quiet, patient, and cheerful disposition, and his countenance, bright and
free from anxiety, gave hope that he might pull through. The sickness
and feeling of squeamishness may have been produced by the long in-
halation of chloroform. The soreness of throat, dependent on inflamma-
tion of the muscles and cellular tissue of the neck, at last prevented
deglutition.

The tumor weighed lOf lbs. It involved the whole of the scapula,
with the exception of the glenoid cavity, the coracoid process, and the
acromion; and these were closely enveloped at their bases by the growth.
It was of the ordinary nodular character on its outer surface ; but toward
the chest it presented a smooth concavity, corresponding with the con-
vexity of tlie thorax. The muscles were spread out into thin aponeuroses
in those positions where they usually pass over bone ; but from the ventral

SUEGERY.

433

surface the nodules projected between the fibres of the scapularis. On
section, the tumor consisted of transparent cartilage, which was occupied
in part by masses of cancellous bone (resembling an osteophyte), with,,
also, scattered points of greater density. The bony matter was more
abundant toward the concavity of the tumor, where it approached to
about two or three lines from the surface, and extended to a depth of about
an inch and a half. •

The ^(?6^-??i(?/'^e«i examination was made on October 7th by Dr. Lees.
The left scapula had been removed by a T-sbaped incision. The flaps
were connected by wire-sutures. On the left side of the neck, behind
and below the ear, was a swelling with a doughy feel. The subcutaneous
areolar tissue and intermuscular tissue were infiltrated with sanious-look-
ing pus and serum. This condition extended to the deep muscles of the
neck and to the post-pharyngeal areolar tissue. Larynx, trachea, and
bronclii healthy. Pleura healthy. Lungs congested, but crepitant. I^eri-
cardium healthy. All the cavities of the heart were filled with Coagula,
partly decolorized, and extending into large vessels ; valves and orifices
healthy. In the peritoneum numerous old adhesions connected intestines
with abdominal walls. Liver fatty. Spleen soft and pulpy. Kidneys
healthy. Pharynx, oesophagus, stomach, pancreas, and intestines healthy.
Ureters and bladder healthy.

Exsection of the eotire scapula, with preservation of tlie
entire arm, is an operation of very recent date, first performed,
it is believed, by Langenbeck, in 1S55. The removal of the
arm along with the scapula had, however, been many times
performed, and, as a matter both of interest and instruction
to om- readers, we reproduce from Dr. Rogers's admirable
paper, printed in the American Joiirnol of lledical Sciences^
a table of the operations thus far recorded. By Dr. Rogers's
courtesy and assistance we have been enabled to. add a
column, showing where the cases are recorded. This adds
greatly to the value of the table ; for, without it, subsequent
investigators would derive but comparatively little assistance
from this otherwise very complete monograph. And besides,
several additional cases are now included in the table, some
that had escaped the previous search, and some have been com-
municated not before recorded, and two new cases have occur-
red since the date of Dr. Rogers's paper.

Dr. R. inclines to the opinion that in cases of malignant
disease he would prefer the removal of the whole scapula
rather than merely the diseased portions of it, and for the
following reasons :

1. That the results are quite as good to the future useful-
ness of the arm.

2. That tlie dangers attending the operation are scarcely
ever greater, generally less even, than when only a portion of
the bone is removed.

3. The liability of the disease to retimi is probably less.
In cases of necrosis and caries, however, these principles are
not applicable.

434 EEPORTS 01^ PKOGEESS OF MEDICmE.

Tabular Statement of tlie Ojyeratiom imohing the

NO.

OPERATOR.

DATE.

OPERATION.

DISEASE.

Mr. Cummings.

1808

Ampntation of arm, including the
scapula.

Gunshot comminution of
these bones.

Yan "Walther...

1811

Attempt to remove the greater
part of the scapula.

" Spongy swelling upon the
bone. '

JLbiy

Removal of about three-quarters
of the scapula, measuring from
behind forward. The patient
was a boy of IG years.

Osteo- cancer of a remarka-
bly vascular form.

•

Heymann, of
Coblentz.

1823

Removal of all the bone except
the neck, siipra-spinous fossa,
and the acromion process.

Osteo-cancer in a young man
of 22 years.

Janson, of Ly-
ons.

1824

Removal of all the bone except its
processes and the neck and gle-
noid cavity.

Osteo-cancer of the bone in
a female of 45 years.

Wutzer, of Miin-
ster.

1825

Removal of all of the bone except
its processes and glenoid cavity.
Patient a man of 44 years.

Osteo-cancer of the medul-
lary variety.

Castara, of Lu-
neville, France.

1040

Attempted removal of the greater
part of the bone.

" Tumor of the scapula "...

8
9

Mr. Luke

Mr. Skey

1828
1830

Removal of three-quarters of the
bone, measuring from behind
forward.

Removed all of the bone except
the glenoid cavity.

"Supposed malignant dis-
ease of the bone," the pa-
tient being a girl of 14
years.

"Fibrous tumor" of large
size, patient being a man
of 40 years.

Gaetani Bey

1830

Removed the scapula and upper
extremity.

Gunshot wound comminut-
ing these bones.

1833

Removed the entire bone except
the glenoid cavity and acromion.

Caries ; the patient being a
female of only 8 years.

Dr. Crosby, of
Hauover, U.
States.

1835

Removal of the scapula, arm, and
clavicle, except the sternal end.

Osteo-sarcoma, patient a
male 30 years of age.

Syme. of Edin-
burgh.

1836

Removed the neck and glenoid
cavity, and processes and head
of the humeras.

En chondroma in an adult
male.

1837

Removed the scapula and clavicle
six years after amputation at
the shoulder, and 19 years after
amputation at the metacarpus.

Osteo-sarcoma, the patient
being, at the date of the
last operation, 40 years old.

1838

Removed the scapula and arm

Gunshot comminution of

these bones in a boy of 14
years.

Twitchell, of
Keene, N. H.

1838

Removal of scapula, arm, and
part of clavicle.

Not known, but probably
malignant.

SUEGEEY.

Removal of all or the greater part of the Scapula.

435

Kecovery

REMAKKS.

This accident occurred to an adult male.

Died fov.rteeu days after the This patient was a man 30 years of age.
operation, of suppuration The operation was abandoned at an
and exhaustion. advanced stage, on account of the pa-

tient's having fainted, and it was re-
garded as too formidable to again un-
dertake.

Died soon after of a return of The haemorrhage during this operation

the

is described as having been frightful
it chiefly taking place' at the time the
body of the scapula was divided to sep
aratc the diseased from the sound bone

useful
side.

arm on this same

Kecovery, with good use of the
arm, but he died a year after
the operation, of return of
the disease. |
She was discharged 2 months This growth is said to have been from
after the operation, with a the infra-spinous fossa, and to have
projected forward into the axilla so
much as to prevent the arm from fall-
ing nearer to the side than 45°.

Eecovery, with good use of the
arm,bu t the disease returned
at length, and the patient
died of it 4 years after the
operation.

Patient died of air in the yeins This accident is reported to have occur-
during the operation. | red during the division of the bone be-

1 tween the sound and diseased tissue.
Recovered with a most usefuLThis operation is described as having
been a very bloody one, and that more
than twenty arteries were tied during
it.

Haemorrhage said to have been frightful.

Recovery, with a useful arm.
but died of return of the dis-
ease.

Recovery, though the patient
. was a boy of only 14 years.

Caries extended to the neigh-
boring bones, and the pa-
tient died 9 months after
the operation.

Recoveiy. Died 4 years sub-
sequently from redevelop-
ment of the disease in the
lumbar vertebrae.

No subsequent history

Recovery, and, at last ac-
counts, 30 years after the
last operation, the patient
was healthy and active.

Recovery

Recovery, but died some
months subsequently from
redevelopment of disease.

This case is reported to have been com
plicated with tuberculosis, and was:
probably a tubercular disease of the|
bones. 'So far as the arm was con-
cerned, this case was successful, a very
useful ann being preserved.

This case was never reported ; I am in-
debted to Prof. A, B. Crosby, M. D.,
sou of the operator, for this account of
the case.

AUTHORITIES.

Fergusson's Surg.,
Eng. ed., 1852, p
308.

Besume of Capital
Sursiical Opera
tions.byDr. G. B.
Giiuthcr. Leipsic
1861, p. 36.

Edinb. Med. and
Surg. Jour., vol.
xvi., pp. 66. 215
Quoted by South
in his edition of
Chelius, vol. iii
p. 762.

Gunther, ibid.

Malgaine, Sledecine
Operatoire. p. 246
South' 8 Chelius
vol. iii., p. 762.

Giinther, op. cit.

Gunther, op. cit.

London Med. Gaz.,
vol. v., 1830; and
Lancet, Jan., 1859.

London Lancet,
Jan., 1859, p. 13.

Arch. Chirurg. Fran-
9aise et Etrang.,
and Boston Med.
and Surg. Jour.,
1842, p. 338.

Giinther, op. cit.

Edinb. Med. and
Surg. Jour., 1836,
vol. xlvi., p. 269.

The malisnant character of this disease Amer. Jour, of Med.

is sufficiently demonstrated by the fact Science, vol. xxi.,

that it returned twice after operations' old series, 1837, p.

for its removal. It is, therefore, a case 390.

well calculated to encourage the sur geon to operate for

the removal of cancerous bones.
It is reported also that this subject re- Giinther, op. cit.

ceived so severe an injury of the scrot um at the same time,

that castration was necessary, and was performed at the

same time. |
This case was never reported ; Dr. G. B. Twitchell, nephew

of the operator, has furnished these notes ; his uncle

kept no record pf this case. I

436 EEPOETS 01^ PEOGEESS OF MEDICESTE.

Tabular Statement of tlie Ojjerations involving the Removal

NO.

OPERATOR.

DATE.

OPERATION.

DISEASE.

McClellan, of
Philadelphia.

1838

Removed the scapula, arm, and
most of the clavicle,' at one op-
eration.

Encephaloma in a boy of 17
years.

Mr. Travers

1838

Removed all the scapula below the
spine.

"Medullary sarcoma;" the
patient was an adult male.

Ei,?aud, ofStras-
hourg.

1842

Removed the scapula and outer
end of clavicle eight months after
amputation at the shoulder.

Osteo-sarcoma ; patient was
a man 51 years old.

Dr. Cooper, of

1842

Removed one-third of the scapula

Machine injury

British Guiana.

and outer third of the clavicle.

21
22

Petrequin, of

Lyons.
Mussey

1844
1845

Removed all the scapula except
the glenoid cavity and processes.

Removed the scapula, arm, and
outer half of clavicle at one op-
eration.

Osteo-sarcoma ; the patient

being a boy of 20,
Osteo-cancer ; age of patient

not given.

Dr. Lewis, of
Boston,

1845

Removal of the scapula and clavi-
cle, and a fragment of the arm.

Machine injury, comminut-
ing these bones.

Dr. Gilbert, of
Philadelphia.

1846

Removal of neck and glenoid cav-
ity, and processes and arm at
one operation.

Osteo-cancer ; the patient
was a medical man.

25
26

27
28

Textor, Jr

Mr. Fergusson .

Langenbeck. . . ,

Textor, Jr., of
Heidelberg.

1846
1847

1848
1849

Removed all of the infra-spinous
' fossa except a narrow border on
its posterior edge.

Removed the scapula and outer
end of the clavicle three years
after amputation at the shoul-
der-joint.

Removed all the scapula except
the glenoid cavity and coronoid
process.

Removed the greater part of the
infra-spinous fossa of the scap-
ula.

Enchondroma; the patient
was a child of two years
and two months old.

Caries ; the patient w&b an
adult male.

Fracture comminuted of the
bone ; patient was an adult
male.

Osteo-cancer of large size ;
the patient was a man of
56 years.

Langenbeck

1850

Removed the scapula except the
coronoid process.

Enchondroma softened ; the
patient was a man of 30
years.

Dr. S. D. Gross.

1850

Removed all of the scapula except
the head and acromion process.

Osteo-cancer; the patient
was an adult male.

Hertz, of Erlan-
gen.

Barrier, of Ly-
ons.

1852
1853

Removed all the bone except the
glenoid cavity and coronoid pro-
cess.

Removed the infra-spinous por-
tion of the scapula.

Medullary cancer; the pa-
tient was a female of 20
years.

Enchondroma of large size;
patient an adult.

Enslehardt, of
Riga.

1853

Removed all the scapula except
the glenoid cavity and processes.

Necrosis ; the patient was a
man of 27 years.

Langenbeck . . .

1855

Removed the entire scapula and
three inches of the clavicle.

Osteo-cancer of the encepha-
loid variety; patient a boy
of 12 years.

SUEGEEY.

of all or tlie greater 'part of the Scapula — Continued.

437

AtTTHORITIES.

Kecovered from the operation McClellan claimed that, so far as he McClellau's Surg.,

and did well for a time, but
finally died of return of the
disease 6 months after the
operation.

laiS, p. 412.

knew, this was the first case in which
the arm. scapula, and clavicle had been'
remoTed by the surirecn for disease at'
a single operation. "This was an error.:
as both Crosby's and Twitchell's casesi
antedated his. |
The patient died one year after : There is no record pertaininc: to the state London Med. Gaz.,
the operation, of a return of of the arm after the operation in this 1838; South'eChe-

the disease.

Kecovered. and was enjoying
good health 3 years after the
last operation,

Eecovered

Died 25 days after the opera-
tion.

Kecovered, and was in good
health 9 years after the op-
eration.

Died 5 months after the opera-
tion, of return of the disease,

"Was discharged well in 40 days
Ayith good use of the arm,

case. The hsemorrhage attending the' lius, vol, iii,, p.
operation is recorded as very severe, I 762,
This case affords as much encourage- London Lancet and
ment to the surgeon as Mussey's case,' Boston Med, and

I Surs. Jour., 1S14,
I p. 208.

This case is reported more in detail N. Y. Jour, of Med.,
among the cases of tearing away from, vol. i., old series,
the body of the arm and scapula, ! 1842.

BuU. deTAcad. Imp,

! 1859-"60, p. 289.
It will be remarked that this operation Gross's Surgery,
was almost exactly similar to McClel-| vol. ii., p. 1041,
lan's, though its 'results were vastly
better. :
Died soon after the operation. jThis patient is reported as having died Statement by letter
I in consequence more of other severe of Dr. Winslow
injuries tlian those involving the arm Lewis, Surgeon,
and scapula. ! etc.

It is reported that at a later peri.xl this'Amer. Jour, of Med.
surgeon performed a second almost ex-' Sciences, vol. xiv.,
actly similar operation, but I have! Oct., 1847, p. 360.
failed to find any record of it. I
This is the youngest subject on whom Giinther, op. cit
this operation is recorded to have been '
performed.

Kecovery perfect and perma-
nent.

Died of pyaemia on the 21st
day after the operation.

Recovered, with good use of
the arm, but the disease re-
turned and destroyed the
patient.

Died 17 hours after the opera
tion.

Recovered. No record of the-
condition of the arm.

Died of loss of blood an hour
after the operation.

Died within 24 hours after the
operation.

Recovered, and at A}i months
after was healthy.

Trans. Medico-Chir.l
Soc. for 1&47; also!
Fergusson"6 Surg.,i
1833. p, 309.
Giinther, op. cit.

It is reported that seven distinct opera- Giinther, op. cit, ;
tions were performed at various inter- 1 Virchow has also
vals upon tliis patient for the removal! published a full
of reappearing cancerous growths. | history of the case.

It stands recorded that, in the opinion of Giinther, op. cit.
the medical men present at this opera-
tion, the chloroform had the greater;
part in the production of the fatal re-
sults. I

Dr. Gross reports that this patient died Amer. Jour, of Med
of pleuro-pneumonia three months af-] Sci,, vol. xxv,
ter the operation, and does not thiukj 1853, p. 348; also
that the fatal disease had any connec- Gross's Surgery,
tion with the former disease of thej vol. ii., p, 1041.
scapula, I

Giinther, op. cit.

, Bull, dePAcad. Imp,
I 18o9-"60, p. 295.

! Giinther, op. cit.

Died of a return of the disease At the operation 2)^ inches of the clavi- Gunther, op. cit.

10 months after operation,

tie were removed, but, on account of
necrosis at the point of division, half
an inch more was subsequently re- 1
moved. Xo account is given oi" thel
degree of uselulness of the arm after
the operation. I

438

EEPOETS 01^ PROGEESS OF MEDICmE.

Tabular Statement of the Operatio7is in'cohing tlie Remoxal

South

Syme

Heyfelder

Dr. Crawford, of
Ayr. England
Dr. Caruoclian
• of New York

1852

1856

1857

1857
1857

Mr. Jones, of 1858
Jersey.

Niepce.

Dr. Hammer, of
St. Louis.

43 Mr. Syme

Schuh, of Vien-
na.

Dr. Walter, of
Pittsburg, Pa,

Langenbeck

Busch, of Bonn

Busch, of Bonn
Neudorfer

Mr. Paget.

1860

No
date.

No
date.
1862

1863

OPEHATIOX.

Removed all of the bone from the
base of the acromion.

Removed the entire scapula.

Removed the scapula and head of
the humerus.

Removed the scapula

Removed nearly three-quarters of
the scapula, the division being
in an oblique direction from be-
low upward across the spine.

Removed the entire scapula and
about an inch of the outer ex-
tremity of the clavicle.

Removed the arm, scapula, and
clavicle.

Removed all of the scapula and
three-fourths of an inch of the
outer end of the clavicle.

Osteo-sarcoma in a man of
30 years.

"Sanguineous cyst of the
bone," by others regarded
as a vascular encephalo-
ma; patient a female of
70 years.

Caries in an adult of 40 years,
3 months after resection of
the spine of the scapula.

Not stated

Caries; the patient was an
adult male.

Caries; the patient was a
girl of 15 years.

Machine injury.

Osteo-cancep; the patient
was a girl of 18 years.

Removed the entire scapula and Osteo-cancer; the patient
outer end of clavicle about two was a man of 43 years,
inciies, the head of the humerus
having been removed some time!
before.

1860 Removed the entire scapula from Osteo-cancer
a child of eight years.

Removed, by enucleation, all of Necrosis ; the patient was a
the scapula except the neck, boy of 17 years at the time
glenoid cavity, and acromion. of the operation.

Removed the scapula and three- Malignant tumor developed
fourths of the clavicle, 5 month's from seat of fracture of the
after amputation, at the shoul- humerus, and returned iu
der-joint. the scapula and clavicle.

Removed scapula and part of clav- Osteo-cancer; patient a fe-
icle after amputation of the arm. male of 16 years.

Removed the entire scapula ex- Cause not stated

cept the glenoid cavity. |

Removed the greater part of the Necrosis, following a gun-
scapula, sliot comminution of the
bone in an adult

Removed all the infra-spinous por-
tion of the bone except the infe-
rior angle, and also part of the
spine.

Osteo-cancer in a boy of 15
years.

SUKGEEY.

439

of all or tlie greater part of the Scapula — Continued.

P.ESTJLT.

REMARKS.

AUTHORITIES.

Good use of the arm, but at
last account the disease -vvas
returning.

Wound healed promptly, and During the progress of the cicatrization

the head of the humerus was exposed
for some time. This is the first re-
corded case of removal of the entire
scapula in Great Britain.

the patient had the best pros-
pect of retaining a useful
arm, when she died of old
age about 2 months after the
operation. I

Died on the eighth day after;

the operation, of pyaemia.

Very little blood was lost The report of this case is very meagre.

Eecovery, with good use of the
arm.

Times and Gazette
I for Jan., 1856, p.
' 37.

Syme's Surgery, by
McLean.

Recovered promptly and per-
manently. Six years after
the operation was in good
health, with a most useful
arm.

Recovery

This was the first, and, so far as I know,
the last case of removal of the entire
scapula for caries, preserving the arm,
that has been performed in Great Brit-
ain.

Gunther, op. cit..

and Deutsche Kli

nik, 1855.
Times and Gazette,

Aug. 8, 1857, p. 155,
Oral statement of

that surgeon.

London Lancet, 1859,

Bull, del' Acad. Imp
1864^^65, p. 723.

Recovered, with a useful arm, 'Dr. Hammer performed a preliminary St. Louis Medical
but finally died of return of operation several days before this op^- Reporter, March,
the disease 10 months after eration, at which he discovered that^ 1866, p. 1.
the operation.

the tumor upon the scapula was an
outgrowth from the bone. A piece of
the mass was removed for microscopic
examination, and, having been found
cancerous, the whole bone was re-
moved a few days after.
Recovered, and had a useful This is the case alluded to by Mr. Fer- Syme's Surgery, by

arm. and was enjoying good, gusson as the neplus ultra of conserva-
health some years' after the tive sursery.
operation.

At last accounts, which were
soon after the healing of the
wound, there was free move-
ment of the fore-arm. but the
arm could be moved only by
aid of the opposite hand.
No later history.

Recovered, and S'months after
the operati(m had a perfect
use of the arm, and the bone;
was nearly perfectly repro-
duced.

Died, IX years after, of di?
ease of the lungs of malig-
nant character. |

Recovered from the operation.!
and 2 years after she earned
her living by work in a fac-
tory.

Died of exhausting suppura-
tion.

Recovered, with a useful arm.

Velpeau alludes to a case recorded by
Rislau, and another by Chopart, in
both of which a reprodtiction of bone
took place after a sequestrum in the
scapula had been removed. Dr. Wal-
ter states that his patient had a nearly
perfect scapula, reproduced by the pe-
riosteum left behind.

Died of return of the disease, I .

McLean.

Giinther, op. cit.,
and Report of
General Hospital
Vienna, 1860.

Philadelphia Medi-
cal and Sur<:ical
Reporter, 1861, p.
557, Sept,

Deutsche Klinik,
1860, p. 217.

Allgem. Medic. Cen-
tral Ztg., 1861, p.

Langenbeck's Ar-
chives.

Lano;enbeck's Ar-
chives.

Lond. Lancet, 1863.
vol. i., p. 39i
Amer. edition.

440 EEP0RT3 ON PEOGEESS OF INLpDICENTE.

Tabular Statement of the Operations inrolmng the Removal

OPERATOR.

DATE.

OPERATION.

DISEASE,

51
52

Weinker, of
1 Giessen.

1863
1863

Eeraoved all of the scapula except
the glenoid cavity and acromion.

Removed the scapula and outer
half of the clavicle with the arm.

Encephaloma ; the patient
1 was a young man of 17^
1 years,

Osteo-cancer ; the paticHt
1 was a man of 40 years.

Michaux, of Ju-
vain, Belgium.

1864

Removed the entire scapula and
no more.

Encephaloma

Buck, of New
York.

1864

Removed the scapula and part of
the clavicle.

Osteo-cancer ; the patient
was an adult male.

1865

Removed all of the scapula except
the acromion process.

Encephaloma; the patient
was a man of 25 years.

56
57

Fergnason
Mr. Pollock....

1865
1865

Removed all of the scapula below
the spine.

Removed the entire scapula ex-
cept tha acromion.

Fibro-recurrent tumor, in-
volving all of the infra-spi-
nous f(5ssa; the patient
was a girl of 19 years.

Osteo-cancer of large size:
the patient was a girl of
16 years.

58
59

Fergueson

F. H. Hamilton,
of jSTew York!

1866

1866
Feb.

Removed all the scapula left by
the operation No. 52, the cla\'l-
cle, and the arm.

Removed the entii-e scapula

Fibro-recnrrent tumor; the
patient was 20 years of age
at the time of this opera-
tion.

Necrosis from gunshot
wound.

60
61

Dr. Buchanan,
of Glasgow.

1866
Dec.
26th.

1867

Removed the scapula, part of the
clavicle, and the arm, at one
operation.

Injury which carried away
the arm at the shoulder-
joint; exposed and com-
minuted tlie scapula ; girl
of 17 years,

Osteo-cancer; this patient
was a man of 40 years.

Stephen Roeers,
of New York.

1867

Removed the entire scapula and
no more.

Osteo-cancer of the encepha-
loid variety in a girl of 7
years.

Sidney Jones,
London.

1868

Removed all of the scapula except
the acromion.

Enchondroma in a man of
43.

E. Krakowizer,
of New York.

1868 1

Removed the scapula 5 years after
amputation, at the shoulder-
joint.

SUEGEEY.

of all or the greater -part of the Scajmla — Continued.

441

Died of exhaustion withiu 24 This case was the theme of an inaugural
hours after the operation. | dissertation at Felsing in 1S63.

Recovered, and was in good!

health some years after the

operation.
Eecovered. with a useful arm,

but the disease returned, and

the patient died 10 months

after the operation.
Eecovered. but a few months

after died of a return of the

disease.

ATTTHORITIES.

Syme's Surgery, by
'McLean.

Gazette Medicale
1866.

Eecovered from the operation,
and at the end of the first
mouth had considerable an-
tero-posterior movement of
the arm. There is no record
of the case after that date.

Recovered from the operation
promptly, with good use ofl
the arm. |

This patient had previously lost the arm Oral statement of
by amputation for the same disease, that surgeon,
and in respect to the number of opera-
tions for diseased srowth it resembled,
case Xo. 14 of this table. i
Fergusson claimed this to have been the Lond. Lancet, 1865
third case of removal of the entire p. 524, American
scapula in Great Britain and London., edition.
He opened the joint first in front. This
experience led him to say that, were
he to perform the operation again, he
would isolate the posterior portion of
the scapula first, openinsr the joint
from behind first, leaving the anterior

f)ortion of the incision and disarlicu-
ation to the last. He also advocated
the leaxing of the acromion when it is
not diseased, as tending to reduce the
deformity.

This patient finally became the subject Times and Gazette,
of the operation xlescribed as the 56th 1866
one of this table. !

Recovered from the operation. This was precisely the operation of Fer- Lond. Lancet, 1865,

and had a useful arm 11

weeks after the operation,

date of last report of her.
Recovered from the operation.

but there is no subsequent

history.

gusson, with his suggestion of isolat-
ing the timior from behind first car-
ried into practice by Mr. Pollock.

Recovered with useful arm.

p. 526, American
edition.

Times and Gazette,
1865.

Two months after the operation, there Communicated
was no obsen-able reproduction of, that surgeon,
bone, though the periosteum remained
in its place. The bone was detached
from the periosteum and tissues, so
that it was verv easilv removed.
Little loss of blood, but the It is similar to Dr. Cooper's and Dr.
patient died within 24 hours, Lewis's cases,
after the operation , of shock. |

Times and Gazette,
Jan., 1867.

Died of shock three days after
the operation.

This operation was like McClellan's, as Lond. Lancet. Nov.

Recovered from the operation,
but died of return of the dis-
ease 6 months after the op-
eration.

Died on the fourth day after
the operation.

Died 7 days after the opera-
tion, of exhaustion.

2, 1867, p. 552.

to extent, but its unfortunate termina-
tion was probably induced by the con-
dition of low vitality of rhe patient, in-
dicated by the fatty degeneration of
the heart," kidneys, and liver. j

This patient had good use of the arm till Amer. Jonr. of Med.
its movements were impeded by new Sciences for Oct.,
cancerous growths about the shoulder, j 1868.
Patient died of apncea from the pres-
sure of mediastinal cancer. |

Not more than four ounces of blood were Lond. Lancet. Nov.
lost, and the death from exhaustion i 21, 1868, p. 665.
was suspected to be, in part at least,
owing to the chloroform used. I

This case is interesting as one of recur- Communicated by
rent enchondroraa in a bone not af-j that surgeon, who
fected by the first tumor. | will report In fa-

I ture in detail.

442 mSCELLAlS'EOUS AND SCIENTIFIC NOTES.

The following abstract from tlie table will exhibit an out-
line of the ten, and only cases, known to the history of sur-
gery, in which the entire scapula was remoyed, with preserva-
tion of the arm :

Langenbeck, in 1855, removed the entire scapula and three inches of
the clavicle.

Syme, in 1856, removed the entire scapula, and no more.

Heyfelder, in 1857, removed the scapula; at the same operation the
head of the humerus was also removed.

Jones, in 1858, removed tlie entire scapula and about an inch from the
outer end of the clavicle.

Hammer, in 1860, removed the entire scapula and about three-fourths
of an inch from the clavicle at its acromial end.

Syme, in 1860, removed the entire scapula and outer end of the clavicle,
the head of the humerus having been removed at a previous operation.

Schuh, in 1860, removed the entire scapula, and- no more.

Michaux, in 1864, removed the whole scapula, and no more.

Hamilton, in 1866, removed the entire scapula, and no more.

Eogers, in 1867, removed the whole scapula, and no more.

The five following cases are, however, practically equiva-
lent to tlie above :

Langenbeck, in 1850, removed all of the scapula except the coronoid
process.

South, in 1852, removed all of the bone except the acromion process.
Fergusson, in 1865, removed all except the acromion.
Pollock, same year, removed all except the acromion.
Sydney Jones, case quoted at length above, is similar to the three last
mentioned.

The Infants' Hospital. — This institution — temporarily lo-
cated in one wing of the Inebriate Asylum, until the building
now erecting on Kandall's Island shall have been completed —
has been, by the action of the Commissioners of Public Char-
ities and Corrections, separated from the control of the Charity-
Hospital stafif, and placed in charge of a special medical
board, consisting of Drs. Austin Flint, Sr., Geo. T. Elliot,
Isaac E. Taylor, Abram Jacobi, Lewis Smith, and E. S.
Dunster. Dr. F. A. Castle is the House-Physician.

Supposed Death fkom Chloroform. — Dr. Yan Buskirk,
of Gorham, Ohio, was found dead in his bed recently. Death
was supposed to have been caused by the inhalation of chloro-
form taken to relieve a nervous headache.

MISCELLAIS'EOUS AND SCIENTIFIC NOTES. 448

At the anniversary meeting of tlie I^ew-York Academy
of Medicine, held at the College of Physicians and Surgeons,
December 10, 1868, Prof Austin Flint, Jr., delivered the an-
nual address. His subject was, " The Past, Present, and Fu-
ture of Medicine," and was presented in an unusually interest-
ing manner. The address is to be published by the Academy.

Medical Jouenal Association. — The programme for Janu-
ary, 1869, is as follows :

January 8. — " Treatment of Aneurism of the Arteria Innomi-
nata." By Prof H. B. Sands, M. D.

" 15. — " Angesthetics and their Administration." By
D. H. Goodwillie, M. D.

" 22. — " Embolism in the Eye." By Hermann Knapp,
M. D.

" 27.—" Kesume on Insanity." By J. C. Smith, M. D.

De. Isaac CuMMmos, late House-Physician of the Demilt
Dispensary, died suddenly at his residence, December 15,
1868.

At a meeting of the physicians attached to the Dispensary,
held on the 16th December, 1868, mth the object of uniting
in an expression of their sentiments regarding the death of the
late house-physician of that institution, Dr. Isaac Cummings,
the following preamble and resolutions were adopted :

Whereas, it has pleased Almighty God to remove from us
by death our late colleague, Isaac Cummings, M. D., while
yet in the prime of life, and at a period of greatest usefulness :
we, therefore.

Resolve, that we recognize in this dispensation of Provi-
dence the loss of a highly-esteemed friend and valued counsel-
lor ; that the Demilt Dispensary has in him lost one of its
oldest and ablest officers ; tliat the poor who seek its benefits
have lost a good and skilful physician ; and that the profession
has lost an eminent member.

Resolved, that we sympathize with his family in their
bereavement, as well as in the affliction of those who will lose
his uniform kindness and honest advice.

Resolved, that these resolutions be published in the medical
journals and in the daily papers of this city ; that a copy of
the same be sent to the family of the deceased, and to the
Board of Managers of the Demilt Dispensary.

444 MISCELLANEOUS AIs^D SCEENTIFIC NOTES.

Editor New Yorh Medical Journal —

Dear Sir : Tlie following report of a very rare accident lias
been sent to me by Dr. Marsh, U. S. A., who is stationed at
West Point, New York, he having, at my request, obtained
the consent of the Surgeon-General to its publication. Disloca-
tion of the metacarpal bone of the thumb is pretty common in
either direction — dislocations of the other metacarpal bones
backward are also not very rare, but a dislocation of the me-
tacarpal bones of tlie fingers forioard is exceedingly rare. I
have seen but one other case reported. Yours truly,

F. H. HA:^^LT0N.

Forward Dislocation of the Proximal End of the Sec-
ond Metacarpal Bone. — April 1, 1868. — Charles C— — , corpo-
ral of ordnance department, aged 26 years, was holding a drill
in his right hand for another man to strike, when suddenly the
hammer-head flew off, and struck a glancing blow on the back
of his hand. The hand was covered with a thick buckskin
glove, and the hammer-head weighed about seven pounds.
His hand was rendered helpless by the blow, and, on taking off
his mitten, he noticed an irregularity in its appearance. I
saw him about half an hour after the .accident. There was
already some sw^elling, but not sufficient to conceal a marked
depression in the back of the hand over the carpal end of the
second metacarpal bone. The bone was felt running down
toward the palm, and on a lower (more anterior) level than
the next metacarpal bone. It was fixed in this position, and
no crepitus could be detected. As there was evidently a dis-
location, I attempted to reduce it by making extension from
the finger, and at the same time pressing with my thumb in
the palm of the hand against the base of the metacarpal bone.
It almost immediately, and Avith a snap, returned to its proper
place, and the deformity disappeared. I then bandaged the
hand with a ball of tow in the palm. The swelling gradually
subsided, and on April 13th he was able to use the finger sufii-
ciently to return to duty, although its full strength did not re-
turn for some time longer.

The case was seen also by Surgeon J. F. Head, U. S. A.

SuLPHUEET OF PoTASH IN "Whooping Cough. — Dr. Mackcl-
can calls attention, in the Dominion Medical Journal^ to this
remedy. He was led to the use of it from a notice of it which
he saw in a French medical journal forty years ago, and since

MISCELLAISTEOUS AND SCIENTIFIC NOTES.

445

that time liis success lias been so uniform tliat lie has used no
other remedy. He says :

^' The mode of administration I have adopted is to dissolve it
in a mixture of syrup and distilled or rain water, in the propor-
tion of one of the former to three parts of the latter (hard water,
which sometimes contains sulphuric acid, partially decomposing
it), the dose being oue grain for each year up to four years of
age, and after that half a grain additional for each year ; the
smaller doses being administered in a teaspoonful of fluid, and
the larger more diluted, in proportion to the quantity of the salt
in each dose.

''Its beneficial effects are not perceived for five days, when
the intervals between the paroxysms of cough become longer,
and after that their violence diminishes from day to day, until
at the end often or fourteen days it is seldom necessary to pur-
sue the treatment further.

" As the drug easily spoils by keeping, it is important to
have it fresh. If it dissolves perfectly in the syrup and water,
and the mixture is of a greenish color, it may be relied on ;
but if there is any sediment, it has been decomposed by ex-
posure to air, and becomes a sulphate."

Another Death from Chloroform. — Dr. E. A. Clark,
Resident Physician of the St. Louis City Hospital, reports, in
the Humholdt Medical Archives^ another death from the
inhalation of chloroform, the first serious accident witnessed
by him in several years of hospital practice. The patient, 38
years of age, had haemorrhoids with prolapsus of the rectum
which had become strangulated externally. The tumor being
so painful that no manipulation could be performed, it was
determined to bring the patient under the influence of chloro-
form. He was apparently in the full vigor of health, and an
examination of the heart and lungs before the inhalation of
the anaesthetic revealed no abnormal condition. The chloro-
form was administered " by pouring about a drachm upon a
napkin, folded in such manner as to admit the admixture of a
suflicient quantity of air." After the inhalation had been con-
tinued for a couple of minutes, manipulation of the tumor
showed that the patient was still susceptible to pain. An ad-
ditional drachm of chloroform was, therefore, poured upon the
napkin. Soon the patient began to be afiected with the
spasmodic movements not infrequently observed in partial

446 MisCELLA]S"EOUS AND SCIENTIFIC NOTES.

anaesthesia. They were not, however, severe or protracted, and
soon gave way to relaxation, and the chloroform was then dis-
continued. The rest of the report we give in the doctor's own
words : " I observed that his face was more livid than nsual,
bnt the favorable condition of his pulse and respiration decided
me to proceed with the operation. The patient was turned
upon his right side in order t© place him in the most favorable
position for manipulating the tumor, but in about one minute
from the time the chloroform was withdrawn, it was observed
that he had ceased breathing, and that the pulse, both at the
wrist and carotids, was imperceptible, while the superficial
vessels were full and distended, and the face of a dark livid
color. He was immediately placed upon his back, the head
lowered, and cold w^ater dashed upon the face and chest, with
the efifect of causing three or four long, full inspirations, with-
out, however, afi[ecting the circulation in the least. We then
commenced a vigorous artificial respiration, at the same time
withdrawing the tongue from the mouth and elevating the
epiglottis with the finger.

This was continued without any relaxation for an hour and
forty minutes, but without in the least reviving the action of
the heart, which, I am confident, never beat again from the
moment that natural respiration ceased ; he was dead from that
instant.

post-moT^tem^ made eighteen hours after death, revealed
a considerable serous exudation beneath the arachnoid, which
was doubtless the result of the venous congestion of the brain
which was found to exist ; the ventricles were empty, and in
every way normal, except a congested condition of the choroid
plexus ; the heart was found to be entirely empty, containing
scarcely a drop of blood, while all the valves, as well as the
walls of the heart, were in a perfectly healthy condition. The
lungs were likewise healthy, presenting, however, some hypos-
tatic congestion on their posterior surface.

From the above detail of facts, the immediate cause of
death in this case would seem indeed obscure, though probably
not more so than in others not attributable to organic lesions.
From, however, the empty condition of the heart, it would be
most reasonable to suppose that death was the result of a
sudden spasmodic contraction of the heart, which continued
until life w^as extinct, this probably being the efifect of the
anaesthetic upon the ganglionic nervous system. At all events,
we can hardly suppose it to have been the result of syncope, as
is generally thought to be the rationale of most cases of death
occurring Irom the administration of chloroform. This seems
to be apparent in the present case, from the congested condi-

MISCELLANEOUS AXD SCEEXTIFIC NOTES. 447

tion of the blood-vessels of tlie brain, as well as from tlie fact
that we failed to resuscitate him by lowering the head beneath
the level of the body, a method so generally successful, where
a condition of syncope is supposed to exist, in cases threatening
death.

Deputt-Inspector-Gexeeal Loxgmoee, of the British ser-
vice, professor of military surgery in the army medical school
at Xetley, has been appointed honorary surgeon to her Majesty
the Queen, vice Dr. ilelvin, Inspector-General of Hospitals,
deceased.

Heee is an item, either hygienic or moral — as you choose
to look at it — which we think should be set down to our credit.
Will our suburban friends, who are constantly complimenting
]S"ew York as the embodiment of every thing that is rascally
and wicked, make a note of it I —

" At a recent meeting of the Metropolitan Board of Health,
the sanitary superintendent of Brooklyn reported that he had
made careful microscopical examination of twelve specimens
of bread purchased at as many bakeries in Xew York city, and
had found them all to be without any deleterious constituents.
The bread was taken from among that on regular sale, and
was obtained from shops in the poorer localities of the city,
such as Cherry, Mulberry, Sixth, and other streets of that char-
acter. The bread was afterward delivered to Prof. Chandler,
who will make a chemical analysis of it, and report to the
Board."

Artificial Sulphate of Quentne. — A young chemist, at-
tached to the Yenereal Hospital of Paris, claims to have dis-
covered a process for manufacturing this substance. He keeps
the mode of preparatioii secret, but states that it is obtained
from mineral substances like m'ea or alcohol, which have both
been synthetically manufactured from inorganic materials.

This preparation appears in the form of a white crystal-
line powder, the taste of which ofiers the peculiar bitterness
of sulphate of quinine. The crystals, when viewed under the
microscope, are shorter and thicker than those of the ordi-
nary sulphate, although otherwise similar in form. Its chemi-
cal composition is also said to be slightly different ; it is a tri-
basic salt of quinine — that is to say, it contains three equiva-
lents of quinine for one of sulphmic acid. It is fairly soluble

448 MISCELLAlSrEOUS AND SCIEOTIFIC NOTES.

in water, but cannot be dissolved in dilute sulphuric acid, like
the other sulphate ; it is therefore generally prescribed as a
powder. Several experiments have been tried with it, in
cases of intermittent fever more especially, and it is said to act
favorably. But the most important feature in its history is
that it only costs half the j)rice of our ordinary sulphate
of quinine. If, therefore, all this is not a hoax (and pharma-
ceutical ingenuity has rendered most physicians skeptical on
these subjects), the inventor will undoubtedly realize a hand-
some fortune, besides rendering an invaluble service to the
poorer classes. — Medical Times and Gazette.

The Medical Times and Gazette thus comments on our re-
marks entitled " A Point of Ethics," in the July number of
the Journal :

"By an editorial note in the JYeio-Yorh Medical Journal
we learn with great surprise that a journal whicli occupies so
deservedly a high position and enjoys so large a circulation
as the America7i Journal of Medical Science steadily refuses
the insertion of any advertisements relating to books written
by authors, however eminent, if these are published by any
other house, however respectable, than that of its own propri-
etors, Messrs. Lea, of Philadelphia. The writer well ob-
serves :

' All members of the profession are entitled to expect that each medical
jom-nal shall consent to advertise medical works written b.y proper men,
and published by houses of respectabihty other than that responsible for
the journal in question. The refusal of such advertisements, and their ex-
clusion from a medical joarnal aiming to represent American medical lit-
erature, must show a spirit at variance with that exalted purpose which
should give the tone to all medical journals, and even impair confidence in
the fairness of reviews of publications of rival houses.'

" Well, we certainly in this matter exhibit a more liberal
spirit than our American cousins. J^owhere can the competi-
tion of medical and literary journals be more keen than it is
in London, but certain it is that no publisher who might be
proprietor of any of them would ever dream of depriving a
rival of his legitimate publicity. With regard to the Amer-
ican journal in question, the case is especially hard, as it is
almost the only one that circulates everywhere, all over the
Union and in Europe. For ourselves, we have often felt the
want of complete lists of new American books similar to
those with which we are so abundantly furnished of our own
productions."

NEW YORK

MEDICAL JOURNAL:

A MONTHLY EE COED OF

MEDICIM AXD THE COLLATERAL SCIEXCES.

Vol. yilL] FEBRUARY, 1869. [Xo. 5.

Art. I. — On tlie Mechanism of tlie Crepitant and the
Subcrepitant Rale, By AusTm FLmT, M. D., Pro-
fessor of tlie Principles and Practice of Medicine
in tlie Bellevue Hospital Medical College.

(Read at a meeting of tlie New York Medical Journal Association,
December 13, 1868.)

My chief object in this paper is, first, to give an
account of the manner in which the crepitant and the
subcrepitant rale may be artificially produced, using
for this purpose a new commodity called the " jDatent
india-rubber sponge ; " and, second, to show that the
crepitant rale may be proved, by means of this article,
to be caused by the sudden separation of coherent
surfaces, and not by bubbling. Before proceeding,
however, to this twofold object, it will be proper to
notice the opinions entertained respecting the mechan-
ism of these rales, from the time of Laennec, and at
the present moment.

450

MECHANISM OF THE CREPITAISTT

In the immortal treatise by Laeimec on " Mediate
Auscultation," tlie crepitant rale is described under the
name, " tlie moist crepitant rale or crepitation." Laen-
nec likened the sound to that caused by the crackling
of salt when throAvn into a heated vessel ; also to that
which is heard when a dried bladder is inflated, or,
as he says, ^' still better," to the crepitation of healthy
inflated lung when it is pressed between the fingers.
He adds that the crepitating sound is accompanied by
a well-marked sensation of moisture. He attributes
the sign to the bubbling of liquid in the air-cells, the
bubbles seeming to be extremely small. Bubbling
which in a greater degree conveys the sensation of
moisture, and which appears to be caused by larger
bubbles, he calls the subcrepitant rale. This is the
account in the first part of the work, under the head-
ing, " Auscultation of Kales." In the chapter on " Peri-
pneumonia," of which affection he considers the crepi-
tant rale a pathognomonic sign, he says, " it gives the
impression of very small bubbles, of equal size, and
it seems to have very little moisture." A discrepancy
is here apparent. In his first account he says the
" sensation of moisture is well marked " " Hen mar-
quee,'''' In the second account he says the sign has
very little moisture, " il jparait tres-peu Tiumider
The discre]3ancy, probably, goes to show that the ac-
curacy of his observation in this instance was affected
by his theory of the mechanism, viz., that it is caused
by bubbling. Considered without any reference to
mechanism, the sound is undoubtedly diy ; and it is
now distinguished from the subcrepitant rale, as a dry^
crackling sound. Laennec did not distinguish with
precision the crepitant from the subcrepitant rale.
He did not limit the former to the act of inspiration,

AND THE SUBCEEPITAJSTT rIlE. 451

wHicL. was first done by Dance. This limitation is
now generally admitted to be one of the distinctive
features of the crepitant rale. The equality of the
crepitations, which was pointed out by Laennec, is an-
other distinctive feature of this rale ; and additional
distinguishing characters of it are its rapid evolution,
and its being heard at the end of inspiration when-
ever it accompanies a portion only of the inspiratory
act.

The significance and value of the crepitant rale, as
a diagnostic sign, were much discussed by Laennec's
commentators, but the theory of the mechanism was,
so far as I know, first called in question by M. Beau,
who attributed it to the friction of the pulmonary
vessels^ rendered morbidly dry (dessecliees) by incipi-
ent inflammation. As will be presently seen, M. Beau
was not very far from the true explanation, but he
failed in reaching it.

In 1842, five years after the publication of the
fourth edition of Laennec's treatise, edited by Andral,
the late Dr. Edson Carr, of Canandaigua, New York,
communicated a paper for the American Journal of
Medical Sciences^ entitled Suggestions as to the Cause
of the Crepitant Ehonchus." This paper occupies only
two and a half pages of the Journal. After referring
to the hypothesis of Beau, Dr. Carr considers that in the
first stage of pneumonia the air-vesicles contain a
certain quantity of thick and tenacious matter which
he calls mucus, by means of which the walls of the
vesicles, at the end of the act of expiration, become
coherent, or glued together. He then proceeds to ex-
plain the mechanism of the crepitant rale, as follows :
" Now, during every inspiration^ the air, rushing
into and distending the vesicles, necessarily over-

452

JVIECHANISM OF THE CREPITANT

comes tliese coliesions ; and would not tlie separa-
tion of these membranes, tlius glued together by tena-
cious mucus, naturally produce precisely sucli sounds
as constitute the crepitant rale of pneumonia ? " He
adds : " A great variety of experiments might here be in-
troduced to illustrate this view of the phenomena. One
of the most simple is that of moistening the thumb
and finger with very thick paste or mucilage, and al-
ternately pinching them together and separating them,
when held near the ear. By repeating and modifying
this simple experiment, sounds may be produced so per-
fectly imitating the crepitant rale of pneumonia, that I
am persuaded no one who will take the trouble to try
it will doubt this exj^lanation of its cause." '

Dr. Carr, whom I had the pleasure of knowing per-
sonally, was a man of a high order of mind ; and he
was distinguished among his associates for his pro-
fessional attainments. Notwithstanding his comj)ara-
tively limited opportunities for clinical observation, he
cultivated zealously, and with much success, the study
and practice of auscultation ; and, in a paper read at a
medical society meeting, he anticipated Skoda in the
application of the principle of consonance to the ex-
planation of certain auscultatory phenomena. The
article on the crepitant rale, in 1842, is the only pub-
lished paper by Dr. Carr, on this subject, that I know
of, although his death did not take place for twenty
years or more after the date of that publication.

Dr. Carr's short paper attracted very little atten-
tion. I do not recollect ever having seen a reference
to it in any foreign work on auscultation. In a con-

^ It is a noteworthy fact that all the examples suggested for the illus-
tration of this rale afford no support to the bubbliug theory. In addition
to the illustrations cited are, the expansion of a dry sponge after it has
been compressed, and rubbing a lock of hair close to the ear.

THE SUBCEEPITAOT eAlE.

453

versation witli Robin, in Paris, in 1854, he told me lie
had never heard of the crepitant rale having been ex-
plained in that way, and he at once declared the
explanation to be, in his judgment, the correct one ; but
he did not remember to introduce the explanation in
the subsequent editions of Nysten's Dictionary, of
which he is the editor. From the date of Dr. Carr's
article to the present time, as previously, and inclusive
of the present time, most writers on auscultation have
been satisfied to adopt the theory of bubbles origi-
nally offered by Laennec, notwithstanding the difficul-
ties in the way of reconciling this theory witb certain
obvious facts, namely, the absolute dryness of the
sound, and the limitation of the rale to the act of in-
spiration.

The writings of Walshe furnish an exception to
the statement just made. Impressed with the difficul-
ties pertaining to this theory, Walshe, in the second
edition of his work, published in 1854, considers two
other hypotheses. One of these attributes tlie r41e to
" the sudden expansion of the cells, unfolding witb
crackling noise minute portions of exudation seated
between tbe vesicles in the actual parenchyma." The
other attributes it to " the mere abrupt unfolding of
the vesicles themselves." He concludes that the the-
ory of Laennec is most probably the true one." In a
foot-note he admits that " the bubbling theory fails to
explain the limitation of the rbonchus to inspiration,"
and decidedly expresses bis dissatisfaction with this
theory. In the third edition of his work on diseases
of the lungs, which appeared in 1860, this author en-
ters into a fuller consideration of the mechanism of the
rkle. He expresses still more decidedly his dissatis-
faction witb the theory of bubbling, and he is disposed

45 i MECHANISM OF THE CREPITANT

to believe tliat the production of tlie rale within tlie
vesicles may ^'legitimately be questioned." He con-
cludes, as tlie most probable supposition, that it occurs
in the parenchyma of the lung itself, that is, in the
intervesicular structure, and that " its physical cause
is the sudden and forcible expansion of the paren-
chyma, glued together, as it were, by the viscid exuda-
tion with which it is infiltrated." He admits, in con-
clusion, that this explanation " is not wholly unopen to
objection." In this consideration of the subject, Walshe
comes so near the truth, that it seems to me certain
he could not have read either Dr. Carr's article or the
account of his explanation given in a work, an ex-
tract from which I beg permission to introduce in this
connection.

In the first edition of a work on physical explora-
tion, witten by the author of this paper, and pub-
lished in 1856, Dr. Carr's explanation of the crepitant
rale is adopted in the following terms : " The most
rational theory, and the one which meets best the ob-
jections to that of Laennec, was offered several years
ago by Dr. Carr, of Canandaigua, N. Y. Dr. Carr at-
tributes the production of the sound to the abrupt
separation of the walls of the cells which had become
adherent by means of the viscid exudation incident

to the early stage of inflammation. A viscid

exudation within the cells and bronchioles belongs
among the local phenomena of the disease (pneumonia);
and as it is not readily removed by expectoration, but
accumulates until the cells are filled, and the lung so-
lidified, the constancy of the rale for a certain time is
intelligible. Its occurrence with inspiration only is
fully explained by this theory. The conditions for
the production of the sound are only present after the

AND THE SUBCEEPITANT rIlE.

455

lungs have collapsed with expiration, when the agglu-
tinated walls of vesicles and bronchioles are separated
with the expansion of the lung by the inspiratory act.
Adopting Dr. Carr's ex|)lanation, it would be expected,
as observation shows it to be true, that the sound
would be present in the early stage of pneumonitis,
the air in this stage still entering the vesicles, and sub-
sequently cease, nearly or entirely, in proportion to the
extent of the completeness of the subsequent solidifi-
cation. The fact that, when solidification has taken
place, a certain number of cells are not filled with the
morbid exudation, and remain in the condition which
characterizes all the cells in the early stage, explains the
persistence of the rale in some cases during the second
stage of pneumonitis, and its being developed, under
some circumstances, by forced inspiration and especially
at the end of the insjDiratory act. The theory of Dr. Carr
is also equally applicable to cases of oedema and haemop-
tysis, in w^hich the crepitant rale is observed. In these af-
fections the vesicles contain a liquid which is glutinous,
although in a less degree than in pneumonitis ; and
we can readily understand that the necessary physical
conditions are present sometimes, but not constantly,
on account of the greater facility with which the
liquid escapes from the cells into the bronchial tubes,
thus giving rise to the bubbling rales — the subcrepi-
tant and mucous." '

It would be affectation not to admit that I derive a
certain degree of personal gratification in the demonstra
tion of the correctness of Dr. Carr's explanation, from

^ This extract is from the second edition, in which a few verbal al-
terations were made, but the sense in no respect altered. In the second
edition I added to the vesicles the bronchioles as the seat of the crepitan
rale.

456

MECHANISM OF THE CEEPITANT

the fact tliat no other work on auscultation, within my
knowledge, has adopted this explanation. Of promi-
nent contemporaries I may name Earth and Roger, Ful-
ler, Gerhard, Bowditch, Hughes, Blakiston, Latham,
Gairdner, and Skoda (London edition, 1853), as adher-
ing to the bubbling theory.' Gerhard, in his treatise on
the chest, edition of 1846, attributes the rale in part to
bubbles, and in part to " the dilatation of the thick-
ened and stiffened vesicles." My friend Dr. Loom is,
of this city, in his recent publication, entitled " Les-
sons on Physical Diagnosis," after stating that there are
two views as to the mechanism, viz., one attributing it
to bubbling, and the other to the separation of the
walls of the air-cells glued together by a viscid secre-
tion, expresses the opinion that " it may probably be
produced in both these ways." He introduces, how-
ever, a diagram from the work on diagnosis, by Da
Costa, in which bubbles are figured within the air-
calls. In the late work on Internal Pathology and
Therapeutics, by Niemeyer, I find the following sen-
tence : " Perhaps it (the crepitant rale) originates in the
following manner : the alveolar walls are glued together
by a viscid exudation during expiration, while they
are forcibly separated by the entrance of air during in-
spiration."

Referring to other late works on the practice of
medicine and to works on diagnosis, Aitken, in a table
of the Rales, Rhonchi, or Rattles, gives the mechanism
of crepitation as follows : " Probably due to the sud-

^TMs statement requires modification. Since writing this paper, the
fact that certain distinguished German authors on auscultation have adopt-
ed the explanation by Carr, and attributed to him priority, has been brought
to my notice by my friend Prof. A. Jacobi. Vide Appendix to this
paper.

^ Quoted from the French translation, Paris, 1865.

AIO) THE SUBCEEPITAOT eAlE.

457

den and forcible expansion of delicate tissue, altered
in its physical proj)erties by tlie inflammatory state,
and whicli probably undergoes minute ruptures." This
language is not very clear. I presume that the author
means to adopt the explanation by Walshe. Under
the head of pneumonia, however, he uses this expres-
sion, " The bubbles composing the pneumonic crepita-
tion." Tanner says nothing respecting the mechanism.
I do not find any opinion as to the mechanism in Ben-
nett's Practice. In Wood's Practice (third edition) it
is stated that the r41e may depend on " the successive
bursting of very minute bubbles," or " as suggested by
Dr. Carr, of Canandaigua, N. Y., upon the separation of
the walls of the cells agglutinated by the plastic exuda-
tion." Dickson (second edition) does not give any ex-
planation. Watson ascribes it to bubbling. Maxson
gives the same explanation. Trousseau, in his Cli-
nique Medicale^^ waives discussion of the different theo-
ries relating to the mechanism. Da Costa, in his work
on Diagnosis, as implied already, adopts the bubbling
theory. In the " Traite de Diagnostique Medicale^^^ par
V. A. Racle, the mechanism is not considered. Finally,
in the article on Auscultation, by Alfred Luton, in the
" Noitveau Dictionnaire de Medecine et de Chirwgie^^
now in course of publication in Paris, I find Dr. Carr's
explanation presented and adopted, but the explana-
tion is credited to a French writer, J. Parrot, and to
Wintrich, in Germany. The latter, who had prece-
dence in j)oint of time, is stated to have given the ex-
planation in 1854, twelve years after the publication of
Dr. Carr's paper. After referring to the idea of Beau,
that the rale is due to the friction of the cell-walls
which are morbidly dry, Luton says : " This idea was
conjectured, but not proved. At a later date, J. Parrot

458

MECHAOTSM OF THE CREPITANT

extended this idea, and rendered it more probable by
suj)posing tlaat during inspiration tlie air tends to sepa-
rate tlie walls of vesicles, tliese walls having in expi-
ration come into contact and become agglutinated by
means of the bloody mucus which is characteristic of
pneumonic expectoration ; in fact, a sound like the crep-
itant rale can be obtained by the separation of two
surfaces to which a viscid matter has been aj)plied.
This theory, which has also been proposed in Germany,
by Wintrich (1854), seems to us very acceptable ; it is
the only one which accounts for all the peculiarities of
the rale. The rale, however, should not be referred
exclusively to the pulmonary vesicles, but, as stated
by Wintrich, the minute bronchial tubes, into which
the cells open, taking part in its production."

The opinions which have been noticed relate to the
mechanism of the crepitant rale. As regards the sub-
crepitant rale there have not been differences of opinion.
That this is a bubbling rale no one can doubt. The
character of the sounds, their occurrence in both inspi-
ration and expiration, the inequality of the sounds
which enter into the rale, and the comparative slow-
ness of their evolution, constitute adequate evidence of
bubbles. I shall, however, presently show that this
explanation of the mechanism may be demonstrated
to be the correct one.

I will introduce here a clinical fact which has not
been sufficiently considered ; and the imperfect appre-
ciation of this fact, as it seems to me, has occasioned
not a small share of the confusion respecting the dif-
ferential characters of the crepitant and the subcrepi-
tant rale. The fact to which I refer is this : These two
rales are often found in combination ; in other words,
associated with the very fine crackling sounds of the

AND THE SUBCKEPITAISTT eAlE.

459

crepitant, are more or less of the fine bubbling sounds
of the subcrepitant rale. If botb these rales be attrib-
uted to bubbling, and the differential characters to
the difference in size of the spaces in which the bub-
bles burst, it would hardly be expected that there
would be a sharp line of demarcation between the two.
It is usual to say, not that the two rales are combined,
but that the one merges into the other. The difference
in the mechanism being demonstrated, an essential dif-
ference in the sounds is established ; the one cannot be
converted into the other, but the two may be united
in varying proportions. Whenever a " sensation of moist-
ure " (to use the language of Laennec) is apparent, not-
withstanding the distinctive characters of the crep-
itant rale are present, there are bubbling sounds in
addition to crepitation. It is owing to this combina-
tion that some writers have been led to state the oc-
currence of crepitation sometimes in the act of expira-
tion. Not infrequently, in the resolving stage of pneu-
monia, both rales are present very obviously, the sub-
crepitant preceding the crepitant rale in the act of in-
spiration, and present alone in the act of expiration.
I have for many years been accustomed to demonstrate
the combination of the two rales at the bedside ; and
in the artificial exemplification of the subcrepitant
rale, which I shall presently give, it will be seen that
with it is associated crepitation, unless pains are taken
to prevent the production of the latter.

After this introduction, which I fear may have
seemed protracted, but which, as it seems to me, is
appropriate, I proceed to the object of this paper as
stated at the outset.

For my knowledge of the artificial production of
the crepitant rale in the way I am about to describe,

460

MECHAIS^ISM OF THE CEEPITANT

I am indebted to mj friend and associate, Dr. Henry
F. Walker. Dr. Walker happened to purchase an arti-
cle labelled " Patent India-rubber Sponge," which is de-
signed to take the place of the ordinary sponge for the
toilet. This article consists of a block of india-rubber
which has been made to assume a cellular arrange-
ment, evidently by the introduction of air or gas while
the substance is in a liquid state and during its conge-
lation. On examining the article, it will be seen to be
made up of cells of unequal size, the appearance being
very like that of a portion of emphysematous lung.
The elasticity of the india-rubber causes the article to
exj)and after it has been compressed, the well-known
cohesiveness of this substance offering a certain amount
of resistance to the expansion. IN^ow, after having ex-
amined the structure, if each one present will com-
press with the fingers the article which I shall ask you
presently to pass around, holding ' it close to the ear,
and then allow it to expand, it will be afc once per-
ceived that a crepitant rale is beautifully represented.
The fineness and the dryness of this rale are perfectly
exemplified. It will be observed that the compression -
of the article causes no sound. This act of compression
is to be considered as taking the place of expiration.
The expansion is analogous to the movement of the
lung in inspiration. The compression brings the walls
of the cells into contact, and, from the adhesiveness of
the substance, they cohere with a certain amount of
force. There being no liquid present, the rale must
be produced by the separation of the cell- walls by the
elasticity of the substance. The intensity of the crepi-
tation will be found to be proportionate to the force
of the compression, the cell-walls being brought more

AXD THE SUBCEEPITAXT eIlE.

461

completely into contact and tlie cohesion being greater
according to the amount of comjDressing force.

Purchasing the article for another purjDose, Dr. Walk-
er was led to notice this unexpected application, and
being associated with me in giving j)ractical lessons in
auscultation, he called my attention to its usefulness,
as affording an exact representation of the crepitant
rale preparatory to the demonstration of this sign in
cases of pneumonia. It is indeed highly useful for this
purpose. But, in addition, it serves to demonstrate
that the crepitant rale in cases of disease is produced,
not by bubbling, but by the separation of the coherent
walls of the cells and bronchioles. The representation
of this sign is so complete by means of this article,
that I do not see hoAV any one can doubt that the
mechanism is the same. I assume, therefore, that the
explanation of the crepitant rale, published more than
twenty-five years ago, by our countryman Carr, is
proved to be the true explanation ; and I claim in be-
half of his memoiy the credit of the explanation which,
by the author of the article on AuscultatioD, in the
new French Dictionary of Medicine and Surgery, is
accorded to others. As a friend of the late Dr. Carr, I
cannot but have a feeling of regret that he did not live
to see the correctness of his explanation established.
As it is, justice to his memory, in respect of the origi-
nality and priority of the explanation, will be gratifying
to numerous friends who held him in high esteem for
his professional attainments and private worth.

The production of the crepitant rale, in the manner
now illustrated, demonstrates the error of attributino^
the fineness of the rale to the small size of the cells.
The fineness is not less marked when produced by the
india-mbber sponge than when it emanates from the

462

MECHANISM OF THE CREPITAJN^T

pulmonary vesicles and bronchioles. Dr. Carr's mode
of illustration, by pressing together and separating the
finger and thumb moistened with thick paste or muci-
lasce, also demonstrates this error.

In concluding my remarks on the crepitant rale, I
will refer to an explanation of the peculiar quality of
the inspiratory sound in the normal vesicular murmur,
which, so far as I know, is original with me. Quoting
from my work on physical exploration (2d ed., p. 133),
I say with reference to this point as follows: '^May
not the peculiar quality (called the vesicular quality)
be owing to the separation of the walls of the cells,
or bronchioles, which, to a greater or less extent, are in
contact, and, owing to the moisture of the tissues, be-
come slightly adherent during the partial collapse of
the lung at the end of an explication ? We shall see
hereafter that this is the most rational explanation of
an important and highly distinctive physical sign of
disease, namely, the crepitant rale. The fact that the
air does not circulate freely in the air-cells and bron-
chioles with each inspiratory act, renders probable the
explanation suggested by the foregoing inquiry. Other
facts supporting this explanation are, the increase of
this peculiar quality of sound in the inspiratory act
which succeeds a forced expiration in the act of cough-
ing ; the diminution 'of the quality in cases of perma-
nent dilatation of the air-cells, or emphysema, and the
limitation of this quality to the inspiratory sound."
In view of the demonstration of the mechanism of the
crepitant rale, the correctness of the explanation of the
vesicular quality in normal respiration, which is offered
in the foregoing quotation, seems to me extremely prob-
able. We have the crepitant rale in pneumonia, be-
cause the air-vesicles and bronchioles are glued to-

AND THE SUBCKEPITANT kAlE.

463

getlier at the end of expiration by a viscid morbid prod-
uct. We have a slight approach to this rale in health,
in the vesicular quality of the inspiratory sound, be-
cause the air-vesicles and bronchioles are very slightly
coherent at the end of expiration. The peculiar quality
of the inspiratory sound in the normal vesicular mur-
mur, Laennec compared to a " slight crepitation,"
but in view of his theory of the crepitant rale he could
not, of course, suppose that the mechanism of this
slight crepitation and of the crepitant rale is the same.

A good imitation of the vesicular quality in the in-
spiration of health is obtained by wetting a fine ordi-
nary sponge, squeezing it as dry as possible, then com-
pressing it and allowing it to expand close to the ear.
The liquid may be so effectually squeezed out of an
ordinary sponge that there is not enough left for bub-
bling; but the moisture occasions a very slight co-
hesion of the cells when] pressure is made, and the
expansion gives such an approach to crepitation as con-
stitutes the vesicular quality in the normal vesicular
murmur. This mode of representing the vesicular
quality goes to prove its mechanism.

Concerning the mechanism of the subcrepitant rale,
as already stated, there is no difference of opinion.
This r41e is produced by the bubbling of liquid ; it is
therefore essentially different from the crepitant rale.
The article which, as has just been seen, represents
crepitation, may be used to exemplify the subcrepi-
tant rkle, and to illustrate certain points relating to the
differentiation of the two r^les. The application of
the ^' india-rubber sponge " to show the mechanism of
the subcrepitant rale was suggested by Dr. William J.
Chandler, one of the house physicians at Bellevue Hos-
pital. If a portion of the "sponge" be compressed

464

MECHANISM OF THE CEEPITAI^T

and allowed to expand under water, tlie cells are filled
witL. liquid ; and, now, holding it close to tlie ear and
alternately pressing it and relaxing the pressure, fine
bubbling sounds are produced. That bubbling is
caused by the pressure, is shown when the portion of
" sponge," of the cells filled with liquid; is compressed
under water ; small bubbles, of unequal size, in great
abundance, rise to the surface. This artificial subcrep-
itant rale is produced alike by the pressure of the
" sponge " and by the expansion after the pressure ;
thus, the fact of the occurrence of this rale, as a morbid
sign, in both inspiration and ex23iration is illustrated.

The bubbling, as thus produced, is very fine, and
the resemblance of the subcrepitant to the crepitant
rale is admirably shown by producing alternately, with
two portions of sponge,'^ one portion dry and the
other filled with liquid, the representations of the two
rales. This may be practised with advantage in order
to exercise the ear in discriminating the differential
characters of these two r^les.

The bubbling is most apparent as contrasted with
the dry crackling of the crepitant rale, by filling the
" sponge " as completely as possible with water, and
making light pressure, the "sponge" being brought
very close to the ear. If strong pressure be made so
as to expel much of the liquid, the expansion causes a
mixture of the bubbling and crackling sounds, that is,
the two rMes are combined. This is an illustration of
what often occurs in pneumonia, especially during the
stage of resolution, and also in cases of oedema of the
lung ; the crepitant and the subcrepitant rale are mixed
in variable proportions.

The bubbling is extremely fine if the " sponge "
contain very little liquid. After strong compression,

AND THE SUBCEEPITANT eAlE. 4()5

SO as to squeeze out the water as mucli as possible, these
bubbles become extremely small and resemble closely
crepitation, both during the pressure and the expan-
sion. I suppose this is owing to the liquid being con-
fined to the minute cells, the forcible compression hav-
ing expelled it from the larger cells. A very small
quantity of liquid in the " sponge " suffices to produce
bubbling. For a day or more after wetting the
" sponge " it retains liquid enough for bubbling, as
shown by the character of the sound, and its being
produced by pressure as well as by expansion, that is,
with the movement rej^resenting expiration as well as
the movement which represents inspiration. Under
these circumstances, however, crepitation and subcrep-
itation are combined, the former predominating in the
exj)ansion movement. When the " sponge " is moist,
but not containing liquid enough for distinct bubbling,
the crepitation is intensified ; that is, it is more marked
than when the " sponge " is perfectly dry.

I suppose it to be a fair inference from the pro-
duction of very fine bubbling, with a small quantity
of liquid, as just stated, that bubbling is produced in
the air-vesicles and bronchioles of the lungs as well
as in the bronchial tubes. If this be true, the sub-
crepitant rale is not exclusively a bronchial, but also a
vesicular rale. It is an error, therefore, to consider, as
is generally done, the crepitant as the only vesicular
r^le. Clinically, a subcre]3itant rale may occupy a por-
tion of inspiration, and exist in expiration, while a
crepitant rale is heard at the end of the inspira-
tory act after the subcrepitant rale has ceased. This
fact, as already stated, I have repeatedly observed,
^^ot only does this occur, but vesicular bubbling and
vesicular crackling take place at the same instant.

466

MECHANISM OF THE CREPITANT

This is probably tlie explanation, in some cases, in
which, to the ear of one, the r41e seems to be a crepitant,
and to the ear of another a subcrepitant. It is gen-
erally considered, whenever the character of the sound
renders it doubtful whether a rkle be a crepitant or
subcrepitant, if it be heard in expiration the rale must
be a subcrepitant; but this is not proof of the ab-
sence of the crepitant r41e, since the two r41es maybe
combined, both being produced within the air-vesicles.
Of course, I assume, that all fine bubbling sounds,
whether produced in the air- vesicles or bronchial tubes,
come under the head of the subcrepitant rMe, the
crepitant rale being exclusively due to the separation
of coherent surfaces within the cells and bronchioles.

I have made some observations to determine whether
the character of the bubbling is affected by the kind of
liquid. A portion of the " sponge," filled either with
thin mucilage or with glycerine, gives bubbling sounds
not differing much from those produced when water is
used. It may be inferred from this that the subcrep-
itant rkle is the same whether the bubbling liquid
in the air-vesicles or tubes be serum, mucus, pus, or
blood. The pitch of the r^les is affected by the con-
dition of the lung as regards solidification or other*
wise — ^but this is a matter foreign to the present topic.

From the very small quantity of liquid in the
" sponge " required for bubbling, it follows that when
the crepitant rMe is produced alone, that is, not as-
sociated with the subcrepitant, the air-vesicles and
bronchioles must be nearly free from liquid. In fact,
the production of a subcrepitant rale, either with or
without the crepitant, with an extremely small quan-
tity of liquid, goes to show that the crepitant rk\e ex-
isting alone denotes only a sticky condition of the walls
of the cells and bronchioles.

AND THE SUBCEEPITANT eAlE.

467

Tlie important points presented, in connection with,
the artificial illustrations which have been given of the
crepitant and the subcrepitant rale, are recapitulated
in the following propositions :

1. The crepitant rkle is caused by the separation
of the walls of the air-vesicles and bronchioles, in the
manner explained by the late Dr. Edson Carr, of Ca-
nandaigua, N. Y.,in 1842.

2. It is highly probable that the peculiar quality
pertaining to the inspiratory sound in the healthy mur-
mur of respiration is due to the same cause, the cohe-
sion of the walls of the air- vesicles and bronchioles
not being sufficient to give rise to a crepitant rale.

3. The subcrepitant r41e is caused by the bubbling
of liquid in minute bronchial tubes, and also in the
air-vesicles and bronchioles. .

4. The essential distinctive character of the crepitant
r41e, as contrasted with the subcrepitant, is its dryness.
The term " dry crackling " exj)resses this character,
whereas, the phrase " fine bubbling " expresses the
character of the sound in the subcrepitant r41e. In
addition, the crepitant r^le is not produced in expira-
tion, whereas, the subcrepitant may be produced in
expiration as well as in inspiration.

5. Very fine bubbling due to liquid in the air-vesi-
cles and bronchioles resembles the fine crackling sound
which characterizes the crepitant r41e; and the dis-
crimination of the former from the latter requires a
nice perception of differences in sound and some prac-
tice in comparing the two r^les. The artificial pro-
duction of the two rales may be made highly useful by
affording this practice.

6. The crepitant and the subcrepitant r41e are not
infrequently found in combination. They are likely to

468

MECHAmSM OF THE CEEPITANT

"be combined whenever tlie air-vesicles and broncliioles
contain liquid of any kind.

7. In view of tlie fact that for the artificial pro-
duction of the crepitant rale no liquid is necessary,
and in view of the fact that for the production of fine
bubbling sounds an extremely small amount of liquid
only is required, wherever in disease a crepitant rale
exists, without the coexistence of the subcrepitant
rale, it is probable that there is a morbid adhesiveness
of the inner surface of the aii^-vesicles and bronchioles
without the presence of an appreciable amount of
liquid. Hence, in the cases in which the crepitant rale
exists alone in either the first stage of pneumonia or
in the resolving stage, the morbid product within the
air-vesicles and bronchioles must be either a glutinous
matter sufficient to give adhesiveness to the walls but
not enough for bubbling, or the product is a semi-solid,
in which bubbles are not readily produced ; and, in cases
of oedema of the lungs, or when blood is present in
the air- vesicles and bronchioles, the crepitant rale can
hardly be expected to occur without being associated
with the subcrepitant.'

8. The characters of the subcrepitant rale are ma-
terially the same, although the bubbling is produced in
liquids differing as regards consistence.

^The following well-known clinical fact exemplifies the occurrence of
the crepitant rale without any accumulation of liquid in the au'-vesicles :
A feeble patient, with any disease, after keeping the recumbent posture on
the back for some time, and breathing quietly, if raised to the sitting pos-
ture, frequently has for a few successive deep inspirations a well-marked
crepitant rale over the inferior posterior aspect of the chest on both
sides. The lining membrane of more or less of the cells and bronchioles,
having been in contact for some time, adheres sufficiently to furnish the rale
when these cells and bronchioles are forcibly separated, the rale, under these
circumstances, remaining during a few acts of breathing and perhaps only
heard with the first inspiration.

AND THE SUBCREPITANT eIlE.

469

I may add, in conclusion, tliat bubbling, coarser
than that which constitutes the subcrepitant r41e, in
other words, moist bronchial rales, produced in tubes
of larger size than those in which the bubbling is fine,
may be artificially represented by the compression and
expansion close to the ear of an ordinary sponge con-
taining liquid in abundance.

APPENDIX.

After the reading of the foregoing paper at a meeting
of the "Journal Association," December 18, 1868, my
friend. Prof A. Jacobi, with whom I had previously con-
versed respecting the subject of the paper, presented
some extracts from certain German authors, in which
the explanation by Carr is not only adopted, but due
reference is made to his publication in 1842. The ex-
tracts, which were translated by Prof Jacobi, and kindly
placed at my disposal, are herewith appended. That
they were unknown to me when my paper was writ-
ten, is owing to the fact that for knowledge of what
is contained in German literature I am obliged to re-
sort exclusively to English or French translations.

The following is from Wintrich's work on Diseases
of the Respiratory Organs, published in 1854, p. 167 :
" While the lungs are Avithin the closed thorax, they
cannot contract to such an extent that the alveoli and
smallest bronchi ao-o^lutinate, therefore there can be
no crepitant rale proper in healthy lungs. But when
the mucous membrane swells in the alveoli or smallest
bronchi, and is covered with tough mucus, or with a
tough pneumonic exudation, there is the possibility
during expiration of such an approximation that cohe-
sion may take j)lace. Now, when a rapid forcible in-
spiratory current enters the smallest bronchi and the

470

MECHANISM OF THE CEEPITAJSTT

alveoli during the expansion of the lungs, tlie agglu-
tinated portions are torn apart, and tlius give rise to
the rkle. During expiration the walls approach each
other again, but this produces no sound. Previous to
myself, Carr had an entirely similar idea. — {Amei'ican
Journal of Medical Sciences^ Octohei% 1842, p. 360.) "

The treatise on Percussion and Auscultation by Jo-
seph Skoda, translated by Markham, published in Lon-
don in 1853, and republished in this country in 1854,
does not contain Carr's explanation. In the edition of
1864, however, Skoda adopts this exjDlanation as set
forth by Wintrich, and accords the priority to Carr in
the following terms : " The vesicular r41e (the crepi-
tant r41e of Laennec) can accompany inspiration only
in consequence of its mechanism. I am entirely of the
opinion of Wintrich, that the mechanism of the crepi-
tant rale does not consist in the formation and burst-
ing of bubbles in liquid contained in the alveoli — the
former opinion — but that it is produced by the sudden
separation of the walls of the smallest bronchi and
alveoli, coherent from mucus, by the rushing-in current
of air. The walls, adapting themselves to each other
during expiration, cannot produce a sound. Experi-
ments with lungs outside the cadaver leave no doubt
as to the fact. In harmony with all this is the observa-
tion that the crepitant rale is frequently not heard ex-
cept in forced inspirations, and only during a limited
period, and then disappears for some time. The above
opinion was first pronounced by Carr. — (American
Journal, 1842.) "

The following extract is from page 163, in a Manual
of Auscultation and Percussion, etc., by C. Gerhardt,
Tubingen, 1866 : " Crepitant rale, similar to the sound
of salt in the fire, or that of the friction of hair near the

AliTD THE SUBCEEPITAITT kIlE.

471

ear. It is mostly found very exclusively, and always in
sucli a manner that it may be denominated as moist, al-
thougli the above comparisons do not corroborate this
latter character. In patients this r^le is mostly heard
under circumstances which allow of the supposition of
the coexistence of air and liquid in the alveoli, princi-
pally in the first and second stages of pneumonia and in
pulmonary oedema. However, it is difficult to imagine
that a j)erceptible sound should be produced in the al-
veoli by the formation and bursting of very small bub-
bles ; but it is just as difficult to prove its impossibility.
Thus, we ought to consider the above supposition as not
fully proved to be the correct one. But this much is cer-
tain, that the crepitant r41e can originate in a different
manner. There is a perceptible crepitant rale when
the lungs removed from a recently-slaughtered animal
are being inflated. And there are crepitant rales in
patients which cannot be explained by liquid in the al-
veoli. When debilitated patients, who have lain on the
back for a long time, begin to draw deep inhalations,
there is over the lower lobes posteriorly, during the
first inhalations, a crepitant r41e of rather a dry char-
acter. In both cases it is to be assumed that, while
the lungs were collapsed, the walls of the alveoli were
attached to each other, and the rale is occasioned by
the tearing asunder during inflation."

Again, at page 196, this author speaks of the pe-
culiar sound, similar to the vesicular, crepitant rale,
in peritonitis with fibrino-purulent exudation.

472

A CLINICAL LECTUEE ON

Aet. II. — A Clinical Lecture on Thoracic and Ab-
dominal Aneurism, By Prof. Skoda, of Vienna.
Prepared for the New Yor'k Medical Journal
by A. Kesslee, M. D., of Hartford, Conn.

A liigUy-interesting case of aneurism of the as-
cending aorta, wliicL. recently came under my obser-
vation, suggested to me tlie ttouglit of writing out the
substance of a clinical lecture given in the Allge-
meine Krankenliaus^ of Vienna, by Professor Skoda,
^ last winter, in illustration of several cases treated at
the time ; and as it embodies the latest views of that
distinguished authority on this important and by no
means fully cleared U23 subject, it may 23rove accept-
able to many readers of medical literature.

Acute and chronic inflammations of the arteries
lead to aneurism. The former is of rare occurrence,
and principally owing to traumatic causes, lesions, etc.,
while the latter happens more frequently, and is either
dependent on a vitiated, anomalous nutrition, a general
diathesis, or a morbid disposition of the vessels. A
chronic inflammation of the arteries, giving rise to
spontaneous aneurism, is either the expression of an
anatomical degeneration of the arterial coats, or of a
faulty state of the blood ; j)erfectly sound vessels, with
healthy blood coursing in them, are never the seat of
aneurism al affections. The inflammation originates
chiefly in the adventitia^ but, with the enlargement of
the tumor, the arterial coats become gradiially involved.
Young persons and females are but seldom affected.
The disease is most frequent with men of advanced
life, and especially among those that have to perform
severe labor and undergo great fatigue.

THOEACIC AND ABDOMINAL ANEUEISM. 473

Aneurism of tlie ascending aorta does not greatly
interfere witli the circulation, although the vessel —
which enlarges during the ventricular systole and pos-
sesses sufficient contracting power during the diastole
to carry forward the current of the blood — becomes, by
the loss of its muscular tone, much reduced in its con-
tractility ; and despite the retention of blood within
the aneurismal sac, the tumor, as such, causes no circu-
latory disturbances. But often, in consequence of its
being com]3ressed behind the aneurismal spot, the ar-
tery receives very little blood from the sac, and a dim-
inution of the circulation and obstruction in the capil-
laries naturally ensue. Aneurism of the ascending
portion of the aorta is generally combined with in-
sufficiency ; often, too, with stenosis of the semilunar
valves. The dyspnoea usually signalizing and accom-
panying it is not jDroduced by the pressure of the sac
upon the lung parenchyma, and the consequent oblit-
eration of the respiratory surface. The distressing
symptom just mentioned owes its existence chiefly to
the fact that the sac, in pushing its way toward the
atrium and cavity of the heart, obstructs the circula-
tion in the right ventricle, and produces congestion of
the veins, the latter becoming enormously distended by
the diminished contractile power of the ventricle. In
approaching the walls of the chest, the aneurism can
and does quite often impart to the neighboring region
the same chronic inflammation ivhich it suffers, not by
pressure merely, but by a gradual extension of the in-
flammatory process. The lung-substance is frequently
forced out of its place, or undergoes a partial absorp-
tion, which leads finally to its total destruction. The
nerves in the vicinity, especially the vagus, respond to
the presence of the aneurism, and its pressure upon the

474

A CLmiCAL LECTUEE ON

posterior mediastinum, oesopliagns, and spinal column,
manifests often by excruciating pain and by various
disturbances the effects of the aneurismal tumor.

The principal diagnostic signs of aneurism of the
ascending aorta are, a prominence on the thoracic wall,
an ujDlifting of the chest during the systole, distinct
from that of the heart, dulness on percussion, and pain
over the visibly elevated spot ; whereas, tumors, not
of an aneurismal character, move with the systole of
the heart, only in one particular direction, the aneurism
responds to the systolic impetus by a pulsation, which
is symmetrical and uniform in all directions. Other
important symptoms are — 1. A rushing, systolic mur-
mur, caused by the roughness of the inner arterial
surface, although the same sound may be produced by
neoplasms. 2. Insufficiency of the aortic valves,
and hence the diminished force of the circulation.
3. Eetardation of the radial pulse, though this
symptom may also be owing to the lessened contrac-
tility of the artery, and deserves, on that account, no
pathognomonic value.

Absence of any tone or murmur in the aneurismal
sac is without significance. In larger aneurisms, to be
sure, the heart-sounds, especially if already intensified,
are invariably perceived with greater force and loudness
over the tumor, and this is rather characteristic for an
aneurism of large size, but not so in those of a smaller
circumference. Aneurisms of the ascending portion of
the aorta usually open to the right of the sternum,
rarely to the left. But even if thus situated, we are
not justified in ascribing them to the pulmonary artery,
this vessel enjoying an almost perfect immunity from
the invasion of the said affection. Unless the aneu-
rism is large enough to present itself to the eye as a

THOEACIC AND ABDOMINAL ANEURISM. 475

prominent tumor, with all tlie characteristic signs de-
scribed above, the recognition of its true nature is ex-
tremely difficult, and the differential diagnosis between
an aneurism and a neoplasm, in or contiguous to the
artery, cannot be established with any precision. Pain
and a rushing sound may be chance phenomena in the
artery ; alone they are not characteristic of aneurism,
and render its diagnosis only probable. The most es-
sential, in fact, the pathognomonic symptom, is insuffi-
ciency of the valves of the aorta, especially the pres-
ence of a loud first sound over the tumor ; whereas, in
carcinoma and other neoplasms, the first tone is dull
and hardly audible, and the diastolic sounds entu^ely
normal. Smaller aneurisms, not reaching up to the pa-
rietes pectoris, cannot be diagnosticated. Mere rushing
murmurs may be due and ascribable to unevenness and
roughness of the inner surface of the artery. Small
aneurisms burst oftener than large ones, and such a
process may take place in cases that were not at all
perceived in life. What has been described as a dis-
secting aneurism cannot be properly classed among
the spontaneous affections of that kind ; it is merely
an enlargement and distention of the arterial walls.

The aneurisms of the arch of the aorta manifest al-
most the same symptoms as those of the ascending por-
tion ; but they produce always a pressure upon the left
bronchus, and arrest, in consequence, the respiration in
the corresponding lung. They press also upon the
trachea, and cause there severe irritation, and a copious
secretion from the mucous membrane of that organ.
Destruction of the cartilaginous rings, maceration of
the inner membranes of the respiratory tract, and haemor-
rhages, are further sequels of a serious and often fatal
character. The pulsation of the aneurism is distinctly
heard in the fossa jugularis.

476

A CLmiCAL LECTUEE OIT

Aneurisms of the descending portion of the aorta
are mucli rarer, and their diagnosis is made only with
great difficulty. Pulsation is, even in larger ones,
seldom perceptible, but they lead usually to a de-
struction of the vertebrae, v^^hich are gradually absorbed
and worn away by the adhesion of the sac to the de-
nuded portion of the bone, and give rise to excessive
lancinating pain in the back. A systolic murmur and
double tone, audible upon any circumscribed spot in
the dorsal region, and which is quite painful, render
the dias^nosis of aneurism of the descending^ aorta
pretty certain. Murmurs in this 2:)ortion of the artery
are quite uncommon, and can, therefore, almost with
certainty be connected with aneurismal tumors. Phys-
ical exploration, pressure uj)on the back and ribs, and
dulness on j)ercussion of the painful region, aid in the
true recognition of the disease. Another very impor-
tant symjDtom is the retardation of the pulse in the
lower arteries through the compression of the aorta '
below the aneurismal sac, or w^ith the calibre of the
vessel becoming excessively diminished, an entire ces-
sation of the same in the femoral, crural, and the other
arteries of the extremity ; the smooth flow of the blood,
without its usual undulating motion, accounts for the
absence of the pulse. In obliterations of the aorta, a
collateral circulation establishes itself, in the course of
time, which is easily discoverable. If such collateral
circulation be not perceptible, especially in the dorsal
arteries, obliteration of the thoracic aorta is out of
question, and the diagnosis of aneurism of the descend-
ing portion is rendered almost certain.

, The abdominal aorta is even more rarely the seat
of an aneurismal affection, but the diagnosis of it is
comparatively easy, as the pulsating tumor can readily

THOEACIC AND ABDOMINAL ANEUEISM. 477

be felt througli the soft parietes, and its genuine char-
acter is placed beyond doubt, if the tumor enlarges
uniformly in all directions, synchronous with the ven-
tricular systole, a fact that can best be ascertained by
grasping closely and on all sides the aneurismal sac,
with the full hand, and following its motion.

We meet very often with a violent pulsation of
the abdominal aorta, without being able to discover an
aneurism. This pulsation is usually accompanied with
great pain and opjDression, but is by no means a charac-
teristic sign of aneurism. It may be regarded as a
peculiar disease, probably owing to a morbid altera-
tion of the muscular coat, and elasticity of the artery,
which, becoming irritated, together with its sheathing
tissue, give rise to the accompanying pain and trouble-
some sensations. And it is very probable that this
pulsation is not merely confined to the abdominal
aorta, but also present in the thoracic portion of the
same vessel, only we are unable to trace it there.
Many distressing and even alarming symptoms of a
gastric, nephritic, and nervous character, great oppres-
sion, debility, and prostration, appear in the course of
this disease, but its termination is rarely fatal, and the
most threatenino; disturbances abate often without
any therapeutic interference. Rest, horizontal posture,
and cold applications, exert but little influence upon
the pulsMions. Digitalis may afford some momentary
relief, by retarding the contractions of the heart. Ful-
ness and distention of the abdomen aggravate the
mischief; a bland and scanty, diet is indicated, and
among remedial agents, quinia, with or without digita-
lis, appears to be the most useful and reliable. For-
merly the pulsation of the abdominal artery was always
identified with the existence of an aneurism ; but re-

478

A NEW MODIFICATION OF

cent investigations and pathological anatomy have al-
ready established the fallacy of that view.

Aet. III. — A New Modification of Sims^s Sjpecuhim.
By AiiausTus F. Eeich, M. D., Baltimore, Md.

That Sims's speculum is unequalled in the facility it
affords for exploration and treatment, is a fact so well
established, and so generally acknowledged by gyne-
cologists, as to make it superfluous to dilate upon it at
the present time. The principal obstacle to its intro-
duction into general practice has been the necessity of
the presence and aid of, not only an assistant, but a
skilled assistant, in order to develop its real value.
And even when in the hands of the most skilful as-
sistant, especially during tedious operations, it becomes
frequently necessary for the operator to put down his
instruments, and correct the • position of the speculum
with his own hands, because he finds it next to impos-
sible to convey to the assistant a description of the re-
quired position by any other means. This difficulty
will be unavoidable while the speculum is supported
by the hands of an assistant, and consequently liable
to move independently of the patient's body, and as
long as the assistant cannot be in such a situation as
to enable him to see whether the speculum is in its
proper position or not. Considering the large number
of cases that can only be relieved by the aid of this
speculum, and that quite a number of these patients
cannot be induced to submit to an exposure before a
third person, we need not be astonished at the numer-
ous modifications of Sims's speculum presented to the
profession during the comparatively short space of time

Sms's SPECULUM.

479

tliat has elapsed since lie first published the invention.
Although all these contrivances were intended to en-
able the practitioner to use it without an assistant, not
one of them can be claimed to be equal to Sims's un-
modified instrument when in the hands of a skilfal as-
sistant. Nevertheless, all who have been obliged to
perform an operation upon the interior of the va-
gina, requiring a little unusual time, will agree with
me when I say that the assistant holding the speculum
is at best a necessary evil^ and that any contrivance
which will secure the speculum to the patient's body
in such a manner as to produce the same exposure of
the interior of the vagina, and permit equal access to
the uterus, without the aid of an assistant, would be
quite a boon to the profession as well as to the patients.

Being convinced that a want of such a modification
really existed, and that none of those published had
fully supplied it, I proceeded to analyze the motions
produced by the assistant's hands when using the spec-
ulum, and found that they consisted, after the instru-
ment had been introduced, of only two motions : he
draws the perinseum backward and a little upward,
both of which motions are easily imitated by levers. *
The principal point to be considered was, where to
place the fulcrum, and from what point the necessary
force was to be exerted. The internal surface of the
inferior edge of the ]3ubes, being the point against
which most specula exert the force required to retract
the perinseum, was rejected, because it will not bear as
much pressure as will often be required in young and
muscular subjects. After considering several other
places that might be chosen, it was determined to place
it on the posterior surface of the sacrum, and make
extension from the left shoulder by means of a strap.

480

A TfEW MODIFICATION^ OF

Without detaining the reader with a description of the

ing merely the result of the same, represented in the
accompanying illustrations.

A. The speculum, the right wing of which is longer than the left, to support the right
buttock when the patient is in the left lateral semi-prone position.

B. A plate fitting over and closing the fenestrum with which the speculum is provided,
to facilitate operations for recto-vaginal fistula and other affections of the posterior wall of
the vagina.

C. A depressor, having a sliding as well as circular motion ; it may he securely fixed in
any suitable -position by simply tightening the screw D, by means of which it is attached to
the speculum. A few turns of the same screw in the other direction will detach the depres-
sor and washer in which it slides, leaving the opening of the speculum perfectly free. The
depressor may then be used with the hand, as an ordinary one.

E. The fulcrum plate, intended to rest upon the sacrum.

F. A screw, by means of which the speculum can be detached, and others of different
sizes secured to the levers.

G. A screw by which the angle of the speculum may be adjusted after it is introduced
into the vagina.

H. The ascending lever, measuring six and one-half inches from the joint to the top of
the buckle.

I. The descending lever.

K. A strap passing under the right axilla and over the left shoulder, the united ends of
which are drawn through a spring-buckle on the top of the ascending lever, which seizes
and holds the strap at any degree of tension.

Fig. 1.

They represent an instrument that will do all that
an assistant can do with the unmodified speculum,

SIMS'S SPECULra.

481

without getting fatigued as he will, and one that is sure
to follow all the motions of the patient, without losing
its relative position to her body. ]S"ay, more than this,
it will remain in its position whether she is standing,
walking, kneeling, or in the left lateral semi-prone po-
sition, and at the same time securely keep the garments
of the patient (crinoline and all) out of the opera-
tor's way.

Fig. 2

Eepresents the speculum as used ■witli a patient upon her knees. It is evident that, on
tightening the strap, the fulcrum plate, levers, and speculum will slide upward as far as the
yielding peringeum will permit, and then the levers wiU hegin to act and draw the peri-
naeum backward.

Diffident of my own judgment in a matter the suc-
cess of which would afford me personal gratification, I
referred the instrument to the members of the Patho-
logical Society of Baltimore, and also to those of the
Baltimore Medical Association, at their second meeting
in the month of May last, and, upon illustrating its use
upon a patient, present for that purpose, was gratified
to find that it met with the approval of all jDresent ;

482 PHOSPHOEUS I^^ LOCOMOTOE ATAXIA.

some of wliom liave already supplied themselves with
the instrument.'

Aet. IV. — PJwsjyhorus in Locomotor Ataxia. By
Waltee Lambeet, M. B., Amherstburg, Ontario,
Canada.

Miss F. B., aged 22, had been suffering slightly
with . anaemia and scanty menstruation for about one
year. At different times, she took ferruginous prepa-
rations, with decidedly good effects ; but, as soon as re-
lieved, she would leave off taking the medicine, and
her trouble would return. She also had asrue once or
t>vice during the summer, it being very prevalent at
that time in the neighborhood. For it she was spe-
cifically treated, and from it she soon recovered.

For the chlorosis I sometimes gave mistura ferri
comp. (Grifiith's), sometimes tinct. ferri and quinise
disulj^h. ; lastly, I was giHng her syr. ferri iodidi, with
cod-liver oil. In September last, from exj^osure to
wet and cold, her menses ceased, and all the symptoms
of progressive locomotor ataxia set in. Her parents,
who live in the country, came for more medicine, and
casually told me that their daughter walked with great
difficulty, and that her menses did not come on at their
usual period ; consequently I went to see her, and in
her attempting to shake hands with me she grasped
me by the wrist. This excited my fears immediately
that she had Duchenne's disease. Upon further ex-
amination, my diagnosis was verified. The patient, in
attempting to walk, staggered and swayed her body
from side to side to keep her equilibrium. She would

^ The modified speculum was made under my directions, by Mr. Rosen-
dorn, surgical-instrument maker, N'o. 18 South Sliarp Street, Baltimore,
Md., from whom the instrument can be obtained.

PHOSPHOEUS IN LOCOMOTOR ATAXIA. 483

suddenly halt to recover herself, and then would
plunge forward, seemingly in a great hurry to reach the
point to which she desired to go. She was unable to
feed herself, from the want of coordinate action of the
muscles, and, in fact, unless she was watching her
hands continually, she was liable to drop whatever she
had in them. Her speech was also affected; she was
not able to articulate some words perfectly.

What is passing strange in this case is, that
I was giving her syr. ferri ioclidi at the very time that
the disease manifested itself; the very medicine that
Dr. Julius Althaus used with so much benefit in his
case, the only one recorded, until lately, that had been
much benefited by medicine.

As soon as I recognized the disease, I gave potass,
bromid. grs. xv., ter in die, and submitted the patient
to the action of magneto-electricity once every twenty-
four hours. I also gave two pills of aloes and iron,
which produced too much relaxation, the effect con-
tinuing two or three days. This, in fact, seemed to
prostrate her to such an extent that she was obliged
to take to her bed, and there remain for a time. For-
tunately, just then I received the September number
of the ^^eio Yorh Medical Journal^ and in it saw that
Dr. Dujardin Baumetz had given phosphorus in this
disease, with excellent effects. I immediately ordered
acidi phosphorici dil. m. xv., ter in die, in simple syrup.
The next day her menses came on, and in a short time
she began to improve. In a few days I increased the
dose to twenty, twenty-five, and then to thirty minims.
After ten or twelve days, I omitted the acid, and gave
her the pyro-phosphate of iron for a week, and then
returned to the acid. I continued the electricity every
alternate day. In two weeks she was able to sit up,

484 suppoETmG a^t> coi^Fmma appaeatus, etc.

and had sufficient control over tlie muscles of lier up-
per extremities to be able to knit. In one month she
could walk about the house tolerably well. Now it is
something over two months ; she can take long walks,
do housework almost as well as ever, and has become
very fleshy. The electricity has been discontinued
for about one month, and she is not at all reo:ular
with her medicine at the present time. However,
I have the most sanguine hopes that she will perfectly
recover. The improvement has been so great that it
is impossible to discern any thing wrong with her,
except a very slight irregularity in her walk.'

Aet. V. — Remarlcs on the Advantages of a Supjport-
ing and Confining Apparatus^ and a Self -retain-
ing Specnluni in the Operation of Vesico-vaginal
Fistule ; Models of Certain Forms of Suture ;
tlieir Results practically contrasted in tlie same
Cases and upon the same Fistidous Openings,
By Nathais^ Bozemai^, M. D., New York.

■(These remarks, in substance, were made before the New York Medical Journal Asso-
ciation, Nov. 20th.)

SUPPOETIIs^G AND CO^^FimNa APPAEATUS.

I WOULD remark that I have had this apparatus
constructed specially to receive and supjDort the 23a-
tient in an old position for the ojDeration of vesico-vagi-
nal fistule, which I denominate the right-angle posi-
tion^ upon the hnees and chest. This position was first
proposed by Prof. Roux, nearly forty years ago, and
was adoj^ted soon afterward by Prof. Wutzer, in Bonn.
But, as employed by these surgeons, two of the most

^ We are informed by Dr. Lambert, in a note received since this article
was in type, that tlie patient has perfectly recovered under this treat-
ment.—E. S. D.

SUPPOETIl^G AND CONFINma APPAEATUS, ETC. 48 5

important advantages of it were not appreciated : first,
freedom of the abdomen from pressure ; and second,
effectiveness with which the patient could be secured
without the aid of assistants.

In our construction of the apparatus here presented
we claim to have secured the above important ad-
vantages, and to have utilized the position for all op-
erations upon the anterior wall of the vagina, and, we
may add, operations generally about the anus and rec-
tum of both sexes.

Having previously described and pointed out the
many advantages of this contrivance before another
society in the city, it is not necessary that I should do
so again on this occasion. Suffice it to say, in its use
three principal objects are sought to be attained :

1. Extension of the vertebral column and relaxa-
tion of the abdominal muscles essential to free gravita-
tion forward of the pelvic and abdominal viscera.

2. Suj)port and mechanical confinement of the pa-
tient by controlling muscular action at certain poiats
without encumbering the abdomen, or interfering with
the functions of respiration and circulation.

3. The safe administration of anaesthetics.

Fig 1

486 suppoETmG and coi^Fmma appaeatus, etc.

As may be seen, the apparatus is admirably adapt-
ed to all of these purposes. It is forty-four inches in
length and eighteen in width. The construction, as
seen, is simple and strong. It is light, weighing only
seventeen pounds, and very portable when folded up.
It may be placed for use ujDon any kind of table, to
which it is made fast by the weight of the patient and
a couple of small clamps.

Fig. 1 is an illustration of the apparatus in use.
The whole figure is here exposed, in order that the
relationship of every part of the apparatus to the
body may be seen. In actual use, we would observe,
there is little or no exposure of the person, the patient
being placed in position, and secured as here shown,
under a sheet. In fact, there is less exposure in this
position than any of the others usually employed, for
the reason that the patient is so steadily and securely
held that her clothing does not become disarranged, as
ordinarily results from her resistance and struggle
under the pain of the operation.

The apparatus, as may be seen, is placed upon and
secured to the table, A B. The patient first kneels
upon a couple of cushions, the thighs being perpen-
dicular to the table and received against the two up-
right splints, held in position by the corresponding
braces. Around each thigh and splint is placed a pad,
over which are buckled two strong straps to secure the
whole. In a similar manner the ankles are confined.
The lower limbs thus arranged and secured, muscular
action is effectually controlled.

The patient is next required to bend the body for-
ward until the chest and head are received upon theii^
appropriate supports; she then voluntarily extends
the vertebral column, which position is maintained

SUPPOETma AND CONFINTN-a APPAKATUS, ETC. 487

by tlie long girtli seen passing across the loins. In
this way she is deprived of all power to raise the body
from its support, or otherwise to make any effective
resistance. Eelaxation of the abdominal mnscles and
gravitation forward of the pelvic and abdominal vis-
cera are thus permanently secured.

In this position the chest and head suffer no re-
straint. Respiration and circulation go on smoothly.
In short, the entire body is easy and comfortable, and
the patient can remain for hours with as little fatigue
as upon the back. Anaesthetics can be given with as
much safety in this as in any other position ; and I am
induced to believe, from our experience so far, that it is
even better on some accounts. In vomiting, for in-
stance, no ingesta are liable to reach the larnyx, and
consequently no delay is experienced in the operation
from apprehended strangulation, as very often hajDpens.
The face being downward, every thing from the stomach
is freely ejected, and the effort does not in the least inter-
fere with the progress of the operation. I have now
given ether and chloroform about thirty times in this
position, without a single untoward occurrence, and
from our convictions based upon this experience I have
no hesitation in recommending it as entii^ely safe, with
the observance of ordinary precautions.

When the patient is disengaged from the apparatus,
it is doubled up, the hinge-joint C being placed near
its middle for the purpose. The head-sup]Dort, at-
tached by two hinges and held in position by a brace,
drops down as soon as the latter is removed, and is
placed beneath: the chest-support, to which it is fast-
ened. The two supports are thereby made to stand
back to back, occupying the least possible space.
When thus folded up and set upon the floor, the ap-
paratus resembles somewhat an ordinary chaii\

488 suppoETma a-nb cootestino appaeatus, etc.

As showing the high estimate t]iat we place upon
the many advantages of this simply-constructed appa-
ratus, I would observe that I do not believe a patient
can be found, I care not what her size, strength, or
temperament may be, who cannot be effectually se-
cured with it without the aid of assistants.

THE SPECULUM.

In this connection we would call attention to cer-
tain alterations and improvements which we have made
in our spring and self -retaining speculuin since the first
description of it was published in the New York Med-
ical Record^ nearly a year ago. During the period of.
these improvements we have continued to use the in-
strument with the above supporting ajDjDaratus, and in
every instance it has given entire satisfaction. In fact,
we have had no occasion, since its adoption, to use any
other form of speculum for examinations or opera-
tions about the cervix uteri. The main part of it has
required but little change or alteration since its first
application. The attachment, however, intended for
the elevation and support of the posterior wall of the
vagina, has been variously modified. The standing
arch first used and described was soon discarded,
for the reason that it could be employed only in a cer-
tain class of cases. Side springs were then substi-
tuted, which proved quite effective, though their man-
agement was somewhat difiicult in inexperienced
hands. In order to overcome this trouble, we attached
to each of these springs a spatula-shaped dej^ressor,
about four inches in length, intended to elevate the
springs and to support in a longitudinal direction the
posterior wall of the vagina. This w^as effected by
seizing the outer end of each depressor and pushing

suppoETma Ais^D coNrmmo appaeatus, etc. 489

up tlie spring to its proper place, whicli being done,
this end of the depressor was next slid outward be-
neath the perinseum to its place of suj3port upon the
corresponding projecting arch, as is here shown in our
medium-sized speculum. This arrangement we found
admirably adapted to the purpose above named in the
position upon the back, as well as that upon the knees
and chest. With the patient in either of these posi-
tions we have been able to do with the instrument,
thus completed, any thing in the way of examinations
and operations without the aid of an assistant. Many
have objected to these depressors, under the belief that
. they complicate the instrument. We have, therefore,
made an effort to simplify the working of this part of
the instrument still further, which we think we have
done in the substitution of one broad depressor for the
two heretofore employed in connection with the side
springs, which are now dispensed with. This depres-
sor is entirely separate from the main part of the in-
strument ; it is about four inches in length, one in
width toward its point, and one and a quarter at its
outer end, where there is a short neck or handle, an
inch and a half in length, turning upward .at an obtuse
angle. It is thin and slightly flexible, and is bent to sui
the curves of the posterior wall of the vagina, to which
it is firmly applied from the perinseum to the posterior
cul de sac. To the under surface of it, near the outer
end, is attached along the centre a small triangular
plate, the base presenting backward and the apex
forward, with a flange on the side edges. These
grooves or flanges are intended to guide the depressor
to its proper j^lace when received upon the projecting
arches of the speculum previously introduced into the
vagina and expanded. The arrangement is such that

490 SUPPOETIXG AND CONFESTOG APPAEATTJS, ETC.

tlie depressor can be slid in upon tlie projecting arches
at any stage of expansion, and in tliat relationship is
securely held by the resistance of the perinaeum and
the recto-vamnal wall.

Fig. 2.

The illustrative cut Fig. 2 is a one-third size, and
a three-quarter view of our medium-sized speculum.
The instrument is represented partially expanded. The
dotted lines in front and between the expanded or
flaring blades are intended to show the shape and po-
sition of our last improvement of the attachment for
supporting the posterior wall of the vagina. The re-
lationship of it to the projecting arches of the main
instrument is very clearly shown. The accompanying
edge view of the same represents veiy well the curves
described and the jDeculiar mechanism of the triangular
plate on the under surface of it.

The main part of the instmment, hav^g already
been minutely described, may be passed over here.
Before leaving the subject, however, we will briefly
sum up the principal peculiarities of the instmment
for which we claim originality, to -svit :

SUPPOETING AI^D CONFESTJ^G APPAEATUS, ETC. 491

1. Tlie system of leverage employed, wliicli gives
us increased power over increased resistance.

2. Transverse dilatation witli uniformly varying
movement of tlie blades, wliicli gives us a thin and
favorable form of tlie points for introduction, and a
reversal of the size of the two ends of the instrument
when expanded within the vagina. By virtue of this
fiaring expansion of tlie hlades ivitlim the ascending
rami of the iscliia^ the instrument is made self retain-
ing^ which distinguishes it from all others of this class
previously constructed.

3. The elasticity of flexure belonging to the work-
ing-point of the instrument, which gives it an easy
adaptation to the soft parts, both in the vagina and at
its mouth. This is also a fea1:ure of the instrument
that particularly distinguishes it from other valved
specula, heretofore in use.

4. The applicability of it in all positions, and the
advantages secured to the physician or surgeon, of ma-
king all examinations, or of doing all operations re-
quired upon the vaginal walls and cervix uteri with-
out the aid of assistants.

The arrangement and working of this last improve-
ment can be fully understood by an examination of
the whole instrument, which I here present. As now
completed, it is, I think, as simple and effective as it
is possible to make it. A^Tiether it will ever be
adopted in general j)ractice, or not, is a matter of no
moment to the obstetric surgeon. As an instrument
perfect in its adaptation to all oj^erations upon the
anterior wall of the vagina and the cervix uteri,
without the aid of an assistant, we think it must
sooner or later hold the first rank.

Since the adoption of our supportiag apparatus

492 SUPPOETESTG AND COOTmma APPARATUS, ETC.

and tliis speculum, we laave had six consecutive cases
of vesico-vaginal fistule, presenting eiglit fistulous open-
ings, one a vesico-uterine. All of these fistules have
been closed at seven operations — one operation less
than the actual number of openings. These operations,
I may add, have been witnessed by nearly a hundred
physicians and surgeons of this and neighboring cities,
among whom I may mention Profs. Willard Parker,
A. C. Post, Jas. E. Wood, Isaac E. Taylor, Drs. Thos.
C. Finnell, Lothar Voss, John O. Stone, K. F. Cha-
bert, of Ploboken, De "Witt C. Enos, of Brooklyn, E. B.
Bontecou, of Troy, and S. H. Tewksbury, of Portland.

Already, I may here observe, several modifications
of this instrument have been made, but as yet we have
seen no improvement U23on the original. The most
important of them is that of my friend. Dr. J. C. Nott,'
of this city. Although this gentleman does not do
me the justice to say his instrument is a modification
of ours, it is nevertheless true, for the main feature of
it I am entitled to the credit of priority, as any
one can see at a glance by comparing the two in-
struments. The self-retaining principle of his instrii-
ment is due entirely to the flaring expansion of two
of liis Uades within the rami of the ischia^ the main
principle upon which our instrument was first con-
structed. This principle of expansion within the pelvic
bones, in order to secure the important desideratum of
self-retention in the construction of our speculum, I
may be i3ermitted to say, I worked out by a series of
experiments, extending through a period of nearly two
years. I am therefore warranted in saying, from a care-
ful examination of the records of the profession, that
no one, previous to the first published account of our

^ Americau Journal of Medical Sciences, October. 1868.

suppoETma AisT) cOiS^riOTis^a appaeatus, etc. 493

speculum, January, 1868, had ever attempted to con-
struct an instrument upon tLe same principle ; and that,
from our experience witli it thus far, we believe it to
be the only princij^le upon which any simple and use-
ful self-retaining speculum can ever be constructed. '

SUTURES.

As to the foiTQ of suture used, we would say a word.

While we regard the two unprovements just de-
scribed of very great value, and we think they mark a
new era in the history of vesico-vaginal fistule ; still
the fact must not be lost sight of, that the kind of
suture employed is no less important now than it has
always been. Although the above stated results show
an extraordinary amount of sucqess considering the
character of the cases, yet this is not to be attributed
alone to the improvements above described. Much of
it is due to the suture — the button suture, so called
from its peculiar mode of action.

This form of suture we devised and first applied
nearly fourteen years ago, and no other suture have we
ever had occasion to use, in such cases, to the present
moment. It is composed of silver wire, a leaden plate,
and perforated shot.

We claim for it :

1. Separate and independent action of the sutures.

2. Perfect coaptation of the edges of the fistule,
and power to hold them in a certain relationship dur-
ing the reparative process.

3. Perfect steadiness and support of the edges of
the fistule.

^ Those who may have ordered our speculum before it was completed,
can have the last improyement attached by Messrs. George Tiemann &
Co., of this city, with but little additional cost.

494 sTJPPORTmo and coOTmnsra apparatus, etc.

4. Protection of tlie denuded eds^es of the fistule
from the vaginal and uterine discharges, and from the
urine, when there happens to l3e more than one open-
ing, and it is not convenient or desirable to close both
at the same sitting.

Here we have all the elements of success haj)pily
combined, which accord fally with principles recognized
by all surgeons in the treatment of wounds in any of
the external parts of the body.

Fig. 3.

A very good idea of this form of suture, and the
many advantages claimed for it, may be had from an
examination of this model which I have made with a
piece of buckskin. The leaden plate or button is two
inches long, five-eighths of an inch wide, and grooved
on the under surface with such an instrument as Fig.
3 represents, which I have invented, and term the hut-
ton-forming forceps. There are seven perforations along
the centre throuo^h which the two ends of each of the
seven sutures are passed. On the toj) surface of the
button are seen seven perforated shot, compressed
upon the doubled ends of each wire. To the under or
grooved surface of the button, the edges of the fistule,
represented by the sides of the slip in the j)iece of
buckskin, are smoothly and firmly applied, presenting,
as may be seen, a line of aj)proximation somewhat
curved, though corresponding exactly with the line of
holes described. This line, although elevated and de-
pressed at certain points, is as perfect as it is possible

SUPPOETINO AND CONFmmG APPAEATUS, ETC. 495

to make it from one angle of the opening to the other.
At every point the coaptated edges are seen to "be
under the most complete control, and the closure on the
opposite side is so even and perfect that it would be
scarcely possible for a drop of water to enter. I will
refer incidentally to the- case in which this very button
was used :

Case I. — Mrs. K., aged about forty- one, above medmm stature, lost con-
trol over ber bladder at tbe birtb of ber second child, July, 1853. She
presented herself a few months ago, with a fistulous opening, involving the
root of the uretlira, the whole of the trigone, and a part of tbe has fond of
the bladder. The enormous chasm admitted three fingers into the bladder,
and through it protruded constantly the superior fundus of the organ. A
more miserable and wretched condition than this poor woman presented,
the imagination can scarcely picture. During her fifteen years of affliction
five or six operations were performed, some of them by eminent surgeons,
though no permanent relief had been afforded up to the time she came
under our care. The first application of this suture apparatus, as you see
it here, resulted in a complete closure"of the opening on the eighth day.
This operation, I beheve, was witnessed by one or two gentlemen present.

To show now the relationship of the urethra to the
edges of the fistule as approximated in the above case,
we have attached a tube to the model between the fifth
and sixth sutures, through which is j)assed an elastic
catheter No. 6, just as it was used in the operation.'
This kind of a catheter I prefer to all others on ac-
count of the comfort to the patient and the ease with
which it can be kept 023en without removal, simj^lyby
runnino' a wire throuo^h it. This same catheter, we
would remark, was lodged in the bladder five days,
and by an examination it will be seen that not the
slightest roughness ensued.

Fig. 5, intended to illustrate a fistule of smaller
size than the above represents, nevertheless, a button
almost precisely the same shape as the one described.
Here only six sutures were required. From this cut

^ See Fig. 4, on next page.

496 suppoRTmo anb coNFiNiisra apparatus, etc

an excellent idea may be obtained of tlie adjustment
of tlie sutures previously to passing tlie button down

Fig. 4.

Fig. 4 is an illiistration of the apparatus, only a portion of the cattieter being shown.

SUPPOETING AIN^D COT^FmmO APPAKATUS, ETC. 497

upon tliem, tlie latter being represented liere on the
double ends of tlie wires, sliding down to its proper
place.

I will here cite another case, a lady of this city,
upon whom we recently operated successfully with this
form of suture, which is of unusual interest, from the
circumstances attending its history and the result ob-
tained :

Case II. — Mrs. G. ; aged 34 ; medium stature ; AveU formed ; rather
stout; nervous temperament; health to all appearances good. "While on a
visit to Long Branch, September, 1854, was taken in labor, and after five
days was delivered, without instruments, of a still-born child, said to have
weighed eighteen pounds. A vesico-vaginal fistule was the result — incon-
tinence of urine being discovered almost immediately after the completion
of labor. She states that she was not able to leave her bed for several
months, owing to a loss of power over the lower extremities.

Returning to this city, she applied to a surgeon for relief, who (January
8, 1855) performed an operation for closure of the fistule, found to be situ-
ated just across the root of the urethra, and large enough to admit two
fingers into the blctdder. The clamp suture of Dr. J. M. Sims was employed,
which was attended with only partial success, the failure being at the left
angle. Little or no benefit, however, resulted, as regarded the incon-
tinence.

September, 1858, a second operation was performed by the same surgeon,
the clamp sutm-e being employed again. A total failure resulted this time
from the suture apparatus sloughing out.

December, 1861, the same surgeon performed his third operation, using
the clamp suture again. Now union took place in the middle of the fistule,
leaving a small opening at each angle. Still the incontinence of urine con-
tinued with but little if any abatement.

February, 1868, she was admitted into the iTew York State Woman's
Hospital, and was operated upon there the fourth time by the distinguished
surgeon at the head of that institution. Now both of the smaU fistules
above described, as we are informed, were converted into one by a division
of the intervening slip of tissue. The opening thus formed was then closed
with the interrupted silver suture. The result was a total failure.

In April the same surgeon performed his second (the fifth) operation,
using again the interrupted sUver suture. Result, a partial closure, though
little or no control over the urine was aflTorded, the incontinence proving
to be about as it was after the third operation.

In September the patient was admitted into our private institution. A
fistule large enough to admit a I^o. 6 bougie was found in a mass of cica-

498 STJPPOETIXa AKD CO]STESTN-G APPAEATUS, ETC.

tricial tissue, situated just above the left angle of the original. fistule, far
to the left side. October I7th, the parts being found in a suitable condition
from our preliminary treatment, we proceeded to close the fistule with
our button suture, the patient being placed in the position previously de-
scribed, and our small-sized speculum introduced. Present, Dr. "W. O.
Baldwin, President-elect of the American Medical Association, and Drs.
Finnell, 'Sott, Sabine, Carroll, and Morton, of this city.

xVfter cutting out pretty freely the hardened tissues resulting from the
repeated operations which had been performed, we found it necessary to
introduce only three sutures, which was quickly done, and the whole
secured on our button principle. The duration of the operation did not
exceed three-quarters of an hour, including the time taken up in explaining
the several stages of the operation to the gentlemen present. The patient
was kept all the while nnder the influence of chloroform, which had a most
happy effect. As an interesting fact, we will state that this was the fifty-
second time that this patient had been anaesthetized.

l^othing unusual occurred in the after-treatment. An elastic catheter
No. 6 was kept constantly in the bladder, and the patient requu-ed to lie
upon her right side. On the eighth day we removed the suture apparatus,
and found the fistule entirely closed. After a few days the catheter was
discontinued, and the patient then, allowed to leave her bed. To her great
delight, she now found that she had entire control over her bladder, this
power having been lost upward of fourteen years. She was discharged a
few days ago, feeling perfectly sound and well.

We would remark liere that this lady, an intelli-
gent person, during her long affliction, as might be suj)-
posed, watched very closely the results of treatment in
her own case, and she indulged a peculiar fancy of
collectins: the various sutures which from time to time
were used upon her, including clamp suture, inter-
rupted silver suture, and button suture. Such a col-
lection of sutures, I venture to say, the misfortunes of
but few women have ever supplied. From the interest
therefore attached to these relics of scientific j)rogress,
the long-suffering of the patient, and the final triumph
of aii) in the case, it cannot be considered out of j)lace
here to examine critically these several surgical ap-
pliances which have been brought into such close jux-
taposition by their aj^plication to one and the same
fistulous opening.

SXTPPORTING AND CONFmmG APPARATUS, ETC. 499

The collection, as seen, we have placed upon a
piece of buckskin, so that every part of the respective
forms of sutnre can be examined in its proper relation-
ship. The first surgeon alluded to in connection with
the early history of the case performed and has seen
performed five of the six operations described, and to
him we are indebted for not only a correct and reliable
history of the case from the beginning to the end of
treatment, but the arrangement in the order of theu^
use of the various forms of suture named, which is as
follows :

1. The clamp suture, three applications — unsuc-
cessfal.

2. The interrupted silver suture, two applications
— unsuccessful.

3. The button suture, one application — cure in
eight days.

CLAMP SUTURE.

The first pair of clamps is one and five-eighths of
an inch in length, and each clamp has four holes in it,
corresponding to the four sutures used. In the piece
of buckskin I have made a slit one and one-half inches
in length, corresponding to the length of the original
fistule. To this slit or opening I have applied and
secured the same clamps just as they were used in the
case. By examination of the model, a most excellent
idea can be had of the peculiar mechanism of this form
of suture. Although great care here was taken to intro-
duce the sutures on a line equidistant from the edges
of the slit, yet there is a want of parallelism in the two
clamps. The result of which is, slight inversion near
one extremity of the line of approximation, and ever-
sion toward the other, a very common cause of failure
in the use of this suture when it was in voo^ue.

500 suppoETmo AND coNFimNa appaeatus, etc.

A view of the edges of the slit on the opposite side,
supposed to be in the Madder, will satisfy the most
casual observer, I dare say, why this form of suture was
formei'ly attended with so little success. The line
formed by the coaptated edges, as may be seen, is im-
perfect, and the latter move freely upon each other.
There is, so to speak, a rocking motion of the two
edges, and fluid at almost ever^^ point can insinuate
itself and reach the opposite side.

' Fig. 6.

Fig. 6 affords a very good idea of this form of suture, and the original size of the
• fistule.

The second pair of damps employed in the case,
as here shown, is one and one-quarter inches long, with
which three sutures were used. This operation was a
total failure, as may be inferred from the peculiar con-
dition of the clamps, which are seen to be incrusted
from one end to the other with earthy matter, a cir-
cumstance which very often caused, in this operation,
the included tissues, clamps, and sutures all to slough
out, leaving an opening two, three, and four times the
size of the original fistule.

The thvrd pair of damps employed has been lost,
which we regret very much, though, from what we can
learn, they were about the same length as the last pair
described.

lOTEERUPTED SILVEE SUTUEE.

We come now to sjDeak of the interrupted silver
suture employed in the fourth and fifth operations.

SUPPOETma AND COlSTFININa APPAEATUS, ETC. 501

The patient was not able, unfortunately, to secure the
sutures used in the first of these operations, but she
was told that nine were introduced. The number of
sutures employed in the second operation was thirteen,
seven of which are here shown, the other six having
been lost.

We have made in this same piece of buckskin a slit
an inch in length, corresponding to the size of the
fistule at the last operation, judging from the extent
of the cicatrix left. The thirteen sutures, the number
then used, we have introduced and secured in the usual
way by twisting. The twisted ends of each, half an
inch long, are turned down flat, alternately upon the
right and left. The introduction and adjustment of
these sutures will be recognized by every one as the
plan usually followed by experienced surgeons, both as
reo-ards the distance of introduction from the edo^es of
the slit and the intervals that usually separate them.
It is a principle insisted upon by the advocates of this
form of suture to introduce all the sutures as near the
edges of the fistule as possible, rarely exceeding, the
eighth of an inch. In fact, the rule is absolute, and
cannot be departed from without endangering the suc-
cess of the operation by causing inversion. Especially
is this the case when the fistule is of considerable size,
and the traction is consequently great upon the sutures.
The turning of the double ends of the wire down fiat
upon the tissues on the two sides of the line of approxi-
mation is a feeble attempt to counteract this tendency
of the edges of the fistule to invert. The mre splint
thus formed, it must be admitted, afibrds some support
and steadiness to the coaptated edges ; still it cannot
prevent their inversion, excepting in small fistules
where there is a redundancy of tissue.

o0'2 SFPPOETizs^G ANjy coNrmma appaeatus, etc.

We would direct attention now to the approximated
edges of this slit on the other side of the j)iece of buck-
skin, supposed to be the vesical side of the septum.
Here they are seen to gape from one angle to the other,
and every suture can be counted at the bottom of the
trian ovular furrow formed. Inversion of the edo:es
exists throughout, notwithstanding the extreme near-
ness to them at which the sutures are introduced
on the ojDposite side, where closure is as firm and com-
plete as it is possible to make it. The effect of this in-
verted condition of the edges is that very little over
half of the thickness of the buckskin or septum is in
contact ; the balance of the two surfaces thus separated
is exposed, as in the bladder, to the poisonous action
of the urine. Those who have had experience in such
matters need not be told how uncertain any operation
•must be with the edges of the fistule brought together
in such a relationship.

The crowding of the sutures in, as we have shown,
to prevent inversion, and to secure some steadiness and
support to the included tissues, is a practice also very
often fraught with great mischief, as adopted in large
fistules when the traction is necessarily great. The
circulation under such circumstances is liable to be in-
terrupted, and the vitality of the included tissues de-
stroyed, resulting very often in a slough and loss of
tissue, which may seriously jeopardize the success of a
subsequent operation.

BUTTON STJTUEE.

Let us next examine the button suture. Here is to
be seen a leaden plate, about one-twentieth of an inch
in thickness, one inch in length, something over half
an inch in width, formed as before described, and along
the centre three perforations or holes, a quarter of an

SUPPORTma AOT) CONFIiraG APPAEATUS, ETC. 503

incli apart. Tlie three sutures and the perforated shot
used with it are placed by its side in the collection.
The whole of the apparatus is here shown just as it
was removed from the seat of the fistule in Case II.,
on the eighth day of the operation.

Fig. 7.

Fig. 7 shows tlie inteiTupted sutnre, the number employed in the case, and the peculiar
mode of adjusting them, to secure the advantages of a wire splint.

Fig. 8 is intended to show the button suture as it was applied in the case.

Kow we have made a third slit in this same piece
of buckskin, which is precisely the same length as the
one used to illustrate the application of the thirteen
interrupted silver sutures. Here we have introduced
three sutures only, at a distance of upward of a quarter
of an inch from the cut surfaces or edges, about a quarter
of an inch apart, and have secured them with just such
a button and perforated shot as above described. The
coaptation of the edges, as shown, is smooth and per-
fect throuo-hout, notwithstandins: there are but three
sutures used, ten less than of the intermpted silver
suture. On the opposite side, supposed to be in the
bladder, the seat of the operation can scarcely be made
out. Considerable force upon the parts is even re-
quired to indicate the line at a single point fonned by
the coaptated edges, and as to motion of the tissues
included within the loops of the sutures there is none.
Perfect coaptation, steadiness, support, and protection
are afforded at all points. The edges here, instead of
being inverted, as shown in the application of the in-
terrupted silver suture, are turned away from the

Fig. 8.

504 SFPPOKTING Amy COUfFimNG APPARATUS, ETC.

bladder, as indicated on this side of the septum, by a
depression at tlie seat of operation. In this position
and relationship they are maintained throughout the
reparative process.

The difference between the princij)le and mechanism
of the button and interrupted silver sutures may be
briefly summed up as follows :

BUTTON SUTUEE. IXTEEErPTED SILTEE SUTrEE.

1. Large wire, No. 26. 1. Small wire, Nos. 28 and 29.

2. Three to five sutures to tlie 2. Five to twelve sutures to the
inch. inch.

3. Sutures introduced from a quar- 3. Sutures introduced from a slx-
ter to half an inch from the edges of teenth to an eighth of an inch from
the fistule. the edges of the fistule.

4. Sutures secured with a leaden 4. Sutures secured hj twisting
plate and perforated shot. and turning their ends down flat to

form a wire splint.

5. Sutures not exposed In the 5. Sutures all exposed in the blad-
hladder. der by gaping of the edges- of the

fistule.

6. Edges of the fistule turned out, 6. Edges of the fistule turned in,
and controlled in that relationship. and not controlled.

7. Perfect steadiness and support 7. Little or no steadiness of the
of the approximated edges of the fis- approximated edges of the fistule.
tule.

8. Protection of the denuded edges 8. ISTo protection of the denuded
of the fistule from irritating dis- edges of the fistule.

charges,

9. The apparatus easily and quick- 9. The sutures troublesome and
ly removed. tedious to remove.

10. Operation as certain in large 10. Operation has but little cer-
fistules as in small ones. tainty in lai-ge fistules, success de-
pending on frequent repetitions.

These are the essential differences in the above two
forms of suture which, in general practice, have been
repeatedly demonstrated and proven, not only in the
same class of cases, but upon the same fistulous open-
ings— the most practical and conclusive test to which
any operative procedure could jDossibly be subjected,
as all must admit. And the result of no operation,
under whatever circumstances performed, can be so
well seen and noted as that of vesico-vaginal fistule.

SUPPOETIT^G AND CONFINING APPAEATUS, ETC. 505

In tlais manner were proven, some years ago, tlie
many faults of tlie old clamp suture whicli we liave
here described. One of several cases, in whicli both
this and the button suture were successively applied,
we will mention. In this case, during a j)rotracted
course of treatment of three or four years, the former
suture was applied by Dr. Sims himself twelve or
fifteen times without success.' With the button su-
ture, the two fistules that remained were closed each in
eight days with the result of a jDcrfect cure, and we
have not the slightest doubt, from our somewhat ex-
tensive experience since, that in the second case here
cited the same result could have been secured in the
outset of the treatment by the latter form of suture.

The ultimate and complete success with this suture
in the case may be attributed by some to advantages
gained by previous operations in diminishing the size
of the fistule, but such an explanation is without foun-
dation, and can result only from a want of experience
or familiarity with the principle of the operation.
According to the facts stated, at the time of the fifth
and sixth, the last two operations, the fistule was about
the same size, but how different were the results !

The final operation, we are warranted in saying,
would have been easier and just as certain had the fis-
tule been of its original size and condition, admitting
readily as it did two fingers into the bladder. As we
found it, there was an obstacle to contend with not
present at the beginning of the treatment,, which now
seriously militated against success, namely, cicatricial
hardening of the tissues from repeated operations.
This feature of the case is of im^Dortance, and should
not be lost sight of in the estimate of the final result.

See Louisville (Ky.) Revww, May, 1856, Case IV.

506 SUPPOETING AND COOTimNa APPAEATUS, ETC.

As to the size of any fistule, provided the edges are
movable, it is a matter of no consideration — the opera-
tion with this form of suture being just as certain when
large as when small. Case I. affords the strongest
proof of the fact. Here the fistulous opening was
large enough to admit three fingers, instead of two, as
in Case II., and yet in the former case the operation re-
quiring seven sutures was just as successful and satis-
factory as in the latter, where only three sutures were
called for. This, we may add, is an important and
distinguishing peculiarity of this button suture, and
explains why the percentage of successful operations
in a given number of cases does and will exceed that
of all other known methods.

In speaking here of the results of these practical
tests in the same cases, we wish it understood that no
disparagement is meant to the skill of the several sur-
geons who preceded us. The entire competency of all
of them to secure the greatest amount of attainable
success with their favorite forms of suture is admitted,
and we cheerfully accord to them as much judgment
in the operation as we have, or any other surgeon or
surgeons. The difference in the results of practice
shown is to be found in the methods of operating, not
in the superior skill of one surgeon over another.

The mode adopted of presenting the subject is
intended to get at facts, and facts only, regarding the
respective merits of the several forms of suture de-
scribed. We think the importance of the subject
warrants it, and, if there is a difference in the results
and practice favorable to one or the other, the profes-
sion should know it.

What we wish is a fair and honest report of cases
and results of operations of whatever form of suture

PKOCEEDINGS OF SOCIETIES.

507

adopted. Facts will speak for tLemselves, and, wlien
well authenticated, even one, to tlie practical mind, is
worth a thousand opinions or assertions of any one, it
matters not who he may be, or w^hat are his oppor-
tunities and advantages.

|Pr0mbmgs of S>atuim.

MEDICAL SOCIETY OF THE COUNTY OF ^E^Y YORK.
Stated Meeting, January 4c, 1869.
Dr. Geo. T. Elliot, President, in the chair.

Aftee the reading of the Secretary's minutes, the President
announced that, at the last meeting of the Comitia Minora, it
was voted to grant certificates of membership to Drs. A. H.
Smith, J. G. !N^ott, and Joseph Kammerer.

The reports of the various committees were then presented,
after which the paper of the evening was read, by Prof. Wm.
A. Hammond, M. D., on the " Physiology and Pathology of
the Cerebellum."

(As this paper will be published in full in the forthcoming number of
the Psychological Journal^ we present here only the points which, in the
author's opinion, may be accepted as established in the present state of our
knowledge.)

1. The cerebellum, contrary to Gall's theory, exercises no
special or exclusive influence over the generative organs. For,
although it sometimes happens that injmy or disease of this
organ produces aberration of the sexual impulse, the relation
exists with other parts of the brain and with the spinal cord.

2. It has no special or exclusive power to coordinate the
muscular actions, and this proposition is supported by the fol-
lowing facts :

a. The consequences of removal of the cerebellum, if the
animal survives the immediate effects of the operation, are not
enduring.

1). The entire removal of the organ from some animals does
not apparently interfere in the slightest degree, even for a mo-
ment, with the regularity and order of their movements.

508

PEOCEEDINGS OF SOCIETIES.

G. The disorder of moyement which results in birds and
mammals, immediately after injury of the cerebellum, is not
due to any loss of coordinating power, but is the result of ver-
tigo.

d. The phenomena of cerebellar disease, or injury, as ex-
hibited in man, are not such as show any derangement of the '
coordinating power.

e. In those diseases, such as locomotor ataxia and aphasia,
of which the chief phenomena relate to derangement of the
coordinating power, the lesion is not in the cerebellum, and
the symptoms are altogether different from those which are
due to cerebellar disease or injury.

These several propositions were supported at length by ar-
guments drawn from experiments and pathology.

Prof J. 0. Dalton expressed his warm admiration of the
paper just read ; briefly alluded to the several theories it had
reviewed, as showing the intrinsic difficulty of the subject ;
and suggested some general reasons for their successive rise
and fall. He spoke of the light we should naturally expect
to find thrown upon a problem of this kind by comparative
anatomy ; and of the false coloring it was liable to give, unless
we adopted the most careful precautions. Among these were
two especially important :

1. In comparing the sizes of a given ganglion in different
animals, we must consider not only its absolute size, and its
size with reference to that of the animal, but also the propor-
tion it bears to the rest of the brain.

2. We must compare animals not too widely apart in the
scale, if we would reach trustworthy conclusions. Suppose,
for instance, that, to test the theory of the coordinative power
of the cerebellum, we were to compare the cod and the por-
poise. They are of equal size, live in the same waters, have
similar habits, have swimming movements almost precisely
alike, differing only in direction. We might expect, on our
theory, to find the cerebellum of the same size in each. But
the one is a fish, the other a mammalian, and we should find
the former with a much smaller cerebellum, and also with the
whole brain much smaller. Compare, on the other hand, the
dog and the cat. They are as similar in their general habits

PEOCEEDmGS OF SOCIETIES.

509

as were the animals just now considered. Their intelligence
is about equal, and their brains, as a whole, are about equally
developed. But the cat is far more varied and delicate, and
fastidious in her movements; and her cerebellum shows a
much greater proportionate size.

The speaker thought that, on the whole, the results of com-
parative study and of experiments made it probable that the
theory, that the cerebellum is the muscular coordinator, is
substantially correct, though perhaps requiring some degree
of modification. The objection, that the disordered movements
consequent upon removal of a large part of the cerebellum
soon give place (where the animal lives) to regularly cooordi-
nated ones, was to be met by supposing that the cerebellum,
like other parts of the brain and other organs of the body,
would bear the loss of a certain amount of its tissue ; and that
the paralysis of function at first observed was due to shock of
the organ as a whole.

A very striking and important part of the paper was that
discriminating between vertigo and the loss of the power of
coordination. The term vertigo should include in its defini-
tion the loss of power to estimate distances and positions.
The distinction Dr. Hammond had drawn wuuld probably be
of great service in clearing up the subject. Possibly the cere-
bellum might preside over the function of locating external
objects, and owe to this its influence npon coordination.

Prof. Austin Flint, Jr., after characterizing the paper as
the most complete exposition and the fairest discussion of the
facts bearing on the question which had yet appeared, said
that he would glance at two or three of the topics from a dif-
ferent point of view.

The value of the experiments, in which a definite part of
the cerebellum was supposed to be removed, was much dimin-
ished (except in cases where the supposition was verified by
post-mortem\ by the great difficulties of the operation, when
performed upon birds ; and by the lower organization of the
animals when performed upon reptiles, to which we had al-
ways to have recourse, if we would remove the whole gan-
glion. The chief difficulties were the excessive hsemorrhage
encountered and the risk of touching the medulla oblongata.

510

PEOCEEDmGS OF SOCIETIES.

rendering it impossible to estimate just liow mncli of the organ
one had excised. In experimenting upon reptiles, the dis-
crimination between purely reflex motions and those due to
voluntary action, was a matter of the greatest moment. Among
the former might justly be classed many, which, to a casual
observer, would seem to indicate special coordinative action.
An essential point, in all experiments on the nervous system,
was to use no anaesthetic.

Accepting the coordinative function of the cerebellum, Dr.
Flint explained its return after lesion to the organ substan-
tially as Dr. Dalton had done. He illustrated, by reference to
the kidneys, the fact that [N'atm'e provides for all important
functions an excess of apparatus over ordinary needs. A man
may live in health for years with one kidney completely dis-
organized. Dogs show no sign of suffering from the removal
of one kidney, unless something chances to derange the func-
tion of the remaining one, when they die of uraemia. So when
cerebellar disease is slow in its progress, exciting no disturb-
ance of the uninvaded portion of the ganglion, we may have
no symptoms until the disorganization has progressed so far as
to leave an insufficient portion of the organ to meet the func-
tional demands. This explained, in accordance with the coor-
dinative theory, some cases that might otherwise seem to mili-
tate strongly against it. The case that had been cited of the girl,
who lived to be eleven years old, and yet was congenitally
destitute of a cerebellum, presented more difficulty. But per-
haps the coordinative power might 'have its place partially
supplied by some other associated but not identical power ;
just as, in persons blind from birth, we find the touch and the
special senses miraculously acute, and doing much to compen-
sate for the lack of sight, though of course unable to give the
faintest conception of vision.

Dr. Flint concluded that the view advanced in the paper,
that the cerebellum was simply a supplementary ganglion, in-
tended to reenforce the other parts of the brain, could not be
sustained. It had a function of its own, and that function had
some connection with muscular movement.

REVIEWS.

511

I. — TJie Diagnosis^ Pathology^ and Treatment of Diseases

of Women, including the Diagnosis of Pregnancy. By
G-RAiLEY Hewitt, M. D., Lond., F. K. C. P., Professor of
Midwifery and Diseases of Women, University College, and
Obstetric Physician to the Hospital, etc., etc. First Ameri-
can (from the second London) edition ; revised and enlarged.
With one hundred and sixteen Illustrations. Philadelphia :
Lindsay & Blakiston. 1868. 8vo. Pp. 707.

II. — A Practical Treatise on the Diseases of Women.
By T. Gaillaed Thomas, M. D., Professor of Obstetrics
and the Diseases of Women and Children in the College of
Physicians and Surgeons, IS^ew York, Physician to Bellevue
Hospital, etc., etc. Philadelphia : Hemy C. Lea. 1868.
8vo. Pp. 625.

III. — The Diseases peculiar to Women, including Displace-
ments of the Uterus. By Hugh L. Hodge, M. D., Emeri-
tus Professor of Obstetrics, and the Diseases of Women
and Children, in the University of Pennsylvania. With
Hlustrations. Second edition ; revised and enlarged. Phil-
adelphia : Henry C. Lea. 1868. 8vo. Pp. 531.

lY. — A Handhooh of Uterine Therapeutics, and of the Dis-
eases of Women. By Edwakd John Tilt, M. D., Member
of the Poyal College of Physicians, Consulting Physician
to the Farringdon General Dispensary, etc., etc. Second
American edition ; thoroughly revised and amended. ^sTew
York : D. Appleton & Co. 1869. 8vo. Pp. 345.

I. The diagnosis of the diseases of women was the main
purpose of the fii'st edition (1863) of Dr. Grailey Hewitt's
work ; pathogeny and treatment were secondary and digres-
sive, and hence got but scanty notice. The present edition
has, in some measure, been recast, and large useful additions
have been made to the chapters on Pathology and Therapeu
tics, and they are now quite satisfactory. The disadvantages
of a faulty arrangement are, however, as prominent as before,
making repetition unavoidable, and obliging the reader to re-

512

EEYIEWS.

fer back and forth to fill in the subject. Dr. Hewitt's style
is neither elegant nor idiomatic, but it is plain, direct, and
readable ; and both as a writer and an observer he is conscien-
tious, painstaking, and practical. The number and good
quality of the original illustrations in this volume are note-
worthy ; there are over sixty, and the greater jiart are care
fully-planned representations of cases which have been under
the author's observation ; they were first drawn in outline,
life gize, by himself, and afterward reduced by the camera ;
they embody the results obtained by examination of the case
while under treatment. By these means an exact idea of the
size and relations of certain pelvic tumors is attempted to
be given by two sectional views of the same one, and often
quite happily.

Part I. treats of diagnosis, the first section giving the data
obtained without physical examination, and the second the
data obtainable with physical examination. The former in-
cludes menstrual derangements, haemorrhages, and substances
expelled from the generative organs, non-sanguineous dis-
charges, disorders of micturition, symptoms referable to the
rectum, abnormal sensations referable to the sexual organs, etc.
In the latter the several ways of physical exploration, the in-
struments to be used, and the parts and conditions to be noted,
are described. In this section the chapters on the examination
of the abdomen are particularly full, clear, and good. To our
mind it is the most valuable part of the book, and well worth
careful study.

Pathology and Therapeutics occupy Part II. In treating
of the disorders of the womb and its appendages. Dr. Hewitt
shows an acquaintance with, and an intelligent appreciation
of, what has been done by others, and large and cultivated
personal observation. He is a sensible practitioner, and under-
stands the laws of life, and therefore owns the importance of
the body as a whole, and the need of keeping up general vital-
ity even when disease seems to be most local. If in his thera-
peutics there is nothing strikingly new, there is much that is
discreet, and little countenance is given to methods and reme-
dies of doubtful character. It is often as important to know
what to avoid and when not to do, as it is what to use and

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513

when to meddle. We could wish that some of the chapters of
this part had been fuller, and that on some points more decided
lan2:iiao:e had been held.

In a supplementary chapter Sterility is considered, though
much on this subject had been anticipated in the body of the
work, when speaking of the mechanical treatment of dysmen-
orrhoea, vaginismus, leucorrhoea, etc.

"We rate Dr. Hewitt's book as one of worth. It will b6
particularly useful to those wlio value accurate and discrimi-
nating diagnosis, and clear and careful investigation of symp-
toms.

II. — Circumstances beyond our control have made us re-
gretfully put off the publication of this notice of Dr. Thomas's
Practical Treatise until now. The penalty is that we miss the
pleasure and credit of having foretold its success. The voice
of the profession has justly established it where the praise or
blame of the reviewer can be of small avail. In this volume
the whole subject of diseases of women is gone over with sur-
prising thoroughness and ability, and we know of no work, of
the same scope and character, of which a first edition is so free
of shortcomings as this. A marked feature is the orderly ar-
rangement and excellent proportion of the vast material the
author had to handle : this has been done in a business-like
way and with rare discretion ; each subject has its due allot-
ment, and the author has been but seldom tempted to indulge
a preference, or sb'ght an ungenial theme. The work is singu-
larly compact as well as comprehensive, and while conspicuous
for its completeness, it is free, both in its parts and as a whole,
from diffuse abundance. That there should be deficiencies
and blemishes is in the nature of things ; but many of these are
of a kind which, while they do not greatly affect the present
value of the book, will most likely be lessened or abated in
after editions ; others belong to the very design of the author,
which is, to set forth the " latest aspect " of gynecology. In
doing this. Dr. Thomas has shown much book-study, and fair
dealing with the views of others, and has well utilized a large
and mature clinical experience. We would prefer at times
more individualism, less listing of the views of others, and

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greater generalization of the author's own experience. We
venture this remark, because we think that, while his reserve
shows a modesty which may raise our respect, it is to the cost
of a class of readers for whom this text-book was written,
who need the guiding hand of the master, and a certain tone
of positiveness, when brought to face the conflict of opinions
too often found among those who are looked upon as author-
ities.

We might wish, too, that the student and young practi-
tioner had been warned against, the extreme surgical tendency
of the writings of some of the gynecologists of the hour ; the
doubtful usefulness and great risk of many of the proposed
operations pointed out ; and the conditions, which warrant a
resort to them, clearly set forth.

The portions of the work treating of pathogeny are the
least satisfying, and are hardly abreast with the doctrines of the
day. French pathological husks have of late fallen into such
just discredit, that we regret to find them still disfiguring the
study of womb disorders.

Dr. Thomas's first chapter is a rather sketchy historical ac-
count of uterine pathology ; indeed throughout the volume he
constantly " makes former times shake hands with latter," by
well-timed references to the authors of the Grreek and Eoman
schools. Justice has hardly been done to the English writers
of the beginning of the century, to whom we really owe so
much ; it has been truly said, " The key-note of the only true
and scientific method of investigating uterine diseases has in
reality been struck in the admirable works of Clarke and
Gooch." The Germans are passed over in silence, and among
our countrymen the honored names of Dewees, Hodge, and
M.Qig^,j[)rwfidgebant . ..eo magis quod illomcm effigies non vide-
hantur. There are those who, by dash and "go," slide to the
forefront, and win golden opinions of the many; but their
hold is unsure and their glory brittle ; such do little in the
main for science or art : right direction in both is most often
given by the patient search of quiet thinkers and earnest
workers.

Chapter II., on the Etiology of Uterine Diseases in Amer-
ica, is highly practical and merits attention ; it will be read

EEVIEWS.

515

with interest and profit. Diagnosis of the Diseases of the Fe-
male Genital Organs is the subject of the third chapter, which
is thoroughly good. Every thing needful is fully, concisely,
and intelligibly told. Of one of the chief causes of faulty
diagnosis Dr. Thomas says :

The source of difficulty is almost always the same. The failure has
not been due to having drawn incorrect conclusions from the means, but
to not having brought these means fully into action, and properly applied
them to the solution of the case in hand. In many instances uterine dis-
ease being suspected, the physician employs the vaginal touch, and follows
it by the speculum. If the os and cervix be diseased, he is successful in
diagnosis ; but, if not, be becomes discouraged, forgetful of the fact tbat the
rectal touch, uterine probe, dilatation by tents, conjoined with manipula-
tion and other means, should be resorted to, and that, without appealing
to these, even the most skilful diagnostician would be as helpless as him-
self. There are means at our command for exploring every tissue within
the pelvis, the uterus, the ovaries, the areolar tissue, etc. ; and, until they
are brought into service carefully, systematically, and thoroughly, no one
can feel that he has done justice to his powders of diagnosis, or allowed
himself full opportunity for drawing correct conclusions (p. 62). '

The importance, nay the necessity, of the principle of peri-
neal retraction, by which the atmosphere becomes the dilating
factor, in ocular examination, is insisted on, and' the imperfect
results got by the specula in common use are pointed out.
" 'No one," he writes, " who has not tested the two methods
of examination is really entitled to an opinion upon the point,
and I cannot doubt the conclusion of him who has done so
faithfully and intelligently."

In the fourth chapter Diseases of the Vulva are considered,
and at the end Coccyodynia is treated of. We must demur to
the recommendation to have speedy recourse to " one of the
radical methods of cure " proposed by Sir James Simpson for
this affection. It is often, we suspect, a reflected symptom of
uterine disorder, and disappears when this is relieved. Lusch-
ka, however, has lately asserted, that the small aciniform body
in the posterior part of the ano-perineal region, which he dis-
covered in 1859, a.nd described under the name of Steissdruse^
or the coccygeal gland, and as an adenoid appendage to the
nervous system, resembling the pituitary body in the cranial
cavity, is the seat of cocygodinia (Yirchow's Archiv f. Path,

516

EEVIEWS.

Anat. und Pliys.^ Bel. xviii., 1860 ; Anat. cles Menschen^ Bd.
ii., p. 187)/ If this prove true, the removal or destruction of
the so-called gland would be the proper cure of this painful
affection.

Eupture of the Perinseum is the subject of Chapter Y.
Yaginismus follows, and Dr. Thomas, speaking of Burns's op-
eration, and the American modification of it, says "it is at
present regarded as the only reliable method of cure ; " and
yet Scanzoni has recorded one hundred cases successfully re-
lieved without resorting to it. We saw a year ago a horrible
instance of mutilation in a young married woman, the result
of the revival of this operation. We believe that it is rarely,
if ever, justifiable.

Lack of space will hinder us from giving even an abstract
of the contents of this volume, and we must limit ourselves to
a brief notice of two or three subjects. Yesico-vaginal Fistula
is well handled in a few pages, but we were surprised to find,
in an article which generally shows such correct and thorough
knowledge, no mention of Dr. G. Simon, of Rostock (now of
Heidelberg), who has operated more frequently and with
larger success than any other European sm-geon, and has done
so much to put the oj^eration on a true scientific basis.

Six chapters are devoted to the important and vexed ques-
tion of the inflammatory affections of the uterus. Dr. Thomas
begins his general remarks with the following sentences :

He who desires to becorae conversant with the diseases of women, to
fiQly comprehend their pathology, and to be successfal in their treatment,
will do well to make the thorough understanding of inflammation of the
non-pregnant uterus the basis of his education in this department of medi-
cine. It is true that many diseased states of tlie pelvic viscera of the fe-
male are due to other causes, but it is not less true that the majority either

^ After Luschka, Krause {Zeitschrift f. Eat. Med., Bd. x., H. 2), Heschl
{(Est. Zeit.f. Prat. Heil., No. 14, 1860), Henle {Jahresbericht, 1860), and
Kolliker {Gewebelehre., 4 Auf., H. 2, § 539), have described it; and, within
the last three years, Julius Arnold, of Heidelberg, and G. Meyer, of Got-
tingen, have given full accounts of its structure and probable aflSnities.
Dr. Alexander Macalister, Demonstrator of Anatomy, Eoyal College of
Surgeons, Ireland, has published {Brit. Med. Jour., No. 367, 1868) a very
minute account of this body. He is disposed to think that it is not only a
small rete mirabile, but likewise the centre of nerve-power, or a terminal
sympathetic ganglion. It has nothing in common with secretory glands,
as its closed follicles are certainly vascular and not truly adenoid, and Dr.
Macalister proposes to call it glomerulus arterio-coccydeus.

EEVIEWS.

517

take theii* rise in this, or in their progress become complicated by it, so
that it forces itself constantly upon the notice of the gynecologist as the
keystone of the arch upon which rest his knowledge and usefulness. These
facts were, to a certain extent, recognized by the physicians of the Grecian
and Roman schools, but, judging from those of their works which have
reached us, their appreciation did not compare in thoroughness with that
of our century. After the revival of letters, the importance of the patho-
logical view, which gave to metritis such prominence and moment, was
almost entirely lost sight of until the beginning of the nineteenth century,
when Recamier and Lisfranc reinstated it. It has been already stated that
to Dr. J. H. Bennet [Henry Beunet?] we owe its dissemination not only
in his country but throughout America (p. 189).

We have here the key-note to all which follows in the
ample chapters on Acute Endometritis, Acute Metritis, Chron-
ic Cervical Metritis, Chronic Cervical Endometritis, Chronic
Corporeal Endometritis, and Chronic Corporeal Metritis.

Dr. Thomas is of the strictest sect of the French school, and
the exposition of his views on uterine inflammation, temperate
but decided, has a strong Gallic flavor. We cannot quite go
along with him. l^ames, however faulty, become a necessity for
want of better ones, and from inconvenience of change, and
may or may not convey a true idea of the nature of the dis-
order to which they are attached, and hence are compara-
tively unimportant ; but a pathogenic theory of precise pur-
pose will, if faulty, work much mischief to medicine as a
practical art. We have no room and little mind to discuss at
this time the part of inflammation in womb disorders ; the
few words we will say shall be limited to the subject of
chronic metritis. If by this term it is intended to express the
equivalent of what is commonly implied by the inflammatory
processus, there are good grounds to doubt its accuracy ; if
used in an arbitrary sense, to express those tissue-changes
which follow derangements of nutrition, the result of an irrita-
ment, it will serve as well as another, so long as it is not mis-
leading. Lisfranc has been saddled with a large share of re-
sponsibility for the doctrine of the overwhelming influence of '
inflammation in uterine disease. If we rightly understood his
teachings, he never went so far ; by the word engorgement^ he
meant something more than congestion^ and less than inflam-
mation^ as expressions of condition. Kead by the light of later

518

EEVIEWS.

pathological dogmas, he would not be found much astray.
But his pupils bettered their instructions, urging them beyond
reasonableness and the intention of the master. Their ex-
tra vao^ances and onesided ness are not a natural outcome from
his precepts. To them, metritis and its whole gamut seem to
be as necessary and comforting as the blessed word Meso-
potamia was to the pious old woman, and with as much un-
derstanding of its meaning. The entity inflammation, fallen
from its high and palmy state, is hanging by its eyelids as a
pathogenic factor in most of the organs of the body ; its last
resting-place seems to be the womb, and here still it has a
good foothold. Why should uterine pathology alone be cum-
bered by an outworn theory ?

We cannot but believe that the time is not far off when
this vexed, but important, question will be reopened, and
examined in a fair-judging, and not peremptory and dogmatic,
spirit, uninfluenced by prejudice, prescription, or tradition ;
and that, measured by a new standard, and settled by the re-
quirements of a more enlightened knowledge of the laws of
life, present differences will be reconciled, hostile opinions con-
ciliated, and the angry voice of adverse factions be heard
" not any more forever." The reproach is often made that
timid thinkers find safety in what Bacon called " middle
principles ; " but we suspect they come across a goodly amount
of truth in their refuge.

" Virtus est medium vitiorum, et utrimque reductum."

Scanzoni, who has written an excellent monograph on
Chronic Metritis (1863), embodying much observation and ex-
perience, and which has been overlooked by Dr. Thomas,
says : " There are a great number of cases where not only
there is no inflammation at the beginning, but where even
its existence cannot be suspected. On the contrary, we may
afiirm with certainty what are the causes which have pro-
voked the chronic hypersemia and the consequent anatomical
changes ; and yet, in such, induration of the uterine tissue, of
more or less extent, is noticed. These cases often present
great difficulties in their etiological explanation, for we cannot
admit 'an inflammatory beginning. It is possible that, in these.

EEVIEWS.

519

instances of really passive lijpersemia, an exudative processus
may intercur occasionally, but we cannot prove it. Supposing
even tliatit were demonstrable, it would not on tliat account be
an essential condition for the explanation of the various lesions
of nutrition heretofore described." — {Die Chronische Metri-
tis^ p. 43.) And he concludes his chapter on the pathology of
the disorder in this wise : " The term chronic metritis is not
strictly proper in all cases to which the name has been given.
Many even of the engorgements of the womb (gebarmutter
anschwellungen) have nothing of inflammation in the exact
sense of the word; they are nutrition troubles (nutritions
storungen), just as we see them happen in other organs after
long-continued hypergemia " (1. c. p. 43).

Of the treatment of chronic metritis Dr. Thomas is not
very consoling. He says :

No one in the present state of uterine pathology and therapeutics
can write very positively on this subject, for it really constitutes one of
the opprobria of gynecology. The rules laid down for the treatment of
parenchymatous disease below the os internum will disappoint us here.
We cannot, from the same means, expect the same flattering results. . .
Unfortunately, in corporeal inflammation they often all fail to accomplish
a good result. Nevertheless, since some cases are relieved by them, and
a smaller number cured, it is our duty to essay them cautiously — so cau-
tiously as to feel assured that, if we accomplish no good, at least we shall
do no evil (p. 256).

This confession of judgment reminds us of Gil Bias's con-
versation with his master during the fever at Yalladolid:
" Sir," said I one evening to Dr. Sangrado, " I take heaven to
witness that I followed your method with the utmost exact-
ness, yet, nevertheless, every one of my patients leave me in
the lurch. It looks as if they took a pleasure to bring our
practice to grief." " I have not often," replied the doctor,
" the satisfaction of curing those who fall into my hands ; and
if I were not as sure of my principles as I am, I should begin
to believe them contrary to the disorders I treat." " If you
•take my advice," I said, " we will change our method ; the
worst that can happen will be that we shall be no worse off."
" I would willingly," answered Doctor Sangrado, " make the
experiment, but I have published a book, and would you have
me discredit my own work ? "

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■ "Wlien we reflect tliat every ailment whicli can afflict
woman has been referred to some form of uterine inflamma-
tion, our author's language is not encouraging to the fair
sufferers, nor flattering to our art ; but we would fain be-
lieve that it is less hopeful than it might be. When tissue-
changes happen in any organ to the degree so frequently met
with in those long-lasting disorders which collectively go
under the name of chronic metritis, a return to health is
tedious and often incomplete. Yet we believe, as we shall
come more generally to look upon this class of womb troubles
as we do upon like textural alterations in other organs, our diffi-
culties will lessen, and failure will be the exception and suc-
cess the rule. With a truer pathology and more rational
therapeutics, there will be less trust in local means, and larger
faith in constitutional treatment. Strong testimony in behalf
of these views has been lately given by Dr. Henry Bennet,
the chief British apostle of the inflammatory theory. At a
meeting of the Obstetrical Society of London, October 7,
1868, he said : " He was profoundly convinced, that the real
benefit to be derived from the treatment of uterine diseases
generally was oftener prospective than present. For his own
part, he looked for the real result six months, a year, or more,
after the entire cessation of treatment. , . . Once treat-
ment ended, he usually placed his patients under a good home
hygiene system, including cold-water uterine douches, and then,
if the patient be really free from inflammation. Nature un-
aided generally does the rest, fines down hypertrophied tissues,
a/thd restores the uterus to its natural sizeP — (The Lancet,
October 24, 1868.) We have strong hopes for the phlogistic
school ; Dr. Bennet has made a long stride toward truth.

If space allowed it, we should be glad to follow the author
through the volume, but we can only briefly enumerate some
of the remaining chapters. In treating of uterine displace-
ments, no mention is made of a purely mechanical variety
of prolapsus which happens in women past child-bearing age,
and is due to absorption of the fat, and the atrophy of the
other tissues, which pad the pelvis and helj? to keep the womb
in place; a form to which Dr. Barnes particularly has di-
rected attention, and names prolapsus from senile atrophy.

REVIEWS.

521

Dr. Thomas, speaking of the radical cure of procidentia uteri
by surgical means, says " the operation has been known and
practised for a long time on the continent of Europe, es-
pecially in Germany," but he does not distinguish between
Elytroraphy or Kolporaphy, in which an attempt is made
to narrow the vagina, and Episioraphy, or closure of the ex-
ternal labia. The first notice that we find of Kolporaphy
Qcolpos, vagina, and raj^he, suture) is in the feuiUeton of the
Gazette Medicale^ January 8, 1831, in a letter from Berlin.
Speaking of Dieffenbach, the writer says : II a le j^i'emier
gueri les prolapsus de I'uterus au moyen de I'excision d'une
partie de la eirconference du vagin. La cicatrice qui se forme
retrecissant le diametre du vagin ne permet plus la sortie de
I'uterus. La meme operation a ete executee avec succes pour
le prolapsus du rectum." Here we have the so-called Ameri-
can operations for cystocele and rectocele. In 1836, Diefi'en-
bach, in a paper published in the Medicin. Zeitung^ ^N'o. 31,
1836 {American Journal of Medical Sciences^ August, 1837,
p. 509), states, that besides several cases of prolapsus associated
with sloughing of the vagina, in six of which there were radi-
cal cures following cicatrization, he had frequently performed
the operation of dissecting away strips of the mucous mem-
brane of the vagina, and bringing the parts together by suture.
Some of Dieffenbach's operations must have been done, then,
as early as 1830. In IS'ovember 26, 1831, the late Dr. Mar-
shall Hall published a case of procidentia uteri which had
been operated successfully on by Mr. Heming, of Kentish-town,
by a new method suggested by him to the operator. After
the womb had been pressed down by the patient, a strip of the
vaginal mucous membrane, two and a half inches wide, was
removed from the neck of the womb to the outlet, on the
anterior face ; a stitch was put in through both edges of the
wound, near the neck of the womb, the womb itself returned,
and the threads tied firmly {Medical Gazette^ vol. ix., 1831).
On the 24th of November, 1833, Mr. Ireland, of Dublin, op-
erated on a case by a modification of Hall and Heming's
method. He made parallel incisions on the sides of the va-
gina, to avoid the bladder and rectum, and which converged
at their extremities. He applied all his sutures before retm-n-

522

EEVIEWS.

ing the womb {Dublin Journal of Med. and Cliem. Science^
vol. vi., p. 484, 1834). In August, 1835, Yelpeauand A. Be-
rard presented to the Academie Royale de Medecine a case
each of procidentia uteri on which they had operated by Ire-
land's method somewhat modified. Yelpeau describes his op-
eration as follows : " Trois lambeaux etaient enleves de la mu-
queuse du vagin — un anterieur, et deux lateraux — chacun large
de dix lignes ; chaque lambeau etait pris de partir de la vulve
et eu deux et demie pouces de long." The ligatures were
inserted by both operators before the womb was put back.
Yelpeau's patient was fifty years of age ; nothing imtoward
followed in either case, and the haemorrhage at the time was
slight. — {Gaz. Med. 1835 ; Archives Gen. de Medecine^ 2ieme
serie, t. viii.) On the 25th August of the same year, Dr.
Gerardin, of Metz, sent a communication to the Academie,
in which he claims that, in a paper read before the medical
society of his town, in 1822, he had proposed, in cases of pro-
cidentia uteri, to contract the vagina, or in women who had
ceased to menstruate to obliterate it, by the removal of a zone of
the mucous membrane of the vagina around the prolapsed tu-
mor. He does not assert that he had even operated ; indeed,
he owns frankly that by his reclamation : "Ha voulu assurer
a I'operation son origine, et maintenir a la chirurgie frangaise la
priorite de I'invention si non celle de I'execution." {Gaz. Med.^
1835, p. 558.) This charming reminds us of Lamartine's

patriotic egotism, in his assertion that, when God has a new
idea to give to the world he always puts it in the head of a
Frenchman. Tanchou claims to have done the operation, but
kept it a secret until after the publication of Heming's case,
when he put in his claim to priority. The late Dr. Laugier, in
1833, cauterized the vagina in prolapsus with the acid nitrate
of mercury, and the white iron, with a view of causing its nar-
rowing ; and in his communication to the Academie de Mede-
cine, August 25, 1835, states that he had then in the Hopital
ITecker a patient recently cured by that method. Dr. Evory
Kennedy, of Dublin, in a letter to Sir Benjamin Brodie (Tlie
Lancet^ June 8, 1839), mentions having treated many cases of
falling of the womb successfully by the actual cautery at a
white heat. He applied it high up, taking in more or less of

EEVIEWS.

523

the circumference of tlie canal, and producing an eschar vary-
ing in extent, according to the degree of relaxation. He had
used acids and caustics, but found them inferior to the iron at
a white heat. Mr. A. Colles at the same time was using the
cautery, but he made a ring-eschar high up in the vagina.
Dr. Kennedy gives no dates. Mr. Benjamin Phillips, in the
winter of 1837, used fuming nitric acid in a case of proci-
dentia, brushing it over a large surface of the vagina with a
camel's-hair brush. The pain was not severe nor long con-
tinued. The whole thickness of the mucous tissue sloughed,
and there was a granulating surface. At the end of a month
there was no sensible improvement, but, from that time, the
disposition to displacement gradually lessened and then ceased.
On examination, two years afterward, the capacity of the va-
gina was found materially smaller — reduced to the size of that
of a woman who had not borne children. — (The Medical Ga-
zette, June, 1839.)

Such were the several means that had been employed to
radically cure procidentia uteri, by narrowing the vagina by
means of cicatricial contraction, when Dr. Marion Sims first
operated, in 1856. His method and Dr. Emmett's modifica-
tions of it are minutely described by Dr. Thomas. It may be
very naturally asked what are the merits of the principle, and
what has been the real success of tlie operation. When re-
vived by Dr. Sims, it had fallen into disuse in Europe. The
cases of Yelpeau and Berard, although at first promising,
turned out failures. Of the three cases of the latter, in one
the prolapsus returned in twenty days ; in another, two opera-
tions were done, and both were unsuccessful ; the third, exhib-
ited to the Academic de Medecine, in June, 1835, as a ' plein
succes,' was reported in August of the same year to be unre-
lieved. Scanzoni performed kolporaphy, after Ireland's and
Yelpeau's method, fifteen times, without a single success. We
have now under our charge a patient operated upon nine years
ago by Sims's method ; in a year the cicatrices had given way,
and the procidentia returned. Three years ago she was op-
erated on twice by Emmett's method ; in little more than
a year the bands gave way, and her condition was worse
than before, for the vagina was so deformed by the cica-

524

KEVIEWS.

trices that it became impossible to adjust a pessary. In tbis
case there was a practical loss of perinsemn, and it is diffi-
cult to imagine bow elytrorapby could bave succeeded, with-
out having been preceded by perineoraphy. We have heard of
another similar case, while this article is passing through the
press, where two operations were done a year ago by Emmett's
method, and with supposed success, in which the procidentia
has been reproduced. Heming's case was examined two
years after the operation, at St. Bartholomew's Hospital, and
the womb and bladder were found in place.

Dr. Thomas does not speak of episioraphy — epision^ labium,
and raphe^ suture — or occlusion of the vaginal outlet by adhe-
sion of the labia, thus converting a procidentia into a prolap-
sus. This operation was proposed and first done by Fricke,
of Hamburg, March 3, 1832. — {Annal der Chirurg.-Abthei-
lungs der Allgemeines Krankenhauses in Hamburg, Bd. 2,
1833.) In 1835 he sent a communication to the French
Academy of Medicine, reporting four cases and three successes.
In 1839, Dr. Geddings, of Charleston (then of Baltimore), per-
formed episioraphy folir times ; two of the cases were known
to have been successful, and of the other two no doubt was
entertained of the results, from the condition of the parts
when the patients went to the country. — (American Journal
of the Medical Sciences, August, 1840.) We cannot find
that subsequently Fricke reported any more successes ; Loscher
had a happy issue, and Knorre one, but several failures.
Scanzoni tried it four times, and failed; Roux and Yel-
peau, each once ; and Stoltz several times. Malgaigne per-
formed an operation similar to Dr. Geddings, in 1837 ; and
Dr. Simon, now of Hiedelberg, several subsequently; and
they were all failures.

With regard to the several methods that have been pro-
posed for the radical cure of this infirmity by surgical means,
we confess, after much examination of the subject, and from
our own observations, to have come to the conclusion that
its advocates have been rather over-sanguine as to lasting
relief, and to agree with Dr. Courty, who writes :

" The disadvantage of all these operations is, that they
expose the patient to the risk of serious dangers for the cure

REVIEWS.

525

of an infirmity which, as a rule, gives rise to none ; and, more-
over, to substitute for this infirmity a deformity, which is
only permissible in old women, but which in younger ones
may be followed by other troubles, and expose them to new
dangers. . . . These operations seem to us only indicated
where there is extreme relaxation of the vulva and vagina, and
where cystocele and rectocele are present, not only as consecu-
tive elements and secondary complications, but as chief ele-
ments and serious complications of the displacement of the
womb." — {Traits Pratique des Maladies de V Uterus^ p. 749.)

Versions and Flexions of the Uterus are largely treated
of, and the multitude of mechanical means for their rectifica-
tion described, Dr. Thomas giving them the benefit of im-
partial suffrage.

In speaking of Inversion of the Uterus, and of the several
ways of replacing the organ in cases of long standing, Dr.
Thomas gives credit to Yiardel for the method lately pro-
posed and successfully practised by Dr. T. A. Emmett, namely,
dilating with the fingers the constricting neck and forcing
up first the tissue which came forth last " (p. 345). We have
both editions of Yiardel 's work before us, and we can find
nothing in Chapter III., De la Precijpitation ou Chute de la
Mat/rice apres V Accouchement^ et de la Maniere de la reduire^
which would in the least justify Yiardel's right to priority ;
nor does the accompanying engraving, representing the mode
of reduction, show any similarity of method. (2ieme ed.,
p. 345.)

Excellent summaries are given of Peri-Uterine Cellulitis,
Pelvic Hematocele, Fibrous Tumors of the Uterus, Uterine
Polypi, Cancer of the Uterus, Diseases resulting from Preg-
nancy, and Functional Disorders of the Uterus. The chapter
on Ovariatomy has been prepared with much care and judg-
ment, and is a complete digest, showing the practical acquaint-
ance of the author with the subject. Diseases of the Fallopian
Tubes close the volume.

III. M. de Fontenelle is described by Yoltaire, under the
thin guise of the Secretary of the Saturnian Academy of Sci-
ences, as " homme de beaucoup d'esprit, qui n'avait, a la ve-

526

EEVIEWS.

rite, rien invente, mais qui rendait "an fort bon compte des
inventions des antres." The systematic digester of original
material, who cleverly works it up for easy appropriation and
daily use, is, in this fast age, unquestionably a blessing, par-
ticularly for those whose assimilative faculty is weak. But,
however much may be the well-earned popularity of those who
fix and epitomize the shifting doctrines of the day, it is most
always ephemeral ; while they who live laborious days in dili-
gent observation, and register the teachings of experience, who
love truth beyond immediate gain, and write, not to put
money in their purses, but to better their kind, have, oftentimes
after patient abiding, the just meed of enduring reputation.
The present eye praises the present object, but time is wonder-
fully even-handed.

" Scribendi recte, sapere est et principium et fons."

The second edition of Dr. Hodge's work " On Diseases pecu-
liar to Females " embodies the. results of the personal experi-
ence and reflections of an active and honorable professional life
of near half a century. A chief object of the author is " not
merely to present what he deems a more correct theory and prac-
tice in inflammatory diseases of the uterus, but also to insist that
a very large proportion of the so-called cases of metritis are in
reality but examples of irritation, where inflammation has sub-
sided, or where it has actually never existed." To carry this out,
the chapter on uterine inflammation has been altered and en-
larged, and is preceded by an Introduction, in which the views
of many high authorities on the several subjects of irritation,
congestion, and inflammation, in contrast with those advocated
by the author, are given, so that " the difference of opinion
and practice may be more distinctly observed." Here
Dr. Hodge shows his familiarity with recent gynecological
literature, and his criticisms are sober and well-founded.
His own views agree with what we know happens under
similar circumstances in other organs of the bod}^, and, we be-
lieve, that until they are applied to those conditions now
grouped under the indistinctive name of .metritis, it will
continue to be a subject of wrangle to the pathologist, and
its treatment a therapeutic failm-e and reproach. We might

EEYIE^S.

527

wish that our author had chosen another name for these disor-
ders of the womb than that of Irritable Uterus, which hardly
indicates their pathogeny. We have long been satisfied, both
from clinical and post-mortem observations, that the destruc-
tive process inflammation has, as a rule, no part in these af-
fections, and that we must look for their intrinsic pathological
nature in those differential nutritional changes, which, under
the influence of the " reiz," or irritation, stimulated by the
momentum excitans, cause multiplication of the connective-
tissue elements, or periplasts, ending in stromal hyperplasia.
The time-honored word " plastic exudation " should then be
consigned to the tomb of the Capulets, and we must look to
overgrowth of the intercellular substance for a true and simple
explanation of the processus. To pm*sue further at this time a
question, whose importance cannot be overrated, would be
to trespass on our space, and we for the present dismiss the
subject, with an earnest invitation to our readers to examine
it by the lights of modern pathology. On no subject has there
been so much repetition of error from book to book, sometimes
wilful, but more often in the spirit of Kichter's sheep, every
one leaping at the same spot, though the bar had been let
down, which made the bell-wether jump. Currency has thus
been given to mischievous doctrines that had no other founda-
tion than the prejudice or ignorance of their originators ; ex-
ceptions have been confounded with rules ; and accidents mis-
taken for essential properties.

A large part of this volume is given to the con-
sideration of the Misplacements of the Uterus. TTe' par-
ticularly commend the author's observations on this sub-
ject to students and practitioners. It has never before been
so thoroughly and scientifically handled. Ample justice is
being done to Dr. Hodge's pessaries, and to the principles of
treating womb misplacements which he has so long taught. At
a recent meeting of the Obstetrical Society of London, strong
and willing testimony was given to the excellence of these in-
struments by Drs. Priestly, Savage, Barnes, and others, and
Dr. Tilt, as we shall presently see, thoroughly indorses them.
Dr. Savage remarked that " Hodge's was the best pessary,
because in shape it corresponded with the contracted vagina,

528

KEVIEWS.

and with it the lateral vaginal action was unhindered, and the
series of curative processes permitted ; " and further, he dep-
recated bringing out modifications of this instrument under
new names, ^'when the one thing to remember was the
principle." In these views Dr. Barnes expressed his con-
currence.

In uttering the hope that this work may be marked,
learned, and digested by all practitioners who may be espe-
cially devoted to the treatment of diseases of women, we feel that
we only urge the recognition of doctrines which have stood the
test of observation and time, and which, when generally
accepted, will save much woman misery, and go far toward
redeeming one branch of our art from just reproach. But there
is another feature of this volume which should not be overlooked,
and that is its healthy tone. We have a sensational litera-
ture, a sensational drama, and we are, we fear, drifting toward
a sensational gynecology. latro-mechanical ideas have an irra-
tional and unmerited preeminence ; each day brings forth a new
machine for stretching, or cutting, or rectifying the womb ;
and some wonderful feat of the knife is blazoned to catch the
credulous. It has lately been well said, that to use remedies
with patience and skill, and with an intelligent belief in their
powers to do good, requires far higher faculties than are needed
to slit the OS uteri. There is, moreover, and we regretfully
allude to it, a growing leaning toward methods of investiga-
tion, which are simply nasty, and outrage decency. The plea
that scientific inquiry justifies the means, scarcely deserves
serious thought ; once admitted, it cannot be limited, and every
sort of vileness and crime would get a precious ally and advo-
cate. Science is soiled when put to base purposes ; it truly
then becomes the apostle's " science falsely so called." The
teachings and spirit of such works as Dr. Hodge's are alike
contrary to the misaiming cleverness of mere handicraft, to-
the evils of unnecessary digital or other examinations, and to
practices which bring peril to the body and poison to the
mind. That we stand not alone in our estimate of the un-
fortunate tendencies we speak of, the following sentences by
a valued contemporary, received after our article was written,
will show :

EEVIEWS. 529

Practitioners who are mucli consulted about the diseases of these ,
organs, know full well the peculiar mental and moral effects that are pro-
duced by the constant direction of the attention to them. There is much
reason to believe that, in manj instances, morbid uterine sensations are
simply intensified and maintained by local treatment, of whatever kind;
and there is a strong and growing feeling, particularly amongst country
practitioners, that all uterine specialists are not unmixed benefactors to the
human race. There is a growing belief that, in a majority of ailing women,
there may be found sufficient flexion, or displacement, or congestion, or
tenderness, or ulceration of the uterus, to furnish grounds for the employ-
ment of local means, and that these means often do more mischief than
good. On the other hand, it is perfectly beyond question, that many women,
with real and serious uterine ailments, suffer much unnecessary pain and
dist-ress so long as local treatment is neglected, and are speedily restored to
health and comfort when it is used. On the whole, we lean to the opinion
that cases of the latter kind are outnumbered by the former. We incline
to the belief, that for every wonian who is greatly relieved, or altogether
cured, there will be others who leave the hands of the uterine specialist in
much the same state as when they went to him, except — and the exception
is important — that they have become accustomed to think perpetually
about their genital organs, and to have -them examined and manipulated.
. . . . We would strongly urge, with regard to the sound and the pessary,
the famous question that Lord Melbourne was wont to ask with reference
to political activity : Cannot you leave it alone ? If the doubt were in every
case, " Is not tiiis an instance in which local treatment may be dispensed
with ? rather than, " Is it not one in which local treatment may be used ? "
— we are sure that there need be no neglect of any patient requiring it;
and at the same time there would be less of the dissatisfaction which is now
somewhat widely felt, and not altogether uncalled for, at the prominence
given by some specialists to trifling variations in the condition of the uterine
organs. — {The Lancet^ November 28, 1868.)

TV. The profession is largely indebted to Dr. Tilt, first,
for his advocacy of the doctrine that the distempers of the
womb are not all bounded by the cervix, and that fimdal
disorder, often connected with affections of the ovary and of
the adjacent peritonsenm, merits a share of the attention of
practitioners; and, second, for having resisted the mechan-
ical bias of the gynecology of the day. ^Vlien he first made
knovTi his views, cervical metritis and lunar caustic were
pretty much every thing in uterine pathology and therapeu-
tics. His works are favorites; they are pleasantly written,
show industry, information, and straightforwardness, and con-
tain much that is valuable. The " Hand-book of Uterine The-

530

EEVTEWS.

rapeutics and of the Diseases of Women " lias reached a third
edition in England, has been translated into German, and a
French translation is about .appearing. The present edition,
the second American, has been revised by the anthor for the
l^ew York publishers.

The main points insisted upon in this work are — (1.) The
paramount importance of hygiene for the relief and cure of
diseases of women. (2.) The constitutional nature of many of
these disorders, and the impossibility of curing them without
constitutional remedies. (3.) The manifest reaction of uterine
affections on the female system, and the impossibility of cm-ing
many womb complaints without surgical measures. (4.) The
great value of therapeutics to assuage and cure diseases of
women, and a belief in the value of those remedial measures
that are as old as medicine itself. AYe have room only to re-
fer to a few of the innumerable subjects treated of.

In an excellent Introduction, which we commend to all
young practitioners, amongst many sensible remarks. Dr.
Tilt writes :

I wish this enlarged edition to be taken as mj protest against the dis-
paragement of a large amount of therapeutical wisdom that has been
handed down to us for our guidance in the treatment of disease, from one
generation of medical observers to another, notwithstanding the advance
of civilization, the increase of medical knowledge, and the various systems
that have, each in its turn, ruled over medicine. It is not surprising that
many of those who devote themselves to the study of the diseases of women
should have participated in this loss of therapeutical faith, and should have
favored an exaggerated development of obstetric surgery. This work will
sufficiently show that I do not wish to disparage the use of surgery in the
treatment of diseases of women, .... but it is worse than useless for a
host of complaints for which there are approved remedies. — {Freface^
p. vii.)

"With rare exceptions, of which cancer is a prominent example, those
who treat diseases of women may deal largely in hope, and I feel my
duty is not well done toward a patient, if she leaves me without the belief
that her cure is certain, though it may be delayed. One great advantage
of experience is that it teaches us hope. ... If their courage can be
kept up, so as to make them persevere witli more or less active treatment,
during one, two, or even three years, one is justified in instilling hope as
the best way of working cures. The hope that is held out will, of course,
be proportionate to the nature of the disease and its duration, or the
practitioner's reputation will be seriously damaged (p. 9).

EEVEEWS.

531

In Chapter I., " On Surgical Appliances and Modes of Ex-
amination," the author, speaking of the univalve speculum —
which was the common speculum in use two hundred' years
ago, and is described hj Dionis in his Cours W Oimxitions de
Chirurgie^ and figiu*ed at page 246 of the 3d edition, 1777 —
and of the suitable position of the patient, says : " Most wo-
men would rather continue to bear the annoyance of chronic
uterine affections, than in presence of an assistant submit to be
rolled over on the front, in a left lateral semi-prone position."
This is not our experience, nor that of any one who makes
this, the only reliable and satisfactory method of ocular exami-
nation, the rule. On the contrary, patients become them-
selves satisfied that it is more thorough than other modes,
whilst it has greatly the advantage over them on the score of
delicacy; and Dr. Tilt himself admits that " a frame of mind
eminently calculated to give efiicacy to treatment," is one in
which the j^atient " leaves the consulting-room convinced that
her complaint has been better understood than heretofore, and
by one who is anxious to cure her."

Dr. Tilt is a decided advocate for gradual dilatation of the
cervix, and rightly uses it —

when its narrowness prevents the ascfent of the semen into the womb,
or leads to the retention of the menstrual fluid, and to the formation of
clots, which cannot be expelled without great and protracted pain. The
same operation is required, whenever the cervical canal does not afford
free egress to the mucus and matter secreted by the lining membrane of
the body of the womb, or to the membranes which it exfoliates (p. 31).

He adds :

Dilatation must not be attempted until inflammation of the cervix has
been subdued, and until that of the body of the womb has become pas-
sive, and it is only by supposing that Dr. M, Sims overlooked these con-
ditions, that I can understand his having thrice seen metro-peritonitis fol-
low the gradual dilatation of the cervix for the relief of uterine stricture.
While thus asking us to believe that the gradual dilatation of the cervix is
a dangerous process, this distinguished surgeon wishes us to admit that no
serious results are to be feared when the cervix is so rapidly dilated as to
permit, in a few hours, the passage of the index-finger. If the first mode
of dilatation be dangerous, the second is more so, although quite justifiable
for the diagnosis and cure of internal polypi and of intractable disease of
the uterine cavity. The only bad results that I have observed to be

532

EEVIEWS.

caused by the gradual dilatation of the cervix, are uneasiness, uterine
pains, an increase of mucous discharge, a little loss of blood, and the
advance of the menstrual period. I have seen no other e\il results
fojlow dilatation, so I do not side with those who represent this process as
dangerous, and the slitting up of the womb free from danger (p. 34).

With respect to hysterotomy, Dr. Tilt writes very sensibly :

So great has been of late the tendency to represent the shtting up of
the cervix as the sovereign remedy for all uterine affections difficult of
cure, that the proposal requires to be carefully considered before it be
adopted by othei- British surgeons (p. 282).

The tediousness of the process of dilatation, the difficulty of doing it
well, and its inutihty in a certain number of cases, have caused the slitting
up of the cervix to be preferred by many. I own that in my previous
editions I have been too much opposed to the operation, and that it must
be considered another of the many improvements that we owe to the in-
ventive genius of Sir J. Simpson. ... If I have exaggerated the
dangers of the operation, others have exaggerated its advantages. The
tenor of Dr. M. Sims's valuable work is to represent pregnancy as insured
by slitting up the cervix, and the assertion that he had done so 500 times in
the Women's Hospital of ISTew York [pretty well in an institution of
twenty-five or thu'ty beds, a portion of which were always occupied
by vesico-vaginal fistula cases — Rev.] shows to what extent he carried the
practice. ... I have no hesitation in sanctioning hysterotomy where
it is difficult to introduce a l^o. 1 or 2 bougie, and when the vaginal ex-
tremity of the cervix has a conical shape, for in that case it is obviously
difficult, if not impossible, for the semen to enter the womb, even if there
be no strictm*e (pp. 350-2).

Dr. Tilt iiicises his stricture tissues, layer by layer, with
scissors and bistoury, in broad daylight, thinking it better to
operate " with the full knowledge of what one is doing, rather
than to work in the dark, with more or less complicated in-
struments."

Of arsenic he speaks well, having given it, " with good
results, in cases of chronic uterine subacute inflammation,
w^ith marked tendency to relapses." This accords with our
experience of the drug in this class of affections, and we are
glad to record our author's favorable testimony. His views
w^ith regard to the Turkish bath, in the treatment of uterine
disorders, we can indorse cordially. They are applicable in a
limited number of cases, and then, when cautiously used,
are decidedly beneficial :

REVIEWS.

533

In chronic inflammation of the body of the womb, there is often a
state of languor and debility, which predisposes to relapse, and I have
found that Turkish baths, taken once or twice a week, brought up the vital
powers to the utmost limit of their capabihty in the shortest possible
time. My worse cases of uterine inflammation— those accompanied by
obstinately distressing pain or singular nervous symptoms — have occurred
in women who had a deficient action of the skin, who were always cold
and never perspired. This indicates the Turkish bath (p. 74).

This state of the skin happens in a very large proportion
of such cases, and the Turkish bath, as a fillip to cutaneous
action, is of much service ; this done, it should be laid aside.
The mistake that has been made, is making it a method of
treatment, and not a part of one.

With respect to Uterine Flexions, Dr. Tilt says : " 'Not-
withstanding all that has been written to the contrary, I still
believe that if practitioners would carefully eliminate 'the con-
gestion or subacute inflammation that attends uterine flexions,
they would very seldom require the application of pessaries "
(p. 279).

We well remember when Yelpeau taught, and demon-
strated too, that all the varied forms of uterine suffering were
produced by misplacements and flexions of the womb, whilst,
on the same day, Lisfranc, at La Pitie, would affirm that they
were all due to engorgement, and that le petit marechal de la
Charite did not know what he was talking about. The
recent debates in the Obstetrical Society of London show
that these opposite views are as stiffly maintained to-day as they
were a quarter of a century ago, and that time has done but
little to modify them. It is strange to see gynecologists
divided into two hostile camps on a question which, as has
been remarked, "if special experience be worth any thing,
and if the statements of those particular specialists be accepted
as trustworthy, ought to be set at rest in a week. . . . We
fail altogether to see any real incompatibility between these
opinions. Abundant evidence has been adduced in favor of
both ; and impartial observers can only remain in doubt with
regard to the relative frequency of the one or of the other
sequence of events." — {The Zancet, December, 1868.)

Dr. Tilt admits, however, that pessaries are in many cases

534

BEYIEWS.

necessary, and says : " One of the best instruments for main-
taining the flexed womb in a right position is dne to Ameri-
can ingenuity. ... In my last edition I drew attention
to these instruments [Hodge's], and urged their more exten-
sive trial, and I am glad to find that my ow^n experience of
their utility is confirmed by Drs. F. Churchill and Grraily
Hewitt " (p. 280).

The following sentences have much sound doctrine :

Too great importance has been attributed to ulceration of the cervix,
in the production of diseases of women. ... If this be sound pa-
thology, it stands to reason, that to cure uterine ulceration, the first indica-
tion is to strengthen the conservative force by suitable food and stimulants
and by tonics. At a rough guess, I dare say that, by these means, some
fifty per cent, of ulcerative lesions of the uterine mucous membrane are
cured. If, in addition to tonics, vaginal injections, and the other injec-
tions set forth in the chapter on Home Treatment, are carefully carried
out, perhaps thirty per cent, of somewhat more sever cases of uterine
ulceration would get well. With regard to the remaining twenty per cent.
. . in such patients ulceration will not lieal without caustic treatment
(p. 152).

Chapter lY., on Sedatives, may be profitably read. We
are satisfied that, were this class of remedies more frequently
used, both generally and topically, in uterine affections, pa-
tients would be greatly the gainers. The chapter on Caustics
is an elaborate one, and the author here is disposed to ride a
hobby ; indeed, on this subject, he is more the earnest and
clever pleader than the impartial judge. We cannot agree
with Dr. Tilt as to the harmlessness of the issue treatment by
caustic potash applied to the neck of the womb. We have
frequently seen a bad condition set uj), even when there has
been no immediate alarming effects. In Dr. Tilt's hands it
may have been followed by all the benefits he asserts, but we
still think ourselves justifiable in giving a warning against
the practice.

AYe should be glad to notice other portions of the work,
but ^ve must bring this article to a close. Though not always
at one with Dr. Tilt, we bear willing testimony to the excel-
lence and usefulness of his book. It will be largely read and
duly prized.

REPOETS 01^ PROGEESS OF MEDICINE.

535

OPHTHALMOLOGY.

By Henry D. Koyes, M. D., Professor of Ophthalmology in Bellevue Hos-
pital Medical College ; Surgeon to New York Eye and Ear Infirmary.

MUSCLES OF THE EYE.

1. — Nystagmus. By. Dr. L. Kugel, of Bucharest. [Awnales d'Oculistique,

tome lix., Mai-Juni, 1868, p. 209. Archivfllr Ophth., bd. xiii., ii,, s. 413.]

Ix this affection the incessant oscillation of the eyes has been commonly
attributed hitherto to some primary lesion of the muscles or nerves, but
Dr. Kiigel, in tlie above article, as well as in others wliich he has written
in the Archives for ophthalmology, shows that it has in most cases a very
different origin. He divides the cases into three classes: 1. When the
trouble appears in early infancy, and is produced by a serious anomaly of
refraction, or of the membranes at the bottom of the eye. The anomalies
of refraction are opacities in the media, hypermetropic astigmatism regular
and irregular, and extreme degrees of myopia. In all these cases the
retina receives an imperfect image, and is so feebly impressed as not to
excite the due amount of reflex action to enable the muscles to act in har-
mony. When the muscles have learned to direct the yellow spot of the
retince upon an object, nystagmus is not liable to be caused by opacities
of the cornea or internal disease taking place at a later period. But while
some cause of amblyopia lies at the bottom of nystagmus, there is not in-
frequently an auxiliary muscular defect. Such secondary forms are as
follows: the patient holds an object to one side and looks at it, with the
head turned to the opposite side. At this angle the oscillation is least.
Again, the nystagmus is least when the object is held in the median plane,
while it increases if the object be at either side. Class second contains
cases of choroido-retinitis, and these do not appear in infancy. Both eyes
are always diseased, and to such a serious degree that the macula lutea fails
to have its proper superiority over the rest of the retina, and there is no
motive for the muscles to fix this point upon an object in preference to
other parts.

In class third are included cases of true muscular debility, insufficiency
of the recti interni, fi-equently attended by weakness of the ciliary muscle.
The trembling of the eye does not appear until by protracted effort the
muscles become exhausted.

Treatment is most satisfactory in the third class, and for them prisms
or spectacles are the more usual means, and also tenotomy. In the first
class operations may be performed to mitigate the ill effect of opacities in
the cornea or lens, yiz., iridectomy, keratonyxis, etc., and glasses may also
be chosen to correct in some degree the hypermetropia, myopia, or astig-
matism. For the second class there is naturally no remedy.

OEBIT.

2. — Woujtd of the Brain dy Penetration through the OrMt. By Dr.

PviEDLE. [Schmidt's Jahrbucb, 1868, p. 315.]

A man received a thrust of the point of an umbrella into the inner angle
of the left eye. The i^tick was two and a half inches long, and pushed out
the globe, which returned to its place when the stick was pulled out. Tiie

536 EEPOETS OjS" PROaEESS OF IMEDICINE.

patient was kept under strict antiphlogistic treatment for fifteen (lays, and
no trouble occurred. On the sixteenth daj came a chill and violent head-
ache, the pupil became enlarged, the patient could not sit up, soon could
neither speak nor swallow.

The left half of the face, the right arm and foot became paralyzed, the
left arm became convulsed, and the patient died in delirium and sopor.

Autopsy showed fracture of the left anterior clinoid process and the
adjacent portion of the temporal bone. The surface of the sella turcica
had a hole as big as a pea, with ragged edges, made by the point of the
stick. The ethmoid plate on the inner side of the orbit had been perfo-
rated, as well as a part of the frontal and lachrymal bones.

ISTeitlier the globe nor its muscles had been injured. The track of the
wound was one inch and five lines long, and passed from without inward,
and from below upward. The superior turbinated bone and a part of the
vomer were also fractured.

In the brain there was no suppuration, but great hj-perjBmia of the left
hemisphere, congestion of tlie vessels at the base, as well as of the corpus
striatum and optic thalamus of each side; bloody serum ia the right
ventricle; infiltration of the pituitary body, and moderate extravasation on
the sella turcica.

3. — Tearing out of the Eye'baTl hy the Ring of a Door-Key. By Dr.

Heregott. [Schmidt's Jahrbuch, 1868, p. 219.]

The patient was an epileptic of eighteen years, and was seized with a
fit while opening a door. She fell with her right eye upon the key, which
was in the lock. AYhen seen by the doctor she was in bed, and the eyelids
greatly swollen, and at first nothing but severe contusion was thought to
have occurred But it was stated that the eyeball had been found banging
in the ring of the key. On examination the globe was discovered to be held
by a few shreds of conjunctiva, the muscles were all torn from the sclera,
at a few millimeters' distance, while the optic nerve was torn out from its
insertion. The patient made a good recovery.

4. — Fibro-plastic Tumor i?i a Rectus Muscle. By Dr. J. Yose Solomon.

[British Medical Journal, Jan., 1868 — in Schmidt's Jahrbuch, 1868,
No. 4, p. 56.]

A tumor was found in the external rectus muscle of the left eye of a
child four years old. It was as large as a hazel-nut, hard and smooth,
concealed behind the outer wall of the orbit. There 'had been no injury ;
it had been noticed several months. In the operation an incision was
made in the direction of the fibres, the insertion of the muscle loosened
and turned back. The tumor was enclosed in the sheath. It was dissected
out of the orbit, and more than one-third of the muscle was sacrificed. The
conjunctiva was then properly replaced, and the tendon of the internus
divided so as to restore the equilibrium of tl:e muscles so far as possible.
Six months after there had been no relapse, and moderate converging stra-
bismus remained. The tumor was firm, white, and of homogeneous struc-
ture. Two small cavities, filled with pus, were found within it. Micro-
scopic structure not xletailed. Such a case is extremely rare.

NERVES OF ORBIT.

5. — Comminuted, Fracture of Nasal Bones and Riglit Superior Maxilla;

Sinking of Eyeljall into Maxillary Sinus. With Illustration. By
Prof. Langenbeck. [Archiv fiir Ophth., bd. xiii., ii., s. 447.]

De. Langenbeck gives an account of a railroad official whose head

OPHTHALMOLOaY.

537

was caught between a locomotive and its tender. The eyelids were torn
away from the orbit, and a deep wound ran down from the inner canthus
to the upper lip. A probe could be passed into the antrum, not a trace
of the eyeball could be found; while in the orbit was a bluish-black pul-
sating mass. The nasal bones comminuted. Patient conscious, but sleepy,
pulse slow, violent pain on right side of head. A week afterward, as head-
symptoms disappeared, and the extravasated blood had been somewhat ab-
sorbed, a closer scrutiny could be made. The eyeball was discovered to
have escaped from the orbit into the antrum by a hole, in the orbital
margin of the upper jaw, big enough to admit the linger easily — the axis of
the eye standing vertical, the cornea downward.

The fragments of bone were adjusted as well as possible, and the eye-
ball replaced in the orbit. It was uninjured, and vision was perfect.

About ten weeks after, by two blepharoplastic operations the eyelids
were brought into a tolerably good condition. They could be closed, and
usually so remained, but could be opened enough to expose the cornea and
permit sight. The globe was however perfectly immovable. About five
months after the injury, ulceration and suppuration of the cornea occurred,
and the globe atrophied.

6. — Paralysis of l)otJi Sixth NevGes. — Autopsy. By Dr. F. Maoris. —

[Schmidt's Jahrbuch, 1868. 6, p. 352.]

The history of the case is not stated ; only the morb:d appearances are
given, and these are sufficiently curious. The calibre of the cavernous
sinus w^as unusually large. The carotid was atheromatous, and made a
remarkably strong S-shaped curve. From the perpendicular turn of the
S a branch was given off to the base of the skull, toward the ganglion of
Gasser. Between this twig and the side of the carotid the abduceus nerve
was entangled and compressed. That part of it between the brain and
the carotid was of normal size, while in front of the vessel the nerve was
atrophied to half its usual thickness. This condition existed on both sides.

Another anomaly was found in this subject: in that a supernumerary
bundle of muscular fibres took origin from the most posterior part of the
external rectus of the right eye, and was inserted into the sclera at the
outer border of the inferior rectus— its course was obliquely forward and
inward.

LACHEYMAL APPAEATUS.

7. — TTie Cure of Stricture of the Ductus ad Nasum ly Internal Division.

By Dr. J. Stilling. [Cassel, 1868, with a Plate; pp. 24.]
In this account of a new theory of curing strictures of the nasal duct,
Dr. Stilling professes to follow the analogy of treatment of strictures of the
urethra. He first gives a careful detail of the anatomy of the lachrymal
passages ; and the fact which bears most strongly upon the practice pro-
posed is the existence, beneath the mucous membrane of the nasal duct, of
a noticeable amount of erectile tissue — a layer which Henle particularly
describes. This is mingled with elastic fibres, and unstriped muscular
fibres. The novelty in treatment consists in dividing the stricture from
within by incisions in three or four directions, and leaving the parts after-
ward untouched. No sounds or probes are to be employed, except in the
prehminary exploration. The superior punctum is opened, and then Dr.
StilKng uses a short and narrow-bladed knife, which tapers to a moder-
ately sharp point, to cut the stricture. The instrument is straight, and,
being tir^t plunged to its full length into the duct, the blade is withdrawn,
turned around a little to be again pushed in, and yet again, so as to cut the

538

EEPOETS ON PEOGEESS OF MEDICrN"E.

stricture with the greatest freedom. If blood flow freely from the nose,
the operation may be considered to be well done, and a full-size conical
probe (Weber's) may be introduced, other ill effects follow than a

little ecchymosis of the lower lid. In two weeks, as the average time, the
parts are healed. Dr. Stilling narrates nine cases which presented the or-
dinary features of lachrymal catarrh and obstruction, in which this simple
treatment effected a complete cure. He was able to verify the result
after several months. The cases which Dr. Stilling regards as curable in
this way are those for which the treatment by Bowman's probe would or-
dinarily be undertaken.

8. — Treatment of Stricture of tTie Lachry mo-nasal Passages ly Internal

Division. By Dr. Waelomont. [Annales d'Oculistique, tome Ix.
Sept.-Oct., 1868, p. 117.]

The mode of treatment suggested by Dr. Stilling has been adopted by
Dr. Warlomont, and in the above paper he narrates the history of eight
cases, and says that he has treated a score besides, whose history is abso-
lutely the same. Whether the cure will be permanent, he does not affirm
positively, but in some an experience of five or six months has exhibited
complete relief from lachrymal trouble.

One case (obs. iv) is that of a young and pretty girl, 20 years old, who
for more than three years had been treated by Bowman's probes, and could
pass No. 4. This was done twice a week, but the epiphora continued.
After having Stilling's operation done, she found herself in a week more
comfortable than for three years previous. The cure became complete, and
was known to remain for five months.

In some cases the canal was found beset by rugosities, and the obstruc-
tion to be so hard as to creak under the knife. It was necessary sometimes
to use considerable force. In all cases the small conical sound of Weber
was first used, both to explore the canal and prepare the way for the knife,
by dilating the passage as fully as it was capable of doing. After the
stricture had been freely divided, an injection of warm water was some-
times made on the following day. Usually the catarrhal secretion from
the sac began to diminish, the swelling of the sac to subside, and fistulous
openings to close without any further treatment. Slight conjunctivitis
would also disappear, while troublesome ophthalmia tarsi and ectropium
would require a few weeks' treatment.

If, in extreme cases of lachrymal catarrh, the disease did not disappear
spontaneously. Dr. Warlomont recommends a proceeding, devised by Dr.
Libbrichtof Gaud, for facilitating the introduction of medicated fluids into
the sac. A stylet made of platina,in size equal to probe No. 1 of Bowman, and
grooved on three sides, is worn in the nasal duct. It is about one and a
half inches long, and bent at its upper end into the form of a hook, so as not
to sink out of place. It is designed to favor the penetration of fluid, which
may be simply dropped into the inner angle of the lids. The substance
preferred by Dr. Libbricht is chloride of zinc in solution of about gr. i to
3 j, dropped into the eye three times daily, and continued seldom longer
than two or three weeks. This mode of proceeding is a good substitute
for injections by the syringe, which require to be done by the physician,
and arc consequently not done as often as the disease requires.

9. — Treatment of Disease of the Lachrymal Sac. By Prof. Alfred

Graefe, of Halle. [Zehender's Monatsblatter fiir Augenheilkunde,
August, 1868, s. 223.]

The author suggests one or two new points. To aid in voiding the sac
of secretion, he causes the patient to perform the manoeuvre of Valsalva,

ophthal:\[ology.

539

namely, blowing forcibly while mouth and nose are closed. If this be
done immediately after a probe has been passed, the air will find its way
into the lower end of the nasal duct and escape by the canaliculi, bringing
with it more or less of the catarrhal secretion. For two or three days only
will this manoeuvre be practicable, when another introduction of the
sound will permit it to be repeated for another period. To avoid the ac-
cident of emphysema, Avhich might ensue if tlie probe have torn the mu-
cous membrane. Prof. Graefe cautions us to put the finger lightly on the
sac, as the patient is blowing for the first time. After the passage has
been dilated a little, there is slight danger of this occurrence.

Prof. Graefe also uses a douche apparatus, recommended by Dr. Her-
zenstein, in place of a syringe, for effective cleansing of the passages — a
small tube is inserted hito the canahculus, and this is by a flexible tube
connected with a pump.

But cases are sometimes met in which the stricture is wholly over-
come, and the catarrhal secretion dried up, while epiphora contiimes. In
one such case the cause was found to be hypertrophy of the caruncle,
which, by pressing on the canaliculus, impeded the entrance of tears. The
excision of the caruncle relieved the epiphora. The mass need not be
very large to cause such trouble; and, in cases where the duct is brought
to proper size, the catarrh of the sac is cured, the eyelids are in correct
position, and the muscular apparatus sound, and yet epiphora continues,
Prof. Graefe recommends the trial of this operation of excision of the
caruncle.

CONJUNCTIVA.

10. — Pathology of Trachoma^ from Examination of the Eyelids of cer-
tain Domestic Animals. An Inaugural Thesis. By Dr. Paul Blum-
BEEG. [Dorpat, 1867. Quoted in Zehender, April-May, 1868, p. 132.]
The author examined the conjunctiva of the pig, the dog, the rabbit, the
horse, and the ox, in reference to their proneness to occurrence of trachoma,
and to ascertain in what the so-called trachoma follicles consist. He found
that these become developed in the conjunctiva when it consists of adenoid
tissue — that is, of fibres of connective tissue in which are embedded
lymphoid cells. In the pig, the adenoid character is strongly marked in
the culs de sac of the conjunctiva, becomes less decided on its tarsal por-
tion, and least in the conjunctiva bulbi. Of mucous follicles there are
none. In the pig, trachoma follicles are very abundant. The conjunctiva
of the dog, rabbit, horse, and ox, is adenoid in the adult, but in the young
subject is not. In the cat, the conjunctiva always consists of simple fibril-
lated connective tissue. If the membrane normally possess the adenoid
structure, it will exhibit trachoma ; if its structure be not such, there will
not be trachoma.

In human beings the same fact is true; for in infancy, where the con-
junctiva is composed of merely connective tissue, trachoma is very rare,
but the disposition to its occurrence increases as the membrane acquires
more of the adenoid character. If a trachomatous eyelid be immersed for
one or two days in vinegar, the trachoma follicles will be exposed , by
merely brushing away the epithelium. Pricking them with the point of a
needle, a quantity of lymphoid cells will escape, and leave behind a cavity
traversed by very dehcate fibres of areolar tissue — the blood-vessels are
only on the surface of the follicle, not within.

The author, therefore, regards trachoma follicles as neither glands nor
congenital structures, but simple hyperplastic growths of lymphoid cells,
which have undergone proliferation. He compares the trachoma follicle,
in its relations to the adenoid tissue, to the relations which obtain between-

540 EEPORTS ON PEOGEESS OF MEDICINE.

a lipoma and normal adipose tissue. Furthermore, the hypertrophy of the
cells causes atrophy of the connective tissue, especially of that which is
contained within the trachoma follicle, and, as it grows by pressure, it be-
comes enveloped in a membrane of connective tissue.

11. — Tlie Track of Foreign Bodies which enter the Vitreous Humor. By
Dr. K. BERLm. [Archiv filr Ophth., b. xiii., ii., s. 275.]

Penetrating Wounds of the Eye. Illustrated ly Experiments on JRahMts.
By Dr. Lubeisky, of Kronstadt. [Archiv ftir Ophth., bd. xiii., ii., s.
377.]

Dr. Berlin has made careful examination of eleven eyes which he
enucleated on account of penetration of foreign bodies into the vitreous
chamber. In two cases the foreign body was stuck in the sclerotic
wound ; in three cases it remained in contact with the opposite inner wall
of the sclera ; in six cases it was found at the bottom of the eye, often in
the vicinity of the lens or ciliary body.

On making a minute inspection of these six cases, it became evident
that the foreign body came into this position by rebound from the pos-
terior wall of the eye. This was proven by finding a spot on this wall
where the retina and choroid had been wounded, and this lesion, in a
straight line with the point of entrance of the offending body, whether
this was in the cornea or anterior part of the sclera.

The fact of impact on the back wall of the eye was indicated in many
cases by adhesion of the choroid and retina at this point to the sclera. If
detachment of the retina had occurred, besides attachment at the papilla,
there would be oftentimes a second attachment at the spot of impact.
Another sign, indicating this fact, is, that sometimes from the sac in
which the foreign body may be encapsuled a fibrous cord proceeds back-
ward, to be attached to some point of the fundus.

This fact that foreign bodies so frequently, namely, in six out of eleven
cases, taken at random, behave in tiiis way, has hitherto been almost
entirely overlooked. But, as to their final resting-place, it is not always
at the spot where they fall, after the rebound from the back surface of the
interior of the globe. Their position may subsequently be altered by two
kinds of morbid action : First, a subretinal effusion, as it slowly increases,
may push it in front of itself; second, if enveloped in vitreous opacities,
these, as they contract, will carry it with them. The direction in which
it is displaced by the first cause is accidental; by the second, it is always
drawn toward the axis of the eye.

The important practical deductions from this paper are : first, the
tendency of penetrating foreign bodies not to pass entirely through the
eye, but to remain lodged within it; secondly, to understand the signs by
which we may become convinced that a foreign body is actually lodged
within the vitreous chamber.

If a foreign body simply penetrate the iris, or lie just behind it, it
necessarily causes iritis and oftentimes hypopyon ; and is frequently en-
veloped in a mass of yellowish plastic exudation, that forms a little tumor,
and points out its exact situation.

If the body be in the lens, after the first reaction passes away, and the
irritation which depends on the more or less rapid swelling of the lens,
and often assumes the glaucomatous type, no other symptoms remain save
those of cataract. But it must be observed, that quite often such eyes are
very intolerant of operative interference — the reaction which ensues may
be excessive. In case the foreign body should subsequently drop into the
anterior or posterior chamber, inflaunnation may spontaneously arise; but
if it remain in the lens, the eye commonly continues quiescent.

OPHTHALMOLOGY.

541

If the foreign body get into the vitreous, the inflammation generally
takes on the character of irido-choroiditis or irido-cyclitis. The globe
may finally atroph}', or, if the foreign body be simply suspended in the
vitreous, the eye may for years be free from any signs of irritation. But
internal irritation will in the end almost certainly begin.

The signs by which to become convinced that a foreign body has passed
into the deep parts of the eye are to be gathered from the history : the
discovery of an external scar or wound; the marks of its having passed
through the iris or lens; the nature of the inflammation; and, finally, the
kind of injury to vision.

To omit certain signs, generally well understood, which indicate the
penetration of a foreign body, we will consider the following: An inflam-
mation, whose severity is out of proportion to the apparent gravity of the
wound, implies the lodgment of a foreign body. If in the vitreous, the
immediate damage to sight may be in the form of a cloud floating be-
fore the eye — which is due to obscuration by the foreign body or by a
blood- clot. The loss of sight at a later period will be central or peripheral,
or both, and more or less complete. But a very important sign is limita-
tion or encroachments on the field of vision. A general impairment of
sight (leaving cataract out of view) depends on blood in the vitreous, or
vitreous opacities, the result of inflammation. Contraction of the visual
field is caused by subretinal eflrusion, or by wound of the retina, which
cuts ofi" the conductivity of more or less optic nerve-fibres.

The author describes minutely the microscopic changes in several eyes
which he examined, but we may not quote any further. One point may
be selected, that, in one eye, extirpated two days after the injury, the op-
tic nerve-fibres were found to have undergone precisely the same changes
which have been noved in nephritic retinitis. This layer was thickened by a
collection of ghstening pedunculated bodies, described by Zenker as modi-
fied nerve-cells ; by Virchow, a-s sclerosed nerve-cells ; by H. Mliller, as diver-
ticulated nerve-fibres. The last explanation is most generally accepted.

Dr. Lubrisky inflicted 38 wounds upon 23 rabbits' eyes, with a knife,
and afterward examined them anatomically at various periods. The fol-
lowing facts may be gleaned from his statements : The sclerotic wound
never closes by direct union of its edges — an intermediate tissue is formed
to which the conjunctiva and choroid cohere, and the latter often projects
appreciably into the eye.

The choroid about the wound becomes bereft of pigment, and the epi-
thelial cells are irregular in size and distribution.

The edges of the retinal wound do not unite together, but rather with
the cicatricial tissue. As soon as the scar begins to project inward, the
retina becomes detached. One of the changes in it is, that, on its outer
surface, fibres begin to dovelop, and as they grow they throw the retina
into folds, the nerve-elements disappear, and, as this fibrous tissue con-
tracts, _detachment takes place.

12. — Observations upon Foreign Bodies in the Vitreous Body. Dr. E.

Berlin. [Archiv fiir Ophthal., xiv., ii., 274-332.]

In this second paper on this topic. Dr. B. adds 11 new cases, making in
aU35.

He found in nine of the new ones that the posterior wall of the globe
had been wounded by the foreign body. He details the history, treatment,
and autopsy often eyes, giving minute details of microscopic appearances.
The most interesting point is the examination of the visual field, and the
value to be attached to the symptom of its being encroached upon — as a
sign of the presence of the intruding body in the eye. The mode of map-
ping the field is as follows: The patient commonly has traumatic cataract.

542

EEPOETS 01^ PROGEESS OF MEDICmE.

He must have bright light, withiii three or four feet, for central fixation,
The peripheral field is examiuecl bv a small bright light, carried around in
remote positions — it may, from time to time, be shaded by the hand. The
mirror of an ophthalmoscope maybe used when a light is behind a patient.
The movable light may have a tin chimney, with a small hole in it.

This examination will take time, but, well conducted, gives valuable in-
formation. Great diminution of central vision is commonly due to blood
in the vitreous.

Another point to be studied is, whether the situation at which the visual
field is impaired may not help us to discover the site of the foreign body.
In a certain case, the visual field was damaged outward and upward — the
foreign body was, therefore, supposed to lie at the inner and lower quad-
rant of the globe. A cut was made at the inner border of the rectus infe-
rior, 4^'" from the cornea, running 3'" inward. A hard body was encoun-
tered by the edge of the knife, but the forceps failed to find it. The eye
was enucleated, and the incision found to have actually grazed the posterior
edge of the piece of steel. On examining his specimens. Dr. B, found that
compact bodies, which did not adhere to the inner wall, sank to the bot-
tom of the eye, while those of a scaly form floated in the vitreous ; the
hea\ier sort were always in the anterior and lower quadrants, and could
generally be hit by an incision S'" distant from the cornea, parallel to the
equator, and 3'" to 4'" long.

Whether mere removal of the foreign body would suffice, in lien of ex-
tirpation of the eye, is a question to be decided by the pecuharities of each
particular case.

COENEA.

IS.— Memoir on the Cause of Opacities in the Cornea. [Zehender, April-
May, 1868, p. 144.]

This treatise cites a series of experiments intended to show that opa-
cities are induced by the penetration into the cornea of morbid secretions
from the conjunctiva.

14. — Keratoconus. By A. v. Geaefe. [Berliner Klin. Wochenschrift,
Js^o. 28, 1868.]

The distortion in the form of the cornea known as staphyloma pellu-
cidum, or conical cornea, presents the symptoms of extreme myopia, but is
very imperfectly corrected by concave glasses. The curve has been meas-
ured by Dr. Leber, at Prof. Graefe's instigation, and found to be that of a
hyperboloid, and while, in a certain case, at the apex the radius is as short
as 2 mm., at the lateral parts of the staphyloma it was 10 mm. The
radius of the normal cornea is about 8 mm. The apex is often more or
less opaque, but only in the most prominent cases : during the early stages
the apex remains transparent. Sometimes the ectasia is the result of an
ulceration, but the majority of cases have never had any such cause. The
only explanation is, that the middle of the cornea becomes afi*ected by a real
atrophy; upon what this may depend as a remote cause is unknown. The
means of relief hitherto in use have been suitable glasses, both spherical
and cylindrical, the latter afi'ording considerable diminution of the irregu-
lar astigmatism which always exists; these combined with a stenopaic
hole or slit. For surgical treatment, frequent paracentesis, and a pressure
bandage, have been employed with slight advantage, and also two iris op-
erations, iridectomy and iriddesis, single or double. It is often true that
by none of these means does the patient obtain as much improvement in
sight as is desirable. Prof. Graefe has put in practise a method to which
he has already called attention. He endeavors to flatten the cornea by

OPHTHALMOLOaY.

543

producing a cicatrix and opacity upon its apex, and afterward to make an
iridectomy. He shaves off a bit of the summit of the cornea, about three-
quarters or one line in diameter, not so as to open the anterior chamber, and
touches tlie raw surface once in three to six days, very lightly, with a
pointed stick of laijis mitigatus (2 to 1). neutralizing the caustic carefully
with salt and water. Tlie treatment may continue for six or eight weeks,
and the vision for a time is made worse than before. There is also some
risk of the production of a greater amount of infiltration of the cornea
than is desirable, or, perhaps, of destructive inflammation. Dr. Meyer, of
Paris, treated a case under Prof. Graefe's direction in tliis way with satis-
factory result, and Graefe relates a case in which, at the beginning, vision
was -gL, and was improved to |. Before treatment he could read Jager, No.
16, at 3'', and afterward, with concave glasses, could read the same print
at 3 feet. The precise period at which the iridectomy is done is not indi-
cated.

15. — Ulceration of the Cornea in Young Children the Effect of Encepha-
litis. By Dr. J. Hieschbekg. [Berhner Klin. Wochenschrift. Xo. 31,
1868.]

This affection is rare, and attacks infants of two to six months old: the
trouble of the cornea is only an incident in the graver malady. While for
the first or second week the infants seem healthy, soon marasmus sets in,
the digestive organs are disturbed, there is no fever, none of the usual
symptoms of brain-disease. The cornere quickly become infiltrated with
wliitish-yellow substance, they rapidly fall into slough, suppuration takes
place, and may involve the entire globe. The disease assumes the aspect
of a profound impairment of nutrition of the membrane. The result is not
only loss of sight, but of hfe. The autopsy shows fatty degeneration of the
cells of the neuroglia and of the white substance of the brain, especially of
the hemispheres.

In the summer of 1867 six cases were seen in Graefe's clinique, and
then only a few single cases occurred, until the summer of 1868, when
within two months seven cases presented themselves. All presented sim-
ilar symptoms ; in one the disease continued two months before the fatal
termination.

lEIS.

16. — Anatomy of the Iris. [Fr. Merkel's Zeitschrift fiir ration, med. Bd.
31, page 136, 1868. Zehender Monatsblatter, 1868, page 254.]

This is an investigation into the question of the existence of the dilata-
tor iridis. Valentin Briicke, Budge, and Kolliker, have asserted its pres-
ence— others, and among the latest Grtinhageu, have denied it. Dr. Mer-
kel used a saturated solution of oxalic acid in water to remove the layer
of pigment on the back surface of the iris, and says that in a rabbit's eye the
connective tissue after fourteen days will be so transparent as to make it
easy to see all the other elements of the iris. He recognizes the radiating
fibres as muscular, but admits that they form a very thin layer — their cells
are long, and sometimes almost equal to the radius of the iris — they are
grouped in bundles from their origin at the ciliary margin — the bundles are
connected with each other by single fibres or smaller bundles, which cross
over from one to another. These transverse bridges become stronger and
thicker as we approach the sphincter, until finally the radiating direction
is lost in a reticulum of fibres running in every way. Out of this network
the fibres may either bend into a circular course or unite with the sphincter
at nearly right angles.

In man the radiating muscular fibres do not unite in bundles as in the

544

EEPOKTS OK PEOGEESS OF MEDICINE.

rabbit, but constitute an unbroken layer, AYbicb, without forming a net-
work, passes into the sphincter by a few processes.

It must be added to the above — that Griinliagen, having tried Merkel's
mode of investigation, is still unable to convince himself of the existence
in mammalia of a dilatator pupillaa.

CATAEACT.

17. — A71 Improved Method of Extraction of Cataract with Results of 107
Operations. By J. K. Wolfe, M. D., with Illustrations, pp. 71, Lon-
don, 1868.

Extraction of Hard Cataract a Cross-section. By Dr. H. Kijchlee, pp.
37. Erlangen, 1868.

Report of a Second Hundred Extractions of Cataract the Linear Sec-
tion at the Sclerotic Margin. By Dr. H. Knapp. [Archiv fiir Ophthal-
mologie. Bd. xiv., 1. s. 285-317.]

The above citations indicate the interest which is felt among ophthal-
mologists in the treatment of cataract. No less than three new methods of
extraction are brought forward. One certainly claims the merit of original-
ity, viz., that in Avhich the section is made transversely across the middle of
the cornea, including the limbus at each end. The capsule is opened by a
small sharp hook ; and the lens expelled by pressure on the globe, which
may or may not be combined with the use of the hook in separating the
lips of the wound — of course the lens must make a quarter revolution in
coming out. The author asserts that there is no difficulty in bringing out
even large and soft lenses quite clean.

Another peculiarity of Dr. Kiichler's method is the bandage which he
applies, which is double-headed, and makes many turns over both eyes,
and is finally made immovable by being enveloped with a few turns of
coarse lace (perhaps mosquito-netting is the thing), and smearing the whole
with a thin layer of plaster of Paris. In this solid helmet the head re-
mains for six or seven days.

Of course a scar remains on the cornea, directly across the pupil. The
author details various experiments to show how little interference with
sight such a line will cause — much will depend on the width of the scar
compared with the size of the pupil.

The results in twenty-eight operations are as follows: In eighteen per-
fect sight, five able to read coarse print, four obtained a little sight (these
were all complicated cataracts), one suppuration.

In ten cases, there was a secondary operation for artificial pupil ; six
times there was prolapse of vitreous at the operation; in seven, there was
a considerable residuum of cortical matter ; in six, peripheral synechiaa
took place; in six cases, the cornea collapsed after tlie section, but this is
asserted not to prejudice the healing by first intention.

The author's reason for this operation is the great facility with which
it can be done. His results are scarcely as good as those of modified linear
extraction, and the number of his cases too small to cover all the possibil-
ities of accident.

An interesting fact is, that in 1861, when he did this operation for the
tfirst time, and on an eye which had extensive posterior synechioe, he in-
roduced a suture into the apex of the cornea, which he allowed to remain
four hours, and then removed — the wound seemed at that time partially
united, and subsequently did well. Another remark may be made, viz,
that this operation is linear extraction in the purest sense — the section
being on a great circle of the globe.

Dr. J. A. Wolfe, of Edinburgh, reports one hundred and seven opera-
tions by a method which he describes as peculiar to himself; but we fail

OPHTHALMOLOGY.

545

to find in it featnres witli which we have not been familiar. He makes au
iridectomy npward six weeks before the extraction ; he makes a section
at the margin of the cornea, which is one line longer than one-third of the
circumference — the chord of the arc is 5"' or eleven millimeters. He
does this with a narrow Beer's knife: at the apex of the section he turns
the blade, so as to leave a conjunctival bridge, which he divides with scis-
sors. The subsequent steps are as usual. The operation is like that of
Desmarres, save the precedent iridectomy. His results are good, as
shown by the following table:

Senile.

Trau-
matic.

Glauco-
matous.

Total.

107

Results of operation, as respects healing: successes 103, failure 4=107.
Results as regards sight: successes 90, failure 11=107.

18. — Prof. Geaefe, in Archiv fur OplitJialmologie^ Bd. xiii. ii. s. 549-566,
gives an account of his present mode of effecting the expulsion of the
lens and also makes incidental observations on certain points in the
operation.

At the time of writing this article, which was in the latter part of 1867,
he had added to his previously published cases two hundred and thirty
operations — these having been done in the preceding eight months. To
all of these he applied the method of expulsion which he calls the pushing
manoeuvre.

In only two cases was he obliged to use a traction instrument within
the eye — ^in one of these the wound was too small, in the other the vitreous
escaped during the section. The modus operandi is as follows : The lids
are still kept apart by the spring speculum, and now that the last step of
the operation is to be done, the fixation forceps are removed from beneath
the middle of the cornea, and applied at a point V" to lines to the
nasal side, so as to be out of the way of the spoon. The spoon is of hard
rubber, highly polished, with a narrow bowl, bent on the shaft at a pretty
sharp angle, and somewhat elastic. Its convex surface is applied to the
lower edge of the cornea, and the upper part of the rim pressed against
the limbus, the bowl being turned half upward. While making steady
pressure, he moves the spoon a little upward, for the distance of about V,
and during this movement, the edge of the lens appears in the wound. The
convex rim of the spoon is now made to press toward the centre of the
eye, but as the lens emerges more and more, the line of pressure is corre-
spondingly changed so as to follow after it. The force acts more and more
in an upward direction, and finally comes to lie at a tangent to the surface of
the cornea. In fact, the spoon pushes the lens out of the eye, and does
not cease its function until all the lens, including cortex, is expelled. The
fixation forceps must not make the least pressure, but is kept in use until
the act is completed — the same is true of the speculum.

The amount of force needful is various in different cases — there is great
difference in the tension of eyes after the section has been made. In some
a mere touch of the spoon suffices. In others the cornea collapses, and the
spoon must be buried deep in the eye, to procure the needful expulsive

546

EEP0ET3 ON^ PROaEESS OF :MEDICI]S'E.

force. It seems as if serious damage were being inflicted on the cor-
nea, but experience proves the contrary. That the cornea does not suf-
fer, either by loss of epithehut)i or by contusion, has been satisfactorily de-
monstrated. As to loss of epithelium, no abrasion has ever been discovered.
As to injury by contusion, Prof. Graefe felt some anxiety. He noted, in
twenty-eiglit operations, that "the spoon, to be eftective, must be firmly
pressed on the cornea," and in seven of these cases adds the qualification
that the pressure is " ad maximum." In the seven specified cases, the heal-
ing was perfectly normal, and out of the twenty-eight cases, tliere were
but three which had any disturbance — of these three, one had a perfect
result, one a half result, and one doubtful. In this way the spoon may be
considered innocuous to the cornea.

Prof. Graefe keeps the fixation forceps in his own hand, and does not
deem it needful to press with a spoon on the posterior hp of the wound,
to aid its opening. He thinks the lens itself, acting like a wedge, the best
dilator of the wound.

He assigns as the proper lengtli of the section a measurement of b'"^
from one angle of the wound to tlie other, this being the length of the chord
of the arc. He does not now make the wound quite so jDerpendicular to the
sclera as formerly, but permits it to be a little more oblique. By this
change the height of the flap, which is the distance between the middle of
the arc audits chord, instead ot being i'" or becomes V", almost 1 mm.
Prof. Graefe acknowledges the truth and merit of the investigations of
Adolph Weber (which were reported in the February number of this Jour-
nal in 1867), to the effect that a hnear wound closes more accurately than
a flap wound. The wound on its inner surface will measure 4f' about
ten mm.

The excision of the iris should be made deep in the wound, and its
whole length. This must be done even when the iris does not spontane-
ously prolapse. The deformity of the pupil, produced by entanglement of
the iris at the angles of the wound, is more injurious to sight than the
fullest degree of coloboma which iridectomy can cause.

The capsule must be torn to the fullest possible degree.

In these two hundred and thirty cases, prolapse of vitreous has been less
frequent than before — it happened only nine times— less than four per
cent. In three out of the nine, the escape occurred at the section, and
was caused by synchisis of the humor.

The removal of cortical matter has been very easy and complete by the
pressure of the spoon, and if it be noticed that the surface is disposed to come
off of the lower part of the lens, the spoon must be reapplied at the lower
edge of the cornea, and the pressure repeated in the same way as before.

The total result is declared to be better than in the cases previously re-
ported, both in regard to healing and sight. Prof. Graefe's first operation
was done May 19, 1865. In the Archives, Bd. xii. ii. s. 151 (1866), he
gives the number of his operations at three hundred — and the results in
sight to be ninety per cent. (v.=^ to f), that four per cent, would by secon-
dary operations come within the category of perfect residts, that is, have
\ and better: — the remaining six per cent, consist of total losses and
imperfect results.

Now that the experience of this operation in Prof. Graefe's hands has
risen to between five hundred and six hundred cases, and perhaps more,
we may hope for statistical statements of great reliability ; and, without
doubt, no other method of extracting cataract can exhibit similarly brilliant
triumphs.

An interesting statement is given, in a foot-note, respecting the compar-
ative advantages of flap and linear extraction. In forty patients in whom

^OPHTHALMOLOGY.

547

on one eye flap extraction had been done with bad success, Prof. Graefe
has done modified linear extraction on the other eye with entire success,
save in two instances — one a total loss, the other a half result. In nine
cases, where flap extraction had been done sucessfnlly on one eye, modified
linear extraction was done on the other with perfect result. Eight of these
patients declared their preference for the last operation, because the after-
treatment was less burdensome — sight in the two eyes about alike. The
one, who preferred flap operation, did so because his eye, operated on
by Graefe's method, was more dazzled than the other, yet its vision was
sharper.

19. — Vofi Gvaefe^s Method of Extracting Cataract^ and the Advocates of
the Corneal Section. Bv Dr. J. Jacobsox. [Archiv. fur Ophthal., Bd.
xiv., 11, 247.]

The title of this article suggests a polemic character, and such, in part,
it is. Dr. Ilasner has published several bitter attacks on Graefe's method,
which have been replied to by Graefe. In Dr. Jacobson's espousal of the
modified linear extraction the operation has gained its most brilliant con-
vert. He first pointed out the importance of a scleral section, and of a
large iridectomy, but made a flap. His residts were the best ever published
up to that time. Xow he modestly gives up his own mode for Graefe's, in-
sisting strenuously on the scleral section of suflicient size, on a broad iridec-
tomy up to the ciliary attachment, and prefers to give chloroform.

He shows by cases how little disads'antage to sight results from the
coloboma. and admits that certain dangers are almost impossible by this
operation which belong to his own method, and much more to corneal ex-
traction. The chief advantage of Graefe's mode lies in the indisposition of
the wound to gape, like a flap-wound, whether in the sclera or cornea.

Dr. Ivnapp gives an accoimt of a second series of 100 extractions by
Graefe's method, the results as respects sight being :

Total loss 2

Imperfect result (v. = -^^ to -j^) 12
Perfect result (v. = -l" to -jL ) ye

Of the second category. Dr. Knapp says at least 7 would, by absorption
of the remaining lens matter, so far improve as to pass into the third class,
and give the result : total loss, 2 per cent. ; imperfect result, 5 per cent. ;
perfect result, 93 per cent.

The section which the author makes is such that puncture and counter-
puncture are in the sclera, as close to the iris as possible, the middle of the
cut approaching the transparent cornea within |- a millimeter, but never
closer, the greatest length being 9 to 9^ millimeters, measured in a straight
line from one angle of the wound to the other, and at its ioner surface.

This opening is sufl&cient for the expulsion of the largest cataract, whose
dimensions never exceed 9 mm. in equatorial diameter, and 4 mm. thick-
ness. Dr. K. goes into a mathematical discussion to prove that a wound
in the sclera, whose opening is 9.5 mm. long, will permit a gaping of 4 mm.,
and in so doing will be made no shorter than 9 ram. The length of the
arc, of which 9.5 is the chord, will be 10.14 mm.

This measurement pertains to the inner lip of the woimd. To this
must be added the thickness of the sclera, which is stated at 1.3 mm., and,
being doubled, we have 9.5 mm. -f 2.6 mm. = 12.1 mm. for the length of
the outer wound taken as the chord of the arc.

The usual diameter of the cornea is 12 mm., and it follows that the
wound made by Dr. K. is situated in the sclera, so that a line dropped
perpendicularly from its extremities would totich the cornea as a tangent.

The limited number of suppurations is ascribed to the fact that the

548

EEP0ET3 ON PEOGTEESS OF :MEDICnrE.

wound is exclusively sclerotic. This, however, has the effect of causing
prolapsus of vitreous humor to a greater or less amount, 18 times iu the
100 cases. In explanation of this frequency of this accident, he says that
oftentimes the middle of the section was at 1 mm. or more rather than
^ mm. from the edge of the cornea. In 6 of these cases portions of lens-
matter were retained in the eye.

In 10 other cases, making in all 16 times, portions of lens remained be-
hind. This makes a total of 28 times tliat the operation was complicated
by untoward occurrences. It must also be observed that Dr. K-. was very
rigorous in his search for remaining lens-matter, looking for it by oblique
illumination.

In 72 cases the operation was perfectly smooth. In 84 cases, the heal-
ing was entirely satisfactory.

In 9 cases iritis occurred. Of these, 2 were after perfect operations; 5
after loss of vitreous. In these vision varied between i and and with
a chance in the worst for improvement by secondary operation. In 3 cases
secondary hsemorrhage occurred. Vision attained was from -|- to In 2
cases the vitreous was found by the ophthalmoscope to be hazy, while the
operation had been good ; vision, i.

The 2 suppurations occurred, one in an old man with Morgagnian cata-
ract, the other in a healthy woman, 52 years old. The operation was per-
fectly satisfactory.

The average time of treatment for the 100 cases was 17.8 days. The
number of secondary operations is not given. Iridectomy or extraction of
capsule is said to have been indicated not more than 5 times. On the
.other hand, discission of delicate opacities was done in 10 cases, and, imi-
tating Mr. Critchett and Mr. Bowman, done within three weeks of the
operation, and safely.

Dr. Knapp carefully analyzes his cases to ascertain what causes are
most active in producing bad results, and the most iniurious he finds to be
the retention of lens-matter in cases of prolapse of vitreous. The simple
retention of lens-matter damaged the healing in only 2 out of 10 times, by
causing iritis, and sight in 6 was less than -f; in the remaining 4 it was bet-
ter than 1.

Prolapse of vitreous caused no disturbance in healing or sight in 6 out
of 12 times. In rhe other 6 cases sight ranged from ^ to -^w- the
6 cases where both accidents occurred, viz., retention of lens-matter and
loss of vitreous, in 4 the healing was normal; in 2 iritis followed. Sight
in the 4 was from |- to in the last 2 was each

Dr. Knapp remarks that while the danger of suppuration is very greatly
reduced by making the section in the sclera, it is not entirely avoided.
For this reason he concludes that it is better to bring the middle of the
section up to within i a millimeter of the cornea, and perliaps nearer, be-
cause the lens will then escape more easily, the wound is more linear, and
prolapse of vitreous much less liable to take place.

He speaks favorably of discission of slight capsular opacities within a
few weeks after the operation. In this commendation uiany will be dis-
posed to wait further experience before venturing to adopt a suggestion
which is so much opposed to what good operators have hitherto considered
prudent. He is not sanguine about the good result of operations for re-
moving both lens and capsule together, which Pagenstecher and Wecker
have practised, and which Dr. K. has done a number of times. lie finds
that iritis, secondary hemorrhage, and chronic changes in the vitreous are
among its consequences.

lie has found the expulsion of the lens greatly facilitated by the hard
rubber spoon used to uuike pressure on the lower edge of the cornea. He
gives the fixation forceps to an assistant, with one hand makes pressure on

0PHTHAL3I0L0GY.

549

the lower edge of tlie cornea, and by a curette also presses on the posterior
lip of the wound. The assistant is cautioned not to drag on the eye. He
makes tlie iridectomy before opening the capsule, and does the latter very
thoroughly, but so as not to luxate the lens.

Many of his patients were discharged at a time when their sight was
still improving, and among his formerly reported cases he finds 10 with
v.=l, 1 with V. 1*0, becoming y.=1: and so with other cases. On the
whole, Dr. K.'s testimony in favor of Graefe's operation is extremely satis-
factory, because his results are good and his analysis exhaustive.

20. — Extrdction of Hard Cataract tcith the Capsule. By Dr. Feed. Beeg-
MAXX. [Archiv fur Ophthalmologic, Bd. xiii., 11, s. 383-397.]

This paper gives an account of 13 operations done by Dr. Knapp, 10 of
which were lenses of full size, requiring the use of the spoon, and 3 were
shrivelled cataracts which could be removed with forceps. The section
made upward, and chloroform not given. Loss of vitreous at the operation
occurred only 4 times, and once only in large quantity. xVnother difficulty
unexpectedly occurred, that 5 times the capsule ruptured in bringing out
the lens, and gave rise to difficulty in evacuating the cortical matter.

Dr. B. says that where the lens and capsule were extracted entire no
iritis followed, but this comparatively favorable statement is modified by a
remark in a late paper of Dr. Knapp, who has seen iritis ensue in such a
case.

Xot less than 9 times was secondary haemorrhage observed — happening
from the second to the fourth day. In 2 cases it was several times repeated.
The ciliary body was the probable source of the bleeding.

Opacities of the vitreous, both diffused and menibraniformi, were very
common and abundant.

The average time of treatment was 18 days. The vision in 6 was better
than -jiy, fi-om ^ to in 3 was ^ to in 3 consisted in mere percep-
tion of light. Such results do not encourage further trials of this method.
Yet it must be added that it is adapted to over-ripe cataracts in which the
central part of the capsule has become greatly thickened. And, secondly,
this operation becomes easier the older the patient, because the zonula
seems to become atrophied. But age of the cataract is not. the equivalent
of age of the patient.

CHOEOID.

21. — Tudercules in the Choroid. By A. v. Geaefe and T. Lebee.
[Archiv filr Ophthalm., B. xiv., 66th, i. s. 183-206. Soelberg -Wells.
Med. Times and Gazette, Xo. 914, January 4. 1868. Zehender
Monatsblatter, 1868, July, 218.]

Tubercular choroiditis was a term formerly applied to a peculiar sort
of inflammation, but, since Cohnheim drew attention to the occurrence of
miliary tubercles in the choroid, the term must be given up. The first to
notice and describe their occurrence was Ed. Jaeger, in 1858 {Zeltschrift
fiir Ration. Med. Jahrg.., 1, Xo, 2.) Galizowski, Mans, and Wells have
related cases. In the Berlin Pathological Institute, within fourteen months,
eighteen cases have been seen by Cohnheim. Both eyes are atfected, and
it would appear that the choroid becomes affected in no other form of
tuberculosis than the miliary. Herein, the ophthalmoscope may again
offer valuable diagnostic help to the general practitioner, in view of the
difficulties which often invest the recognition of miliary tuberculosis.
Prof Graefe gives the following points to be borne in mind as belonging
to choroidal tubercles: 1. They cluster about the region of the posterior
pole, the yellow spot, and the nerve. 2. They have a rounded form, and

550 EEPOETS ON PROGEESS OF 3IEDICmE.

are from |- mm. to 2.5 mm. in diameter. 3. The larger tbey- become the more
the color becomes discharged from their centre — there is seldom any in-
crease of pigment around them, although this has a few times been noticed.
4. Their prominence makes them conspicuous, especially when iospected
by the upright image.

Prof. Graefe details the history of a case in Prof. Griesinger's ward as
follows: A man 32 years old, who was dumb, had suffered four weeks
before entering the hospital with severe headache and phosphenes. At
the time of entrance he had fever and pain in the forehead; on the left
chest in front and above percussion tympanitic, behind and above dull,
all over the left chest breathing rough and occasionally tubular ; in the
right vesicular, breathing rather sharp. Slight facial paralysis on the
right side. The fever continued, the respiration a little accelerated, con-
sciousness became gradually dull; he would groan, gnash his teeth, etc.
Prof. Griesinger, from these symptoms, inferred the diagnosis of miliary
tuberculosis of the pia mater, and desired an ophthalmoscopic examination.
In both eyes there was extreme hyperaemia of the retinal vessels both
small and large, but no infiltration of the tissue. A few rounded spots,
varying from ^ to 1 mm. in diameter, as estimated with the inverted image,
were found not far from the optic papilla. They were of lighter color
than the adjacent fundus, from a pale pink to a yellowish or whitisii tint.
They could not be discerned to have any prominence above the surface —
but the examination was made under great difficulties. Patient died the
following day, and Dr. Cohnheim found old tubercales of the lungs and
acute deposit of miliary tubercles in almc :t every organ of the body ; and
.also meningitis tuberculosa with htemorrliagic encephalitis. In the eyes,
whose posterior portions alone could be removed, tubercular nodules were
found in the choroid ; in one eye 12, in the other 9. Many of these were
invisible to the ophthalmoscope, chiefly because they had not induced any
pigmentary changes and were very small.

Another case is related: A child 15 months old, who was suddenly
taken with coma and vomiting, after a slight diarrhoea : in the lungs, noth-
ing but slight catarrh; respiration rapid, irregular, pulse 100. The first
examination of the right eye disclosed nothing; but a few days after,
Avhen the left was inspected, 8 tubercular spots were found in it and 2 in
the right. They were ^ to ^ the nerve diameter in size, and of a pale-red
color with indistinct, border ; in no case was there abnormal pigmentation.
The child was comatose. An increase in the number and size of the tuber-
cles could be detected from day to day. Death ensued in a few days, and,
at the section, miliary tubercles were found all over the body — in lungs,
liver, spleen, kidneys, heart, lymphatic glands, choroids and in the me-
ninges of the brain. In the eye, no more than two nodules were found in
addition to what were observed by the ophthalmoscope — one very eccen-
tric, the otlier very small.

As to the microscopic relations of these deposits, nothing is said in
this article.

As an appendix, it is stated that Dr. Cohnheim, in his experiments
upon the inoculability of tubercle, has found in Guinea pigs that the de-
posit occurs in the choroid as well as in other tissues. The matter for
inoculation was taken from a cheesy tuberculous gland, and the animal
died after five weeks. Miliary tubercles were found in all the viscera.

Mr. Wells brought to the notice of the London Pathological Society a
similar case, which is perhaps the same which was by him submitted to
Mr. Yernon for microscopic examination (see Ophthalmic Hospital Re-
ports, vol. vi., 2, 162).

The following points may be selected from Mr. Vernon's report :

OPHTHALMOLOGY.

551

When the choroid was separated from the sclerotic, the spots could not be
seen through the thickness of the choroid. By low powers their connec-
tion with the larger vessels could not be traced. Under high powers it
was seen that the pigment epithelium was almost entirely absent over the
spots, but the elastic himina perfect. Beneath were large numbers ot
colorless cells of uniform size, closely packed together, each containing
one or more nuclei, and except that they were smaller, not to be dis-
tinguished from cells of pus or lymph. The outer layer of these cells
blended gradually with the stroma of the choroid, and cells of a like
character and appearance were scattered thickly amongst the dark pig-
ment-cells. At this spot, however, the cells were not so uniform in size;
here and there were larger cells full of nuclei, and the cell-walls could not
so easily be distinguished.

22. — Treatment of Iriclo-choroiditis. Tico Cases from the Clinic of
Prof. Ed. Juxge, St. Petersburg. [Zehenders Monatsblatter, Au-
gust, 1868, 239.]

The usual antiphlogi sties failing to check the disease, and large masses
of exudation appearing in the anterior chamber, recourse was had to
paracentesis. Tliis was done daily, if possible, and with marked accelera-
tion of absorption, and insprovement in the inflammation. It was done
from eight to ten times. Is"© accidents occurred, aud to one patient it was
not painful, to the other it was. TVhen this proceeding was adopted, all
other remedies, namely, purgatives and mercurials, were laid aside, except
atropia.

EETINA AND OPTIC NEEVE.

23. — Temporary Blindness in Typhus and Scarlatina. By Dr. Ebert.
[Berlin Khn. Wochenschrift, v. 2, 1868, In Zehender, March, 1868, 91.]
Dr. Ebert communicated to the Berlin Medical Society four cases of

transitory blindness in typhus and scarlet fever. In the one case of typlius
the subject was a girl ten years old, who, on the fourteenth day, had a co-
pious bleeding from the nose; the next day she was so blind as to be una-
IdIc to perceive light. This condition lasted about forty hours, and by the
third day vision was completely restored.

In the three cases of scarlet fever the blindness continued from one to
three days, and developed under sym])toms of acute intercurrent nephritis.
In one, on the seventeenth day, slight oedema of the face, feet, and back
occurred; urine scanty, dark, and highly albuminous : on the twenty- fourth
day vomiting, violent headache, pain over the eyes, and dehrium — the
urine red, muddy, and no albumen — sopor set in, and tonic convulsions for
a few minutes. The somnolence increased, urine and fasces voided invol-
untarily, and the next morning, with extreme headache, complete blindness
took place. There was no perception of hght until noon of the second day,
and on the third day both sight and intelligence were restored. During
the blindness the pupils responded to light, and when the sight returned
albumen reappeared in the urine. On the second day of blindness the
eyes were examined by the ophthalmoscope, but, besides a little sinuosity
of the vessels of the retina in the left eye, nothing at all could be dis-
covered.

One of the three cases was fotal ; in all, the symptoms were similar.
Dr. Ebert was disposed to consider the cause of the amaurosis to be oedema
at the point of origin of the optic nerves from the brain, analogous to
oedema observed in the lungs and skin under the same circumstances.
Prof. Graefe called attention to the fact that, during the period of blind-
ness, the pupil continued its activity. This implies that the interruption of

552

EEPOETS OIT PEOGEESS OF IklEDICIIfE.

oomniniiication lies between the corpora quadrigeraina and that part of the
sensoriuni which presides over the perception of light. The movements
of the pupils are to he explained as a reflex action, the perception of light
reaching as far as the corpora quadrigemina, hut not going beyond into the
deeper parts of the brain. In many severe and acute diseases, sudden
blindness may happen, and be permanent. The ophthalmoscope may not
tind any lesion for weeks, until at length atrophy of the optic nerves de-
clares itself. In these cases the pupil does not respond to the light, and
this always gives the prognosis a less favorable character. Not, how^ever,
so as to preclude the possibility of returning sight, because there are lesions
of the optic nerves and of the tubercula quadrigemina which may ulti-
mately disappear. Prof. Graefe would, therefore, attribute the blindness
in Dr. Ebert's cases, not to a lesion of the optic nerves, but of the brain, at
some point between the tubercula quadrigemina and the locality which
presides over perception of light.

24. — Double Amaurosis after Hmmetemesis and Intermittent Spinal Neu-
ralgia. By Dr. Jacobs. [Berl. Klin. Wochenschrift. Zehender, March,
1868, page 90.]

A woman, 42 years old, at the age of 36 was attacked with nausea,
pain in the stomach, and vomiting of blood, the quantity filling an ordinary
chamber-pot, and she fell into prolonged syncope. After two days, bloody
vomiting recurred, and the blood was voided per rectum. At this time a
pain of "unspeakable " severity occurred in the back of the neck, and lasted
several days. This was considered to be malarial, and relieved by quinine
. and opium. On the twelfth day after the hsemetemesis she began to com-
plain of loss of sight, the pupils were enlarged and reacted feebly to light.
The vision daily diminished, and after five days there was no perception of
light, the pupils large and immovable. Three weeks after the sight-trou-
ble began, the interior of the eye was ophthalmoscopically examined by
Dr. Warren, who found the retinal veins swollen, and in the retinoe were
black spots and apoplectic clots. After six years the patient was again
examined, and the optic nerve and retinoe were found atrophied. She re-
mains perfectly blind.

25. — Atropine Changes in the Optic N'er'ce^ and Eemarlcs upon its Normal
Structure. By Dr. Tn. Lebee. [Archiv. ftir Ophthal., xiv., 11, 164-
220.]

Without attempting a minute analysis of this elaborate article, the fol-
lowing points may be cited as having a general interest: It is well known
that atrophy of the optic nerve ensues after the most diverse affections of
the nerve-centres. But a special interest attaches to its occurrence in gray
degeneration of the posterior columns of the spinal cord, because the optic
nerve undergoes precisely the same alterations. Of the same nature is the
atrophy of the nerve in the progressive paralysis of the insane ; in them the
motor troubles have been shown by Westphal to depend on gray degener-
ation of the posterior columns of the cord. The same change takes place
in a part of the lateral columns in another class of cases, usually simply
called cases of general paralysis ; the lesion is styled chronic myelitis, and
consists in the development of granule- cells.

When both the optic nerve and spinal cord become thus affected, it can-
not be by simple continuation of tissue, as when the brain and optic nerve
are diseased. They are not so related to each other as to permit such con-
tinuity; on the other hand, each tissue must be regarded as being primarily
and independently the seat of the disease. It is hoped that a careful study
of the process in the optic-nerves may throw some light on its nature in
the spinal cord, whose structure is so much more intricate.

ophthal:mology .

553

The cases examined are described in their captions as follows, and this
serves to give a general notion of their character: Case 1. Paralysis and
imbecility ; chronic meningitis, with adhesion of the pia mater to the brain.
Myelitis (granule-cells) in a part of the lateral columns of the cord. Gray
degeneration of both optic nerves. Case 2^ Paralysis and imbecility ; com-
plete amaurosis. Atrophy of the brain, hydrocephalus, myelitis of the an-
terior, lateral, and posterior columns of the cord, gray degeneration of the
optic and olfactory nerves. Case 3. Softening of the cerebrum in several
spots; contraction of the left half of the body; insanity. Gray degenera-
tion of the posterior columns of the cord. Commencing gray degeneration
in the optic nerves, especially in the left.

In all these cases there were atrophy of the optic nerves, disease of the
spinal cord, and impairment of the mind. The psychical disturbance, in
the third case, due to the brain softening; the other two cases belong to
the category of spinal-cord disease in the paralyzed insane.

The lesions of the nerves may be summed up as atrophy of the nerve-
fibres, increase in the intermediate connective tissue or neuroglia, with or
"without increase of its cells, and development of granule-cells and amyloid
bodies. In the spinal cord the changes were the same, and, in situation,
presented further analogy; in both, cases the surface and outer layers were
farthest advanced in degeneration. In both the lesion takes place in dis-
tinct spots, and the bundles of atrophied nerve-fibres present similar ar-
rangements. In neither structure is there any evidence that the atrophy
of nerve-substance is due to extreme development of connective tissue,
such as would result from ordinary inflammation. It is true that, when
granule-cells are found in great abundance in the cord or brain, the condi-
tion is called myelitis and encephalitis— by analogy, the same condition in
the nerve must be styled neuritis; but as to the fitness of this nomencla-
ture Dr. L. does not commit himself — he merely points out the resem-
blance.

The only alteration in the blood-vessels is that their outer or fibrous
coat is increased in thickness, and often sclerosed. This is not always to
be seen, but sometimes strongly marked.

The ophthalmoscopic appearances in the first two cases were, a shallow ex-
cavation, opaque white color of the optic nerve — this the usual condition, and
depending on the comparative predominance in the papilla of connective
tissue. In the third case the papillae began to be whitened, but their level
scarcely changed. The gray degeneration had advanced to the lamina cri-
brosa, but as the papillfe were nearly normal, the faded color must be ex-
plained by the shrinking of the minute blood-vessels. It has be<en long
observed that signs of atrophy first make their appearance on the outer
half of the optic disk. This is explained by the anatomy of the papilla,
whose outer half is always flatter than the inner half; because the fibres
which radiate on this side go obliquely upward and downward to pass
around the macula lutea. On the inner side their course is more direct,
they are heaped in a thicker layer, and this half will not so quickly exhibit
a whitish decolorization as will the thinner inner half.

26. — Troubles of tlie Eye depending on Diseases of the Spinal Cord. By
Dr. G. Dujaedix-Beaumetz. [Paris, 1868, pages 46.]
In this little volume are brought together eight cases of chronic disease
of the spinal marrow, which were complicated by visual disorders. Loco-
motor ataxy is the usual spinal affection, while the eye-troubles are of three
classes, viz.: lesions of the optic nerves and retina; paralysis of the ex-
ternal muscles; disturbances of the pupil. The first two ai'e essentially
the lesions of the cord propagated to the optic and motor nerves; some-
times the fifth becomes implicated. The pupil is at first very small, may

554 EEPOETS ON PEOGRESS OF MEDICmE.

be distorted, while the iritic contractions are not impeded. Sometimes
both, sometimes only one pupil is affected. The phenomena may for a
time disappear, and afterward return. In explanation of this lesion, it is
stated by M. Donezan that, while the cervical gans^lion may, to the naked
eye, be changed, its microscopic structure is not altered, but the filaments
of the nerve were utterly degenerated. In other cases no such lesion could
be seen, and the cause must be found in the cord at the place where this
filament is given off. It is unimportant to the production of the oculo-pu-
pillary symptoms whether the anterior or posterior columns be diseased, it
is only needful that what is called the cilio-spinal portion should be af-
fected, and this lies between the last cervical and sixth dorsal vertebrae,
inclusive.

The attempt to trace a continuity or direct connection between the dis-
ease in the cord and that in the optic and other motor nerves of the eye
utterly fails. The same is stated by Dr. Leber (vide supra).

27. — AnatomiscTie Untersuchungen uber Glioma Retince. Von Dr. J.
HiRSOHBEEG. [Archiv. fiir Ophthalmdlogie, Band xiv., 2, seite 30-
102.]

Zusdtze uber Intraocularen Tumoren. Yon A. v. Graefe. [Ibid., xiv.,
2, s. 103-144.]

Fall von Caverndsem Sarcom der Aderlant. Von Dr. Th. Leber. [Ibid.,

xiv., 2, s. 221-227.]
Die Intraocularen ^eschwiilste. Von Dr. H. Knapp. [Seiten 223, 1868.]
Anatomical Investigations into Glioma RetincB. By Dr. J. Hirschberg.
Supplementary Odservations upon Intraocular Tumors. By Dr. A. von

Graefe.

A Case of Cavernous Sarcoma of the Choroid. By Dr. Th. Leber, [Ar-
chiv. fur Ophthalmologic.]

Intraocular Tumors., from Clinical Operations and Anatomical Investi-
gations. By Dr. H. Knapp. With seventy Illustrations and one col-
ored Plate. Svo, pages 223, 1868.

In the articles and treatise above designated we have an elaborate ac-
count of the most common forms of tumors which occur within the eye.
Dr. Hirschberg gives a description of the anatomical appearances of eight
eyes, which were enucleated by Prof. Graefe, and in which there was
glioma of the retina. Prof. Graefe offers observations founded upon an
experience, as he says, of about 150 cases of tumors growing within the
eye. Prof. Knapp gives a minute acccunt of fourteen eyes which he extir-
pated, and general remarks upon the whole subject; his drawings are very
clear, and the whole brochure is characterized by thorough treatment of
the subject.

We may attempt to convey only the salient features of the papers, and
rather as a digest of them all than by quoting particularly from each or all
of them.

The tumors which form in the eye are chiefly glioma, sarcoma, carci-
noma, and gummata. Sometimes these types are combined, and there are
other forms which occasionally occur. The most common are glioma,
which begins in the retina, and sarcoma, which belongs to the choroid.
The first of these is the disease which, in its extreme degrees, corresponds
to the old name of encephaloid of the eye, or fungus hcematodes; a name
which would cover any kind of protuberance which was greatly inclined
to bleed and to grow with rapidity. Of course, the advance of morbid
anatomy has rendered this term valueless in an anatomical sense. Glioma

OPHTHAKMOLOGY.

555

is a name first given by Virehow to a growth whose type is in the layer of
granuLir cells of the retina. Its distinctive elements are cells about as
large as the white corpuscles of the blood, with a large nucleus, and with
or without one or more nucleoli; they are embedded in a homogeneous
matrix, which, after a thne, appears fibrillated. Sarcoma presents varie-
ties of type, but is a tumor of firmer consistence, and contains round and
fusiform cells, which may be small or large, mingled with a fibrous inter-
cellular substance, and this in varying proportions. Dr. Knapp divides
sarcoma into the melano-sarcoma, the simple white sarcoma, the vascular,
and the inflammatory sa; ma. There is also described by Dr. Leber a
case of sarcoma with cav rnous structure.

In the anatomical sense, neither glioma nor sarcoma is a cancerous dis-
ease, although both may be mixed in the same growth ; for example,
Yirchow describes a case which he calls sarcoma carcinomatosum, in which,
besides the round and fusiform cells belonging properly to sarcoma, were
alveoli filled with large roand or polygonal cells packed closely together,
some colorless, others colored. The latter elements belong to the car-
cinomatous type. But both sarcoma and glioma are to be considered malig-
nant diseases, inasmuch as they may recur at the same spot, are liable to
occur in other organs, and are often fatal.

These growths in the eye have an interest for general pathology, because
they can be studied from their very beginning, and they may help to solve
the general question of curability, and, when removed early, there is en-
tire certainty that the whole of the disease has been gotten rid of.

Glioma is especially the disease of children ; it may afi:ect both eyes simul-
taneously or in succession. It is the most common cause of the visible
yellow reflex seen through the pupil called first by Beer cat's eye amau-
rosis. It is first made known by partial or total blindness, and by the
ophthalmoscope is recognized in the form of small yellowish nodules or
plaques in the retina. Xo inflammatory symptoms precede, and by this
fact the disease will be distinguished from similar appearances which
result from plastic choroiditis, in consequence of cerebro-spinal meningitis.
When the deposit has begun it steadily increases — it soon excites sub-retinal
effusion — it invades the choroid and fills up the vitreous — it extends outside
of the eye along the optic nerve. When it has filled the globe to a certain
point, it causes symptoms of irritation and tension, in a word, the phe-
nomena of glaucoma. It makes its appearance outside of the eyeball in
from one to three years. If this occur on the back part of the globe it is
difficult to recognize, until the movements are visibly impeded or the globe
becomes prominent. Before escaping fi*om the globe the glioma may
cause internal suppuration and atrophy of the bulb. To diagnosticate a
tumor within a phthisical bulb is not easy. On this point Graefe relates
an instructive case. A patient had had sub-retinal eftusion, afterward the
eye became glaucomatous, and during this period the eye was, of course,
very painful, and as atrophy ensued the pain did not relent. Then the
woman was sent to Professor Graefe for enucleation of the eye. He, from
the history, suspected the existence of tumor as the cause of the primary
sub-retinal eff'usion, and had his suspicions confirmed by the ensuing glau-
coma, the atrophy, the painfulness of the eye, and its peculiar physiognomy.
"When phthisis bulbi and tumor coincide, the globe has a pecuhar flattening
of its front portion, while the equatorial diameters remain as great as
usual. Very soon retro-bulbar growth takes place, and this gives the
atrophied ball a degree of exophthalmus.

It may be remarked, as Graefe states, that increase of tension, united
^v^th sub-retinal efiusion, gives strong reason for suspecting the growth
of an intraocular tumor, because sub-retinal eftusion, when caused by the

556 REPORTS ON PROGRESS OF MEDICINE.

ordinary lesions, is attended witli normal or diminished tension. Sarcoma
may give rise to phthisis bulbi, and Graefe thinks this tends to retard the
increase of the tumor, but such is not the effect on glioma. It extends
chiefly along the nerve, it is never regressive. It may undergo fatty de-
generation, partial calcification, and pigmentation from htemorrhage. It
contains a large number of blood-vessels. It soon involves the orbital tis-
sues, and, if the patient survive, may present an enormous mass of "protu-
berant and disgusting substance. It invades the brain, and may extend to
the spinal cord, as is related by Dr. Knapp in his sixth case. Metastasis
upon other viscera may take place, but is not so common in ghoma as in
sarcoma. Dr. Knapp has seen congenital glioma, has known four children
out of seven in one family to have it, and of his seven cases six were boys.
The prognosis is bad, perhaps not quite hopeless, if the eye be extirpated
early. Graefe insists strongly, and with great wisdom, on the necessity of
excising as much as possible of the optic nerve when the globe is enu-
cleated. He does this with a long slender curved knife, which is passed
deep into the orbit before the connections of the eye are severed. It
is much easier to cut the nerve thus, than to pick it up after the eye
is out; its end is concealed by the blood and muscles so as to be almost
indistinguishable. Dr. Knapp advises that, if the operation is not done
until glaucomatous symptoms have begun, we should not be content with
simple enucleation, but remove all the contents of the orbit; because,
at this stage the germs of glioma are almost certain to have been
disseminated in the orbital tissues. The disease is certain to recur in the
orbit if it have not been thoroughly extu'pated. We are not certain that
rigorous and entire ablation will protect the patient from a fatal issue
from subsequent appearance of the disease at some other point — in the
brain, in the diploe of the cranial bones, etc. But we do make it very
unlikely to reappear in the orbit, and Graefe, from the experience of about
fifty cases of glioma, urges the earliest possible removal of the eye.

Sarcoma has certain features in which it differs broadly from glioma.
It occurs in youth and adults, not in young children, does not affect both
eyes, except in very rare cases; grows slowly, one case remained stationary
ten years; is subject to regressive metamorphosis by fatty degeneration; is
very liable to development of pigment, constituting the melanotic tumor
of former times ; it imperils life, not so often from direct extension to the
brain, but by metastasis to remote organs, especially the liver, but also the
kidneys, spleen, etc. ; it extends outside of the eye along the sheath of the
nerve; it forms extraocular tumors, but may be completely extirpated
with more certainty than can glioma, and is not as liable to repetitions in
the orbit. • Graefe has seen three cases, in which the second eye became
bUnd by simple atrophy of the nerve, and in two of these cases melanotic
tumors were found at the base of the brain pressing in the chiasm. In a}l
forms of intraocular tumors the patient is liable to severe attacks of pain
from hasmorrhage, which suddenly increases the tension, as well as from
true glaucomatous symptoms — also sub-retinal effusion usually occurs at an
early period in both glioma and sarcoma. The refractive media remain
clear until inflammatory symptoms are set up.

The diagnosis between glioma and sarcoma is founded upon the age of
the subject, the former belonging to the very young, and the latter never
yet known to affect both eyes. Glioma begins as several nodules or a patch ;
has a ghstening, yellow color. Sarcoma begins as a single node, is -white
or black, less vascular, and overlaid by the retina. If there be post-retinal
effusion and the fluid turbid, a sarcoma may be entirely concealed for a
time ; but as it grows it pushes the retina forward in a bosselated form, and
shows more or less of its dark color. Dr. Knapp recommends the use of

MISCELLAIS-EOUS AND SCIENTIFIC NOTES. 557

direct siinliglit in a dark room, to make tlie case clearer, and tliis can do a
blind eye no liarm except by its heat. In glioma, if the retina be detached,
a bright, ochrey, yellow color shines close behind the lens, while a sar-
coma, if large and white, will have a more dim and gray color. The retina
in glioma is smooth, but in sarcoma floats about unless it have acquired ad-
hesion.

The diagnosis between gliomatous and sarcomatous tumors has a value
upon prognosis, rather than as regards treatment — removal being necessary
at an early period in both — but the prospect of saving life is much better
in sarcoma. In one case Graefe knows the patient to be surviving ten
years after the operation.

"We notice, among tlie patents recently issued at Washing-,
ton, one in the name of Dr. Alfred C. Garratt, of Boston,
Mass., for a new battery, for medical purposes.

Academy of MEDicmE. — At the annual meeting, held
January 7, 1869, the following-named officers were elected :
President, Dr. H. D. Bulkley ; Vice-President, Joseph C.
Hutchison ; Trustee, Dr. James L. Banks ; Committee on
Admissions, Dr. Wm. T. White, long term — Dr. John H.
Hinton, short term ; Committee on Medical Ethics, Dr. T. C.
Pinnell ; Committee on Medical Education, Dr. John C.
Dra23er.

Pathological Society. — The following-named officers
were elected at the annual meeting, held January 13, 1869 :
President, , Lewis A. Sayre, M. D. ; Yice-Presidents, J. C.
Hutchinson, M. D. ; E. Lee Jones, M. D. ; Secretary, George
Shrady, M. D. ; Treasurer, W. B. Bibbins, M. D.

National Institute. — Academy of Medical Sciences. —
This Academy was organized December 31, 1868, by the selec-
tion of the following officers to serve during the year 1869 :
President, Austin Flint, Sr., M. D. ; Yice-President, Wm. A.
Hammond, M. D. ; Secretary," D. B. St. John Eoosa, M. D. ;
Treasurer, Otis 'N. Fessenden, M. D. ; Council, Thomas M.
Markoe, M. D. ; Frank H. Hamilton, M. D.

5 58 MISCELLANEOUS AjSD SCIEOTIFIC NOTES.

This Academy is the seventh organized under the Consti-
tution of the JS'ational Institute. It is hoped that the Insti-
tute will be in full and perfect working order during the present
year, and that it will become, from the nature of the organiza-
tion, and the combination of so many elements, prominent
among our scientific associations, and an honor to this country.
Every effort will be made to give the broadest possible scope
to its workings, and make it in fact as well as in name a
national affair.

Dr. Usher Parsons died in Providence, P. L, December
19, 1868, at the age of eighty years. Dr. Parsons was a
surgeon in the Xavy in the War of 1812, and was present at
the battle of Lake Erie, under Commodore Perry. He was a
native of Maine, and entered the ^^avy at tlie age of twenty-
three. He resigned in 1823, and was subsequently appointed
Professor of Anatomy in Dartmouth College, but soon after
settled in practice at Providence, P. I., where for many years
he was regarded as the leading member of the profession.
He was well known as an autlior, and contributor to the
medical journals.

The death of M. Sichel, the celebrated ophthalmologist,
of Paris, is announced.

Dr. a. E. Peticolas, Superintendent of the Eastern Luna-
tic Asylum at Williamsburg, Virginia, and formerly Professor
of Anatomy in the Pichmond Medical School, committed sui-
cide, l^ovember 28, 1868, by leaping from a window in one
of the upper stories of the asylum. He had for some time past
been insane. Dr. Moore, late Surgeon-General of the Confed-
erate Army, has been appointed to fill the vacancy caused by
Dr. Peticolas's death.

Dr. CoHNHEm, well known to the profession in this coun-
try by his pathological researches, has been appointed Profes-
sor of Pathological Anatomy at Kiel.

Kemoval of the Entire Tongue. — Dr. Fen wick, of Mont-
real, Canada, assisted by Professor G. W. Campbell, of the

MISCELLAKEOUS AND SCIENTIFIC IS^OTES. 559

McGill University, removed the entire tongue on account of
epithelioma, on the 20th of N'ovember last. The operation was
speedy and bloodless, and qnite similar to that of Mr. K^unneley,
of Leeds, England. The month was entered from the floor,
the incision being in the median line, between the chin and
hyoid bone — the dissection being then carried between the
genio-hyoid muscles. Through this opening the chain of a
Chassaignac's ecrasenr was carried on a long curved needle
back to the base of the tongue, close to the epiglottis. The
process of cutting through the tongue with the chain occupied
nine and a half minutes. The case progressed most favorably,
the patient being able to return to his home, a distance of one
hundred and ninety miles, on the twelfth day after the opera-
tion. This is said to be the first occasion of the performance
of this operation in Canada.

.Mr. Sampson Gamgee has also recently performed this
operation at the Queen's Hospital, Birmingham, England, but
not with an equally favorable result. His plan of operation
differed somewhat from Dr. Fenwick's procedure. Following
the method proposed by Professor Regnoli, of Pisa, he made a
semilunar incision along the base of the lower jaw from the
symphysis outward on either side, to a point just anterior to
the facial artery. A second incision was carried vertically
downward from the symphysis to the hyoid bone. The tri-
angular flaps thus formed were dissected back. Entrance was
then made, as in the previous case, through the floor of the
mouth, and the tongue, being drawn down through the wound,
was transfixed at its base and removed by a double, or rather
by two ecraseurs cutting right and left. The extent of disease
was much greater than in Dr. Fenwick's case, and the patient
died on the ninth day after the operation.

De. Lespiatjd, one of the staff of the Hospital of Yal-de-
Grace, has recently inoculated himself with tubercular matter
fi'om a phthisical subject. The result of this heroic experi-
mentation will be looked for with interest ; but we cannot
help thinking that, whichever way it may turn, it will prove
of little ' practical value. Yillemin's experiments have now
often been repeated on the lower animals, and his conclusions

560

MISCELLANEOUS ANT> SCLEOTIEIC NOTES.

shown to be erroneous, or at least delnsive ; but this is proba-
bly the first instance of putting the human body to the direct
test of questioning by experimentation with tubercular matter.
We may readily applaud M. Lespiaud's heroism, but, at the
same time, the thought will obtrude itself — might not this
daring have been put to better uses ?

Doctors' and La^vtees' Patrons. — I have known many
people who would listen to any quack in medicine, and swal-
low almost any prescription, but never one who, when he found
himself involved in a legal difficulty, did not desire the advice
of a legal practitioner, and the best, too, whose services he could
command. A man, who is positive and dogmatical with his
physician or his clergyman, is apt to be submissive to his
lawyer, for the reason that when he meddles with the law he
knows that he is trifling with edged tools, which may cut deep
when he least expects it. " What are you going to do next ? "
said a client to an astute old lawyer in a neighboring city.

I am going," said the lawyer, " to file a demurrer." " A de-
murrer, and what is that ? " "A demurrer is what your Maker
never intended that you should imderstand!" — Geo. Wm.
Brovm.

Prof. Claude Bernard and Dr. Beown-Sequard. — The
chair of General Physiology at the Sorbonne, Paris, created for
Magendie, and so worthily filled by Claude Bernard, has been
transferred to the Museum of Natural History. By this means
a large laboratory will be secured — the government expending
100,000 francs for the purchase and completion of instruments
— and the professor be enabled to pursue his investigations and
exj^eriments publicly.

The chair of Comparative Physiology of the Museiun passes
to the Sorbonne, under the title of the Chair of Physiology,
and this it was understood would be given to Dr. Brown-
Sequard ; but the Lancet (January 2, 1869) announces that
the chair of Comparative Medicine, which had been created
for Rayer, and which, since his death, has remained unoccu-
pied, will be again put up, and given to Dr. Brown-Sequard,
under the new name of the chair of Comparative Pathology.

MISCELLAISTEOUS ATO SCIEOTIFIC NOTES. 561

Adyice to Students on taking- Kotes of Lectures. — Sur-
veying the careers of some of my old companions, I see
that some who took but few notes have become distin-
guished men of robust intellect ; and, on the other hand, I
see others, whose note-books would form a librar}'-, who have
settled down into the most humdrum routine — very types of
mediocrity. I therefore conclude that a man of many notes
will not necessarily make a man of note. What is the great
end of education ? It is not simply to heap up the greatest
amount of knowledge in the mind. The aim should rather be
to discipline the intellect, to give precision and quickness to
the faculties of perception and observation, to strengthen the
power of reasoning and comparing, so as to form just and
rapid conclusions upon the cases and problems that arise in
daily practice. " J'aime mieux," said Montaigne, " forger
mon ame, que la meubler." 'Now, this end is not attained, I
think, by trusting to note-books. The art of writing and the
invention of printing have even been thought by some to have
done doubtful service in strengthening tlie human intellect,
however vast may be their influence in extending and diftus-
ing knowledge. Plato said that, without this delusive aid of
alphabetical writing, " men would have been compelled to ex-
ercise the understanding and the memory, and by deep medi-
tation to make truth thoroughly their own. ]^ow, on the con-
trary, much knowledge is traced on paper, but little is en-
graved on the soul." Quintilian too said, "Memorise ple-
rumque inheeret tidelius, quod nulla scribendi securitate laxa-
tur." And I may enforce this argument by quoting the opin-
ion of one honored alike amongst women and amongst men,
and deserving of special honor in this hospital. Florence
Mghtingale says, " If you find it help you to take notes, by
all means do so ; I think it more often tames than strengthens
the memory and ojDservation." What I have said of note-tak-
ing does not apply to recording facts and observations. There
is no better means of training the mind to the habit of orderly
observation and precision in judgment than the methodical
practice of taking notes of cases of sickness. The power of
taking a case correctly, seizing the important points, and
avoiding that prolixity and repetition which render subsequent
study of the history tedious and repulsive, is invaluable to the
student and to the practical physician. Each well-recorded
case has its individual worth as an exercise and as a record of
facts ; and cases acquire an interest and impart instruction
which cannot be limited when their number affords the ma-
terials for comparison, and for drawing general conclusions. —
Fro7n Barneses Introductory Lecture at SL Thomas's Hosjntal.

562

MISCELLAT^^EOUS AND SCIEOTIFIC NOTE&.

Aphorisms fok Bathers. — The committee of the Eoyal
Hmnane Society have issued the following niles for the giiid-
ance of bathers. They were framed by Dr. Christian and Dr.
Sieveking. These rules, which are sensible and practical,
cannot be too extensively known :

" Avoid bathing within two hours after a meal.

" Avoid bathing ^vhen exhausted by fatigue or from any
other cause.

" Avoid bathing wdien the body is cooling after perspira-
tion ; but —

" Bathe when the body is warm, provided no time is lost
in getting into the water.

" Avoid chilling the body by sitting or standing naked on
the banks or in boats after having been in the water.

" Avoid remaining too long in the water. Leave the
water immediately there is the slightest feeling of chilliness.

" Avoid bathing altogether in the open air if, after having
been a short time in the water, there is a sense of chilliness
with numbness of the hands and feet.

" The vigorous and strong may bathe early in the morning
on an empty stomach.

" The young, and those that are weak, had better bathe
three hours after a meal. The best time for such is from two
to three hours after breakfast.

" Those who are subject to attacks of giddiness and faint-
ness, and those who suffer from palpitation and other sense of
discomfort at the heart, should not bathe without first consult-
ing their medical adviser." — Lancet^ Aug. 8, 1868.

A NEW Speculum Oculi especially adapted for Graefe's
operation (modified linear extraction) for Cataract. By
Charles A. Hart, M. D., of ISTew York City.

In the summer of 1867, while performing for the first time
Graefe's operation for cataract, I became very much embar-
rassed, and nearly foiled, during the formation of the flap, from
the heel of the knife rubbing, and catching upon the spring or
heel of the ordinary speculum I was using. This I had noticed
before with other operators, but up to this period had failed
fully to appreciate the annoyance and danger it caused ; but,
having once experienced it, I determined, if possible, to obtain
some safer and better appliance for separating the lids.

Not being able to find, among the numerous instruments
for this purpose, any thing to fulfil the required indications, I
devised the following instrument, composed of wire, with the

MISCELLATTEOUS AND SCIEOTIFIC NOTES.

563

heel or spring bent at an angle of about 45°, wbicli allows
it to rest alongside of the nose. The ^^^-^^^^^ f
extreme points of the retractors are VT^'^^y'"^^
left long, and furnished with a small >^
roughened bulb, by which the instru- I
ment is seized for adjustment.

The advantages of this arrangement over other ocular
speculums are —

First. The external commissure is left unoccupied by the
spring, so that a free space is afforded for the manipulations
of the instrument to be used.

Second. It is easier of adjustment ; the smooth springs
of the others frequently allowing them to slip from the fingers,
there being no roughened point to seize them by.

Third. It is equally applicable to operations upon the
nasal side of the globe, by simply reversing the adjustment.

Since devising the instrument, it has been used a number
of times by my friend Dr. Ceccarini and myself, in Graefe's
and other operations, with entire satisfaction, and I take pleas-
ure in offering it to the profession, feeling assured that its
merits, for linear extraction at least, w^ill recommend it for
adoption. The instrument is made by Messrs. Tiemann & Co.,
of this city.

Influence of Maertage on the Duration of Human
Life. — Dr. Stark has recently directed attention to the "In-
fluence of Marriage on the Death-rates of Men and Women in
Scotland." The following extract, quoted in the London and
Edinburgh Monthly Medical Journal of 1841 from the Bui-
letin Med. Beige of 1839, will show how many of the most
important of Dr. Stark's conclusions have been anticipated:
"Bellefroid, a Belgian physician, has recently published a
statistical memoir, in which he states that marriage greatly
increases the probability of life in both sexes. Women, he
says, who marry at twenty have a chance of life of eleven
years greater than that of those who remain single. The same
doctrine holds true, apparently, at all periods of life. The
probabilities of life for married men exceed those of bachelors
by nineteen years, thus exceeding that of the married female
by eight years — a difference probably caused by the mortality
resulting from childbirth. Thus it appears that, from the age
of twenty to thirty, the mortality of husbands to bachelors is

564 mSCELLANEOUS AISTD SCIEJ^TIFIC NOTES.

as one to twelve, while that of wives to spinsters is only as
one to six for the same period of life."

How TO TEST THE PuEiTY OF Watek. — It 13 of importance
to be able to test the quality of w^ater, not only w^hen for
special pui'poses absolutely pure w^ater is required, but even in
cases where such purity is not requisite, it may be of great
interest to ascertain of what the impurities consist. The fol-
lowing short notice of the tests for the most commonly occur-
ring impurities, will be welcome and useful to many of our
readers.

Pure Water must satisfy the following Conditions.

1. It must have no residue whatever when evaporated in a
clear porcelain or platina dish.

2. It must form no precipitate with a solution of nitrate
of silver, w^aich would indicate common salt, some other
chloride, or hydrochloric acid.

3. It must not precipitate with a solution of chloride of
barium, which would indicate a sulphate or sulphuric acid.

4. It must form no precipitate with oxalate of ammonia,
as this would indicate some soluble salt of lime.

5. It must not assume any dark or other shade of color
when passing sulpliuretted hydrogen gas through it, or mixing
it with the solution of a sulphide salt, as this would indicate
the presence of lead, iron, or some other metal.

6. It must not become milky by the addition of lime-water,
or a clear solution of sugar of lead, as this would indicate
carbonic acid.

7. It must not discolor by adding solutions of corrosive
sublimate, or chloride of gold, or sulphate of zinc, which dis-
coloring would indicate the presence of organic substances.
When boiling water with chloride of gold, the least trace of
organic matter will reduce the gold, and color the water
brown.

Results of these Tests,

1. Almost all spring-waters are found to leave a residue
upon evaporation.

2. Common salt is not only found in most springs and
rivers, but even in rain-water, many miles inland, when the
wind blows from the ocean.

3. Sulphuric acid and sulphates are found in many springs.
The Oak Orchard Spring, N. Y., for instance, is very rich in
the free acid.

4. AVaters from lime regions all contain lime in large
quantities, and, in fact, this is the most common impurity of
spring-waters.

MISCELLANEOUS AND SdENTIEIC NOTES. 565

5. Iron is contained in large quantity in the so-called
chalybeate springs; also copper and other metals are en-
countered ; lead incidentally, by the lead tubes through which
it often is made to pass.

6. Carbonic acid is the most common impurity, even dis-
tilled water is not always free from it. Water will naturally
absorb carbonic acid gas from the atmosphere, which latter
always contains it ; its principal source of supply being derived
from the exhalations of man and animals.

7. Organic substances are often found in the water of run-
ning brooks, streams, and rivers, and are of course obtained
from the vegetation and animal life in the water itself, and
from the shores along which it floats.

B.emar'ks,.

1. The healthfulness of water depends on the nature of
the residue left after evaporation; for many chemical and
other operations, where absolutely pure water is requii'ed, the
leaving of residue at once proves the water unfit for use.

2. The existence of small quantities of common salt in the •
water is not objectionable, it being not injurious to health.

3. Sulphuric acid and sulphates may be objectionable for
daily use; however, such waters are used medically to stop
diarrhoea and excessive tendency to perspiration.

4. Lime-waters do not agree with some constitutions, pro-
ducing diarrhoea and divers disturbances ; very small quanti-
ties of lime, however, are not injm-ious.

5. Iron is healthy, and is a tonic; in fact, this metal and
manganese are the only ones which may be used in large
doses, not only with impunity, but even mth benefit ; how-
ever, there is also a limit. Over-doses of iron may produce
diarrhoea, and slight eruptions of the shin, or pimples.

6. Carbonic acid is not objectionable when drinking the
water; on the contrary, it makes it more palatable, and most
mineral waters owe their reputation to this substance.

7. Organic substances are perhaps the most objectionable,
principally when decaying ; such watei^ may even propagate
diseases, and require careful filtering, or boiling, or both, to
make them fit for internal consumption. — Scientific American.

The Medical Aspects of a Fast Lite. — We do not mean a
life of excitement and dissipation, or a disregard of moral con-
siderations, but that species of go-aheadisni which we see in
its freest development, perhaps, among the Americans. In no
country in the world is the struggle for gain more actively
carried on than in the United States, and those who have
watched the habits of the commercial classes in London and

566

MISCELLANEOUS AND SCIENTIFIC NOTES.

'New York, declare that the industry of the former is as child's
play compared with the unremitting energy of the latter.
The number of New York lawyers and merchants who take
what Englishmen would call a vacation is said to be exceed-
ingly small ; and, according to the correspondent of the Dally
ifewSj they send their wives and families to the seaside or the
mountains, where they join them at night, or run down by rail
from Saturday to Sunday. The consequence of all this high-
pressure business energy, combined, as it frequently is, with a
considerable amount of excitement and anxiety, and a devo-
tion to iced drinks and whiskey, is an increased occurrence of
cases of nervous exhaustion, often ending in paralysis or
lunacy. It will be remembered that, during the period of
extreme heat at ^New York, there was a very unusual preva-
lence of heat-apoplexy, and if, as we are informed, ardent
spirits are consumed there very much as beer is in this coun-
try, w^e need not be surprised at it. As the late Sir Charles
Napier remarked, in reference to the maintenance of his own
health, the heat of India found no ally in the alcohol in his
brain. The moderate consumption of bitter beer and the
enjoyment of a thorough holiday in the country, or at the sea-
side for some weeks, by our city merchants, are undoubtedly
much more favorable to the maintenance of health and life
than the habits of their hard-working, energetic cousins of
New York. — Lcmcet.

Hovf TO Disguise the Taste of QummE. — Dr. K. "W.
Parke, of Mobile, Ala., says that chocolate will completely dis-
guise the taste of this medicine.

Let the patient obtain a few " chocolate drops " from the
confectioner, and he can take quinine in solution without tast-
ing it. Immediately after each dose is swallowed, put two or
three chocolate drops in the mouth and chew them up, and the
bitter taste of quinine will no longer be perceived. Chocolate,
perhaps, would answer the same purpose, but I have not tried
it. Any one can satisfy himself of the truth of the above
statement by filling the mouth wdth a solution of quinine, and
using the chocolate drops immediately after ejecting it. By
this simple means, the solution of quinine can be used, when
otherwise the pillular form w^ould have to be resorted to.
Oftentimes it is desirable to get the patient quickly under the
influence of the remedy, which could not be done where pills
are used. — Med. and Surg, Rejporter.

M. AuziAS Tueenne on Eabies. — This ingenious investi-
gator, in a paper lately read before the Academy of Medicine

MISCELLAIS-EOUS AND SCIENTIFIC NOTES. 5G7

of Paris, endeavors to establish a parallel between the phe-
nomena of rabies and those of syphilis. It will be remembered
that Marochetti considered that the virus, after having been
absorbed by the wound, enters the circulation, and then gathers
under the tongue. From the third to the ninth day little
vesicles or pustules appear on either side of the frenum linguss ;
they contain the virus, and are called lyssse. Marochetti be-
lie v^ed that by cauterizing these vesicles the further progress of
the disease might be stayed. Experience has not confirmed
his views ; but M. Turenne, starting from these phenomena,
has attempted to liken rabies to syphilis, and the lysssB to the
infecting chancre. — Lancet.

Distinguished Madmen. — Another and very different illus-
tration of Insanity in Fact is to be found in the long list of
the world's most distinguished statesmen, generals, philos-
ophers, men of science, poets, and musical composers, who
were at some period of their lives, and in some form, insane in
a medical sense.

" What thin partitions do our souls divide !
Great wits to madness nearly are allied " —

is true of all times and peoples ; and of no time or people more
true than of our own. Were we to confine ourselves even to
Scotland at the present day, or to our own memory or expe-
rience, it would not be difficult to draw up a long sad catalogue
of distinguished men — of great ones of the past or present —
whose reason became beclouded. But to do this would be
invading the privacies and outraging the proprieties that belong
to domestic life. The details of the existence of celebrities
who lived in remoter ages have been given to history, and are
public property ; and, in their case, there is not the same deli-
cacy required in quoting them for our example or purpose.
We cannot here, however, do more than give a few of the
principal instances that occur — instances of men whose names
are, and are likely to remain, household words :

Socrates (according to Plato and Xenophon), Luther, Shel-
ley, all had hallucinations. Joan of Arc gloried in her celes-
tial visions. Mohammed, Yan Helmont, Loyola, St. Francis
Xavier, St. Dominic, Swedenborg, Cordan, Lavater, Zimmer-
man— all had visions. Julius Caesar and l^apoleon were
epileptic ; Cromwell, Dr. Francia, Dr. Johnson, Beethoven,
were hypochondriacal. Chateaubriand and George Sand had
suicidal impulses. Paganini was cataleptic ; Moliere was sub-
ject to convulsions. Metastasio early suffered from nervous
affections ; Donizetti died in an asylum ; and Linnaeus died in
senile dementia. Peter the Great,' Sir Isaac E'ewton, Tasso,

568 MISCELLANEOUS ATO SCIEOTIFIC NOTES.

Swift, Cowper, Cliatterton, Lucretius, Charles Y., Riclielieu,
Rousseau, Fourrier, Pascal, Auguste Comte, Albertus Magnus,
were all, at some period of their lives, insane ; while Bernardin
St. Pierre and St. Simon were also probably so. — Excelsior, or
Murray Royal Institution Literary Gazette.

Detection of Arsenic in Cases of Poisoning. — M. Buch-
ner has several times recognized the presence of sulphide of
arsenic in the bodies of persons poisoned by arsenious acid.
Certainly this fact has never been observed except where the
corpse has been in a more or less advanced state of putrefac-
tion ; the sulphurization would appear to be due to sulphuret-
ted hydrogen, a constant product of putrefactive decomposition.
The last observation upon this point M. Buchner has made was
upon the remains of a woman wdio had been poisoned eleven
months previously. The large intestine was in full decompo-
sition, and there were yellow marks uj)on the mucous mem-
brane, caused by a tine powder which could not be removed by
washing. This powder resembled the yellow deposit which is
produced in arsenical solutions by sulphuretted hydrogen ;
further, it gave the characteristic reactions of sulphide of arse-
nic. Examining now whether the arsenic had been adminis-
tered as sulphide, he concluded in the negative, for the follow-
ing reasons : The contents of the stomach and small intestine
being boiled with hydrochloric acid, and the vapors from the
distillation of the acid collected in w^ater, in a few minutes a
quantity of chloride of arsenic was obtained ; such would not
have been the case with sulphide of arsenic, notwithstanding
that this sulphide is not absolutely unacted ui^on by boiling
concentrated hydrochloric acid. The sulphide of arsenic being
insoluble in pure water and in acidulated water, it would not
be carried into the circulation, also it would* not be found in
the liver and spleen, both of which in this particular case were
saturated with arsenic. A part of the stomach and small intes-
tine, cut up and placed in the dyalyser with water acidulated
with hydrochloric acid, gave at the end of twenty-four hours a
solution containing arsenious acid in sensible proportion, a fact
proving that all the arsenic had not passed into the state of
sulphide. — Chemical News.

Advice to Students — The Importance of Keeping
Eecords of Cases. — Every student should keep a record of
his cases. But note-taking, to be of any service, is by no
means so easy as it appears. Like other things, it requires an
apprenticesliip. Johnson, referring to the numerous corrections
made by Milton in his earlier works, observes that " wliat we
hope ever to do with ease, we must first learn to do with

mSCELLAlSTEOUS AT^D SCIENTIFIC NOTES. 569

diligence" — a remark that is eminently applicable to note-
taking. To make a satisfactory report of a case demands
orderly arrangement and a good method, keen, careful, and
patient observation, and accm-ate description of symptoms and
phenomena ; and to these may be added intelligent apprecia-
tion of what is essential. The unpractised hand makes a sad
jmnble of a really valnable case by leaving out the important
and inserting unessential particulars ; and nothing but constant
practice will enable him to take such notes as will be useful
for reference at a subsequent period. The student will, perhaps,
best consult his own advantage by limiting his efforts to taking
three or four well-selected cases at a time, and following them
out thoroughly, whether to recovery or to a fatal issue. The
time absolutely required to enter the particulars of an impor-
tant case is very considerable. Take, for example, a patient
affected with renal disease. The report of such a case cannot
be considered complete, unless, in addition to the details of the
variations in the quantity, specific gravity, and chemical char-
acters of the lU'ine, thermometrical observations, and a careful
ophthalmoscopic examination have been superadded. But all
these require assiduous labor. "From one such case, neverthe-
less, the student will learn far more tlian from sauntering round
with the physician for a month. Evening work should con-
sist in reading diligently some sound and practical work on
the cases actually under observation. If this plan be diligently
carried out, the student will find at the end of a year that there
are few diseases or sm-gical affections which have not fallen under
his notice. Such a plan will enable him to avail himself of the
opportunities he now possesses of learning the mode of appli-
cation of the different ingenious instrmnents by which the in-
terior of the body is explored. The use of the ophthalmoscope,
the laryngoscope, and the endoscope he will find very difiicult
to learn in after-years by himself, and he will be puzzled to
describe or avail himself of what is actually under his eyes ;
while a few lessons from a good teacher will in a short time
give him such a grasp of the subject as will enable him readily
to pursue and extend it as opportunity offers. — Lancet.

Solvent Power of Glycerine. — The solvent power of
glycerine, upon several substances commonly used in medicine
and the arts, is as follows : One part of sulphur requires 2,000
parts of glycerine ; iodine, 100 parts ; red iodide of mer-
cury, 340 parts ; corrosive sublimate, 14 parts ; sulphate of
quinine, 48 parts ; tannin, 6 parts ; veratria, 96 parts ; atro-
pia, 50 parts ; hydrochlorate of morphia, 19 parts ; tartar
emetic, 50 parts ; iodide of sulphur, 60 parts ; iodide of po-
tassium, 3 parts; sulphide of potassium, 10 parts.

570

MISCELLAlSrEOFS A^B SCIEOTIFIO KOTES.

The late Prof. Serres, of Paris, has left £2,400 to the
Academie de Medeciue, the interest of which, every three
years, is to be given as a prize to the best work on general
Embryology, applied, as far as possible, to Physiology and
Medicine.

Fungi and Disease. — The question which is now on the
tajns in professional circles, and which it is of the highest in-
terest to obtain a satisfactory reply to, is : In how far do fungi
and disease stand to each other in the relation of cause to
effect ? Professor Hallier, Mr. Simon, Dr. Salisbury, and all
that school, believe implicitly in the influence of fungi as
causes of disease. On the other side, we have two very able
authorities in this country in Dr. Thudichum and the Pev. J.
M. Berkeley, who utterly deny the fungus hypothesis. 'Now,
it must be admitted that up to this time the advocates of the
fungus theory, on whom the omis ])r6bandi fairly lies, have
failed in all cases to do more than show the- coincidence of
fimgi and disease. But this is but small ground for the in-
ference they draw from the observation. As has been often
suggested, both the disease and the fungus may be coincident
terms of the same unknown condition. The crucial test is a
tolerably easy one. Let Dr. Salisbury and his party j)ropa-
gate their fungi, and then, by inoculation, reproduce the
disease with which the parent fungi were originally associ-
ated. This would convince every one. But really, till it is
accomplished, it is unwise to push too far a fascinating liypoth-
esis, which too sanguine practitioners may make the basis of
an unsound and therefore dangerous practice. — Med, Times
and Gaz.

A JSTew Galvanic Battery. — The Telegrapher says that a
new voltaic combination of great power has just been exhib-
ited to some of the learned societies of Great Britain. It is
the invention of Messrs. Dr. La Pue and Hugo Miller, and
has been designed for Mr. Gassiott. The elements consist of
small cylinders of pure zinc and chloride of silver.

In the battery shown, the cylinders were only three inches
long and about the size of a goose-quill, arranged, in two
ounce phials cut down to two-thirds of their length ; but a
series of ten such couples decomposed water with great ra-
pidity. By the chemical action taking place in the cell, the
chloride of silver is reduced and chloride of zinc formed.
The action proceeds so long as any chloride remains, for the
reduced silver adheres to the wire as a spongy mass, which
allows the liquid to permeate to any unreduced chloride.

MISCELLAl^^OUS ATO SCIEimriC T^OTES. 571

The first cost of such a battery will be considerable ; but
as the only loss will be a little zinc, it will be very economical
in working. M. Gassiott, it is said, is having a battery
of one thousand pairs constructed, of which, no doubt, the
scientific world will, in good time, hear and learn much. —
Scientific American.

Monstrous Berth. — The Berlin journals give an account
of a remarkable monster of which the wife of a joiner at
Schkeudnitz was delivered on the 26th of May. It was a
still-born child, apparently of normal length, but with a some-
what large thorax. Between the shoulders two well-formed
and shaped heads are to be seen, covered with hair ; the fea-
tm*es are well wrought, each head being on a rather long but
• strong neck, and between the two necks a third arm projects,
which is somewhat bigger than the two normal arms ; the
hand of that ann has two thumbs in an opposite direction,
producing the impression of two arms having been united in
one. One day before delivery, all the signs of a living
foetus had been observed. Tlie mother had borne several
healthy children, and in this instance, too, the time of preg-
nancy was perfectly normal. — Medical Press and Circular.

"We learn, upon reliable authority, that there is every pros-
pect that the attempt which is being made, to add an impor-
tant staple to the resources of the island of Jamaica, in the
cultivation of cinchonas, will be attended with success.
Under the direction of Mr. Bobert Thomson, operations were
at fii-st ^confined to propagation, which was undertaken in a
systematic way in the early part of 1866. At the present
time, as the result of the growth of cuttings and of seed fur-
nished by Dr. Hooker from Ceylon, there are about 25,000
plants in vigorous growth. In May, 1867, a score of Cinchona
siniarubra were transferred to a site of an altitude of 3,700
feet, when they were about six inches in height. At the be-
ginning of the present year, they had grown to that of three
feet. The larger number, however, of the 25,000 were in pots ;
500 only had been planted out at a height of 5,200 feet. Mr.
Thomson, we understand, is fully impressed with the opinion
that the cultivation of the cinchona will be highly remunera-
tive.— Standard.

Social Statistics of Exglaxd. — In the mean time the
publication of the annual statistics of the police department
give a very faint and imperfect idea of the condition of
society under the existing an-angements. In England and
TTales there are nearly one million of paupers. The wretched-

572 MISCELLANEOUS AT^D SCIEOTIFIC TfOTES.

ly poor, who are helped bj private charity, but are not upon
the rates, are a much larger number. The persons registered
as belonging to the dangerous or criminal classes are 112,403.
Of these the known thieves and depredators are 22,889 ; pros-
titutes, 25,619 ; suspected persons, 28,3Y8 ; vagrants, 32,558.
Of these various classes, 15,109 are under 16 years old. But
these figures really give but a partial idea of the extent of
these social evils, which no ten days' revolution can drive
across the frontier. But even this imperfect record gives some
curious results in its analysis. One might suppose that "the
social evil " would be rife in the large manufacturing towns.
It is the contrary. The rule there is early marriage or con-
cubinage. Women of known bad characters, and registered
as such by the police, exist, in proportion to the population, in
commercial ports 1 in 202 ; in the pleasure-towns, resorts of
the rich and idle, 1 in 243 ; agricultural towns, 1 in 296 ; Lon-
don, 1 in 573 ; in manufacturing towns, from 1 in 651 to 1 in
873. Perhaps the character of the towns engaged in the wool-
len manufacture is, upon the whole, the worst of any, as the
returns show 1 bad character in each 99 of the population.
Yet this amount of vice and crime does not affect one like the
vast amount of disease, poverty, and misery, found in all the
great centres of population, and which make life itself, to the
reflecting and philanthropic, a continual suffering.

The poor law, as a remedy for pauperism, is an admitted
failure. It has created a pauper class. It does nothing to
prevent and much to continue the pauper condition. It has en-
couraged improvidence, early marriage, and increase of popula-
tion. It has diminished parental responsibility, l^o country in
Europe has the same burdens of pauperism and crime. In sev-
eral Continental states, which make no boast of power and pros-
perity, or even of superior enlightenment, the entire population
are educated, industrious, and comfortably provided for. Why
need England, which has so much to boast of and boasts so
much, in these all-important social matters, drag in the rear
of civilization ? But there are some signs of amendment.
This is a season of self-examination and confession; let us hope
that it will be followed by repentance and reformation.

President IIaven, of the University of Michigan, in his
last report to the board of trustees, comments on the question
of introducing into the faculty homoeopathic professors, viz. :

I believe that good reasons do exist why a " Professor of
Homoeopathy " should not be appointed, and I believe that
all unprejudiced persons will be able to see them. I beg here
explicitly to state that I do not argue in behalf of the medical

MISCELLANEOUS AND SCIENTIFIC NOTES. 573

profession, or " Allopathy," or any particular class. I am not
conscious of any particular interest in any class or party, on
this subject. So far as I am personally concerned, it might be
more politic to say nothing on the subject, but, as a custodian
of the interests of the university, I must express what the in-
terests of sound education seem to me to require, irrespective
of part}^ or sect.

Observe, then, first, that we have no Professor of "Allopa-
thy" in the University of Michigan. This is no subterfuge,
but a solemn fact. If a grant of money was offered to the uni-
versity on condition that a Professor of Allopathy should be
appointed, I should be compelled to show the unreasonable-
ness of the condition. We do not want in a university pro-
fessors of special ideas or theories, who believe that their spe-
cial ideas or theories embrace all truth in their respective
schools, and that all outside of their special ideas or theories is
false and to be rooted up and condemned. You make the uni-
versity, by such a course, a place of strife and discord, and not
a place for the harmonious inculcation of all truth. What we
want in the department of medicine and surgery is a number
of professors who shall present all the subjects and all the in-
formation properly belonging to the science and art of medi-
cine and surgery. They should be, as they are. Professors of
Anatomy^ Physiology^ Pathology^ Sicrgery^ Diseases in Gen-
eral, Diseases of particular classes, Chemistry, Materia Med-
ica, etc., etc. — embracing the whole orb of the science and
art of medicine and surgery — but not Professors of " Allopa-
thy," " Homoeopathy," " Hydropathy," or any other special
theory ; and the graduates should receive, not a title — Ho-
moeopathic Doctor," or " Allopathic Doctor," or " Hydropathic
Doctor," or doctor of any particular kind, but simply the old,
time-honored M. D. — Doctor of Medicine.

This is no sublimated, unapproachable theory, but the only
proper basis of a university. The university does not establish'
a department of medicine and surgery in the interests of any
particular class of physicians, or in the interest of conflict-
ing classes of physicians, or with the special purpose of making
doctors of any particular kind, or of all kinds, but to teach the
science fully and broadly — not in conflicting schools and de-
bates, but, as far as possible, thoroughly — without reference to
local interests and partisan distinctions. Once establish the
precedent that every party in the world shall be recognized
by name, and have a professor bearing its jpa/rtisan name^
and irreparable injury is done to the university.

A FACT of some interest, if it be confirmed by further ex-
periments, has recently been announced by the French medi-

574 MISCELLA^TEOUS AND SCIENTIFIC NOTES.

cal jonruals. M. Teleplio Desmartis, a medical experimenter
of Bordeaux, has succeeded, it is said, in inoculating upon
plants tubercular matter taken from the human lung. The
result has been the production of a particular kind of myce-
lium. This leads M. Desmartis to establish a comparison be-
tween tubercle and sphacelia, or ergot of rye. — Lancet.

Fkom a recent Vienna journal we translate an item that
may interest our readers :

" Among the students attending the clinical lectures of Dr.
Politzer on aural surgery is a young American lady, who has
crossed the ocean for the purpose of devoting herself at the
Vienna University to the study of diseases of the ear, with the
intention of practising aural surgery as a specialty in her
native country. This young lady, 19 years old, is the daugh-
ter of a JSTew-York lawyer, and by diligent private studies emi-
nently qualified to pursue the career she has entered upon.
She is the first lady that has ever — though as an extraordinary
student {ausserordentliche Florerin) — been matriculated here,
and the present dean of the medical faculty. Professor Dr.
Briicke, deserves all praise for having permitted her at once,
disregarding all academic prejudices, to attend lectures. All
the blanks, matriculation and examination papers, had to be
altered to suit this particular case. Miss Laura M., a pre-
possessing personage, with modest demeanor, who, in her plain
but elegant toilet, shuns scrupulously all conspicuousness, fre-
quents diligently the otiatric lectures of Dr. Politzer, attends
besides several private courses on anatomy and pathology, and
spends several hours daily in the anatomical theatre dissecting.
Her associates have already become used to the presence of a
woman in their midst, and the more so as she combines in the
different manipulations and operations skill and assurance with
womanly neatness and tenderness."

Treatment or Stricture by the Magneto-Electric Cur-
rent.— Dr. Chadsey, of this city, has kindly furnished us the
notes of the case of stricture referred to by him at the Novem-
ber meeting of the County Medical Society, and reported in
the December number of this Journal :

When practising in the country, in the winter of 1844, I
was called several miles from my residence — Ballston Spa,
Saratoga County, New York — late in the afternoon, to see a
strong, healthy, hard-working, temperate man about 40 years
old. I found him in great distress, his bladder very much
distended, and that difficulty in micturition had existed for

mSCELLAlS-EOUS AND SCIENTIFIC XOTES.

575

over a week and entire suppression for two days. The cause
was hard work in getting out timber upon the mountains, and
exposure to cold while riding home at night. This had been
his daily employment for some time j^reyious. He had had
no gonorrhoea, nor had he receiyed any injmy other than above
described that I could learn. I immediately introduced a
common-sized silver catheter, and found a stricture of the
urethra about two-thirds of the distance from the end of the
penis to the bladder. The stricture was so firm that it re-
sisted all the efforts I dared to make to pass the catheter. I
tried a common-sized gum-elastic catheter, with like success.
I had no smaller catheters or bougies with me. The stricture
was very firm. It extended about an inch and a lialf. Above
it I could feel the ui'ethra very much distended with urine. It
was night, the snow deep, and no assistance or proper in-
struments for operating could be procm-ed before the next
day, and my patient would probably die before morning with-
out relief He had taken diuretics for several days with no
benefit. I placed his feet in warm water — applied flannels
dipped in hot water to the scrotum, sacrum, and abdomen —
bled him from the arm two pints. Injected warm olive-oil
and goose-oil into the urethra and pressed it hard against the
stricture, and tried to overcome the stricture with the catheter
repeatedly, but did not succeed in relieving liim. I had in mj
sleigh an electro-magnetic battery, made by Pike, of this city ;
one of the first he made, I think, as I had used it several years.
I had it brought in. I cut a small orifice in the end of the
gum-elastic catheter, introduced into the catheter a common-
sized steel knitting-needle properly bent, and introduced the ca-
theter into the lu-ethra up to the stricture^ — pressed the knitting-
needle through the orifice in the end of the catheter hard against
the stricture, applied the positive pole of the battery to the knit-
ting-needle, and the negative pole on the outside of the scro-
tum over and above the stricture, and let the battery play upon
it, gradually increasmg its force for about twenty minutes,
wlien I found a little urine escaping through the catheter
around the knitting-needle. I stopped the battery and re-
moved the catheter, when a small stream followed, which gradu-
ally increased in size until the bladder was evacuated of a
very large quantity of urine. The opening from the bladder
into the urethra had been so long distended that the sphincter
muscle did not perfectly contract but let the urine pass off as
it was secreted during the night. The next morning before
I left I introduced the silver catheter into the bladder, and
found the urethra where the stricture had been nearly as large
as at any other place between that point and the end of the
penis. "Wliile the catheter was in the urethra, and the end

576 MISCELLAT^EOtrS A]S"D SdENTIFIC ISTOTES.

jnst witliin the bladder, I let the electro-magnetic battery
plav upon the urethra and the sphincter muscle lightly as be-
fore, by connecting the positiye pole with the catheter, and
passing the negatiye oyer the external parts for about ten
minutes, when, after withdrawing the instrument, the sphinc-
ter contracted perfectly, and my patient said he was well.
I introduced the silyer catheter into the bladder once a day
for three days thereafter, and found no indications of a return
of the stricture. I saw my patient ten years thereafter, and
he had had no return of the stricture. I haye applied the
electro-magnetic current seyeral times since, in nearly the
same manner, to partial strictures, with success.

A Blow to the Fuxgus Theoky of Disease. — In a short
communication to the Centralhlatt^ Drs. Bergman n and
Schmiedeberg describe a crystalline substance, to which they
haye applied the name " sulphate of sepsin," obtained from
putrefying materials, and which, they belieye, represents the
proper poison of organic substance undergoing this kind of fer-
mentation. It is obtained by diffusion through parchment-
paper, precipitation with corrosiye sublimate from an alkaline
solution, removal of the mercury by silver, of silver by sul-
phuretted hydrogen, evaporation, and puritication of the resi-
due. Large, well-defined, acicular needles are thus obtained,
which are deliquescent in the air, and, exposed to heat, melt
and carbonize. They possess a powerfully-poisonous action.
A solution containing scarcely more than one-hundredth of a
gramme was injected into the veins of two dogs. Vomiting
was immediately induced, and after a short time diarrhoea,
which in the course of an hour became bloody. After nine
hours the animals were killed, and on examination their stom-
achs and large intestines were found ecchymosed and the
small intestine congested. Frogs could be killed in the same
manner. — Lancet.

Prof. Fischer, of Berlin, has been engaged in a series of
elaborate experiments, to test the value of this supposed dis-
covery. He was unable to obtain the crystals described by
Bergmann and Schmiedeberg. He arrives at the conclusion
that there are several putrid poisons in putrefying pus, some
of which are diffusible through animal tissue, others non-
diffusible ; and, although there can be little doubt that the
active principles of these poisons are bodies with distinctive
characteristics, yet they cannot be isolated by any means at
present known to science.

NEW YOKK

MEDICAL JOURNAL:

A MONTHLY EE CO ED OF

MEDICmE AND THE COLLATERAL SCIEifCES.

YoL. YIIL] JVL^CH, 1869. [Xo. 6.

Akt. I. — Itemarlcs on Di\ Say re's Paper entitled '''A
Nev) Operation for Artificial Hip-joint^ in Bony
Anchylosis^ By Louis Batjee, M.D., of Brook-
lyn.

Dr. Sayre's paper was placed before the profession
in 1863, at tlie meeting of the Medical Society of the
State of New York ; it subsequently made its appear-
ance in the public transactions of that body, and
also in pamphlet fonn.

The title was so striking, that it naturally attracted
my attention, as no doubt it did that of many who, like
myself, take an interest in the advancement of surgical
art.

After a careful perusal of the paper, I could not
helj) noticing grave discrepancies, nor withhold a pass-
ing remark on its pretensions, in the later edition of
my work on " Orthopedic Surgery."

578 EEMAEKS OX DR. SAYEe's PAPER, ETC.

That I hacl no specific desire to disclose tlie weak
points and the literary and professional errors of Dr.
Sayre's paper, is plainly evident from the fact that I
withheld my criticism four years, and inserted it in so
unpretentious a manner as not to invite particular at-
tention. No one, who is at all familiar with the inti-
mate relations which he and myself entertained for at
least a decade of years without interruption, can sus-
pect me of unfriendly feelings toward the author.

That the author has taken offence at my strictures
is painfully evident, from his late article, published in
the January number of the Neio Yorh Medical Jour-
nal.

To meet the respective charges of "false state-
ments," " detraction," and " slander," I find myself
under the necessity of placing my scientific estimate
of Dr. Sayre's pa]3er on record, leaving the adjudica-
tion of my offence to the profession at large.

Before entering upon my task, I wish to state here,
that I never received the letter which Dr. Sayre has
spread before the profession. I certainly agree with
him that the miscarriage of the said letter is entirely
inexplicable. Neither has any message from Dr. Sayre
been transmitted to me by the publisher of my book ;
nor do I think that an approach in either way could
have changed my views in reference to the "new
operation," or modified the criticism j)ronounced. It
is altogether preferable that the author should have sub-
mitted his grievances to the profession, and thus elicit a
more appropriate review on the merits or demerits of
his literary and surgical enterj^rise.

It will not be expected that I should pay any at-
tention whatever to the array of letters Avhich con-
stitute so formidable an appendix to the before-men-

REMAEKS OX DR. SAYEe's PAPEE, ETC. 579

tioned publication. These may be needful indorse-
ments for the author, but are of no material import to
the analysis upon which, the coin23laint is based. I
have only to deal ^vith the pamphlets which Dr. Sayi^e
had the goodness to send me.

It appears that on the 11th of June, and the 6th
of November, 1862, respectively. Dr. Sayre performed
two operations : one upon Robert Anderson, of Ken-
tucky ; the other upon Miss Susan M. Losee, of Buffalo,
N. Y.

These operations were undertaken for the ostensible
pui^pose of both removing the deformity caused by bony-
anchylosis of their respective hip-joints, and improv-
ing the locomotion of both patients, by the establish-
ment of artificial joints. The doctor claims that these
operations were novel and unprecedented in character
and orio'inal in desio-n.

The naivete with which Dr. Sayre sj^eaks of his
operation as evolving a " great surgical princij^le," and
a " new scientific fact," is j)ainfally noticeable by all
his well-Avishers ; and the audacity with which he
charges me with " slander and detraction," because of
my " false statements " and my " confounding " Dr.
Rhea Barton's operation with his, is certainly start-
ling.

According to Dr. Sayi^e's conception, Rhea Barton's
operation " was not intended to produce an artificial
joint, but simply to anchylose the limb in an improved
position."

I could refer him to the thii^d volume of the Kortli
American Medical and Surgical Journal^ in which the
article of Dr. Barton originally appeared. This alone
would be an unexceptionable defence against the im-
putations ^vhich the author has hurled at me. Inas-

580 EEMAEKS o:n de. sayee's papee, etc.

much, however, as that journal may not be conven-
ient to himself and to readers in general, I will refer
him to the excellent standard work of American Sur-
gery, by Professor Gross, which certainly graces or
ought to grace his library, as it does that of every
practitioner who lays claims to surgical proficiency.

In the first volume, and on page 1038, the author
will readily find the information, that —

1. Dr. Khea Barton's operation was performed in
the year 1826.

2. That he divided the bone throuo-h the o^reat
trochanter and part of its neck."

3. That twenty days after the operation the limb
was gently and cautiously moved in different direc-
tions," and

4. That the patient eventually " could not only ro-
tate the foot, but abduct it twenty inches, and carry it
backward and forward to a still greater extent."

In addition to this, I can further inform the author
• that this very patient of Dr. Rhea Barton retained the
use of his artificial joint for six consecutive years, when
it became gradually obliterated, though it had been in
constant use.'

Barton performed another operation ; Rogers ' fol-
lowed in 1830, in a patient forty-seven years old, in
which the success was so perfect that all the move-
ments of the extremity could be executed.

Textor the elder' performed this operation in 1841.
Pseudarthrosis ensued, but the patient died of pulmo-
nary tubermlosis six months afterward — a case almost
as successful as the second of Dr. Sayre.

^ Heyfelder's Resections, Vienna, 1861, p. 93.

Ried on Resections, p. 895.
' Heyfelder on Resections, p. 94.

EEMARKS 01^ DE. SAYKe's PAPER, ETC. 581

In 1847, Maisonneuve ' operated with tlie same
intent upon a young man eighteen years of age ; and
G. Ross"" in 1857, uj)on a woman twenty-three years
old. In both cases, the divided bones united firmly
by callus.

From the preceding quotations it appears that —

1. I am not guilty of any misstatement, con-
founding, detraction or slander ; and —

2. The very same ojDerations have been per-
formed for the very same purpose, at the same place,
and with almost the same technical execution, long-
before Dr. Sayre entered the professional arena.

I can well imao:ine that the author feels mortified,
not only at being deprived of the originality of the
operation in so unceremonious a manner, but also at
being instructed in the literature of his own language,
and acquainted with the merits of his own countryman
by a foreigner. But, Dr. Sayre having taken the ini-
tiative in this controversy, I could not spare him the
correction.

Most of the operators before mentioned exsected a
triangular piece of bone with regular surfaces. Dr.
Sayre claims to have so manipulated the chain saw,
that there were left, on one extremity of the divided
bone, a convex surface, and on the other a concave one.
But even in this " original suggestion" Professor Meyer,
of AVurtzberg,' has preceded the author by six years.
The practical value of the semicircular method is at
best very dubious, and offers no apparent advantage
over the triangular. The ensuing suppuration has
surely no respect for the author's mathematical finesse;

' Gazette des Hopitaux, 1847, p. 94.

Contributions to Orthopedic Surgery, Altona, 1858, p. 25.
^ Deutsche Klinik, Berlin, 1856.

582

EEMAEKS ON DE. SAYEe's PAPEE, ETC.

it will destroy and carry off tlie two liorns of tlie one —
as lias been experienced in botli cases j)ublislied — and
spontaneously round off' the surface of the other.

Again, the author claims to have chosen a new
location for the division of the bone. As far as I can
ascertain, all the surgeons who have preceded him in
the operation have selected a j)lace above the insertion
of the iliaco-psoas muscle. A few lines more, above or
below, cannot make any material difference, so long as
the lesser trochanter remains below the division.

All reliable authors insist, moreover, that the bone
should be allowed to form its new connection, and the
wound to close, before the establishment of passive
motion. For, as long as suppuration exists, the danger
of pyaemia prevails, and no prudent surgeon feels in-
clined to prolong this period by premature interference.

The undue haste with which the author disturbed
the process of repair on the tenth day after the second
operation (Losee), by passive motions commenced and
continued to the 1st of February, 1863, i. e., eighty-
four days, besides preventing the bones from coming
in contact,, was so daring a practice, and so entirely
beyond the province of all therapeutical maxims, that
disaster seemed inevitable.

In fine, the author claims, for both his operations,
" success and recovery." To estimate that " success "
and that "recovery," which is purported to have been
attained, it will be necessary to analyze minutely the
clinical facts which the author enumerates in his paper.

The case of Robert Anderson was taken in hand and
oj^erated upon, as already stated, on the 11th of June,
1862. The deformity was successfully overcome by
the operation. The wound healed kindly, and, after
the discharge of an unmentioned amount of sequestrated

EEMAEKS Oi^ DE. SAYEe's PAPEE, ETC. 583

* bone, tlie j)atient rei^orted liiinself well April 11, 1863.
This proves the recovery of tlie patient, with a straight
and useful extremity. Thus far the merits of Dr. Sap^e
are conceded. But, when he insists that he " succeeded
in establishing a pseudarthrosis," he either deludes
himself and others, or has furnished such fragmentary
evidence that serious doubts must necessarily arise.
The hospital records of Dr. Shaw simply prove that
the patient, with the aid of crutches, could walk on the
even floor of the corridor into the amphitheatre, sit
do^vn, and get up again.

Next, Anderson was examined by Dr. Sayre in the
latter part of December, 1862. This examination did
not furnish the very least accejitable proof of pseudar-
throsis. The letter received . from the j^atient shows
that he can use the affected liinb with a certain des^ree
of facility, and that he was well satisfied with the result
of the operation, as, indeed, he ought to have been.

How easily even distinguished surgeons may be
misled, is exemplified in the case of jMaisonneuve. When
he exhibited a patient, on the 19th of January, 1849,
to the Societe Chirurgicale of Paris, he did it under the
fullest conviction that he had secured mobility at the
place of operation ; this conviction was confirmed by the
locomotive feats of the patient, which were more perfect
than Dr. Sayre claims in the case of Anderson. Mai-
sonneuve was brought to acknowledge his error by Mi-
chon and Gosselin.' It was clearly demonstrated, beyond
the shadow of a doubt, that the movements of the
extremity concerned were executed by -the opposite
hij)-joint, the ilio-sacral synchondi^osis, and the spine ;
and that the femur was completely consolidated.

Barwell likewise bears testimony to the difficul-

^ Gazette des Hopitaiix, p. 54, 1849.

58 i EEMAEKS ON DR. SAYEe's PAPEE, ETC.

ties of discriminating between the movements per-
formed between the affected and substituted joints.
Under the caption of Anchylosis of the Hip-joint/ he
makes the following statement : A patient was in
Charing-Cross Hospital, at the end of the last, and the
beginning of the present year, in whom the mobility
was remarkably developed ; it was impossible to come
to any conclusive judgment until chloroform was ad-
ministered."

Being myself familiar with the adroitness with
which patients substitute other joints in place of the
anchylosed hip-joint, and aware that mistakes happen
with the best of diagnosticians. Dr. Sayre must pardon
me when I consider his statement, and the evidence
adduced, insufficient to establish the fact that pseu-
darthrosis was achieved in the case of Anderson.

For this very reason, I did not refer to Anderson's
case in my criticism. But my reticence shows only the
doubts I entertain in reference to the reality of pseu-
darthrosis, and should not be construed into a denial
or detraction.

In putting a " new scientific fact " upon record, or
giving to the profession the details of a " new, feasible,
and perfectly successful operation," the profession has
the right to insist on the most positive and accurate
proofs.

In the case of Miss Susan M. Losee, certain vital
points are obscure or ignored, and to others, of trifling
importance, superlative prominence is given. It is also
impossible to understand, completely, from the paper,
the chronological succession of events. If we gather
the truth from the vague statement, the operation was
performed on the 6th of November, 1862, and the fatal

^ Barwell oq Joints, London, 1861, p. 320.

HEMAKKS ON DR. SAYRe's PAPER, ETC. 585

catastrophe occurred on the I7tli of May, 1864. In
singular contrast with the dates given, is the publica-
tion of the reprint of the Transactions of the State
Medical Society in 1863.^

The author informs us that within " a period of
nearly four months," the patient had " entirely recov-
ered."

On the 20th of July, 1863, we have the additional
assurance that the new operation was perfectly suc-
cessful," and the patient free from all danger. But for
the singular ^' sequel," the operation would have been
one of unparalleled surgical brilliancy. In spite of this
statement, however, it appears that the wound was
like a volcano, sometimes quiescent, sometimes erup-
tive. Small fragments of bone were discharged a few
months after the operation. On the 20th of April,
" the wound became inflamed and puffed out." Two
days later an abscess formed and the " wound opened,
and a small, curved piece of bone escaped," which was
" quite rough and jagged." The day before the sin-
gular death, the wound again parted; and, on jpost-

^ By the courtesy of the Editor, I am informed that Dr. Sayre has cor-
rected the date given in the history of the case (page 356), from July 20 to
February 20, and that this correction will appear in the present number of
the Journal. It is somewhat singular that this discrepancy should have
escaped Dr. Sayre's observation until now, and that the article should have
three times been published with this glaring error. In. accepting this cor-
rection, I withdraw the strictures based on this point. The date of the
death is thus brought a year nearer the date of the operation, and, there-
fore, the chances for the occurrence of pyfcraia are proportionately in-
creased.

I am sorry to add that this correction, however, only produces a new
chronological and pathological discrepancy, for, on the supposition of the
correctness of the dates as now given, we find that she was suffering from
acute disease, and hepatization of the left lung, at the very time when we
may infer that she was beginning to use the limb, and to " bear nearly her
whole weight upon it."

586

KEMAEKS OX DR. SAYRE's PAPER, ETC.

mortem examination, a " small spicula and four fibril-
lae ( ! ) of bone lialf an incli in length, and as thick as
the lead of an ordinary pencil," were found.

The operation, in one sense, was indeed a perfect
success. A union of the bones, under the bold treat-
ment employed, was effectually prevented. It is pos-
sible that some exfoliation of the bones might have
occurred, even if perfect rest for a suitable time had
been observed. It is, however, very evident that " in-
creasing passive motion," and constant disturbance of
repair, must have materially enhanced the liability of
osseous decay, and furthered the unpleasant sequel."

The effort made to disconnect the death of the
patient from the operation and after-treatment, is ob-
viously unsuccessful.

The disastrous effects ascribed to the codeia ' and
the alleged transgressions of the nurse are not very
apparent.

That the ends of the bones were at no time sound,
is proven by the author's own record ; and that there
is exceeding danger from pyaemic infection, as long as
the osseous structure is decaying and granulating, not-
withstanding the temporary closure of the wound, is
admitted by every well-informed surgeon.

^According to the United States Dispensatory, by Wood and Bache,
ninth ed., p. 534, Dr. Gregory experimented with the nitrate of codeia,
in four and six grain doses, upon himself and upon his pupils, without pro-
ducing more than an " agreeable excitement."

"Barbier, of Amiens, administered codeia uncomMned in numerous
cases, in doses of from one to two grains." " In sufficient quantity, it in-
duced sleep without those marks of cerebral congestion occasioned by
opium."

From these statements, it is obvious that the convulsions of Miss Losee
have no connection whatever with the administration of codeia at one-
eighth and one-quarter grain doses — more especially the second attack,
which was preceded by only one dose of codeia, the one-eighth part of a
grain.

EEMAEKS ON DR. SAYEe's PAPEE, ETC. 587

The unfortunately superficial and cursory post-mor-
tem examination gives but little ground upon wliicli
to establish an opinion. The alleged disuse of flannels,
and the delinquencies of the nurse in the administra-
tion of codeia, cannot account for an acute tuberculo-
sis.

It must be taken for granted that the doctor had
fully satisfied himself in regard to the thoracic organs
of his patient, before the operation. The pulmonary
troubles of Miss Losee commenced suddenly, without
any premonition, on the 5th of February, 1864, and
terminated her life in two months and a half. The
disease is said to have taken a very acute course, and
in a short time obliterated the entire left lung, so that
no respiration could be detected on that side " (!),
cough very distressing, and no expectoration at any
time."

Notwithstanding the aggravations of a constitution
already enfeebled by a severe operation, the irritation
caused by sequestrated bone, the purulent discharge,
and the inevitable confinement, the patient rallied
and the pulmonary infiltration receded, while the apex
of the lung implicated became the seat of an abscess,
" which Dr. Flint thought was the result of an apo-
plectic effusion."

Whatever might have been the nature of the at-
tack as described, it was obviously unconnected with
tubercular disease. The clinical character of the case
is incompatible with the views of the author. Irre-
spective of the obvious causes, the lung-disease was too
sudden and rapid to admit of a tubercular interpreta-
tion. It is neither at all likely, nor demonstrated by
experience, that such an extensive tubercular infiltra-
tion could have occurred and afterward limited itself in

588 EEMAEKS 01^ DE. SAYEe's PAPEE, ETC.

sucli a circumscribed manner. Multilocular abscesses
were found in both lungs. These abscesses were
entirely sej)arated from eacli other ; they had no com-
munication with the bronchial tubes. During the de-
velopment of the disease, not the least expectoration
occurred. Pathological facts of such a direct character
cannot be covered over by a microscopic examination,
which at best affords a negative result in tubercular
disease, as the testimony of the most renowned micro-
scopists shows.

It seems exceedingly strange that, in this case, pub-
lished for the express purpose of demonstrating the
feasibility and practicability of a claimed netv opera-
tion^ the autopsy allowed should not have been a
thorough one. If the examination had not been un-
dertaken with a preconceived idea of the pathological
points, it is inex]3licable why the abdominal organs,
and esjDecially the liver and kidneys, were not care-
fully and minutely examined, and why the brain did
not receive proper attention.

Granting, for the mere sake of argument, that tuber-
culosis of an acute character did really destroy Miss
Losee, such a theory is not in the least degree incom-
patible with the processes of pyaemia, as the experi-
ments of Villemin and others clearly demonstrate.

Whether the convulsions preceding the death of
the patient were caused by uraemia, or by thrombosis
and emboli of the cerebral vessels, cannot unfortunately
be determined at this stage of the inquiry. Most of
the symptoms presented in the case of Miss Losee are
in every respect compatible with the views I have j)re-
viously expressed — and which I still hold — in regard
to the cause of death.

In reference to the specimen, but little remains to

E^klBOLIC DISEASES OF THE EYE.

589

be said. luasmucli as I have myself, with clue care,
examined its pathological character, I am fully able
to form and express an opinion without the spectacles
of others. I most emphatically admit that, with the
exception of some morbid appearances of the femur.
Dr. Sayre has fully succeeded in establishing an arti-
ficial joint ^vith its ordinary attributes, of which the
specimen is a very appropriate representative. But he
must pardon me when I utterly fail to recognize,
with him, all the physiological attributes of a perfect
hip-joint, and moreover an extra ligamentum teres.

Poetic coloration is obviously out of place in path-
ological anatomy.

Art. II. — Mnholic Diseases of tlie Eye, By H. Ki^^app,
M. D., of New York, late Professor of Ophthal-
mology at the University of Heidelberg.

(These remarks, in substance, were made before the New York Medical Journal Asso-
ciation, January 22, 1869.)

Our knowledge of embolic diseases in general is
yet of a recent date, but already it has thrown full
light on so many morbid processes, formerly quite
inexplicable, that it may with justice be called one of
the greatest acquisitions pathology has made in modern
times, and it alone would secure to the name of VircTiow
a prominent place in the history of medical discover-
ies. Soon after the invention of the ophthalmoscope,
" which crowns the forehead of Helmholtz (now Profes-
sor in Heidelberg) with the laurel of immortality,"
Professor Virchow j^rophesied that it must be possible
to observe directly^ with this instrument, emboli in tJie
living eye. Four years later the prophecy was realized by

590

EMBOLIC DISEASES OF THE EYE.

a third no less illustrious representative of tlie German
school and of medical progress, that of Professor Vo7i
Graefe. It is not without intention, gentlemen, that I
pronounce these glorious names, for only some five or six
weeks ago I had the honor to listen, in the New York
Academy of Medicine, to a lecture on Medical Progress
in the Present Century, and therein not one German
investigator was mentioned. Despite these omissions,
the lecture was very elaborate and excellent. Had it
not been so, and had it been delivered by a lesser man
than Austin Flinty &n., I should not have minded it.
But since even the most learned cannot aim at com-
pleteness, and we all here form an association for mu-
tual assistance, I thought it might not be an unfit sub-
ject for a minor mind to fill up some one or other of
the omissions of the great.

Out of the large series of embolic diseases, I can
exhibit before you only one branch, embolism in the
eye^ and even this Avould take the time of several even-
ings, if I were to describe it fully. Nevertheless, I
shall try to give you an uncurtailed picture of it, but
executed in such a way, that the known parts are
only roughly sketched, while I shall more minutely
draw those which are but little elucidated, and point
out others that are not yet known at all.

Embolic diseases of the eye may be thus divided :

A. Thrombosis (a) of the retinal, (5) of the cho-
roidal, and ( ) of the ophthalmic veins.

B. Capillary embolia ( ) of the choroid, and ( Z> )
of the retina.

C. JEmholia (^a) of the choroidal, and (^) of the
retinal arteries.

In thrombosis we must always distinguish between
primary and secondary.

EMBOLIC DISEASES OF THE EYE.

591

A (rt). Primary tJiromhosis of retinctl veins lias
never heen described. Yet there are conditions for its
development in several eye-diseases, where the venous
current is checked in a high degree, so that coaguLation
of blood ap23ears possible, especially under favorable
conditions of the general system. In glaucoma^ the
retinal veins are compressed at the point of their exit
from the eye ; they are swollen and tortuous. A notable
retardation of the current must be the consequence.
At the same time, the increase of intraocular pressure
allows only of smaller supply of aiierial blood into
the eye. Often even the continuous arterial current
is interrupted, and the increase of intravascular pressure,
caused by the systole of the heart, throws a certain
quantity of blood into the retina, while during the
diastole of the heart the retinal artery may be entirely
compressed by the tension from the globe. In this
way we find, in glaucoma, different causes for the retar-
dation of the venous current : 1. Impediment at the
outset by compression of the venous trunks. 2. The
greater filling of veins and capillaries consequent to
the pressure on the trunks, increasing the column of
blood to be moved by the ^^s a tergo. 3. Weakening
of the latter through compression of the arteries by
the increased tension of the eye.

Although we know that, in blood-vessels with
healthy walls, normal blood, even when stagnating,
will for days remain fluid, the conditions for coagula-
tion under the circumstances just described aj)pear so
favorable, that I think it fit for ophthalmoscopists to
direct their attention to this j)oint. Quite similar are
the conditions in certain forms of neuro-retinitis^ where
an exudation into the ocular end of the ophthalmic nerve
compresses the central retinal arteries as well as the

592

EMBOLIC DISEASES OF THE EYE.

veins, causing swelling of the latter, and not unfre-
quently lisemorrliages. As we see tliese hsemorrliages
most abundant in that form of retinitis whicli is de-
pendent on Bright' s disease, where the coagulability
of the blood is increased, I do not think it quite devoid
of seDse to take into consideration the question whether
the retinal haemorrhages in this disease may not be in
some connection with thrombosis in the retinal veins
or capillaries.

Another pathological state which may possibly
occasion primary retinal thrombosis is detachment of
the retina., especially one form of it, which I may be
allowed to point out here for the first time ; I mean
detachment caused hy contraction of tendinous cords
such as are seen in rare cases of plastic (intersti-
tial) retinitis. Although such cords are not so very
uncommon after certain forms of retinitis, especially
syphilitic, they very rarely cause detachment. One
striking example of it, however, I had the opportunity
of examining by the favor of my esteemed colleague.
Dr. C. it. Agneiv, The retina was detached, or, rather,
folded up like a frill or ruffle, and through its tissue
ran a number of grayish- white cords, lying, in part,
beneath the retinal vessels, in part enveloj)ing them.
The vessels were evidently compressed by these cords,
for they disappeared or became very narrow where
they passed through them, but were exquisitely tortuous
and engorged in their neighborhood. Some looked so
very dark red, that an extreme slackening, or perhaps
an arrest of the blood-current within them, might be
fairly assumed.

I feel the lack of positiveness in the above state-
ments, but analogy led me to point them out. I do not
wish to pass them for more than mere possibilities, apt

EMBOLIC DISEASES OF THE EYE.

593

perhaps to be tlie forerunners of some direct and useful
observations.

Secondary tJiromhosis in the retinal veins has not
yet been described either. Of this, however, I am able
to give an exquisite example occasioned by embolic
occlusion of one branch of the retinal artery, and shall
describe it hereafter, when I speak of this case in full.

A (])), Primary thrombosis of the choroidal veins
is wholly iinlcnoivn. Secondary thrombosis may arise
either from embolism in the capillaries of the choroid,
or be, in a retrograde direction, an extension of throm-
bosis in the orbital veins. One dreadful case of it I
shall never forget. It occurred in the course of ery-
sipelas and phlegmone of the orbit, running under
quite the same symptoms as metastatic choroiditis. I
enucleated the eyeball on account of extreme painful-
ness and imminent danger in the other eye. The ana-
tomic examination stated the origin of the suppuration
lying in the choroid. The transition of the suppuration
from the orbit into the globe can only be accounted
for by conveyance of some mischievous material through
or along the blood-vessels ; and this admitted, the sim-
plest way and that most conforming to analogy is to
assume a stagnation and coagulation of the blood in
the vasa vorticosa, extending into the globe and causing
thrombosis of the choroidal veins and capillaries, and,
in consequence thereof, pysemic abscess. The other
eye of the same patient (a healthy man of twenty-four
years) became similarly affected ; erysipelatous swell-
ing and formation of several abscesses in the orbit,
protrusion of the eye, diffuse opacity of the refracting
media, but never so intense as to prevent the ophthal-
moscopic aspect of the fundus ; retinal vessels hyper-
aemic, diffuse turbidity of the retina, entire loss of sight.

594

EMBOLIC DISEASES OF THE EYE.

All the symptoms disaj)p eared in the course of four
weeks ; the fundus only showed tortuous retinal veins ;
blindness remained. In this eye, too, I think throm-
bosis was conveyed from the orbit through the vortex
veins into the eye, but did not extend in such a fatal
degree to the capillaries, and became retrogressive
without causing destructive suppuration.

A (c). JF^rimary thrombosis of the orbital veins may
happen as a result of injuries, orbital phlegmone. ery-
sipelas, etc. Great swelling by hypergemia and oedema,
pulsation in the orbit by collateral fluxion, inflamma-
tion and formation of abscess, protrusion of the eyeball,
pain and fever, will be the principal symptoms. It
mostly heals, but in some cases the thrombosis may
extend through the cerebral ophthalmic vein into the
cavernous and other sinuses, and cause death, which
occurrence is confirmed by two good examples of 2^ost-
mortem examination. The inverse, centrifugal 23ro-
gression of the thrombosis from the orbital veins to
those of the globe has just been spoken of

Secondary thrombosis in the ophthalmic veins may
proceed either from thrombosis of the cerebral sinuses
toward the eye, or from the latter to the orbital veins
and the cerebral sinuses, thus accounting for the oc-
currence of death after severe inflammation of and oper-
ation on the eye-ball. Besides the cerebral symptoms,
those of the eye are : protrusion of the globe, hyper-
semia and oedema of the orbital, conjunctival and pal-
pebral tissue, photophobia, wide, immovable pupil,
amblyopia, and paralysis of the ocular muscles.

I must pass rapidly over this highly interesting
subject of the connection between ophthalmic and cere-
bral thrombosis, having already given a full description
of it in vol. xiv., pp. 220-236, of the Archiv fur

EMBOLIC DISEASES OF THE EYE. 595

OpJiihalmologie^ in a paper on tlie Obstruction of tlie
Blood-vessels of the Eye.

B (a). Capillary embolia {or perhaps thrombosis)
in the choroid is observed in nephritic retinitis. It
was first noticed and described by H. Midler as scle-
rosis of the choriocapillaris. I liave seen and examined
one exquisitely marked specimen of it. Part of the
capillaries of the choroid were filled with a uniform,
finely-granulated substance, which penetrated to a
certain extent into the smaller venous and arterial
twio:s. As a collectino- trunk on both sides of the
capillaries was seen choked, the one must have been
an artery, the other a vein. This finely-granular mass
looked very similar to molecular fat, but did not dis-
solve in ether, a fact which pleads for its fibrinous
character. Neither red nor white blood-corpuscles, nor
any other structural elements, were contained in it.
The choroid was quite normal, aside from these small
islands of plugged capillaries. Here is another prom-
ising subject for further studies. I may be allowed to
make one suggestion on its symptomatic signification.
All physicians know that every variety of diminution
of sight is met with in Bright's disease. In the major-
ity of cases this is accounted for by very marked
changes in the retina, but in some nothing very con-
spicuous is found on ophthalmoscopic examination.
In such instances, the weakness of sight is ascribed to
the presence of a detrimental substance in the blood
impairing the functions of the brain, and was called by
Professor Frerichs uroemic amblyopia. It is possible
that a number of such cases fall under the head of
capillary embolia of the choroid.

Another group of cases of capillary embolia of the
choroid most probably consists of those ocular affec-

596

EMBOLIC DISEASES OF THE EYE.

tions we see in cerebrospinal meningitis and certain
other severe constitutional diseases, typhus, etc. No
such eyes have been subjected to a thorough anatomo
pathological investigation, but the symptoms during
life are so similar to the cases of metastatic choroiditis
we witness in puerperal fever, that I have no doubt
both processes are of similar origin. The destructive
ophthalmia occurring in severe cases of puerperal fever
is sufficiently known in its symptoms. I have myself ex-
amined three such eyes during life and microscopically
after death. There are regular pysemic abscesses formed
in the choroid, which commonly destroy all the structures
of the eye, but, in rare cases, are arrested at a certain stage
of their course. Then the pus, investing the inner side
of the choroid, becomes more or less inspissated ; the
eye shrinks, but retains its shape, being incurably blind.
Under these conditions, I have seen about thirty eyes
perish in the epidemics of cerebro-spinal meningitis
which reigned, four years ago, in the upper valley of
the Rhine, between Basel and Mannheim. The results
of my experience and anatomical research of these dis-
eases I have published already in an article on Me-
tastatic Choroiditis (^ArcJiiv /. Oplitlialmol.^ xiii., pp.
72-181). Therefore T shall not dwell on the subject
any longer.

B (Z>). Capillary embolism of the retina has never
been observed, although the retina is the most fitted loca-
tion to study embolism during life with the ophthalmo-
scope, and after death under the microscope. Since I
do not know any reason why it should not occur in the
retina as well as in other structures, I think that due
attention paid to it will be rewarded.

C {a). Embolism of ciliary arteries is very little
studied as yet. There are only a few cases of it on record.

EMBOLIC DISEASES OF THE EYE. 597

and they all belong to me. {Arch, f. Ojphthalmol.^ xiv.,
pp. 237-251.) I liave seen more instances of it than I
have described, but all did not allow of a definite di-
agnosis. The novelty and general importance of this
disease will justify a brief summary of its symptoms.
A 23atient suffering from cardiac disease, especially
when combined with acute articular rheumatism, per-
ceives quite unexpectedly, on awaking in the mom-
insr, or in the course of one or several hours durino^ the
day, a general haziness before one eye. This haziness
increases in one part of the visual field very consider-
ably, even to absolute blindness : scotoma, or defect in
the visual field. The defect has in most instances a
triangular shape, the apex at or near the centre of the
field of vision, the basis at the periphery. Both sides
of the triangle are mostly stTaight lines. The extent
of the ano-le varies from 35° to 90°. In cases where
the apex of the triangular scotoma does not reach the
point of fixation, the patient enjoys good central vision,
being able sometimes to read small print. Besides the
general cloudiness and the scotoma or defect in the
field, the patient complains of photopsy and chro-
mopsy, but no pain or other symptom of distress is
felt. The eye looks healthy in its external appearance,
sometimes there is some discoloration of the iris and
slight circumcorneal injection. Motion and tension of
the globe are normal.

In ophthalmoscopic examination we find, in the first
days, the background of the eye lightly veiled. Never-
theless, its details can be recognized. There invariably
exists a less or higher degree of retinal hypersemia :
the optic disk appears redder, the veins are dilated
and tortuous. Besides that, serous infiltration at the
optic disk and in its vicinity is manifested by diffuse

598

EMBOLIC DISEASES OF THE EYE.

grayish turbidity and swelling of tlie retina. Botli
tlie liypersemia and oedema of the retina are always
more marked and extended further toward the periph-
ery, in that direction which corresponds to the scotoma
in the visual field. Sometimes there is an increase of
swelling and cloudiness in the retina, and a much
greater dilatation and tortuosity of its veins, at one
certain circumscribed spot in the aifected quadrant of
the fundus. This spot then is distinctly raised, and
quite resembles retinal detachment. On examining
the intensity of the scotoma in the visual field, we find
it darkest in a place corresj)onding to this more infil-
trated and hyperaemic portion of the retina.

Beside tliose symptoms, slight floating opacities in
the vitreous body may occur, but I never observed
ecchymoses, which is rather surprising. Probably they
will be observed when more cases come to our notice.
After a few days' aggravation, the mild cases begin to
improve, and get well in one or some weeks. Others
have a slower course, and are apt to relapse in conjunc-
tion with exacerbations of the cardiac disease. I ob-
served one such case for eight months, until all symp-
toms had completely disappeared. First the general
cloudiness in the field of vision fades away, then the
scotoma gets gradually less dark, until at last it dis-
appears too. The retinal hypersemia and infiltration
diminish proportionately witli the improvement of
sight ; but, whenever there is a circumscribed raised
opacity in the retina observed, it leaves very long a
slight grayish-Avhite veil on the fundus of the eye. Till
now, I have not seen any marked changes in the cho-
roid after the affection had terminated.

Combined with these symptoms are the general
symptoms of the cardiac disease and its consequences.

EMOLIC DISEASES OF THE EYE.

599

Nearly always there are cerebral s}Tiiptoms present
leading to the assumption of embolisms in tlie brain,
and once I found tlie other eye had lost its sight by
total embolism of the central retinal artery.

The diagnosis of emholism of a ciliary artery^ after
such a definite complexity of symptoms during life, has
not yet been verified by autopsy. It was derived from
the alterations of structure, the functional disturbance of
the living eye, and the history of the disease. Cardiac
disease, especially endocarditis, sudden appearance of a
circumscribed scotoma or triano-ular defect in the vis-

ual field, hypersemia and oedema of the corresponding
part of the background of the eye, which in the retina
are due to collateral fiuxion, further the' simultaneous
occurrence of embolic symptoms in the brain, and, in
one case, evident embolism of the central retinal artery
of the other eye : these symptoms made the diagnosis
so probable, that it might almost be called certain.
But there are cases in which this series of symptoms is
less complete, and the diagnosis must be made jDrobable
by exclusion of other possible afi:ections. I think here
too is opportunity for further studies, and I would
particularly recommend j)1^7sicians to watch those
sudden obscurations in the visual field of patients
affected with endocarditis.

C (])), Embolism of tlie central retinal artery was
first described^ in 1858, by Prof. v. Graefe, Since that
time, about twenty-four cases are on record, five
from myself Of a sixth and most remarkable one
I shall speak hereafter. The symptoms briefly enu-
merated are : sudden, almost instantaneous loss of
vision without pain or inflammation. Retinal arteries
extremely thin, like slender threads. Veins likewise
thin, but somewhat thickening toAvard the periphery.

600

EMBOLIC DISEASES OF THE EYE.

By pressure upon the globe, no change in the conforma-
tion of the retinal vessels, especially no arterial pulsa-
tion, can be produced.

After some days the region of the yellow spot be-
comes grayish opaque ; in rare cases, some ecchymoses
between yellow spot and optic disk set in. After a fort-
night the i-etinal vessels begin to be refilled to a certain
degree, pressure again produces arterial pulsation, the
opacity around the yellow spot disajDpears. The ulti-
mate result is atrophy of the optic nerve and total
blindness. The causes are mostly endocarditis ; in one
case I found an aneurism of the common carotid artery.
In some cases, where a cause has not been detected,
atheroma of the arteries may be supposed. In one in-
stance I found this disease occasioned by stabbing with
a knife into the orbit.

Three cases are on record, in which sight was not
lost; in one, from Steffan^ it reacquired about one-tenth
of the normal, in another, from Schneller^ one half,
and in the third, from myself, it was completely
restored. In these cases, at least in the latter, the
embolic obstruction was incomplete, and a sufficient
arterial supply soon reestablished, partly by macera-
tion or contraction of the embolic mass, partly by col-
lateral circulation.

JEmbolism of hranclies of the retinal artery has only
twice been observed, by Prof. Saemisch and Dr. HirscJi-
mann. There was a defect in the field of vision, ex-
tending throughout its lower half In the first case,
the principal upper artery was thin from its exit of the
papilla, until at some short distance it was abruptly
metamorphosed into a white cord, the result of second-
ary changes in the walls of the artery, common in
obstructed vessels. In the second case, no such change

EMBOLIC DISEASES OF THE EYE. f)01

had taken place, but the artery appeared ever after-
ward as an extremely tliin red thread. To these two
cases I can add a third., ])erliaps the most interesting of
all on record.

A lady, laboring under an acute exacerbation of
endocarditis, felt on a sudden, while reading, a mist
spreading over the book. On shutting the eyes alter-
nately she found out at once that the left eye only
was obscured. Two weeks afterward she came to con-
sult me, her sight not having improved, nor got any
worse either. Nothing abnormal in external appear-
ance; motion and tension of the globe normal too.
She read ordinary print with that eye, but finest with
the other. The field of vision was deficient : the inner
lower quadrant totally failing, the apex not exactly
reaching the point of fixation. With the ophthalmo-
scope, I found the low^er half of the optic disk and five-
sixths of the background of the eye in a healthy con-
dition, but the most remarkable chano-es in a triano-u-
lar space, lying with its acute angle in the optic disk,
while one side went horizontally outward, the other
one diagonally outward and upward, defining an angle
of about 50°. The retinal artery emerged in the cen-
tre of the optic disk and divided, as usual, in one U23per
and one lower principal branch. The latter ran its
normal course, while the former was covered midway
between the centre and the margin of the optic disk
by a gray, slightly-elevated speck.

In the direct prolongation of the vessel, a very
slender red line emerged out of the speck and ran up-
ward as far as the length of one diameter of the optic
disk. There it swelled abruptly to nearly the calibre
of the corresponding lower branch, had a double out
line, and continued its course toward the periphery in

602

EMBOLIC DISEASES OF THE EYE.

a normal ^vsij. The beginning of the inner branch
was marked by a short, oval, dark-red swelling, out of
which three small arteries came forth.

The explanation of these conditions is the follow-
ing : An embolus, from the endocardium, was carried
through the arteria centralis retinae as far as the first
division of the upper of its primary branches. There
it plugged one secondary branch (the upper) com-
pletely, the other (inner one) incompletely. At some
distance from the optic disk, an anastomatic vessel
fi'om the choroid communicated with the upper branch,
and conveyed a considerable amount of blood into the
channel beyond the point of its occlusion, thus establish-
ing a collateral circulation.

But, what was most remarkable, was a Jicemor-
rliagic infarctus of the retina. I think this is the first
and only instance that a hcemorrhagic infarctus has
heen directly seen in the living hody. It was triangu-
lar in shape, corresponding exactly to the defect in the
visual field. All the veins were engorged, dark red,
and tortuous, some not to be traced up toward the
papilla. Numerous smaller and larger hsemorrhagic
patches encompassed and covered the small venous
twigs, while the branches of the artery ran through
the ecchymoses without giving rise to any extravasa-
tion. In the neighborhood, the twigs of the lower
retinal veins and arteries were somewhat more swollen
and tortuous than usual. The retinal tissue in the
whole triangular region of the infarctus was diffusely
gray. These changes extended from the optic 2:>apilla
until the perijDhery of the ophthalmoscopic field of
vision. The explanation is as follows:

An embolus plugged the artery entirely. The
blood ^vas driven by the elasticity of the arterial tunics

EMBOLIC DISEASES OF THE EYE.

603

into the capillaries and veins, where it stagnated, the
vis a tergo being absent. The stagnating blood coagu-
lated. Then a small amount of blood flowed into these
same capillaries and veins from the neighboring twigs
— collateral fluxion — causing a greater filling of the
former, since the coagulated blood offered resistance to
the current. This stagnating blood, and the want of
sujDply with arterial blood, brought the walls of the
veins and capillaries into unhealthy nutritive con-
ditions ; relaxation, dilatation, and ruj)ture of the ves-
sels, extravasation of blood, and transudation of serum,
were the consequences. All this was directly ascer-
tained with the ophthalmoscope.

The collateral circulation caused gradual absorp
tion of the ecchymoses. The retina got more trans-
parent, the veins smaller and straighter, and, after
about six weeks, a sufficient regular current was re-
established. When I saw the patient last, six months
^ after the attack, no ecchymosis was left, the artery was
in the same condition as in the commencement of the
affection, the veins still som-ewhat tortuous, and the
retina a little misty. The acuteness of vision in the
centre was nearly normal; the defect in the visual
field had not changed.

In conclusion, I may add yet, that this highly inter-
esting subject of emholism in the eye may he studied
experimentally. The late O. Weber, our much re-
gretted professor of surgery in Heidelberg, injected
serous pus into the crural vein of a cat. Two days
later, death. Among embolisms in different parts of
the body, there w^ere found some in the visual tract
of both eyes, and the retina of the right eye showed
numerous ecchymoses and exquisitely distinct emboli
of the smaller arteries, their peripheral ends ischsemic,

604:

FEACTUEE OF THE FIBULA, ETC.

the corresponding veins engorged and some of tliem
burst, similar conditions to those observed in tlie case
just above described.

Aet. III. — FTCicture of the Fibula^ tivo and a half
inches from the Summit of its Malleolus^ with Dis-
placement of the Astragalus^ Itupture of the Inter-
nal Lateral Ligaments^ and Outward Dislocation of
the Left Foot / Apparatus removed thirty-ninth day^
and Cure perfect. By J. Theus. Tayloe, M. D.,
^ New York City.

Me. J , of this city, aged sixty, enjoying good

health, and of sound constitution, on the 7th of March
. last made a false step on a stairway, the foot being ab-
ducted; hence this injury. The jar w^as not very great,
and merely occasioned by the last step of a flight hap-
pening to be two or three inches higher than the rest.

I saw him two hours afterward, at No. 5 Bond
Street, and found the ankle much swollen and dis-
colored, and the foot everted to an extreme degree^ and
very much drawn upward and outward by muscular
action. There was not, however, any great difficulty
in reduction nor was it productive of much pain. The
limb was then bandaged secundum artem.^ in order to
control muscular irritability, and thereby retain the
parts in more j)erfect accord, and over this a cushion,
splint and two rollers (a la Dupuytren) were applied,
which completed the dressing. The limb was then
placed at an easy elevation on its outer aspect, reposing
upon pillows, and directed to be moistened from time to
time with a lotion of arnica, laudanum, and iced- water,
of suitable strength ; and such doses of Battley's liq.

FEACTURE OF THE FIBULA, ETC.

605

opii seel, as might be necessary to allay pain and pro-
mote sleep. For tliree days inflammatory symptoms
ran liigli, and it was necessaiy to control tlie febrile
reaction by ajDpropriate treatment ; and tlie bandages
had to be loosened quite frequently, and the limb
douched with cold water ; moreover, the heel became
so much irritated as to threaten an abscess. This, how-
ever, was fortunately prevented by dressing with al-
mond-oil and cotton bats, removing all pressure, and
maintaining as great an elevation as could be comfort-
ably borne. The lotion was discontinued on the third
day, as all febrile symptoms had disappeared, and the
engorgement of the parts greatly diminished. On the
seventh day the first dressings were cut away, the limb
being placed with its outer, aspect upon a board cov-
ered with a Scultetus bandage and cotton batting, so as
to 23revent the least disturbance of the bones, and effect-
ually guard against reddslocation from muscular spasm^
as had occurred during the first dressing, owing to the
unskilfalness of the assistant. The many -tailed band-
age was then accurately applied in the usual manner,
over the cotton batting from the toes to the knee ; a well-
fitting pad, and a single splint twenty inches long,
two and one-half wide above, and one and three-quar-
ters below, light, thin, springy, hollowed on the side
next the pad, and made of well-seasoned Northern
pine, were then fitted to the inside of the leg, extending
from the knee to below the sole of the foot, and prop-
erly secured by the usual turns of roller heloiv the
hnee, and a figure of eight around the foot and ankle,
so as to constantly maintain as perfect an adduction
and inversion of tlie foot as possible.

It w^as, however, soon discovered that the splint had
too much mobility, being constantly disposed to slip for-

606 FEACTUEE OF THE FIBULA, ETC.

ward ; and to correct this it became necessary to secure
it more effectually by two and a half turns of broad
adhesive strap passed around it^ opposite the ankle,
from behind forward and within outward, then below
and around the foot back to the point of departure ;
and thence over the splint, and behind and around the
leg, and back to the same.

This dressing was continued until the sixteenth
day ; but great care was taken to unbandage the limb
frequently (about every other day), and have it well
sponged with cold water, rubbed, and anointed with
almond-oil, and sufficient movement given to the joint
to guard against anchylosis, and keep up the tone of
the muscular system. Then, as it had become necessary
for the gentleman to leave his room, and go about in
the discharge of important duties, the immovable ap-
. paratus noio to he described was resorted to, viz. :

1. The limb was sponged, rubbed, and anointed
as above, and enveloped tliicMy in cotton batting to a
nicety ; the elasticity of which would prevent the band-
ages from exercising such undue pressure as would in-
terfere with its normal circulation and nutrition, or
render the' patient uncomfortable. 2. This was se-
cured by a bandage of Scultetus, each tail being in turn
fastened by a brushing of the prepared chalk and pow-
dered gum arable and water mixture,' carefully
made, and triturated smoothly to the consistency of
cream. 3. The outside of the bandage was then
thoroughly brushed and rubbed with the same, and
made to fit perfectly, and without a wrinkle. 4. The
sole and sides of the foot and ankle were next well
protected from danger of pressure by carefully-ar-

^ Vide Braithwaite's Eetrospect, Part li., p. 123.

FRACTUEE OF THE FIBULA, ETC. (^OT

ranged compresses of cotton batting ; over whicli
two supporting hands of tlie nsnal stout roller material,
two and a half inches wide, and reaching from the
head of the fibula down the leg, under the foot, and up
to the tubercle of the tibia, were firmly applied, being
first saturated with the mixture. The object of these
bands was to maintain the foot in a fixed position of
adduction and inversion during the treatment, so as to
keep the fractured bones in apposition, and effectually
prevent (as very often occurs) the lower fragment from
gliding within the upper toward the tibia, whereby
the foot would be permanently distorted outward, to
the great injury of locomotion, and deformity of the
limb. 5. These supporting straps were then care-
fully secured by tioo layers of bandage rolled in
the mixture, and accurately applied from the toes to
the knee, which completed the dressing. Great care
was taken to hold the foot in position {cis ahove^ until
the apparatus was again thickly coated with the mix-
ture and smoothed with the hand, when the limb was
laid on its outer aspect upon a pillow covered with
lint-cotton. The next morning I found the dressing
almost entirely dry, and quite firm when it had been
exposed to the atmosphere, but still moist on the side
next to the pillow. The position of the limb was
therefore reversed to the inner aspect, and by night
the whole apparatus had dried perfectly, and assumed
an almost stony hardness ; and the gentleman could
move the stiffened leg at will in any direction, and
made no complaint whatever of discomfort from pres-
sure. At my next visit I found him sitting up quite
comfortably, after a good night's rest, and most anxious
to try a pair of Crandall's admirable crutches. Sup
port was first attempted to be given by a girth passed

608

rEACTURE OF THE FIBULA, ETC.

under a gaiter slipper, to the sole of which it was
secured by a strap, and then slung around the neck.
There was, however, some difficulty in locomotion ; so
the band was changed to below the knee, and thence
behind the thigh, and back to the neck ; but I soon
abandoned this likewise, and left the limb supported
alone by its muscular system. In two days the gen-
tleman had acquired good use of the crutch, and after
this time went about attending to his business with
perfect facility ; and, strange to say, never suffered from
the fixed, rigid confinement of the apparatus dur-
ing the twenty-three days it was worn. It was then
removed by my friend Dr. Meredith Clymer, who
kindly attended the case for me during a visit South ;
and he reports that " notwitJistanding the twenty-iJiree
days of immobility^ the limb exhibited no marbling^
as after ordinary bandaging ; and that he found its
nutrition very little if at all beloio the normal standard^
and the cnre jperfectP He ordered douches of cold wa-
ter, frictions, gentle motion of the joint {to be gradually
increased)^ and a roller from the toes to the knee dur-
ing the day. I returned to the city four days after-
ward (the forty-third of the injury), and found the
gentleman doing excellently well, in high spirits, and
making admirable use of a rocking-chair, the move-
ment of which, the foot being on the floor, was pre-
cisely Avhat was required to impart tone to the mus-
cles, and sufficient mobility to the joint. I directed
the treatment ordered by Dr. Clymer to be continued,
merely substituting a gum-elastic stocking for the
roller ; and this was worn for a month or two during
the day ; and the patient directed to support the limb
on a cushion whenever practicable; so as to relieve
the engorgement of the debilitated member after exer.-

FEACTUEE OF THE FIBULA, ETC.

609

cise. Both crutclies were used for a montli more, and
then one, assisted by a ^^'alking-stick in the other hand,
for about the same time ; and the gentleman especially
cautioned not to throw too much stress on the injured
limb, for fear that the callus should give way under the
premature j)ressure. It took some time for the joint
to regain its full mobility, and the muscles their lost
power; but he now adducts, abducts, flexes, and ex-
tends the foot normally, and walks so well that no one
could perceive that the limb had been injured exce|)t
on very close scrutiny. The cure therefore is absolutely
perfect ; and there is no doubt that the natural elas-
ticity of step will be recovered in due time.

Immovable dressings may be traced back to Hip-
pocrates, who used waxed bandages in the general treat-
ment of fractures ; ' and starch and flour for securing a
fractured nose. The Greeks have long used a mixture
of prepared chalk and white of eggs, rubbed up mth
oil and butter.' Ambroise Pare, following HIjdjdo-
crates, recommends the wax dressings ]^ he gives another

"Tliuris, Mastichls, Koti Armeniceuve,

Sanguinis Draconis . . aa | ss.

Aluminis Koclioe, Kesin^ Pini Sicci aa 3 ij.

Pulverisentur Subtilissim^

Item Farinoe volatilis . . . § ss.

Albuminorum ovorum . . quantum sufficit.

Incorporentur omnia simul, et fiat medicamentum."

and likewise a third j)reparation,' with which he was
dressed for compound fracture of both bones of the
leg : On me pensa avec un medicament tel que nous
peusmes pratiquer an dit lieu; le quel nous compo-
sames de blanc d'oeuf, de farine de froment, de suye de

^ Hippocrates, chap, viii., De Fracturis.

' lb., Sent, 46, section 2d, De Articulis, 467.

' Velpeau, Clin. Chirurg., p. 62.

* A. Pare, (Euvres, t. v., p. 303. 'lb., p. 306.

610 FRACTUEE OF THE FIBULA, ETC.

four, avec dii beiirre frais fondu."' Guy de Cliauliac
mentions a pre23aration of wax, or wHte of egg beaten
up/ Belloste, a Frencli surgeon, in 1696, eggs "beaten
up with rose-oil and vinegar.' Moscate, in 1739, wMte
of eggs alone." Cheselden, of London, in 1750, eggs
and flour." Baron Larrey, in Ms Moscow campaign,
white of eggs, subacetate of lead, and camphorated
alcohol ; suppoii^ing the bandages with compresses,
straw splints, etc.; and in 1830 revived and brought
into general notice this almost-forgotten practice, by
the publication of his observations." Velpeau, as early
as 1823, used vinegar and flour; in 1830, white of eggs,
Goulard's lotion, and camphorated brandy, but sub-
sequently introduced dextrine, which he preferred to
all others. His formula is 5 dextrine, 100 ; camj)ho-
rated brandy, 60, and hot-water, parts 50.''' Seutin, of
Belgium, introduced the starch-bandage in 1834, sup-
ported by pasteboards.'' Dieffenbach, the plaster of
Paris.'* Lafargue, the plaster of Paris and starch com-
bined.'' Sir Charles Bell recommended, in 1827, white
of eggs and flour, or resin sj)rinkled on the bandage
and dipped in alcohol or glue." Mr. Alfred Smee,
in 1840, gum-arabic and prepared chalk ;" gum-arabic
alone is used in four English hospitals at this time,
and glue in two." All these dressings require the

' A. Pare, CEuvres, t. v., p. 303.

^ Guj de Chauliac, Chirurgerie, p. 356.

« Le Chimrgien de I'Hopital, 169G.

^ Mem. de I'Acad. de Chirurgerie, t. iv.

" Cheselden, Anatomy, p. 452.

" Larrev's Clinique des Hopitaux Militaires.

" Yelpean, op. cit., p. 469, et seq.

" Seutin, (Euvres. " Dieffenbach. Lafargue.

" BelPs Surgery, vol. ii., p. 196.

Loudon Lancet, January, 1840.
' Dublin Quarterly, February, 1865, p. 149.

FEACTUEE OF THE FIBULA, ETC.

Gil

support of splints until they harden, except the plaster
of Paris, which sets so rapidly, that the limb, when it
is aj^plied, may be sustained (after the method of Mal-
gaigne) by the fingers of two assistants."

The important j)rinciple of deamhidation ^vas first
developed by Mr. Amesbury, of London, in his work
on fractures (1827) ; but he had previously practised
it for fifteen years. He says : " With my apparatus
the patient can move the limb, get out of bed, and
walk with crutches," etc. ; and M. Theodore Leger,
about the same time, made a machine which enabled
the patient to walk even without the supjDort of
crutches."' The above is in part taken from Yelpeau's
admirable and candid work, ^vho thus concludes his
notice of these very interesting points : General de-
ductions— 1. The idea of immovable dressings for
fractures has existed since antiquity. 2. It was first
methodized and systematized by Larrey. 3. Seutin
yet more fally generalized and varied its applications.

4. Seutin substituted starch for the egg mixtiuTs ; and
the roller and pasteboards for tow and wooden splints.

5. To me (Velpeau) belongs the last simplification of
this dressing, the generalization of the roller and com-
jyression. 6. Deambulation had been vaguely indicated
before B^rard ; but he was the first to reason it out
explicitly ; and to Seutin belongs the honor of having
rendered its generalization possible and easy."

PEmciPLEs.— " The indications to be fulfilled in
the treatment of all fractures and luxations," says Pare,
" are three : 1. To replace the parts in position. 2. To
maintain them there ; and 3. To guard against the su-

" Malgaigne, Traite des Fractures, vol. i.
^° Amesbury 's ^ork on Fractures, p. 21.
Yelpean, Clinique Chirurgica^e, t. ii. Same.

612

FEACTURE OF THE FIBULA, ETC.

pervention of any bad accidents. " And he shows a
perfect knowledge of the fracture in question at p. 328,
altliougli at p. 297 lie says that " one may walk upon
the foot when the fibula is broken, because it only
serves to support the muscles, and this is the case
when the fractui^e is four or more inches from the mal-
leolus. Percival Pott was the first surgeon, either of
ancient or modern times, who philosophically explained
the mechanism of fracture of the fibula, with outward
dislocation of the foot, so accurately portrayed in his
plates.'* Hence we of England and America have
long called it, after him. Pott's fracture. He, like Am-
broise Pare and Sir A. Cooper, had his leg broken ;
therefore it ^vas, perhaps, that he studied these injuries
so carefully. Boyer divides the honors between Pott
and Fabre, but lays no claim to the discovery him-
self" Desault is by no means so elaborate in his de-
scription of it as Pott or Boyer."' Dupuytren alludes
to Pott on the same footing with David, Fabre, Broom-
field, Pouteau, Boyer, and Charles Bell, but gives
priority to Duverney and J. L. Petit." Malgaigne
does full justice to all parties, and blames Duj)uytren
for so coldly alluding to Boyer, from whom he ex-
tensively drew the ideas which were elaborated into his
method."' M. Nelaton mentions Bloomfield, Pouteau,
,Boyer, and Desault, but entirely ignores the claims of
the celebrated Englishman."

Methods. — HijDjDocrates used the waxed dressings

" A. Par6, op. cit., t. ii.

" Pott's Works, vol. i., pp. 433-438, and Commentaries of Galen and
Van Swieten. Boyer, Surgery (Stephens), vol. ii., p. 123.

Desault (Caldwell), p. 382, et seq..

Dupuytren, Clinique Chirurgicale, t. i., p. 194, et seq.
"^^ Malgaigne, op. cit.

" M. N61aton, Patliologie Chirurgicale, t. i., p. 811, et seq.

FRACTUEE OF THE FIBULA, ETC.

613

immediately after reduction, and over these suitable
compresses were attached to the limb, which was then
reposed on cushions, supported by a board, at an
easy elevation, and in the straight position. Before
applying the bandages, he saturated them with the
cerate, which was likewise freely rubbed upon the
limb.'" This dressing was removed every other day
(if required), and the parts carefully bathed, until the
seventh or eleventh day : when the patient could bear
more permanent dressing, as follows : 1. The skin
was anointed as before. 2. Three bandages were ap-
plied, seemed, at each turn with the cerate, and well
rubbed with it. 3. Suitable compresses were fitted to
the limb ; and over these. 4. Splints of requisite
length (see next page), which were secured by
some turns of bandage. Celsus followed this method,
somewhat modified, using six instead of three band-
ages, large instead of small compresses; and wine
and oil in lieu of cerate.'' There is no doubt that the
many-tailed bandage, so long credited to Scultetus, was
habitually used by HiiDpocrates.'" Time has set his
thousand years seal upon the excellence of the above
princi]3les, which we find successfully advocated by so
many of the illustrati of our profession, extending
through age after age, down to oui^ o^vn day. Am-
broise Pare was of this number, and devoted his life
to the study of the great master whom he so con-
stantly followed, and often even surpassed. Thus, he
anointed the member after reduction, impregnated the
bandages, and applied suitable compresses to maintain
the parts in position ; he, moreover, directs them to be

Hippocrates, De Fracturis.

Paulas ^gineta (Sydenham), vol. ii., pp. 459, 507.
" Coinmqntator, do.

614

FEACTUEE CF THE FIBULA, ETO.

wet witli oxycrate in simijle fractures, and strong wine
in tlie compound variety ; and used three rollers, one
extending from tlie fracture upward to the knee, another
from the same point to the toes, and the third from the
toes to the knee, applied contrariwise to the first/''
In his own case of comj)ound fracture of both bones,
he used the eggs, flour, etc., as before mentioned,
which he calls, in the edition of 1564, an easy remedy
for a recent fracture for want of another ; " and in that
of 1575, "a good village medicament promptly ap-
plied.'"' He thus describes the completion of liis
dressing : " And when the bandages were completed,
splints were applied ; some three fingers broad, others
two ; and all half a foot long, hollowed to fit the limb, and
tapering toward the ends. These were placed at one
finger's interval from each other all around the limb,
and then tied with small ribbons, such as ladies use for
tying their hair, and were made to fit more tightly at
the seat of fracture than elsewhere. The limb was
then suitably supported by compresses of tow envel-
oped in linen, and the dressing was finished by two
long straw splints, strengthened each by a little stick
running along its centre, and encased in a half sheet.
These splints extended from the heel nearly to the
groin, and were secured at four points ; and thus the
leg could not be perverted, or turned to one side or
the other. It was then placed in a straight position, and
not bent (which shows that he often used, as at p. 288,
bent splints, and practised the semiflexed ]3osition), and
elevated at a moderate height, gently and uniformly,
in order to avoid pain, congestion, inflammation, and
other accidents. " Pare used splints and gutters of

" Ambroise Par6, op. cit.,"p. 303. lb., op. cit., p. 331.

lb., note to p. 330. lb., pp., 288, 330, 331.

FEACTUEE OF THE FIBULA, ETC.

615

wood, lead, zinc, leather, pasteboards, and bark of
trees ; and modified bis apparatus according to tbe
injury and its seat. " Guy de Cbauliac says : ^' We
must replace tbe bones in tbeir niveau^ and take care
tbat there be no inequality, and that the muscles be
not constrained, for bones have their particular reduc-
tions. They being reduced, before the application of
the proper bandage, an embrocation is made with oil-
of-roses ; and we make use of the cerate, or the white
of eggs beaten up. We moisten the compresses and
bands with oxycrate or strong wine, and must not use
splints at the first dressing, especially if there has been
a great contusion ; but when the accidents are ap-
peased, to maintain the reduced bones in good position.
The fracture beino^ bandao^ed and accommodated, it
only remains for us to place the limb in an easy j)os-
ture. If the fracture be complicated, we should place
the bones in position, and use the bandage of eighteen
tails ; in order to examine the parts more frequently
without disturbing the reduced bones. And if the pain
should be great, we must at once undo the bandage
for fear of gangrene.'" The difference that there is
between the dressing for luxation and fracture is, that
the luxation should be reduced before the application
of the dressing ; but, on the contrary, the dressing
should be made before the reduction of the fracture."
Pott used the eighteen-tailed bandage, compresses of
suitable size and shape, and two lateral bent splints,
extending from above the knee to below the ankle, and
maintained the limb semiflexed, and reposing on its
outer as]3ect upon pillows. He practised the " semi
flexed position in all fractures, except those of the

" Ambroise Pare, note to p. 330.

" Guy de Chauliac, Chirurgerie, p. 356. lb., ib., p. 360.

616

FRACTUEE OF THE FIBULA, ETC.

olecranon process, and patella." Boyer used two lateral
splints ; tlie outer extending a little beyond tlie sole of
the foot, and the inner reaching no farther than the
malleolus. He likewise employed the Scultetus band-
age." Desault used two lateral compresses, sustained
by two strong sj)lints, and one compress in front of the
tibia, and 'another behind the os calcis, secured by band-
ages." Dupuyti'en a wedge-shaped cushion, one splint
and two bandages to secure them, as previously de-
scribed. He was the first to oarry out the right prin-
ciple, and maintain an adducted and inverted position
of the foot hy this apparatus. He thus treated 207
cases, and cured perfectly 202 ; three died of the injury
itself or its accidents, and two of complications inde-
pendent of it. All these cases preserved the normal
shape except two, who had the heel elongated and
thrown backward, and the inferior extremity of the
tibia a little salient anteriorly. There was always a
certain immobility of the joint, combined with obliquity
of the foot, on the removal of the apparatus ; but they
disappeared in a few days with frictions, exercise, etc.
Sometimes, however, the dressing was changed to the
outer aspect, when the limb would be restored to
its proper shape in a few hours."' Sir Charles
Bell applied on the inside of the leg and foot a
single splint, fenestrated to receive the inner' mal-
leolus, with suitable compresses ; and reposed the
member, semiflexed, on its outer aspect." Sir
A. Cooper employed the bandage of Scultetus and
angular splints, one on either side of the limb, etc., and

Pott's Works, vol. i., pp. 417-440.
" Boyer, Surgery (Stephens), vol. ii., p. 123.

Desault (Caldwell), p. 382, et seq.
" Dupuytren, Clinique Chirurgicale, t. i., p. 194, et seq.

Sir Charles Bell, Surgery, vol. ii., p. 184.

FRACTUJRE OF THE FIBULA, ETC.

617

directed tlie great toe to be kept in line with tlie pa-
tella ; " and tlius cured himself. Malgaigne used two
pillows supported by lateral splints, until the inflam-
matory j)eriod had passed, and then applied an im-
movable dressing of starch or dextrine, but in cer-
tain cases preferred plaster of Paris. He always sup-
ported the dextrine and starch dressings with splints
until desiccation.*' M* Maisonneuve does so likewise,
and practises the primary dressing after the method
of Velpeau/' M. Nelaton sustains them with his
high authority, and, though he treats the subject
briefly, yet throws a flood of light upon it. He says
that one of the great objects accomplished by Du]3uy-
tren's philosophical method was to give such flaccidity
to the tissues on the inner side of the foot and ankle
as to bring the ruptured lateral ligaments into juxta-
position ; and he maintains that in all cases of outward
dislocation, with fracture of fibula, these ligaments
must of necessity he ruptured.^^ Sir William Fer-
gusson prefers Mclntyre's apparatus, as modified by
Mr. Amesbury, and above all Mr. Liston's splint, for
all cases of fracture of tibia or fibula, with or with-
out dislocation ; and advocates the straight position
of the limb in accordance with the HijDpocratic teach-
ings. He approves of starch bandages after inflam-
mation has ceased and union of the bones commenced."
Mr. Syme,'" Mr. Erichsen," and Liston," all indorse
Dupuytren's method ; and Chelius concurs with them,

*^ Sir A. Cooper, Dislocations and Fractures, p. 278.

Malgaigne, op. cit. Maisonneuve.

M. Xelaton, op. cit. t. i.

Fergusson, Practical Surgery, p. 309.
'° Syme, Surgery, p. 252.

" Ericlisen, Science and Art of Surgery, pp. 233, 234.
Liston, Practical Surgery, p. 69.

618

FEACTUEE OF THE FIBULA, ETC.

but sometimes uses two lateral splints, a let Boyer,
the inner reaching to the malleolus, and the outer be-
yond the sole of the foot.'' Our American surgeons
mostly concur with these high authorities. — Vide Profs.
Gibson,'" Gross and Hamilton,'" et al. Drs. Harris and
Randolph and Dr. Geo. JSTorris introduced the method
of Seutin into the old Pennsylvania. Hospital more
than thirty years ago." I make this reference, as I have
not the works of Seutin, and they cannot be found at the
libraries. Velpeau advocated the early ajDplication of
the dextrine dressing, and applied the bandages so for-
cibly as to exercise considerable comjpression upon the
limb. He says : " It must not, however, be believed
that this is beyond reach of accidents; like all others, it
has its reverses; but they should not in any manner
be imputed to it." '' His method is thus described :
" The foot being strongly supported and carried inward
by the assistant who is making extension, the sur-
geon, after enveloj^ing the limb in fine dry linen, ap-
j)lies over it upon the anterior interosseal fossa, on both
sides of the tendo achillis, and behind the malleolus,
graduated compresses, which he secures by two or
three layers of dextrined bandages extending from the
root of the toes to the knee ; and, to maintain the foot
forward and inw^ard, a wooden splint may be applied
until the complete drying of the bandages." '* The
late distinguished Dr. Valentine Mott directs that
" pieces of pasteboard be added to the above dressing,
that we should readjust the bandages from time to

" Chelius, System of Surgerj, yoJ. i. pp., 581, 582.

^* Prof. Gibson, Surgery.

" Gross, System of Surgery, vol. ii., p. 202.

Hamilton, Fractures and Dislocations, p. 459.
" Vol. i., Medical Examiner.
" Velpeau, op. cit. Ibid.

FEACTUEE OF THE FIBULA, ETC. 619

time, and maintain the foot inward and forward'^until
comj^lete desiccation. We thus procure, without any
effort or fatigue to the patient, all the advantages of
Dupuytren's dressing united to those of the bandage
of Scultetus, and the ordinary splint and compressing
bandages.""

It were easy to increase this long list of authorities ;
but already, perhaps, too many have been given for
the j)atience ' of the reader on all the points. I will
therefore hurry to the conclusion.

CONCLUSION.

These various apparatus are, as we have seen, often
applied at the first dressing, immediately after the re-
ception of the injury ; and this method is recommended
by very high authorities ; yet I think that in cases at
all grave, and surely in such as above described, it
would be, to say the least of it, very bad surgery ; not
only endangering the life of the patient, but inevita-
bly productive of great suffering from the pressure of
a prematurely applied, fixed, and unyielding apparatus
to an engorged and yet swelling limb. If, how^ever,
we defer such procedure for a week or eleven days (af-
ter Hippocrates), or much better, I think, as in this in-
stance, to the sixteenth day, the results, things being
equal, must be more favorable. It is a great satisfac-
tion to the patient to be assured that the period of in-
flammation has passed by without material injury to
so important a joint ; and of this no surgeon can be cer-
tain unless the parts be frequently inspected, in the
7iude state^ throughout the earlier days of treatment.
In this consisted the peculiar excellence of the method
of Dupuytren, which admitted the application of such

Mott and Velpean, vol. i., p. 188.

620

FEACTUEE OF THE FIBULA, ETC.

lotions or cataplasms as miglit be requii'ed without
disturbing liis ajDparatus ; and Malgaigne, by securing
tlie limb in easy jDosition between pillows until the
fixed dressings could be safely applied, has beyond
doubt improved upon his illustrious predecessor. For
when ive hioio that no danger can result from their ap-
plication, that the joint is safe, the bones in apposition,
all engorgement and inflammation subsided, and that
every thing that remains to done is to secure the limb
in such a manner that the patient may take exercise,
breathe fresh air, and nourish (so as to assist the all-im-
portant process of bone-formation) ; then only^ and not
till tJien^ has the time arrived,

I purposely delayed doing so, as narrated, for the
above reasons ; and would not even then perhaps have
been, willing to dispense with Duj)uytren's apparatus
(assisted by the Scultetus bandage to control muscu-
lar sj)asm, and give more absolute repose to the limb ;
and likewise by the two and a half turns of adhesive
strap, which fulfilled the indications much better than
M. Nelaton's dextrined bandaore could have done in

securing the splint^ as the dressings had to he removed
so frequently), but that I felt sure of being able to
maintain the requisite position of adduction and inver-
sion of the foot hy the two supporting hands^ ivhich
are my own ; and constitute, I think, the essence of
the treatment, and the apparatus. I was thus enabled
to sustain the parts in position without being con-
strained to use the splint^ as is the case with all the
movaUe dressings of our day^ except the plaster of
Paris.

I therefore claim to be the first who has practised
a method by which two simple straps, so applied as to
carry out the right principle, enable us to dispense

FEACTUEE OF THE FIBULA, ETC.

621

witli the splint after tlie fixed dressings ; and I more-
over maintain that splints will never again be required
at all in tlie treatment of these cases. For as these two
supporting "bits of bandage, impregnated with the gum-
arabic mixture, answered so admirably in this instance,
on the sixteenth day (assisted only by the outer parts
of the dressing), so I insist that the same supporting
power would have been equally applicable at the first
dressing, immediately after the reception of the injury,
if rightly applied. Thus for instance : we first reduce the
dislocation and fracture by extending the foot obliquely
inward, the leg being bent uj)on the thigh to quiet
muscular contractions. 2. The foot is held by an as-
sistant, in such a position of adduction and inversion
combined, as to move the upper end of the inferior
fragment of the fibula, from its inclination toward the
tibia, and bring it in apposition with the superior frag-
ment. 3. Compresses of cotton batting must then be
placed upon the external malleolus, sole of the foot, and
malleolus internus ; and over these two or more strips
of adhesive plaster, two and a half to three inches wdde,
firmly applied from witliout to within^ beginning at the
head of the fibula, extending down the outer aspect of
the limb, beneath and across the sole of the foot, and
thence obliquely upward to the tubercle of the tibia.
Last, the leg should be enveloped in cotton batting,
and the eighteen-tailed bandage carefully adjusted, so
as to give support to the limb without exercising un-
due pressure : which may then be reposed semiflexed
upon pillows, lying on either aspect, until the deam-
bulating period have arrived, when the immovable ap-
paratus will be resorted to as before described.

622

SOME UNUSUAL PHENOMENA

Aet. IV. — Some Unusual Plienomena attending Anms-
tJiesict' By Feedekic D. Lente, M. D., of Cold
Spring, New York.

In a recent number of Hiclimond and Louisville
Medical Jo%irnal^ and copied into tlie Boston Medical
and Surgical Journal an article by Dr. W. H. Shep-
herd, entitled " Apparent Exercise of Volition during
Ansestliesia complete in all other Respects." The writer
thinks it very extraordinary that, although the anaes-
thesia was apparently perfect, the patient's jaws were
firmly closed. " The resistance," he says, " was not
such as we find in tonic spasm, but appeared to be the
result of voluntary effort, and nevej* yielded, although
the anaesthetic (chloroform) was used until the condi-
tion of the pupils forbade its further employment."
There was, he adds, the usual relaxation of the other
muscles of the body.

A rigid condition of certain muscles, under perfect
anaesthesia, is not, I think, so very uncommon, and even
the perfect exercise of volition is also quite possible,
as I have seen exemplified in two cases so remarkable
that I am tempted, by reading the report of Dr. Shep-
herd's case, to give them publicity, although the long
period which has elapsed since their occuiTence, and
the possession of no notes, must render the report
very meagre.

During the first year of the use of anaesthesia in the
New York Hospital, to which I was, at the time, tem-
porarily attached, as surgical assistant, a case of pe-
rineal section occurred in the practice, I think, of Dr.
Gurdon Buck. The operation was without a guide
through the stricture, and the most tedious and diffi-
cult of the kind that I have ever witnessed. The pa-

ATTEl^DINa AI^iESTHESIA.

623

tient was on the table over an hour, and tlie exemption
from pain was, all the Avhile, complete ; and yet he was
laughing and talking, and making droll remarks, in
conversation with the bystanders, most of the time. I
remember one of the house-staff making notes of some
of his queer sayings. The other case was a tedious 0])eYS.-
tion for necrosis of the tibia. The subject was an un-
usually stupid boy, some fifteen years of age ; and yet,
under perfect exemption from pain (etherization), he
sang numerous comic songs, and made rather witty
remarks on the peculiarities of the surgeons around
him. The pain, on examining the disease with the
probe, previous to the operation, was unusually severe,
judging from the .outcries of the patient. I cannot
remember how often a reapplication of the ether was
required, but the sponge was away from the face a
good part of the time consumed in the operation.
These cases were not deemed extraordinary at the time,
and no note was taken of them, as it was then the
infancy of anaesthesia, and it was considered quite
likely that these events would become not unusual
occurrences. But I have never since, to my recollec-
tion, met with a record of any thing precisely similar,
although it is sufficiently common for patients to re-
cover their mental faculties to such a deOTee as to enable
them to answer questions intelligently, and to cooper-
ate, to some extent, in any necessary movement of the
body after the operation has been completed some min-
utes, and yet feel no pain during the handling and
dressing of the wound.

Two cases of troublesome rigidity of muscles, which
I call to mind as having happened in my private prac-
tice, are briefly as follows : Mrs. N., a rather nervous
married lady, about thirty years of age, had visited a

624

SOME imUSFAL PHEjS-QMENA, ETC.

neiglilDoring village for the purpose of Laving a num-
ber of teeth extracted ; and, according to her statement,
had exhausted a pint of ether in the vain attem23t of
a j)hysician to anaesthetize her. She was assured that
such a thing was impossible in her case. However, I
undertook the job, and with three ounces of ether, and
within the space of four or five minutes (ether enough
and time enough to etherize any patient) I had her
breathing stertorously, and thoroughly relaxed except
the muscles which it was most important to have in
that condition, namely, the masseters. It required a
strong leverage with a pair of stout forcej^s to force
the jaws open, so that Mr. Davis, the dentist in attend-
ance, could extract the teeth. On recovery, she exhib-
ited no unusual phenomena, and insisted, for some time,
that it was her sister, standing by, and not herself, who
had undergone the operation.

A young man, and healthy, who had suffered am-
putation of the leg below the knee some months pre-
viously, wished a peg-leg, but the knee-joint was an-
chylosed in the straight position, and required to be
flexed for this pur|)ose. I accordingly administered
ether to relax the muscles, as well as to annul pain.
The anaesthesia was quite comjDlete, the resj)iration
stertorous, and yet the muscles of the thigh were as
rigid as iron. The etherization was pushed to the
verge of danger, in the hope of producing relaxation,
and thus maintained for several minutes, but unsuc-
cessfully. The patient was therefore allowed to recover
somewhat from its effects; and before the return of
consciousness or sensibility, the muscles then becoming
slightly relaxed, the stump was suddenly flexed by a
powerful effort on my part, and the adhesions thus rup-
tured. In this case, I cannot call to mind whether the

CLI]S^ICAL EECOEDS FEOM PRIVATE PEACTICE. 625

other muscles of the body were likewise rigid. In fact,
the untoward and perplexing effect of the anaesthetic
was so annoying that I paid no particular attention to
the state of the general muscular system. I cannot pre-
tend to say whether voluntary effort had any influence
in determining the muscular contraction in these two
eases. A moderately firm contraction of the maxillary
muscles is not an uncommon occurrence in dental oper-
ations under an anaesthetic.

I. — Partially-encysted Stone in the Bladder, complicated loitli
Perineal am.d Femoral Fistula. By Feaxk A. Staxfokd,
M. D., Columbus, Ga.

Joseph Aguera, aged seventeen years, was the subject of
this very unique and interesting case. He had had symptoms
of stone since his earhest recollection, and at the time first
seen by me was in a most miserable condition. Besides the
painfal symptoms which usually accompany this difficulty, I
found him with two fistulous openings, through both of which
there was a constant flow of mine : one of these was situated
in the peringeum, while one occupied the upper and inner as-
pect of the thigh. Through both a constant escape of urine
was taking place, and the parts adjacent were kept excoriated
in consequence.

Jidy 17, 1866. — Two days after his first sounding, when I
detected the stone, placing him under the influence of chloro-
form, and with the assistance of Drs. Bozeman, Foard, Moses,
and others, I made a bilateral section of the peringeum into the
bladder. The stone was readily come in contact with, when,
after several inefiectual eftbrts at its extraction, it was ascer-
tained to be partially encysted. It was occupying the infun-
dibuhform portion of the bladder, the lower and anterior por-
tion being free, while the upper part was firmly embraced in
a cyst. Passing a bistomw guided by the finger down upon this,

626

CLmiCAL RECORDS

I made a free division of its surface down upon the stone
proper, when it was easily removed from its bed, and extracted
through the perineal opening.

The patient made a regular and good recovery. The fistu-
l8B ceased to discharge urine, and after a few days the cyst,
verv much like those we often find containino; sebaceous mat-
ter, was passed with the discharges through the opening. The
fistulse were clearly caused by the fixed position of the stone
near the neck of the bladder, held so by the cyst.

The accompanying plate gives the exact siz6 and view of the
stone, after its removal, and as now seen in my collection : A.
Upper portion, round, covered by the cyst ; B. The line of extent
of cyst, constricting the stone in the shape of a neck ; C. The
lower portion of stone free and exposed in the bladder ; D.
Debris, broken in my attempts at removal. The weight of
the stone and fragments was ten drachms.

July 13, 1868. — Joseph is now in full health, and has been
attending school since shortly after the operation.

II. — Ojperation of Artificial Joint for Fracture of Tibia and
Fihula. By A. D. Hull, M. D., Lansingburg, E". Y.

^N^OTiciNG Dr. Sayre's article upon artificial hip-joints, I

FEOM PKIVATE PRACTICE.

627

thouglit the following case of artificial joint might not be un-
interesting :

I was called late one cold evening in December, 1860,

to see, within one block of my office, a Mrs. Mary C ,

a servant, aged thirty-five years, weight one hundred and sixty
pounds. She was sitting upon a chair, in a house next where
she lived, and was considerably intoxicated. She was found
in the alley in rear of the house where she lived, falling down
and getting up and trying to walk, and was brought where I
met her. On examination, there was a compound fracture of
the fibula, just above the external malleolus, and dislocation of
the tibia inward, at the ankle-joint ; the foot was turned out-
ward, the bones protruded through the flesh, and she had
been walking on the ends of the bones. The malleolus re-
mained ill situ. She was removed to where she lived, laid
upon a couch, and I removed one-half inch of the articulated
portion of the tibia and fractured end of the fibula, replaced
the bones in their proper places in connection with the joint,
and placed the whole in a felt splint adapted to the foot and
leg.

The second day after the operation, she was taken to the
Marshall Infirmary, and I saw no more of her until, about four
months after, I met her one day walking in the street with a
cane. She could then bear her weight on this foot, had tree
motion, and handled it about as well as the other. She soon
laid her cane aside, and at this time, at an ordinary gait, no
one would think she had ever been lame.

Let me remark, lest some of the profession should doubt
the necessity or utility of this operation, why I resolved to do
it. Some three months previous, I had been called to a case,
a man sixty years of age, who had been .thrown from a wagon,
producing precisely the same injury, viz., fracture of the fibula
close to the malleolus, and dislocation of the tibia inward at
the ankle-joint through the flesh. This happened three
months pre^dous to my seeing it, and had been attended, dm*-
ing this time, by a physician who died about the time the
patient came into my hands. The limb had been dressed with a
splint and bandage, and an attempt made to keep the foot in line
with the leg, but the swelling about the joint was so great and

628

CLINICAL RECOEDS

the conltraction of the outer muscles so marked, that the pain was
unendurable with the limb so confined, and all dressing had to
be removed. With the limb thus unconfined, the foot immedi-
ately turned out and the bones protruded. Upon consultation
with Dr. Bontecue, of Troy, w^e decided to cut off a portion of
the tibia, and we accordingly did so, with the happiest results
so far as the success of the operation was concerned ; the parts
were adapted and placed in a felt splint. Previous to the
operation the discharge of pus had been very great, but it now
soon ceased, and the wound rapidly healed, so that at the end
of two weeks the joint seemed quite firm. Unfortunately, at
this time the patient was attacked with acute pleuropneu-
monia, and died in five days. He had been a free liver.

This joint would undoubtedly have been anchylosed, as
the cartilaginous surfaces had been destroyed by suppura-
tion.

III. — Double Floating Kidney. By Heney Shiff, M. D.,
N'ew York.

Miss J. C , aged twenty-six, of a rather weak constitu-
tion, has never had any serious illness. She suffered slightly
from chlorosis at fifteen, before the establishment of menstrua-
tion, but has always been regular since that time.

At the beginning of last December, she had an attack of
pleurisy, for which she applied to me, after having been fifteen
days without medical advice, and of which she is now well.

Six years ago, she felt pain in the region of the right kid-
ney, which she describes as having been pulling and dragging.
It caused nausea, but she never vomited. The pain was very
slight when at rest, but became distressing with any exertion,
and increased mostly when she raised her right arm. She was
for several days unable, on account of the pain, to comb her
hair with her right hand.

A few weeks after the appearance of the pain, she noticed
a tumor on the right side of her abdomen. This tumor, very
small at first, has gradually been growing larger.

She has all along been able, by lying on her back and
making pressure upon the tumor, to cause it to disappear en-
tirely.

FRO:\r PRIVATE PRACTICE.

629

Two years afterward, she felt the same kind of pain in the
region of the left kidney, but it did not give her the feeling of
nausea, as the pain on the right side had done. Shortly
after the appearance of this pain, she noticed a tumor on the
leftside of her abdomen. This tumor, very small at first, has
also increased in size, but is much smaller than that on the
right side. It has always been movable, and she has at all
times been able by pressure upon the tumor to cause it to dis-
appear. This she can do standing as well as lying on her back.

Having become alarmed by the presence of these tumors,
she asked my opinion about them;, and a recent examina-
tion revealed the following state :

When she stands, there is to be felt just below the last rib
on the left side, and touching it, a well-marked tumor, the out-
lines of which are, however, somewhat indistinct. It is about
two inches in both diameters, and dull on percussion. By
pressing upon the tumor, it disappears entirely ; and the place
formerly occupied by it is sonorous on percussion.

On the right side, there is an oblong tumor, about three
inches by two, the longest diameter being parallel with the
longitudinal axis of the body and touching the umbilicus. The
outlmes of this tumor are very distinct, and it has the shape
of the kidney. An arterial pulsation can be felt at its side.
There is dulness by percussion over it. When pressure, even
moderate, is applied upon it, the patient lying on her back, it
disappears entirely; the place formerly occupied by it becomes
sonorous when percussed. The arterial pulsation can be felt
still, where the tumor was, and it can be followed up by the
finger some two or three inches in a slanting direction toward
the right ribs. These pulsations are due very probably to the
renal artery.

There is pain in the region of the stomach when the tumor
of the left side is pushed backward. There is no pain when
the tumor on the right side is pushed back ; but the patient
complains of a constant uneasiness on the right side. She de-
scribes it as a dragging fi'om the back, with a desii^ to lean
forward. But any exertion, such as lifting a weight, or lean-
ing forward for some time, as when washing linen, causes very
distressing pain ; at the same time a cold sweat covers her

630

CLmiCAL RECORDS

body, and slie feels as if slie were going to faint if she continued
the exertion.

Floating kidney is by no means rare, though it seldom
comes under the notice of the physician, because, in the great
majority of the cases where it exists, it gives rise to no symp-
toms whatever. The researches of Dr. Walther, of Dresden,
show that floating kidney is to be found in a great many -per-
sons who are not even aware of any thing abnormal. Out of
thirty-flve observations collected by Dr. Fritz, of Paris,* thirty
were in females. It is also much more common on the right
side. Cruveilhier seem§ to think that the use of the corset in
the female and wearing too tight clothes in the male are the
main causes of the displacement ; and explains the greater fre-
quency on tlie right side, by the fact that the spleen and
stomach on the left hypochondrium offer more resistance to
pressure than the organs on the right side.

Trousseau relates the case of a man, who had been several
times treated for peritonitis, where the tumor became occa-
sionally painful after exertion ; and that of a woman, who had
been told the tumor was of malignant character. He advises,
when there is any pain, to apply poultices, with rest in bed ;
and, after the pain has been subdued by these means, to cause
the patient to wear a belt with pads placed so as to give sup-
port to the prolapsed kidney. Such a belt I prescribed to my
patient with apparently some benefit. I should have stated the
urine was normal in every respect.

ly. — Ahscess in the Abdominal Walls communicating with
the Intestinal Canal, originating from Inflammation and
Ulceration of the Vermiform A]^i:>endix ; Pymmia:
Death. By E. C. Hui.-, M. D., Albany, IST. Y.

A. B. S , aged sixty-two years, gas-fltter. Has for years

been subject to occasional attacks of dyspepsia. September
28, 1868, complained of pain and tenderness in the right iliac
fossa. There seemed to be some inflammatory action in the
neighborhood of the caput coli. No general peritonitis. This
inflammation gradually subsided under the influence of opium
and rest, with the external application of hop poultices, leav-
ing a hard cake or induration in its seat. October 19th. He sat

FROM PRIVATE PRACTICE.

631

up and moved about the room, and seemed to be doing, well.
October 25tli. After several movements of tlie bowels, lie again
complained of pain in tlie right iliac fossa, and had a severe
chill, which greatly exhausted him. October 2Tth. Had several
chills, followed by extreme weakness and depression. Novem-
ber 3d. Has had more chills, complains of no pain, but is
rapidly losing strength. Muscular tremor, and picking at the
bedclothes. Is perfectly rational. ISTovember 7th. Frequent
chills, failing in strength. Bed-sores. Had a movement of
the bowels, which seemed to contain purulent matter. Novem-
ber 9th. Had a natural movement of the bowels, followed by
a proper discharge of fluid blood. November 11th. One chill
during the night. November 12th. No chill, feels brighter,
and thinks he is going to get well. November 13th. Began
to sink early this morning and died at 9.30 p. m. Was per-
fectly conscious to the last.

Autopsy eighteen hours after death.
. Body emaciated, skin slightly jaundiced.
Head not examined.

Thorax. — Lungs normal, except some adhesions about the
apices. Cardiac valves were normal, but the muscular structure
was friable.

Abdomen. — Injection of the peritonseum with adhesion of
the viscera and parietes in the right iliac fossa. The appendix
vermiformis was adherent to the abdominal walls, and com-
municated by a perforation with an abscess in the muscular
tissue of the abdominal wall. A portion of the -ileum was ad-
herent at the same point, and communicated by an ulceration
with the cavity of the abscess, which was large enough to hold
a horse-chestnut, and contained feculent and purulent matter.
When the intestine was straightened out by breaking up the
adhesions and dividing the mesentery, the point of ulceration
in the ileum was found to be about eiofhteen inches distant
from the ileo-csecal valve, and between these two points the
ileum descended into the cavity of the pelvis and was firmly
adherent to the rectum, where it formed an acute angle in the
shape of the letter Y. At this point it was full of dark, clotted
blood. The portal veins in the liver were filled with pus,
but no proper metastatic abscesses were found in that organ.

632

CLIXICAL EECOEDS, ETC.

The spleen was enlarged and infiltrated ; there was a san-
guino-pimilent fluid. A large abscess had formed under the
peritonienm in the left liTpochondriac region, and was bound-
ed by the adjacent spleen and convex surface of the kidney.
Its contents had fused down along the sub-peritoneal con-
nective tissue to the point where the psoas-magnus passes un-
der Poupart's ligament.

Y. — Coxo-femoral Dislocation at Four Years of Age. By
Stephex Eogees. M. D.. Xew York City.

Ox account of the acknowledged rarity of the accident, I
am induced to send you the following history of a case of
dislocation of the hip-joint in a child of four years of age :

A well-grown, healthy girl of fom* years, while playing,
slipped upon the caq^et, and fell, her lower extremities being,
as is supposed, extremely abducted. Her cries from pain at-
tracted the attention of her mother, who found the child un-
able to move the right leg and thigh. The family physician
soon saw the little patient, and recognized the character of the
accident suffered, but properly regarded it as a very un-
usual and delicate piece of surgery, and sought assistance. I
saw the patient within four hours after the accident, and im-
der chloroform verified, beyond a doubt, the first diagnosis of
the physician of the family, viz., dislocation of the head of the
femm* upon the dorsimi ilii. This decided, the leg was flexed
upon the thigh, the knee carried from its position against the
opposite thigh near the patella, upward over the opposite side
of the pelvis from that of the injiu-ed joint, then outward over
the umbilicus to the perpendicular line of the dislocated joint ;
thence the thigh was extended without the slightest difiiculty,
the head of the bone having resumed its natiu'al position.
The precise stage of this manipulation, at which the head of
the bone slipped into the acetabulum, was marked by a sen-
sation which would be described by jar in the movement^
and took place at the moment of the commencement of the
extension movement of the thigh. Surgeons will recognize
the manipulation practised in this case, as the one which,
though not new in fact, was so clearly demonstrated and
forcibly advocated by Dr. AV. W. Keid, of Eochester, Y.,

PE0CEEDIXG5 OF SOCIETIES.

633

as to entitle him to a claim of originality.' All deformity
and immobility at once disappeared.

The patient had no untoward symptom, and, after a
forced quietude of ten days, walked and ran as if nothing-
had ever occuiTed to her joint. Coxo-femoral dislocations, in
a subject so young as this, are very rarely recorded. Dr.
Gross remarks that '* it is a very uncommon thing to meet
^vith a luxation of the hip-joint in childi-en" ^ Dr. Hamilton '
refers to am on the dorsimi ilii at one year and six months ;
one at two years and one month ; one at three years ; one at
three years and six months ; and tv:o at fom* years. He also
refers to one into the ischiatic notch at three years, a total of
seven cases of luxation of this joint at four years and under,
which, added to the one here recorded, completes the list so
far as I know. I should be glad to see this history call forth
unrecorded experience with this class of cases, and reference
to cases which have been published, but escaped my observa-
tion.*

XETT YORK acade:m:y of :mxdicixe.
Stated Meeting^ January 21, 1S69.

Abstract of the Inaugm-al Address of Dr. H. D. Bulklet,
President-elect.

Dr. Bulkley, on taking the chair, spoke happily of tke re-
sponsibilities attaching, not only to the office he had been
called to fill, but to fellowship in the Academy as well — re-
sponsibilities commensurate with the dignity of an institution
whose history was the brilliant record of some of the best
efforts of so many distinguished men ; with the unlimited

' " Transactions of the State Society " for 1852.
' " System of Surgery," vol. ii., p. 175. .
^ "Fractures and Dislocations," p. 620.

* A case occurring in the practice of Dr. Fanning, of Catskill, N". T.,
in a child two years and six months of age, will be found recorded in this
Journal for September, 1867. — E. S. D.

634

PE0CEEDING3 OF SOCIETIES.

opportunities for original investigation presented by tliis me-
tropolitan citj ; and with the demands of a profession which
calls upon all its members to devote the finest fruits of their
toil to the common weal.

The speaker dwelt upon the urgent necessity for a build-
ing which should be recognized as the suitable home for such
an Academy, which should attract the medical men of Is^ew
York, not alone as the meeting-place of this Society and of
others that might cluster around it, but by its library and mu-
seum, its rooms for reading and for conversation, where, be-
sides enjoying social intercourse and gleaning the freshest
intelligence, one could be sure of finding facilities for the pur-
suit of his most elaborate researches. The building committee
were commendably active, and, if their labors met the proper
response, we might soon see the foundation of an edifice that
should do honor to the profession and to the country.

In order rightly to make use of the privileges and to meet
the responsibilities above referred to, every member must bear
m mind the necessity of one thing — work. And the organiza-
tion of the Academy was such as to utilize the labors of all to
the best advantaoce. The several sections brouo;ht the best re-
suits of their sessions to the meetings of the common body for
further discussion, and in this way had been initiated some of
the best debates in the history of the Academy. The Ob-
stetrical Section was now full of vigor, and that of Theory
and Practice gave signs of a renewal of its old "\dtality ; with
proper efibrt, the others would soon follow. With the sections
thus to elaborate for discussion the material constantly accu-
mulating, and with the original papers which the Academy
had a right to expect from those fellows who had already done
so much to advance medical science, and from those who,
though younger in their labors, were equally earnest, the only
difficulty would soon be lack of time at the meetings properly
to dispose of the mass of valuable matter presented.

A CoMPREHExsrs'E TiTLE. — Tlic Celebrated Surgeon Lan-

genbeck, of Berhn, rejoices in the following official title :

" Geheim Ober-Medicinal Eath Genera 1-Arzt Professor Dr.
von Langenbeck."

EEVIEWS.

635

Art. I. — The use of the Laryngoscope in Diseases of the
Throaty with an Essay on Hoarseness^ Loss of Voice, and
Stridulous Breathing in relation to Nervo-muscular Affec-
tions of the Larynx. By Morell Mackexzie, M. D.
Second edition. Witli Additions, and a Chapter on the Ex-
amination of the jS^asal Passages. Bj T. Solis Cohex,
M. D. Philadelphia: Lindsay & Blakiston, 1869.
After a carefnl perusal of the above work, we desire to
call attention, first, to the original matter by Dr. j\Iackenzie,
and next to the additions by the editor. Dr. Cohen.

The first eight chapters, pages 9-147, are a verbatim re-
print of the first London edition, issued in 1865, of the author's
work, with which many of the profession are sufficiently famil-
iar. ]^ot one new fact ha\dng been added, nor a single sentence
changed in these chapters, comment is unnecessary. In Chap-
ter IX., pages 147-158, we find, what pm*port to be, the
principal additions on the use of the laryngoscope, from the
* second London edition. This chapter is presented under a
misnomer, since, in place of additions to the use of the laryngo-
scope, it really contains the history of some valuable cases of
intra-laryngeal surgery, by no means a novelty, ^vith a descrip-
tion of the instruments used.

Chapter X., pages 159-182, by the editor. Dr. Cohen, con-
taining a description of instruments familiar to laryngoscopists,
might better have been omitted. These instruments, with
scarcely an exception, were first fully described in Dr. Pup-
paner's book " On the Principles and Practice of Laryngo-
scopy," published about a year ago. If additions are made by an
editor to an author's work, we have a right to expect some-
thing that will enhance the value of the work in question, or
that something new be presented. In either of tliese requisites
is fulfilled here. X ]^ro;pos, regarding the importation of in-
struments, why can English instruments not be as easily ob-
tained as the German ones ? We find it equally convenient
to obtain the one as the other.

The value of the present edition is much enhanced by the

636

EEVIEWS.

addition, Chapter XI., pages 183-260, of Mackenzie's valuable
monograph on " Hoarseness, Loss of Voice, and Stridulous
Breathing, in relation to ITervo-muscnlar Affections of the
Larynx." This essay was first published in 1863, but in the
present edition its scope is much enlarged. The favorable re-
sults obtained in the treatment of nervous affections of the
larynx since the introduction of laryngoscopy, and the more
rational employment of galvanism as a remedial agent, may
well challenge comparison with any branch of therapeutics.
But why should the editor omit the appendix on atrophy of
the vocal cords and give us the essay in an incomplete form ?
The snbject-matter is of too great importance that we should
be willing to be deprived of part of it, nay, of even a single
paragraph or sentence. Another omission in this monograph
we cannot j)ass unnoticed. It also applies to the editor's ad-
dition to this chapter. We refer to the total silence on the
treatment of aphonia, that is, cases of recent standing, by what
Professor Yan Briins calls " the gjnnnastics of the larynx."
That cases of aphonia, dependent upon a temporary abnormal
condition of the nervous system, yield readily to this mode of
treatment, that is, the well-regulated exercise of the vocal"
cords in the presence of the laryngoscopist, admits of no doubt.
Besides, Yan Briins, Tobold, of Berlin, and Dr. Kuppaner, of
'New York, have reported successful cases. It is a satisfaction
to know that cases of aphonia can be cured without either
medicine or galvanism, and we should have been glad to have
ascertained the author's opinion on this subject. The aj^pen-
dix on " Rhinoscopy," covering twelve pages in the original
edition, ably and comprehensively written, will be missed with
surprise by all familiar with Mackenzie's work. For what
reason the editor has seen fit to ignore a portion of the author's
own work, and substitute therefor what professes to be an origi-
nal chapter on the same subject by himself, we are the more
at loss to discover, inasmuch as Chapter XIII., by Dr. Cohen,
presents nothing that is not really found in the original ap-
pendix, except, perhaps, the mention of a hard-rubber tongue-
depressor, of which there are many kinds, one as good as the
other.

Barring these exceptions, we are delighted to see this new

EEVIEWS.

637

edition of Mackenzie, hoping that it may find its way exten-
sively into the hands of the profession.

Art. II. — Pronouncing Medical Lexicon^ containing the cor-
rect Pronunciation and Definition of Terms used in Med-
icine and the Collateral Sciences. With Addenda^ contain-
ing Abbreviations used in Prescriptions^ and List of Poi-
sons and their Antidotes. By C. H. Cleaveland, M. D.
Eleventh edition. Philadelphia: Lindsay & Blakiston,
1869. 16mo, pp. 302.

This chunky little volume, which is presented to us with
a most attractive exterior, was prepared — the author virtu-
ally tells us in his preface — for the especial enlightenment of
that class of practitioners whose early education has been
neglected, and who therefore are wont to take unauthorized lib-
erties both in the pronunciation and application of the learned
terms with which our chosen science is fettered and hedged in.
This loading down of scientific language with Greek and Latin
terms may be unfortunate for the class above alluded to, but the
legacy has been imposed upon us, and we cannot throw it off. We
must therefore do the next best thing when using these terms —
endeavor to use them correctly. N"ow, when one sets himself up
as a teacher in such matters, it is proper, to say the least, that he
should be especially careful in his teachings — indeed, he ought to
be sure of what he advises — for the unfortunates to whom his
book is directed are not able to judge of the accuracy or inac-
curacy of what is set before them, but accept every thing at
first sight as correct ; and so, if the teachings have been bad,
they are confirmed in their blundering mispronunciation or
bewildering misapplications of technical terms. This is pre-
cisely the effect that the study of the little book before us
would have on one not well up in the use, meaning, and
pronunciation of medical terms. We do not intend to say
that the book is thoroughly bad — ^but there is so much in it
that is bad, that its value as a guide is entirely lost upon those
for whom it is prepared, for they can never be sure when it is
right ; and on the other hand, those who can make this distinc-
tion have no need of the book at any time. In the matter of pro-

638

REVIEWS.

nunciation, tTie errors are comparatively so few that it is to be
regretted tliey were not amended, and thus fixed some vahie
upon the book. But economy, rather than orthoepy, appears
to have had the larger claim on the author's attention, and so,
in successive editions, he has used over and over the old ste-
reotj^Ded plates, repeating errors which we doubt not have
already been pointed out. Take the Latin words ending in
ims^ the rule is that these words shorten the penult ; but there
are about a dozen exceptions to this rule, and it is singularly un-
fortunate that three of these exceptions are words in common
use in medical language : they are anticus^posticics, and itmhili-
cus. They lengthen and therefore accentuate the penult. In the
book before us the accent is thrown back on the antepenult,
where it does not belong. We cannot stop to make good our
assertion with regard to the words we have observed that are
wrongly accentuated, but mereiy on a most cursory examina-
tion mention a few of those in most common use. We give
the accentuation after the author, that our readers may judge
for themselves : cicatrix^ coccygis^ eczema, exanthemdta,2^rurigo,
impetigo J glandula, pruritus, fremitus, veneris, vesica. There
are also many other words, in less common use, which are
given with incorrect accentuation.

It is in the matter of definition, however, that this book is
most worthless, and of positive injury to a beginner. We
need only open the book at random, to pick out some most
absurdly choice specimens ; but, to avoid all appearance of par-
tiality, we will commence on the first page, and we find
" Abalienation ; corporeal or mental decay ; " " Abaran-Temo,
a Brazilian tree " — wonderfully explicit, that, to say nothing
of the practical uselessness of the term, which is out of place
in a pocket lexicon. " Abdominal Pregnancy, pregnancy when
the foetus is above the uterus in the oviduct." How is it,
should the foetus be out of the oviduct or to one or other side
of the uterus ? On the next page we find " Abelmoschus ; an
evergreen shrub." " Abies ; fir, an evergreen tree ; " and on al-
most every page we find similarly unsatisfactory explanations
of botanical names. " An African plant," " an evergreen
shrub," " a Brazilian tree," etc., may convey a definite idea to
our author's mind, but the most of us poor mortals, we fear,
are too stupid to be much enlightened or edified thereby. We

KEYIEWS.

639

should be inclined to exclaim with the oracular Solon Shingle,
Jes' so," and then inquire what it all means.

But we cannot undertake to follow the author's pages
seriatim. Life is too short since the antediluvian era to in-
dulge in the thankless task of pointing out all of other people's
short-comings and wrong-doings, however instructive or bene-
ficial such a task might be ; and besides, in this instance, lejeic
n^en vaut j^cts la chandelle. We may, however, note an occa-
sional glaring absurdity or inconsistency merely to substantiate
the position we have taken. Apoplexy is defined as " a disease
of the brain." " Comatose, the state of profound stupor in
congestive fevers." " Diabetes, a disease characterized by
dextrine or sugar in the urine." " Diosma, a medicinal plant."
" Entozoa, parasitical animals," " Inferior, name of certain
muscles." " Shingles, an erysipelatous eruption around the
middle of the body." " Catalepsy, a species of apoplexy."
" Volvulus, ileac passion." " Throbbing, pulsating pain."

But these instances must suffice. Any one, who chooses to
amuse hunself, can find scores of others equally unsatisfactory,
incorrect, or absurd. As to the matter of omission of terms
now in common and daily use, we have nothing to say except
that the book is in this respect most strikingly and lamentably
deficient. We have given thus much space to this book, vastly
more than it is worth, for the reason that we have noticed that
some of our exchanges, evidently without having looked inside
the covers of the book, have praised it most extravagantly. If
any of om' numerous readers should be tempted to buy the
book, we would repeat to them Mr. Punch's advice to the
young man about to be married, and simply say, " DonHP

Aet. III. — A History of the Medical Department of the Uni-
versity of Pennsylvania^ from its Foundation in 1765.
With Sketches of the Lives of Deceased Professors. By Jo-
seph Caesox, M. D., Professor of Materia Medica in the
University of Pennsylvania, etc. Philadelphia : Lindsay
& Blakiston, 1869. 8vo, pp. 227.

The early history of medical teaching in this country is
the early history of the Medical Department of the University

640

EEVIEWS.

of Pennsylvania, and of "its founders and first professors,
who were prominent in tlie enterprise of transferring medical
education from the Old World to the N^ew, and who by their
learning, talents, and energy contributed to its success." The
materials of this history have been carefully collected and ar-
ranged by Professor Carson, of the University, who has done
his pious task discreetly and acceptably.

It is probable that the first anatomical demonstrations in
the United States were given in Philadelphia, about 1751, by
Dr. Cadwalader, of that city, who had been a pupil of the
celebrated Cheselden. Dr. William Hunter, a native of Scot-
land, and a relative of the celebrated Hunters, soon aftei set-
tling in this country, gave lectures on anatomy at ISTewport,
Ehode Island, in 1754, '55 and '56. In 1762, Dr. William
Shippen, Jr., returned from Europe, and in the Pennsylva-
nia Gazette^ ^November 25, 1762, may be read the following
announcement : " Dr. Shippen's Anatomical Lectures will
begin to-morrow evening, at six o'clock, at his father's house
in Fourth Street : Tickets for the course to be had of the Doc-
tor, at five pistoles each, and any gentlemen who incline to
see the subjects prepared for the lectures, and learn the art of
Dissecting, Injections, etc., are to pay five pistoles more."
The Introductory was delivered in the State-House ; the num-
ber of students who attended this course was twelve ; three
courses were delivered, and the Medical School of America
had its origin here. Up to this time there was no systematic
instruction in medicine anywhere in these colonies ; all the med-
ical education to be got in the country was limited to the of-
fices or shops of the preceptors, where a training in the handi-
craft of the profession was got. This apprenticeship, which
lasted seven years, was no sinecure, and had its vexations.
" The pupil (or apprentice as he was called) lived for the
most part with his master — was constantly subject to his or-
ders, whether in the task for preparing medicines to be used
in his daily rounds, in carrying them to the patients, or in mak-
ing fires, keeping the ofiice clean, and other household duties
now devolving upon domestics" (p. 30). We find that quite
a number of these students, on the completion of their term of
service, went to Europe, attracted by the reputation of the

EEVIEWS.

641

schools at Edinburgli, Leyden, and Paris, and the hospitals
of London.

We said that the Medical School had its origin in Dr. Ship-
pen's lectures ; they were in full operation when Dr. John Mor-
gan arrived from Eui'ope, in 1765. These two gentlemen were
the fathers of systematic medical teaching in this country. It
would appear from a letter of the celebrated Dr. Fothergill,
written in April, 1762, that the matter of a medical school in
the province had been already agitated. Sending some crayon
anatomical drawings to the Pennsylvania Hospital, he writes :
" In the want of real subjects, these will have their use, and I
have recommended it to Dr. Shippen to give a course of An-
atomical Lectures to such as may attend. He is very well
qualified for the subject, and will soon be follovjedhy an able
assistant, Dr. Morgan, hoth of whom, I apprehend, vnll not
only he usefiil to the Province m their employments, hut, if
suitahly countenanced hy the Legislature, will he ahle to erect
a School of Physic amongst you, that may draw students from
various parts of America and the West Indies, and at least
furnish them with a better idea of the rudiments of their pro-
fession, than they have at present the means of acquiring on
your side of the water " (p. 42). Morgan having served four
years in the provincial army dming the French War, spent
five in Europe, under the most celebrated masters in every
branch of medicine, having during that time, as he tells us,
expended in this pursuit a sum of money of which the very
interest would prove no contemptible income.' He graduated
as M. D. at Edinburgh, in 1763, his thesis being the mode of
formation of pus, which he maintained was a secretion, thus
anticipating Mr. John Hunter, there being no proof, accord-
ing to Dr. James CuiTy, that the latter taught or even adopt-
ed such an opinion until a considerably later period. Dr.
Morgan, while in England, became a proficient in injecting the
glandular organs with wax, and preparing them by subsequent
corrosion, and his skill in this sort of anatomical preparation
was rewarded, when he went to Paris, by his being made a
member of the Academy of Surgery. He was also elected a
Fellow of the Eoyal Society of London, was admitted a Licen-
ciate of the College of Physicians, London, and a member of the

642

REVIEWS.

College of Physicians, Edinburgh. When in Italy, he visited
the venerable Morgagni at Padua, who was so pleased with
him that he claimed kindred with him from the resem-
blance of their names, writing on a copy of his works which
he gave him: "Affino suo, medico prseclarissimo Johanni
Morgan, doriat auctor." Dr. Morgan seems to have been the
first physician in Philadelphia who followed the European
habit of graduates of medicine, and restricted himself to sim-
ply prescribing for the sick, separating himself from the hand-
icraft, which requires distinct skill and long special training.
He insisted too on the distinction being made between medi-
cine proper and pharmacy.

Shippen had been sent to Europe in 1757, graduating at
Edinburgh in 1761. While in London, he resided in the
family of Mr. John Hunter, but was also associated with
Dr. William Hunter and Mr. Hewson. He devoted quite
a share of attention to the rising department of obstetrics,
and his thesis was entitled " De Placentae cum Utero
nexu." These two zealous young men seem to have con-
certed while abroad the plan of establishing a medical school
in their native city, and Shippen's anatomical lectures paved
the way, before Morgan's return. The latter had, moreover,
secured the favor of the Proprietor, the Honorable Thomas
Penn, in behalf of his " proposal for introducing new pro-
fessorships into the Academy for the instruction of all such as
shall incline to go into the study and practice of Physic and
Surgery," who wrote a letter to the Board of Trustees recom-
mending that what Morgan had to offer concerning his scheme
of lectures might "be taken with all becoming respect and expe-
dition " into their most serious consideration. Approving let-
ters from Fothergill, W. Hunter, Watson, and Cullen, were
at the same time presented. The College of Philadelphia had
been founded in 1749, sixteen years before. The trustees ap-
proved the project, and " entertaining a high sense of Dr. Mor-
gan's qualifications, and the high honors paid to him by dif-
ferent learned bodies and societies in Europe, they unanimous-
ly elected him professor of the theory and Practice of Physic "
{Minutes) ; and thus on May 3, 1765, was the first medical pro-
fessorship in America created. The population of the city of

EEVIEWS.

643

Philadelphia at this time was about twenty-five thousand, and
of the colonies in the aggregate less than three millions. In
September foUowmg, Dr. Shippen was, on application to the
Board, nnanimously elected Professor of Anatomy and Sur-
gery. It is noteworthy that, at this time (1Y65), five of the
most prominent physicians were members of the Board of
Trustees of the College, yet there was no attempt to secure a
place for any one of their own members, although one of
them, Dr. Thomas Cadwalader, had, as we have seen, been
the earliest teacher of anatomy in the country. For two years
lectures were delivered by the two professors under the sanc-
tion of the College. In connection with their labors. Dr.
Thomas Bond, one of the physicians to the Pennsylvania Hos-
pital, began a course of Clinical Lectures in that institution.
It may be told here, for it is worthy of record, that, at the
time of an application for its charter to the Provincial As-
sembly— ■

" One of the objections oifered to the measure was, that the cost of
medical attendance would alone be sufficient to consume all the money
that could be raised, it was met by the offer on the part of Dr. Zachary and
the Bonds to attend the patients gratuitously for three years. This became
the settled understanding with the Board of Physicians and Surgeons ; nor
have we learned that the compact has ever been annulled or abrogated during
the period of one hundred and seventeen years (from 1751 to the present
date), an instance of disinterested philanthropy which has been generally
followed in the charitable institutions depending on medical attendance
throughout the length and breadth of the land (p. 37).

In such striking contrast w^as this with the custom then and
now of Europe, especially in Great Britain, where the students'
fees are quite an item in the income of hospital physicians, that
the notorious Brissot particularly mentions it in his travels in
the United States in 1788.

In 1767 the medical gentlemen of the Board of Trustees,
with the two professors and the provost, framed a set of rules
for the Physic School. These were submitted to the Board of
Trustees, and adopted May 12, 1767 ; they regulated the confer-
ring of the usual degrees in physic on deserving students — the
bachelor's degree, and the doctor's degree. In the announce-
ment given to the public press, it is stated that —

644

EEYIEWS.

"This scheme of a medical education is proposed to be on as extensive
and liberal a plan as in the most respectable Euroiuan seminaries, and the
utmost provision is made for rendering a Degree a real mark of honor, the
reward only of distinguished learning and abilities."

In January, 1768, Dr. Adam Kuhn returned from Europe,
and was at once appointed Professor of Materia Medica and
Botany. He held the chair of Materia Medica for twenty-one
years, when he was transferred to the chair of Practice.

The next event is an important one in the history of the
school, and about which there has been some controversy — the
bestowal of the first medical honors in America. It should
be mentioned here that in 1768 a medical school had been
organized in N^ew York City, under the direction and govern-
ment of King's College,^ now Columbia College. In an in-
augural address, delivered at the opening of Putger's Medical
College, ISTovember 6, 1828, the late Dr. David Hosack claims
to correct an alleged error of the late Dr. Thomas Sewell, of
"Washington city, " relative to the first medical degrees con-
ferred in the colonies, now the United States. . . . He dates
the first medical degrees as conferred at the commencement
held in Philadelphia, in June, 1771, whereas the doctorate had
been previously conferred in the month of May of the preceding
year [1770] in the city of JS'ew York." The late Dr. John B.
Beck, in " An Historical Sketch of the State of Medicine in
the American Colonies " {Transactions New York State Medi-

^ The instructors in this school were : Samuel Glossy, M. D., Professor
of Anatomy ; John Jones, M. D., Professor of Surgery ; Peter Middleton,
M. D., Professor of Physiology and Pathology ; James Smith, M. D., Pro-
fessor of Chemistry and Materia Medica ; John V. B. Tennant, M. D.,
Professor of Midwifery ; and Samuel Bard, M. D., Professor of Theory and
Practice. During the occupation of the city by the British, the lectures
ceased ; and after the peace an attempt was made to reestablish the school,
but it was unsuccessful. In 1792 Columbia College organized a Medical
Faculty, and placed Dr. Samuel Bard, son of Dr. John Bard, one of the
early Philadelphia physicians, who removed to New York, at its head ;
but it appears from the records of the college that, from that date to 1811,
only thirty-four students completed their courses of study, and received the
honors of that institution ; so that when Dr. Morgan wrote to Hewson, re-
specting the T^Tew York rivalship, " for my part, I do not seem to be under
great apprehensions," he judged rightly.

REVIEWS.

645

cat Society^ 1850), says : " The first medical degrees were given
by the College of Xew York. In 1769, the degree of Bachelor
in Medicine was conferred upon Samual Kissam and Eobert
Tucker. In 1770 the degree of Doctor of Medicine was con-
ferred on the last of these gentlemen, and in May of the fol-
lowing year [1771] upon the former. In June, 1771, the .de-
gree of Doctor in Medicine was confen*ed on four students of
the Philadelphia College, being the first given in the institu-
tion." ^N^ow, the facts are, that, on the tvnerdy-first ofJune^ 1768,
at a commencement of the College of Philadelphia, the degree
of Bachelor of Medicine was conferred on ten gentlemen, namely:
Messrs. John Ai'cher, of ISTew Castle County ; Benjamin Cowell,
of Bucks ; Samuel Duffield and Jonathan Potts, of Philadelphia ;
Jonathan Elmer, of Xew Jersey ; Humphrey PuUerton, of
Lancaster County ; David Jackson, of Chester Coimty ; John
Lawrence, of East Jersey ; James Tilton, of Kent County ;
and Xicholas Way, of Wilmington. The ceremonies are noted
with exactness in the minutes of the Board of Trustees of that
date, which sets forth with the declaration that ''this day
[June 21, 1768] may be considered as the Mrthday of medica I
honors in America. "^"^ A Latin oration, De Honoribus qui in
omni oevo in veros Medicinee cultores coUati fuerint, was de-
livered by Mr. John Lawrence. A dispute, whether the retina
or tunica choroides be the immediate seat of vision, was in-
geniously maintained by Mr. Cowell for the retina, and Mr.
EuUerton for the choroid. Then came, Questio, num detur
fluidum nervosum ? Mr. Duffield holding the affirmative, and
Mi\ Way the negative, both with great learning. Xext, Mr.
Tilton delivered an essay on respiration, and we are told that
the manner in which it was performed did credit to his abilities.
The provost afterward conferred the degrees ; and an elegant
valedictory oration was spoken by Mr. Potts. All this is circum-
stantial enough. Besides, Dr. Morgan writes prospectively to
Mr. William Hewson, of London, November 20, 1767 : '' I have
twenty pupils this year at about five guineas each. J^ext yea/r
[1768] we shall confer the degree of Bachelor in Physic on
several of them., and that of Doctor in three years after. J^ew
York has copied us, and has six professors, three of whom you
know. . . . Time will show in what light we are to con-
sider the rivalship."

646

KEVIEWS.

In June, 1769, tlie degree of Bachelor of Medicine was
conferred on eight candidates. At the commencement in
June, 1771, fonr of the graduates, who had received tlie pri-
mary degree in 1768, now received that of Doctor of Medicine ;
they were, Jonatlian Potts, James Tilton, I^Ticholas Way, and
Jonathan Elmer ; their theses were written in Latin, and were
published, according to the enacted rules of the Board, and are
now in existence. Dr. Beck, in the interesting paper referred
to, is in error when he states that the only inaugural disserta-
tion published until after the War of our Independence was
from the New York College, and by Dr. Samuel Kissam, " On
the Anthelmintic Virtue of the Phasceolus Zuratensis," a copy
of which is in the library of tlie ^N^ew York Historical Society.

With regard, then, to the claim of precedence for the first
medical honors in America between l^ew York and Philadel-
phia, "it appears that the claim of priority of conferring
degrees in medicine must be awarded to the Philadelphia
School [1768], while the precedence of conferring the doctorate
• must be given to New York [1770] " (p. 68).

In 1769 Dr. Benjamin Push, on his return from Europe,
was elected Professor of Chemistry ; so that, for the session of
1769-'70, there were five professors — Morgan, of Theory and
Practice ; Shippen, Jr., of Anatomy, Surgery, and Midwifery ;
Kuhn, of Materia Medica and Botany ; Push, of Chemistry ;
and Bond, of Clinical Medicine. " Push was but twenty-four
years old ; Kuhn, but twenty-eight ; Shippen, thirty-three ;
and Morgan, thirty-four. Bond only had arrived at that age
when experience is supposed to bring the greatest wisdom, he
was over fifty years" (p. 75).

We must refer our readers to Dr. Carson's interesting
volume for the history of the growth and maturity of this an-
cient school of medicine ; this nursery of medical teachers of the
American continent. The old Alma Mater is as vio-orous as
ever ; age has not withered her ; her way of life is still full of the
spirit of youth ; and she yet keeps true to the gathered memo-
ries of those wdio made, and those who have kept, her fame.

"There may these gentle guests delight to dwell,
And bless the scene they loved in life so well."

BIBLIOGEAPHICAL AlsB LITEEAEY NOTES. 647

Many years since, the reading of De Quincey's " Confes-
sions " aroused T\'ithin ns the intensest desire to taste the pleas-
ures of opinm-eating, and though then a mere fledgling, the
opinion was formed, which subsequent and more mature expe-
rience has substantiated, that his book would only be productive
of evil, especially to the yoimg and susceptible reader; for
there are few, we apprehend, but would yield something to the
seductive influence of the wondrous, word-compelling power
displayed by that marvellous-minded man in his dangerous
narrative.

It was, therefore, with no little misgiving that we took up
the volume' now before us, fearing that, from the very nature
of the subject treated of, perhaps more of bad than of good
influences might be evoked. But a careful perusal of its en-
tire contents enables us to record our opinion that, rightly
studied, the tendency of the teachings here conveyed can only
be salutary ; and we earnestly commend the book to all phy-
sicians, although the class of readers for whom it is prepared
will derive precious little consolation from a perusal of its pages.

It consists of a series of individual narratives, collected by
an anonymous compiler, and intended especially for opium-
eaters ; as the instances narj-ated of success in breaking oft"
the habit may serve them for encouragement and guidance.
The first narrative, however, is the only really satisfactory one
recorded of success in this laudable undertaking. But the
other instances show the terrible sufierings entailed upon the
victims of the opium-eating habit, and still more vividly do they
point out the agonizing distresses — worse than death itself —
which invariably are aroused by the withdrawal of the accus-
tomed stimulus. And herein lies the greatest obstacle to cure,
for few there be of nerve enough to pass through so dreadful
an ordeal. Death itself — to say nothing of the relentless
bondage in which this habit holds its unhappy victim — would
be preferable to most men.

^ The Opium Habit, Tvith Suggestions as to the Remedv. >sew York :
Harper & Brothers. 1868. 12mo, pp. 335.

648 BIBLIOGEAPHICAL AND LITEEARY NOTES.

But we cannot undertake an analysis of the book. It is
of absorbing interest, too much so, we fear, for a calm survey
of its teachings. While the narrative portions of the volume
will most interest the general reader, there are, incident-
ally scattered through the book, many facts that the thought-
ful physician may turn to good account. But the part that
most naturally comes within his province is the closing chap-
ter, contributed by Fitz-Hugh Ludlow, entitled " Outlines
of the Opium-Cure." With a masterly pen he here maps out
for us a systematic and rational line of treatment to be pursued,
premising the one essential condition that special and well-
appointed institutions are absolutely necessary for the proper
management of these fearful cases. In this we think the pro-
fession will entirely accord w^ith him, but experiences on a
larger scale than are thus far recorded are wanting, to bear out
the author's sanguine expectations of a cure in so large a pro-
portion of cases.

The first edition of Dr. Hartshorne's " Essentials of the
Principles and Practice of Medicine " ^ w^as noticed in the sixth
volume of The Journal. The present one has been revised and
enlarged by some thirty-odd pages. The title is a palpable
misnomer — a good catch-title for a publisher, but unworthy
an author ; and Dr. Hartshorne would be the last to claim
that all that is necessary in the principles and practice of
medicine is to be found in this libellus. If this were so, how
foolish it would be for physicians to purchase and waste time
in reading Aitkin, Flint, Wood, Bennett, Williams ! It is
simply a medical primer, a first-class book, and contains the
outlines of the science and art of physic ; and, as such, is of
the very best quality. It is much superior to any other work
of its sort ; and, if rightly used, will be found highly useful.
Dr. Hartshorne not only knows what others have done or are
doing, but he uses wisely his faculties of observation and reason,
and has very decided opinions of his own, which he does not

^ Essentials of tlie Principles and Practice of Medicine. A Handbook
for Students and Practitioners. By Henry Hartshoi-ne, M. D., etc. Sec-
ond edition, revised and improved. Philadelphia: Heury C. Lea. 1869.
Small 8vo, pp. 452.

BIBLIOGEAPHICAL AND LITERARY NOTES. 649

hesitate to express, even when in opposition to the current
doctrines of the day. In a work so generally accurate, we are
surprised to find the statement that amyloid degeneration
" consists in the conversion of tissue into a substance having
physical and chemical properties resembling those of starch or
cellulose " (p. 44), which has for some time been abundantly
proved to be a chemical error of Yirchow.

This book of Mr. Marshall ^ will be found useful by those
who do not care to go very deeply into the science of phys-
iology, and who are satisfied with getting their knowledge of
the subject through a medium which makes it undergo a very
extensive process of dilution. In the main, the author is clear
and concise ; but the absence of references to his statements
unfits the book for the purposes of any but superficial students,
or the general reader.

A prominent and useful feature of the treatise is the com-
parative physiology, a part of the science not ordinarily suffi-
ciently considered by the medical student, and not deeply
touched upon in the present volume. However, what there
is of it may serve a good turn with some, who otherwise
would know nothing whatever of the matter ; but the fact
that this part of the book is printed in small type will doubt-
less make many pass it over as non-essential.

The English edition was issued in two volumes. The
American publisher, however, has seen fit to compress them
into one unwieldy and ugly volume, printed on bad paper,
and no better, in appearance, than hundreds of others which
have come from the same house.

The additions of Professor Smith, though not extensive,
supply several omissions of the author, and add to the value
of his treatise.

Thirty years ago it was heresy in Dublin to speak of two
kinds of continued fever, although at that time so much had
been done toward both the symptomatology and therapeutics
of fevers by eminent Irish physicians, particularly the late Dr.

^ Outlines of Physiology, Human and Comparative. By John Marshall,
F. E. S., etc. With Additions hy Francis G. Smith, M. D., etc. Philadel
phia : Henry C. Lea. 1868. 870, pp. 1026.

650 BIBLIOGRAPHICAL AI^D LITER AEY Is^OTES.

Graves, and Dr. Stokes. Several years previoiislv, Dr. A. P.
Stewart, then of Glasgow, and afterward of the Middlesex Hos-
pital, London, had attempted to show the non-identity of
typhous and typhoid fevers, but his observations, founded on
over three thousand cases, during the years 1836, '37, '38, as
well as the facts and arguments of both French and American
physicians, failed to bring conviction to the medical mind of
Britain ; nor were the essential differences of the two forms
of fever, both in origin, morbid phenomena, and anatomical
characters, generally recognized there until the publication of
Dr. (now Sir William) Jenner's paj)ers, in 1846. There are yet
those who maintain the identity of the two disorders, and
among the ablest and most persevering is another eminent
Dublin physician, Dr. Henry Kennedy, who believes that
ty]3hus and typhoid fever are the result of a single poison, and
that no other hypothesis can explain so well all the difficul-
ties of the case.

The object, says Dr. Hudson, " I have had in view in
delivering the ensuing lectures,^ and in now publishing them,
is to furnish the student with a guide to his bedside analysis
of each case, by treating of febrile phenomena in succession :
first, generally or abstractedly ; and secondly, in their relation
to each form of the disease — " thus forming in his mind an
ideal of fever, such as he may readily apply to the case before
him, and which he may certainly find to conform to that case,
be it of what species, or how complicated soever it may "
(Preface, v.).

We can cordially recommend this work to our readers, as
one of practical merit, and, though not adding any thing to the
stock of knowledge, yet wliat is known and approved is gen-
erally well put.

We welcome with pleasure the appearance of this new
periodical,*^ devoted to cutaneous and venereal diseases. The

^ Lectures on the Study of Fever. By Alfred Hudson, M. D., M. R. I. A.,
Physician to the Meath Hospital. Philadelphia: Henry C. Lea. 1869. 8vo,
pp. 316.

^ Annales de Dermatologie et de Syphiligraphie, puhliees par le Dr. A.
Doyon. Premiere annSe, No. I. Paris : Victor Masson et Fils. 1869.

BIBLIOGRAPHICAL AIS^D LITERARY NOTES. 651

editor, Dr. A. Dojon, of Lyons, is already known to venereal
specialists by his valuable contributions to sypliiligrapliy. The
present number contains a " Contribution to the Study of Gon-
orrhoeal Rlieumatism," by Alfred Fournier, the one of the nu-
merous venereal specialists in Paris who promises to be a sec-
ond Ricord in deserved rej^utation ; an article on the use of
ice in certain affections of the testicle (especially gonorrhoeal
epididymitis), by our valued and always entertaining, though
visionary friend. Dr. Diday ; one on venereal diseases of the
uterus l^y the able, learned, and sound Rollet; another on
" Diatheses in diseases of the skin with reference to treatment ; "
together with a bibliography, and a review of articles in medi-
cal journals pertaining to the skin and s}^3hilis.

The list of " collaborateurs " announced embraces the names
of those best known in these specialties in France, and several
others in Germany and Italy. This journal will be indispen-
sable to specialists, and of importance to all who take an inter-
est in the subject of which it treats.

The present volume,^ besides the Minutes of the Nineteenth
Meeting of the Association, and of the several Sections, with
the address of the President, contains but few papers which
claim even a passing notice. It is unusually barren. The
reports on the Climatology and Epidemic Diseases of West
Yirginia, the District of Columbia, Texas, and Pennsylvania,
are interesting and instructive as far as they go, but are open
to the charge of want of thoroughness and completeness.
The several articles which ^vill particularly claim and deserve
notice are : " On the Conveyance of Cholera from Hindostan
through Asia to Europe and America," by Dr. John C.
Peters ; the " Report of the Committee on Ophthalmology,"
by Dr. Joseph S. Hildreth ; Report on the Treatment of
Club Foot," by Dr. Lewis A. Sayre ; " A IS'ew Method of re-
constructing the Lower Lip after its Removal by Disease," by
Dr. Gurdon Buck ; and " The Treatment of Syphilis by
Hypodennic Injection," by Dr. Elsberg.

^ The Transactions of the American Medical Association. Instituted
1847. Yol. xix. Philadelphia : Printed for the Association. 1868. 8vo,
pp. 497.

652

BIBLIOGEAPHICAL AND LITER AEY Is^OTES.

In one respect this voliime is an improvement on some of
its predecessoi^ ; tbere are no prize essays. The Treasurer,
in his report, wites : " A great abuse has grown up in the
Association, and has largely assisted in the impoverishment of
the treasury. The Association is permitted to give an annual
prize of one hundred dollars for an essay of great worth, if
such a one should be presented, and even to vote one
hundred dollars to a second, if several should be presented of
great value. Under this permission it has become a custom
to vote away two hundred dollars annually to the .two best
essays presented, whatever be their intrinsic merit ; thus, not
only voting away two hundred dollars, but entailing a heavy
expense for printing and illustrating essays that may deserve
no such distinction. Will the Association give special heed
to this fact ? " The Association seems to have heard and
heeded, and hence we have the gratifying intelligence that
" the Treasurer has the honor to report that the American
Medical Association is again solvent."

Ix using oxygen for the treatment of disease. Dr. Birch ^
prefers the gas itself administered by iuhalation, though he
mentions with approval oxygenated water, nitrous-oxide water,
ozonified oil, perchloric acid and its compounds, and oxyge-
nated bread. The solution of peroxide of hydrogen, proposed
and recommended by Dr. E-ichardson, he does not tind gener-
ally useful.

As to the aftections in which oxygen is deemed advan-
tageous, they are generally those which are due to or accompa-
nied by a depressed condition of the system. In such dis-
eases it would seem to be a^iori indicated, and Dr. Birch
gives several interesting cases of its success. We incline to
the opinion, however, that he is over-enthusiastic in its praise,
and that fuller experience will not conhrm all he alleges in
favor of its efficacy.

Messrs. Wm. Wood & Co. will issue in May next the first
number of tlie "Archives of Oj)hthalmology and Otology,"

^ On the Action and Use of Oxygen in the Treatment of various Dis-
eases otherwise incurable or very intractable. By S. B. Bird), M. D.,
etc. Second edition. London, 1868. 12mo, pp. 149.

BIBLIOGEAPHICAL AND LITERAKY IS^OTES.

653

edited by Profs. H. Knapp, M. D., of Xew York, and S. Moo?,
M. D., of Heidelberg, Germany. The " Arcliives " will con-
tain only original papers, and will be printed simultaneously
in English here, and in German at Heidelberg. The same
plates and illustrations will be used for both editions. The
well-known reputation of the editors is a sufficient guarantee
of the scientific ability of this new publication, which com-
mends itself to all interested in these special studies. The edi-
tion will be limited, and subscribers are therefore requested to
send in their names early.

The Lippincotts announce " The Structural Lesions of the
Skin," by Dr. H. F. Damon.

Messrs. W. A. TowjsSExd & Adams announce a reprint of
Dr. Letheby's " Lectures on Food," which are now appearing
in the Journal of Chemistry.

We have received from Messrs. Wm. Wood (fc Co. a copy
of Klob's Pathological Anatomy of the Female Sexual Or-
gans," translated by Drs. Kammerer and Dawson. On the
first appearance of this book, we gave it quite an extended
notice, and now we need only say that the externals of the
volume are much more creditable than imder the former pub-
lishers. There is no change made in the body of the book,
and consequently we have no change to make in our com-
ments thereon.

The Humboldt Medical Archives, one of the most enter-
prising and successful of our numerous exchanges, changes its
title to the Medical Archives, with the commencement of the
new year and volume. Dr. E. A. Clark, Eesident-Physician
of the St. Louis City Hospital, will hereafter be associated
with Dr. "Whitehill in the editorial manao-ement of this
journal.

We have received from Dr. S. W. Butler, the publisher
and editor of the Medical and Surgical Reporter, a copy of
his visiting list. We have previously called attention to the
advantages which this list presents, and have now only to re-

654 BIBLIOGEAPHICAL AND LEDEEAEY IS^OTES.

new them. The patent clasp, a most admirable contrivance,
adds greatly to the convenience of using this little book.

"We have received from the Messrs. Churchill, of London,
a copy of the third edition of Tilt's Hand-Book of Uterine
Therapeutics. The lengthy notice which in the last number we
gave of the American edition dispenses us from any further
notice of the work.

Me. Bekkeley Hill's new work on Syphilis and local Con-
tagious Disorders has appeared from the press of James Wal-
ton, London, and is also reprinted in this country by H. C.
Lea.

De. Wilson Fox has published, through the M'Millans, of
London, his observations on the Artificial Production of Tu-
bercle. The volume is issued in superb style — quarto form —
with chromo-lithographs and engravings.

Feom Triibner's press w^e observe a second edition of Dr.
Chapman's " Sea- Sickness and how to Prevent it." Our readers
will recall this method as the pet plan of Dr. Chapman, by
applying his ice-bags to the spine. We are informed by a phy-
sician who has experimented with this method, that unques-
tionably, in many cases, it proves efficacious.

Messes. John Chuechill & Co. have nearl}^ ready a second
and enlarged edition of Dr. F. W. Pavy's treatise on Diabetes,
its Nature and Treatment.

The Yorlesungen," or lectures of Dr. Lewis Biichner,
upon the theories of Darwin, and their relations to science
and philosophy in general, are to be translated into English,
and will be published, it is understood, by Leypoldt & Holt, of
this city.

The St. Louis Medical Rejporter has changed hands. Dr.
O. F. Potter retires from the editorship, and is succeeded by
Drs. W. M. McPheeters and G. M. B. Maughs. It will now ap-
pear in monthly issues instead of, as previously, semi-monthly.

BIBLIOGRAPHICAL AIS^D LITERARY NOTES.

655

In tlie Atlantic Monthly for March, Dr. Henry I. Bow-
clitch completes his adimrable seriesof papers on Consumption.
These papers are prepared especially for the instruction ot
the public, but every medical man in the country should read
them. They are not only interesting, but valuable and in-
structive in the highest degree. We hope soon to give our
readers a full abstract of them.

Feench literature has recently contributed a number of new
works on medicine, of which we notice the following :
" Physiology and Instruction of the Deaf and Dumb accord-
ing to the Physiology of ditferent Languages," by Dr. E.
Fournie. " Studies on the different Forms of Encephalitis,"
by G. Hay ems. A translation of I^iemeyer's Internal Pa-
thology and Therapeutics." " Gestation in Relation to its
Influence on the Physiological and Pathological Constitution
of Woman," by Dr. Th. David. " Elementary Treatise on
Surgery," by Dr. Fano.

" Theorie Physiologique de la Musique fondee sur rfitude
des Sensations Auditives." Par H, Helmholtz, Professeur de
Physiologic a I'Universite de Heidelberg, etc. Traduit de
I'Allemand par M. G. Gueroult, ancien eleve de I'Ecole
Polytechnique ; avec le concours pour la partie musicale
de M. Wolff. Avec figures dans le texte. Paris : Victor
Masson et Fils. 1868. A Physiological Theory of Music
based upon a Study of Auditory Sensations." By H.
Helmholtz, Professor of Physiology in Heidelberg Uni-
versity, etc. 544 pages. Translated from original Ger-
man by M. G. Gueroult, formerly Pupil of the Poly-
technic School ; and with the assistance, in the musical
portion, of M. Wolff. With figures in the text. Paris :
Victor Masson & Son. 1868.

" Lorain, Etudes de Medecine Clinique et de Physiologic
Pathologique." Le Cholera observe a I'Hopital Saint Antoine,
Paris, 1868. Avec 8 planches graphiques intercalees dans
le texte, et en partie coloriees. Paris : J. B. Bailliere. " Lo-
rain, Studies in Clinical Medicine and in Pathological
Physiology." The Cholera of 1868, as observed in Hospital
St. Antoine, Paris. With 8 partially colored plates in the
text.

656 BIBLIOGEAPHICA.L AND LITEEAEY NOTES.

Dr. Christol's " Legons de Clinique Chirurgicale," delivered
at the Hotel Dieu, of Lyons ; published in numbers.

The following medical additions to literature are announced
from Paris : " Aphorisms on Venereal Diseases," with a special
formulary, by Edward Langlebert. Syphilis — Jerome Fra-
castor's Latin poem, translated by the same author.

" Mexico, from a Medico-Chirurgical Point of Yiew," by
Leon Coindet, chief surgeon of the 1st and 2d divisions of the
Mexican Army.

" Photographic Studies of the I^'ervous System of Man
and some of the higher Animals, from Dissections of congelated
IS^erve Tissues," by Dr. Pierre Pondanovsky ; 203 Photographs
in 20 Plates.

" A Memoir on Surgical Intoxication," by M. Maissoneuve.
" The Method of Continuous Aspiration as a means of Cure
after Capital Amputations," by M. Maissoneuve.

Books Eeceived. — Annual Eeport of the Surgeon-General, United
States Army, for 1868.

This report shows that, during tlie'year, very satisfactory and decided
progress has been made in the preparation of the materials for the forth-
coming Medical and Surgical History of the War. Eight chromo-Htho-
graphs, eight lithographs, three diagrams, and one hundred and twenty-
two woodcuts have been completed during the year. Eive hundred pages
of manuscript are ready for the printer, and a large amount of statistical
material is in such a stage of advance that it can be made ready for the
press at a short notice. This History, if it ever be completed, will undoubt-
edly be one of the most valuable and important publications ever issued;
and we hope to see a wise liberality manifested by Congress in furthering
80 useful a work.

An Inquiry into the Physiological and Medicinal Properties of the Vera-
trum Viride, together with some Physiological and Chemical Observations
upon the Alkaloid Yeratria. Prize Essay, to which the American Medical
Association awarded the Gold Medal for 1863. By Samuel E. Percy,
M. D. Eeprint from the Transactions of the American Medical Associa-
tion. From the Author.

Digitalis; its Chemical, Physiological and Therapeutical Action.
An Essay to which was awarded a Prize by the American Medical Asso-
ciation, May, 1866. By Samuel E. Percy, M. D. Eeprint from the Trans-
actions of the American Medical Association. From the Author.

Vaccination Impartially Eeviewed. By Ferdinand E. Jencken, M. D.
London : John Churchill & Sons. 1868. Pamplilet, pp. 28. From the
Publisher.

REPOETS OX PR0GEES3 OF MEDICIXE.

657

De, Wattee's Doctrines of Life. Reprint from the St. Louis Medical
and Surgical Journal. Pamphlet, pp. 28. From the Author.

Physician's Medical Compend and Pharmaceutical Formula. Compiled
hj Edward H. Hance. Philadelphia: Hance, Griffith & Co. 1868.
12rao, pp. 214.

Thirteenth Annual Report of the Trustees of the State Lunatic Hos-
pital at ]S'orthampton, Mass. Pamphlet, pp. 43.

OPHTHALMOLOGY.

Br Hexet D. Xoyes. M. D., Professor of Ophthalmology in Bellevue Hos-
pital Medical College ; Surgeon to Xew York Eye and Ear Infirmary.

(Concluded from the Febraary Journal, page 557.)

28. — The use of Calalar Bean in Fistula of the Cornea. By Dr. William
Zehexdee. [Klinische Monatsblatter fur Augenheilkunde, February,
1868, pp. 35.]

By fistula of tlie cornea is not meant a permanent opening through
which the aqueous humor must constantly di-ain, but that in consequence
of ulceration an exceedingly thin spot is left, which from time to time gives
way and empties the anterior chamber ; the globe remains at all times rather
soft, the anterior chamber imperfectly filled. The condition is often very
difficult to cure, and may lead to atrophy of the globe by irido-choroiditis.
Atropia and a pressure bandage, the cauterization of the ulcer with nitrate
of silver, are the chief remedies employed. Dr. Zehender had under treat-
ment a girl ten years old, whose left eye was attacked by blenorrhoea, and
a large ulceration of the lower portion of the cornea — perforation and adhe-
sion of the iris ensued, and a fistula was formed. The usual remedies were
employed for six weeks or more, without preventing the reopening of tlie
fistula once in several days. The place where perforation occurred was at
the margin of the pupil, which was dilated to a medium degree. The ex-
tract of calabar bean was then tried — one drop of a fluid preparation daily.

On the seventeenth day the aqueous again escaped, but not again. The
treatment was kept up five weeks longer, and after the lapse of several
months the cornea remained healed. The opacity of the cornea was so
extensive as to make it impossible to see the exact relations of the fistula
to the edge of the pupil, but Dr. Zehender thinks they must have been in
contact with each other. It is easy to see how the active contraction of
the pupil would present a barrier to the rupture of the thin spot of the
cornea, and give it an opportunity to attain sufficient strength to withstand
unaided the pressure of the fluids of the eye.

29. — Disease of the Cornece in a Ca^e of Extensive Cutaneous Ancesthesioj
(Elephantiasis Grtecorum Ansestheticum ?). By Dr. Chisholm. of Charles-
ton, U. S. [Ophthalmic Hospital Reports, vol. vi., 2. pp. 126-131.]

The subject of this disease was a man 44 years old, in whom the general
malady had existed about eighteen years. He had lost many of the pha-

658 EEP0RT3 ON PEOGEESS OF SIEDICmE.

langeal bones of the hands and feet. Anassthesia has become general, and
he can feel pain in being pricked only over the upper portions of the spine,
the back of the head, ancf the chest from under the arm-pits to the waist.
The fingers and toes are contracted, and the extremities of his feet ulcer-
ated, and give rise to an offensive ichor. Though he cannot feel the prick
of a pin on his feet, and once scalded them with boiling water without
knowing it until the cuticle came off, if he treads on a pebble he has a
sharp pain shooting up the limb. His mucous surface is healthy, except a
moderate amount of ozena. Four years ago a red spot appeared upon the
lower edge of the left cornea, and gradually developed itself into a fleshy,
vascular thick mass, coextensive with the whole cornea. Ko pain accom-
panied the process. After three years a similar change began in the right
cornea, and has involved its lower half, changing it into thick, opaque,
pinkish, fibro-ceUular tissue. The margin at the sclerotic juncture is
abruptly elevated one-fifth of an inch. It slopes oft" to the normal level
at the neighborhood of the pupil, and fades into a cloudy opacity. The
thick, fleshy, red disk, which replaces the left cornea, is about three-
eighths of an inch above the level of the sclera, and its edges steep. It
is described as covered by a comparatively healthy and not much thick-
ened conjunctiva. In it a few large vessels run to the shghtly depressed
centre of the disk and then disappear in its substance. The ocular conjunc-
tiva only slightly injected, and otherwise healthy. Lachrymal secretion is
in excess. Irides healthy. Patient never had syphilis and has been treated
by all possible medicines without avail.

30. — The so-called Canal of Fontana or ScMemm — the Circular Venous
Sinus — (the space between the cornea, sclera, and ciliary muscle.) By
Dr. P. Pelechin, of St. Petersburg. [Archiv. fur Ophthal., b. xiii., 11. s.
422-446.]

The canal above alluded to has been commonly considered to be a vein.
Schlemm declared that he found it filled with blood in a man who had
been hanged; others have professed to be able to fill it by injection. Dr.
Pelechin made an extensive series of investigations on men and animals,
both macroscopic and microscopic — performed injections of veins and ar-
teries by various methods, examined eyes of men and animals which had
been hanged, dissected more than a hundred human eyes, and the following
are his conclusions: Anatomy. — 1. The canal of Fontana is a space which,
in the eyes of men, rabbits, dogs, cats, rats, and swine, is formed by the
attachment of the ciliary muscle to the place of junction of the cornea
and sclera, and in men and rabbits is formed chiefly of elastic fibres from
the sclera. 2. In oxen and horses the canal is made by a separation of the
ciliary muscle itself, whose inner bundles unite with the sclera. 3. In birds
the canal is proportionately larger than in oxen, but similarly formed. 4.
That it is also found in fishes, but is smaller.

Physiology. — Multiplied experiments, in which most complete injections
of all the capillaries were obtained, proved that the canal is not a venous
sinus, nor any kind of blood-vessel. It was also proven not to be a lym-
phatic duct. Whether it communicated with the aqueous chamber was not
satisfactorily determined.

The function of this space is declared, in accordance with the hypothesis
of Helmholtz, to be to afford space for the peripheral parts of the iris to
draw back in near vision. When relaxed, the iris takes hold on the an-
terior border of the canal of Schlemm (Fontana), when tense it takes hold
of the posterior border. The distance between the situations is 0.45 milli-
metres.

The size of the canal in man (its section is oval) is for its long
diameter 0,6'", for its short diameter 0.2'".

OPHTHALMOLOGY.

659

31. — Pathological Specimens recently added to the Mttseuni of the Boyal
Ophthalmic Hospital. [Opb. Hospital Reports, vol. vi., 2, 155.] Mr.
B. J. Veenox.

An account is given of four eyes, in three of which were tumors, and the
fourth contained a haematocele, which simulated a melanoma. The first was
a glioma, the second a glio-sarcoma, the third a melanoma. The first two
were children, the third a woman, jet. 66. The fourth is interesting, in view
of the error of diagnosis. Five months before operation, patient received
a blow on the eye while chopping wood ; by this he lost sight. After two
months he received another blow, and the eye then became painful, and
began to enlarge. Three months after, when he came to the hospital, the
lids were swelled and dusky, eyeball very prominent, much enlarged, and
in the upper cihary region was a staphyloma of deep-black color, and very
tense. He was in considerable pain, and the case was thought to be one
of rapid melanosis. The globe was wounded in the excision, and this was
followed by a gush of bloody fluid, and collapse of the bulb.

The eyeball, on examination, Avas found to have been reduced to a mere
bag, in which hardly any traces of the normal structure of the globe could
be recognized, its sole contents seeming to consist of a dark-colored fluid,
with some partially decolorized blood-clots adhering to the sclerotic. The
sclerotic appeared to have been distended, and then to have split in many
directions; the continuity of the wall of the bag had been maintained by
the orbital fascia and the expanded tendons of the muscles. The scle-
rotic was much thickened, very brittle, .and its inner surface of yellow
color, an appearance much resembling that of an atheromatous artery.

82. — Tumors of the OrMt and the Glole. By Dr. J. Hieschberg. [Ze-
hender Khu. Monatsblatter fiir Augen. 1868, June, 153.]

Three cases, operated on by Prof. Graefe, are reported, two being tu-
mors behind the eye, and one a tumor of the globe itself, both external and
internal.

One case is remarkable. The tumor had been growing in the orbit six
years, and for one year had caused blindness of that eye. Tliere was subret-
inal effusion, and also subchoroidal effusion at the upper half of the fundus,
the sac projecting far into the vitreous, and having a bluish-gray look : vision
consisted of recognition of the hand in a good light. The tumor extirpated
Avithout interfering with the eye, and three weeks after patient could count
fingers at eight feet, and the visual field was perfect. The subretinal
effusion was completely absorbed; loth the retina and choroid per-
fectly restored to their proper place. This result is surprising, and well
worthy of remembrance. It happened to Prof. Graefe once before, after
the evacuation of an orbital abscess. This shows that subretinal effusions,
from external pressure and irritation, have a much more hopeful prognosis
than when caused by prolongation of the globe, as in posterior staphyloma.

33. — Cases of Neuritis Optica., Reuro-retinitis., and Retinitis. By J. W.
Htjlke. [Ophthalmic Hospital Reports, vol. vi., 2, page 89, 1868.]

There are 39 cases, more or less completely recorded, and classed under
four heads: 1. Those from injury ; 2. Those resulting from an intracranial
disorder; 3. Those dependent on dyscrasia; 4. Miscellaneous. Of the
first class there are 2 cases; of the second class, 12 cases, in one of which
an autopsy was made, and showed a node at the sella turcica and the
hollow for the cavernous sinus, and the upper surface of the petrosal
bone, meningitis, and softening of the anterior cerebral lobe. The cor-
responding optic nerve was healthy in general appearance for three-

660

EEPOETS 01^ PKOGEESS OF MEDICmE.

fourths of its length within the orbit, but at a point four lines from the
globe it began to enlarge, and continued to increase up to the eye. The
tumefaction depended on infiltration bj products of inflammation!^

In the third class are IT cases, viz. : syphilis, 5; antemia, from rapid
child-bearing, prolonged suckling, and leucorrhoea, 6 ; phthisis pulmonalis,
1 ; rheumatism, 3, although the connection as cause and effect is not con-
sidered certain ; diphtheria, 2, one a girl 18, and the other a girl 14. This
lesion is not often seen, and deserves to be remembered.

In the fourth class, one is ascribed to masturbation and sexual excesses,
another to disease of the aortic valves, the others to unknon-n causes.

The cases are very briefly noted, and could not be further condensed ;
the ocular changes were such as are usually seen.

34. — The Formation of Pigment in tJie Optic DisTc and Eetina. By Dr.
H. Knapp. [Archiv fiir Ophthalmologic, B. xiv., Abth. 11, s. 252-261.]

Effusions of Blood in the Optic N'erve and Morbid Deposits of Figment in
the Optic Fislc. By Dr. Weckee. [Zehender's Monatsblatter fiir Au-
genheilkunde, 1868, 204.]

These papers refer to a lesion of the papi)la, which is extremely rare.
Ed. Jaeger and Liebreich alone have published cases. The pigment ap-
pears in the peripheral parts of the nerve, but is by no means to be con-
founded with the pigment which so frequently marks the choroidal ring.
Liebreich's case was the result of an injury ; of Jaeger's no history is given.
Dr. Knapp's case was a young woman who, for three days, sufiered se-
verely from headache and fever. On awaking in the morning she found
herself totally blind, and remained so until the examination, which was six
years after the occurrence, while the head-symptoms soon vanished. He
found both papillaa atrophied and covered with black pigment at their
periphery. The condition is shown by a chromo-lithograpb.

Liebreich supposed the pigment generated in new-formed cells of con-
nective tissue, which, in atrophy of the optic nerve, replaces the nerve-
fibres. Dr. K. believes it to be the result of a haemorrhage into the inter-
vaginal space of the optic-nerve sheath, the blood to have penetrated this
space from a cerebral apoplexy, and shows itself by oozing through the
lamina cribrosa. Dr. K. has examined two eyeballs, in which extravasa-
tions were found in the intervaginal space, near the sclera. The clot makes
so much pressure on the retinal vessels and the nerve-fibres as to produce
immediate blindness. That this theory of the pigmentation of the papilla
is correct, Dr. K. thinks is shown by a case in which the outer wall of the
orbit w^as blown away by a pistol loaded with shot; it was an attempt at
suicide, and the muzzle was pressed against the temple. The muscles of
the globe, and the optic nerve, were exposed to view up to the apex of
the orbit. When he saw the patient, the cavity was filled with blood and
inflammatory secretions — the eye was totally blind. By the ophthalmo-
scope a mass of blood was found on the lower and outer side of the papilla,
running out a little distance into the retina; no other lesion. After five
months the case again examined, the wound closed, the upper lid para-
lyzed, the eye turned a little downward, movable in all directions, though
not quite to the full extent, its form and tension normal, still blind. In
the fundus was a black and white mass, covering the outer half of the
nerve, and running out to the yellow spot. This was a pseudo-membrane,
and the pigment on its borders, and at another place below it, was due to
transformation of the clot previously observed.

Dr. Wecker publishes three cases of hasmorrhage into the papilla, all
having a traumatic origin, but in no case was pigmentation afterward ob-
served. In one the bleeding followed ii-idectomy for glaucoma, and was

OPHTHALMOLOGY.

661

wliolly absorbed in twelve weeks. the second case a tumor was re-
moved from the orbit, and a third of the surface of the nerve was covered
by a clot, the visual field perfect v=l : in six weeks the blood- was gone.
The third case was seen only once ; he was operated on for pterygium.
Dr. W. thinks the blood in these cases X3ame from the vessels of the papilla.
Dr. Knapp traces the blood in his case to an intracranial source, and be-
lieves it to have travelled down along the intervaginal space, and subse-
quently left its mark in the pigment which he saw.

A case, presumed to be haemorrhage into the sheath of the nerve, was
published by Dr. Sands in the JS^eio York Medical Journal, for November,
1866, page 106.

35. — Emlolus of the Arteria Centralis Retinm. By Dr. R. Schirmee.

[Zehender's Monatsblat. fur Augenheilkunde, 1868, Feb., page 38.]
Occlusion of the Blood-vessels of the Eye. By Dr. H. Knapp. [Archiv.

fur Ophthalmologie, B. xiv., II., s. 205-252.]
Embolism of the Arteria Centralis Betince. By Dr. L. Weckee-

[Schmidt's Jahrbuch, 1868, No. 7, p. 76.]

Dr. Schirmer reports one, and Dr. Knapp five cases of occlusion of
central artery of the retina by embolus, except one, which was caused by
a wound in the orbit. In one case the cause was atheroma of the aorta
and its valves ; in another, aneurism of the common carotid ; in another,
atheroma of the arteries ; in two cases no cause could be found. The symp-
toms are sudden loss of sight, though often retaining perception of light,
and visual field concentrically shrunken. If the remote cause do not lie in
some concomitant brain-trouble, there will be no headache, dizziness, etc.,
but under certain etiological conditions there may be cerebral symptoms.
The lesions in the eye are what Graefe first pointed out, the arteries exces-
sively small, containing blood for a little distance beyond the papilla, then
often entirely empty, the veins fullest at the periphery, sometimes tortu-
ous, and tapering to a point at the papilla; the papilla a yellowish white,
not the dead white or gray of atrophy ; no pulsation producible in the ar-
teries by pressure with the finger on the globe; the retina soon becomes
infiltrated, and the macula has a more or less positive red color.

Dr. Schirmer saw his patient four hours after the attack. The borders
of the nerve were sharp, and the retina perfectly transparent, the macula
red, but he says not the redness of ecchymosis, merely the color seen in
many children. On the second day the papilla became more red, pervaded
by infiltration, which also extended into the contiguous retina ; the macula
remained free.

In one of Dr. Knapp's cases the obstruction was not complete, and sight
returned; but the issue of these cases is generally complete blindness, from
atrophy of the nerve.

Dr. Knapp also relates four cases of thrombosis of the sinuses of the
brain, in which grave ophthalmic symptoms occurred. He examined the
eye of one case; the other three cases are quoted from DuchecTc's "Hand-
buch der Spec. Path, und Therap.'' The distinctive symptoms were pro-
trusion of the globe, redness and oedema of the connective tissue of the
orbit and conjunctiva, intolerance of light, fixed and dilated pupil, loss of
sight, and paralysis of ocular muscles. These local signs are added to other
and grave symptoms of cerebral origin. In no case is it intimated that any
search was made for pulsation over the region of the eye and temple. It
would be natural to expect its occurrence in these acute cases, as well as
in chronic cases, which are alluded to above.

Dr. Knapp justly remarks that the fatal meningitis which sometimes

662

EEP0ET5 OX PROGEESS OF 3IEDIC]:XE.

follows sliglit pHeginonoas inflammation of the face may, perhaps, often
be explained by thrombosis of the orbital veins, involvement of the si-
nuses, thus the cerebral mischief. Such was probably the process in the
case of the lamented Dr. Conant, of this city.

Dr. Knapp adds two cases of embolism of the ciliary arteries. The di-
agnosis in tliese cases cannot be regarded as absolute, yet is, at least, prob-
able ; in both there was heart-disease — one chronic, the other acute. The
former had had embolus of the retinal artery of one eye, and the other eye
was attacked with what was considered a similar lesion of the posterior
ciliary arteries. This occurred at a time of exacerbation of the heart-trou-
ble; his sight suddenly became darkened, and the cause was infiltration of
the retina between the yellow spot and the nerve, as well as of the papilla;
the peripheral retina healthy. The patient finally recovered vision one-half.

Three cases are cited: A woman of 22 years, who fell from her chair in
syncope, and found herself bhnd in one eye. Xo special cause to be as-
signed for the embolus of the vessels.

Another woman, V2 years old, who became suddenly blind in one eye
after taking a warm bath. Xo other cause than sclerosis of the arteries.

A man, 52, in whom the loss of sight in the eye was not complete, and
the retinal vessels were found to be only partially occluded. Xo opacity
of the retina at the macula. Both veins and arteries reduced to half size,
and some arteries were mere threads. The nerve hazy, and its outlines
indistinct. The sight improved under treatment — v at first=^, it became
f . At one foot the visual field was only about five inches in diameter, and
this did not increase as vision improved.

36. — A Case of Anisomefropia : also fJie General Theory of this Error of
Vision. By Dr. H. Kaisee, of Diebursr. [Archiv fur Ophth., Bd. xiii.,
11, s. 352.]

The author, who is 49 years old, and in early life had a slight injury of
the left eye, found himself obhged to use glasses to correct presbyopia.
In one eye the defect of accommodation called for -1-15; in the other for
+ 20. The term anisometropia he uses to express the fact of difiference of
optical value of the two eyes. He ascertained, by careful measurement,
the cardinal points of each eye, both in the vertical and horizontal meridi-
ans. He gives an extended mathematical discussion of these matters, in-
cluding the moderate degree of astigmatism which his eyes have. He
found that the astigmatism of the lens in some degree corrected the astig-
matism of the cornea. He also remarks, that if the astigmatism of the lens
and of the cornea should happen to be in the same meridian, or, in other
words, their asymmetry should be ahke, then, in the act of near vision, the
astigmatism would become greater than it is in distant vision (page 361).

fie gives this rule for choosing glasses when there is anisometropia :
Determine for each eye separately the glass needed for its near point of
comfortable vision, then give each eye the same glass, and one which shall be
a mean between the two. If the difterence be an odd number, take that
glass which shall be nearest to the weakest eye.

The author was first impelled to take glasses by presbyopia accompa-
nied by a disposition to converging strabismus. By using, for one eye, the
left, 4-15, and for the other 4-20, the presbyopia was neutralized, but soon
the strabismic tendency recurred. After working a time with these glasses,
on taking them off" for seeing at a greater yet moderate distance, e. g., for
playing billiai'ds, he found himself extremely sensitive to the dissimilarity
of the accommodation of his eyes, and the eftbrt of seeing became very
painful. He then chose numbers not quite so difterent, viz., left 4-16,
right 4- 18. By these he was for some time made comfortable ; but having

OPHTHALMOLOGY.

663

studied more closely the optical theory of the matter, he came to the con-
clusion that it would be best to use for each eye +17. Immediately on
trying this he "vvas perfectly convinced of the correctness of his theor}-.
For near vision, +17 fully answers the purpose; on being taken off, for
distant sight, there is no disagreeable sense of strain. His eyes are, under
all circumstances, perfectly comfortable. The difference between -^^ and
^=-^-'^ by adding half of this, viz., to we get almost exactly

The principle here enunciated deserves careful consideration, and, if
fully borne out by experience, will be a great advance in practical physio-
logical optics.

BLOOD-YESSELS OF EYE AXD OEBIT.

S7.—A Svmmanj of the Results of Ligation of tTie Carotid for Pulsatirig
Tumors of tlie OrMt. By Dr. Zehexdeu. [Zehender's Monatsblatter
fnr Aug., 1868, pages 99-119.]

In 1867, two cases of successful treatment of pulsating tumors of tlie
orbit were published in the British journals — one by Mr. Joseph Bell, in
the Edinhurgli Medical Journal ; another by Dr. J. Z. Lawrence, in the
OpMTiahnic Eetiew.

Dr. Zehender takes occasion to survey the whole subject, and attempts
to report all the cases that have been made known ; he gives 31 cases, put-
ting them into a table, with various particulars. He remari^s that he was
unable to get a paper by Dr. Morton on the same subject, published in the
American Journal of .Medical Science, April, 1865. By comparing the
two papers, I find that Dr. Morton gives five cases, of whicli four are Amer-
ican, and, perhaps, the fifth also, which Dr. Zehender does not possess.
I have added a number never yet published, as will be seen below.

In these cases the eyeball always protrudes. Two questions arise in •
diagnosis — first, as to the nature of the tumor ; second, where it is situated.
The tumors may be traumatic aneurisms, spontaneous aneurisms of the oph-
thalmic artery (Guthrie found one in each orbit), arterio-venous aneurisms,
cavernous, or erectile or malignant tumors. Some of the cases operated on
have been for nasvi of the skin, which penetrated into the orbit. The di-
agnosis of the exact nature of the swelling it is sometimes very difficult to
make, at other times it is easy. One remarkable <^ase must not be forgot-
ten, where Mr. Bowman tied the carotid for pulsating exophthalinus, in
the firm conviction that the woman had orbital aneurism. She died, and
autopsy revealed the arteries to be perfectly healthy; the ophthalmic vein
was plugged up as it entered the cavernous sinus. This obstruction was
all that could be found to account for the pulsation and protrusion of the
globe.

An intracranial lesion may cause the symptoms: cases of this kind,
are aneurisms near the sella turcica {Kunnelly)\ a hasmorrhage around the
carotid, causing obliteration of the ophthalmic artery and dilation of the
vein {Gendrin); aneurism of the internal carotid communicating with the
cavernous sinus, diagnosticated during life and proven by autopsy {Nela-
ton) ; carcinomatous tumor at the cavernous sinus {Xunnelly, Lenoir).

The diagnosis between intracranial and intraorbital lesion is aided by
these considerations — a comparatively good degree of vision, and, perhaps,
accompanying paralysis of some muscles, indicate intracranial disease;
great injury to sight, absence of paralysis, and detection of a tumor by the
finger, bespeak ordital trouble.

The cause of pulsating exoplithalmus is commonly some injury ; some-
times it has occurred during pregnancy, once during delivery. In four
cases the disease has affected both sides. One surgeon has done six opera-
tions {Xunnelly).

664

EEPORTS 01^ PEOGEESS OF MEDICINE.

Olber remedies, besides ligation of the carotid, have been used, but
none deserve mention save compression of the artery and injection of styp-
tics into tlio tumor. Success has followed compression of the carotid by
Gioppi, Scaramiizza, and Freeman.

In making up the subjoined tables I have collated those of Zehender
and Morton, and have, by the kindness of Dr. J. R. Wood, been able to
add some which are related in a paper which he published, giving the
''Early History of the Operation of Ligature of the Priraitire Carotid Ar-
tery, with a report of 48 unpublished cases ; and also a Summary of 44
cases, with Remarks by Valentine Mott, M. D. Reprinted from the New
York Journal of Medicine for July, 1857."

Among Zeliender's cases is one of orbital aneurism, seen, but not op-
erated on, by Mr. Poland, and referred to by him in ''Royal London Ophth.
Hosp. Reports," vol. ii., page 221. The patient had previously had the
right carotid tied for aneurism in the right orbit. Mr. Poland thinks
because this patient was, in many respects, similar to one operated on by
Dr. Van Buren, of Xevv York, that in Dr. Van Buren's account of his case
the word left had been by mistake written for right. But I am assured
by Dr. Y. B. that his patient's left carotid was tied for aneurism in the left
orbit. By pressing on the left carotid of Mr. Poland's patient, the pulsa-
tion and pain of the tumor ceased; in a few hours he was to ligate this
vessel in the same maimer that the other had been previously treated,
when the patient left the hospital.

By applying personally to Dr. Yan Buren and to Dr. Buck, I am able
to give the correct account of these cases. Mr. Poland did not see Dr.
Yan Buren's patient, but he did, no doubt, see Dr. Buck's patient, the his-
tory of whose case has never yet been published. I give an abstract of it
below, and of one other case hitherto unpublished, operated on by Dr.
Halsted.

There is still another American case, published in the JVeto YorTc Medi-
cal Record, April 15, 1868, vol. iii., No. 52, page 75, in which Dr. Foote, of
Cincinnati, tied loth carotids for an orbital aneurism, making two cases in
this countiy in which this has been done.

Through the kindness of Dr. Poore, I can give the following extracts from
the case-books of the New York Hospital :

The first case is Dr. Yan Buren's, already published, but which I re-
produce in condensed form:

Robert Duggan, set. 23, May, 1854, by a fall sustained injury of the
head, w-ith symptoms of fracture at base of skull; was unconscious, etc.,
and serum issued from left ear ; slight converging strabismus, chiefly of left
eye ; paralysis of left 7th nerve appeared on the 16th day ; on the 22d day
exophthalmus took place, and a iDruit was heard about the temple — sight
almost perfect. On the 26th day the left carotid tied. The ligature
dropped 15 days after. On the 18th day Iruit reappeared, but could be
checked by pressure on right carotid. Sometimes bruit would cease spon-
taneously. In September, 1854, discharged much relieved. A note is ap-
pended that, a year and a half afterward, patient was seen and his condi-
tion was good.

The following case, in which Dr. Buck tied both carotids, is doubtless
the one seen by Mr. Poland:

John Hays, aged 22, sailor, entered New York Hospital in December,
1857. Ten weeks previous had a fall from aloft to the deck, and struck on
his feet; was insensible until next day, then found his sight gone. Four
weeks after pain commenced at inner angle of right eye, with throbbing
and whizzing in the ear. At present time has marked exophthalmus, eye
displaced outward and downward, veins of upper lid enlarged and tortu-
ous, especially those occupying outer half of lid, pulsation distinct, and ar-

OPHTHALMOLOGY.

6G5

rested by pressure on right Ccarotid, conjunctival and scleral vessels dis-
tended, pupil widely dilated and immovable.

December 22, 1857, v'l^ht common carotid ligated by Dr. Gurdon Buck;
tumor did not subside; pulsation less marked. January 1, 1858, oxoph-
thalmus decreasing. February 4th, pulsation increasing, exophthalmus in-
creasing. June 11th, discharged in about the same condition as when ad-
mitted.

February, 1859, patient returned to the hospital, having been to sea and
made a visit to London, where he had been •examined in one of the hospi-
tals. Exophthalmus greater, eye has scarcely any perception of light, lan-
cinating pain in eye, and extending to temple. Left common carotid tied
by Dr. Buck February 23, 1859. A few minutes after, a thrill still percep-
tible in tumor, but less distinct. June 15th, protrusion nearly disappeared,
has perception of light but not of objects; at times a bruit heard in the
tumor. November, 1859, no longer any bruit, tumor all gone, vision nil,
pupil enlarged.

In the two cases following the carotid was tied by Dr. Halsted :
Ernst Krause, 37, entered New York Hospital December 10, 1857, hav-
ing fallen through a hatchway. After eight days complained of noise in
left ear, left pupil sluggish, more contracted than right; on the 10th day
diplopia, injection of both eyeballs. February 2d, almost two months after
injury, ptosis of rigAt upper lid. February 8tb, left eye begins to pro-
trude, chemosis in both eyes, distinct bruit heard on left temple, and all
over the head, most decided over left frontal sinus, pulsation detected by
pressure on the eyeball. February 14th, left carotid tied; immediately
pulsation and bruit ceased, tumor diminished. February 15th, ptosis of
right upper lid diminishing, noise in ear gone. On the 20th bruit and noise
in ear returned. April 3d, discharged cured, no bruit, sight occasionally
dimmed.

Tumor of orbit, ligature of carotid, and afterward extirpation:
Sarah L. Cook, 13, had tumor protruding fi-om outer canthus of left
eye, which had been growing for 3^ years, and pushed the eye forward.
There was offensive discharge fi'om the nose. The tumor pulsated, and
left carotid tied May 11, 1858. The exophthalmus immediately dimin-
ished, but soon began to increase, and more rapidly than before. Child
entered hospital February 7, 1859. Sight unimpaired until two months
before; has now only perception of light, movements of eye perfect, pupil
active. February 8th, both eye and tumor removed. On April 2d dis-
charged cured.

The following case of ligature of both carotids, by Dr. Foote, and re-
ported by Dr. WiUiams, of Cincinnati, seems to have been overlooked by
Dr. Zehender, and I condense the account:

Dennis C, 20, seven months before entering hospital, June 15, 1867,
had a blow and depression of skull 2|- inches long, from vertex to left fron-
tal boss. Immediately afterward the eyeball protruded. When examined,
the external vessels of left eye were very much increased in number and
size ; pulsation, thrill, and bruit very strong. By ophthalmoscope (and this
is the first recorded case thus examined), the retinal vessels seem much en-
larged and tortuous, the optic nerve swollen, borders ill defined, gray in
color, and speckled by minute ecchymosis. Along the veins some extrava-
sations, the whole appearance that of neuro-retinitis. June 22d, carotid
tied, thrill and murmur ceased, but returned in two hours. Vision, which
consisted in ability to count fingers at two feet, unaffected. After 30 days,
symptoms not being relieved, the other carotid tied ; bruit and thrill silenced,
but returned in five minutes. After 14 days left eye examined again by
ophthalmoscope. Swelhng and opacity of papilla nearly gone, retinal exu-
dation and ecchymosis almost gone, vessels of aerve, arteries, and veins

666 EEPOETS OlS" PEOGEESS OF MEDICINE.

both, instantly and completely emptied by the least possible pressure of tlie
finger. " I could see them grow pale even before I was conscious of making
any pressure. Still more interesting was the slowness with which both
sets of vessels filled after the pressure was relaxed, and the entire absence
of pulsation. This was true of retinal vessels in both eyes." Three weeks
after second operation vision improved, bruit very faint. August 21st, dis-
charged cured.

Dr. A. B. Mott gave me the date of his father's case, ISTo. 11, and stated
to me the facts respecting his t)wn cases of orbital tumor, where he tied
the carotid and extirpated the tumor at one sitting.

The following case was given me by "Dr. Frank H. Hamilton, in a brief
note :

A child of Mr. Gardener, OKfton, Canada West, aged 2 years. A
tumor began to present itself near the outer angle of the right eye about
six weeks before I operated, February 12, 1860. The tumor was half
the size of a Sicily orange, elastic, pulsating, and to the ear presented a
rasping sound at each pulsation. The eye w^as pushed inward and pro-
truding. Sight of this eye totally lost. Assisted by Dr. Lothrop, of Buf-
falo, Dr. ISTewburn, of Canada, and my pupil. Dr. Damainville, I proceeded
at once, having placed the child under the influence of chloroform, to tie
the carotid.

After the application of the ligature, the pulsation in the tumor and
rasping sound ceased, and its size was sensibly diminished.

I learned, subsequently, that, after a short time, the ligature came away,
but that the progress of the tumor was only temporarily delayed, and that
the child finally died of what proved to be a vascular malignant growth.

COUNTRY.

England.
England.
France..

4 United States,

United States.

England

United States.

France

United State;-

France

England.
England.

England

United States.
United States,

England

United States,

21 United States.
22Englaud

23l United States.

United States.
Eni'land

1809
1813
1829

1829
1829
1834
1836

1839
1839
1839

1S42
1844
1815

1851
1851

18.52
1852
18.54
1854
1354

ia55

1856
1857
1857
1858

Travers . . .
Dalryraple.
Roux

Dudley

Jobert

Velpeau.. ,

Wood

Herpin

Petreqiiin.

OPEKATOK. RESULT,

Warren
Warren
Scott...
Busk...

Walton . .
Brain wl.

Nunnelly...
V. Mott....
Van Buren.

Curling

A. B. Mott.

Coe

Nunnelly. ,

Van Buren ,
Woodward ,
Nunnelly. .,

Success
Success
Partial
success.
Success
Failure.
Success
Success

Success
Success
Partial
success.
Success
Success
Death , .

Success
Failure.

Success
Success
Success
Success
Success

Success
Success

Death

13th day
Death
8th w'k.
Death..

Aneurism by anastomosis.

Do. do.
Aneurism by anastomosis; pain and exoph-

thalmus.
Spontaneous aneurism.
Traumatic aneurism.

Do. do.
Traumatic aneurism ; years after confirmed by

autopsy.
Spontaneous aneurism.
Traumatic aneurism.

Do. do.

Aneurism by anastomosis— infant.
Spontaneous aneurism.

Pulsating tumor, not cured by ligature nor
by electro punctures.

Aneurism by anastomosis— infant 5 months.

Traumatic aneurism; tumor cured afterward
by injection and two introductions of a hot
needle.

Traumatic aneurism.

Aneurism by anastomosis— infant.

Traumatic aneurism.
Do. do.

Malignant disease in orbit; several extirpa-
tions of mass been followed by relapses ; the
last removal of tumor, combined with liga-
ture of carotid, prevented recurrence for 14
years (verbal statement).

Traumatic aneurism.

Spontaneous aneurism ; slow during preg-
nancy.

Eucephaloid cancer; death from pyjemia.

Cancerous tumor of orbit and brain.

Spontaneous aneurism; man G5 years old;
cerebral arteries atheromatous.

OPIITHxVL>rOLOGY.

667

COHN'TRT. DATE. OPERATOR. RESULT

28 .En gland.

27|Eng]and.

28 England.
29, England.

30 England.

31 England.
S2 England.
33 England.

ii United States,

35 Poland

3<j France

37 United States,

38. France

39 England

40 England

41 United States,

42 United States.

43 United States.

44 United States,

45 United States,

1858 [Bowman . . ,

1859 jNunnelly..,

1860 iBowman . . .

1860 iSvme

1861 Hart

1862 IGreig

1863 iXunneUy..,
1863 INunneUy...

1864 jMorton

1864 ISzokalski..
1864 iLegouest...
1864 A. B. Mott.

1867? Lenoir

1867 Lawrence . .

1867 Bell

1857 Buck

1859 j

1857 iHalsted

1858 Halsted

1867 Foote....
1860 Hamilton

Death jlnjury, no aneurism, but ophthalmic vein oc-
8th day. : eluded as it entered the cavernous sinus.
Success, Spontaneous aneurism ; occurred during preg-
nancy.

Success Spontaneous aneurism.
Success' Do. do.
Success Traumatic aneurism.
SuccessI Do. do.
Success| Do. do.

Partial Death 1^ years after; multiple cancerous ta-
success.i mors.

Success Spontaneous aneurism; sudden during preg-
j nancy.

Success Traumatic aneurism; pressure tried in vain.
Success Traumatic aneurism : 6th nerve paralyzed.
Success Cancerous tumor extirpated and carotid tied ;

I no relapse after 1)4 years.
Failure. Encephaloid tumors"; death after 9 months.
Success Traumatic aneurism.
Success Do. do.

Success Traumatic aneurism ; both carotids tied at in-

I terval of 2 years ; case seen by Mr. Poland.
Success Traumatic aneurism.

Failure. I Tumor in orbit ; after 9 months eye and tumor

! removed: no immediate return".
Success Both carotids tied at interval of 30 days.
Failure Traumatic aneurism; death some time aftei-.

TaMe of Results of Ligature of Carotid for Orhital Disease.

DISEASE.

SUCCESS.'

PARTIAL
SUCCESS.

FAILURE.

DEATH.

T0TAI-.

Aneurism spontaneous

Aneurism traumatic

Aneurism by anastomosis

Solid tumors, " malignant " and others . . .
Occlusion of ophthalmic vein and of cav-
ernous sinus

Total .

The two successful cases of malignant orbital tumors were treated both
by extirpation and ligature of the carotid.

OrMtal Aneurisms treated 'by Injection.

KO.

COUXTRT. DATE. I OPERATOR.

SUBSTANCE.

Brainard Fern lactatis Success.

Do.
Do.
Do.
Do.

1 England

2 I France Bourguet Ferri perchloridi

3 France Desouveaus Ferri sesqui chloridi

4 France j Wecker j Ditto..

5 England 1858 Walton , Tannin

6 lEngland | 1858 iTaylor jTannin

Do.

OrMtal Aneurism treated Compressi

COUXTRT. DATE.l OPERATOR.

DURATION OF PRESSURE.

1 Italy I 1858 |Gioppi IFour days intermittinsly

2 Italy

3 Canada. .

4 Ensrland.

Success.

1858 ScaramuzzaiEiffhteen days intermittingly (7 hrs. 20 min.)..
1861 Freeman ...jPressure on tumor, cold lotions and digitalis,

I I several weeks

Baum .Twice daily for 5 minutes during 10 days

Do.

Failure.

5 England ; Hart Several hours daily for 3 weeks T. '. | Do.

6 Ensland iNunnelly. . . For a very long period I Do.

7 France Legouest. . . During 4 days | Do.

SiPoland Szokalski . . iFifty-six hours ] Do.

668 EEPOETS OIT PEOGEESS OF MEDICmE.

In all cases but one the pressure was on tlie artery in the neck. It is
probable this sort of treatment has been tried without success in many
other instances.

The following treatises and articles are not included in the above
summary :

LcQons sur la Cataracte par £m. Toucher, pages 280. Paris, 1868.
DesMethodesd'Extraction de la Cataracte et del'Extraction semi-elliptiqne,

nouveau procede par L, de Luce (de Vire), pages 54. Paris, 1868.
Phalvologische Studien — elne Streitschrift iiber die Staar Operationen — von

Prof, von Hamer. Prag, 1868.
Der Mechanismus der Accommodation des Menschlichen Auges nach Beo-

bachtuugen im Leben — dargestellt von Dr. E. A. Coccius, pp. 153.

Leipzig, 1868.

Experimental Untersnchungen liber der Mechanismus der Accommodation

von V. Hensen und C. Voelckers, pp. 60. Kiel, 1868.
Die Theorie der Augenfehler und der Brille von Dr. Hermann Scheffler,

pp. 191. Wieu, 1868.
Du Strabisrae dans ses Applications a la Physiologic de la Vision, par Emile

Javal, pp. 77. Paris, 1868.
Tiber den Mechanismus der Accommodation des Menschlichen Auges von

Dr. Albert Schumann, pp. 24. Dresden, 1868.
Ophthalmologisches aus deni Jahre, 1867, von Dr. F. Ileymann, pp. 52.

Leipzig, 1868.

Eetinitis Nyctalopica, by Dr. Arlt, of Vienna — a translation of an article
in the "Bericht iiber die Augenklinik," by Dr. J. F. Weightman, of
Philadelphia.

Atropia; its Chemical, Physiological, and Therapeutic Action, together

with Experiments instituted to ascertain its Toxicological Properties.

By Samuel R. Percy, M. D., pp. 47. New York, 1868.
Enucleation of the Eyeball — Section of the Ciliary ISTerves and Optic Nerve.

Some Unnecessary Causes of Impaired Vision. By B. Joy Jeffries, M. D.

Boston, 1868.

Du Diagnostic des Maladies des yeux par la Chromatoscopie retinienne,

precede d'une etude sur les lois physiques et physiologiques des Cou-

leurs, par X. Galezowski, pp. 266. Paris, 1868.
Handbuch der Augenheilkunde filr praktische Arzte von Dr. J. Ptheindorf,

pp. 232. Leipzig und Heidelberg, 1868.
Gesammelte Abhandlungen iiber Physiologische optik, von Dr. A. Classen,

pp. 175. Berlin, 1868.
Der intraoculare Druck und die Innervations verhaltnisse der Iris, von

augenarztliche standpunkte aus betrachtet, von Prof. Stellwag, pp. 100.

Wien, 1868.

Archiv ftir Ophthalmologic — General Eegister zu Band 1-10, bearbeitet

von Dr. L. Wurm, pp. 67. Breslau, 1868.
Lehrbuch der Ophthalmoscopic, von Dr. Ludwig Mauthner, pp. 468.

Wien, 1868.

A Treatise on the Diseases of the Eye, bv Soelberg Wells. London and
Philadelphia, 1869, pp. 741.

MISCELLANEOUS AND SCIENTIFIC NOTES. 669

The connection of the undersigned with the New Yoek Medical Jour-
nal has been but nominal for tlie last two years. With this number it
ceases altogether.

The Journal will continue under the editorial supervision of De. E. B.

DUNSTEE.

WILLIAM A. HAMMOND.

We ask the especial attention of our readers to the publishers' announce-
ment of a reduction in the subscription price of the Journal. A large pro-
portion of our subscriptions expire with the present number, and our
patrons, in remitting for the coming year, will please bear in mind this
reduction.

The success of the Journal since it passed into the hands of the present
publishers has been, in the highest degree, substantial and encouraging.
We congratulate our subscribers on this success, which inures entirely to
their advantage, as we are authorized to state that still farther improve-
ments will be made just in proportion to the endorsement and support
received from the profession ; with this assurance from the publishers, we
the more willingly call upon our subscribers to aid in extending the cir-
culation, and thus assist in improving the character of the Journal.

We desire to direct tlie attention of onr readers to tlie re-
port on Oplitlialmology, by Professor l^oyes, completed in this
number of the Jonrnal. The report is the most complete one
ever issned in tlie English language, covering the same length
of time — one year. The general practitioner will find in it
much that he may avail himself of in his every-day work, while
its value to those engaged in this special study can hardly be
overestimated. We would especially call the attention of sur-
geons to that part of the report on ligature of the carotid.
More cases are here brought together by Dr. Noyes than have
previously been collected in any single paper. The labor in-
volved in the preparation of a report of this magnitude and
character is simply immense, as any one can testify who has
ever undertaken such work, and we have reason to congrat-
ulate our readers that the author has been willing so freely to
give the results of that labor to the profession.

670 MISCELLAITEOFS AND SCIENTIFIC NOTES.

OuE readers will observe that we have opened up a new
department of the Journal, in which, under the head " Clinical
Records from Private Practice," we have grouped together a
number of interesting cases. It seems to us that the cooper-
ation of our readers is only needed to make this a most valu-
ble feature in the Journal. We shall be pleased to receive
contributions for this dex3artment, and venture to suggest, to
those who may so favor us, three important points :

1. Make the narrative as brief as possible consistent with
an intelligent appreciation of the case.

2. Do not fail to give an outline of the treatment pursued.

3. Always state ,the result, waiting a sufficient time, in
case of recovery, to justify that statement.

The State Medical Society. — We had the satisfaction of
being present, merely as a looker-on, at the recent meeting of
this Society in Albany, and are pleased to record the fact
that the session was one of especial interest and instruction.
If any one thing struck us more prominently than another, it
was the entire harmony of the proceedings, and the evident
interest manifested by all. It speaks well for our profession
that a three days' session should have left, so far as we were
able to learn, from careful inquiry and observation, such
kindly and pleasing impressions upon all who were present,
either as spectators or delegates. The papers presented were
of a high order, and were received with satisfaction. We
should be pleased to give our readers a report of the proceed-
ings, but the scope of this Journal hardly warrants it. Those
who are interested, however, will find a full report in the col-
umns of our enterprising contemporary, the Medical Record^
of this city. In the election of Professor White, of Buffalo, as
President, and Dr. BmT, of Binghamton, as Yice-President,
for the ensuing year, we have every guarantee that the inter-
ests of the Society will not suffer, and that we shall have a
continuance of that hearty good-will and fellowship so mani-
fested this year. We need scarcely add that the efficient
Treasurer and Secretary were reelected. A pleasing in-
cident of the meeting was the announcement, by the vener-
able Dr. Corliss, of his intention to offer a prize for an Essay

MISCELLANEOUS AND SCIENTLFIC IS^OTES. 671

on Tubercular Consumption. The cash prize this year was
awarded to Dr. J. C. Hutchinson, of Brooklyn, for his Essay
on Acupuncture. We are glad to note that ]N^ew York City
was so well represented at this meeting, but it seems to us
hardly just that with her large number of delegates, and with
the many who are now and have been for years eligible for
permanent membership, she should have no larger representa-
tion than a country district which some years will not furnish
enou2:h deles-ates to fill the two vacancies to which each dis-
trict is annually entitled. We hope to see some revision made
of this disproportionate representation. Drs. James L. Banks
and J. B. Yan Kleek were elected permanent members from
this district.

The Ameeican Medical Association^. — We are informed
by Dr. James P. Hibberd, of Bichmond, Indiana, that a first-
class steamer will be chartered to carry delegates from Cairo
to ]^ew Orleans and return, fare not to exceed §35.00, includ-
ing meals and state-room. The time from Cairo will be about
four days. Should the delegates from the l^orth select this
route, the trip will undoubtedly be both pleasant and profit-
able. Further particulars will be published as soon as the
aiTangements are completed.

The Long Islaot) Medical College Hospital. — A new
and beautiful little hospital, capable of accommodating about
forty patients, has just been added to this institution, while the
entire college buildings have been put in perfect repair, adding
vastly to the comfort both of the students and the teachers.
The hospital, with the Dispensary attached to the institution,
affords a large amount of clinical material for class-demonstra-
tions. The lectures open on the 1st of this month.

Hendoo Bemedy you Elephantiasis. By Charles A.
Hast, M. D., New York City.

In a book upon Asiatic history and sciences, published
in London in 1Y92, and principally compiled by Sir AVil-
liam Jones, occurs a translation of an article furnished by a
Delhi native physician, and prefixed by a short notice of the
disease by the translator.

The elephantiasis nigrum, the judMm of the Arabs, is so

672 MISCELLA^'EOUS AXD SCEEIS'TIFIC NOTES.

well known, at least by pathological description, to all physi
cians, that I over these remarks of the translator, more
interesting to antiquarians than to ^^hysicians, and condense
the account of the Hindoo physician, At'har Ali Khan, of
Delhi, himself. Given to him by a friend, who apparently
learned it on a journey to Lucknow in 1783, it is represented
as a secret of the Hindoo physicians, who applied it to the cure
of palsy ^ distortions of the face, relaxations of the nerves^''
and especially to t\ie judhdm (elephantiasis nigrum), and the
Persian fire (lues venerea). The receipt is as follows :

" Take of white arsenic, fine and fresh, one told / of picked
black pepper, six times as much ; let both be well beaten at
intervals for fom- days successively in an iron mortar, and then
reduce to an imj^alpable powder in one of stone, with a stone
pestle, and completely levigated, a little water being mixed
with them ; make pills of them as large as tares, or small pulse,
and keep them dry in a shady place.

" One of these pills must be swallowed morning and even-
ing with some letel-leaf or, in countries where betel is not at
hand, with cold water ; if the body be cleansed from foulness
and obstructions by gentle cathartics and bleeding before the
medicine is administered, the remedy will be speedier." By
a foot-note of the translator, we find the tola to consist of 105
grs. Considering the size of the tares or pulse as about that of
a two gr. pill, the dose would consist of tvjo-sevenths of a gradn
of arsenic, and one and fire-sevenths of hlaclh jpepj^er .

At^har Ali goes on to say that, conformable to the direc-
tions of his learned friend, he prepared the medicine ; and in
the same year gave it to numbers who were reduced by the
disease above mentioned to the j)oint of death ; God is his
witness, that they grew better day by day, were at last com-
pletely cured, and are now living (except one or two who died
of their disorders), to attest the truth of this assertion. One of
the first patients was a Par see, named Memechehr, who had
come from Surat to this city, and had fixed his abode near
the writer's house ; he was so cruelly afflicted with the con-
firmed lues, here called the Persian fire, that his hands and
feet were entirely ulcerated, and almost corroded, so that he
became an object of disgust and abhorrence. This man con-
sulted the writer on his case, the state of which he disclosed
without reserve ; some blood was taken from him on the same
day, and a cathartic administered on the next. On the third
day he began to take the arsenic pills, and, by the blessing of
God, the virulence of his disorder abated by degrees, until
signs of returning health appeared ; in a fortnight his recov-
ery was complete, and lie was bathed according to the prac-

MISCELLANEOUS AND SCLEISTTIFIC IS^OTES.

678

tice of our physicians. He seemed to have no virus left in liis
Mood, and none lias since been perceived in liim."

" But the power of this medicine has chiefly been tried in
the cure of the judhdm^ as the word is pronounced in India,
a disorder infecting the whole mass of blood, and thence
called by some Jisdcli Mun. The former name is derived from
an Arabic root, signifying in general amputations, maiming^
excision^ and particularly tlie truncation or erosion of the
fingers^ which happens in the last stage of the disease. It is
extremely contagious, and for that reason the Prophet said,
'Ferru mind hongdhumi camd teferru mind I dfad^ or ' Flee
from a person afflicted with the judhdm, as you would flee
from a lion.'' It is lierediiarij ^ and in that respect is classed
by medical writers with the goiit^ the consumjption, and the
white leprosy.

" In February, in the year just mentioned, one ShaiJch
JRamazd ni, who then was an upper servant to the board of
revenue, had so corrujDt a mass of blood that a black leprosy
of his joints was approaching, and most of his limbs began
to be ulcerated ; and in this condition he applied to the writer,
and requested immediate assistance. Though the disordered
state of his blood was evident on inspection, and requu*ed no
particular declaration of it, yet many questions were put to
him, and it was clear from his answers that he was a con-
firmed judhdm : he then lost a good deal of blood, and, after
due preparation, took the arsenic pills. After the first week
his malady seemed alleviated ; in the second, it was consid-
erably diminished ; and, in the third, so entirely removed that
the patient went into the Bath of Health, as a token that he
no longer needed a physician."

It is noticeable that the good effects of this medicine were
as marked in the cases of syphilis as in those of elephantiasis,
insomuch that tliis and the apparent resemblance of the last
stages of the former to the symptoms of the latter led this
Hindoo physician to imagine that syphilis often ended in ele-
phantiasis. This, of course, we know is a mistake, and that
mercury, while curing syphilis, only inflames elephantiasis,
but arsenic has been used for the former, and with beneficial
results ; so that there can be no reason to doubt its eftects
when applied to the latter, for which it was more particularly
meant. The rapidity of the cures is in a great degree owing
to the spare habit and healthy constitution common to almost
all the natives of the East, whose food is to so great an extent
vegetable ; as was noticed in Algiers by the French physicians
in suppurating wounds on native subjects. This drug has
never had a fair trial by either Em-opean or American sur-

674 MISCELLANEOUS AND SCIENTIFIC NOTES.

geons, and in my estimation it is not less likely to succeed
than the present fashionable method of ligating arteries for
the cure of elephantiasis, a method of treatment which recent
experiences have shown to be largely nnreliable.

Caebolate of Lixe axd Scarlatixa. — The best authori-
ties do not consider scarlatina to be contagious. It undoubt-
edly sj)reads through some epidemic influence independent of
contagion. It is possible that, under some extreme conditions
of filth and want of ventilation, it may be infectious, and par-
ticularly when accompanied by putrid sore throat. There is
no certain preventive known. Belladonna has had this repu-
tation to some extent ; but extensive experiments show that
it cannot be relied upon. He who shall discover the real
cause of scarlatina, and a certain preventive for it, will merit
honor and reputation certainly equal to that of the discoverer
of vaccination.

There is a tendency among physicians, at the present time,
to attribute many diseases to microscopic spores, or fungi, or
animalculge. There may be some reason for this, though,
when these are found in the blood and secretions, it is by no
means certain whether they are the cause or the effect of the
disease. However this may be, it is certain that carbolic acid
will surely destroy all microscopic life, whether animal or
vegetable. If, then, the cause of scarlatina is any thing of this
description, and there is some reason to think it may be, car-
bolic acid may be useful as a preventive. I have recommend-
ed it, and it has been used to some extent in this city with
appa/'ently good results in the disinfection of rooms where
scarlatina exists, and in preventing the spread of the disease.
But I am well aware of the universal tendency, in relation to
these subjects, to jump at conclusions, and accept them as
true upon entirely insufficient evidence. I would not, there-
fore, offer the experiments already tried as of any value as
proof ; but would recommend a trial of carbolic acid as a pre-
ventive of scarlatina on account of its well-known properties
of destroying all microscopical animal and vegetable life. It
is not simply a deodorizer, but is an actual disinfectant, or de-
stroyer of infection, and is the best disinfectant known for
general use.

The best and only preparation of it, for general practical use
in the sick-room, is the carlolate of lime, which is a dry powder
of a bright-pink color. Let this be kept exposed in the rooms
where children are sick, and in other rooms if desired, in
small quantities, just sufficient to make the coal-tar odor per-
ceptible at all times. A more agreeable odor of the acid may

MISCELLANEOUS XNJ). SCEEOTIFIC iS"OTES.

675

be made by pouring tlie solution oi the pure acid on dry
slaked lime, but tins would be much more expensive and prob-
ably not as efficient.

The carbolate of lime has been used, in the same manner,
quite extensively, to mitigate the severity of the spasms in
Avhooping-cough, and I think the evidence is sufficient to show
that it has been found useful for this purpose. — From January
Bejport of Br. E. J/. Snow, Supt. of Health, etc., Provi-
dence, R. I.

De. Duxlap, of Ohio, the well-known ovariotomist, has
recently performed his fortieth operation. Kine of his cases
have been unsuccessful, but in two out of the nine death was
accidental, being due respectively to chloroform and to an
overdose of morphine. Excluding these two cases, the mortal-
ity is about 1 7 per cent.

Of the last twenty-three cases of ovariotomy by Dr. Thom-
as Keith, of Edinburgh, all except one are now alive and well.
The last operation was done in December, 1868.

Me. Spexcee Wells, in a note to the Boston Medical and
Surgical Journal, gives the following statistics of his opera-
tions for ovariotomy :

1st 100 cases, 66 recovered, and 34 died.
2d 100 " 72 " 28 "

3d 100 " 77 " 23 "

300 215 85
A general mortality of 28 per cent.

M. Kcebeele furnishes {Gazette Hebdornadaire, August 7th)
an elaborate account, accompanied by several tables, of the
ovariotomy operations he has performed. Commencing in
1862, he has, to the present time, performed the operation
sixty-nine times. All these cases he has published, whatever
their results, as they have arisen, and this is the general reca-
pitulation of the whole : As the general result, the recoveries
amount to two-thirds, but in the last twenty-two cases there
have been only five deaths. During the first year there were
6 cases, with 1 death ; in the second, 4 cases and 2 deaths ; in
the third, 8 cases and 2 deaths ; in the fourth, 9 cases and 4
deaths ; in the fifth, 19 cases and 9 deaths ; and in the sixth,
23 cases and 6 deaths — total, 69 cases and 21 deaths. The re-
sults as regards the most serious cases, owing to the improve-

676 MISCELLANEOUS AND SCIENTIFIC NOTES.

merits which have been effected in the operation, have greatly
improved during the later years. Thus, while during 1867-68,
of 11 cas graves 6 recoA^ered, in 12 cas graves occurring during
the preceding two years only 2 recoveries took place. — Med.
Times and Gazette^ Aug. 22, 1868.

The Effect on Man of a Residence at Geeat Heights
ABOVE THE Level OF THE Sea. — At the meeting of October
26, 1868, of the Boston Society for Medical Improvement, Prof.
Robert von Sclilagintweit, of Giessen, in Hessen, was present
by invitation, and made an interesting address on this sub-
ject— ^the abstract of which we copy from the Boston Medical
and Surgical Journal : " There is a height above which
human life is impossible ; in a balloon Mr. Glaisher fainted
when 32,000 feet above the level of the sea ; probably no man
could live at an elevation greater than 34,000 to 36,000 feet ;
this will, however, depend much on the state of the atmos-
phere, the idiosyncrasies of individuals, and the habit of living in
high places. The professor himself, on first reaching an eleva-
vation of 17,000 to 18,0*00 feet, felt great inconvenience and
distress, but at another visit was not much affected. People
living at a moderate elevation, on going higher suffer full as
much as the unaccustomed traveller. In ' High Asia ' the
effects of elevation are shown by headache, haemoptysis, dysp-
noea, anorexia, muscular debility, and low spirits, all increased
at night, and at times every one gasps for air, apparently in
vain ; moments occur when every one believes that he must
inevitably be suffocated. In the day-time epistaxis may occur,
but if the nose is not too much irritated it seldom occurs. He
had never seen bleeding from the eyes, lips, or ears. All
these symptoms disappear as soon as one begins to descend.
In the Andes it is said besides these symptoms are also intense
headache, swoons, bleeding from the nose, lips, gums, and eye-
lids, especially the tunica conjunctiva. The height at which
these symptoms come on among the Andes is not nearly so
great as in High Asia ; in the latter country being not below
16,500 feet, while in the Andes the effect of height has been
repeatedly felt as low as 10,700 feet, lower than anywhere
else. JSTo satisfactory explanation of this fact has yet been
given ; Prof S. thought it might be owing to the different
geological construction, but the existence of volcanoes in the
Andes would not wholly account for the difference. In bal-
loons, symptoms do not come on till a much greater height is
reached, bodily exertion rendering one much more likely to
suffer ; in a balloon the passengers keep perfectly still, any

:^^scELLA^^EOus and scientific notes. 677

exertion at a great lieiglit causing intense depression and
greatly heiglitening the pnlse. Cold does not increase tlie in-
tensity of tlie snffering, but wind decidedly. One could stay
for days at heights of"l 6,500 feet and not suffer duidng the
first portion, but at evening a breeze usually sprung up, ren-
dering every one sick ; in the morning the appetite came back
and the bad symptoms were gone. The effect of great heights
is influenced by the state of the atmosphere (wliich is always
better in the morning than in the evening), the existence of
wind, or clouds, or electricity. There is a great decrease in
the atmospheric pressure, the barometer at the height of
22,259 feet showing only ISy^Q- inches. In High Asia, at a
height of 18,600 or 18,800 feet, the atmospheric pressure is
one-half of that at the level of the sea. These symptoms, which
all are liable to in great heights, prevent human beings from
living there, even if a^l conditions are at hand for their
thriving well.

In none of the pastures in Thibet is tlie height greater than
16,320 feet, and they are only used in certain portions of the
year. A French author, Paul de Carmoy, has described a
village in the Peruvian Andes, named Pueblo de Ocorm-o, at
a height of 18,454: feet, whose inhabitants spend all the year
there, but from his own experience Prof, von Schlagintweit
thinks this impossible ; Carmoy's statement rests either on an
erroneous observation or on a wrong measm-ement; he has
probably mistaken a transitory settlement, only inhabited for
a few days, for a permanent abode.

Dr. Parks said some years ago he ascended Monte Eosa,
and when near the summit, in the midst of a flm-ry of wind
and snow, had an -attack of dyspnoea and other disagreeable
feelings, which all passed away on reaching the summit.

Prof, von Schlagintweit said these symptoms were not
usually felt on the Alps, which were only on the confines of
the elevation at which these symptoms were likely to occur.
They might be felt in an exceptional case, in a storm, as in
Dr. Parks's experience, or by people of highly nervous tem-
peraments.

Why should this influence show itself at so much lower an
elevation among the Andes than in the Alps or elsewhere ?
Whole villages live in Asia at the height of 10,500 feet above
the level of the sea. The inhabitants are robust, with well-
developed chests ; their stature is somewhat less than that of
Europeans or Americans, but their strength is enonnous, that
of the women as well as the men. The diet varies with the
race, some living on vegetable, some on animal food alone.
The Hindoos live principally on rice ; they also make use of
an intoxicating licpior made of millet.

678 MISCELLANEOUS AXD SCIENTIFIC NOTES.

Animal traces are found at very great lieiglits ; the yak
{Bos grimniens) at 19,400 feet, wild horse {Kyang) and several
species of wild sheep and ibex at 18,600, but very fcAv birds.

As to the diseases: in Thibet we find goitre but seldom,
while it is common in some Himalaya valleys; rheumatism
is very common, as is also constipation ; small-pox causes fear-
ful ravages in Thibet ; no apoplexy ; no phthisis, bnt, on the
contrary, consumptives find great relief in these high alti-
tudes. Prof, von Schlagintweit anticipates happy results from
the study of the hygiene of high regions.

Ikfanticide. — The distinction between the evidence re-
quired, where secret disposition of the dead body of an ille-
gitimate child and murder are alleged, has been illustrated in
a late trial in one of the English courts.

A girl had been delivered of a^child, of which she had
certainly disposed. But no body could be found which could
be identified as that of her child. Although the proof of de-
livery was complete and indisputable, tlie accused was ac-
quitted. The judge remarked, that, had the girl been charged
with niurder, she could liave been convicted on the evidence
adduced.

FRo:sr the Annual Eeport of the Surgeon-General, U. S.
Army, for 1868, it appears that, for the widte troops^ the total
number of cases of all kinds reported nnder treatment was
one hundred and thirty-one thousand five hundred and eighty-
one (131,581), or two thousand nine hundred and eight (2,908)
per thousand (1,000) of strength — nearly three entries on the
Bick report during the year for each man. Of this number
of cases, one hundred and eighteen thousand nine hundred
and twenty-five (118,925) were for disease alone, and twelve
thousand six hundred and fifty-six (12,656) for wounds, acci-
dents, and injuries ; being two thousand six hundred and
twenty-eight (2,628) j^er thousand (1,000) of strength for dis-
ease, and two hundred and eighty (280) per thousand (1,000)
of strength for wounds, accidents, and injuries. The average
number constantly on sick report was two thousand eight liun-
dred and fifty-two (2,852), of whom two thousand five hundred
and ten (2,510) were sick and three hundred and forty-two
(342) wounded, or fifty-five (55) per thousand (1,000) constantly
under treatment for disease, and eight (8) per thousand (1,000)
for wounds and injuries. The total number of deaths, from
all causes reported, was one thousand three hundred and fifty-
three (1,353) ; of which, one thousand one hundred and sev-
enty-five (1,175) were frdm disease, and one hundred and sev-

]\nSCELLAjST:OUS AXD SCIEJ^TIFIC NOTES.

G79

enty-eight (ITS) for wounds, accidents, and injuries ; being at
the rate of twenty-six (26) deaths from disease and fonr (tt)
from wounds to each thousand (1,000) of strength. Of the
deaths from disease, four hundred and twenty -seven (427)
were from yellow fever, one hundred and thirty-nine (139)
from cholera, and six hundred and nine (609), or thirteen
(13) deatlis per thousand (1,000) of strength, from all other
diseases. The proportion of deaths from all causes to cases
treated was one (1) death to ninety-seven (97) cases.

Mne hundred and eighty-four (984) white soldiers, or
twenty-two (22) per thousand (1,000) of strength, were dis-
charged upon surgeons' certificate of disability.

A Xew Test for distixguishixg BLooD-sTAms. — This
test, devised by Dr. Day, of Geelong, Australia, consists
in treating a watery solution of the suspected substance with a
little tincture of guiacum, and, afterward, with a drop ol
the ethereal tincture of peroxide of hydrogen — the result is
a strong blue color, which indicates the presence of blood.
The test is regarded as valuable in cases where the blood-
globules have become so altered by long drying, or by soak-
ing in water, that they can no longer be recognized by the
microscope. As, however, it cannot decide, even negatively,
the question, whether the blood be human or not, it cannot
have much weight in medico-legal examinations. The test
and its mode of operation are described as follows : •

If a drop of blood be mixed witli half an ounce of distilled water, and
a drop or two of guiacum be added, a cloudy precipitate of the resin is
thrown down; and the solution has a faint tint, due to the quantity of the
tincture used. If now a drop of an ethereal solution of peroxide ot
hydrogen be added, a blue tint will appear, which will gradually deepen
and spread after a fe^' minutes' exposure to the air. This test acts better
when very small quantities of blood are used; as otherwise, if the blood
is in excess, the solution is red, and gives, with antozone, a purplish or
dirty-green color. So minute and delicate is the reaction, that, in a case
where the microscope failed to identify any blood from a stain in a man's
trousers. Dr. Day succeeded in obtaining sixty impressions.

Water has the eifect of destroying the shape of the blood-corpuscle,
and so it cannot sometimes be recognized by the microscope; but, it in no
way interferes with this new chemical test. Its accuracy may be thus
shown. A piece of linen was stained with blood in the year 184:0 (Guy's
Forensic Medicine^ 3d ed., p. 316); from this a fibre was taken, contain-
ing at its extremity a most minute stain of blood ; this was placed on a
white slab, and treated first with a drop of tincture of guiacum, and then
with a drop of "ozonized ether;'' and, although the quantity was so
small, and no less than twenty-eight years old, the characteristic blue ap-
peared at once. We have found the same result in blood obtained from
the urine in a case of hasmaturia, and also in blood drawn from diftereut
animals. Di-. Taylor, in the G-uy's Hospital Reports^ has shown that red
coloring matters, cochineal, kino, catechu, carmine, etc., exert no such in-

fluence; and, as far as it is at present known, no other red stain w\\\ pro-
duce this result.

BLnck cnrrants will cause a stain resembling that of blood more than^
any other ; but antozone has no effect npon it.

Ink-stains will cause a blue with guiacum; so will rust-stains produced
by citric or acetic acid on iron; but then, 7^0 " ozonized ether " need be
used, and this at once distinguishes such stains from blood. Ozonized
ether " is a wrong term to use ; for it contains antozone, and not ozone ;
and to this is due its reaction. Ether which contained an ozonide would
blue guiacnm resin, whether blood were present or not. The test-solu-
tion is the ethereal solution of peroxide of hydrogen, which is an antozo-
nide.

The so-called " ozonized essential oils," as oil of turpentine, lavender,
etc., really contain antozone; and to this may be ascribed their use in de-
tecting blood; for at first oil of turpentine was used, instead of the per-
oxide of hydrogen ; but the results were unsatisfactory.

If the blood-stain be on dark cloth, the test, as above described, may
be used; but then an impression must be taken olf on white blotting-
paper, otherwise, the blue color will not be visible.

The exact nature of the chemical change that takes place is doubtful ;
bnt the test is so simple and easy of application, and, above all, so very
delicate, that it is likely to become very generally used. Tliis test fails,
as other tests have failed before, to show whether the blood-stain is
human or not. The microscope will point out whether a corpuscle comes
from a fish, a reptile, or a mammal; but we do not think any microscopist
would rely on the mere size of the corpuscle to say whether a cell came
from one class of mammals or anothei', seeing that slight difierences in the
• density of the fluid considerably alter the shape of the corpuscle. — British
Med. Jour.

In the Cincinnaii Lancet and Observer for December,
1868, Dr. J. I. Rooker, of Castleton, Indiana, publishes a sup-
plementary account of the condition of a patient on whom he
performed the operation of castration, in 1861, for the cure of
epilepsy. It will be remembered that Dr. Eooker was most
severely criticised for the performance of this operation. The
patient was a confirmed victim to the vice of masturbation,
and every repetition of the act produced an epileptic fit. The
case proving intractable to all ordinary treatment, and being
apparently hopeless, both testicles were removed by Dr.
Eooker. Since that time (spring of 1861), there has been but
one epileptic fit, which occurred on the day following the
operation.

Eecently, Dr. Eooker saw this patient, and had him ex-
' amined by a number of other physicians.

" lie stated that previous to the operation ' he was not able
to do a day's work, owing to general debility and loss of
mind ; ' that he had had attacks of epilepsy almost every day

MISCELLANEOUS Al^TD SCLENTIFIC NOTES.

681

for tlie past eight years. In short, he was an object of charity.
At present, with the exception of the ' chills,' was in the en-
joyment of excellent health ; that his weight had increased
from one hnndred and twenty to one hnndred and sixty
pounds, and that the ' nervousness ' had all left him ; and that
he conld do as much labor as any man. Is able to read and
write; stated that he had but little .'passion left for the
women.' I could not detect any change in his voice. He is
glad the operation was performed. His intellect appears as
good as any of his class."

Dr. Rooker adds that, while he is no advocate for an indis-
criminate resort to this operation, he is fully satisfied with the
results in this case.

Deaths from Chlorofoem. — A case of death by chloroform
is reported {Brit. Med. Jour.^ Dec. 19, 1868), in London. A
druggist, who had been in the habit of taking chloroform to
relieve pain in the face, was found dead in the evening with a
handkerchief in his right hand and an empty phial, which had
contained chloroform.

Another case of similar kind is recorded by Dr. W. B.
Slayter, in the Provincial Medical Journal (I^ov., 1868). A del-
icate man was found dead in his bed, with a bottle of chloro-
form lying beside him. From the evidence at the inquest, it
appeared that he had been in the habit of inhaling chloroform
from time to time to relieve the paroxysms of asthma. On
the night of his death he took a little over an ounce.

The same physician records, in the same journal, still
another case, which occurred in the Provincial and City Hos-
pital. A man, aged 1-0, vv^as placed under the influence of
chloroform for amputation of thigh owing to inflammation of
knee-joint. Chloroform was administered in the usual way
on a towel. In a few minutes the patient was fully under its
influence, breathing good, pulse strong. The limb was then
amputated about the middle third of the thigh, the arteries
were tied without delay, and about the usual quantity of blood
was lost. Immediately the leg was ofl", the, chloroform was
discontinued ; at that time the patient was breathing naturally,
and the pulse was very good. About three or four minutes
after this, the teeth became firmly clinched, respirations ster-
torous and gasping, pulse very small, and skin covered with a
clammy perspiration. The jaws were immediately forced
open and the tongue drawn forward; artificial respiration,
stimulants, and other remedies were applied, but in vain. The
patient died about ten minutes after the first alarming syra])

682

MISCELLA^^EOUS AND SCIENTIFIC NOTES.

toms set in. On examining the diseased joint tlie synovial
membrane was found to be converted into a gelatinous mass ;
the cartilage covering the inner condyle was perfectly sound,
that covering the onter condyle, the heads of the tibia and
fibula, was completely destroyed and the bones roughened.
Post-mortem examination about thirty hours after death. The
heart-substance, valves, and aorta, were perfectly healthy,
cavities quite empty. The lungs, stomach, spleen, intestines,
and kidneys were all healthy, but quite pale from want of
blood. The brain was quite pale, and its blood-vessels empty.
— Medical News and Library.

At Wrexham a coroner's inquest has shown that death
occurred from this agent, properly administered by a qualified
man for an operation for fistula.

At Leicester, Mrs. Adams, thirty-three years of age, died
from the efiects of chloroform given for the operation of ex-
tracting the stumps of several teeth. The evidence at the in-
quest showed that every precaution was used, her own attend-
ant and another medical man being present. The jury found
that deceased died from chloroform, " in reference to which
more than usual precaution had been taken." These cases
show the dangers that exist even in the hands of skilled per-
sons. A forcible example of the folly of those who are not
qualified being intrusted with such an agent is seen in the sad
case of the Hon. and Rev. Arthur Sugden, who died from
taking chloroform by the stomach in mistake. The deceased
gentleman kept the drug by him, and was in the habit of in-
haling it sometimes to relieve neuralgia, from which he suf-
fered. On one occasion he seems to have swallowed a large
dose in mistake for something more innocent. It appeared the
late gentleman had also " a diseased heart " — a fact that w^ould
render his inhaling chloroform more than usually hazardous,
and be an additional reason why he ought not to have been
intrusted with the drug. — Medical Press and Circidar.

Army Personal. — The following changes have occurred
in the medical corps since the date of publication of our last
report :

Promoted. — Assistant-Surgeon P. C. Davis, to be Surgeon,
to date October 17, 1868, vice B. Randall, retired ; Assistant-
Surgeon James F. Weeds, to be Surgeon, to date October 27,
1868, vice L. E". Holden, retired.

A]L>])ointed. — Frederick W. Elbreg, Augustus TV. Wiggin,

MISCELLAISTEOUS AND SCIEOTIFIC NOTES. 688

"Wasliington Matthews, William R. Steinmetz, John D. Hall,
Curtis E. Mnnn, Ezra Woodruff, Philip F. Harvey, William
H. King, Stevens G. Cowdry, John M. Dickson, Charles B.
B}Tne, Frank Reynolds, and Clarence Ewen, to be Assistant-
Surgeons, to date I^ovember 16, 1868.

Betired. — Surgeon Burton Randall, October IT, 1868 ;
Surgeon L. Holden, October 27, 1868.

Resigned. — Assistant-Surgeon J. Randall, to date Oc-
tober 17, 1868.

The Academy of Medicine has issued a powerful appeal
to the profession to aid, by the contribution of funds, the erec-
tion of a new building. The Academy has now on hand a
fund of some §12,000 devoted to this purpose. The needs of
such a building are evident, and, with a wise liberality, the
Academy proposes to make it subservient to the interests of the
profession at large, and to place it at the disposal of the other
medical societies of this city for their meetings, etc. It will
also afford, what is now much needed in this city, the op-
portunity for founding a medical library which shall be
available to the profession. Promises of several very valuable
libraries have been made to the Academy so soon as a suitable
building shall be furnished in which to deposit them.

A Case of Procidentia Uteri of Seventeen Years' Stand-
ing, CURED BY KOLPORAPHY AND MoDIFIED PeRINEORAPIIY.

— Falling of the womb followed the birth of the patient's
last child. She was unable to walk, or in any way to gain a
livelihood, and was only free from pain when lying down.
The womb was altogether external to the A^agina. It was
much enlarged, thickened, indurated, and around the os and
upon different parts of the vagina were several small ulcera-
tions. Pessaries of different forms had been used to support
the vv^omb, but without effect.

Mr. Norton, of St. Mary's Hospital, removed an elliptical
piece of the mucous membrane of the vesical wall of the va-
gina, three inches and a half in length by two inches in
breadth. The cut margins were then brought together by
means of ten silver-wire sutures, and the uterus replaced. The
bowels were confined by opiates until the sixth day, and then
relieved by castor-oil. The vagina was syringed daily with
warm water, and the sutures were removed in eight days.

684

MISCELLANEOUS XNB SCIENTIFIC NOTES.

Fourteen days after tlie first operation, Mr. ]Srortoii re-
moved by a horse-slioe incision ratlier more than an inch, of
the miicons membrane of tlie posterior and lateral walls of
the vagina, inclnding the cutaneons margins of the fourchette.
The denuded surfaces were now approximated as in the opera-
tion for ruptured perinasum, and were firmlv fixed by means of
silver-wire quilled sutures; the projecting lips were more
evenly adapted by a second row of wire sutm-es somewhat
deeply placed. Tlie bowels were kept cpiiet for a week by
opiates. The quilled sutures were removed after forty-eight
hours, and the others in seven days.

Within a fortnight of the second operation, the patient
left the hospital apparently cured. A year and a half after
the operation, she remained well, and, being a milk-carrier,
was bearing excessive weights, suftering from no inconvenience.
— Zancet, January 23, 1869.

The Anthropological Revieio for January contains as an
original article a paper entitled The Formation of the Mixed
Human Eaces." This paper is a translation from M. Quatre-
fage's " Heport on the Progress of Anthropology in France,"
etc., and was made by Dr. Dunster for the Quarterly Journal
of Psychological Medicine and Medical Jurisjyrudeiice^ and it
appeared in that Journal in July last. The Anthrojyological
Hemew copies it entire — eighteen closely-printed pages — but
it gives no credit whatever for the article, leaving its readers
to infer that it was prepared for that journal.

The Toland Medical College of San Francisco, Cal., grad-
uated six young gentlemen at its recent commencement,
l^Tovember 5, 1868.

Heney G. Ty eight, ]\[. D. — We regret to announce the
death of this physician, of chronic pulmonary disease, at the
early age of forty-one. Dr. Wright was Physician to the Lon-
don Samaritan Free Hospital for Woman, and the author of
several successful books. His work on Headaches had passed
through four editions, and has been reprinted in this country ;
that on Uterine Disorders was favorably reviewed in this Jour-
nal, May, 1868. He wrote at one time much for The Lancet^
and was a frequent contributor to the Saturday Revieio and
Pall Mall Gazette. Dr. Wright visited the United States in

MISCELLANEOUS AND SCIENTIFIC NOTES. 685

1856, on his return from Australia, wliitlier he had gone on
account of failing health.

Something like a Stomach. — M. Decroix, Yeterinaiy Sur-
geon to the Garde de Paris, writing to the Academie de
Medecine, states that for the last eight years he has been in
the habit of eating the flesh of all the horses that have died in
his service, no matter what their disease, whether farcy, glan-
ders, typhoid, charhon^ or what not ! In his opinion, the flesh
of phthisical cows and oxen may be sold without the least
detriment to the public health.

Some time since ^ we called the attention of our readers to
a physiological puzzle occurring in the practice of Professor
Richet, at La Pitie, in Paris. It was the preservation of sen-
sibility in the parts supplied by the musculo-spiral nerve,
after complete division of that nerve. Dr. J. C. ]N'ott, of this
city, in connection with this case,^ recalled attention to a case
occurring under his own observation, and which had previously
been commented on at length in ■ our pages.^ We have now
another instance of this peculiar condition of things observed
in a patient at St. Bartholomew's Hospital, in the service of
Mr. Savory. A large tumor — which proved to be a neuroma
- — was removed from the lower third of the right arm. The
musculo-spiral nerve was seen to enter into and emerge from
the substance of the tumor, and the nerve was divided about
an inch from either extremity of the tumor. Thus no less than
five or six inches of the nerve were entirely removed. The
patient made a good and speedy recovery.

From the time of the operation, the muscles on the back of
the forearm were paralyzed ; but on testing the sensibility of
the skin which is supplied by branches of the radial nerve, it
(the sensibility) was but little if any impaired. The rest of the
report we give in Mr. Savory's own words :

"When the skin upon the outer part of the back of the hand,
or over the back of the thumb and forefinger, was liglitly
pricked, the man cried out sharply. He could distinguish in
the same region two points of contact when they were not
more than an inch apart, both in the long and transverse axes

^ New York Medical Journal, June, 1868.

= See Journal, August, 1868. ^ May, 1866.

686 MISCELLANEOUS AND SCIENTIFIC NOTES.

of tlie hand ; when they were closer than this on any part of
the back of either hand or forearm, he confused them ; and,
indeed, in comparing the sensibility of this region with that of
the inner portion of the back of the hand, and two inner fin-
gers, or Avith the corresponding part of the opposite hand, no
very striking difference conld be detected. All portions, too,
of the back and sides of the middle finger appeared equally
sensitive. He could distinguish also between the contact of
hot and cold bodies in this region as well as in other parts. He
always remarked the distinction between the touch of a cold
steel sound and one that had been previously dipped in hot
water. When desired to experiment upon liimself by touching,
scratching, or pricking the different parts, he repeatedly de-
clared either that he could perceive no difference of sensibility,
or that the radial portion of the dorsum of the hand was rather
more sensitive than the other half. Tliese observations were
carefully repeated in various ways, day after day, with a uni-
form result ; indeed, the man at last got tired of them, conclud-
ing, no doulDt, that the existence of acute sensibility had been
abundantly proved. It need hardly be said that in many of
tliese experiments the man was blindfolded, and otherwise
prevented from forming any idea of what we did except through
the sense of touch.

ISTow, wdiat is the interpretation of this remarkable fact ?
All anatomists will agree that, so far as ordinary dissection
goes, the skin on the outer half or thereabout of the back of
the hand, and of the back of the thumb, forefinger, and outer
portion of the back of the middle finger, is supplied only by
branches of the radial nerve ; and when any variation is noticed
in the distribution of this nerve to the back of the hand, it is
almost always that it supplies more than the usual proportion
of integument, going on sometimes to the ring-finger. I can-
not doubt therefore that in this instance the parts in question
w^ere supplied in the usual way — only through the branches of
the radial nerve. But then how could these parts retain sen-
sibility after the removal of some inches of the nerve-trunk ?
I can only account for it thus : We know that in the forearm,
just above the wrist, some small branches of the external cuta-
neous nerve communicate with the radial, and it may be that
at this junction the radial receives filaments from the external
cutaneous, which so pass down to be distributed, with the fila-
ments of the radial, even to the skin of the hand. This seems
to me to be the most probable view of the matter — indeed, the
only reasonable one. There should assuredly be more diffi-
culty in conceiving such a transference of the filaments of the
ulnar and radial on the back of the hand. The arrangement

MISCELLANEOUS AND SCIEOTIFIC NOTES.

687

of the small branches so near their distribntion wonlcl hardly
admit of this. But if this explanation be the true one, it sug-
gests a much larger question. Are nerves so isolated in their
distribution as they are now believed to be ? Is not the pur-
pose of the communication between different nerves in their
course more extensive and complete than lias been hitherto
recognized ? The question is one which appears to be beyond
the reach of any ordinary dissection, and perhaps it will be
best answered hereafter by observation and experiment in cases
like the present one.^

The Army Medical Museum continues to increase in value
and usefulness. During the year, six hundred and seventy,
three (673) specimens have been added to the surgical section,
one hundred and twenty-one (121) to the medical section, two
hundred and two (202) to the section of comparative anatomy,
six hundred and eighty-seven (687) specimens and one hun-
dred and fourteen (lli) photographic negatives of microsco-
pical specimens to the microscopical section. An anatomical
section of one hundred and sixty-three (163) specimens has
been formed, and is rendered of especial interest by the large
proportion of typical crania of the Xorth American abori-
gines which it contains. A collection of one hundred and
eighty-seven (187) specimens of Indian weapons and utensils
has also been added. Two hundred and sixty-six (266) dis-
carded specimens, the histories of which could not be found at
the period of publication of the Catalogue of the Surgical Sec-
tion, have been identified and restored to the collection. For
pui-poses of exchange with other museums, or with learned
societies, either for specimens or publications, four thousand
fom' hundred and seventy-two (4,1:72) photographs, illustra-
tive of injuries and operations, have been printed. There
were during the year fourteen thousand four hundred and
forty-eight (11,41:8) visitors to the Museum, including many
military surgeons of eminence. — From Report of the Surgeon-
General^ U. S. Army.

De. J. Blackbuex sends to the Lancet a description, ac-
companied by an engraving, of an enormous biliary calculus,
passed without any aggravation of the usual signs of passing a

^ In the Buffalo Medical and SurgkalJoicrnal for June, 1868, Dr. J. F.
Miner records three cases which were suggested by our report of Professor
Richet's case. Dr. Miner's case, however, are not parallel, although, in
one where three inches of the median nerve were excised on account of
intense pain supervening on the healing of a gunshot wound, there was, if
we understand the case correctly, hut a shght diminution of sensibihty.

68 S MISCELLA^'EOUS A^^D SCIENTIFIC NOTES.

gall-stone. The stone measures three and tliree-eiglitlis inclies
' in length, one and a half inches in its widest part, and weighs
one ounce and six drachms.

Teaxsveese HEEiMAPHKODmsM. — TTe are indebted to the
kindness of Dr. W. W. Ely, of Kochester, is^. Y., for the fol-
lowing contribution to the study of comparative anatomy :

The term liermaphrodite, although not strictly applicable
to any instances except those in which the two sexes are fully
represented in the same individual, as in certain of the lower
organisms, is nevertheless a convenient designation for abnor-
mal developments of the generative organs where the sexual
characteristics are more or less blended. Transverse hermaph-
roditism, therefore, according to Dr. Simpson, comprises those
cases in which the internal and the external organs of genera-
tion belong to different sexes. Examples of this development
■^^^H^^afeoiesti^^cattle^ha^^^een called " Free Martins." Similar
malformation^, hafeVbeen ^&und in other animals, and even in
th€s»lw.mian subject. The following instance in the deer oc-
cuiTed to thev writei^-inj^ugust last. The animal had been
killed in hunting a few hours before my examination. It was
panially clressed, for the convenience of transportation, leaving
the pelvic organs in situ, and in this condition it weighed 139
lbs. It was supposed to be a doe, with an unusual development
of horns. The antlers were like those of a buck, large and
branching, each having four prongs. The external sexual
organs were of the female type. There was a well-formed
udder of a size proportionate to that of the animal. The vul-
va were perfectly normal. The vagina was abou. half the
usual length, narrow, and contracted toward the bladder,
where it "terminated. The urethra was short, and opened
into the upper part of the vagina. There was neither uterus
nor penis. The vesicul^ seminales were also wanting. Two
small testicles were found attached to the peritoneum, and
connected by this membrane with the bladder. The vasa
deferentia were represented by short, impervious cords, which
could only be traced a few inches^ and might have been sev-
ered when the viscera were removed. The horns were in the
velvet, showing that they were subject to the periodical
growth of these organs, as in the perfect male.

Eerata. — In Dr. Sayre's article on Artificial Hip-joint,
January number, page 356, for Jnly 20 read February 20 ;
page 357, lines 11 and 14, for February read April. The
coiTection of these dates lessens very materially the signifi-
cance of some of the sti-ictures made by Dr. Bauer in his reply
to the paper alluded to.

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